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Amacher SA, Arpagaus A, Sahmer C, Becker C, Gross S, Urben T, Tisljar K, Sutter R, Marsch S, Hunziker S. Prediction of outcomes after cardiac arrest by a generative artificial intelligence model. Resusc Plus 2024; 18:100587. [PMID: 38433764 PMCID: PMC10906512 DOI: 10.1016/j.resplu.2024.100587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 02/01/2024] [Accepted: 02/11/2024] [Indexed: 03/05/2024] Open
Abstract
Aims To investigate the prognostic accuracy of a non-medical generative artificial intelligence model (Chat Generative Pre-Trained Transformer 4 - ChatGPT-4) as a novel aspect in predicting death and poor neurological outcome at hospital discharge based on real-life data from cardiac arrest patients. Methods This prospective cohort study investigates the prognostic performance of ChatGPT-4 to predict outcomes at hospital discharge of adult cardiac arrest patients admitted to intensive care at a large Swiss tertiary academic medical center (COMMUNICATE/PROPHETIC cohort study). We prompted ChatGPT-4 with sixteen prognostic parameters derived from established post-cardiac arrest scores for each patient. We compared the prognostic performance of ChatGPT-4 regarding the area under the curve (AUC), sensitivity, specificity, positive and negative predictive values, and likelihood ratios of three cardiac arrest scores (Out-of-Hospital Cardiac Arrest [OHCA], Cardiac Arrest Hospital Prognosis [CAHP], and PROgnostication using LOGistic regression model for Unselected adult cardiac arrest patients in the Early stages [PROLOGUE score]) for in-hospital mortality and poor neurological outcome. Results Mortality at hospital discharge was 43% (n = 309/713), 54% of patients (n = 387/713) had a poor neurological outcome. ChatGPT-4 showed good discrimination regarding in-hospital mortality with an AUC of 0.85, similar to the OHCA, CAHP, and PROLOGUE (AUCs of 0.82, 0.83, and 0.84, respectively) scores. For poor neurological outcome, ChatGPT-4 showed a similar prediction to the post-cardiac arrest scores (AUC 0.83). Conclusions ChatGPT-4 showed a similar performance in predicting mortality and poor neurological outcome compared to validated post-cardiac arrest scores. However, more research is needed regarding illogical answers for potential incorporation of an LLM in the multimodal outcome prognostication after cardiac arrest.
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Affiliation(s)
- Simon A. Amacher
- Intensive Care Medicine, Department of Acute Medical Care, University Hospital Basel, Basel, Switzerland
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
- Emergency Medicine, Department of Acute Medical Care, University Hospital Basel, Basel, Switzerland
| | - Armon Arpagaus
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Christian Sahmer
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Christoph Becker
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
- Emergency Medicine, Department of Acute Medical Care, University Hospital Basel, Basel, Switzerland
| | - Sebastian Gross
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Tabita Urben
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Kai Tisljar
- Intensive Care Medicine, Department of Acute Medical Care, University Hospital Basel, Basel, Switzerland
| | - Raoul Sutter
- Intensive Care Medicine, Department of Acute Medical Care, University Hospital Basel, Basel, Switzerland
- Medical Faculty, University of Basel, Basel, Switzerland
- Division of Neurophysiology, Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Stephan Marsch
- Intensive Care Medicine, Department of Acute Medical Care, University Hospital Basel, Basel, Switzerland
- Medical Faculty, University of Basel, Basel, Switzerland
| | - Sabina Hunziker
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
- Medical Faculty, University of Basel, Basel, Switzerland
- Post-Intensive Care Clinic, University Hospital Basel, Basel, Switzerland
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Scharink D, Hunfeld M, Albrecht M, Dulfer K, de Hoog M, van Gils A, de Jonge R, Buysse C. An 18-year, single centre, retrospective study of long-term neurological outcomes in paediatric submersion-related cardiac arrests. Resusc Plus 2024; 18:100632. [PMID: 38646092 PMCID: PMC11026833 DOI: 10.1016/j.resplu.2024.100632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/27/2024] [Accepted: 04/01/2024] [Indexed: 04/23/2024] Open
Abstract
Aim Investigate long-term outcome in paediatric submersion-related cardiac arrests (CA). Methods Children (age one day-17 years) were included if admitted to the Erasmus MC Sophia Children's Hospital, after drowning with CA, between 2002 and 2019. Primary outcome was survival with favourable neurological outcome, defined as a Paediatric Cerebral Performance Category (PCPC) score of 1-3 at longest available follow-up. Secondary outcome were age-appropriate neuropsychological assessments at longest available follow-up. Results Upon hospital admission, 99 children were included (median age at time of CA 3.2 years [IQR 2.0-5.9] and 65% males). Forty children died in-hospital (no return of circulation (45%) or withdrawal of life sustaining therapies (55%)) and 4 children deceased after hospital discharge due to complications following the drowning-incident. Among survivors, with a median follow-up of 2.3 years [IQR 0.2-5.5], 47 children had favourable neurological outcome (i.e. PCPC 1-3) and 8 children unfavourable (unfavourable outcome group total n = 52, i.e. PCPC 4-5 or deceased). Twenty-six (47%) children participated in a neuropsychological assessment (median follow-up 4.0 years [IQR 2.3-8.7]). Compared with normative test data, participants obtained worse general (p = 0.008) and performance (p = 0.003) intelligence scores, processing speed (p = 0.002) and visual motor integration scores (p = 0.0012). Conclusions Although overall outcome in survivors was favourable at longest available follow-up, significant deficits in neuropsychological assessments were found. This study underlines the need for a standardized long term follow-up program as standard of care in paediatric drowning with CA.
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Affiliation(s)
- Denne Scharink
- Department of Neonatal and Paediatric Intensive Care, Division of Paediatric Intensive Care, Erasmus MC Sophia Children’s Hospital, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Maayke Hunfeld
- Department of Neonatal and Paediatric Intensive Care, Division of Paediatric Intensive Care, Erasmus MC Sophia Children’s Hospital, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
- Department of Paediatric Neurology, Erasmus MC Sophia Children’s Hospital, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Marijn Albrecht
- Department of Neonatal and Paediatric Intensive Care, Division of Paediatric Intensive Care, Erasmus MC Sophia Children’s Hospital, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Karolijn Dulfer
- Department of Neonatal and Paediatric Intensive Care, Division of Paediatric Intensive Care, Erasmus MC Sophia Children’s Hospital, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Matthijs de Hoog
- Department of Neonatal and Paediatric Intensive Care, Division of Paediatric Intensive Care, Erasmus MC Sophia Children’s Hospital, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Annabel van Gils
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC Sophia Children’s Hospital, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Rogier de Jonge
- Department of Neonatal and Paediatric Intensive Care, Division of Paediatric Intensive Care, Erasmus MC Sophia Children’s Hospital, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Corinne Buysse
- Department of Neonatal and Paediatric Intensive Care, Division of Paediatric Intensive Care, Erasmus MC Sophia Children’s Hospital, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
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Kim JH, Lee J, Shin H, Lim TH, Jang BH, Cho Y, Kim W, Choi KS, Kim JG, Ahn C, Lee H, Namgung M, Na MK, Kwon SM. Association between QRS characteristics in pulseless electrical activity and survival outcome in cardiac arrest patients: A systematic review and meta-analysis. PREHOSP EMERG CARE 2024:1-12. [PMID: 38787646 DOI: 10.1080/10903127.2024.2360139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 05/13/2024] [Indexed: 05/26/2024]
Abstract
Objective: Recent studies have shown inconsistent results regarding the association between QRS characteristics and survival outcomes in patients with cardiac arrest and pulseless electrical activity (PEA) rhythms. This meta-analysis aimed to identify the usefulness of QRS width and frequency as prognostic tools for outcomes in patients with cardiac arrest and PEA rhythm.Methods: Extensive searches were conducted using Medline, Embase, and the Cochrane Library to find articles published from database inception to 4 June 2023. Studies that assessed the association between the QRS characteristics of cardiac arrest patients with PEA rhythm and survival outcomes were included. The Newcastle-Ottawa Scale was used to assess the methodological quality of the included studies.Results: A total of 9,727 patients from seven observational studies were included in this systematic review and meta-analysis. The wide QRS group (QRS ≥ 120 ms) was associated with significantly higher odds of mortality than the narrow QRS group (QRS < 120 ms) (odds ratio (OR) = 1.86, 95% confidence interval (CI) = 1.11-3.11, I2 = 58%). The pooled OR for mortality was significantly higher in patients with a QRS frequency of < 60/min than in those with a QRS frequency of ≥ 60/min (OR = 1.90, 95% CI = 1.19-3.02, I2 = 65%).Conclusions: Wide QRS width or low QRS frequency is associated with increased odds of mortality in patients with PEA cardiac arrest. These findings may be beneficial to guide the disposition of cardiac arrest patients with PEA during resuscitation.
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Affiliation(s)
- Jae Hwan Kim
- Department of Emergency Medicine, College of Medicine, Chung-Ang University, Seoul, Republic of Korea
| | - Juncheol Lee
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Hyungoo Shin
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Tae Ho Lim
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Bo-Hyoung Jang
- Department of Preventive Medicine, College of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Youngsuk Cho
- Department of Emergency Medicine, Hallym University, Kangdong Sacred Heart Hospital, Seoul, Republic of Korea
| | - Wonhee Kim
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Kyu-Sun Choi
- Department of Neurosurgery, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Jae Guk Kim
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Chiwon Ahn
- Department of Emergency Medicine, College of Medicine, Chung-Ang University, Seoul, Republic of Korea
| | - Heekyung Lee
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Myeong Namgung
- Department of emergency medicine, College of Medicine, Chung-Ang University Gwangmyeong Hospital, Gyeonggi-do, Republic of Korea
| | - Min Kyun Na
- Department of Neurosurgery, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Sae Min Kwon
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Republic of Korea
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Kenda M, Lang M, Nee J, Hinrichs C, Dell'Orco A, Salih F, Kemmling A, Nielsen N, Wise M, Thomas M, Düring J, McGuigan P, Cronberg T, Scheel M, Moseby-Knappe M, Leithner C. Regional Brain Net Water Uptake in Computed Tomography after Cardiac Arrest - A Novel Biomarker for Neuroprognostication. Resuscitation 2024:110243. [PMID: 38796092 DOI: 10.1016/j.resuscitation.2024.110243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 05/10/2024] [Indexed: 05/28/2024]
Abstract
BACKGROUND Selective water uptake by neurons and glial cells and subsequent brain tissue oedema are key pathophysiological processes of hypoxic-ischemic encephalopathy (HIE) after cardiac arrest (CA). Although brain computed tomography (CT) is widely used to assess the severity of HIE, changes of brain radiodensity over time have not been investigated. These could be used to quantify regional brain net water uptake (NWU), a potential prognostic biomarker. METHODS We conducted an observational prognostic accuracy study including a derivation (single center cardiac arrest registry) and a validation (international multicenter TTM2 trial) cohort. Early (<6 hours) and follow-up (>24 hours) head CTs of CA patients were used to determine regional NWU for grey and white matter regions after co-registration with a brain atlas. Neurological outcome was dichotomized as good versus poor using the Cerebral Performance Category Scale (CPC) in the derivation cohort and Modified Rankin Scale (mRS) in the validation cohort. RESULTS We included 115 patients (81 derivation, 34 validation) with out-of-hospital (OHCA) and in-hospital cardiac arrest (IHCA). Regional brain water content remained unchanged in patients with good outcome. In patients with poor neurological outcome, we found considerable regional water uptake with the strongest effect in the basal ganglia. NWU >8% in the putamen and caudate nucleus predicted poor outcome with 100% specificity (95%-CI: 86% to 100%) and 43% (moderate) sensitivity (95%-CI: 31% to 56%). CONCLUSION This pilot study indicates that NWU derived from serial head CTs is a promising novel biomarker for outcome prediction after CA. NWU >8% in basal ganglia grey matter regions predicted poor outcome while absence of NWU indicated good outcome. NWU and follow-up CTs should be investigated in larger, prospective trials with standardized CT acquisition protocols.
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Affiliation(s)
- Martin Kenda
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology and Experimental Neurology, Augustenburger Platz 1, 13353 Berlin, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Junior Digital Clinician Scientist Program, Charitéplatz 1, 10117 Berlin, Germany.
| | - Margareta Lang
- Department of Clinical Sciences Lund, Radiology, Lund University, Helsingborg Hospital, Lund, Sweden
| | - Jens Nee
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Nephrology and Intensive Care Medicine, Circulatory Arrest Center Berlin, Berlin, Germany
| | - Carl Hinrichs
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Nephrology and Intensive Care Medicine, Circulatory Arrest Center Berlin, Berlin, Germany
| | - Andrea Dell'Orco
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Neuroradiology, Campus Charité Mitte, Germany
| | - Farid Salih
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology and Experimental Neurology, Augustenburger Platz 1, 13353 Berlin, Germany
| | - André Kemmling
- Department of Neuroradiology, University Hospital Marburg, Marburg, Germany
| | - Niklas Nielsen
- Anaesthesiology and Intensive Care, Department of Clinical Sciences Lund, Helsingborg Hospital, Lund University, Lund, Sweden
| | - Matt Wise
- Adult Critical Care, University Hospital of Wales, Cardiff, UK
| | | | - Joachim Düring
- Department of Clinical Sciences, Anesthesia and Intensive Care, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Peter McGuigan
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK; Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, UK
| | - Tobias Cronberg
- Department of Neurology, Skane University Hospital, Lund, Sweden
| | - Michael Scheel
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Neuroradiology, Campus Charité Mitte, Germany
| | - Marion Moseby-Knappe
- Department of Clinical Sciences Lund, Neurology and Rehabilitation, Lund University, Skåne University Hospital, Lund, Sweden
| | - Christoph Leithner
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology and Experimental Neurology, Augustenburger Platz 1, 13353 Berlin, Germany
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Amacher SA, Sahmer C, Becker C, Gross S, Arpagaus A, Urben T, Tisljar K, Emsden C, Sutter R, Marsch S, Hunziker S. Post-intensive care syndrome and health-related quality of life in long-term survivors of cardiac arrest: a prospective cohort study. Sci Rep 2024; 14:10533. [PMID: 38719863 PMCID: PMC11079009 DOI: 10.1038/s41598-024-61146-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 05/02/2024] [Indexed: 05/12/2024] Open
Abstract
Patients discharged from intensive care are at risk for post-intensive care syndrome (PICS), which consists of physical, psychological, and/or neurological impairments. This study aimed to analyze PICS at 24 months follow-up, to identify potential risk factors for PICS, and to assess health-related quality of life in a long-term cohort of adult cardiac arrest survivors. This prospective cohort study included adult cardiac arrest survivors admitted to the intensive care unit of a Swiss tertiary academic medical center. The primary endpoint was the prevalence of PICS at 24 months follow-up, defined as impairments in physical (measured through the European Quality of Life 5-Dimensions-3-Levels instrument [EQ-5D-3L]), neurological (defined as Cerebral Performance Category Score > 2 or Modified Rankin Score > 3), and psychological (based on the Hospital Anxiety and Depression Scale and the Impact of Event Scale-Revised) domains. Among 107 cardiac arrest survivors that completed the 2-year follow-up, 46 patients (43.0%) had symptoms of PICS, with 41 patients (38.7%) experiencing symptoms in the physical domain, 16 patients (15.4%) in the psychological domain, and 3 patients (2.8%) in the neurological domain. Key predictors for PICS in multivariate analyses were female sex (adjusted odds ratio [aOR] 3.17, 95% CI 1.08 to 9.3), duration of no-flow interval during cardiac arrest (minutes) (aOR 1.17, 95% CI 1.02 to 1.33), post-discharge job-loss (aOR 31.25, 95% CI 3.63 to 268.83), need for ongoing psychological support (aOR 3.64, 95% CI 1.29 to 10.29) or psychopharmacologic treatment (aOR 9.49, 95% CI 1.9 to 47.3), and EQ-visual analogue scale (points) (aOR 0.88, 95% CI 0.84 to 0.93). More than one-third of cardiac arrest survivors experience symptoms of PICS 2 years after resuscitation, with the highest impairment observed in the physical and psychological domains. However, long-term survivors of cardiac arrest report intact health-related quality of life when compared to the general population. Future research should focus on appropriate prevention, screening, and treatment strategies for PICS in cardiac arrest patients.
