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Yao Z, Zhao Y, Lu L, Li Y, Yu Z. Extracerebral multiple organ dysfunction and interactions with brain injury after cardiac arrest. Resusc Plus 2024; 19:100719. [PMID: 39149223 PMCID: PMC11325081 DOI: 10.1016/j.resplu.2024.100719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Revised: 07/02/2024] [Accepted: 07/03/2024] [Indexed: 08/17/2024] Open
Abstract
Cardiac arrest and successful resuscitation cause whole-body ischemia and reperfusion, leading to brain injury and extracerebral multiple organ dysfunction. Brain injury is the leading cause of death and long-term disability in resuscitated survivors, and was conceptualized and treated as an isolated injury, which has neglected the brain-visceral organ crosstalk. Extracerebral organ dysfunction is common and is significantly associated with mortality and poor neurological prognosis after resuscitation. However, detailed description of the characteristics of post-resuscitation multiple organ dysfunction is lacking, and the bidirectional interactions between brain and visceral organs need to be elucidated to explore new treatment for neuroprotection. This review aims to describe current concepts of post-cardiac arrest brain injury and specific characteristics of post-resuscitation dysfunction in cardiovascular, respiratory, renal, hepatic, adrenal, gastrointestinal, and neurohumoral systems. Additionally, we discuss the crosstalk between brain and extracerebral organs, especially focusing on how visceral organ dysfunction and other factors affect brain injury progression. We think that clarifying these interactions is of profound significance on how we treat patients for neural/systemic protection to improve outcome.
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Affiliation(s)
- Zhun Yao
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Yuanrui Zhao
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Liping Lu
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Yinping Li
- Department of Pathophysiology, Hubei Province Key Laboratory of Allergy and Immunology, Taikang Medical School (School of Basic Medical Sciences), Wuhan University, Wuhan 430060, China
| | - Zhui Yu
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan 430060, China
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Senthil K, Ranganathan A, Piel S, Hefti MM, Reeder RW, Kirschen MP, Starr J, Morton S, Gaudio HA, Slovis JC, Herrmann JR, Berg RA, Kilbaugh TJ, Morgan RW. Elevated serum neurologic biomarker profiles after cardiac arrest in a porcine model. Resusc Plus 2024; 19:100726. [PMID: 39149222 PMCID: PMC11325790 DOI: 10.1016/j.resplu.2024.100726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 07/07/2024] [Accepted: 07/08/2024] [Indexed: 08/17/2024] Open
Abstract
Introduction Swine exhibit cerebral cortex mitochondrial dysfunction and neuropathologic injury after hypoxic cardiac arrest treated with hemodynamic-directed CPR (HD-CPR) despite normal Cerebral Performance Category scores. We analyzed the temporal evolution of plasma protein biomarkers of brain injury and inflammatory cytokines, as well as cerebral cortical mitochondrial injury and neuropathology for five days following pediatric asphyxia-associated cardiac arrest treated with HD-CPR. Methods One-month-old swine underwent asphyxia associated cardiac arrest, 10-20 min of HD-CPR (goal SBP 90 mmHg, coronary perfusion pressure 20 mmHg), and randomization to post-ROSC survival duration (24, 48, 72, 96, 120 h; n = 3 per group) with standardized post-resuscitation care. Plasma neurofilament light chain (NfL), glial fibrillary acidic protein (GFAP), and cytokine levels were collected pre-injury and 1, 6, 24, 48, 72, 96, and 120 h post-ROSC. Cerebral cortical tissue was assessed for: mitochondrial respirometry, mass, and dynamic proteins; oxidative injury; and neuropathology. Results Relative to pre-arrest baseline (9.4 pg/ml [6.7-12.6]), plasma NfL was increased at all post-ROSC time points. Each sequential NfL measurement through 48 h was greater than the previous value {1 h (12.7 pg/ml [8.4-14.6], p = 0.01), 6 h (30.9 pg/ml [17.7-44.0], p = 0.0004), 24 h (59.4 pg/ml [50.8-96.1], p = 0.0003) and 48 h (85.7 pg/ml [61.9-118.7], p = 0.046)}. Plasma GFAP, inflammatory cytokines or cerebral cortical tissue measurements were not demonstrably different between time points. Conclusions In a swine model of pediatric cardiac arrest, plasma NfL had an upward trajectory until 48 h post-ROSC after which it remained elevated through five days, suggesting it may be a sensitive marker of neurologic injury following pediatric cardiac arrest.
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Affiliation(s)
- Kumaran Senthil
- Children's Hospital of Philadelphia and Perelman School of Medicine at University of Pennsylvania, Department of Anesthesiology and Critical Care Medicine, USA
- Children's Hospital of Philadelphia, Resuscitation Science Center, USA
| | - Abhay Ranganathan
- Children's Hospital of Philadelphia, Resuscitation Science Center, USA
| | - Sarah Piel
- Children's Hospital of Philadelphia, Resuscitation Science Center, USA
- University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Department of Cardiology, Pulmonology and Vascular Medicine, Germany
- University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Cardiovascular Research Institute, Germany
| | | | - Ron W Reeder
- University of Utah, Department of Pediatrics, USA
| | - Matthew P Kirschen
- Children's Hospital of Philadelphia and Perelman School of Medicine at University of Pennsylvania, Department of Anesthesiology and Critical Care Medicine, USA
- Children's Hospital of Philadelphia, Resuscitation Science Center, USA
| | - Jonathan Starr
- Children's Hospital of Philadelphia, Resuscitation Science Center, USA
| | - Sarah Morton
- Children's Hospital of Philadelphia, Resuscitation Science Center, USA
| | - Hunter A Gaudio
- Children's Hospital of Philadelphia, Resuscitation Science Center, USA
| | - Julia C Slovis
- Children's Hospital of Philadelphia and Perelman School of Medicine at University of Pennsylvania, Department of Anesthesiology and Critical Care Medicine, USA
- Children's Hospital of Philadelphia, Resuscitation Science Center, USA
| | - Jeremy R Herrmann
- Children's Hospital of Philadelphia and Perelman School of Medicine at University of Pennsylvania, Department of Anesthesiology and Critical Care Medicine, USA
- Children's Hospital of Philadelphia, Resuscitation Science Center, USA
| | - Robert A Berg
- Children's Hospital of Philadelphia and Perelman School of Medicine at University of Pennsylvania, Department of Anesthesiology and Critical Care Medicine, USA
- Children's Hospital of Philadelphia, Resuscitation Science Center, USA
| | - Todd J Kilbaugh
- Children's Hospital of Philadelphia and Perelman School of Medicine at University of Pennsylvania, Department of Anesthesiology and Critical Care Medicine, USA
- Children's Hospital of Philadelphia, Resuscitation Science Center, USA
| | - Ryan W Morgan
- Children's Hospital of Philadelphia and Perelman School of Medicine at University of Pennsylvania, Department of Anesthesiology and Critical Care Medicine, USA
- Children's Hospital of Philadelphia, Resuscitation Science Center, USA
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Pong Chan W, Nguyen C, Kim N, Tripodis Y, Gilmore UEJ, Greer DM, Beekman R. A Practical Magnetic-Resonance Imaging Score for Outcome Prediction in Comatose Cardiac Arrest Survivors. Resuscitation 2024:110370. [PMID: 39178939 DOI: 10.1016/j.resuscitation.2024.110370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Revised: 08/04/2024] [Accepted: 08/16/2024] [Indexed: 08/26/2024]
Abstract
AIM Magnetic Resonance Imaging (MRI) is an important prognostic tool in cardiac arrest (CA) survivors given its sensitivity for detecting hypoxic-ischemic brain injury (HIBI), however, it is limited by poorly defined objective thresholds. To address this limitation, we evaluated a qualitative MRI score for predicting neurological outcome in CA survivors. METHODS Adult comatose CA survivors who underwent MRI were retrospectively identified at a single academic medical center. Two blinded neurointensivists qualitatively scored HIBI amongst 12 MRI brain regions. Scores were summated to form four distinct score groups: cortex, deep grey nuclei (DGN), cortex-DGN combined, and total (cortex, DGN, brainstem, and cerebellum). Poor neurological outcome was defined as Cerebral Performance Category (CPC) score 3-5 at hospital discharge. Inter-rater reliability was tested using intra-class correlation (ICC) and discrimination of poor neurological outcome assessed using area under the receiver operating curve (AUC). RESULTS Our cohort included 219 patients with median time to MRI of 96 (IQR 81-110) hours. ICC (95% CI) was good to excellent across all MRI scores: cortex 0.92 (0.89-0.94), DGN 0.88 (0.80-0.92), cortex-DGN 0.94 (0.92-0.95), and total 0.93 (0.91-0.95). AUC (95% CI) for poor outcome was good across all MRI scores: cortex 0.84 (0.78-0.90), DGN 0.83 (0.77-0.89), cortex-DGN 0.83 (0.77-0.89), and total 0.83 (0.77-0.88). CONCLUSION A simplified, qualitative MRI score had excellent reliability and good discrimination for poor neurologic outcome. Further work is necessary to externally validate our findings in an independent, ideally prospective, cohort.
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Affiliation(s)
- Wang Pong Chan
- Department of Neurology, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA; Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA.
| | - Christine Nguyen
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA.
| | - Noah Kim
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA.
| | - Yorghos Tripodis
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA.
| | - UEmily J Gilmore
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA.
| | - David M Greer
- Department of Neurology, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA.
| | - Rachel Beekman
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA.
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4
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Nyholm B, Grand J, Obling LER, Hassager C, Møller JE, Schmidt H, Othman MH, Kondziella D, Horn J, Kjaergaard J. Validating quantitative pupillometry thresholds for neuroprognostication after out-of-hospital cardiac arrest. A predefined substudy of the Blood Pressure and Oxygenations Targets After Cardiac Arrest (BOX)-trial. Intensive Care Med 2024:10.1007/s00134-024-07574-6. [PMID: 39162825 DOI: 10.1007/s00134-024-07574-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Accepted: 07/26/2024] [Indexed: 08/21/2024]
Abstract
PURPOSE Out-of-hospital cardiac arrest (OHCA) survivors face significant risks of complications and death from hypoxic-ischemic brain injury leading to withdrawal of life-sustaining treatment (WLST). Accurate multimodal neuroprognostication, including automated pupillometry, is essential to avoid inappropriate WLST. However, inconsistent study results hinder standardized threshold recommendations. We aimed to validate proposed pupillometry thresholds with no false predictions of unfavorable outcomes in comatose OHCA survivors. METHODS In the multi-center BOX-trial, quantitative measurements of automated pupillometry (quantitatively assessed pupillary light reflex [qPLR] and Neurological Pupil index [NPi]) were obtained at admission (0 h) and after 24, 48, and 72 h in comatose patients resuscitated from OHCA. We aimed to validate qPLR < 4% and NPi ≤ 2, predicting unfavorable neurological conditions defined as Cerebral Performance Category 3-5 at follow-up. Combined with 48-h neuron-specific enolase (NSE) > 60 μg/L, pupillometry was evaluated for multimodal neuroprognostication in comatose patients with Glasgow Motor Score (M) ≤ 3 at ≥ 72 h. RESULTS From March 2017 to December 2021, we consecutively enrolled 710 OHCA survivors (mean age: 63 ± 14 years; 82% males), and 266 (37%) patients had unfavorable neurological outcomes. An NPi ≤ 2 predicted outcome with 0% false-positive rate (FPR) at all time points (0-72 h), and qPLR < 4% at 24-72 h. In patients with M ≤ 3 at ≥ 72 h, pupillometry thresholds significantly increased the sensitivity of NSE, from 42% (35-51%) to 55% (47-63%) for qPLR and 50% (42-58%) for NPi, maintaining 0% (0-0%) FPR. CONCLUSION Quantitative pupillometry thresholds predict unfavorable neurological outcomes in comatose OHCA survivors and increase the sensitivity of NSE in a multimodal approach at ≥ 72 h.
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Affiliation(s)
- Benjamin Nyholm
- Department of Cardiology, The Heart Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
| | - Johannes Grand
- Department of Cardiology, The Heart Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Laust E R Obling
- Department of Cardiology, The Heart Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Christian Hassager
- Department of Cardiology, The Heart Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jacob Eifer Møller
- Department of Cardiology, The Heart Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Cardiology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Henrik Schmidt
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Marwan H Othman
- Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Daniel Kondziella
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Janneke Horn
- Department of Intensive Care, Amsterdam Neuroscience, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Jesper Kjaergaard
- Department of Cardiology, The Heart Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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5
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Bougouin W, Lascarrou JB, Chelly J, Benghanem S, Geri G, Maizel J, Fage N, Sboui G, Pichon N, Daubin C, Sauneuf B, Mongardon N, Taccone F, Hermann B, Colin G, Lesieur O, Deye N, Chudeau N, Cour M, Bourenne J, Klouche K, Klein T, Raphalen JH, Muller G, Galbois A, Bruel C, Jacquier S, Paul M, Sandroni C, Cariou A. Performance of the ERC/ESICM-recommendations for neuroprognostication after cardiac arrest: insights from a prospective multicenter cohort. Resuscitation 2024:110362. [PMID: 39151721 DOI: 10.1016/j.resuscitation.2024.110362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2024] [Revised: 08/09/2024] [Accepted: 08/11/2024] [Indexed: 08/19/2024]
Abstract
Brief abstract: In a multicentre network of 28 ICUs in France and Belgium, all comatose patients who fulfilled the 2021 ERC-ESICM criteria for poor outcome after cardiac arrest died or survived with severe neurological disability, even after excluding patients with active WLST to limit self-fulfilling prophecy bias. However, in almost half of the patients, these criteria were not fulfilled, resulting in an indeterminate outcome; in these patients, normal NSE levels and benign EEG predicted neurological recovery, helping reduce prognostic uncertainty. AIM To investigate the performance of the 2021 ERC/ESICM-recommended algorithm for predicting poor outcome after cardiac arrest (CA) and potential tools for predicting neurological recovery in patients with indeterminate outcome. METHODS Prospective, multicenter study on out-of-hospital CA survivors from 28 ICUs of the AfterROSC network. In patients comatose with a Glasgow Coma Scale motor score ≤3 at ≥72 hours after resuscitation, we measured: 1) the accuracy of neurological examination, biomarkers (neuron-specific enolase, NSE), electrophysiology (EEG and SSEP) and neuroimaging (brain CT and MRI) for predicting poor outcome (modified Rankin scale score≥4 at 90 days), and 2) the ability of low or decreasing NSE levels and benign EEG to predict good outcome in patients whose prognosis remained indeterminate. RESULTS Among 337 included patients, the ERC-ESICM algorithm predicted poor neurological outcome in 175 patients, of whom 106 (60%) had withdrawal of life-sustaining treatment (WLST). Among the 69 patients without active WLST, the positive predictive value for an unfavourable outcome was 100% [95-100]%. The specificity of individual predictors ranged from 90% for EEG to 100% for clinical examination and SSEP. Among the remaining 162 patients with indeterminate outcome, a combination of 2 favourable signs predicted good outcome with 99[96-100]% specificity and 23[11-38%]% sensitivity. Conclusion All comatose resuscitated patients not undergoing WLST who fulfilled the ERC-ESICM criteria for poor outcome after CA had poor outcome at three months, even if a self-fulfilling prophecy cannot be completely excluded. In patients with indeterminate outcome (half of the population), favourable signs predicted neurological recovery, reducing prognostic uncertainty.
