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Hongo T, Naito H, Nasu M, Yumoto T, Kosaki Y, Yorifuji T, Hifumi T, Inoue A, Sakamoto T, Kuroda Y, Nakao A. Prognostic performance of gray-white matter ratio in adult out-of-hospital cardiac arrest patients after receiving extracorporeal cardiopulmonary resuscitation. Resuscitation 2024:110351. [PMID: 39098375 DOI: 10.1016/j.resuscitation.2024.110351] [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: 05/24/2024] [Revised: 07/27/2024] [Accepted: 07/29/2024] [Indexed: 08/06/2024]
Abstract
BACKGROUND Gray-to-white matter ratio (GWR), measured by computed tomography (CT), is commonly used to predict poor neurological outcomes after out-of-hospital cardiac arrest (OHCA). The prognostic performance of GWR in OHCA patients receiving extracorporeal cardiopulmonary resuscitation (ECPR) is not known. METHODS This study is a secondary analysis of data from the SAVE-J II registry, a retrospective, multicenter study. Participants were divided into four groups according to average GWR (aGWR) values ranging from 1.00 to 1.39, separated by 0.1 intervals. The aGWR values were calculated for bilateral basal ganglia, centrum semiovale, and high convexity obtained by head CT within 24 h after ECPR. Primary outcome was poor neurological outcomes at 30-day. RESULTS In total, 1,146 OHCA patients treated with ECPR were included in our analysis. Overall, participants with lower aGWR more likely had poor neurological outcomes, aGWR 1.00-1.09 (94.6%), aGWR 1.10-1-19 (87.8%), aGWR 1.20-1.29 (78.5%), and aGWR 1.30-1.39 (70.3%). Multivariable logistic regression showed that lower aGWR was associated with poor neurological outcome at 30-day, aGWR 1.30-1.39: reference, aGWR 1.00-1.09: adjusted odds ratio (aOR) 10.01 (95% confidence interval (CI) [3.58-27.99]), aGWR 1.10-1.19: aOR 4.83 (95% CI [2.31-10.12]), aGWR 1.20-1.29: aOR 2.16 (95% CI [1.02-4.55]). Receiver operating characteristic curve analysis revealed that the prognostic performance of aGWR had an area under the curve of 0.628, 95% CI [0.59-0.66]). The aGWR threshold of 1.005 for predicting poor neurological outcome reached 100% specificity with 0.1% sensitivity. CONCLUSION Early neuro-prognostication depending on GWR may not be sufficient after ECPR and requires a multimodal approach.
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Affiliation(s)
- Takashi Hongo
- Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Department of Emergency, Critical Care, and Disaster Medicine, 2-5-1 Shikata, Kita, Okayama, 700-8558, Japan
| | - Hiromichi Naito
- Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Department of Emergency, Critical Care, and Disaster Medicine, 2-5-1 Shikata, Kita, Okayama, 700-8558, Japan.
| | - Michitaka Nasu
- Department of Emergency and Critical Care Medicine, Urasoe General Hospital, 1-56-1,Maeda, Urasoe, Okinawa Japan
| | - Tetsuya Yumoto
- Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Department of Emergency, Critical Care, and Disaster Medicine, 2-5-1 Shikata, Kita, Okayama, 700-8558, Japan
| | - Yoshinori Kosaki
- Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Department of Emergency, Critical Care, and Disaster Medicine, 2-5-1 Shikata, Kita, Okayama, 700-8558, Japan
| | - Takashi Yorifuji
- Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Department of Epidemiology, 2-5-1 Shikata, Kita, Okayama, 700-8558, Japan
| | - Toru Hifumi
- St. Luke's International Hospital, Department of Emergency and Critical Care Medicine, Akashi, Chuo, Tokyo, 104-8560, Japan
| | - Akihiko Inoue
- Hyogo Emergency Medical Center, Department of Emergency and Critical Care Medicine, 1-3-1 Wakihamakaigandori, Chuo, Kobe, Hyogo, 651-0073, Japan
| | - Tetsuya Sakamoto
- Teikyo University School of Medicine, Department of Emergency Medicine, 2-11-1 Kaga, Itabashi, Tokyo, 173-8606, Japan
| | - Yasuhiro Kuroda
- Kagawa University Hospital, Department of Emergency, Disaster, and Critical Care Medicine, 1750-1 Ikenobe, Miki, Kita, Kagawa, 761-0793, Japan
| | - Atsunori Nakao
- Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Department of Emergency, Critical Care, and Disaster Medicine, 2-5-1 Shikata, Kita, Okayama, 700-8558, Japan
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Senay B, Ibekwe E, Gokun Y, Elmer J, Hinduja A. Clinical Factors Associated With Mode of Death Following Cardiac Arrest. Am J Crit Care 2024; 33:290-297. [PMID: 38945819 DOI: 10.4037/ajcc2024145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
BACKGROUND Death after resuscitation from cardiac arrest is common. Although associated factors have been identified, knowledge about their relationship with specific modes of death is limited. OBJECTIVE To identify clinical factors associated with specific modes of death following cardiac arrest. METHODS This study involved a retrospective medical record review of patients admitted to a single health care center from January 2015 to March 2020 after resuscitation from cardiac arrest who died during their index hospitalization. Mode of death was categorized as either brain death, withdrawal of life-sustaining therapies due to neurologic causes, death due to medical causes, or withdrawal of life-sustaining therapies due to patient preference. Clinical characteristics across modes of death were compared. RESULTS The analysis included 731 patients. Death due to medical causes was the most common mode of death. Compared with the other groups of patients, those with brain death were younger, had fewer comorbidities, were more likely to have experienced unwitnessed and longer cardiac arrest, and had more severe acidosis and hyperglycemia on presentation. Patients who died owing to medical causes or withdrawal of life-sustaining therapies due to patient preference were older and had more comorbidities, fewer unfavorable cardiac arrest characteristics, and fewer days between cardiac arrest and death. CONCLUSIONS Significant associations were found between several clinical characteristics and specific mode of death following cardiac arrest. Decision-making regarding withdrawal of care after resuscitation from cardiac arrest should be based on a multimodal approach that takes account of a variety of personal and clinical factors.
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Affiliation(s)
- Blake Senay
- Blake Senay is a neurocritical care fellow, The Ohio State University, Columbus
| | - Elochukwu Ibekwe
- Elochukwu Ibekwe is a neurology resident, The Ohio State University, Columbus
| | - Yevgeniya Gokun
- Yevgeniya Gokun is a senior biostatistician, Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University
| | - Jonathan Elmer
- Jonathan Elmer is an associate professor, Department of Emergency Medicine, Critical Care Medicine, and Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Archana Hinduja
- Archana Hinduja is an associate professor, Department of Neurocritical Care, The Ohio State University
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Steinberg A. Emergent Management of Hypoxic-Ischemic Brain Injury. Continuum (Minneap Minn) 2024; 30:588-610. [PMID: 38830064 DOI: 10.1212/con.0000000000001426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE This article outlines interventions used to improve outcomes for patients with hypoxic-ischemic brain injury after cardiac arrest. LATEST DEVELOPMENTS Emergent management of patients after cardiac arrest requires prevention and treatment of primary and secondary brain injury. Primary brain injury is minimized by excellent initial resuscitative efforts. Secondary brain injury prevention requires the detection and correction of many pathophysiologic processes that may develop in the hours to days after the initial arrest. Key physiologic parameters important to secondary brain injury prevention include optimization of mean arterial pressure, cerebral perfusion, oxygenation and ventilation, intracranial pressure, temperature, and cortical hyperexcitability. This article outlines recent data regarding the treatment and prevention of secondary brain injury. Different patients likely benefit from different treatment strategies, so an individualized approach to treatment and prevention of secondary brain injury is advisable. Clinicians must use multimodal sources of data to prognosticate outcomes after cardiac arrest while recognizing that all prognostic tools have shortcomings. ESSENTIAL POINTS Neurologists should be involved in the postarrest care of patients with hypoxic-ischemic brain injury to improve their outcomes. Postarrest care requires nuanced and patient-centered approaches to the prevention and treatment of primary and secondary brain injury and neuroprognostication.
