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Aoki M, Aso S, Okada Y, Kawauchi A, Ogasawara T, Tagami T, Sawada Y, Yasunaga H, Kitamura N, Oshima K. Association between gasping and survival among out-of-hospital cardiac arrest patients undergoing extracorporeal cardiopulmonary resuscitation: The SOS-KANTO 2017 study. Resusc Plus 2024; 18:100622. [PMID: 38577151 PMCID: PMC10992710 DOI: 10.1016/j.resplu.2024.100622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 03/18/2024] [Accepted: 03/19/2024] [Indexed: 04/06/2024] Open
Abstract
Aim This study aimed to assess the association between gasping and survival among out-of-hospital cardiac arrest (OHCA) patients requiring extracorporeal cardiopulmonary resuscitation (ECPR). Methods This prospective, multicenter, observational study was conducted between 2019 and 2021. We categorized adult patients requiring ECPR into those with or without gasping prior to hospital arrival. The primary outcome was the 30-day survival. We performed multivariable logistic regression analyses fitted with generalized estimating equations and subgroup analyses based on the initial rhythm and age. Results Of the 9,909 patients with OHCA requiring ECPR, 332 were enrolled in the present study, including 92 (27.7%) and 240 (72.3%) with and without gasping, respectively. The 30-day survival was higher in patients with gasping than in those without gasping (35.9% [33/92] vs. 16.2% [39/240]). In the logistic regression analysis, gasping was significantly associated with improved 30-day survival (adjusted odds ratio: 3.01; 95% confidence interval, 1.64-5.51). Subgroup analyses demonstrated similar trends in patients with an initial non-shockable rhythm and older age. Conclusions Gasping was associated with improved survival in OHCA patients requiring ECPR, even those with an initial non-shockable rhythm and older age. Clinicians may select the candidates for ECPR appropriately based on the presence of gasping.
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Affiliation(s)
- Makoto Aoki
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Gunma, Japan
- Division of Traumatology, Research Institute, National Defense Medical College, Saitama, Japan
| | - Shotaro Aso
- Department of Real World Evidence, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
| | - Yohei Okada
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Akira Kawauchi
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Gunma, Japan
| | - Tomoko Ogasawara
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School Musashikosugi Hospital, Kanagawa, Japan
| | - Yusuke Sawada
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, the University of Tokyo, Tokyo, Japan
| | - Nobuya Kitamura
- Department of Emergency and Critical Care Medicine, Kimitsu Chuo Hospital, Chiba Japan
| | - Kiyohiro Oshima
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Gunma, Japan
| | - SOS-KANTO 2017 Study Group
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Gunma, Japan
- Division of Traumatology, Research Institute, National Defense Medical College, Saitama, Japan
- Department of Real World Evidence, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
- Department of Emergency and Critical Care Medicine, Nippon Medical School Musashikosugi Hospital, Kanagawa, Japan
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Gunma, Japan
- Department of Clinical Epidemiology and Health Economics, School of Public Health, the University of Tokyo, Tokyo, Japan
- Department of Emergency and Critical Care Medicine, Kimitsu Chuo Hospital, Chiba Japan
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2
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Tam J, Elmer J. Enhancing post-arrest prognostication through good outcome prediction. Resuscitation 2024; 199:110236. [PMID: 38740253 DOI: 10.1016/j.resuscitation.2024.110236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 04/29/2024] [Accepted: 05/03/2024] [Indexed: 05/16/2024]
Affiliation(s)
- Jonathan Tam
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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3
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Amiri M, Raimondo F, Fisher PM, Cacic Hribljan M, Sidaros A, Othman MH, Zibrandtsen I, Bergdal O, Fabritius ML, Hansen AE, Hassager C, Højgaard JLS, Jensen HR, Knudsen NV, Laursen EL, Møller JE, Nersesjan V, Nicolic M, Sigurdsson ST, Sitt JD, Sølling C, Welling KL, Willumsen LM, Hauerberg J, Larsen VA, Fabricius ME, Knudsen GM, Kjærgaard J, Møller K, Kondziella D. Multimodal Prediction of 3- and 12-Month Outcomes in ICU Patients with Acute Disorders of Consciousness. Neurocrit Care 2024; 40:718-733. [PMID: 37697124 PMCID: PMC10959792 DOI: 10.1007/s12028-023-01816-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 07/21/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND In intensive care unit (ICU) patients with coma and other disorders of consciousness (DoC), outcome prediction is key to decision-making regarding prognostication, neurorehabilitation, and management of family expectations. Current prediction algorithms are largely based on chronic DoC, whereas multimodal data from acute DoC are scarce. Therefore, the Consciousness in Neurocritical Care Cohort Study Using Electroencephalography and Functional Magnetic Resonance Imaging (i.e. CONNECT-ME; ClinicalTrials.gov identifier: NCT02644265) investigates ICU patients with acute DoC due to traumatic and nontraumatic brain injuries, using electroencephalography (EEG) (resting-state and passive paradigms), functional magnetic resonance imaging (fMRI) (resting-state) and systematic clinical examinations. METHODS We previously presented results for a subset of patients (n = 87) concerning prediction of consciousness levels in the ICU. Now we report 3- and 12-month outcomes in an extended cohort (n = 123). Favorable outcome was defined as a modified Rankin Scale score ≤ 3, a cerebral performance category score ≤ 2, and a Glasgow Outcome Scale Extended score ≥ 4. EEG features included visual grading, automated spectral categorization, and support vector machine consciousness classifier. fMRI features included functional connectivity measures from six resting-state networks. Random forest and support vector machine were applied to EEG and fMRI features to predict outcomes. Here, random forest results are presented as areas under the curve (AUC) of receiver operating characteristic curves or accuracy. Cox proportional regression with in-hospital death as a competing risk was used to assess independent clinical predictors of time to favorable outcome. RESULTS Between April 2016 and July 2021, we enrolled 123 patients (mean age 51 years, 42% women). Of 82 (66%) ICU survivors, 3- and 12-month outcomes were available for 79 (96%) and 77 (94%), respectively. EEG features predicted both 3-month (AUC 0.79 [95% confidence interval (CI) 0.77-0.82]) and 12-month (AUC 0.74 [95% CI 0.71-0.77]) outcomes. fMRI features appeared to predict 3-month outcome (accuracy 0.69-0.78) both alone and when combined with some EEG features (accuracies 0.73-0.84) but not 12-month outcome (larger sample sizes needed). Independent clinical predictors of time to favorable outcome were younger age (hazard ratio [HR] 1.04 [95% CI 1.02-1.06]), traumatic brain injury (HR 1.94 [95% CI 1.04-3.61]), command-following abilities at admission (HR 2.70 [95% CI 1.40-5.23]), initial brain imaging without severe pathological findings (HR 2.42 [95% CI 1.12-5.22]), improving consciousness in the ICU (HR 5.76 [95% CI 2.41-15.51]), and favorable visual-graded EEG (HR 2.47 [95% CI 1.46-4.19]). CONCLUSIONS Our results indicate that EEG and fMRI features and readily available clinical data predict short-term outcome of patients with acute DoC and that EEG also predicts 12-month outcome after ICU discharge.
