Commenting period (July 16, 2023 08:25 – August 16, 2023 00:00) is closed
MON-03B-v1
0 General Document comments
0 Sentence and Paragraph comments
0 Image and Video comments
RECOVER 2.0 Worksheet
QUESTION ID: MON-03B
PICO Question:
In cats and dogs that have experienced ROSC after CPA (P), does measurement of creatinine (I) as opposed to non-measurement (C), improve ... (O)?
Outcomes:
Duration of post-arrest hospitalization,Favorable neurologic outcome,Prediction of recurrent CPA,Survival to Discharge
Prioritized Outcomes (1= most critical; final number = least important):
1. Favorable neurologic outcome
2. Survival to discharge
3. Duration of post-arrest hospitalization
4. Prediction of recurrent CPA
5.
Domain chairs: Selena Lane, Ben Brainard
Evidence evaluators: Stefania Scarabelli, Aaron Galton
Conflicts of interest: none
Search strategy: See attached document
Evidence Review:
|
Study Design |
Reduced Quality Factors
0 = no serious, - = serious,
- - = very serious |
Positive Quality Factors
0 = none, + = one, ++ = multiple |
Dichotomous Outcome Summary |
Non-Dichotomous Outcome Summary
Brief description |
Overall Quality
High, moderate, low, |
||||||||
|
No of studies |
Study Type |
RoB |
Indirectness |
Imprecision |
Inconsistency |
Large Effect |
Dose-Response |
Confounder |
# Intervention with Outcome |
# Control with Outcome |
RR (95% CI) |
|
|
|
Outcome 1: Favorable neurologic outcome |
|||||||||||||
|
6 |
OB |
0 |
- - |
0 |
- |
0 |
0 |
0 |
|
|
|
|
Very low |
|
1 |
EXP |
0 |
- - |
- |
0 |
0 |
0 |
0 |
|
|
|
|
Very low |
|
Outcome 2: Survival to discharge |
|||||||||||||
|
9 |
OB |
0 |
-- |
- |
- |
0 |
0 |
0 |
|
|
|
|
Very low |
|
Outcome 3: Prediction of recurrent CPA |
|||||||||||||
|
0 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Outcome: Duration of post-arrest hospitalization |
|||||||||||||
|
0 |
|
|
|
|
|
|
|
|
|
|
|
|
|
PICO Question Summary
|
Introduction |
|
Acute kidney injury (AKI) is common in patients experiencing ROSC as a consequence of prolonged hypoxemia and hypoperfusion, as well as ischemia-reperfusion injury.1 In both survivors of CPA and many critically ill populations, AKI is considered an adverse outcome that can ultimately affect duration of hospitalization, survival to discharge and long-term prognosis, independent of underlying cause. This PICO question addressed the utility of post-arrest creatinine measurement to improve outcome after ROSC.
|
|
Consensus on science |
|
Outcome 1: Favorable neurologic outcome
For the most critical outcome of favorable neurologic outcome, 6 observational studies in people (very low quality of evidence, downgraded for very serious indirectness and inconsistency) and 1 experimental study in dogs (very low quality of evidence, downgraded for very serious indirectness and imprecision) were identified that were relevant to the PICO question.1–6 Four of the 5 observational studies in people showed a lower frequency of FNO in patients developing AKI in the PCA period. One prospective observational study showed that post-arrest patients with less favorable neurologic outcomes had significantly higher rates of AKI than those with FNO (64% vs. 38%, P=0.004).2 Another observational study of adult people in the PCA period showed an odds ratio for poor neurologic outcome of 3.81 (95% CI 1.98-7.33, P = 0.0001) for patients with static or increasing plasma creatinine concentrations 24 hours post-ROSC compared to those whose creatinine decreased during the first 24 hours.3 Yonemoto et al. used admission creatinine to estimate GFR in a prospective observational study of 5112 people and showed that odds ratios for FNO decreased as GFR decreased.6 Isenschmid at al. did a multivariate analysis of admission creatinine (in umol/L) and demographic data including co-morbidities and found an adjusted odds ratio for poor neurologic outcome of 44.33 (95% confidence interval 6.99 to 281.36, P < 0.001).4 In 282 children with ROSC, severe AKI was associated with worse neurologic function following arrest in a study evaluating the utility of therapeutic hypothermia in the PCA period.7 The only observational study in people that did not show an association between AKI and FNO was a retrospective study of 199 people that showed no difference in neurologic outcomes at 3 months post-ROSC between patients with evidence of AKI (85/199, 43%) and those without evidence of AKI.1 The single experimental study in dogs investigated gender-specific differences in 24-hour outcome following ROSC after 9 minutes of untreated cardiac arrest followed by CPR.5 Neurologic outcome was not significantly different between male and female dogs; however, creatinine concentrations progressively increased at 6, 12, and 24 hours post-arrest in female dogs.