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Beekman R, Gilmore EJ. Cerebral edema following cardiac arrest: Are all shades of gray equal? Resuscitation 2024; 198:110213. [PMID: 38636600 DOI: 10.1016/j.resuscitation.2024.110213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 04/05/2024] [Indexed: 04/20/2024]
Affiliation(s)
- Rachel Beekman
- Department of Neurology, Yale School of Medicine, New Haven, CT, United States.
| | - Emily J Gilmore
- Department of Neurology, Yale School of Medicine, New Haven, CT, United States
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Ratay C, Elmer J, Callaway CW, Flickinger KL, Coppler PJ. Brain computed tomography after resuscitation from in-hospital cardiac arrest. Resuscitation 2024; 198:110181. [PMID: 38492716 DOI: 10.1016/j.resuscitation.2024.110181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 03/05/2024] [Accepted: 03/08/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND Few data characterize the role of brain computed tomography (CT) after resuscitation from in-hospital cardiac arrest (IHCA). We hypothesized that identifying a neurological etiology of arrest or cerebral edema on brain CT are less common after IHCA than after resuscitation from out-of-hospital cardiac arrest (OHCA). METHODS We included all patients comatose after resuscitation from IHCA or OHCA in this retrospective cohort analysis. We abstracted patient and arrest clinical characteristics, as well as pH and lactate, to estimate systemic illness severity. Brain CT characteristics included quantitative measurement of the grey-to-white ratio (GWR) at the level of the basal ganglia and qualitative assessment of sulcal and cisternal effacement. We compared GWR distribution by stratum (no edema ≥1.30, mild-to-moderate <1.30 and >1.20, severe ≤1.20) and newly identified neurological arrest etiology between IHCA and OHCA groups. RESULTS We included 2,306 subjects, of whom 420 (18.2%) suffered IHCA. Fewer IHCA subjects underwent post-arrest brain CT versus OHCA subjects (149 (35.5%) vs 1,555 (82.4%), p < 0.001). Cerebral edema for IHCA versus OHCA was more often absent (60.1% vs. 47.5%) or mild-to-moderate (34.3% vs. 27.9%) and less often severe (5.6% vs. 24.6%). A neurological etiology of arrest was identified on brain CT in 0.5% of IHCA versus 3.2% of OHCA. CONCLUSIONS Although severe edema was less frequent in IHCA relative to OHCA, mild-to-moderate or severe edema occurred in one in three patients after IHCA. Unsuspected neurological etiologies of arrest were rarely discovered by CT scan in IHCA patients.
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Affiliation(s)
- Cecelia Ratay
- 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
| | - Clifton W Callaway
- Department of Emergency 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
| | - Patrick J Coppler
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Hirsch KG, Abella BS, Amorim E, Bader MK, Barletta JF, Berg K, Callaway CW, Friberg H, Gilmore EJ, Greer DM, Kern KB, Livesay S, May TL, Neumar RW, Nolan JP, Oddo M, Peberdy MA, Poloyac SM, Seder D, Taccone FS, Uzendu A, Walsh B, Zimmerman JL, Geocadin RG. Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement from the American Heart Association and Neurocritical Care Society. Neurocrit Care 2024; 40:1-37. [PMID: 38040992 PMCID: PMC10861627 DOI: 10.1007/s12028-023-01871-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 06/08/2023] [Indexed: 12/03/2023]
Abstract
The critical care management of patients after cardiac arrest is burdened by a lack of high-quality clinical studies and the resultant lack of high-certainty evidence. This results in limited practice guideline recommendations, which may lead to uncertainty and variability in management. Critical care management is crucial in patients after cardiac arrest and affects outcome. Although guidelines address some relevant topics (including temperature control and neurological prognostication of comatose survivors, 2 topics for which there are more robust clinical studies), many important subject areas have limited or nonexistent clinical studies, leading to the absence of guidelines or low-certainty evidence. The American Heart Association Emergency Cardiovascular Care Committee and the Neurocritical Care Society collaborated to address this gap by organizing an expert consensus panel and conference. Twenty-four experienced practitioners (including physicians, nurses, pharmacists, and a respiratory therapist) from multiple medical specialties, levels, institutions, and countries made up the panel. Topics were identified and prioritized by the panel and arranged by organ system to facilitate discussion, debate, and consensus building. Statements related to postarrest management were generated, and 80% agreement was required to approve a statement. Voting was anonymous and web based. Topics addressed include neurological, cardiac, pulmonary, hematological, infectious, gastrointestinal, endocrine, and general critical care management. Areas of uncertainty, areas for which no consensus was reached, and future research directions are also included. Until high-quality studies that inform practice guidelines in these areas are available, the expert panel consensus statements that are provided can advise clinicians on the critical care management of patients after cardiac arrest.
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Affiliation(s)
| | | | - Edilberto Amorim
- San Francisco-Weill Institute for Neurosciences, University of California, San Francisco, USA
| | - Mary Kay Bader
- Providence Mission Hospital Nursing Center of Excellence/Critical Care Services, Mission Viejo, USA
| | | | | | | | | | | | | | - Karl B Kern
- Sarver Heart Center, University of Arizona, Tucson, USA
| | | | | | | | - Jerry P Nolan
- Warwick Medical School, University of Warwick, Coventry, UK
- Royal United Hospital, Bath, UK
| | - Mauro Oddo
- CHUV-Lausanne University Hospital, Lausanne, Switzerland
| | | | | | | | | | - Anezi Uzendu
- St. Luke's Mid America Heart Institute, Kansas City, USA
| | - Brian Walsh
- University of Texas Medical Branch School of Health Sciences, Galveston, USA
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7
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Hirsch KG, Abella BS, Amorim E, Bader MK, Barletta JF, Berg K, Callaway CW, Friberg H, Gilmore EJ, Greer DM, Kern KB, Livesay S, May TL, Neumar RW, Nolan JP, Oddo M, Peberdy MA, Poloyac SM, Seder D, Taccone FS, Uzendu A, Walsh B, Zimmerman JL, Geocadin RG. Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement From the American Heart Association and Neurocritical Care Society. Circulation 2024; 149:e168-e200. [PMID: 38014539 PMCID: PMC10775969 DOI: 10.1161/cir.0000000000001163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
The critical care management of patients after cardiac arrest is burdened by a lack of high-quality clinical studies and the resultant lack of high-certainty evidence. This results in limited practice guideline recommendations, which may lead to uncertainty and variability in management. Critical care management is crucial in patients after cardiac arrest and affects outcome. Although guidelines address some relevant topics (including temperature control and neurological prognostication of comatose survivors, 2 topics for which there are more robust clinical studies), many important subject areas have limited or nonexistent clinical studies, leading to the absence of guidelines or low-certainty evidence. The American Heart Association Emergency Cardiovascular Care Committee and the Neurocritical Care Society collaborated to address this gap by organizing an expert consensus panel and conference. Twenty-four experienced practitioners (including physicians, nurses, pharmacists, and a respiratory therapist) from multiple medical specialties, levels, institutions, and countries made up the panel. Topics were identified and prioritized by the panel and arranged by organ system to facilitate discussion, debate, and consensus building. Statements related to postarrest management were generated, and 80% agreement was required to approve a statement. Voting was anonymous and web based. Topics addressed include neurological, cardiac, pulmonary, hematological, infectious, gastrointestinal, endocrine, and general critical care management. Areas of uncertainty, areas for which no consensus was reached, and future research directions are also included. Until high-quality studies that inform practice guidelines in these areas are available, the expert panel consensus statements that are provided can advise clinicians on the critical care management of patients after cardiac arrest.