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Affiliation(s)
- Simon A Amacher
- Intensive Care Medicine, Department of Acute Medical Care, University Hospital Basel, Basel, Switzerland
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031, Basel, Switzerland
- Emergency Medicine, Department of Acute Medical Care, University Hospital Basel, Basel, Switzerland
| | - Christian Sahmer
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031, Basel, Switzerland
| | - Christoph Becker
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031, Basel, Switzerland
- Emergency Medicine, Department of Acute Medical Care, University Hospital Basel, Basel, Switzerland
| | - Sebastian Gross
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031, Basel, Switzerland
| | - Armon Arpagaus
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031, Basel, Switzerland
| | - Tabita Urben
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031, Basel, Switzerland
| | - Kai Tisljar
- Intensive Care Medicine, Department of Acute Medical Care, University Hospital Basel, Basel, Switzerland
| | - Christian Emsden
- Intensive Care Medicine, Department of Acute Medical Care, University Hospital Basel, Basel, Switzerland
- Post-Intensive Care Clinic, University Hospital Basel, Basel, Switzerland
| | - Raoul Sutter
- Intensive Care Medicine, Department of Acute Medical Care, University Hospital Basel, Basel, Switzerland
- Medical Faculty, University of Basel, Basel, Switzerland
- Division of Neurophysiology, Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Stephan Marsch
- Intensive Care Medicine, Department of Acute Medical Care, University Hospital Basel, Basel, Switzerland
- Medical Faculty, University of Basel, Basel, Switzerland
| | - Sabina Hunziker
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031, Basel, Switzerland.
- Post-Intensive Care Clinic, University Hospital Basel, Basel, Switzerland.
- Medical Faculty, University of Basel, Basel, Switzerland.
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Vassar R, Mehta N, Epps L, Jiang F, Amorim E, Wietstock S. Mortality and Timing of Withdrawal of Life-Sustaining Therapies After Out-of-Hospital Cardiac Arrest: Two-Center Retrospective Pediatric Cohort Study. Pediatr Crit Care Med 2024; 25:241-249. [PMID: 37982686 DOI: 10.1097/pcc.0000000000003412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
OBJECTIVES Pediatric out-of-hospital cardiac arrest (OHCA) is associated with substantial morbidity and mortality. Limited data exist to guide timing and method of neurologic prognostication after pediatric OHCA, making counseling on withdrawal of life-sustaining therapies (WLSTs) challenging. This study investigates the timing and mode of death after pediatric OHCA and factors associated with mortality. Additionally, this study explores delayed recovery after comatose examination on day 3 postarrest. DESIGN This is a retrospective, observational study based on data collected from hospital databases and chart reviews. SETTING Data collection occurred in two pediatric academic hospitals between January 1, 2016, and December 31, 2020. PATIENTS Patients were identified from available databases and electronic medical record queries for the International Classification of Diseases , 10th Edition (ICD-10) code I46.9 (Cardiac Arrest). Patient inclusion criteria included age range greater than or equal to 48 hours to less than 18 years, OHCA within 24 hours of admission, greater than or equal to 1 min of cardiopulmonary resuscitation, and return-of-spontaneous circulation for greater than or equal to 20 min. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS One hundred thirty-five children (65% male) with a median age of 3 years (interquartile range 0.6-11.8) met inclusion criteria. Overall, 63 of 135 patients (47%) died before hospital discharge, including 34 of 63 patients (54%) after WLST. Among these, 20 of 34 patients underwent WLST less than or equal to 3 days postarrest, including 10 of 34 patients who underwent WLST within 1 day. WLST occurred because of poor perceived neurologic prognosis in all cases, although 7 of 34 also had poor perceived systemic prognosis. Delayed neurologic recovery from coma on day 3 postarrest was observed in 7 of 72 children (10%) who ultimately survived to discharge. CONCLUSIONS In our two centers between 2016 and 2020, more than half the deaths after pediatric OHCA occurred after WLST, and a majority of WLST occurred within 3 days postarrest. Additional research is warranted to determine optimal timing and predictors of neurologic prognosis after pediatric OHCA to better inform families during goals of care discussions.
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Affiliation(s)
- Rachel Vassar
- Division of Pediatric Neurology, Department of Neurology, Benioff Children's Hospital, University of California, San Francisco, CA
| | - Nehali Mehta
- Division of Pediatric Neurology, Department of Neurology, Benioff Children's Hospital, University of California, San Francisco, CA
- Department of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Lane Epps
- Department of Emergency Medicine, University of California, San Francisco, CA
| | - Fei Jiang
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Edilberto Amorim
- Department of Neurology, University of California, San Francisco, San Francisco, CA
- Division of Neurology, Zuckerberg San Francisco General Hospital, San Francisco, CA
| | - Sharon Wietstock
- Division of Pediatric Neurology, Department of Neurology, Benioff Children's Hospital, University of California, San Francisco, CA
- Division of Pediatric Neurology, Department of Neurology, Benioff Children's Hospital Oakland, University of California, San Francisco, Oakland, CA
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7
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Hirsch KG, Tamura T, Ristagno G, Sekhon MS. Wolf Creek XVII Part 8: Neuroprotection. Resusc Plus 2024; 17:100556. [PMID: 38328750 PMCID: PMC10847936 DOI: 10.1016/j.resplu.2024.100556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024] Open
Abstract
Introduction Post-cardiac arrest brain injury (PCABI) is the primary determinant of clinical outcomes for patients who achieve return of spontaneous circulation after cardiac arrest (CA). There are limited neuroprotective therapies available to mitigate the acute pathophysiology of PCABI. Methods Neuroprotection was one of six focus topics for the Wolf Creek XVII Conference held on June 14-17, 2023 in Ann Arbor, Michigan, USA. Conference invitees included international thought leaders and scientists in the field of CA resuscitation from academia and industry. Participants submitted via online survey knowledge gaps, barriers to translation, and research priorities for each focus topic. Expert panels used the survey results and their own perspectives and insights to create and present a preliminary unranked list for each category that was debated, revised and ranked by all attendees to identify the top 5 for each category. Results Top 5 knowledge gaps included developing therapies for neuroprotection; improving understanding of the pathophysiology, mechanisms, and natural history of PCABI; deploying precision medicine approaches; optimizing resuscitation and CPR quality; and determining optimal timing for and duration of interventions. Top 5 barriers to translation included patient heterogeneity; nihilism & lack of knowledge about cardiac arrest; challenges with the translational pipeline; absence of mechanistic biomarkers; and inaccurate neuro-triage and neuroprognostication. Top 5 research priorities focused on translational research and trial optimization; addressing patient heterogeneity and individualized interventions; improving understanding of pathophysiology and mechanisms; developing mechanistic and outcome biomarkers across post-CA time course; and improving implementation of science and technology. Conclusion This overview can serve as a guide to transform the care and outcome of patients with PCABI. Addressing these topics has the potential to improve both research and clinical care in the field of neuroprotection for PCABI.
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Affiliation(s)
- Karen G. Hirsch
- Department of Neurology, Stanford University, Stanford, CA, United States
| | - Tomoyoshi Tamura
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Giuseppe Ristagno
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Mypinder S. Sekhon
- Division of Critical Care Medicine and Department of Medicine, University of British Columbia, Vancouver, Canada
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8
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Qing K, Forgacs P, Schiff N. EEG Pattern With Spectral Analysis Can Prognosticate Good and Poor Neurologic Outcomes After Cardiac Arrest. J Clin Neurophysiol 2024; 41:236-244. [PMID: 36007069 PMCID: PMC9905375 DOI: 10.1097/wnp.0000000000000958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To investigate the prognostic value of a simple stratification system of electroencephalographical (EEG) patterns and spectral types for patients after cardiac arrest. METHODS In this prospectively enrolled cohort, using manually selected EEG segments, patients after cardiac arrest were stratified into five independent EEG patterns (based on background continuity and burden of highly epileptiform discharges) and four independent power spectral types (based on the presence of frequency components). The primary outcome is cerebral performance category (CPC) at discharge. Results from multimodal prognostication testing were included for comparison. RESULTS Of a total of 72 patients, 6 had CPC 1-2 by discharge, all of whom had mostly continuous EEG background without highly epileptiform activity at day 3. However, for the same EEG background pattern at day 3, 19 patients were discharged at CPC 3 and 15 patients at CPC 4-5. After adding spectral analysis, overall sensitivity for predicting good outcomes (CPC 1-2) was 83.3% (95% confidence interval 35.9% to 99.6%) and specificity was 97.0% (89.5% to 99.6%). In this cohort, standard prognostication testing all yielded 100% specificity but low sensitivity, with imaging being the most sensitive at 54.1% (36.9% to 70.5%). CONCLUSIONS Adding spectral analysis to qualitative EEG analysis may further improve the diagnostic accuracy of EEG and may aid developing novel measures linked to good outcomes in postcardiac arrest coma.
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Affiliation(s)
- Kurt Qing
- New York-Presbyterian Weill Cornell Medical Center
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Sugimoto M, Takayama W, Inoue A, Hifumi T, Sakamoto T, Kuroda Y, Otomo Y. Impact of Lactate Clearance on Clinical and Neurological Outcomes of Patients With Out-of-Hospital Cardiac Arrest Treated With Extracorporeal Cardiopulmonary Resuscitation: A Secondary Data Analysis. Crit Care Med 2024:00003246-990000000-00300. [PMID: 38411442 DOI: 10.1097/ccm.0000000000006245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
OBJECTIVES Serial evaluations of lactate concentration may be more useful in predicting outcomes in patients with out-of-hospital cardiac arrest (OHCA) than a single measurement. This study aimed to evaluate the impact of lactate clearance (LC) on clinical and neurologic outcomes in patients with OHCA who underwent extracorporeal cardiopulmonary resuscitation (ECPR). DESIGN Retrospective multicenter observational study. SETTING Patients with OHCA receiving ECPR at 36 hospitals in Japan between January 1, 2013, and December 31, 2018. PATIENTS This study evaluated 1227 patients, with lactateinitial assessed upon emergency department admission and lactatesecond measured subsequently. To adjust for the disparity in the time between lactate measurements, the modified 6-hour LC was defined as follows: ([lactateinitial-lactatesecond]/lactateinitial) × 100 × (6/the duration between the initial and second measurements [hr]). The patients were divided into four groups according to the modified 6-hour LC with an equivalent number of patients among LC quartiles: Q1 (LC < 18.8), Q2 (18.8 < LC < 59.9), Q3 (60.0 < LC < 101.2), and Q4 (101.2 < LC). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The 30-day survival rates increased as the 6-hour LC increased (Q1, 21.2%; Q2, 36.8%; Q3, 41.4%; Q4, 53.6%; p for trend < 0.001). In the multivariate analysis, the modified 6-hour LC was significantly associated with a 30-day survival rate (adjusted odds ratio [AOR], 1.003; 95% CI, 1.001-1.005; p < 0.001) and favorable neurologic outcome (AOR, 1.002; 95% CI, 1.000-1.004; p = 0.027). CONCLUSIONS In patients with OHCA who underwent ECPR, an increase in the modified 6-hour LC was associated with favorable clinical and neurologic outcome. Thus, LC can be a criterion to assess whether ECPR should be continued.
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Affiliation(s)
- Momoko Sugimoto
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University Hospital of Medicine, Yushima, Bunkyo-ku, Tokyo, Japan
| | - Wataru Takayama
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University Hospital of Medicine, Yushima, Bunkyo-ku, Tokyo, Japan
| | - Akihiko Inoue
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Tetsuya Sakamoto
- Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Yasuhiro Kuroda
- Department of Emergency Medicine, Kagawa University School of Medicine, Kagawa, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University Hospital of Medicine, Yushima, Bunkyo-ku, Tokyo, Japan
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10
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Beer BN, Kellner C, Goßling A, Sundermeyer J, Besch L, Dettling A, Kirchhof P, Blankenberg S, Bernhardt AM, Brunner S, Colson P, Eckner D, Frank D, Eitel I, Frey N, Eden M, Graf T, Kupka D, Landmesser U, Majunke N, Maniuc O, Möbius-Winkler S, Morrow DA, Mourad M, Noel C, Nordbeck P, Orban M, Pappalardo F, Patel SM, Pauschinger M, Reichenspurner H, Schulze PC, Schwinger RHG, Wechsler A, Skurk C, Thiele H, Varshney AS, Sag CM, Krais J, Westermann D, Schrage B. Complications in patients with cardiogenic shock on veno-arterial extracorporeal membrane oxygenation therapy: distribution and relevance. Results from an international, multicentre cohort study. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:203-212. [PMID: 37875127 DOI: 10.1093/ehjacc/zuad129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 09/16/2023] [Accepted: 10/11/2023] [Indexed: 10/26/2023]
Abstract
AIMS Veno-arterial extracorporeal membrane oxygenation therapy (VA-ECMO) restores circulation and tissue oxygenation in cardiogenic shock (CS) patients, but can also lead to complications. This study aimed to quantify VA-ECMO complications and analyse their association with overall survival as well as favourable neurological outcome (cerebral performance categories 1 + 2). METHODS AND RESULTS All-comer patients with CS treated with VA-ECMO were retrospectively enrolled from 16 centres in four countries (2005-2019). Neurological, bleeding, and ischaemic adverse events (AEs) were considered. From these, typical VA-ECMO complications were identified and analysed separately as device-related complications. n = 501. Overall, 118 were women (24%), median age was 56.0 years, median lactate was 8.1 mmol/L. Acute myocardial infarction caused CS in 289 patients (58%). Thirty-days mortality was 40% (198/501 patients). At least one device-related complication occurred in 252/486 (52%) patients, neurological AEs in 108/469 (23%), bleeding in 192/480 (40%), ischaemic AEs in 123/478 (26%). The 22% of patients with the most AEs accounted for 50% of all AEs. All types of AEs were associated with a worse prognosis. Aside from neurological ones, all AEs and device-related complications were more likely to occur in women; although prediction of AEs outside of neurological AEs was generally poor. CONCLUSION Therapy and device-related complications occur in half of all patients treated with VA-ECMO and are associated with a worse prognosis. They accumulate in some patients, especially in women. Aside from neurological events, identification of patients at risk is difficult, highlighting the need to establish additional quantitative markers of complication risk to guide VA-ECMO treatment in CS.
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Affiliation(s)
- Benedikt N Beer
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Caroline Kellner
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alina Goßling
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jonas Sundermeyer
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Lisa Besch
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Angela Dettling
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Stefan Blankenberg
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Alexander M Bernhardt
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
- Department of Cardiothoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Brunner
- Department of Internal Medicine I, LMU University Hospital, Munich, Germany
| | - Pascal Colson
- Department of Anesthesiology and Critical Care Medicine, CHU Montpellier, University Montpellier, Montpellier, France
| | - Dennis Eckner
- Department of Cardiology, Paracelsus Medical University Nürnberg, Nürnberg, Germany
| | - Derk Frank
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
- Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Ingo Eitel
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
- University Heart Center Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Norbert Frey
- Department of Cardiology, Angiology and Pneumology, University Hospital Heidelberg, Heidelberg, Germany
| | - Matthias Eden
- Department of Cardiology, Angiology and Pneumology, University Hospital Heidelberg, Heidelberg, Germany
| | - Tobias Graf
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
- University Heart Center Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Danny Kupka
- Department of Internal Medicine I, LMU University Hospital, Munich, Germany
| | - Ulf Landmesser
- Department of Cardiology, Campus Benjamin Franklin, Charité University Hospital, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin/Institute of Health (BIH), Berlin, Germany
| | - Nicolas Majunke
- Department of Internal Medicine and Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Octavian Maniuc
- Department of Internal Medicine I, University Hospital Würzburg, Würburg, Germany
| | | | - David A Morrow
- Cardiovascular Division, Brigham and Women's Hospital, Boston, USA
| | - Marc Mourad
- Department of Anesthesiology and Critical Care Medicine, CHU Montpellier, University Montpellier, Montpellier, France
| | - Curt Noel
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
- Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Peter Nordbeck
- Department of Internal Medicine I, University Hospital Würzburg, Würburg, Germany
| | - Martin Orban
- Department of Internal Medicine I, LMU University Hospital, Munich, Germany
| | - Federico Pappalardo
- Department of Cardiothoracic and Vascular Anaesthesia and Intensive Care, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Sandeep M Patel
- Department of Interventional Cardiology, St.Rita's Medical Center, Lima, USA
| | - Matthias Pauschinger
- Department of Cardiology, Paracelsus Medical University Nürnberg, Nürnberg, Germany
| | - Hermann Reichenspurner
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
- Department of Cardiothoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | | | - Antonia Wechsler
- Department of Internal Medicine II, Klinikum Weiden, Weiden, Germany
| | - Carsten Skurk
- Department of Cardiology, Campus Benjamin Franklin, Charité University Hospital, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin/Institute of Health (BIH), Berlin, Germany
| | - Holger Thiele
- Department of Internal Medicine and Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Anubodh S Varshney
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Palo Alto, USA
| | - Can Martin Sag
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Jannis Krais
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Dirk Westermann
- Department of Cardiology and Angiology I, University Heart Center Freiburg, Bad Krozingen, Germany
| | - Benedikt Schrage
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
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11
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Molinski NS, Kenda M, Leithner C, Nee J, Storm C, Scheel M, Meddeb A. Deep learning-enabled detection of hypoxic-ischemic encephalopathy after cardiac arrest in CT scans: a comparative study of 2D and 3D approaches. Front Neurosci 2024; 18:1245791. [PMID: 38419661 PMCID: PMC10899383 DOI: 10.3389/fnins.2024.1245791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 01/31/2024] [Indexed: 03/02/2024] Open
Abstract
Objective To establish a deep learning model for the detection of hypoxic-ischemic encephalopathy (HIE) features on CT scans and to compare various networks to determine the best input data format. Methods 168 head CT scans of patients after cardiac arrest were retrospectively identified and classified into two categories: 88 (52.4%) with radiological evidence of severe HIE and 80 (47.6%) without signs of HIE. These images were randomly divided into a training and a test set, and five deep learning models based on based on Densely Connected Convolutional Networks (DenseNet121) were trained and validated using different image input formats (2D and 3D images). Results All optimized stacked 2D and 3D networks could detect signs of HIE. The networks based on the data as 2D image data stacks provided the best results (S100: AUC: 94%, ACC: 79%, S50: AUC: 93%, ACC: 79%). We provide visual explainability data for the decision making of our AI model using Gradient-weighted Class Activation Mapping. Conclusion Our proof-of-concept deep learning model can accurately identify signs of HIE on CT images. Comparing different 2D- and 3D-based approaches, most promising results were achieved by 2D image stack models. After further clinical validation, a deep learning model of HIE detection based on CT images could be implemented in clinical routine and thus aid clinicians in characterizing imaging data and predicting outcome.
