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Aalberts N, Westhall E, Johnsen B, Hahn K, Kenda M, Cronberg T, Friberg H, Preuß S, Ploner CJ, Storm C, Nee J, Leithner C, Endisch C. Cortical somatosensory evoked potential amplitudes and clinical outcome after cardiac arrest: a retrospective multicenter study. J Neurol 2023; 270:5999-6009. [PMID: 37639017 PMCID: PMC10632270 DOI: 10.1007/s00415-023-11951-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/14/2023] [Accepted: 08/17/2023] [Indexed: 08/29/2023]
Abstract
OBJECTIVE Bilaterally absent cortical somatosensory evoked potentials (SSEPs) reliably predict poor outcome in comatose cardiac arrest (CA) patients. Cortical SSEP amplitudes are a recent prognostic extension; however, amplitude thresholds, inter-recording, and inter-rater agreement remain uncertain. METHODS In a retrospective multicenter cohort study, we determined cortical SSEP amplitudes of comatose CA patients using a standardized evaluation pathway. We studied inter-recording agreement in repeated SSEPs and inter-rater agreement by four raters independently determining 100 cortical SSEP amplitudes. Primary outcome was assessed using the cerebral performance category (CPC) upon intensive care unit discharge dichotomized into good (CPC 1-3) and poor outcome (CPC 4-5). RESULTS Of 706 patients with SSEPs with median 3 days after CA, 277 (39.2%) had good and 429 (60.8%) poor outcome. Of patients with bilaterally absent cortical SSEPs, one (0.8%) survived with CPC 3 and 130 (99.2%) had poor outcome. Otherwise, the lowest cortical SSEP amplitude in good outcome patients was 0.5 µV. 184 (42.9%) of 429 poor outcome patients had lower cortical SSEP amplitudes. In 106 repeated SSEPs, there were 6 (5.7%) with prognostication-relevant changes in SSEP categories. Following a standardized evaluation pathway, inter-rater agreement was almost perfect with a Fleiss' kappa of 0.88. INTERPRETATION Bilaterally absent and cortical SSEP amplitudes below 0.5 µV predicted poor outcome with high specificity. A standardized evaluation pathway provided high inter-rater and inter-recording agreement. Regain of consciousness in patients with bilaterally absent cortical SSEPs rarely occurs. High-amplitude cortical SSEP amplitudes likely indicate the absence of severe brain injury.
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Affiliation(s)
- Noelle Aalberts
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Erik Westhall
- Department of Clinical Sciences Lund, Clinical Neurophysiology, Lund University, Skane University Hospital, Getingevägen 4, 22185, Lund, Sweden
| | - Birger Johnsen
- Department of Clinical Neurophysiology, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 165, 8200, Aarhus N, Denmark
| | - Katrin Hahn
- Department of Neurology, Campus Mitte, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Martin Kenda
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- BIH Charité Junior Digital Clinician Scientist Program, BIH Biomedical Innovation Academy, Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Tobias Cronberg
- Department of Clinical Sciences Lund, Neurology, Lund University, Skane University Hospital, Getingevägen 4, 22185, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences Lund, Intensive and Perioperative Care, Lund University, Skane University Hospital, Getingevägen 4, 22185, Lund, Sweden
| | - Sandra Preuß
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Christoph J Ploner
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Christian Storm
- Department of Nephrology and Intensive Care Medicine, Cardiac Arrest Center of Excellence Berlin, Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Jens Nee
- Department of Nephrology and Intensive Care Medicine, Cardiac Arrest Center of Excellence Berlin, Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Christoph Leithner
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Christian Endisch
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
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Gourd NM, Bigham C, Broomfield N, Nye L, Stapleton L, Stead E, Smith A, Baker A, Chynoweth J, Hosking J, Hudson N, Nikitas N. Enhanced analysis of somatosensory evoked potentials at 20-30 milliseconds can predict neurological outcome after cardiac arrest. Clin Neurophysiol 2023; 153:141-151. [PMID: 37487420 DOI: 10.1016/j.clinph.2023.06.020] [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: 12/19/2022] [Revised: 06/12/2023] [Accepted: 06/17/2023] [Indexed: 07/26/2023]
Abstract
OBJECTIVE This study attempted to test the effectiveness of an enhanced analysis of the 20-30 ms complex of somatosensory evoked potentials, in predicting the short-term outcome of comatose survivors of out of hospital cardiac arrest and compare it with the current clinical practice. METHODS Single-centre, prospective, observational study. Median nerve SSEP recording performed at 24-36 h post-return of spontaneous circulation. Recording was analysed using amplitude measurements of P25/30 and Peak-To-Trough of 20-30 ms complex and thresholds to decide P25/30 presence. Neurological outcome was dichotomised into favourable and unfavourable. RESULTS 89 participants were analysed. 43.8% had favourable and 56.2% unfavourable outcome. The sensitivity, specificity, positive and negative predictive values of the present SSEP and favourable outcome were calculated. P25/30 presence and size of PTT improved positive predictive value and specificity, while maintained similar negative predictive value and sensitivity, compared to the current practice. Inter-interpreter agreement was also improved. CONCLUSIONS Enhanced analysis of the SSEP at 20-30 ms complex could improve the short-term prognostic accuracy for short-term neurological outcome in comatose survivors of cardiac arrest. SIGNIFICANCE Peak-To-Trough analysis of the 20-30 ms SSEP waveform appears to be the best predictor of neurological outcome following out of hospital cardiac arrest. It is also the easiest and most reliable to analyse.
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Affiliation(s)
- Nicholas M Gourd
- University Hospitals Plymouth NHS Trust, Derriford Hospital, Plymouth, UK
| | - Colin Bigham
- Department of Intensive Care Medicine, University Hospitals Plymouth NHS Trust, Derriford Hospital, Plymouth, UK
| | - Nicola Broomfield
- Department of Neurophysiology, University Hospitals Plymouth NHS Trust, Derriford Hospital, Plymouth, UK
| | - Lucy Nye
- Department of Neurophysiology, University Hospitals Plymouth NHS Trust, Derriford Hospital, Plymouth, UK
| | - Liana Stapleton
- Department of Intensive Care Medicine, University Hospitals Plymouth NHS Trust, Derriford Hospital, Plymouth, UK
| | - Emma Stead
- Department of Neurophysiology, University Hospitals Plymouth NHS Trust, Derriford Hospital, Plymouth, UK
| | - Andrew Smith
- Department of Neurophysiology, University Hospitals Plymouth NHS Trust, Derriford Hospital, Plymouth, UK
| | - Amy Baker
- Peninsula Medical School (Faculty of Health), University of Plymouth, UK
| | - Jade Chynoweth
- Peninsula Medical School (Faculty of Health), University of Plymouth, UK
| | - Joanne Hosking
- Peninsula Medical School (Faculty of Health), University of Plymouth, UK
| | - Nigel Hudson
- Department of Neurophysiology, University Hospitals Plymouth NHS Trust, Derriford Hospital, Plymouth, UK
| | - Nikitas Nikitas
- Department of Intensive Care Medicine, University Hospitals Plymouth NHS Trust, Derriford Hospital, Plymouth, UK; Peninsula Medical School (Faculty of Health), University of Plymouth, UK.
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Kromm J, Bencsik C, Soo A, Ainsworth C, Savard M, van Diepen S, Kramer A. Somatosensory evoked potential for post-arrest neuroprognostication. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:532-539. [PMID: 37283039 DOI: 10.1093/ehjacc/zuad060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 06/01/2023] [Indexed: 06/08/2023]
Affiliation(s)
- Julie Kromm
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Alberta Health Services, Alberta, Canada
| | - Caralyn Bencsik
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Alberta Health Services, Alberta, Canada
| | - Andrea Soo
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Alberta Health Services, Alberta, Canada
| | - Craig Ainsworth
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Martin Savard
- Département de Médecine, Université Laval, Quebec City, Quebec, Canada
| | - Sean van Diepen
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
- Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Andreas Kramer
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Alberta Health Services, Alberta, Canada
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Rajajee V, Muehlschlegel S, Wartenberg KE, Alexander SA, Busl KM, Chou SHY, Creutzfeldt CJ, Fontaine GV, Fried H, Hocker SE, Hwang DY, Kim KS, Madzar D, Mahanes D, Mainali S, Meixensberger J, Montellano F, Sakowitz OW, Weimar C, Westermaier T, Varelas PN. Guidelines for Neuroprognostication in Comatose Adult Survivors of Cardiac Arrest. Neurocrit Care 2023; 38:533-563. [PMID: 36949360 PMCID: PMC10241762 DOI: 10.1007/s12028-023-01688-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 01/30/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND Among cardiac arrest survivors, about half remain comatose 72 h following return of spontaneous circulation (ROSC). Prognostication of poor neurological outcome in this population may result in withdrawal of life-sustaining therapy and death. The objective of this article is to provide recommendations on the reliability of select clinical predictors that serve as the basis of neuroprognostication and provide guidance to clinicians counseling surrogates of comatose cardiac arrest survivors. METHODS A narrative systematic review was completed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Candidate predictors, which included clinical variables and prediction models, were selected based on clinical relevance and the presence of an appropriate body of evidence. The Population, Intervention, Comparator, Outcome, Timing, Setting (PICOTS) question was framed as follows: "When counseling surrogates of comatose adult survivors of cardiac arrest, should [predictor, with time of assessment if appropriate] be considered a reliable predictor of poor functional outcome assessed at 3 months or later?" Additional full-text screening criteria were used to exclude small and lower-quality studies. Following construction of the evidence profile and summary of findings, recommendations were based on four GRADE criteria: quality of evidence, balance of desirable and undesirable consequences, values and preferences, and resource use. In addition, good practice recommendations addressed essential principles of neuroprognostication that could not be framed in PICOTS format. RESULTS Eleven candidate clinical variables and three prediction models were selected based on clinical relevance and the presence of an appropriate body of literature. A total of 72 articles met our eligibility criteria to guide recommendations. Good practice recommendations include waiting 72 h following ROSC/rewarming prior to neuroprognostication, avoiding sedation or other confounders, the use of multimodal assessment, and an extended period of observation for awakening in patients with an indeterminate prognosis, if consistent with goals of care. The bilateral absence of pupillary light response > 72 h from ROSC and the bilateral absence of N20 response on somatosensory evoked potential testing were identified as reliable predictors. Computed tomography or magnetic resonance imaging of the brain > 48 h from ROSC and electroencephalography > 72 h from ROSC were identified as moderately reliable predictors. CONCLUSIONS These guidelines provide recommendations on the reliability of predictors of poor outcome in the context of counseling surrogates of comatose survivors of cardiac arrest and suggest broad principles of neuroprognostication. Few predictors were considered reliable or moderately reliable based on the available body of evidence.
