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Gramespacher H, Schmieschek MHT, Warnke C, Adler C, Bittner S, Dronse J, Richter N, Zaeske C, Gietzen C, Schlamann M, Baldus S, Fink GR, Onur OA. Analysis of Cerebral CT Based on Supervised Machine Learning as a Predictor of Outcome After Out-of-Hospital Cardiac Arrest. Neurology 2024; 103:e209583. [PMID: 38857458 DOI: 10.1212/wnl.0000000000209583] [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: 06/12/2024] Open
Abstract
BACKGROUND AND OBJECTIVES In light of limited intensive care capacities and a lack of accurate prognostic tools to advise caregivers and family members responsibly, this study aims to determine whether automated cerebral CT (CCT) analysis allows prognostication after out-of-hospital cardiac arrest. METHODS In this monocentric, retrospective cohort study, a supervised machine learning classifier based on an elastic net regularized logistic regression model for gray matter alterations on nonenhanced CCT obtained after cardiac arrest was trained using 10-fold cross-validation and tested on a hold-out sample (random split 75%/25%) for outcome prediction. Following the literature, a favorable outcome was defined as a cerebral performance category of 1-2 and a poor outcome of 3-5. The diagnostic accuracy was compared with established and guideline-recommended prognostic measures within the sample, that is, gray matter-white matter ratio (GWR), neuron-specific enolase (NSE), and neurofilament light chain (NfL) in serum. RESULTS Of 279 adult patients, 132 who underwent CCT within 14 days of cardiac arrest with good imaging quality were identified. Our approach discriminated between favorable and poor outcomes with an area under the curve (AUC) of 0.73 (95% CI 0.59-0.82). Thus, the prognostic power outperformed the GWR (AUC 0.66, 95% CI 0.56-0.76). The biomarkers NfL, measured at days 1 and 2, and NSE, measured at day 2, exceeded the reliability of the imaging markers derived from CT (AUC NfL day 1: 0.87, 95% CI 0.75-0.99; AUC NfL day 2: 0.90, 95% CI 0.79-1.00; AUC NSE day: 2 0.78, 95% CI 0.62-0.94). DISCUSSION Our data show that machine learning-assisted gray matter analysis of CCT images offers prognostic information after out-of-hospital cardiac arrest. Thus, CCT gray matter analysis could become a reliable and time-independent addition to the standard workup with serum biomarkers sampled at predefined time points. Prospective studies are warranted to replicate these findings.
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Affiliation(s)
- Hannes Gramespacher
- From the Department of Neurology (H.G., M.H.T.S., C.W., J.D., N.R., G.R.F., O.A.O.), Faculty of Medicine and University Hospital Cologne; Division of Cardiology, Pneumology, Angiology and Intensive Care (C.A., S. Baldus), Department of Internal Medicine III, University of Cologne; Department of Neurology (S. Bittner), University Medical Center Mainz; Cognitive Neuroscience (N.R., O.A.O.), Institute of Neuroscience and Medicine (INM-3), Research Center Jülich; and Institute for Diagnostic and Interventional Radiology (C.Z., C.G., M.S.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany
| | - Maximilian H T Schmieschek
- From the Department of Neurology (H.G., M.H.T.S., C.W., J.D., N.R., G.R.F., O.A.O.), Faculty of Medicine and University Hospital Cologne; Division of Cardiology, Pneumology, Angiology and Intensive Care (C.A., S. Baldus), Department of Internal Medicine III, University of Cologne; Department of Neurology (S. Bittner), University Medical Center Mainz; Cognitive Neuroscience (N.R., O.A.O.), Institute of Neuroscience and Medicine (INM-3), Research Center Jülich; and Institute for Diagnostic and Interventional Radiology (C.Z., C.G., M.S.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany
| | - Clemens Warnke
- From the Department of Neurology (H.G., M.H.T.S., C.W., J.D., N.R., G.R.F., O.A.O.), Faculty of Medicine and University Hospital Cologne; Division of Cardiology, Pneumology, Angiology and Intensive Care (C.A., S. Baldus), Department of Internal Medicine III, University of Cologne; Department of Neurology (S. Bittner), University Medical Center Mainz; Cognitive Neuroscience (N.R., O.A.O.), Institute of Neuroscience and Medicine (INM-3), Research Center Jülich; and Institute for Diagnostic and Interventional Radiology (C.Z., C.G., M.S.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany
| | - Christoph Adler
- From the Department of Neurology (H.G., M.H.T.S., C.W., J.D., N.R., G.R.F., O.A.O.), Faculty of Medicine and University Hospital Cologne; Division of Cardiology, Pneumology, Angiology and Intensive Care (C.A., S. Baldus), Department of Internal Medicine III, University of Cologne; Department of Neurology (S. Bittner), University Medical Center Mainz; Cognitive Neuroscience (N.R., O.A.O.), Institute of Neuroscience and Medicine (INM-3), Research Center Jülich; and Institute for Diagnostic and Interventional Radiology (C.Z., C.G., M.S.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany
| | - Stefan Bittner
- From the Department of Neurology (H.G., M.H.T.S., C.W., J.D., N.R., G.R.F., O.A.O.), Faculty of Medicine and University Hospital Cologne; Division of Cardiology, Pneumology, Angiology and Intensive Care (C.A., S. Baldus), Department of Internal Medicine III, University of Cologne; Department of Neurology (S. Bittner), University Medical Center Mainz; Cognitive Neuroscience (N.R., O.A.O.), Institute of Neuroscience and Medicine (INM-3), Research Center Jülich; and Institute for Diagnostic and Interventional Radiology (C.Z., C.G., M.S.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany
| | - Julian Dronse
- From the Department of Neurology (H.G., M.H.T.S., C.W., J.D., N.R., G.R.F., O.A.O.), Faculty of Medicine and University Hospital Cologne; Division of Cardiology, Pneumology, Angiology and Intensive Care (C.A., S. Baldus), Department of Internal Medicine III, University of Cologne; Department of Neurology (S. Bittner), University Medical Center Mainz; Cognitive Neuroscience (N.R., O.A.O.), Institute of Neuroscience and Medicine (INM-3), Research Center Jülich; and Institute for Diagnostic and Interventional Radiology (C.Z., C.G., M.S.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany
| | - Nils Richter
- From the Department of Neurology (H.G., M.H.T.S., C.W., J.D., N.R., G.R.F., O.A.O.), Faculty of Medicine and University Hospital Cologne; Division of Cardiology, Pneumology, Angiology and Intensive Care (C.A., S. Baldus), Department of Internal Medicine III, University of Cologne; Department of Neurology (S. Bittner), University Medical Center Mainz; Cognitive Neuroscience (N.R., O.A.O.), Institute of Neuroscience and Medicine (INM-3), Research Center Jülich; and Institute for Diagnostic and Interventional Radiology (C.Z., C.G., M.S.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany
| | - Charlotte Zaeske
- From the Department of Neurology (H.G., M.H.T.S., C.W., J.D., N.R., G.R.F., O.A.O.), Faculty of Medicine and University Hospital Cologne; Division of Cardiology, Pneumology, Angiology and Intensive Care (C.A., S. Baldus), Department of Internal Medicine III, University of Cologne; Department of Neurology (S. Bittner), University Medical Center Mainz; Cognitive Neuroscience (N.R., O.A.O.), Institute of Neuroscience and Medicine (INM-3), Research Center Jülich; and Institute for Diagnostic and Interventional Radiology (C.Z., C.G., M.S.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany
| | - Carsten Gietzen
- From the Department of Neurology (H.G., M.H.T.S., C.W., J.D., N.R., G.R.F., O.A.O.), Faculty of Medicine and University Hospital Cologne; Division of Cardiology, Pneumology, Angiology and Intensive Care (C.A., S. Baldus), Department of Internal Medicine III, University of Cologne; Department of Neurology (S. Bittner), University Medical Center Mainz; Cognitive Neuroscience (N.R., O.A.O.), Institute of Neuroscience and Medicine (INM-3), Research Center Jülich; and Institute for Diagnostic and Interventional Radiology (C.Z., C.G., M.S.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany
| | - Marc Schlamann
- From the Department of Neurology (H.G., M.H.T.S., C.W., J.D., N.R., G.R.F., O.A.O.), Faculty of Medicine and University Hospital Cologne; Division of Cardiology, Pneumology, Angiology and Intensive Care (C.A., S. Baldus), Department of Internal Medicine III, University of Cologne; Department of Neurology (S. Bittner), University Medical Center Mainz; Cognitive Neuroscience (N.R., O.A.O.), Institute of Neuroscience and Medicine (INM-3), Research Center Jülich; and Institute for Diagnostic and Interventional Radiology (C.Z., C.G., M.S.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany
| | - Stephan Baldus
- From the Department of Neurology (H.G., M.H.T.S., C.W., J.D., N.R., G.R.F., O.A.O.), Faculty of Medicine and University Hospital Cologne; Division of Cardiology, Pneumology, Angiology and Intensive Care (C.A., S. Baldus), Department of Internal Medicine III, University of Cologne; Department of Neurology (S. Bittner), University Medical Center Mainz; Cognitive Neuroscience (N.R., O.A.O.), Institute of Neuroscience and Medicine (INM-3), Research Center Jülich; and Institute for Diagnostic and Interventional Radiology (C.Z., C.G., M.S.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany
| | - Gereon R Fink
- From the Department of Neurology (H.G., M.H.T.S., C.W., J.D., N.R., G.R.F., O.A.O.), Faculty of Medicine and University Hospital Cologne; Division of Cardiology, Pneumology, Angiology and Intensive Care (C.A., S. Baldus), Department of Internal Medicine III, University of Cologne; Department of Neurology (S. Bittner), University Medical Center Mainz; Cognitive Neuroscience (N.R., O.A.O.), Institute of Neuroscience and Medicine (INM-3), Research Center Jülich; and Institute for Diagnostic and Interventional Radiology (C.Z., C.G., M.S.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany
| | - Oezguer A Onur
- From the Department of Neurology (H.G., M.H.T.S., C.W., J.D., N.R., G.R.F., O.A.O.), Faculty of Medicine and University Hospital Cologne; Division of Cardiology, Pneumology, Angiology and Intensive Care (C.A., S. Baldus), Department of Internal Medicine III, University of Cologne; Department of Neurology (S. Bittner), University Medical Center Mainz; Cognitive Neuroscience (N.R., O.A.O.), Institute of Neuroscience and Medicine (INM-3), Research Center Jülich; and Institute for Diagnostic and Interventional Radiology (C.Z., C.G., M.S.), Faculty of Medicine and University Hospital Cologne, University of Cologne, Germany
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Iten M, Moser A, Wagner F, Haenggi M. Performance of the MRI lesion pattern score in predicting neurological outcome after out of hospital cardiac arrest: a retrospective cohort analysis. Crit Care 2024; 28:215. [PMID: 38956665 DOI: 10.1186/s13054-024-05007-w] [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: 04/17/2024] [Accepted: 06/27/2024] [Indexed: 07/04/2024] Open
Abstract
BACKGROUND Despite advances in resuscitation practice, patient survival following cardiac arrest remains poor. The utilization of MRI in neurological outcome prognostication post-cardiac arrest is growing and various classifications has been proposed; however a consensus has yet to be established. MRI, though valuable, is resource-intensive, time-consuming, costly, and not universally available. This study aims to validate a MRI lesion pattern score in a cohort of out of hospital cardiac arrest patients at a tertiary referral hospital in Switzerland. METHODS This cohort study spanned twelve months from February 2021 to January 2022, encompassing all unconscious patients aged ≥ 18 years who experienced out-of-hospital cardiac arrest of any cause and were admitted to the intensive care unit (ICU) at Inselspital, University Hospital Bern, Switzerland. We included patients who underwent the neuroprognostication process, assessing the performance and validation of a MRI scoring system. RESULTS Over the twelve-month period, 137 patients were admitted to the ICU, with 52 entering the neuroprognostication process and 47 undergoing MRI analysis. Among the 35 MRIs indicating severe hypoxic brain injury, 33 patients (94%) experienced an unfavourable outcome (UO), while ten (83%) of the twelve patients with no or minimal MRI lesions had a favourable outcome. This yielded a sensitivity of 0.94 and specificity of 0.83 for predicting UO with the proposed MRI scoring system. The positive and negative likelihood ratios were 5.53 and 0.07, respectively, resulting in an accuracy of 91.49%. CONCLUSION We demonstrated the effectiveness of the MLP scoring scheme in predicting neurological outcome in patients following cardiac arrest. However, to ensure a comprehensive neuroprognostication, MRI results need to be combined with other assessments. While neuroimaging is a promising objective tool for neuroprognostication, given the absence of sedation-related confounders-compared to electroencephalogram (EEG) and clinical examination-the current lack of a validated scoring system necessitates further studies. Incorporating standardized MRI techniques and grading systems is crucial for advancing the reliability of neuroimaging for neuroprognostication. TRIAL REGISTRATION Registry of all Projects in Switzerland (RAPS) 2020-01761.
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Affiliation(s)
- Manuela Iten
- Department of Intensive Care Medicine, Inselspital, University Hospital Bern, Bern, Switzerland.
| | - Antonia Moser
- Department of Intensive Care Medicine, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Franca Wagner
- University Institute for Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland
| | - Matthias Haenggi
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
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3
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Kim D, Kwon H, Kim SM, Kim JS, Kim YJ, Kim WY. Normal value of neuron-specific enolase for predicting good neurological outcomes in comatose out-of-hospital cardiac arrest survivors. PLoS One 2024; 19:e0305771. [PMID: 38917136 PMCID: PMC11198821 DOI: 10.1371/journal.pone.0305771] [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: 11/05/2023] [Accepted: 06/04/2024] [Indexed: 06/27/2024] Open
Abstract
Research on prognostic factors for good outcomes in out-of-hospital cardiac arrest (OHCA) survivors is lacking. We assessed whether normal levels of normal neuron-specific enolase (NSE) value would be useful for predicting good neurological outcomes in comatose OHCA survivors treated with targeted temperature management (TTM). This registry-based observational study with consecutive adult (≥18 years) OHCA survivors with TTM who underwent NSE measurement 48 hours after cardiac arrest was conducted from October 2015 to November 2022. Normal NSE values defined as the upper limit of the normal range by the manufacturer (NSE <16.3 μg/L) and guideline-suggested (NSE < 60 μg/L) were examined for good neurologic outcomes, defined as Cerebral Performance Categories ≤2, at 6 months post-survival. Among 226 OHCA survivors with TTM, 200 patients who underwent NSE measurement were enrolled. The manufacturer-suggested normal NSE values (<16.3 μg/L) had a specificity of 99.17% for good neurological outcomes with a very low sensitivity of 12.66%. NSE <60 μg/L predicted good outcomes with a sensitivity of 87.34% and specificity of 72.73%. However, excluding 14 poor-outcome patients who died from multi-organ dysfunction excluding hypoxic brain injury, the sensitivity and specificity of normal NSE values were 12.66% and 99.07% of NSE < 16.3 μg/L, and 87.34% and 82.24% of NSE < 60 μg/L. The manufacturer-suggested normal NSE had high specificity with low sensitivity, but the guideline-suggested normal NSE value had a comparatively low specificity for good outcome prediction in OHCA survivors. Our data demonstrate normal NSE levels can be useful as a tool for multimodal appropriation of good outcome prediction.
