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Bencsik C, Josephson C, Soo A, Ainsworth C, Savard M, van Diepen S, Kramer A, Kromm J. The Evolving Role of Electroencephalography in Postarrest Care. Can J Neurol Sci 2024:1-13. [PMID: 38572611 DOI: 10.1017/cjn.2024.55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
Electroencephalography is an accessible, portable, noninvasive and safe means of evaluating a patient's brain activity. It can aid in diagnosis and management decisions for post-cardiac arrest patients with seizures, myoclonus and other non-epileptic movements. It also plays an important role in a multimodal approach to neuroprognostication predicting both poor and favorable outcomes. Individuals ordering, performing and interpreting these tests, regardless of the indication, should understand the supporting evidence, logistical considerations, limitations and impact the results may have on postarrest patients and their families as outlined herein.
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Affiliation(s)
- Caralyn Bencsik
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
| | - Colin Josephson
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Centre for Health Informatics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Andrea Soo
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
| | - Craig Ainsworth
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Martin Savard
- Département de Médecine, Université Laval, Quebec City, QC, Canada
| | - Sean van Diepen
- Department of Critical Care Medicine, University of Alberta, Edmonton, AB, Canada
- Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Andreas Kramer
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Julie Kromm
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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2
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Peluso L, Stropeni S, Macchini E, Peratoner C, Ferlini L, Legros B, Minini A, Bogossian EG, Garone A, Creteur J, Taccone FS, Gaspard N. Delayed Deterioration of Electroencephalogram in Patients with Cardiac Arrest: A Cohort Study. Neurocrit Care 2024; 40:633-644. [PMID: 37498454 DOI: 10.1007/s12028-023-01791-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 06/23/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND The aim of this study was to assess the prevalence of delayed deterioration of electroencephalogram (EEG) in patients with cardiac arrest (CA) without early highly malignant patterns and to determine their associations with clinical findings. METHODS This was a retrospective study of adult patients with CA admitted to the intensive care unit (ICU) of a university hospital. We included all patients with CA who had a normal voltage EEG, no more than 10% discontinuity, and absence of sporadic epileptic discharges, periodic discharges, or electrographic seizures. Delayed deterioration was classified as the following: (1) epileptic deterioration, defined as the appearance, at least 24 h after CA, of sporadic epileptic discharges, periodic discharges, and status epilepticus; or (2) background deterioration, defined as increasing discontinuity or progressive attenuation of the background at least 24 h after CA. The end points were the incidence of EEG deteriorations and their association with clinical features and ICU mortality. RESULTS We enrolled 188 patients in the analysis. The ICU mortality was 46%. Overall, 30 (16%) patients presented with epileptic deterioration and 9 (5%) patients presented with background deterioration; of those, two patients presented both deteriorations. Patients with epileptic deterioration more frequently had an out-of-hospital CA, and higher time to return of spontaneous circulation and less frequently had bystander resuscitation than others. Patients with background deterioration showed a predominantly noncardiac cause, more frequently developed shock, and had multiple organ failure compared with others. Patients with epileptic deterioration presented with a higher ICU mortality (77% vs. 41%; p < 0.01) than others, whereas all patients with background deterioration died in the ICU. CONCLUSIONS Delayed EEG deterioration was associated with high mortality rate. Epileptic deterioration was associated with worse characteristics of CA, whereas background deterioration was associated with shock and multiple organ failure.
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Affiliation(s)
- Lorenzo Peluso
- Departement of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, 20072, Pieve Emanuele, Italy.
- Department of Intensive Care, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium.
- Departement of Anesthesiology and Intensive Care, Humanitas Gavazzeni, Via Mauro Gavazzeni, 21, 24125, Bergamo, Italy.
| | - Serena Stropeni
- Department of Intensive Care, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Elisabetta Macchini
- Department of Intensive Care, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Caterina Peratoner
- Department of Intensive Care, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Lorenzo Ferlini
- Department of Neurology, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Benjamin Legros
- Department of Neurology, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Andrea Minini
- Department of Intensive Care, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Elisa Gouvea Bogossian
- Department of Intensive Care, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Andrea Garone
- Department of Intensive Care, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Nicolas Gaspard
- Department of Neurology, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
- Department of Neurology, Yale University Medical School, 15, York Street, New Haven, CT, 06510, USA
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3
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Schiewe R, Bein B. [Post Resuscitation Care]. Anasthesiol Intensivmed Notfallmed Schmerzther 2024; 59:237-250. [PMID: 38684159 DOI: 10.1055/a-2082-8777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
After successful resuscitation, further treatment has a decisive influence regarding patient outcome. Not only overall survival, but also the neurological outcome that is crucial for patients' quality of life can be positively influenced by optimized post-cardiac arrest treatment. The management of various consequences of post-cardiac arrest syndrome is discussed in the current version of the ERC-guidelines in the chapter "post resuscitation care". A step-by-step approach based on an algorithm provides the necessary structure. The immediate treatment and stabilization of patients after ROSC is followed by the diagnosis of the triggering pathology in order to initiate adequate therapy. During the subsequent intensive care treatment, the focus is on optimizing neurological recovery.
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4
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Hirsch KG, Abella BS, Amorim E, Bader MK, Barletta JF, Berg K, Callaway CW, Friberg H, Gilmore EJ, Greer DM, Kern KB, Livesay S, May TL, Neumar RW, Nolan JP, Oddo M, Peberdy MA, Poloyac SM, Seder D, Taccone FS, Uzendu A, Walsh B, Zimmerman JL, Geocadin RG. Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement from the American Heart Association and Neurocritical Care Society. Neurocrit Care 2024; 40:1-37. [PMID: 38040992 PMCID: PMC10861627 DOI: 10.1007/s12028-023-01871-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 06/08/2023] [Indexed: 12/03/2023]
Abstract
The critical care management of patients after cardiac arrest is burdened by a lack of high-quality clinical studies and the resultant lack of high-certainty evidence. This results in limited practice guideline recommendations, which may lead to uncertainty and variability in management. Critical care management is crucial in patients after cardiac arrest and affects outcome. Although guidelines address some relevant topics (including temperature control and neurological prognostication of comatose survivors, 2 topics for which there are more robust clinical studies), many important subject areas have limited or nonexistent clinical studies, leading to the absence of guidelines or low-certainty evidence. The American Heart Association Emergency Cardiovascular Care Committee and the Neurocritical Care Society collaborated to address this gap by organizing an expert consensus panel and conference. Twenty-four experienced practitioners (including physicians, nurses, pharmacists, and a respiratory therapist) from multiple medical specialties, levels, institutions, and countries made up the panel. Topics were identified and prioritized by the panel and arranged by organ system to facilitate discussion, debate, and consensus building. Statements related to postarrest management were generated, and 80% agreement was required to approve a statement. Voting was anonymous and web based. Topics addressed include neurological, cardiac, pulmonary, hematological, infectious, gastrointestinal, endocrine, and general critical care management. Areas of uncertainty, areas for which no consensus was reached, and future research directions are also included. Until high-quality studies that inform practice guidelines in these areas are available, the expert panel consensus statements that are provided can advise clinicians on the critical care management of patients after cardiac arrest.
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Affiliation(s)
| | | | - Edilberto Amorim
- San Francisco-Weill Institute for Neurosciences, University of California, San Francisco, USA
| | - Mary Kay Bader
- Providence Mission Hospital Nursing Center of Excellence/Critical Care Services, Mission Viejo, USA
| | | | | | | | | | | | | | - Karl B Kern
- Sarver Heart Center, University of Arizona, Tucson, USA
| | | | | | | | - Jerry P Nolan
- Warwick Medical School, University of Warwick, Coventry, UK
- Royal United Hospital, Bath, UK
| | - Mauro Oddo
- CHUV-Lausanne University Hospital, Lausanne, Switzerland
| | | | | | | | | | - Anezi Uzendu
- St. Luke's Mid America Heart Institute, Kansas City, USA
| | - Brian Walsh
- University of Texas Medical Branch School of Health Sciences, Galveston, USA
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5
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Nikolovski SS, Lazic AD, Fiser ZZ, Obradovic IA, Tijanic JZ, Raffay V. Recovery and Survival of Patients After Out-of-Hospital Cardiac Arrest: A Literature Review Showcasing the Big Picture of Intensive Care Unit-Related Factors. Cureus 2024; 16:e54827. [PMID: 38529434 PMCID: PMC10962929 DOI: 10.7759/cureus.54827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2024] [Indexed: 03/27/2024] Open
Abstract
As an important public health issue, out-of-hospital cardiac arrest (OHCA) requires several stages of high quality medical care, both on-field and after hospital admission. Post-cardiac arrest shock can lead to severe neurological injury, resulting in poor recovery outcome and increased risk of death. These characteristics make this condition one of the most important issues to deal with in post-OHCA patients hospitalized in intensive care units (ICUs). Also, the majority of initial post-resuscitation survivors have underlying coronary diseases making revascularization procedure another crucial step in early management of these patients. Besides keeping myocardial blood flow at a satisfactory level, other tissues must not be neglected as well, and maintaining mean arterial pressure within optimal range is also preferable. All these procedures can be simplified to a certain level along with using targeted temperature management methods in order to decrease metabolic demands in ICU-hospitalized post-OHCA patients. Additionally, withdrawal of life-sustaining therapy as a controversial ethical topic is under constant re-evaluation due to its possible influence on overall mortality rates in patients initially surviving OHCA. Focusing on all of these important points in process of managing ICU patients is an imperative towards better survival and complete recovery rates.
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Affiliation(s)
- Srdjan S Nikolovski
- Pathology and Laboratory Medicine, Cardiovascular Research Institute, Loyola University Chicago Health Science Campus, Maywood, USA
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
| | - Aleksandra D Lazic
- Emergency Center, Clinical Center of Vojvodina, Novi Sad, SRB
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
| | - Zoran Z Fiser
- Emergency Medicine, Department of Emergency Medicine, Novi Sad, SRB
| | - Ivana A Obradovic
- Anesthesiology, Resuscitation, and Intensive Care, Sveti Vračevi Hospital, Bijeljina, BIH
| | - Jelena Z Tijanic
- Emergency Medicine, Municipal Institute of Emergency Medicine, Kragujevac, SRB
| | - Violetta Raffay
- School of Medicine, European University Cyprus, Nicosia, CYP
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
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6
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Perman SM, Elmer J, Maciel CB, Uzendu A, May T, Mumma BE, Bartos JA, Rodriguez AJ, Kurz MC, Panchal AR, Rittenberger JC. 2023 American Heart Association Focused Update on Adult Advanced Cardiovascular Life Support: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2024; 149:e254-e273. [PMID: 38108133 DOI: 10.1161/cir.0000000000001194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
Cardiac arrest is common and deadly, affecting up to 700 000 people in the United States annually. Advanced cardiac life support measures are commonly used to improve outcomes. This "2023 American Heart Association Focused Update on Adult Advanced Cardiovascular Life Support" summarizes the most recent published evidence for and recommendations on the use of medications, temperature management, percutaneous coronary angiography, extracorporeal cardiopulmonary resuscitation, and seizure management in this population. We discuss the lack of data in recent cardiac arrest literature that limits our ability to evaluate diversity, equity, and inclusion in this population. Last, we consider how the cardiac arrest population may make up an important pool of organ donors for those awaiting organ transplantation.
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7
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Hirsch KG, Abella BS, Amorim E, Bader MK, Barletta JF, Berg K, Callaway CW, Friberg H, Gilmore EJ, Greer DM, Kern KB, Livesay S, May TL, Neumar RW, Nolan JP, Oddo M, Peberdy MA, Poloyac SM, Seder D, Taccone FS, Uzendu A, Walsh B, Zimmerman JL, Geocadin RG. Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement From the American Heart Association and Neurocritical Care Society. Circulation 2024; 149:e168-e200. [PMID: 38014539 PMCID: PMC10775969 DOI: 10.1161/cir.0000000000001163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
The critical care management of patients after cardiac arrest is burdened by a lack of high-quality clinical studies and the resultant lack of high-certainty evidence. This results in limited practice guideline recommendations, which may lead to uncertainty and variability in management. Critical care management is crucial in patients after cardiac arrest and affects outcome. Although guidelines address some relevant topics (including temperature control and neurological prognostication of comatose survivors, 2 topics for which there are more robust clinical studies), many important subject areas have limited or nonexistent clinical studies, leading to the absence of guidelines or low-certainty evidence. The American Heart Association Emergency Cardiovascular Care Committee and the Neurocritical Care Society collaborated to address this gap by organizing an expert consensus panel and conference. Twenty-four experienced practitioners (including physicians, nurses, pharmacists, and a respiratory therapist) from multiple medical specialties, levels, institutions, and countries made up the panel. Topics were identified and prioritized by the panel and arranged by organ system to facilitate discussion, debate, and consensus building. Statements related to postarrest management were generated, and 80% agreement was required to approve a statement. Voting was anonymous and web based. Topics addressed include neurological, cardiac, pulmonary, hematological, infectious, gastrointestinal, endocrine, and general critical care management. Areas of uncertainty, areas for which no consensus was reached, and future research directions are also included. Until high-quality studies that inform practice guidelines in these areas are available, the expert panel consensus statements that are provided can advise clinicians on the critical care management of patients after cardiac arrest.
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8
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Smith D, Kenigsberg BB. Management of Patients After Cardiac Arrest. Crit Care Clin 2024; 40:57-72. [PMID: 37973357 DOI: 10.1016/j.ccc.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Cardiac arrest remains a significant cause of morbidity and mortality, although contemporary care now enables potential survival with good neurologic outcome. The core acute management goals for survivors of cardiac arrest are to provide organ support, sustain adequate hemodynamics, and evaluate the underlying cause of the cardiac arrest. In this article, the authors review the current state of knowledge and clinical intensive care unit practice recommendations for patients after cardiac arrest, particularly focusing on important areas of uncertainty, such as targeted temperature management, neuroprognostication, coronary evaluation, and hemodynamic targets.
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Affiliation(s)
- Damien Smith
- Department of Medicine, MedStar Washington Hospital Center, 110 Irving Street Northwest, Washington, DC 20010, USA
| | - Benjamin B Kenigsberg
- Department of Critical Care, MedStar Washington Hospital Center, 110 Irving Street Northwest, Washington, DC 20010, USA; Division of Cardiology, MedStar Washington Hospital Center, 110 Irving Street Northwest, Washington, DC 20010, USA.
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9
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Kumar A, Ridha M, Claassen J. Prognosis of consciousness disorders in the intensive care unit. Presse Med 2023; 52:104180. [PMID: 37805070 PMCID: PMC10995112 DOI: 10.1016/j.lpm.2023.104180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 10/03/2023] [Indexed: 10/09/2023] Open
Abstract
Assessments of consciousness are a critical part of prognostic algorithms for critically ill patients suffering from severe brain injuries. There have been significant advances in the field of coma science over the past two decades, providing clinicians with more advanced and precise tools for diagnosing and prognosticating disorders of consciousness (DoC). Advanced neuroimaging and electrophysiological techniques have vastly expanded our understanding of the biological mechanisms underlying consciousness, and have helped identify new states of consciousness. One of these, termed cognitive motor dissociation, can predict functional recovery at 1 year post brain injury, and is present in up to 15-20% of patients with DoC. In this chapter, we review several tools that are used to predict DoC, describing their strengths and limitations, from the neurological examination to advanced imaging and electrophysiologic techniques. We also describe multimodal assessment paradigms that can be used to identify covert consciousness and thus help recognize patients with the potential for future recovery and improve our prognostication practices.
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Affiliation(s)
- Aditya Kumar
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, New York, NY, USA
| | - Mohamed Ridha
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, New York, NY, USA
| | - Jan Claassen
- Department of Neurology, Columbia University Medical Center, New York-Presbyterian Hospital, New York, NY, USA.
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10
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Jagarlamudi NS, Soni K, Ahmed SS, Makkapati NSR, Janarthanam S, Vallejo-Zambrano CR, Patel KC, Xavier R, Ponnada PK, Zaheen I, Ehsan M. Unveiling Breakthroughs in Post-resuscitation Supportive Care for Out-of-Hospital Cardiac Arrest Survivors: A Narrative Review. Cureus 2023; 15:e44783. [PMID: 37809191 PMCID: PMC10558054 DOI: 10.7759/cureus.44783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2023] [Indexed: 10/10/2023] Open
Abstract
Survivors of out-of-hospital cardiac arrest (OHCA) experience significant mortality rates and neurological impairment, potentially attributed to the hypoxic-ischemic injury sustained amid the cardiac arrest episode. Post-resuscitation care plays a crucial role in determining outcomes for survivors of OHCA. Supportive therapies have proven to be influential in shaping these outcomes. However, targeting higher blood pressure or oxygen levels during the post-resuscitative phase has not been shown to offer any mortality or neurological benefits. In terms of maintaining hemodynamic instability after resuscitation, it is recommended to use norepinephrine rather than epinephrine. While extracorporeal cardiopulmonary resuscitation has shown promising results, targeted temperature management has been found ineffective in improving outcomes despite its previous potential. This review also investigates various challenges and barriers associated with the practical implementation of these supportive therapies in clinical settings. The review also highlights areas ripe for future research and proposes potential directions to further enhance post-resuscitation supportive care for OHCA survivors.
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Affiliation(s)
| | - Kriti Soni
- Internal Medicine, Dr. D. Y. Patil Medical College, Hospital & Research Center, Pune, IND
| | - Saima S Ahmed
- Internal Medicine, Dow International Medical College, Karachi, PAK
| | | | - Sujaritha Janarthanam
- Internal Medicine, Sri Ramachandra Institute of Higher Education and Research Center, Chennai, IND
| | | | | | - Roshni Xavier
- Internal Medicine, Rajagiri Hospital, Aluva, IND
- Internal Medicine, Carewell Hospital, Malappuram, IND
| | | | - Iqra Zaheen
- Internal Medicine, Jinnah Medical and Dental College, Karachi, PAK
| | - Muhammad Ehsan
- General Medicine, International Medical Graduates (IMG) Helping Hands, Lahore, PAK
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11
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Sumner BD, Hahn CW. Prognosis of Cardiac Arrest-Peri-arrest and Post-arrest Considerations. Emerg Med Clin North Am 2023; 41:601-616. [PMID: 37391253 DOI: 10.1016/j.emc.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Abstract
There has been only a small improvement in survival and neurologic outcomes in patients with cardiac arrest in recent decades. Type of arrest, length of total arrest time, and location of arrest alter the trajectory of survival and neurologic outcome. In the post-arrest phase, clinical markers such as blood markers, pupillary light response, corneal reflex, myoclonic jerking, somatosensory evoked potential, and electroencephalography testing can be used to help guide neurological prognostication. Most of the testing should be performed 72 hours post-arrest with special considerations for longer observation periods in patients who underwent TTM or who had prolonged sedation and/or neuromuscular blockade.