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Affiliation(s)
- Moshgan Amiri
- Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Federico Raimondo
- Brain and Behaviour, Institute of Neuroscience and Medicine, Research Center Jülich, Jülich, Germany
- Institute of Systems Neuroscience, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Patrick M Fisher
- Neurobiology Research Unit, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Melita Cacic Hribljan
- Department of Neurophysiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Annette Sidaros
- Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Neurophysiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Marwan H Othman
- Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Ivan Zibrandtsen
- Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Neurophysiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Ove Bergdal
- Department of Neurosurgery, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Maria Louise Fabritius
- Department of Neuroanaesthesiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Adam Espe Hansen
- Department of Radiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Christian Hassager
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Joan Lilja S Højgaard
- Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Helene Ravnholt Jensen
- Department of Neuroanaesthesiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Niels Vendelbo Knudsen
- Department of Neuroanaesthesiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Emilie Lund Laursen
- Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Jacob E Møller
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Vardan Nersesjan
- Biological and Precision Psychiatry, Copenhagen Research Center for Mental Health, Copenhagen University Hospital, Copenhagen, Denmark
| | - Miki Nicolic
- Department of Neurophysiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Sigurdur Thor Sigurdsson
- Department of Neuroanaesthesiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Jacobo D Sitt
- Institut du Cerveau - Paris Brain Institute, Inserm, Centre nationl de la recherche scientifique, Assistance Publique - Hôpitaux de Paris, Sorbonne Université, Hôpital de La Pitié Salpêtrière, Paris, France
| | - Christine Sølling
- Department of Neuroanaesthesiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Karen Lise Welling
- Department of Neuroanaesthesiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Lisette M Willumsen
- Department of Neurosurgery, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - John Hauerberg
- Department of Neurosurgery, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Vibeke Andrée Larsen
- Department of Radiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Martin Ejler Fabricius
- Department of Neurophysiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Gitte Moos Knudsen
- Neurobiology Research Unit, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jesper Kjærgaard
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Kirsten Møller
- Department of Neuroanaesthesiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Daniel Kondziella
- Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
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Nikolovski SS, Lazic AD, Fiser ZZ, Obradovic IA, Tijanic JZ, Raffay V. Recovery and Survival of Patients After Out-of-Hospital Cardiac Arrest: A Literature Review Showcasing the Big Picture of Intensive Care Unit-Related Factors. Cureus 2024; 16:e54827. [PMID: 38529434 PMCID: PMC10962929 DOI: 10.7759/cureus.54827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2024] [Indexed: 03/27/2024] Open
Abstract
As an important public health issue, out-of-hospital cardiac arrest (OHCA) requires several stages of high quality medical care, both on-field and after hospital admission. Post-cardiac arrest shock can lead to severe neurological injury, resulting in poor recovery outcome and increased risk of death. These characteristics make this condition one of the most important issues to deal with in post-OHCA patients hospitalized in intensive care units (ICUs). Also, the majority of initial post-resuscitation survivors have underlying coronary diseases making revascularization procedure another crucial step in early management of these patients. Besides keeping myocardial blood flow at a satisfactory level, other tissues must not be neglected as well, and maintaining mean arterial pressure within optimal range is also preferable. All these procedures can be simplified to a certain level along with using targeted temperature management methods in order to decrease metabolic demands in ICU-hospitalized post-OHCA patients. Additionally, withdrawal of life-sustaining therapy as a controversial ethical topic is under constant re-evaluation due to its possible influence on overall mortality rates in patients initially surviving OHCA. Focusing on all of these important points in process of managing ICU patients is an imperative towards better survival and complete recovery rates.
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Affiliation(s)
- Srdjan S Nikolovski
- Pathology and Laboratory Medicine, Cardiovascular Research Institute, Loyola University Chicago Health Science Campus, Maywood, USA
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
| | - Aleksandra D Lazic
- Emergency Center, Clinical Center of Vojvodina, Novi Sad, SRB
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
| | - Zoran Z Fiser
- Emergency Medicine, Department of Emergency Medicine, Novi Sad, SRB
| | - Ivana A Obradovic
- Anesthesiology, Resuscitation, and Intensive Care, Sveti Vračevi Hospital, Bijeljina, BIH
| | - Jelena Z Tijanic
- Emergency Medicine, Municipal Institute of Emergency Medicine, Kragujevac, SRB
| | - Violetta Raffay
- School of Medicine, European University Cyprus, Nicosia, CYP
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
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5
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Tanaka Gutiez M, Beuchat I, Novy J, Ben-Hamouda N, Rossetti AO. Outcome of comatose patients following cardiac arrest: When mRS completes CPC. Resuscitation 2023; 192:109997. [PMID: 37827427 DOI: 10.1016/j.resuscitation.2023.109997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 10/05/2023] [Accepted: 10/06/2023] [Indexed: 10/14/2023]
Abstract
AIM Good outcome in patients following cardiac arrest (CA) is usually defined as Cerebral Performance Category (CPC) 1-2, while CPC 3 is debated, and CPC 4-5 represent poor outcome. We aimed to assess when the modified Rankin Scale (mRS) can improve CPC outcome description, especially in CPC 3. We further aimed to correlate neuron specific enolase (NSE) with both functional measures to explore their relationship with neuronal damage. METHODS Peak NSE within the first 48 hours, and CPC and mRS at 3 months were prospectively collected for 665 consecutive comatose adults following CA treated between April 2016 and April 2023. For each CPC category, mRS was described. We considered good outcome as mRS 1-3, in line with existing recommendations. CPC and mRS were correlated to peak serum NSE using non-parametric assessments. RESULTS CPC 1, 2, 4 and 5 correlated almost perfectly with mRS in terms of good and poor outcomes. However, CPC 3 was heterogeneously associated to the dichotomized mRS (53.1% had good outcome (mRS 0-3), 46.9% poor outcome (mRS 4-6)). NSE was strongly correlated with CPC (Spearman's rho 0.616, P < 0.001) and mRS (Spearman's rho 0.613, P < 0.001). CONCLUSION CPC and mRS correlate similarly with neuronal damage. Whilst CPC 1-2 and CPC 4-5 are strongly associated with mRS 0-3 and, respectively, with mRS 5-6, CPC 3 is heterogenous: both good and poor mRS scores are found within this category. Therefore, we suggest that the mRS should be routinely assessed in patients with CPC 3 to refine outcome description.
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Affiliation(s)
- Masumi Tanaka Gutiez
- Department of Neurology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland; Department of Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - Isabelle Beuchat
- Department of Neurology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Jan Novy
- Department of Neurology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Nawfel Ben-Hamouda
- Department of Adult Intensive Care Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Andrea O Rossetti
- Department of Neurology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
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6
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Yamamoto R, Tamura T, Haiden A, Yoshizawa J, Homma K, Kitamura N, Sugiyama K, Tagami T, Yasunaga H, Aso S, Takeda M, Sasaki J. Frailty and Neurologic Outcomes of Patients Resuscitated From Nontraumatic Out-of-Hospital Cardiac Arrest: A Prospective Observational Study. Ann Emerg Med 2023; 82:84-93. [PMID: 36964008 DOI: 10.1016/j.annemergmed.2023.02.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 02/01/2023] [Accepted: 02/09/2023] [Indexed: 03/26/2023]
Abstract
STUDY OBJECTIVE To elucidate the clinical utility of the Clinical Frailty Scale score for predicting poor neurologic functions in patients resuscitated from out-of-hospital cardiac arrest (OHCA). METHODS This was a prospective, multicenter, observational study conducted between 2019 and 2021. The study included adults with nontraumatic OHCA admitted to the intensive care unit after return of spontaneous circulation (ROSC). Pre-arrest high Clinical Frailty Scale score was defined as 5 or more. Favorable neurologic outcomes defined as a Cerebral Performance Category score of 2 or less at 30 days after admission were compared between patients with and without high Clinical Frailty Scale scores. Multivariable logistic regression analyses fitted with generalized estimating equations were performed to adjust for patient characteristics, out-of-hospital information, and resuscitation content and account for within-institution clustering. RESULTS Of 9,909 patients with OHCA during the study period, 1,216 were included, and 317 had a pre-arrest high Clinical Frailty Scale score. Favorable neurologic outcomes were fewer among patients with high Clinical Frailty Scale scores. The high Clinical Frailty Scale score group showed a lower percentage of favorable neurologic outcomes after OHCA than the low Clinical Frailty Scale score group (6.1% vs 24.4%; adjusted odds ratio, 0.45 [95% confidence interval 0.22 to 0.93]). This relationship remained in subgroups with cardiogenic OHCA, with ROSC after hospital arrival, and without a high risk of dying (Clinical Frailty Scale score of 7 or less), whereas the neurologic outcomes were comparable regardless of pre-arrest frailty in those with noncardiogenic OHCA and with ROSC before hospital arrival. CONCLUSIONS Pre-arrest high Clinical Frailty Scale score was associated with unfavorable neurologic functions among patients resuscitated from OHCA. The Clinical Frailty Scale score would help predict clinical consequences following intensive care after ROSC.