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Affiliation(s)
- Dongju Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyojeong Kwon
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Min Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - June-Sung Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Youn-Jung Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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4
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Bang HJ, Youn CS, Sandroni C, Park KN, Lee BK, Oh SH, Cho IS, Choi SP. Good outcome prediction after out-of-hospital cardiac arrest: A prospective multicenter observational study in Korea (the KORHN-PRO registry). Resuscitation 2024; 199:110207. [PMID: 38582440 DOI: 10.1016/j.resuscitation.2024.110207] [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: 02/07/2024] [Revised: 03/29/2024] [Accepted: 04/01/2024] [Indexed: 04/08/2024]
Abstract
AIM To assess the ability of clinical examination, biomarkers, electrophysiology and brain imaging, individually or in combination to predict good neurological outcomes at 6 months after CA. METHODS This was a retrospective analysis of the Korean Hypothermia Network Prospective Registry 1.0, which included adult out-of-hospital cardiac arrest (OHCA) patients (≥18 years). Good outcome predictors were defined as both pupillary light reflex (PLR) and corneal reflex (CR) at admission, Glasgow Coma Scale Motor score (GCS-M) >3 at admission, neuron-specific enolase (NSE) <17 µg/L at 24-72 h, a median nerve somatosensory evoked potential (SSEP) N20/P25 amplitude >4 µV, continuous background without discharges on electroencephalogram (EEG), and absence of anoxic injury on brain CT and diffusion-weighted imaging (DWI). RESULTS A total of 1327 subjects were included in the final analysis, and their median age was 59 years; among them, 412 subjects had a good neurological outcome at 6 months. GCS-M >3 at admission had the highest specificity of 96.7% (95% CI 95.3-97.8), and normal brain DWI had the highest sensitivity of 96.3% (95% CI 92.9-98.4). When the two predictors were combined, the sensitivities tended to decrease (ranging from 2.7-81.1%), and the specificities tended to increase, ranging from81.3-100%. Through the explorative variation of the 2021 European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) prognostication strategy algorithms, good outcomes were predicted, with a specificity of 83.2% and a sensitivity of 83.5% in patients by the algorithm. CONCLUSIONS Clinical examination, biomarker, electrophysiology, and brain imaging predicted good outcomes at 6 months after CA. When the two predictors were combined, the specificity further improved. With the 2021 ERC/ESICM guidelines, the number of indeterminate patients and the uncertainty of prognostication can be reduced by using a good outcome prediction algorithm.
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Affiliation(s)
- Hyo Jin Bang
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea
| | - Chun Song Youn
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea.
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli"-IRCCS, Largo Francesco Vito, 1, 00168, Rome, Italy
| | - Kyu Nam Park
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea
| | - Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University Hospital, 42, Jebong-ro, Donggu, Gwangju, Republic of Korea
| | - Sang Hoon Oh
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea
| | - In Soo Cho
- Department of Emergency Medicine, KEPCO Medical Center, 308, Uicheon-ro, Dobong-gu, Seoul, Republic of Korea
| | - Seung Pill Choi
- Department of Emergency Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 03312, Republic of Korea
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Steinberg A, Yang Y, Fischhoff B, Callaway CW, Coppler P, Geocadin R, Silbergleit R, Meurer WJ, Ramakrishnan R, Yeatts SD, Elmer J. Clinicians' approach to predicting post-cardiac arrest outcomes for patients enrolled in a United States clinical trial. Resuscitation 2024; 199:110226. [PMID: 38685376 DOI: 10.1016/j.resuscitation.2024.110226] [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: 02/22/2024] [Revised: 04/16/2024] [Accepted: 04/20/2024] [Indexed: 05/02/2024]
Abstract
PURPOSE Perceived poor prognosis can lead to withdrawal of life-sustaining therapies (WLST) in patients who might otherwise recover. We characterized clinicians' approach to post-arrest prognostication in a multicenter clinical trial. METHODS Semi-structured interviews were conducted with clinicians who treated a comatose post-cardiac arrest patient enrolled in the Influence of Cooling Duration on Efficacy in Cardiac Arrest Patients (ICECAP) trial (NCT04217551). Two authors independently analyzed each interview using inductive and deductive coding. The clinician reported how they arrived at a prognosis for the specific patient. We summarized the frequency with which clinicians reported using objective diagnostics to formulate their prognosis, and compared the reported approaches to established guidelines. Each respondent provided demographic information and described local neuroprognostication practices. RESULTS We interviewed 30 clinicians at 19 US hospitals. Most claimed adherence to local hospital neuroprognostication protocols (n = 19). Prognostication led to WLST for perceived poor neurological prognosis in 15/30 patients, of whom most showed inconsistencies with guidelines or trial recommendations, respectively. In 10/15 WLST cases, clinicians reported relying on multimodal testing. A prevalent theme was the use of "clinical gestalt," defined as prognosticating based on a patient's overall appearance or a subjective impression in the absence of objective data. Many clinicians (21/30) reported using clinical gestalt for initial prognostication, with 9/21 expressing high confidence initially. CONCLUSION Clinicians in our study state they follow neuroprognostication guidelines in general but often do not do so in actual practice. They reported clinical gestalt frequently informed early, highly confident prognostic judgments, and few objective tests changed initial impressions. Subjective prognostication may undermine well-designed trials.
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Affiliation(s)
- Alexis Steinberg
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Yanran Yang
- Department of Engineering and Public Policy, Carnegie Mellon University, Pittsburgh, PA; Global Health Research Center, Duke Kunshan University, Suzhou, China
| | - Baruch Fischhoff
- Department of Engineering and Public Policy, Carnegie Mellon University, Pittsburgh, PA; Institute for Politics and Strategy, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Patrick Coppler
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Romergryko Geocadin
- Department of Neurology, Neurosurgery, Anesthesiology-Critical Care Medicine, Johns Hopkins University, Baltimore, MD. USA
| | - Robert Silbergleit
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI. USA
| | - William J Meurer
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI. USA; Department of Neurology, University of Michigan, Ann Arbor, MI. USA
| | - Ramesh Ramakrishnan
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC. USA
| | - Sharon D Yeatts
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC. USA
| | - Jonathan Elmer
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Sarton B, Tauber C, Fridman E, Péran P, Riu B, Vinour H, David A, Geeraerts T, Bounes F, Minville V, Delmas C, Salabert AS, Albucher JF, Bataille B, Olivot JM, Cariou A, Naccache L, Payoux P, Schiff N, Silva S. Neuroimmune activation is associated with neurological outcome in anoxic and traumatic coma. Brain 2024; 147:1321-1330. [PMID: 38412555 PMCID: PMC10994537 DOI: 10.1093/brain/awae045] [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: 08/20/2023] [Revised: 12/22/2023] [Accepted: 01/09/2024] [Indexed: 02/29/2024] Open
Abstract
The pathophysiological underpinnings of critically disrupted brain connectomes resulting in coma are poorly understood. Inflammation is potentially an important but still undervalued factor. Here, we present a first-in-human prospective study using the 18-kDa translocator protein (TSPO) radioligand 18F-DPA714 for PET imaging to allow in vivo neuroimmune activation quantification in patients with coma (n = 17) following either anoxia or traumatic brain injuries in comparison with age- and sex-matched controls. Our findings yielded novel evidence of an early inflammatory component predominantly located within key cortical and subcortical brain structures that are putatively implicated in consciousness emergence and maintenance after severe brain injury (i.e. mesocircuit and frontoparietal networks). We observed that traumatic and anoxic patients with coma have distinct neuroimmune activation profiles, both in terms of intensity and spatial distribution. Finally, we demonstrated that both the total amount and specific distribution of PET-measurable neuroinflammation within the brain mesocircuit were associated with the patient's recovery potential. We suggest that our results can be developed for use both as a new neuroprognostication tool and as a promising biometric to guide future clinical trials targeting glial activity very early after severe brain injury.
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Affiliation(s)
- Benjamine Sarton
- Critical Care Unit, University Teaching Hospital of Purpan, F-31059 Toulouse Cedex 9, France
- Toulouse NeuroImaging Center, Toulouse University, Inserm 1214, UPS, F-31300 Toulouse, France
| | - Clovis Tauber
- Imaging and Brain laboratory, UMRS Inserm U930, Université de Tours, F-37000 Tours, France
| | - Estéban Fridman
- Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY 10065, USA
| | - Patrice Péran
- Toulouse NeuroImaging Center, Toulouse University, Inserm 1214, UPS, F-31300 Toulouse, France
| | - Beatrice Riu
- Critical Care Unit, University Teaching Hospital of Purpan, F-31059 Toulouse Cedex 9, France
| | - Hélène Vinour
- Critical Care Unit, University Teaching Hospital of Purpan, F-31059 Toulouse Cedex 9, France
| | - Adrian David
- Critical Care Unit, University Teaching Hospital of Purpan, F-31059 Toulouse Cedex 9, France
| | - Thomas Geeraerts
- Neurocritical Care Unit, University Teaching Hospital of Purpan, F-31059 Toulouse Cedex 9, France
| | - Fanny Bounes
- Critical Care Unit, University Teaching Hospital of Rangueil, F-31400 Toulouse Cedex 9, France
| | - Vincent Minville
- Critical Care Unit, University Teaching Hospital of Rangueil, F-31400 Toulouse Cedex 9, France
| | - Clément Delmas
- Cardiology Department, University Teaching Hospital of Purpan, F-31059 Toulouse Cedex 9, France
| | - Anne-Sophie Salabert
- Toulouse NeuroImaging Center, Toulouse University, Inserm 1214, UPS, F-31300 Toulouse, France
| | - Jean François Albucher
- Neurology Department, University Teaching Hospital of Purpan, F-31059 Toulouse Cedex 9, France
| | - Benoit Bataille
- Critical Care Unit, Hôtel Dieu Hospital, F-11100 Narbonne, France
| | - Jean Marc Olivot
- Neurology Department, University Teaching Hospital of Purpan, F-31059 Toulouse Cedex 9, France
| | - Alain Cariou
- Critical Care Unit, APHP, Cochin Hospital, F-75014 Paris, France
| | - Lionel Naccache
- Institut du Cerveau et de la Moelle épinière, ICM, PICNIC Lab, F-75013 Paris, France
| | - Pierre Payoux
- Toulouse NeuroImaging Center, Toulouse University, Inserm 1214, UPS, F-31300 Toulouse, France
| | - Nicholas Schiff
- Brain and Mind Research Institute, Weill Cornell Medical College, New York, NY 10065, USA
| | - Stein Silva
- Critical Care Unit, University Teaching Hospital of Purpan, F-31059 Toulouse Cedex 9, France
- Toulouse NeuroImaging Center, Toulouse University, Inserm 1214, UPS, F-31300 Toulouse, France
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Arctaedius I, Levin H, Larsson M, Friberg H, Cronberg T, Nielsen N, Moseby-Knappe M, Lybeck A. 2021 European Resuscitation Council/European Society of Intensive Care Medicine Algorithm for Prognostication of Poor Neurological Outcome After Cardiac Arrest-Can Entry Criteria Be Broadened? Crit Care Med 2024; 52:531-541. [PMID: 38059722 DOI: 10.1097/ccm.0000000000006113] [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] [Indexed: 12/08/2023]
Abstract
OBJECTIVES To explore broadened entry criteria of the 2021 European Resuscitation Council/European Society of Intensive Care Medicine (ERC/ESICM) algorithm for neuroprognostication including patients with ongoing sedation and Glasgow Coma Scale-Motor score (GCS-M) scores 4-5. DESIGN Retrospective multicenter observational study. SETTING Four ICUs, Skane, Sweden. PATIENTS Postcardiac arrest patients managed at targeted temperature 36°C, 2014-2018. Neurologic outcome was assessed after 2-6 months according to the Cerebral Performance Category scale. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS In 794 included patients, median age was 69.5 years (interquartile range, 60.6-77.0 yr), 241 (30.4%) were female, 550 (69.3%) had an out-of-hospital cardiac arrest, and 314 (41.3%) had a shockable rhythm. Four hundred ninety-five patients were dead at follow-up, 330 of 495 died after a decision on withdrawal of life-sustaining therapies. At 72 hours after cardiac arrest 218 patients remained unconscious. The entry criteria of the original algorithm (GCS-M 1-3) was fulfilled by 163 patients and 115 patients with poor outcome were identified, with false positive rate (FPR) of 0% (95% CI, 0-79.4%) and sensitivity of 71.0% (95% CI, 63.6-77.4%). Inclusion of patients with ongoing sedation identified another 13 patients with poor outcome, generating FPR of 0% (95% CI, 0-65.8%) and sensitivity of 69.6% (95% CI, 62.6-75.8%). Inclusion of all unconscious patients (GCS-M 1-5), regardless of sedation, identified one additional patient, generating FPR of 0% (95% CI, 0-22.8) and sensitivity of 62.9% (95% CI, 56.1-69.2). The few patients with true negative prediction (patients with good outcome not fulfilling guideline criteria of a poor outcome) generated wide 95% CI for FPR. CONCLUSION The 2021 ERC/ESICM algorithm for neuroprognostication predicted poor neurologic outcome with a FPR of 0%. Broadening inclusion criteria to include all unconscious patients regardless of ongoing sedation identified an additional small number of patients with poor outcome but did not affect the FPR. Results are limited by high rate of withdrawal of life-sustaining therapies and few patients with true negative prediction.
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Affiliation(s)
- Isabelle Arctaedius
- Anesthesia & Intensive Care, Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Lund, Sweden
| | - Helena Levin
- Anaesthesia & Intensive Care, Department of Clinical Sciences Lund, Lund University and Department of Research & Education, Skane University Hospital, Lund, Sweden
| | - Melker Larsson
- Anesthesia & Intensive Care, Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Lund, Sweden
| | - Hans Friberg
- Anesthesia & Intensive Care, Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Malmö, Sweden
| | - Tobias Cronberg
- Neurology, Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Lund, Sweden
| | - Niklas Nielsen
- Anesthesia & Intensive Care, Department of Clinical Sciences Lund, Lund University, Helsingborg Hospital, Helsingborg, Sweden
| | - Marion Moseby-Knappe
- Neurology and Rehabilitation Medicine, Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Lund, Sweden
| | - Anna Lybeck
- Anesthesia & Intensive Care, Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Lund, Sweden
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8
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Maciel CB, Busl KM, Elmer J. Death Foretold: Are We Truly Improving Outcome Prediction After Cardiac Arrest or Nurturing Self-Fulfilling Prophecies? Crit Care Med 2024; 52:656-659. [PMID: 38483220 DOI: 10.1097/ccm.0000000000006149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Affiliation(s)
- Carolina B Maciel
- Department of Neurology, Division of Neurocritical Care, University of Florida College of Medicine, Gainesville, FL
- Department of Neurology, University of Utah, Salt Lake City, UT
| | - Katharina M Busl
- Department of Neurology, Division of Neurocritical Care, University of Florida College of Medicine, Gainesville, FL
| | - Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA
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9
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Thuccani M, Joelsson S, Lilja L, Strålin A, Nilsson J, Redfors P, Rawshani A, Herlitz J, Lundgren P, Rylander C. The capacity of neurological pupil index to predict the absence of somatosensory evoked potentials after cardiac arrest - An observational study. Resusc Plus 2024; 17:100567. [PMID: 38328749 PMCID: PMC10848026 DOI: 10.1016/j.resplu.2024.100567] [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: 12/22/2023] [Revised: 01/17/2024] [Accepted: 01/21/2024] [Indexed: 02/09/2024] Open
Abstract
Background In neurologic prognostication of comatose survivors from cardiac arrest, two independent predictors of poor outcome are the loss of the Pupillary light reflex (PLR) and the loss of the N20 response from Somatosensory Evoked potentials (SSEP). The PLR can be quantitatively assessed by pupillometry. Both tests depend on the midbrain, in which a dysfunction reflects a severe hypoxic injury. We reasoned that a certain level of defective PLR would be predictive of a bilaterally absent SSEP N20 response. Method Neurological Pupil index (NPi) from the pupillometry and the SSEP N20 response were registered >48 h after cardiac arrest in comatose survivors. Clinical data were retrospectively analyzed. A receiver operating characteristic curve was used to evaluate the capacity of NPi to predict bilaterally absent SSEP N20 response. An NPi threshold value resulting in <5% false positive rate (FPR) for bilaterally absent N20 response was identified. Results From February 2020 to August 2022, we included 54 patients out of which 49 had conclusive pupillometry and SSEP examinations. The NPi threshold value with FPR < 5% was 3.4, yielding 36% sensitivity (95% CI 18-55) and significantly discriminated between respective groups with preserved and bilaterally absent N20 response to SSEP (p-value <0.01). Conclusion In this limited cohort, NPi < 3.4 in patients remaining comatose >48 hours after cardiac arrest predicted bilateral loss of the SSEP N20 response with a FPR < 5%. If validated in a larger cohort, an NPi threshold may be clinically applied in settings where SSEP is unavailable.