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8
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Srinivasan V, Hall J, Wahlster S, Johnson NJ, Branch K. Associations between clinical characteristics of cardiac arrest and early CT head findings of hypoxic ischaemic brain injury following out-of-hospital cardiac arrest. Resuscitation 2023; 190:109858. [PMID: 37270091 DOI: 10.1016/j.resuscitation.2023.109858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/23/2023] [Accepted: 05/25/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND/OBJECTIVE Post-cardiac arrest patients are vulnerable to hypoxic-ischaemic brain injury (HIBI), but HIBI may not be identified until computed tomography (CT) scan of the brain is obtained post-resuscitation and stabilization. We aimed to evaluate the association of clinical arrest characteristics with early CT findings of HIBI to identify those at the highest risk for HIBI. METHODS This is a retrospective analysis of out-of-hospital cardiac arrest (OHCA) patients who underwent whole-body imaging. Head CT reports were analyzed with an emphasis on findings suggestive of HIBI; HIBI was present if any of the following were noted on the neuroradiologist read: global cerebral oedema, sulcal effacement, blurred grey-white junction, and ventricular compression. The primary exposure was duration of cardiac arrest. Secondary exposures included age, cardiac vs noncardiac etiology, and witnessed vs unwitnessed arrest. The primary outcome was CT findings of HIBI. RESULTS A total of 180 patients (average age 54 years, 32% female, 71% White, 53% witnessed arrest, 32% cardiac etiology of arrest, mean CPR duration of 15 ± 10 minutes) were included in this analysis. CT findings of HIBI were seen in 47 (48.3%) patients. Multivariate logistic regression demonstrated a significant association between CPR duration and HIBI (adjusted OR = 1.1, 95% CI 1.01-1.11, p < 0.01). CONCLUSION Signs of HIBI are commonly seen on CT head within 6 hours of OHCA, occurring in approximately half of patients, and are associated with CPR duration. Determining risk factors for abnormal CT findings can help clinically identify patients at higher risk for HIBI and target interventions appropriately.
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Affiliation(s)
- Vasisht Srinivasan
- Department of Emergency Medicine, University of Washington School of Medicine, United States.
| | - Jane Hall
- Department of Emergency Medicine, University of Washington School of Medicine, United States
| | - Sarah Wahlster
- Department of Neurology, University of Washington School of Medicine, United States; Department of Neurosurgery, University of Washington School of Medicine, United States; Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, United States
| | - Nicholas J Johnson
- Department of Emergency Medicine, University of Washington School of Medicine, United States; Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington School of Medicine, United States
| | - Kelley Branch
- Department of Medicine, Division of Cardiology, University of Washington School of Medicine, United States
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9
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Tam J, Soufleris C, Ratay C, Frisch A, Elmer J, Case N, Flickinger KL, Callaway CW, Coppler PJ. Diagnostic yield of computed tomography after non-traumatic out-of-hospital cardiac arrest. Resuscitation 2023; 189:109898. [PMID: 37422167 DOI: 10.1016/j.resuscitation.2023.109898] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/20/2023] [Accepted: 06/29/2023] [Indexed: 07/10/2023]
Abstract
AIM Determine the frequency with which computed tomography (CT) after out-of-hospital cardiac arrest (OHCA) identifies clinically important findings. METHODS We included non-traumatic OHCA patients treated at a single center from February 2019 to February 2021. Clinical practice was to obtain CT head in comatose patients. Additionally, CT of the cervical spine, chest, abdomen, and pelvis were obtained if clinically indicated. We identified CT imaging obtained within 24 hours of emergency department (ED) arrival and summarized radiology findings. We used descriptive statistics to summarize population characteristics and imaging results, report their frequencies and, post hoc, compared time from ED arrival to catheterization between patients who did and did not undergo CT. RESULTS We included 597 subjects, of which 491 (82.2%) had a CT obtained. Time to CT was 4.1 hours [2.8-5.7]. Most (n = 480, 80.4%) underwent CT head, of which 36 (7.5%) had intracranial hemorrhage and 161 (33.5%) had cerebral edema. Fewer subjects (230, 38.5%) underwent a cervical spine CT, and 4 (1.7%) had acute vertebral fractures. Most subjects (410, 68.7%) underwent a chest CT, and abdomen and pelvis CT (363, 60.8%). Chest CT abnormalities included rib or sternal fractures (227, 55.4%), pneumothorax (27, 6.6%), aspiration or pneumonia (309, 75.4%), mediastinal hematoma (18, 4.4%) and pulmonary embolism (6, 3.7%). Significant abdomen and pelvis findings were bowel ischemia (24, 6.6%) and solid organ laceration (7, 1.9%). Most subjects that had CT imaging deferred were awake and had shorter time to catheterization. CONCLUSIONS CT identifies clinically important pathology after OHCA.
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Affiliation(s)
- Jonathan Tam
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Christopher Soufleris
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Cecelia Ratay
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Adam Frisch
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jonathan Elmer
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Nicholas Case
- Department of Emergency 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
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Patrick J Coppler
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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10
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Penketh J, Nolan JP. Post-Cardiac Arrest Syndrome. J Neurosurg Anesthesiol 2023; 35:260-264. [PMID: 37192474 DOI: 10.1097/ana.0000000000000921] [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: 03/18/2023] [Accepted: 04/06/2023] [Indexed: 05/18/2023]
Abstract
Post-cardiac arrest syndrome (PCAS) is a multicomponent entity affecting many who survive an initial period of resuscitation following cardiac arrest. This focussed review explores some of the strategies for mitigating the effects of PCAS following the return of spontaneous circulation. We consider the current evidence for controlled oxygenation, strategies for blood-pressure targets, the timing of coronary reperfusion, and the evidence for temperature control and treatment of seizures. Despite several large trials investigating specific strategies to improve outcomes after cardiac arrest, many questions remain unanswered. Results of some studies suggest that interventions may benefit specific subgroups of cardiac arrest patients, but the optimal timing and duration of many interventions remain unknown. The role of intracranial pressure monitoring has been the subject of only a few studies, and its benefits remain unclear. Research aimed at improving the management of PCAS is ongoing.