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Affiliation(s)
- Wulfran Bougouin
- AfterROSC Network Group, Paris, France; Université de Paris Cité, Inserm, Paris Cardiovascular Research Center, Paris, France; Ramsay Générale de Santé, Hôpital Privé Jacques Cartier, Massy, France.
| | - Jean-Baptiste Lascarrou
- AfterROSC Network Group, Paris, France; Université de Paris Cité, Inserm, Paris Cardiovascular Research Center, Paris, France; Service de Médecine Intensive Réanimation, University Hospital Center, Nantes, France
| | - Jonathan Chelly
- AfterROSC Network Group, Paris, France; Réanimation Polyvalente, Centre Hospitalier Intercommunal Toulon La Seyne sur Mer, Toulon, France
| | - Sarah Benghanem
- AfterROSC Network Group, Paris, France; Médecine Intensive Réanimation, APHP, CHU Cochin, Université Paris Cité, Paris, France
| | - Guillaume Geri
- AfterROSC Network Group, Paris, France; Réanimation Polyvalente, Groupe Hospitalier Privé Ambroise Paré Hartmann, Neuilly-sur-Seine, France
| | - Julien Maizel
- AfterROSC Network Group, Paris, France; Médecine Intensive Réanimation, CHU Amiens, Amiens, France
| | - Nicolas Fage
- AfterROSC Network Group, Paris, France; Département de médecine intensive réanimation et médecine hyperbare, CHU Angers, Angers, France
| | - Ghada Sboui
- AfterROSC Network Group, Paris, France; Médecine Intensive Réanimation, CH Béthune, Béthune, France
| | - Nicolas Pichon
- AfterROSC Network Group, Paris, France; Médecine Intensive Réanimation, CH Brive‑La‑Gaillarde, Brive, France
| | - Cédric Daubin
- AfterROSC Network Group, Paris, France; CHU de Caen Normandie, Médecine Intensive Réanimation, 14000 CAEN, France
| | - Bertrand Sauneuf
- AfterROSC Network Group, Paris, France; Réanimation Médecine Intensive, Centre Hospitalier Public du Cotentin, 50100 Cherbourg-en-Cotentin, France
| | - Nicolas Mongardon
- AfterROSC Network Group, Paris, France; Service d'Anesthésie‑Réanimation et Médecine Péri-Opératoire, APHP, CHU Henri Mondor, Créteil, France
| | - Fabio Taccone
- AfterROSC Network Group, Paris, France; Réanimation, ERASME, Brussels, Belgium
| | - Bertrand Hermann
- AfterROSC Network Group, Paris, France; Médecine Intensive-Réanimation, AP-HP, Hôpital Européen Georges Pompidou, 20 rue Leblanc, Paris, France
| | - Gwenhaël Colin
- AfterROSC Network Group, Paris, France; Médecine Intensive Réanimation, CHD Vendée, La Roche‑Sur‑Yon, France
| | - Olivier Lesieur
- AfterROSC Network Group, Paris, France; Médecine Intensive Réanimation, CH La Rochelle, La Rochelle, France
| | - Nicolas Deye
- AfterROSC Network Group, Paris, France; Médecine Intensive Réanimation, APHP, CHU Lariboisière, Paris, France
| | - Nicolas Chudeau
- AfterROSC Network Group, Paris, France; Réanimation médico-chirurgicale, CH Le Mans, Le Mans, France
| | - Martin Cour
- AfterROSC Network Group, Paris, France; Médecine Intensive Réanimation, Hospices Civils Lyon, Lyon, France
| | - Jeremy Bourenne
- AfterROSC Network Group, Paris, France; Réanimation des Urgences et Déchocage, CHU La Timone, APHM, Marseille, France
| | - Kada Klouche
- AfterROSC Network Group, Paris, France; Médecine Intensive Réanimation, CHU Montpellier, Montpellier, France
| | - Thomas Klein
- AfterROSC Network Group, Paris, France; Service de Médecine Intensive Réanimation Brabois CHRU Nancy France
| | - Jean-Herlé Raphalen
- AfterROSC Network Group, Paris, France; Médecine Intensive Réanimation, APHP, CHU Necker, Paris, France
| | - Grégoire Muller
- AfterROSC Network Group, Paris, France; Centre Hospitalier Universitaire (CHU) d'Orléans, Médecine Intensive Réanimation, Université de Tours, MR INSERM 1327 ISCHEMIA, Université de Tours, F37000, Tours, France, Clinical Research in Intensive Care and Sepsis-Trial Group for Global Evaluation and Research in Sepsis (CRICS_TRIGGERSep) French Clinical Research Infrastructure Network (F-CRIN) Research Network
| | - Arnaud Galbois
- AfterROSC Network Group, Paris, France; Service de Réanimation Polyvalente, Ramsay-Santé, Hôpital Privé Claude Galien, Quincy‑Sous‑Sénart, France
| | - Cédric Bruel
- AfterROSC Network Group, Paris, France; Service de Réanimation Polyvalente, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Sophie Jacquier
- AfterROSC Network Group, Paris, France; Médecine Intensive Réanimation, CHU Tours, Tours, France
| | - Marine Paul
- AfterROSC Network Group, Paris, France; Médecine Intensive Réanimation, CH Versailles, Le Chesnay, France
| | - 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
| | - Alain Cariou
- AfterROSC Network Group, Paris, France; Université de Paris Cité, Inserm, Paris Cardiovascular Research Center, Paris, France; Ramsay Générale de Santé, Hôpital Privé Jacques Cartier, Massy, France
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Bazbaz A, Varon J. Neuroprognostication, withdrawal of care and long-term outcomes after cardiopulmonary resuscitation. Curr Opin Crit Care 2024:00075198-990000000-00202. [PMID: 39150054 DOI: 10.1097/mcc.0000000000001194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2024]
Abstract
PURPOSE OF REVIEW Survivors of cardiac arrest often have increased long-term risks of mortality and disability that are primarily associated with hypoxic-ischemic brain injury (HIBI). This review aims to examine health-related long-term outcomes after cardiac arrest. RECENT FINDINGS A notable portion of cardiac arrest survivors face a decline in their quality of life, encountering persistent physical, cognitive, and mental health challenges emerging years after the initial event. Within the first-year postarrest, survivors are at elevated risk for stroke, epilepsy, and psychiatric conditions, along with a heightened susceptibility to developing dementia. Addressing these challenges necessitates establishing comprehensive, multidisciplinary care systems tailored to the needs of these individuals. SUMMARY HIBI remains the leading cause of disability among cardiac arrest survivors. No single strategy is likely to improve long term outcomes after cardiac arrest. A multimodal neuroprognostication approach (clinical examination, imaging, neurophysiology, and biomarkers) is recommended by guidelines, but fails to predict long-term outcomes. Cardiac arrest survivors often experience long-term disabilities that negatively impact their quality of life. The likelihood of such outcomes implements a multidisciplinary care an integral part of long-term recovery.
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Affiliation(s)
| | - Joseph Varon
- Dorrington Medical Associates, PA
- The University of Houston College of Medicine, Houston, Texas, USA
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Wijeratne T, Crewther SG, Wijeratne C, Shao R. Serial Systemic Immune-Inflammation Indices (SSIIi) as Prognostic Markers in Persistent Hypoxic Brain Injury Post-cardiac Arrest: A Case Report. Cureus 2024; 16:e67299. [PMID: 39165618 PMCID: PMC11335377 DOI: 10.7759/cureus.67299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2024] [Indexed: 08/22/2024] Open
Abstract
This case report presents a novel exploration of serial systemic immune-inflammation indices (SSIIi) as a potential prognostic biomarker in a critical care setting. The subject of this report is a 31-year-old male who, following a heroin overdose, suffered an asystolic cardiac arrest and subsequently passed away two weeks later in the intensive care unit (ICU). The SSIIi, calculated as platelet count × neutrophil count / lymphocyte count, was monitored throughout his stay. The case demonstrates that SSIIi measurements, particularly within the critical initial 24-72 hours, may provide insight into the patient's immune response dynamics following a severe hypoxic event. Specifically, the data suggest that a persistently elevated SSIIi may be indicative of a maladaptive immune response, characterized by ongoing inflammation, which correlates with a deteriorating clinical trajectory. The rapid escalation and sustained high SSIIi values observed in this patient appear to predict a poor outcome. This case underscores the importance of SSIIi as a potential tool for clinicians to assess prognosis in ICU patients, particularly in cases of acute brain injury where hypoxia is a central factor and sepsis is not present. The findings open avenues for further research into SSIIi as an objective measure for guiding treatment decisions and improving outcomes in similar critical care scenarios.
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Affiliation(s)
- Tissa Wijeratne
- Department of Neurology, Western Health, La Trobe University, St. Albans, AUS
- Department of Neurology and Stroke Services, Australian Institute for Musculoskeletal Science, Sunshine Hospital, St. Albans, AUS
| | - Sheila G Crewther
- Department of Psychology and Public Health, La Trobe University, Bundoora, AUS
| | | | - Richard Shao
- Department of Neurology, Sunshine Hospital, St. Albans, AUS
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Rohaut B, Calligaris C, Hermann B, Perez P, Faugeras F, Raimondo F, King JR, Engemann D, Marois C, Le Guennec L, Di Meglio L, Sangaré A, Munoz Musat E, Valente M, Ben Salah A, Demertzi A, Belloli L, Manasova D, Jodaitis L, Habert MO, Lambrecq V, Pyatigorskaya N, Galanaud D, Puybasset L, Weiss N, Demeret S, Lejeune FX, Sitt JD, Naccache L. Multimodal assessment improves neuroprognosis performance in clinically unresponsive critical-care patients with brain injury. Nat Med 2024; 30:2349-2355. [PMID: 38816609 PMCID: PMC11333287 DOI: 10.1038/s41591-024-03019-1] [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: 09/20/2023] [Accepted: 04/24/2024] [Indexed: 06/01/2024]
Abstract
Accurately predicting functional outcomes for unresponsive patients with acute brain injury is a medical, scientific and ethical challenge. This prospective study assesses how a multimodal approach combining various numbers of behavioral, neuroimaging and electrophysiological markers affects the performance of outcome predictions. We analyzed data from 349 patients admitted to a tertiary neurointensive care unit between 2009 and 2021, categorizing prognoses as good, uncertain or poor, and compared these predictions with observed outcomes using the Glasgow Outcome Scale-Extended (GOS-E, levels ranging from 1 to 8, with higher levels indicating better outcomes). After excluding cases with life-sustaining therapy withdrawal to mitigate the self-fulfilling prophecy bias, our findings reveal that a good prognosis, compared with a poor or uncertain one, is associated with better one-year functional outcomes (common odds ratio (95% CI) for higher GOS-E: OR = 14.57 (5.70-40.32), P < 0.001; and 2.9 (1.56-5.45), P < 0.001, respectively). Moreover, increasing the number of assessment modalities decreased uncertainty (OR = 0.35 (0.21-0.59), P < 0.001) and improved prognostic accuracy (OR = 2.72 (1.18-6.47), P = 0.011). Our results underscore the value of multimodal assessment in refining neuroprognostic precision, thereby offering a robust foundation for clinical decision-making processes for acutely brain-injured patients. ClinicalTrials.gov registration: NCT04534777 .
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Affiliation(s)
- B Rohaut
- Sorbonne Université, Paris, France.
- Paris Brain Institute - ICM, Inserm, CNRS, PICNIC-Lab, Paris, France.
- APHP, Hôpital de la Pitié Salpêtrière, DMU Neurosciences - Neuro ICU, Paris, France.
| | - C Calligaris
- APHP, Hôpital de la Pitié Salpêtrière, DMU Neurosciences - Neuro ICU, Paris, France
- GHU Paris Psychiatrie et Neurosciences, Pole Neuro, Sainte‑Anne Hospital, Anesthesia and Intensive Care Department, Paris, France
| | - B Hermann
- Paris Brain Institute - ICM, Inserm, CNRS, PICNIC-Lab, Paris, France
- APHP, Hôpital de la Pitié Salpêtrière, DMU Neurosciences - Neuro ICU, Paris, France
- GHU Paris Psychiatrie et Neurosciences, Pole Neuro, Sainte‑Anne Hospital, Anesthesia and Intensive Care Department, Paris, France
| | - P Perez
- Paris Brain Institute - ICM, Inserm, CNRS, PICNIC-Lab, Paris, France
- APHP, Hôpital de la Pitié Salpêtrière, DMU Neurosciences - Neuro ICU, Paris, France
| | - F Faugeras
- Paris Brain Institute - ICM, Inserm, CNRS, PICNIC-Lab, Paris, France
| | - F Raimondo
- Paris Brain Institute - ICM, Inserm, CNRS, PICNIC-Lab, Paris, France
| | - J-R King
- Paris Brain Institute - ICM, Inserm, CNRS, PICNIC-Lab, Paris, France
- Laboratoire des systèmes perceptifs, Département d'études cognitives, École normale supérieure, PSL University, CNRS, Paris, France
| | - D Engemann
- Paris Brain Institute - ICM, Inserm, CNRS, PICNIC-Lab, Paris, France
| | - C Marois
- Paris Brain Institute - ICM, Inserm, CNRS, PICNIC-Lab, Paris, France
- APHP, Hôpital de la Pitié Salpêtrière, DMU Neurosciences - Neuro ICU, Paris, France
| | - L Le Guennec
- Sorbonne Université, Paris, France
- APHP, Hôpital de la Pitié Salpêtrière, DMU Neurosciences - Neuro ICU, Paris, France
| | - L Di Meglio
- Sorbonne Université, Paris, France
- APHP, Hôpital de la Pitié Salpêtrière, DMU Neurosciences - Neuro ICU, Paris, France
- GHU Paris Psychiatrie et Neurosciences, Pole Neuro, Sainte‑Anne Hospital, Anesthesia and Intensive Care Department, Paris, France
| | - A Sangaré
- Sorbonne Université, Paris, France
- Paris Brain Institute - ICM, Inserm, CNRS, PICNIC-Lab, Paris, France
- APHP, Hôpital de la Pitié Salpêtrière, DMU Neurosciences - Neurophysiology, Paris, France
| | - E Munoz Musat
- Paris Brain Institute - ICM, Inserm, CNRS, PICNIC-Lab, Paris, France
- APHP, Hôpital de la Pitié Salpêtrière, DMU Neurosciences - Neurophysiology, Paris, France
| | - M Valente
- Paris Brain Institute - ICM, Inserm, CNRS, PICNIC-Lab, Paris, France
| | - A Ben Salah
- Sorbonne Université, Paris, France
- Paris Brain Institute - ICM, Inserm, CNRS, PICNIC-Lab, Paris, France
| | - A Demertzi
- Paris Brain Institute - ICM, Inserm, CNRS, PICNIC-Lab, Paris, France
- Physiology of Cognition GIGA-CRC In Vivo Imaging Center, University of Liège, Liège, Belgium
| | - L Belloli
- Paris Brain Institute - ICM, Inserm, CNRS, PICNIC-Lab, Paris, France
| | - D Manasova
- Paris Brain Institute - ICM, Inserm, CNRS, PICNIC-Lab, Paris, France
| | - L Jodaitis
- Paris Brain Institute - ICM, Inserm, CNRS, PICNIC-Lab, Paris, France
- APHP, Hôpital de la Pitié Salpêtrière, DMU Neurosciences - Neuro ICU, Paris, France
| | - M O Habert
- Sorbonne Université, Paris, France
- APHP, Hôpital de la Pitié Salpêtrière, Departement of Nuclear Medicine, Laboratoire d'Imagerie Biomédicale, Inserm, CNRS, Paris, France
| | - V Lambrecq
- Sorbonne Université, Paris, France
- APHP, Hôpital de la Pitié Salpêtrière, DMU Neurosciences - Neurophysiology, Paris, France
| | - N Pyatigorskaya
- Sorbonne Université, Paris, France
- APHP, Hôpital de la Pitié Salpêtrière, Departement of Neuro-radiology, Paris, France
| | - D Galanaud
- Sorbonne Université, Paris, France
- APHP, Hôpital de la Pitié Salpêtrière, Departement of Neuro-radiology, Paris, France
| | - L Puybasset
- Sorbonne Université, Paris, France
- APHP, Hôpital de la Pitié Salpêtrière, Departement of Neuro-anaesthesiology and Neurocritical care, Paris, France
| | - N Weiss
- Sorbonne Université, Paris, France
- APHP, Hôpital de la Pitié Salpêtrière, DMU Neurosciences - Neuro ICU, Paris, France
| | - S Demeret
- APHP, Hôpital de la Pitié Salpêtrière, DMU Neurosciences - Neuro ICU, Paris, France
| | - F X Lejeune
- Paris Brain Institute - ICM, Inserm, CNRS, Data Analysis Core, Paris, France
| | - J D Sitt
- Paris Brain Institute - ICM, Inserm, CNRS, PICNIC-Lab, Paris, France
| | - L Naccache
- Sorbonne Université, Paris, France
- Paris Brain Institute - ICM, Inserm, CNRS, PICNIC-Lab, Paris, France
- APHP, Hôpital de la Pitié Salpêtrière, DMU Neurosciences - Neurophysiology, Paris, France
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9
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Pollmanns MR, Adams JK, Dafotakis M, Saritas T, Trautwein C, Abu Jhaisha S, Koch A. [Course of neuron-specific enolase after resuscitation-When one value is of no value: a case report]. DER NERVENARZT 2024; 95:730-733. [PMID: 38861016 PMCID: PMC11297048 DOI: 10.1007/s00115-024-01681-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 06/12/2024]
Affiliation(s)
- Maike R Pollmanns
- Klinik für Gastroenterologie, Stoffwechselerkrankungen und internistische Intensivmedizin, Uniklinik RWTH Aachen, Aachen, Deutschland
| | - Jule K Adams
- Klinik für Gastroenterologie, Stoffwechselerkrankungen und internistische Intensivmedizin, Uniklinik RWTH Aachen, Aachen, Deutschland
| | - Manuel Dafotakis
- Klinik für Neurologie, Uniklinik RWTH Aachen, Aachen, Deutschland
| | - Turgay Saritas
- Klinik für Nieren- und Hochdruckkrankheiten, rheumatologische und immunologische Erkrankungen, Uniklinik RWTH Aachen, Aachen, Deutschland
| | - Christian Trautwein
- Klinik für Gastroenterologie, Stoffwechselerkrankungen und internistische Intensivmedizin, Uniklinik RWTH Aachen, Aachen, Deutschland
| | - Samira Abu Jhaisha
- Klinik für Gastroenterologie, Stoffwechselerkrankungen und internistische Intensivmedizin, Uniklinik RWTH Aachen, Aachen, Deutschland
| | - Alexander Koch
- Klinik für Gastroenterologie, Stoffwechselerkrankungen und internistische Intensivmedizin, Uniklinik RWTH Aachen, Aachen, Deutschland.