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Affiliation(s)
- Brian D Sumner
- Institute for Critical Care Medicine, 1468 Madison Avenue, Guggenheim Pavilion 6 East Room 378, New York, NY 10029, USA.
| | - Christopher W Hahn
- Department of Emergency Medicine, Mount Sinai Morningside-West, 1000 10th Avenue, New York, NY 10019, USA
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12
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Abstract
Post-cardiac arrest syndrome (PCAS) is a multicomponent entity affecting many who survive an initial period of resuscitation following cardiac arrest. This focussed review explores some of the strategies for mitigating the effects of PCAS following the return of spontaneous circulation. We consider the current evidence for controlled oxygenation, strategies for blood-pressure targets, the timing of coronary reperfusion, and the evidence for temperature control and treatment of seizures. Despite several large trials investigating specific strategies to improve outcomes after cardiac arrest, many questions remain unanswered. Results of some studies suggest that interventions may benefit specific subgroups of cardiac arrest patients, but the optimal timing and duration of many interventions remain unknown. The role of intracranial pressure monitoring has been the subject of only a few studies, and its benefits remain unclear. Research aimed at improving the management of PCAS is ongoing.
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Affiliation(s)
| | - Jerry P Nolan
- Intensive care unit, Royal United Hospital, Bath
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
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13
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Wilcox J, Redwood S, Patterson T. Cardiac arrest centres: what do they add? Resuscitation 2023:109865. [PMID: 37315916 DOI: 10.1016/j.resuscitation.2023.109865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 05/28/2023] [Accepted: 05/30/2023] [Indexed: 06/16/2023]
Abstract
There are wide regional variations in outcome following resuscitated out of hospital cardiac arrest. These geographical differences appear to be due to hospital infrastructure and provider experience rather than baseline characteristics. It is proposed that post-arrest care be delivered in a systematic fashion by concentrating services in Cardiac Arrest Centres, with greater provider experience, 24-hour access to diagnostics, and specialist treatment to minimise the impact of ischaemia-reperfusion injury and treat the causative pathology. These cardiac arrest centres would provide access to targeted critical care, acute cardiac care, radiology services and appropriate neuro-prognostication. However implementation of cardiac arrest networks with specialist receiving hospitals is complex and requires alignment of pre-hospital care services with those delivered in hospital. Furthermore there are no randomised trial data currently supporting pre-hospital delivery to a Cardiac Arrest Centre and definitions are heterogeneous. In this review article, we propose a universal definition of a Cardiac Arrest Centre and review the current observational data evidence and the potential impact of the ARREST trial.
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Affiliation(s)
- Joshua Wilcox
- Cardiovascular Department, Guy's and St. Thomas' NHS Foundation Trust.
| | - Simon Redwood
- Cardiovascular Department, Guy's and St. Thomas' NHS Foundation Trust; Cardiovascular, FOLSM, King's College London
| | - Tiffany Patterson
- Cardiovascular Department, Guy's and St. Thomas' NHS Foundation Trust
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14
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Fordyce CB, Kramer AH, Ainsworth C, Christenson J, Hunter G, Kromm J, Lopez Soto C, Scales DC, Sekhon M, van Diepen S, Dragoi L, Josephson C, Kutsogiannis J, Le May MR, Overgaard CB, Savard M, Schnell G, Wong GC, Belley-Côté E, Fantaneanu TA, Granger CB, Luk A, Mathew R, McCredie V, Murphy L, Teitelbaum J. Neuroprognostication in the Post Cardiac Arrest Patient: A Canadian Cardiovascular Society Position Statement. Can J Cardiol 2023; 39:366-380. [PMID: 37028905 DOI: 10.1016/j.cjca.2022.12.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 12/13/2022] [Accepted: 12/14/2022] [Indexed: 04/08/2023] Open
Abstract
Cardiac arrest (CA) is associated with a low rate of survival with favourable neurologic recovery. The most common mechanism of death after successful resuscitation from CA is withdrawal of life-sustaining measures on the basis of perceived poor neurologic prognosis due to underlying hypoxic-ischemic brain injury. Neuroprognostication is an important component of the care pathway for CA patients admitted to hospital but is complex, challenging, and often guided by limited evidence. Using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to evaluate the evidence underlying factors or diagnostic modalities available to determine prognosis, recommendations were generated in the following domains: (1) circumstances immediately after CA; (2) focused neurologic exam; (3) myoclonus and seizures; (4) serum biomarkers; (5) neuroimaging; (6) neurophysiologic testing; and (7) multimodal neuroprognostication. This position statement aims to serve as a practical guide to enhance in-hospital care of CA patients and emphasizes the adoption of a systematic, multimodal approach to neuroprognostication. It also highlights evidence gaps.
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Affiliation(s)
- Christopher B Fordyce
- Division of Cardiology, Department of Medicine, Vancouver General Hospital, and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia.
| | - Andreas H Kramer
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta; Department of Critical Care, University of Calgary, Alberta
| | - Craig Ainsworth
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jim Christenson
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia
| | - Gary Hunter
- Division of Neurology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Julie Kromm
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta; Department of Critical Care, University of Calgary, Alberta
| | - Carmen Lopez Soto
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Damon C Scales
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mypinder Sekhon
- Division of Critical Care, Department of Medicine, Vancouver General Hospital, Djavad Mowafaghian Centre for Brain Health, International Centre for Repair Discoveries, University of British Columbia, Vancouver, British Columbia
| | - Sean van Diepen
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta; Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta
| | - Laura Dragoi
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Colin Josephson
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta; Department of Critical Care, University of Calgary, Alberta
| | - Jim Kutsogiannis
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta
| | - Michel R Le May
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Christopher B Overgaard
- Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Martin Savard
- Department of Neurological Sciences CHU de Québec - Hôpital de l'Enfant-Jésus Quebec City, Quebec, Canada
| | - Gregory Schnell
- Division of Cardiology, Department of Medicine, University of Calgary, Calgary, Alberta
| | - Graham C Wong
- Division of Cardiology, Department of Medicine, Vancouver General Hospital, and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia
| | - Emilie Belley-Côté
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Tadeu A Fantaneanu
- Division of Neurology, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Adriana Luk
- Division of Cardiology, Department of Medicine, University of Toronto and the Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Rebecca Mathew
- CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, and the Faculty of Medicine, Division of Critical Care, University of Ottawa, Ottawa, Ontario, Canada
| | - Victoria McCredie
- Interdepartmental Division of Critical Care Medicine, University of Toronto, the Krembil Research Institute, Toronto Western Hospital, University Health Network, and Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Laurel Murphy
- Departments of Emergency Medicine and Critical Care, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jeanne Teitelbaum
- Neurological Intensive Care Unit, Montreal Neurological Institute and Hospital, McGill University, Montreal, Quebec, Canada
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15
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Nutma S, Ruijter BJ, Beishuizen A, Tromp SC, Scholten E, Horn J, van den Bergh WM, van Kranen-Mastenbroek VH, Thomeer EC, Moudrous W, Aries M, van Putten MJ, Hofmeijer J. Myoclonus in comatose patients with electrographic status epilepticus after cardiac arrest: Corresponding EEG patterns, effects of treatment and outcomes. Resuscitation 2023; 186:109745. [PMID: 36822459 DOI: 10.1016/j.resuscitation.2023.109745] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/10/2023] [Accepted: 02/14/2023] [Indexed: 02/23/2023]
Abstract
OBJECTIVE To clarify the significance of any form of myoclonus in comatose patients after cardiac arrest with rhythmic and periodic EEG patterns (RPPs) by analyzing associations between myoclonus and EEG pattern, response to anti-seizure medication and neurological outcome. DESIGN Post hoc analysis of the prospective randomized Treatment of ELectroencephalographic STatus Epilepticus After Cardiopulmonary Resuscitation (TELSTAR) trial. SETTING Eleven ICUs in the Netherlands and Belgium. PATIENTS One hundred and fifty-seven adult comatose post-cardiac arrest patients with RPPs on continuous EEG monitoring. INTERVENTIONS Anti-seizure medication vs no anti-seizure medication in addition to standard care. MEASUREMENTS AND MAIN RESULTS Of 157 patients, 98 (63%) had myoclonus at inclusion. Myoclonus was not associated with one specific RPP type. However, myoclonus was associated with a smaller probability of a continuous EEG background pattern (48% in patients with vs 75% without myoclonus, odds ratio (OR) 0.31; 95% confidence interval (CI) 0.16-0.64) and earlier onset of RPPs (24% vs 9% within 24 hours after cardiac arrest, OR 3.86;95% CI 1.64-9.11). Myoclonus was associated with poor outcome at three months, but not invariably so (poor neurological outcome in 96% vs 82%, p = 0.004). Anti-seizure medication did not improve outcome, regardless of myoclonus presence (6% good outcome in the intervention group vs 2% in the control group, OR 0.33; 95% CI 0.03-3.32). CONCLUSIONS Myoclonus in comatose patients after cardiac arrest with RPPs is associated with poor outcome and discontinuous or suppressed EEG. However, presence of myoclonus does not interact with the effects of anti-seizure medication and cannot predict a poor outcome without false positives.
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Affiliation(s)
- Sjoukje Nutma
- Departments of Neurology and Clinical Neurophysiology, Medical Spectrum Twente, Enschede, the Netherlands; Department of Clinical Neurophysiology, Technical Medical Center, University of Twente, Enschede, the Netherlands.
| | - Barry J Ruijter
- Department of Clinical Neurophysiology, Technical Medical Center, University of Twente, Enschede, the Netherlands
| | - Albertus Beishuizen
- Departments of Neurology and Clinical Neurophysiology, Medical Spectrum Twente, Enschede, the Netherlands
| | - Selma C Tromp
- Departments of Neurology and Clinical Neurophysiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Erik Scholten
- Department of Critical Care, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Janneke Horn
- Department of Critical Care, Amsterdam University Medical Center, Location AMC, Amsterdam, the Netherlands
| | - Walter M van den Bergh
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Elsbeth C Thomeer
- Department of Neurology and Clinical Neurophysiology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Walid Moudrous
- Department of Neurology and Clinical Neurophysiology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Marcel Aries
- Department of Critical Care, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Michel Jam van Putten
- Departments of Neurology and Clinical Neurophysiology, Medical Spectrum Twente, Enschede, the Netherlands; Department of Clinical Neurophysiology, Technical Medical Center, University of Twente, Enschede, the Netherlands
| | - Jeannette Hofmeijer
- Department of Clinical Neurophysiology, Technical Medical Center, University of Twente, Enschede, the Netherlands; Department of Neurology, Rijnstate Hospital, Arnhem, the Netherlands
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16
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Ceric A, May TL, Lybeck A, Cronberg T, Seder DB, Riker RR, Hassager C, Kjaergaard J, Haxhija Z, Friberg H, Dankiewicz J, Nielsen N. Cardiac Arrest Treatment Center Differences in Sedation and Analgesia Dosing During Targeted Temperature Management. Neurocrit Care 2023; 38:16-25. [PMID: 35896768 PMCID: PMC9935704 DOI: 10.1007/s12028-022-01564-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 06/20/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Sedation and analgesia are recommended during targeted temperature management (TTM) after cardiac arrest, but there are few data to provide guidance on dosing to bedside clinicians. We evaluated differences in patient-level sedation and analgesia dosing in an international multicenter TTM trial to better characterize current practice and clinically important outcomes. METHODS A total 950 patients in the international TTM trial were randomly assigned to a TTM of 33 °C or 36 °C after resuscitation from cardiac arrest in 36 intensive care units. We recorded cumulative doses of sedative and analgesic drugs at 12, 24, and 48 h and normalized to midazolam and fentanyl equivalents. We compared number of medications used, dosing, and titration among centers by using multivariable models, including common severity of illness factors. We also compared dosing with time to awakening, incidence of clinical seizures, and survival. RESULTS A total of 614 patients at 18 centers were analyzed. Propofol (70%) and fentanyl (51%) were most frequently used. The average dosages of midazolam and fentanyl equivalents were 0.13 (0.07, 0.22) mg/kg/h and 1.16 (0.49, 1.81) µg/kg/h, respectively. There were significant differences in number of medications (p < 0.001), average dosages (p < 0.001), and titration at all time points between centers (p < 0.001), and the outcomes of patients in these centers were associated with all parameters described in the multivariate analysis, except for a difference in the titration of sedatives between 12 and 24 h (p = 0.40). There were associations between higher dosing at 48 h (p = 0.003, odds ratio [OR] 1.75) and increased titration of analgesics between 24 and 48 h (p = 0.005, OR 4.89) with awakening after 5 days, increased titration of sedatives between 24 and 48 h with awakening after 5 days (p < 0.001, OR > 100), and increased titration of sedatives between 24 and 48 h with a higher incidence of clinical seizures in the multivariate analysis (p = 0.04, OR 240). There were also significant associations between decreased titration of analgesics and survival at 6 months in the multivariate analysis (p = 0.048). CONCLUSIONS There is significant variation in choice of drug, dosing, and titration when providing sedation and analgesics between centers. Sedation and analgesia dosing and titration were associated with delayed awakening, incidence of clinical seizures, and survival, but the causal relation of these findings cannot be proven.
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Affiliation(s)
- Ameldina Ceric
- Division of Anesthesia and Intensive Care, Department of Clinical Sciences Lund, Helsingborg Hospital, Lund University, Svartbrödragränden 3, 251 87, Helsingborg, Sweden.
| | - Teresa L May
- Department of Critical Care, Maine Medical Center, Portland, ME, USA
| | - Anna Lybeck
- Division of Anesthesia and Intensive Care, Department of Clinical Sciences Lund, Skane University Hospital, Lund University, Lund, Sweden
| | - Tobias Cronberg
- Division of Neurology, Department of Clinical Sciences, Skane University Hospital, Lund University, Lund, Sweden
| | - David B Seder
- Department of Critical Care, Maine Medical Center, Portland, ME, USA
| | - Richard R Riker
- Department of Critical Care, Maine Medical Center, Portland, ME, USA
| | - Christian Hassager
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Zana Haxhija
- Division of Anesthesia and Intensive Care, Department of Clinical Sciences Lund, Helsingborg Hospital, Lund University, Svartbrödragränden 3, 251 87, Helsingborg, Sweden
| | - Hans Friberg
- Division of Anesthesia and Intensive Care, Department of Clinical Sciences Lund, Skane University Hospital, Lund University, Malmö, Sweden
| | - Josef Dankiewicz
- Division of Cardiology, Department of Clinical Sciences Lund, Skane University Hospital, Lund University, Lund, Sweden
| | - Niklas Nielsen
- Division of Anesthesia and Intensive Care, Department of Clinical Sciences Lund, Helsingborg Hospital, Lund University, Svartbrödragränden 3, 251 87, Helsingborg, Sweden
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17
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El-Seify M, Shata MO, Salaheldin S, Bawady S, Rezk AR. Evaluation of Serum Biomarkers and Electroencephalogram to Determine Survival Outcomes in Pediatric Post-Cardiac-Arrest Patients. Children (Basel) 2023; 10:children10020180. [PMID: 36832309 PMCID: PMC9955226 DOI: 10.3390/children10020180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 01/06/2023] [Accepted: 01/10/2023] [Indexed: 01/20/2023]
Abstract
Cardiac arrest causes primary and secondary brain injuries. We evaluated the association between neuron-specific enolase (NSE), serum S-100B (S100B), electroencephalogram (EEG) patterns, and post-cardiac arrest outcomes in pediatric patients. A prospective observational study was conducted in the pediatric intensive care unit and included 41 post-cardiac arrest patients who underwent EEG and serum sampling for NSE and S100B. The participants were aged 1 month to 18 years who experienced cardiac arrest and underwent CPR after a sustained return of spontaneous circulation for ≥48 h. Approximately 19.5% (n = 8) of patients survived until ICU discharge. Convulsions and sepsis were significantly associated with higher mortality (relative risk: 1.33 [95% CI = 1.09-1.6] and 1.99 [95% CI = 0.8-4.7], respectively). Serum NSE and S100B levels were not statistically associated with the outcome (p = 0.278 and 0.693, respectively). NSE levels were positively correlated with the duration of CPR. EEG patterns were significantly associated with the outcome (p = 0.01). Non-epileptogenic EEG activity was associated with the highest survival rate. Post-cardiac arrest syndrome is a serious condition with a high mortality rate. Management of sepsis and convulsions affects prognosis. We believe that NSE and S100B may have no benefit in survival evaluation. EEG can be considered for post-cardiac arrest patients.
