Myocardial dysfunction after out-of-hospital cardiac arrest: predictors and prognostic implications.

We aim to determine the incidence of early myocardial dysfunction after out-of-hospital cardiac arrest, risk factors associated with its development, and association with outcome. A retrospective chart review was performed among consecutive out-of-hospital cardiac arrest (OHCA) patients who underwent echocardiography within 24 h of return of spontaneous circulation at three urban teaching hospitals. Our primary outcome is early myocardial dysfunction, defined as a left ventricular ejection fraction < 40% on initial echocardiogram. We also determine risk factors associated with myocardial dysfunction using multivariate analysis, and examine its association with survival and neurologic outcome. A total of 190 patients achieved ROSC and underwent echocardiography within 24 h. Of these, 83 (44%) patients had myocardial dysfunction. A total of 37 (45%) patients with myocardial dysfunction survived to discharge, 39% with intact neurologic status. History of congestive heart failure (OR 6.21; 95% CI 2.54-15.19), male gender (OR 2.27; 95% CI 1.08-4.78), witnessed arrest (OR 4.20; 95% CI 1.78-9.93), more than three doses of epinephrine (OR 6.10; 95% CI 1.12-33.14), more than four defibrillations (OR 4.7; 95% CI 1.35-16.43), longer duration of resuscitation (OR 1.06; 95% CI 1.01-1.10), and therapeutic hypothermia (OR 3.93; 95% CI 1.32-11.75) were associated with myocardial dysfunction. Cardiopulmonary resuscitation immediately initiated by healthcare personnel was associated with lower odds of myocardial dysfunction (OR 0.40; 95% CI 0.17-0.97). There was no association between early myocardial dysfunction and mortality or neurological outcome. Nearly half of OHCA patients have myocardial dysfunction. A number of clinical factors are associated with myocardial dysfunction, and may aid providers in anticipating which patients need early diagnostic evaluation and specific treatments. Early myocardial dysfunction is not associated with neurologically intact survival.

A retrospective cohort study examining the association between body mass index and mortality in severe sepsis.

Body mass index (BMI) is an easily calculated indicator of a patient's body mass including muscle mass and body fat percentage and is used to classify patients as underweight or obese. This study is to determine if BMI extremes are associated with increased 28-day mortality and hospital length of stay (LOS) in emergency department (ED) patients presenting with severe sepsis. We performed a retrospective chart review at an urban, level I trauma center of adults admitted with severe sepsis between 1/2005 and 10/2007, and collected socio-demographic variables, comorbidities, initial and most severe vital signs, laboratory values, and infection sources. The primary outcome variables were mortality and LOS. We performed bivariable analysis, logistic regression and restricted cubic spline regression to determine the association between BMI, mortality, and LOS. Amongst 1,191 severe sepsis patients (median age, 57 years; male, 54.7%; median BMI, 25.1 kg/m(2)), 28-day mortality was 19.9% (95% CI 17.8-22.4) and 60-day mortality was 24.4% (95% CI 21.5-26.5). Obese and morbidly obese patients were younger, less severely ill, and more likely to have soft tissue infections. There was no difference in adjusted mortality for underweight patients compared to the normal weight comparator (OR 0.74; CI 0.42-1.39; p = 0.38). The obese and morbidly obese experienced decreased mortality risk, vs. normal BMI; however, after adjustment for baseline characteristics, this was no longer significant (OR 0.66; CI 0.42-1.03; p = 0.06). There was no significant difference in LOS across BMI groups. Neither LOS nor adjusted 28-day mortality was significantly increased or decreased in underweight or obese patients with severe sepsis. Morbidly obese patients may have decreased 28-day mortality, partially due to differences in initial presentation and source of infection. Larger, prospective studies are needed to validate these findings related to BMI extremes in patients with severe sepsis.

The effect of obesity on clinical outcomes in presumed sepsis: a retrospective cohort study.

Sepsis is a major cause of hospital admissions and mortality. Nevertheless, there are significant gaps in our knowledge of the epidemiology of sepsis in obese people, who now represent more than one-third of the population in the United States. The objective of this study was to measure the association between obesity and mortality from presumed sepsis. A retrospective cohort study was used of 1,779 adult inpatients with presumed sepsis at a Tertiary Care Academic Institution from March 1, 2007 to June 30, 2011. Cases of sepsis were identified using a standardized algorithm for sepsis antibiotic treatment. Exposure (i.e., obesity) was defined as a body mass index ≥30 kg/m(2). Multivariable logistic regression was used to assess the adjusted association between obesity and mortality. Patients with presumed sepsis were of a median age of 60.9 years (interquartile range 49.7-71) and 41.1 % were women. A total of 393 patients died, resulting in a 28-day in-hospital mortality of 22.1 %. In adjusted analysis, obesity was not significantly associated with increased mortality (odds ratio 1.11, 95 % CI 0.85-1.41, P = 0.47). There was also no difference in the in-hospital length of stay (P = 0.45) or maximum percent change in serum creatinine (P = 0.32) between obese and non-obese patients. Finally, there was no difference in the proportion of initial inadequate vancomycin levels (P = 0.1) after presumed sepsis. Obesity was not associated with increased mortality in patients with presumed sepsis. Further research is needed to determine how excess adiposity modulates inflammation from sepsis.