Little is known about the association between serum potassium level on hospital arrival and neurological outcome after out-of-hospital cardiac arrest (OHCA). We investigated whether the serum potassium level on hospital arrival had prognostic indications for patients with OHCA.
Methods:
This prospective, multicenter observational study conducted in Osaka, Japan (CRITICAL study) enrolled consecutive patients with OHCA transported to 14 participating institutions from 2012 to 2016. We included adult patients aged ⩾18 years with OHCA of cardiac origin who achieved return of spontaneous circulation and whose serum potassium level on hospital arrival was available. Based on the serum potassium level, patients were divided into four quartiles: Q1 (K ⩽3.8 mEq/L), Q2 (3.8< K⩽4.5 mEq/L), Q3 (4.5< K⩽5.6 mEq/L) and Q4 (K >5.6 mEq/L). The primary outcome was one-month survival with favorable neurological outcome, defined as cerebral performance category scale 1 or 2.
Results:
A total of 9822 patients were registered, and 1516 of these were eligible for analyses. The highest proportion of favorable neurological outcome was 44.8% (189/422) in Q1 group, followed by 30.3% (103/340), 11.7% (44/375) and 4.5% (17/379) in the Q2, Q3 and Q4 groups, respectively (p<0.001). In the multivariable analysis, the proportion of favorable neurological outcome decreased as the serum potassium level increased (p<0.001).
Conclusions:
High serum potassium level was significantly and dose-dependently associated with poor neurological outcome. Serum potassium on hospital arrival would be one of the effective prognostic indications for OHCA achieving return of spontaneous circulation.
NeumarRWShusterMCallawayCW, et al. Part 1: Executive summary: 2015 American Heart Association Guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation2015; 132: S315–S367.
2.
MonsieursKGNolanJPBossaertLL, et al. European Resuscitation Council Guidelines for resuscitation 2015: Section 1. Executive summary. Resuscitation2015; 95: 1–80.
3.
Fire and Disaster Management Agency. Report on a study on social system development to improve survival from emergency cardiovascular disease, http://www.fdma.go.jp/neuter/topics/fieldList9_3.html (2017, accessed 25 August 2018).
4.
CallawayCWDonninoMWFinkEL, et al. Part 8: Post-cardiac arrest care: 2015 American Heart Association Guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation2015; 132: S465–S482.
5.
NolanJPSoarJCariouA, et al. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines for post-resuscitation care 2015: Section 5 of the European Resuscitation Council Guidelines for resuscitation 2015. Resuscitation2015; 95: 202–222.
6.
LaverSFarrowCTurnerD, et al. Mode of death after admission to an intensive care unit following cardiac arrest. Intensive Care Med2004; 30: 2126–2128.
7.
PichlerGFazekasF.Cardiopulmonary arrest is the most frequent cause of the unresponsive wakefulness syndrome: A prospective population-based cohort study in Austria. Resuscitation2016; 103: 94–98.
8.
FogelWKriegerDVeithM, et al. Serum neuron-specific enolase as early predictor of outcome after cardiac arrest. Crit Care Med1997; 25: 1133–1138.
9.
Hachimi-IdrissiSvan der AuweraMSchiettecatteJ, et al. S-100 protein as early predictor of regaining consciousness after out of hospital cardiac arrest. Resuscitation2002; 53: 251–257.
10.
HayashidaKSuzukiMYonemotoN, et al. Early lactate clearance is associated with improved outcomes in patients with postcardiac arrest syndrome: A prospective, multicenter observational study (SOS-KANTO 2012 Study). Crit Care Med2017; 45: e559-e566.
11.
ShinozakiKOdaSSadahiroT, et al. Blood ammonia and lactate levels on hospital arrival as a predictive biomarker in patients with out-of-hospital cardiac arrest. Resuscitation2011; 82: 404–409.
12.
SicaDAStruthersADCushmanWC, et al. Importance of potassium in cardiovascular disease. J Clin Hypertens (Greenwich)2002; 4: 198–206.
13.
GumzMLRabinowitzLWingoCS.An integrated view of potassium homeostasis. N Engl J Med2015; 373: 60–72.
14.
McDonoughAAYounJH.Potassium homeostasis: The knowns, the unknowns, and the health benefits. Physiology (Bethesda)2017; 32: 100–111.
15.
NúñezJBayés-GenísAZannadF, et al. Long-term potassium monitoring and dynamics in heart failure and risk of mortality. Circulation2018; 137: 1320–1330.
16.
AldahlMJensenACDavidsenL, et al. Associations of serum potassium levels with mortality in chronic heart failure patients. Eur Heart J2017; 38: 2890–2896.
17.