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Affiliation(s)
- Magda El-Seify
- Department of Pediatrics, Chest Unit, Ain Shams University Hospitals, Cairo 11566, Egypt
| | - Mennatallah O. Shata
- Department of Pediatrics, Neurology Unit, Ain Shams University Hospitals, Cairo 11566, Egypt
| | - Sondos Salaheldin
- Department of Pediatrics, Ain Shams University Hospitals, Cairo 11566, Egypt
| | - Somia Bawady
- Department of Clinical Pathology, Ain Shams University Hospitals, Cairo 11566, Egypt
| | - Ahmed R. Rezk
- Department of Pediatrics, Intensive Care Unit, Ain Shams University Hospitals, Cairo 11566, Egypt
- Correspondence:
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18
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Coppler PJ, Elmer J. Status Epilepticus. Crit Care Clin 2023; 39:87-102. [DOI: 10.1016/j.ccc.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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19
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Ornowska M, Wormsbecker A, Andolfatto G, Leung T, Khan I, Medvedev G. The use of ketamine as a neuroprotective agent following cardiac arrest: A scoping review of current literature. CNS Neurosci Ther 2022; 29:104-110. [PMID: 36184822 PMCID: PMC9804040 DOI: 10.1111/cns.13983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 09/12/2022] [Accepted: 09/13/2022] [Indexed: 02/06/2023] Open
Abstract
AIMS The objective of this article is to summarize the state of the literature surrounding the use of ketamine as a neuroprotective agent following cardiac arrest. METHODS Five electronic databases were used to search for studies related to the use of ketamine for neuroprotection following cardiac arrest. This search was performed once in May 2020, and an updated search was conducted in May 2021 and March 2022. RESULTS All searches combined retrieved 181 results; no clinical trials were identified. As such, the authors were limited to writing a scoping review of the literature rather than a systematic review. CONCLUSIONS The current state of the literature describes the mechanism of action of ketamine as a neuroprotective agent through its action as an NMDA antagonist. There is evidence of its efficacy as a neuroprotective agent in preclinical models of cardiac arrest. Current published clinical work supports the use of ketamine ameliorating neurologic outcomes in other conditions such as epilepsy, traumatic brain injury, and depression. The current state of the literature is reflective of the notion that the use of ketamine following cardiac arrest may result in improved neurologic outcomes. Future research directions should focus on the use of ketamine as a possible clinical intervention following cardiac arrest.
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Affiliation(s)
- Marlena Ornowska
- Department of Biomedical PhysiologySimon Fraser UniversityBurnabyBritish ColumbiaCanada
| | - Andrew Wormsbecker
- Royal Columbian Hospital, Fraser Health AuthorityNew WestminsterBritish ColumbiaCanada,Division of Critical Care, Department of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Gary Andolfatto
- Department of Emergency Medicine, Department of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Tim S. Leung
- Royal Columbian Hospital, Fraser Health AuthorityNew WestminsterBritish ColumbiaCanada,Faculty of Pharmaceutical SciencesUniversity of British ColumbiaVancouverBritish ColumbiaCanada,Lower Mainland Pharmacy ServicesVancouverBritish ColumbiaCanada
| | - Idan Khan
- Royal Columbian Hospital, Fraser Health AuthorityNew WestminsterBritish ColumbiaCanada,Department of Emergency Medicine, Department of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - George Medvedev
- Royal Columbian Hospital, Fraser Health AuthorityNew WestminsterBritish ColumbiaCanada,Division of Neurology, Department of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
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20
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Grindegård L, Cronberg T, Backman S, Blennow K, Dankiewicz J, Friberg H, Hassager C, Horn J, Kjaer TW, Kjaergaard J, Kuiper M, Mattsson-Carlgren N, Nielsen N, van Rootselaar AF, Rossetti AO, Stammet P, Ullén S, Zetterberg H, Westhall E, Moseby-Knappe M. Association Between EEG Patterns and Serum Neurofilament Light After Cardiac Arrest. Neurology 2022; 98:e2487-e2498. [PMID: 35470143 PMCID: PMC9231840 DOI: 10.1212/wnl.0000000000200335] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 02/21/2022] [Indexed: 01/09/2023] Open
Abstract
Background and Objectives EEG is widely used for prediction of neurologic outcome after cardiac arrest. To better understand the relationship between EEG and neuronal injury, we explored the association between EEG and neurofilament light (NfL) as a marker of neuroaxonal injury, evaluated whether highly malignant EEG patterns are reflected by high NfL levels, and explored the association of EEG backgrounds and EEG discharges with NfL. Methods We performed a post hoc analysis of the Target Temperature Management After Out-of-Hospital Cardiac Arrest trial. Routine EEGs were prospectively performed after the temperature intervention ≥36 hours postarrest. Patients who awoke or died prior to 36 hours postarrest were excluded. EEG experts blinded to clinical information classified EEG background, amount of discharges, and highly malignant EEG patterns according to the standardized American Clinical Neurophysiology Society terminology. Prospectively collected serum samples were analyzed for NfL after trial completion. The highest available concentration at 48 or 72 hours postarrest was used. Results A total of 262/939 patients with EEG and NfL data were included. Patients with highly malignant EEG patterns had 2.9 times higher NfL levels than patients with malignant patterns and NfL levels were 13 times higher in patients with malignant patterns than those with benign patterns (95% CI 1.4–6.1 and 6.5–26.2, respectively; effect size 0.47; p < 0.001). Both background and the amount of discharges were independently strongly associated with NfL levels (p < 0.001). The EEG background had a stronger association with NfL levels than EEG discharges (R2 = 0.30 and R2 = 0.10, respectively). NfL levels in patients with a continuous background were lower than for any other background (95% CI for discontinuous, burst-suppression, and suppression, respectively: 2.26–18.06, 3.91–41.71, and 5.74–41.74; effect size 0.30; p < 0.001 for all). NfL levels did not differ between suppression and burst suppression. Superimposed discharges were only associated with higher NfL levels if the EEG background was continuous. Discussion Benign, malignant, and highly malignant EEG patterns reflect the extent of brain injury as measured by NfL in serum. The extent of brain injury is more strongly related to the EEG background than superimposed discharges. Combining EEG and NfL may be useful to better identify patients misclassified by single methods. Trial Registration Information ClinicalTrials.gov NCT01020916.
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Affiliation(s)
- Linnéa Grindegård
- From Neurology (L.G., T.C., N.M.-C., M.M.-K.), Clinical Neurophysiology (S.B., E.W.), Cardiology (J.D.), and Anaesthesia and Intensive Care (H.F.), Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Mölndal, Sweden; Department of Cardiology (C.H.), Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Denmark; Departments of Intensive Care (J.H.) and Neurology/Clinical Neurophysiology (A.-F-V.R.), Amsterdam Neuroscience, Amsterdam UMC, Academic Medical Center, University of Amsterdam, the Netherlands; Departments of Clinical Neurophysiology (T.W.K.) and Cardiology (J.K.), Rigshospitalet University Hospital, Copenhagen, Denmark; Department of Intensive Care (M.K.), Medical Center Leeuwarden, the Netherlands; Clinical Memory Research Unit, Faculty of Medicine (N.M.-C.), and Wallenberg Centre for Molecular Medicine (N.M.-C.), Lund University; Anaesthesia and Intensive Care, Department of Clinical Sciences Lund (N.N.), Lund University, Helsingborg Hospital, Sweden; Department of Neurology (A.O.R.), CHUV and University of Lausanne, Switzerland; Department of Anesthesia and Intensive Care (P.S.), Centre Hospitalier de Luxembourg; Department of Life Sciences and Medicine (P.S.), Faculty of Science, Technology and Medicine, University of Luxembourg; Clinical Studies Sweden (S.U.), Skåne University Hospital, Lund; Department of Neurodegenerative Disease (H.Z.), UCL Institute of Neurology; UK Dementia Research Institute at UCL (H.Z.), London, UK; and Hong Kong Center for Neurodegenerative Diseases (H.Z.), China.
| | - Tobias Cronberg
- From Neurology (L.G., T.C., N.M.-C., M.M.-K.), Clinical Neurophysiology (S.B., E.W.), Cardiology (J.D.), and Anaesthesia and Intensive Care (H.F.), Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Mölndal, Sweden; Department of Cardiology (C.H.), Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Denmark; Departments of Intensive Care (J.H.) and Neurology/Clinical Neurophysiology (A.-F-V.R.), Amsterdam Neuroscience, Amsterdam UMC, Academic Medical Center, University of Amsterdam, the Netherlands; Departments of Clinical Neurophysiology (T.W.K.) and Cardiology (J.K.), Rigshospitalet University Hospital, Copenhagen, Denmark; Department of Intensive Care (M.K.), Medical Center Leeuwarden, the Netherlands; Clinical Memory Research Unit, Faculty of Medicine (N.M.-C.), and Wallenberg Centre for Molecular Medicine (N.M.-C.), Lund University; Anaesthesia and Intensive Care, Department of Clinical Sciences Lund (N.N.), Lund University, Helsingborg Hospital, Sweden; Department of Neurology (A.O.R.), CHUV and University of Lausanne, Switzerland; Department of Anesthesia and Intensive Care (P.S.), Centre Hospitalier de Luxembourg; Department of Life Sciences and Medicine (P.S.), Faculty of Science, Technology and Medicine, University of Luxembourg; Clinical Studies Sweden (S.U.), Skåne University Hospital, Lund; Department of Neurodegenerative Disease (H.Z.), UCL Institute of Neurology; UK Dementia Research Institute at UCL (H.Z.), London, UK; and Hong Kong Center for Neurodegenerative Diseases (H.Z.), China
| | - Sofia Backman
- From Neurology (L.G., T.C., N.M.-C., M.M.-K.), Clinical Neurophysiology (S.B., E.W.), Cardiology (J.D.), and Anaesthesia and Intensive Care (H.F.), Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Mölndal, Sweden; Department of Cardiology (C.H.), Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Denmark; Departments of Intensive Care (J.H.) and Neurology/Clinical Neurophysiology (A.-F-V.R.), Amsterdam Neuroscience, Amsterdam UMC, Academic Medical Center, University of Amsterdam, the Netherlands; Departments of Clinical Neurophysiology (T.W.K.) and Cardiology (J.K.), Rigshospitalet University Hospital, Copenhagen, Denmark; Department of Intensive Care (M.K.), Medical Center Leeuwarden, the Netherlands; Clinical Memory Research Unit, Faculty of Medicine (N.M.-C.), and Wallenberg Centre for Molecular Medicine (N.M.-C.), Lund University; Anaesthesia and Intensive Care, Department of Clinical Sciences Lund (N.N.), Lund University, Helsingborg Hospital, Sweden; Department of Neurology (A.O.R.), CHUV and University of Lausanne, Switzerland; Department of Anesthesia and Intensive Care (P.S.), Centre Hospitalier de Luxembourg; Department of Life Sciences and Medicine (P.S.), Faculty of Science, Technology and Medicine, University of Luxembourg; Clinical Studies Sweden (S.U.), Skåne University Hospital, Lund; Department of Neurodegenerative Disease (H.Z.), UCL Institute of Neurology; UK Dementia Research Institute at UCL (H.Z.), London, UK; and Hong Kong Center for Neurodegenerative Diseases (H.Z.), China
| | - Kaj Blennow
- From Neurology (L.G., T.C., N.M.-C., M.M.-K.), Clinical Neurophysiology (S.B., E.W.), Cardiology (J.D.), and Anaesthesia and Intensive Care (H.F.), Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Mölndal, Sweden; Department of Cardiology (C.H.), Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Denmark; Departments of Intensive Care (J.H.) and Neurology/Clinical Neurophysiology (A.-F-V.R.), Amsterdam Neuroscience, Amsterdam UMC, Academic Medical Center, University of Amsterdam, the Netherlands; Departments of Clinical Neurophysiology (T.W.K.) and Cardiology (J.K.), Rigshospitalet University Hospital, Copenhagen, Denmark; Department of Intensive Care (M.K.), Medical Center Leeuwarden, the Netherlands; Clinical Memory Research Unit, Faculty of Medicine (N.M.-C.), and Wallenberg Centre for Molecular Medicine (N.M.-C.), Lund University; Anaesthesia and Intensive Care, Department of Clinical Sciences Lund (N.N.), Lund University, Helsingborg Hospital, Sweden; Department of Neurology (A.O.R.), CHUV and University of Lausanne, Switzerland; Department of Anesthesia and Intensive Care (P.S.), Centre Hospitalier de Luxembourg; Department of Life Sciences and Medicine (P.S.), Faculty of Science, Technology and Medicine, University of Luxembourg; Clinical Studies Sweden (S.U.), Skåne University Hospital, Lund; Department of Neurodegenerative Disease (H.Z.), UCL Institute of Neurology; UK Dementia Research Institute at UCL (H.Z.), London, UK; and Hong Kong Center for Neurodegenerative Diseases (H.Z.), China
| | - Josef Dankiewicz
- From Neurology (L.G., T.C., N.M.-C., M.M.-K.), Clinical Neurophysiology (S.B., E.W.), Cardiology (J.D.), and Anaesthesia and Intensive Care (H.F.), Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Mölndal, Sweden; Department of Cardiology (C.H.), Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Denmark; Departments of Intensive Care (J.H.) and Neurology/Clinical Neurophysiology (A.-F-V.R.), Amsterdam Neuroscience, Amsterdam UMC, Academic Medical Center, University of Amsterdam, the Netherlands; Departments of Clinical Neurophysiology (T.W.K.) and Cardiology (J.K.), Rigshospitalet University Hospital, Copenhagen, Denmark; Department of Intensive Care (M.K.), Medical Center Leeuwarden, the Netherlands; Clinical Memory Research Unit, Faculty of Medicine (N.M.-C.), and Wallenberg Centre for Molecular Medicine (N.M.-C.), Lund University; Anaesthesia and Intensive Care, Department of Clinical Sciences Lund (N.N.), Lund University, Helsingborg Hospital, Sweden; Department of Neurology (A.O.R.), CHUV and University of Lausanne, Switzerland; Department of Anesthesia and Intensive Care (P.S.), Centre Hospitalier de Luxembourg; Department of Life Sciences and Medicine (P.S.), Faculty of Science, Technology and Medicine, University of Luxembourg; Clinical Studies Sweden (S.U.), Skåne University Hospital, Lund; Department of Neurodegenerative Disease (H.Z.), UCL Institute of Neurology; UK Dementia Research Institute at UCL (H.Z.), London, UK; and Hong Kong Center for Neurodegenerative Diseases (H.Z.), China
| | - Hans Friberg
- From Neurology (L.G., T.C., N.M.-C., M.M.-K.), Clinical Neurophysiology (S.B., E.W.), Cardiology (J.D.), and Anaesthesia and Intensive Care (H.F.), Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Mölndal, Sweden; Department of Cardiology (C.H.), Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Denmark; Departments of Intensive Care (J.H.) and Neurology/Clinical Neurophysiology (A.-F-V.R.), Amsterdam Neuroscience, Amsterdam UMC, Academic Medical Center, University of Amsterdam, the Netherlands; Departments of Clinical Neurophysiology (T.W.K.) and Cardiology (J.K.), Rigshospitalet University Hospital, Copenhagen, Denmark; Department of Intensive Care (M.K.), Medical Center Leeuwarden, the Netherlands; Clinical Memory Research Unit, Faculty of Medicine (N.M.-C.), and Wallenberg Centre for Molecular Medicine (N.M.-C.), Lund University; Anaesthesia and Intensive Care, Department of Clinical Sciences Lund (N.N.), Lund University, Helsingborg Hospital, Sweden; Department of Neurology (A.O.R.), CHUV and University of Lausanne, Switzerland; Department of Anesthesia and Intensive Care (P.S.), Centre Hospitalier de Luxembourg; Department of Life Sciences and Medicine (P.S.), Faculty of Science, Technology and Medicine, University of Luxembourg; Clinical Studies Sweden (S.U.), Skåne University Hospital, Lund; Department of Neurodegenerative Disease (H.Z.), UCL Institute of Neurology; UK Dementia Research Institute at UCL (H.Z.), London, UK; and Hong Kong Center for Neurodegenerative Diseases (H.Z.), China
| | - Christian Hassager
- From Neurology (L.G., T.C., N.M.-C., M.M.-K.), Clinical Neurophysiology (S.B., E.W.), Cardiology (J.D.), and Anaesthesia and Intensive Care (H.F.), Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Mölndal, Sweden; Department of Cardiology (C.H.), Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Denmark; Departments of Intensive Care (J.H.) and Neurology/Clinical Neurophysiology (A.-F-V.R.), Amsterdam Neuroscience, Amsterdam UMC, Academic Medical Center, University of Amsterdam, the Netherlands; Departments of Clinical Neurophysiology (T.W.K.) and Cardiology (J.K.), Rigshospitalet University Hospital, Copenhagen, Denmark; Department of Intensive Care (M.K.), Medical Center Leeuwarden, the Netherlands; Clinical Memory Research Unit, Faculty of Medicine (N.M.-C.), and Wallenberg Centre for Molecular Medicine (N.M.-C.), Lund University; Anaesthesia and Intensive Care, Department of Clinical Sciences Lund (N.N.), Lund University, Helsingborg Hospital, Sweden; Department of Neurology (A.O.R.), CHUV and University of Lausanne, Switzerland; Department of Anesthesia and Intensive Care (P.S.), Centre Hospitalier de Luxembourg; Department of Life Sciences and Medicine (P.S.), Faculty of Science, Technology and Medicine, University of Luxembourg; Clinical Studies Sweden (S.U.), Skåne University Hospital, Lund; Department of Neurodegenerative Disease (H.Z.), UCL Institute of Neurology; UK Dementia Research Institute at UCL (H.Z.), London, UK; and Hong Kong Center for Neurodegenerative Diseases (H.Z.), China
| | - Janneke Horn
- From Neurology (L.G., T.C., N.M.-C., M.M.-K.), Clinical Neurophysiology (S.B., E.W.), Cardiology (J.D.), and Anaesthesia and Intensive Care (H.F.), Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Mölndal, Sweden; Department of Cardiology (C.H.), Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Denmark; Departments of Intensive Care (J.H.) and Neurology/Clinical Neurophysiology (A.-F-V.R.), Amsterdam Neuroscience, Amsterdam UMC, Academic Medical Center, University of Amsterdam, the Netherlands; Departments of Clinical Neurophysiology (T.W.K.) and Cardiology (J.K.), Rigshospitalet University Hospital, Copenhagen, Denmark; Department of Intensive Care (M.K.), Medical Center Leeuwarden, the Netherlands; Clinical Memory Research Unit, Faculty of Medicine (N.M.-C.), and Wallenberg Centre for Molecular Medicine (N.M.-C.), Lund University; Anaesthesia and Intensive Care, Department of Clinical Sciences Lund (N.N.), Lund University, Helsingborg Hospital, Sweden; Department of Neurology (A.O.R.), CHUV and University of Lausanne, Switzerland; Department of Anesthesia and Intensive Care (P.S.), Centre Hospitalier de Luxembourg; Department of Life Sciences and Medicine (P.S.), Faculty of Science, Technology and Medicine, University of Luxembourg; Clinical Studies Sweden (S.U.), Skåne University Hospital, Lund; Department of Neurodegenerative Disease (H.Z.), UCL Institute of Neurology; UK Dementia Research Institute at UCL (H.Z.), London, UK; and Hong Kong Center for Neurodegenerative Diseases (H.Z.), China
| | - Troels W Kjaer