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Affiliation(s)
- Meena Thuccani
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sara Joelsson
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Neurophysiology, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Linus Lilja
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Anaesthesia and Intensive Care, Karlstad Central Hospital, Karlstad, Sweden
| | - Axel Strålin
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Josefin Nilsson
- Department of Clinical Neurophysiology, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Petra Redfors
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Araz Rawshani
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Johan Herlitz
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Prehospen – Centre for Prehospital Research, University of Borås, Sweden
| | - Peter Lundgren
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Prehospen – Centre for Prehospital Research, University of Borås, Sweden
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Christian Rylander
- Anaesthesiology and Intensive Care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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10
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Lee JS, Bang HJ, Youn CS, Kim SH, Park S, Kim HJ, Park KN, Oh SH. Prognostic Performance of Initial Clinical Examination in Predicting Good Neurological Outcome in Cardiac Arrest Patients Treated with Targeted Temperature Management. Ther Hypothermia Temp Manag 2024; 14:24-30. [PMID: 37219575 DOI: 10.1089/ther.2023.0002] [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] [Indexed: 05/24/2023] Open
Abstract
Prognostication studies of cardiac arrest patients have mainly focused on poor neurological outcomes. However, an optimistic prognosis for good outcome could provide both justification to maintain and escalate treatment and evidence-based support to persuade family members or legal surrogates after cardiac arrest. The aim of the study was to evaluate the utility of clinical examinations performed after return of spontaneous circulation (ROSC) in predicting good neurological outcomes in out-of-hospital cardiac arrest (OHCA) patients treated with targeted temperature management (TTM). This retrospective study included OHCA patients treated with TTM from 2009 to 2021. Initial clinical examination findings related to the Glasgow coma scale (GCS) motor score, pupillary light reflex, corneal reflex (CR) and breathing above the set ventilator rate were assessed immediately after ROSC and before the initiation of TTM. The primary outcome was good neurological outcome at 6 months after cardiac arrest. Of 350 patients included in the analysis, 119 (34%) experienced a good neurological outcome at 6 months after cardiac arrest. Among the parameters of the initial clinical examinations, specificity was the highest for the GCS motor score, and sensitivity was the highest for breathing above the set ventilator rate. A GCS motor score of >2 had a sensitivity of 42.0% (95% confidence interval [CI] = 33.0-51.4) and a specificity of 96.5% (95% CI = 93.3-98.5). Breathing above the set ventilator rate had a sensitivity of 84.0% (95% CI = 76.2-90.1) and a specificity of 69.7% (95% CI = 63.3-75.6). As the number of positive responses increased, the proportion of patients with good outcomes increased. Consequently, 87.0% of patients for whom all four examinations were positive experienced good outcomes. As a result, the initial clinical examinations predicted good neurological outcomes with a sensitivity of 42.0-84.0% and a specificity of 69.7-96.5%. When more examinations with positive results are achieved, a good neurological outcome can be expected.
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Affiliation(s)
- Ji-Sook Lee
- Department of Emergency Medicine, Seoul St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyo Jin Bang
- Department of Emergency Medicine, Seoul St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chun Song Youn
- Department of Emergency Medicine, Seoul St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Soo Hyun Kim
- Department of Emergency Medicine, Eunpyeong St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - SangHyun Park
- Department of Emergency Medicine, Yeouido St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyo Joon Kim
- Department of Emergency Medicine, Seoul St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Kyu Nam Park
- Department of Emergency Medicine, Seoul St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sang Hoon Oh
- Department of Emergency Medicine, Seoul St. Mary Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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11
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Berg KM, Bray JE, Ng KC, Liley HG, Greif R, Carlson JN, Morley PT, Drennan IR, Smyth M, Scholefield BR, Weiner GM, Cheng A, Djärv T, Abelairas-Gómez C, Acworth J, Andersen LW, Atkins DL, Berry DC, Bhanji F, Bierens J, Bittencourt Couto T, Borra V, Böttiger BW, Bradley RN, Breckwoldt J, Cassan P, Chang WT, Charlton NP, Chung SP, Considine J, Costa-Nobre DT, Couper K, Dainty KN, Dassanayake V, Davis PG, Dawson JA, Fernanda de Almeida M, De Caen AR, Deakin CD, Dicker B, Douma MJ, Eastwood K, El-Naggar W, Fabres JG, Fawke J, Fijacko N, Finn JC, Flores GE, Foglia EE, Folke F, Gilfoyle E, Goolsby CA, Granfeldt A, Guerguerian AM, Guinsburg R, Hatanaka T, Hirsch KG, Holmberg MJ, Hosono S, Hsieh MJ, Hsu CH, Ikeyama T, Isayama T, Johnson NJ, Kapadia VS, Daripa Kawakami M, Kim HS, Kleinman ME, Kloeck DA, Kudenchuk P, Kule A, Kurosawa H, Lagina AT, Lauridsen KG, Lavonas EJ, Lee HC, Lin Y, Lockey AS, Macneil F, Maconochie IK, John Madar R, Malta Hansen C, Masterson S, Matsuyama T, McKinlay CJD, Meyran D, Monnelly V, Nadkarni V, Nakwa FL, Nation KJ, Nehme Z, Nemeth M, Neumar RW, Nicholson T, Nikolaou N, Nishiyama C, Norii T, Nuthall GA, Ohshimo S, Olasveengen TM, Gene Ong YK, Orkin AM, Parr MJ, Patocka C, Perkins GD, Perlman JM, Rabi Y, Raitt J, Ramachandran S, Ramaswamy VV, Raymond TT, Reis AG, Reynolds JC, Ristagno G, Rodriguez-Nunez A, Roehr CC, Rüdiger M, Sakamoto T, Sandroni C, Sawyer TL, Schexnayder SM, Schmölzer GM, Schnaubelt S, Semeraro F, Singletary EM, Skrifvars MB, Smith CM, Soar J, Stassen W, Sugiura T, Tijssen JA, Topjian AA, Trevisanuto D, Vaillancourt C, Wyckoff MH, Wyllie JP, Yang CW, Yeung J, Zelop CM, Zideman DA, Nolan JP. 2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Resuscitation 2024; 195:109992. [PMID: 37937881 DOI: 10.1016/j.resuscitation.2023.109992] [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] [Indexed: 11/09/2023]
Abstract
The International Liaison Committee on Resuscitation engages in a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation and first aid science. Draft Consensus on Science With Treatment Recommendations are posted online throughout the year, and this annual summary provides more concise versions of the final Consensus on Science With Treatment Recommendations from all task forces for the year. Topics addressed by systematic reviews this year include resuscitation of cardiac arrest from drowning, extracorporeal cardiopulmonary resuscitation for adults and children, calcium during cardiac arrest, double sequential defibrillation, neuroprognostication after cardiac arrest for adults and children, maintaining normal temperature after preterm birth, heart rate monitoring methods for diagnostics in neonates, detection of exhaled carbon dioxide in neonates, family presence during resuscitation of adults, and a stepwise approach to resuscitation skills training. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research. Additional topics are addressed with scoping reviews and evidence updates.
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12
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Wimmer H, Stensønes SH, Benth JŠ, Lundqvist C, Andersen GØ, Draegni T, Sunde K, Nakstad ER. Outcome prediction in comatose cardiac arrest patients with initial shockable and non-shockable rhythms. Acta Anaesthesiol Scand 2024; 68:263-273. [PMID: 37876138 DOI: 10.1111/aas.14337] [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: 03/02/2023] [Revised: 09/16/2023] [Accepted: 09/19/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND Prognosis after out-of-hospital cardiac arrest (OHCA) is presumed poorer in patients with non-shockable than shockable rhythms, frequently leading to treatment withdrawal. Multimodal outcome prediction is recommended 72 h post-arrest in still comatose patients, not considering initial rhythms. We investigated accuracy of outcome predictors in all comatose OHCA survivors, with a particular focus on shockable vs. non-shockable rhythms. METHODS In this observational NORCAST sub-study, patients still comatose 72 h post-arrest were stratified by shockable vs. non-shockable rhythms for outcome prediction analyzes. Good outcome was defined as cerebral performance category 1-2 within 6 months. False positive rate (FPR) was used for poor and sensitivity for good outcome prediction accuracy. RESULTS Overall, 72/128 (56%) patients with shockable and 12/50 (24%) with non-shockable rhythms had good outcome (p < .001). For poor outcome prediction, absent pupillary light reflexes (PLR) and corneal reflexes (clinical predictors) 72 h after sedation withdrawal, PLR 96 h post-arrest, and somatosensory evoked potentials (SSEP), all had FPR <0.1% in both groups. Unreactive EEG and neuron-specific enolase (NSE) >60 μg/L 24-72 h post-arrest had better precision in shockable patients. For good outcome, the clinical predictors, SSEP and CT, had 86%-100% sensitivity in both groups. For NSE, sensitivity varied from 22% to 69% 24-72 h post-arrest. The outcome predictors indicated severe brain injury proportionally more often in patients with non-shockable than with shockable rhythms. For all patients, clinical predictors, CT, and SSEP, predicted poor and good outcome with high accuracy. CONCLUSION Outcome prediction accuracy was comparable for shockable and non-shockable rhythms. PLR and corneal reflexes had best precision 72 h after sedation withdrawal and 96 h post-arrest.
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Affiliation(s)
- Henning Wimmer
- Department of Acute Medicine, Oslo University Hospital, Ullevål, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Jūratė Šaltytė Benth
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Health Services Research Unit, Akershus University Hospital, Nordbyhagen, Norway
| | - Christofer Lundqvist
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Health Services Research Unit, Akershus University Hospital, Nordbyhagen, Norway
- Department of Neurology, Akershus University Hospital, Nordbyhagen, Norway
| | - Geir Ø Andersen
- Department of Cardiology, Oslo University Hospital, Ullevål, Norway
| | - Tomas Draegni
- Department of Research and Development, Oslo University Hospital, Ullevål, Norway
| | - Kjetil Sunde
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Anaesthesia and Intensive Care, Oslo University Hospital, Ullevål, Norway
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13
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Berg KM, Bray JE, Ng KC, Liley HG, Greif R, Carlson JN, Morley PT, Drennan IR, Smyth M, Scholefield BR, Weiner GM, Cheng A, Djärv T, Abelairas-Gómez C, Acworth J, Andersen LW, Atkins DL, Berry DC, Bhanji F, Bierens J, Bittencourt Couto T, Borra V, Böttiger BW, Bradley RN, Breckwoldt J, Cassan P, Chang WT, Charlton NP, Chung SP, Considine J, Costa-Nobre DT, Couper K, Dainty KN, Dassanayake V, Davis PG, Dawson JA, de Almeida MF, De Caen AR, Deakin CD, Dicker B, Douma MJ, Eastwood K, El-Naggar W, Fabres JG, Fawke J, Fijacko N, Finn JC, Flores GE, Foglia EE, Folke F, Gilfoyle E, Goolsby CA, Granfeldt A, Guerguerian AM, Guinsburg R, Hatanaka T, Hirsch KG, Holmberg MJ, Hosono S, Hsieh MJ, Hsu CH, Ikeyama T, Isayama T, Johnson NJ, Kapadia VS, Kawakami MD, Kim HS, Kleinman ME, Kloeck DA, Kudenchuk P, Kule A, Kurosawa H, Lagina AT, Lauridsen KG, Lavonas EJ, Lee HC, Lin Y, Lockey AS, Macneil F, Maconochie IK, Madar RJ, Malta Hansen C, Masterson S, Matsuyama T, McKinlay CJD, Meyran D, Monnelly V, Nadkarni V, Nakwa FL, Nation KJ, Nehme Z, Nemeth M, Neumar RW, Nicholson T, Nikolaou N, Nishiyama C, Norii T, Nuthall GA, Ohshimo S, Olasveengen TM, Ong YKG, Orkin AM, Parr MJ, Patocka C, Perkins GD, Perlman JM, Rabi Y, Raitt J, Ramachandran S, Ramaswamy VV, Raymond TT, Reis AG, Reynolds JC, Ristagno G, Rodriguez-Nunez A, Roehr CC, Rüdiger M, Sakamoto T, Sandroni C, Sawyer TL, Schexnayder SM, Schmölzer GM, Schnaubelt S, Semeraro F, Singletary EM, Skrifvars MB, Smith CM, Soar J, Stassen W, Sugiura T, Tijssen JA, Topjian AA, Trevisanuto D, Vaillancourt C, Wyckoff MH, Wyllie JP, Yang CW, Yeung J, Zelop CM, Zideman DA, Nolan JP. 2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Circulation 2023; 148:e187-e280. [PMID: 37942682 PMCID: PMC10713008 DOI: 10.1161/cir.0000000000001179] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Abstract
The International Liaison Committee on Resuscitation engages in a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation and first aid science. Draft Consensus on Science With Treatment Recommendations are posted online throughout the year, and this annual summary provides more concise versions of the final Consensus on Science With Treatment Recommendations from all task forces for the year. Topics addressed by systematic reviews this year include resuscitation of cardiac arrest from drowning, extracorporeal cardiopulmonary resuscitation for adults and children, calcium during cardiac arrest, double sequential defibrillation, neuroprognostication after cardiac arrest for adults and children, maintaining normal temperature after preterm birth, heart rate monitoring methods for diagnostics in neonates, detection of exhaled carbon dioxide in neonates, family presence during resuscitation of adults, and a stepwise approach to resuscitation skills training. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research. Additional topics are addressed with scoping reviews and evidence updates.
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14
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Park JS, Kim EY, You Y, Min JH, Jeong W, Ahn HJ, In YN, Lee IH, Kim JM, Kang C. Combination strategy for prognostication in patients undergoing post-resuscitation care after cardiac arrest. Sci Rep 2023; 13:21880. [PMID: 38072906 PMCID: PMC10711008 DOI: 10.1038/s41598-023-49345-1] [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: 03/31/2023] [Accepted: 12/07/2023] [Indexed: 12/18/2023] Open
Abstract
This study investigated the prognostic performance of combination strategies using a multimodal approach in patients treated after cardiac arrest. Prospectively collected registry data were used for this retrospective analysis. Poor outcome was defined as a cerebral performance category of 3-5 at 6 months. Predictors of poor outcome were absence of ocular reflexes (PR/CR) without confounding factors, a highly malignant pattern on the most recent electroencephalography, defined as suppressed background with or without periodic discharges and burst-suppression, high neuron-specific enolase (NSE) after 48 h, and diffuse injury on imaging studies (computed tomography or diffusion-weighted imaging [DWI]) at 72-96 h. The prognostic performances for poor outcomes were analyzed for sensitivity and specificity. A total of 130 patients were included in the analysis. Of these, 68 (52.3%) patients had poor outcomes. The best prognostic performance was observed with the combination of absent PR/CR, high NSE, and diffuse injury on DWI [91.2%, 95% confidence interval (CI) 80.7-97.1], whereas the combination strategy of all available predictors did not improve prognostic performance (87.8%, 95% CI 73.8-95.9). Combining three of the predictors may improve prognostic performance and be more efficient than adding all tests indiscriminately, given limited medical resources.