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Affiliation(s)
- Noah S. Molinski
- Department for Neuroradiology, Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Martin Kenda
- Department of Neurology with Experimental Neurology, Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, Berlin, Germany
| | - Christoph Leithner
- Department of Neurology with Experimental Neurology, Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Jens Nee
- Department of Nephrology and Medical Intensive Care, Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Christian Storm
- Department of Nephrology and Medical Intensive Care, Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Michael Scheel
- Department for Neuroradiology, Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Aymen Meddeb
- Department for Neuroradiology, Charité – Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, Berlin, Germany
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12
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Sarkisian L, Isse YA, Gerke O, Obling LER, Paulin Beske R, Grand J, Schmidt H, Højgaard HF, Meyer MAS, Borregaard B, Hassager C, Kjaergaard J, Møller JE. Survival and neurological outcome after bystander versus lay responder defibrillation in out-of-hospital cardiac arrest: A sub-study of the BOX trial. Resuscitation 2024; 195:110059. [PMID: 38013147 DOI: 10.1016/j.resuscitation.2023.110059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/15/2023] [Accepted: 11/20/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND AND AIM Bystander defibrillation is associated with increased survival with good neurological outcome after out-of-hospital cardiac arrest (OHCA). Dispatch of lay responders could increase defibrillation rates, however, survival with good neurological outcome in these remain unknown. The aim was to compare long-term survival with good neurological outcome in bystander versus lay responder defibrillated OHCAs. METHODS This is a sub-study of the BOX trial, which included OHCA patients from two Danish tertiary cardiac intensive care units from March 2017 to December 2021. The main outcome was defined as 3-month survival with good neurological performance (Cerebral Performance Category of 1or 2, on a scale from 1 (good cerebral performance) to 5 (death or brain death)). For this study EMS witnessed OHCAs were excluded. RESULTS Of the 715 patients, a lay responder arrived before EMS in 125 cases (16%). In total, 81 patients were defibrillated by a lay responder (11%), 69 patients by a bystander (10%) and 565 patients by the EMS staff (79%). The 3-month survival with good neurological outcome was 65% and 81% in the lay responder and bystander defibrillated groups, respectively (P = 0.03). CONCLUSION In patients with OHCA, 3-month survival with good neurological outcome was higher in bystander defibrillated patients compared with lay responder defibrillated patients.
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Affiliation(s)
- Laura Sarkisian
- Research Unit of Cardiology, Department of Cardiology, Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense C, Denmark; OPEN, Odense Patient Data Explorative Network, Odense University Hospital, Odense, Denmark.
| | - Yusuf Abdi Isse
- Department of Cardiology, The Heart Center, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark.
| | - Oke Gerke
- Department of Nuclear Medicine, Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense C, Denmark; Department of Clinical Research, University of Southern Denmark, J.B. Winsløws Vej 19, 5000 Odense C, Denmark.
| | - Laust Emil Roelsgaard Obling
- Department of Cardiology, The Heart Center, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark.
| | - Ramus Paulin Beske
- Department of Cardiology, The Heart Center, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark.
| | - Johannes Grand
- Department of Cardiology, The Heart Center, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark.
| | - Henrik Schmidt
- Department of Cardiology, The Heart Center, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark; Odense University Hospital, Department of Anesthesiology, J.B. Winsløws Vej 4, 5000 Odense C, Denmark.
| | | | - Martin Abild Stengaard Meyer
- Department of Cardiology, The Heart Center, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark.
| | - Britt Borregaard
- Research Unit of Cardiology, Department of Cardiology, Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense C, Denmark; Department of Clinical Research, University of Southern Denmark, J.B. Winsløws Vej 19, 5000 Odense C, Denmark.
| | - Christian Hassager
- Department of Cardiology, The Heart Center, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark.
| | - Jesper Kjaergaard
- Department of Cardiology, The Heart Center, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark.
| | - Jacob Eifer Møller
- Research Unit of Cardiology, Department of Cardiology, Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense C, Denmark; Department of Cardiology, The Heart Center, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark; Department of Clinical Research, University of Southern Denmark, J.B. Winsløws Vej 19, 5000 Odense C, Denmark.
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13
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Bachista KM, Moore JC, Labarère J, Crowe RP, Emanuelson LD, Lick CJ, Debaty GP, Holley JE, Quinn RP, Scheppke KA, Pepe PE. Survival for Nonshockable Cardiac Arrests Treated With Noninvasive Circulatory Adjuncts and Head/Thorax Elevation. Crit Care Med 2024; 52:170-181. [PMID: 38240504 DOI: 10.1097/ccm.0000000000006055] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
OBJECTIVES Cardiac arrests remain a leading cause of death worldwide. Most patients have nonshockable electrocardiographic presentations (asystole/pulseless electrical activity). Despite well-performed basic and advanced cardiopulmonary resuscitation (CPR) interventions, patients with these presentations have always faced unlikely chances of survival. The primary objective was to determine if, in addition to conventional CPR (C-CPR), expeditious application of noninvasive circulation-enhancing adjuncts, and then gradual elevation of head and thorax, would be associated with higher likelihoods of survival following out-of-hospital cardiac arrest (OHCA) with nonshockable presentations. DESIGN Using a prospective observational study design (ClinicalTrials.gov NCT05588024), patient data from the national registry of emergency medical services (EMS) agencies deploying the CPR-enhancing adjuncts and automated head/thorax-up positioning (AHUP-CPR) were compared with counterpart reference control patient data derived from the two National Institutes of Health clinical trials that closely monitored quality CPR performance. Beyond unadjusted comparisons, propensity score matching and matching of time to EMS-initiated CPR (TCPR) were used to assemble cohorts with corresponding best-fit distributions of the well-established characteristics associated with OHCA outcomes. SETTING North American 9-1-1 EMS agencies. PATIENTS Adult nontraumatic OHCA patients receiving 9-1-1 responses. INTERVENTIONS In addition to C-CPR, study patients received the CPR adjuncts and AHUP (all U.S. Food and Drug Administration-cleared). MEASUREMENTS AND MAIN RESULTS The median TCPR for both AHUP-CPR and C-CPR groups was 8 minutes. Median time to AHUP initiation was 11 minutes. Combining all patients irrespective of lengthier response intervals, the collective unadjusted likelihood of AHUP-CPR group survival to hospital discharge was 7.4% (28/380) vs. 3.1% (58/1,852) for C-CPR (odds ratio [OR], 2.46 [95% CI, 1.55-3.92]) and, after propensity score matching, 7.6% (27/353) vs. 2.8% (10/353) (OR, 2.84 [95% CI, 1.35-5.96]). Faster AHUP-CPR application markedly amplified odds of survival and neurologically favorable survival. CONCLUSIONS These findings indicate that, compared with C-CPR, there are strong associations between rapid AHUP-CPR treatment and greater likelihood of patient survival, as well as survival with good neurological function, in cases of nonshockable OHCA.
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Affiliation(s)
- Kerry M Bachista
- Department of Emergency Medicine, Mayo Clinic Alix School of Health Sciences, Mayo Clinic in Florida, Jacksonville, FL
| | - Johanna C Moore
- Hennepin Healthcare, Department of Emergency Medicine, University of Minnesota School of Medicine, Minneapolis, MN
| | - José Labarère
- Quality of Care Unit, Université Grenoble Alpes, Grenoble, France
| | | | - Lauren D Emanuelson
- Division of Quality Improvement and Compliance, Advanced Medical Transport of Central Illinois, Peoria, IL
| | - Charles J Lick
- Division of Emergency Medical Services, Allina Health, Minneapolis, MN
| | - Guillaume P Debaty
- Department of Emergency Medicine, University Hospital of Grenoble Alpes, Grenoble, France
| | - Joseph E Holley
- Memphis Fire Department, City of Memphis, TN
- Division of Emergency Medical Services, State of Tennessee Department of Health, Nashville, TN
| | - Ryan P Quinn
- EMS Division, City of Edina Fire Department, Edina, MN
| | - Kenneth A Scheppke
- Florida Department of Health, Tallahassee, FL
- Office of the Medical Director, Palm Beach County Fire Rescue, West Palm Beach, FL
| | - Paul E Pepe
- Department of Emergency Medicine, Mayo Clinic Alix School of Health Sciences, Mayo Clinic in Florida, Jacksonville, FL
- Emergency Medical Services Division, St. Johns County Fire Rescue, St. Augustine, FL
- Hennepin Healthcare, Department of Emergency Medicine, University of Minnesota School of Medicine, Minneapolis, MN
- Quality of Care Unit, Université Grenoble Alpes, Grenoble, France
- Clinical and Operational Research, ESO, Austin, TX
- Division of Quality Improvement and Compliance, Advanced Medical Transport of Central Illinois, Peoria, IL
- Division of Emergency Medical Services, Allina Health, Minneapolis, MN
- Department of Emergency Medicine, University Hospital of Grenoble Alpes, Grenoble, France
- Memphis Fire Department, City of Memphis, TN
- Division of Emergency Medical Services, State of Tennessee Department of Health, Nashville, TN
- EMS Division, City of Edina Fire Department, Edina, MN
- Florida Department of Health, Tallahassee, FL
- Office of the Medical Director, Palm Beach County Fire Rescue, West Palm Beach, FL
- Department of Management, Policy and Community Health, University of Texas Health Sciences Center, Houston, School of Public Health, Houston, TX
- Dallas County Fire Rescue Department, Dallas County, Dallas, TX
- Executive Offices, Metropolitan EMS Medical Directors Global Alliance, Fort Lauderdale, FL
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14
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Case NP, Callaway CW, Elmer J, Coppler PJ. Simple approach to quantify hypoxic-ischemic brain injury severity from computed tomography imaging files after cardiac arrest. Resuscitation 2024; 195:110050. [PMID: 37977348 PMCID: PMC10922650 DOI: 10.1016/j.resuscitation.2023.110050] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Grey-white ratio (GWR) can estimate severity of cytotoxic cerebral edema secondary to hypoxic-ischemic brain injury after cardiac arrest and predict progression to death by neurologic criteria (DNC). Current approaches to calculating GWR are not standardized and have variable interrater reliability. We tested if measures of variance of brain density on early computed tomographic (CT) imaging after cardiac arrest could predict DNC. METHODS We performed a retrospective cohort study, identifying post-arrest patients treated between 2011 and 2020 at our single center. We extracted demographic data from our registry and Digital Imaging and Communication in Medicine (DICOM) files for each patient's first brain CT. We analyzed slices 15-20 of each DICOM, corresponding to the level of the basal ganglia while accommodating differences in patient anatomy. We extracted pixel arrays and converted the radiodensities to Hounsfield units (HU). To focus on brain tissue densities, we excluded HU > 60 and < 10. We calculated the variance of each patient's HU distribution and the difference between the means of a two-group Gaussian finite mixture model. We compared these novel metrics to existing measures of cerebral edema, then randomly divided our data into 80% training and 20% test sets and used logistic regression to predict DNC. RESULTS Of 1,133 included subjects, 457 (40%) were female, mean (standard deviation) age was 58 (16) years, and 115 (10%) progressed to DNC. CTs were obtained a median [interquartile range] of 4.2 [2.8-5.7] hours post-arrest. Our novel measures correlated weakly with GWR. HU variance, but not difference between mixture model means, differed significantly between subjects with and without sulcal or cistern effacement. GWR outperformed our novel measures in predicting progression to DNC with an area under the receiver operating characteristic curve (AUC) of 0.82, compared to HU variance (AUC = 0.73) and the difference between mixture model means (AUC = 0.56). CONCLUSION There are differences in the distribution of HU on post-arrest CT in patients with qualitative measures of cerebral edema. Current methods to quantify cerebral edema outperform simple measures of attenuation variance on early brain CT. Further analyses could investigate if these measures of variance, or other distributional characteristics of brain density, have improved predictive performance on brain CTs obtained later in the clinical course or derived from discrete regions of anatomical interest.
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Affiliation(s)
- Nicholas P Case
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Patrick J Coppler
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
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15
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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] [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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16
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Spears WE, Greer DM. Hypothermia to 33 °C Following Cardiac Arrest: Time to Close the Freezer Door for Good? JAMA Neurol 2024; 81:115-117. [PMID: 38109090 DOI: 10.1001/jamaneurol.2023.4831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Affiliation(s)
- William E Spears
- Department of Neurology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | - David M Greer
- Department of Neurology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
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17
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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] [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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18
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Slovis JC, Bach A, Beaulieu F, Zuckerberg G, Topjian A, Kirschen MP. Neuromonitoring after Pediatric Cardiac Arrest: Cerebral Physiology and Injury Stratification. Neurocrit Care 2024; 40:99-115. [PMID: 37002474 PMCID: PMC10544744 DOI: 10.1007/s12028-023-01685-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 01/30/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Significant long-term neurologic disability occurs in survivors of pediatric cardiac arrest, primarily due to hypoxic-ischemic brain injury. Postresuscitation care focuses on preventing secondary injury and the pathophysiologic cascade that leads to neuronal cell death. These injury processes include reperfusion injury, perturbations in cerebral blood flow, disturbed oxygen metabolism, impaired autoregulation, cerebral edema, and hyperthermia. Postresuscitation care also focuses on early injury stratification to allow clinicians to identify patients who could benefit from neuroprotective interventions in clinical trials and enable targeted therapeutics. METHODS In this review, we provide an overview of postcardiac arrest pathophysiology, explore the role of neuromonitoring in understanding postcardiac arrest cerebral physiology, and summarize the evidence supporting the use of neuromonitoring devices to guide pediatric postcardiac arrest care. We provide an in-depth review of the neuromonitoring modalities that measure cerebral perfusion, oxygenation, and function, as well as neuroimaging, serum biomarkers, and the implications of targeted temperature management. RESULTS For each modality, we provide an in-depth review of its impact on treatment, its ability to stratify hypoxic-ischemic brain injury severity, and its role in neuroprognostication. CONCLUSION Potential therapeutic targets and future directions are discussed, with the hope that multimodality monitoring can shift postarrest care from a one-size-fits-all model to an individualized model that uses cerebrovascular physiology to reduce secondary brain injury, increase accuracy of neuroprognostication, and improve outcomes.
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Affiliation(s)
- Julia C Slovis
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood - 6105, Philadelphia, PA, 19104, USA.
| | - Ashley Bach
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood - 6105, Philadelphia, PA, 19104, USA
| | - Forrest Beaulieu
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood - 6105, Philadelphia, PA, 19104, USA
| | - Gabe Zuckerberg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood - 6105, Philadelphia, PA, 19104, USA
| | - Alexis Topjian
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood - 6105, Philadelphia, PA, 19104, USA
| | - Matthew P Kirschen
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood - 6105, Philadelphia, PA, 19104, USA
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19
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Battaglini D, Bogossian EG, Anania P, Premraj L, Cho SM, Taccone FS, Sekhon M, Robba C. Monitoring of Brain Tissue Oxygen Tension in Cardiac Arrest: a Translational Systematic Review from Experimental to Clinical Evidence. Neurocrit Care 2024; 40:349-363. [PMID: 37081276 DOI: 10.1007/s12028-023-01721-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 03/24/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND Cardiac arrest (CA) is a sudden event that is often characterized by hypoxic-ischemic brain injury (HIBI), leading to significant mortality and long-term disability. Brain tissue oxygenation (PbtO2) is an invasive tool for monitoring brain oxygen tension, but it is not routinely used in patients with CA because of the invasiveness and the absence of high-quality data on its effect on outcome. We conducted a systematic review of experimental and clinical evidence to understand the role of PbtO2 in monitoring brain oxygenation in HIBI after CA and the effect of targeted PbtO2 therapy on outcomes. METHODS The search was conducted using four search engines (PubMed, Scopus, Embase, and Cochrane), using the Boolean operator to combine mesh terms such as PbtO2, CA, and HIBI. RESULTS Among 1,077 records, 22 studies were included (16 experimental studies and six clinical studies). In experimental studies, PbtO2 was mainly adopted to assess the impact of gas exchanges, drugs, or systemic maneuvers on brain oxygenation. In human studies, PbtO2 was rarely used to monitor the brain oxygen tension in patients with CA and HIBI. PbtO2 values had no clear association with patients' outcomes, but in the experimental studies, brain tissue hypoxia was associated with increased inflammation and neuronal damage. CONCLUSIONS Further studies are needed to validate the effect and the threshold of PbtO2 associated with outcome in patients with CA, as well as to understand the physiological mechanisms influencing PbtO2 induced by gas exchanges, drug administration, and changes in body positioning after CA.
