1
|
Zhang Y, Zhang H, Fu S. Relative saliency affects attentional capture and suppression of color and face singleton distractors: evidence from event-related potential studies. Cereb Cortex 2024; 34:bhae176. [PMID: 38679483 DOI: 10.1093/cercor/bhae176] [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: 11/18/2023] [Revised: 03/30/2024] [Accepted: 04/09/2024] [Indexed: 05/01/2024] Open
Abstract
Prior research has yet to fully elucidate the impact of varying relative saliency between target and distractor on attentional capture and suppression, along with their underlying neural mechanisms, especially when social (e.g. face) and perceptual (e.g. color) information interchangeably serve as singleton targets or distractors, competing for attention in a search array. Here, we employed an additional singleton paradigm to investigate the effects of relative saliency on attentional capture (as assessed by N2pc) and suppression (as assessed by PD) of color or face singleton distractors in a visual search task by recording event-related potentials. We found that face singleton distractors with higher relative saliency induced stronger attentional processing. Furthermore, enhancing the physical salience of colors using a bold color ring could enhance attentional processing toward color singleton distractors. Reducing the physical salience of facial stimuli by blurring weakened attentional processing toward face singleton distractors; however, blurring enhanced attentional processing toward color singleton distractors because of the change in relative saliency. In conclusion, the attentional processes of singleton distractors are affected by their relative saliency to singleton targets, with higher relative saliency of singleton distractors resulting in stronger attentional capture and suppression; faces, however, exhibit some specificity in attentional capture and suppression due to high social saliency.
Collapse
Affiliation(s)
- Yue Zhang
- Department of Psychology and Center for Brain and Cognitive Sciences, School of Education, Guangzhou University, 230 Wai Huan Xi Road, Guangzhou Higher Education Mega Center, Guangzhou 510006, China
| | - Hai Zhang
- Department of Psychology and Center for Brain and Cognitive Sciences, School of Education, Guangzhou University, 230 Wai Huan Xi Road, Guangzhou Higher Education Mega Center, Guangzhou 510006, China
| | - Shimin Fu
- Department of Psychology and Center for Brain and Cognitive Sciences, School of Education, Guangzhou University, 230 Wai Huan Xi Road, Guangzhou Higher Education Mega Center, Guangzhou 510006, China
| |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
Wang SL, Li N, Feng SY, Li Y. Serum neurofilament light chain as a predictive marker of neurologic outcome after cardiac arrest: a meta-analysis. BMC Cardiovasc Disord 2023; 23:193. [PMID: 37061702 PMCID: PMC10105388 DOI: 10.1186/s12872-023-03220-z] [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: 01/20/2023] [Accepted: 03/31/2023] [Indexed: 04/17/2023] Open
Abstract
OBJECTIVE Recently, an increasing number of studies have suggested using serum neurofilament light (NfL) chain to predict the neurologic outcome after cardiac arrest. However, the predictive ability of this approach remains inconclusive. Meta-analysis was performed on related studies to assess the ability of serum NfL to predict the neurologic outcome after cardiac arrest. MATERIALS AND METHODS PubMed, ScienceDirect and Embase were systematically searched from the date of their inception until June 2022. Data were extracted to calculate the area under the receiver operating characteristic curve (AUC), the sensitivity, the specificity and the publication bias to evaluate the predictive power of serum NfL using Stata 14.0. RESULTS Nine studies were included in the present meta-analysis. Seven studies involving 1296 participants reported serum NfL 24 h post arrest for predicting the neurological outcome, and the AUC was 0.92 (77% sensitivity and 96% specificity). Seven studies involving 1020 participants reported serum NfL 48 h post arrest for predicting the neurological outcome, and the AUC was 0.94 (78% sensitivity and 98% specificity). Four studies involving 804 participants reported serum NfL 72 h post arrest for predicting the neurological outcome, and the AUC was 0.96 (90% sensitivity and 98% specificity). No significant publication bias was observed among the included studies. CONCLUSION The present meta-analysis results support the potential use of serum NfL as an early biomarker of neurologic outcome, especially 72 h post arrest.
Collapse
Affiliation(s)
- Shu Li Wang
- Emergency Deparment, Cangzhou Central Hospital, No.16 Xinhua Road, Yunhe Qu, Cangzhou City, 061000, China
| | - Nan Li
- Emergency Deparment, Cangzhou Central Hospital, No.16 Xinhua Road, Yunhe Qu, Cangzhou City, 061000, China
| | - Shun Yi Feng
- Emergency Deparment, Cangzhou Central Hospital, No.16 Xinhua Road, Yunhe Qu, Cangzhou City, 061000, China
| | - Yong Li
- Emergency Deparment, Cangzhou Central Hospital, No.16 Xinhua Road, Yunhe Qu, Cangzhou City, 061000, China.
| |
Collapse
|
4
|
Fordyce CB, Kramer AH, Ainsworth C, Christenson J, Hunter G, Kromm J, Lopez Soto C, Scales DC, Sekhon M, van Diepen S, Dragoi L, Josephson C, Kutsogiannis J, Le May MR, Overgaard CB, Savard M, Schnell G, Wong GC, Belley-Côté E, Fantaneanu TA, Granger CB, Luk A, Mathew R, McCredie V, Murphy L, Teitelbaum J. Neuroprognostication in the Post Cardiac Arrest Patient: A Canadian Cardiovascular Society Position Statement. Can J Cardiol 2023; 39:366-380. [PMID: 37028905 DOI: 10.1016/j.cjca.2022.12.014] [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: 08/04/2022] [Revised: 12/13/2022] [Accepted: 12/14/2022] [Indexed: 04/08/2023] Open
Abstract
Cardiac arrest (CA) is associated with a low rate of survival with favourable neurologic recovery. The most common mechanism of death after successful resuscitation from CA is withdrawal of life-sustaining measures on the basis of perceived poor neurologic prognosis due to underlying hypoxic-ischemic brain injury. Neuroprognostication is an important component of the care pathway for CA patients admitted to hospital but is complex, challenging, and often guided by limited evidence. Using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to evaluate the evidence underlying factors or diagnostic modalities available to determine prognosis, recommendations were generated in the following domains: (1) circumstances immediately after CA; (2) focused neurologic exam; (3) myoclonus and seizures; (4) serum biomarkers; (5) neuroimaging; (6) neurophysiologic testing; and (7) multimodal neuroprognostication. This position statement aims to serve as a practical guide to enhance in-hospital care of CA patients and emphasizes the adoption of a systematic, multimodal approach to neuroprognostication. It also highlights evidence gaps.
Collapse
Affiliation(s)
- Christopher B Fordyce
- Division of Cardiology, Department of Medicine, Vancouver General Hospital, and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia.
| | - Andreas H Kramer
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta; Department of Critical Care, University of Calgary, Alberta
| | - Craig Ainsworth
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jim Christenson
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia
| | - Gary Hunter
- Division of Neurology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Julie Kromm
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta; Department of Critical Care, University of Calgary, Alberta
| | - Carmen Lopez Soto
- Department of Critical Care, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Damon C Scales
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mypinder Sekhon
- Division of Critical Care, Department of Medicine, Vancouver General Hospital, Djavad Mowafaghian Centre for Brain Health, International Centre for Repair Discoveries, University of British Columbia, Vancouver, British Columbia
| | - Sean van Diepen
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta; Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta
| | - Laura Dragoi
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Colin Josephson
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta; Department of Critical Care, University of Calgary, Alberta
| | - Jim Kutsogiannis
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta
| | - Michel R Le May
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Christopher B Overgaard
- Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Martin Savard
- Department of Neurological Sciences CHU de Québec - Hôpital de l'Enfant-Jésus Quebec City, Quebec, Canada
| | - Gregory Schnell
- Division of Cardiology, Department of Medicine, University of Calgary, Calgary, Alberta
| | - Graham C Wong
- Division of Cardiology, Department of Medicine, Vancouver General Hospital, and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia
| | - Emilie Belley-Côté
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Tadeu A Fantaneanu
- Division of Neurology, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Adriana Luk
- Division of Cardiology, Department of Medicine, University of Toronto and the Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Rebecca Mathew
- CAPITAL Research Group, Division of Cardiology, University of Ottawa Heart Institute, and the Faculty of Medicine, Division of Critical Care, University of Ottawa, Ottawa, Ontario, Canada
| | - Victoria McCredie
- Interdepartmental Division of Critical Care Medicine, University of Toronto, the Krembil Research Institute, Toronto Western Hospital, University Health Network, and Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Laurel Murphy
- Departments of Emergency Medicine and Critical Care, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jeanne Teitelbaum
- Neurological Intensive Care Unit, Montreal Neurological Institute and Hospital, McGill University, Montreal, Quebec, Canada
| |
Collapse
|
5
|
Baker AK, Griffith JL. To Treat or Not to Treat: Ethics of Management of Refractory Status Myoclonus Following Pediatric Anoxic Brain Injury. Semin Pediatr Neurol 2023; 45:101033. [PMID: 37003631 DOI: 10.1016/j.spen.2023.101033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 02/01/2023] [Accepted: 02/08/2023] [Indexed: 02/16/2023]
Abstract
The development of status myoclonus (SM) in a postcardiac arrest patient has historically been thought of as indicative of not only a poor neurologic outcome but of neurologic devastation. In many instances, this may lead clinicians to initiate conversations about withdrawal of life sustaining therapies (WLST) regardless of the time from return of spontaneous circulation (ROSC). Recent studies showing a percentage of patients may make a good recovery has called into question whether a self-fulfilling prophecy has developed where the concern for a poor neurologic outcome leads clinicians to prematurely discuss WLST. The issue is only further complicated by changing terminology, lack of neuro-axis localization, and limited data regarding association with electroencephalogram (EEG) characteristics, all of which could aid in the understanding of the severity of neurologic injury associated with SM. Here we review the initial literature reporting SM as indicative of poor neurologic outcome, the studies that call this into question, the various definitions of SM and related terms as well as data regarding association with EEG backgrounds. We propose that improved prognostication on outcomes results from combining the presence of SM with other clinical variables (eg EEG patterns, MRI findings, and clinical exam). We discuss the ethical implications of using SM as a prognostic tool and its impact on decisions about life-sustaining care in children following cardiac arrest. We advocate for prognostication efforts to be delayed for at least 72 hours following ROSC and thus to treat SM in those early hours and days.
Collapse
Affiliation(s)
- Alyson K Baker
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE; Children's Hospital and Medical Center, Omaha, NE.
| | - Jennifer L Griffith
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO; Department of Neurology, Washington University School of Medicine, St. Louis, MO
| |
Collapse
|
6
|
Luck TG, Locke K, Sherman BC, Vibbert M, Hefton S, Shah SO. The SLANT Score Predicts Poor Neurologic Outcome in Comatose Survivors of Cardiac Arrest: An External Validation Using a Retrospective Cohort. Neurocrit Care 2023; 38:129-137. [PMID: 35896769 DOI: 10.1007/s12028-022-01570-8] [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: 03/02/2022] [Accepted: 06/29/2022] [Indexed: 10/16/2022]
Abstract
BACKGROUND Hypoxic brain injury is the leading cause of death in comatose patients following resuscitation from cardiac arrest. Neurological outcome can be difficult to prognosticate following resuscitation, and goals of care discussions are often informed by multiple prognostic tools. One tool that has shown promise is the SLANT score, which encompasses five metrics including initial nonshockable rhythm, leukocyte count after targeted temperature management, total adrenaline dose during resuscitation, lack of bystander cardiopulmonary resuscitation, and time to return of spontaneous circulation. This cohort study aimed to provide an external validation of this score by using a database of comatose cardiac arrest survivors from our institution. METHODS We retrospectively queried our database of cardiac arrest survivors, selecting for patients with coma, sustained return of spontaneous circulation, and use of targeted temperature management to have a comparable sample to the index study. We calculated SLANT scores for each patient and separated them into risk levels, both according to the original study and according to a Youden index analysis. The primary outcome was poor neurologic outcome (defined by a cerebral performance category score of 3 or greater at discharge), and the secondary outcome was in-hospital mortality. Univariable and multivariable analyses, as well as a receiver operator characteristic curve, were used to assess the SLANT score for independent predictability and diagnostic accuracy for poor outcomes. RESULTS We demonstrate significant association between a SLANT group with increased risk and poor neurologic outcome on univariable (p = 0.005) and multivariable analysis (odds ratio 1.162, 95% confidence interval 1.003-1.346, p = 0.046). A receiver operating characteristic analysis indicates that SLANT scoring is a fair prognostic test for poor neurologic outcome (area under the curve 0.708, 95% confidence interval 0.536-0.879, p = 0.024). Among this cohort, the most frequent SLANT elements were initial nonshockable rhythm (84.5%) and total adrenaline dose ≥ 5 mg (63.9%). There was no significant association between SLANT score and in-hospital mortality (p = 0.064). CONCLUSIONS The SLANT score may independently predict poor neurologic outcome but not in-hospital mortality. Including the SLANT score as part of a multimodal approach may improve our ability to accurately prognosticate comatose survivors of cardiac arrest.