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Affiliation(s)
| | - Jerry P Nolan
- Intensive care unit, Royal United Hospital, Bath
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
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11
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Coppler PJ, Elmer J, Doshi A, Guyette FX, Okubo M, Ratay C, Frisch AN, Steinberg A, Weissman A, Arias V, Drumheller BC, Flickinger KL, Faro J, Schmidhofer M, Rhinehart ZJ, Hansra BS, Fong-Isariyawongse J, Barot N, Baldwin ME, Murat Kaynar A, Darby JM, Shutter LA, Mettenburg J, Callaway CW. Duration of cardiopulmonary resuscitation and phenotype of post-cardiac arrest brain injury. Resuscitation 2023; 188:109823. [PMID: 37164175 DOI: 10.1016/j.resuscitation.2023.109823] [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: 02/24/2023] [Revised: 04/17/2023] [Accepted: 05/01/2023] [Indexed: 05/12/2023]
Abstract
BACKGROUND Patients resuscitated from cardiac arrest have variable severity of primary hypoxic ischemic brain injury (HIBI). Signatures of primary HIBI on brain imaging and electroencephalography (EEG) include diffuse cerebral edema and burst suppression with identical bursts (BSIB). We hypothesize distinct phenotypes of primary HIBI are associated with increasing cardiopulmonary resuscitation (CPR) duration. METHODS We identified from our prospective registry of both in-and out-of-hospital CA patients treated between January 2010 to January 2020 for this cohort study. We abstracted CPR duration, neurological examination, initial brain computed tomography gray to white ratio (GWR), and initial EEG pattern. We considered four phenotypes on presentation: awake; comatose with neither BSIB nor cerebral edema (non-malignant coma); BSIB; and cerebral edema (GWR ≤ 1.20). BSIB and cerebral edema were considered as non-mutually exclusive outcomes. We generated predicted probabilities of brain injury phenotype using localized regression. RESULTS We included 2,440 patients, of whom 545 (23%) were awake, 1,065 (44%) had non-malignant coma, 548 (23%) had BSIB and 438 (18%) had cerebral edema. Only 92 (4%) had both BSIB and edema. Median CPR duration was 16 [IQR 8-28] minutes. Median CPR duration increased in a stepwise manner across groups: awake 6 [3-13] minutes; non-malignant coma 15 [8-25] minutes; BSIB 21 [13-31] minutes; cerebral edema 32 [22-46] minutes. Predicted probability of phenotype changes over time. CONCLUSIONS Brain injury phenotype is related to CPR duration, which is a surrogate for severity of HIBI. The sequence of most likely primary HIBI phenotype with progressively longer CPR duration is awake, coma without BSIB or edema, BSIB, and finally cerebral edema.
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Affiliation(s)
- Patrick J Coppler
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ankur Doshi
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Masashi Okubo
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Cecelia Ratay
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Adam N Frisch
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Alexis Steinberg
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Alexandra Weissman
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Valerie Arias
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Byron C Drumheller
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - John Faro
- Department of Medicine, Soin Medical Center - Kettering Health, Beavercreek, OH, USA
| | - Mark Schmidhofer
- Department of Medicine, Division of Cardiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Zachary J Rhinehart
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Barinder S Hansra
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Medicine, Division of Cardiology, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Niravkumar Barot
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Maria E Baldwin
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - A Murat Kaynar
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joseph M Darby
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Lori A Shutter
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joseph Mettenburg
- Department of Radiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
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Elmer J, Kurz MC, Coppler PJ, Steinberg A, DeMasi S, De-Arteaga M, Simon N, Zadorozny VI, Flickinger KL, Callaway CW. Time to Awakening and Self-Fulfilling Prophecies After Cardiac Arrest. Crit Care Med 2023; 51:503-512. [PMID: 36752628 PMCID: PMC10023349 DOI: 10.1097/ccm.0000000000005790] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
OBJECTIVES Withdrawal of life-sustaining therapies for perceived poor neurologic prognosis (WLST-N) is common after resuscitation from cardiac arrest and may bias outcome estimates from models trained using observational data. We compared several approaches to outcome prediction with the goal of identifying strategies to quantify and reduce this bias. DESIGN Retrospective observational cohort study. SETTING Two academic medical centers ("UPMC" and "University of Alabama Birmingham" [UAB]). PATIENTS Comatose adults resuscitated from cardiac arrest. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS As potential predictors, we considered clinical, laboratory, imaging, and quantitative electroencephalography data available early after hospital arrival. We followed patients until death, discharge, or awakening from coma. We used penalized Cox regression with a least absolute shrinkage and selection operator penalty and five-fold cross-validation to predict time to awakening in UPMC patients and then externally validated the model in UAB patients. This model censored patients after WLST-N, considering subsequent potential for awakening to be unknown. Next, we developed a penalized logistic model predicting awakening, which treated failure to awaken after WLST-N as a true observed outcome, and a separate logistic model predicting WLST-N. We scaled and centered individual patients' Cox and logistic predictions for awakening to allow direct comparison and then explored the difference in predictions across probabilities of WLST-N. Overall, 1,254 patients were included, and 29% awakened. Cox models performed well (mean area under the curve was 0.93 in the UPMC test sets and 0.83 in external validation). Logistic predictions of awakening were systematically more pessimistic than Cox-based predictions for patients at higher risk of WLST-N, suggesting potential for self-fulfilling prophecies to arise when failure to awaken after WLST-N is considered as the ground truth outcome. CONCLUSIONS Compared with traditional binary outcome prediction, censoring outcomes after WLST-N may reduce potential for bias and self-fulfilling prophecies.
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Affiliation(s)
- 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
| | - Michael C. Kurz
- Department of Emergency Medicine, University of Alabama-Birmingham Birmingham Alabama USA
- Department of Surgery, Division of Acute Care Surgery, University of Alabama-Birmingham Birmingham Alabama USA
- Center for Injury Science, University of Alabama-Birmingham Birmingham Alabama USA
| | - Patrick J Coppler
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA USA
| | - Alexis Steinberg
- 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
| | - Stephanie DeMasi
- Department of Emergency Medicine, Virginia Comonwealth University, Richmond, Virginia, USA
| | - Maria De-Arteaga
- Information, Risk and Operations Management Department, McCombs School of Business, University of Texas at Austin, Austin, TX USA
| | - Noah Simon
- Department of Biostatistics, University of Washington School of Public Health, Seattle, WA USA
| | | | - Katharyn L. Flickinger
- 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
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Aoki T, Wong V, Endo Y, Hayashida K, Takegawa R, Okuma Y, Shoaib M, Miyara SJ, Yin T, Becker LB, Shinozaki K. Bio-physiological susceptibility of the brain, heart, and lungs to systemic ischemia reperfusion and hyperoxia-induced injury in post-cardiac arrest rats. Sci Rep 2023; 13:3419. [PMID: 36854715 PMCID: PMC9974929 DOI: 10.1038/s41598-023-30120-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 02/15/2023] [Indexed: 03/02/2023] Open
Abstract
Cardiac arrest (CA) patients suffer from systemic ischemia-reperfusion (IR) injury leading to multiple organ failure; however, few studies have focused on tissue-specific pathophysiological responses to IR-induced oxidative stress. Herein, we investigated biological and physiological parameters of the brain and heart, and we particularly focused on the lung dysfunction that has not been well studied to date. We aimed to understand tissue-specific susceptibility to oxidative stress and tested how oxygen concentrations in the post-resuscitation setting would affect outcomes. Rats were resuscitated from 10 min of asphyxia CA. Mechanical ventilation was initiated at the beginning of cardiopulmonary resuscitation. We examined animals with or without CA, and those were further divided into the animals exposed to 100% oxygen (CA_Hypero) or those with 30% oxygen (CA_Normo) for 2 h after resuscitation. Biological and physiological parameters of the brain, heart, and lungs were assessed. The brain and lung functions were decreased after CA and resuscitation indicated by worse modified neurological score as compared to baseline (222 ± 33 vs. 500 ± 0, P < 0.05), and decreased PaO2 (20 min after resuscitation: 113 ± 9 vs. baseline: 128 ± 9 mmHg, P < 0.05) and increased airway pressure (2 h: 10.3 ± 0.3 vs. baseline: 8.1 ± 0.2 mmHg, P < 0.001), whereas the heart function measured by echocardiography did not show significant differences compared before and after CA (ejection fraction, 24 h: 77.9 ± 3.3% vs. baseline: 82.2 ± 1.9%, P = 0.2886; fractional shortening, 24 h: 42.9 ± 3.1% vs. baseline: 45.7 ± 1.9%, P = 0.4658). Likewise, increases of superoxide production in the brain and lungs were remarkable, while those in the heart were moderate. mRNA gene expression analysis revealed that CA_Hypero group had increases in Il1b as compared to CA_Normo group significantly in the brain (P < 0.01) and lungs (P < 0.001) but not the heart (P = 0.4848). Similarly, hyperoxia-induced increases in other inflammatory and apoptotic mRNA gene expression were observed in the brain, whereas no differences were found in the heart. Upon systemic IR injury initiated by asphyxia CA, hyperoxia-induced injury exacerbated inflammation/apoptosis signals in the brain and lungs but might not affect the heart. Hyperoxia following asphyxia CA is more damaging to the brain and lungs but not the heart.
