Coagulation measures after cardiac arrest (CMACA)

PLOS ONE RESEARCH ARTICLE Coagulation measures after cardiac arrest (CMACA) Hyo Joon Kim ID1, Kurz Michael2, Jung Hee Wee3, Joo Suk Oh ID4, Won Young Kim5, In Soo Cho ID6, Mi Jin Lee7, Dong Hun Lee8, Yong Hwan Kim9, Chun Song Youn ID1* a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 1 Department of Emergency Medicine, Seoul St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea, 2 Department of Emergency Medicine, University of Alabama School of Medicine, Birmingham, Alabama, United States of America, 3 Department of Emergency Medicine, Yeouido St. Mary’s Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea, 4 Department of Emergency Medicine, Uijeongbu St. Mary’s Hospital, The Catholic University of Korea College of Medicine, Uijeongbu, Korea, 5 Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea, 6 Department of Emergency Medicine, Hanil General Hospital, Korea Electric Power Medical Corporation, Seoul, Korea, 7 Department of Emergency Medicine, Kyungpook National University School of Medicine, Daegu, Korea, 8 Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Korea, 9 Department of Emergency Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea * OPEN ACCESS Citation: Kim HJ, Michael K, Wee JH, Oh JS, Kim WY, Cho IS, et al. (2023) Coagulation measures after cardiac arrest (CMACA). PLoS ONE 18(1): e0279653. https://doi.org/10.1371/journal. pone.0279653 Editor: Chiara Lazzeri, Azienda Ospedaliero Universitaria Careggi, ITALY Received: May 8, 2022 Accepted: December 4, 2022 Published: January 6, 2023 Peer Review History: PLOS recognizes the benefits of transparency in the peer review process; therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. The editorial history of this article is available here: https://doi.org/10.1371/journal.pone.0279653 Copyright: © 2023 Kim et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: All relevant data are within the paper and its Supporting Information file Funding: This research was supported by ZOLL Foundation. There was no additional external funding received for this study. Abstract Background During cardiac arrest (CA) and after cardiopulmonary resuscitation, activation of blood coagulation and inadequate endogenous fibrinolysis occur. The aim of this study was to describe the time course of coagulation abnormalities after out-of-hospital CA (OHCA) and to examine the association with clinical outcomes in patients undergoing targeted temperature management (TTM) after OHCA. Methods This prospective, multicenter, observational cohort study was performed in eight emergency departments in Korea between September 2018 and September 2019. Laboratory findings from hospital admission and 24 hours after return of spontaneous circulation (ROSC) were analyzed. The primary outcome was cerebral performance category (CPC) at discharge, and the secondary outcome was in-hospital mortality. Results A total of 170 patients were included in this study. The lactic acid, prothrombin time (PT), activated partial thrombin time (aPTT), international normalized ratio (INR), and D-dimer levels were higher in patients with poor neurological outcomes at admission and 24 h after ROSC. The lactic acid and D-dimer levels decreased over time, while fibrinogen increased over time. PT, aPTT, and INR did not change over time. The PT at admission and D-dimer levels 24 h after ROSC were associated with neurological outcomes at hospital discharge. Coagulation-related factors were moderately correlated with the duration of time from collapse to ROSC. PLOS ONE | https://doi.org/10.1371/journal.pone.0279653 January 6, 2023 1 / 10 PLOS ONE Competing interests: None of the authors has declared a conflict of interest. Coagulation measures after cardiac arrest Conclusion The time-dependent changes in coagulation-related factors are diverse. Among coagulation-related factors, PT at admission and D-dimer levels 24 h after ROSC were associated with poor neurological outcomes at hospital discharge in patients treated with TTM. Introduction Despite advances in critical care, including targeted temperature management (TTM), outof-hospital cardiac arrest (OHCA) still has high mortality and morbidity rates [1, 2]. Systemic inflammation and increased coagulation due to whole-body ischemia and reperfusion after cardiac arrest (CA) play an important role in hypoxic brain injury and multiple organ dysfunction. Once OHCA occurs, a lack of pulsatile blood flow facilitates rapid clot formation and subsequent return of spontaneous circulation (ROSC), distributing the clot burden throughout the vasculature and vital organs [3]. Therefore, optimal postarrest care requires careful management of the complex interaction between clot formation and its natural resolution. The most common causes of OHCA are acute coronary syndrome (ACS) and pulmonary thromboembolism (PTE), which require treatment with systemic anticoagulation. Such therapy requires delicate titration that is problematic without a more complete understanding of coagulation dysfunction after CA. Moreover, TTM, which is considered the standard of care for postcardiac arrest syndrome (PCAS) patients, is known to impair coagulation and alter the metabolism of anticoagulation therapies. Coagulopathy in critically ill patients, such as those with sepsis and trauma, is known to be associated with poor outcomes [4–7]. Elevated Ddimer levels and high disseminated intravascular coagulation (DIC) scores are related to poor outcomes in PCAS patients [8–10]. Nevertheless, coagulation abnormalities after CA are not fully understood. The prognostic implication of coagulation-related factors measured repeatedly has not been studied in PCAS patients treated with TTM. The aim of this study was to describe the time course of coagulation abnormalities after OHCA and to examine the association with clinical outcomes in patients undergoing TTM after OHCA. Methods Study design and setting This prospective, multicenter, observational cohort study was performed in eight emergency departments of university-affiliated teaching hospitals in Korea between September 2018 and September 2019. Adult (over 19 years of age) comatose OHCA patients with ROSC treated with TTM irrespective of their initial rhythm and etiology of CA were enrolled. Patients were excluded if they had a cerebral performance category (CPC) > 3 before CA, if they had traumatic CA, if they had a do-not-resuscitate order (DNAR), if they had preexisting hereditary or induced coag (...truncated)