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Affiliation(s)
- Venkatakrishna Rajajee
- Departments of Neurology and Neurosurgery, 3552 Taubman Health Care Center, SPC 5338, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109-5338, USA.
| | - Susanne Muehlschlegel
- Departments of Neurology, Anesthesiology, and Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | | | | | - Katharina M Busl
- Departments of Neurology and Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Sherry H Y Chou
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Gabriel V Fontaine
- Departments of Pharmacy and Neurosciences, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Herbert Fried
- Department of Neurosurgery, Denver Health Medical Center, Denver, CO, USA
| | - Sara E Hocker
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - David Y Hwang
- Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Keri S Kim
- Pharmacy Practice, University of Illinois, Chicago, IL, USA
| | - Dominik Madzar
- Department of Neurology, University of Erlangen, Erlangen, Germany
| | - Dea Mahanes
- Departments of Neurology and Neurosurgery, University of Virginia Health, Charlottesville, VA, USA
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | | | | | - Oliver W Sakowitz
- Department of Neurosurgery, Neurosurgery Center Ludwigsburg-Heilbronn, Ludwigsburg, Germany
| | - Christian Weimar
- Institute of Medical Informatics, Biometry, and Epidemiology, University Hospital Essen, Essen, Germany
- BDH-Clinic Elzach, Elzach, Germany
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Oishi T, Triplett JD, Laughlin RS, Hocker SE, Berini SE, Hoffman EM. Short-Acting Neuromuscular Blockade Improves Inter-rater Reliability of Median Somatosensory Evoked Potentials in Post-cardiac arrest Prognostication. Neurocrit Care 2023; 38:600-611. [PMID: 36123569 DOI: 10.1007/s12028-022-01601-4] [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: 06/09/2022] [Accepted: 08/29/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although median nerve somatosensory evoked potentials are routinely used for prognostication in comatose cardiac arrest survivors, myogenic artifact can reduce inter-rater reliability, leading to unreliable or inaccurate results. To minimize this risk, we determined the benefit of neuromuscular blockade agents in improving the inter-rater reliability and signal-to-noise ratio of SSEPs in the context of prognostication. METHODS Thirty comatose survivors of cardiac arrest were enrolled in the study, following the request from an intensivist to complete an SSEP for prognostication. Right and left median nerve SSEPs were obtained from each patient, before and after administration of an NMB agent. Clinical histories and outcomes were retrospectively reviewed. The SSEP recordings before and after NMB were randomized and reviewed by five blinded raters, who assessed the latency and amplitude of cortical and noncortical potentials (vs. absence of response) as well as the diagnostic quality of cortical recordings. The inter-rater reliability of SSEP interpretation before and after NMB was compared via Fleiss' κ score. RESULTS Following NMB administration, Fleiss' κ score for cortical SSEP interpretation significantly improved from 0.37 to 0.60, corresponding to greater agreement among raters. The raters were also less likely to report the cortical recordings as nondiagnostic following NMB (40.7% nondiagnostic SSEPs pre-NMB; 17% post-NMB). The SNR significantly improved following NMB, especially when the pre-NMB SNR was low (< 10 dB). Across the raters, there were three patients whose SSEP interpretation changed from bilaterally absent to bilaterally present after NMB was administered (potential false positives without NMB). CONCLUSIONS NMB significantly improves the inter-rater reliability and SNR of median SSEPs for prognostication among comatose cardiac arrest survivors. To ensure the most reliable prognostic information in comatose post-cardiac arrest survivors, pharmacologic paralysis should be consistently used before recording SSEPs.
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Affiliation(s)
- Tatsuya Oishi
- Department of Neurology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55902, USA.
| | - James D Triplett
- Department of Neurology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55902, USA
- Department of Neurology, Concord Repatriation General Hospital, Concord, NSW, Australia
| | - Ruple S Laughlin
- Department of Neurology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55902, USA
| | - Sara E Hocker
- Department of Neurology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55902, USA
| | - Sarah E Berini
- Department of Neurology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55902, USA
| | - Ernest M Hoffman
- Department of Neurology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55902, USA
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Benghanem S, Pruvost-Robieux E, Bouchereau E, Gavaret M, Cariou A. Prognostication after cardiac arrest: how EEG and evoked potentials may improve the challenge. Ann Intensive Care 2022; 12:111. [PMID: 36480063 PMCID: PMC9732180 DOI: 10.1186/s13613-022-01083-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 11/07/2022] [Indexed: 12/13/2022] Open
Abstract
About 80% of patients resuscitated from CA are comatose at ICU admission and nearly 50% of survivors are still unawake at 72 h. Predicting neurological outcome of these patients is important to provide correct information to patient's relatives, avoid disproportionate care in patients with irreversible hypoxic-ischemic brain injury (HIBI) and inappropriate withdrawal of care in patients with a possible favorable neurological recovery. ERC/ESICM 2021 algorithm allows a classification as "poor outcome likely" in 32%, the outcome remaining "indeterminate" in 68%. The crucial question is to know how we could improve the assessment of both unfavorable but also favorable outcome prediction. Neurophysiological tests, i.e., electroencephalography (EEG) and evoked-potentials (EPs) are a non-invasive bedside investigations. The EEG is the record of brain electrical fields, characterized by a high temporal resolution but a low spatial resolution. EEG is largely available, and represented the most widely tool use in recent survey examining current neuro-prognostication practices. The severity of HIBI is correlated with the predominant frequency and background continuity of EEG leading to "highly malignant" patterns as suppression or burst suppression in the most severe HIBI. EPs differ from EEG signals as they are stimulus induced and represent the summated activities of large populations of neurons firing in synchrony, requiring the average of numerous stimulations. Different EPs (i.e., somato sensory EPs (SSEPs), brainstem auditory EPs (BAEPs), middle latency auditory EPs (MLAEPs) and long latency event-related potentials (ERPs) with mismatch negativity (MMN) and P300 responses) can be assessed in ICU, with different brain generators and prognostic values. In the present review, we summarize EEG and EPs signal generators, recording modalities, interpretation and prognostic values of these different neurophysiological tools. Finally, we assess the perspective for futures neurophysiological investigations, aiming to reduce prognostic uncertainty in comatose and disorders of consciousness (DoC) patients after CA.
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Affiliation(s)
- Sarah Benghanem
- grid.411784.f0000 0001 0274 3893Medical ICU, Cochin Hospital, Assistance Publique – Hôpitaux de Paris (AP-HP), 27 Rue du Faubourg Saint-Jacques, 75014 Paris, France ,grid.508487.60000 0004 7885 7602Medical School, University Paris Cité, Paris, France ,After ROSC Network, Paris, France ,grid.7429.80000000121866389UMR 1266, Institut de Psychiatrie et, INSERM FHU NeuroVascNeurosciences de Paris-IPNP, 75014 Paris, France
| | - Estelle Pruvost-Robieux
- grid.508487.60000 0004 7885 7602Medical School, University Paris Cité, Paris, France ,Neurophysiology and Epileptology Department, GHU Psychiatry and Neurosciences, Sainte Anne, 75014 Paris, France ,grid.7429.80000000121866389UMR 1266, Institut de Psychiatrie et, INSERM FHU NeuroVascNeurosciences de Paris-IPNP, 75014 Paris, France
| | - Eléonore Bouchereau
- Department of Neurocritical Care, G.H.U Paris Psychiatry and Neurosciences, 1, Rue Cabanis, 75014 Paris, France ,grid.7429.80000000121866389UMR 1266, Institut de Psychiatrie et, INSERM FHU NeuroVascNeurosciences de Paris-IPNP, 75014 Paris, France
| | - Martine Gavaret
- grid.508487.60000 0004 7885 7602Medical School, University Paris Cité, Paris, France ,Neurophysiology and Epileptology Department, GHU Psychiatry and Neurosciences, Sainte Anne, 75014 Paris, France ,grid.7429.80000000121866389UMR 1266, Institut de Psychiatrie et, INSERM FHU NeuroVascNeurosciences de Paris-IPNP, 75014 Paris, France
| | - Alain Cariou
- grid.411784.f0000 0001 0274 3893Medical ICU, Cochin Hospital, Assistance Publique – Hôpitaux de Paris (AP-HP), 27 Rue du Faubourg Saint-Jacques, 75014 Paris, France ,grid.508487.60000 0004 7885 7602Medical School, University Paris Cité, Paris, France ,After ROSC Network, Paris, France ,grid.462416.30000 0004 0495 1460Paris-Cardiovascular-Research-Center (Sudden-Death-Expertise-Center), INSERM U970, Paris, France
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Kenda M, Cheng Z, Guettler C, Storm C, Ploner CJ, Leithner C, Scheel M. Inter-rater agreement between humans and computer in quantitative assessment of computed tomography after cardiac arrest. Front Neurol 2022; 13:990208. [PMID: 36313501 PMCID: PMC9606648 DOI: 10.3389/fneur.2022.990208] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 08/12/2022] [Indexed: 11/16/2022] Open
Abstract
Background Head computed tomography (CT) is used to predict neurological outcome after cardiac arrest (CA). The current reference standard includes quantitative image analysis by a neuroradiologist to determine the Gray-White-Matter Ratio (GWR) which is calculated via the manual measurement of radiodensity in different brain regions. Recently, automated analysis methods have been introduced. There is limited data on the Inter-rater agreement of both methods. Methods Three blinded human raters (neuroradiologist, neurologist, student) with different levels of clinical experience retrospectively assessed the Gray-White-Matter Ratio (GWR) in head CTs of 95 CA patients. GWR was also quantified by a recently published computer algorithm that uses coregistration with standardized brain spaces to identify regions of interest (ROIs). We calculated intraclass correlation (ICC) for inter-rater agreement between human and computer raters as well as area under the curve (AUC) and sensitivity/specificity for poor outcome prognostication. Results Inter-rater agreement on GWR was very good (ICC 0.82–0.84) between all three human raters across different levels of expertise and between the computer algorithm and neuroradiologist (ICC 0.83; 95% CI 0.78–0.88). Despite high overall agreement, we observed considerable, clinically relevant deviations of GWR measurements (up to 0.24) in individual patients. In our cohort, at a GWR threshold of 1.10, this did not lead to any false poor neurological outcome prediction. Conclusion Human and computer raters demonstrated high overall agreement in GWR determination in head CTs after CA. The clinically relevant deviations of GWR measurement in individual patients underscore the necessity of additional qualitative evaluation and integration of head CT findings into a multimodal approach to prognostication of neurological outcome after CA.