- From Neurology (L.G., T.C., N.M.-C., M.M.-K.), Clinical Neurophysiology (S.B., E.W.), Cardiology (J.D.), and Anaesthesia and Intensive Care (H.F.), Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Mölndal, Sweden; Department of Cardiology (C.H.), Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Denmark; Departments of Intensive Care (J.H.) and Neurology/Clinical Neurophysiology (A.-F-V.R.), Amsterdam Neuroscience, Amsterdam UMC, Academic Medical Center, University of Amsterdam, the Netherlands; Departments of Clinical Neurophysiology (T.W.K.) and Cardiology (J.K.), Rigshospitalet University Hospital, Copenhagen, Denmark; Department of Intensive Care (M.K.), Medical Center Leeuwarden, the Netherlands; Clinical Memory Research Unit, Faculty of Medicine (N.M.-C.), and Wallenberg Centre for Molecular Medicine (N.M.-C.), Lund University; Anaesthesia and Intensive Care, Department of Clinical Sciences Lund (N.N.), Lund University, Helsingborg Hospital, Sweden; Department of Neurology (A.O.R.), CHUV and University of Lausanne, Switzerland; Department of Anesthesia and Intensive Care (P.S.), Centre Hospitalier de Luxembourg; Department of Life Sciences and Medicine (P.S.), Faculty of Science, Technology and Medicine, University of Luxembourg; Clinical Studies Sweden (S.U.), Skåne University Hospital, Lund; Department of Neurodegenerative Disease (H.Z.), UCL Institute of Neurology; UK Dementia Research Institute at UCL (H.Z.), London, UK; and Hong Kong Center for Neurodegenerative Diseases (H.Z.), China
| | - Jesper Kjaergaard
- From Neurology (L.G., T.C., N.M.-C., M.M.-K.), Clinical Neurophysiology (S.B., E.W.), Cardiology (J.D.), and Anaesthesia and Intensive Care (H.F.), Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Mölndal, Sweden; Department of Cardiology (C.H.), Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Denmark; Departments of Intensive Care (J.H.) and Neurology/Clinical Neurophysiology (A.-F-V.R.), Amsterdam Neuroscience, Amsterdam UMC, Academic Medical Center, University of Amsterdam, the Netherlands; Departments of Clinical Neurophysiology (T.W.K.) and Cardiology (J.K.), Rigshospitalet University Hospital, Copenhagen, Denmark; Department of Intensive Care (M.K.), Medical Center Leeuwarden, the Netherlands; Clinical Memory Research Unit, Faculty of Medicine (N.M.-C.), and Wallenberg Centre for Molecular Medicine (N.M.-C.), Lund University; Anaesthesia and Intensive Care, Department of Clinical Sciences Lund (N.N.), Lund University, Helsingborg Hospital, Sweden; Department of Neurology (A.O.R.), CHUV and University of Lausanne, Switzerland; Department of Anesthesia and Intensive Care (P.S.), Centre Hospitalier de Luxembourg; Department of Life Sciences and Medicine (P.S.), Faculty of Science, Technology and Medicine, University of Luxembourg; Clinical Studies Sweden (S.U.), Skåne University Hospital, Lund; Department of Neurodegenerative Disease (H.Z.), UCL Institute of Neurology; UK Dementia Research Institute at UCL (H.Z.), London, UK; and Hong Kong Center for Neurodegenerative Diseases (H.Z.), China
| | - Michael Kuiper
- From Neurology (L.G., T.C., N.M.-C., M.M.-K.), Clinical Neurophysiology (S.B., E.W.), Cardiology (J.D.), and Anaesthesia and Intensive Care (H.F.), Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Mölndal, Sweden; Department of Cardiology (C.H.), Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Denmark; Departments of Intensive Care (J.H.) and Neurology/Clinical Neurophysiology (A.-F-V.R.), Amsterdam Neuroscience, Amsterdam UMC, Academic Medical Center, University of Amsterdam, the Netherlands; Departments of Clinical Neurophysiology (T.W.K.) and Cardiology (J.K.), Rigshospitalet University Hospital, Copenhagen, Denmark; Department of Intensive Care (M.K.), Medical Center Leeuwarden, the Netherlands; Clinical Memory Research Unit, Faculty of Medicine (N.M.-C.), and Wallenberg Centre for Molecular Medicine (N.M.-C.), Lund University; Anaesthesia and Intensive Care, Department of Clinical Sciences Lund (N.N.), Lund University, Helsingborg Hospital, Sweden; Department of Neurology (A.O.R.), CHUV and University of Lausanne, Switzerland; Department of Anesthesia and Intensive Care (P.S.), Centre Hospitalier de Luxembourg; Department of Life Sciences and Medicine (P.S.), Faculty of Science, Technology and Medicine, University of Luxembourg; Clinical Studies Sweden (S.U.), Skåne University Hospital, Lund; Department of Neurodegenerative Disease (H.Z.), UCL Institute of Neurology; UK Dementia Research Institute at UCL (H.Z.), London, UK; and Hong Kong Center for Neurodegenerative Diseases (H.Z.), China
| | - Niklas Mattsson-Carlgren
- From Neurology (L.G., T.C., N.M.-C., M.M.-K.), Clinical Neurophysiology (S.B., E.W.), Cardiology (J.D.), and Anaesthesia and Intensive Care (H.F.), Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Mölndal, Sweden; Department of Cardiology (C.H.), Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Denmark; Departments of Intensive Care (J.H.) and Neurology/Clinical Neurophysiology (A.-F-V.R.), Amsterdam Neuroscience, Amsterdam UMC, Academic Medical Center, University of Amsterdam, the Netherlands; Departments of Clinical Neurophysiology (T.W.K.) and Cardiology (J.K.), Rigshospitalet University Hospital, Copenhagen, Denmark; Department of Intensive Care (M.K.), Medical Center Leeuwarden, the Netherlands; Clinical Memory Research Unit, Faculty of Medicine (N.M.-C.), and Wallenberg Centre for Molecular Medicine (N.M.-C.), Lund University; Anaesthesia and Intensive Care, Department of Clinical Sciences Lund (N.N.), Lund University, Helsingborg Hospital, Sweden; Department of Neurology (A.O.R.), CHUV and University of Lausanne, Switzerland; Department of Anesthesia and Intensive Care (P.S.), Centre Hospitalier de Luxembourg; Department of Life Sciences and Medicine (P.S.), Faculty of Science, Technology and Medicine, University of Luxembourg; Clinical Studies Sweden (S.U.), Skåne University Hospital, Lund; Department of Neurodegenerative Disease (H.Z.), UCL Institute of Neurology; UK Dementia Research Institute at UCL (H.Z.), London, UK; and Hong Kong Center for Neurodegenerative Diseases (H.Z.), China
| | - Niklas Nielsen
- From Neurology (L.G., T.C., N.M.-C., M.M.-K.), Clinical Neurophysiology (S.B., E.W.), Cardiology (J.D.), and Anaesthesia and Intensive Care (H.F.), Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Mölndal, Sweden; Department of Cardiology (C.H.), Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Denmark; Departments of Intensive Care (J.H.) and Neurology/Clinical Neurophysiology (A.-F-V.R.), Amsterdam Neuroscience, Amsterdam UMC, Academic Medical Center, University of Amsterdam, the Netherlands; Departments of Clinical Neurophysiology (T.W.K.) and Cardiology (J.K.), Rigshospitalet University Hospital, Copenhagen, Denmark; Department of Intensive Care (M.K.), Medical Center Leeuwarden, the Netherlands; Clinical Memory Research Unit, Faculty of Medicine (N.M.-C.), and Wallenberg Centre for Molecular Medicine (N.M.-C.), Lund University; Anaesthesia and Intensive Care, Department of Clinical Sciences Lund (N.N.), Lund University, Helsingborg Hospital, Sweden; Department of Neurology (A.O.R.), CHUV and University of Lausanne, Switzerland; Department of Anesthesia and Intensive Care (P.S.), Centre Hospitalier de Luxembourg; Department of Life Sciences and Medicine (P.S.), Faculty of Science, Technology and Medicine, University of Luxembourg; Clinical Studies Sweden (S.U.), Skåne University Hospital, Lund; Department of Neurodegenerative Disease (H.Z.), UCL Institute of Neurology; UK Dementia Research Institute at UCL (H.Z.), London, UK; and Hong Kong Center for Neurodegenerative Diseases (H.Z.), China
| | - Anne-Fleur van Rootselaar
- From Neurology (L.G., T.C., N.M.-C., M.M.-K.), Clinical Neurophysiology (S.B., E.W.), Cardiology (J.D.), and Anaesthesia and Intensive Care (H.F.), Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Mölndal, Sweden; Department of Cardiology (C.H.), Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Denmark; Departments of Intensive Care (J.H.) and Neurology/Clinical Neurophysiology (A.-F-V.R.), Amsterdam Neuroscience, Amsterdam UMC, Academic Medical Center, University of Amsterdam, the Netherlands; Departments of Clinical Neurophysiology (T.W.K.) and Cardiology (J.K.), Rigshospitalet University Hospital, Copenhagen, Denmark; Department of Intensive Care (M.K.), Medical Center Leeuwarden, the Netherlands; Clinical Memory Research Unit, Faculty of Medicine (N.M.-C.), and Wallenberg Centre for Molecular Medicine (N.M.-C.), Lund University; Anaesthesia and Intensive Care, Department of Clinical Sciences Lund (N.N.), Lund University, Helsingborg Hospital, Sweden; Department of Neurology (A.O.R.), CHUV and University of Lausanne, Switzerland; Department of Anesthesia and Intensive Care (P.S.), Centre Hospitalier de Luxembourg; Department of Life Sciences and Medicine (P.S.), Faculty of Science, Technology and Medicine, University of Luxembourg; Clinical Studies Sweden (S.U.), Skåne University Hospital, Lund; Department of Neurodegenerative Disease (H.Z.), UCL Institute of Neurology; UK Dementia Research Institute at UCL (H.Z.), London, UK; and Hong Kong Center for Neurodegenerative Diseases (H.Z.), China
| | - Andrea O Rossetti
- From Neurology (L.G., T.C., N.M.-C., M.M.-K.), Clinical Neurophysiology (S.B., E.W.), Cardiology (J.D.), and Anaesthesia and Intensive Care (H.F.), Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Mölndal, Sweden; Department of Cardiology (C.H.), Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Denmark; Departments of Intensive Care (J.H.) and Neurology/Clinical Neurophysiology (A.-F-V.R.), Amsterdam Neuroscience, Amsterdam UMC, Academic Medical Center, University of Amsterdam, the Netherlands; Departments of Clinical Neurophysiology (T.W.K.) and Cardiology (J.K.), Rigshospitalet University Hospital, Copenhagen, Denmark; Department of Intensive Care (M.K.), Medical Center Leeuwarden, the Netherlands; Clinical Memory Research Unit, Faculty of Medicine (N.M.-C.), and Wallenberg Centre for Molecular Medicine (N.M.-C.), Lund University; Anaesthesia and Intensive Care, Department of Clinical Sciences Lund (N.N.), Lund University, Helsingborg Hospital, Sweden; Department of Neurology (A.O.R.), CHUV and University of Lausanne, Switzerland; Department of Anesthesia and Intensive Care (P.S.), Centre Hospitalier de Luxembourg; Department of Life Sciences and Medicine (P.S.), Faculty of Science, Technology and Medicine, University of Luxembourg; Clinical Studies Sweden (S.U.), Skåne University Hospital, Lund; Department of Neurodegenerative Disease (H.Z.), UCL Institute of Neurology; UK Dementia Research Institute at UCL (H.Z.), London, UK; and Hong Kong Center for Neurodegenerative Diseases (H.Z.), China
| | - Pascal Stammet
- From Neurology (L.G., T.C., N.M.-C., M.M.-K.), Clinical Neurophysiology (S.B., E.W.), Cardiology (J.D.), and Anaesthesia and Intensive Care (H.F.), Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Mölndal, Sweden; Department of Cardiology (C.H.), Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Denmark; Departments of Intensive Care (J.H.) and Neurology/Clinical Neurophysiology (A.-F-V.R.), Amsterdam Neuroscience, Amsterdam UMC, Academic Medical Center, University of Amsterdam, the Netherlands; Departments of Clinical Neurophysiology (T.W.K.) and Cardiology (J.K.), Rigshospitalet University Hospital, Copenhagen, Denmark; Department of Intensive Care (M.K.), Medical Center Leeuwarden, the Netherlands; Clinical Memory Research Unit, Faculty of Medicine (N.M.-C.), and Wallenberg Centre for Molecular Medicine (N.M.-C.), Lund University; Anaesthesia and Intensive Care, Department of Clinical Sciences Lund (N.N.), Lund University, Helsingborg Hospital, Sweden; Department of Neurology (A.O.R.), CHUV and University of Lausanne, Switzerland; Department of Anesthesia and Intensive Care (P.S.), Centre Hospitalier de Luxembourg; Department of Life Sciences and Medicine (P.S.), Faculty of Science, Technology and Medicine, University of Luxembourg; Clinical Studies Sweden (S.U.), Skåne University Hospital, Lund; Department of Neurodegenerative Disease (H.Z.), UCL Institute of Neurology; UK Dementia Research Institute at UCL (H.Z.), London, UK; and Hong Kong Center for Neurodegenerative Diseases (H.Z.), China
| | - Susann Ullén
- From Neurology (L.G., T.C., N.M.-C., M.M.-K.), Clinical Neurophysiology (S.B., E.W.), Cardiology (J.D.), and Anaesthesia and Intensive Care (H.F.), Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Mölndal, Sweden; Department of Cardiology (C.H.), Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Denmark; Departments of Intensive Care (J.H.) and Neurology/Clinical Neurophysiology (A.-F-V.R.), Amsterdam Neuroscience, Amsterdam UMC, Academic Medical Center, University of Amsterdam, the Netherlands; Departments of Clinical Neurophysiology (T.W.K.) and Cardiology (J.K.), Rigshospitalet University Hospital, Copenhagen, Denmark; Department of Intensive Care (M.K.), Medical Center Leeuwarden, the Netherlands; Clinical Memory Research Unit, Faculty of Medicine (N.M.-C.), and Wallenberg Centre for Molecular Medicine (N.M.-C.), Lund University; Anaesthesia and Intensive Care, Department of Clinical Sciences Lund (N.N.), Lund University, Helsingborg Hospital, Sweden; Department of Neurology (A.O.R.), CHUV and University of Lausanne, Switzerland; Department of Anesthesia and Intensive Care (P.S.), Centre Hospitalier de Luxembourg; Department of Life Sciences and Medicine (P.S.), Faculty of Science, Technology and Medicine, University of Luxembourg; Clinical Studies Sweden (S.U.), Skåne University Hospital, Lund; Department of Neurodegenerative Disease (H.Z.), UCL Institute of Neurology; UK Dementia Research Institute at UCL (H.Z.), London, UK; and Hong Kong Center for Neurodegenerative Diseases (H.Z.), China
| | - Henrik Zetterberg
- From Neurology (L.G., T.C., N.M.-C., M.M.-K.), Clinical Neurophysiology (S.B., E.W.), Cardiology (J.D.), and Anaesthesia and Intensive Care (H.F.), Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Mölndal, Sweden; Department of Cardiology (C.H.), Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Denmark; Departments of Intensive Care (J.H.) and Neurology/Clinical Neurophysiology (A.-F-V.R.), Amsterdam Neuroscience, Amsterdam UMC, Academic Medical Center, University of Amsterdam, the Netherlands; Departments of Clinical Neurophysiology (T.W.K.) and Cardiology (J.K.), Rigshospitalet University Hospital, Copenhagen, Denmark; Department of Intensive Care (M.K.), Medical Center Leeuwarden, the Netherlands; Clinical Memory Research Unit, Faculty of Medicine (N.M.-C.), and Wallenberg Centre for Molecular Medicine (N.M.-C.), Lund University; Anaesthesia and Intensive Care, Department of Clinical Sciences Lund (N.N.), Lund University, Helsingborg Hospital, Sweden; Department of Neurology (A.O.R.), CHUV and University of Lausanne, Switzerland; Department of Anesthesia and Intensive Care (P.S.), Centre Hospitalier de Luxembourg; Department of Life Sciences and Medicine (P.S.), Faculty of Science, Technology and Medicine, University of Luxembourg; Clinical Studies Sweden (S.U.), Skåne University Hospital, Lund; Department of Neurodegenerative Disease (H.Z.), UCL Institute of Neurology; UK Dementia Research Institute at UCL (H.Z.), London, UK; and Hong Kong Center for Neurodegenerative Diseases (H.Z.), China
| | - Erik Westhall
- From Neurology (L.G., T.C., N.M.-C., M.M.-K.), Clinical Neurophysiology (S.B., E.W.), Cardiology (J.D.), and Anaesthesia and Intensive Care (H.F.), Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Mölndal, Sweden; Department of Cardiology (C.H.), Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Denmark; Departments of Intensive Care (J.H.) and Neurology/Clinical Neurophysiology (A.-F-V.R.), Amsterdam Neuroscience, Amsterdam UMC, Academic Medical Center, University of Amsterdam, the Netherlands; Departments of Clinical Neurophysiology (T.W.K.) and Cardiology (J.K.), Rigshospitalet University Hospital, Copenhagen, Denmark; Department of Intensive Care (M.K.), Medical Center Leeuwarden, the Netherlands; Clinical Memory Research Unit, Faculty of Medicine (N.M.-C.), and Wallenberg Centre for Molecular Medicine (N.M.-C.), Lund University; Anaesthesia and Intensive Care, Department of Clinical Sciences Lund (N.N.), Lund University, Helsingborg Hospital, Sweden; Department of Neurology (A.O.R.), CHUV and University of Lausanne, Switzerland; Department of Anesthesia and Intensive Care (P.S.), Centre Hospitalier de Luxembourg; Department of Life Sciences and Medicine (P.S.), Faculty of Science, Technology and Medicine, University of Luxembourg; Clinical Studies Sweden (S.U.), Skåne University Hospital, Lund; Department of Neurodegenerative Disease (H.Z.), UCL Institute of Neurology; UK Dementia Research Institute at UCL (H.Z.), London, UK; and Hong Kong Center for Neurodegenerative Diseases (H.Z.), China
| | - Marion Moseby-Knappe
- From Neurology (L.G., T.C., N.M.-C., M.M.-K.), Clinical Neurophysiology (S.B., E.W.), Cardiology (J.D.), and Anaesthesia and Intensive Care (H.F.), Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Malmö; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, the Sahlgrenska Academy, University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Mölndal, Sweden; Department of Cardiology (C.H.), Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Denmark; Departments of Intensive Care (J.H.) and Neurology/Clinical Neurophysiology (A.-F-V.R.), Amsterdam Neuroscience, Amsterdam UMC, Academic Medical Center, University of Amsterdam, the Netherlands; Departments of Clinical Neurophysiology (T.W.K.) and Cardiology (J.K.), Rigshospitalet University Hospital, Copenhagen, Denmark; Department of Intensive Care (M.K.), Medical Center Leeuwarden, the Netherlands; Clinical Memory Research Unit, Faculty of Medicine (N.M.-C.), and Wallenberg Centre for Molecular Medicine (N.M.-C.), Lund University; Anaesthesia and Intensive Care, Department of Clinical Sciences Lund (N.N.), Lund University, Helsingborg Hospital, Sweden; Department of Neurology (A.O.R.), CHUV and University of Lausanne, Switzerland; Department of Anesthesia and Intensive Care (P.S.), Centre Hospitalier de Luxembourg; Department of Life Sciences and Medicine (P.S.), Faculty of Science, Technology and Medicine, University of Luxembourg; Clinical Studies Sweden (S.U.), Skåne University Hospital, Lund; Department of Neurodegenerative Disease (H.Z.), UCL Institute of Neurology; UK Dementia Research Institute at UCL (H.Z.), London, UK; and Hong Kong Center for Neurodegenerative Diseases (H.Z.), China
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Urbano V, Alvarez V, Schindler K, Rüegg S, Ben-Hamouda N, Novy J, Rossetti AO. Continuous versus routine EEG in patients after cardiac arrest-Analysis of a randomized controlled trial (CERTA) - RESUS-D-22-00369. Resuscitation 2022; 176:68-73. [PMID: 35654226 DOI: 10.1016/j.resuscitation.2022.05.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 05/18/2022] [Accepted: 05/24/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Electroencephalography (EEG) is essential to assess prognosis in patients after cardiac arrest (CA). Use of continuous EEG (cEEG) is increasing in critically-ill patients, but it is more resource-consuming than routine EEG (rEEG). Observational studies did not show a major impact of cEEG versus rEEG on outcome, but randomized studies are lacking. METHODS We analyzed data of the CERTA trial (NCT03129438), including comatose adults after CA undergoing cEEG (30-48 hours) or two rEEG (20-30 minutes each). We explored correlations between recording EEG type and mortality (primary outcome), or Cerebral Performance Categories (CPC, secondary outcome), assessed blindly at 6 months, using uni- and multivariable analyses (adjusting for other prognostic variables showing some imbalance across groups). RESULTS We analyzed 112 adults (52 underwent rEEG, 60 cEEG,); 31 (27.7%) were women; 68 (60.7%) patients died. In univariate analysis, mortality (rEEG 59%, cEEG 65%, p=0.318) and good outcome (CPC 1-2; rEEG 33%, cEEG 27%, p=0.247) were comparable across EEG groups. This did not change after multiple logistic regressions, adjusting for shockable rhythm, time to return of spontaneous circulation, serum neuron-specific enolase, EEG background reactivity, regarding mortality (rEEG vs cEEG: OR 1.60, 95% CI 0.43 - 5.83, p=0.477), and good outcome (OR 0.51, 95% CI 0.14 - 1.90, p=0.318). CONCLUSION This analysis suggests that cEEG or repeated rEEG are related to comparable outcomes of comatose patients after CA. Pending a prospective, large randomized trial, this finding does not support the routine use of cEEG for prognostication in this setting. Trial registration Continuous EEG Randomized Trial in Adults (CERTA); NCT03129438; July 25, 2019.