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Affiliation(s)
- Denise Battaglini
- Anesthesiology and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Elisa Gouvea Bogossian
- Department of Intensive Care, Hospital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Pasquale Anania
- Department of Neurosurgery, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.
| | - Lavienraj Premraj
- Griffith University School of Medicine, Gold Coast, QLD, Australia
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Sung-Min Cho
- Departments of Neurology, Surgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hospital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Mypinder Sekhon
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Chiara Robba
- Anesthesiology and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
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20
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Tinti L, Lawson T, Molteni E, Kondziella D, Rass V, Sharshar T, Bodien YG, Giacino JT, Mayer SA, Amiri M, Muehlschlegel S, Venkatasubba Rao CP, Vespa PM, Menon DK, Citerio G, Helbok R, McNett M. Research considerations for prospective studies of patients with coma and disorders of consciousness. Brain Commun 2024; 6:fcae022. [PMID: 38344653 PMCID: PMC10853976 DOI: 10.1093/braincomms/fcae022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 01/04/2024] [Accepted: 01/26/2024] [Indexed: 03/02/2024] Open
Abstract
Disorders of consciousness are neurological conditions characterized by impaired arousal and awareness of self and environment. Behavioural responses are absent or are present but fluctuate. Disorders of consciousness are commonly encountered as a consequence of both acute and chronic brain injuries, yet reliable epidemiological estimates would require inclusive, operational definitions of the concept, as well as wider knowledge dissemination among involved professionals. Whereas several manifestations have been described, including coma, vegetative state/unresponsive wakefulness syndrome and minimally conscious state, a comprehensive neurobiological definition for disorders of consciousness is still lacking. The scientific literature is primarily observational, and studies-specific aetiologies lead to disorders of consciousness. Despite advances in these disease-related forms, there remains uncertainty about whether disorders of consciousness are a disease-agnostic unitary entity with a common mechanism, prognosis or treatment response paradigm. Our knowledge of disorders of consciousness has also been hampered by heterogeneity of study designs, variables, and outcomes, leading to results that are not comparable for evidence synthesis. The different backgrounds of professionals caring for patients with disorders of consciousness and the different goals at different stages of care could partly explain this variability. The Prospective Studies working group of the Neurocritical Care Society Curing Coma Campaign was established to create a platform for observational studies and future clinical trials on disorders of consciousness and coma across the continuum of care. In this narrative review, the author panel presents limitations of prior observational clinical research and outlines practical considerations for future investigations. A narrative review format was selected to ensure that the full breadth of study design considerations could be addressed and to facilitate a future consensus-based statement (e.g. via a modified Delphi) and series of recommendations. The panel convened weekly online meetings from October 2021 to December 2022. Research considerations addressed the nosographic status of disorders of consciousness, case ascertainment and verification, selection of dependent variables, choice of covariates and measurement and analysis of outcomes and covariates, aiming to promote more homogeneous designs and practices in future observational studies. The goal of this review is to inform a broad community of professionals with different backgrounds and clinical interests to address the methodological challenges imposed by the transition of care from acute to chronic stages and to streamline data gathering for patients with disorders of consciousness. A coordinated effort will be a key to allow reliable observational data synthesis and epidemiological estimates and ultimately inform condition-modifying clinical trials.
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Affiliation(s)
- Lorenzo Tinti
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan 20156, Italy
| | - Thomas Lawson
- Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Erika Molteni
- Biomedical Engineering Department, School of Biomedical Engineering and Imaging Sciences, King’s College London, London SE1 7EU, UK
| | - Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen 2100, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen 2200, Denmark
| | - Verena Rass
- Department of Neurology, Neuro-Intensive Care Unit, Medical University of Innsbruck, Innsbruck 6020, Austria
| | - Tarek Sharshar
- Neuro-Intensive Care Medicine, Anaesthesiology and ICU Department, GHU-Psychiatry and Neurosciences, Pole Neuro, Sainte-Anne Hospital, Institute of Psychiatry and Neurosciences of Paris, INSERM U1266, Université Paris Cité, Paris 75006, France
| | - Yelena G Bodien
- Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Charlestown, MA 02129, USA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Charlestown, MA 02129, USA
| | - Stephan A Mayer
- Department of Neurology, New York Medical College, Valhalla, NY 10595, USA
- Department of Neurosurgery, New York Medical College, Valhalla, NY 10595, USA
| | - Moshgan Amiri
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen 2100, Denmark
| | - Susanne Muehlschlegel
- Department of Neurology and Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Chethan P Venkatasubba Rao
- Division of Vascular Neurology and Neurocritical Care, Baylor College of Medicine and CHI Baylor St Luke’s Medical Center, Houston, TX 77030, USA
| | - Paul M Vespa
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Cambridge CB2 1TN, UK
| | - Giuseppe Citerio
- NeuroIntensive Care, IRCSS Fondazione San Gerardo dei Tintori, Monza 20900, Italy
- School of Medicine and Surgery, Università Milano Bicocca, Milan 20854, Italy
| | - Raimund Helbok
- Department of Neurology, Neuro-Intensive Care Unit, Medical University of Innsbruck, Innsbruck 6020, Austria
- Department of Neurology, Johannes Kepler University, Linz 4040, Austria
| | - Molly McNett
- College of Nursing, The Ohio State University, Columbus, OH 43210, USA
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21
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Pluta R, Czuczwar SJ. Ischemia-Reperfusion Programming of Alzheimer's Disease-Related Genes-A New Perspective on Brain Neurodegeneration after Cardiac Arrest. Int J Mol Sci 2024; 25:1291. [PMID: 38279289 PMCID: PMC10816023 DOI: 10.3390/ijms25021291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 01/17/2024] [Accepted: 01/18/2024] [Indexed: 01/28/2024] Open
Abstract
The article presents the latest data on pathological changes after cerebral ischemia caused by cardiac arrest. The data include amyloid accumulation, tau protein modification, neurodegenerative and cognitive changes, and gene and protein changes associated with Alzheimer's disease. We present the latest data on the dysregulation of genes related to the metabolism of the amyloid protein precursor, tau protein, autophagy, mitophagy, apoptosis, and amyloid and tau protein transport genes. We report that neuronal death after cerebral ischemia due to cardiac arrest may be dependent and independent of caspase. Moreover, neuronal death dependent on amyloid and modified tau protein has been demonstrated. Finally, the results clearly indicate that changes in the expression of the presented genes play an important role in acute and secondary brain damage and the development of post-ischemic brain neurodegeneration with the Alzheimer's disease phenotype. The data indicate that the above genes may be a potential therapeutic target for brain therapy after ischemia due to cardiac arrest. Overall, the studies show that the genes studied represent attractive targets for the development of new therapies to minimize ischemic brain injury and neurological dysfunction. Additionally, amyloid-related genes expression and tau protein gene modification after cerebral ischemia due to cardiac arrest are useful in identifying ischemic mechanisms associated with Alzheimer's disease. Cardiac arrest illustrates the progressive, time- and area-specific development of neuropathology in the brain with the expression of genes responsible for the processing of amyloid protein precursor and the occurrence of tau protein and symptoms of dementia such as those occurring in patients with Alzheimer's disease. By carefully examining the common genetic processes involved in these two diseases, these data may help unravel phenomena associated with the development of Alzheimer's disease and neurodegeneration after cerebral ischemia and may lead future research on Alzheimer's disease or cerebral ischemia in new directions.
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Affiliation(s)
- Ryszard Pluta
- Department of Pathophysiology, Medical University of Lublin, 20-090 Lublin, Poland;
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22
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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] [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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23
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Qing K, Alkhachroum A, Claassen J, Forgacs P, Schiff N. The Electrographic Effects of Ketamine on Patients With Refractory Status Epilepticus After Cardiac Arrest: A Single-Center Retrospective Cohort. J Clin Neurophysiol 2024:00004691-990000000-00119. [PMID: 38194637 DOI: 10.1097/wnp.0000000000001065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024] Open
Abstract
PURPOSE To investigate the effects of ketamine on patients with refractory status epilepticus after cardiac arrest. METHODS In this retrospective cohort, selected EEG segments from patients after cardiac arrest were classified into different EEG patterns (based on background continuity and burden of epileptiform discharges) and spectral profiles (based on the presence of frequency components). For patients who received ketamine, EEG data were compared before, during, and after ketamine infusion; for the no-ketamine group, EEG data were compared at three separated time points during recording. Ketamine usage was determined by clinical providers. Electrographic improvement in epileptiform activity was scored, and the odds ratio was calculated using the Fisher exact test. Functional outcome measures at time of discharge were also examined. RESULTS Of a total of 38 patients with postcardiac arrest refractory status epilepticus, 13 received ketamine and 25 did not. All patients were on ≥2 antiseizure medications including at least one sedative infusion (midazolam). For the ketamine group, eight patients had electrographic improvement, compared with only two patients in the no-ketamine group, with an odds ratio of 7.19 (95% confidence interval 1.16-44.65, P value of 0.0341) for ketamine versus no ketamine. Most of the patients who received ketamine had myoclonic status epilepticus, and overall neurologic outcomes were poor with no patients having a favorable outcome. CONCLUSIONS For postarrest refractory status epilepticus, ketamine use was associated with electrographic improvement, but with the available data, it is unclear whether ketamine use or EEG improvement can be linked to better functional recovery.
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Affiliation(s)
- Kurt Qing
- Department of Neurology, New York-Presbyterian Hospital Weill Cornell, New York, New York, U.S.A
| | - Ayham Alkhachroum
- Department of Neurology, University of Miami, Miami, Florida, U.S.A.; and
| | - Jan Claassen
- Department of Neurology, Columbia University Medical Center, New York, New York, U.S.A
| | - Peter Forgacs
- Department of Neurology, New York-Presbyterian Hospital Weill Cornell, New York, New York, U.S.A
| | - Nicholas Schiff
- Department of Neurology, New York-Presbyterian Hospital Weill Cornell, New York, New York, U.S.A
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24
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Robba C, Zanier ER, Lopez Soto C, Park S, Sonneville R, Helbolk R, Sarwal A, Newcombe VFJ, van der Jagt M, Gunst J, Gauss T, Figueiredo S, Duranteau J, Skrifvars MB, Iaquaniello C, Muehlschlegel S, Metaxa V, Sandroni C, Citerio G, Meyfroidt G. Mastering the brain in critical conditions: an update. Intensive Care Med Exp 2024; 12:1. [PMID: 38182945 PMCID: PMC10770006 DOI: 10.1186/s40635-023-00587-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 12/18/2023] [Indexed: 01/07/2024] Open
Abstract
Acute brain injuries, such as traumatic brain injury and ischemic and hemorragic stroke, are a leading cause of death and disability worldwide. While characterized by clearly distict primary events-vascular damage in strokes and biomechanical damage in traumatic brain injuries-they share common secondary injury mechanisms influencing long-term outcomes. Growing evidence suggests that a more personalized approach to optimize energy substrate delivery to the injured brain and prognosticate towards families could be beneficial. In this context, continuous invasive and/or non-invasive neuromonitoring, together with clinical evaluation and neuroimaging to support strategies that optimize cerebral blood flow and metabolic delivery, as well as approaches to neuroprognostication are gaining interest. Recently, the European Society of Intensive Care Medicine organized a 2-day course focused on a practical case-based clinical approach of acute brain-injured patients in different scenarios and on future perspectives to advance the management of this population. The aim of this manuscript is to update clinicians dealing with acute brain injured patients in the intensive care unit, describing current knowledge and clinical practice based on the insights presented during this course.
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Affiliation(s)
- Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Elisa R Zanier
- Department of Acute Brain and Cardiovascular Injury, Mario Negri Institute for Pharmacological Research IRCCS, Milan, Italy.
| | - Carmen Lopez Soto
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK
| | - Soojin Park
- Departments of Neurology and Biomedical Informatics, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Romain Sonneville
- Department of Intensive Care Medicine, Hôpital Bichat-Claude Bernard, Université Paris Cité, INSERM UMR 1137, IAME, APHP.Nord, Paris, France
| | - Raimund Helbolk
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
- Department of Neurology, Johannes Kepler University, Linz, Austria
- Clinical Research Institute Neuroscience, Johannes Kepler University, Linz, Austria
| | - Aarti Sarwal
- Wake Forest Baptist Health Center, Winston-Salem, NC, USA
| | | | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC-University Medical Centre, Room Ne-415, PO BOX 2040, 3000 CA, Rotterdam, The Netherlands
| | - Jan Gunst
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Tobias Gauss
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Grenoble, Universitaire Grenoble Alpes, Grenoble, France
- INSERM U1216, Grenoble Institut Neurosciences, Grenoble, France
| | - Samy Figueiredo
- Department of Anaesthesiology and Critical Care Medicine, Bicêtre Hospital, Université Paris-Saclay, Assistance Publique des Hôpitaux de Paris, Équipe DYNAMIC, Inserm UMR 999, Le Kremlin-Bicêtre, France
| | - Jacques Duranteau
- Department of Anaesthesiology and Critical Care Medicine, Bicêtre Hospital, Université Paris-Saclay, Assistance Publique des Hôpitaux de Paris, Équipe DYNAMIC, Inserm UMR 999, Le Kremlin-Bicêtre, France
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Carolina Iaquaniello
- Neuroanesthesia and Intensive Care, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Susanne Muehlschlegel
- Division of Neurosciences Critical Care, Departments of Neurology and Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Victoria Metaxa
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, SE5 9RS, 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
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Geert Meyfroidt
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
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Dhakal K, Rosenthal ES, Kulpanowski AM, Dodelson JA, Wang Z, Cudemus-Deseda G, Villien M, Edlow BL, Presciutti AM, Januzzi JL, Ning M, Taylor Kimberly W, Amorim E, Brandon Westover M, Copen WA, Schaefer PW, Giacino JT, Greer DM, Wu O. Increased task-relevant fMRI responsiveness in comatose cardiac arrest patients is associated with improved neurologic outcomes. J Cereb Blood Flow Metab 2024; 44:50-65. [PMID: 37728641 PMCID: PMC10905635 DOI: 10.1177/0271678x231197392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/27/2023] [Accepted: 06/29/2023] [Indexed: 09/21/2023]
Abstract
Early prediction of the recovery of consciousness in comatose cardiac arrest patients remains challenging. We prospectively studied task-relevant fMRI responses in 19 comatose cardiac arrest patients and five healthy controls to assess the fMRI's utility for neuroprognostication. Tasks involved instrumental music listening, forward and backward language listening, and motor imagery. Task-specific reference images were created from group-level fMRI responses from the healthy controls. Dice scores measured the overlap of individual subject-level fMRI responses with the reference images. Task-relevant responsiveness index (Rindex) was calculated as the maximum Dice score across the four tasks. Correlation analyses showed that increased Dice scores were significantly associated with arousal recovery (P < 0.05) and emergence from the minimally conscious state (EMCS) by one year (P < 0.001) for all tasks except motor imagery. Greater Rindex was significantly correlated with improved arousal recovery (P = 0.002) and consciousness (P = 0.001). For patients who survived to discharge (n = 6), the Rindex's sensitivity was 75% for predicting EMCS (n = 4). Task-based fMRI holds promise for detecting covert consciousness in comatose cardiac arrest patients, but further studies are needed to confirm these findings. Caution is necessary when interpreting the absence of task-relevant fMRI responses as a surrogate for inevitable poor neurological prognosis.