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Affiliation(s)
- Martin Kenda
- Department of Neurology With Experimental Neurology, Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany
- BIH Charité Junior Digital Clinician Scientist Program, Berlin Institute of Health at Charité—Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, Berlin, Germany
- *Correspondence: Martin Kenda
| | - Zhuo Cheng
- Department of Neuroradiology, Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Christopher Guettler
- Department of Neuroradiology, Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Christian Storm
- Department of Nephrology and Intensive Care Medicine—Circulatory Arrest Center Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph J. Ploner
- Department of Neurology With Experimental Neurology, Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Leithner
- Department of Neurology With Experimental Neurology, Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Michael Scheel
- Department of Neuroradiology, Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany
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Arciniegas-Villanueva AV, Fernández-Diaz EM, Gonzalez-Garcìa E, Sancho-Pelluz J, Mansilla-Lozano D, Segura T. Functional and Prognostic Assessment in Comatose Patients: A Study Using Somatosensory Evoked Potentials. Front Hum Neurosci 2022; 16:904455. [PMID: 35860398 PMCID: PMC9289095 DOI: 10.3389/fnhum.2022.904455] [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: 03/25/2022] [Accepted: 05/31/2022] [Indexed: 11/13/2022] Open
Abstract
Aim The functional prognosis of patients after coma following either cardiac arrest (CA) or acute structural brain injury (ABI) is often uncertain. These patients are associated with high mortality and disability. N20 and N70 somatosensory evoked potentials (SSEP) are used to predict prognosis. We evaluated the utility of SSEP (N20–N70) as an early indicator of long-term prognosis in these patients. Methods This was a retrospective cohort study of patients (n = 120) admitted to the intensive care unit (ICU) with a diagnosis of coma after CA (n = 60) or ABI (n = 60). An SSEP study was performed, including N20 and N70 at 24–72 h, after coma onset. Functional recovery was assessed 6–12 months later using the modified Glasgow scale (mGS). The study was approved by our local research ethics committee. Results In the CA and ABI groups, the absence of N20 (36% of CA patients and 41% of ABI patients; specificity = 100%) or N70 (68% of CA patients and 78% of ABI patients) was a strong indicator of poor outcome. Conversely, the presence of N70 was an indicator of a good outcome (AC: specificity = 84.2%, sensitivity = 92.7%; ABI: specificity = 64.2% sensitivity = 91.3%). Conclusion Somatosensory evoked potentials are useful early prognostic markers with high specificity (N20) and sensitivity (N70). Moreover, N70 has additional potential value for improving the prediction of good long-term functional outcomes. Clinical Trial Registration: [https://clinicaltrials.gov/], identifier [2018/01/001].
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Affiliation(s)
- Andrea Victoria Arciniegas-Villanueva
- Escuela de Doctorado, Universidad Católica de Valencia San Vicente Mártir, Valencia, Spain
- Neurophysiology Service, Hospital de Manises, Valencia, Spain
- *Correspondence: Andrea Victoria Arciniegas-Villanueva,
| | | | | | - Javier Sancho-Pelluz
- Neurobiología y Neurofisiología, Facultad de Medicina y Ciencias de la Salud, Universidad Católica de Valencia San Vicente Mártir, Valencia, Spain
| | | | - Tomás Segura
- Neurology Service, Hospital General Universitario de Albacete, Albacete, Spain
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Arciniegas-Villanueva AV, Fernández-Diaz EM, González-García E, Sancho-Pelluz J, Mansilla-Lozano D, Diaz-Maroto MI, Segura T. The Added Value of Somatosensory Potential N70 in Neurological Prognosis After Coma by Acute Brain Structural Injury: A Retrospective Study. Ann Neurosci 2022; 29:129-136. [DOI: 10.1177/09727531221100255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 03/11/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Coma after acute brain structural injury (ABI) are associated with high mortality and disability. Somatosensory evoked potentials (SSEP) N20 and N70 are used to predict prognosis. Purpose: We assessed the utility of SSEP (N20-N70) as an early indicator of long-term functional prognosis in these patients. Methods: We conducted a retrospective cohort study of patients admitted to the intensive care unit (ICU) with a diagnosis of coma after ABI (n=60). An SSEP study including N20 and N70 was performed 24–72 hours after coma onset. Functional recovery was evaluated 6 to 12 months later using the Modified Glasgow Scale (mGS). The study was approved by our local research ethics committee. Results: The absence of N20 (41% specificity=100%) or N70 (78%) was a strong indicator of a poor outcome. In contrast, the presence of N70 was an indicator of a good outcome (specificity=64.2% sensitivity=91.3%). Conclusion: SSEP N20 and N70 are useful early prognostic markers with high specificity (N20) and sensitivity (N70). N70 has potential additional value for improving the prediction of good functional outcomes in the long term.
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Affiliation(s)
- Andrea Victoria Arciniegas-Villanueva
- Neurophysiology Service, Hospital de Manises, Valencia, Spain
- Escuela de Doctorado, Universidad Católica de Valencia San Vicente Mártir, Valencia, Spain
| | | | | | - Javier Sancho-Pelluz
- Neurobiología y Neurofisiología, Facultad de Medicina y Ciencias de la Salud, Universidad Católica de Valencia San Vicente Mártir, Valencia, Spain
| | | | | | - Tomás Segura
- Neurology Service, Hospital General Universitario de Albacete, Albacete, Spain
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10
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Ryczek R, Kwasiborski PJ, Rzeszotarska A, Dymus J, Galas A, Kaźmierczak-Dziuk A, Karasek AM, Mielniczuk M, Buksińska-Lisik M, Korsak J, Krzesiński P. Neuron-Specific Enolase and S100B: The Earliest Predictors of Poor Outcome in Cardiac Arrest. J Clin Med 2022; 11:2344. [PMID: 35566469 PMCID: PMC9102826 DOI: 10.3390/jcm11092344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 04/03/2022] [Accepted: 04/18/2022] [Indexed: 02/05/2023] Open
Abstract
Background: Proper prognostication is critical in clinical decision-making following out-of-hospital cardiac arrest (OHCA). However, only a few prognostic tools with reliable accuracy are available within the first 24 h after admission. Aim: To test the value of neuron-specific enolase (NSE) and S100B protein measurements at admission as early biomarkers of poor prognosis after OHCA. Methods: We enrolled 82 consecutive patients with OHCA who were unconscious when admitted. NSE and S100B levels were measured at admission, and routine blood tests were performed. Death and poor neurological status at discharge were considered as poor clinical outcomes. We evaluated the optimal cut-off levels for NSE and S100B using logistic regression and receiver operating characteristic (ROC) analyses. Results: High concentrations of both biomarkers at admission were significantly associated with an increased risk of poor clinical outcome (NSE: odds ratio [OR] 1.042 per 1 ng/dL, [1.007−1.079; p = 0.004]; S100B: OR 1.046 per 50 pg/mL [1.004−1.090; p < 0.001]). The dual-marker approach with cut-off values of ≥27.6 ng/mL and ≥696 ng/mL for NSE and S100B, respectively, identified patients with poor clinical outcomes with 100% specificity. Conclusions: The NSE and S100B-based dual-marker approach allowed for early discrimination of patients with poor clinical outcomes with 100% specificity. The proposed algorithm may shorten the time required to establish a poor prognosis and limit the volume of futile procedures performed.