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Affiliation(s)
- Ryo Yamamoto
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan.
| | - Tomoyoshi Tamura
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Akina Haiden
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Jo Yoshizawa
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Koichiro Homma
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Nobuya Kitamura
- Department of Emergency and Critical Care Medicine, Kimitsu Chuo Hospital, Chiba, Japan
| | - Kazuhiro Sugiyama
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School Musashikosugi Hospital, Kanagawa, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Shotaro Aso
- Department of Biostatistics and Bioinformatics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Munekazu Takeda
- Department of Critical Care and Emergency Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
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Yanagawa Y, Takeuchi I, Nagasawa H, Ohsaka H, Ishikawa K. Outcome in intoxicated patients transported by a physician-staffed helicopter in Japan from 2015 to 2020. Acute Med Surg 2023; 10:e904. [PMID: 37929069 PMCID: PMC10622606 DOI: 10.1002/ams2.904] [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: 05/04/2023] [Revised: 09/22/2023] [Accepted: 10/10/2023] [Indexed: 11/07/2023] Open
Abstract
Aim We retrospectively investigated the current status of poisoned patients who had been transported by a physician-staffed helicopter emergency medical service and their final outcomes using data from the JAPAN DOCTOR HELICOPTER REGISTRY SYSTEM. Methods The following details of dispatch activity were collected from the database of the JAPAN DOCTOR HELICOPTER REGISTRY SYSTEM: patient age and sex, timing of dispatch request, presence of cardiac arrest, vital signs, medical intervention, main etiology of intoxication, and final outcome. The patients were divided into two groups: those with a good outcome and those with a poor outcome. The variables were compared between the two groups. Results A total of 336 patients were intoxicated. Psychotropic drug overdose was the dominant cause, followed by carbon monoxide and ethanol. The median Glasgow Coma Scale score was significantly higher in the good outcome group than in the poor outcome group. The rates of cardiac arrest, interventions to secure an airway and/or assist with ventilation, and drug administration were significantly lower in the good outcome group than in the poor outcome group. There were no records concerning the decontamination of the intoxicating substance at the scene or during air evacuation. Conclusion The study suggests that various factors may influence the outcomes of patients with different types of intoxication. These findings offer valuable insights that could help to establish effective treatment strategies and the operation of doctor helicopters for intoxicated patients.
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Affiliation(s)
- Youichi Yanagawa
- Department of Acute Critical Care Medicine, Shizuoka HospitalJuntendo UniversityIzunokuniJapan
| | - Ikuto Takeuchi
- Department of Acute Critical Care Medicine, Shizuoka HospitalJuntendo UniversityIzunokuniJapan
| | - Hiroki Nagasawa
- Department of Acute Critical Care Medicine, Shizuoka HospitalJuntendo UniversityIzunokuniJapan
| | - Hiromichi Ohsaka
- Department of Acute Critical Care Medicine, Shizuoka HospitalJuntendo UniversityIzunokuniJapan
| | - Kouhei Ishikawa
- Department of Acute Critical Care Medicine, Shizuoka HospitalJuntendo UniversityIzunokuniJapan
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8
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Aldujeli A, Haq A, Tecson KM, Kurnickaite Z, Lickunas K, Bailey S, Tatarunas V, Braukyliene R, Baksyte G, Aldujeili M, Khalifeh H, Briedis K, Ordiene R, Unikas R, Hamadeh A, Brilakis ES. A prospective observational study on impact of epinephrine administration route on acute myocardial infarction patients with cardiac arrest in the catheterization laboratory (iCPR study). Crit Care 2022; 26:393. [PMID: 36539907 PMCID: PMC9764590 DOI: 10.1186/s13054-022-04275-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 12/09/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Epinephrine is routinely utilized in cardiac arrest; however, it is unclear if the route of administration affects outcomes in acute myocardial infarction patients with cardiac arrest. OBJECTIVES To compare the efficacy of epinephrine administered via the peripheral intravenous (IV), central IV, and intracoronary (IC) routes. METHODS Prospective two-center pilot cohort study of acute myocardial infarction patients who suffered cardiac arrest in the cardiac catheterization laboratory during percutaneous coronary intervention. We compared the outcomes of patients who received epinephrine via peripheral IV, central IV, or IC. RESULTS 158 participants were enrolled, 48 (30.4%), 50 (31.6%), and 60 (38.0%) in the central IV, IC, and peripheral IV arms, respectively. Peripheral IV epinephrine administration route was associated with lower odds of achieving return of spontaneous circulation (ROSC, odds ratio = 0.14, 95% confidence interval = 0.05-0.36, p < 0.0001) compared with central IV and IC administration. (There was no difference between central IV and IC routes; p = 0.9343.) The odds of stent thrombosis were significantly higher with the IC route (IC vs. peripheral IV OR = 4.6, 95% CI = 1.5-14.3, p = 0.0094; IC vs. central IV OR = 6.0, 95% CI = 1.9-19.2, p = 0.0025). Post-ROSC neurologic outcomes were better for central IV and IC routes when compared with peripheral IV. CONCLUSION Epinephrine administration via central IV and IC routes was associated with a higher rate of ROSC and better neurologic outcomes compared with peripheral IV administration. IC administration was associated with a higher risk of stent thrombosis. Trial registration This trial is registered at NCT05253937 .
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Affiliation(s)
- Ali Aldujeli
- grid.48349.320000 0004 0575 8750Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Kaunas, Lithuania ,grid.45083.3a0000 0004 0432 6841Institute of Cardiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Ayman Haq
- Abbott Northwestern Hospital/Minneapolis Heart Institute Foundation, Minneapolis, MN USA
| | - Kristen M. Tecson
- grid.486749.00000 0004 4685 2620Baylor Scott & White Research Institute, Dallas, TX USA
| | - Zemyna Kurnickaite
- grid.48349.320000 0004 0575 8750Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Kaunas, Lithuania
| | - Karolis Lickunas
- grid.48349.320000 0004 0575 8750Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Kaunas, Lithuania
| | - Som Bailey
- Medical City Fort Worth, Fort Worth, TX USA
| | - Vacis Tatarunas
- grid.45083.3a0000 0004 0432 6841Institute of Cardiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | | | - Giedre Baksyte
- grid.48349.320000 0004 0575 8750Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Kaunas, Lithuania
| | | | | | - Kasparas Briedis
- grid.48349.320000 0004 0575 8750Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Kaunas, Lithuania
| | - Rasa Ordiene
- grid.48349.320000 0004 0575 8750Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Kaunas, Lithuania
| | - Ramunas Unikas
- grid.48349.320000 0004 0575 8750Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Kaunas, Lithuania
| | - Anas Hamadeh
- Texas Cardiovascular Institute, Fort Worth, TX USA
| | - Emmanouil S. Brilakis
- Abbott Northwestern Hospital/Minneapolis Heart Institute Foundation, Minneapolis, MN USA
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Elbadawi A, Sedhom R, Baig B, Mahana I, Thakker R, Gad M, Eid M, Nair A, Kayani W, Denktas A, Elgendy IY, Jneid H. Targeted Hypothermia vs Targeted Normothermia in Survivors of Cardiac Arrest: A Systematic Review and Meta-Analysis of Randomized Trials. Am J Med 2022; 135:626-633.e4. [PMID: 34958763 DOI: 10.1016/j.amjmed.2021.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 10/30/2021] [Accepted: 11/11/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND The role of targeted hypothermia in patients with coma after cardiac arrest has been challenged in a recent randomized clinical trial. METHODS We performed a computerized search of MEDLINE, EMBASE, and Cochrane databases through July 2021 for randomized trials evaluating the outcomes of targeted hypothermia vs normothermia in patients with coma after cardiac arrest with shockable or non-shockable rhythm. The main study outcome was mortality at the longest reported follow-up. RESULTS The final analysis included 8 randomized studies with a total of 2927 patients, with a weighted follow-up period of 4.9 months. The average targeted temperature in the hypothermia arm in the included trials varied from 31.7°C to 34°C. There was no difference in long-term mortality between the hypothermia and normothermia groups (56.2% vs 56.9%, risk ratio [RR] 0.96; 95% confidence interval [CI], 0.87-1.06). There was no significant difference between hypothermia and normothermia groups in rates of favorable neurological outcome (37.9% vs 34.2%, RR 1.31; 95% CI, 0.99-1.73), in-hospital mortality (RR 0.88; 95% CI, 0.77-1.01), bleeding, sepsis, or pneumonia. Ventricular arrhythmias were more common among the hypothermia vs normothermia groups (RR 1.36; 95% CI, 1.17-1.58; P = .42). Sensitivity analysis, excluding the Targeted Hypothermia vs Targeted Normothermia after Out-of-Hospital Cardiac Arrest (TTM2) trial, showed favorable neurological outcome with hypothermia vs normothermia (RR 1.45; 95% CI, 1.17-1.79). CONCLUSION Targeted temperature management was not associated with improved survival or neurological outcomes compared with normothermia in comatose patients after cardiac arrest. Further studies are warranted to further clarify the value of targeted hypothermia compared with targeted normothermia.
