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McDevitt WM, Rowberry TA, Davies P, Bill PR, Notghi LM, Morris KP, Scholefield BR. The Prognostic Value of Somatosensory Evoked Potentials in Children After Cardiac Arrest: The SEPIA Study. J Clin Neurophysiol 2021; 38:30-35. [PMID: 31702709 DOI: 10.1097/wnp.0000000000000649] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Absent cortical somatosensory evoked potentials (SSEPs) reliably predict poor neurologic outcome in adults after cardiac arrest (CA). However, there is less evidence to support this in children. In addition, targeted temperature management, test timing, and a lack of blinding may affect test accuracy. METHODS A single-center, prospective cohort study of pediatric (aged 24 hours to 15 years) patients in which prognostic value of SSEPs were assessed 24, 48, and 72 hours after CA. Targeted temperature management (33-34°C for 24 hours) followed by gradual rewarming to 37°C was used. Somatosensory evoked potentials were graded as present, absent, or indeterminate, and results were blinded to clinicians. Neurologic outcome was graded as "good" (score 1-3) or "poor" (4-6) using the Pediatric Cerebral Performance Category scale 30 days after CA and blinded to SSEP interpreter. RESULTS Twelve patients (median age, 12 months; interquartile range, 2-150; 92% male) had SSEPs interpreted as absent (6/12) or present (6/12) <72 hours after CA. Outcome was good in 7 of 12 patients (58%) and poor in 5 of 12 patients (42%). Absent SSEPs predicted poor outcome with 88% specificity (95% confidence interval, 53% to 98%). One patient with an absent SSEP had good outcome (Pediatric Cerebral Performance Category 3), and all patients with present SSEPs had good outcome (specificity 100%; 95% confidence interval, 51% to 100%). Absence or presence of SSEP was consistent across 24-hour (temperature = 34°C), 48-hour (t = 36°C), and 72-hour (t = 36°C) recordings after CA. CONCLUSIONS Results support SSEP utility when predicting favorable outcome; however, predictions resulting in withdrawal of life support should be made with caution and never in isolation because in this very small sample there was a false prediction of unfavorable outcome. Further prospective, blinded studies are needed and encouraged.
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Affiliation(s)
- William M McDevitt
- Department of Neurophysiology, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, United Kingdom
| | - Tracey A Rowberry
- Paediatric Intensive Care Unit, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, United Kingdom
| | - Paul Davies
- Institute of Child Health, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, United Kingdom
| | - Peter R Bill
- Department of Neurophysiology, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, United Kingdom
| | - Lesley M Notghi
- Department of Neurophysiology, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, United Kingdom
| | - Kevin P Morris
- Paediatric Intensive Care Unit, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, United Kingdom
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom ; and
| | - Barnaby R Scholefield
- Paediatric Intensive Care Unit, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, United Kingdom
- Birmingham Acute Care Research Group, University of Birmingham, Birmingham, United Kingdom
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Gul SS, Huesgen KW, Wang KK, Mark K, Tyndall JA. Prognostic utility of neuroinjury biomarkers in post out-of-hospital cardiac arrest (OHCA) patient management. Med Hypotheses 2017; 105:34-47. [PMID: 28735650 DOI: 10.1016/j.mehy.2017.06.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 05/04/2017] [Accepted: 06/23/2017] [Indexed: 12/30/2022]
Abstract
Despite aggressive intervention, patients who survive an out-of-hospital cardiac arrest (OHCA) generally have very poor prognoses, with nationwide survival rates of approximately 10-20%. Approximately 90% of survivors will have moderate to severe neurological injury ranging from moderate cognitive impairment to brain death. Currently, few early prognostic indicators are considered reliable enough to support patients' families and clinicians' in their decisions regarding medical futility. Blood biomarkers of neurological injury after OHCA may be of prognostic value in these cases. When most bodily tissues are oxygen-deprived, cellular metabolism switches from aerobic to anaerobic respiration. Neurons are a notable exception, however, being dependent solely upon aerobic respiration. Thus, after several minutes without circulating oxygen, neurons sustain irreversible damage, and certain measurable biomarkers are released into the circulation. Prior studies have demonstrated value in blood biomarkers in prediction of survival and neurologic impairment after OHCA. We hypothesize that understanding peptide biomarker kinetics in the early return of spontaneous circulation (ROSC) period, especially in the setting of refractory cardiac arrest, may assist clinicians in determining prognosis earlier in acute resuscitation. Specifically, during and after immediate resuscitation and return of ROSC, clinicians and families face a series of important questions regarding patient prognosis, futility of care and allocation of scarce resources such as the early initiation of extracorporeal cardiopulmonary resuscitation (ECPR). The ability to provide early prognostic information in this setting is highly valuable. Currently available, as well as potential biomarkers that could be good candidates in prognostication of neurological outcomes after OHCA or in the setting of refractory cardiac arrest will be reviewed and discussed.