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Affiliation(s)
- Valentina Urbano
- Department of Neurology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Vincent Alvarez
- Department of Neurology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland; Department of Neurology, Hôpital du Valais, Sion, Switzerland
| | - Kaspar Schindler
- Sleep-Wake-Epilepsy-Center, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stephan Rüegg
- Department of Neurology, University Hospital Basel, and University of Basel, Basel, Switzerland
| | - Nawfel Ben-Hamouda
- Department of Adult Intensive Care Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Jan Novy
- Department of Neurology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Andrea O Rossetti
- Department of Neurology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
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22
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Snider SB, Fischer D, McKeown ME, Cohen AL, Schaper FLWVJ, Amorim E, Fox MD, Scirica B, Bevers MB, Lee JW. Regional Distribution of Brain Injury After Cardiac Arrest: Clinical and Electrographic Correlates. Neurology 2022; 98:e1238-e1247. [PMID: 35017304 PMCID: PMC8967331 DOI: 10.1212/wnl.0000000000013301] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 12/27/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Disorders of consciousness, EEG background suppression, and epileptic seizures are associated with poor outcome after cardiac arrest. Our objective was to identify the distribution of diffusion MRI-measured anoxic brain injury after cardiac arrest and to define the regional correlates of disorders of consciousness, EEG background suppression, and seizures. METHODS We analyzed patients from a single-center database of unresponsive patients who underwent diffusion MRI after cardiac arrest (n = 204). We classified each patient according to recovery of consciousness (command following) before discharge, the most continuous EEG background (burst suppression vs continuous), and the presence or absence of seizures. Anoxic brain injury was measured with the apparent diffusion coefficient (ADC) signal. We identified ADC abnormalities relative to controls without cardiac arrest (n = 48) and used voxel lesion symptom mapping to identify regional associations with disorders of consciousness, EEG background suppression, and seizures. We then used a bootstrapped lasso regression procedure to identify robust, multivariate regional associations with each outcome variable. Last, using area under receiver operating characteristic curves, we then compared the classification ability of the strongest regional associations to that of brain-wide summary measures. RESULTS Compared to controls, patients with cardiac arrest demonstrated ADC signal reduction that was most significant in the occipital lobes. Disorders of consciousness were associated with reduced ADC most prominently in the occipital lobes but also in deep structures. Regional injury more accurately classified patients with disorders of consciousness than whole-brain injury. Background suppression mapped to a similar set of brain regions, but regional injury could no better classify patients than whole-brain measures. Seizures were less common in patients with more severe anoxic injury, particularly in those with injury to the lateral temporal white matter. DISCUSSION Anoxic brain injury was most prevalent in posterior cerebral regions, and this regional pattern of injury was a better predictor of disorders of consciousness than whole-brain injury measures. EEG background suppression lacked a specific regional association, but patients with injury to the temporal lobe were less likely to have seizures. Regional patterns of anoxic brain injury are relevant to the clinical and electrographic sequelae of cardiac arrest and may hold importance for prognosis. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that disorders of consciousness after cardiac arrest are associated with widely lower ADC values on diffusion MRI and are most strongly associated with reductions in occipital ADC.
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Affiliation(s)
- Samuel B Snider
- From the Division of Neurocritical Care, Department of Neurology, (S.B.S., D.F., M.E.M., M.B.B.), Departments of Neurology, Psychiatry, and Radiology (A.L.C., F.L.W.V.J.S., M.D.F.), Center for Brain Circuit Therapeutics, Division of Cardiology, Department of Medicine (B.S.), and Division of Epilepsy, Department of Neurology (J.W.L.), Brigham and Women's Hospital, Harvard Medical School; Departments of Neurology and Radiology (A.L.C.), Computational Radiology Laboratory, Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California at San Francisco; Neurology Service (E.A.), Zuckerberg San Francisco General Hospital, CA; Departments of Neurology and Radiology (M.D.F.), Athinoula A. Martinos Centre for Biomedical Imaging, Massachusetts General Hospital, Charlestown; and Department of Neurology (M.D.F.), Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
| | - David Fischer
- From the Division of Neurocritical Care, Department of Neurology, (S.B.S., D.F., M.E.M., M.B.B.), Departments of Neurology, Psychiatry, and Radiology (A.L.C., F.L.W.V.J.S., M.D.F.), Center for Brain Circuit Therapeutics, Division of Cardiology, Department of Medicine (B.S.), and Division of Epilepsy, Department of Neurology (J.W.L.), Brigham and Women's Hospital, Harvard Medical School; Departments of Neurology and Radiology (A.L.C.), Computational Radiology Laboratory, Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California at San Francisco; Neurology Service (E.A.), Zuckerberg San Francisco General Hospital, CA; Departments of Neurology and Radiology (M.D.F.), Athinoula A. Martinos Centre for Biomedical Imaging, Massachusetts General Hospital, Charlestown; and Department of Neurology (M.D.F.), Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Morgan E McKeown
- From the Division of Neurocritical Care, Department of Neurology, (S.B.S., D.F., M.E.M., M.B.B.), Departments of Neurology, Psychiatry, and Radiology (A.L.C., F.L.W.V.J.S., M.D.F.), Center for Brain Circuit Therapeutics, Division of Cardiology, Department of Medicine (B.S.), and Division of Epilepsy, Department of Neurology (J.W.L.), Brigham and Women's Hospital, Harvard Medical School; Departments of Neurology and Radiology (A.L.C.), Computational Radiology Laboratory, Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California at San Francisco; Neurology Service (E.A.), Zuckerberg San Francisco General Hospital, CA; Departments of Neurology and Radiology (M.D.F.), Athinoula A. Martinos Centre for Biomedical Imaging, Massachusetts General Hospital, Charlestown; and Department of Neurology (M.D.F.), Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Alexander Li Cohen
- From the Division of Neurocritical Care, Department of Neurology, (S.B.S., D.F., M.E.M., M.B.B.), Departments of Neurology, Psychiatry, and Radiology (A.L.C., F.L.W.V.J.S., M.D.F.), Center for Brain Circuit Therapeutics, Division of Cardiology, Department of Medicine (B.S.), and Division of Epilepsy, Department of Neurology (J.W.L.), Brigham and Women's Hospital, Harvard Medical School; Departments of Neurology and Radiology (A.L.C.), Computational Radiology Laboratory, Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California at San Francisco; Neurology Service (E.A.), Zuckerberg San Francisco General Hospital, CA; Departments of Neurology and Radiology (M.D.F.), Athinoula A. Martinos Centre for Biomedical Imaging, Massachusetts General Hospital, Charlestown; and Department of Neurology (M.D.F.), Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Frederic L W V J Schaper
- From the Division of Neurocritical Care, Department of Neurology, (S.B.S., D.F., M.E.M., M.B.B.), Departments of Neurology, Psychiatry, and Radiology (A.L.C., F.L.W.V.J.S., M.D.F.), Center for Brain Circuit Therapeutics, Division of Cardiology, Department of Medicine (B.S.), and Division of Epilepsy, Department of Neurology (J.W.L.), Brigham and Women's Hospital, Harvard Medical School; Departments of Neurology and Radiology (A.L.C.), Computational Radiology Laboratory, Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California at San Francisco; Neurology Service (E.A.), Zuckerberg San Francisco General Hospital, CA; Departments of Neurology and Radiology (M.D.F.), Athinoula A. Martinos Centre for Biomedical Imaging, Massachusetts General Hospital, Charlestown; and Department of Neurology (M.D.F.), Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Edilberto Amorim
- From the Division of Neurocritical Care, Department of Neurology, (S.B.S., D.F., M.E.M., M.B.B.), Departments of Neurology, Psychiatry, and Radiology (A.L.C., F.L.W.V.J.S., M.D.F.), Center for Brain Circuit Therapeutics, Division of Cardiology, Department of Medicine (B.S.), and Division of Epilepsy, Department of Neurology (J.W.L.), Brigham and Women's Hospital, Harvard Medical School; Departments of Neurology and Radiology (A.L.C.), Computational Radiology Laboratory, Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California at San Francisco; Neurology Service (E.A.), Zuckerberg San Francisco General Hospital, CA; Departments of Neurology and Radiology (M.D.F.), Athinoula A. Martinos Centre for Biomedical Imaging, Massachusetts General Hospital, Charlestown; and Department of Neurology (M.D.F.), Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Michael D Fox
- From the Division of Neurocritical Care, Department of Neurology, (S.B.S., D.F., M.E.M., M.B.B.), Departments of Neurology, Psychiatry, and Radiology (A.L.C., F.L.W.V.J.S., M.D.F.), Center for Brain Circuit Therapeutics, Division of Cardiology, Department of Medicine (B.S.), and Division of Epilepsy, Department of Neurology (J.W.L.), Brigham and Women's Hospital, Harvard Medical School; Departments of Neurology and Radiology (A.L.C.), Computational Radiology Laboratory, Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California at San Francisco; Neurology Service (E.A.), Zuckerberg San Francisco General Hospital, CA; Departments of Neurology and Radiology (M.D.F.), Athinoula A. Martinos Centre for Biomedical Imaging, Massachusetts General Hospital, Charlestown; and Department of Neurology (M.D.F.), Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Benjamin Scirica
- From the Division of Neurocritical Care, Department of Neurology, (S.B.S., D.F., M.E.M., M.B.B.), Departments of Neurology, Psychiatry, and Radiology (A.L.C., F.L.W.V.J.S., M.D.F.), Center for Brain Circuit Therapeutics, Division of Cardiology, Department of Medicine (B.S.), and Division of Epilepsy, Department of Neurology (J.W.L.), Brigham and Women's Hospital, Harvard Medical School; Departments of Neurology and Radiology (A.L.C.), Computational Radiology Laboratory, Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California at San Francisco; Neurology Service (E.A.), Zuckerberg San Francisco General Hospital, CA; Departments of Neurology and Radiology (M.D.F.), Athinoula A. Martinos Centre for Biomedical Imaging, Massachusetts General Hospital, Charlestown; and Department of Neurology (M.D.F.), Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Matthew B Bevers
- From the Division of Neurocritical Care, Department of Neurology, (S.B.S., D.F., M.E.M., M.B.B.), Departments of Neurology, Psychiatry, and Radiology (A.L.C., F.L.W.V.J.S., M.D.F.), Center for Brain Circuit Therapeutics, Division of Cardiology, Department of Medicine (B.S.), and Division of Epilepsy, Department of Neurology (J.W.L.), Brigham and Women's Hospital, Harvard Medical School; Departments of Neurology and Radiology (A.L.C.), Computational Radiology Laboratory, Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California at San Francisco; Neurology Service (E.A.), Zuckerberg San Francisco General Hospital, CA; Departments of Neurology and Radiology (M.D.F.), Athinoula A. Martinos Centre for Biomedical Imaging, Massachusetts General Hospital, Charlestown; and Department of Neurology (M.D.F.), Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jong Woo Lee
- From the Division of Neurocritical Care, Department of Neurology, (S.B.S., D.F., M.E.M., M.B.B.), Departments of Neurology, Psychiatry, and Radiology (A.L.C., F.L.W.V.J.S., M.D.F.), Center for Brain Circuit Therapeutics, Division of Cardiology, Department of Medicine (B.S.), and Division of Epilepsy, Department of Neurology (J.W.L.), Brigham and Women's Hospital, Harvard Medical School; Departments of Neurology and Radiology (A.L.C.), Computational Radiology Laboratory, Boston Children's Hospital, Harvard Medical School, MA; Department of Neurology (E.A.), Weill Institute for Neurosciences, University of California at San Francisco; Neurology Service (E.A.), Zuckerberg San Francisco General Hospital, CA; Departments of Neurology and Radiology (M.D.F.), Athinoula A. Martinos Centre for Biomedical Imaging, Massachusetts General Hospital, Charlestown; and Department of Neurology (M.D.F.), Berenson-Allen Center for Noninvasive Brain Stimulation, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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23
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Moseby-Knappe M, Mattsson-Carlgren N, Stammet P, Backman S, Blennow K, Dankiewicz J, Friberg H, Hassager C, Horn J, Kjaergaard J, Lilja G, Rylander C, Ullén S, Undén J, Westhall E, Wise MP, Zetterberg H, Nielsen N, Cronberg T. Serum markers of brain injury can predict good neurological outcome after out-of-hospital cardiac arrest. Intensive Care Med 2021; 47:984-994. [PMID: 34417831 PMCID: PMC8421280 DOI: 10.1007/s00134-021-06481-4] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 07/13/2021] [Indexed: 12/31/2022]
Abstract
Purpose The majority of unconscious patients after cardiac arrest (CA) do not fulfill guideline criteria for a likely poor outcome, their prognosis is considered “indeterminate”. We compared brain injury markers in blood for prediction of good outcome and for identifying false positive predictions of poor outcome as recommended by guidelines. Methods Retrospective analysis of prospectively collected serum samples at 24, 48 and 72 h post arrest within the Target Temperature Management after out-of-hospital cardiac arrest (TTM)-trial. Clinically available markers neuron-specific enolase (NSE) and S100B, and novel markers neurofilament light chain (NFL), total tau, ubiquitin carboxy-terminal hydrolase L1 (UCH-L1) and glial fibrillary acidic protein (GFAP) were analysed. Normal levels with a priori cutoffs specified by reference laboratories or defined from literature were used to predict good outcome (no to moderate disability, Cerebral Performance Category scale 1–2) at 6 months. Results Seven hundred and seventeen patients were included. Normal NFL, tau and GFAP had the highest sensitivities (97.2–98% of poor outcome patients had abnormal serum levels) and NPV (normal levels predicted good outcome in 87–95% of patients). Normal S100B and NSE predicted good outcome with NPV 76–82.2%. Normal NSE correctly identified 67/190 (35.3%) patients with good outcome among those classified as “indeterminate outcome” by guidelines. Five patients with single pathological prognostic findings despite normal biomarkers had good outcome. Conclusion Low levels of brain injury markers in blood are associated with good neurological outcome after CA. Incorporating biomarkers into neuroprognostication may help prevent premature withdrawal of life-sustaining therapy. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-021-06481-4.