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Affiliation(s)
- Ayman Elbadawi
- Section of Cardiology, Baylor College of Medicine, Houston, Texas
| | - Ramy Sedhom
- Department of Internal Medicine, Einstein Medical Center, Philadelphia, Penn
| | - Basarat Baig
- Department of Pulmonary and Critical Care Medicine, Brown University, Providence, RI
| | - Ingy Mahana
- Department of Internal Medicine, Medstar Washington Hospital Center, Washington, DC
| | - Ravi Thakker
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas
| | - Mohamed Gad
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Mennallah Eid
- Department of Internal Medicine, Lincoln Medical Center, New York, NY
| | - Ajith Nair
- Section of Cardiology, Baylor College of Medicine, Houston, Texas
| | - Waleed Kayani
- Section of Cardiology, Baylor College of Medicine, Houston, Texas
| | - Ali Denktas
- Section of Cardiology, Baylor College of Medicine, Houston, Texas
| | - Islam Y Elgendy
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Hani Jneid
- Section of Cardiology, Baylor College of Medicine, Houston, Texas.
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10
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Kumar M, Perucki W, Hiendlmayr B, Mazigh S, O'Sullivan DM, Fernandez AB. The Association of Serum Magnesium Levels and QT Interval with Neurological Outcomes After Targeted Temperature Management. Ther Hypothermia Temp Manag 2022; 12:210-214. [PMID: 35467975 DOI: 10.1089/ther.2021.0038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Targeted temperature management (TTM) is associated with corrected QT (QTc) prolongation and decrease in serum magnesium (Mg) levels that may lead to recurrent ventricular arrhythmia and poor neurological outcomes. We aimed to evaluate the association between QTc interval and Mg levels during TTM with neurological outcomes. We reviewed the electrocardiograms of 366 patients who underwent TTM during the induction, maintenance, and rewarming phase after cardiac arrest. We reviewed the association of change in QTc interval, and Mg levels with neurological outcomes. In total, 71.3% of the patients had a significant increase in QTc interval defined as >60 ms or any QTc >500 ms during TTM. Poor neurological outcome was associated with persistent prolongation of QTc after rewarming (507 vs. 483 ms, p = 0.046) and higher Mg levels at presentation (2.08 ± 0.41 mg/dL, p = 0.014). Supplemental Mg did not have any significant change in their QTc. Patients with prolonged QTc during TTM should be promptly evaluated for QTc-prolonging factors given its association with worse neurological outcomes. The inverse correlation between Mg levels and poor neurological outcomes deserves further investigation.
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Affiliation(s)
- Manish Kumar
- Department of Medicine, Pat and Jim Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - William Perucki
- Department of Medicine, Pat and Jim Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington, Connecticut, USA.,Division of Cardiology, Hartford Hospital, Hartford, Connecticut, USA
| | - Brett Hiendlmayr
- Division of Cardiology, Hartford Hospital, Hartford, Connecticut, USA
| | - Silya Mazigh
- Department of Medicine, Pat and Jim Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - David M O'Sullivan
- Department of Research, Research Administration, Hartford HealthCare, Hartford, Connecticut, USA
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11
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Survivorship from Cardiac Arrest: Outcomes Uncensored by Withdrawal of Life Sustaining Therapy. Resuscitation 2022; 174:102-103. [DOI: 10.1016/j.resuscitation.2022.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 03/08/2022] [Indexed: 11/20/2022]
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12
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Kim HB, Nguyen HT, Jin Q, Tamby S, Gelaf Romer T, Sung E, Liu R, Greenstein JL, Suarez JI, Storm C, Winslow RL, Stevens RD. Computational Signatures for Post-Cardiac Arrest Trajectory Prediction: Importance of Early Physiological Time Series. Anaesth Crit Care Pain Med 2021; 41:101015. [PMID: 34968747 DOI: 10.1016/j.accpm.2021.101015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/19/2021] [Accepted: 11/22/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND There is an unmet need for timely and reliable prediction of post-cardiac arrest (CA) clinical trajectories. We hypothesized that physiological time series (PTS) data recorded on the first day of intensive care would contribute significantly to discrimination of outcomes at discharge. PATIENTS AND METHODS Adult patients in the multicenter eICU database who were mechanically ventilated after resuscitation from out-of-hospital CA were included. Outcomes of interest were survival, neurological status based on Glasgow motor subscore (mGCS) and surrogate functional status based on discharge location (DL), at hospital discharge. Three machine learning predictive models were trained, one with features from the electronic health records (EHR), the second using features derived from PTS collected in the first 24 hours after ICU admission (PTS24), and the third combining PTS24 and EHR. Model performances were compared, and the best performing model was externally validated in the MIMIC-III dataset. RESULTS Data from 2,216 admissions were included in the analysis. Discrimination of prediction models combining EHR and PTS24 features was higher than models using either EHR or PTS24 for prediction of survival (AUROC 0.83, 0.82 and 0.79 respectively), neurological outcome (0.87, 0.86 and 0.79 respectively), and DL (0.80, 0.78 and 0.76 respectively). External validation in MIMIC-III (n = 86) produced similar model performance. Feature analysis suggested prognostic significance of previously unknown EHR and PTS24 variables. CONCLUSION These results indicate that physiological data recorded in the early phase after CA resuscitation contain signatures that are linked to post-CA outcome. Additionally, they attest to the effectiveness of ML for post-CA predictive modeling.