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Affiliation(s)
- Kiran Dhakal
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - Eric S Rosenthal
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Annelise M Kulpanowski
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - Jacob A Dodelson
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - Zihao Wang
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - Gaston Cudemus-Deseda
- Department of Cardiac Anesthesiology and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Marjorie Villien
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - Brian L Edlow
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Alexander M Presciutti
- Department of Psychiatry, Center for Health Outcomes and Interdisciplinary Research, Massachusetts General Hospital, Boston, MA, USA
| | - James L Januzzi
- Department of Medicine, Cardiology Division, Massachusetts General Hospital and Baim Institute for Clinical Research, Boston, MA, USA
| | - MingMing Ning
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - W Taylor Kimberly
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Edilberto Amorim
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | | | - William A Copen
- Department of Radiology, Neuroradiology Division, Massachusetts General Hospital, Boston, MA, USA
| | - Pamela W Schaefer
- Department of Radiology, Neuroradiology Division, Massachusetts General Hospital, Boston, MA, USA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, MA, USA
| | - David M Greer
- Department of Neurology, Boston University School of Medicine, Boston Medical Center, Boston, MA, USA
| | - Ona Wu
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
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Hasin Y, Helviz Y, Einav S. Multiorgan failure in patients after out of hospital resuscitation: a retrospective single center study. Intern Emerg Med 2024; 19:159-173. [PMID: 37589938 DOI: 10.1007/s11739-023-03389-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 07/27/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Information on extracerebral system dysfunction is important for assessing the needs of critically ill patients after cardiac arrest. AIMS To describe the prevalence of organ dysfunction and patient severity after out of hospital cardiac arrest (OHCA) using scores commonly used in intensive care and the association between these and mortality. METHODS Retrospective analysis of observational data collected in real time in a tertiary medical center where care withdrawal is mostly illegal. Adult patients after nontraumatic OHCA with ROSC who survived for more than two hours were included. Primary outcome-prevalence of organ failure, based on common definitions for organ dysfunction, in the 1 days of hospitalization. Secondary outcomes-rates of survival to hospital discharge and survival with a good neurological outcome (CPC 1 or 2), and associations between organ dysfunction SOFA and APACHE-II scores and outcomes. Associations were assessed using fisher's exact test for categorical variables and Mann-Whitney and T test for continuous variables. Multivariable models were also constructed for all measurements showing associations in previous tests. For severity scores compatibility, we used receiver-operating curve (ROC). RESULTS Overall 369 patients (median age 75 years, 65% male) were included. Most arrests (64%) were witnessed, bystander CPR was provided in 15%. Median call to arrival time was 4 min. The presenting rhythm was asystole in 48% and VT/VF in 22%. Cardiovascular causes of arrest predominated (48%, n = 178). The median length of hospitalization was 5 days. Overall 28% of the patients (n = 98) survived to hospital discharge, mostly with a good neurological status (18.7%, n = 57). The rates of organ dysfunction were: hemodynamic instability 65% (n = 247), respiratory dysfunction 94% (n = 296), kidney dysfunction 70% (n = 259), hepatic dysfunction 14% (n = 50). The median SOFA score on day 1 was 9 and the median APACHE II score was 34. Modeling was limited by missing data. Neurological dysfunction (i.e. GCS and seizures) and kidney injury were consistently correlated with the outcomes in the multivariable models. Severity of critical illness assessed by above scoring systems correlated with mortality (all ROC curves had an AUC ranging between 0.728 and 0.849). CONCLUSIONS Multiorgan failure is common after ROSC (1-4). Therefore, the management of patients after ROSC may require advanced multidisciplinary care. Scores describing the severity of critical illness should be routinely reported in resuscitation research. Our unique setting where withdrawal of care is illegal, allows assessment of extremely ill patients and may assist in defining margins for futility.
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Affiliation(s)
- Yaacov Hasin
- Department of Internal Medicine A, Hadassah Hebrew University Medical Center, Kalman Yaakov Man St, Ein Kerem, 91120, Jerusalem, Israel.
| | - Yigal Helviz
- Intensive Care Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Sharon Einav
- Intensive Care Unit, Shaare Zedek Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
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Guo Y, Gharibani P, Agarwal P, Cho S, Thakor NV, Geocadin RG. Hyperacute autonomic and cortical function recovery following cardiac arrest resuscitation in a rodent model. Ann Clin Transl Neurol 2023; 10:2223-2237. [PMID: 37776065 PMCID: PMC10723251 DOI: 10.1002/acn3.51907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 08/29/2023] [Accepted: 09/11/2023] [Indexed: 10/01/2023] Open
Abstract
OBJECTIVE There is a complex interaction between nervous and cardiovascular systems, but sparse data exist on brain-heart electrophysiological responses to cardiac arrest resuscitation. Our aim was to investigate dynamic changes in autonomic and cortical function during hyperacute stage post-resuscitation. METHODS Ten rats were resuscitated from 7-min cardiac arrest, as indicators of autonomic response, heart rate (HR), and its variability (HRV) were measured. HR was monitored through continuous electrocardiography, while HRV was assessed via spectral analysis, whereby the ratio of low-/high-frequency (LF/HF) power indicates the balance between sympathetic/parasympathetic activities. Cortical response was evaluated by continuous electroencephalography and quantitative analysis. Parameters were quantified at 5-min intervals over the first-hour post-resuscitation. Neurological outcome was assessed by Neurological Deficit Score (NDS, range 0-80, higher = better outcomes) at 4-h post-resuscitation. RESULTS A significant increase in HR was noted over 15-30 min post-resuscitation (p < 0.01 vs.15-min, respectively) and correlated with higher NDS (rs = 0.56, p < 0.01). LF/HF ratio over 15-20 min was positively correlated with NDS (rs = 0.75, p < 0.05). Gamma band power surged over 15-30 min post-resuscitation (p < 0.05 vs. 0-15 min, respectively), and gamma band fraction during this period was associated with NDS (rs ≥0.70, p < 0.05, respectively). Significant correlations were identified between increased HR and gamma band power during 15-30 min (rs ≥0.83, p < 0.01, respectively) and between gamma band fraction and LF/HF ratio over 15-20 min post-resuscitation (rs = 0.85, p < 0.01). INTERPRETATIONS Hyperacute recovery of autonomic and cortical function is associated with favorable functional outcomes. While this observation needs further validation, it presents a translational opportunity for better autonomic and neurologic monitoring during early periods post-resuscitation to develop novel interventions.
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Affiliation(s)
- Yu Guo
- Department of Biomedical EngineeringJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Payam Gharibani
- Division of Neuroimmunology, Department of NeurologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Prachi Agarwal
- Department of Electrical and Computer EngineeringJohns Hopkins Whiting School of EngineeringBaltimoreMarylandUSA
| | - Sung‐Min Cho
- Departments of Neurology, Anesthesiology‐Critical Care Medicine and NeurosurgeryJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Nitish V. Thakor
- Department of Biomedical EngineeringJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Romergryko G. Geocadin
- Departments of Neurology, Anesthesiology‐Critical Care Medicine and NeurosurgeryJohns Hopkins University School of MedicineBaltimoreMarylandUSA
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Fan C, Sung C, Chen C, Chen C, Chen L, Chen Y, Chen J, Chiang W, Huang C, Huang EP. Updated trends in the outcomes of out-of-hospital cardiac arrest from 2017-2021: Prior to and during the coronavirus disease (COVID-19) pandemic. J Am Coll Emerg Physicians Open 2023; 4:e13070. [PMID: 38029023 PMCID: PMC10680430 DOI: 10.1002/emp2.13070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 10/10/2023] [Accepted: 10/31/2023] [Indexed: 12/01/2023] Open
Abstract
Objective This study aims to describe out-of-hospital cardiac arrest (OHCA) characteristics and trends before and during the coronavirus disease-2019 (COVID-19) pandemic in Taiwan. Methods We conducted a retrospective cohort study using a 5-year interrupted time series analysis. Eligible adults with non-traumatic OHCAs from January 2017 to December 2021 in 3 hospitals (university medical center, urban second-tier hospital, and rural second-tier hospital) were retrospectively enrolled. Variables were extracted from the emergency medical service reports and medical records. The years 2020 and 2021 were defined as the COVID-19 pandemic period. Outcomes included survival to admission after a sustained return of spontaneous circulation, survival to hospital discharge, and good neurological outcomes (cerebral performance category score 1 or 2). Results We analyzed 2819 OHCA, including 1227 from a university medical center, 617 from an urban second-tier hospital, and 975 from a rural second-tier hospital. The mean age was 71 years old, and 60% of patients were males. During the COVID-19 pandemic period, video-assisted endotracheal tube intubation replaced the traditional direct laryngoscopy intubation. The trends of outcomes in the pre-pandemic and pandemic periods varied among different hospitals. Compared with the pre-pandemic period, the outcomes at the university medical center during the COVID-19 pandemic were significantly poorer in several respects. The survival rate on admission dropped from 44.6% to 39.4% (P = 0.037), and the survival rate to hospital discharge fell from 17.5% to 14.9% (P = 0.042). Additionally, there was a notable decrease in patients' good neurological outcomes, declining from 13.2% to 9.7% (P = 0.048). In contrast, the outcomes in urban and rural second-tier hospitals during the COVID-19 pandemic did not significantly differ from those in the pre-pandemic period. Conclusions COVID-19 may alter some resuscitation management in OHCAs. There were no overall significant differences in outcomes before and during COVID-19 pandemic, but there were significant differences in outcomes when stratified by hospital types.
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Affiliation(s)
- Cheng‐Yi Fan
- Department of Emergency MedicineNational Taiwan University Hospital Hsin‐Chu BranchHsinchuTaiwan
| | - Chih‐Wei Sung
- Department of Emergency MedicineNational Taiwan University Hospital Hsin‐Chu BranchHsinchuTaiwan
- Department of Emergency MedicineCollege of MedicineNational Taiwan UniversityTaipeiTaiwan
| | - Ching‐Yu Chen
- Department of Emergency MedicineNational Taiwan University Hospital Yun‐Lin BranchDouliuTaiwan
| | - Chi‐Hsin Chen
- Department of Emergency MedicineNational Taiwan University Hospital Hsin‐Chu BranchHsinchuTaiwan
| | - Likwang Chen
- Institute of Population Health SciencesNational Health Research InstitutesMiaoliTaiwan
| | - Yun‐Chang Chen
- Department of Emergency MedicineNational Taiwan University Hospital Yun‐Lin BranchDouliuTaiwan
| | - Jiun‐Wei Chen
- Department of Emergency MedicineNational Taiwan University Hospital Hsin‐Chu BranchHsinchuTaiwan
| | - Wen‑Chu Chiang
- Department of Emergency MedicineCollege of MedicineNational Taiwan UniversityTaipeiTaiwan
- Department of Emergency MedicineNational Taiwan University Hospital Yun‐Lin BranchDouliuTaiwan
- Department of Emergency MedicineNational Taiwan University HospitalTaipeiTaiwan
| | - Chien‐Hua Huang
- Department of Emergency MedicineCollege of MedicineNational Taiwan UniversityTaipeiTaiwan
- Department of Emergency MedicineNational Taiwan University HospitalTaipeiTaiwan
| | - Edward Pei‐Chuan Huang
- Department of Emergency MedicineNational Taiwan University Hospital Hsin‐Chu BranchHsinchuTaiwan
- Department of Emergency MedicineCollege of MedicineNational Taiwan UniversityTaipeiTaiwan
- Department of Emergency MedicineNational Taiwan University HospitalTaipeiTaiwan
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Htet NN, Jafari D, Walker JA, Pourmand A, Shaw A, Dinh K, Tran QK. Trend of Outcome Metrics in Recent Out-of-Hospital-Cardiac-Arrest Research: A Narrative Review of Clinical Trials. J Clin Med 2023; 12:7196. [PMID: 38002808 PMCID: PMC10672249 DOI: 10.3390/jcm12227196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 11/10/2023] [Accepted: 11/13/2023] [Indexed: 11/26/2023] Open
Abstract
Cardiopulmonary resuscitation (CPR) research traditionally focuses on survival. In 2018, the International Liaison Committee on Resuscitation (ILCOR) proposed more patient-centered outcomes. Our narrative review assessed clinical trials after 2018 to identify the trends of outcome metrics in the field OHCA research. We performed a search of the PubMed database from 1 January 2019 to 22 September 2023. Prospective clinical trials involving adult humans were eligible. Studies that did not report any patient-related outcomes or were not available in full-text or English language were excluded. The articles were assessed for demographic information and primary and secondary outcomes. We included 89 studies for analysis. For the primary outcome, 31 (35%) studies assessed neurocognitive functions, and 27 (30%) used survival. For secondary outcomes, neurocognitive function was present in 20 (22%) studies, and survival was present in 10 (11%) studies. Twenty-six (29%) studies used both survival and neurocognitive function. Since the publication of the COSCA guidelines in 2018, there has been an increased focus on neurologic outcomes. Although survival outcomes are used frequently, we observed a trend toward fewer studies with ROSC as a primary outcome. There were no quality-of-life assessments, suggesting a need for more studies with patient-centered outcomes that can inform the guidelines for cardiac-arrest management.
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Affiliation(s)
- Natalie N. Htet
- Department of Emergency Medicine, Stanford University, Stanford, CA 94305, USA;
| | - Daniel Jafari
- Donald and Barbara Zucker School of Medicine Hofstra Northwell, Hempstead, NY 11549, USA;
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY 11030, USA
| | - Jennifer A. Walker
- Department of Emergency Medicine, Baylor Scott and White All Saints Medical Center, Fort Worth, TX 76104, USA;
- Department of Emergency Medicine, Burnett School of Medicine, Texas Christian University, Fort Worth, TX 76109, USA
| | - Ali Pourmand
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC 20037, USA;
| | - Anna Shaw
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Khai Dinh
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Quincy K. Tran
- Research Associate Program in Emergency Medicine and Critical Care, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Program in Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD 21201, USA
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30
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Adams D, Nathanson BH, White CN, Jackson EA, Mader TJ, Coute RA. Predicting Neurologically Intact Survival for Advanced Age Adults After Successful Resuscitation of Out-of-Hospital Cardiac Arrest. Am J Cardiol 2023; 207:222-228. [PMID: 37757519 DOI: 10.1016/j.amjcard.2023.08.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/14/2023] [Accepted: 08/20/2023] [Indexed: 09/29/2023]
Abstract
We sought to predict survival to hospital discharge with favorable neurologic outcome for advanced age adults (≥65 years) after successful resuscitation of non-traumatic out-of-hospital cardiac arrest (OHCA). A retrospective observational cohort analysis was performed using the national Cardiac Arrest Registry to Enhance Survival database from January 1, 2013 to December 31, 2021. All nontraumatic OHCA occurring in advanced age adults who survived to hospital admission were included. The primary outcome was survival with favorable neurologic outcome defined as a cerebral performance category score of 1 or 2 at hospital discharge. Multivariable logistic regression including patient variables (age category, gender, co-morbidities) and OHCA characteristics (location, rhythm category, witnessed status, and who initiated cardiopulmonary resuscitation) were used to predict hospital outcome. 83,574 patients met study inclusion criteria with 19,298 (23.1%) surviving with favorable neurologic outcome. The median age was 75 years (interquartile range 69 to 82 years), 58.9% were male, and a majority of events occurred at home (67.3%). Age was found to have a linear, negative association with outcome. Survival with cerebral performance category 1 or 2 ranged from 28.8% in those between the age of 65 to 69 years (n = 23,161) and 13.7% for those age >90 years (n = 4,666). The regression model produced outcome probabilities ranging from 2.6% to 80.8% with a cross-validated AUROC of 0.742 (95% confidence interval 0.738 to 0.746) and a Brier score of 0.151. In conclusion, a simple model with basic patient and OHCA characteristics can predict hospital outcomes in advanced age adults with good discrimination and calibration.
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Affiliation(s)
- Dylana Adams
- Department of Emergency Medicine, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama
| | | | - Christopher N White
- Department of Emergency Medicine, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama
| | - Elizabeth A Jackson
- Division of Cardiovascular Disease, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama
| | - Timothy J Mader
- Department of Emergency Medicine, UMass Chan Medical School-Baystate, Springfield, Massachusetts; Department of Healthcare Delivery and Population Science, UMass Chan Medical School-Baystate, Springfield, Massachusetts
| | - Ryan A Coute
- Department of Emergency Medicine, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama.
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Tanaka Gutiez M, Beuchat I, Novy J, Ben-Hamouda N, Rossetti AO. Outcome of comatose patients following cardiac arrest: When mRS completes CPC. Resuscitation 2023; 192:109997. [PMID: 37827427 DOI: 10.1016/j.resuscitation.2023.109997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 10/05/2023] [Accepted: 10/06/2023] [Indexed: 10/14/2023]
Abstract
AIM Good outcome in patients following cardiac arrest (CA) is usually defined as Cerebral Performance Category (CPC) 1-2, while CPC 3 is debated, and CPC 4-5 represent poor outcome. We aimed to assess when the modified Rankin Scale (mRS) can improve CPC outcome description, especially in CPC 3. We further aimed to correlate neuron specific enolase (NSE) with both functional measures to explore their relationship with neuronal damage. METHODS Peak NSE within the first 48 hours, and CPC and mRS at 3 months were prospectively collected for 665 consecutive comatose adults following CA treated between April 2016 and April 2023. For each CPC category, mRS was described. We considered good outcome as mRS 1-3, in line with existing recommendations. CPC and mRS were correlated to peak serum NSE using non-parametric assessments. RESULTS CPC 1, 2, 4 and 5 correlated almost perfectly with mRS in terms of good and poor outcomes. However, CPC 3 was heterogeneously associated to the dichotomized mRS (53.1% had good outcome (mRS 0-3), 46.9% poor outcome (mRS 4-6)). NSE was strongly correlated with CPC (Spearman's rho 0.616, P < 0.001) and mRS (Spearman's rho 0.613, P < 0.001). CONCLUSION CPC and mRS correlate similarly with neuronal damage. Whilst CPC 1-2 and CPC 4-5 are strongly associated with mRS 0-3 and, respectively, with mRS 5-6, CPC 3 is heterogenous: both good and poor mRS scores are found within this category. Therefore, we suggest that the mRS should be routinely assessed in patients with CPC 3 to refine outcome description.