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Affiliation(s)
- Robert Ryczek
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, 04-141 Warsaw, Poland; (R.R.); (A.G.); (A.K.-D.); (A.M.K.); (M.M.); (P.K.)
| | - Przemysław J. Kwasiborski
- Department of Internal Diseases and Cardiology, Regional Hospital in Miedzylesie, 04-749 Warsaw, Poland
| | - Agnieszka Rzeszotarska
- Department of Clinical Transfusion, Military Institute of Medicine, 04-141 Warsaw, Poland; (A.R.); (J.K.)
| | - Jolanta Dymus
- Department of Laboratory Diagnostics, Military Institute of Medicine, 04-141 Warsaw, Poland;
| | - Agata Galas
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, 04-141 Warsaw, Poland; (R.R.); (A.G.); (A.K.-D.); (A.M.K.); (M.M.); (P.K.)
| | - Anna Kaźmierczak-Dziuk
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, 04-141 Warsaw, Poland; (R.R.); (A.G.); (A.K.-D.); (A.M.K.); (M.M.); (P.K.)
| | - Anna M. Karasek
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, 04-141 Warsaw, Poland; (R.R.); (A.G.); (A.K.-D.); (A.M.K.); (M.M.); (P.K.)
| | - Marta Mielniczuk
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, 04-141 Warsaw, Poland; (R.R.); (A.G.); (A.K.-D.); (A.M.K.); (M.M.); (P.K.)
| | - Małgorzata Buksińska-Lisik
- Third Department of Internal Diseases and Cardiology, Second Faculty of Medicine, Medical University of Warsaw, 04-749 Warsaw, Poland;
| | - Jolanta Korsak
- Department of Clinical Transfusion, Military Institute of Medicine, 04-141 Warsaw, Poland; (A.R.); (J.K.)
| | - Paweł Krzesiński
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, 04-141 Warsaw, Poland; (R.R.); (A.G.); (A.K.-D.); (A.M.K.); (M.M.); (P.K.)
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11
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The Levels of Circulating MicroRNAs at 6-Hour Cardiac Arrest Can Predict 6-Month Poor Neurological Outcome. Diagnostics (Basel) 2021; 11:diagnostics11101905. [PMID: 34679603 PMCID: PMC8534364 DOI: 10.3390/diagnostics11101905] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 10/09/2021] [Accepted: 10/12/2021] [Indexed: 12/13/2022] Open
Abstract
Early prognostication in cardiac arrest survivors is challenging for physicians. Unlike other prognostic modalities, biomarkers are easily accessible and provide an objective assessment method. We hypothesized that in cardiac arrest patients with targeted temperature management (TTM), early circulating microRNA (miRNA) levels are associated with the 6-month neurological outcome. In the discovery phase, we identified candidate miRNAs associated with cardiac arrest patients who underwent TTM by comparing circulating expression levels in patients and healthy controls. Next, using a larger cohort, we validated the prognostic values of the identified early miRNAs by measuring the serum levels of miRNAs, neuron-specific enolase (NSE), and S100 calcium-binding protein B (S100B) 6 h after cardiac arrest. The validation cohort consisted of 54 patients with TTM. The areas under the curve (AUCs) for poor outcome were 0.85 (95% CI (confidence interval), 0.72–0.93), 0.82 (95% CI, 0.70–0.91), 0.78 (95% CI, 0.64–0.88), and 0.77 (95% CI, 0.63–0.87) for miR-6511b-5p, -125b-1-3p, -122-5p, and -124-3p, respectively. When the cut-off was based on miRNA levels predicting poor outcome with 100% specificity, sensitivities were 67.7% (95% CI, 49.5–82.6), 50.0% (95% CI, 32.4–67.7), 35.3% (95% CI, 19.7–53.5), and 26.5% (95% CI, 12.9–44.4) for the above miRNAs, respectively. The models combining early miRNAs with protein biomarkers demonstrated superior prognostic performance to those of protein biomarkers.
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12
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Abstract
Improved understanding of post-cardiac arrest syndrome and clinical practices such as targeted temperature management have led to improved mortality in this cohort. Attention has now been placed on development of tools to aid in predicting functional outcome in comatose cardiac arrest survivors. Current practice uses a multimodal approach including physical examination, neuroimaging, and electrophysiologic data, with a primary utility in predicting poor functional outcome. These modalities remain confounded by self-fulfilling prophecy and the withdrawal of life-sustaining therapies. To date, a reliable measure to predict good functional outcome has not been established or validated, but the use of quantitative somatosensory evoked potential (SSEP) shows potential for this use. MEDLINE and EMBASE search using words "Cardiac Arrest" and "SSEP," "Somato sensory evoked potentials," "qSSEP," "quantitative SSEP," "targeted temperature management in cardiac arrest" was conducted. Relevant recent studies on targeted temperature management in cardiac arrest, plus studies on SSEP in cardiac arrest in the setting of hypothermia and without hypothermia, were included. In addition, animal studies evaluating the role of different components of SSEP in cardiac arrest were reviewed. SSEP is a specific indicator of poor outcomes in post-cardiac arrest patients but lacks sensitivity and has not clinically been established to foresee good outcomes. Novel methods of analyzing quantitative SSEP (qSSEP) signals have shown potential to predict good outcomes in animal and human studies. In addition, qSSEP has potential to track cerebral recovery and guide treatment strategy in post-cardiac arrest patients. Lying beyond the current clinical practice of dichotomized absent/present N20 peaks, qSSEP has the potential to emerge as one of the earliest predictors of good outcome in comatose post-cardiac arrest patients. Validation of qSSEP markers in prospective studies to predict good and poor outcomes in the cardiac arrest population in the setting of hypothermia could advance care in cardiac arrest. It has the prospect to guide allocation of health care resources and reduce self-fulfilling prophecy.
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13
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Olasveengen TM, Skrifvars MB, Taccone F, Soar J. Postreanimationsbehandlung. Notf Rett Med 2021. [DOI: 10.1007/s10049-021-00892-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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14
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Olasveengen TM, Skrifvars MB, Taccone F, Soar J. European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2021: post-resuscitation care. Intensive Care Med 2021; 47:369-421. [PMID: 33765189 PMCID: PMC7993077 DOI: 10.1007/s00134-021-06368-4] [Citation(s) in RCA: 417] [Impact Index Per Article: 139.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 02/08/2021] [Indexed: 12/13/2022]
Abstract
The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation and organ donation.
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Affiliation(s)
- Jerry P. Nolan
- University of Warwick, Warwick Medical School, Coventry, CV4 7AL UK
- Royal United Hospital, Bath, BA1 3NG UK
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy
- Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Bernd W. Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
| | - Alain Cariou
- Cochin University Hospital (APHP) and University of Paris (Medical School), Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anaesthesia and Intensive Care Medicine, Lund University, Skane University Hospital, Lund, Sweden
| | - Cornelia Genbrugge
- Acute Medicine Research Pole, Institute of Experimental and Clinical Research (IREC), Université Catholique de Louvain, Brussels, Belgium
- Emergency Department, University Hospitals Saint-Luc, Brussels, Belgium
| | - Kirstie Haywood
- Warwick Research in Nursing, Division of Health Sciences, Warwick Medical School, University of Warwick, Room A108, Coventry, CV4 7AL UK
| | - Gisela Lilja
- Department of Clinical Sciences Lund, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Véronique R. M. Moulaert
- Department of Rehabilitation Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Nikolaos Nikolaou
- Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Theresa Mariero Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Markus B. Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Fabio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB UK
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15
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Mariero Olasveengen T, Skrifvars MB, Taccone F, Soar J. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2021: Post-resuscitation care. Resuscitation 2021; 161:220-269. [PMID: 33773827 DOI: 10.1016/j.resuscitation.2021.02.012] [Citation(s) in RCA: 358] [Impact Index Per Article: 119.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation, and organ donation.
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Affiliation(s)
- Jerry P Nolan
- University of Warwick, Warwick Medical School, Coventry CV4 7AL, UK; Royal United Hospital, Bath, BA1 3NG, UK.
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy; Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Bernd W Böttiger
- University Hospital of Cologne, Kerpener Straße 62, D-50937 Cologne, Germany
| | - Alain Cariou
- Cochin University Hospital (APHP) and University of Paris (Medical School), Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anaesthesia and Intensive Care Medicine, Lund University, Skane University Hospital, Lund, Sweden
| | - Cornelia Genbrugge
- Acute Medicine Research Pole, Institute of Experimental and Clinical Research (IREC) Université Catholique de Louvain, Brussels, Belgium; Emergency Department, University Hospitals Saint-Luc, Brussels, Belgium
| | - Kirstie Haywood
- Warwick Research in Nursing, Room A108, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Gisela Lilja
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Neurology, Lund, Sweden
| | - Véronique R M Moulaert
- University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Groningen, The Netherlands
| | - Nikolaos Nikolaou
- Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Theresa Mariero Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Norway
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Finland
| | - Fabio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol BS10 5NB, UK
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16
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McDevitt WM, Quinn L, Bill PR, Morris KP, Scholefield BR, Seri S. Reliability in the assessment of paediatric somatosensory evoked potentials post cardiac arrest. Clin Neurophysiol 2021; 132:765-769. [PMID: 33571884 DOI: 10.1016/j.clinph.2020.12.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 11/15/2020] [Accepted: 12/06/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To measure inter- and intra-rater agreement in the interpretation of cortical somatosensory evoked potential (SSEP) components following paediatric cardiac arrest (CA) in multi-professional neurophysiology teams. METHODS Thirteen professionals blinded to patient outcome interpreted 96 SSEPs in paediatric patients 24-/48-/72-hours following CA. Of these, 34 were duplicates used to assess intra-rater agreement. Consistent interpretations (absent/present/indeterminate) between scientists (who record/identify SSEP components) and neurophysiologists (who provide prognostic SSEP interpretation) were expressed as percentages. Rates of agreement were calculated using Fleiss' kappa coefficient (K). RESULTS Unanimous agreement between professionals was present in 40% (95%CI: 28-54%) of the interpreted SSEPs, with a K value of 0.62 (95%CI: 0.55-0.70) based on average agreement. Agreement was similar between neurophysiologists (K = 0.67; 95%CI: 0.57-0.77) and scientists (K = 0.62; 95%CI: 0.54-0.70) but lower in patients < 2 years old (K = 0.23; 95%CI: 0.14-0.33) and in those with poor outcome (K = 0.21; 95%CI: 0.07-0.35). No SSEP was unanimously interpreted as absent and 92% (95%CI: 89-95%) of duplicate SSEPs were interpreted consistently. CONCLUSION Despite substantial agreement when interpreting prognostic SSEPs, this was significantly lower in children with poor outcome and of younger age. SIGNIFICANCE Clinicians using SSEPs in the intensive care unit should be aware of the inter-rater variability when interpreting SSEPs as absent.