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Affiliation(s)
- Han B Kim
- Department of Biomedical Engineering, Whiting School of Engineering, Johns Hopkins University, Baltimore, Maryland, USA; Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Hieu T Nguyen
- Department of Biomedical Engineering, Whiting School of Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Qingchu Jin
- Department of Biomedical Engineering, Whiting School of Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sharmila Tamby
- Department of Computer Science, Whiting School of Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Tatiana Gelaf Romer
- Department of Biomedical Engineering, Whiting School of Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Eric Sung
- Department of Biomedical Engineering, Whiting School of Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ran Liu
- Department of Biomedical Engineering, Whiting School of Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Joseph L Greenstein
- Department of Biomedical Engineering, Whiting School of Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jose I Suarez
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christian Storm
- Department of Nephrology and Intensive Care Medicine, Charité-Universitätsmedizin, Berlin, Germany
| | - Raimond L Winslow
- Department of Biomedical Engineering, Whiting School of Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Robert D Stevens
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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13
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Flickinger KL, Jaramillo S, Repine MJ, Koller AC, Holm M, Skidmore E, Callaway C, Rittenberger JC. One-year outcomes in individual domains of the cerebral performance category extended. Resusc Plus 2021; 8:100184. [PMID: 34934994 DOI: 10.1016/j.resplu.2021.100184] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 11/05/2021] [Accepted: 11/13/2021] [Indexed: 01/14/2023] Open
Abstract
Background Physical and cognitive impairments are common after cardiac arrest, and recovery varies. This study assessed recovery of individual domains of the Cerebral Performance Category- Extended (CPC-E) 1-year after cardiac arrest. We hypothesized patients would have recovery in all CPC-E domains 1-year after the index cardiac arrest. Methods Prospective cohort study of cardiac arrest survivors evaluating outcome measures mRS, CPC, and CPC-E. Outcomes were assessed at discharge, 3-months, 6-months, and 1-year. We defined recovery of a CPC-E domain when >90% of patients had scores of 1-2 in that domain. Results Of 156 patients discharged, 57 completed the CPC-E at discharge, and were included in the analysis. 37 patients had follow-up at 3-months, and 23 patients had follow-up at 6 and 12 months. Only 16 patients had assessments at all four timepoints. Domains of alertness (N = 56, 98%) logical thinking (N = 56; 98%), and attention (N = 55; 96%) recovered by hospital discharge. BADL (N = 34; 92%) and motor skills (N = 36; 97%) recovered by 3-months. Most patients (N = 20; 87%) experienced slight-to-no disability or symptoms (mRS 0-2/CPC 1-2) at 1-year follow up. CPC-E domains of short term memory (78%), mood (87%), fatigue (22%), complex ADL (78%), and return to work (65%) did not recover by 1-year. Conclusions CPC-E domains of alertness, logical thinking, and attention recover rapidly, while domains of short term memory, mood, fatigue, complex ADL and return to work remain chronically impaired 1-year after cardiac arrest. These deficits are not detected by mRS and CPC. Interventions to improve recovery in these domains are needed.
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Affiliation(s)
- Katharyn L Flickinger
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Stephany Jaramillo
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Melissa J Repine
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Allison C Koller
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Margo Holm
- Department of Occupational Therapy, University of Pittsburgh School of Health and Rehabilitation Sciences, Pittsburgh, PA, USA
| | - Elizabeth Skidmore
- Department of Occupational Therapy, University of Pittsburgh School of Health and Rehabilitation Sciences, Pittsburgh, PA, USA
| | - Clif Callaway
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jon C Rittenberger
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Occupational Therapy, University of Pittsburgh School of Health and Rehabilitation Sciences, Pittsburgh, PA, USA.,Department of Emergency Medicine, Guthrie Robert Packer Hospital, Sayre, PA, USA
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14
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Prognostication of patients in coma after cardiac arrest: Public perspectives. Resuscitation 2021; 169:4-10. [PMID: 34634358 DOI: 10.1016/j.resuscitation.2021.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 09/30/2021] [Accepted: 10/01/2021] [Indexed: 11/24/2022]
Abstract
AIM To elicit preferences for prognostic information, attitudes towards withdrawal of life-sustaining treatment (WLST) and perspectives on acceptable quality of life after post-anoxic coma within the adult general population of Germany, Italy, the Netherlands and the United States of America. METHODS A web-based survey, consisting of questions on respondent characteristics, perspectives on quality of life, communication of prognostic information, and withdrawal of life-sustaining treatment, was taken by adult respondents recruited from four countries. Statistical analysis included descriptive analysis and chi2-tests for differences between countries. RESULTS In total, 2012 respondents completed the survey. In each country, at least 84% indicated they would prefer to receive early prognostic information. If a poor outcome was predicted with some uncertainty, 37-54% of the respondents indicated that WLST was not to be allowed. A conscious state with severe physical and cognitive impairments was perceived as acceptable quality of life by 17-44% of the respondents. Clear differences between countries exist, including respondents from the U.S. being more likely to allow WLST than respondents from Germany (OR = 1.99, p < 0.001) or the Netherlands (OR = 1.74, p < 0.001) and preferring to stay alive in a conscious state with severe physical and cognitive impairments more than respondents from Italy (OR = 3.76, p < 0.001), Germany (OR = 2.21, p < 0.001), or the Netherlands (OR = 2.39, p < 0.001). CONCLUSIONS Over one-third of the respondents considered WLST unacceptable when there is any remaining prognostic uncertainty. Respondents had a more positive perspective on acceptable quality of life after coma than what is currently considered acceptable in medical literature. This indicates a need for a closer look at the practice of WLST based on prognostic information, to ensure responsible use of novel prognostic tests.
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15
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Neuroprognostication after Cardiac Arrest: Who Recovers? Who Progresses to Brain Death? Semin Neurol 2021; 41:606-618. [PMID: 34619784 DOI: 10.1055/s-0041-1733789] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Approximately 15% of deaths in developed nations are due to sudden cardiac arrest, making it the most common cause of death worldwide. Though high-quality cardiopulmonary resuscitation has improved overall survival rates, the majority of survivors remain comatose after return of spontaneous circulation secondary to hypoxic ischemic injury. Since the advent of targeted temperature management, neurologic recovery has improved substantially, but the majority of patients are left with neurologic deficits ranging from minor cognitive impairment to persistent coma. Of those who survive cardiac arrest, but die during their hospitalization, some progress to brain death and others die after withdrawal of life-sustaining treatment due to anticipated poor neurologic prognosis. Here, we discuss considerations neurologists must make when asked, "Given their recent cardiac arrest, how much neurologic improvement do we expect for this patient?"
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16
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Mertens M, van Til J, Bouwers-Beens E, Boenink M. Chasing Certainty After Cardiac Arrest: Can a Technological Innovation Solve a Moral Dilemma? NEUROETHICS-NETH 2021. [DOI: 10.1007/s12152-021-09473-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
AbstractWhen information on a coma patient’s expected outcome is uncertain, a moral dilemma arises in clinical practice: if life-sustaining treatment is continued, the patient may survive with unacceptably poor neurological prospects, but if withdrawn a patient who could have recovered may die. Continuous electroencephalogram-monitoring (cEEG) is expected to substantially improve neuroprognostication for patients in coma after cardiac arrest. This raises expectations that decisions whether or not to withdraw will become easier. This paper investigates that expectation, exploring cEEG’s impacts when it becomes part of a socio-technical network in an Intensive Care Unit (ICU). Based on observations in two ICUs in the Netherlands and one in the USA that had cEEG implemented for research, we interviewed 25 family members, healthcare professionals, and surviving patients. The analysis focuses on (a) the way patient outcomes are constructed, (b) the kind of decision support these outcomes provide, and (c) how cEEG affects communication between professionals and relatives. We argue that cEEG can take away or decrease the intensity of the dilemma in some cases, while increasing uncertainty for others. It also raises new concerns. Since its actual impacts furthermore hinge on how cEEG is designed and implemented, we end with recommendations for ensuring responsible development and implementation.
