Hypoxic ischemic brain injury following in hospital cardiac arrest – Lessons from autopsy

Cognitive impairment and psychopathology in out-of-hospital cardiac arrest survivors in Denmark: The REVIVAL cohort study protocol

INTRODUCTION

Cognitive impairment and psychopathology caused by brain hypoxia and the traumatic impact of critical illness are common in cardiac arrest survivors and can lead to negative consequences of everyday life functioning, and further impact mental health in relatives. Most studies have dealt with the mere survival rate after cardiac arrest and not with long-term consequences to mental health in cardiac arrest survivors. Importantly, we face a gap in our knowledge about suitable screening tools in the early post-arrest phase for long-term risk prediction of mental health problems. This study aims to evaluate the efficacy of a novel screening procedure to predict risk of disabling cognitive impairment and psychopathology 3 months after cardiac arrest. Furthermore, the study aims to evaluate long-term prevalence of psychopathology in relatives.

METHODS AND ANALYSES

In this multicentre prospective cohort study, out-of-hospital cardiac arrest survivors and their relatives will be recruited. The post-arrest screening includes the Montreal Cognitive Assessment (MoCA), the Hospital Anxiety and Depression Scale (HADS), the Impact of Event Scale-Revised (IES-R) and the Acute Stress Disorder Interview (ASDI) and is conducted during hospitalisation. In a subsample of the patients, functional MRI is done, and cortisol determination collected. At 3-month follow-up, the primary study outcomes for 200 survivors include the Danish Affective Verbal Learning Test-26 (VAMT-26), Delis-Kaplan Executive Function System tests (trail making, colour-word interference, word and design fluency), Rey's Complex Figure and Letter-number sequencing subtest of Wechsler Adult Intelligence Scale-IV, HADS and IES-R. For the relatives, they include HADS and IES-R.

ETHICS AND DISSEMINATION

The study is approved by the local regional Research Ethics Committee (H-18046155) and the Danish Data Protection Agency (RH-2017-325, j.no.05961) and follows the latest version of the Declaration of Helsinki. The results will be published in peer-reviewed journals and may impact the follow-up of cardiac arrest survivors.

Cardiopulmonary resuscitation practices in the Netherlands: results from a nationwide survey

Background

Survival rates after in-hospital cardiac arrest are low and vary across hospitals. The ERC guidelines state that more research is needed to explore factors that could influence survival. Research into the role of cardiopulmonary resuscitation (CPR) practices is scarce. The goal of this survey is to gain information about CPR practices among hospitals in the Netherlands.

Methods

A survey was distributed to all Dutch hospital organizations (n = 77). Items investigated were general hospital characteristics, pre-, peri- and post-resuscitation care. Characteristics were stratified by hospital teaching status.

Results

Out of 77 hospital organizations, 71 (92%) responded to the survey, representing 99 locations. Hospitals were divided into three categories: university hospitals (8%), teaching hospitals (64%) and non-teaching hospitals (28%). Of all locations, 96% used the most recent guidelines for Advanced Life Support and 91% reported the availability of a Rapid Response System. Training frequencies varied from twice a year in 41% and once a year in 53% of hospital locations. The role of CPR team leader and airway manager is most often fulfilled by (resident) anaesthetists in university hospitals (63%), by emergency department professionals in teaching hospitals (43%) and by intensive care professionals in non-teaching hospitals (72%). The role of airway manager is most often attributed to (resident) anaesthetists in university hospitals (100%), and to intensive care professionals in teaching (82%) and non-teaching hospitals (79%).

Conclusion

The majority of Dutch hospitals follow the ERC guidelines but there are differences in the presence of an ALS certified physician, intensity of training and participation of medical specialties in the fulfilment of roles within the CPR-team.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4166-2) contains supplementary material, which is available to authorized users.

Retracted: microRNA-129-5p involved in the neuroprotective effect of dexmedetomidine on hypoxic-ischemic brain injury by targeting COL3A1 through the Wnt/β-catenin signaling pathway in neonatal rats