Collapse
Affiliation(s)
- Trevor G Luck
- Drexel University College of Medicine, Philadelphia, PA, USA
| | - Katherine Locke
- Drexel University College of Medicine, Philadelphia, PA, USA
| | | | - Matthew Vibbert
- Division of Neurocritical Care, Department of Neurosurgery, Jefferson Hospital for Neuroscience, Thomas Jefferson University, 909 Walnut Street, 3rd Floor, Philadelphia, PA, 19107, USA
| | - Sara Hefton
- Division of Neurocritical Care, Department of Neurosurgery, Jefferson Hospital for Neuroscience, Thomas Jefferson University, 909 Walnut Street, 3rd Floor, Philadelphia, PA, 19107, USA
| | - Syed Omar Shah
- Division of Neurocritical Care, Department of Neurosurgery, Jefferson Hospital for Neuroscience, Thomas Jefferson University, 909 Walnut Street, 3rd Floor, Philadelphia, PA, 19107, USA.
| |
Collapse
|
7
|
Kim JG, Shin H, Lim TH, Kim W, Cho Y, Jang BH, Choi KS, Na MK, Ahn C, Lee J. Efficacy of Quantitative Pupillary Light Reflex for Predicting Neurological Outcomes in Patients Treated with Targeted Temperature Management after Cardiac Arrest: A Systematic Review and Meta-Analysis. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58060804. [PMID: 35744068 PMCID: PMC9230846 DOI: 10.3390/medicina58060804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 06/12/2022] [Accepted: 06/13/2022] [Indexed: 11/17/2022]
Abstract
Background and objectives: This study aims to evaluate the usefulness of the quantitative pupillary light reflex as a prognostic tool for neurological outcomes in post-cardiac arrest patients treated with targeted temperature management (TTM). Material and Methods: We systematically searched MEDLINE, EMBASE, and the Cochrane Library (search date: 9 July 2021) for studies on post-cardiac arrest patients treated with TTM that had measured the percent constriction of pupillary light reflex (%PLR) with quantitative pupillometry as well as assessed the neurological outcome. For an assessment of the methodological quality of the included studies, two authors utilized the prognosis study tool independently. Results: A total of 618 patients from four studies were included in this study. Standardized mean differences (SMDs) were calculated to compare patients with good or poor neurological outcomes. A higher %PLR measured at 0–24 h after hospital admission was related to good neurological outcomes at 3 months in post-cardiac arrest patients treated with TTM (SMD 0.87; 95% confidence interval 0.70–1.05; I2 = 0%). A higher %PLR amplitude measured at 24–48 h after hospital admission was also associated with a good neurological outcome at 3 months in post-cardiac arrest patients treated with TTM, but with high heterogeneity (standardized mean difference 0.86; 95% confidence interval 0.40–1.32; I2 = 70%). The evidence supporting these findings was of poor quality. For poor neurological outcome, the prognosis accuracy of %PLR was 9.19 (pooled diagnostic odds ratio, I2 = 0%) and 0.75 (area under the curve). Conclusions: The present meta-analysis could not reveal that change of %PLR was an effective tool in predicting neurological outcomes for post-cardiac arrest patients treated with TTM owing to a paucity of included studies and the poor quality of the evidence.
Collapse
Affiliation(s)
- Jae-Guk Kim
- Department of Emergency Medicine, College of Medicine, Hallym University, Chuncheon 24253, Korea; (J.-G.K.); (W.K.); (Y.C.)
| | - Hyungoo Shin
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul 04763, Korea; (H.S.); (J.L.)
| | - Tae-Ho Lim
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul 04763, Korea; (H.S.); (J.L.)
- Correspondence: ; Tel.: +82-2-2290-9825
| | - Wonhee Kim
- Department of Emergency Medicine, College of Medicine, Hallym University, Chuncheon 24253, Korea; (J.-G.K.); (W.K.); (Y.C.)
| | - Youngsuk Cho
- Department of Emergency Medicine, College of Medicine, Hallym University, Chuncheon 24253, Korea; (J.-G.K.); (W.K.); (Y.C.)
| | - Bo-Hyoung Jang
- Department of Preventive Medicine, College of Korean Medicine, Kyung Hee University, Seoul 02447, Korea;
| | - Kyu-Sun Choi
- Department of Neurosurgery, Hanyang University College of Medicine, Seoul 04763, Korea; (K.-S.C.); (M.-K.N.)
| | - Min-Kyun Na
- Department of Neurosurgery, Hanyang University College of Medicine, Seoul 04763, Korea; (K.-S.C.); (M.-K.N.)
| | - Chiwon Ahn
- Department of Emergency Medicine, College of Medicine, Chung-Ang University, Seoul 06974, Korea;
| | - Juncheol Lee
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul 04763, Korea; (H.S.); (J.L.)
| |
Collapse
|
8
|
Chou SY, Bamodu OA, Chiu WT, Hong CT, Chan L, Chung CC. Artificial neural network-boosted Cardiac Arrest Survival Post-Resuscitation In-hospital (CASPRI) score accurately predicts outcome in cardiac arrest patients treated with targeted temperature management. Sci Rep 2022; 12:7254. [PMID: 35508580 PMCID: PMC9068683 DOI: 10.1038/s41598-022-11201-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 04/14/2022] [Indexed: 01/04/2023] Open
Abstract
Existing prognostic models to predict the neurological recovery in patients with cardiac arrest receiving targeted temperature management (TTM) either exhibit moderate accuracy or are too complicated for clinical application. This necessitates the development of a simple and generalizable prediction model to inform clinical decision-making for patients receiving TTM. The present study explores the predictive validity of the Cardiac Arrest Survival Post-resuscitation In-hospital (CASPRI) score in cardiac arrest patients receiving TTM, regardless of cardiac event location, and uses artificial neural network (ANN) algorithms to boost the prediction performance. This retrospective observational study evaluated the prognostic relevance of the CASPRI score and applied ANN to develop outcome prediction models in a cohort of 570 patients with cardiac arrest and treated with TTM between 2014 and 2019 in a nationwide multicenter registry in Taiwan. In univariate logistic regression analysis, the CASPRI score was significantly associated with neurological outcome, with the area under the receiver operating characteristics curve (AUC) of 0.811. The generated ANN model, based on 10 items of the CASPRI score, achieved a training AUC of 0.976 and validation AUC of 0.921, with the accuracy, precision, sensitivity, and specificity of 89.2%, 91.6%, 87.6%, and 91.2%, respectively, for the validation set. CASPRI score has prognostic relevance in patients who received TTM after cardiac arrest. The generated ANN-boosted, CASPRI-based model exhibited good performance for predicting TTM neurological outcome, thus, we propose its clinical application to improve outcome prediction, facilitate decision-making, and formulate individualized therapeutic plans for patients receiving TTM.
Collapse
Affiliation(s)
- Szu-Yi Chou
- Graduate Institute of Neural Regenerative Medicine, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan, ROC.,Ph.D. Program for Neural Regenerative Medicine, College of Medical Science and Technology, Taipei Medical University and National Health Research Institutes, Taipei, Taiwan, ROC
| | - Oluwaseun Adebayo Bamodu
- Department of Medical Research & Education, Shuang Ho Hospital, Taipei Medical University, New Taipei City, 235, Taiwan, ROC.,Department of Urology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, 235, Taiwan, ROC.,Department of Hematology & Oncology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, 235, Taiwan, ROC
| | - Wei-Ting Chiu
- Department of Neurology, Shuang Ho Hospital, Taipei Medical University, 291, Zhongzheng Road, Zhonghe District, New Taipei City, 235, Taiwan, ROC.,Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei City, 110, Taiwan, ROC.,Division of Critical Care Medicine, Department of Emergency and Critical Care Medicine, Taipei Medical University-Shuang Ho Hospital, New Taipei City, 235, Taiwan, ROC
| | - Chien-Tai Hong
- Department of Neurology, Shuang Ho Hospital, Taipei Medical University, 291, Zhongzheng Road, Zhonghe District, New Taipei City, 235, Taiwan, ROC.,Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei City, 110, Taiwan, ROC
| | - Lung Chan
- Department of Neurology, Shuang Ho Hospital, Taipei Medical University, 291, Zhongzheng Road, Zhonghe District, New Taipei City, 235, Taiwan, ROC. .,Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei City, 110, Taiwan, ROC.
| | - Chen-Chih Chung
- Department of Neurology, Shuang Ho Hospital, Taipei Medical University, 291, Zhongzheng Road, Zhonghe District, New Taipei City, 235, Taiwan, ROC. .,Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei City, 110, Taiwan, ROC. .,Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei City, 110, Taiwan, ROC.
| |
Collapse
|
9
|
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] [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.