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Affiliation(s)
- William M McDevitt
- Department of Neurophysiology, Birmingham Women's and Children's NHS Foundation Trust, UK.
| | - Laura Quinn
- Institute of Applied Health Research, University of Birmingham, UK; Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, UK
| | - Peter R Bill
- Department of Neurophysiology, Birmingham Women's and Children's NHS Foundation Trust, UK
| | - Kevin P Morris
- Institute of Applied Health Research, University of Birmingham, UK; Paediatric Intensive Care Unit, Birmingham Women's and Children's NHS Foundation Trust, UK
| | - Barnaby R Scholefield
- Paediatric Intensive Care Unit, Birmingham Women's and Children's NHS Foundation Trust, UK; Birmingham Acute Care Research Group, University of Birmingham, UK
| | - Stefano Seri
- Department of Neurophysiology, Birmingham Women's and Children's NHS Foundation Trust, UK; Aston Brain Centre, College of Health and Life Sciences, Aston University, UK
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17
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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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18
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Does a combination of ≥2 abnormal tests vs. the ERC-ESICM stepwise algorithm improve prediction of poor neurological outcome after cardiac arrest? A post-hoc analysis of the ProNeCA multicentre study. Resuscitation 2020; 160:158-167. [PMID: 33338571 DOI: 10.1016/j.resuscitation.2020.12.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/24/2020] [Accepted: 02/13/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Bilaterally absent pupillary light reflexes (PLR) or N20 waves of short-latency evoked potentials (SSEPs) are recommended by the 2015 ERC-ESICM guidelines as robust, first-line predictors of poor neurological outcome after cardiac arrest. However, recent evidence shows that the false positive rates (FPRs) of these tests may be higher than previously reported. We investigated if testing accuracy is improved when combining PLR/SSEPs with malignant electroencephalogram (EEG), oedema on brain computed tomography (CT), or early status myoclonus (SM). METHODS Post-hoc analysis of ProNeCA multicentre prognostication study. We compared the prognostic accuracy of the ERC-ESICM prognostication strategy vs. that of a new strategy combining ≥2 abnormal results from any of PLR, SSEPs, EEG, CT and SM. We also investigated if using alternative classifications for abnormal SSEPs (absent-pathological vs. bilaterally-absent N20) or malignant EEG (ACNS-defined suppression or burst-suppression vs. unreactive burst-suppression or status epilepticus) improved test sensitivity. RESULTS We assessed 210 adult comatose resuscitated patients of whom 164 (78%) had poor neurological outcome (CPC 3-5) at six months. FPRs and sensitivities of the ≥2 abnormal test strategy vs. the ERC-ESICM algorithm were 0[0-8]% vs. 7 [1-18]% and 49[41-57]% vs. 63[56-71]%, respectively (p < .0001). Using alternative SSEP/EEG definitions increased the number of patients with ≥2 concordant test results and the sensitivity of both strategies (67[59-74]% and 54[46-61]% respectively), with no loss of specificity. CONCLUSIONS In comatose resuscitated patients, a prognostication strategy combining ≥2 among PLR, SSEPs, EEG, CT and SM was more specific than the 2015 ERC-ESICM prognostication algorithm for predicting 6-month poor neurological outcome.
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19
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Good outcome despite absence of cortical somatosensory evoked potentials after cardiac arrest: Fact or artifact? Case report and literature review. Clin Neurophysiol 2020; 131:2537-2539. [DOI: 10.1016/j.clinph.2020.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 08/21/2020] [Accepted: 08/21/2020] [Indexed: 11/21/2022]
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20
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Sandroni C, D'Arrigo S, Cacciola S, Hoedemaekers CWE, Kamps MJA, Oddo M, Taccone FS, Di Rocco A, Meijer FJA, Westhall E, Antonelli M, Soar J, Nolan JP, Cronberg T. Prediction of poor neurological outcome in comatose survivors of cardiac arrest: a systematic review. Intensive Care Med 2020; 46:1803-1851. [PMID: 32915254 PMCID: PMC7527362 DOI: 10.1007/s00134-020-06198-w] [Citation(s) in RCA: 172] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/15/2020] [Indexed: 12/17/2022]
Abstract
Purpose To assess the ability of clinical examination, blood biomarkers, electrophysiology, or neuroimaging assessed within 7 days from return of spontaneous circulation (ROSC) to predict poor neurological outcome, defined as death, vegetative state, or severe disability (CPC 3–5) at hospital discharge/1 month or later, in comatose adult survivors from cardiac arrest (CA). Methods PubMed, EMBASE, Web of Science, and the Cochrane Database of Systematic Reviews (January 2013–April 2020) were searched. Sensitivity and false-positive rate (FPR) for each predictor were calculated. Due to heterogeneities in recording times, predictor thresholds, and definition of some predictors, meta-analysis was not performed. Results Ninety-four studies (30,200 patients) were included. Bilaterally absent pupillary or corneal reflexes after day 4 from ROSC, high blood values of neuron-specific enolase from 24 h after ROSC, absent N20 waves of short-latency somatosensory-evoked potentials (SSEPs) or unequivocal seizures on electroencephalogram (EEG) from the day of ROSC, EEG background suppression or burst-suppression from 24 h after ROSC, diffuse cerebral oedema on brain CT from 2 h after ROSC, or reduced diffusion on brain MRI at 2–5 days after ROSC had 0% FPR for poor outcome in most studies. Risk of bias assessed using the QUIPS tool was high for all predictors. Conclusion In comatose resuscitated patients, clinical, biochemical, neurophysiological, and radiological tests have a potential to predict poor neurological outcome with no false-positive predictions within the first week after CA. Guidelines should consider the methodological concerns and limited sensitivity for individual modalities. (PROSPERO CRD42019141169) Electronic supplementary material The online version of this article (10.1007/s00134-020-06198-w) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli"- IRCCS, Largo Francesco Vito, 1, 00168, Rome, Italy.,Institute of Anesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Sonia D'Arrigo
- Department of Intensive Care, Emergency Medicine and Anesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli"- IRCCS, Largo Francesco Vito, 1, 00168, Rome, Italy.
| | - Sofia Cacciola
- Department of Intensive Care, Emergency Medicine and Anesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli"- IRCCS, Largo Francesco Vito, 1, 00168, Rome, Italy
| | | | - Marlijn J A Kamps
- Intensive Care Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Mauro Oddo
- Department of Intensive Care Medicine, University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Arianna Di Rocco
- Department of Public Health and Infectious Disease, Sapienza University, Rome, Italy
| | - Frederick J A Meijer
- Department of Radiology and Nuclear Medicine, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Erik Westhall
- Department of ClinicalSciences, Clinical Neurophysiology, Lund University, Skane University Hospital, Lund, Sweden
| | - Massimo Antonelli
- Department of Intensive Care, Emergency Medicine and Anesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli"- IRCCS, Largo Francesco Vito, 1, 00168, Rome, Italy.,Institute of Anesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Jasmeet Soar
- Critical Care Unit, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Jerry P Nolan
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK
| | - Tobias Cronberg
- Department of Clinical Sciences Lund, Neurology, Lund University, Skane University Hospital, Lund, Sweden
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21
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Comanducci A, Boly M, Claassen J, De Lucia M, Gibson RM, Juan E, Laureys S, Naccache L, Owen AM, Rosanova M, Rossetti AO, Schnakers C, Sitt JD, Schiff ND, Massimini M. Clinical and advanced neurophysiology in the prognostic and diagnostic evaluation of disorders of consciousness: review of an IFCN-endorsed expert group. Clin Neurophysiol 2020; 131:2736-2765. [PMID: 32917521 DOI: 10.1016/j.clinph.2020.07.015] [Citation(s) in RCA: 91] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 07/06/2020] [Accepted: 07/26/2020] [Indexed: 12/13/2022]
Abstract
The analysis of spontaneous EEG activity and evoked potentialsis a cornerstone of the instrumental evaluation of patients with disorders of consciousness (DoC). Thepast few years have witnessed an unprecedented surge in EEG-related research applied to the prediction and detection of recovery of consciousness after severe brain injury,opening up the prospect that new concepts and tools may be available at the bedside. This paper provides a comprehensive, critical overview of bothconsolidated and investigational electrophysiological techniquesfor the prognostic and diagnostic assessment of DoC.We describe conventional clinical EEG approaches, then focus on evoked and event-related potentials, and finally we analyze the potential of novel research findings. In doing so, we (i) draw a distinction between acute, prolonged and chronic phases of DoC, (ii) attempt to relate both clinical and research findings to the underlying neuronal processes and (iii) discuss technical and conceptual caveats.The primary aim of this narrative review is to bridge the gap between standard and emerging electrophysiological measures for the detection and prediction of recovery of consciousness. The ultimate scope is to provide a reference and common ground for academic researchers active in the field of neurophysiology and clinicians engaged in intensive care unit and rehabilitation.