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Affiliation(s)
- S S Gul
- Department of Emergency Medicine, University of Florida, 1329, SW 16th Street, Suite 5270, Gainesville, FL 32608, United States
| | - K W Huesgen
- Department of Emergency Medicine, University of Florida, 1329, SW 16th Street, Suite 5270, Gainesville, FL 32608, United States
| | - K K Wang
- Program for Neurotrauma, Neuroproteomics & Biomarker Research, Department of Psychiatry, McKnight Brain Institute, University of Florida, 1149 Newell Drive, Gainesville, FL 32610, United States
| | - K Mark
- Department of Emergency Medicine, University of Florida, 1329, SW 16th Street, Suite 5270, Gainesville, FL 32608, United States
| | - J A Tyndall
- Department of Emergency Medicine, University of Florida, 1329, SW 16th Street, Suite 5270, Gainesville, FL 32608, United States.
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The predictive value of soluble urokinase plasminogen activator receptor (SuPAR) regarding 90-day mortality and 12-month neurological outcome in critically ill patients after out-of-hospital cardiac arrest. Data from the prospective FINNRESUSCI study. Resuscitation 2014; 85:1562-7. [PMID: 25193800 DOI: 10.1016/j.resuscitation.2014.08.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 08/11/2014] [Accepted: 08/13/2014] [Indexed: 12/31/2022]
Abstract
AIM The whole body ischaemia-reperfusion after cardiac arrest (CA) induces a systemic inflammation-reperfusion response. The expression of urokinase plasminogen activator receptor (uPAR) is known to be induced after hypoxia and increased levels of soluble form suPAR have been measured after hypoxia and ischaemia. Our aim was to evaluate, whether ischaemia/reperfusion injury after out-of-hospital cardiac arrest (OHCA) increases suPAR concentrations in serum and to evaluate the prognostic value of suPAR regarding 90-day mortality and 12-month neurological outcome. METHODS This is a pre-determined substudy of prospective FINNRESUSCI study. Total of 287 patients treated in the intensive care units after OHCA and with consent from the next-of-kin and serum samples between baseline and day 4 were included. Outcome and neurological outcome were evaluated according the Pittsburgh Cerebral Performance Categories (CPC). Kaplan-Meier survival curves, areas under receiver operational characteristics curves and positive likelihood ratios for mortality and poor neurological outcome were calculated. RESULTS Non-survivors had higher levels of suPAR after OHCA. Kaplan-Meier survival curves indicated high 90-day mortality in the highest concentration quintiles. LR+ for 1-year CPC 3-5 was 1.8-2.7 for the whole patient cohort and in shockable rhythms 2.0-2.4. In therapeutic hypothermia prognostic value remained. CONCLUSIONS We found that high SuPAR concentrations were associated with poor outcome in patients with OHCA admitted to critical care. However, suPAR alone had inadequate predictive value for poor outcome and did not associate with 12-month neurological outcome.
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Greer DM, Rosenthal ES, Wu O. Neuroprognostication of hypoxic-ischaemic coma in the therapeutic hypothermia era. Nat Rev Neurol 2014; 10:190-203. [PMID: 24614515 DOI: 10.1038/nrneurol.2014.36] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Neurological prognostication after cardiac arrest has always been challenging, and has become even more so since the advent of therapeutic hypothermia (TH) in the early 2000s. Studies in this field are prone to substantial biases--most importantly, the self-fulfilling prophecy of early withdrawal of life-sustaining therapies--and physicians must be aware of these limitations when evaluating individual patients. TH mandates sedation and prolongs drug metabolism, and delayed neuronal recovery is possible after cardiac arrest with or without hypothermia treatment; thus, the clinician must allow an adequate observation period to assess for delayed recovery. Exciting advances have been made in clinical evaluation, electrophysiology, chemical biomarkers and neuroimaging, providing insights into the underlying pathophysiological mechanisms of injury, as well as prognosis. Some clinical features, such as pupillary reactivity, continue to provide robust information about prognosis, and EEG patterns, such as reactivity and continuity, seem promising as prognostic indicators. Evoked potential information is likely to remain a reliable prognostic tool in TH-treated patients, whereas traditional serum biomarkers, such as neuron-specific enolase, may be less reliable. Advanced neuroimaging techniques, particularly those utilizing MRI, hold great promise for the future. Clinicians should continue to use all the available tools to provide accurate prognostic advice to patients after cardiac arrest.
