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Bazbaz A, Varon J. Neuroprognostication, withdrawal of care and long-term outcomes after cardiopulmonary resuscitation. Curr Opin Crit Care 2024:00075198-990000000-00202. [PMID: 39150054 DOI: 10.1097/mcc.0000000000001194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2024]
Abstract
PURPOSE OF REVIEW Survivors of cardiac arrest often have increased long-term risks of mortality and disability that are primarily associated with hypoxic-ischemic brain injury (HIBI). This review aims to examine health-related long-term outcomes after cardiac arrest. RECENT FINDINGS A notable portion of cardiac arrest survivors face a decline in their quality of life, encountering persistent physical, cognitive, and mental health challenges emerging years after the initial event. Within the first-year postarrest, survivors are at elevated risk for stroke, epilepsy, and psychiatric conditions, along with a heightened susceptibility to developing dementia. Addressing these challenges necessitates establishing comprehensive, multidisciplinary care systems tailored to the needs of these individuals. SUMMARY HIBI remains the leading cause of disability among cardiac arrest survivors. No single strategy is likely to improve long term outcomes after cardiac arrest. A multimodal neuroprognostication approach (clinical examination, imaging, neurophysiology, and biomarkers) is recommended by guidelines, but fails to predict long-term outcomes. Cardiac arrest survivors often experience long-term disabilities that negatively impact their quality of life. The likelihood of such outcomes implements a multidisciplinary care an integral part of long-term recovery.
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Affiliation(s)
| | - Joseph Varon
- Dorrington Medical Associates, PA
- The University of Houston College of Medicine, Houston, Texas, USA
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Coppler PJ, Brown M, Moschenross DM, Gopalan PR, Presciutti AM, Doshi AA, Sawyer KN, Frisch A, Callaway CW, Elmer J. Impact of Preexisting Depression and Anxiety on Hospital Readmission and Long-Term Survival After Cardiac Arrest. J Intensive Care Med 2024; 39:542-549. [PMID: 38073090 PMCID: PMC11090726 DOI: 10.1177/08850666231218963] [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] [Indexed: 12/21/2023]
Abstract
BACKGROUND While sudden cardiac arrest (CA) survivors are at risk for developing psychiatric disorders, little is known about the impact of preexisting mental health conditions on long-term survival or postacute healthcare utilization. We examined the prevalence of preexisting psychiatric conditions in CA patients who survived hospital discharge, characterized incidence and reason for inpatient psychiatry consultation during these patients' acute hospitalizations, and determined the association of pre-CA depression and anxiety with hospital readmission rates and long-term survival. We hypothesized that prior depression or anxiety would be associated with higher hospital readmission rates and lower long-term survival. METHODS We conducted a retrospective cohort study including patients resuscitated from in- and out-of-hospital CA who survived both admission and discharge from a single hospital between January 1, 2010, and December 31, 2017. We identified patients from our prospective registry, then performed a structured chart review to abstract past psychiatric history, prescription medications for psychiatric conditions, and identify inpatient psychiatric consultations. We used administrative data to identify readmissions within 1 year and vital status through December 31, 2020. We used multivariable Cox regressions controlling for patient demographics, medical comorbidities, discharge Cerebral Performance Category and disposition, depression, and anxiety history to predict long-term survival and hospital readmission. RESULTS We included 684 subjects. Past depression or anxiety was noted in 24% (n = 162) and 19% (n = 129) of subjects. A minority of subjects (n = 139, 20%) received a psychiatry consultation during the index hospitalization. Overall, 262 (39%) subjects had at least 1 readmission within 1 year. Past depression was associated with an increased hazard of hospital readmission (hazard ratio 1.50, 95% CI 1.11-2.04), while past anxiety was not associated with readmission. Neither depression nor anxiety were independently associated with long-term survival. CONCLUSIONS Depression is an independent risk factor for hospital readmission in CA survivors.
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Affiliation(s)
- Patrick J. Coppler
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - McKenzie Brown
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Darcy M. Moschenross
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Priya R. Gopalan
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alexander M. Presciutti
- Center for Health Outcomes and Interdisciplinary Research, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Ankur A. Doshi
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Kelly N. Sawyer
- 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
| | - Clifton W. Callaway
- 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 Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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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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Presciutti AM, Flickinger KL, Coppler PJ, Ratay C, Doshi AA, Perman SM, Vranceanu AM, Elmer J. Protective positive psychology factors and emotional distress after cardiac arrest. Resuscitation 2023:109846. [PMID: 37207872 DOI: 10.1016/j.resuscitation.2023.109846] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 05/09/2023] [Accepted: 05/11/2023] [Indexed: 05/21/2023]
Abstract
BACKGROUND There is a critical need to identify factors that can prevent emotional distress post-cardiac arrest (CA). CA survivors have previously described benefitting from utilizing positive psychology constructs (mindfulness, existential well-being, resilient coping, social support) to cope with distress. Here, we explored associations between positive psychology factors and emotional distress post-CA. METHODS We recruited CA survivors treated from 4/2021-9/2022 at a single academic medical center. We assessed positive psychology factors (mindfulness [Cognitive and Affective Mindfulness Scale-Revised], existential well-being [Meaning in Life Questionnaire Presence of Meaning subscale], resilient coping [Brief Resilient Coping Scale], perceived social support [ENRICHD Social Support Inventory]) and emotional distress (posttraumatic stress [Posttraumatic Stress Checklist-5], anxiety and depression symptoms [PROMIS Emotional Distress - Anxiety and Depression Short Forms 4a]) just before discharge from the index hospitalization. We selected covariates for inclusion in our multivariable models based on an association with any emotional distress factor (p < 0.10). For our final, multivariable regression models, we individually tested the independent association of each positive psychology factor and emotional distress factor. RESULTS We included 110 survivors (mean age 59 years, 64% male, 88% non-Hispanic White, 48% low income); 36.4% of survivors scored above the cut-off for at least one measure of emotional distress. In separate adjusted models, each positive psychology factor was independently associated with emotional distress (β: -0.20 to -0.42, all p < 0.05). CONCLUSIONS Higher levels of mindfulness, existential well-being, resilient coping, and perceived social support were each associated with less emotional distress. Future intervention development studies should consider these factors as potential treatment targets.