Collapse
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
| |
Collapse
|
10
|
Duan J, Zhai Q, Shi Y, Ge H, Zheng K, Du L, Duan B, Yu J, Ma Q. Optimal Time of Collapse to Return of Spontaneous Circulation to Apply Targeted Temperature Management for Cardiac Arrest: A Bayesian Network Meta-Analysis. Front Cardiovasc Med 2022; 8:784917. [PMID: 35071355 PMCID: PMC8777010 DOI: 10.3389/fcvm.2021.784917] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 11/30/2021] [Indexed: 12/14/2022] Open
Abstract
Background: Both the American Heart Association (AHA) and European Resuscitation Council (ERC) have strongly recommended targeted temperature management (TTM) for patients who remain in coma after return of spontaneous circulation (ROSC). However, the role of TTM, especially hypothermia, in cardiac arrest patients after TTM2 trials has become much uncertain. Methods: We searched four online databases (PubMed, Embase, CENTRAL, and Web of Science) and conducted a Bayesian network meta-analysis. Based on the time of collapse to ROSC and whether the patient received TTM or not, we divided this analysis into eight groups (<20 min + TTM, <20 min, 20–39 min + TTM, 20–39 min, 40–59 min + TTM, 40–59 min, ≥60 min + TTM and ≥60 min) to compare their 30-day and at-discharge survival and neurologic outcomes. Results: From an initial search of 3,023 articles, a total of 9,005 patients from 42 trials were eligible and were included in this network meta-analysis. Compared with other groups, patients in the <20 min + TTM group were more likely to have better survival and good neurologic outcomes (probability = 46.1 and 52.5%, respectively). In comparing the same time groups with and without TTM, only the survival and neurologic outcome of the 20–39 min + TTM group was significantly better than that of the 20–39 min group [odds ratio = 1.41, 95% confidence interval (1.04–1.91); OR = 1.46, 95% CI (1.07–2.00) respectively]. Applying TTM with <20 min or more than 40 min of collapse to ROSC did not improve survival or neurologic outcome [ <20 min vs. <20 min + TTM: OR = 1.02, 95% CI (0.61–1.71)/OR = 1.03, 95% CI (0.61–1.75); 40–59 min vs. 40–59 min + TTM: OR = 1.50, 95% CI (0.97–2.32)/OR = 1.40, 95% CI (0.81–2.44); ≧60 min vs. ≧60 min + TTM: OR = 2.09, 95% CI (0.70–6.24)/OR = 4.14, 95% CI (0.91–18.74), respectively]. Both survival and good neurologic outcome were closely related to the time from collapse to ROSC. Conclusion: Survival and good neurologic outcome are closely associated with the time of collapse to ROSC. These findings supported that 20–40 min of collapse to ROSC should be a more suitable indication for TTM for cardiac arrest patients. Moreover, the future trials should pay more attention to these patients who suffer from moderate injury. Systematic Review Registration: [https://inplasy.com/?s=202180027], identifier [INPLASY202180027]
Collapse
Affiliation(s)
- Jingwei Duan
- Emergency Department, Peking University Third Hospital, Beijing, China
| | - Qiangrong Zhai
- Emergency Department, Peking University Third Hospital, Beijing, China
| | - Yuanchao Shi
- First Clinical Medicine School, Lanzhou University, Lanzhou, China
| | - Hongxia Ge
- Emergency Department, Peking University Third Hospital, Beijing, China
| | - Kang Zheng
- Emergency Department, Peking University Third Hospital, Beijing, China
| | - Lanfang Du
- Emergency Department, Peking University Third Hospital, Beijing, China
| | - Baomin Duan
- Emergency Department, Kaifeng Center Hospital, Kaifeng, China
| | - Jie Yu
- The George Institute for Global Health, The University of New South Wales Sydney, Sydney, NSW, Australia
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- Department of Cardiology, Peking University Third Hospital, Beijing, China
- Jie Yu
| | - Qingbian Ma
- Emergency Department, Peking University Third Hospital, Beijing, China
- *Correspondence: Qingbian Ma
| |
Collapse
|
11
|
Wang CH, Wu CY, Liu CCY, Hsu TC, Liu MA, Wu MC, Tsai MS, Chang WT, Huang CH, Lee CC, Chen SC, Chen WJ. Neuroprognostic Accuracy of Quantitative Versus Standard Pupillary Light Reflex for Adult Postcardiac Arrest Patients: A Systematic Review and Meta-Analysis. Crit Care Med 2021; 49:1790-1799. [PMID: 34259437 DOI: 10.1097/ccm.0000000000005045] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES An automated infrared pupillometer measures quantitative pupillary light reflex using a calibrated light stimulus. We examined whether the timing of performing quantitative pupillary light reflex or standard pupillary light reflex may impact its neuroprognostic performance in postcardiac arrest comatose patients and whether quantitative pupillary light reflex may outperform standard pupillary light reflex in early postresuscitation phase. DATA SOURCES PubMed and Embase databases from their inception to July 2020. STUDY SELECTION We selected studies providing sufficient data of prognostic values of standard pupillary light reflex or quantitative pupillary light reflex to predict neurologic outcomes in adult postcardiac arrest comatose patients. DATA EXTRACTION Quantitative data required for building a 2 × 2 contingency table were extracted, and study quality was assessed using standard criteria. DATA SYNTHESIS We used the bivariate random-effects model to estimate the pooled sensitivity and specificity of standard pupillary light reflex or quantitative pupillary light reflex in predicting poor neurologic outcome during early (< 72 hr), middle (between 72 and 144 hr), and late (≧ 145 hr) postresuscitation periods, respectively. We included 39 studies involving 17,179 patients. For quantitative pupillary light reflex, the cut off points used in included studies to define absent pupillary light reflex ranged from 0% to 13% (median: 7%) and from zero to 2 (median: 2) for pupillary light reflex amplitude and Neurologic Pupil index, respectively. Late standard pupillary light reflex had the highest area under the receiver operating characteristic curve (0.98, 95% CI [CI], 0.97-0.99). For early standard pupillary light reflex, the area under the receiver operating characteristic curve was 0.80 (95% CI, 0.76-0.83), with a specificity of 0.91 (95% CI, 0.85-0.95). For early quantitative pupillary light reflex, the area under the receiver operating characteristic curve was 0.83 (95% CI, 0.79-0.86), with a specificity of 0.99 (95% CI, 0.91-1.00). CONCLUSIONS Timing of pupillary light reflex examination may impact neuroprognostic accuracy. The highest prognostic performance was achieved with late standard pupillary light reflex. Early quantitative pupillary light reflex had a similar specificity to late standard pupillary light reflex and had better specificity than early standard pupillary light reflex. For postresuscitation comatose patients, early quantitative pupillary light reflex may substitute for early standard pupillary light reflex in the neurologic prognostication algorithm.
Collapse
Affiliation(s)
- Chih-Hung Wang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Cheng-Yi Wu
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Carolyn Chia-Yu Liu
- Department for Continuing Education, The Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, United Kingdom
| | - Tzu-Chun Hsu
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Michael A Liu
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI
| | - Meng-Che Wu
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Min-Shan Tsai
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Wei-Tien Chang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chien-Hua Huang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chien-Chang Lee
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Shyr-Chyr Chen
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Wen-Jone Chen
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| |
Collapse
|
12
|
Wurm R, Arfsten H, Muqaku B, Ponleitner M, Bileck A, Altmann P, Rommer P, Seidel S, Hubner P, Sterz F, Heinz G, Gerner C, Adlbrecht C, Distelmaier K. Prediction of Neurological Recovery After Cardiac Arrest Using Neurofilament Light Chain is Improved by a Proteomics-Based Multimarker Panel. Neurocrit Care 2021; 36:434-440. [PMID: 34342833 DOI: 10.1007/s12028-021-01321-1] [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: 03/20/2021] [Accepted: 07/19/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND Continuous advances in resuscitation care have increased survival, but the rate of favorable neurological outcome remains low. We have shown the usefulness of proteomics in identifying novel biomarkers to predict neurological outcome. Neurofilament light chain (NfL), a marker of axonal damage, has since emerged as a promising single marker. The aim of this study was to assess the predictive value of NfL in comparison with and in addition to our established model. METHODS NfL was measured in plasma samples drawn at 48 h after cardiac arrest using single-molecule assays. Neurological function was recorded on the cerebral performance category (CPC) scale at discharge from the intensive care unit and after 6 months. The ability to predict a dichotomized outcome (CPC 1-2 vs. 3-5) was assessed with receiver operating characteristic (ROC) curves. RESULTS Seventy patients were included in this analysis, of whom 21 (30%) showed a favorable outcome (CPC 1-2), compared with 49 (70%) with an unfavorable outcome (CPC 3-5) at discharge. NfL increased from CPC 1 to 5 (16.5 pg/ml to 641 pg/ml, p < 0.001). The addition of NfL to the existing model improved it significantly (Wald test, p < 0.001), and the combination of NfL with a multimarker model showed high areas under the ROC curve (89.7% [95% confidence interval 81.7-97.7] at discharge and 93.7% [88.2-99.2] at 6 months) that were significantly greater than each model alone. CONCLUSIONS The combination of NfL with other plasma and clinical markers is superior to that of either model alone and achieves high areas under the ROC curve in this relatively small sample.
Collapse
Affiliation(s)
- Raphael Wurm
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Henrike Arfsten
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Besnik Muqaku
- Department of Analytical Chemistry, Faculty of Chemistry, University of Vienna, Vienna, Austria
| | - Markus Ponleitner
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Andrea Bileck
- Department of Analytical Chemistry, Faculty of Chemistry, University of Vienna, Vienna, Austria
| | - Patrick Altmann
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Paulus Rommer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Stefan Seidel
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Pia Hubner
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Fritz Sterz
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Gottfried Heinz
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Christopher Gerner
- Department of Analytical Chemistry, Faculty of Chemistry, University of Vienna, Vienna, Austria
| | | | - Klaus Distelmaier
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
13
|
Treatment and Prognosis After Hypoxic-Ischemic Injury. Curr Treat Options Neurol 2021. [DOI: 10.1007/s11940-021-00682-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
14
|
Outcome Related to Level of Targeted Temperature Management in Postcardiac Arrest Syndrome of Low, Moderate, and High Severities: A Nationwide Multicenter Prospective Registry. Crit Care Med 2021; 49:e741-e750. [PMID: 33826582 DOI: 10.1097/ccm.0000000000005025] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES The optimal target temperature during targeted temperature management for patients after cardiac arrest remains under debate. The aim of this study was to evaluate the association between targeted temperature management at lower target temperatures and the neurologic outcomes among patients classified by the severity of postcardiac arrest syndrome. DESIGN A multicenter observational study from the out-of-hospital cardiac arrest registry of the Japanese Association for Acute Medicine, which is a nationwide prospective registry of out-of-hospital cardiac arrest patients. SETTING A total of 125 critical care medical centers or hospitals with an emergency care department across Japan. PATIENTS A total of 1,111 out-of-hospital cardiac arrest patients who had received targeted temperature management. MEASUREMENTS AND MAIN RESULTS We divided all 1,111 postcardiac arrest syndrome patients treated with targeted temperature management into two groups: those who received targeted temperature management at a lower target temperature (33-34°C) and those who received targeted temperature management at a higher target temperature (35-36°C). In regard to classification of the patients, we divided the patients into three categories of severity (low, moderate, and high severities) using the risk classification tool, post-Cardiac Arrest Syndrome for Therapeutic hypothermia, which was previously validated. The primary outcome was the percentage of patients with a good neurologic outcome at 30 days, and the secondary outcome was the survival rate at 30 days. Multivariate analysis showed that targeted temperature management at 33-34°C was significantly associated with a good neurologic outcome and survival at 30 days in the moderate severity (odds ratio, 1.70 [95% CI, 1.03-2.83] and 1.90 [95% CI, 1.15-3.16], respectively), but not in the patients of low or high severity (pinteraction = 0.033). Propensity score analysis also showed that targeted temperature management at 33-34°C was associated with a good neurologic outcome in the moderate-severity group (p = 0.022). CONCLUSIONS Targeted temperature management at 33-34°C was associated with a significantly higher rate of a good neurologic outcome in the moderate-severity postcardiac arrest syndrome group, but not in the low- or high-severity group.
Collapse
|
15
|
Du L, Zheng K, Feng L, Cao Y, Niu Z, Song Z, Liu Z, Liu X, Xiang X, Zhou Q, Xiong H, Chen F, Zhang G, Ma Q. The first national survey on practices of neurological prognostication after cardiac arrest in China, still a lot to do. Int J Clin Pract 2021; 75:e13759. [PMID: 33098255 DOI: 10.1111/ijcp.13759] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 10/04/2020] [Indexed: 02/05/2023] Open
Abstract
AIMS To investigate current awareness and practices of neurological prognostication in comatose cardiac arrest (CA) patients. METHODS An anonymous questionnaire was distributed to 1600 emergency physicians in 75 hospitals which were selected randomly from China between January and July 2018. RESULTS 92.1% respondents fulfilled the survey. The predictive value of brain stem reflex, motor response and myoclonus was confirmed by 63.5%, 44.6% and 31.7% respondents, respectively. Only 30.7% knew that GWR value < 1.1 indicated poor prognosis and only 8.1% know the most commonly used SSEP N20. Status epilepticus, burst suppression and suppression were considered to predict poor outcome by only 35.0%, 27.4% and 20.9% respondents, respectively. Only 46.7% knew NSE and only 24.7% knew S-100. Only a few respondents knew that neurological prognostication should be performed later than 72 hours from CA either in TTM or non-TTM patients. In practice, the most commonly used method was clinical examination (85.4%). Only 67.9% had used brain CT for prognosis and 18.4% for MRI. NSE (39.6%) was a little more widely used than S-100β (18.0%). However, SSEP (4.4%) and EEG (11.4%) were occasionally performed. CONCLUSIONS Neurological prognostication in CA survivors had not been well understood and performed by emergency physicians in China. They were more likely to use clinical examination rather than objective tools, especially SSEP and EEG, which also illustrated that multimodal approach was not well performed in practice.