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Affiliation(s)
- A Comanducci
- IRCCS Fondazione Don Carlo Gnocchi, Milan, Italy
| | - M Boly
- Department of Neurology and Department of Psychiatry, University of Wisconsin, Madison, USA; Wisconsin Institute for Sleep and Consciousness, Department of Psychiatry, University of Wisconsin-Madison, Madison, USA
| | - J Claassen
- Department of Neurology, Columbia University Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - M De Lucia
- Laboratoire de Recherche en Neuroimagerie, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - R M Gibson
- The Brain and Mind Institute and the Department of Physiology and Pharmacology, Western Interdisciplinary Research Building, N6A 5B7 University of Western Ontario, London, Ontario, Canada
| | - E Juan
- Wisconsin Institute for Sleep and Consciousness, Department of Psychiatry, University of Wisconsin-Madison, Madison, USA; Amsterdam Brain and Cognition, Department of Psychology, University of Amsterdam, Amsterdam, the Netherlands
| | - S Laureys
- Coma Science Group, Centre du Cerveau, GIGA-Consciousness, University and University Hospital of Liège, 4000 Liège, Belgium; Fondazione Europea per la Ricerca Biomedica Onlus, Milan 20063, Italy
| | - L Naccache
- Inserm U 1127, CNRS UMR 7225, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France; Sorbonne Université, UPMC Université Paris 06, Faculté de Médecine Pitié-Salpêtrière, Paris, France
| | - A M Owen
- The Brain and Mind Institute and the Department of Physiology and Pharmacology, Western Interdisciplinary Research Building, N6A 5B7 University of Western Ontario, London, Ontario, Canada
| | - M Rosanova
- Department of Biomedical and Clinical Sciences "L. Sacco", University of Milan, Milan, Italy; Fondazione Europea per la Ricerca Biomedica Onlus, Milan 20063, Italy
| | - A O Rossetti
- Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - C Schnakers
- Research Institute, Casa Colina Hospital and Centers for Healthcare, Pomona, CA, USA
| | - J D Sitt
- Inserm U 1127, CNRS UMR 7225, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France
| | - N D Schiff
- Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, 1300 York Avenue, New York, NY 10065, USA
| | - M Massimini
- IRCCS Fondazione Don Carlo Gnocchi, Milan, Italy; Department of Biomedical and Clinical Sciences "L. Sacco", University of Milan, Milan, Italy
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22
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Celani MG, Carrai R, Cantisani TA, Scarpino M, Ercolani MV, Lolli F, Lanzo G, Costa P, Lanteri P, Bignamini AA, Amantini A, Grippo A. Is there inter-observer variation in the interpretation of SSEPs in comatose cardiac arrest survivors? Further considerations following the Italian multicenter ProNeCa study. Resuscitation 2020; 155:207-210. [PMID: 32795599 DOI: 10.1016/j.resuscitation.2020.07.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 07/23/2020] [Accepted: 07/30/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Bilateral absence of N20 peak in median nerve Somatosensory Evoked Potentials (SSEPs) is considered the most valid predictor of poor outcome in comatose survivors after cardiopulmonary resuscitation. We investigated the consistency in interpreting SSEP recordings in a multicentre study. METHODS 44 SSEP recordings randomly extracted from 600 recordings of 392 patients included in the "Prognostication of Neurological outcome after Cardiac Arrest (ProNeCa) study" were blindly read by three expert neurophysiologists. Agreement between raters, and individual agreement of each rater vs. reference standard (RS), were calculated using Kappa Coefficients. Inter-rater reliability was calculated with Intra-class Correlation Coefficient (ICC). RESULTS When raters had to evaluate the presence of N20 with normal amplitude, the inter-rater agreement was very high (Kappa = 0.84). In the case of N20 absence the agreement was good (Kappa = 0.66), but when N20 amplitude was low, the agreement decreased to moderate (Kappa = 0.579) becoming even weaker when it was "Non Assessable" (Kappa = 0.107). The agreement of each rater with the RS had a range from moderate to very good; rater1 Kappa = 0.589 (95%CI 0.397-0.781; p < 0.001), rater2 Kappa = 0.644 (95%CI 0.460-0.828; p < 0.001), rater3 Kappa = 0.859 (95%CI 0.698-1.000; p < 0.001). The ICC was barely good, 0.682 (95%CI 0.539-0.798; p = 0.0075). CONCLUSION Different health professionals, using different equipment in a multicentre study, had very good inter-rater agreement in interpreting SSEP records. The interpretation of "Non Assessable" SEPPs, mainly in relation to noise level, is still a crucial issue because it increases rater uncertainty. For this reason, it is important to focus on improving recording quality and interpretation of records.
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Affiliation(s)
| | - Riccardo Carrai
- IRCCS Fondazione Don Carlo Gnocchi, Firenze, Italy; SODc Neurofisiopatologia, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, AOU Careggi, Firenze, Italy
| | | | - Maenia Scarpino
- IRCCS Fondazione Don Carlo Gnocchi, Firenze, Italy; SODc Neurofisiopatologia, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, AOU Careggi, Firenze, Italy
| | | | - Francesco Lolli
- Dipartimento di Scienze Biomediche Sperimentali e Cliniche, Università degli Studi di Firenze, Italy
| | - Giovanni Lanzo
- SODc Neurofisiopatologia, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, AOU Careggi, Firenze, Italy
| | - Paolo Costa
- Neurofisiologia Clinica, Dpt. Di Neuroscience e Salute Mentale, Ospedale CTO, Città della Salute e della Scienza di Torino, Italy
| | - Paola Lanteri
- Neurofisiopatologia, Dpt di Tecnologia Diagnostica ed Applicata, Fondazione IRCCS Istituto Neurologico "C. Besta" Milano, Italy
| | | | | | - Antonello Grippo
- IRCCS Fondazione Don Carlo Gnocchi, Firenze, Italy; SODc Neurofisiopatologia, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, AOU Careggi, Firenze, Italy
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Optimal combination of clinical examinations for neurologic prognostication of out-of-hospital cardiac arrest patients. Resuscitation 2020; 155:91-99. [PMID: 32710915 DOI: 10.1016/j.resuscitation.2020.07.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 06/27/2020] [Accepted: 07/11/2020] [Indexed: 11/27/2022]
Abstract
AIM Targeted temperature management (TTM) may alter the results of clinical examination and delay motor response recovery; hence, re-establishing the accuracy and optimal timing of performing clinical examinations are crucial. Therefore, we aimed to identify the optimal combination and timing of clinical examinations for predicting the neurologic outcomes in patients undergoing TTM. METHODS We conducted a retrospective analysis of prospectively collected multicentre registry data. All enrolled patients were supposed to undergo pupil light reflex (PLR), corneal reflex (CR), and Glasgow Coma Scale for 7 days after return of spontaneous circulation (ROSC). We investigated the timing of each examination based on the ROSC and rewarming completion times. The primary outcome was poor neurologic outcome (cerebral performance category 3,4, or 5) at 6 months after cardiac arrest. RESULTS A total of 715 patients treated with TTM within 2 years, were enrolled. The PLR is more specific than the other examinations, and the specificity of the combination of PLR with CR was 100% 72 h after the ROSC or 24 h after rewarming completion. The sensitivity for the combination of PLR with CR 72 h after the ROSC was 55.3 (49.8-60.7) %, which was not different from that noted 24 h after rewarming completion (P = 0.65). CONCLUSION The combination of PLR with CR showed specificity approaching 100% 72 h after the ROSC or 24 h after rewarming completion. These findings can provide a clinical reference for predicting the neurological outcomes in patients undergoing TTM, especially in institutions without up-to-date facilities.
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24
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Added value of somato-sensory evoked potentials amplitude for prognostication after cardiac arrest. Resuscitation 2020; 149:17-23. [DOI: 10.1016/j.resuscitation.2020.01.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 12/31/2019] [Accepted: 01/22/2020] [Indexed: 12/13/2022]
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25
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Rothstein TL. SSEP retains its value as predictor of poor outcome following cardiac arrest in the era of therapeutic hypothermia. Crit Care 2019; 23:327. [PMID: 31647028 PMCID: PMC6813072 DOI: 10.1186/s13054-019-2576-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 08/19/2019] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVES To re-evaluate the role of median nerve somatosensory evoked potentials (SSEPs) and bilateral loss of the N20 cortical wave as a predictor of unfavorable outcome in comatose patients following cardiac arrest (CA) in the therapeutic hypothermia (TH) era. METHODS Review the results and conclusions drawn from isolated case reports and small series of comatose patients following CA in which the bilateral absence of N20 response has been associated with recovery, and evaluate the proposal that SSEP can no longer be considered a reliable and accurate predictor of unfavorable neurologic outcome. RESULTS There are many methodological limitations in those patients reported in the literature with severe post anoxic encephalopathy who recover despite having lost their N20 cortical potential. These limitations include lack of sufficient clinical and neurologic data, severe core body hypothermia, specifics of electrophysiologic testing, technical issues such as background noise artifacts, flawed interpretations sometimes related to interobserver inconsistency, and the extreme variability in interpretation and quality of SSEP analysis among different clinicians and hospitals. CONCLUSIONS The absence of the SSEP N20 cortical wave remains one of the most reliable early prognostic tools for identifying unfavorable neurologic outcome in the evaluation of patients with severe anoxic-ischemic encephalopathy whether or not they have been treated with TH. When confounding factors are eliminated the false positive rate (FPR) approaches zero.