YanagawaYSakamotoTSatoH.Relationship between laboratory findings and the outcome of cardiopulmonary arrest. Am J Emerg Med2009; 27: 308–312.
18.
YamadaTKitamuraTHayakawaK, et al. Rationale, design, and profile of Comprehensive Registry of In-Hospital Intensive Care for OHCA Survival (CRITICAL) study in Osaka, Japan. J Intensive Care2016; 4: 10.
IwamiTKawamuraTHiraideA, et al. Effectiveness of bystander-initiated cardiac-only resuscitation for patients with out-of-hospital cardiac arrest. Circulation2007; 116: 2900–2907.
21.
IwamiTNicholGHiraideA, et al. Continuous improvements in “chain of survival” increased survival after out-of-hospital cardiac arrests: A large-scale population-based study. Circulation2009; 119: 728–734.
22.
Japan Resuscitation Council. 2015 Japanese guidelines for emergency care and cardiopulmonary resuscitation. Tokyo: Igaku-Shoin, 2016.
23.
KitamuraTIwamiTKawamuraT, et al. Nationwide public-access defibrillation in Japan. N Engl J Med2010; 362: 994–1004.
24.
KitamuraTKiyoharaKSakaiT, et al. Public-access defibrillation and out-of-hospital cardiac arrest in Japan. N Engl J Med2016; 375: 1649–1659.
25.
CumminsROChamberlainDAAbramsonNS, et al. Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: The Utstein Style. A statement for health professionals from a task force of the American Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, and the Australian Resuscitation Council. Circulation1991; 84: 960–975.
26.
LanePWNelderJA.Analysis of covariance and standardization as instances of prediction. Biometrics1982; 38: 613–621.
27.
MatsuoSImaiEHorioM, et al.; Collaborators developing the Japanese equation for estimated GFR. Revised equations for estimated GFR from serum creatinine in Japan. Am J Kidney Dis2009; 53: 982–992.
28.
PunPHSmarzTRHoneycuttEF, et al. Chronic kidney disease is associated with increased risk of sudden cardiac death among patients with coronary artery disease. Kidney Int2009; 76: 652–658.
29.
GoASChertowGMFanD, et al. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med2004; 351: 1296–1305.
30.
LinCHTuYFChiangWC, et al. Electrolyte abnormalities and laboratory findings in patients with out-of-hospital cardiac arrest who have kidney disease. Am J Emerg Med2013; 31: 487–493.
31.
KandaY.Investigation of the freely available easy-to-use software ‘EZR’ for medical statistics. Bone Marrow Transplant2013; 48: 452–458.
32.
ShinJLimYSKimK, et al. Initial blood pH during cardiopulmonary resuscitation in out-of-hospital cardiac arrest patients: A multicenter observational registry-based study. Crit Care2017; 21: 322.
33.
ChoYMLimYSYangHJ, et al. Blood ammonia is a predictive biomarker of neurologic outcome in cardiac arrest patients treated with therapeutic hypothermia. Am J Emerg Med2012; 30: 1395–1401.
34.
SkrifvarsMBPettiläVRosenbergPH, et al. A multiple logistic regression analysis of in-hospital factors related to survival at six months in patients resuscitated from out-of-hospital ventricular fibrillation. Resuscitation2003; 59: 319–328.
35.
JainNKotlaSLittleBB, et al. Predictors of hyperkalemia and death in patients with cardiac and renal disease. Am J Cardiol2012; 109: 1510–1513.
36.
GoyalASpertusJAGoschK, et al. Serum potassium levels and mortality in acute myocardial infarction. JAMA2012; 307: 157–164.
37.
KovesdyCPAppelLJGramsME, et al. Potassium homeostasis in health and disease: A scientific workshop cosponsored by the National Kidney Foundation and the American Society of Hypertension. J Am Soc Hypertens2017; 11: 783–800.
PonikowskiPVoorsAAAnkerSD, et al.; ESC Scientific Document Group. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J2016; 37: 2129–2200.
40.
AnJNLeeJPJeonHJ, et al. Severe hyperkalemia requiring hospitalization: Predictors of mortality. Crit Care2012; 16: R225.
41.
BrownRS.Potassium homeostasis and clinical implications. Am J Med1984; 77: 3–10.
42.
GeddesLARoederRARundellAE, et al. The natural biochemical changes during ventricular fibrillation with cardiopulmonary resuscitation and the onset of postdefibrillation pulseless electrical activity. Am J Emerg Med2006; 24: 577–581.
43.
InamasuJ1NakamuraYSaitoR, et al. Normokalemia and hyperglycemia in subarachnoid hemorrhage patients resuscitated from prehospital cardiopulmonary arrest. Resuscitation2002; 54: 255–258.