Collapse
Affiliation(s)
- Lanfang Du
- Emergency Department, The Peking University Third Hospital, Beijing, China
| | - Kang Zheng
- Emergency Department, The Peking University Third Hospital, Beijing, China
| | - Lu Feng
- Emergency Department, The Peking University Third Hospital, Beijing, China
| | - Yu Cao
- Emergency Department, West China Hospital, Chengdu City, China
| | - Zhendong Niu
- Emergency Department, West China Hospital, Chengdu City, China
| | - Zhenju Song
- Emergency Department, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhi Liu
- Emergency Department, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Xiaowei Liu
- Emergency Department, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Xudong Xiang
- Emergency Department, Second Xiangya Hospital, Central South University, Changsha, China
| | - Qidi Zhou
- Emergency Department, Peking University Shenzhen Hospital, Shenzhen City, China
| | - Hui Xiong
- Emergency Department, Peking University First Hospital, Beijing, China
| | - Fengying Chen
- Emergency Department, The Affiliated Hospital of Innor Mongolia Medical University, Huherhaote City, China
| | - Guoqiang Zhang
- Emergency Department, China-Japan Friendship Hospital, Beijing, China
| | - Qingbian Ma
- Emergency Department, The Peking University Third Hospital, Beijing, China
| |
Collapse
|
16
|
Loza A, del Nogal F, Macías D, León C, Socías L, Herrera L, Yuste L, Ferrero J, Vidal B, Sánchez J, Zabalegui A, Saavedra P, Lesmes A. Predictors of mortality and neurological function in ICU patients recovering from cardiac arrest: A Spanish nationwide prospective cohort study. Med Intensiva 2020; 44:463-474. [DOI: 10.1016/j.medin.2020.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 01/24/2020] [Accepted: 02/09/2020] [Indexed: 12/24/2022]
|
17
|
Optimal combination of clinical examinations for neurologic prognostication of out-of-hospital cardiac arrest patients. Resuscitation 2020; 155:91-99. [PMID: 32710915 DOI: 10.1016/j.resuscitation.2020.07.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 06/27/2020] [Accepted: 07/11/2020] [Indexed: 11/27/2022]
Abstract
AIM Targeted temperature management (TTM) may alter the results of clinical examination and delay motor response recovery; hence, re-establishing the accuracy and optimal timing of performing clinical examinations are crucial. Therefore, we aimed to identify the optimal combination and timing of clinical examinations for predicting the neurologic outcomes in patients undergoing TTM. METHODS We conducted a retrospective analysis of prospectively collected multicentre registry data. All enrolled patients were supposed to undergo pupil light reflex (PLR), corneal reflex (CR), and Glasgow Coma Scale for 7 days after return of spontaneous circulation (ROSC). We investigated the timing of each examination based on the ROSC and rewarming completion times. The primary outcome was poor neurologic outcome (cerebral performance category 3,4, or 5) at 6 months after cardiac arrest. RESULTS A total of 715 patients treated with TTM within 2 years, were enrolled. The PLR is more specific than the other examinations, and the specificity of the combination of PLR with CR was 100% 72 h after the ROSC or 24 h after rewarming completion. The sensitivity for the combination of PLR with CR 72 h after the ROSC was 55.3 (49.8-60.7) %, which was not different from that noted 24 h after rewarming completion (P = 0.65). CONCLUSION The combination of PLR with CR showed specificity approaching 100% 72 h after the ROSC or 24 h after rewarming completion. These findings can provide a clinical reference for predicting the neurological outcomes in patients undergoing TTM, especially in institutions without up-to-date facilities.
Collapse
|
18
|
Management of temperature control in post-cardiac arrest care: an expert report. Med Intensiva 2020; 45:164-174. [PMID: 32703653 DOI: 10.1016/j.medin.2020.06.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 06/03/2020] [Accepted: 06/04/2020] [Indexed: 02/06/2023]
Abstract
Targeted temperature management (TTM) through induced hypothermia (between 32-36 oC) is currently regarded as a first-line treatment during the management of post-cardiac arrest patients admitted to the Intensive Care Unit (ICU). The aim of TTM is to afford neuroprotection and reduce secondary neurological damage caused by anoxia. Despite the large body of evidence on its benefits, the TTM is still little used in Spain. There are controversial issues referred to its implementation, such as the optimal target body temperature, timing, duration and the rewarming process. The present study reviews the best available scientific evidence and the current recommendations contained in the international guidelines. In addition, the study focuses on the practical implementation of TTM in post-cardiac arrest patients in general and cardiological ICUs, with a discussion of the implementation strategies, protocols, management of complications and assessment of the neurological prognosis.
Collapse
|
19
|
Impact of Structured Pathways for Postcardiac Arrest Care: A Systematic Review and Meta-Analysis. Crit Care Med 2020; 47:e710-e716. [PMID: 31306259 DOI: 10.1097/ccm.0000000000003827] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVES Recent research has demonstrated value in selected therapeutic and prognostic interventions delivered to patients following cardiac arrest. The aim of this work was to determine if the implementation of a structured care pathway, which combines different interventions, could improve outcomes in survivors of cardiac arrest. DATA SOURCES PubMed and review of citations in retrieved articles. STUDY SELECTION Randomized trials and prospective observational studies conducted in adult cardiac arrest patients, which evaluated the impact on outcome of a structured care pathway, defined as an organized set of interventions designed specifically for postcardiac arrest patients. DATA EXTRACTION Data collected included study characteristics and methodologic quality, populations enrolled, interventions that were part of the cardiac arrest structured care pathway, and outcomes. The principal outcome was favorable functional status defined as a Cerebral Performance Category score of 1-2 at or after hospital discharge. DATA SYNTHESIS The systematic search retrieved 481 articles of which nine (total, 1,994 patients) were selected for systematic review, and six (1,422 patients) met criteria for meta-analysis. Interventions in the care pathways included early coronary angiography with or without percutaneous coronary intervention (eight studies), targeted temperature management (nine studies), and protocolized management in the ICU (seven studies). Neurologic prognostication was not a part of any of the structured pathways. Meta-analysis found significantly higher odds of achieving a favorable functional outcome in patients who were treated in a structured care pathway, when compared with standard care (odds ratio, 2.35; 95% CI, 1.46-3.81). CONCLUSIONS Following cardiac arrest, patients treated in a structured care pathway may have a substantially higher likelihood of favorable functional outcome than those who receive standard care. These findings suggest benefit of a highly organized approach to postcardiac arrest care, in which a cluster of evidence-based interventions are delivered by a specialized interdisciplinary team. Given the overall low certainty of evidence, definitive recommendations will need confirmation in additional high-quality studies.
Collapse
|
20
|
Ong HN, Chen WJ, Chuang PY, Lee BC, Huang CH, Huang CC, Chang WT, Tsai MS. Prognosis Value of Gray-White-Matter Ratios in Comatose Survivors After In-Hospital Cardiac Arrest. J Acute Med 2020; 10:9-19. [PMID: 32995150 PMCID: PMC7517952 DOI: 10.6705/j.jacme.202003_10(1).0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 06/18/2019] [Accepted: 07/11/2019] [Indexed: 06/11/2023]
Abstract
BACKGROUND The gray-white-matter ratio (GWR) measured on cerebral non-contrasted computed tomography (NCCT) has been reported to help the prognostication of mortality or comatose status of out-of-hospital cardiac arrest (OHCA) victims. Since the etiologies and resuscitative process differ significantly between patients with OHCA and in-hospital cardiac arrest (IHCA), the predictive ability of GWR in IHCA survivors remains unclear. METHODS This retrospective observational study conducted in a single tertiary medical center in Taiwan enrolled all the non-traumatic IHCA adults with sustained return of spontaneous circulation (ROSC) and had received cerebral NCCT examination within 24 hours following cardiac arrest. The GWR of survivor and non-survivor as well as good and poor neurological outcome were analyzed. RESULTS A total of 79 IHCA patients with 68.4% in male gender and mean age of 66-year-old were enrolled in the current study. 34 patients (43.0%) survived to hospital discharge and 20 patients (25.3%) were discharged with good neurological outcome. The median GWR of patients with good and poor outcomes in either aspect of survival or neurological function did not show significant difference. The area under the plotted receiver of characteristic curves of each GWR also did not show satisfactory predictive performance. CONCLUSIONS The use of GWR for outcome prognosis of patients in emergency department whom progressed to circulatory failure did not show promising result.
Collapse
Affiliation(s)
- Hooi-Nee Ong
- National Taiwan University Medical College and Hospital Department of Emergency Medicine Taipei Taiwan
| | - Wen-Jone Chen
- National Taiwan University Medical College and Hospital Department of Emergency Medicine Taipei Taiwan
| | - Po-Ya Chuang
- Taipei Medical University School of Health Care Administration Taipei Taiwan
| | - Bo-Ching Lee
- National Taiwan University Medical College and Hospital Department of Radiology Taipei Taiwan
| | - Chien-Hua Huang
- National Taiwan University Medical College and Hospital Department of Emergency Medicine Taipei Taiwan
| | - Chun-Chieh Huang
- Far Eastern Memorial Hospital Department of Radiology New Taipei City Taiwan
| | - Wei-Tien Chang
- National Taiwan University Medical College and Hospital Department of Emergency Medicine Taipei Taiwan
| | - Min-Shan Tsai
- National Taiwan University Medical College and Hospital Department of Emergency Medicine Taipei Taiwan
- National Taiwan University Hospital Hsin-Chu Branch Department of Emergency Medicine Hsinchu Taiwan
| |
Collapse
|
21
|
Wang CH, Chang WT, Su KI, Huang CH, Tsai MS, Chou E, Lu TC, Chen WJ, Lee CC, Chen SC. Neuroprognostic accuracy of blood biomarkers for post-cardiac arrest patients: A systematic review and meta-analysis. Resuscitation 2020; 148:108-117. [DOI: 10.1016/j.resuscitation.2020.01.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 12/26/2019] [Accepted: 01/09/2020] [Indexed: 01/12/2023]
|
22
|
Joffe AR, Brin G, Farrow S. Unreliable Early Neuroprognostication After Severe Carbon Monoxide Poisoning Is Likely Due to Cytopathic Hypoxia: A Case Report and Discussion. J Child Neurol 2020; 35:111-115. [PMID: 31621482 DOI: 10.1177/0883073819879833] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A 17-year-old girl was found unconscious in a running vehicle. She developed very severe acute respiratory distress syndrome (which was treated with rescue high-frequency oscillation), hemodynamic instability, acute kidney injury, rhabdomyolysis, and remained comatose with a Glasgow Coma Scale score of 3 and gasping respirations for 67 hours (when the Glasgow Coma Scale score improved to 6, with tachypnea to Paco 2 28 and pH 7.5). By 92 hours, she was obeying commands, and she was extubated at 96 hours, shortly after which she was conversing with family and texting on her phone. A magnetic resonance imaging (MRI) scan 6 days after being found showed subacute infarctions affecting the medial aspect of the globus pallidus bilaterally as well as a small cortical/subcortical infarction in the right parietal lobe. At a 7-week follow-up, she had no delayed-onset signs of brain injury. This case demonstrated that neurologic prognostication after carbon monoxide poisoning may be unreliable for more than 72 hours after injury. We discuss that it is possible that the mitochondrial dysfunction induced by carbon monoxide was responsible for a functional coma without irreversible brain injury, similar to the mechanism of cytopathic hypoxia in multiple-organ dysfunction that allows some other organ recovery without necrosis in survivors.