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Affiliation(s)
- Tomoaki Aoki
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Vanessa Wong
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Yusuke Endo
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Kei Hayashida
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Ryosuke Takegawa
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Yu Okuma
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Department of Neurosurgery, Sonoda Daiichi Hospital, Tokyo, Japan
| | - Muhammad Shoaib
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, NY, USA
| | - Santiago J Miyara
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Tai Yin
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Lance B Becker
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, NY, USA
| | - Koichiro Shinozaki
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA.
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, NY, USA.
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Hinduja A, Gokun Y, Ibekwe E, Senay B, Elmer J. Risk factors for development of cerebral edema following cardiac arrest. Resuscitation 2022; 181:297-303. [PMID: 36280215 DOI: 10.1016/j.resuscitation.2022.10.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 10/13/2022] [Accepted: 10/15/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Cerebral edema following cardiac arrest is a well-known complication of resuscitation and portends a poor outcome. We identified predictors of post-cardiac arrest cerebral edema and tested the association of cerebral edema with discharge outcome. METHODS We performed a retrospective chart review including patients admitted at a single center between January 2015-March 2020 following resuscitation from in-hospital and out-of-hospital cardiac arrest who had head computed tomography imaging. Our primary outcome was moderate-to-severe cerebral edema, which we defined as loss of grey-white differentiation with effacement of the basal and ambient cisterns and radiographic evidence of uncal herniation. We used logistic regression to test associations of demographic information, clinical predictors and comorbidities with moderate-severe cerebral edema. RESULTS We identified 727 patients who met the inclusion criteria, of whom 102 had moderate-to-severe cerebral edema. We identified six independent predictors of moderate-to-severe cerebral edema: younger age, prolonged arrest duration, pulseless electrical activity/asystole as initial rhythm, unwitnessed cardiac arrest, hyperglycemia on admission, and lower Glasgow coma score on presentation. Of patients with moderate-to-severe cerebral edema, 2% survived to discharge, 56% had withdrawal of life-sustaining therapies and 42% progressed to death by neurological criteria. CONCLUSIONS Our study identified several risk factors associated with the development of cerebral edema following cardiac arrest. Further studies are needed to determine the benefits of early interventions in these high-risk patients.
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Affiliation(s)
- Archana Hinduja
- Department of Neurology, The Ohio State University, Columbus, OH, United States.
| | - Yevgeniya Gokun
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University, Columbus, OH, United States
| | - Elochukwu Ibekwe
- Department of Neurology, The Ohio State University, Columbus, OH, United States
| | - Blake Senay
- Department of Neurology, The Ohio State University, Columbus, OH, United States
| | - Jonathan Elmer
- Department of Emergency Medicine, Critical Care Medicine and Neurology, University of Pittsburgh, PA, United States
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15
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Seder DB, Ryzhov S. Therapeutic opportunities for cerebral edema after resuscitation. Resuscitation 2022; 181:168-169. [PMID: 36423738 DOI: 10.1016/j.resuscitation.2022.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 11/14/2022] [Indexed: 11/23/2022]
Affiliation(s)
- David B Seder
- Maine Medical Center Department of Critical Care Services, Portland, ME, USA; MaineHealth Institute for Research, Scarborough, ME, USA
| | - Sergey Ryzhov
- Maine Medical Center Department of Critical Care Services, Portland, ME, USA; MaineHealth Institute for Research, Scarborough, ME, USA
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16
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Brain-Lung Crosstalk: Management of Concomitant Severe Acute Brain Injury and Acute Respiratory Distress Syndrome. Curr Treat Options Neurol 2022; 24:383-408. [PMID: 35965956 PMCID: PMC9363869 DOI: 10.1007/s11940-022-00726-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2022] [Indexed: 12/15/2022]
Abstract
Purpose of Review To summarize pathophysiology, key conflicts, and therapeutic approaches in managing concomitant severe acute brain injury (SABI) and acute respiratory distress syndrome (ARDS). Recent Findings ARDS is common in SABI and independently associated with worse outcomes in all SABI subtypes. Most landmark ARDS trials excluded patients with SABI, and evidence to guide decisions is limited in this population. Potential areas of conflict in the management of patients with both SABI and ARDS are (1) risk of intracranial pressure (ICP) elevation with high levels of positive end-expiratory pressure (PEEP), permissive hypercapnia due to lung protective ventilation (LPV), or prone ventilation; (2) balancing a conservative fluid management strategy with ensuring adequate cerebral perfusion, particularly in patients with symptomatic vasospasm or impaired cerebrovascular blood flow; and (3) uncertainty about the benefit and harm of corticosteroids in this population, with a mortality benefit in ARDS, increased mortality shown in TBI, and conflicting data in other SABI subtypes. Also, the widely adapted partial pressure of oxygen (PaO2) target of > 55 mmHg for ARDS may exacerbate secondary brain injury, and recent guidelines recommend higher goals of 80–120 mmHg in SABI. Distinct pathophysiology and trajectories among different SABI subtypes need to be considered. Summary The management of SABI with ARDS is highly complex, and conventional ARDS management strategies may result in increased ICP and decreased cerebral perfusion. A crucial aspect of concurrent management is to recognize the risk of secondary brain injury in the individual patient, monitor with vigilance, and adjust management during critical time windows. The care of these patients requires meticulous attention to oxygenation and ventilation, hemodynamics, temperature management, and the neurological exam. LPV and prone ventilation should be utilized, and supplemented with invasive ICP monitoring if there is concern for cerebral edema and increased ICP. PEEP titration should be deliberate, involving measures of hemodynamic, pulmonary, and brain physiology. Serial volume status assessments should be performed in SABI and ARDS, and fluid management should be individualized based on measures of brain perfusion, the neurological exam, and cardiopulmonary status. More research is needed to define risks and benefits in corticosteroids in this population.