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10
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Wtorek P, Weiss MJ, Singh JM, Hrymak C, Chochinov A, Grunau B, Paunovic B, Shemie SD, Lalani J, Piggott B, Stempien J, Archambault P, Seleseh P, Fowler R, Leeies M. Beliefs of physician directors on the management of devastating brain injuries at the Canadian emergency department and intensive care unit interface: a national site-level survey. Can J Anaesth 2024; 71:1145-1153. [PMID: 38570415 PMCID: PMC11269388 DOI: 10.1007/s12630-024-02749-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 01/24/2024] [Accepted: 01/29/2024] [Indexed: 04/05/2024] Open
Abstract
PURPOSE Insufficient evidence-based recommendations to guide care for patients with devastating brain injuries (DBIs) leave patients vulnerable to inconsistent practice at the emergency department (ED) and intensive care unit (ICU) interface. We sought to characterize the beliefs of Canadian emergency medicine (EM) and critical care medicine (CCM) physician site directors regarding current management practices for patients with DBI. METHODS We conducted a cross-sectional survey of EM and CCM physician directors of adult EDs and ICUs across Canada (December 2022 to March 2023). Our primary outcome was the proportion of respondents who manage (or consult on) patients with DBI in the ED. We conducted subgroup analyses to compare beliefs of EM and CCM physicians. RESULTS Of 303 eligible respondents, we received 98 (32%) completed surveys (EM physician directors, 46; CCM physician directors, 52). Most physician directors reported participating in the decision to withdraw life-sustaining measures (WLSM) for patients with DBI in the ED (80%, n = 78), but 63% of these (n = 62) said this was infrequent. Physician directors reported that existing neuroprognostication methods are rarely sufficient to support WLSM in the ED (49%, n = 48) and believed that an ICU stay is required to improve confidence (99%, n = 97). Most (96%, n = 94) felt that providing caregiver visitation time prior to WLSM was a valid reason for ICU admission. CONCLUSION In our survey of Canadian EM and CCM physician directors, 80% participated in WLSM in the ED for patients with DBI. Despite this, most supported ICU admission to optimize neuroprognostication and patient-centred end-of-life care, including organ donation.
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Affiliation(s)
- Piotr Wtorek
- Section of Critical Care Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.
- Health Sciences Centre, JJ399-820 Sherbrook St., Ann Thomas Building, Winnipeg, MB, R3A 1R9, Canada.
| | - Matthew J Weiss
- Transplant Québec, Montreal, QC, Canada
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
- Division of Critical Care, Department of Pediatrics, Centre Mère-Enfant Soleil du CHU de Québec, Quebec City, QC, Canada
| | - Jeffrey M Singh
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Carmen Hrymak
- Section of Critical Care Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada
- Transplant Manitoba, Gift of Life Program, Shared Health Manitoba, Winnipeg, MB, Canada
| | - Alecs Chochinov
- Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Brian Grunau
- Department of Emergency Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Bojan Paunovic
- Section of Critical Care Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Sam D Shemie
- McGill University, Montreal Children's Hospital, Montreal, QC, Canada
| | | | | | - James Stempien
- Department of Emergency Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Patrick Archambault
- Department of Anesthesiology and Critical Care, Université Laval, Laval, QC, Canada
| | - Parisa Seleseh
- Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Rob Fowler
- Department of Critical Care Medicine, Sunnybrook Hospital, Toronto, ON, Canada
| | - Murdoch Leeies
- Section of Critical Care Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
- Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada
- Transplant Manitoba, Gift of Life Program, Shared Health Manitoba, Winnipeg, MB, Canada
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11
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Lee DH, Lee BK, Cho YS, Kim DK, Ryu SJ, Min JH, Park JS, Jeung KW. Validation of neuron-specific enolase in cardiac arrest patients with limited withdrawal of life-sustaining therapy. Heliyon 2024; 10:e34618. [PMID: 39113971 PMCID: PMC11305282 DOI: 10.1016/j.heliyon.2024.e34618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 07/12/2024] [Accepted: 07/12/2024] [Indexed: 08/10/2024] Open
Abstract
Aim We validated the prognostic performance of neuron-specific enolase (NSE) according to the recommended values in cardiac arrest (CA) survivors. Methods We analyzed the data of adult CA survivors who underwent targeted temperature management between January 2014 and December 2020. We measured the NSE level 48 h and 72 h after CA. We performed receiver operating characteristics (ROC) and used the reference value (17 μg/L) and the guidelines-suggested value (60 μg/L) as thresholds. The primary outcome was 6-month neurological outcomes with Cerebral Performance Category (CPC), dichotomized into good (CPC 1 or 2) or poor (CPC 3-5). Results Of the 513 included patients, 346 (67.4 %) patients had poor neurological outcomes. The area under ROC (AUC) of NSE at 48 h was 0.887 (95 % confidence intervals [CIs], 0.851-0.909) with the Youden index of 35.6 μg/L. A false positive rate (FPR) of <2 % was observed (54.1 μg/L). The thresholds values (17, 60) had a sensitivity of 86.1% and 56.7 % and a specificity of 66.7%and 98.8 %, respectively. The AUC of NSE at 72 h was 0.892 (95 % CIs, 0.849-0.920) with the Youden index of 30.4 μg/L. The threshold values (17, 60) had a sensitivity of 86.0%and 59.4 % with a specificity of 72.2%and 98.3 %, respectively. An FPR of <2 % was observed (53.6 μg/L). Among the 156 patients and 113 patients with NSE at 48 h and at 72 h ≤ 17 μg/L, respectively, 109 and 83 patients had good neurological outcomes. Conclusions The cut-off value of NSE (60 μg/L) was acceptable to predict poor neurological outcomes with an FPR <2 % in cardiac arrest survivors, irrespective of at 48 or 72 h. NSE (17 μg/L) can function as mitigating factor to deter early WLST.
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Affiliation(s)
- Dong Hun Lee
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Yong Soo Cho
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Dong Ki Kim
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Seok Jin Ryu
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Jin Hong Min
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea
| | - Jung Soo Park
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea
| | - Kyung Woon Jeung
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
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12
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Shivdat S, Zhan T, De Palma A, Zheng WL, Krishnamurthy P, Paneerselvam E, Snider S, Bevers M, O'Reilly UM, Lee JW, Westover MB, Amorim E. Early Burst Suppression Similarity Association with Structural Brain Injury Severity on MRI After Cardiac Arrest. Neurocrit Care 2024:10.1007/s12028-024-02047-6. [PMID: 39043984 DOI: 10.1007/s12028-024-02047-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 06/13/2024] [Indexed: 07/25/2024]
Abstract
BACKGROUND Identical bursts on electroencephalography (EEG) are considered a specific predictor of poor outcomes in cardiac arrest, but its relationship with structural brain injury severity on magnetic resonance imaging (MRI) is not known. METHODS This was a retrospective analysis of clinical, EEG, and MRI data from adult comatose patients after cardiac arrest. Burst similarity in first 72 h from the time of return of spontaneous circulation were calculated using dynamic time-warping (DTW) for bursts of equal (i.e., 500 ms) and varying (i.e., 100-500 ms) lengths and cross-correlation for bursts of equal lengths. Structural brain injury severity was measured using whole brain mean apparent diffusion coefficient (ADC) on MRI. Pearson's correlation coefficients were calculated between mean burst similarity across consecutive 12-24-h time blocks and mean whole brain ADC values. Good outcome was defined as Cerebral Performance Category of 1-2 (i.e., independence for activities of daily living) at the time of hospital discharge. RESULTS Of 113 patients with cardiac arrest, 45 patients had burst suppression (mean cardiac arrest to MRI time 4.3 days). Three study participants with burst suppression had a good outcome. Burst similarity calculated using DTW with bursts of varying lengths was correlated with mean ADC value in the first 36 h after cardiac arrest: Pearson's r: 0-12 h: - 0.69 (p = 0.039), 12-24 h: - 0.54 (p = 0.002), 24-36 h: - 0.41 (p = 0.049). Burst similarity measured with bursts of equal lengths was not associated with mean ADC value with cross-correlation or DTW, except for DTW at 60-72 h (- 0.96, p = 0.04). CONCLUSIONS Burst similarity on EEG after cardiac arrest may be associated with acute brain injury severity on MRI. This association was time dependent when measured using DTW.
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Affiliation(s)
- Shawn Shivdat
- Harvard College, Cambridge, MA, USA
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Tiange Zhan
- Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Alessandro De Palma
- Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, MA, USA
- Department of Computing, Imperial College London, London, UK
| | - Wei-Long Zheng
- Department of Computer Science and Engineering, Shanghai Jiao Tong University, Shanghai, China
| | | | - Ezhil Paneerselvam
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Samuel Snider
- Division of Neurocritical Care, Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Matthew Bevers
- Division of Neurocritical Care, Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Una-May O'Reilly
- Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Jong Woo Lee
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
- Division of Epilepsy, Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - M Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Edilberto Amorim
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.
- Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, MA, USA.
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, Zuckerberg San Francisco General Hospital, 1001 Potrero Ave, Building 1, Suite 312, San Francisco, CA, 94110, USA.
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13
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Bitar R, Khan UM, Rosenthal ES. Utility and rationale for continuous EEG monitoring: a primer for the general intensivist. Crit Care 2024; 28:244. [PMID: 39014421 PMCID: PMC11251356 DOI: 10.1186/s13054-024-04986-0] [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: 02/06/2024] [Accepted: 06/09/2024] [Indexed: 07/18/2024] Open
Abstract
This review offers a comprehensive guide for general intensivists on the utility of continuous EEG (cEEG) monitoring for critically ill patients. Beyond the primary role of EEG in detecting seizures, this review explores its utility in neuroprognostication, monitoring neurological deterioration, assessing treatment responses, and aiding rehabilitation in patients with encephalopathy, coma, or other consciousness disorders. Most seizures and status epilepticus (SE) events in the intensive care unit (ICU) setting are nonconvulsive or subtle, making cEEG essential for identifying these otherwise silent events. Imaging and invasive approaches can add to the diagnosis of seizures for specific populations, given that scalp electrodes may fail to identify seizures that may be detected by depth electrodes or electroradiologic findings. When cEEG identifies SE, the risk of secondary neuronal injury related to the time-intensity "burden" often prompts treatment with anti-seizure medications. Similarly, treatment may be administered for seizure-spectrum activity, such as periodic discharges or lateralized rhythmic delta slowing on the ictal-interictal continuum (IIC), even when frank seizures are not evident on the scalp. In this setting, cEEG is utilized empirically to monitor treatment response. Separately, cEEG has other versatile uses for neurotelemetry, including identifying the level of sedation or consciousness. Specific conditions such as sepsis, traumatic brain injury, subarachnoid hemorrhage, and cardiac arrest may each be associated with a unique application of cEEG; for example, predicting impending events of delayed cerebral ischemia, a feared complication in the first two weeks after subarachnoid hemorrhage. After brief training, non-neurophysiologists can learn to interpret quantitative EEG trends that summarize elements of EEG activity, enhancing clinical responsiveness in collaboration with clinical neurophysiologists. Intensivists and other healthcare professionals also play crucial roles in facilitating timely cEEG setup, preventing electrode-related skin injuries, and maintaining patient mobility during monitoring.
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Affiliation(s)
- Ribal Bitar
- Department of Neurology, Massachusetts General Hospital, 55 Fruit St., Lunder 644, Boston, MA, 02114, USA
| | - Usaamah M Khan
- Department of Neurology, Massachusetts General Hospital, 55 Fruit St., Lunder 644, Boston, MA, 02114, USA
| | - Eric S Rosenthal
- Department of Neurology, Massachusetts General Hospital, 55 Fruit St., Lunder 644, Boston, MA, 02114, USA.
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14
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Huang SS, Huang CH, Hsu NT, Ong HN, Lin JJ, Wu YW, Chen WT, Chen WJ, Chang WT, Tsai MS. Application of Phosphorylated Tau for Predicting Outcomes Among Sudden Cardiac Arrest Survivors. Neurocrit Care 2024:10.1007/s12028-024-02055-6. [PMID: 38982004 DOI: 10.1007/s12028-024-02055-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 06/21/2024] [Indexed: 07/11/2024]
Abstract
BACKGROUND Phosphorylated Tau (p-Tau), an early biomarker of neuronal damage, has emerged as a promising candidate for predicting neurological outcomes in cardiac arrest (CA) survivors. Despite its potential, the correlation of p-Tau with other clinical indicators remains underexplored. This study assesses the predictive capability of p-Tau and its effectiveness when used in conjunction with other predictors. METHODS In this single-center retrospective study, 230 CA survivors had plasma and brain computed tomography scans collected within 24 h after the return of spontaneous circulation (ROSC) from January 2016 to June 2023. The patients with prearrest Cerebral Performance Category scores ≥ 3 were excluded (n = 33). The neurological outcomes at discharge with Cerebral Performance Category scores 1-2 indicated favorable outcomes. Plasma p-Tau levels were measured using an enzyme-linked immunosorbent assay, diastolic blood pressure (DBP) was recorded after ROSC, and the gray-to-white matter ratio (GWR) was calculated from brain computed tomography scans within 24 h after ROSC. RESULTS Of 197 patients enrolled in the study, 54 (27.4%) had favorable outcomes. Regression analysis showed that higher p-Tau levels correlated with unfavorable neurological outcomes. The levels of p-Tau were significantly correlated with DBP and GWR. For p-Tau to differentiate between neurological outcomes, an optimal cutoff of 456 pg/mL yielded an area under the receiver operating characteristic curve of 0.71. Combining p-Tau, GWR, and DBP improved predictive accuracy (area under the receiver operating characteristic curve = 0.80 vs. 0.71, p = 0.008). CONCLUSIONS Plasma p-Tau levels measured within 24 h following ROSC, particularly when combined with GWR and DBP, may serve as a promising biomarker of neurological outcomes in CA survivors, with higher levels predicting unfavorable outcomes.
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Affiliation(s)
- Sih-Shiang Huang
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | - Chien-Hua Huang
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | | | - Hooi-Nee Ong
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | - Jr-Jiun Lin
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | | | - Wei-Ting Chen
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | - Wen-Jone Chen
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
- Cardiology Division, Department of Internal Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
- Department of Internal Medicine, Min-Shen General Hospital, Taoyuan, Taiwan
| | - Wei-Tien Chang
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | - Min-Shan Tsai
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan.
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15
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Kramser N, Duse DA, Gröne M, Stücker B, Voß F, Tokhi U, Jung C, Horn P, Kelm M, Erkens R. Amiodarone Administration during Cardiopulmonary Resuscitation Is Not Associated with Changes in Short-Term Mortality or Neurological Outcomes in Cardiac Arrest Patients with Shockable Rhythms. J Clin Med 2024; 13:3931. [PMID: 38999496 PMCID: PMC11242294 DOI: 10.3390/jcm13133931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 07/02/2024] [Accepted: 07/03/2024] [Indexed: 07/14/2024] Open
Abstract
Background: The search for the best therapeutic approach in cardiopulmonary resuscitations (CPR) remains open to question. In this study, we evaluated if Amiodarone administration during CPR was associated with short-term mortality or neurological development. Methods: A total of 232 patients with sudden cardiac arrest (CA) with shockable rhythms were included in our analysis. Propensity score matching based on age, gender, type of CA, and CPR duration was used to stratify between patients with and without Amiodarone during CPR. Primary endpoints were short-term mortality (30-day) and neurological outcomes assessed by the cerebral performance category. Secondary endpoints were plasma lactate, phosphate levels at hospital admission, and the peak Neuron-specific enolase. Results: Propensity score matching was successful with a caliper size used for matching of 0.089 and a sample size of n = 82 per group. The 30-day mortality rates were similar between both groups (p = 0.24). There were no significant differences in lactate levels at hospital admission and during the following five days between the groups. Patients receiving Amiodarone showed slightly higher phosphate levels at hospital admission, while the levels decreased to a similar value during the following days. Among CA survivors to hospital discharge, no differences between the proportion of good neurological outcomes were detected between the two groups (p = 0.58), despite slightly higher peak neuron-specific enolase levels in CA patients receiving Amiodarone (p = 0.03). Conclusions: Amiodarone administration is not associated with short-term mortality or neurological outcomes in CA patients with shockable rhythms receiving CPR.