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Affiliation(s)
- Ted L Rothstein
- Department of Neurology, George Washington University, Washington, DC, USA.
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26
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Ruijter BJ, Tjepkema-Cloostermans MC, Tromp SC, van den Bergh WM, Foudraine NA, Kornips FHM, Drost G, Scholten E, Bosch FH, Beishuizen A, van Putten MJAM, Hofmeijer J. Early electroencephalography for outcome prediction of postanoxic coma: A prospective cohort study. Ann Neurol 2019; 86:203-214. [PMID: 31155751 PMCID: PMC6771891 DOI: 10.1002/ana.25518] [Citation(s) in RCA: 106] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Revised: 05/28/2019] [Accepted: 05/31/2019] [Indexed: 02/03/2023]
Abstract
Objective To provide evidence that early electroencephalography (EEG) allows for reliable prediction of poor or good outcome after cardiac arrest. Methods In a 5‐center prospective cohort study, we included consecutive, comatose survivors of cardiac arrest. Continuous EEG recordings were started as soon as possible and continued up to 5 days. Five‐minute EEG epochs were assessed by 2 reviewers, independently, at 8 predefined time points from 6 hours to 5 days after cardiac arrest, blinded for patients’ actual condition, treatment, and outcome. EEG patterns were categorized as generalized suppression (<10 μV), synchronous patterns with ≥50% suppression, continuous, or other. Outcome at 6 months was categorized as good (Cerebral Performance Category [CPC] = 1–2) or poor (CPC = 3–5). Results We included 850 patients, of whom 46% had a good outcome. Generalized suppression and synchronous patterns with ≥50% suppression predicted poor outcome without false positives at ≥6 hours after cardiac arrest. Their summed sensitivity was 0.47 (95% confidence interval [CI] = 0.42–0.51) at 12 hours and 0.30 (95% CI = 0.26–0.33) at 24 hours after cardiac arrest, with specificity of 1.00 (95% CI = 0.99–1.00) at both time points. At 36 hours or later, sensitivity for poor outcome was ≤0.22. Continuous EEG patterns at 12 hours predicted good outcome, with sensitivity of 0.50 (95% CI = 0.46–0.55) and specificity of 0.91 (95% CI = 0.88–0.93); at 24 hours or later, specificity for the prediction of good outcome was <0.90. Interpretation EEG allows for reliable prediction of poor outcome after cardiac arrest, with maximum sensitivity in the first 24 hours. Continuous EEG patterns at 12 hours after cardiac arrest are associated with good recovery. ANN NEUROL 2019;86:203–214
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Affiliation(s)
- Barry J Ruijter
- Department of Clinical Neurophysiology, Technical Medical Center, University of Twente, Enschede
| | | | - Selma C Tromp
- Departments of Neurology and Clinical Neurophysiology, St Antonius Hospital, Nieuwegein
| | - Walter M van den Bergh
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen
| | | | | | - Gea Drost
- Departments of Neurology and Neurosurgery, University Medical Center Groningen, University of Groningen, Groningen
| | - Erik Scholten
- Department of Intensive Care, St Antonius Hospital, Nieuwegein
| | - Frank H Bosch
- Department of Intensive Care, Rijnstate Hospital, Arnhem
| | | | - Michel J A M van Putten
- Department of Clinical Neurophysiology, Technical Medical Center, University of Twente, Enschede.,Departments of Neurology and Clinical Neurophysiology, Medical Spectrum Twente, Enschede
| | - Jeannette Hofmeijer
- Department of Clinical Neurophysiology, Technical Medical Center, University of Twente, Enschede.,Department of Neurology, Rijnstate Hospital, Arnhem, the Netherlands
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Oh SH, Park KN, Choi SP, Oh JS, Kim HJ, Youn CS, Kim SH, Chang K, Kim SH. Beyond dichotomy: patterns and amplitudes of SSEPs and neurological outcomes after cardiac arrest. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:224. [PMID: 31215475 PMCID: PMC6582536 DOI: 10.1186/s13054-019-2510-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 06/10/2019] [Indexed: 01/06/2023]
Abstract
Background We hypothesized that the absence of P25 and the N20–P25 amplitude in somatosensory evoked potentials (SSEPs) have higher sensitivity than the absence of N20 for poor neurological outcomes, and we evaluated the ability of SSEPs to predict long-term outcomes using pattern and amplitude analyses. Methods Using prospectively collected therapeutic hypothermia registry data, we evaluated whether cortical SSEPs contained a negative or positive short-latency wave (N20 or P25). The N20–P25 amplitude was defined as the largest difference in amplitude between the N20 and P25 peaks. A good or poor outcome was defined as a Glasgow-Pittsburgh Cerebral Performance Category (CPC) score of 1–2 or 3–5, respectively, 6 months after cardiac arrest. Results A total of 192 SSEP recordings were included. In all patients with a good outcome (n = 51), both N20 and P25 were present. Compared to the absence of N20, the absence of N20–P25 component improved the sensitivity for predicting a poor outcome from 30.5% (95% confidence interval [CI], 23.0–38.8%) to 71.6% (95% CI, 63.4–78.9%), while maintaining a specificity of 100% (93.0–100.0%). Using an amplitude < 0.64 μV, i.e., the lowest N20–P25 amplitude in the good outcome group, as the threshold, the sensitivity for predicting a poor neurological outcome was 74.5% (95% CI, 66.5–81.4%). Using the highest N20–P25 amplitude in the CPC 4 group (2.31 μV) as the threshold for predicting a good outcome, the sensitivity and specificity were 52.9% (95% CI, 38.5–67.1%) and 96.5% (95% CI, 91.9–98.8%), respectively. The predictive performance of the N20–P25 amplitude was good, with an area under the receiver operating characteristic curve (AUC) of 0.94 (95% CI, 0.90–0.97). The absence of N20 was statistically inferior regarding outcome prediction (p < 0.05), and amplitude analysis yielded significantly higher AUC values than did the pattern analysis (p < 0.05). Conclusions The simple pattern analysis of whether the N20–P25 component was present had a sensitivity comparable to that of the N20–P25 amplitude for predicting a poor outcome. Amplitude analysis was also capable of predicting a good outcome. Electronic supplementary material The online version of this article (10.1186/s13054-019-2510-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- 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
| | - 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.
| | - Seung Pill Choi
- Department of Emergency Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Joo Suk Oh
- Department of Emergency Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Han Joon Kim
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 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
| | - Soo Hyun Kim
- 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
| | - Kiyuk Chang
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seong Hoon Kim
- Department of Neurology, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Scarponi F, Zampolini M, Zucchella C, Bargellesi S, Fassio C, Pistoia F, Bartolo M. Identifying clinical complexity in patients affected by severe acquired brain injury in neurorehabilitation: a cross sectional survey. Eur J Phys Rehabil Med 2019; 55:191-198. [DOI: 10.23736/s1973-9087.18.05342-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Muzyka IM, Estephan B. Somatosensory evoked potentials. HANDBOOK OF CLINICAL NEUROLOGY 2019; 160:523-540. [DOI: 10.1016/b978-0-444-64032-1.00035-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Abstract
PURPOSE The reliability of somatosensory evoked potentials (SSEPs) in predicting outcome in comatose survivors of cardiac arrest treated with therapeutic hypothermia (TH) has been questioned. We investigated whether the absence of cortical (N20) responses was a reliable predictor of a nonawakening in the setting of TH. METHODS A retrospective review was conducted in cardiac arrest survivors treated with TH admitted to a single tertiary care hospital from April, 2010 to March, 2013 who underwent SSEP testing at various time points after cardiac arrest. N20 responses were categorized as normal, present but abnormal, bilaterally absent, or inadequate for interpretation. Neurologic outcome was assessed at discharge by the Cerebral Performance Category Scale (CPC). RESULTS Ninety-three SSEP studies were performed in 73 patients. Fourteen patients had absent N20 responses; all had poor outcome (CPC 4-5). Eleven patients had absent N20 s during hypothermia, three of whom had follow-up SSEPs after rewarming and cortical responses remained absent. Fifty-seven patients had N20 peaks identified and had variable outcomes. Evaluation of 1 or more N20 peaks was limited or inadequate in 11.4% of SSEPs performed during the cooling because of artifact. CONCLUSIONS Somatosensory evoked potentials remain a reliable prognostic indicator in patients undergoing TH. The limited sample size of patients who had SSEP performed during TH and repeated after normothermia added to the effect of self-fulfilling prophecy limit the interpretation of the reliability of this testing when performed during cooling. Further prospective, multicenter, large scale studies correlating cortical responses in SSEPs during and after TH are warranted. Technical challenges are commonplace during TH and caution is advised in the interpretation of suboptimal recordings.