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17
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Kulpanowski AM, Copen WA, Hancock BL, Rosenthal ES, Schoenfeld DA, Dodelson JA, Edlow BL, Kimberly WT, Amorim E, Westover MB, Ning MM, Schaefer PW, Malhotra R, Giacino JT, Greer DM, Wu O. Severe cerebral edema in substance-related cardiac arrest patients. Resuscitation 2022; 173:103-111. [PMID: 35149137 PMCID: PMC9282938 DOI: 10.1016/j.resuscitation.2022.01.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 01/01/2022] [Accepted: 01/31/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Studies of neurologic outcomes have found conflicting results regarding differences between patients with substance-related cardiac arrests (SRCA) and non-SRCA. We investigate the effects of SRCA on severe cerebral edema development, a neuroimaging intermediate endpoint for neurologic injury. METHODS 327 out-of-hospital comatose cardiac arrest patients were retrospectively analyzed. Demographics and baseline clinical characteristics were examined. SRCA categorization was based on admission toxicology screens. Severe cerebral edema classification was based on radiology reports. Poor clinical outcomes were defined as discharge Cerebral Performance Category scores > 3. RESULTS SRCA patients (N = 86) were younger (P < 0.001), and more likely to have non-shockable rhythms (P < 0.001), be unwitnessed (P < 0.001), lower Glasgow Coma Scale scores (P < 0.001), absent brainstem reflexes (P < 0.05) and develop severe cerebral edema (P < 0.001) than non-SRCA patients (N = 241). Multivariable analyses found younger age (P < 0.001), female sex (P = 0.008), non-shockable rhythm (P = 0.01) and SRCA (P = 0.05) to be predictors of severe cerebral edema development. Older age (P < 0.001), non-shockable rhythm (P = 0.02), severe cerebral edema (P < 0.001), and absent pupillary light reflexes (P = 0.004) were predictors of poor outcomes. SRCA patients had higher proportion of brain deaths (P < 0.001) compared to non-SRCA patients. CONCLUSIONS SRCA results in higher rates of severe cerebral edema development and brain death. The absence of statistically significant differences in discharge outcomes or survival between SRCA and non-SRCA patients may be related to the higher rate of withdrawal of life-sustaining treatment (WLST) in the non-SRCA group. Future neuroprognostic studies may opt to include neuroimaging markers as intermediate measures of neurologic injury which are not influenced by WLST decisions.
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Affiliation(s)
- Annelise M Kulpanowski
- Athinoula A Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA, United States
| | - William A Copen
- Department of Radiology, Massachusetts General Hospital, Boston, MA, United States
| | - Brandon L Hancock
- Athinoula A Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA, United States
| | - Eric S Rosenthal
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - David A Schoenfeld
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, United States
| | - Jacob A Dodelson
- Athinoula A Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA, United States
| | - Brian L Edlow
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - W Taylor Kimberly
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Edilberto Amorim
- Department of Neurology, University of California San Francisco, San Francisco, CA, United States
| | - M Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Ming Ming Ning
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Pamela W Schaefer
- Department of Radiology, Massachusetts General Hospital, Boston, MA, United States
| | - Rajeev Malhotra
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, United States
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA, United States
| | - David M Greer
- Department of Neurology, Boston University and Boston Medical Center, Boston, MA, United States
| | - Ona Wu
- Athinoula A Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA, United States.
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Zhou F, Wang H, Jian M, Wang Z, He Y, Duan H, Gan L, Cao Y. Gray-White Matter Ratio at the Level of the Basal Ganglia as a Predictor of Neurologic Outcomes in Cardiac Arrest Survivors: A Literature Review. Front Med (Lausanne) 2022; 9:847089. [PMID: 35372375 PMCID: PMC8967346 DOI: 10.3389/fmed.2022.847089] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 02/09/2022] [Indexed: 02/05/2023] Open
Abstract
Loss of gray-white matter discrimination is the primary early imaging finding within of cranial computed tomography in cardiac arrest survivors, and this has been also regarded as a novel predictor for evaluating neurologic outcome. As displayed clearly on computed tomography and based on sensitivity to hypoxia, the gray-white matter ratio at basal ganglia (GWR-BG) region was frequently detected to assess the neurologic outcome by several studies. The specificity of GWR-BG is 72.4 to 100%, while the sensitivity is significantly different. Herein we review the mechanisms mediating cerebral edema following cardiac arrest, demonstrate the determination procedures with respect to GWR-BG, summarize the related researches regarding GWR-BG in predicting neurologic outcomes within cardiac arrest survivors, and discuss factors associated with predicting the accuracy of this methodology. Finally, we describe the effective measurements to increase the sensitivity of GWR-BG in predicting neurologic outcome.
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Affiliation(s)
- Fating Zhou
- Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Hongxia Wang
- Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Mengyao Jian
- Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Zhiyuan Wang
- Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Yarong He
- Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Haizhen Duan
- Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Lu Gan
- Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Yu Cao
- Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, China
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Elmer J, Liu C, Pease M, Arefan D, Coppler PJ, Flickinger K, Mettenburg JM, Baldwin ME, Barot N, Wu S. Deep learning of early brain imaging to predict post-arrest electroencephalography. Resuscitation 2022; 172:17-23. [PMID: 35041875 PMCID: PMC8923981 DOI: 10.1016/j.resuscitation.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 01/05/2022] [Accepted: 01/06/2022] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Guidelines recommend use of computerized tomography (CT) and electroencephalography (EEG) in post-arrest prognostication. Strong associations between CT and EEG might obviate the need to acquire both modalities. We quantified these associations via deep learning. METHODS We performed a single-center, retrospective study including comatose patients hospitalized after cardiac arrest. We extracted brain CT DICOMs, resized and registered each to a standard anatomical atlas, performed skull stripping and windowed images to optimize contrast of the gray-white junction. We classified initial EEG as generalized suppression, other highly pathological findings or benign activity. We extracted clinical information available on presentation from our prospective registry. We trained three machine learning (ML) models to predict EEG from clinical covariates. We used three state-of-the-art approaches to build multi-headed deep learning models using similar model architectures. Finally, we combined the best performing clinical and imaging models. We evaluated discrimination in test sets. RESULTS We included 500 patients, of whom 218 (44%) had benign EEG findings, 135 (27%) showed generalized suppression and 147 (29%) had other highly pathological findings that were most commonly (93%) burst suppression with identical bursts. Clinical ML models had moderate discrimination (test set AUCs 0.73-0.80). Image-based deep learning performed worse (test set AUCs 0.51-0.69), particularly discriminating benign from highly pathological findings. Adding image-based deep learning to clinical models improved prediction of generalized suppression due to accurate detection of severe cerebral edema. DISCUSSION CT and EEG provide complementary information about post-arrest brain injury. Our results do not support selective acquisition of only one of these modalities, except in the most severely injured patients.