Our study aims to elucidate the mechanisms how microRNA-129-5p (miR-129-5p) involved in the neuroprotective effect of dexmedetomidine (DEX) on hypoxic-ischemic brain injury (HIBI) by targeting the type III procollagen gene (COL3A1) through the Wnt/β-catenin signaling pathway in neonatal rats. A total of 120 rats were obtained, among which 15 rats were selected as sham group and rest rats as model, DEX, DEX + negative control (DEX + NC), DEX + miR-129-5p mimics, DEX + miR-129-5p inhibitors, DEX + XAV-939, and DEX + miR-129-5p inhibitors + XAV-939 groups. A dual-luciferase reporter assay was performed for the target relationship between miR-129-5p and COL3A1. Weight rate and water content of cerebral hemisphere were detected. Quantitative real-time polymerase chain reaction and Western blot analysis were conducted to detect miR-129-5p expression and expressions of COL3A1, E-cadherin, T-cell factor (TCF)- 4, and β-catenin. The DEX, DEX + miR-129-5p mimics, DEX + XAV-939 groups had increased weight rate of the cerebral hemisphere, but decreased water content of left cerebral hemisphere, levels of COL3A1, β-catenin, TCF-4, and E-cadherin in the hippocampus compared with the model and DEX + miR-129-5p inhibitors groups. COL3A1 was verified as the target gene of the miR-129-5p. Compared with the DEX + NC and DEX + miR-129-5p inhibitors + XAV-939 groups, the DEX + XAV-939 and DEX + miR-129-5p mimics groups had elevated weight rate of the cerebral hemisphere, but reduced water content of left cerebral hemisphere, levels of COL3A1, β-catenin, TCF-4, and E-cadherin in the hippocampus. Our findings demonstrate that miR-129-5p improves the neuroprotective role of DEX in HIBI by targeting COL3A1 through the Wnt/β-catenin signaling pathway in neonatal rats.

Effect of interplay between age and low-flow duration on neurologic outcomes of extracorporeal cardiopulmonary resuscitation

Purpose

Caseloads of extracorporeal cardiopulmonary resuscitation (ECPR) have increased considerably, and hospital mortality rates remain high and unpredictable. The present study evaluated the effects of the interplay between age and prolonged low-flow duration (LFD) on hospital survival rates in elderly patients to identify subgroups that can benefit from ECPR.

Methods

Adult patients who received ECPR in our institution (2006–2016) were classified into groups 1, 2, and 3 (18–65, 65–75, and > 75 years, respectively). Data regarding ECPR and adverse events during hospitalization were collected prospectively. The primary end point was favorable neurologic outcome (cerebral performance category 1 or 2) at hospital discharge.

Results

In total, 482 patients were divided into groups 1, 2, and 3 (70.5%, 19.3%, and 10.2%, respectively). LFDs were comparable among the groups (40.3, 41.0, and 44.3 min in groups 1, 2, and 3, P = 0.781, 0.231, and 0.382, respectively). Favorable neurologic outcome rates were nonsignificantly lower in group 3 than in the other groups (27.6%, 24.7%, and 18.4% for group 1, 2, and 3, respectively). Subgroup analysis revealed that the favorable neurologic outcome rates in group 1 were 36.7%, 25.4%, and 13.0% for LFDs of < 30, 30–60, and > 60 min, respectively (P = 0.005); in group 2, they were 32.1%, 21.2%, and 23.1%, respectively (P = 0.548); in group 3 they were 25.0%, 20.8%, and 0.0%, respectively (P = 0.274).

Conclusion

On emergency consultation for ECPR, age and low-flow duration should be considered together to predict neurologic outcome.

Electronic supplementary material

The online version of this article (10.1007/s00134-018-5496-y) contains supplementary material, which is available to authorized users.

Noninvasive monitoring of brain edema after hypoxia in newborn piglets

BackgroundDevelopment of cerebral edema after brain injury carries a high risk for brain damage and death. The present study tests the ability of a noninvasive cerebral edema monitoring system that uses near-infrared spectroscopy (NIRS) with water as the chromophore of interest to detect brain edema following hypoxia.MethodsVentilated piglets were exposed to hypoxia for 1 h, and then returned to normal oxygen levels for 4 h. An NIRS sensor was placed on the animal's head at baseline, and changes in light attenuation were converted to changes in H₂O. Cerebral water content and aquaporin-4 protein (AQP4) expression were measured.ResultsThe system detected changes in NIRS-derived water signal as early as 2 h after hypoxia, and provided fivefold signal amplification, representing a 10% increase in brain water content and a sixfold increase in AQP4, 4 h after hypoxia. Changes in water signal correlated well with changes in cerebral water content (R=0.74) and AQP4 expression (R=0.97) in the piglet brain.ConclusionThe data show that NIRS can detect cerebral edema early in the injury process, thus providing an opportunity to initiate therapy at an earlier and more effective time-point after an insult than is available with current technology.

Brain resuscitation and prognosis after cardiac arrest

Brain injury represents the major cause of long-term disability and mortality among patients resuscitated from cardiac arrest. Brain-directed therapies include maintenance of normal oxygenation, hemodynamic support to optimize cerebral perfusion, glycemic control, and targeted temperature management. Pertinent guidelines and recommendations are reviewed for brain-directed treatment. The latest clinical trial data regarding targeted temperature management are also reviewed. Contemporary prognostication among initially comatose cardiac arrest survivors uses a combination of clinical and electrophysiologic tests. The most recent guidelines for prognostication after cardiac arrest are reviewed. Ongoing research regarding the effects of induced hypothermia on prognostic algorithms is also reviewed.