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Affiliation(s)
- Nicolas Kramser
- Department of Cardiology, Pulmonology and Angiology, Medical Faculty, Heinrich Heine University of Düsseldorf, 40225 Düsseldorf, Germany
| | - Dragos Andrei Duse
- Department of Cardiology, Pulmonology and Angiology, Medical Faculty, Heinrich Heine University of Düsseldorf, 40225 Düsseldorf, Germany
| | - Michael Gröne
- Department of Cardiology, Pulmonology and Angiology, Medical Faculty, Heinrich Heine University of Düsseldorf, 40225 Düsseldorf, Germany
| | - Bernd Stücker
- Department of Cardiology, Pulmonology and Angiology, Medical Faculty, Heinrich Heine University of Düsseldorf, 40225 Düsseldorf, Germany
| | - Fabian Voß
- Department of Cardiology, Pulmonology and Angiology, Medical Faculty, Heinrich Heine University of Düsseldorf, 40225 Düsseldorf, Germany
| | - Ursala Tokhi
- Department of Cardiology, Pulmonology and Angiology, Medical Faculty, Heinrich Heine University of Düsseldorf, 40225 Düsseldorf, Germany
| | - Christian Jung
- Department of Cardiology, Pulmonology and Angiology, Medical Faculty, Heinrich Heine University of Düsseldorf, 40225 Düsseldorf, Germany
- Cardiovascular Research Institute Düsseldorf (CARID), 40225 Düsseldorf, Germany
| | - Patrick Horn
- Department of Cardiology, Pulmonology and Angiology, Medical Faculty, Heinrich Heine University of Düsseldorf, 40225 Düsseldorf, Germany
| | - Malte Kelm
- Department of Cardiology, Pulmonology and Angiology, Medical Faculty, Heinrich Heine University of Düsseldorf, 40225 Düsseldorf, Germany
- Cardiovascular Research Institute Düsseldorf (CARID), 40225 Düsseldorf, Germany
| | - Ralf Erkens
- Department of Cardiology, Pulmonology and Angiology, Medical Faculty, Heinrich Heine University of Düsseldorf, 40225 Düsseldorf, Germany
- Department of Cardiology and Electrophysiology, St. Agnes-Hospital Bocholt, 46397 Bocholt, Germany
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16
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Johnson NJ, Matin N, Singh A, Davis AP, Liao HC, Town JA, Tirschwell DL, Nash MG, Longstreth WT, Khot SP. Cerebrospinal Creatine Kinase BB Isoenzyme: A Biomarker for Predicting Outcome After Cardiac Arrest. Neurocrit Care 2024:10.1007/s12028-024-02037-8. [PMID: 38955930 DOI: 10.1007/s12028-024-02037-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 05/31/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND Cerebrospinal fluid creatine kinase BB isoenzyme (CSF CK-BB) after cardiac arrest (CA) has been shown to have a high positive predictive value for poor neurological outcome, but it has not been evaluated in the setting of targeted temperature management (TTM) and modern CA care. We aimed to evaluate CSF CK-BB as a prognostic biomarker after CA. METHODS We performed a retrospective cohort study of patients with CA admitted between 2010 and 2020 to a three-hospital health system who remained comatose and had CSF CK-BB assayed between 36 and 84 h after CA. We examined the proportion of patients at hospital discharge who achieved favorable or intermediate neurological outcome, defined as Cerebral Performance Category score of 1-3, compared with those with poor outcome (Cerebral Performance Category score 4-5) for various CSF CK-BB thresholds. We also evaluated additive value of bilateral absence of somatosensory evoked potentials (SSEPs). RESULTS Among 214 eligible patients, the mean age was 54.7 ± 4.8 years, 72% of patients were male, 33% were nonwhite, 17% had shockable rhythm, 90% were out-of-hospital CA, and 83% received TTM. A total of 19 (9%) awakened. CSF CK-BB ≥ 230 U/L predicted a poor outcome at hospital discharge, with a specificity of 100% (95% confidence interval [CI] 82-100%) and sensitivity of 69% (95% CI 62-76%). When combined with bilaterally absent N20 response on SSEP, specificity remained 100% while sensitivity increased to 80% (95% CI 73-85%). Discordant CK-BB and SSEP findings were seen in 13 (9%) patients. CONCLUSIONS Cerebrospinal fluid creatine kinase BB isoenzyme levels accurately predicted poor neurological outcome among CA survivors treated with TTM. The CSF CK-BB cutoff of 230 U/L optimizes sensitivity to 69% while maintaining a specificity of 100%. CSF CK-BB could be a useful addition to multimodal neurological prognostication after CA.
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Affiliation(s)
- Nicholas J Johnson
- Department of Emergency Medicine, Harborview Medical Center, University of Washington School of Medicine, University of Washington, 325 Ninth Avenue, Box 359108, Seattle, WA, 98104, USA.
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA.
| | | | - Amita Singh
- Department of Neurology, University of Florida, Gainesville, FL, USA
| | - Arielle P Davis
- Department of Neurology, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Hsuan-Chien Liao
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
| | - James A Town
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - David L Tirschwell
- Department of Neurology, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Michael G Nash
- Center for Biomedical Statistics, University of Washington, Seattle, WA, USA
| | - W T Longstreth
- Department of Neurology, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Sandeep P Khot
- Department of Neurology, Harborview Medical Center, University of Washington, Seattle, WA, USA
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17
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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 PMCID: PMC11220945 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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18
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Lang M, Kenda M, Scheel M, Martola J, Wheeler M, Owen S, Johnsson M, Annborn M, Dankiewicz J, Deye N, Düring J, Friberg H, Halliday T, Jakobsen JC, Lascarrou JB, Levin H, Lilja G, Lybeck A, McGuigan P, Rylander C, Sem V, Thomas M, Ullén S, Undén J, Wise MP, Cronberg T, Wassélius J, Nielsen N, Leithner C, Moseby-Knappe M. Standardised and automated assessment of head computed tomography reliably predicts poor functional outcome after cardiac arrest: a prospective multicentre study. Intensive Care Med 2024; 50:1096-1107. [PMID: 38900283 PMCID: PMC11245448 DOI: 10.1007/s00134-024-07497-2] [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: 03/13/2024] [Accepted: 05/21/2024] [Indexed: 06/21/2024]
Abstract
PURPOSE Application of standardised and automated assessments of head computed tomography (CT) for neuroprognostication after out-of-hospital cardiac arrest. METHODS Prospective, international, multicentre, observational study within the Targeted Hypothermia versus Targeted Normothermia after out-of-hospital cardiac arrest (TTM2) trial. Routine CTs from adult unconscious patients obtained > 48 h ≤ 7 days post-arrest were assessed qualitatively and quantitatively by seven international raters blinded to clinical information using a pre-published protocol. Grey-white-matter ratio (GWR) was calculated from four (GWR-4) and eight (GWR-8) regions of interest manually placed at the basal ganglia level. Additionally, GWR was obtained using an automated atlas-based approach. Prognostic accuracies for prediction of poor functional outcome (modified Rankin Scale 4-6) for the qualitative assessment and for the pre-defined GWR cutoff < 1.10 were calculated. RESULTS 140 unconscious patients were included; median age was 68 years (interquartile range [IQR] 59-76), 76% were male, and 75% had poor outcome. Standardised qualitative assessment and all GWR models predicted poor outcome with 100% specificity (95% confidence interval [CI] 90-100). Sensitivity in median was 37% for the standardised qualitative assessment, 39% for GWR-8, 30% for GWR-4 and 41% for automated GWR. GWR-8 was superior to GWR-4 regarding prognostic accuracies, intra- and interrater agreement. Overall prognostic accuracy for automated GWR (area under the curve [AUC] 0.84, 95% CI 0.77-0.91) did not significantly differ from manually obtained GWR. CONCLUSION Standardised qualitative and quantitative assessments of CT are reliable and feasible methods to predict poor functional outcome after cardiac arrest. Automated GWR has the potential to make CT quantification for neuroprognostication accessible to all centres treating cardiac arrest patients.
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Affiliation(s)
- Margareta Lang
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Radiology, Helsingborg Hospital, Helsingborg, Sweden
| | - Martin Kenda
- Berlin Institute of Health at Charité-Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Junior Digital Clinician Scientist Program, Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Michael Scheel
- Department of Neuroradiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Juha Martola
- HUS Medical Imaging Center, Radiology, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Matthew Wheeler
- University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, Wales, UK
| | - Stephanie Owen
- University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, Wales, UK
| | - Mikael Johnsson
- Department of Radiology, Helsingborg Hospital, Helsingborg, Sweden
| | - Martin Annborn
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Anaesthesia and Intensive Care, Helsingborg Hospital, Helsingborg, Sweden
| | - Josef Dankiewicz
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Cardiology, Skåne University Hospital, Lund, Sweden
| | - Nicolas Deye
- Department of Medical and Toxicological Intensive Care Unit, Inserm UMR-S 942, Assistance Publique des Hopitaux de Paris, Lariboisière University Hospital, Paris, France
| | - Joachim Düring
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Anaesthesia and Intensive Care, Skåne University Hospital, Malmö, Sweden
| | - Hans Friberg
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Anaesthesia and Intensive Care, Skåne University Hospital, Malmö, Sweden
| | - Thomas Halliday
- Department of Operation and Intensive Care, Linköping University Hospital, Linköping, Sweden
| | - Janus Christian Jakobsen
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jean-Baptiste Lascarrou
- Medecine Intensive Reanimation, Movement-Interactions-Performance,, Nantes Université, CHU Nantes, MIP, UR 4334, 44000, Nantes, France
| | - Helena Levin
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Research and Education, Skåne University Hospital, Lund, Sweden
| | - Gisela Lilja
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Neurology, Skåne University Hospital, Lund, Sweden
| | - Anna Lybeck
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Anaesthesia and Intensive Care, Skåne University Hospital, Lund, Sweden
| | - Peter McGuigan
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Christian Rylander
- Anaesthesia and Intensive Care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Victoria Sem
- Department of Anaesthesia and Intensive Care, Central Hospital of Karlstad, Karlstad, Sweden
| | - Matthew Thomas
- Intensive Care Unit, University Hospitals Bristol and Weston, Bristol, UK
| | - Susann Ullén
- Clinical Studies Sweden‑Forum South, Skåne University Hospital, Lund, Sweden
| | - Johan Undén
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Operation and Intensive Care, Hallands Hospital Halmstad, Halmstad, Sweden
| | - Matt P Wise
- Adult Critical Care, University Hospital of Wales, Cardiff, UK
| | - Tobias Cronberg
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Neurology, Skåne University Hospital, Lund, Sweden
| | - Johan Wassélius
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden
| | - Niklas Nielsen
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Anaesthesia and Intensive Care, Helsingborg Hospital, Helsingborg, Sweden
| | - Christoph Leithner
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Marion Moseby-Knappe
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden.
- Department of Neurology, Skåne University Hospital, Lund, Sweden.
- Department of Rehabilitation, Skåne University Hospital, 22185, Lund, Sweden.
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19
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Liu G, Wang Y, Tian F, Chen W, Cui L, Jiang M, Zhang Y, Gao K, Su Y, Wang H. Quantitative EEG reactivity induced by electrical stimulation predicts good outcome in comatose patients after cardiac arrest. Ann Intensive Care 2024; 14:99. [PMID: 38935167 PMCID: PMC11211292 DOI: 10.1186/s13613-024-01339-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Accepted: 06/17/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND EEG reactivity is a predictor for neurological outcome in comatose patients after cardiac arrest (CA); however, its application is limited by variability in stimulus types and visual assessment. We aimed to evaluate the prognostic value of the quantitative analysis of EEG reactivity induced by standardized electrical stimulation and for early prognostication in this population. METHODS This prospective observational study recruited post-CA comatose patients in Xuanwu Hospital, Capital Medical University (Beijing, China) between January 2016 and June 2023. EEG reactivity to electrical or traditional pain stimulation was randomly performed via visual and quantitative analysis. Neurological outcome within 6 months was dichotomized as good (Cerebral Performance Categories, CPC 1-2) or poor (CPC 3-5). RESULTS Fifty-eight post-CA comatose patients were admitted, and 52 patients were included in the final analysis, of which 19 (36.5%) had good outcomes. EEG reactivity induced with the electrical stimulation had superior performance to the traditional pain stimulation for good outcome prediction (quantitative analysis: AUC 0.932 vs. 0.849, p = 0.048). When using the electrical stimulation, the AUC of EEG reactivity to predict good outcome by visual analysis was 0.838, increasing to 0.932 by quantitative analysis (p = 0.039). Comparing to the traditional pain stimulation by visual analysis, the AUC of EEG reactivity for good prognostication by the electrical stimulation with quantitative analysis was significantly improved (0.932 vs. 0.770, p = 0.004). CONCLUSIONS EEG reactivity induced by the standardized electrical stimulation in combination with quantitative analysis is a promising formula for post-CA comatose patients, with increased predictive accuracy.
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Affiliation(s)
- Gang Liu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing, 100053, China
| | - Yuan Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing, 100053, China
| | - Fei Tian
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing, 100053, China
| | - Weibi Chen
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing, 100053, China
| | - Lili Cui
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing, 100053, China
| | - Mengdi Jiang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing, 100053, China
| | - Yan Zhang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing, 100053, China
| | - Keming Gao
- Department of Psychiatry, Mood Disorders Program, University Hospitals Cleveland Medical Center/Case Western Reserve University, Cleveland, OH, 44106, USA
| | - Yingying Su
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing, 100053, China.
| | - Hongxing Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing, 100053, China.
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20
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Hou HX, Pang L, Zhao L, Xing J. Ferroptosis-related gene MAPK3 is associated with the neurological outcome after cardiac arrest. PLoS One 2024; 19:e0301647. [PMID: 38885209 PMCID: PMC11182507 DOI: 10.1371/journal.pone.0301647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 03/19/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND Neuronal ferroptosis is closely related to the disease of the nervous system, and the objective of the present study was to recognize and verify the potential ferroptosis-related genes to forecast the neurological outcome after cardiac arrest. METHODS Cardiac Arrest-related microarray datasets GSE29540 and GSE92696 were downloaded from GEO and batch normalization of the expression data was performed using "sva" of the R package. GSE29540 was analyzed to identify DEGs. Venn diagram was applied to recognize ferroptosis-related DEGs from the DEGs. Subsequently, The Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analysis were performed, and PPI network was applied to screen hub genes. Receiver operating characteristic (ROC) curves were adopted to determine the predictive value of the biomarkers, and the GSE92696 dataset was applied to further evaluate the diagnostic efficacy of the biomarkers. We explore transcription factors and miRNAs associated with hub genes. The "CIBERSORT" package of R was utilized to analyse the proportion infiltrating immune cells. Finally, validated by a series of experiments at the cellular level. RESULTS 112 overlapping ferroptosis-related DEGs were further obtained via intersecting these DEGs and ferroptosis-related genes. The GO and KEGG analysis demonstrate that ferroptosis-related DEGs are mainly involved in response to oxidative stress, ferroptosis, apoptosis, IL-17 signalling pathway, autophagy, toll-like receptor signalling pathway. The top 10 hub genes were selected, including HIF1A, MAPK3, PPARA, IL1B, PTGS2, RELA, TLR4, KEAP1, SREBF1, SIRT6. Only MAPK3 was upregulated in both GSE29540 and GAE92696. The AUC values of the MAPK3 are 0.654 and 0.850 in GSE29540 and GSE92696 respectively. The result of miRNAs associated with hub genes indicates that hsa-miR-214-3p and hsa-miR-483-5p can regulate the expression of MAPK3. MAPK3 was positively correlated with naive B cells, macrophages M0, activated dendritic cells and negatively correlated with activated CD4 memory T cells, CD8 T cells, and memory B cells. Compared to the OGD4/R24 group, the OGD4/R12 group had higher MAPK3 expression at both mRNA and protein levels and more severe ferroptosis. CONCLUSION In summary, the MAPK3 ferroptosis-related gene could be used as a biomarker to predict the neurological outcome after cardiac arrest. Potential biological pathways provide novel insights into the pathogenesis of cardiac arrest.
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Affiliation(s)
- Hong xiang Hou
- Department of Emergency, The First Hospital of Jilin University, Changchun, China
| | - Li Pang
- Department of Emergency, The First Hospital of Jilin University, Changchun, China
| | - Liang Zhao
- Rehabilitation Department, The First Hospital of Jilin University, Changchun, China
| | - Jihong Xing
- Department of Emergency, The First Hospital of Jilin University, Changchun, China
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21
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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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22
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Tam J, Elmer J. Enhancing post-arrest prognostication through good outcome prediction. Resuscitation 2024; 199:110236. [PMID: 38740253 DOI: 10.1016/j.resuscitation.2024.110236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 04/29/2024] [Accepted: 05/03/2024] [Indexed: 05/16/2024]
Affiliation(s)
- Jonathan Tam
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jonathan Elmer
- Department of Emergency Medicine, 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 Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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23
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Benghanem S, Kubis N, Gayat E, Loiodice A, Pruvost-Robieux E, Sharshar T, Foucrier A, Figueiredo S, Bouilleret V, De Montmollin E, Bagate F, Lefaucheur JP, Guidet B, Appartis E, Cariou A, Varnet O, Jost PH, Megarbane B, Degos V, Le Guennec L, Naccache L, Legriel S, Woimant F, Gregoire C, Cortier D, Crassard I, Timsit JF, Mazighi M, Sonneville R. Prognostic value of early EEG abnormalities in severe stroke patients requiring mechanical ventilation: a pre-planned analysis of the SPICE prospective multicenter study. Crit Care 2024; 28:173. [PMID: 38783313 PMCID: PMC11119574 DOI: 10.1186/s13054-024-04957-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Accepted: 05/17/2024] [Indexed: 05/25/2024] Open
Abstract
INTRODUCTION Prognostication of outcome in severe stroke patients necessitating invasive mechanical ventilation poses significant challenges. The objective of this study was to assess the prognostic significance and prevalence of early electroencephalogram (EEG) abnormalities in adult stroke patients receiving mechanical ventilation. METHODS This study is a pre-planned ancillary investigation within the prospective multicenter SPICE cohort study (2017-2019), conducted in 33 intensive care units (ICUs) in the Paris area, France. We included adult stroke patients requiring invasive mechanical ventilation, who underwent at least one intermittent EEG examination during their ICU stay. The primary endpoint was the functional neurological outcome at one year, determined using the modified Rankin scale (mRS), and dichotomized as unfavorable (mRS 4-6, indicating severe disability or death) or favorable (mRS 0-3). Multivariable regression analyses were employed to identify EEG abnormalities associated with functional outcomes. RESULTS Of the 364 patients enrolled in the SPICE study, 153 patients (49 ischemic strokes, 52 intracranial hemorrhages, and 52 subarachnoid hemorrhages) underwent at least one EEG at a median time of 4 (interquartile range 2-7) days post-stroke. Rates of diffuse slowing (70% vs. 63%, p = 0.37), focal slowing (38% vs. 32%, p = 0.15), periodic discharges (2.3% vs. 3.7%, p = 0.9), and electrographic seizures (4.5% vs. 3.7%, p = 0.4) were comparable between patients with unfavorable and favorable outcomes. Following adjustment for potential confounders, an unreactive EEG background to auditory and pain stimulations (OR 6.02, 95% CI 2.27-15.99) was independently associated with unfavorable outcomes. An unreactive EEG predicted unfavorable outcome with a specificity of 48% (95% CI 40-56), sensitivity of 79% (95% CI 72-85), and positive predictive value (PPV) of 74% (95% CI 67-81). Conversely, a benign EEG (defined as continuous and reactive background activity without seizure, periodic discharges, triphasic waves, or burst suppression) predicted favorable outcome with a specificity of 89% (95% CI 84-94), and a sensitivity of 37% (95% CI 30-45). CONCLUSION The absence of EEG reactivity independently predicts unfavorable outcomes at one year in severe stroke patients requiring mechanical ventilation in the ICU, although its prognostic value remains limited. Conversely, a benign EEG pattern was associated with a favorable outcome.