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Postreanimationsbehandlung. Notf Rett Med 2017. [DOI: 10.1007/s10049-017-0331-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Choudhary R. Multimodel quantitative analysis of somatosensory evoked potentials after cardiac arrest with graded hypothermia. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2017; 2016:1846-1849. [PMID: 28268685 DOI: 10.1109/embc.2016.7591079] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Cardiac arrest (CA) is one of the most prominent causes of morbidity and mortality in adults. Therapeutic hypothermia (TH) is a recommended treatment to improve survival and functional outcome following CA, however, it is unclear what degree of TH is most beneficial. It has been suggested that TH of 33°C provides no survival or outcome benefits over TH of 36°C. Additionally, there is a lack of verified objective quantitative prognostic tools for comatose CA patients under TH. In this study, we calculated three quantitative markers of somatosensory evoked potentials (SSEP) to examine their potential to track recovery in the early period following CA under graded TH. A total of 16 rats were randomly divided among 4 temperature groups (n=4/group): normothermia (N0, 36.5-37.5°C), hypothermia 1 (H1, 30-32°C), hypothermia 2 (H2, 32-34°C) and hypothermia 3 (H3, 34-36°C). All rats underwent a 15min baseline SSEP recording followed by 9min asphyxial-CA, resulting in severe cerebral injury, and immediate temperature management following resuscitation for 6 hours. SSEP recordings were maintained in 15 min intervals from 30min-4hrs after resuscitation. The N10 amplitude, N10 latency and quantitative SSEP phase space area (qSSEP-PSA) were calculated for the early recovery period and normalized to their respective baselines. Functional recovery was determined by the neurological deficit scale (NDS). N10 amplitude was significantly larger in H1, H2 and H3 compared to N0. N10 latency was significantly longer in H1 than all temperature groups and all hypothermia groups had significantly longer latencies than N0. qSSEP-PSA had significantly better recovery in H1 and H2 than N0. Animals with good outcome (72hr NDS>50) had better recovery of all markers. N10 amplitude was significantly correlated with N10 latency and qSSEP-PSA. The results importantly demonstrate that quantified SSEPs have the potential to objectively track recovery following CA with graded TH.
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An Update on Cardiopulmonary Resuscitation in Children. CURRENT ANESTHESIOLOGY REPORTS 2017. [DOI: 10.1007/s40140-017-0216-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Nolan JP, Soar J, Cariou A, Cronberg T, Moulaert VRM, Deakin CD, Bottiger BW, Friberg H, Sunde K, Sandroni C. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines for Post-resuscitation Care 2015: Section 5 of the European Resuscitation Council Guidelines for Resuscitation 2015. Resuscitation 2016; 95:202-22. [PMID: 26477702 DOI: 10.1016/j.resuscitation.2015.07.018] [Citation(s) in RCA: 745] [Impact Index Per Article: 93.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Jerry P Nolan
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK; School of Clinical Sciences, University of Bristol, UK.
| | - Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK
| | - Alain Cariou
- Cochin University Hospital (APHP) and Paris Descartes University, Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Division of Neurology, Lund University, Lund, Sweden
| | - Véronique R M Moulaert
- Adelante, Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, The Netherlands
| | - Charles D Deakin
- Cardiac Anaesthesia and Cardiac Intensive Care and NIHR Southampton Respiratory Biomedical Research Unit, University Hospital, Southampton, UK
| | - Bernd W Bottiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Hans Friberg
- Department of Clinical Sciences, Division of Anesthesia and Intensive Care Medicine, Lund University, Lund, Sweden
| | - Kjetil Sunde
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Claudio Sandroni
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy
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Interrater variability of EEG interpretation in comatose cardiac arrest patients. Clin Neurophysiol 2015; 126:2397-404. [DOI: 10.1016/j.clinph.2015.03.017] [Citation(s) in RCA: 93] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 03/03/2015] [Accepted: 03/06/2015] [Indexed: 11/19/2022]
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Endisch C, Storm C, Ploner CJ, Leithner C. Amplitudes of SSEP and outcome in cardiac arrest survivors. Neurology 2015; 85:1752-60. [DOI: 10.1212/wnl.0000000000002123] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 07/16/2015] [Indexed: 11/15/2022] Open
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Survey on current practices for neurological prognostication after cardiac arrest. Resuscitation 2015; 90:158-62. [PMID: 25676323 DOI: 10.1016/j.resuscitation.2015.01.018] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 01/12/2015] [Accepted: 01/16/2015] [Indexed: 11/21/2022]
Abstract
PURPOSE To investigate current practices and timing of neurological prognostication in comatose cardiac arrest patients. METHODS An anonymous questionnaire was distributed to the 8000 members of the European Society of Intensive Care Medicine during September and October 2012. The survey had 27 questions divided into three categories: background data, clinical data, decision-making and consequences. RESULTS A total of 1025 respondents (13%) answered the survey with complete forms in more than 90%. Twenty per cent of respondents practiced outside of Europe. Overall, 22% answered that they had national recommendations, with the highest percentage in the Netherlands (>80%). Eighty-nine per cent used induced hypothermia (32-34 °C) for comatose cardiac arrest patients, while 11% did not. Twenty per cent had separate prognostication protocols for hypothermia patients. Seventy-nine per cent recognized that neurological examination alone is not enough to predict outcome and a similar number (76%) used additional methods. Intermittent electroencephalography (EEG), brain computed tomography (CT) scan and evoked potentials (EP) were considered most useful. Poor prognosis was defined as cerebral performance category (CPC) 3-5 (58%) or CPC 4-5 (39%) or other (3%). When prognosis was considered poor, 73% would actively withdraw intensive care while 20% would not and 7% were uncertain. CONCLUSION National recommendations for neurological prognostication after cardiac arrest are uncommon and only one physician out of five uses a separate protocol for hypothermia treated patients. A neurological examination alone was considered insufficient to predict outcome in comatose patients and most respondents advocated a multimodal approach: EEG, brain CT and EP were considered most useful. Uncertainty regarding neurological prognostication and decisions on level of care was substantial.
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Sandroni C, Cariou A, Cavallaro F, Cronberg T, Friberg H, Hoedemaekers C, Horn J, Nolan JP, Rossetti AO, Soar J. Prognostication in comatose survivors of cardiac arrest: An advisory statement from the European Resuscitation Council and the European Society of Intensive Care Medicine. Resuscitation 2014; 85:1779-89. [DOI: 10.1016/j.resuscitation.2014.08.011] [Citation(s) in RCA: 245] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 08/25/2014] [Indexed: 02/07/2023]
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Prognostication in comatose survivors of cardiac arrest: an advisory statement from the European Resuscitation Council and the European Society of Intensive Care Medicine. Intensive Care Med 2014; 40:1816-31. [PMID: 25398304 PMCID: PMC4239787 DOI: 10.1007/s00134-014-3470-x] [Citation(s) in RCA: 234] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 08/22/2014] [Indexed: 01/02/2023]
Abstract
Objectives To review and update the evidence on predictors of poor outcome (death, persistent vegetative state or severe neurological disability) in adult comatose survivors of cardiac arrest, either treated or not treated with controlled temperature, to identify knowledge gaps and to suggest a reliable prognostication strategy. Methods GRADE-based systematic review followed by expert consensus achieved using Web-based Delphi methodology, conference calls and face-to-face meetings. Predictors based on clinical examination, electrophysiology, biomarkers and imaging were included. Results and conclusions Evidence from a total of 73 studies was reviewed. The quality of evidence was low or very low for almost all studies. In patients who are comatose with absent or extensor motor response at ≥72 h from arrest, either treated or not treated with controlled temperature, bilateral absence of either pupillary and corneal reflexes or N20 wave of short-latency somatosensory evoked potentials were identified as the most robust predictors. Early status myoclonus, elevated values of neuron-specific enolase at 48–72 h from arrest, unreactive malignant EEG patterns after rewarming, and presence of diffuse signs of postanoxic injury on either computed tomography or magnetic resonance imaging were identified as useful but less robust predictors. Prolonged observation and repeated assessments should be considered when results of initial assessment are inconclusive. Although no specific combination of predictors is sufficiently supported by available evidence, a multimodal prognostication approach is recommended in all patients. Electronic supplementary material The online version of this article (doi:10.1007/s00134-014-3470-x) contains supplementary material, which is available to authorized users.
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Horn J, Taccone FS, Koelman H. Reply to letter: False positive absent somatosensory evoked potentials in cardiac arrest with therapeutic hypothermia. Resuscitation 2014; 85:e137. [DOI: 10.1016/j.resuscitation.2014.04.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 04/02/2014] [Indexed: 11/28/2022]
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Pfeiffer G, Pfeifer R, Isenmann S. Cerebral hypoxia, missing cortical somatosensory evoked potentials and recovery of consciousness. BMC Neurol 2014; 14:82. [PMID: 24720818 PMCID: PMC3991862 DOI: 10.1186/1471-2377-14-82] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2013] [Accepted: 03/17/2014] [Indexed: 11/22/2022] Open
Abstract
Background Bilaterally absent N20 components of the sensory evoked potentials (SEP) from the median nerve are regarded as accurately predicting poor outcome after cardiac arrest. Case presentation We are reporting on a patient, who regained consciousness despite this ominous finding. Early after cardiac arrest, MRI showed signal alterations in diffusion weighted imaging (DWI) bilaterally in the primary visual and sensorimotor cortex and in the basal ganglia. SEP were repeatedly absent. The patient survived shut out form sensory and visual experience and locked in for voluntary movements, but kept her verbal competence in several languages. Conclusion SEP inform about integrity only of a narrow cortical strip. It is unguarded, but common practice, to conclude from absent SEP, that a patient has suffered diffuse cortical damage after cardiac arrest. Cerebral MRI with DWI helps to avoid this prognostic error and furthers understanding of the sometimes very peculiar state of mind after cardiac arrest.
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Affiliation(s)
- Gustav Pfeiffer
- Abteilung weiterführende Neurorehabilitation, Fachklinik Bad Liebenstein, Kurpromenade 2, 36448 Bad Liebenstein, Germany.
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100% reliability does not exist in diagnostics; SSEP in postanoxic coma. Resuscitation 2013; 84:1299. [DOI: 10.1016/j.resuscitation.2013.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Accepted: 07/28/2013] [Indexed: 11/22/2022]
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