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Affiliation(s)
- Jung Soo Park
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon, Republic of Korea
| | - Eun Young Kim
- Department of Neurology, Chungnam National University Sejong Hospital, 20, Bodeum 7-ro, Sejong, Republic of Korea
| | - Yeonho You
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon, Republic of Korea
| | - Jin Hong Min
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon, Republic of Korea
| | - Wonjoon Jeong
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon, Republic of Korea
| | - Hong Joon Ahn
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon, Republic of Korea
| | - Yong Nam In
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon, Republic of Korea
| | - In Ho Lee
- Department of Radiology, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
- Department of Radiology, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon, Republic of Korea
| | - Jae Moon Kim
- Department of Neurology, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon, Republic of Korea
| | - Changshin Kang
- Department of Emergency Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon, Republic of Korea.
- Department of Emergency Medicine, College of Medicine, Chungnam National University, 282 Mokdong-ro, Jung-gu, Daejeon, Republic of Korea.
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15
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Vlachos S, Rubenfeld G, Menon D, Harrison D, Rowan K, Maharaj R. Early and late withdrawal of life-sustaining treatment after out-of-hospital cardiac arrest in the United Kingdom: Institutional variation and association with hospital mortality. Resuscitation 2023; 193:109956. [PMID: 37661013 DOI: 10.1016/j.resuscitation.2023.109956] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 08/23/2023] [Accepted: 08/24/2023] [Indexed: 09/05/2023]
Abstract
AIM Frequency and timing of Withdrawal of Life-Sustaining Treatment (WLST) after Out-of-Hospital Cardiac Arrest (OHCA) vary across Intensive Care Units (ICUs) in the United Kingdom (UK) and may be a marker of lower healthcare quality if instituted too frequently or too early. We aimed to describe WLST practice, quantify its variability across UK ICUs, and assess the effect of institutional deviation from average practice on patients' risk-adjusted hospital mortality. METHODS We conducted a retrospective multi-centre cohort study including all adult patients admitted after OHCA to UK ICUs between 2010 and 2017. We identified patient and ICU characteristics associated with early (within 72 h) and late (>72 h) WLST and quantified the between-ICU variation. We used the ICU-level observed-to-expected (O/E) ratios of early and late-WLST frequency as separate metrics of institutional deviation from average practice and calculated their association with patients' hospital mortality. RESULTS We included 28,438 patients across 204 ICUs. 10,775 (37.9%) had WLST and 6397 (59.4%) of them had early-WLST. Both WLST types were strongly associated with patient-level demographics and pre-existing conditions but weakly with ICU-level characteristics. After adjustment, we found unexplained between-ICU variation for both early-WLST (Median Odds Ratio 1.59, 95%CrI 1.49-1.71) and late-WLST (MOR 1.39, 95%CrI 1.31-1.50). Importantly, patients' hospital mortality was higher in ICUs with higher O/E ratio of early-WLST (OR 1.29, 95%CI 1.21-1.38, p < 0.001) or late-WLST (OR 1.39, 95%CI 1.31-1.48, p < 0.001). CONCLUSIONS Significant variability exists between UK ICUs in WLST frequency and timing. This matters because unexplained higher-than-expected WLST frequency is associated with higher hospital mortality independently of timing, potentially signalling prognostic pessimism and lower healthcare quality.
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Affiliation(s)
- Savvas Vlachos
- King's College London, School of Cardio-Vascular Medicine and Sciences, Strand, London WC2R 2LS, UK.
| | - Gordon Rubenfeld
- University of Toronto, Interdepartmental Division of Critical Care, ON M5S Toronto, Ontario, Canada
| | - David Menon
- University of Cambridge, Department of Medicine, CB2 1TN Cambridge, UK
| | - David Harrison
- Intensive Care National Audit & Research Centre, Department of Statistics, WC1V 6AZ London, UK
| | - Kathryn Rowan
- National Institute for Health and Care Research, W1T 7HA London, UK
| | - Ritesh Maharaj
- London School of Economics and Political Science, Department of Health Policy and Health Economics, WC2A 2AE London, UK
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Järpestam S, Martinell L, Rylander C, Lilja L. Post-cardiac arrest intensive care in Sweden: A survey of current clinical practice. Acta Anaesthesiol Scand 2023; 67:1249-1255. [PMID: 37314010 DOI: 10.1111/aas.14298] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 05/11/2023] [Accepted: 05/31/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND European guidelines recommend targeted temperature management (TTM) in post-cardiac arrest care. A large multicentre clinical trial, however, showed no difference in mortality and neurological outcome when comparing hypothermia to normothermia with early treatment of fever. The study results were valid given a strict protocol for the assessment of prognosis using defined neurological examinations. With the current range of recommended TTM temperatures, and applicable neurological examinations, procedures may differ between hospitals and the variation of clinical practice in Sweden is not known. AIM The aim of this study was to investigate current practice in post-resuscitation care after cardiac arrest as to temperature targets and assessment of neurological prognosis in Swedish intensive care units (ICUs). METHODS A structured survey was conducted by telephone or e-mail in all Levels 2 and 3 (= 53) Swedish ICUs during the spring of 2022 with a secondary survey in April 2023. RESULTS Five units were not providing post-cardiac arrest care and were excluded. The response rate was 43/48 (90%) of the eligible units. Among the responding ICUs, normothermia (36-37.7°C) was applied in all centres (2023). There was a detailed routine for the assessment of neurological prognosis in 38/43 (88%) ICUs. Neurological assessment was applied 72-96 h after return of spontaneous circulation in 32/38 (84%) units. Electroencephalogram and computed tomography and/or magnetic resonance imaging were the most common technical methods available. CONCLUSION Swedish ICUs use normothermia including early treatment of fever in post-resuscitation care after cardiac arrest and almost all apply a detailed routine for the assessment of neurological prognosis. However, available methods for prognostic evaluation varies between hospitals.
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Affiliation(s)
- Sara Järpestam
- School of Medical Sciences, University of Örebro, Örebro, Sweden
| | - Louise Martinell
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Christian Rylander
- Anaesthesiology and Intensive Care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Linus Lilja
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Anaesthesia and Intensive Care, Karlstad Central Hospital, Karlstad, Sweden
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17
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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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18
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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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19
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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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20
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Fordyce CB, Kramer AH, Ainsworth C, Christenson J, Hunter G, Kromm J, Lopez Soto C, Scales DC, Sekhon M, van Diepen S, Dragoi L, Josephson C, Kutsogiannis J, Le May MR, Overgaard CB, Savard M, Schnell G, Wong GC, Belley-Côté E, Fantaneanu TA, Granger CB, Luk A, Mathew R, McCredie V, Murphy L, Teitelbaum J. Neuroprognostication in the Post Cardiac Arrest Patient: A Canadian Cardiovascular Society Position Statement. Can J Cardiol 2023; 39:366-380. [PMID: 37028905 DOI: 10.1016/j.cjca.2022.12.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 12/13/2022] [Accepted: 12/14/2022] [Indexed: 04/08/2023] Open
Abstract
Cardiac arrest (CA) is associated with a low rate of survival with favourable neurologic recovery. The most common mechanism of death after successful resuscitation from CA is withdrawal of life-sustaining measures on the basis of perceived poor neurologic prognosis due to underlying hypoxic-ischemic brain injury. Neuroprognostication is an important component of the care pathway for CA patients admitted to hospital but is complex, challenging, and often guided by limited evidence. Using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to evaluate the evidence underlying factors or diagnostic modalities available to determine prognosis, recommendations were generated in the following domains: (1) circumstances immediately after CA; (2) focused neurologic exam; (3) myoclonus and seizures; (4) serum biomarkers; (5) neuroimaging; (6) neurophysiologic testing; and (7) multimodal neuroprognostication. This position statement aims to serve as a practical guide to enhance in-hospital care of CA patients and emphasizes the adoption of a systematic, multimodal approach to neuroprognostication. It also highlights evidence gaps.
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Affiliation(s)
- Christopher B Fordyce
- Division of Cardiology, Department of Medicine, Vancouver General Hospital, and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia.
| | - Andreas H Kramer
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta; Department of Critical Care, University of Calgary, Alberta
| | - Craig Ainsworth
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jim Christenson
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia
| | - Gary Hunter
- Division of Neurology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Julie Kromm
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta; Department of Critical Care, University of Calgary, Alberta
| | - Carmen Lopez Soto
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Damon C Scales
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mypinder Sekhon
- Division of Critical Care, Department of Medicine, Vancouver General Hospital, Djavad Mowafaghian Centre for Brain Health, International Centre for Repair Discoveries, University of British Columbia, Vancouver, British Columbia
| | - Sean van Diepen
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta; Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta
| | - Laura Dragoi
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Colin Josephson
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta; Department of Critical Care, University of Calgary, Alberta
| | - Jim Kutsogiannis
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta
| | - Michel R Le May
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Christopher B Overgaard
- Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Martin Savard
- Department of Neurological Sciences CHU de Québec - Hôpital de l'Enfant-Jésus Quebec City, Quebec, Canada
| | - Gregory Schnell
- Division of Cardiology, Department of Medicine, University of Calgary, Calgary, Alberta
| | - Graham C Wong
- Division of Cardiology, Department of Medicine, Vancouver General Hospital, and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia
| | - Emilie Belley-Côté
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Tadeu A Fantaneanu
- Division of Neurology, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Adriana Luk
- Division of Cardiology, Department of Medicine, University of Toronto and the Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Rebecca Mathew
- CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, and the Faculty of Medicine, Division of Critical Care, University of Ottawa, Ottawa, Ontario, Canada
| | - Victoria McCredie
- Interdepartmental Division of Critical Care Medicine, University of Toronto, the Krembil Research Institute, Toronto Western Hospital, University Health Network, and Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Laurel Murphy
- Departments of Emergency Medicine and Critical Care, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jeanne Teitelbaum
- Neurological Intensive Care Unit, Montreal Neurological Institute and Hospital, McGill University, Montreal, Quebec, Canada
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Song H, Bang HJ, You Y, Park JS, Kang C, Kim HJ, Park KN, Oh SH, Youn CS. Novel serum biomarkers for predicting neurological outcomes in postcardiac arrest patients treated with targeted temperature management. Crit Care 2023; 27:113. [PMID: 36927495 PMCID: PMC10022069 DOI: 10.1186/s13054-023-04400-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 03/09/2023] [Indexed: 03/18/2023] Open
Abstract
OBJECTIVE To determine the clinical feasibility of novel serum biomarkers in out-of-hospital cardiac arrest (OHCA) patients treated with target temperature management (TTM). METHODS This study was a prospective observational study conducted on OHCA patients who underwent TTM. We measured conventional biomarkers, neuron‑specific enolase and S100 calcium-binding protein (S-100B), as well as novel biomarkers, including tau protein, neurofilament light chain (NFL), glial fibrillary acidic protein (GFAP), and ubiquitin C-terminal hydrolase-L1 (UCH-L1), at 0, 24, 48, and 72 h after the return of spontaneous circulation identified by SIMOA immunoassay. The primary outcome was poor neurological outcome at 6 months after OHCA. RESULTS A total of 100 patients were included in this study from August 2018 to May 2020. Among the included patients, 46 patients had good neurologic outcomes at 6 months after OHCA. All conventional and novel serum biomarkers had the ability to discriminate between the good and poor neurological outcome groups (p < 0.001). The area under the curves of the novel serum biomarkers were highest at 72 h after cardiac arrest (CA) (0.906 for Tau, 0.946 for NFL, 0.875 for GFAP, and 0.935 for UCH-L1). The NFL at 72 h after CA had the highest sensitivity (77.1%, 95% CI 59.9-89.6) in predicting poor neurological outcomes while maintaining 100% specificity. CONCLUSION Novel serum biomarkers reliably predicted poor neurological outcomes for patients with OHCA treated with TTM when life-sustaining therapy was not withdrawn. Cutoffs from two large existing studies (TTM and COMACARE substudy) were externally validated in our study. The predictive power of the novel biomarkers was the highest at 72 h after CA.
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Affiliation(s)
- Hwan Song
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, Republic of Korea
| | - Hyo Jin Bang
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, Republic of Korea
| | - Yeonho You
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Jung Soo Park
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Changshin Kang
- Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Hyo Joon Kim
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, Republic of Korea
| | - Kyu Nam Park
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, Republic of Korea
| | - Sang Hoon Oh
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, Republic of Korea
| | - Chun Song Youn
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, Republic of Korea.
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22
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Neurophysiological and Clinical Correlates of Acute Posthypoxic Myoclonus. J Clin Neurophysiol 2023; 40:117-122. [PMID: 36521068 DOI: 10.1097/wnp.0000000000000937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
SUMMARY Prognostication following cardiorespiratory arrest relies on the neurological examination, which is supported by neuroimaging and neurophysiological testing. Acute posthypoxic myoclonus (PHM) is a clinical entity that has prognostic significance and historically has been considered an indicator of poor outcome, but this is not invariably the case. "Malignant" and more "benign" forms of acute PHM have been described and differentiating them is key in understanding their meaning in prognosis. Neurophysiological tests, electroencephalogram in particular, and clinical phenotyping are crucial in defining subtypes of acute PHM. This review describes the neurophysiological and phenotypic markers of malignant and benign forms of acute PHM, a clinical approach to evaluating acute PHM following cardiorespiratory arrest in determining prognosis, and gaps in our understanding of acute PHM that require further study.
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23
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Andersen SK, Steinberg A. What happens after they leave the hospital? Resuscitation 2022; 181:1-2. [PMID: 36243224 DOI: 10.1016/j.resuscitation.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Sarah K Andersen
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Alexis Steinberg
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Neurology, Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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24
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Elmer J, Coppler PJ, Jones BL, Nagin DS, Callaway CW. Bayesian Outcome Prediction After Resuscitation From Cardiac Arrest. Neurology 2022; 99:e1113-e1121. [PMID: 35790421 PMCID: PMC9536746 DOI: 10.1212/wnl.0000000000200854] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 04/29/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Postarrest prognostication research does not typically account for the sequential nature of real-life data acquisition and interpretation and reports nonintuitive estimates of uncertainty. Bayesian approaches offer advantages well suited to prognostication. We used Bayesian regression to explore the usefulness of sequential prognostic indicators in the context of prior knowledge and compared this with a guideline-concordant algorithm. METHODS We included patients hospitalized at a single center after cardiac arrest. We extracted prospective data and assumed these data accrued over time as in routine practice. We considered predictors demographic and arrest characteristics, initial and daily neurologic examination, laboratory results, therapeutic interventions, brain imaging, and EEG. We fit Bayesian hierarchical generalized linear multivariate models predicting discharge Cerebral Performance Category (CPC) 4 or 5 (poor outcomes) vs 1-3 including sequential clinical and prognostic data. We explored outcome posterior probability distributions (PPDs) for individual patients and overall. As a comparator, we applied the 2021 European Resuscitation Council and European Society of Intensive Care Medicine (ERC/ESICM) guidelines. RESULTS We included 2,692 patients of whom 864 (35%) were discharged with a CPC 1-3. Patients' outcome PPDs became narrow and shifted toward 0 or 1 as sequentially acquired information was added to models. These changes were largest after arrest characteristics and initial neurologic examination were included. Using information typically available at or before intensive care unit admission, sensitivity predicting poor outcome was 51% with a 0.6% false-positive rate. In our most comprehensive model, sensitivity for poor outcome prediction was 76% with 0.6% false-positive rate (FPR). The ERC/ESICM algorithm applied to 547 of 2,692 patients and yielded 36% sensitivity with 0% FPR. DISCUSSION Bayesian models offer advantages well suited to prognostication research. On balance, our findings support the view that in expert hands, accurate neurologic prognostication is possible in many cases before 72 hours postarrest. Although we caution against early withdrawal of life-sustaining therapies, rapid outcome prediction can inform clinical decision making and future clinical trials.