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17
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Schriefl C, Schoergenhofer C, Grafeneder J, Poppe M, Clodi C, Mueller M, Ettl F, Jilma B, Wallmueller P, Buchtele N, Weikert C, Losert H, Holzer M, Sterz F, Schwameis M. Prolonged Activated Partial Thromboplastin Time after Successful Resuscitation from Cardiac Arrest is Associated with Unfavorable Neurologic Outcome. Thromb Haemost 2020; 121:477-483. [PMID: 33186992 DOI: 10.1055/s-0040-1719029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Coagulation abnormalities after successful resuscitation from cardiac arrest may be associated with unfavorable neurologic outcome. We investigated a potential association of activated partial thromboplastin time (aPTT) with neurologic outcome in adult cardiac arrest survivors. Therefore, we included all adults ≥18 years of age who suffered a nontraumatic cardiac arrest and had achieved return of spontaneous circulation between January 2013 and December 2018. Patients receiving anticoagulants or thrombolytic therapy and those subjected to extracorporeal membrane oxygenation support were excluded. Routine blood sampling was performed on admission as soon as a vascular access was available. The primary outcome was 30-day neurologic function, assessed by the Cerebral Performance Category scale (3-5 = unfavorable neurologic function). Multivariable regression was used to assess associations between normal (≤41 seconds) and prolonged (>41 seconds) aPTT on admission (exposure) and the primary outcome. Results are given as odds ratio (OR) with 95% confidence intervals (95% CIs). Out of 1,591 cardiac arrest patients treated between 2013 and 2018, 360 patients (32% female; median age: 60 years [interquartile range: 48-70]) were eligible for analysis. A total of 263 patients (73%) had unfavorable neurologic function at day 30. aPTT prolongation >41 seconds was associated with a 190% increase in crude OR of unfavorable neurologic function (crude OR: 2.89; 95% CI: 1.78-4.68, p < 0.001) and with more than double the odds after adjustment for traditional risk factors (adjusted OR: 2.01; 95% CI: 1.13-3.60, p = 0.018). In conclusion, aPTT prolongation on admission is associated with unfavorable neurologic outcome after successful resuscitation from cardiac arrest.
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Affiliation(s)
| | | | - Juergen Grafeneder
- Department of Clinical Pharmacology, Medical University of Vienna, Austria
| | - Michael Poppe
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Christian Clodi
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Matthias Mueller
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Florian Ettl
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Austria
| | - Pia Wallmueller
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Nina Buchtele
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | | | - Heidrun Losert
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Michael Holzer
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Fritz Sterz
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Michael Schwameis
- Department of Emergency Medicine, Medical University of Vienna, Austria
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Baird A, Coppler PJ, Callaway CW, Dezfulian C, Flickinger KL, Elmer J. Rate of intra-arrest epinephrine administration and early post-arrest organ failure after in-hospital cardiac arrest. Resuscitation 2020; 156:15-18. [PMID: 32853724 DOI: 10.1016/j.resuscitation.2020.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 07/15/2020] [Accepted: 08/11/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Data supporting epinephrine administration during resuscitation of in-hospital cardiac arrest (IHCA) are limited. We hypothesized that more frequent epinephrine administration would predict greater early end-organ dysfunction and worse outcomes after IHCA. METHODS We performed a retrospective cohort study including patients resuscitated from IHCA at one of 67 hospitals between 2010 and 2019 who were ultimately cared for at a single tertiary care hospital. Our primary exposure of interest was rate of intra-arrest epinephrine bolus administration (mg/min). We considered several outcomes, including severity of early cardiovascular failure (modeled using Sequential Organ Failure Assessment (SOFA) cardiovascular subscore), early neurological and early global illness severity injury (modeled as Pittsburgh Cardiac Arrest Category (PCAC)). We used generalized linear models to test for independent associations between rate of epinephrine administration and outcomes. RESULTS We included 695 eligible patients. Mean age was 62 ± 15 years, 416 (60%) were male and 172 (26%) had an initial shockable rhythm. Median arrest duration was 16 [IQR 9-25] min, and median rate of epinephrine administration was 0.2 [IQR 0.1-0.3] mg/min. Higher rate of epinephrine predicted worse PCAC, and lower survival in patients with initial shockable rhythms. There was no association between rate of epinephrine and other outcomes. CONCLUSION Higher rates of epinephrine administration during IHCA are associated with more severe early global illness severity.
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Affiliation(s)
- Andrew Baird
- Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Patrick J Coppler
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Cameron Dezfulian
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Katharyn L Flickinger
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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Cardiac arrest survivors lost to follow-up after 3-Months, 6-Months and 1-Year. Resuscitation 2020; 150:8-16. [DOI: 10.1016/j.resuscitation.2020.02.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 01/30/2020] [Accepted: 02/17/2020] [Indexed: 11/15/2022]
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20
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Sawyer KN, Camp-Rogers TR, Kotini-Shah P, Del Rios M, Gossip MR, Moitra VK, Haywood KL, Dougherty CM, Lubitz SA, Rabinstein AA, Rittenberger JC, Callaway CW, Abella BS, Geocadin RG, Kurz MC. Sudden Cardiac Arrest Survivorship: A Scientific Statement From the American Heart Association. Circulation 2020; 141:e654-e685. [DOI: 10.1161/cir.0000000000000747] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Cardiac arrest systems of care are successfully coordinating community, emergency medical services, and hospital efforts to improve the process of care for patients who have had a cardiac arrest. As a result, the number of people surviving sudden cardiac arrest is increasing. However, physical, cognitive, and emotional effects of surviving cardiac arrest may linger for months or years. Systematic recommendations stop short of addressing partnerships needed to care for patients and caregivers after medical stabilization. This document expands the cardiac arrest resuscitation system of care to include patients, caregivers, and rehabilitative healthcare partnerships, which are central to cardiac arrest survivorship.
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21
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Unexpected cardiac arrests occurring inside the ICU: outcomes of a French prospective multicenter study. Intensive Care Med 2020; 46:1005-1015. [DOI: 10.1007/s00134-020-05992-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 02/26/2020] [Indexed: 11/30/2022]
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An international, consensus-derived Core Outcome Set for Cardiac Arrest effectiveness trials: the COSCA initiative. Curr Opin Crit Care 2020; 25:226-233. [PMID: 30925524 DOI: 10.1097/mcc.0000000000000612] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE OF REVIEW Accurate and relevant assessment is essential to determining the impact of ill-health and the relative benefit of healthcare. This review details the recent development of a core outcome set for cardiac arrest effectiveness trials - the COSCA initiative. RECENT FINDINGS The reported heterogeneity in outcome assessment and a lack of outcome reporting guidance were key triggers for the development of the COSCA. The historical failure of existing research to adequately capture the perspective of survivors and their family members in defining survival is described. Working collaboratively with international stakeholders - including survivors, family members and advocates - as research partners and participants ensured that a range of perspectives were considered throughout all stages of COSCA development. Three core domains and methods of assessment were recommended: survival - at 30 days or hospital discharge; neurological function assessed at 30 days or hospital discharge with the modified Rankin Scale; and health-related quality of life assessed at 90 days (as a minimum) with one of three generic measures. SUMMARY The COSCA recommendation describes a small group of outcomes that should be reported as a minimum across large, randomized clinical effectiveness trials for cardiac arrest.
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Geocadin RG, Callaway CW, Fink EL, Golan E, Greer DM, Ko NU, Lang E, Licht DJ, Marino BS, McNair ND, Peberdy MA, Perman SM, Sims DB, Soar J, Sandroni C. Standards for Studies of Neurological Prognostication in Comatose Survivors of Cardiac Arrest: A Scientific Statement From the American Heart Association. Circulation 2019; 140:e517-e542. [DOI: 10.1161/cir.0000000000000702] [Citation(s) in RCA: 153] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Significant improvements have been achieved in cardiac arrest resuscitation and postarrest resuscitation care, but mortality remains high. Most of the poor outcomes and deaths of cardiac arrest survivors have been attributed to widespread brain injury. This brain injury, commonly manifested as a comatose state, is a marker of poor outcome and a major basis for unfavorable neurological prognostication. Accurate prognostication is important to avoid pursuing futile treatments when poor outcome is inevitable but also to avoid an inappropriate withdrawal of life-sustaining treatment in patients who may otherwise have a chance of achieving meaningful neurological recovery. Inaccurate neurological prognostication leading to withdrawal of life-sustaining treatment and deaths may significantly bias clinical studies, leading to failure in detecting the true study outcomes. The American Heart Association Emergency Cardiovascular Care Science Subcommittee organized a writing group composed of adult and pediatric experts from neurology, cardiology, emergency medicine, intensive care medicine, and nursing to review existing neurological prognostication studies, the practice of neurological prognostication, and withdrawal of life-sustaining treatment. The writing group determined that the overall quality of existing neurological prognostication studies is low. As a consequence, the degree of confidence in the predictors and the subsequent outcomes is also low. Therefore, the writing group suggests that neurological prognostication parameters need to be approached as index tests based on relevant neurological functions that are directly related to the functional outcome and contribute to the quality of life of cardiac arrest survivors. Suggestions to improve the quality of adult and pediatric neurological prognostication studies are provided.