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Affiliation(s)
- Sarah Benghanem
- AP-HP.Centre, Medical ICU, Cochin Hospital, Paris, France
- University Paris Cité, Medical School, Paris, France
- INSERM UMR 1266, Institut de Psychiatrie et Neurosciences de Paris-IPNP, Paris, France
| | - Nathalie Kubis
- University Paris Cité, Medical School, Paris, France
- APHP.Nord, Clinical Physiology Department, UMRS_1144, Université Paris Cite, Paris, France
| | - Etienne Gayat
- University Paris Cité, Medical School, Paris, France
- APHP.Nord, Department of Anesthesiology and Critical Care, DMU Parabol, Université Paris Cite, Paris, France
| | | | - Estelle Pruvost-Robieux
- University Paris Cité, Medical School, Paris, France
- INSERM UMR 1266, Institut de Psychiatrie et Neurosciences de Paris-IPNP, Paris, France
- Neurophysiology and Epileptology Department, GHU Psychiatry & Neurosciences, Sainte Anne, Paris, France
| | - Tarek Sharshar
- University Paris Cité, Medical School, Paris, France
- Department of Neuroanesthesiology and Intensive Care, Sainte Anne Hospital, Paris, France
| | - Arnaud Foucrier
- APHP, Department of Anesthesiology and Critical Care, Beaujon University Hospital, Clichy, France
| | - Samy Figueiredo
- APHP, Department of Anesthesiology and Critical Care, Bicêtre University Hospitals, Le Kremlin Bicêtre, France
| | - Viviane Bouilleret
- Neurophysiology and Epileptology Department, Bicêtre University Hospitals, Le Kremlin Bicêtre, France
| | | | - François Bagate
- APHP, Department of Intensive Care Medicine, Henri Mondor University Hospital and Université de Paris Est Créteil, Créteil, France
| | | | - Bertrand Guidet
- APHP, Department of Intensive Care Medicine, Saint Antoine University Hospital, Paris, France
| | - Emmanuelle Appartis
- Neurophysiology Department, Saint Antoine University Hospital, Paris, France
| | - Alain Cariou
- AP-HP.Centre, Medical ICU, Cochin Hospital, Paris, France
- University Paris Cité, Medical School, Paris, France
| | - Olivier Varnet
- APHP, Department of Physiology, Bichat-Claude Bernard University Hospital, 75018, Paris, France
| | - Paul Henri Jost
- APHP, Department of Anesthesiology and Intensive Care, Henri Mondor Hospital, Creteil, France
| | | | - Vincent Degos
- APHP, Department of Anesthesiology and Neurointensive Care, Pitié Salpétrière Hospital, Paris, France
| | - Loic Le Guennec
- APHP, Medical ICU, Pitié Salpétrière Hospital, Paris, France
| | - Lionel Naccache
- APHP, Department of Physiology, Pitié Salpétrière Hospital, Paris, France
| | | | | | - Charles Gregoire
- Department of Intensive Care, Rothschild Hospital Foundation, Paris, France
| | - David Cortier
- Department of Intensive Care, Foch Hospital, Paris, France
| | | | - Jean-François Timsit
- APHP, Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, 46 rue Henri Huchard, 75018, Paris, France
- Université Paris Cité, INSERM UMR 1137, IAME, Paris, France
| | - Mikael Mazighi
- APHP Nord, Department of Neurology, Lariboisière University Hospital, Department of Interventional Neuroradiology, Fondation Rothschild Hospital, FHU Neurovasc, Paris, France
- Université Paris Cité, INSERM UMR 1144, Paris, France
| | - Romain Sonneville
- APHP, Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, 46 rue Henri Huchard, 75018, Paris, France.
- Université Paris Cité, INSERM UMR 1137, IAME, Paris, France.
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Beekman R, Gilmore EJ. Cerebral edema following cardiac arrest: Are all shades of gray equal? Resuscitation 2024; 198:110213. [PMID: 38636600 DOI: 10.1016/j.resuscitation.2024.110213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 04/05/2024] [Indexed: 04/20/2024]
Affiliation(s)
- Rachel Beekman
- Department of Neurology, Yale School of Medicine, New Haven, CT, United States.
| | - Emily J Gilmore
- Department of Neurology, Yale School of Medicine, New Haven, CT, United States
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Bencsik CM, Kramer AH, Couillard P, MacKay M, Kromm JA. Postarrest Neuroprognostication: Practices and Opinions of Canadian Physicians. Can J Neurol Sci 2024; 51:404-415. [PMID: 37489539 DOI: 10.1017/cjn.2023.261] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
BACKGROUND Objective, evidence-based neuroprognostication of postarrest patients is crucial to avoid inappropriate withdrawal of life-sustaining therapies or prolonged, invasive, and costly therapies that could perpetuate suffering when there is no chance of an acceptable recovery. Postarrest prognostication guidelines exist; however, guideline adherence and practice variability are unknown. OBJECTIVE To investigate Canadian practices and opinions regarding assessment of neurological prognosis in postarrest patients. METHODS An anonymous electronic survey was distributed to physicians who care for adult postarrest patients. RESULTS Of the 134 physicians who responded to the survey, 63% had no institutional protocols for neuroprognostication. While the use of targeted temperature management did not affect the timing of neuroprognostication, an increasing number of clinical findings suggestive of a poor prognosis affected the timing of when physicians were comfortable concluding patients had a poor prognosis. Variability existed in what factors clinicians' thought were confounders. Physicians identified bilaterally absent pupillary light reflexes (85%), bilaterally absent corneal reflexes (80%), and status myoclonus (75%) as useful in determining poor prognosis. Computed tomography, magnetic resonance imaging, and spot electroencephalography were the most useful and accessible tests. Somatosensory evoked potentials were useful, but logistically challenging. Serum biomarkers were unavailable at most centers. Most (79%) physicians agreed ≥2 definitive findings on neurologic exam, electrophysiologic tests, neuroimaging, and/or biomarkers are required to determine a poor prognosis with a high degree of certainty. Distress during the process of neuroprognostication was reported by 70% of physicians and 51% request a second opinion from an external expert. CONCLUSION Significant variability exists in post-cardiac arrest neuroprognostication practices among Canadian physicians.
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Affiliation(s)
- Caralyn M Bencsik
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
| | - Andreas H Kramer
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Philippe Couillard
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | | | - Julie A Kromm
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Calgary, AB, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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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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Hermann B, Candia‐Rivera D, Sharshar T, Gavaret M, Diehl J, Cariou A, Benghanem S. Aberrant brain-heart coupling is associated with the severity of post cardiac arrest brain injury. Ann Clin Transl Neurol 2024; 11:866-882. [PMID: 38243640 PMCID: PMC11021613 DOI: 10.1002/acn3.52000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 12/24/2023] [Indexed: 01/21/2024] Open
Abstract
OBJECTIVE To investigate autonomic nervous system activity measured by brain-heart interactions in comatose patients after cardiac arrest in relation to the severity and prognosis of hypoxic-ischemic brain injury. METHODS Strength and complexity of bidirectional interactions between EEG frequency bands (delta, theta, and alpha) and ECG heart rate variability frequency bands (low frequency, LF and high frequency, HF) were computed using a synthetic data generation model. Primary outcome was the severity of brain injury, assessed by (i) standardized qualitative EEG classification, (ii) somatosensory evoked potentials (N20), and (iii) neuron-specific enolase levels. Secondary outcome was the 3-month neurological status, assessed by the Cerebral Performance Category score [good (1-2) vs. poor outcome (3-4-5)]. RESULTS Between January 2007 and July 2021, 181 patients were admitted to ICU for a resuscitated cardiac arrest. Poor neurological outcome was observed in 134 patients (74%). Qualitative EEG patterns suggesting high severity were associated with decreased LF/HF. Severity of EEG changes were proportional to higher absolute values of brain-to-heart coupling strength (p < 0.02 for all brain-to-heart frequencies) and lower values of alpha-to-HF complexity (p = 0.049). Brain-to-heart coupling strength was significantly higher in patients with bilateral absent N20 and correlated with neuron-specific enolase levels at Day 3. This aberrant brain-to-heart coupling (increased strength and decreased complexity) was also associated with 3-month poor neurological outcome. INTERPRETATION Our results suggest that autonomic dysfunctions may well represent hypoxic-ischemic brain injury post cardiac arrest pathophysiology. These results open avenues for integrative monitoring of autonomic functioning in critical care patients.
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Affiliation(s)
- Bertrand Hermann
- Faculté de MédecineUniversité Paris CitéParisFrance
- Medical Intensive Care UnitHEGP Hospital, Assistance Publique ‐ Hôpitaux de Paris‐Centre (APHP.Centre)ParisFrance
- INSERM UMR 1266, Institut de Psychiatrie et Neurosciences de Paris (IPNP)Université Paris CitéParisFrance
| | - Diego Candia‐Rivera
- Sorbonne Université, Paris Brain Institute (ICM), INRIA, CNRS UMR 722, INSERM U1127, AP‐HP Hôpital Pitié‐SalpêtrièreParisFrance
| | - Tarek Sharshar
- Faculté de MédecineUniversité Paris CitéParisFrance
- INSERM UMR 1266, Institut de Psychiatrie et Neurosciences de Paris (IPNP)Université Paris CitéParisFrance
- GHU Paris Psychiatrie Neurosciences, Service hospitalo‐universitaire de Neuro‐anesthésie réanimationParisFrance
| | - Martine Gavaret
- Faculté de MédecineUniversité Paris CitéParisFrance
- INSERM UMR 1266, Institut de Psychiatrie et Neurosciences de Paris (IPNP)Université Paris CitéParisFrance
- Neurophysiology and Epileptology DepartmentGHU Paris Psychiatrie et NeurosciencesParisFrance
| | - Jean‐Luc Diehl
- Faculté de MédecineUniversité Paris CitéParisFrance
- Medical Intensive Care UnitHEGP Hospital, Assistance Publique ‐ Hôpitaux de Paris‐Centre (APHP.Centre)ParisFrance
- Université Paris Cité, INSERM, Innovative Therapies in HaemostasisParisFrance
- Biosurgical Research Lab (Carpentier Foundation)ParisFrance
| | - Alain Cariou
- Faculté de MédecineUniversité Paris CitéParisFrance
- Medical Intensive Care UnitCochin Hospital, Assistance Publique ‐ Hôpitaux de Paris‐Centre (APHP‐Centre)ParisFrance
- Paris‐Cardiovascular‐Research‐CenterINSERM U970ParisFrance
| | - Sarah Benghanem
- Faculté de MédecineUniversité Paris CitéParisFrance
- INSERM UMR 1266, Institut de Psychiatrie et Neurosciences de Paris (IPNP)Université Paris CitéParisFrance
- Medical Intensive Care UnitCochin Hospital, Assistance Publique ‐ Hôpitaux de Paris‐Centre (APHP‐Centre)ParisFrance
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28
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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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Hamaguchi T, Takiguchi T, Seki T, Tominaga N, Nakata J, Yamamoto T, Tagami T, Inoue A, Hifumi T, Sakamoto T, Kuroda Y, Yokobori S, Study Group TSJI. Association between pupillary examinations and prognosis in patients with out-of-hospital cardiac arrest who underwent extracorporeal cardiopulmonary resuscitation: a retrospective multicentre cohort study. Ann Intensive Care 2024; 14:35. [PMID: 38448746 PMCID: PMC10917711 DOI: 10.1186/s13613-024-01265-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 02/16/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND In some cases of patients with out-of-hospital cardiac arrest (OHCA) who underwent extracorporeal cardiopulmonary resuscitation (ECPR), negative pupillary light reflex (PLR) and mydriasis upon hospital arrival serve as common early indicator of poor prognosis. However, in certain patients with poor prognoses inferred by pupil findings upon hospital arrival, pupillary findings improve before and after the establishment of ECPR. The association between these changes in pupillary findings and prognosis remains unclear. This study aimed to clarify the association of pupillary examinations before and after the establishment of ECPR in patients with OHCA showing poor pupillary findings upon hospital arrival with their outcomes. To this end, we analysed retrospective multicentre registry data involving 36 institutions in Japan, including all adult patients with OHCA who underwent ECPR between January 2013 and December 2018. We selected patients with poor prognosis inferred by pupillary examinations, negative pupillary light reflex (PLR) and pupil mydriasis, upon hospital arrival. The primary outcome was favourable neurological outcome, defined as Cerebral Performance Category 1 or 2 at hospital discharge. Multivariable logistic regression analysis was performed to evaluate the association between favourable neurological outcome and pupillary examination after establishing ECPR. RESULTS Out of the 2,157 patients enrolled in the SAVE-J II study, 723 were analysed. Among the patients analysed, 74 (10.2%) demonstrated favourable neurological outcome at hospital discharge. Multivariable analysis revealed that a positive PLR at ICU admission (odds ration [OR] = 11.3, 95% confidence intervals [CI] = 5.17-24.7) was significantly associated with favourable neurological outcome. However, normal pupil diameter at ICU admission (OR = 1.10, 95%CI = 0.52-2.32) was not significantly associated with favourable neurological outcome. CONCLUSION Among the patients with OHCA who underwent ECPR and showed poor pupillary examination findings upon hospital arrival, 10.2% had favourable neurological outcome at hospital discharge. A positive PLR after the establishment of ECPR was significantly associated with favourable neurological outcome.
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Affiliation(s)
- Takuro Hamaguchi
- Department of Emergency and Critical Care Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, Japan
| | - Toru Takiguchi
- Department of Emergency and Critical Care Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, Japan.
- Department of Healthcare Information Management, The University of Tokyo Hospital, Tokyo, Japan.
| | - Tomohisa Seki
- Department of Healthcare Information Management, The University of Tokyo Hospital, Tokyo, Japan
| | - Naoki Tominaga
- Department of Emergency and Critical Care Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, Japan
| | - Jun Nakata
- Division of Cardiovascular Intensive Care, Department of Cardiovascular Medicine, Nippon Medical School Hospital, Tokyo, Japan
| | - Takeshi Yamamoto
- Division of Cardiovascular Intensive Care, Department of Cardiovascular Medicine, Nippon Medical School Hospital, Tokyo, Japan
| | - Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, Japan
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Akihiko Inoue
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Tetsuya Sakamoto
- Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Yasuhiro Kuroda
- Department of Emergency Medicine, Kagawa University School of Medicine, Kagawa, Japan
| | - Shoji Yokobori
- Department of Emergency and Critical Care Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, Japan
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30
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Fischer D, Edlow BL. Coma Prognostication After Acute Brain Injury: A Review. JAMA Neurol 2024:2815829. [PMID: 38436946 DOI: 10.1001/jamaneurol.2023.5634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Importance Among the most impactful neurologic assessments is that of neuroprognostication, defined here as the prediction of neurologic recovery from disorders of consciousness caused by severe, acute brain injury. Across a range of brain injury etiologies, these determinations often dictate whether life-sustaining treatment is continued or withdrawn; thus, they have major implications for morbidity, mortality, and health care costs. Neuroprognostication relies on a diverse array of tests, including behavioral, radiologic, physiological, and serologic markers, that evaluate the brain's functional and structural integrity. Observations Prognostic markers, such as the neurologic examination, electroencephalography, and conventional computed tomography and magnetic resonance imaging (MRI), have been foundational in assessing a patient's current level of consciousness and capacity for recovery. Emerging techniques, such as functional MRI, diffusion MRI, and advanced forms of electroencephalography, provide new ways of evaluating the brain, leading to evolving schemes for characterizing neurologic function and novel methods for predicting recovery. Conclusions and Relevance Neuroprognostic markers are rapidly evolving as new ways of assessing the brain's structural and functional integrity after brain injury are discovered. Many of these techniques remain in development, and further research is needed to optimize their prognostic utility. However, even as such efforts are underway, a series of promising findings coupled with the imperfect predictive value of conventional prognostic markers and the high stakes of these assessments have prompted clinical guidelines to endorse emerging techniques for neuroprognostication. Thus, clinicians have been thrust into an uncertain predicament in which emerging techniques are not yet perfected but too promising to ignore. This review illustrates the current, and likely future, landscapes of prognostic markers. No matter how much prognostic markers evolve and improve, these assessments must be approached with humility and individualized to reflect each patient's values.