Collapse
Affiliation(s)
- Ari R Joffe
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stollery Children's Hospital and University of Alberta, Edmonton, Alberta, Canada
| | - Geoff Brin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stollery Children's Hospital and University of Alberta, Edmonton, Alberta, Canada
| | - Sarah Farrow
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stollery Children's Hospital and University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
23
|
Lopez Soto C, Dragoi L, Heyn CC, Kramer A, Pinto R, Adhikari NKJ, Scales DC. Imaging for Neuroprognostication After Cardiac Arrest: Systematic Review and Meta-analysis. Neurocrit Care 2020; 32:206-216. [PMID: 31549351 DOI: 10.1007/s12028-019-00842-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Predicting neurological outcome in comatose survivors of cardiac arrest relies on clinical findings, radiological and neurophysiological test results. To evaluate the predictive accuracy of brain computed tomography (CT) and magnetic resonance imaging (MRI) for prognostication of neurological outcomes after cardiac arrest. METHODS We searched MEDLINE (database inception to August 2018) and included all observational cohort studies or randomized controlled trials including adult (16 years or older) survivors of cardiac arrest which evaluated the diagnostic accuracy of CT or MRI for predicting neurologic outcome or mortality. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. All review stages were conducted independently by 2 reviewers, and where possible data were pooled using bivariate meta-analysis. The main outcome was to evaluate the of accuracy of CT and MRI in neuroprognostication of patients after cardiac arrest. RESULTS We included 44 studies that examined brain CT (n = 24) or MRI (n = 21) in 4008 (n per study, 9-398) patients. Decreased grey to white matter ratio on CT (20 studies) was useful for predicting poor neurological outcome (sensitivity 0.44, 95% CI 0.29-0.60; specificity 0.97, 95% CI 0.93-0.99; positive likelihood ratio [LR+] 13.8, 95% CI 6.9-27.7). Similarly, diffusion-weighted imaging (DWI) on MRI (16 studies; sensitivity 0.77, 95% CI 0.65-0.85; specificity 0.92, 95% CI 0.85-0.96; LR+ 9.2, 95% CI 5.2-16.4) and DWI and fluid-attenuated inversion recovery (FLAIR) MRI (4 studies, sensitivity 0.70, 95% CI 0.43-0.88; specificity 0.95, 95% CI 0.79-0.99; LR+ 13.4, 95% CI 3.5-51.2) were useful for predicting poor neurological outcomes. We found marked heterogeneity in timing of radiological examinations and neurological assessments relative to the cardiac arrest. CONCLUSION Decreased grey to white matter ratio on CT and DWI or DWI and FLAIR on MRI are useful adjuncts for predicting poor early neurological outcome after cardiac arrest.
Collapse
Affiliation(s)
- Carmen Lopez Soto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Laura Dragoi
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Chinthaka C Heyn
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Andreas Kramer
- Departments of Critical Care Medicine and Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Neill K J Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Damon C Scales
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
| |
Collapse
|
24
|
Monk A, Patil S. Infrared pupillometry to help predict neurological outcome for patients achieving return of spontaneous circulation following cardiac arrest: a systematic review protocol. Syst Rev 2019; 8:286. [PMID: 31767023 PMCID: PMC6876106 DOI: 10.1186/s13643-019-1209-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 10/22/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite advances in resuscitation care, mortality rates following cardiac arrest (CA) remain high. Between one-quarter (in-hospital CA) and two-thirds (out of hospital CA) of patients admitted comatose to intensive care die of neurological injury. Neuroprognostication determines an informed and timely withdrawal of life sustaining treatment (WLST), sparing the patient unnecessary suffering, alleviating family distress and allowing a more utilitarian use of resources. The latest Resuscitation Council UK (2015) guidance on post-resuscitation care provides the current multi-modal neuroprognostication strategy to predict neurological outcome. Its modalities include neurological examination, neurophysiological tests, biomarkers and radiology. Despite each of the current strategy's predictive modalities exhibiting limitations, meta-analyses show that three, namely PLR (pupillary light reflex), CR (corneal reflex) and N20 SSEP (somatosensory-evoked potential), accurately predict poor neurological outcome with low false positive rates. However, the quality of evidence is low, reducing confidence in the strategy's results. While infrared pupillometry (IRP) is not currently used as a prognostication modality, it can provide a quantitative and objective measure of pupillary size and PLR, giving a definitive view of the second and third cranial nerve activity, a predictor of neurological outcome. METHODS The proposed study will test the hypothesis, "in those patients who remain comatose following return of spontaneous circulation (ROSC) after CA, IRP can be used early to help predict poor neurological outcome". A comprehensive review of the evidence using a PRISMA-P (2015) compliant methodology will be underpinned by systematic searching of electronic databases and the two authors selecting and screening eligible studies using the Cochrane data extraction and assessment template. Randomised controlled trials and retrospective and prospective studies will be included, and the quality and strength of evidence will be assessed using the Grading of Recommendation, Assessment and Evaluation (GRADE) approach. DISCUSSION IRP requires rudimentary skill and is objective and repeatable. As a clinical prognostication modality, it may be utilised early, when the strategy's other modalities are not recommended. Corroboration in the evidence would promote early use of IRP and a reduction in ICU bed days. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018118180.
Collapse
Affiliation(s)
- Alex Monk
- Emergency Department, Chelsea and Westminster Hospital, 369 Fulham Road, Chelsea, London, SW10 9NH, England.
| | - Shashank Patil
- Emergency Department, Chelsea and Westminster Hospital, 369 Fulham Road, Chelsea, London, SW10 9NH, England.,Kings College London, Room No 213, St Thomas' House, Westminster Bridge Road, London, SE1 7EH, England
| |
Collapse
|
25
|
Endoh H, Kamimura N, Honda H, Nitta M. Early prognostication of neurological outcome by heart rate variability in adult patients with out-of-hospital sudden cardiac arrest. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:323. [PMID: 31623658 PMCID: PMC6798365 DOI: 10.1186/s13054-019-2603-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 09/06/2019] [Indexed: 01/20/2023]
Abstract
Background Most deaths of comatose survivors of out-of-hospital sudden cardiac arrest result from withdrawal of life-sustaining treatment (WLST) decisions based on poor neurological prognostication and the family’s intention. Thus, accurate prognostication is crucial to avoid premature WLST decisions. However, targeted temperature management (TTM) with sedation or neuromuscular blockade against shivering significantly affects early prognostication. In this study, we investigated whether heart rate variability (HRV) analysis could prognosticate poor neurological outcome in comatose patients undergoing hypothermic TTM. Methods Between January 2015 and December 2017, adult patients with out-of-hospital sudden cardiac arrest, successfully resuscitated in the emergency department and admitted to the intensive care unit of the Niigata University in Japan, were prospectively included. All patients had an initial Glasgow Coma Scale motor score of 1 and received hypothermic TTM (at 34 °C). Twenty HRV-related variables (deceleration capacity; 4 time-, 3 geometric-, and 7 frequency-domain; and 5 complexity variables) were computed based on RR intervals between 0:00 and 8:00 am within 24 h after return of spontaneous circulation (ROSC). Based on Glasgow Outcome Scale (GOS) at 2 weeks after ROSC, patients were divided into good outcome (GOS 1–2) and poor outcome (GOS 3–5) groups. Results Seventy-six patients were recruited and allocated to the good (n = 22) or poor (n = 54) outcome groups. Of the 20 HRV-related variables, ln very-low frequency (ln VLF) power, detrended fluctuation analysis (DFA) (α1), and multiscale entropy (MSE) index significantly differed between the groups (p = 0.001), with a statistically significant odds ratio (OR) by univariate logistic regression analysis (p = 0.001). Multivariate logistic regression analysis of the 3 variables identified ln VLF power and DFA (α1) as significant predictors for poor outcome (OR = 0.436, p = 0.006 and OR = 0.709, p = 0.024, respectively). The area under the receiver operating characteristic curve for ln VLF power and DFA (α1) in predicting poor outcome was 0.84 and 0.82, respectively. In addition, the minimum value of ln VLF power or DFA (α1) for the good outcome group predicted poor outcome with sensitivity = 61% and specificity = 100%. Conclusions The present data indicate that HRV analysis could be useful for prognostication for comatose patients during hypothermic TTM.
Collapse
Affiliation(s)
- Hiroshi Endoh
- Department of Emergency & Critical Care Medicine, Niigata University Faculty of Medicine, 1-757 Asahimachi-dori, Chuo-ku, Niigata, 951-8520, Japan. .,Advanced Emergency and Critical Care Center, Niigata University Medical & Dental Hospital, 1-754 Asahimachi-dori, Chuo-ku, Niigata, 951-8520, Japan.
| | - Natuo Kamimura
- Department of Emergency & Critical Care Medicine, Niigata University Faculty of Medicine, 1-757 Asahimachi-dori, Chuo-ku, Niigata, 951-8520, Japan.,Advanced Emergency and Critical Care Center, Niigata University Medical & Dental Hospital, 1-754 Asahimachi-dori, Chuo-ku, Niigata, 951-8520, Japan
| | - Hiroyuki Honda
- Advanced Emergency and Critical Care Center, Niigata University Medical & Dental Hospital, 1-754 Asahimachi-dori, Chuo-ku, Niigata, 951-8520, Japan
| | - Masakazu Nitta
- Advanced Emergency and Critical Care Center, Niigata University Medical & Dental Hospital, 1-754 Asahimachi-dori, Chuo-ku, Niigata, 951-8520, Japan
| |
Collapse
|
26
|
Estimating the False Positive Rate of Absent Somatosensory Evoked Potentials in Cardiac Arrest Prognostication. Crit Care Med 2019; 46:e1213-e1221. [PMID: 30247243 DOI: 10.1097/ccm.0000000000003436] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES Absence of somatosensory evoked potentials is considered a nearly perfect predictor of poor outcome after cardiac arrest. However, reports of good outcomes despite absent somatosensory evoked potentials and high rates of withdrawal of life-sustaining therapies have raised concerns that estimates of the prognostic value of absent somatosensory evoked potentials may be biased by self-fulfilling prophecies. We aimed to develop an unbiased estimate of the false positive rate of absent somatosensory evoked potentials as a predictor of poor outcome after cardiac arrest. DATA SOURCES PubMed. STUDY SELECTION We selected 35 studies in cardiac arrest prognostication that reported somatosensory evoked potentials. DATA EXTRACTION In each study, we identified rates of withdrawal of life-sustaining therapies and good outcomes despite absent somatosensory evoked potentials. We appraised studies for potential biases using the Quality in Prognosis Studies tool. Using these data, we developed a statistical model to estimate the false positive rate of absent somatosensory evoked potentials adjusted for withdrawal of life-sustaining therapies rate. DATA SYNTHESIS Two-thousand one-hundred thirty-three subjects underwent somatosensory evoked potential testing. Five-hundred ninety-four had absent somatosensory evoked potentials; of these, 14 had good functional outcomes. The rate of withdrawal of life-sustaining therapies for subjects with absent somatosensory evoked potential could be estimated in 14 of the 35 studies (mean 80%, median 100%). The false positive rate for absent somatosensory evoked potential in predicting poor neurologic outcome, adjusted for a withdrawal of life-sustaining therapies rate of 80%, is 7.7% (95% CI, 4-13%). CONCLUSIONS Absent cortical somatosensory evoked potentials do not infallibly predict poor outcome in patients with coma following cardiac arrest. The chances of survival in subjects with absent somatosensory evoked potentials, though low, may be substantially higher than generally believed.
Collapse
|
27
|
Geocadin RG, Callaway CW, Fink EL, Golan E, Greer DM, Ko NU, Lang E, Licht DJ, Marino BS, McNair ND, Peberdy MA, Perman SM, Sims DB, Soar J, Sandroni C. Standards for Studies of Neurological Prognostication in Comatose Survivors of Cardiac Arrest: A Scientific Statement From the American Heart Association. Circulation 2019; 140:e517-e542. [DOI: 10.1161/cir.0000000000000702] [Citation(s) in RCA: 153] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Significant improvements have been achieved in cardiac arrest resuscitation and postarrest resuscitation care, but mortality remains high. Most of the poor outcomes and deaths of cardiac arrest survivors have been attributed to widespread brain injury. This brain injury, commonly manifested as a comatose state, is a marker of poor outcome and a major basis for unfavorable neurological prognostication. Accurate prognostication is important to avoid pursuing futile treatments when poor outcome is inevitable but also to avoid an inappropriate withdrawal of life-sustaining treatment in patients who may otherwise have a chance of achieving meaningful neurological recovery. Inaccurate neurological prognostication leading to withdrawal of life-sustaining treatment and deaths may significantly bias clinical studies, leading to failure in detecting the true study outcomes. The American Heart Association Emergency Cardiovascular Care Science Subcommittee organized a writing group composed of adult and pediatric experts from neurology, cardiology, emergency medicine, intensive care medicine, and nursing to review existing neurological prognostication studies, the practice of neurological prognostication, and withdrawal of life-sustaining treatment. The writing group determined that the overall quality of existing neurological prognostication studies is low. As a consequence, the degree of confidence in the predictors and the subsequent outcomes is also low. Therefore, the writing group suggests that neurological prognostication parameters need to be approached as index tests based on relevant neurological functions that are directly related to the functional outcome and contribute to the quality of life of cardiac arrest survivors. Suggestions to improve the quality of adult and pediatric neurological prognostication studies are provided.