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Affiliation(s)
- Marion Moseby-Knappe
- Department of Clinical Sciences Lund, Neurology, Skåne University Hospital, Lund University, Getingevägen 4, 222 41, Lund, Sweden.
| | - Niklas Mattsson-Carlgren
- Department of Clinical Sciences Lund, Neurology, Skåne University Hospital, Lund University, Getingevägen 4, 222 41, Lund, Sweden.,Clinical Memory Research Unit, Faculty of Medicine, Lund University, Lund, Sweden.,Wallenberg Centre for Molecular Medicine, Lund University, Lund, Sweden
| | - Pascal Stammet
- Medical and Health Department, National Fire and Rescue Corps, Luxembourg, Luxembourg
| | - Sofia Backman
- Department of Clinical Sciences Lund, Clinical Neurophysiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, The Sahlgrenska Academy, Institute of Neuroscience and Physiology, University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Josef Dankiewicz
- Department of Clinical Sciences Lund, Cardiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences Lund, Anaesthesia and Intensive Care, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Christian Hassager
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Janneke Horn
- Department of Intensive Care, Amsterdam Neuroscience, Amsterdam UMC, Location Academic Medical Center, Amsterdam, The Netherlands
| | - Jesper Kjaergaard
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Gisela Lilja
- Department of Clinical Sciences Lund, Neurology, Skåne University Hospital, Lund University, Getingevägen 4, 222 41, Lund, Sweden
| | - Christian Rylander
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska Academy, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Susann Ullén
- Clinical Studies Sweden-Forum South, Skane University Hospital, Lund, Sweden
| | - Johan Undén
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden.,Department of Operation and Intensive Care, Lund University, Hallands Hospital Halmstad, Halland, Sweden
| | - Erik Westhall
- Department of Clinical Sciences Lund, Clinical Neurophysiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Matt P Wise
- Adult Critical Care, University Hospital of Wales, Cardiff, UK
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, The Sahlgrenska Academy, Institute of Neuroscience and Physiology, University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK.,UK Dementia Research Institute at UCL, London, UK.,Hong Kong Center for Neurodegenerative Diseases, Hong Kong, China
| | - Niklas Nielsen
- Department of Clinical Sciences Lund, Anaesthesia and Intensive Care, Helsingborg Hospital, Lund University, Lund, Sweden
| | - Tobias Cronberg
- Department of Clinical Sciences Lund, Neurology, Skåne University Hospital, Lund University, Getingevägen 4, 222 41, Lund, Sweden
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24
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Bhagat D, Lewis A. Treatment and Prognosis After Hypoxic-Ischemic Injury. Curr Treat Options Neurol 2021; 23. [DOI: 10.1007/s11940-021-00682-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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25
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Abstract
Seizures are frequently triggered by an inciting event and result from uninhibited excitation and/or decreased inhibition of a pool of neurons. If physiologic seizure abortive mechanisms fail, the ensuing unrestrained synchronization of neurons-status epilepticus-can be life-threatening and is associated with the potential for marked morbidity in survivors and high medical care costs. Prognosis is intimately related to etiology and its response to therapeutic measures. Timely implementation of pharmacologic therapy while concurrently performing a stepwise workup for etiology are paramount. Neurodiagnostic testing should guide titration of pharmacologic therapies, and help determine if there is a role for immune modulation.
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Affiliation(s)
- Pouya Alexander Ameli
- Department of Neurology, University of Florida McKnight Brain Institute, 1149 Newell Drive, Gainesville, FL 32610, USA; Department of Neurosurgery, University of Florida McKnight Brain Institute, 1149 Newell Drive, Gainesville, FL 32610, USA
| | - Abdalla A Ammar
- Department of Pharmacy, Yale New Haven Health, 55 Park Street, New Haven, CT 06511, USA
| | - Kent A Owusu
- Department of Pharmacy, Yale New Haven Health, 55 Park Street, New Haven, CT 06511, USA; Care Signature, Yale New Haven Health, 20 York Street, New Haven, CT, 06510, USA
| | - Carolina B Maciel
- Department of Neurology, University of Florida McKnight Brain Institute, 1149 Newell Drive, Gainesville, FL 32610, USA; Department of Neurosurgery, University of Florida McKnight Brain Institute, 1149 Newell Drive, Gainesville, FL 32610, USA; Department of Neurology, Yale University, 20 York Street, New Haven, CT, 06510, USA; Department of Neurology, University of Utah, 383 Colorow Drive, Salt Lake City, UT, 84132, USA.
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26
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Olasveengen TM, Skrifvars MB, Taccone F, Soar J. Postreanimationsbehandlung. Notf Rett Med 2021. [DOI: 10.1007/s10049-021-00892-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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27
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Kim YM, Jeung KW, Kim WY, Park YS, Oh JS, You YH, Lee DH, Chae MK, Jeong YJ, Kim MC, Ha EJ, Hwang KJ, Kim WS, Lee JM, Cha KC, Chung SP, Park JD, Kim HS, Lee MJ, Na SH, Kim ARE, Hwang SO. 2020 Korean Guidelines for Cardiopulmonary Resuscitation. Part 5. Post-cardiac arrest care. Clin Exp Emerg Med 2021; 8:S41-S64. [PMID: 34034449 PMCID: PMC8171174 DOI: 10.15441/ceem.21.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 03/07/2021] [Accepted: 03/19/2021] [Indexed: 12/20/2022] Open
Affiliation(s)
- Young-Min Kim
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Kyung Woon Jeung
- Department of Emergency Medicine, Chonnam National University College of Medicine, Gwangju, Korea
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, Ulsan University College of Medicine, Seoul, Korea
| | - Yoo Seok Park
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Joo Suk Oh
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Yeon Ho You
- Department of Emergency Medicine, Chungnam National University College of Medicine, Daejeon, Korea
| | - Dong Hoon Lee
- Department of Emergency Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Minjung Kathy Chae
- Department of Emergency Medicine, Ajou University College of Medicine, Suwon, Korea
| | - Yoo Jin Jeong
- Department of Emergency Medicine, Chonnam National University College of Medicine, Gwangju, Korea
| | - Min Chul Kim
- Department of Internal Medicine, Chonnam National University College of Medicine, Gwangju, Korea
| | - Eun Jin Ha
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kyoung Jin Hwang
- Department of Neurology, Kyung Hee University College of Medicine, Seoul, Korea
| | - Won-Seok Kim
- Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jae Myung Lee
- Department of General Surgery, Korea University College of Medicine, Seoul, Korea
| | - Kyoung-Chul Cha
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sung Phil Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - June Dong Park
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Han-Suk Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Mi Jin Lee
- Department of Emergency Medicine, Kyoungbook University College of Medicine, Daegu, Korea
| | - Sang-Hoon Na
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Ai-Rhan Ellen Kim
- Department of Pediatrics, Ulsan University College of Medicine, Seoul, Korea
| | - Sung Oh Hwang
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - on behalf of the Steering Committee of 2020 Korean Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
- Department of Emergency Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Chonnam National University College of Medicine, Gwangju, Korea
- Department of Emergency Medicine, Asan Medical Center, Ulsan University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Chungnam National University College of Medicine, Daejeon, Korea
- Department of Emergency Medicine, Chung-Ang University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Ajou University College of Medicine, Suwon, Korea
- Department of Internal Medicine, Chonnam National University College of Medicine, Gwangju, Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
- Department of Neurology, Kyung Hee University College of Medicine, Seoul, Korea
- Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
- Department of General Surgery, Korea University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Kyoungbook University College of Medicine, Daegu, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Pediatrics, Ulsan University College of Medicine, Seoul, Korea
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Beekman R, Maciel CB, Balu R, Greer DM, Gilmore EJ. Neuromonitoring After Cardiac Arrest: Can Twenty-First Century Medicine Personalize Post Cardiac Arrest Care? Neurol Clin 2021; 39:273-92. [PMID: 33896519 DOI: 10.1016/j.ncl.2021.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Cardiac arrest survivors comprise a heterogeneous population, in which the etiology of arrest, systemic and neurologic comorbidities, and sequelae of post-cardiac arrest syndrome influence the severity of secondary brain injury. The degree of secondary neurologic injury can be modifiable and is influenced by factors that alter cerebral physiology. Neuromonitoring techniques provide tools for evaluating the evolution of physiologic variables over time. This article reviews the pathophysiology of hypoxic-ischemic brain injury, provides an overview of the neuromonitoring tools available to identify risk profiles for secondary brain injury, and highlights the importance of an individualized approach to post cardiac arrest care.
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29
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Olasveengen TM, Skrifvars MB, Taccone F, Soar J. European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2021: post-resuscitation care. Intensive Care Med 2021; 47:369-421. [PMID: 33765189 PMCID: PMC7993077 DOI: 10.1007/s00134-021-06368-4] [Citation(s) in RCA: 386] [Impact Index Per Article: 128.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 02/08/2021] [Indexed: 12/13/2022]
Abstract
The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation and organ donation.
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Affiliation(s)
- Jerry P. Nolan
- University of Warwick, Warwick Medical School, Coventry, CV4 7AL UK
- Royal United Hospital, Bath, BA1 3NG UK
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy
- Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Bernd W. Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
| | - Alain Cariou
- Cochin University Hospital (APHP) and University of Paris (Medical School), Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anaesthesia and Intensive Care Medicine, Lund University, Skane University Hospital, Lund, Sweden
| | - Cornelia Genbrugge
- Acute Medicine Research Pole, Institute of Experimental and Clinical Research (IREC), Université Catholique de Louvain, Brussels, Belgium
- Emergency Department, University Hospitals Saint-Luc, Brussels, Belgium
| | - Kirstie Haywood
- Warwick Research in Nursing, Division of Health Sciences, Warwick Medical School, University of Warwick, Room A108, Coventry, CV4 7AL UK
| | - Gisela Lilja
- Department of Clinical Sciences Lund, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Véronique R. M. Moulaert
- Department of Rehabilitation Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Nikolaos Nikolaou
- Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Theresa Mariero Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Markus B. Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Fabio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB UK
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30
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Mariero Olasveengen T, Skrifvars MB, Taccone F, Soar J. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2021: Post-resuscitation care. Resuscitation 2021; 161:220-269. [PMID: 33773827 DOI: 10.1016/j.resuscitation.2021.02.012] [Citation(s) in RCA: 315] [Impact Index Per Article: 105.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation, and organ donation.
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Affiliation(s)
- Jerry P Nolan
- University of Warwick, Warwick Medical School, Coventry CV4 7AL, UK; Royal United Hospital, Bath, BA1 3NG, UK.
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy; Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Bernd W Böttiger
- University Hospital of Cologne, Kerpener Straße 62, D-50937 Cologne, Germany
| | - Alain Cariou
- Cochin University Hospital (APHP) and University of Paris (Medical School), Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anaesthesia and Intensive Care Medicine, Lund University, Skane University Hospital, Lund, Sweden
| | - Cornelia Genbrugge
- Acute Medicine Research Pole, Institute of Experimental and Clinical Research (IREC) Université Catholique de Louvain, Brussels, Belgium; Emergency Department, University Hospitals Saint-Luc, Brussels, Belgium
| | - Kirstie Haywood
- Warwick Research in Nursing, Room A108, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Gisela Lilja
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Neurology, Lund, Sweden
| | - Véronique R M Moulaert
- University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Groningen, The Netherlands
| | - Nikolaos Nikolaou
- Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Theresa Mariero Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Norway
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Finland
| | - Fabio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol BS10 5NB, UK
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31
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Khazanova D, Douglas VC, Amorim E. A matter of timing: EEG monitoring for neurological prognostication after cardiac arrest in the era of targeted temperature management. Minerva Anestesiol 2021; 87:704-713. [PMID: 33591136 DOI: 10.23736/s0375-9393.21.14793-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Neuromonitoring with electroencephalography (EEG) is an essential tool in neurological prognostication post-cardiac arrest. EEG allows reliable and real-time assessment of early changes in background patterns, development of seizures and epileptiform activity, as well as testing for background reactivity to stimuli despite use of sedation or targeted temperature management. Delayed emergence of consciousness post-cardiac arrest is common, therefore longitudinal monitoring of EEG allows the detection of trends indicative of neurological improvement before coma recovery can be observed clinically. In this review, we summarize essential recent literature in EEG monitoring for neurological prognostication post-cardiac arrest in the context of targeted temperature management, with a particular focus on the importance of the evolution of EEG patterns in the first few days following resuscitation.
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Affiliation(s)
- Darya Khazanova
- Department of Neurology, University of California, San Francisco, CA, USA.,Division of Neurology, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Vanja C Douglas
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Edilberto Amorim
- Department of Neurology, University of California, San Francisco, CA, USA - .,Division of Neurology, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
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32
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Minini A, Annoni F, Peluso L, Bogossian EG, Creteur J, Taccone FS. Which Target Temperature for Post-Anoxic Brain Injury? A Systematic Review from "Real Life" Studies. Brain Sci 2021; 11:186. [PMID: 33546105 DOI: 10.3390/brainsci11020186] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 01/29/2021] [Indexed: 11/30/2022] Open
Abstract
There is a persistent debate on the optimal target temperature to use during cooling procedures in cardiac arrest survivors. A large randomized clinical trial (RCT) including more than 900 patients showed that targeted temperature management (TTM) at 33 °C had similar mortality and unfavorable neurological outcome (UO) rates as TTM at 36 °C in out-of-hospital cardiac arrest patients with any initial rhythm. Since then, several observational studies have been published on the effects of changes in target temperature (i.e., from 33 to 36 °C) on patients’ outcome. We performed a systematic literature search from 1 January 2014 to 4 December 2020 and identified ten retrospective studies (very low levels of certainty; high risk of bias), including 5509 patients, that evaluated TTM at 33 °C vs. TTM at 36 °C on the occurrence of UO (n = eight studies) and mortality (n = ten studies). TTM at 33 °C was associated with a lower risk of UO when studies assessing neurological outcome with the Cerebral Performance Categories were analyzed (OR 0.80 [95% CIs 0.72–0.98]; p = 0.03). No differences in mortality were observed within the two TTM strategies. These results suggest that an inappropriate translation of TTM protocols from large well-conducted randomized trials into clinical management may result in unexpected effects on patients’ outcome. As for all newly commercialized drugs, epidemiological studies and surveillance programs with an adequate follow-up on large databases are necessary to understand how RCTs are implemented into medical practice.
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Abstract
PURPOSE OF REVIEW Randomized controlled trials investigating the initial pharmacological treatment of status epilepticus have been recently published. Furthermore, status epilepticus arising in comatose survivors after cardiac arrest has received increasing attention in the last years. This review offers an updated assessment of status epilepticus treatment in these different scenarios. RECENT FINDINGS Initial benzodiazepines underdosing is common and correlates with development of status epilepticus refractoriness. The recently published ESETT trial provides high-level evidence regarding the equivalence of fosphenytoin, valproate, and levetiracetam as a second-line option. Myoclonus or epileptiform transients on electroencephalography occur in up to 1/3 of patients surviving a cardiac arrest. Contrary to previous assumptions regarding an almost invariable association with death, at least 1/10 of them may awaken with reasonably good prognosis, if treated. Multimodal prognostication including clinical examination, EEG, somatosensory evoked potentials, biochemical markers, and neuroimaging help identifying patients with a chance to recover consciousness, in whom a trial with antimyoclonic compounds and at times general anesthetics is indicated. SUMMARY There is a continuous, albeit relatively slow progress in knowledge regarding different aspect of status epilepticus; recent findings refine some treatment strategies and help improving patients' outcomes. Further high-quality studies are clearly needed to further improve the management of these patients, especially those with severe, refractory status epilepticus forms.
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34
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Tarulli A. Coma and Related Disorders. Neurology 2021. [DOI: 10.1007/978-3-030-55598-6_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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35
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36
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Bader MK, Livesay SL, Severson AJ, Hamilton LA, Figueroa SA, Cahoon WD, Blissitt PA, Wavra T. Clinical Q & A: Translating Therapeutic Temperature Management from Theory to Practice. Ther Hypothermia Temp Manag 2020; 10:248-253. [PMID: 33306005 DOI: 10.1089/ther.2020.29078.mkb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Mary Kay Bader
- Neuroscience and Spine Institute (NSI), Mission Hospital, Mission Viejo, California, USA
| | - Sarah L Livesay
- Harborview Medical Center, University of Washington, Seattle, Washington, USA.,Rush University, Chicago, Illinois, USA
| | - Amanda J Severson
- Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Leslie A Hamilton
- College of Pharmacy, University of Tennessee Health Science Center, Knoxville, Tennessee, USA
| | - Stephen A Figueroa
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | - Patricia A Blissitt
- Harborview Medical Center, Seattle, Washington, USA.,Swedish Medical Center, Seattle, Washington, USA.,Clinical Faculty, School of Nursing, University of Washington, Seattle, Washington, USA
| | - Teresa Wavra
- Cardiovascular CNS, Mission Hospital, Mission Viejo, California, USA
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37
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Soar J, Berg KM, Andersen LW, Böttiger BW, Cacciola S, Callaway CW, Couper K, Cronberg T, D'Arrigo S, Deakin CD, Donnino MW, Drennan IR, Granfeldt A, Hoedemaekers CWE, Holmberg MJ, Hsu CH, Kamps M, Musiol S, Nation KJ, Neumar RW, Nicholson T, O'Neil BJ, Otto Q, de Paiva EF, Parr MJA, Reynolds JC, Sandroni C, Scholefield BR, Skrifvars MB, Wang TL, Wetsch WA, Yeung J, Morley PT, Morrison LJ, Welsford M, Hazinski MF, Nolan JP. Adult Advanced Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2020; 156:A80-A119. [PMID: 33099419 PMCID: PMC7576326 DOI: 10.1016/j.resuscitation.2020.09.012] [Citation(s) in RCA: 126] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations for advanced life support includes updates on multiple advanced life support topics addressed with 3 different types of reviews. Topics were prioritized on the basis of both recent interest within the resuscitation community and the amount of new evidence available since any previous review. Systematic reviews addressed higher-priority topics, and included double-sequential defibrillation, intravenous versus intraosseous route for drug administration during cardiac arrest, point-of-care echocardiography for intra-arrest prognostication, cardiac arrest caused by pulmonary embolism, postresuscitation oxygenation and ventilation, prophylactic antibiotics after resuscitation, postresuscitation seizure prophylaxis and treatment, and neuroprognostication. New or updated treatment recommendations on these topics are presented. Scoping reviews were conducted for anticipatory charging and monitoring of physiological parameters during cardiopulmonary resuscitation. Topics for which systematic reviews and new Consensuses on Science With Treatment Recommendations were completed since 2015 are also summarized here. All remaining topics reviewed were addressed with evidence updates to identify any new evidence and to help determine which topics should be the highest priority for systematic reviews in the next 1 to 2 years.