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Affiliation(s)
- Jonathan Elmer
- From the Department of Emergency Medicine (J.E., P.J.C., C.C.); Department of Critical Care Medicine (J.E.); Department of Neurology (J.E.); Department of Psychiatry (B.L.J.), University of Pittsburgh; and the School of Public Policy & Management (D.S.N.), Heinz College, Carnegie Mellon University, Pittsburgh, PA.
| | - Patrick J Coppler
- From the Department of Emergency Medicine (J.E., P.J.C., C.C.); Department of Critical Care Medicine (J.E.); Department of Neurology (J.E.); Department of Psychiatry (B.L.J.), University of Pittsburgh; and the School of Public Policy & Management (D.S.N.), Heinz College, Carnegie Mellon University, Pittsburgh, PA
| | - Bobby L Jones
- From the Department of Emergency Medicine (J.E., P.J.C., C.C.); Department of Critical Care Medicine (J.E.); Department of Neurology (J.E.); Department of Psychiatry (B.L.J.), University of Pittsburgh; and the School of Public Policy & Management (D.S.N.), Heinz College, Carnegie Mellon University, Pittsburgh, PA
| | - Daniel S Nagin
- From the Department of Emergency Medicine (J.E., P.J.C., C.C.); Department of Critical Care Medicine (J.E.); Department of Neurology (J.E.); Department of Psychiatry (B.L.J.), University of Pittsburgh; and the School of Public Policy & Management (D.S.N.), Heinz College, Carnegie Mellon University, Pittsburgh, PA
| | - Clifton W Callaway
- From the Department of Emergency Medicine (J.E., P.J.C., C.C.); Department of Critical Care Medicine (J.E.); Department of Neurology (J.E.); Department of Psychiatry (B.L.J.), University of Pittsburgh; and the School of Public Policy & Management (D.S.N.), Heinz College, Carnegie Mellon University, Pittsburgh, PA
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Keijzer HM, Lange PA, Meijer FJ, Tonino BA, Blans MJ, Klijn CJ, Hoedemaekers CW, Hofmeijer J, Helmich RC. MRI markers of brain network integrity relate to neurological outcome in postanoxic coma. Neuroimage Clin 2022; 36:103171. [PMID: 36058165 PMCID: PMC9446009 DOI: 10.1016/j.nicl.2022.103171] [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: 02/10/2022] [Revised: 08/18/2022] [Accepted: 08/23/2022] [Indexed: 12/14/2022]
Abstract
AIM Current multimodal approaches leave approximately half of the comatose patients after cardiac arrest with an indeterminate prognosis. Here we investigated whether early MRI markers of brain network integrity can distinguish between comatose patients with a good versus poor neurological outcome six months later. METHODS We performed a prospective cohort study in 48 patients after cardiac arrest submitted in a comatose state to the Intensive Care Unit of two Dutch hospitals. MRI was performed at three days after cardiac arrest, including resting state functional MRI and diffusion-tensor imaging (DTI). Resting state fMRI was used to quantify functional connectivity within ten resting-state networks, and DTI to assess mean diffusivity (MD) in these same networks. We contrasted two groups of patients, those with good (n = 29, cerebral performance category 1-2) versus poor (n = 19, cerebral performance category 3-5) outcome at six months. Mutual associations between functional connectivity, MD, and clinical outcome were studied. RESULTS Patients with good outcome show higher within-network functional connectivity (fMRI) and higher MD (DTI) than patients with poor outcome across 8/10 networks, most prominent in the default mode network, salience network, and visual network. While the anatomical distribution of outcome-related changes was similar for functional connectivity and MD, the pattern of inter-individual differences was very different: functional connectivity showed larger inter-individual variability in good versus poor outcome, while the opposite was observed for MD. Exploratory analyses suggested that it is possible to define network-specific cut-off values that could help in outcome prediction: (1) high functional connectivity and high MD, associated with good outcome; (2) low functional connectivity and low MD, associated with poor outcome; (3) low functional connectivity and high MD, associated with uncertain outcome. DISCUSSION Resting-state functional connectivity and mean diffusivity-three days after cardiac arrest are strongly associated with neurological recovery-six months later in a complementary fashion. The combination of fMRI and MD holds potential to improve prediction of outcome.
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Affiliation(s)
- Hanneke M. Keijzer
- Department of Neurology, Rijnstate Hospital, 6800 TA Arnhem, the Netherlands,Department of Neurology, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Centre, 6500 HC Nijmegen, the Netherlands,Corresponding author at: Department of Neurology, Rijnstate Hospital, PO box 9555 TA Arnhem, the Netherlands.
| | - Puck A.M. Lange
- Department of Neurology, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Centre, 6500 HC Nijmegen, the Netherlands
| | - Frederick J.A. Meijer
- Department of Medical Imaging, Radboud University Medical Centre, 6500 HC Nijmegen, the Netherlands
| | - Bart A.R. Tonino
- Department of Radiology, Rijnstate Hospital, 6800 TA Arnhem, the Netherlands
| | - Michiel J. Blans
- Department of Intensive Care Medicine, Rijnstate Hospital, Arnhem, the Netherlands
| | - Catharina J.M. Klijn
- Department of Neurology, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Centre, 6500 HC Nijmegen, the Netherlands
| | - Cornelia W.E. Hoedemaekers
- Department of Intensive Care Medicine, Radboud University Medical Centre, 6500 HC Nijmegen, the Netherlands
| | - Jeannette Hofmeijer
- Department of Neurology, Rijnstate Hospital, 6800 TA Arnhem, the Netherlands,Department of Clinical Neurophysiology, University of Twente, Faculty of Science and Technology, 7522 NB Enschede, the Netherlands
| | - Rick C. Helmich
- Department of Neurology, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Centre, 6500 HC Nijmegen, the Netherlands
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Concordance in multimodal prognostication after cardiac arrest: improving accuracy or comparing apples to oranges? Resuscitation 2022; 179:114-115. [PMID: 36031074 DOI: 10.1016/j.resuscitation.2022.08.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 08/12/2022] [Indexed: 11/24/2022]
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27
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Coppler PJ, Elmer J. Novel pupillary assessment in post anoxic coma. Resuscitation 2022; 176:66-67. [PMID: 35654227 DOI: 10.1016/j.resuscitation.2022.05.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 05/23/2022] [Indexed: 12/22/2022]
Affiliation(s)
- Patrick J Coppler
- 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
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28
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External validation of the 2020 ERC/ESICM prognostication strategy algorithm after cardiac arrest. Crit Care 2022; 26:95. [PMID: 35399085 PMCID: PMC8996564 DOI: 10.1186/s13054-022-03954-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 03/18/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Purpose
To assess the performance of the post-cardiac arrest (CA) prognostication strategy algorithm recommended by the European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) in 2020.
Methods
This was a retrospective analysis of the Korean Hypothermia Network Prospective Registry 1.0. Unconscious patients without confounders at day 4 (72–96 h) after return of spontaneous circulation (ROSC) were included. The association between the prognostic factors included in the prognostication strategy algorithm, except status myoclonus and the neurological outcome, was investigated, and finally, the prognostic performance of the prognostication strategy algorithm was evaluated. Poor outcome was defined as cerebral performance categories 3–5 at 6 months after ROSC.
Results
A total of 660 patients were included in the final analysis. Of those, 108 (16.4%) patients had a good neurological outcome at 6 months after CA. The 2020 ERC/ESICM prognostication strategy algorithm identified patients with poor neurological outcome with 60.2% sensitivity (95% CI 55.9–64.4) and 100% specificity (95% CI 93.9–100) among patients who were unconscious or had a GCS_M score ≤ 3 and with 58.2% sensitivity (95% CI 53.9–62.3) and 100% specificity (95% CI 96.6–100) among unconscious patients. When two prognostic factors were combined, any combination of prognostic factors had a false positive rate (FPR) of 0 (95% CI 0–5.6 for combination of no PR/CR and poor CT, 0–30.8 for combination of No SSEP N20 and NSE 60).
Conclusion
The 2020 ERC/ESICM prognostication strategy algorithm predicted poor outcome without an FPR and with sensitivities of 58.2–60.2%. Any combinations of two predictors recommended by ERC/ESICM showed 0% of FPR.
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29
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Perkins GD, Nolan JP. Advanced Life Support Update. Crit Care 2022; 26:73. [PMID: 35337353 DOI: 10.1186/s13054-022-03912-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2022. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2022 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .
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Affiliation(s)
- Gavin D Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK. .,Critical Care Unit, Heartlands Hospital, University Hospital Birmingham, Birmingham, UK.
| | - Jerry P Nolan
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK.,Critical Care Unit, Royal United Hospital Bath, Bath, UK
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30
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Sandroni C, D'Arrigo S, Cacciola S, Hoedemaekers CWE, Westhall E, Kamps MJA, Taccone FS, Poole D, Meijer FJA, Antonelli M, Hirsch KG, Soar J, Nolan JP, Cronberg T. Prediction of good neurological outcome in comatose survivors of cardiac arrest: a systematic review. Intensive Care Med 2022; 48:389-413. [PMID: 35244745 PMCID: PMC8940794 DOI: 10.1007/s00134-022-06618-z] [Citation(s) in RCA: 62] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 01/03/2022] [Indexed: 12/11/2022]
Abstract
PURPOSE To assess the ability of clinical examination, blood biomarkers, electrophysiology or neuroimaging assessed within 7 days from return of spontaneous circulation (ROSC) to predict good neurological outcome, defined as no, mild, or moderate disability (CPC 1-2 or mRS 0-3) at discharge from intensive care unit or later, in comatose adult survivors from cardiac arrest (CA). METHODS PubMed, EMBASE, Web of Science and the Cochrane Database of Systematic Reviews were searched. Sensitivity and specificity for good outcome were calculated for each predictor. The risk of bias was assessed using the QUIPS tool. RESULTS A total of 37 studies were included. Due to heterogeneities in recording times, predictor thresholds, and definition of some predictors, meta-analysis was not performed. A withdrawal or localisation motor response to pain immediately or at 72-96 h after ROSC, normal blood values of neuron-specific enolase (NSE) at 24 h-72 h after ROSC, a short-latency somatosensory evoked potentials (SSEPs) N20 wave amplitude > 4 µV or a continuous background without discharges on electroencephalogram (EEG) within 72 h from ROSC, and absent diffusion restriction in the cortex or deep grey matter on MRI on days 2-7 after ROSC predicted good neurological outcome with more than 80% specificity and a sensitivity above 40% in most studies. Most studies had moderate or high risk of bias. CONCLUSIONS In comatose cardiac arrest survivors, clinical, biomarker, electrophysiology, and imaging studies identified patients destined to a good neurological outcome with high specificity within the first week after cardiac arrest (CA).
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Affiliation(s)
- Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli"-IRCCS, Largo Francesco Vito, 1, 00168, Rome, Italy.,Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Sonia D'Arrigo
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli"-IRCCS, Largo Francesco Vito, 1, 00168, Rome, Italy.
| | - Sofia Cacciola
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli"-IRCCS, Largo Francesco Vito, 1, 00168, Rome, Italy
| | | | - Erik Westhall
- Department of Clinical Sciences Lund, Clinical Neurophysiology, Lund University, Skane University Hospital, Lund, Sweden
| | - Marlijn J A Kamps
- Intensive Care Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Daniele Poole
- Department of Anaesthesiology and Intensive Care, San Martino Hospital, Belluno, Italy
| | - Frederick J A Meijer
- Department of Radiology and Nuclear Medicine, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Massimo Antonelli
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli"-IRCCS, Largo Francesco Vito, 1, 00168, Rome, Italy.,Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Karen G Hirsch
- Department of Neurology, Stanford University, Stanford, USA
| | - Jasmeet Soar
- Critical Care Unit, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Jerry P Nolan
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK
| | - Tobias Cronberg
- Department of Clinical Sciences Lund, Neurology, Lund University, Skane University Hospital, Lund, Sweden
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31
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Wihersaari L, Reinikainen M, Furlan R, Mandelli A, Vaahersalo J, Kurola J, Tiainen M, Pettilä V, Bendel S, Varpula T, Latini R, Ristagno G, Skrifvars MB. Neurofilament light compared to neuron-specific enolase as a predictor of unfavourable outcome after out-of-hospital cardiac arrest. Resuscitation 2022; 174:1-8. [PMID: 35245610 DOI: 10.1016/j.resuscitation.2022.02.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 02/22/2022] [Accepted: 02/24/2022] [Indexed: 11/28/2022]
Abstract
AIM We compared the prognostic abilities of neurofilament light (NfL) and neuron-specific enolase (NSE) in patients resuscitated from out-of-hospital cardiac arrest (OHCA) of various aetiologies. METHODS We analysed frozen blood samples obtained at 24 and 48 hours from OHCA patients treated in 21 Finnish intensive care units in 2010 and 2011. We defined unfavourable outcome as Cerebral Performance Category (CPC) 3-5 at 12 months after OHCA. We evaluated the prognostic ability of the biomarkers by calculating the area under the receiver operating characteristic curves (AUROCs [95% confidence intervals]) and compared these with a bootstrap method. RESULTS Out of 248 adult patients, 12-month outcome was unfavourable in 120 (48.4%). The median (interquartile range) NfL concentrations for patients with unfavourable and those with favourable outcome, respectively, were 688 (146-1804) pg/mL vs. 31 (17-61) pg/mL at 24 h and 1162 (147-4361) pg/mL vs. 36 (21-87) pg/mL at 48 h, p < 0.001 for both. The corresponding NSE concentrations were 13.3 (7.2-27.3) µg/L vs. 8.5 (5.8-13.2) µg/L at 24 h and 20.4 (8.1-56.6) µg/L vs. 8.2 (5.9-12.1) µg/L at 48 h, p < 0.001 for both. The AUROCs to predict an unfavourable outcome were 0.90 (0.86-0.94) for NfL vs. 0.65 (0.58-0.72) for NSE at 24 h, p < 0.001 and 0.88 (0.83-0.93) for NfL and 0.73 (0.66-0.81) for NSE at 48 h, p < 0.001. CONCLUSION Compared to NSE, NfL demonstrated superior accuracy in predicting long-term unfavourable outcome after OHCA.