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Affiliation(s)
- 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; Neurology Division, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Chang Liu
- Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Matthew Pease
- Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Dooman Arefan
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Patrick J. Coppler
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Katharyn Flickinger
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Joseph M. Mettenburg
- Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Maria E. Baldwin
- Department of Neurology, Pittsburgh VA Medical Center, Pittsburgh, PA, USA
| | - Niravkumar Barot
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Shandong Wu
- Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, PA, USA,Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA,Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, USA,Intelligent Systems Program, University of Pittsburgh, Pittsburgh, PA, USA
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Schick A, Prekker ME, Kempainen RR, Mulder M, Moore J, Evans D, Hall J, Rodinm H, Larson J, Caraganis A. Association of hypoxic ischemic brain injury on early CT after out of hospital cardiac arrest with neurologic outcome. Am J Emerg Med 2022; 54:257-262. [DOI: 10.1016/j.ajem.2022.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 01/28/2022] [Accepted: 02/02/2022] [Indexed: 02/02/2023] Open
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Abstract
PURPOSE OF REVIEW Most patients who are successfully resuscitated after cardiac arrest are initially comatose and require mechanical ventilation and other organ support in an ICU. Knowledge about the optimal strategy for treating these patients is evolving rapidly. This review will summarize the evidence on key aspects of postarrest care and prognostication, with a focus on actionable parameters that may impact patient survival and neurologic outcomes. RECENT FINDINGS Optimal targets for arterial blood oxygen and carbon dioxide in comatose postcardiac arrest patients remain uncertain. Observational data are conflicting and the few randomized controlled trials to date have failed to show that different ranges of blood oxygen and carbon dioxide values impact on biomarkers of neurological injury. The Targeted Temperature Management 2 (TTM-2) trial has documented no difference in 6-month mortality among comatose postcardiac arrest patients managed at 33 oC versus controlled normothermia. An extensive systematic review of the evidence on prognostication of outcome among comatose postcardiac arrest patients underpins new prognostication guidelines. SUMMARY Clinical guidelines for postresuscitation care have recently been updated and incorporate all the available science supporting the treatment of postcardiac arrests. At a minimum, fever should be strictly avoided in comatose postcardiac patients. Prognostication must involve multiple modalities and should not be attempted until assessment confounders have been sufficiently excluded.
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Richter J, Sklienka P, Chatterjee N, Maca J, Zahorec R, Burda M. Elevated jugular venous oxygen saturation after cardiac arrest. Resuscitation 2021; 169:214-219. [PMID: 34678332 DOI: 10.1016/j.resuscitation.2021.10.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 09/28/2021] [Accepted: 10/08/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND We performed a retrospective analysis of our earlier study on cerebral oxygenation monitoring by jugular venous oximetry (SjvO2) in patients of out-of-hospital cardiac arrest (OHCA). The study was focused on high SjvO2 values (≥75%) and their association with neurological outcomes and serum neuron-specific enolase (NSE) concentration. METHOD Forty OHCA patients were divided into (i) high (Group I), (ii) normal (Group II), and (iii) low (Group III) SjvO2, with the mean SjvO2 ≥ 75%, 55-74% and <55% respectively. The neurological outcome was evaluated using the Cerebral Performance Category scale (CPC) on the 90th day after cardiac arrest (post-CA). NSE concentration was determined after ICU admission and then at 24, 48, and 72 hours (h) post-CA. RESULTS High mean SjvO2 occurred in 67% of patients, while no patients had low mean SjvO2. The unfavourable outcome was significantly more common in Group I than Group II (74% versus 23%, p < 0.01). Group I patients had significantly higher median NSE than Group II at 48 and 72 h post-CA. A positive correlation was found between SjvO2 and PaCO2. Each 1 kPa increase in CO2 led to an increase of SjvO2 by 2.2 %+/-0.66 (p < 0.01) in group I and by 5.7%+/-1.36 (p < 0.0001) in group II. There was no correlation between SjvO2 and MAP or SjvO2 and PaO2. CONCLUSION High mean SjvO2 are often associated with unfavourable outcomes and high NSE at 48 and 72 hours post-CA. Not only low but also high SjvO2 values may require therapeutic intervention.
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Affiliation(s)
- Jaromir Richter
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Ostrava, Ostrava, Czech Republic.
| | - Peter Sklienka
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Ostrava, Ostrava, Czech Republic
| | - Nilay Chatterjee
- Department of Anaesthetics, Yeovil Hospital, Yeovil, United Kingdom
| | - Jan Maca
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Ostrava, Ostrava, Czech Republic; Department of Intensive Care Medicine and Forensic Studies, Institute of Physiology and Pathophysiology Faculty Of Medicine, University of Ostrava, Czech Republic
| | - Roman Zahorec
- Second Department of Anesthesiology and Intensive Medicine, Medical School, Comenius University, Bratislava, Slovak Republic
| | - Michal Burda
- Institute for Research and Applications of Fuzzy Modeling, University of Ostrava, Czech Republic
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23
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Perkins GD, Callaway CW, Haywood K, Neumar RW, Lilja G, Rowland MJ, Sawyer KN, Skrifvars MB, Nolan JP. Brain injury after cardiac arrest. Lancet 2021; 398:1269-1278. [PMID: 34454687 DOI: 10.1016/s0140-6736(21)00953-3] [Citation(s) in RCA: 94] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 04/20/2021] [Accepted: 04/20/2021] [Indexed: 12/16/2022]
Abstract
As more people are surviving cardiac arrest, focus needs to shift towards improving neurological outcomes and quality of life in survivors. Brain injury after resuscitation, a common sequela following cardiac arrest, ranges in severity from mild impairment to devastating brain injury and brainstem death. Effective strategies to minimise brain injury after resuscitation include early intervention with cardiopulmonary resuscitation and defibrillation, restoration of normal physiology, and targeted temperature management. It is important to identify people who might have a poor outcome, to enable informed choices about continuation or withdrawal of life-sustaining treatments. Multimodal prediction guidelines seek to avoid premature withdrawal in those who might survive with a good neurological outcome, or prolonging treatment that might result in survival with severe disability. Approximately one in three admitted to intensive care will survive, many of whom will need intensive, tailored rehabilitation after discharge to have the best outcomes.
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Affiliation(s)
- Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK; Critical Care Unit, University Hospitals Birmingham, Birmingham, UK.
| | - Clifton W Callaway
- University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Robert W Neumar
- Department of Emergency Medicine, Michigan Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor, MI, USA
| | - Gisela Lilja
- Neurology, Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Lund, Sweden
| | - Matthew J Rowland
- Kadoorie Centre for Critical Care Research, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Kelly N Sawyer
- University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jerry P Nolan
- Warwick Medical School, University of Warwick, Coventry, UK; Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK
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24
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Wiklund L, Sharma A, Patnaik R, Muresanu DF, Sahib S, Tian ZR, Castellani RJ, Nozari A, Lafuente JV, Sharma HS. Upregulation of hemeoxygenase enzymes HO-1 and HO-2 following ischemia-reperfusion injury in connection with experimental cardiac arrest and cardiopulmonary resuscitation: Neuroprotective effects of methylene blue. PROGRESS IN BRAIN RESEARCH 2021; 265:317-375. [PMID: 34560924 DOI: 10.1016/bs.pbr.2021.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Oxidative stress plays an important role in neuronal injuries after cardiac arrest. Increased production of carbon monoxide (CO) by the enzyme hemeoxygenase (HO) in the brain is induced by the oxidative stress. HO is present in the CNS in two isoforms, namely the inducible HO-1 and the constitutive HO-2. Elevated levels of serum HO-1 occurs in cardiac arrest patients and upregulation of HO-1 in cardiac arrest is seen in the neurons. However, the role of HO-2 in cardiac arrest is not well known. In this review involvement of HO-1 and HO-2 enzymes in the porcine brain following cardiac arrest and resuscitation is discussed based on our own observations. In addition, neuroprotective role of methylene blue- an antioxidant dye on alterations in HO under in cardiac arrest is also presented. The biochemical findings of HO-1 and HO-2 enzymes using ELISA were further confirmed by immunocytochemical approach to localize selective regional alterations in cardiac arrest. Our observations are the first to show that cardiac arrest followed by successful cardiopulmonary resuscitation results in significant alteration in cerebral concentrations of HO-1 and HO-2 levels indicating a prominent role of CO in brain pathology and methylene blue during CPR followed by induced hypothermia leading to superior neuroprotection after return of spontaneous circulation (ROSC), not reported earlier.