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38
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Berg KM, Soar J, Andersen LW, Böttiger BW, Cacciola S, Callaway CW, Couper K, Cronberg T, D’Arrigo S, Deakin CD, Donnino MW, Drennan IR, Granfeldt A, Hoedemaekers CW, Holmberg MJ, Hsu CH, Kamps M, Musiol S, Nation KJ, Neumar RW, Nicholson T, O’Neil BJ, Otto Q, de Paiva EF, Parr MJ, Reynolds JC, Sandroni C, Scholefield BR, Skrifvars MB, Wang TL, Wetsch WA, Yeung J, Morley PT, Morrison LJ, Welsford M, Hazinski MF, Nolan JP, Issa M, Kleinman ME, Ristagno G, Arafeh J, Benoit JL, Chase M, Fischberg BL, Flores GE, Link MS, Ornato JP, Perman SM, Sasson C, Zelop CM. Adult Advanced Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2020; 142:S92-S139. [DOI: 10.1161/cir.0000000000000893] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
This
2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations
for advanced life support includes updates on multiple advanced life support topics addressed with 3 different types of reviews. Topics were prioritized on the basis of both recent interest within the resuscitation community and the amount of new evidence available since any previous review. Systematic reviews addressed higher-priority topics, and included double-sequential defibrillation, intravenous versus intraosseous route for drug administration during cardiac arrest, point-of-care echocardiography for intra-arrest prognostication, cardiac arrest caused by pulmonary embolism, postresuscitation oxygenation and ventilation, prophylactic antibiotics after resuscitation, postresuscitation seizure prophylaxis and treatment, and neuroprognostication. New or updated treatment recommendations on these topics are presented. Scoping reviews were conducted for anticipatory charging and monitoring of physiological parameters during cardiopulmonary resuscitation. Topics for which systematic reviews and new Consensuses on Science With Treatment Recommendations were completed since 2015 are also summarized here. All remaining topics reviewed were addressed with evidence updates to identify any new evidence and to help determine which topics should be the highest priority for systematic reviews in the next 1 to 2 years.
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39
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Panchal AR, Bartos JA, Cabañas JG, Donnino MW, Drennan IR, Hirsch KG, Kudenchuk PJ, Kurz MC, Lavonas EJ, Morley PT, O’Neil BJ, Peberdy MA, Rittenberger JC, Rodriguez AJ, Sawyer KN, Berg KM, Arafeh J, Benoit JL, Chase M, Fernandez A, de Paiva EF, Fischberg BL, Flores GE, Fromm P, Gazmuri R, Gibson BC, Hoadley T, Hsu CH, Issa M, Kessler A, Link MS, Magid DJ, Marrill K, Nicholson T, Ornato JP, Pacheco G, Parr M, Pawar R, Jaxton J, Perman SM, Pribble J, Robinett D, Rolston D, Sasson C, Satyapriya SV, Sharkey T, Soar J, Torman D, Von Schweinitz B, Uzendu A, Zelop CM, Magid DJ. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S366-S468. [DOI: 10.1161/cir.0000000000000916] [Citation(s) in RCA: 371] [Impact Index Per Article: 92.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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40
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Sinkin MV, Kaimovsky IL, Komoltsev IG, Trifonov IS, Shtekleyn AA, Tsygankova ME, Guekht AB. [Electroencephalography in acute stroke]. Zh Nevrol Psikhiatr Im S S Korsakova 2020; 120:10-16. [PMID: 33016671 DOI: 10.17116/jnevro202012008210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To determine the incidence of non-convulsive status epilepticus, epileptiform activity, rhythmic and periodic patterns in patients with acute stroke. MATERIAL AND METHOD An analysis of electroencephalography (EEG) in 86 stroke patients in the neurointensive care unit of the tertiary medical center was performed. Criteria for starting EEG recording were epileptic seizures or clinical suspicion of uncontrolled epileptic status. The ictal-interictal continuum biomarkers and the diagnostic value of EEG for prediction of survival and recovery were assessed. RESULTS Pathological changes on EEG were recorded in 84% of patients. These patients showed the absence of the dominant occipital rhythm (66%) and hemispheric slowing (42%). Diffuse slowing below the theta range was observed in 41% of patients. EEG reactivity was absent in 20%. Sporadic epileptiform discharges were recorded in 36% of patients and rhythmic and periodic patterns in 26%. Reliable predictors of the unfavorable outcome were the absence of dominant occipital rhythm, lack of reactivity, and low amplitude of the background EEG. No association between the recording of epileptiform activity and the probability of death was shown. CONCLUSION The most useful EEG biomarkers for predicting survival are amplitude, dominant frequency of background EEG activity and reactivity to external stimulus. Sporadic epileptiform discharges, rhythmic, and periodic patterns are not mandatory associated with a negative prognosis in stroke patients.
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Affiliation(s)
- M V Sinkin
- Sklifosovsky Research Institute of Emergenscy Medicine, Moscow, Russia.,Evdokimov Moscow State University of Medical Dentistry, Moscow, Russia
| | - I L Kaimovsky
- Evdokimov Moscow State University of Medical Dentistry, Moscow, Russia.,Buyanov City Clinical Hospital, Moscow, Russia
| | - I G Komoltsev
- Buyanov City Clinical Hospital, Moscow, Russia.,Moscow Research and Clinical Center for Neuropsychiatry of the Healthcare Department, Moscow, Russia
| | - I S Trifonov
- Evdokimov Moscow State University of Medical Dentistry, Moscow, Russia
| | - A A Shtekleyn
- Peoples' Friendship University of Russia, Moscow, Russia
| | - M E Tsygankova
- Federal Center of Brain and Neurotechnology of the Federal Biomedical Agency, Moscow, Russia
| | - A B Guekht
- Moscow Research and Clinical Center for Neuropsychiatry of the Healthcare Department, Moscow, Russia.,Pirogov Russian National Research Medical University, Moscow, Russia
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41
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Coppler PJ, Callaway CW, Guyette FX, Baldwin M, Elmer J. Early risk stratification after resuscitation from cardiac arrest. J Am Coll Emerg Physicians Open 2020; 1:922-931. [PMID: 33145541 PMCID: PMC7593432 DOI: 10.1002/emp2.12043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 02/12/2020] [Accepted: 02/18/2020] [Indexed: 01/08/2023] Open
Abstract
Emergency clinicians often resuscitate cardiac arrest patients, and after acute resuscitation, clinicians face multiple decisions regarding disposition. Recent evidence suggests that out-of-hospital cardiac arrest patients with return of spontaneous circulation have higher odds of survival to hospital discharge, long-term survival, and improved functional outcomes when treated at centers that can provide advanced multidisciplinary care. For community clinicians, a high volume cardiac arrest center may be hours away. While current guidelines recommend against neurological prognostication in the first hours or days after return of spontaneous circulation, there are early findings suggestive of irrecoverable brain injury in which the patient would receive no benefit from transfer. In this Concepts article, we describe a simplified approach to quickly evaluate neurological status in cardiac arrest patients and identify findings concerning for irrecoverable brain injury. Characteristics of the arrest and resuscitation, initial neurological assessment, and brain computed tomography together can identify patients with high likelihood of irrecoverable anoxic injury. Patients who may benefit from centers with access to continuous electroencephalography are discussed. This approach can be used to identify patients who may benefit from rapid transfer to cardiac arrest centers versus those who may benefit from care close to home. Risk stratification also can provide realistic expectations for recovery to families.
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Affiliation(s)
- Patrick J. Coppler
- Department of Emergency MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvania
| | - Clifton W. Callaway
- Department of Emergency MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvania
| | - Francis X. Guyette
- Department of Emergency MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvania
| | - Maria Baldwin
- Department of NeurologyUniversity of Pittsburgh School of MedicinePittsburghPennsylvania
| | - Jonathan Elmer
- Department of Emergency MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvania
- Department of NeurologyUniversity of Pittsburgh School of MedicinePittsburghPennsylvania
- Department of Critical Care MedicineUniversity of Pittsburgh School of MedicinePittsburghPennsylvania
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42
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Cronberg T, Greer DM, Lilja G, Moulaert V, Swindell P, Rossetti AO. Brain injury after cardiac arrest: from prognostication of comatose patients to rehabilitation. Lancet Neurol 2020; 19:611-622. [PMID: 32562686 DOI: 10.1016/s1474-4422(20)30117-4] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 03/30/2020] [Accepted: 04/01/2020] [Indexed: 02/08/2023]
Abstract
More patients are surviving cardiac arrest than ever before; however, the burden now lies with estimating neurological prognoses in a large number of patients who were initially comatose, in whom the ultimate outcome is unclear. Neurologists, neurointensivists, and clinical neurophysiologists must accurately balance the concern that overly conservative prognostication could leave patients in a severely disabled state, with the possibility that inaccurately pessimistic prognostication could lead to the withdrawal of life-sustaining treatment in patients who might otherwise have a good functional outcome. Prognostic tools have improved greatly, including electrophysiological tests, neuroimaging, and chemical biomarkers. Conclusions about the prognosis should be delayed at least 72 h after arrest to allow for the clearance of sedative drugs. Cognitive impairments, emotional problems, and fatigue are common among patients who have survived cardiac arrest, and often go unrecognised despite being related to caregiver burden and a decreased participation in society. Through simple screening, these problems can be identified, and patients can be provided with adequate information and rehabilitation.
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Affiliation(s)
- Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden.
| | - David M Greer
- Department of Neurology, Boston University School of Medicine, Boston, MA, USA
| | - Gisela Lilja
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Véronique Moulaert
- Department of Rehabilitation Medicine, University of Groningen, University Medical Centre Groningen, Netherlands
| | | | - Andrea O Rossetti
- Department of Clinical Neurosciences, University Hospital and University of Lausanne, Lausanne, Switzerland
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43
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Sandroni C, D'Arrigo S, Cacciola S, Hoedemaekers CWE, Kamps MJA, Oddo M, Taccone FS, Di Rocco A, Meijer FJA, Westhall E, Antonelli M, Soar J, Nolan JP, Cronberg T. Prediction of poor neurological outcome in comatose survivors of cardiac arrest: a systematic review. Intensive Care Med 2020; 46:1803-1851. [PMID: 32915254 PMCID: PMC7527362 DOI: 10.1007/s00134-020-06198-w] [Citation(s) in RCA: 153] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/15/2020] [Indexed: 12/17/2022]
Abstract
Purpose To assess the ability of clinical examination, blood biomarkers, electrophysiology, or neuroimaging assessed within 7 days from return of spontaneous circulation (ROSC) to predict poor neurological outcome, defined as death, vegetative state, or severe disability (CPC 3–5) at hospital discharge/1 month or later, in comatose adult survivors from cardiac arrest (CA). Methods PubMed, EMBASE, Web of Science, and the Cochrane Database of Systematic Reviews (January 2013–April 2020) were searched. Sensitivity and false-positive rate (FPR) for each predictor were calculated. Due to heterogeneities in recording times, predictor thresholds, and definition of some predictors, meta-analysis was not performed. Results Ninety-four studies (30,200 patients) were included. Bilaterally absent pupillary or corneal reflexes after day 4 from ROSC, high blood values of neuron-specific enolase from 24 h after ROSC, absent N20 waves of short-latency somatosensory-evoked potentials (SSEPs) or unequivocal seizures on electroencephalogram (EEG) from the day of ROSC, EEG background suppression or burst-suppression from 24 h after ROSC, diffuse cerebral oedema on brain CT from 2 h after ROSC, or reduced diffusion on brain MRI at 2–5 days after ROSC had 0% FPR for poor outcome in most studies. Risk of bias assessed using the QUIPS tool was high for all predictors. Conclusion In comatose resuscitated patients, clinical, biochemical, neurophysiological, and radiological tests have a potential to predict poor neurological outcome with no false-positive predictions within the first week after CA. Guidelines should consider the methodological concerns and limited sensitivity for individual modalities. (PROSPERO CRD42019141169) Electronic supplementary material The online version of this article (10.1007/s00134-020-06198-w) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli"- IRCCS, Largo Francesco Vito, 1, 00168, Rome, Italy.,Institute of Anesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Sonia D'Arrigo
- Department of Intensive Care, Emergency Medicine and Anesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli"- IRCCS, Largo Francesco Vito, 1, 00168, Rome, Italy.
| | - Sofia Cacciola
- Department of Intensive Care, Emergency Medicine and Anesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli"- IRCCS, Largo Francesco Vito, 1, 00168, Rome, Italy
| | | | - Marlijn J A Kamps
- Intensive Care Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Mauro Oddo
- Department of Intensive Care Medicine, University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Arianna Di Rocco
- Department of Public Health and Infectious Disease, Sapienza University, Rome, Italy
| | - Frederick J A Meijer
- Department of Radiology and Nuclear Medicine, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Erik Westhall
- Department of ClinicalSciences, Clinical Neurophysiology, Lund University, Skane University Hospital, Lund, Sweden
| | - Massimo Antonelli
- Department of Intensive Care, Emergency Medicine and Anesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli"- IRCCS, Largo Francesco Vito, 1, 00168, Rome, Italy.,Institute of Anesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Jasmeet Soar
- Critical Care Unit, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Jerry P Nolan
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK
| | - Tobias Cronberg
- Department of Clinical Sciences Lund, Neurology, Lund University, Skane University Hospital, Lund, Sweden
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Amorim E, Mo SS, Palacios S, Ghassemi MM, Weng WH, Cash SS, Bianchi MT, Westover MB. Cost-effectiveness analysis of multimodal prognostication in cardiac arrest with EEG monitoring. Neurology 2020; 95:e563-e575. [PMID: 32661097 PMCID: PMC7455344 DOI: 10.1212/wnl.0000000000009916] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 01/10/2020] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE To determine cost-effectiveness parameters for EEG monitoring in cardiac arrest prognostication. METHODS We conducted a cost-effectiveness analysis to estimate the cost per quality-adjusted life-year (QALY) gained by adding continuous EEG monitoring to standard cardiac arrest prognostication using the American Academy of Neurology Practice Parameter (AANPP) decision algorithm: neurologic examination, somatosensory evoked potentials, and neuron-specific enolase. We explored lifetime cost-effectiveness in a closed system that incorporates revenue back into the medical system (return) from payers who survive a cardiac arrest with good outcome and contribute to the health system during the remaining years of life. Good outcome was defined as a Cerebral Performance Category (CPC) score of 1-2 and poor outcome as CPC of 3-5. RESULTS An improvement in specificity for poor outcome prediction of 4.2% would be sufficient to make continuous EEG monitoring cost-effective (baseline AANPP specificity = 83.9%). In sensitivity analysis, the effect of increased sensitivity on the cost-effectiveness of EEG depends on the utility (u) assigned to a poor outcome. For patients who regard surviving with a poor outcome (CPC 3-4) worse than death (u = -0.34), an increased sensitivity for poor outcome prediction of 13.8% would make AANPP + EEG monitoring cost-effective (baseline AANPP sensitivity = 76.3%). In the closed system, an improvement in sensitivity of 1.8% together with an improvement in specificity of 3% was sufficient to make AANPP + EEG monitoring cost-effective, assuming lifetime return of 50% (USD $70,687). CONCLUSION Incorporating continuous EEG monitoring into cardiac arrest prognostication is cost-effective if relatively small improvements in sensitivity and specificity are achieved.
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Affiliation(s)
- Edilberto Amorim
- From Harvard Medical School (E.A., S.S.M., S.S.C., M.T.B., M.B.W.); Department of Neurology (E.A., S.S.C., M.T.B., M.B.W.), Massachusetts General Hospital, Boston; Department of Neurology (E.A.), University of California, San Francisco; and Computer Science and Artificial Intelligence Laboratory (E.A., S.P.) and Department of Electrical Engineering and Computer Science (M.M.G., W.-H.W.), Massachusetts Institute of Technology, Cambridge.
| | - Shirley S Mo
- From Harvard Medical School (E.A., S.S.M., S.S.C., M.T.B., M.B.W.); Department of Neurology (E.A., S.S.C., M.T.B., M.B.W.), Massachusetts General Hospital, Boston; Department of Neurology (E.A.), University of California, San Francisco; and Computer Science and Artificial Intelligence Laboratory (E.A., S.P.) and Department of Electrical Engineering and Computer Science (M.M.G., W.-H.W.), Massachusetts Institute of Technology, Cambridge.
| | - Sebastian Palacios
- From Harvard Medical School (E.A., S.S.M., S.S.C., M.T.B., M.B.W.); Department of Neurology (E.A., S.S.C., M.T.B., M.B.W.), Massachusetts General Hospital, Boston; Department of Neurology (E.A.), University of California, San Francisco; and Computer Science and Artificial Intelligence Laboratory (E.A., S.P.) and Department of Electrical Engineering and Computer Science (M.M.G., W.-H.W.), Massachusetts Institute of Technology, Cambridge
| | - Mohammad M Ghassemi
- From Harvard Medical School (E.A., S.S.M., S.S.C., M.T.B., M.B.W.); Department of Neurology (E.A., S.S.C., M.T.B., M.B.W.), Massachusetts General Hospital, Boston; Department of Neurology (E.A.), University of California, San Francisco; and Computer Science and Artificial Intelligence Laboratory (E.A., S.P.) and Department of Electrical Engineering and Computer Science (M.M.G., W.-H.W.), Massachusetts Institute of Technology, Cambridge
| | - Wei-Hung Weng
- From Harvard Medical School (E.A., S.S.M., S.S.C., M.T.B., M.B.W.); Department of Neurology (E.A., S.S.C., M.T.B., M.B.W.), Massachusetts General Hospital, Boston; Department of Neurology (E.A.), University of California, San Francisco; and Computer Science and Artificial Intelligence Laboratory (E.A., S.P.) and Department of Electrical Engineering and Computer Science (M.M.G., W.-H.W.), Massachusetts Institute of Technology, Cambridge
| | - Sydney S Cash
- From Harvard Medical School (E.A., S.S.M., S.S.C., M.T.B., M.B.W.); Department of Neurology (E.A., S.S.C., M.T.B., M.B.W.), Massachusetts General Hospital, Boston; Department of Neurology (E.A.), University of California, San Francisco; and Computer Science and Artificial Intelligence Laboratory (E.A., S.P.) and Department of Electrical Engineering and Computer Science (M.M.G., W.-H.W.), Massachusetts Institute of Technology, Cambridge
| | - Matthew T Bianchi
- From Harvard Medical School (E.A., S.S.M., S.S.C., M.T.B., M.B.W.); Department of Neurology (E.A., S.S.C., M.T.B., M.B.W.), Massachusetts General Hospital, Boston; Department of Neurology (E.A.), University of California, San Francisco; and Computer Science and Artificial Intelligence Laboratory (E.A., S.P.) and Department of Electrical Engineering and Computer Science (M.M.G., W.-H.W.), Massachusetts Institute of Technology, Cambridge
| | - M Brandon Westover
- From Harvard Medical School (E.A., S.S.M., S.S.C., M.T.B., M.B.W.); Department of Neurology (E.A., S.S.C., M.T.B., M.B.W.), Massachusetts General Hospital, Boston; Department of Neurology (E.A.), University of California, San Francisco; and Computer Science and Artificial Intelligence Laboratory (E.A., S.P.) and Department of Electrical Engineering and Computer Science (M.M.G., W.-H.W.), Massachusetts Institute of Technology, Cambridge.