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Rittenberger JC. In search of a needle. Resuscitation 2018; 131:A5-A6. [DOI: 10.1016/j.resuscitation.2018.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 08/06/2018] [Indexed: 10/28/2022]
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Dhakar MB, Sivaraju A, Maciel CB, Youn TS, Gaspard N, Greer DM, Hirsch LJ, Gilmore EJ. Electro-clinical characteristics and prognostic significance of post anoxic myoclonus. Resuscitation 2018; 131:114-120. [PMID: 29964146 DOI: 10.1016/j.resuscitation.2018.06.030] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 06/21/2018] [Accepted: 06/27/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To systematically examine the electro-clinical characteristics of post anoxic myoclonus (PAM) and their prognostic implications in comatose cardiac arrest (CA) survivors. METHODS Fifty-nine CA survivors who developed myoclonus within 72 h of arrest and underwent continuous EEG monitoring were included in the study. Retrospective chart review was performed for all relevant clinical variables including time of PAM onset ("early onset" when within 24 h) and semiology (multi-focal, facial/ocular, whole body and limbs only). EEG findings including background, reactivity, epileptiform patterns and EEG correlate to myoclonus were reviewed at 6, 12, 24, 48 and 72 h after the return of spontaneous circulation (ROSC). Outcome was categorized as either with recovery of consciousness (Cerebral Performance Category (CPC) 1-3) or without recovery of consciousness (CPC 4-5) at the time of discharge. RESULTS Seven of the 59 patients (11.9%) regained consciousness, including 6/51 (11.8%) with early onset PAM. Patients with recovery of consciousness had shorter time to ROSC, and were more likely to have preserved brainstem reflexes and normal voltage background at all times. No patient with suppression burst or low voltage background (N = 52) at any point regained consciousness. In the subset where precise electro-clinical correlation was possible, all (5/5) those with recovery of consciousness had multi-focal myoclonus and most (4/5) had midline-maximal spikes over a continuous background. No patient with any other semiology (N = 21) regained consciousness. CONCLUSIONS Early onset PAM is not always associated with lack of recovery of consciousness. EEG can help discriminate between patients who may or may not regain consciousness by the time of hospital discharge.
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Affiliation(s)
- Monica B Dhakar
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA; Department of Neurology, Yale University School of Medicine, New Haven, CT, USA.
| | - Adithya Sivaraju
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Carolina B Maciel
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA; Department of Neurology, University of Florida, Gainesville, FL, USA
| | - Teddy S Youn
- Department of Neurology, University of Florida, Gainesville, FL, USA
| | - Nicolas Gaspard
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA; Department of Neurology, Université Libre de Bruxelles - Hôpital Erasme, Bruxelles, Belgium
| | - David M Greer
- Department of Neurology, Boston University, Boston, MA, USA
| | - Lawrence J Hirsch
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Emily J Gilmore
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
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COSCA (Core Outcome Set for Cardiac Arrest) in Adults: An Advisory Statement From the International Liaison Committee on Resuscitation. Resuscitation 2018; 127:147-163. [DOI: 10.1016/j.resuscitation.2018.03.022] [Citation(s) in RCA: 114] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Haywood K, Whitehead L, Nadkarni VM, Achana F, Beesems S, Böttiger BW, Brooks A, Castrén M, Ong ME, Hazinski MF, Koster RW, Lilja G, Long J, Monsieurs KG, Morley PT, Morrison L, Nichol G, Oriolo V, Saposnik G, Smyth M, Spearpoint K, Williams B, Perkins GD. COSCA (Core Outcome Set for Cardiac Arrest) in Adults: An Advisory Statement From the International Liaison Committee on Resuscitation. Circulation 2018; 137:e783-e801. [PMID: 29700122 DOI: 10.1161/cir.0000000000000562] [Citation(s) in RCA: 151] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cardiac arrest effectiveness trials have traditionally reported outcomes that focus on survival. A lack of consistency in outcome reporting between trials limits the opportunities to pool results for meta-analysis. The COSCA initiative (Core Outcome Set for Cardiac Arrest), a partnership between patients, their partners, clinicians, research scientists, and the International Liaison Committee on Resuscitation, sought to develop a consensus core outcome set for cardiac arrest for effectiveness trials. Core outcome sets are primarily intended for large, randomized clinical effectiveness trials (sometimes referred to as pragmatic trials or phase III/IV trials) rather than for pilot or efficacy studies. A systematic review of the literature combined with qualitative interviews among cardiac arrest survivors was used to generate a list of potential outcome domains. This list was prioritized through a Delphi process, which involved clinicians, patients, and their relatives/partners. An international advisory panel narrowed these down to 3 core domains by debate that led to consensus. The writing group refined recommendations for when these outcomes should be measured and further characterized relevant measurement tools. Consensus emerged that a core outcome set for reporting on effectiveness studies of cardiac arrest (COSCA) in adults should include survival, neurological function, and health-related quality of life. This should be reported as survival status and modified Rankin scale score at hospital discharge, at 30 days, or both. Health-related quality of life should be measured with ≥1 tools from Health Utilities Index version 3, Short-Form 36-Item Health Survey, and EuroQol 5D-5L at 90 days and at periodic intervals up to 1 year after cardiac arrest, if resources allow.
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Callaway CW. Improving Neurological, Functional, and Participatory Survival After Cardiac Arrest. Circ Cardiovasc Qual Outcomes 2018; 11:e004456. [DOI: 10.1161/circoutcomes.117.004456] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Clifton W. Callaway
- From the Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA
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Steinberg A, Rittenberger JC, Baldwin M, Faro J, Urban A, Zaher N, Callaway CW, Elmer J. Neurostimulant use is associated with improved survival in comatose patients after cardiac arrest regardless of electroencephalographic substrate. Resuscitation 2017; 123:38-42. [PMID: 29221942 DOI: 10.1016/j.resuscitation.2017.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 11/25/2017] [Accepted: 12/03/2017] [Indexed: 01/13/2023]
Abstract
AIM Identify EEG patterns that predict or preclude favorable response in comatose post-arrest patients receiving neurostimulants. METHODS We examined a retrospective cohort of consecutive electroencephalography (EEG)-monitored comatose post-arrest patients. We classified the last day of EEG recording before neurostimulant administration based on continuity (continuous/discontinuous), reactivity (yes/no) and malignant patterns (periodic discharges, suppression burst, myoclonic status epilepticus or seizures; yes/no). In subjects who did not receive neurostimulants, we examined the last 24h of available recording. For our primary analysis, we used logistic regression to identify EEG predictors of favorable response to treatment (awakening). RESULTS In 585 subjects, mean (SD) age was 57 (17) years and 227 (39%) were female. Forty-seven patients (8%) received a neurostimulant. Neurostimulant administration independently predicted improved survival to hospital discharge in the overall cohort (adjusted odds ratio (aOR) 4.00, 95% CI 1.68-9.52) although functionally favorable survival did not differ. No EEG characteristic predicted favorable response to neurostimulants. In each subgroup of unfavorable EEG characteristics, neurostimulants were associated with increased survival to hospital discharge (discontinuous background: 44% vs 7%, P=0.004; non-reactive background: 56% vs 6%, P<0.001; malignant patterns: 63% vs 5%, P<0.001). CONCLUSION EEG patterns described as ominous after cardiac arrest did not preclude survival or awakening after neurostimulant administration. These data are limited by their observational nature and potential for selection bias, but suggest that EEG patterns alone should not affect consideration of neurostimulant use.