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Affiliation(s)
- L Wihersaari
- Department of Anaesthesiology and Intensive Care, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland.
| | - M Reinikainen
- Department of Anaesthesiology and Intensive Care, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - R Furlan
- Clinical Neuroimmunology Unit, Institute of Experimental Neurology, Division of Neuroscience, IRCCS Ospedale San Raffaele, Milan, Italy
| | - A Mandelli
- Clinical Neuroimmunology Unit, Institute of Experimental Neurology, Division of Neuroscience, IRCCS Ospedale San Raffaele, Milan, Italy
| | - J Vaahersalo
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - J Kurola
- Centre for Prehospital Emergency Care, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - M Tiainen
- University of Helsinki and Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - V Pettilä
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - S Bendel
- Department of Anaesthesiology and Intensive Care, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - T Varpula
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - R Latini
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - G Ristagno
- Department of Pathophysiology and Transplantation, University of Milan, Italy; Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - M B Skrifvars
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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32
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Gakuba C, Launey Y, Quintard H. Prognosis for acute brain injury: Nobody's Perfect. Anaesth Crit Care Pain Med 2021; 40:100985. [PMID: 34924153 DOI: 10.1016/j.accpm.2021.100985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Clément Gakuba
- Normandie Univ, UNICAEN, CHU de Caen, Service d'Anesthésie-Réanimation chirurgicale, 14000 Caen, France; Normandie Univ, UNICAEN, INSERM, U1237, PhIND "Physiopathology and Imaging of Neurological Disorders", Institut Blood and Brain at Caen-Normandie, Cyceron, 14000 Caen, France
| | - Yoann Launey
- Réanimation chirurgicale, Centre Hospitalier Universitaire de Rennes, 35000 Rennes, France
| | - Hervé Quintard
- Soins intensifs, Hopitaux Universitaires de Genève, 1201 Genève, Switzerland.
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33
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The accuracy of various neuro-prognostication algorithms and the added value of neurofilament light chain dosage for patients resuscitated from shockable cardiac arrest: An ancillary analysis of the ISOCRATE study. Resuscitation 2021; 171:1-7. [PMID: 34915084 DOI: 10.1016/j.resuscitation.2021.12.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 12/07/2021] [Accepted: 12/08/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE In current guidelines, neurological prognostication after cardiopulmonary resuscitation is based on a multimodal approach bundled in algorithms. Biomarkers are of particular interest because they are unaffected by interpretation bias. We assessed the predictive value of serum neurofilament light chains (NF-L) in patients with a shockable rhythm who received cardiopulmonary resuscitation, and evaluated the predictive value of a modified algorithm where NF-L dosage is included. METHODS All patients who were included participated in the randomized ISOCRATE trial. NF-L values 48 h after ROSC were compared for patients with a good (Cerebral Performance Category (CPC) 1 or 2) and a poor prognosis (CPC 3 to 5 or death). The benefit of adding NF-L dosage to the current guideline algorithm was then assessed for NF-L thresholds of 500 and 1,200 pg/ml as previously described. RESULTS NF-L was assayed for 49 patients. In patients with good versus those with poor outcomes, median NF-L values at 48 h were 72 ± 78 and 7,755 ± 9,501 pg/ml respectively (P < 0.0001; AUC [95 %CI] = 0.87 [0.74;0.99]). The sensitivity of the modified ESICM/ERC 2021 algorithm after adding NF-L with thresholds of 500 and 1,200 pg/ml was 0.74 (CI 95% 0.51-0.88) and 0.68 (CI 95% 0.46-0.86), respectively, versus 0.53 (CI 95% 0.32-0.73) for the unmodified algorithm. In three instances the specificity was 1. CONCLUSION High NF-L plasma levels 48 h after cardiac arrest was significantly associated with a poor outcome. Adjunction to the current guideline algorithm of an NF-L assay with a 500 pg/ml threshold 48 h after cardiac arrest provided the best sensitivity compared to the algorithm alone, while specificity remained excellent.
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Heart rate complexity: An early prognostic marker of patient outcome after cardiac arrest. Clin Neurophysiol 2021; 134:27-33. [PMID: 34953334 DOI: 10.1016/j.clinph.2021.10.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 09/21/2021] [Accepted: 10/23/2021] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Early prognostication in comatose patients after cardiac arrest (CA) is difficult but essential to inform relatives and optimize treatment. Here we investigate the predictive value of heart-rate variability captured by multiscale entropy (MSE) for long-term outcomes in comatose patients during the first 24 hours after CA. METHODS In this retrospective analysis of prospective multi-centric cohort, we analyzed MSE of the heart rate in 79 comatose patients after CA while undergoing targeted temperature management and sedation during the first day of coma. From the MSE, two complexity indices were derived by summing values over short and long time scales (CIs and CIl). We splitted the data in training and test datasets for analysing the predictive value for patient outcomes (defined as best cerebral performance category within 3 months) of CIs and CIl. RESULTS Across the whole dataset, CIl provided the best sensitivity, specificity, and accuracy (88%, 75%, and 82%, respectively). Positive and negative predictive power were 81% and 84%. CONCLUSIONS Characterizing the complexity of the ECG in patients after CA provides an accurate prediction of both favorable and unfavorable outcomes. SIGNIFICANCE The analysis of heartrate variability by means of MSE provides accurate outcome prediction on the first day of coma.
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Abstract
PURPOSE OF REVIEW Most patients who are successfully resuscitated after cardiac arrest are initially comatose and require mechanical ventilation and other organ support in an ICU. Knowledge about the optimal strategy for treating these patients is evolving rapidly. This review will summarize the evidence on key aspects of postarrest care and prognostication, with a focus on actionable parameters that may impact patient survival and neurologic outcomes. RECENT FINDINGS Optimal targets for arterial blood oxygen and carbon dioxide in comatose postcardiac arrest patients remain uncertain. Observational data are conflicting and the few randomized controlled trials to date have failed to show that different ranges of blood oxygen and carbon dioxide values impact on biomarkers of neurological injury. The Targeted Temperature Management 2 (TTM-2) trial has documented no difference in 6-month mortality among comatose postcardiac arrest patients managed at 33 oC versus controlled normothermia. An extensive systematic review of the evidence on prognostication of outcome among comatose postcardiac arrest patients underpins new prognostication guidelines. SUMMARY Clinical guidelines for postresuscitation care have recently been updated and incorporate all the available science supporting the treatment of postcardiac arrests. At a minimum, fever should be strictly avoided in comatose postcardiac patients. Prognostication must involve multiple modalities and should not be attempted until assessment confounders have been sufficiently excluded.
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36
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Sandroni C, Cronberg T, Sekhon M. Brain injury after cardiac arrest: pathophysiology, treatment, and prognosis. Intensive Care Med 2021; 47:1393-1414. [PMID: 34705079 PMCID: PMC8548866 DOI: 10.1007/s00134-021-06548-2] [Citation(s) in RCA: 155] [Impact Index Per Article: 51.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 09/28/2021] [Indexed: 01/03/2023]
Abstract
Post-cardiac arrest brain injury (PCABI) is caused by initial ischaemia and subsequent reperfusion of the brain following resuscitation. In those who are admitted to intensive care unit after cardiac arrest, PCABI manifests as coma, and is the main cause of mortality and long-term disability. This review describes the mechanisms of PCABI, its treatment options, its outcomes, and the suggested strategies for outcome prediction.
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Affiliation(s)
- Claudio Sandroni
- Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy. .,Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli", IRCCS, Università Cattolica del Sacro Cuore, Largo Francesco Vito, 1, 00168, Rome, Italy.
| | - Tobias Cronberg
- Department of Clinical Sciences Lund, Neurology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Mypinder Sekhon
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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Perkins GD, Callaway CW, Haywood K, Neumar RW, Lilja G, Rowland MJ, Sawyer KN, Skrifvars MB, Nolan JP. Brain injury after cardiac arrest. Lancet 2021; 398:1269-1278. [PMID: 34454687 DOI: 10.1016/s0140-6736(21)00953-3] [Citation(s) in RCA: 81] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 04/20/2021] [Accepted: 04/20/2021] [Indexed: 12/16/2022]
Abstract
As more people are surviving cardiac arrest, focus needs to shift towards improving neurological outcomes and quality of life in survivors. Brain injury after resuscitation, a common sequela following cardiac arrest, ranges in severity from mild impairment to devastating brain injury and brainstem death. Effective strategies to minimise brain injury after resuscitation include early intervention with cardiopulmonary resuscitation and defibrillation, restoration of normal physiology, and targeted temperature management. It is important to identify people who might have a poor outcome, to enable informed choices about continuation or withdrawal of life-sustaining treatments. Multimodal prediction guidelines seek to avoid premature withdrawal in those who might survive with a good neurological outcome, or prolonging treatment that might result in survival with severe disability. Approximately one in three admitted to intensive care will survive, many of whom will need intensive, tailored rehabilitation after discharge to have the best outcomes.
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Affiliation(s)
- Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK; Critical Care Unit, University Hospitals Birmingham, Birmingham, UK.
| | - Clifton W Callaway
- University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Robert W Neumar
- Department of Emergency Medicine, Michigan Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor, MI, USA
| | - Gisela Lilja
- Neurology, Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Lund, Sweden
| | - Matthew J Rowland
- Kadoorie Centre for Critical Care Research, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Kelly N Sawyer
- University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jerry P Nolan
- Warwick Medical School, University of Warwick, Coventry, UK; Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK
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38
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Maciel CB. Neurologic Outcome Prediction in the Intensive Care Unit. Continuum (Minneap Minn) 2021; 27:1405-1429. [PMID: 34618766 DOI: 10.1212/con.0000000000001053] [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: 11/15/2022]
Abstract
PURPOSE OF REVIEW The burden of severe and disabling neurologic injury on survivors, families, and society can be profound. Neurologic outcome prediction, or neuroprognostication, is a complex undertaking with many important ramifications. It allows patients with good prognoses to be supported aggressively, survive, and recover; conversely, it avoids inappropriate prolonged and costly care in those with devastating injuries. RECENT FINDINGS Striving to maintain a high prediction performance during prognostic assessments encompasses acknowledging the shortcomings of this task and the challenges created by advances in medicine, which constantly shift the natural history of neurologic conditions. Embracing the unknowns of outcome prediction and the boundaries of knowledge surrounding neurologic recovery and plasticity is a necessary step toward refining neuroprognostication practices and improving the accuracy of prognostic impressions. The pillars of modern neuroprognostication include comprehensive characterization of neurologic injury burden (primary and secondary injuries), gauging cerebral resilience and estimated neurologic reserve, and tying it all together with individual values surrounding the acceptable extent of disability and the difficulties of an arduous convalescence journey. SUMMARY Comprehensive multimodal frameworks of neuroprognostication using different prognostic tools to portray the burden of neurologic injury coupled with the characterization of individual values and the degree of cerebral reserve and resilience are the cornerstone of modern outcome prediction.
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Voß F, Karbenn M, Hoffmann T, Schweitzer J, Jung C, Bernhard M, Kienbaum P, Kelm M, Westenfeld R. Sublingual microcirculation predicts survival after out-of-hospital cardiac arrest. Microcirculation 2021; 28:e12729. [PMID: 34564926 DOI: 10.1111/micc.12729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 08/16/2021] [Accepted: 09/20/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Despite successful resuscitation with return of spontaneous circulation (ROSC), the prediction of survival in patients suffering out-of-hospital cardiac arrest (OHCA) remains difficult. Several studies have shown alterations in sublingual microcirculation in the critical ill. We hypothesized that early alterations in sublingual microcirculation may predict short-term survival after OHCA. METHODS We prospectively included all adults admitted to our university hospital between April and September 2019 with ROSC following OHCA. Sidestream dark-field microscopy to obtain sublingual microcirculation was performed at admission and after 6, 12 and 24 hours. Primary outcome was survival until discharge. RESULTS Twenty-five patients were included. Six hours after ROSC, the proportion of perfused small vessels (PPVsmall ) was lower in non-survivors than in survivors (85 ± 7.9 vs. 75 ± 6.6%; p = .01). PPVsmall did not correlate with serum lactate. Stratification for survival with cutoff values >78.4% for PPVsmall 6 h post-admission and <5.15 mmol/l for initial serum lactate as suggested by ROC-Analyses results in a positive predictive value of 100% and a negative one of 67% for our study population. CONCLUSION Estimating short-term prognosis of OHCA patients with ROSC may be supported by measuring the PPVsmall at the sublingual microcirculation 6 hours after admission.
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Affiliation(s)
- Fabian Voß
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | - Matthias Karbenn
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | - Till Hoffmann
- Institute of Transplantation Diagnostics and Cell Therapeutics, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Julian Schweitzer
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | - Christian Jung
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | - Michael Bernhard
- Emergency Department, Medical Faculty, University Hospital, Heinrich-Heine-University, Düsseldorf, Germany
| | - Peter Kienbaum
- Department of Anesthesiology, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | - Malte Kelm
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany.,CARID (Cardiovascular Research Institute Düsseldorf), Düsseldorf, Germany
| | - Ralf Westenfeld
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
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Moseby-Knappe M, Mattsson-Carlgren N, Stammet P, Backman S, Blennow K, Dankiewicz J, Friberg H, Hassager C, Horn J, Kjaergaard J, Lilja G, Rylander C, Ullén S, Undén J, Westhall E, Wise MP, Zetterberg H, Nielsen N, Cronberg T. Serum markers of brain injury can predict good neurological outcome after out-of-hospital cardiac arrest. Intensive Care Med 2021; 47:984-994. [PMID: 34417831 PMCID: PMC8421280 DOI: 10.1007/s00134-021-06481-4] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 07/13/2021] [Indexed: 12/31/2022]
Abstract
Purpose The majority of unconscious patients after cardiac arrest (CA) do not fulfill guideline criteria for a likely poor outcome, their prognosis is considered “indeterminate”. We compared brain injury markers in blood for prediction of good outcome and for identifying false positive predictions of poor outcome as recommended by guidelines. Methods Retrospective analysis of prospectively collected serum samples at 24, 48 and 72 h post arrest within the Target Temperature Management after out-of-hospital cardiac arrest (TTM)-trial. Clinically available markers neuron-specific enolase (NSE) and S100B, and novel markers neurofilament light chain (NFL), total tau, ubiquitin carboxy-terminal hydrolase L1 (UCH-L1) and glial fibrillary acidic protein (GFAP) were analysed. Normal levels with a priori cutoffs specified by reference laboratories or defined from literature were used to predict good outcome (no to moderate disability, Cerebral Performance Category scale 1–2) at 6 months. Results Seven hundred and seventeen patients were included. Normal NFL, tau and GFAP had the highest sensitivities (97.2–98% of poor outcome patients had abnormal serum levels) and NPV (normal levels predicted good outcome in 87–95% of patients). Normal S100B and NSE predicted good outcome with NPV 76–82.2%. Normal NSE correctly identified 67/190 (35.3%) patients with good outcome among those classified as “indeterminate outcome” by guidelines. Five patients with single pathological prognostic findings despite normal biomarkers had good outcome. Conclusion Low levels of brain injury markers in blood are associated with good neurological outcome after CA. Incorporating biomarkers into neuroprognostication may help prevent premature withdrawal of life-sustaining therapy. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-021-06481-4.