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Affiliation(s)
- David Fischer
- Division of Neurocritical Care, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Charlestown
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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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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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33
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Portell Penadés E, Alvarez V. A Comprehensive Review and Practical Guide of the Applications of Evoked Potentials in Neuroprognostication After Cardiac Arrest. Cureus 2024; 16:e57014. [PMID: 38681279 PMCID: PMC11046378 DOI: 10.7759/cureus.57014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2024] [Indexed: 05/01/2024] Open
Abstract
Cardiorespiratory arrest is a very common cause of morbidity and mortality nowadays, and many therapeutic strategies, such as induced coma or targeted temperature management, are used to reduce patient sequelae. However, these procedures can alter a patient's neurological status, making it difficult to obtain useful clinical information for the reliable estimation of neurological prognosis. Therefore, complementary investigations are conducted in the early stages after a cardiac arrest to clarify functional prognosis in comatose cardiac arrest survivors in the first few hours or days. Current practice relies on a multimodal approach, which shows its greatest potential in predicting poor functional prognosis, whereas the data and tools to identify patients with good functional prognosis remain relatively limited in comparison. Therefore, there is considerable interest in investigating alternative biological parameters and advanced imaging technique studies. Among these, somatosensory evoked potentials (SSEPs) remain one of the simplest and most reliable tools. In this article, we discuss the technical principles, advantages, limitations, and prognostic implications of SSEPs in detail. We will also review other types of evoked potentials that can provide useful information but are less commonly used in clinical practice (e.g., visual evoked potentials; short-, medium-, and long-latency auditory evoked potentials; and event-related evoked potentials, such as mismatch negativity or P300).
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34
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Kline KE, Russell AL, Stezoski JP, Gober IG, Dimeo EG, Janesko-Feldman K, Drabek T, Kochanek PM, Wagner AK. Differential Effects of Targeted Temperature Management on Sex-Dependent Outcomes After Experimental Asphyxial Cardiac Arrest. Ther Hypothermia Temp Manag 2024. [PMID: 38386544 DOI: 10.1089/ther.2023.0061] [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: 02/24/2024] Open
Abstract
Asphyxial cardiac arrest (ACA) survivors face lasting neurological disability from hypoxic ischemic brain injury. Sex differences in long-term outcomes after cardiac arrest (CA) are grossly understudied and underreported. We used rigorous targeted temperature management (TTM) to understand its influence on survival and lasting sex-specific neurological and neuropathological outcomes in a rodent ACA model. Adult male and female rats underwent either sham or 5-minute no-flow ACA with 18 hours TTM at either ∼37°C (normothermia) or ∼36°C (mild hypothermia). Survival, temperature, and body weight (BW) were recorded over the 14-day study duration. All rats underwent neurological deficit score (NDS) assessment on days 1-3 and day 14. Hippocampal pathology was assessed for cell death, degenerating neurons, and microglia on day 14. Although ACA females were less likely to achieve return of spontaneous circulation (ROSC), post-ROSC physiology and biochemical profiles were similar between sexes. ACA females had significantly greater 14-day survival, NDS, and BW recovery than ACA males at normothermia (56% vs. 29%). TTM at 36°C versus 37°C improved 14-day survival in males, producing similar survival in male (63%) versus female (50%). There were no sex or temperature effects on CA1 histopathology. We conclude that at normothermic conditions, sex differences favoring females were observed after ACA in survival, NDS, and BW recovery. We achieved a clinically relevant ACA model using TTM at 36°C to improve long-term survival. This model can be used to more fully characterize sex differences in long-term outcomes and test novel acute and chronic therapies.
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Affiliation(s)
- Kelsey E Kline
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Neuroscience, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ashley L Russell
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jason P Stezoski
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ian G Gober
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Emma G Dimeo
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Neuroscience, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Keri Janesko-Feldman
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Tomas Drabek
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Patrick M Kochanek
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Neuroscience, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Amy K Wagner
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Neuroscience, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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35
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Beer BN, Kellner C, Goßling A, Sundermeyer J, Besch L, Dettling A, Kirchhof P, Blankenberg S, Bernhardt AM, Brunner S, Colson P, Eckner D, Frank D, Eitel I, Frey N, Eden M, Graf T, Kupka D, Landmesser U, Majunke N, Maniuc O, Möbius-Winkler S, Morrow DA, Mourad M, Noel C, Nordbeck P, Orban M, Pappalardo F, Patel SM, Pauschinger M, Reichenspurner H, Schulze PC, Schwinger RHG, Wechsler A, Skurk C, Thiele H, Varshney AS, Sag CM, Krais J, Westermann D, Schrage B. Complications in patients with cardiogenic shock on veno-arterial extracorporeal membrane oxygenation therapy: distribution and relevance. Results from an international, multicentre cohort study. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:203-212. [PMID: 37875127 DOI: 10.1093/ehjacc/zuad129] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 09/16/2023] [Accepted: 10/11/2023] [Indexed: 10/26/2023]
Abstract
AIMS Veno-arterial extracorporeal membrane oxygenation therapy (VA-ECMO) restores circulation and tissue oxygenation in cardiogenic shock (CS) patients, but can also lead to complications. This study aimed to quantify VA-ECMO complications and analyse their association with overall survival as well as favourable neurological outcome (cerebral performance categories 1 + 2). METHODS AND RESULTS All-comer patients with CS treated with VA-ECMO were retrospectively enrolled from 16 centres in four countries (2005-2019). Neurological, bleeding, and ischaemic adverse events (AEs) were considered. From these, typical VA-ECMO complications were identified and analysed separately as device-related complications. n = 501. Overall, 118 were women (24%), median age was 56.0 years, median lactate was 8.1 mmol/L. Acute myocardial infarction caused CS in 289 patients (58%). Thirty-days mortality was 40% (198/501 patients). At least one device-related complication occurred in 252/486 (52%) patients, neurological AEs in 108/469 (23%), bleeding in 192/480 (40%), ischaemic AEs in 123/478 (26%). The 22% of patients with the most AEs accounted for 50% of all AEs. All types of AEs were associated with a worse prognosis. Aside from neurological ones, all AEs and device-related complications were more likely to occur in women; although prediction of AEs outside of neurological AEs was generally poor. CONCLUSION Therapy and device-related complications occur in half of all patients treated with VA-ECMO and are associated with a worse prognosis. They accumulate in some patients, especially in women. Aside from neurological events, identification of patients at risk is difficult, highlighting the need to establish additional quantitative markers of complication risk to guide VA-ECMO treatment in CS.
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Affiliation(s)
- Benedikt N Beer
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Caroline Kellner
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alina Goßling
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jonas Sundermeyer
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Lisa Besch
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Angela Dettling
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Stefan Blankenberg
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Alexander M Bernhardt
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
- Department of Cardiothoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Brunner
- Department of Internal Medicine I, LMU University Hospital, Munich, Germany
| | - Pascal Colson
- Department of Anesthesiology and Critical Care Medicine, CHU Montpellier, University Montpellier, Montpellier, France
| | - Dennis Eckner
- Department of Cardiology, Paracelsus Medical University Nürnberg, Nürnberg, Germany
| | - Derk Frank
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
- Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Ingo Eitel
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
- University Heart Center Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Norbert Frey
- Department of Cardiology, Angiology and Pneumology, University Hospital Heidelberg, Heidelberg, Germany
| | - Matthias Eden
- Department of Cardiology, Angiology and Pneumology, University Hospital Heidelberg, Heidelberg, Germany
| | - Tobias Graf
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
- University Heart Center Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Danny Kupka
- Department of Internal Medicine I, LMU University Hospital, Munich, Germany
| | - Ulf Landmesser
- Department of Cardiology, Campus Benjamin Franklin, Charité University Hospital, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin/Institute of Health (BIH), Berlin, Germany
| | - Nicolas Majunke
- Department of Internal Medicine and Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Octavian Maniuc
- Department of Internal Medicine I, University Hospital Würzburg, Würburg, Germany
| | | | - David A Morrow
- Cardiovascular Division, Brigham and Women's Hospital, Boston, USA
| | - Marc Mourad
- Department of Anesthesiology and Critical Care Medicine, CHU Montpellier, University Montpellier, Montpellier, France
| | - Curt Noel
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
- Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Peter Nordbeck
- Department of Internal Medicine I, University Hospital Würzburg, Würburg, Germany
| | - Martin Orban
- Department of Internal Medicine I, LMU University Hospital, Munich, Germany
| | - Federico Pappalardo
- Department of Cardiothoracic and Vascular Anaesthesia and Intensive Care, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Sandeep M Patel
- Department of Interventional Cardiology, St.Rita's Medical Center, Lima, USA
| | - Matthias Pauschinger
- Department of Cardiology, Paracelsus Medical University Nürnberg, Nürnberg, Germany
| | - Hermann Reichenspurner
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
- Department of Cardiothoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | | | - Antonia Wechsler
- Department of Internal Medicine II, Klinikum Weiden, Weiden, Germany
| | - Carsten Skurk
- Department of Cardiology, Campus Benjamin Franklin, Charité University Hospital, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin/Institute of Health (BIH), Berlin, Germany
| | - Holger Thiele
- Department of Internal Medicine and Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Anubodh S Varshney
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Palo Alto, USA
| | - Can Martin Sag
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Jannis Krais
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Dirk Westermann
- Department of Cardiology and Angiology I, University Heart Center Freiburg, Bad Krozingen, Germany
| | - Benedikt Schrage
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
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Hirsch KG, Abella BS, Amorim E, Bader MK, Barletta JF, Berg K, Callaway CW, Friberg H, Gilmore EJ, Greer DM, Kern KB, Livesay S, May TL, Neumar RW, Nolan JP, Oddo M, Peberdy MA, Poloyac SM, Seder D, Taccone FS, Uzendu A, Walsh B, Zimmerman JL, Geocadin RG. Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement from the American Heart Association and Neurocritical Care Society. Neurocrit Care 2024; 40:1-37. [PMID: 38040992 PMCID: PMC10861627 DOI: 10.1007/s12028-023-01871-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 06/08/2023] [Indexed: 12/03/2023]
Abstract
The critical care management of patients after cardiac arrest is burdened by a lack of high-quality clinical studies and the resultant lack of high-certainty evidence. This results in limited practice guideline recommendations, which may lead to uncertainty and variability in management. Critical care management is crucial in patients after cardiac arrest and affects outcome. Although guidelines address some relevant topics (including temperature control and neurological prognostication of comatose survivors, 2 topics for which there are more robust clinical studies), many important subject areas have limited or nonexistent clinical studies, leading to the absence of guidelines or low-certainty evidence. The American Heart Association Emergency Cardiovascular Care Committee and the Neurocritical Care Society collaborated to address this gap by organizing an expert consensus panel and conference. Twenty-four experienced practitioners (including physicians, nurses, pharmacists, and a respiratory therapist) from multiple medical specialties, levels, institutions, and countries made up the panel. Topics were identified and prioritized by the panel and arranged by organ system to facilitate discussion, debate, and consensus building. Statements related to postarrest management were generated, and 80% agreement was required to approve a statement. Voting was anonymous and web based. Topics addressed include neurological, cardiac, pulmonary, hematological, infectious, gastrointestinal, endocrine, and general critical care management. Areas of uncertainty, areas for which no consensus was reached, and future research directions are also included. Until high-quality studies that inform practice guidelines in these areas are available, the expert panel consensus statements that are provided can advise clinicians on the critical care management of patients after cardiac arrest.
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Affiliation(s)
| | | | - Edilberto Amorim
- San Francisco-Weill Institute for Neurosciences, University of California, San Francisco, USA
| | - Mary Kay Bader
- Providence Mission Hospital Nursing Center of Excellence/Critical Care Services, Mission Viejo, USA
| | | | | | | | | | | | | | - Karl B Kern
- Sarver Heart Center, University of Arizona, Tucson, USA
| | | | | | | | - Jerry P Nolan
- Warwick Medical School, University of Warwick, Coventry, UK
- Royal United Hospital, Bath, UK
| | - Mauro Oddo
- CHUV-Lausanne University Hospital, Lausanne, Switzerland
| | | | | | | | | | - Anezi Uzendu
- St. Luke's Mid America Heart Institute, Kansas City, USA
| | - Brian Walsh
- University of Texas Medical Branch School of Health Sciences, Galveston, USA
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Veyret S, Girard L, Puech B, Dangers L, Jabot J, Neuschwander A, Braunberger E, Allyn J, Allou N, Vidal C. The IMPACT Score: A New Score to Predict the Risk of Early Mortality in Cardiogenic Shock Patients Treated With Venoarterial Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2024; 38:451-458. [PMID: 38185567 DOI: 10.1053/j.jvca.2023.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 11/07/2023] [Accepted: 11/19/2023] [Indexed: 01/09/2024]
Abstract
OBJECTIVES Venoarterial extracorporeal membrane oxygenation (VA-ECMO) requires considerable human and financial resources. Few studies have focused on early mortality (ie, occurring within 72 hours after VA-ECMO implantation). The objective of this study was to establish a prognosis score-the IMPACT score (prediction of early mortality associated with VA-ECMO using preimplantation characteristics)-by determining the risk factors associated with early mortality. DESIGN This was a retrospective and observational study. SETTING The study was conducted at a University hospital. PARTICIPANTS This single-center retrospective study included 147 patients treated with VA-ECMO for cardiogenic shock between 2014 and 2021. METHODS The primary outcome was early mortality (ie, occurring within 72 hours after VA-ECMO implantation). Multivariate logistic regression was performed using a bootstrapping methodology to identify factors independently associated with early mortality. To construct the score, identified variables had points (pts) assigned corresponding to their odds ratio. RESULTS A total of 147 patients were included in the study. Early mortality (<72 hours) was 26% (38 patients). Four variables were established: cardiac arrest (2 pts), lactate levels (3 pts), platelet count <100 g/L (4 pts), and renal-replacement therapy (5 pts). The IMPACT score had an area under the receiver operating characteristic curve of 0.78 (95% CI 0.86-0.70) to predict early mortality. CONCLUSIONS In the authors' experience, 26% of patients treated with VA-ECMO presented early mortality. The IMPACT score is a reliable predictor of early mortality and may assist with VA-ECMO initiation decision-making.
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Affiliation(s)
- Simon Veyret
- Service de Réanimation polyvalente, Center Hospitalier Universitaire Felix Guyon Allée des Topazes, Saint Denis, France
| | - Léandre Girard
- Service de Réanimation polyvalente, Center Hospitalier Universitaire Felix Guyon Allée des Topazes, Saint Denis, France
| | - Bérénice Puech
- Service de Réanimation polyvalente, Center Hospitalier Universitaire Felix Guyon Allée des Topazes, Saint Denis, France
| | - Laurence Dangers
- Service de Réanimation polyvalente, Center Hospitalier Universitaire Felix Guyon Allée des Topazes, Saint Denis, France
| | - Julien Jabot
- Service de Réanimation polyvalente, Center Hospitalier Universitaire Felix Guyon Allée des Topazes, Saint Denis, France
| | - Arthur Neuschwander
- Service de Réanimation de Chirurgie Cardio-thoracique et Vasculaire, Center Hospitalier Universitaire Felix Guyon Allée des Topazes, Saint Denis, France
| | - Eric Braunberger
- Service de Chirurgie Cardio-thoracique et Vasculaire, Center Hospitalier Universitaire Felix Guyon Allée des Topazes, Saint Denis, France
| | - Jérôme Allyn
- Service de Réanimation polyvalente, Center Hospitalier Universitaire Felix Guyon Allée des Topazes, Saint Denis, France
| | - Nicolas Allou
- Service de Réanimation polyvalente, Center Hospitalier Universitaire Felix Guyon Allée des Topazes, Saint Denis, France
| | - Charles Vidal
- Service de Réanimation polyvalente, Center Hospitalier Universitaire Felix Guyon Allée des Topazes, Saint Denis, France.
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Sangare A, Rohaut B, Borden A, Zyss J, Velazquez A, Doyle K, Naccache L, Claassen J. A Novel Approach to Screen for Somatosensory Evoked Potentials in Critical Care. Neurocrit Care 2024; 40:237-250. [PMID: 36991177 DOI: 10.1007/s12028-023-01710-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 02/27/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND Somatosensory evoked potentials (SSEPs) help prognostication, particularly in patients with diffuse brain injury. However, use of SSEP is limited in critical care. We propose a novel, low-cost approach allowing acquisition of screening SSEP using widely available intensive care unit (ICU) equipment, specifically a peripheral "train-of-four" stimulator and standard electroencephalograph. METHODS The median nerve was stimulated using a train-of-four stimulator, and a standard 21-channel electroencephalograph was recorded to generate the screening SSEP. Generation of the SSEP was supported by visual inspection, univariate event-related potentials statistics, and a multivariate support vector machine (SVM) decoding algorithm. This approach was validated in 15 healthy volunteers and validated against standard SSEPs in 10 ICU patients. The ability of this approach to predict poor neurological outcome, defined as death, vegetative state, or severe disability at 6 months, was tested in an additional set of 39 ICU patients. RESULTS In each of the healthy volunteers, both the univariate and the SVM methods reliably detected SSEP responses. In patients, when compared against the standard SSEP method, the univariate event-related potentials method matched in nine of ten patients (sensitivity = 94%, specificity = 100%), and the SVM had 100% sensitivity and specificity when compared with the standard method. For the 49 ICU patients, we performed both the univariate and the SVM methods: a bilateral absence of short latency responses (n = 8) predicted poor neurological outcome with 0% FPR (sensitivity = 21%, specificity = 100%). CONCLUSIONS Somatosensory evoked potentials can reliably be recorded using the proposed approach. Given the very good but slightly lower sensitivity of absent SSEPs in the proposed screening approach, confirmation of absent SSEP responses using standard SSEP recordings is advised.