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Affiliation(s)
- Alexander M Presciutti
- Center for Health Outcomes and Interdisciplinary Research, Department of Psychiatry, Massachusetts General Hospital; Department of Psychiatry, Harvard Medical School.
| | | | - Patrick J Coppler
- Department of Emergency Medicine, University of Pittsburgh School of Medicine
| | - Cecelia Ratay
- Department of Emergency Medicine, University of Pittsburgh School of Medicine
| | - Ankur A Doshi
- Department of Emergency Medicine, University of Pittsburgh School of Medicine
| | - Sarah M Perman
- Department of Emergency Medicine, University of Colorado School of Medicine
| | - Ana-Maria Vranceanu
- Center for Health Outcomes and Interdisciplinary Research, Department of Psychiatry, Massachusetts General Hospital; Department of Psychiatry, Harvard Medical School
| | - Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh School of Medicine; Department of Critical Care Medicine, University of Pittsburgh School of Medicine; Department of Neurology, University of Pittsburgh School of Medicine
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Fernandez Hernandez S, Busl KM, Maciel CB. Hibernation as a path to recovery-is waiting worth the wait? When does improvement in neurologic function happen in survivors of cardiac arrest with an early poor exam? Resuscitation 2023; 188:109829. [PMID: 37178903 DOI: 10.1016/j.resuscitation.2023.109829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 05/04/2023] [Indexed: 05/15/2023]
Affiliation(s)
| | - Katharina M Busl
- Department of Neurology, University of Florida College of Medicine, Gainesville, Florida, USA, 32611; Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA, 32611
| | - Carolina B Maciel
- Department of Neurology, University of Florida College of Medicine, Gainesville, Florida, USA, 32611; Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA, 32611; Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA; Department of Neurology, University of Utah, Salt Lake City, UT, USA, 84132.
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Hayamizu M, Kodate A, Sageshima H, Tsuchida T, Honma Y, Mizugaki A, Yoshida T, Saito T, Katabami K, Wada T, Maekawa K, Hayakawa M. Delayed neurologic improvement and long-term survival of patients with poor neurologic status after out-of-hospital cardiac arrest: a retrospective cohort study in Japan. Resuscitation 2023:109790. [PMID: 37024037 DOI: 10.1016/j.resuscitation.2023.109790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 03/26/2023] [Accepted: 03/28/2023] [Indexed: 04/08/2023]
Abstract
AIM To assess survival duration and frequency of delayed neurologic improvement in patients with poor neurologic status at discharge from emergency hospitals after out-of-hospital cardiac arrest (OHCA). METHODS This retrospective cohort study included OHCA patients admitted to two tertiary emergency hospitals in Japan between January 2014 and December 2020. Pre-hospital, tertiary emergency hospital, and post-acute care hospital data, were retrospectively collected by reviewing medical records. Neurologic improvements were defined as an improvement of Cerebral Performance Category (CPC) scores from 3 or 4 at hospital discharge to 1 or 2. The primary outcome was neurologic improvement after discharge, while the secondary outcome was survival time after cardiac arrest. RESULTS Of all patients (n=1,012) admitted to tertiary emergency hospitals after OHCA during the observation period, 239 with CPC 3 or 4 at discharge were included, and all were Japanese. Median age was 75 years, 64% were male, and 31% had initially shockable rhythms. Neurologic improvements were observed in nine patients (3.6%), higher in CPC 3 (31%) than CPC 4 (1.3%) patients, but not after 6 months from cardiac arrest. The median survival time after cardiac arrest was 386 days (95% confidence interval: 303-469). CONCLUSION Survival probability in patients with CPC 3 or 4 was 50% at 1-year and 20% at 3-year. Neurologic improvements were observed in 3.6% patients, higher in CPC 3 than in CPC 4 patients. During the first 6 months after OHCA, the neurologic status may improve in patients with CPC 3 or 4.
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Affiliation(s)
- Mariko Hayamizu
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Akira Kodate
- Department of Emergency and Critical Care Medicine, Sapporo City General Hospital, Sapporo, Japan
| | - Hisako Sageshima
- Department of Emergency and Critical Care Medicine, Sapporo City General Hospital, Sapporo, Japan
| | - Takumi Tsuchida
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Japan; Department of Emergency and Critical Care Medicine, Sapporo City General Hospital, Sapporo, Japan
| | - Yoshinori Honma
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Asumi Mizugaki
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Tomonao Yoshida
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Tomoyo Saito
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Kenichi Katabami
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Takeshi Wada
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Kunihiko Maekawa
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Mineji Hayakawa
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Japan.
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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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