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Lin JJ, Hsu MH, Hsia SH, Lin YJ, Wang HS, Kuo HC, Chiang MC, Chan OW, Lee EP, Lin KL, The iCNS Group. Epileptiform Discharge and Electrographic Seizures during the Hypothermia Phase as Predictors of Rewarming Seizures in Children after Resuscitation. J Clin Med 2020; 9:E2151. [PMID: 32650443 DOI: 10.3390/jcm9072151] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 07/05/2020] [Accepted: 07/06/2020] [Indexed: 11/17/2022] Open
Abstract
The aim of this study was to determine the frequency, timing, and predictors of rewarming seizures in a cohort of children undergoing therapeutic hypothermia after resuscitation. We retrospectively reviewed consecutive pediatric patients undergoing therapeutic hypothermia after resuscitation admitted to our pediatric intensive care unit between January 2000 and December 2019. Continuous electroencephalographic monitoring was performed during hypothermia (24 h for cardiac aetiologies and 72 h for asphyxial aetiologies), rewarming (72 h), and then an additional 12 h of normothermia. Thirty comatose children undergoing therapeutic hypothermia after resuscitation were enrolled, of whom 10 (33.3%) had rewarming seizures. Two (20%) of these patients had their first seizure during the rewarming phase. Four (40%) patients had electroclinical seizures, and six (60%) had nonconvulsive seizures. The median time from starting rewarming to the onset of rewarming seizures was 37.3 h (range 6 to 65 h). The patients with interictal epileptiform activity and electrographic seizures during the hypothermia phase were more likely to have rewarming seizures compared to those without interictal epileptiform activity or electrographic seizures (p = 0.019 and 0.019, respectively). Therefore, in high-risk patients, continuous electroencephalographic monitoring for a longer duration may help to detect rewarming seizures and guide clinical management.
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46
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Moseby-Knappe M, Westhall E, Backman S, Mattsson-Carlgren N, Dragancea I, Lybeck A, Friberg H, Stammet P, Lilja G, Horn J, Kjaergaard J, Rylander C, Hassager C, Ullén S, Nielsen N, Cronberg T. Performance of a guideline-recommended algorithm for prognostication of poor neurological outcome after cardiac arrest. Intensive Care Med 2020; 46:1852-1862. [PMID: 32494928 PMCID: PMC7527324 DOI: 10.1007/s00134-020-06080-9] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 04/30/2020] [Indexed: 11/29/2022]
Abstract
Purpose To assess the performance of a 4-step algorithm for neurological prognostication after cardiac arrest recommended by the European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM). Methods Retrospective descriptive analysis with data from the Target Temperature Management (TTM) Trial. Associations between predicted and actual neurological outcome were investigated for each step of the algorithm with results from clinical neurological examinations, neuroradiology (CT or MRI), neurophysiology (EEG and SSEP) and serum neuron-specific enolase. Patients examined with Glasgow Coma Scale Motor Score (GCS-M) on day 4 (72–96 h) post-arrest and available 6-month outcome were included. Poor outcome was defined as Cerebral Performance Category 3–5. Variations of the ERC/ESICM algorithm were explored within the same cohort. Results The ERC/ESICM algorithm identified poor outcome patients with 38.7% sensitivity (95% CI 33.1–44.7) and 100% specificity (95% CI 98.8–100) in a cohort of 585 patients. An alternative cut-off for serum neuron-specific enolase, an alternative EEG-classification and variations of the GCS-M had minor effects on the sensitivity without causing false positive predictions. The highest overall sensitivity, 42.5% (95% CI 36.7–48.5), was achieved when prognosticating patients irrespective of GCS-M score, with 100% specificity (95% CI 98.8–100) remaining. Conclusion The ERC/ESICM algorithm and all exploratory multimodal variations thereof investigated in this study predicted poor outcome without false positive predictions and with sensitivities 34.6–42.5%. Our results should be validated prospectively, preferably in patients where withdrawal of life-sustaining therapy is uncommon to exclude any confounding from self-fulfilling prophecies. Electronic supplementary material The online version of this article (10.1007/s00134-020-06080-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marion Moseby-Knappe
- Department of Clinical Sciences Lund, Neurology, Skåne University Hospital, Lund University, Getingevägen 4, 222 41, Lund, Sweden.
| | - Erik Westhall
- Department of Clinical Sciences Lund, Clinical Neurophysiology, Skane University Hospital, Lund University, Lund, Sweden
| | - Sofia Backman
- Department of Clinical Sciences Lund, Clinical Neurophysiology, Skane University Hospital, Lund University, Lund, Sweden
| | - Niklas Mattsson-Carlgren
- Department of Clinical Sciences Lund, Neurology, Skåne University Hospital, Lund University, Getingevägen 4, 222 41, Lund, Sweden.,Clinical Memory Research Unit, Department of Clinical Sciences Malmö, Lund University, Lund, Sweden.,Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden
| | - Irina Dragancea
- Department of Clinical Sciences Lund, Neurology, Skåne University Hospital, Lund University, Getingevägen 4, 222 41, Lund, Sweden
| | - Anna Lybeck
- Department of Clinical Sciences Lund, Anaesthesia and Intensive Care, Skane University Hospital, Lund University, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences Lund, Anaesthesia and Intensive Care, Skane University Hospital, Lund University, Malmö, Sweden
| | - Pascal Stammet
- Medical and Health Department, National Fire and Rescue Corps, Luxembourg, Luxembourg
| | - Gisela Lilja
- Department of Clinical Sciences Lund, Neurology, Skåne University Hospital, Lund University, Getingevägen 4, 222 41, Lund, Sweden
| | - Janneke Horn
- Department of Intensive Care, Amsterdam UMC, Location Academic Medical Center, Amsterdam, The Netherlands
| | - Jesper Kjaergaard
- Department of Cardiology, Rigshospitalet and Department of Clinical Medicine,, University of Copenhagen, Copenhagen, Denmark
| | - Christian Rylander
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Christian Hassager
- Department of Cardiology, Rigshospitalet and Department of Clinical Medicine,, University of Copenhagen, Copenhagen, Denmark
| | - Susann Ullén
- Clinical Studies Sweden - Forum South, Skane University Hospital, Lund, Sweden
| | - Niklas Nielsen
- Department of Clinical Sciences Lund, Anaesthesia and Intensive Care, Helsingborg Hospital, Lund University, Lund, Sweden
| | - Tobias Cronberg
- Department of Clinical Sciences Lund, Neurology, Skåne University Hospital, Lund University, Getingevägen 4, 222 41, Lund, Sweden
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Elmer J, Coppler PJ, Solanki P, Westover MB, Struck AF, Baldwin ME, Kurz MC, Callaway CW. Sensitivity of Continuous Electroencephalography to Detect Ictal Activity After Cardiac Arrest. JAMA Netw Open 2020; 3:e203751. [PMID: 32343353 PMCID: PMC7189220 DOI: 10.1001/jamanetworkopen.2020.3751] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE Epileptiform electroencephalographic (EEG) patterns are common after resuscitation from cardiac arrest, are associated with patient outcome, and may require treatment. It is unknown whether continuous EEG monitoring is needed to detect these patterns or if brief intermittent monitoring is sufficient. If continuous monitoring is required, the necessary duration of observation is unknown. OBJECTIVE To quantify the time-dependent sensitivity of continuous EEG for epileptiform event detection, and to compare continuous EEG to several alternative EEG-monitoring strategies for post-cardiac arrest outcome prediction. DESIGN, SETTING, AND PARTICIPANTS This observational cohort study was conducted in 2 academic medical centers between September 2010 and January 2018. Participants included 759 adults who were comatose after being resuscitated from cardiac arrest and who underwent 24 hours or more of EEG monitoring. MAIN OUTCOMES AND MEASURES Epileptiform EEG patterns associated with neurological outcome at hospital discharge, such as seizures likely to cause secondary injury. RESULTS Overall, 759 patients were included in the analysis; 281 (37.0%) were female, and the mean (SD) age was 58 (17) years. Epileptiform EEG activity was observed in 414 participants (54.5%), of whom only 26 (3.4%) developed potentially treatable seizures. Brief intermittent EEG had an estimated 66% (95% CI, 62%-69%) to 68% (95% CI, 66%-70%) sensitivity for detection of prognostic epileptiform events. Depending on initial continuity of the EEG background, 0 to 51 hours of monitoring were needed to achieve 95% sensitivity for the detection of prognostic epileptiform events. Brief intermittent EEG had a sensitivity of 7% (95% CI, 4%-12%) to 8% (95% CI, 4%-12%) for the detection of potentially treatable seizures, and 0 to 53 hours of continuous monitoring were needed to achieve 95% sensitivity for the detection of potentially treatable seizures. Brief intermittent EEG results yielded similar information compared with continuous EEG results when added to multivariable models predicting neurological outcome. CONCLUSIONS AND RELEVANCE Compared with continuous EEG monitoring, brief intermittent monitoring was insensitive for detection of epileptiform events. Monitoring EEG results significantly improved multimodality prediction of neurological outcome, but continuous monitoring appeared to add little additional information compared with brief intermittent monitoring.
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Affiliation(s)
- Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Patrick J. Coppler
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Pawan Solanki
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | - Maria E. Baldwin
- Department of Neurology, Pittsburgh VA Medical Center, Pittsburgh, Pennsylvania
| | - Michael C. Kurz
- Department of Emergency Medicine, University of Alabama at Birmingham School of Medicine
| | - Clifton W. Callaway
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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48
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Abstract
Cardiac arrest (CA) afflicts ~ 550,000 people each year in the USA. A small fraction of CA sufferers survive with a majority of these survivors emerging in a comatose state. Many CA survivors suffer devastating global brain injury with some remaining indefinitely in a comatose state. The pathogenesis of global brain injury secondary to CA is complex. Mechanisms of CA-induced brain injury include ischemia, hypoxia, cytotoxicity, inflammation, and ultimately, irreversible neuronal damage. Due to this complexity, it is critical for clinicians to have access as early as possible to quantitative metrics for diagnosing injury severity, accurately predicting outcome, and informing patient care. Current recommendations involve using multiple modalities including clinical exam, electrophysiology, brain imaging, and molecular biomarkers. This multi-faceted approach is designed to improve prognostication to avoid "self-fulfilling" prophecy and early withdrawal of life-sustaining treatments. Incorporation of emerging dynamic monitoring tools such as diffuse optical technologies may provide improved diagnosis and early prognostication to better inform treatment. Currently, targeted temperature management (TTM) is the leading treatment, with the number of patients needed to treat being ~ 6 in order to improve outcome for one patient. Future avenues of treatment, which may potentially be combined with TTM, include pharmacotherapy, perfusion/oxygenation targets, and pre/postconditioning. In this review, we provide a bench to bedside approach to delineate the pathophysiology, prognostication methods, current targeted therapies, and future directions of research surrounding hypoxic-ischemic brain injury (HIBI) secondary to CA.
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Affiliation(s)
- Melika Hosseini
- Department of Neurology, School of Medicine, University of California, Irvine, USA
| | - Robert H Wilson
- Department of Neurology, School of Medicine, University of California, Irvine, USA
- Beckman Laser Institute, University of California, Irvine, USA
| | - Christian Crouzet
- Department of Neurology, School of Medicine, University of California, Irvine, USA
- Beckman Laser Institute, University of California, Irvine, USA
| | - Arya Amirhekmat
- Department of Neurology, School of Medicine, University of California, Irvine, USA
| | - Kevin S Wei
- Department of Neurology, School of Medicine, University of California, Irvine, USA
| | - Yama Akbari
- Department of Neurology, School of Medicine, University of California, Irvine, USA.
- Beckman Laser Institute, University of California, Irvine, USA.
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Beretta S, Coppo A, Bianchi E, Zanchi C, Carone D, Stabile A, Padovano G, Sulmina E, Grassi A, Bogliun G, Foti G, Ferrarese C, Pesenti A, Beghi E, Avalli L. Neurological outcome of postanoxic refractory status epilepticus after aggressive treatment. Epilepsy Behav 2019; 101:106374. [PMID: 31300383 DOI: 10.1016/j.yebeh.2019.06.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 06/11/2019] [Indexed: 10/26/2022]
Abstract
Refractory status epilepticus (RSE) occurs in up to 30% of patients following resuscitation after cardiac arrest. The impact of aggressive treatment of postanoxic RSE on long-term neurological outcome remains uncertain. We investigated neurological outcome of cardiac arrest patients with RSE treated with a standardized aggressive protocol with antiepileptic drugs and anesthetics, compared with patients with other electroencephalographic (EEG) patterns. A prospective cohort of 166 consecutive patients with cardiac arrest in coma was stratified according to four independent EEG patterns (benign; RSE; generalized periodic discharges (GPDs); malignant nonepileptiform) and multimodal prognostic indicators. Primary outcomes were survival and cerebral performance category (CPC) at 6 months. Refractory status epilepticus occurred in 36 patients (21.7%) and was treated with an aggressive standardized protocol as long as multimodal prognostic indicators were not unfavorable. Refractory status epilepticus started after 3 ± 2.3 days after cardiac arrest and lasted 4.7 ± 4.3 days. A benign electroencephalographic patterns was recorded in 76 patients (45.8%), a periodic pattern (GPDs) in 13 patients (7.8%), and a malignant nonepileptiform EEG pattern in 41 patients (24.7%). The four EEG patterns were highly associated with different prognostic indicators (low flow time, clinical motor seizures, N20 responses, neuron-specific enolase (NSE), neuroimaging). Survival and good neurological outcome (CPC 1 or 2) at 6 months were 72.4% and 71.1% for benign EEG pattern, 54.3% and 44.4% for RSE, 15.4% and 0% for GPDs, and 2.4% and 0% for malignant nonepileptiform EEG pattern, respectively. Aggressive and prolonged treatment of RSE may be justified in cardiac arrest patients with favorable multimodal prognostic indicators. This article is part of the Special Issue "Proceedings of the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures".
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Affiliation(s)
- Simone Beretta
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy.
| | - Anna Coppo
- Department of Intensive Care, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Elisa Bianchi
- Department of Neuroscience, IRCCS Mario Negri Institute for Pharmacological Research, Milano, Italy
| | - Clara Zanchi
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Davide Carone
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Andrea Stabile
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Giada Padovano
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Endrit Sulmina
- Department of Intensive Care, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Alice Grassi
- Department of Intensive Care, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Graziella Bogliun
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Giuseppe Foti
- Department of Intensive Care, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Carlo Ferrarese
- Epilepsy Center, Department of Neurology, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
| | - Antonio Pesenti
- Department of Anesthesia, Critical Care and Emergency, IRCCS Ospedale Maggiore Policlinico, Milano, Italy
| | - Ettore Beghi
- Department of Neuroscience, IRCCS Mario Negri Institute for Pharmacological Research, Milano, Italy
| | - Leonello Avalli
- Department of Intensive Care, San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza, Italy
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50
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Abstract
PURPOSE OF REVIEW The goal of this review is to highlight the influence of therapeutic maneuvers on neuro-prognostication measures administered to comatose survivors of cardiac arrest. We focus on the effect of sedation regimens in the setting of targeted temperature management (TTM), one of the principle interventions known to improve neurological recovery after cardiac arrest. Further, we discuss the critical need for novel markers, as well as refinement of existing markers, among patients receiving extracorporeal membrane oxygenation (ECMO) in the setting of failed conventional resuscitation, known as extracorporeal cardiopulmonary resuscitation (ECPR). RECENT FINDINGS Automated pupillometry may have some advantage over standard pupillary examination for prognostication following TTM, sedation, or the use of ECMO after cardiac arrest. New serum biomarkers such as Neurofilament light chain have shown good predictive abilities and need further validation in these populations. There is a high-level uncertainty in brain death declaration protocols particularly related to apnea testing and appropriate ancillary tests in patients receiving ECMO. Both sedation and TTM alone and in combination have been shown to affect prognostic markers to varying degrees. The optimal approach to analog-sedation is unknown, and requires further study. Moreover, validation of known prognostic markers, as well as brain death declaration processes in patients receiving ECMO is warranted. Data on the effects of TTM, sedation, and ECMO on biomarkers (e.g., neuron-specific enolase) and electrophysiology measures (e.g., somatosensory-evoked potentials) is sparse. The best approach may be one customized to the individual patient, a precision-medicine approach.
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Affiliation(s)
- Sachin Agarwal
- Division of Neurocritical Care and Hospitalist Neurology, Department of Neurology, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA.
| | - Nicholas Morris
- Department of Neurology, Program in Trauma, University of Maryland Medical Center, Baltimore, MD, USA
| | - Caroline Der-Nigoghossian
- Clinical Pharmacy, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Teresa May
- Division of Pulmonary and Critical Care Medicine, Maine Medical Center, Portland, ME, USA
| | - Daniel Brodie
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
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