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Affiliation(s)
- Masumi Tanaka Gutiez
- Department of Neurology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland; Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - Isabelle Beuchat
- Department of Neurology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Jan Novy
- Department of Neurology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Nawfel Ben-Hamouda
- Department of Adult Intensive Care Medicine, 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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Jung J, Ryu JH, Shon S, Min M, Hyun TG, Chun M, Lee D, Lee M. Predicting in-hospital cardiac arrest outcomes: CASPRI and GO-FAR scores. Sci Rep 2023; 13:18087. [PMID: 37872179 PMCID: PMC10593798 DOI: 10.1038/s41598-023-44312-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 10/06/2023] [Indexed: 10/25/2023] Open
Abstract
It is important to predict the neurological prognoses of in-hospital cardiac arrest (IHCA) patients immediately after recovery of spontaneous circulation (ROSC) to make further critical management. The aim of this study was to confirm the usefulness of the Cardiac Arrest Survival Post-Resuscitation In-hospital (CASPRI) and Good Outcome Following Attempted Resuscitation (GO-FAR) scores for predicting the IHCA immediately after the ROSC. This is a retrospective analysis of patient data from a tertiary general hospital located in South Korea. A total of 488 adult patients who had IHCA and achieved sustained ROSC from September 2016 to August 2021 were analyzed to compare effectiveness of the CASPRI and GO-FAR scores related to neurologic prognosis. The primary outcome was Cerebral Performance Category (CPC) score at discharge, defined as a CPC score of 1 or 2. The secondary outcomes were survival-to-discharge and normal neurological status or minimal neurological damage at discharge. Of the 488 included patients, 85 (20.8%) were discharged with good prognoses (CPC score of 1 or 2). The area under the receiver operating characteristic curve of CASPRI score for the prediction of a good neurological outcome was 0.75 (95% CI 0.69-0.81), whereas that of GO-FAR score was 0.67 (95% CI 0.60-0.73). The results of this study show that these scoring systems can be used for timely and satisfactory prediction of the neurological prognoses of IHCA patients after ROSC.
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Affiliation(s)
- Jonghee Jung
- Department of Emergency Medicine, Pusan National University Yangsan Hospital, Kumoh-ro 20, Mulgum-up, Yangsan-si, Gyeongsangnam-do, 50612, Korea
| | - Ji Ho Ryu
- Department of Emergency Medicine, Pusan National University Yangsan Hospital, Kumoh-ro 20, Mulgum-up, Yangsan-si, Gyeongsangnam-do, 50612, Korea
- Department of Emergency Medicine, Pusan National University School of Medicine, Yangsan-si, Gyeongsangnam-do, 50612, Korea
| | - Seungwoo Shon
- Department of Emergency Medicine, Pusan National University Yangsan Hospital, Kumoh-ro 20, Mulgum-up, Yangsan-si, Gyeongsangnam-do, 50612, Korea
| | - Munki Min
- Department of Emergency Medicine, Pusan National University Yangsan Hospital, Kumoh-ro 20, Mulgum-up, Yangsan-si, Gyeongsangnam-do, 50612, Korea
- Department of Emergency Medicine, Pusan National University School of Medicine, Yangsan-si, Gyeongsangnam-do, 50612, Korea
| | - Tae Gyu Hyun
- Department of Emergency Medicine, Pusan National University Yangsan Hospital, Kumoh-ro 20, Mulgum-up, Yangsan-si, Gyeongsangnam-do, 50612, Korea
| | - Mose Chun
- Department of Emergency Medicine, Pusan National University Yangsan Hospital, Kumoh-ro 20, Mulgum-up, Yangsan-si, Gyeongsangnam-do, 50612, Korea
| | - Daesup Lee
- Department of Emergency Medicine, Pusan National University Yangsan Hospital, Kumoh-ro 20, Mulgum-up, Yangsan-si, Gyeongsangnam-do, 50612, Korea
| | - Minjee Lee
- Department of Emergency Medicine, Pusan National University Yangsan Hospital, Kumoh-ro 20, Mulgum-up, Yangsan-si, Gyeongsangnam-do, 50612, Korea.
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Gaisendrees C, Pooth JS, Luehr M, Sabashnikov A, Yannopoulos D, Wahlers T. Extracorporeal Cardiopulmonary Resuscitation. DEUTSCHES ARZTEBLATT INTERNATIONAL 2023; 120:703-710. [PMID: 37656466 DOI: 10.3238/arztebl.m2023.0189] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 08/04/2023] [Accepted: 08/04/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Around the world, survival rates after cardiac arrest range between <14% for in-hospital (IHCA) and <10% for outof- hospital cardiac arrest (OHCA). This situation could potentially be improved by using extracorporeal membrane oxygenation (ECMO) during cardiopulmonary resuscitation (CPR), i.e. by extracorporeal cardiopulmonary resuscitation (ECPR). METHODS A selective literature search of Pubmed and Embase using the searching string ((ECMO) OR (ECLS)) AND (ECPR)) was carried out in February 2023 to prepare an up-to-date review of published trials comparing the outcomes of ECPR with those of conventional CPR. RESULTS Out of 573 initial results, 12 studies were included in this review, among them three randomized controlled trials comparing ECPR with CPR, involving a total of 420 patients. The survival rates for ECPR ranged from 20% to 43% for OHCA and 20% to 30.4% for IHCA. Most of the publications were associated with a high degree of bias and a low level of evidence. CONCLUSION ECPR can potentially improve survival rates after cardiac arrest compared to conventional CPR when used in experienced, high-volume centers in highly selected patients (young age, initial shockable rhythm, witnessed cardiac arrest, therapy-refractory high-quality CPR). No general recommendation for the use of ECPR can be issued at present.
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Affiliation(s)
- Christopher Gaisendrees
- Department of Cardiac Surgery, Intensive Care Medicine and Thoracic Surgery, University Hospital Cologne, Cologne, Germany; Center for Resuscitation Medicine, University of Minnesota, Minneapolis, USA; Emergency Department (UNZ), Medical Center - University of Freiburg, Medical Faculty, Freiburg, Germany
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Randhawa VK, Hernandez-Montfort J, Kanwar M. Clinical Risk Scores to Guide Therapies for OHCA Survivors: The MIRACLE 2 We've Been Searching For? JACC Cardiovasc Interv 2023; 16:2451-2453. [PMID: 37821190 DOI: 10.1016/j.jcin.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 09/06/2023] [Indexed: 10/13/2023]
Affiliation(s)
- Varinder K Randhawa
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Division of Cardiology, St Michael's Hospital, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
| | - Jaime Hernandez-Montfort
- Advanced Heart Disease, Recovery and Replacement Program, Baylor Scott and White Health, Temple, Texas, USA
| | - Manreet Kanwar
- Cardiovascular Institute, Alleghany General Hospital, Pittsburgh, Pennsylvania, USA
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Kimura N, Nishimura Y, Chung-Esaki H. Factors Associated with Favorable Outcomes in Cardiac Arrest and Target Temperature Management. Ther Hypothermia Temp Manag 2023. [PMID: 37792291 DOI: 10.1089/ther.2023.0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023] Open
Abstract
Current guidelines strongly recommend providing targeted temperature management (TTM) after cardiac arrest, but hypothalamic dysregulation may confound TTM's impact on a patient's ultimate outcome. Although time to reach target temperature has largely been viewed as a process measure for TTM protocols, the difference between initial presenting temperature and target temperature (Δ-temperature) may be a potential surrogate marker of hypothalamic dysregulation. We performed a retrospective observational study to explore whether Δ-temperature was associated with neurologic outcomes and mortality. We included 86 patients (53 with out-of-hospital cardiac arrest [OHCA] and 33 with in-hospital cardiac arrest [IHCA]) in our analysis; more than half of the patients were cooled to 33°C (56.9% in OHCA and 57.6% in IHCA). In univariate logistic regression analysis, Δ-temperature alone did not appear to be statistically associated with mortality or neurologic outcomes regardless of target temperature. In exploratory analysis, longer time from TTM initiation-to-target was associated with worse neurological outcomes in the 33°C target (odds ratio = 0.996, 95% confidence interval = 0.992-1.000). Further research investigating the impact of hypothalamic dysregulation and Δ-temperature as well as the rate of cooling may be warranted to elucidate additional factors contributing to outcomes after cardiac arrest. In addition, our study population was noted to have a higher proportion of Asians and Native Hawaiians/Pacific Islanders, with a potential disparity in outcomes. Future studies may be warranted to ensure generalizability of TTM protocols and findings across populations.
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Affiliation(s)
- Nobuhiko Kimura
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawaii, USA
| | - Yoshito Nishimura
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawaii, USA
| | - Hangyul Chung-Esaki
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawaii, USA
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Steinberg A, Fischhoff B. Cognitive Biases and Shared Decision Making in Acute Brain Injury. Semin Neurol 2023; 43:735-743. [PMID: 37793424 DOI: 10.1055/s-0043-1775596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
Many patients hospitalized after severe acute brain injury are comatose and require life-sustaining therapies. Some of these patients make favorable recoveries with continued intensive care, while others do not. In addition to providing medical care, clinicians must guide surrogate decision makers through high-stakes, emotionally charged decisions about whether to continue life-sustaining therapies. These consultations require clinicians first to assess a patient's likelihood of recovery given continued life-sustaining therapies (i.e., prognosticate), then to communicate that prediction to surrogates, and, finally, to elicit and interpret the patient's preferences. At each step, both clinicians and surrogates are vulnerable to flawed decision making. Clinicians can be imprecise, biased, and overconfident when prognosticating after brain injury. Surrogates can misperceive the choice and misunderstand or misrepresent a patient's wishes, which may never have been communicated clearly. These biases can undermine the ability to reach choices congruent with patients' preferences through shared decision making (SDM). Decision science has extensively studied these biases. In this article, we apply that research to improving SDM for patients who are comatose after acute brain injury. After introducing SDM and the medical context, we describe principal decision science results as they relate to neurologic prognostication and end-of-life decisions, by both clinicians and surrogates. Based on research regarding general processes that can produce imprecise, biased, and overconfident prognoses, we propose interventions that could improve SDM, supporting clinicians and surrogates in making these challenging decisions.
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Affiliation(s)
- Alexis Steinberg
- Department of Critical Care Medicine, Neurology, and Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Baruch Fischhoff
- Department of Engineering and Public Policy, Institute for Politics and Strategy, Carnegie Mellon University, Pittsburgh, Pennsylvania
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Miranda SP, Morris RS, Rabas M, Creutzfeldt CJ, Cooper Z. Early Shared Decision-Making for Older Adults with Traumatic Brain Injury: Using Time-Limited Trials and Understanding Their Limitations. Neurocrit Care 2023; 39:284-293. [PMID: 37349599 DOI: 10.1007/s12028-023-01764-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 05/11/2023] [Indexed: 06/24/2023]
Abstract
Older adults account for a disproportionate share of the morbidity and mortality after traumatic brain injury (TBI). Predicting functional and cognitive outcomes for individual older adults after TBI is challenging in the acute phase of injury. Given that neurologic recovery is possible and uncertain, life-sustaining therapy may be pursued initially, even if for some, there is a risk of survival to an undesired level of disability or dependence. Experts recommend early conversations about goals of care after TBI, but evidence-based guidelines for these discussions or for the optimal method for communicating prognosis are limited. The time-limited trial (TLT) model may be an effective strategy for managing prognostic uncertainty after TBI. TLTs can provide a framework for early management: specific treatments or procedures are used for a defined period of time while monitoring for an agreed-upon outcome. Outcome measures, including signs of worsening and improvement, are defined at the outset of the trial. In this Viewpoint article, we discuss the use of TLTs for older adults with TBI, their potential benefits, and current challenges to their application. Three main barriers limit the implementation of TLTs in these scenarios: inadequate models for prognostication; cognitive biases faced by clinicians and surrogate decision-makers, which may contribute to prognostic discordance; and ambiguity regarding appropriate endpoints for the TLT. Further study is needed to understand clinician behaviors and surrogate preferences for prognostic communication and how to optimally integrate TLTs into the care of older adults with TBI.
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Affiliation(s)
- Stephen P Miranda
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA.
- Perelman Center for Advanced Medicine, 15 South Tower, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA.
| | - Rachel S Morris
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mackenzie Rabas
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Zara Cooper
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
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Urben T, Amacher SA, Becker C, Gross S, Arpagaus A, Tisljar K, Sutter R, Pargger H, Marsch S, Hunziker S. Red blood cell distribution width for the prediction of outcomes after cardiac arrest. Sci Rep 2023; 13:15081. [PMID: 37700019 PMCID: PMC10497505 DOI: 10.1038/s41598-023-41984-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 09/04/2023] [Indexed: 09/14/2023] Open
Abstract
The red blood cell distribution width (RDW) is a routinely available blood marker that measures the variation of the size/volume of red blood cells. The aim of our study was to investigate the prognostic value of RDW in cardiac arrest patients and to assess whether RDW improves the prognostic value of three cardiac arrest-specific risk scores. Consecutive adult cardiac arrest patients admitted to the ICU of a Swiss university hospital were included. The primary outcome was poor neurological outcome at hospital discharge assessed by Cerebral Performance Category. Of 702 patients admitted to the ICU after cardiac arrest, 400 patients (57.0%) survived, of which 323 (80.8%) had a good neurological outcome. Higher mean RDW values showed an independent association with poor neurological outcomes at hospital discharge (adjusted OR 1.27, 95% CI 1.14 to 1.41; p < 0.001). Adding the maximum RDW value to the OHCA- CAHP- and PROLOGUE cardiac arrest scores improved prognostic performance. Within this cohort of cardiac arrest patients, RDW was an independent outcome predictor and slightly improved three cardiac arrest-specific risk scores. RDW may therefore support clinical decision-making.
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Affiliation(s)
- Tabita Urben
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031, Basel, Switzerland
| | - Simon A Amacher
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031, Basel, Switzerland
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
| | - Christoph Becker
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031, Basel, Switzerland
- Department of Emergency Medicine, University Hospital Basel, Basel, Switzerland
| | - Sebastian Gross
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031, Basel, Switzerland
| | - Armon Arpagaus
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031, Basel, Switzerland
| | - Kai Tisljar
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
| | - Raoul Sutter
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
- Medical Faculty, University of Basel, Basel, Switzerland
| | - Hans Pargger
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
- Medical Faculty, University of Basel, Basel, Switzerland
| | - Stephan Marsch
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
- Medical Faculty, University of Basel, Basel, Switzerland
| | - Sabina Hunziker
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031, Basel, Switzerland.
- Medical Faculty, University of Basel, Basel, Switzerland.
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Srinivasan V, Hall J, Wahlster S, Johnson NJ, Branch K. Associations between clinical characteristics of cardiac arrest and early CT head findings of hypoxic ischaemic brain injury following out-of-hospital cardiac arrest. Resuscitation 2023; 190:109858. [PMID: 37270091 DOI: 10.1016/j.resuscitation.2023.109858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/23/2023] [Accepted: 05/25/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND/OBJECTIVE Post-cardiac arrest patients are vulnerable to hypoxic-ischaemic brain injury (HIBI), but HIBI may not be identified until computed tomography (CT) scan of the brain is obtained post-resuscitation and stabilization. We aimed to evaluate the association of clinical arrest characteristics with early CT findings of HIBI to identify those at the highest risk for HIBI. METHODS This is a retrospective analysis of out-of-hospital cardiac arrest (OHCA) patients who underwent whole-body imaging. Head CT reports were analyzed with an emphasis on findings suggestive of HIBI; HIBI was present if any of the following were noted on the neuroradiologist read: global cerebral oedema, sulcal effacement, blurred grey-white junction, and ventricular compression. The primary exposure was duration of cardiac arrest. Secondary exposures included age, cardiac vs noncardiac etiology, and witnessed vs unwitnessed arrest. The primary outcome was CT findings of HIBI. RESULTS A total of 180 patients (average age 54 years, 32% female, 71% White, 53% witnessed arrest, 32% cardiac etiology of arrest, mean CPR duration of 15 ± 10 minutes) were included in this analysis. CT findings of HIBI were seen in 47 (48.3%) patients. Multivariate logistic regression demonstrated a significant association between CPR duration and HIBI (adjusted OR = 1.1, 95% CI 1.01-1.11, p < 0.01). CONCLUSION Signs of HIBI are commonly seen on CT head within 6 hours of OHCA, occurring in approximately half of patients, and are associated with CPR duration. Determining risk factors for abnormal CT findings can help clinically identify patients at higher risk for HIBI and target interventions appropriately.