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Affiliation(s)
- Marion Moseby-Knappe
- Department of Clinical Sciences Lund, Neurology, Skåne University Hospital, Lund University, Getingevägen 4, 222 41, Lund, Sweden.
| | - Niklas Mattsson-Carlgren
- Department of Clinical Sciences Lund, Neurology, Skåne University Hospital, Lund University, Getingevägen 4, 222 41, Lund, Sweden.,Clinical Memory Research Unit, Faculty of Medicine, Lund University, Lund, Sweden.,Wallenberg Centre for Molecular Medicine, Lund University, Lund, Sweden
| | - Pascal Stammet
- Medical and Health Department, National Fire and Rescue Corps, Luxembourg, Luxembourg
| | - Sofia Backman
- Department of Clinical Sciences Lund, Clinical Neurophysiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, The Sahlgrenska Academy, Institute of Neuroscience and Physiology, University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Josef Dankiewicz
- Department of Clinical Sciences Lund, Cardiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences Lund, Anaesthesia and Intensive Care, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Christian Hassager
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Janneke Horn
- Department of Intensive Care, Amsterdam Neuroscience, Amsterdam UMC, Location Academic Medical Center, Amsterdam, The Netherlands
| | - Jesper Kjaergaard
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Gisela Lilja
- Department of Clinical Sciences Lund, Neurology, Skåne University Hospital, Lund University, Getingevägen 4, 222 41, Lund, Sweden
| | - Christian Rylander
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska Academy, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Susann Ullén
- Clinical Studies Sweden-Forum South, Skane University Hospital, Lund, Sweden
| | - Johan Undén
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden.,Department of Operation and Intensive Care, Lund University, Hallands Hospital Halmstad, Halland, Sweden
| | - Erik Westhall
- Department of Clinical Sciences Lund, Clinical Neurophysiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Matt P Wise
- Adult Critical Care, University Hospital of Wales, Cardiff, UK
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, The Sahlgrenska Academy, Institute of Neuroscience and Physiology, University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK.,UK Dementia Research Institute at UCL, London, UK.,Hong Kong Center for Neurodegenerative Diseases, Hong Kong, China
| | - Niklas Nielsen
- Department of Clinical Sciences Lund, Anaesthesia and Intensive Care, Helsingborg Hospital, Lund University, Lund, Sweden
| | - Tobias Cronberg
- Department of Clinical Sciences Lund, Neurology, Skåne University Hospital, Lund University, Getingevägen 4, 222 41, Lund, Sweden
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Lilja L, Thuccani M, Joelsson S, Nilsson J, Redfors P, Lundgren P, Rylander C. The capacity of neurological pupil index to predict absence of somatosensory evoked potentials after cardiac arrest-A study protocol. Acta Anaesthesiol Scand 2021; 65:852-858. [PMID: 33735459 DOI: 10.1111/aas.13822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 03/12/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Anoxic-ischemic brain injury is the most common cause of death after cardiac arrest (CA). Robust methods to detect severe injury with a low false positive rate (FPR) for poor neurological outcome include the pupillary light reflex (PLR) and somatosensory evoked potentials (SSEP). The PLR can be assessed manually or with automated pupillometry which provides the neurological pupil index (NPi). We aim to describe the interrelation between NPi values and the absence of SSEP cortical response and to evaluate the capacity of NPi to predict the absence of cortical SSEP response in comatose patients after CA. METHODS A total of 50 patients will be included in an explorative, prospective, observational study of adult (>18 years) comatose survivors of CA admitted to intensive care in a university hospital. NPi assessed with a hand-held pupillometer will be compared to SSEP signals recorded >48 hours after CA. Primary outcomes are sensitivity, specificity, and odds ratio for NPi to predict bilateral absence of the SSEP N20 signal, with NPi values corresponding to <5% FPRs of SSEP absence. Secondary outcomes are the PLR and SSEP sensitivity, specificity, and odds ratio for poor neurological outcome at hospital discharge and death at 30 days. DISCUSSION The PLR and SSEP may have a systematic interrelation, and a certain NPi threshold could potentially predict the absence of cortical SSEP response. If this can be concluded from the present study, SSEP testing could be excluded in certain patients to save resources in the multimodal prognostication after CA. Editorial comment The interrelation between loss of the pupillary light reflex (PLR) and the loss of cortical response to a somatosensory evoked potential (SSEP) in comatose cardiac arrest patients is not known. This exploratory prospective study is designed to evaluate whether a specific degree of attenuated PLR, as measured by semiautomated pupillometry, can predict the bilateral loss of cortical SSEP response in severe anoxic/ischemic brain injury. Such an interrelation between the two methods would enable the use of pupillometry rather than the more resource demanding SSEP for neurologic prognostication in post cardiac arrest patients. TRIAL REGISTRATION ClinicalTrials.gov, NCT04720482, Registered 21 January 2021, retrospectively registered.
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Affiliation(s)
- Linus Lilja
- Department of Anaesthesiology and Intensive Care Medicine Institute of Clinical Sciences Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
| | - Meena Thuccani
- Department of Molecular and Clinical Medicine Institute of Medicine Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
| | - Sara Joelsson
- Department of Clinical Neurophysiology Institute of Neuroscience and Physiology Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
| | - Josefin Nilsson
- Department of Clinical Neurophysiology Institute of Neuroscience and Physiology Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
| | - Petra Redfors
- Department of Clinical Neuroscience Institute of Neuroscience and Physiology Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
| | - Peter Lundgren
- Department of Molecular and Clinical Medicine Institute of Medicine Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
- Prehospen—Centre for Prehospital Research University of Borås Borås Sweden
| | - Christian Rylander
- Department of Anaesthesiology and Intensive Care Medicine Institute of Clinical Sciences Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
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Multimodal Approach to Predict Neurological Outcome after Cardiac Arrest: A Single-Center Experience. Brain Sci 2021; 11:brainsci11070888. [PMID: 34356123 PMCID: PMC8303816 DOI: 10.3390/brainsci11070888] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 06/29/2021] [Accepted: 06/29/2021] [Indexed: 12/22/2022] Open
Abstract
Introduction: The aims of this study were to assess the concordance of different tools and to describe the accuracy of a multimodal approach to predict unfavorable neurological outcome (UO) in cardiac arrest patients. Methods: Retrospective study of adult (>18 years) cardiac arrest patients who underwent multimodal monitoring; UO was defined as cerebral performance category 3–5 at 3 months. Predictors of UO were neurological pupillary index (NPi) ≤ 2 at 24 h; highly malignant patterns on EEG (HMp) within 48 h; bilateral absence of N20 waves on somato-sensory evoked potentials; and neuron-specific enolase (NSE) > 75 μg/L. Time-dependent decisional tree (i.e., NPi on day 1; HMp on day 1–2; absent N20 on day 2–3; highest NSE) and classification and regression tree (CART) analysis were used to assess the prediction of UO. Results: Of 137 patients, 104 (73%) had UO. Abnormal NPi, HMp on day 1 or 2, the bilateral absence of N20 or NSE >75 mcg/L had a specificity of 100% to predict UO. The presence of abnormal NPi was highly concordant with HMp and high NSE, and absence of N20 or high NSE with HMp. However, HMp had weak to moderate concordance with other predictors. The time-dependent decisional tree approach identified 73/103 patients (70%) with UO, showing a sensitivity of 71% and a specificity of 100%. Using the CART approach, HMp on EEG was the only variable significantly associated with UO. Conclusions: This study suggests that patients with UO had often at least two predictors of UO, except for HMp. A multimodal time-dependent approach may be helpful in the prediction of UO after CA. EEG should be included in all multimodal prognostic models.
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Morris AH, Stagg B, Lanspa M, Orme J, Clemmer TP, Weaver LK, Thomas F, Grissom CK, Hirshberg E, East TD, Wallace CJ, Young MP, Sittig DF, Pesenti A, Bombino M, Beck E, Sward KA, Weir C, Phansalkar SS, Bernard GR, Taylor Thompson B, Brower R, Truwit JD, Steingrub J, Duncan Hite R, Willson DF, Zimmerman JJ, Nadkarni VM, Randolph A, Curley MAQ, Newth CJL, Lacroix J, Agus MSD, Lee KH, deBoisblanc BP, Scott Evans R, Sorenson DK, Wong A, Boland MV, Grainger DW, Dere WH, Crandall AS, Facelli JC, Huff SM, Haug PJ, Pielmeier U, Rees SE, Karbing DS, Andreassen S, Fan E, Goldring RM, Berger KI, Oppenheimer BW, Wesley Ely E, Gajic O, Pickering B, Schoenfeld DA, Tocino I, Gonnering RS, Pronovost PJ, Savitz LA, Dreyfuss D, Slutsky AS, Crapo JD, Angus D, Pinsky MR, James B, Berwick D. Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions. J Am Med Inform Assoc 2021; 28:1330-1344. [PMID: 33594410 PMCID: PMC8661391 DOI: 10.1093/jamia/ocaa294] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 11/10/2020] [Indexed: 02/05/2023] Open
Abstract
Clinical decision-making is based on knowledge, expertise, and authority, with clinicians approving almost every intervention-the starting point for delivery of "All the right care, but only the right care," an unachieved healthcare quality improvement goal. Unaided clinicians suffer from human cognitive limitations and biases when decisions are based only on their training, expertise, and experience. Electronic health records (EHRs) could improve healthcare with robust decision-support tools that reduce unwarranted variation of clinician decisions and actions. Current EHRs, focused on results review, documentation, and accounting, are awkward, time-consuming, and contribute to clinician stress and burnout. Decision-support tools could reduce clinician burden and enable replicable clinician decisions and actions that personalize patient care. Most current clinical decision-support tools or aids lack detail and neither reduce burden nor enable replicable actions. Clinicians must provide subjective interpretation and missing logic, thus introducing personal biases and mindless, unwarranted, variation from evidence-based practice. Replicability occurs when different clinicians, with the same patient information and context, come to the same decision and action. We propose a feasible subset of therapeutic decision-support tools based on credible clinical outcome evidence: computer protocols leading to replicable clinician actions (eActions). eActions enable different clinicians to make consistent decisions and actions when faced with the same patient input data. eActions embrace good everyday decision-making informed by evidence, experience, EHR data, and individual patient status. eActions can reduce unwarranted variation, increase quality of clinical care and research, reduce EHR noise, and could enable a learning healthcare system.
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Affiliation(s)
- Alan H Morris
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine
- Department of Biomedical Informatics
| | - Brian Stagg
- Department of Ophthalmology and Visual Sciences and John Moran Eye Center
| | - Michael Lanspa
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - James Orme
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine
- Department of Biomedical Informatics
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Terry P Clemmer
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine
- Department of Biomedical Informatics
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine, Intermountain Healthcare, Salt Lake City, Utah, USA
- Emeritus
| | - Lindell K Weaver
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine
- Department of Biomedical Informatics
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Frank Thomas
- Department of Value Engineering, University of Utah Hospitals and Clinics, Salt Lake City, Utah, USA
- Emeritus
| | - Colin K Grissom
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine
- Department of Biomedical Informatics
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Ellie Hirshberg
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Thomas D East
- SYNCRONYS, and University of New Mexico Health Sciences Library & Informatics, Albuquerque, New Mexico, USA
| | - Carrie Jane Wallace
- Department of Ophthalmology and Visual Sciences and John Moran Eye Center
- Emeritus
| | - Michael P Young
- Critical Care Division, Renown Medical Center, School of Medicine, University of Nevada, Reno, Nevada, USA
| | - Dean F Sittig
- School of Biomedical Informatics, University of Texas Health Science Center, Houston, Texas, USA
| | - Antonio Pesenti
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Michela Bombino
- Department of Emergency and Intensive Care Medicine, ASST-Monza San Gerardo Hospital, Milan, Italy
| | - Eduardo Beck
- Ospedale di Desio—ASST Monza, UOC Anestesia e Rianimazione, Milan, Italy
| | | | - Charlene Weir
- Department of Biomedical Informatics
- School of Nursing
| | | | - Gordon R Bernard
- Pulmonary, Critical Care, and Allergy Division, Department of Internal Medicine
| | - B Taylor Thompson
- Pulmonary, Critical Care, and Sleep Division , Department of Internal Medicine
| | - Roy Brower
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jonathon D Truwit
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jay Steingrub
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine, University of Massachusetts Medical School-Baystate, Springfield, Massachusetts, USA
| | - R Duncan Hite
- Pulmonary, Critical Care, and Sleep Division, Department of Internal Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Douglas F Willson
- Division of Pediatric Critical Care, Department of Pediatrics, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jerry J Zimmerman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Vinay M Nadkarni
- Department of Anesthesia and Critical Care Medicine
- Department of Pediatrics, Perelman School of Medicine
| | | | - Martha A. Q Curley
- Department of Pediatrics, Perelman School of Medicine
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christopher J. L Newth
- Department of Pediatrics, University of Southern California, Los Angeles, California, USA
| | - Jacques Lacroix
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine and Université de Montréal, Montréal, Canada
| | | | - Kang H Lee
- Asian American Liver Centre, Gleneagles Hospital, Singapore, Singapore
| | - Bennett P deBoisblanc
- Section of Pulmonary/Critical Care & Allergy/Immunology, Louisiana State University School of Medicine, New Orleans, Louisiana, USA
| | | | | | - Anthony Wong
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | | | - David W Grainger
- Department of Biomedical Engineering and Department of Pharmaceutics and Pharmaceutical Chemistry, University of Utah
| | - Willard H Dere
- Department of Biomedical Engineering and Department of Pharmaceutics and Pharmaceutical Chemistry, University of Utah
| | - Alan S Crandall
- Department of Ophthalmology and Visual Sciences and John Moran Eye Center
| | - Julio C Facelli
- Department of Biomedical Informatics
- Center for Clinical and Translational Science, School of Medicine
| | | | | | - Ulrike Pielmeier
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Stephen E Rees
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Dan S Karbing
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Steen Andreassen
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Eddy Fan
- Institute of Health Policy, Management and Evaluation
| | - Roberta M Goldring
- Pulmonary, Critical Care, and Sleep Division, NYU School of Medicine, New York, New York, USA
| | - Kenneth I Berger
- Pulmonary, Critical Care, and Sleep Division, NYU School of Medicine, New York, New York, USA
| | - Beno W Oppenheimer
- Pulmonary, Critical Care, and Sleep Division, NYU School of Medicine, New York, New York, USA
| | - E Wesley Ely
- Pulmonary, Critical Care, and Allergy Division, Department of Internal Medicine
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center
- Tennessee Valley Veterans Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, Tennessee, USA
| | - Ognjen Gajic
- Pulmonary , Critical Care, and Sleep Division, Department of Internal Medicine
| | - Brian Pickering
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - David A Schoenfeld
- Department of Biostatistics, T.H. Chan School of Public Health, Harvard Medical School, Boston, Massachusetts, USA
| | - Irena Tocino
- Department of Radiology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Russell S Gonnering
- Department of Ophthalmology and Visual Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Peter J Pronovost
- Critical Care, Department of Anesthesia, Chief Clinical Transformation Officer, University Hospitals, Highland Hills, Case Western Reserve University, Cleveland, OH, USA
| | - Lucy A Savitz
- Kaiser Permanente Northwest Center for Health Research, Portland, OR, USA
| | - Didier Dreyfuss
- Assistance Publique – Hôpitaux de Paris, Université de Paris, INSERM unit UMR S_1155 (Common and Rare Kidney Diseases), Sorbonne Université, Paris, France
| | - Arthur S Slutsky
- Keenan Research Center, Li Ka Shing Knowledge Institute / ST. Michaels' Hospital and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - James D Crapo
- Department of Internal Medicine, National Jewish Health, Denver, Colorado, USA
| | - Derek Angus
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michael R Pinsky
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Brent James
- Clinical Excellence Research Center (CERC), Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Donald Berwick
- Institute for Healthcare Improvement, Boston, Massachusetts, USA
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Application of a standardized EEG pattern classification in the assessment of neurological prognosis after cardiac arrest: A retrospective analysis. Resuscitation 2021; 165:38-44. [PMID: 34119554 DOI: 10.1016/j.resuscitation.2021.05.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 05/15/2021] [Accepted: 05/30/2021] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Electroencephalogram (EEG) is used in the neurological prognostication after cardiac arrest. "Highly malignant" EEG patterns classified according to Westhall have a high specificity for poor neurological outcome when applied within protocols of recent studies. However, their predictive performance when applied in everyday clinical practice has not been investigated. We studied the prognostic accuracy and the interrater agreement when standardized EEG patterns were analysed and compared to neurological outcome in a patient cohort at a tertiary centre not involved in the original study of the standardized EEG pattern classification. METHODS Comatose patients treated for out-of-hospital cardiac arrest were included. Poor outcome was defined as Cerebral Performance Category 3-5. Two senior consultants and one resident in clinical neurophysiology, blinded to clinical data and outcome, independently reviewed their EEG registrations and categorised the pattern as "highly malignant", "malignant" or "benign". These categories were compared to neurological outcome at hospital discharge. Interrater agreement was assessed using Cohen's Kappa. RESULTS In total, 62 patients were included. The median (IQR) time to EEG was 59 (42-91) h after return of spontaneous circulation. Poor outcome was found in 52 (84%) patients. In 21 patients at least one of the raters considered the EEG to contain a "highly malignant" pattern, all with poor outcome (42% sensitivity, 100% specificity). The interrater agreement varied from kappa 0.62 to 0.29. CONCLUSION "Highly malignant" patterns predict poor neurological outcome with a high specificity in everyday practice. However, interrater agreement may vary substantially even between experienced EEG interpreters.