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Affiliation(s)
- Lars Wiklund
- International Experimental Central Nervous System Injury & Repair (IECNSIR), Department of Surgical Sciences, Anesthesiology & Intensive Care Medicine, Uppsala University Hospital, Uppsala University, Uppsala, Sweden
| | - Aruna Sharma
- International Experimental Central Nervous System Injury & Repair (IECNSIR), Department of Surgical Sciences, Anesthesiology & Intensive Care Medicine, Uppsala University Hospital, Uppsala University, Uppsala, Sweden.
| | - Ranjana Patnaik
- Department of Biomaterials, School of Biomedical Engineering, Indian Institute of Technology, Banaras Hindu University, Varanasi, India
| | - Dafin F Muresanu
- Department of Clinical Neurosciences, University of Medicine & Pharmacy, Cluj-Napoca, Romania; "RoNeuro" Institute for Neurological Research and Diagnostic, Cluj-Napoca, Romania
| | - Seaab Sahib
- Department of Chemistry & Biochemistry, University of Arkansas, Fayetteville, AR, United States
| | - Z Ryan Tian
- Department of Chemistry & Biochemistry, University of Arkansas, Fayetteville, AR, United States
| | - Rudy J Castellani
- Department of Pathology, University of Maryland, Baltimore, MD, United States
| | - Ala Nozari
- Anesthesiology & Intensive Care, Massachusetts General Hospital, Boston, MA, United States
| | - José Vicente Lafuente
- LaNCE, Department of Neuroscience, University of the Basque Country (UPV/EHU), Leioa, Bizkaia, Spain
| | - Hari Shanker Sharma
- International Experimental Central Nervous System Injury & Repair (IECNSIR), Department of Surgical Sciences, Anesthesiology & Intensive Care Medicine, Uppsala University Hospital, Uppsala University, Uppsala, Sweden.
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25
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Azeli Y, Bardají A, Barbería E, Lopez-Madrid V, Bladé-Creixenti J, Fernández-Sender L, Bonet G, Rica E, Álvarez S, Fernández A, Axelsson C, Jiménez-Herrera MF. Clinical outcomes and safety of passive leg raising in out-of-hospital cardiac arrest: a randomized controlled trial. Crit Care 2021; 25:176. [PMID: 34034775 PMCID: PMC8152146 DOI: 10.1186/s13054-021-03593-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 04/30/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND There are data suggesting that passive leg raising (PLR) improves hemodynamics during cardiopulmonary resuscitation (CPR). This trial aimed to determine the effectiveness and safety of PLR during CPR in out-of-hospital cardiac arrest (OHCA). METHODS We conducted a randomized controlled trial with blinded assessment of the outcomes that assigned adults OHCA to be treated with PLR or in the flat position. The trial was conducted in the Camp de Tarragona region. The main end point was survival to hospital discharge with good neurological outcome defined as cerebral performance category (CPC 1-2). To study possible adverse effects, we assessed the presence of pulmonary complications on the first chest X-rays, brain edema on the computerized tomography (CT) in survivors and brain and lungs weights from autopsies in non-survivors. RESULTS In total, 588 randomized cases were included, 301 were treated with PLR and 287 were controls. Overall, 67.8% were men and the median age was 72 (IQR 60-82) years. At hospital discharge, 3.3% in the PLR group and 3.5% in the control group were alive with CPC 1-2 (OR 0.9; 95% CI 0.4-2.3, p = 0.91). No significant differences in survival at hospital admission were found in all patients (OR 1.0; 95% CI 0.7-1.6, p = 0.95) and among patients with an initial shockable rhythm (OR 1.7; 95% CI 0.8-3.4, p = 0.15). There were no differences in pulmonary complication rates in chest X-rays [7 (25.9%) vs 5 (17.9%), p = 0.47] and brain edema on CT [5 (29.4%) vs 10 (32.6%), p = 0.84]. There were no differences in lung weight [1223 mg (IQR 909-1500) vs 1239 mg (IQR 900-1507), p = 0.82] or brain weight [1352 mg (IQR 1227-1457) vs 1380 mg (IQR 1255-1470), p = 0.43] among the 106 autopsies performed. CONCLUSION In this trial, PLR during CPR did not improve survival to hospital discharge with CPC 1-2. No evidence of adverse effects has been found. Clinical trial registration ClinicalTrials.gov: NCT01952197, registration date: September 27, 2013, https://clinicaltrials.gov/ct2/show/NCT01952197 .
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Affiliation(s)
- Youcef Azeli
- Sistema d'Emergències Mèdiques de Catalunya, Carrer de Pablo Iglesias 101-115, L'Hospitalet de Llobregat, Barcelona, Spain.
- Emergency Department, Sant Joan University Hospital, Reus, Spain.
- Institut d'Investigació Sanitària Pere Virgili (IISPV), Reus, Spain.
| | - Alfredo Bardají
- Institut d'Investigació Sanitària Pere Virgili (IISPV), Reus, Spain
- Cardiology Department, Joan XXIII, University Hospital, Tarragona, Spain
- Universitat Rovira i Virgili, Tarragona, Spain
| | - Eneko Barbería
- Universitat Rovira i Virgili, Tarragona, Spain
- Pathology Service, Institute of Legal Medicine and Forensic Sciences of Catalonia, Tarragona, Spain
| | | | | | | | - Gil Bonet
- Cardiology Department, Joan XXIII, University Hospital, Tarragona, Spain
| | - Elena Rica
- Department de Enginyeria Informàtica i Matemàtiques, Universitat Rovira i Virgili, Tarragona, Spain
| | - Susana Álvarez
- Department de Enginyeria Informàtica i Matemàtiques, Universitat Rovira i Virgili, Tarragona, Spain
| | - Alberto Fernández
- Departament d'Enginyeria Química, Universitat Rovira i Virgili, Tarragona, Spain
| | - Christer Axelsson
- Center of Prehospital Research, Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden
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26
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Nolan JP, Ornato JP, Parr MJA, Perkins GD, Soar J. Resuscitation highlights in 2020. Resuscitation 2021; 162:1-10. [PMID: 33577963 DOI: 10.1016/j.resuscitation.2021.01.037] [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: 01/31/2021] [Accepted: 01/31/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND This review is the latest in a series of regular annual reviews undertaken by the editors and aims to highlight some of the key papers published in Resuscitation during 2020. The number of papers submitted to the Journal in 2020 increased by 25% on the previous year.MethodsHand-searching by the editors of all papers published in Resuscitation during 2020. Papers were selected based on then general interest and novelty and were categorised into general themes.ResultsA total of 103 papers were selected for brief mention in this review.ConclusionsResuscitation science continues to evolve rapidly and incorporate all links in the chain of survival.
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Affiliation(s)
- J P Nolan
- University of Warwick, Warwick Medical School, Coventry, CV4 7AL, UK; Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, BA1 3NG, UK.
| | - J P Ornato
- Department of Emergency Medicine, Virginia Commonwealth University Health, Richmond, VA, USA.
| | - M J A Parr
- Intensive Care, Liverpool and Macquarie University Hospitals, University of New South Wales and Macquarie University, Sydney, Australia.
| | - G D Perkins
- Critical Care Medicine, University of Warwick, Warwick Medical School and University Hospitals Birmingham NHS Foundation Trust, Coventry, CV4 7AL, UK.
| | - J Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB, UK.
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