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Affiliation(s)
- Vasisht Srinivasan
- Department of Emergency Medicine, University of Washington School of Medicine, United States.
| | - Jane Hall
- Department of Emergency Medicine, University of Washington School of Medicine, United States
| | - Sarah Wahlster
- Department of Neurology, University of Washington School of Medicine, United States; Department of Neurosurgery, University of Washington School of Medicine, United States; Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, United States
| | - Nicholas J Johnson
- Department of Emergency Medicine, University of Washington School of Medicine, United States; Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington School of Medicine, United States
| | - Kelley Branch
- Department of Medicine, Division of Cardiology, University of Washington School of Medicine, United States
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Ijuin S, Liu K, Gill D, Kyun Ro S, Vukovic J, Ishihara S, Belohlavek J, Li Bassi G, Suen JY, Fraser JF. Current animal models of extracorporeal cardiopulmonary resuscitation: A scoping review. Resusc Plus 2023; 15:100426. [PMID: 37519410 PMCID: PMC10372365 DOI: 10.1016/j.resplu.2023.100426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 06/22/2023] [Accepted: 06/29/2023] [Indexed: 08/01/2023] Open
Abstract
Aim Animal models of Extracorporeal Cardiopulmonary Resuscitation (ECPR) focusing on neurological outcomes are required to further the development of this potentially life-saving technology. The aim of this review is to summarize current animal models of ECPR. Methods A comprehensive database search of PubMed, EMBASE, and Web of Science was undertaken. Full-text publications describing animal models of ECPR between January 1, 2000, and June 30, 2022, were identified and included in the review. Data describing the conduct of the animal models of ECPR, measured variables, and outcomes were extracted according to pre-defined definitions. Results The search strategy yielded 805 unique reports of which 37 studies were included in the final analysis. Most studies (95%) described using a pig model of ECPR with the remainder (5%) describing a rat model. The most common method for induction of cardiac arrest was a fatal ventricular arrhythmia through electrical stimulation (70%). 10 studies reported neurological assessment of animals using physical examination, serum biomarkers, or electrophysiological findings, however, only two studies described a multimodal assessment. No studies reported the use of brain imaging as part of the neurological assessment. Return of spontaneous circulation was the most reported primary outcome, and no studies described the neurological status of the animal as the primary outcome. Conclusion Current animal models of ECPR do not describe clinically relevant neurological outcomes after cardiac arrest. Further work is needed to develop models that more accurately mimic clinical scenarios and can test innovations that can be translated to the application of ECPR in clinical medicine.
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Affiliation(s)
- Shinichi Ijuin
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Japan
| | - Keibun Liu
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Denzil Gill
- Faculty of Medicine, University of Queensland, Brisbane, Australia
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia
| | - Sun Kyun Ro
- Faculty of Medicine, University of Queensland, Brisbane, Australia
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Japan
- Department of Thoracic and Cardiovascular Surgery, Hanyang University Guri Hospital, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Jana Vukovic
- School of Biomedical Sciences, University of Queensland, Brisbane, Australia
| | - Satoshi Ishihara
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Japan
| | - Jan Belohlavek
- Second Department of Internal Medicine, Cardiovascular Medicine, General University Hospital and First Medical School, Charles University in Prague, Czech Republic
| | - Gianluigi Li Bassi
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
- Queensland University of Technology, Brisbane, Australia
| | - Jacky Y Suen
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia
- Queensland University of Technology, Brisbane, Australia
- St. Andrews War Memorial Hospital, Brisbane, Australia
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Hoedemaekers C, Hofmeijer J, Horn J. Value of EEG in outcome prediction of hypoxic-ischemic brain injury in the ICU: A narrative review. Resuscitation 2023; 189:109900. [PMID: 37419237 DOI: 10.1016/j.resuscitation.2023.109900] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/26/2023] [Accepted: 06/29/2023] [Indexed: 07/09/2023]
Abstract
Prognostication of comatose patients after cardiac arrest aims to identify patients with a large probability of favourable or unfavouble outcome, usually within the first week after the event. Electroencephalography (EEG) is a technique that is increasingly used for this purpose and has many advantages, such as its non-invasive nature and the possibility to monitor the evolution of brain function over time. At the same time, use of EEG in a critical care environment faces a number of challenges. This narrative review describes the current role and future applications of EEG for outcome prediction of comatose patients with postanoxic encephalopathy.
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Affiliation(s)
- Cornelia Hoedemaekers
- Department of Critical Care, Radboud University Nijmegen Medical Center, Nijmegen, 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
| | - Janneke Horn
- Department of Critical Care, Amsterdam University Medical Center, Location AMC, Amsterdam, the Netherlands
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Sarigul B, Bell RS, Chesnut R, Aguilera S, Buki A, Citerio G, Cooper DJ, Diaz-Arrastia R, Diringer M, Figaji A, Gao G, Geocadin RG, Ghajar J, Harris O, Hoffer A, Hutchinson P, Joseph M, Kitagawa R, Manley G, Mayer SA, Menon DK, Meyfroidt G, Michael DB, Oddo M, Okonkwo DO, Patel MB, Robertson C, Rosenfeld JV, Rubiano AM, Sahuquillo J, Servadei F, Shutter L, Stein DD, Stocchetti N, Taccone FS, Timmons SD, Tsai E, Ullman JS, Vespa P, Videtta W, Wright DW, Zammit C, Hawryluk GWJ. Prognostication and Goals of Care Decisions in Severe Traumatic Brain Injury: A Survey of The Seattle International Severe Traumatic Brain Injury Consensus Conference Working Group. J Neurotrauma 2023; 40:1707-1717. [PMID: 36932737 DOI: 10.1089/neu.2022.0414] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023] Open
Abstract
Abstract Best practice guidelines have advanced severe traumatic brain injury (TBI) care; however, there is little that currently informs goals of care decisions and processes despite their importance and frequency. Panelists from the Seattle International severe traumatic Brain Injury Consensus Conference (SIBICC) participated in a survey consisting of 24 questions. Questions queried use of prognostic calculators, variability in and responsibility for goals of care decisions, and acceptability of neurological outcomes, as well as putative means of improving decisions that might limit care. A total of 97.6% of the 42 SIBICC panelists completed the survey. Responses to most questions were highly variable. Overall, panelists reported infrequent use of prognostic calculators, and observed variability in patient prognostication and goals of care decisions. They felt that it would be beneficial for physicians to improve consensus on what constitutes an acceptable neurological outcome as well as what chance of achieving that outcome is acceptable. Panelists felt that the public should help to define what constitutes a good outcome and expressed some support for a "nihilism guard." More than 50% of panelists felt that if it was certain to be permanent, a vegetative state or lower severe disability would justify a withdrawal of care decision, whereas 15% felt that upper severe disability justified such a decision. Whether conceptualizing an ideal or existing prognostic calculator to predict death or an unacceptable outcome, on average a 64-69% chance of a poor outcome was felt to justify treatment withdrawal. These results demonstrate important variability in goals of care decision making and a desire to reduce this variability. Our panel of recognized TBI experts opined on the neurological outcomes and chances of those outcomes that might prompt consideration of care withdrawal; however, imprecision of prognostication and existing prognostication tools is a significant impediment to standardizing the approach to care-limiting decisions.
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Affiliation(s)
| | - Randy S Bell
- Uniformed Services University of Health Sciences, Avera Brain and Spine Institute, Sioux Falls, South Dakota, USA
| | - Randall Chesnut
- Departments of Neurological Surgery and Orthopaedic Surgery, School of Global Health, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | | | - Andras Buki
- Department of Neurosurgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
- NeuroIntensive Care, Department of Neuroscience, IRCCS Fondazione San Gerardo dei Tintori, Monza, Italy
| | - D Jamie Cooper
- Intensive Care Medicine, Australian and New Zealand Intensive Care Research Centre, Alfred Hospital, Melbourne, Victoria, Australia
| | - Ramon Diaz-Arrastia
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA
| | - Michael Diringer
- Department of Neurology, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Anthony Figaji
- Department of Neurosurgery, Division of Neurosurgery and Neuroscience Institute, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - Guoyi Gao
- Division of Neurotrauma, Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Romergryko G Geocadin
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jamshid Ghajar
- Department of Neurosurgery, Stanford Neuroscience Health Center, Palo Alto, California, USA
| | | | - Alan Hoffer
- University Hospitals of Cleveland, Cleveland, Ohio, USA
| | - Peter Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Mathew Joseph
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Ryan Kitagawa
- Vivian L Smith Department of Neurosurgery, McGovern Medical School at UTHealth, Houston, Texas, USA
| | - Geoffrey Manley
- Department of Neurosurgery, University of California San Francisco, San Francisco General Hospital & Trauma Center, San Francisco, California, USA
| | - Stephan A Mayer
- Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - David K Menon
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Daniel B Michael
- Department of Neurosurgery, Oakland University William Beaumont School of Medicine, Beaumont Health, Michigan Head & Spine Institute, Southfield, Michigan, USA
| | - Mauro Oddo
- Directorate of Innovation and Clinical Research, CHUV-Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - David O Okonkwo
- Departments of Neurological Surgery, Neurology and Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Mayur B Patel
- Critical Illness, Brain Dysfunction, and Survivorship Center; Center for Health Services Research; Tennessee Valley Healthcare System, Veterans Affairs Medical Center; Section of Surgical Sciences, Department of Surgery, Division of Acute Care Surgery Vanderbilt University Medical Center, Nashville, Tennessee
| | - Claudia Robertson
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Jeffrey V Rosenfeld
- Department of Neurosurgery, The Alfred Hospital, Melbourne, Victoria, Australia
- Department of Surgery, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Andres M Rubiano
- INUB/MEDITECH Research Group, Neurosciences Institute, El Bosque University, Bogotá, Colombia
- MEDITECH Foundation, Clinical Research, Cali, Colombia
| | - Juan Sahuquillo
- Department of Neurosurgery, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Spain
| | - Franco Servadei
- Department of Neurosurgery, IRCCS Humanitas Research Hospital and Humanitas University, Milano, Italy
| | - Lori Shutter
- Critical Care Medicine, Neurology and Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Deborah D Stein
- Program in Trauma, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, Dipartimento Fisiopatologia e Trapianti Universita di Milano, Scuola di Specializzazione Anestesia, Rianimazione, Terapia Intensiva e del Dolore, Neurorianimazione, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milano, Milano, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hospital Erasme, Université Libre de Bruxelles (ULB) Brussels, Belgium
| | - Shelly D Timmons
- Department of Neurological Surgery, Indiana University School of Medicine, Indiana, USA
| | - Eve Tsai
- Division of Neurosurgery, Department of Surgery, University of Ottawa, The Ottawa Hospital, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Jamie S Ullman
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Paul Vespa
- Department of Neurosurgery and Neurology, UCLA School of Medicine, Neurocritical Care, Ronald Reagan UCLA Medical Center, UCLA Medical Center, Santa Monica, California, USA
| | - Walter Videtta
- Intensive Care Medicine, Posadas Hospital, Buenos Aires, Argentina
| | - David W Wright
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Christopher Zammit
- Department of Emergency Medicine, University of Rochester Medical Center, School of Medicine and Dentistry, Rochester, New York, USA
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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] [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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Bencsik CM, Kramer AH, Couillard P, MacKay M, Kromm JA. Postarrest Neuroprognostication: Practices and Opinions of Canadian Physicians. Can J Neurol Sci 2023:1-12. [PMID: 37489539 DOI: 10.1017/cjn.2023.261] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
BACKGROUND Objective, evidence-based neuroprognostication of postarrest patients is crucial to avoid inappropriate withdrawal of life-sustaining therapies or prolonged, invasive, and costly therapies that could perpetuate suffering when there is no chance of an acceptable recovery. Postarrest prognostication guidelines exist; however, guideline adherence and practice variability are unknown. OBJECTIVE To investigate Canadian practices and opinions regarding assessment of neurological prognosis in postarrest patients. METHODS An anonymous electronic survey was distributed to physicians who care for adult postarrest patients. RESULTS Of the 134 physicians who responded to the survey, 63% had no institutional protocols for neuroprognostication. While the use of targeted temperature management did not affect the timing of neuroprognostication, an increasing number of clinical findings suggestive of a poor prognosis affected the timing of when physicians were comfortable concluding patients had a poor prognosis. Variability existed in what factors clinicians' thought were confounders. Physicians identified bilaterally absent pupillary light reflexes (85%), bilaterally absent corneal reflexes (80%), and status myoclonus (75%) as useful in determining poor prognosis. Computed tomography, magnetic resonance imaging, and spot electroencephalography were the most useful and accessible tests. Somatosensory evoked potentials were useful, but logistically challenging. Serum biomarkers were unavailable at most centers. Most (79%) physicians agreed ≥2 definitive findings on neurologic exam, electrophysiologic tests, neuroimaging, and/or biomarkers are required to determine a poor prognosis with a high degree of certainty. Distress during the process of neuroprognostication was reported by 70% of physicians and 51% request a second opinion from an external expert. CONCLUSION Significant variability exists in post-cardiac arrest neuroprognostication practices among Canadian physicians.
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Affiliation(s)
- Caralyn M Bencsik
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
| | - Andreas H 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
| | - Philippe Couillard
- 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 A 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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Lileikyte G, Bakochi A, Ali A, Moseby-Knappe M, Cronberg T, Friberg H, Lilja G, Levin H, Årman F, Kjellström S, Dankiewicz J, Hassager C, Malmström J, Nielsen N. Serum proteome profiles in patients treated with targeted temperature management after out-of-hospital cardiac arrest. Intensive Care Med Exp 2023; 11:43. [PMID: 37455296 DOI: 10.1186/s40635-023-00528-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 06/03/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND Definition of temporal serum proteome profiles after out-of-hospital cardiac arrest may identify biological processes associated with severe hypoxia-ischaemia and reperfusion. It may further explore intervention effects for new mechanistic insights, identify candidate prognostic protein biomarkers and potential therapeutic targets. This pilot study aimed to investigate serum proteome profiles from unconscious patients admitted to hospital after out-of-hospital cardiac arrest according to temperature treatment and neurological outcome. METHODS Serum samples at 24, 48, and 72 h after cardiac arrest at three centres included in the Target Temperature Management after out-of-hospital cardiac arrest trial underwent data-independent acquisition mass spectrometry analysis (DIA-MS) to find changes in serum protein concentrations associated with neurological outcome at 6-month follow-up and targeted temperature management (TTM) at 33 °C as compared to 36 °C. Neurological outcome was defined according to Cerebral Performance Category (CPC) scale as "good" (CPC 1-2, good cerebral performance or moderate disability) or "poor" (CPC 3-5, severe disability, unresponsive wakefulness syndrome, or death). RESULTS Of 78 included patients [mean age 66 ± 12 years, 62 (80.0%) male], 37 (47.4%) were randomised to TTM at 36 °C. Six-month outcome was poor in 47 (60.3%) patients. The DIA-MS analysis identified and quantified 403 unique human proteins. Differential protein abundance testing comparing poor to good outcome showed 19 elevated proteins in patients with poor outcome (log2-fold change (FC) range 0.28-1.17) and 16 reduced proteins (log2(FC) between - 0.22 and - 0.68), involved in inflammatory/immune responses and apoptotic signalling pathways for poor outcome and proteolysis for good outcome. Analysis according to level of TTM showed a significant protein abundance difference for six proteins [five elevated proteins in TTM 36 °C (log2(FC) between 0.33 and 0.88), one reduced protein (log2(FC) - 0.6)] mainly involved in inflammatory/immune responses only at 48 h after cardiac arrest. CONCLUSIONS Serum proteome profiling revealed an increase in inflammatory/immune responses and apoptosis in patients with poor outcome. In patients with good outcome, an increase in proteolysis was observed, whereas TTM-level only had a modest effect on the proteome profiles. Further validation of the differentially abundant proteins in response to neurological outcome is necessary to validate novel biomarker candidates that may predict prognosis after cardiac arrest.