Collapse
|
28
|
Topjian AA, de Caen A, Wainwright MS, Abella BS, Abend NS, Atkins DL, Bembea MM, Fink EL, Guerguerian AM, Haskell SE, Kilgannon JH, Lasa JJ, Hazinski MF. Pediatric Post–Cardiac Arrest Care: A Scientific Statement From the American Heart Association. Circulation 2019; 140:e194-e233. [DOI: 10.1161/cir.0000000000000697] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Successful resuscitation from cardiac arrest results in a post–cardiac arrest syndrome, which can evolve in the days to weeks after return of sustained circulation. The components of post–cardiac arrest syndrome are brain injury, myocardial dysfunction, systemic ischemia/reperfusion response, and persistent precipitating pathophysiology. Pediatric post–cardiac arrest care focuses on anticipating, identifying, and treating this complex physiology to improve survival and neurological outcomes. This scientific statement on post–cardiac arrest care is the result of a consensus process that included pediatric and adult emergency medicine, critical care, cardiac critical care, cardiology, neurology, and nursing specialists who analyzed the past 20 years of pediatric cardiac arrest, adult cardiac arrest, and pediatric critical illness peer-reviewed published literature. The statement summarizes the epidemiology, pathophysiology, management, and prognostication after return of sustained circulation after cardiac arrest, and it provides consensus on the current evidence supporting elements of pediatric post–cardiac arrest care.
Collapse
|
29
|
Kavi T, Desai M, Yilmaz FM, Kakadia B, Burakgazi-Dalkilic E, Shrestha GS. Inter-predictability of Neuroprognostic Modalities After Cardiac Arrest. Cureus 2019; 11:e4489. [PMID: 31259107 PMCID: PMC6581415 DOI: 10.7759/cureus.4489] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Introduction At present, there is an emphasis on a multi-modal approach to neuro-prognostication after cardiac arrest using clinical examination, neurophysiologic testing, laboratory biomarkers, and radiological studies. However, this necessitates significant resource utilization and can be challenging in under-resourced clinical settings. Hence, we sought to determine the inter-predictability and correlation of prognostic tests performed in patients after cardiac arrest. Methods Fifty patients were included through neurophysiology laboratory data for this retrospective study. Clinical, radiological and neurophysiological data were collected. Neurophysiological data were re-evaluated by a board-certified neurophysiologist for the purpose of the study. Chi-square testing was used to evaluate the correlation between different diagnostic modalities. Results We found that a non-reactive electroencephalogram (EEG) had a predictive value of 79% for absent bilateral cortical responses (N20) with somatosensory evoked potentials (SSEP). On the other hand, absent bilateral cortical responses N20 had 87% predictive value for a non-reactive EEG. Also, absent cortical responses and non-reactive EEG had predictive values of 78% and 72% for anoxic injury on magnetic resonance imaging (MRI) brain respectively with a non-significant difference on chi-square testing. Individually, absent bilateral N20 SSEP, a non-reactive EEG and anoxic brain injury on MRI studies were highly predictive of poor outcome [modified Rankin scale (mRS) > 4] at hospital discharge. Conclusion Neuroprognostication in a post-cardiac arrest setting is often limited by self-fulfilling prophecy. Given the lack of absolute correlation between different modalities used in post-cardiac arrest patients, the value of the multi-modal approach to neuro-prognostication is highlighted by this study.
Collapse
Affiliation(s)
- Tapan Kavi
- Neurology, Cooper Neurological Institute, Cooper University Hospital, Camden, USA
| | - Masoom Desai
- Neurology, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Furkan M Yilmaz
- Neurology, Cooper Neurological Institute, Cooper University Hospital, Camden, USA
| | - Bhavika Kakadia
- Neurology, Cooper Neurological Institute, Cooper University Hospital, Camden, USA
| | | | - Gentle S Shrestha
- Critical Care, Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu, NPL
| |
Collapse
|
30
|
Khaira G, Joffe AR. Neurocognitive outcomes in survivors of pediatric E-CPR: Has the Golden age arrived? Resuscitation 2019; 139:353-355. [PMID: 30991080 DOI: 10.1016/j.resuscitation.2019.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 04/02/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Gurpreet Khaira
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stollery Children's Hospital and University of Alberta, Edmonton, Alberta, Canada.
| | - Ari R Joffe
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stollery Children's Hospital and University of Alberta, Edmonton, Alberta, Canada.
| |
Collapse
|
31
|
Abstract
Time to Epileptiform Activity and EEG Background Recovery Are
Independent Predictors After Cardiac Arrest Westhall E, Rose I, Rundgren M, Bro-Jeppesen J, Kjaergaard J, Hassager C,
Lindehammar H, Horn J, Ullen S, Nielsen N, Friberg H, Cronberg T.
Clin Neurophysiol. 2018;129:1660-1668.
doi:10.1016/j.clinph.2018.05.016 Objective: To investigate the temporal development of
electroencephalogram (EEG) and prognosis. Methods: Prospective
observational substudy of the Target Temperature Management trial. Six
sites performed simplified continuous EEG monitoring (cEEG) on comatose
patients after cardiac arrest, blinded to treating physicians. We
determined time points of recovery of a normal-voltage continuous
background activity and the appearance of an epileptiform EEG, defined
as abundant epileptiform discharges, periodic/rhythmic discharges, or
electrographic seizure activity. Results: One hundred thirty-four
patients were included, of which 65 had a good outcome. Early recovery
of continuous background activity (within 24 hours) occurred in 72
patients and predicted good outcome since 55 (76%) had good outcome,
increasing the odds for a good outcome 7 times compared to a late
background recovery. Early appearance of an epileptiform EEG occurred in
38 patients and 34 (89%) had a poor outcome, increasing the odds for a
poor outcome 6 times compared to a late debut. The time to background
recovery and the time to epileptiform activity were highly associated
with outcome and levels of neuron-specific enolase. Multiple regression
analysis showed that both variables were independent predictors.
Conclusions: Time to epileptiform activity and background recovery are
independent prognostic indicators. SIGNIFICANCE: Patients with early
background recovery combined with late appearance of epileptiform
activity may have a good outcome.
Collapse
|
32
|
Neurological Prognostication After Cardiac Arrest in the Era of Target Temperature Management. Curr Neurol Neurosci Rep 2019; 19:10. [DOI: 10.1007/s11910-019-0922-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
|
33
|
Quantitative assessment of pupillary light reflex for early prediction of outcomes after out-of-hospital cardiac arrest: A multicentre prospective observational study. Resuscitation 2018; 131:108-113. [PMID: 29958957 DOI: 10.1016/j.resuscitation.2018.06.027] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 06/16/2018] [Accepted: 06/25/2018] [Indexed: 11/24/2022]
Abstract
AIM To clarify whether quantitative assessment of pupillary light reflexes (PLR) can predict the outcome of post-cardiac arrest (CA) patients during the first 72 h after the return of spontaneous circulation (ROSC). METHODS Fifty adults resuscitated after non-traumatic out-of-hospital CA (OHCA) (mean age 64.1 years old, 36 males) were enrolled in four emergency hospitals. PLR was sequentially measured at 0, 6, 12, 24, 48, and 72 h after ROSC by an automated portable infrared pupillometry. PLR values for each time point were compared between both survivors and non-survivors, and patients with either favourable (Cerebral Performance Category (CPC) 1 or 2) or unfavourable neurological outcomes. RESULTS Twenty-three patients survived for 90 days after CA, and 13 patients achieved favourable neurological outcomes. The PLR values of the survivors and patients with favourable neurological outcomes were consistently greater than those of non-survivors (P < 0.001) and those with unfavourable neurological outcomes (P < 0.001), respectively. The change in PLR over time was not statistically different between the outcome groups. The 0-hour PLR best predicted both 90-day survival (AUC = 0.82, cutoff 3%, sensitivity 0.87, specificity 0.80) and favourable neurological outcomes (AUC = 0.84, cutoff 6%, sensitivity 0.92, specificity 0.74). No patient with a 6-hour PLR less than 3% survived for 90 days after CA. CONCLUSIONS Quantitatively measured PLR was consistently greater in survivors and patients with favourable neurological outcomes during the 72 h after ROSC. Quantitative assessment of PLR at as early as 0 h has a potential role for prognostication in post-CA patients.
Collapse
|
34
|
Palacios-Rubio J, Marina-Breysse M, Quintanilla JG, Gil-Perdomo JM, Juárez-Fernández M, Garcia-Gonzalez I, Rial-Bastón V, Corcobado MC, Espinosa MC, Ruiz F, Gómez-Mascaraque Pérez F, Bringas-Bollada M, Lillo-Castellano JM, Pérez-Castellano N, Martínez-Sellés M, López de Sá E, Martín-Benítez JC, Perez-Villacastín J, Filgueiras-Rama D. Early prognostic value of an Algorithm based on spectral Variables of Ventricular fibrillAtion from the EKG of patients with suddEn cardiac death: A multicentre observational study (AWAKE). ARCHIVOS DE CARDIOLOGIA DE MEXICO 2018; 88:460-467. [PMID: 29885765 DOI: 10.1016/j.acmx.2018.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 04/09/2018] [Accepted: 05/01/2018] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Ventricular fibrillation (VF)-related sudden cardiac death (SCD) is a leading cause of mortality and morbidity. Current biological and imaging parameters show significant limitations on predicting cerebral performance at hospital admission. The AWAKE study (NCT03248557) is a multicentre observational study to validate a model based on spectral ECG analysis to early predict cerebral performance and survival in resuscitated comatose survivors. METHODS Data from VF ECG tracings of patients resuscitated from SCD will be collected using an electronic Case Report Form. Patients can be either comatose (Glasgow Coma Scale - GCS - ≤8) survivors undergoing temperature control after return of spontaneous circulation (RoSC), or those who regain consciousness (GCS=15) after RoSC; all admitted to Intensive Cardiac Care Units in 4 major university hospitals. VF tracings prior to the first direct current shock will be digitized and analyzed to derive spectral data and feed a predictive model to estimate favorable neurological performance (FNP). The results of the model will be compared to the actual prognosis. RESULTS The primary clinical outcome is FNP during hospitalization. Patients will be categorized into 4 subsets of neurological prognosis according to the risk score obtained from the predictive model. The secondary clinical outcomes are survival to hospital discharge, and FNP and survival after 6 months of follow-up. The model-derived categorisation will be also compared with clinical variables to assess model sensitivity, specificity, and accuracy. CONCLUSIONS A model based on spectral analysis of VF tracings is a promising tool to obtain early prognostic data after SCD.