Outcome 2: Survival to discharge
For the next most critical outcome of survival to discharge, 9 observational studies in people were identified that addressed the PICO question (very low quality of evidence, downgraded due to very serious indirectness, serious imprecision, and inconsistency).6–14
In a clinical trial evaluating the utility of therapeutic hypothermia in children experiencing ROSC after CPA, 64% of the children developed AKI, of which 41% developed more severe AKI and 3.5% required renal replacement therapy.7 Severe AKI was associated with lower survival at 28 days and at 12 months post-ROSC. There were several more studies that supported these findings in adult humans experiencing ROSC after arrest events, with the majority of patients developing AKI after arrest experiencing higher in-hospital mortality and lower survival rates over time after discharge.1,6,9–13 Incidence of AKI after cardiac arrest was over 40% in one retrospective analysis, and this patient population mirrored common findings in other reports, with AKI patients exhibiting severe hemodynamic impairment and requiring more intensive interventions post-arrest.1 Another study showed that creatinine concentrations at admission following out-of-hospital cardiac arrest were higher in patients that ultimately developed AKI and 30-day mortality was higher in patients with more advanced (stage 3) AKI compared to those with less severe kidney injury.13 There is some evidence in adults that development of AKI (based on the RIFLE scoring system) was not independently associated with survival to discharge; however, renal injury is common, with more than one-third of patients resuscitated from out-of-hospital cardiac arrest events developing markers of renal dysfunction and 19% of those patients meeting the criteria for AKI.14 Both initial creatinine concentrations or low urine output were predictive of development of AKI and peak creatinine concentrations were identified typically during the first 72 hours after arrest. One of the primary findings in that particular study was that the only predisposing factor for development of AKI post-cardiac arrest was the duration of shock after ROSC. Median duration of shock within the first 24 hours post-ROSC was 10 minutes (range 2-59 min) in the non-AKI group compared to 130 minutes (range 48-250 min) in patients that developed AKI. Time from arrest to ROSC, duration of CPR, and serum lactate immediately after ROSC were not associated with development of AKI in that study. Studies are lacking to answer these same questions for dogs or cats experiencing CPA.
Outcomes 3 and 4: Prediction of recurrent CPA and Duration of post-arrest hospitalization
No studies were identified that directly addressed these outcomes for this PICO question.
None of the studies reviewed compared measurement of creatinine to non-measurement with regard to any of the outcomes investigated for this PICO question. There was no evidence in human or veterinary studies available that answer the PICO question with regard to prediction of recurrent CPA events.
|
|
Treatment recommendation |
|
We recommend measuring serum creatinine concentrations, as an indicator of AKI, as soon as feasible in the PCA period, and subsequently no less often than every 24 hours during hospitalization in dogs and cats that achieve ROSC. (strong recommendation, very low quality of evidence)
|
|
Justification of treatment recommendation |
|
There is consensus in human medicine that post-arrest AKI is associated with worse outcomes, including increased risk of death and decreased frequency of FNO. Therefore, identification of AKI in dogs and cats in the PCA period, especially if the evidence of kidney injury is progressive, may have prognostic value. Despite the frequent measurement of renal values in clinical practice, there is a paucity of literature on creatinine measurement and AKI in dogs and cats experiencing ROSC after CPA. Two experimental studies were reviewed, one in pigs and one in dogs, which provided support for measurement of creatinine in animals after CPR and ROSC.15,16 In an experimental pig model of cardiac arrest, serum creatinine was higher for subjects that experienced CPA when compared to the control group of pigs who did not experience CPA.15 Similarly, in a canine model of cardiac arrest, creatinine concentrations were significantly higher both during CPR and after ROSC, with creatinine increasing approximately 11% and 29% from baseline, respectively.16 Neither study addressed the outcomes evaluated by this particular question and there was no comparison of measurement versus no measurement in study participants.
There have been no studies of the utility of management of AKI guided by serial creatinine measurements to improve outcomes in the PCA period, but monitoring for evidence of development and/or progression of AKI in the PCA period and adjusting management strategies to address kidney injury is likely to be of benefit to these patients. |
|
Knowledge gaps |
|
Currently there is no evidence in dogs and cats that serum creatinine increases in dogs and cats in the PCA period or that increased serum creatinine during CPR or after ROSC are associated with survival to discharge or poor neurologic outcomes. Studies to identify patient factors associated with increased risk of AKI in dogs and cats following ROSC, optimal frequency of creatinine measurement, and to determine whether severity and duration of post-arrest kidney injury has an effect on outcome of these patients are warranted. |
References:
1. Tujjar O, Mineo G, Dell’Anna A, et al. Acute kidney injury after cardiac arrest. Crit Care. 2015;19(1):169.
2. Hasslacher J, Barbieri F, Harler U, et al. Acute kidney injury and mild therapeutic hypothermia in patients after cardiopulmonary resuscitation - a post hoc analysis of a prospective observational trial. Crit Care. 2018;22(1):154.