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Affiliation(s)
- Gabriele Lileikyte
- Department of Clinical Sciences Lund, Anaesthesia and Intensive Care, Lund University, Helsingborg Hospital, Svartbrödragränden 3, 251 87, Helsingborg, Sweden.
| | - Anahita Bakochi
- Swedish National Infrastructure for Biological Mass Spectrometry (BioMS), Lund University, Lund, Sweden
- Department of Clinical Sciences Lund, Infection Medicine, Lund University, Lund, Sweden
| | - Ashfaq Ali
- National Bioinformatics Infrastructure Sweden (NBIS), SciLifeLab, Department of Immunotechnology, Lund University, Lund, Sweden
| | - Marion Moseby-Knappe
- Department of Clinical Sciences Lund, Neurology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Tobias Cronberg
- Department of Clinical Sciences Lund, Neurology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences Lund, Anaesthesia and Intensive Care, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Gisela Lilja
- Department of Clinical Sciences Lund, Neurology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Helena Levin
- Department of Clinical Sciences Lund, Department of Research and Education, Lund University, Skåne University Hospital, Lund, Sweden
| | - Filip Årman
- Swedish National Infrastructure for Biological Mass Spectrometry (BioMS), Lund University, Lund, Sweden
| | - Sven Kjellström
- Swedish National Infrastructure for Biological Mass Spectrometry (BioMS), Lund University, Lund, Sweden
| | - Josef Dankiewicz
- Department of Clinical Sciences Lund, Cardiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Christian Hassager
- Department of Cardiology, Rigshospitalet and Dept of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Johan Malmström
- Department of Clinical Sciences Lund, Infection Medicine, Lund University, Lund, Sweden
| | - Niklas Nielsen
- Department of Clinical Sciences Lund, Anaesthesia and Intensive Care, Lund University, Helsingborg Hospital, Svartbrödragränden 3, 251 87, Helsingborg, Sweden
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Elmer J, Steinberg A, Callaway CW. Paucity of neuroprognostic testing after cardiac arrest in the United States. Resuscitation 2023; 188:109762. [PMID: 36924822 PMCID: PMC10293050 DOI: 10.1016/j.resuscitation.2023.109762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 03/04/2023] [Accepted: 03/08/2023] [Indexed: 03/17/2023]
Abstract
BACKGROUND Withdrawal of life-sustaining therapies for perceived poor neurological prognosis is the most common cause of death for patients hospitalized after resuscitation from cardiac arrest. Accurate neuroprognostication is challenging and high stakes, so guidelines recommend multimodality testing. We quantified the frequency and timing with which guideline recommended diagnostics were acquired prior to in-hospital death after cardiac arrest. METHODS We performed a retrospective cohort study using the Optum® deidentified Electronic Health Record dataset for 2010 to 2021. We included in-hospital decedents admitted after resuscitation from non-traumatic cardiac arrest. We quantified the number of decedents who underwent head computed tomographic imaging, electroencephalography, somatosensory evoked potentials, brain magnetic resonance imaging, or evaluation by a neurologist, as well as the timing of these tests. RESULTS Of 34,585 included patients, median age was 66 [interquartile range 53 - 79] years and 13,609 (39%) were female. Median hospital length of stay was 0 days [0-1] days, and only 16% of deaths occurred on or after day three. Only 3,245 patients (9%) had at least one neurodiagnostic test acquired and only 1,708 (5%) were evaluated by a neurologist. The most common neurological diagnostic test to be obtained was CT imaging, acquired in 3,004 (9%) of the overall cohort. Only 852 patients (2%) of patients had at least two diagnostic modalities obtained. DISCUSSION In this retrospective cohort, we found few patients hospitalized after out-of-hospital cardiac arrest underwent guideline-recommended prognostic testing. If validated in prospective cohorts with more granular clinical information, better guideline adherence and more frequent use of multimodality neuroprognostication offer an opportunity to improve quality of post-arrest care.
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Affiliation(s)
- Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Alexis Steinberg
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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47
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Teixeira FJP, Ahmad B, Gibatova V, Ameli PA, da Silva I, Carneiro T, Roth W, Ford JL, Selfe TK, Greer DM, Busl KM, Maciel CB. Do Neuroprognostic Studies Account for Self-Fulfilling Prophecy Bias in Their Methodology? The SPIN Protocol for a Systematic Review. Crit Care Explor 2023; 5:e0943. [PMID: 37396931 PMCID: PMC10309514 DOI: 10.1097/cce.0000000000000943] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023] Open
Abstract
Self-fulfilling prophecy bias occurs when a perceived prognosis leads to treatment decisions that inherently modify outcomes of a patient, and thus, overinflate the prediction performance of prognostic methods. The goal of this series of systematic reviews is to characterize the extent to which neuroprognostic studies account for the potential impact of self-fulfilling prophecy bias in their methodology by assessing their adequacy of disclosing factors relevant to this bias. Methods Studies evaluating the prediction performance of neuroprognostic tools in cardiac arrest, malignant ischemic stroke, traumatic brain injury, subarachnoid hemorrhage, and spontaneous intracerebral hemorrhage will be identified through PubMed, Cochrane, and Embase database searches. Two reviewers blinded to each other's assessment will perform screening and data extraction of included studies using Distiller SR and following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We will abstract data pertinent to the methodology of the studies relevant to self-fulfilling prophecy bias. Results We will conduct a descriptive analysis of the data. We will summarize the reporting of mortality according to timing and mode of death, rates of exposure to withdrawal of life-sustaining therapy, reasoning behind limitations of supportive care, systematic use of standardized neuroprognostication algorithms and whether the tool being investigated is part of such assessments, and blinding of treatment team to results of neuroprognostic test being evaluated. CONCLUSIONS We will identify if neuroprognostic studies have been transparent in their methodology to factors that affect the self-fulfilling prophecy bias. Our results will serve as the foundation for standardization of neuroprognostic study methodologies by refining the quality of the data derived from such studies.
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Affiliation(s)
- Fernanda J P Teixeira
- Department of Neurology, University of Florida, Gainesville, FL
- Department of Neurology, University of Miami, Miami, FL
| | - Bakhtawar Ahmad
- Department of Neurology, University of Florida, Gainesville, FL
| | | | - Pouya A Ameli
- Department of Neurology, University of Florida, Gainesville, FL
- Department of Neurosurgery, University of Florida, Gainesville, FL
| | - Ivan da Silva
- Department of Neurology, University of Florida, Gainesville, FL
| | - Thiago Carneiro
- Department of Neurology, University of Florida, Gainesville, FL
| | - William Roth
- Department of Neurology, University of Florida, Gainesville, FL
- Department of Neurosurgery, University of Florida, Gainesville, FL
| | - Jenna L Ford
- Department of Neurology, University of Florida, Gainesville, FL
- Department of Neurosurgery, University of Florida, Gainesville, FL
| | - Terry Kit Selfe
- Academic Research Consulting and Services, University of Florida, Gainesville, FL
| | - David M Greer
- Department of Neurology, Boston University, Boston, MA
| | - Katharina M Busl
- Department of Neurology, University of Florida, Gainesville, FL
- Department of Neurosurgery, University of Florida, Gainesville, FL
| | - Carolina B Maciel
- Department of Neurology, University of Florida, Gainesville, FL
- Department of Neurosurgery, University of Florida, Gainesville, FL
- Department of Neurology, University of Utah, Salt Lake City, UT
- Department of Neurology, Yale School of Medicine, New Haven, CT
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48
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Lee S, Park JS, You Y, Min JH, Jeong W, Ahn HJ, In YN, Cho YC, Lee IH, Lee JK, Kang C. Preliminary Prognostication for Good Neurological Outcomes in the Early Stage of Post-Cardiac Arrest Care. Diagnostics (Basel) 2023; 13:2174. [PMID: 37443569 DOI: 10.3390/diagnostics13132174] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 06/15/2023] [Accepted: 06/23/2023] [Indexed: 07/15/2023] Open
Abstract
We investigated prognostic strategies for predicting good outcomes in the early stage of post-cardiac-arrest care using multiple prognostic tests that are available until 24 h after the return of spontaneous circulation (ROSC). A retrospective analysis was conducted on 138 out-of-hospital cardiac-arrest patients who underwent prognostic tests, including the gray-white-matter ratio (GWR-BG), the Glasgow Coma Scale motor (GCS-M) score before sedative administration, and the neuron-specific enolase (NSE) level measured at 24 h after the ROSC. We investigated the prognostic performances of the tests as single predictors and in various combination strategies. Classification and regression-tree analysis were used to provide a reliable model for the risk stratification. Out of all the patients, 55 (44.0%) had good outcomes. The NSE level showed the highest prognostic performance as a single prognostic test and provided improved specificities (>70%) and sensitivities (>98%) when used in combination strategies. Low NSE levels (≤32.1 ng/mL) and high GCS-M (≥4) scores identified good outcomes without misclassification. The overall accuracy for good outcomes was 81.8%. In comatose patients with low NSE levels or high GCS-M scores, the premature withdrawal of life-sustaining therapy should be avoided, thereby complying with the formal prognostication-strategy algorithm after at least 72 h from the ROSC.
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Affiliation(s)
- Sunghyuk Lee
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
| | - Jung Soo Park
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon 35015, Republic of Korea
| | - Yeonho You
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
| | - Jin Hong Min
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon 35015, Republic of Korea
- Department of Emergency Medicine, Chungnam National University Sejong Hospital, 20, Bodeum 7-ro, Sejong 30099, Republic of Korea
| | - Wonjoon Jeong
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon 35015, Republic of Korea
| | - Hong Joon Ahn
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon 35015, Republic of Korea
| | - Yong Nam In
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon 35015, Republic of Korea
- Department of Emergency Medicine, Chungnam National University Sejong Hospital, 20, Bodeum 7-ro, Sejong 30099, Republic of Korea
| | - Yong Chul Cho
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
| | - In Ho Lee
- Department of Radiology, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
- Department of Radiology, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon 35015, Republic of Korea
| | - Jae Kwang Lee
- Department of Emergency Medicine, Konyang University Hospital, College of Medicine, Daejeon 35365, Republic of Korea
| | - Changshin Kang
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon 35015, Republic of Korea
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Rajajee V, Muehlschlegel S, Wartenberg KE, Alexander SA, Busl KM, Chou SHY, Creutzfeldt CJ, Fontaine GV, Fried H, Hocker SE, Hwang DY, Kim KS, Madzar D, Mahanes D, Mainali S, Meixensberger J, Montellano F, Sakowitz OW, Weimar C, Westermaier T, Varelas PN. Guidelines for Neuroprognostication in Comatose Adult Survivors of Cardiac Arrest. Neurocrit Care 2023; 38:533-563. [PMID: 36949360 PMCID: PMC10241762 DOI: 10.1007/s12028-023-01688-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 01/30/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND Among cardiac arrest survivors, about half remain comatose 72 h following return of spontaneous circulation (ROSC). Prognostication of poor neurological outcome in this population may result in withdrawal of life-sustaining therapy and death. The objective of this article is to provide recommendations on the reliability of select clinical predictors that serve as the basis of neuroprognostication and provide guidance to clinicians counseling surrogates of comatose cardiac arrest survivors. METHODS A narrative systematic review was completed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Candidate predictors, which included clinical variables and prediction models, were selected based on clinical relevance and the presence of an appropriate body of evidence. The Population, Intervention, Comparator, Outcome, Timing, Setting (PICOTS) question was framed as follows: "When counseling surrogates of comatose adult survivors of cardiac arrest, should [predictor, with time of assessment if appropriate] be considered a reliable predictor of poor functional outcome assessed at 3 months or later?" Additional full-text screening criteria were used to exclude small and lower-quality studies. Following construction of the evidence profile and summary of findings, recommendations were based on four GRADE criteria: quality of evidence, balance of desirable and undesirable consequences, values and preferences, and resource use. In addition, good practice recommendations addressed essential principles of neuroprognostication that could not be framed in PICOTS format. RESULTS Eleven candidate clinical variables and three prediction models were selected based on clinical relevance and the presence of an appropriate body of literature. A total of 72 articles met our eligibility criteria to guide recommendations. Good practice recommendations include waiting 72 h following ROSC/rewarming prior to neuroprognostication, avoiding sedation or other confounders, the use of multimodal assessment, and an extended period of observation for awakening in patients with an indeterminate prognosis, if consistent with goals of care. The bilateral absence of pupillary light response > 72 h from ROSC and the bilateral absence of N20 response on somatosensory evoked potential testing were identified as reliable predictors. Computed tomography or magnetic resonance imaging of the brain > 48 h from ROSC and electroencephalography > 72 h from ROSC were identified as moderately reliable predictors. CONCLUSIONS These guidelines provide recommendations on the reliability of predictors of poor outcome in the context of counseling surrogates of comatose survivors of cardiac arrest and suggest broad principles of neuroprognostication. Few predictors were considered reliable or moderately reliable based on the available body of evidence.
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Affiliation(s)
- Venkatakrishna Rajajee
- Departments of Neurology and Neurosurgery, 3552 Taubman Health Care Center, SPC 5338, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109-5338, USA.
| | - Susanne Muehlschlegel
- Departments of Neurology, Anesthesiology, and Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | | | | | - Katharina M Busl
- Departments of Neurology and Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Sherry H Y Chou
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Gabriel V Fontaine
- Departments of Pharmacy and Neurosciences, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Herbert Fried
- Department of Neurosurgery, Denver Health Medical Center, Denver, CO, USA
| | - Sara E Hocker
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - David Y Hwang
- Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Keri S Kim
- Pharmacy Practice, University of Illinois, Chicago, IL, USA
| | - Dominik Madzar
- Department of Neurology, University of Erlangen, Erlangen, Germany
| | - Dea Mahanes
- Departments of Neurology and Neurosurgery, University of Virginia Health, Charlottesville, VA, USA
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | | | | | - Oliver W Sakowitz
- Department of Neurosurgery, Neurosurgery Center Ludwigsburg-Heilbronn, Ludwigsburg, Germany
| | - Christian Weimar
- Institute of Medical Informatics, Biometry, and Epidemiology, University Hospital Essen, Essen, Germany
- BDH-Clinic Elzach, Elzach, Germany
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50
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Wahlster S, Danielson K, Craft L, Matin N, Town JA, Srinivasan V, Schubert G, Carlbom D, Kim F, Johnson NJ, Tirschwell D. Factors Associated with Early Withdrawal of Life-Sustaining Treatments After Out-of-Hospital Cardiac Arrest: A Subanalysis of a Randomized Trial of Prehospital Therapeutic Hypothermia. Neurocrit Care 2023; 38:676-687. [PMID: 36380126 DOI: 10.1007/s12028-022-01636-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 10/25/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND The objective of this study is to describe incidence and factors associated with early withdrawal of life-sustaining therapies based on presumed poor neurologic prognosis (WLST-N) and practices around multimodal prognostication after out-of-hospital cardiac arrest (OHCA). METHODS We performed a subanalysis of a randomized controlled trial assessing prehospital therapeutic hypothermia in adult patients admitted to nine hospitals in King County with nontraumatic OHCA between 2007 and 2012. Patients who underwent tracheal intubation and were unconscious following return of spontaneous circulation were included. Our outcomes were (1) incidence of early WLST-N (WLST-N within < 72 h from return of spontaneous circulation), (2) factors associated with early WLST-N compared with patients who remained comatose at 72 h without WLST-N, (3) institutional variation in early WLST-N, (4) use of multimodal prognostication, and (5) use of sedative medications in patients with early WLST-N. Analysis included descriptive statistics and multivariable logistic regression. RESULTS We included 1,040 patients (mean age was 65 years, 37% were female, 41% were White, and 44% presented with arrest due to ventricular fibrillation) admitted to nine hospitals. Early WLST-N accounted for 24% (n = 154) of patient deaths and occurred in half (51%) of patients with WLST-N. Factors associated with early WLST-N in multivariate regressions were older age (odds ratio [OR] 1.02, 95% confidence interval [CI]: 1.01-1.03), preexisting do-not-attempt-resuscitation orders (OR 4.67, 95% CI: 1.55-14.01), bilateral absent pupillary reflexes (OR 2.4, 95% CI: 1.42-4.10), and lack of neurological consultation (OR 2.60, 95% CI: 1.52-4.46). The proportion of patients with early WLST-N among all OHCA admissions ranged from 19-60% between institutions. A head computed tomography scan was obtained in 54% (n = 84) of patients with early WLST-N; 22% (n = 34) and 5% (n = 8) underwent ≥ 1 and ≥ 2 additional prognostic tests, respectively. Prognostic tests were more frequently performed when neurological consultation occurred. Most patients received sedating medications (90%) within 24 h before early WLST-N; the median time from last sedation to early WLST-N was 4.2 h (interquartile range 0.4-15). CONCLUSIONS Nearly one quarter of deaths after OHCA were due to early WLST-N. The presence of concerning neurological examination findings appeared to impact early WLST-N decisions, even though these are not fully reliable in this time frame. Lack of neurological consultation was associated with early WLST-N and resulted in underuse of guideline-concordant multimodal prognostication. Sedating medications were often coadministered prior to early WLST-N and may have further confounded the neurological examination. Standardizing prognostication, restricting early WLST-N, and a multidisciplinary approach including neurological consultation might improve outcomes after OHCA.
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Affiliation(s)
- Sarah Wahlster
- Department of Neurology, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359702, Seattle, WA, USA.
- Department of Anesthesiology, University of Washington, Seattle, WA, USA.
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA.
| | - Kyle Danielson
- Airlift Northwest, University of Washington Medicine, Seattle, WA, USA
| | - Lindy Craft
- Department of Anesthesiology, University of Washington, Seattle, WA, USA
| | - Nassim Matin
- Department of Neurology, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359702, Seattle, WA, USA
| | - James A Town
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Vasisht Srinivasan
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
| | - Glenn Schubert
- Department of Neurology, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359702, Seattle, WA, USA
| | - David Carlbom
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Francis Kim
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Nicholas J Johnson
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
| | - David Tirschwell
- Department of Neurology, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359702, Seattle, WA, USA
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