Collapse
Affiliation(s)
| | - Manuel Marina-Breysse
- Fundación Centro Nacional de Investigaciones Cardiovasculares, Carlos III (CNIC), Madrid, Spain
| | - Jorge G Quintanilla
- Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain; Fundación Centro Nacional de Investigaciones Cardiovasculares, Carlos III (CNIC), Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | | | - Miriam Juárez-Fernández
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Hospital Universitario Gregorio Marañón, Department of Cardiology, Madrid, Spain
| | | | | | - María Carmen Corcobado
- Unidad de Cuidados Intensivos, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
| | - María Carmen Espinosa
- Unidad de Cuidados Intensivos, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
| | - Francisco Ruiz
- Unidad de Cuidados Intensivos, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
| | | | | | - José María Lillo-Castellano
- Fundación Centro Nacional de Investigaciones Cardiovasculares, Carlos III (CNIC), Madrid, Spain; Fundación interhospitalaria para la Investigación Cardiovascular (FIC), Madrid, Spain
| | - Nicasio Pérez-Castellano
- Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Manuel Martínez-Sellés
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Hospital Universitario Gregorio Marañón, Department of Cardiology, Madrid, Spain; Universidad Complutense, Madrid, Spain
| | - Esteban López de Sá
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Hospital Universitario La Paz, Department of Cardiology, Madrid, Spain
| | | | - Julián Perez-Villacastín
- Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Fundación interhospitalaria para la Investigación Cardiovascular (FIC), Madrid, Spain
| | - David Filgueiras-Rama
- Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain; Fundación Centro Nacional de Investigaciones Cardiovasculares, Carlos III (CNIC), Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain.
| |
Collapse
|
35
|
Sandroni C, D'Arrigo S, Nolan JP. Prognostication after cardiac arrest. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:150. [PMID: 29871657 PMCID: PMC5989415 DOI: 10.1186/s13054-018-2060-7] [Citation(s) in RCA: 144] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 05/10/2018] [Indexed: 01/17/2023]
Abstract
Hypoxic-ischaemic brain injury (HIBI) is the main cause of death in patients who are comatose after resuscitation from cardiac arrest. A poor neurological outcome-defined as death from neurological cause, persistent vegetative state, or severe neurological disability-can be predicted in these patients by assessing the severity of HIBI. The most commonly used indicators of severe HIBI include bilateral absence of corneal and pupillary reflexes, bilateral absence of N2O waves of short-latency somatosensory evoked potentials, high blood concentrations of neuron specific enolase, unfavourable patterns on electroencephalogram, and signs of diffuse HIBI on computed tomography or magnetic resonance imaging of the brain. Current guidelines recommend performing prognostication no earlier than 72 h after return of spontaneous circulation in all comatose patients with an absent or extensor motor response to pain, after having excluded confounders such as residual sedation that may interfere with clinical examination. A multimodal approach combining multiple prognostication tests is recommended so that the risk of a falsely pessimistic prediction is minimised.
Collapse
Affiliation(s)
- Claudio Sandroni
- Istituto Anestesiologia e Rianimazione Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario "Agostino Gemelli, Largo Francesco Vito 1, 00168, Rome, Italy.
| | - Sonia D'Arrigo
- Istituto Anestesiologia e Rianimazione Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario "Agostino Gemelli, Largo Francesco Vito 1, 00168, Rome, Italy
| | - Jerry P Nolan
- School of Clinical Science, University of Bristol, Bristol, UK.,Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK
| |
Collapse
|
36
|
André-Obadia N, Zyss J, Gavaret M, Lefaucheur JP, Azabou E, Boulogne S, Guérit JM, McGonigal A, Merle P, Mutschler V, Naccache L, Sabourdy C, Trébuchon A, Tyvaert L, Vercueil L, Rohaut B, Delval A. Recommendations for the use of electroencephalography and evoked potentials in comatose patients. Neurophysiol Clin 2018; 48:143-169. [DOI: 10.1016/j.neucli.2018.05.038] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 05/07/2018] [Indexed: 12/21/2022] Open
|
37
|
Schulz A, Stammet P, Dierolf AM, Vögele C, Beyenburg S, Werer C, Devaux Y. Late heartbeat-evoked potentials are associated with survival after cardiac arrest. Resuscitation 2018; 126:7-13. [DOI: 10.1016/j.resuscitation.2018.02.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 01/19/2018] [Accepted: 02/09/2018] [Indexed: 12/20/2022]
|
38
|
|
39
|
Sarak B, Goodman SG, Brieger D, Gale CP, Tan NS, Budaj A, Wong GC, Huynh T, Tan MK, Udell JA, Bagai A, Fox KA, Yan AT. Electrocardiographic Findings in Patients With Acute Coronary Syndrome Presenting With Out-of-Hospital Cardiac Arrest. Am J Cardiol 2018; 121:294-300. [PMID: 29197473 DOI: 10.1016/j.amjcard.2017.10.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Revised: 10/10/2017] [Accepted: 10/13/2017] [Indexed: 12/22/2022]
Abstract
We sought to characterize presenting electrocardiographic findings in patients with acute coronary syndromes (ACSs) and out-of-hospital cardiac arrest (OHCA). In the Global Registry of Acute Coronary Events and Canadian ACS Registry I, we examined presenting and 24- to 48-hour follow-up ECGs (electrocardiogram) of ACS patients who survived to hospital admission, stratified by presentation with OHCA. We assessed the prevalence of ST-segment deviation and bundle branch blocks (assessed by an independent ECG core laboratory) and their association with in-hospital and 6-month mortality among those with OHCA. Of the 12,040 ACS patients, 215 (1.8%) survived to hospital admission after OHCA. Those with OHCA had higher presenting rates of ST-segment elevation, ST-segment depression, T-wave inversion, precordial Q-waves, left bundle branch block (LBBB), and right bundle branch block (RBBB) than those without. Among patients with OHCA, those with ST-segment elevation had significantly lower in-hospital mortality (20.9% vs 33.0%, p = 0.044) and a trend toward lower 6-month mortality (27% vs 39%, p = 0.060) compared with those without ST-segment elevation. Conversely, among OCHA patients, LBBB was associated with significantly higher in-hospital and 6-month mortality rates (58% vs 22%, p <0.001, and 65% vs 28%, p <0.001, respectively). ST-segment depression and RBBB were not associated with either outcome. Sixty-three percent of bundle branch blocks (RBBB or LBBB) on the presenting ECG resolved by 24 to 48 hours. In conclusion, compared with ACS patients without cardiac arrest, those with OHCA had higher rates of ST-segment elevation, LBBB, and RBBB on admission. Among OHCA patients, ST-segment elevation was associated with lower in-hospital mortality, whereas LBBB was associated with higher in-hospital and 6-month mortality.
Collapse
|
40
|
Understanding Early Decisions to Withdraw Life-Sustaining Therapy in Cardiac Arrest Survivors. A Qualitative Investigation. Ann Am Thorac Soc 2018; 13:1115-22. [PMID: 27073975 DOI: 10.1513/annalsats.201511-751oc] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
RATIONALE Early withdrawal of life-sustaining therapy contributes to the majority of deaths following out-of-hospital cardiac arrest (OHCA), despite current recommendations for delayed neurological prognostication (≥72 h) after treatment with targeted temperature management. Little is known about clinicians' experiences of early withdrawal of life support decisions in patients with OHCA. OBJECTIVES To explore clinicians' experiences and perceptions of early withdrawal of life support decisions and barriers to guideline-concordant neurological prognostication in comatose survivors of OHCA treated with targeted temperature management. METHODS We conducted qualitative interviews with intensive care unit (ICU) physicians and nurses following withdrawal of life support in comatose patients with OHCA treated with targeted temperature management. The study was carried out across 18 academic and community hospitals participating in a multicenter, stepped-wedge, cluster-randomized controlled trial designed to improve quality-of-care processes for patients after OHCA in Ontario, Canada. We used a focused thematic analysis to capture barriers to guideline-concordant neurological prognostication and used these barriers to identify potentially modifiable issues. MEASUREMENTS AND MAIN RESULTS The core thematic finding was a high emotional burden of ICU family-team communication in which strong feelings inhibited information transfer and delayed decision making following OHCA. Four subthemes describing sources of communication strain were identified: (1) requests from family members to provide early outcome predictions, (2) incomplete family comprehension of critical care, (3) family requests for early withdrawal of life support based on their understanding of patients' preferences and values, and (4) family-team communication gaps related to prognostic uncertainty. Participants worried that gaps in timely and clear prognostic information contributed to surrogates' perceptions of a poor outcome and to inappropriately early decisions to withdraw life support. CONCLUSIONS Family-team communication difficulties may be an underestimated factor leading to early withdrawal of life support in ICUs for individuals who initially survive OHCA.
Collapse
|
41
|
Abstract
BACKGROUND Existing studies of quantitative electroencephalography (qEEG) as a prognostic tool after cardiac arrest (CA) use methods that ignore the longitudinal pattern of qEEG data, resulting in significant information loss and precluding analysis of clinically important temporal trends. We tested the utility of group-based trajectory modeling (GBTM) for qEEG classification, focusing on the specific example of suppression ratio (SR). METHODS We included comatose CA patients hospitalized from April 2010 to October 2014, excluding CA from trauma or neurological catastrophe. We used Persyst®v12 to generate SR trends and used semi-quantitative methods to choose appropriate sampling and averaging strategies. We used GBTM to partition SR data into different trajectories and regression associate trajectories with outcome. We derived a multivariate logistic model using clinical variables without qEEG to predict survival, then added trajectories and/or non-longitudinal SR estimates, and assessed changes in model performance. RESULTS Overall, 289 CA patients had ≥36 h of EEG yielding 10,404 h of data (mean age 57 years, 81 % arrested out-of-hospital, 33 % shockable rhythms, 31 % overall survival, 17 % discharged to home or acute rehabilitation). We identified 4 distinct SR trajectories associated with survival (62, 26, 12, and 0 %, P < 0.0001 across groups) and CPC (35, 10, 4, and 0 %, P < 0.0001 across groups). Adding trajectories significantly improved model performance compared to adding non-longitudinal data. CONCLUSIONS Longitudinal analysis of continuous qEEG data using GBTM provides more predictive information than analysis of qEEG at single time-points after CA.
Collapse
|
42
|
Eveson L, Vizcaychipi M, Patil S. Role of bispectral index monitoring and burst suppression in prognostication following out-of-hospital cardiac arrest: a systematic review protocol. Syst Rev 2017; 6:191. [PMID: 28946920 PMCID: PMC5613623 DOI: 10.1186/s13643-017-0584-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 09/18/2017] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Out-of-hospital cardiac arrest (OHCA) is associated with significant mortality or may have a poor neurological outcome. Various community-training programmes have improved practices like bystander cardiopulmonary resuscitation (CPR) and early defibrillation using automated external defibrillator (AED). Post-resuscitation care has also changed significantly in the millennium. Interventions like targeted temperature management (TTM), avoidance of hyperoxia and emergency cardiac catheterisation have given patients a chance of a better neurological outcome. Despite these timely interventions, it is still very difficult to predict neurological outcome. The European Resuscitation Council and European Society of Intensive Care Medicine (ERC-ESICM) published guidance in 2015 with a strong recommendation to delay prognostication for at least 72 h and with an emphasis to adapt a multimodal approach, which includes neurological examination, biomarkers, electroencephalogram (EEG) and radiological tests. These interventions not only have cost attached to them, but the unpredictability has a significant emotional impact on family members. Bispectral index (BIS) monitoring device acts on the principle of EEG and converts the waveform into an absolute number and also measures the burst suppression. We hypothesize that patients who have a low BIS value and high burst suppression within 24 h of presentation will have a poor neurological outcome. The primary objective of this review is to look at BIS monitor as a tool, which could help bring forward the timing of prognostication. METHODS Electronic databases will be systematically searched for randomised controlled trials and prospective or retrospective cohort studies with no language restrictions. The search will be supplemented with grey literature searches of thesis, dissertations and hand searching of relevant journals. Two independent reviewers will screen, select and perform analysis according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) method. The selected studies will be analysed using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system. Meta-analysis will be performed if suitable. DISCUSSION This review will synthesize the evidence on the use of BIS monitors within 24 h of achieving return of spontaneous circulation (ROSC) and may help in early prognostication. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD 42016050224 .