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Affiliation(s)
- David M Greer
- Department of Neurology, Yale University School of Medicine, LLCI 912, 15 York Street, New Haven, CT 06520, USA
| | - Eric S Rosenthal
- Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Ona Wu
- Athinoula A. Martinos Centre for Biomedical Imaging, 149 13th Street CNY 2301, Charlestown, MA 02129, USA
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Taccone F, Cronberg T, Friberg H, Greer D, Horn J, Oddo M, Scolletta S, Vincent JL. How to assess prognosis after cardiac arrest and therapeutic hypothermia. Crit Care 2014; 18:202. [PMID: 24417885 PMCID: PMC4056000 DOI: 10.1186/cc13696] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The prognosis of patients who are admitted in a comatose state following successful resuscitation after cardiac arrest remains uncertain. Although the introduction of therapeutic hypothermia (TH) and improvements in post-resuscitation care have significantly increased the number of patients who are discharged home with minimal brain damage, short-term assessment of neurological outcome remains a challenge. The need for early and accurate prognostic predictors is crucial, especially since sedation and TH may alter the neurological examination and delay the recovery of motor response for several days. The development of additional tools, including electrophysiological examinations (electroencephalography and somatosensory evoked potentials), neuroimaging and chemical biomarkers, may help to evaluate the extent of brain injury in these patients. Given the extensive literature existing on this topic and the confounding effects of TH on the strength of these tools in outcome prognostication after cardiac arrest, the aim of this narrative review is to provide a practical approach to post-anoxic brain injury when TH is used. We also discuss when and how these tools could be combined with the neurological examination in a multimodal approach to improve outcome prediction in this population.
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Vogel D, Markl A, Yu T, Kotchoubey B, Lang S, Müller F. Can Mental Imagery Functional Magnetic Resonance Imaging Predict Recovery in Patients With Disorders of Consciousness? Arch Phys Med Rehabil 2013; 94:1891-8. [DOI: 10.1016/j.apmr.2012.11.053] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2012] [Revised: 11/20/2012] [Accepted: 11/26/2012] [Indexed: 10/26/2022]
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Rana OR, Schröder JW, Baukloh JK, Saygili E, Mischke K, Schiefer J, Weis J, Marx N, Rassaf T, Kelm M, Shin DI, Meyer C, Saygili E. Neurofilament light chain as an early and sensitive predictor of long-term neurological outcome in patients after cardiac arrest. Int J Cardiol 2013; 168:1322-7. [DOI: 10.1016/j.ijcard.2012.12.016] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Revised: 10/10/2012] [Accepted: 12/05/2012] [Indexed: 10/27/2022]
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The Modified Glasgow Outcome Score for the prediction of outcome in patients after cardiac arrest: a prospective clinical proof of concept study. Clin Res Cardiol 2012; 101:533-43. [PMID: 22322567 DOI: 10.1007/s00392-012-0423-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Accepted: 01/26/2012] [Indexed: 10/14/2022]
Abstract
The Glasgow-Pittsburgh cerebral performance categories (GP-CPC) and the Glasgow Outcome Score (GOS) have been used to categorize patients according to their neurological outcome for prognostic predictors in patients after cardiac arrest (CA). We postulated that inclusion of deaths without knowing the cerebral status into the group of patients with poor outcome after CA using the GP-CPC and GOS will lead to dilution of the prognostic power of the investigated biochemical marker. The present study was conducted to verify this issue by employing a modified outcome score, which we termed as Modified Glasgow Outcome Score (MGOS). In the present study, 97 patients were enrolled in a prospective manner. Serum NSE and S100B levels were measured daily for 7 days after admission to the intensive care unit. Neurological outcome was assessed by employing the GOS and MGOS after 6 months. By employing the GOS, 46 patients were categorized into the group of patients with poor outcome and 51 patients survived with good neurological outcome. Patients who died without certified brain damage or with unknown cerebral status after CA (n = 20) were separated from patients with poor outcome in the MGOS. The magnitude of NSE (S100B) elevation in patients with poor outcome categorized by the MGOS was approximately 1.7-fold (1.5) higher as compared with patients divided by the GOS. The mean calculated sensitivities and area under the curve values of NSE and S100B predicting poor outcome classified by the MGOS were significantly higher as compared with the GOS. Conclusively, inclusion of deaths without certified brain damage or with unknown cerebral status into the group of patients with poor outcome will lead to underestimation of the prognostic power of investigated biochemical markers such as NSE and S100B. The MGOS will help to avoid this bias.
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