3. Hasper D, von Haehling S, Storm C, Jörres A, Schefold JC. Changes in serum creatinine in the first 24 hours after cardiac arrest indicate prognosis: an observational cohort study. Crit Care. 2009;13(5):R168.
4. Isenschmid C, Kalt J, Gamp M, et al. Routine blood markers from different biological pathways improve early risk stratification in cardiac arrest patients: Results from the prospective, observational COMMUNICATE study. Resuscitation. 2018;130:138-145.
5. Zwemer CF, O’Connor EM, Whitesall SE, D’Alecy LG. Gender differences in 24-hour outcome following resuscitation after 9 minutes of cardiac arrest in dogs. Crit Care Med. 1997;25(2):330-338.
6. Tamura T, Suzuki M, Hayashida K, et al. Renal Function and Outcome of Out-of-Hospital Cardiac Arrest - Multicenter Prospective Study (SOS-KANTO 2012 Study). Circ J. 2018;83(1):139-146.
7. Cornell TT, Selewski DT, Alten JA, et al. Acute kidney injury after out of hospital pediatric cardiac arrest. Resuscitation. 2018;131:63-68.
8. Chua HR, Glassford N, Bellomo R. Acute kidney injury after cardiac arrest. Resuscitation. 2012;83(6):721-727.
9. Strand K, Søreide E, Kirkegaard H, et al. The influence of prolonged temperature management on acute kidney injury after out-of-hospital cardiac arrest: A post hoc analysis of the TTH48 trial. Resuscitation. 2020;151:10-17.
10. Kim YW, Cha KC, Cha YS, et al. Shock duration after resuscitation is associated with occurrence of post-cardiac arrest acute kidney injury. J Korean Med Sci. 2015;30(6):802-807.
11. Mattana J, Singhal PC. Prevalence and determinants of acute renal failure following cardiopulmonary resuscitation. Arch Intern Med. 1993;153(2):235-239.
12. Roman-Pognuz E, Elmer J, Rittenberger JC, et al. Markers of cardiogenic shock predict persistent acute kidney injury after out of hospital cardiac arrest. Heart Lung. 2019;48(2):126-130.
13. Geri G, Guillemet L, Dumas F, et al. Acute kidney injury after out-of-hospital cardiac arrest: risk factors and prognosis in a large cohort. Intensive Care Med. 2015;41(7):1273-1280.
14. Yanta J, Guyette FX, Doshi AA, Callaway CW, Rittenberger JC. Renal dysfunction is common following resuscitation from out-of-hospital cardiac arrest. Resuscitation. 2013;84(10):1371-1374.
15. Shen P, Xu JF, Gao YZ, et al. Establishment of a swine model of traumatic cardiac arrest induced by haemorrhage and ventricular fibrillation. J Int Med Res. 2020;48(6):300060520931260.
16. Bleske BE, Song J, Chow MS, Kluger J, White CM. Hematologic and chemical changes observed during and after cardiac arrest in a canine model--a pilot study. Pharmacotherapy. 2001;21(10):1187-1191.
Supplemental:
Tujjar 2015: AKI not a predictor of neurologic outcome at 3 months.
Hasslacher 2018: Prospective observational trial of 126 patients post-ROSC.
Patients with FNO were less likely to have AKI (64% vs. 38%, P=0.004)
Hasper 2009: Observational cohort study of 171 adult people
serum creatinine levels decreased in patients with good neurological outcome (CPC 1 or 2) over the ensuing 48 hours
serum creatine levels increased in patients with unfavourable outcome (CPC 3-5).
ROC analysis identified DeltaCrea24 <-0.19 mg/dl as the value for prediction with the highest accuracy. The odds ratio for an unfavourable outcome was 3.81 (95% CI 1.98-7.33, P = 0.0001) in cases of unchanged or increased creatinine levels after 24 hours compared to those whose creatinine levels decreased during the first 24 hours.
Yonemoto 2019: Prospective observational study of 5112 adults with primary cardiac arrest
First obtained creatinine used to estimate GFR
eGFR groups ≥60, 45–59, 30–44, and <30mL/min/1.73m2,
The adjusted OR for favorable neurological outcome decreased with eGFR: 0.74 (95% CI: 0.52–1.06), 0.40 (95% CI: 0.25–0.64), and 0.48 (95% CI:
0.29–0.81), respectively.
survival adjusted OR were 0.74 (95% CI: 0.54–1.03), 0.42 (95% CI:0.28–0.62), and 0.43 (95% CI: 0.28–0.68)
Isenschmid 2018: Prospective observational study of 321 adults achieving ROSC
Multivariate analysis of creatinine and other demographic data, including co-morbidities. Log base 10 transformed, umol/L units
Survival to discharge: 33.91 (6.14 to 187.16), P<0.001
FNO: 44.33 (6.99 to 281.36), P < 0.001
General Document Comments 0
icons on the left to see existing comments.
0 archived comments