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45
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Olasveengen TM, Skrifvars MB, Taccone F, Soar J. Postreanimationsbehandlung. Notf Rett Med 2021. [DOI: 10.1007/s10049-021-00892-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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46
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Thorgeirsdóttir B, Levin H, Spångfors M, Annborn M, Cronberg T, Nielsen N, Lybeck A, Friberg H, Frigyesi A. Plasma proenkephalin A 119-159 and dipeptidyl peptidase 3 on admission after cardiac arrest help predict long-term neurological outcome. Resuscitation 2021; 163:108-115. [PMID: 33930500 DOI: 10.1016/j.resuscitation.2021.04.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 03/20/2021] [Accepted: 04/08/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND A large proportion of adult survivors of cardiac arrest have a poor neurological outcome. Guidelines recommend multimodal neuro-prognostication no earlier than 72-96 h after cardiac arrest. There is great interest in earlier prognostic markers, including very early markers at admission. The novel blood biomarkers proenkephalin A 119-159 (penKid), bioactive adrenomedullin (bio-ADM) and circulating dipeptidyl peptidase 3 (cDPP3) have not been previously investigated for the early prognosis of cardiac arrest survivors. METHODS This multicentre observational study included adult survivors of cardiac arrest admitted to intensive care at four Swedish intensive care units (ICUs) during 2016. Blood samples were collected at ICU admission and batch analysed. The association between admission plasma penKid, bio-ADM and cDPP3 and poor long-term neurological outcome, according to the Cerebral Performance Category (CPC) scale, was assessed by binary logistic regression. Their prognostic performance was assessed using the area under the receiver operating characteristic curve (AUC). RESULTS A total of 190 patients were included, of which 136 patients had suffered out-of-hospital and 54 patients in-hospital cardiac arrest. Poor long-term neurological outcome was associated with elevated admission plasma concentrations of penKid and cDPP3, but not with bio-ADM. The association for penKid, but not for cDPP3, remained after adjusting for clinical cardiac arrest variables with prognostic value (time to return of spontaneous circulation (ROSC), initial rhythm, admission Glasgow coma scale (GCS) motor score and absence of pupillary reflexes). The prognostic performance of above mentioned clinical cardiac arrest variables alone was very good with an AUC of 0.90 (95% confidence interval, CI, 0.86-0.95), but improved further with the addition of penKid resulting in an AUC of 0.93 (95% CI 0.89-0.97, p < 0.026). Plasma penKid and cDPP3 alone provided moderate long-term prognostic information with AUCs of 0.70 and 0.71, respectively. CONCLUSION After cardiac arrest, admission plasma levels of penKid and cDPP3, but not bio-ADM, predicted long-term neurological outcome. When added to clinical cardiac arrest variables, penKid further improved prognostic performance.
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Affiliation(s)
- Bergthóra Thorgeirsdóttir
- Department of Clinical Sciences, Anaesthesiology and Intensive Care, Lund University, SE-22185 Lund, Sweden; Skåne University Hospital, Intensive and Perioperative Care, SE-21428 Malmö, Sweden
| | - Helena Levin
- Department of Clinical Sciences, Anaesthesiology and Intensive Care, Lund University, SE-22185 Lund, Sweden; Skåne University Hospital, Research and Education, SE-22185 Lund, Sweden
| | - Martin Spångfors
- Department of Clinical Sciences, Anaesthesiology and Intensive Care, Lund University, SE-22185 Lund, Sweden; Kristianstad Central Hospital, Anaesthesia and Intensive Care, SE-29185 Kristianstad, Sweden
| | - Martin Annborn
- Department of Clinical Sciences, Anaesthesiology and Intensive Care, Lund University, SE-22185 Lund, Sweden; Helsingborg Hospital, Anaesthesia and Intensive Care, SE-25187 Helsingborg, Sweden
| | - Tobias Cronberg
- Department of Clinical Sciences, Anaesthesiology and Intensive Care, Lund University, SE-22185 Lund, Sweden; Skåne University Hospital, Department of Neurology, SE-22185 Lund, Sweden
| | - Niklas Nielsen
- Department of Clinical Sciences, Anaesthesiology and Intensive Care, Lund University, SE-22185 Lund, Sweden; Helsingborg Hospital, Anaesthesia and Intensive Care, SE-25187 Helsingborg, Sweden
| | - Anna Lybeck
- Department of Clinical Sciences, Anaesthesiology and Intensive Care, Lund University, SE-22185 Lund, Sweden; Skåne University Hospital, Intensive and Perioperative Care, SE-22185 Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anaesthesiology and Intensive Care, Lund University, SE-22185 Lund, Sweden; Skåne University Hospital, Intensive and Perioperative Care, SE-21428 Malmö, Sweden
| | - Attila Frigyesi
- Department of Clinical Sciences, Anaesthesiology and Intensive Care, Lund University, SE-22185 Lund, Sweden; Skåne University Hospital, Intensive and Perioperative Care, SE-22185 Lund, Sweden.
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47
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SSEP amplitude accurately predicts both good and poor neurological outcome early after cardiac arrest; a post-hoc analysis of the ProNeCA multicentre study. Resuscitation 2021; 163:162-171. [PMID: 33819501 DOI: 10.1016/j.resuscitation.2021.03.028] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 03/17/2021] [Accepted: 03/26/2021] [Indexed: 11/23/2022]
Abstract
AIM To assess if, in comatose resuscitated patients, the amplitude of the N20 wave (N20amp) of somatosensory evoked potentials (SSEP) can predict 6-months neurological outcome. SETTING Multicentre study in 13 Italian intensive care units. METHODS The N20amp in microvolts (μV) was measured at 12 h, 24 h, and 72 h from cardiac arrest, along with pupillary reflex (PLR) and a 30-min EEG classified according to the ACNS terminology. Sensitivity and false positive rate (FPR) of N20amp alone or in combination were calculated. RESULTS 403 patients (age 69[58-68] years) were included. At 12 h, an N20amp >3 μV predicted good neurological outcome (Cerebral Performance Categories [CPC] 1-2) with 61[50-72]% sensitivity and 11[6-18]% FPR. Combining it with a benign (continuous or nearly continuous) EEG increased sensitivity to 91[82-96]%. For poor outcome (CPC 3-5), an N20Amp ≤0.38 μV, ≤0.73 μV and ≤1.01 μV at 12 h, 24 h, and 72 h, respectively, had 0% FPR with sensitivity ranging from 61[51-69]% and 82[76-88]%. Sensitivity was higher than that of a bilaterally absent N20 at all time points. At 12 h and 24 h, a highly malignant (suppression or burst-suppression) EEG and bilaterally absent PLR achieved 0% FPR only when combined with SSEP. A combination of all three predictors yielded a 0[0-4]% FPR, with maximum sensitivity of 44[36-53]%. CONCLUSION At 12 h from arrest, a high N20Amp predicts good outcome with high sensitivity, especially when combined with benign EEG. At 12 h and 24 h from arrest a low-voltage N20amp has a high sensitivity and is more specific than EEG or PLR for predicting poor outcome.
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48
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Olasveengen TM, Skrifvars MB, Taccone F, Soar J. European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2021: post-resuscitation care. Intensive Care Med 2021; 47:369-421. [PMID: 33765189 PMCID: PMC7993077 DOI: 10.1007/s00134-021-06368-4] [Citation(s) in RCA: 417] [Impact Index Per Article: 139.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 02/08/2021] [Indexed: 12/13/2022]
Abstract
The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation and organ donation.
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Affiliation(s)
- Jerry P. Nolan
- University of Warwick, Warwick Medical School, Coventry, CV4 7AL UK
- Royal United Hospital, Bath, BA1 3NG UK
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy
- Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Bernd W. Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
| | - Alain Cariou
- Cochin University Hospital (APHP) and University of Paris (Medical School), Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anaesthesia and Intensive Care Medicine, Lund University, Skane University Hospital, Lund, Sweden
| | - Cornelia Genbrugge
- Acute Medicine Research Pole, Institute of Experimental and Clinical Research (IREC), Université Catholique de Louvain, Brussels, Belgium
- Emergency Department, University Hospitals Saint-Luc, Brussels, Belgium
| | - Kirstie Haywood
- Warwick Research in Nursing, Division of Health Sciences, Warwick Medical School, University of Warwick, Room A108, Coventry, CV4 7AL UK
| | - Gisela Lilja
- Department of Clinical Sciences Lund, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Véronique R. M. Moulaert
- Department of Rehabilitation Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Nikolaos Nikolaou
- Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Theresa Mariero Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Markus B. Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Fabio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB UK
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49
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Mariero Olasveengen T, Skrifvars MB, Taccone F, Soar J. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2021: Post-resuscitation care. Resuscitation 2021; 161:220-269. [PMID: 33773827 DOI: 10.1016/j.resuscitation.2021.02.012] [Citation(s) in RCA: 338] [Impact Index Per Article: 112.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation, and organ donation.
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Affiliation(s)
- Jerry P Nolan
- University of Warwick, Warwick Medical School, Coventry CV4 7AL, UK; Royal United Hospital, Bath, BA1 3NG, UK.
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy; Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Bernd W Böttiger
- University Hospital of Cologne, Kerpener Straße 62, D-50937 Cologne, Germany
| | - Alain Cariou
- Cochin University Hospital (APHP) and University of Paris (Medical School), Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anaesthesia and Intensive Care Medicine, Lund University, Skane University Hospital, Lund, Sweden
| | - Cornelia Genbrugge
- Acute Medicine Research Pole, Institute of Experimental and Clinical Research (IREC) Université Catholique de Louvain, Brussels, Belgium; Emergency Department, University Hospitals Saint-Luc, Brussels, Belgium
| | - Kirstie Haywood
- Warwick Research in Nursing, Room A108, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Gisela Lilja
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Neurology, Lund, Sweden
| | - Véronique R M Moulaert
- University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Groningen, The Netherlands
| | - Nikolaos Nikolaou
- Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Theresa Mariero Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Norway
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Finland
| | - Fabio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol BS10 5NB, UK
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50
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Domínguez-Gil B, Ascher N, Capron AM, Gardiner D, Manara AR, Bernat JL, Miñambres E, Singh JM, Porte RJ, Markmann JF, Dhital K, Ledoux D, Fondevila C, Hosgood S, Van Raemdonck D, Keshavjee S, Dubois J, McGee A, Henderson GV, Glazier AK, Tullius SG, Shemie SD, Delmonico FL. Expanding controlled donation after the circulatory determination of death: statement from an international collaborative. Intensive Care Med 2021; 47:265-281. [PMID: 33635355 PMCID: PMC7907666 DOI: 10.1007/s00134-020-06341-7] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 12/21/2020] [Indexed: 12/14/2022]
Abstract
A decision to withdraw life-sustaining treatment (WLST) is derived by a conclusion that further treatment will not enable a patient to survive or will not produce a functional outcome with acceptable quality of life that the patient and the treating team regard as beneficial. Although many hospitalized patients die under such circumstances, controlled donation after the circulatory determination of death (cDCDD) programs have been developed only in a reduced number of countries. This International Collaborative Statement aims at expanding cDCDD in the world to help countries progress towards self-sufficiency in transplantation and offer more patients the opportunity of organ donation. The Statement addresses three fundamental aspects of the cDCDD pathway. First, it describes the process of determining a prognosis that justifies the WLST, a decision that should be prior to and independent of any consideration of organ donation and in which transplant professionals must not participate. Second, the Statement establishes the permanent cessation of circulation to the brain as the standard to determine death by circulatory criteria. Death may be declared after an elapsed observation period of 5 min without circulation to the brain, which confirms that the absence of circulation to the brain is permanent. Finally, the Statement highlights the value of perfusion repair for increasing the success of cDCDD organ transplantation. cDCDD protocols may utilize either in situ or ex situ perfusion consistent with the practice of each country. Methods to accomplish the in situ normothermic reperfusion of organs must preclude the restoration of brain perfusion to not invalidate the determination of death.
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Affiliation(s)
| | - Nancy Ascher
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Alexander M Capron
- Scott H. Bice Chair in Healthcare Law, Policy and Ethics, Department of Medicine and Law, University of Southern California, Los Angeles, CA, USA
| | - Dale Gardiner
- Intensive Care Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Alexander R Manara
- Consultant in Intensive Care Medicine, The Intensive Care Unit, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - James L Bernat
- Department of Neurology and Medicine, Active Emeritus, Dartmouth Geisel School of Medicine, Hanover, NH, USA
| | - Eduardo Miñambres
- Transplant Coordination Unit and Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, School of Medicine, University of Cantabria, Santander, Spain
| | - Jeffrey M Singh
- University of Toronto, and Trillium Gift of Life Network, Toronto, Canada
| | - Robert J Porte
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - James F Markmann
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Kumud Dhital
- Department of Cardiothoracic Surgery, Sant Vincent'S Hospital, Sidney, Australia
| | - Didier Ledoux
- Department of Anesthesia and Intensive Care, University of Liège, Liège, Belgium
| | - Constantino Fondevila
- General and Digestive Surgery, Hospital Clínic, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
| | - Sarah Hosgood
- Department of Surgery, University of Cambridge, Cambridge, UK
| | - Dirk Van Raemdonck
- University Hospitals Leuven and Catholic University Leuven, Leuven, Belgium
| | - Shaf Keshavjee
- Toronto General Hospital, University of Toronto, Toronto, Canada
| | - James Dubois
- Bioethics Research Center, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Andrew McGee
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, Brisbane City, Australia
| | - Galen V Henderson
- Director of Neurocritical Care, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Stefan G Tullius
- Division of Transplant Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sam D Shemie
- Pediatric Intensive Care, Montreal Children's Hospital, McGill University, Medical Advisor, Deceased Donation, Canadian Blood Services, Montreal, Canada
| | - Francis L Delmonico
- Chief Medical Officer, New England Donor Services, 60 1st Ave, Waltham, MA, 02451, USA.
- Department of Surgery, Harvard Medical School at Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
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