Collapse
Affiliation(s)
- Leanne Eveson
- Emergency Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK
| | - Marcela Vizcaychipi
- Anaesthesia & Intensive Care Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK
| | - Shashank Patil
- Emergency Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK.
| |
Collapse
|
43
|
Protocol-driven neurological prognostication and withdrawal of life-sustaining therapy after cardiac arrest and targeted temperature management. Resuscitation 2017; 117:50-57. [DOI: 10.1016/j.resuscitation.2017.05.014] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 04/25/2017] [Accepted: 05/11/2017] [Indexed: 11/19/2022]
|
44
|
Scales DC, Golan E, Pinto R, Brooks SC, Chapman M, Dale CM, Jichici D, Rubenfeld GD, Morrison LJ. Improving Appropriate Neurologic Prognostication after Cardiac Arrest. A Stepped Wedge Cluster Randomized Controlled Trial. Am J Respir Crit Care Med 2017; 194:1083-1091. [PMID: 27115286 DOI: 10.1164/rccm.201602-0397oc] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Predictions about neurologic prognosis that are based on early clinical findings after out-of-hospital cardiac arrest (OHCA) are often inaccurate and may lead to premature decisions to withdraw life-sustaining treatments (LST) in patients who might otherwise survive with good neurologic outcomes. OBJECTIVES To improve adherence to recommendations for appropriate neurologic prognostication after OHCA and reduce deaths from premature decisions to withdraw LST. METHODS This was a pragmatic stepped wedge cluster randomized controlled trial evaluating a multifaceted quality intervention (education, pathways, local champions, audit-feedback). The primary outcome was appropriate neurologic prognostication, defined as (1a) no early withdrawal of LST (WLST) (within 72 h) based on estimates of poor neurologic prognosis and (1b) no WLST between 72 hours and 7 days in absence of clinical predictors of poor neurologic prognosis or (2) surviving beyond 7 days. Secondary outcomes were deaths from early WLST and survival with good neurologic outcome. MEASUREMENTS AND MAIN RESULTS Between June 1, 2011, and June 30, 2014, a total of 905 patients with OHCA were enrolled from ICUs of 18 Ontario hospitals. Rates of appropriate neurologic prognostication increased after the intervention (68% vs. 74% patients; odds ratio [OR], 1.79; 95% confidence interval [CI], 1.01-3.19; P = 0.05). However, rates of survival to hospital discharge (46% vs. 50%; OR, 1.71; 95% CI, 0.97-3.01; P = 0.06) and survival with good neurologic outcome remained similar (38% vs. 43%; OR, 1.43; 95% CI, 0.84-2.86; P = 0.19). CONCLUSIONS A multicenter quality intervention improved rates of appropriate neurologic prognostication after OHCA but did not increase survival with good neurologic outcome. Clinical trial registered with www.clinicaltrials.gov (NCT 01472458).
Collapse
Affiliation(s)
- Damon C Scales
- 1 Department of Critical Care Medicine and.,6 Trauma, Emergency and Critical Care Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,2 Interdepartmental Division of Critical Care.,3 Department of Medicine.,4 Institute for Health Policy, Management and Evaluation.,5 Institute of Clinical and Evaluative Sciences, Toronto, Ontario, Canada
| | - Eyal Golan
- 2 Interdepartmental Division of Critical Care.,3 Department of Medicine.,4 Institute for Health Policy, Management and Evaluation.,7 Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Ruxandra Pinto
- 1 Department of Critical Care Medicine and.,2 Interdepartmental Division of Critical Care
| | - Steven C Brooks
- 8 Department of Emergency Medicine, Faculty of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Martin Chapman
- 1 Department of Critical Care Medicine and.,6 Trauma, Emergency and Critical Care Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,2 Interdepartmental Division of Critical Care
| | - Craig M Dale
- 6 Trauma, Emergency and Critical Care Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,9 Lawrence S. Bloomberg Faculty of Nursing, and
| | - Draga Jichici
- 10 Department of Neurology and Critical Care Medicine, McMaster University, Hamilton, Ontario, Canada; and
| | - Gordon D Rubenfeld
- 1 Department of Critical Care Medicine and.,6 Trauma, Emergency and Critical Care Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,2 Interdepartmental Division of Critical Care.,3 Department of Medicine.,4 Institute for Health Policy, Management and Evaluation
| | - Laurie J Morrison
- 3 Department of Medicine.,4 Institute for Health Policy, Management and Evaluation.,12 Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,11 Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | | |
Collapse
|
45
|
Neuroprognostication after cardiac arrest in the light of targeted temperature management. Curr Opin Crit Care 2017; 23:244-250. [DOI: 10.1097/mcc.0000000000000406] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
46
|
Nishikimi M, Matsuda N, Matsui K, Takahashi K, Ejima T, Liu K, Ogura T, Higashi M, Umino H, Makishi G, Numaguchi A, Matsushima S, Tokuyama H, Nakamura M, Matsui S. A novel scoring system for predicting the neurologic prognosis prior to the initiation of induced hypothermia in cases of post-cardiac arrest syndrome: the CAST score. Scand J Trauma Resusc Emerg Med 2017; 25:49. [PMID: 28490379 PMCID: PMC5424379 DOI: 10.1186/s13049-017-0392-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Accepted: 05/04/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The aim of this study was to develop a scoring system for identifying the post-cardiac arrest syndrome (PCAS) patients with a good potential for recovery prior to the initiation of induced therapeutic hypothermia. METHODS A multi-center, retrospective, observational study was performed. Data of a total of 151 consecutive adults who underwent induced hypothermia after cardiac arrest (77 learning cases from two hospitals and 74 validation cases from two other hospitals) were analyzed. RESULTS In the learning set, 8 factors (initial rhythm, witnessed status and time until return of spontaneous circulation, pH, serum lactate, motor score according to the Glasgow Coma Scale (GCS), gray matter attenuation to white matter attenuation ratio (GWR), serum albumin, and hemoglobin) were found to be strongly correlated with the neurological outcomes. A tentative scoring system was created from the learning data using these factors, and the predictive accuracy (sensitivity and specificity) was evaluated in terms of both internal validation (0.85 and 0.84) and external validation (cutoff 50%: 0.95 and 0.90, 30%: 0.87 and 0.98, 15%: 0.67 and 1.00). Finally, using all the data, we established a post-Cardiac Arrest Syndrome for induced Therapeutic hypothermia (CAST) score to predict the neurologic prognosis prior to initiation of induced hypothermia. CONCLUSIONS The CAST score was developed to predict the neurological outcomes of PCAS patients treated by induced hypothermia. The likelihood of good recovery at 30 days was extremely low in PCAS patients with a CAST score of ≤15%. Prospective validation of the score is needed in the future.
Collapse
Affiliation(s)
- Mitsuaki Nishikimi
- Department of Emergency and Critical Care, Nagoya University Graduate School of Medicine, Tsurumai-cho 65, Syowa-ku, Nagoya, Aichi, 4668560, Japan.
| | - Naoyuki Matsuda
- Department of Emergency and Critical Care, Nagoya University Graduate School of Medicine, Tsurumai-cho 65, Syowa-ku, Nagoya, Aichi, 4668560, Japan
| | - Kota Matsui
- Department of Biostatistics, Nagoya University Graduate School of Medicine, Tsurumai-cho 65, Syowa-ku, Nagoya, Aichi, 4668560, Japan
| | - Kunihiko Takahashi
- Department of Biostatistics, Nagoya University Graduate School of Medicine, Tsurumai-cho 65, Syowa-ku, Nagoya, Aichi, 4668560, Japan
| | - Tadashi Ejima
- Department of Emergency and Critical Care, Nagoya University Graduate School of Medicine, Tsurumai-cho 65, Syowa-ku, Nagoya, Aichi, 4668560, Japan
| | - Keibun Liu
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Asahi-cho 3-21-36, Maebashi, Gunma, 3710014, Japan
| | - Takayuki Ogura
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Asahi-cho 3-21-36, Maebashi, Gunma, 3710014, Japan
| | - Michiko Higashi
- Department of Emergency and Critical Care, Nagoya University Graduate School of Medicine, Tsurumai-cho 65, Syowa-ku, Nagoya, Aichi, 4668560, Japan
| | - Hitoshi Umino
- Department of Emergency and Critical Care, Nagoya University Graduate School of Medicine, Tsurumai-cho 65, Syowa-ku, Nagoya, Aichi, 4668560, Japan
| | - Go Makishi
- Department of Emergency and Critical Care, Nagoya University Graduate School of Medicine, Tsurumai-cho 65, Syowa-ku, Nagoya, Aichi, 4668560, Japan
| | - Atsushi Numaguchi
- Department of Emergency and Critical Care, Nagoya University Graduate School of Medicine, Tsurumai-cho 65, Syowa-ku, Nagoya, Aichi, 4668560, Japan
| | - Satoru Matsushima
- Department of Emergency and Critical Care, Cyutouen General Medical Center, Shobugaike 1-1, Kakegawa, Shizuoka, 4368555, Japan
| | - Hideki Tokuyama
- Department of Emergency and Critical Care, Nagoya University Graduate School of Medicine, Tsurumai-cho 65, Syowa-ku, Nagoya, Aichi, 4668560, Japan
| | - Mitsunobu Nakamura
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Asahi-cho 3-21-36, Maebashi, Gunma, 3710014, Japan
| | - Shigeyuki Matsui
- Department of Biostatistics, Nagoya University Graduate School of Medicine, Tsurumai-cho 65, Syowa-ku, Nagoya, Aichi, 4668560, Japan
| |
Collapse
|
47
|
Tsetsou S, Novy J, Pfeiffer C, Oddo M, Rossetti AO. Multimodal Outcome Prognostication After Cardiac Arrest and Targeted Temperature Management: Analysis at 36 °C. Neurocrit Care 2017; 28:104-109. [DOI: 10.1007/s12028-017-0393-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
|
48
|
The Chinese Expert Consensus on Evaluation of Coma after Cardiopulmonary Resuscitation. Chin Med J (Engl) 2017; 129:2123-7. [PMID: 27569242 PMCID: PMC5009599 DOI: 10.4103/0366-6999.189054] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
|
49
|
Association of brain metabolites with blood lactate and glucose levels with respect to neurological outcomes after out-of-hospital cardiac arrest: A preliminary microdialysis study. Resuscitation 2017; 110:26-31. [DOI: 10.1016/j.resuscitation.2016.10.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 09/22/2016] [Accepted: 10/09/2016] [Indexed: 12/13/2022]
|
50
|
Leão RN, Ávila P, Cavaco R, Germano N, Bento L. Therapeutic hypothermia after cardiac arrest: outcome predictors. Rev Bras Ter Intensiva 2016; 27:322-32. [PMID: 26761469 PMCID: PMC4738817 DOI: 10.5935/0103-507x.20150056] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 11/06/2015] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE The determination of coma patient prognosis after cardiac arrest has clinical, ethical and social implications. Neurological examination, imaging and biochemical markers are helpful tools accepted as reliable in predicting recovery. With the advent of therapeutic hypothermia, these data need to be reconfirmed. In this study, we attempted to determine the validity of different markers, which can be used in the detection of patients with poor prognosis under hypothermia. METHODS Data from adult patients admitted to our intensive care unit for a hypothermia protocol after cardiac arrest were recorded prospectively to generate a descriptive and analytical study analyzing the relationship between clinical, neurophysiological, imaging and biochemical parameters with 6-month outcomes defined according to the Cerebral Performance Categories scale (good 1-2, poor 3-5). Neuron-specific enolase was collected at 72 hours. Imaging and neurophysiologic exams were carried out in the 24 hours after the rewarming period. RESULTS Sixty-seven patients were included in the study, of which 12 had good neurological outcomes. Ventricular fibrillation and electroencephalographic theta activity were associated with increased likelihood of survival and improved neurological outcomes. Patients who had more rapid cooling (mean time of 163 versus 312 minutes), hypoxic-ischemic brain injury on magnetic resonance imaging or neuron-specific enolase > 58ng/mL had poor neurological outcomes (p < 0.05). CONCLUSION Hypoxic-ischemic brain injury on magnetic resonance imaging and neuron-specific enolase were strong predictors of poor neurological outcomes. Although there is the belief that early achievement of target temperature improves neurological prognoses, in our study, there were increased mortality and worse neurological outcomes with earlier target-temperature achievement.
Collapse
Affiliation(s)
- Rodrigo Nazário Leão
- Unidade de Urgência Médica, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Paulo Ávila
- Unidade de Urgência Médica, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Raquel Cavaco
- Unidade de Urgência Médica, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Nuno Germano
- Unidade de Urgência Médica, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Luís Bento
- Unidade de Urgência Médica, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| |
Collapse
|