Interesting paper in AJEM. Hypoxic hepatitis (HH), ‘shock liver’, is defined as an increase in serum aminotransferase levels (20 times the upper normal level) after respiratory or circulatory failure. It is commonly seen in critical illness and after cardiac arrest. In ICU patients HH has been associated with poor outcomes but little is known about what it means in ROSC patients.
Retrospective, observational study that included all patients who achieved ROSC after suffering out-of-hospital cardiac arrest and survived for at least 24h. Exclusion criteria were possible non-hypoxic causes of HH such as hepatitis, hepatotoxic toxins, malignant infiltration and traumatic arrest.
148 patients were enrolled. n=20 had HH. n=128 were non-HH. The percentage presenting with a shockable rhythm was significantly lower in the HH group. The period of no flow during resuscitation was longer in the HH group. No big surprise perhaps.
More interesting was how mortality and neurologic outcome differed between the groups. Only 5 (25%) patients in the HH group were discharged alive. All of them with very poor neurologic outcomes (CPC scores of 3-4, meaning vegetative state or, at best, severe disability.) Conversely, in the non-HH group, 87 (68%) were discharged alive. 58,6% in the non-HH group were discharged with a poor neurological outcome.
The results are not surprising. If the liver has suffered hypoxic damage, a more oxygen dependent organ like the brain is likely to have taken a big hit. But this is also why liver enzymes might be a useful add-on for prognostication.
In this study, ALT peaked around 6-12 hours and AST around 12-24 hours after ROSC.
Hypoxic hepatitis in cardiac arrest reflects longer periods of global poor perfusion. HH is significantly related to death and poor (neurologic) outcome. As always the numbers are tiny but this could be useful for prognosticating these patients.
Study lives here:
Am J Emerg Med. 2015 Sep;33(9):1166-70. doi: 10.1016/j.ajem.2015.05.008. Epub 2015 May 16. Hypoxic hepatitis in survivors of out-of-hospital cardiac arrest. Oh SH1, Kim HJ2, Park KN1, Kim SH1, Kim YM1, Youn CS1, Lim JY1.