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Affiliation(s)
- Alexis Steinberg
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, United States
| | - Jon C Rittenberger
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States.
| | - Maria Baldwin
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, United States; Department of Neurology, Pittsburgh VA Medical Center, Pittsburgh PA, United States
| | - John Faro
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Alexandra Urban
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, United States
| | - Naoir Zaher
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, United States
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States
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Beekman R, Greer DM, Maciel CB. Poor neurologic outcomes after cardiac arrest; a spectrum with individual implications. EPILEPSY & BEHAVIOR CASE REPORTS 2017; 8:85-86. [PMID: 29159067 PMCID: PMC5678751 DOI: 10.1016/j.ebcr.2017.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 08/17/2017] [Accepted: 08/24/2017] [Indexed: 12/28/2022]
Affiliation(s)
- Rachel Beekman
- Department of Neurology, Yale School of Medicine, New Haven, CT 06510, United States
| | - David M Greer
- Department of Neurology, Boston University School of Medicine, Boston, MA 02118, United States
| | - Carolina B Maciel
- Department of Neurology, UF-Health Shands Hospital, University of Florida College of Medicine, Gainesville, FL 32611, United States
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Neurologic Recovery After Cardiac Arrest: a Multifaceted Puzzle Requiring Comprehensive Coordinated Care. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2017; 19:52. [PMID: 28536893 DOI: 10.1007/s11936-017-0548-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OPINION STATEMENT Surviving cardiac arrest (CA) requires a longitudinal approach with multiple levels of responsibility, including fostering a culture of action by increasing public awareness and training, optimization of resuscitation measures including frequent updates of guidelines and their timely implementation into practice, and optimization of post-CA care. This clearly goes beyond resuscitation and targeted temperature management. Brain-directed physiologic goals should dictate the post-CA management, as accumulating evidence suggests that the degree of hypoxic brain injury is the main determinant of survival, regardless of the etiology of arrest. Early assessment of the need for further hemodynamic and electrophysiologic cardiac interventions, adjusting ventilator settings to avoid hyperoxia/hypoxia while targeting high-normal to mildly elevated PaCO2, maintaining mean arterial blood pressures >65 mmHg, evaluating for and treating seizures, maintaining euglycemia, and aggressively pursuing normothermia are key steps in reducing the bioenergetic failure that underlies secondary brain injury. Accurate neuroprognostication requires a multimodal approach with standardized assessments accounting for confounders while recognizing the importance of a delayed prognostication when there is any uncertainty regarding outcome. The concept of a highly specialized post-CA team with expertise in the management of post-CA syndrome (mindful of the brain-directed physiologic goals during the early post-resuscitation phase), TTM, and neuroprognostication, guiding the comprehensive care to the CA survivor, is likely cost-effective and should be explored by institutions that frequently care for these patients. Finally, providing tailored rehabilitation care with systematic reassessment of the needs and overall goals is key for increasing independence and improving quality-of-life in survivors, thereby also alleviating the burden on families. Emerging evidence from multicenter collaborations advances the field of resuscitation at an incredible pace, challenging previously well-established paradigms. There is no more room for "conventional wisdom" in saving the survivors of cardiac arrest.
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Grossestreuer AV, Abella BS, Sheak KR, Cinousis MJ, Perman SM, Leary M, Wiebe DJ, Gaieski DF. Inter-rater reliability of post-arrest cerebral performance category (CPC) scores. Resuscitation 2016; 109:21-24. [PMID: 27650863 DOI: 10.1016/j.resuscitation.2016.09.006] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 08/29/2016] [Accepted: 09/05/2016] [Indexed: 12/25/2022]
Abstract
PURPOSE Cerebral Performance Category (CPC) scores are often an outcome measure for post-arrest neurologic function, collected worldwide to compare performance, evaluate therapies, and formulate recommendations. At most institutions, no formal training is offered in their determination, potentially leading to misclassification. MATERIALS AND METHODS We identified 171 patients at 2 hospitals between 5/10/2005 and 8/31/2012 with two CPC scores at hospital discharge recorded independently - in an in-house quality improvement database and as part of a national registry. Scores were abstracted retrospectively from the same electronic medical record by two separate non-clinical researchers. These scores were compared to assess inter-rater reliability and stratified based on whether the score was concordant or discordant among reviewers to determine factors related to discordance. RESULTS Thirty-nine CPC scores (22.8%) were discordant (kappa: 0.66), indicating substantial agreement. When dichotomized into "favorable" neurologic outcome (CPC 1-2)/"unfavorable" neurologic outcome (CPC 3-5), 20 (11.7%) scores were discordant (kappa: 0.70), also indicating substantial agreement. Patients discharged home (as opposed to nursing/other care facility) and patients with suspected cardiac etiology of arrest were statistically more likely to have concordant scores. For the quality improvement database, patients with discordant scores had a statistically higher median CPC score than those with concordant scores. The registry had statistically lower median CPC score (CPC 1) than the quality improvement database (CPC 2); p<0.01 for statistical significance. CONCLUSIONS CPC scores have substantial inter-rater reliability, which is reduced in patients who have worse outcomes, have a non-cardiac etiology of arrest, and are discharged to a location other than home.
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Affiliation(s)
- Anne V Grossestreuer
- Center for Resuscitation Science, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, United States; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, United States; Leonard Davis Institute of Healthcare Economics, University of Pennsylvania, Philadelphia, PA, United States.
| | - Benjamin S Abella
- Center for Resuscitation Science, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Kelsey R Sheak
- Center for Resuscitation Science, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Marisa J Cinousis
- Center for Resuscitation Science, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Sarah M Perman
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, United States
| | - Marion Leary
- Center for Resuscitation Science, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, United States; School of Nursing, University of Pennsylvania, Philadelphia, PA, United States
| | - Douglas J Wiebe
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, United States
| | - David F Gaieski
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA, United States
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An intervention for cardiac arrest survivors with chronic fatigue: A feasibility study with preliminary outcomes. Resuscitation 2016; 105:109-15. [DOI: 10.1016/j.resuscitation.2016.05.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 04/26/2016] [Accepted: 05/22/2016] [Indexed: 12/17/2022]
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Computed tomography of the brain following out of hospital cardiac arrest: Neuro-prognostication or phrenology? Resuscitation 2016; 104:A3-4. [DOI: 10.1016/j.resuscitation.2016.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Accepted: 05/10/2016] [Indexed: 11/18/2022]
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Sawyer KN, Brown F, Christensen R, Damino C, Newman MM, Kurz MC. Surviving Sudden Cardiac Arrest: A Pilot Qualitative Survey Study of Survivors. Ther Hypothermia Temp Manag 2016; 6:76-84. [DOI: 10.1089/ther.2015.0031] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Kelly N. Sawyer
- Department of Emergency Medicine, Beaumont Health System, Royal Oak, Michigan
| | - Frances Brown
- Michigan School of Professional Psychology, Farmington Hills, Michigan
| | | | - Colleen Damino
- Michigan School of Professional Psychology, Farmington Hills, Michigan
| | - Mary M. Newman
- Sudden Cardiac Arrest Foundation, Pittsburgh, Pennsylvania
| | - Michael C. Kurz
- Department of Emergency Medicine, University of Alabama School of Medicine, Birmingham, Alabama
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Sawyer KN, Kurz MC. Assessing cardiac arrest beyond hospital discharge--We are only as "Good" as the outcomes we measure. Resuscitation 2015. [PMID: 26209415 DOI: 10.1016/j.resuscitation.2015.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Kelly N Sawyer
- Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, MI, United States.
| | - Michael C Kurz
- Department of Emergency Medicine, University of Alabama School of Medicine, Birmingham, AL, United States
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