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Affiliation(s)
- Aude Sangare
- Brain Institute, ICM, CNRS, Sorbonne Université, Inserm U1127, UMR 7225, Paris, France.
- Department of Neurophysiology, Pitié-Salpêtrière, Groupe Hospitalier Universitaire Assistance Publique-Hôpitaux de Paris Sorbonne Université, Paris, France.
- Sorbonne University, Paris, France.
| | - Benjamin Rohaut
- Brain Institute, ICM, CNRS, Sorbonne Université, Inserm U1127, UMR 7225, Paris, France
- Department of Neurophysiology, Pitié-Salpêtrière, Groupe Hospitalier Universitaire Assistance Publique-Hôpitaux de Paris Sorbonne Université, Paris, France
- Neurological Intensive Care Unit, Department of Neurology, Pitié-Salpêtrière, Groupe Hospitalier Universitaire Assistance Publique-Hôpitaux de Paris Sorbonne Université, Paris, France
- Department of Neurology, Columbia University, New York, NY, USA
- New York Presbyterian Hospital, New York, NY, USA
| | - Alaina Borden
- Department of Neurophysiology, Pitié-Salpêtrière, Groupe Hospitalier Universitaire Assistance Publique-Hôpitaux de Paris Sorbonne Université, Paris, France
| | - Julie Zyss
- Department of Neurophysiology, Pitié-Salpêtrière, Groupe Hospitalier Universitaire Assistance Publique-Hôpitaux de Paris Sorbonne Université, Paris, France
| | | | - Kevin Doyle
- Department of Neurology, Columbia University, New York, NY, USA
| | - Lionel Naccache
- Brain Institute, ICM, CNRS, Sorbonne Université, Inserm U1127, UMR 7225, Paris, France
- Department of Neurophysiology, Pitié-Salpêtrière, Groupe Hospitalier Universitaire Assistance Publique-Hôpitaux de Paris Sorbonne Université, Paris, France
- Sorbonne University, Paris, France
| | - Jan Claassen
- Department of Neurology, Columbia University, New York, NY, USA
- New York Presbyterian Hospital, New York, NY, USA
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Gonzalez D, Dahiya G, Mutirangura P, Ergando T, Mello G, Singh R, Bentho O, Elliott AM. Post Cardiac Arrest Care in the Cardiac Intensive Care Unit. Curr Cardiol Rep 2024; 26:35-49. [PMID: 38214836 DOI: 10.1007/s11886-023-02015-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/08/2023] [Indexed: 01/13/2024]
Abstract
PURPOSE OF REVIEW Cardiac arrests constitute a leading cause of mortality in the adult population and cardiologists are often tasked with the management of patients following cardiac arrest either as a consultant or primary provider in the cardiac intensive care unit. Familiarity with evidence-based practice for post-cardiac arrest care is a requisite for optimizing outcomes in this highly morbid group. This review will highlight important concepts necessary to managing these patients. RECENT FINDINGS Emerging evidence has further elucidated optimal care of post-arrest patients including timing for routine coronary angiography, utility of therapeutic hypothermia, permissive hypercapnia, and empiric aspiration pneumonia treatment. The complicated state of multi-organ failure following cardiac arrest needs to be carefully optimized by the clinician to prevent further neurologic injury and promote systemic recovery. Future studies should be aimed at understanding if these findings extend to specific patient populations, especially those at the highest risk for poor outcomes.
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Affiliation(s)
- Daniel Gonzalez
- Department of Medicine, Division of Cardiology, University of Minnesota, 420 Delaware St SE, MMC 508, Minneapolis, MN, 55455, USA
| | - Garima Dahiya
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Duke University, Durham, USA
| | | | | | - Gregory Mello
- University of Minnesota Medical School, Minneapolis, USA
| | - Rahul Singh
- Department of Medicine, Division of Cardiology, University of Minnesota, 420 Delaware St SE, MMC 508, Minneapolis, MN, 55455, USA
| | - Oladi Bentho
- Department of Neurology, University of Minnesota, Minneapolis, USA
| | - Andrea M Elliott
- Department of Medicine, Division of Cardiology, University of Minnesota, 420 Delaware St SE, MMC 508, Minneapolis, MN, 55455, USA.
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Ye L, Lu J, Yuan M, Min J, Zhong L, Xu J. Correlation between Lactate Dehydrogenase to Albumin Ratio and the Prognosis of Patients with Cardiac Arrest. Rev Cardiovasc Med 2024; 25:65. [PMID: 39077353 PMCID: PMC11263156 DOI: 10.31083/j.rcm2502065] [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: 08/17/2023] [Revised: 10/18/2023] [Accepted: 10/24/2023] [Indexed: 07/31/2024] Open
Abstract
Background Cardiac arrest (CA) is a common event in the intensive care unit (ICU), which seriously threatens the prognosis of patients. Therefore, it is crucial to determine a simple and effective clinical indicator to judge the prognosis of patients after a CA for later treatments. The purpose of this study was to investigate the relationship between the lactate dehydrogenase to albumin ratio (LAR) and the prognosis of patients after a CA. Methods The clinical data of participants was obtained from the Medical Information Mart for Intensive Care IV (MIMIC-IV, v2.0; 2008 to 2019). According to the 30-day prognosis, patients were divided into a survivors group (n = 216) and a non-survivors group (n = 304). The optimal LAR threshold was determined using restricted cubic spline (RCS), which divided patients into a high LAR group ( ≥ 15.50, n = 257) and a low LAR group ( < 15.50, n = 263). The ICU hospitalization and 30-day accumulative survival curves of the two groups were plotted following the Kaplan-Meier survival analysis. Multivariate Cox regression was used to analyze the relationship between the LAR and the prognosis of CA patients. Receiver operating characteristic (ROC) curves were drawn to evaluate the predictive efficacy of the LAR on 30-day all-cause mortality, and sensitivity analysis was used to check the reliability of the findings. Results A total of 520 patients with CA were enrolled and the 30-day mortality was 58.46%. The LAR in the non-survivors group was higher than in the survivors group. The RCS showed a linear trend relationship between the LAR and the mortality risk in patients during their ICU stay and 30 days; moreover, as the LAR increased, so did the risk of mortality. The Kaplan-Meier survival curve showed that compared with the low LAR group, the cumulative survival rates of ICU hospitalization and 30 days were lower in the high LAR group among CA patients (p < 0.001). Multivariate Cox regression analysis showed that an elevated LAR ( ≥ 15.50) was an independent risk factor for mortality during ICU stay and 30 days (p < 0.005). ROC analysis suggested that the LAR was superior to the sequential organ failure assessment (SOFA) score in predicting the 30-day all-cause mortality in CA patients (area under the curve (AUC) = 0.676, 95% confidence interval [CI]: 0.629-0.723). To verify the reliability of our findings, we performed sensitivity analyses and found that the findings were reliable. Conclusions An elevated LAR might be a predictor of mortality in patients following a CA during ICU hospitalization and 30 days, thereby it can be used to provide a reference for the clinical management of these patients.
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Affiliation(s)
- Lili Ye
- Department of Intensive Care Unit, Huzhou Central Hospital, Affiliated Huzhou Hospital of Zhejiang University School of Medicine, 313000 Huzhou, Zhejiang, China
| | - Jianhong Lu
- Department of Intensive Care Unit, Huzhou Central Hospital, Affiliated Huzhou Hospital of Zhejiang University School of Medicine, 313000 Huzhou, Zhejiang, China
| | - Meng Yuan
- Department of Intensive Care Unit, Huzhou Central Hospital, Affiliated Huzhou Hospital of Zhejiang University School of Medicine, 313000 Huzhou, Zhejiang, China
| | - Jie Min
- Department of Intensive Care Unit, Huzhou Central Hospital, Affiliated Huzhou Hospital of Zhejiang University School of Medicine, 313000 Huzhou, Zhejiang, China
| | - Lei Zhong
- Department of Intensive Care Unit, Huzhou Central Hospital, Affiliated Huzhou Hospital of Zhejiang University School of Medicine, 313000 Huzhou, Zhejiang, China
| | - Junfei Xu
- Department of Intensive Care Unit, Huzhou Central Hospital, Affiliated Huzhou Hospital of Zhejiang University School of Medicine, 313000 Huzhou, Zhejiang, China
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Battaglini D, Bogossian EG, Anania P, Premraj L, Cho SM, Taccone FS, Sekhon M, Robba C. Monitoring of Brain Tissue Oxygen Tension in Cardiac Arrest: a Translational Systematic Review from Experimental to Clinical Evidence. Neurocrit Care 2024; 40:349-363. [PMID: 37081276 DOI: 10.1007/s12028-023-01721-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 03/24/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND Cardiac arrest (CA) is a sudden event that is often characterized by hypoxic-ischemic brain injury (HIBI), leading to significant mortality and long-term disability. Brain tissue oxygenation (PbtO2) is an invasive tool for monitoring brain oxygen tension, but it is not routinely used in patients with CA because of the invasiveness and the absence of high-quality data on its effect on outcome. We conducted a systematic review of experimental and clinical evidence to understand the role of PbtO2 in monitoring brain oxygenation in HIBI after CA and the effect of targeted PbtO2 therapy on outcomes. METHODS The search was conducted using four search engines (PubMed, Scopus, Embase, and Cochrane), using the Boolean operator to combine mesh terms such as PbtO2, CA, and HIBI. RESULTS Among 1,077 records, 22 studies were included (16 experimental studies and six clinical studies). In experimental studies, PbtO2 was mainly adopted to assess the impact of gas exchanges, drugs, or systemic maneuvers on brain oxygenation. In human studies, PbtO2 was rarely used to monitor the brain oxygen tension in patients with CA and HIBI. PbtO2 values had no clear association with patients' outcomes, but in the experimental studies, brain tissue hypoxia was associated with increased inflammation and neuronal damage. CONCLUSIONS Further studies are needed to validate the effect and the threshold of PbtO2 associated with outcome in patients with CA, as well as to understand the physiological mechanisms influencing PbtO2 induced by gas exchanges, drug administration, and changes in body positioning after CA.
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Affiliation(s)
- Denise Battaglini
- Anesthesiology and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Elisa Gouvea Bogossian
- Department of Intensive Care, Hospital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Pasquale Anania
- Department of Neurosurgery, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.
| | - Lavienraj Premraj
- Griffith University School of Medicine, Gold Coast, QLD, Australia
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Sung-Min Cho
- Departments of Neurology, Surgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hospital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Mypinder Sekhon
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Chiara Robba
- Anesthesiology and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
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Tinti L, Lawson T, Molteni E, Kondziella D, Rass V, Sharshar T, Bodien YG, Giacino JT, Mayer SA, Amiri M, Muehlschlegel S, Venkatasubba Rao CP, Vespa PM, Menon DK, Citerio G, Helbok R, McNett M. Research considerations for prospective studies of patients with coma and disorders of consciousness. Brain Commun 2024; 6:fcae022. [PMID: 38344653 PMCID: PMC10853976 DOI: 10.1093/braincomms/fcae022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 01/04/2024] [Accepted: 01/26/2024] [Indexed: 03/02/2024] Open
Abstract
Disorders of consciousness are neurological conditions characterized by impaired arousal and awareness of self and environment. Behavioural responses are absent or are present but fluctuate. Disorders of consciousness are commonly encountered as a consequence of both acute and chronic brain injuries, yet reliable epidemiological estimates would require inclusive, operational definitions of the concept, as well as wider knowledge dissemination among involved professionals. Whereas several manifestations have been described, including coma, vegetative state/unresponsive wakefulness syndrome and minimally conscious state, a comprehensive neurobiological definition for disorders of consciousness is still lacking. The scientific literature is primarily observational, and studies-specific aetiologies lead to disorders of consciousness. Despite advances in these disease-related forms, there remains uncertainty about whether disorders of consciousness are a disease-agnostic unitary entity with a common mechanism, prognosis or treatment response paradigm. Our knowledge of disorders of consciousness has also been hampered by heterogeneity of study designs, variables, and outcomes, leading to results that are not comparable for evidence synthesis. The different backgrounds of professionals caring for patients with disorders of consciousness and the different goals at different stages of care could partly explain this variability. The Prospective Studies working group of the Neurocritical Care Society Curing Coma Campaign was established to create a platform for observational studies and future clinical trials on disorders of consciousness and coma across the continuum of care. In this narrative review, the author panel presents limitations of prior observational clinical research and outlines practical considerations for future investigations. A narrative review format was selected to ensure that the full breadth of study design considerations could be addressed and to facilitate a future consensus-based statement (e.g. via a modified Delphi) and series of recommendations. The panel convened weekly online meetings from October 2021 to December 2022. Research considerations addressed the nosographic status of disorders of consciousness, case ascertainment and verification, selection of dependent variables, choice of covariates and measurement and analysis of outcomes and covariates, aiming to promote more homogeneous designs and practices in future observational studies. The goal of this review is to inform a broad community of professionals with different backgrounds and clinical interests to address the methodological challenges imposed by the transition of care from acute to chronic stages and to streamline data gathering for patients with disorders of consciousness. A coordinated effort will be a key to allow reliable observational data synthesis and epidemiological estimates and ultimately inform condition-modifying clinical trials.
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Affiliation(s)
- Lorenzo Tinti
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan 20156, Italy
| | - Thomas Lawson
- Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Erika Molteni
- Biomedical Engineering Department, School of Biomedical Engineering and Imaging Sciences, King’s College London, London SE1 7EU, UK
| | - Daniel Kondziella
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen 2100, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen 2200, Denmark
| | - Verena Rass
- Department of Neurology, Neuro-Intensive Care Unit, Medical University of Innsbruck, Innsbruck 6020, Austria
| | - Tarek Sharshar
- Neuro-Intensive Care Medicine, Anaesthesiology and ICU Department, GHU-Psychiatry and Neurosciences, Pole Neuro, Sainte-Anne Hospital, Institute of Psychiatry and Neurosciences of Paris, INSERM U1266, Université Paris Cité, Paris 75006, France
| | - Yelena G Bodien
- Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Charlestown, MA 02129, USA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Charlestown, MA 02129, USA
| | - Stephan A Mayer
- Department of Neurology, New York Medical College, Valhalla, NY 10595, USA
- Department of Neurosurgery, New York Medical College, Valhalla, NY 10595, USA
| | - Moshgan Amiri
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen 2100, Denmark
| | - Susanne Muehlschlegel
- Department of Neurology and Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Chethan P Venkatasubba Rao
- Division of Vascular Neurology and Neurocritical Care, Baylor College of Medicine and CHI Baylor St Luke’s Medical Center, Houston, TX 77030, USA
| | - Paul M Vespa
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Cambridge CB2 1TN, UK
| | - Giuseppe Citerio
- NeuroIntensive Care, IRCSS Fondazione San Gerardo dei Tintori, Monza 20900, Italy
- School of Medicine and Surgery, Università Milano Bicocca, Milan 20854, Italy
| | - Raimund Helbok
- Department of Neurology, Neuro-Intensive Care Unit, Medical University of Innsbruck, Innsbruck 6020, Austria
- Department of Neurology, Johannes Kepler University, Linz 4040, Austria
| | - Molly McNett
- College of Nursing, The Ohio State University, Columbus, OH 43210, USA
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Hirsch KG, Abella BS, Amorim E, Bader MK, Barletta JF, Berg K, Callaway CW, Friberg H, Gilmore EJ, Greer DM, Kern KB, Livesay S, May TL, Neumar RW, Nolan JP, Oddo M, Peberdy MA, Poloyac SM, Seder D, Taccone FS, Uzendu A, Walsh B, Zimmerman JL, Geocadin RG. Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement From the American Heart Association and Neurocritical Care Society. Circulation 2024; 149:e168-e200. [PMID: 38014539 PMCID: PMC10775969 DOI: 10.1161/cir.0000000000001163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
The critical care management of patients after cardiac arrest is burdened by a lack of high-quality clinical studies and the resultant lack of high-certainty evidence. This results in limited practice guideline recommendations, which may lead to uncertainty and variability in management. Critical care management is crucial in patients after cardiac arrest and affects outcome. Although guidelines address some relevant topics (including temperature control and neurological prognostication of comatose survivors, 2 topics for which there are more robust clinical studies), many important subject areas have limited or nonexistent clinical studies, leading to the absence of guidelines or low-certainty evidence. The American Heart Association Emergency Cardiovascular Care Committee and the Neurocritical Care Society collaborated to address this gap by organizing an expert consensus panel and conference. Twenty-four experienced practitioners (including physicians, nurses, pharmacists, and a respiratory therapist) from multiple medical specialties, levels, institutions, and countries made up the panel. Topics were identified and prioritized by the panel and arranged by organ system to facilitate discussion, debate, and consensus building. Statements related to postarrest management were generated, and 80% agreement was required to approve a statement. Voting was anonymous and web based. Topics addressed include neurological, cardiac, pulmonary, hematological, infectious, gastrointestinal, endocrine, and general critical care management. Areas of uncertainty, areas for which no consensus was reached, and future research directions are also included. Until high-quality studies that inform practice guidelines in these areas are available, the expert panel consensus statements that are provided can advise clinicians on the critical care management of patients after cardiac arrest.
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Robba C, Zanier ER, Lopez Soto C, Park S, Sonneville R, Helbolk R, Sarwal A, Newcombe VFJ, van der Jagt M, Gunst J, Gauss T, Figueiredo S, Duranteau J, Skrifvars MB, Iaquaniello C, Muehlschlegel S, Metaxa V, Sandroni C, Citerio G, Meyfroidt G. Mastering the brain in critical conditions: an update. Intensive Care Med Exp 2024; 12:1. [PMID: 38182945 PMCID: PMC10770006 DOI: 10.1186/s40635-023-00587-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 12/18/2023] [Indexed: 01/07/2024] Open
Abstract
Acute brain injuries, such as traumatic brain injury and ischemic and hemorragic stroke, are a leading cause of death and disability worldwide. While characterized by clearly distict primary events-vascular damage in strokes and biomechanical damage in traumatic brain injuries-they share common secondary injury mechanisms influencing long-term outcomes. Growing evidence suggests that a more personalized approach to optimize energy substrate delivery to the injured brain and prognosticate towards families could be beneficial. In this context, continuous invasive and/or non-invasive neuromonitoring, together with clinical evaluation and neuroimaging to support strategies that optimize cerebral blood flow and metabolic delivery, as well as approaches to neuroprognostication are gaining interest. Recently, the European Society of Intensive Care Medicine organized a 2-day course focused on a practical case-based clinical approach of acute brain-injured patients in different scenarios and on future perspectives to advance the management of this population. The aim of this manuscript is to update clinicians dealing with acute brain injured patients in the intensive care unit, describing current knowledge and clinical practice based on the insights presented during this course.
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Affiliation(s)
- Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Elisa R Zanier
- Department of Acute Brain and Cardiovascular Injury, Mario Negri Institute for Pharmacological Research IRCCS, Milan, Italy.
| | - Carmen Lopez Soto
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK
| | - Soojin Park
- Departments of Neurology and Biomedical Informatics, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Romain Sonneville
- Department of Intensive Care Medicine, Hôpital Bichat-Claude Bernard, Université Paris Cité, INSERM UMR 1137, IAME, APHP.Nord, Paris, France
| | - Raimund Helbolk
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
- Department of Neurology, Johannes Kepler University, Linz, Austria
- Clinical Research Institute Neuroscience, Johannes Kepler University, Linz, Austria
| | - Aarti Sarwal
- Wake Forest Baptist Health Center, Winston-Salem, NC, USA
| | | | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC-University Medical Centre, Room Ne-415, PO BOX 2040, 3000 CA, Rotterdam, The Netherlands
| | - Jan Gunst
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Tobias Gauss
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Grenoble, Universitaire Grenoble Alpes, Grenoble, France
- INSERM U1216, Grenoble Institut Neurosciences, Grenoble, France
| | - Samy Figueiredo
- Department of Anaesthesiology and Critical Care Medicine, Bicêtre Hospital, Université Paris-Saclay, Assistance Publique des Hôpitaux de Paris, Équipe DYNAMIC, Inserm UMR 999, Le Kremlin-Bicêtre, France
| | - Jacques Duranteau
- Department of Anaesthesiology and Critical Care Medicine, Bicêtre Hospital, Université Paris-Saclay, Assistance Publique des Hôpitaux de Paris, Équipe DYNAMIC, Inserm UMR 999, Le Kremlin-Bicêtre, France
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Carolina Iaquaniello
- Neuroanesthesia and Intensive Care, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Susanne Muehlschlegel
- Division of Neurosciences Critical Care, Departments of Neurology and Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Victoria Metaxa
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, SE5 9RS, UK
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Geert Meyfroidt
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
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Turella S, Dankiewicz J, Friberg H, Jakobsen JC, Leithner C, Levin H, Lilja G, Moseby-Knappe M, Nielsen N, Rossetti AO, Sandroni C, Zubler F, Cronberg T, Westhall E. The predictive value of highly malignant EEG patterns after cardiac arrest: evaluation of the ERC-ESICM recommendations. Intensive Care Med 2024; 50:90-102. [PMID: 38172300 PMCID: PMC10811097 DOI: 10.1007/s00134-023-07280-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 11/14/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE The 2021 guidelines endorsed by the European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) recommend using highly malignant electroencephalogram (EEG) patterns (HMEP; suppression or burst-suppression) at > 24 h after cardiac arrest (CA) in combination with at least one other concordant predictor to prognosticate poor neurological outcome. We evaluated the prognostic accuracy of HMEP in a large multicentre cohort and investigated the added value of absent EEG reactivity. METHODS This is a pre-planned prognostic substudy of the Targeted Temperature Management trial 2. The presence of HMEP and background reactivity to external stimuli on EEG recorded > 24 h after CA was prospectively reported. Poor outcome was measured at 6 months and defined as a modified Rankin Scale score of 4-6. Prognostication was multimodal, and withdrawal of life-sustaining therapy (WLST) was not allowed before 96 h after CA. RESULTS 845 patients at 59 sites were included. Of these, 579 (69%) had poor outcome, including 304 (36%) with WLST due to poor neurological prognosis. EEG was recorded at a median of 71 h (interquartile range [IQR] 52-93) after CA. HMEP at > 24 h from CA had 50% [95% confidence interval [CI] 46-54] sensitivity and 93% [90-96] specificity to predict poor outcome. Specificity was similar (93%) in 541 patients without WLST. When HMEP were unreactive, specificity improved to 97% [94-99] (p = 0.008). CONCLUSION The specificity of the ERC-ESICM-recommended EEG patterns for predicting poor outcome after CA exceeds 90% but is lower than in previous studies, suggesting that large-scale implementation may reduce their accuracy. Combining HMEP with an unreactive EEG background significantly improved specificity. As in other prognostication studies, a self-fulfilling prophecy bias may have contributed to observed results.
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Affiliation(s)
- Sara Turella
- Department of Intensive Care, Emergency Medicine and Anesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli", IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Josef Dankiewicz
- Department of Clinical Sciences Lund, Cardiology, Lund University, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences Lund, Anaesthesia and Intensive Care, Lund University, Lund, Sweden
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Capital Region, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Christoph Leithner
- Department of Neurology and Experimental Neurology, Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Helena Levin
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Gisela Lilja
- Department of Clinical Sciences Lund, Neurology, Lund University, Lund, Sweden
- Skane University Hospital, Lund, Sweden
| | - Marion Moseby-Knappe
- Department of Clinical Sciences Lund, Neurology and Rehabilitation, Lund University, Lund, Sweden
| | - Niklas Nielsen
- Department of Clinical Sciences Lund, Anesthesiology and Intensive Care Medicine, Helsingborg Hospital, Helsingborg, Sweden
| | - Andrea O Rossetti
- Department of Neurology, University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli", IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Frédéric Zubler
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Tobias Cronberg
- Department of Clinical Sciences Lund, Neurology, Lund University, Lund, Sweden
| | - Erik Westhall
- Department of Clinical Sciences, Clinical Neurophysiology, Lund University, S-221 85, Lund, Sweden.
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Chen CC, Massey SL, Kirschen MP, Yuan I, Padiyath A, Simpao AF, Tsui FR. Electroencephalogram-based machine learning models to predict neurologic outcome after cardiac arrest: A systematic review. Resuscitation 2024; 194:110049. [PMID: 37972682 PMCID: PMC11023717 DOI: 10.1016/j.resuscitation.2023.110049] [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: 09/18/2023] [Revised: 11/07/2023] [Accepted: 11/09/2023] [Indexed: 11/19/2023]
Abstract
AIM OF THE REVIEW The primary aim of this systematic review was to investigate the most common electroencephalogram (EEG)-based machine learning (ML) model with the highest Area Under Receiver Operating Characteristic Curve (AUC) in two ML categories, conventional ML and Deep Neural Network (DNN), to predict the neurologic outcomes after cardiac arrest; the secondary aim was to investigate common EEG features applied to ML models. METHODS Systematic search of medical literature from PubMed and engineering literature from Compendex up to June 2, 2023. One reviewer screened studies that used EEG-based ML models to predict the neurologic outcomes after cardiac arrest. Four reviewers validated that the studies met selection criteria. Nine variables were manually extracted. The top-five common EEG features were calculated. We evaluated each study's risk of bias using the Quality in Prognosis Studies guideline. RESULTS Out of 351 identified studies, 17 studies met the inclusion criteria. Random Forest (RF) (n = 7) was the most common ML model in the conventional ML category (n = 11), followed by Convolutional Neural Network (CNN) (n = 4) in the DNN category (n = 6). The AUCs for RF ranged between 0.8 and 0.97, while CNN had AUCs between 0.7 and 0.92. The top-three commonly used EEG features were band power (n = 12), Shannon's Entropy (n = 11), burst-suppression ratio (n = 9). CONCLUSIONS RF and CNN were the two most common ML models with the highest AUCs for predicting the neurologic outcomes after cardiac arrest. Using a multimodal model that combines EEG features and electronic health record data may further improve prognostic performance.
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Affiliation(s)
- Chao-Chen Chen
- Tsui Laboratory, Children's Hospital of Philadelphia, 734 Schuylkill Ave, Philadelphia, PA 19146, United States; Department of Bioengineering, University of Pennsylvania, 240 Skirkanich Hall, 210 S 33rd St, Philadelphia, PA 19104, United States
| | - Shavonne L Massey
- Department of Neurology and Pediatrics, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, United States; Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, United States
| | - Matthew P Kirschen
- Department of Neurology and Pediatrics, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, United States; Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, United States; Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, United States
| | - Ian Yuan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, United States; Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, United States
| | - Asif Padiyath
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, United States; Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, United States
| | - Allan F Simpao
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, United States; Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, United States
| | - Fuchiang Rich Tsui
- Tsui Laboratory, Children's Hospital of Philadelphia, 734 Schuylkill Ave, Philadelphia, PA 19146, United States; Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, United States; Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, 423 Guardian Dr, Philadelphia, PA 19104, United States; Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, United States.
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Soulier T, Colliot O, Ayache N, Rohaut B. How will tomorrow's algorithms fuse multimodal data? The example of the neuroprognosis in Intensive Care. Anaesth Crit Care Pain Med 2023; 42:101301. [PMID: 37709200 DOI: 10.1016/j.accpm.2023.101301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 09/03/2023] [Indexed: 09/16/2023]
Affiliation(s)
- Théodore Soulier
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute - ICM, CNRS, Inserm, AP-HP, Hôpital de la Pitié Salpêtrière, F-75013, Paris, France.
| | - Olivier Colliot
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute - ICM, CNRS, Inria, Inserm, AP-HP, Hôpital de la Pitié Salpêtrière, F-75013, Paris, France
| | | | - Benjamin Rohaut
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute - ICM, CNRS, Inserm, AP-HP, Hôpital de la Pitié Salpêtrière, F-75013, Paris, France; Department of Neurology, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
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Nyholm B, Grand J, Obling LER, Hassager C, Møller JE, Schmidt H, Othman MH, Kondziella D, Kjaergaard J. Quantitative pupillometry for neuroprognostication in comatose post-cardiac arrest patients: A protocol for a predefined sub-study of the Blood pressure and Oxygenations Targets after Out-of-Hospital Cardiac Arrest (BOX)-trial. Resusc Plus 2023; 16:100475. [PMID: 37779885 PMCID: PMC10540039 DOI: 10.1016/j.resplu.2023.100475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023] Open
Abstract
Background Resuscitation guidelines propose a multimodal prognostication strategy algorithm at ≥72 hours after the return of spontaneous circulation to evaluate neurological outcome for unconscious cardiac arrest survivors. Even though guidelines suggest quantitative pupillometry for assessing pupillary light reflex, threshold values are not yet validated.This study aims to validate pre-specified thresholds of quantitative pupillometry by quantitatively assessing the percentage reduction of pupillary size (qPLR) <4% and Neurological Pupil index (NPi) ≤2 and in predicting unfavorable neurological outcome. Both as an isolated predictor and combined with guideline-suggested neuron-specific enolase (NSE) threshold >60 μg L-1 in the current prognostication strategy algorithm. Methods We conduct this pre-planned diagnostic sub-study in the randomized, controlled, multicenter clinical trial "Blood Pressure and Oxygenation Targets after Out-of-Hospital Cardiac Arrest-trial". Blinded to treating physicians and outcome assessors, measurements of qPLR and NPi are obtained from cardiac arrest survivors at time points (±6 hours) of admission, after 24, 48, and 72 hours, or until the time of awakening or death. Discussion This study will be the largest prospective study investigating the predictive performance of automated quantitative pupillometry in unconscious patients resuscitated from cardiac arrest. We will test specific threshold values of NPi ≤2 and qPLR <4% to predict unfavorable outcome following cardiac arrest. The validation of pupillometry alone and combined with NSE with the criteria of the current prognostication strategy algorithm will hopefully increase the level of evidence and support clinical neuroprognostication with automated quantitative pupillometry in unconscious post-cardiac arrest patients. Trial registration Registered March 30, 2017, at ClinicalTrials.gov (Identifier: NCT03141099).
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Affiliation(s)
- Benjamin Nyholm
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Johannes Grand
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jacob Eifer Møller
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Cardiology, Odense University Hospital, 5000 C Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Henrik Schmidt
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Anesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Marwan H. Othman
- Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Daniel Kondziella
- Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Magliacano A, De Bellis F, Panico F, Sagliano L, Trojano L, Sandroni C, Estraneo A. Long-term clinical evolution of patients with prolonged disorders of consciousness due to severe anoxic brain injury: A meta-analytic study. Eur J Neurol 2023; 30:3913-3927. [PMID: 37246500 DOI: 10.1111/ene.15899] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/08/2023] [Accepted: 05/24/2023] [Indexed: 05/30/2023]
Abstract
BACKGROUND AND PURPOSE The prognosis of prolonged (28 days to 3 months post-onset) disorders of consciousness (pDoC) due to anoxic brain injury is uncertain. The present study aimed to evaluate the long-term outcome of post-anoxic pDoC and identify the possible predictive value of demographic and clinical information. METHOD This is a systematic review and meta-analysis. The rates of mortality, any improvement in clinical diagnosis, and recovery of full consciousness at least 6 months after severe anoxic brain injury were evaluated. A cross-sectional approach searched for differences in baseline demographic and clinical characteristics between survivors and non-survivors, patients improved versus not improved, and patients who recovered full consciousness versus not recovered. RESULTS Twenty-seven studies were identified. The pooled rates of mortality, any clinical improvement and recovery of full consciousness were 26%, 26% and 17%, respectively. Younger age, baseline diagnosis of minimally conscious state versus vegetative state/unresponsive wakefulness syndrome, higher Coma Recovery Scale Revised total score, and earlier admission to intensive rehabilitation units were associated with a significantly higher likelihood of survival and clinical improvement. These same variables, except time of admission to rehabilitation, were also associated with recovery of full consciousness. CONCLUSIONS Patients with anoxic pDoC might improve over time up to full recovery of consciousness and some clinical characteristics can help predict clinical improvement. These new insights could support clinicians and caregivers in the decision-making on patient management.
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Affiliation(s)
| | - Francesco De Bellis
- Polo specialistico riabilitativo, Fondazione Don Carlo Gnocchi, Sant'Angelo dei Lombardi, Italy
| | - Francesco Panico
- Department of Psychology, University of Campania Luigi Vanvitelli, Caserta, Italy
| | - Laura Sagliano
- Department of Psychology, University of Campania Luigi Vanvitelli, Caserta, Italy
| | - Luigi Trojano
- Department of Psychology, University of Campania Luigi Vanvitelli, Caserta, Italy
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario 'Agostino Gemelli' IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Anna Estraneo
- IRCCS Fondazione Don Carlo Gnocchi ONLUS, Florence, Italy
- SM Della Pietà General Hospital, Nola, Italy
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50
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Benghanem S, Pelle J, Cariou A. Biomarkers for neuroprognostication: The time has come for the new wave. Resuscitation 2023; 193:110028. [PMID: 37923114 DOI: 10.1016/j.resuscitation.2023.110028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 10/21/2023] [Indexed: 11/07/2023]
Affiliation(s)
- Sarah Benghanem
- Medical Intensive Care Unit, Cochin University Hospital (AP-HP), Paris, France; University Paris Cité - Medical School, Paris, France
| | - Juliette Pelle
- Medical Intensive Care Unit, Cochin University Hospital (AP-HP), Paris, France; University Paris Cité - Medical School, Paris, France
| | - Alain Cariou
- Medical Intensive Care Unit, Cochin University Hospital (AP-HP), Paris, France; University Paris Cité - Medical School, Paris, France.
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