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Tangonan R, Lazaridis C. Evaluation and Management of Disorders of Consciousness in the Acute Care Setting. Phys Med Rehabil Clin N Am 2024; 35:79-92. [PMID: 37993195 DOI: 10.1016/j.pmr.2023.06.013] [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] [Indexed: 11/24/2023]
Abstract
Acute disorders of consciousness (DOC) are impairments in arousal and awareness that occur within 28 days of an initial injury and can result from a variety of insults. These states range from coma, unresponsive wakefulness, covert consciousness, minimal consciousness, to confusional state. It is important to perform thorough, serial examinations with particular emphasis on the level of consciousness, brainstem reflexes, and motor responses. Evaluation of acute DOC includes laboratory tests, imaging, and electrophysiology testing. Prognostication in the acute phase of DOC must be done cautiously, using open, frequent communication with families, and by acknowledging significant multidimensional uncertainty.
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Affiliation(s)
- Ruth Tangonan
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA.
| | - Christos Lazaridis
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA; Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
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2
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Aalberts N, Westhall E, Johnsen B, Hahn K, Kenda M, Cronberg T, Friberg H, Preuß S, Ploner CJ, Storm C, Nee J, Leithner C, Endisch C. Cortical somatosensory evoked potential amplitudes and clinical outcome after cardiac arrest: a retrospective multicenter study. J Neurol 2023; 270:5999-6009. [PMID: 37639017 PMCID: PMC10632270 DOI: 10.1007/s00415-023-11951-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/14/2023] [Accepted: 08/17/2023] [Indexed: 08/29/2023]
Abstract
OBJECTIVE Bilaterally absent cortical somatosensory evoked potentials (SSEPs) reliably predict poor outcome in comatose cardiac arrest (CA) patients. Cortical SSEP amplitudes are a recent prognostic extension; however, amplitude thresholds, inter-recording, and inter-rater agreement remain uncertain. METHODS In a retrospective multicenter cohort study, we determined cortical SSEP amplitudes of comatose CA patients using a standardized evaluation pathway. We studied inter-recording agreement in repeated SSEPs and inter-rater agreement by four raters independently determining 100 cortical SSEP amplitudes. Primary outcome was assessed using the cerebral performance category (CPC) upon intensive care unit discharge dichotomized into good (CPC 1-3) and poor outcome (CPC 4-5). RESULTS Of 706 patients with SSEPs with median 3 days after CA, 277 (39.2%) had good and 429 (60.8%) poor outcome. Of patients with bilaterally absent cortical SSEPs, one (0.8%) survived with CPC 3 and 130 (99.2%) had poor outcome. Otherwise, the lowest cortical SSEP amplitude in good outcome patients was 0.5 µV. 184 (42.9%) of 429 poor outcome patients had lower cortical SSEP amplitudes. In 106 repeated SSEPs, there were 6 (5.7%) with prognostication-relevant changes in SSEP categories. Following a standardized evaluation pathway, inter-rater agreement was almost perfect with a Fleiss' kappa of 0.88. INTERPRETATION Bilaterally absent and cortical SSEP amplitudes below 0.5 µV predicted poor outcome with high specificity. A standardized evaluation pathway provided high inter-rater and inter-recording agreement. Regain of consciousness in patients with bilaterally absent cortical SSEPs rarely occurs. High-amplitude cortical SSEP amplitudes likely indicate the absence of severe brain injury.
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Affiliation(s)
- Noelle Aalberts
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Erik Westhall
- Department of Clinical Sciences Lund, Clinical Neurophysiology, Lund University, Skane University Hospital, Getingevägen 4, 22185, Lund, Sweden
| | - Birger Johnsen
- Department of Clinical Neurophysiology, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 165, 8200, Aarhus N, Denmark
| | - Katrin Hahn
- Department of Neurology, Campus Mitte, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Martin Kenda
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- BIH Charité Junior Digital Clinician Scientist Program, BIH Biomedical Innovation Academy, Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Tobias Cronberg
- Department of Clinical Sciences Lund, Neurology, Lund University, Skane University Hospital, Getingevägen 4, 22185, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences Lund, Intensive and Perioperative Care, Lund University, Skane University Hospital, Getingevägen 4, 22185, Lund, Sweden
| | - Sandra Preuß
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Christoph J Ploner
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Christian Storm
- Department of Nephrology and Intensive Care Medicine, Cardiac Arrest Center of Excellence Berlin, Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Jens Nee
- Department of Nephrology and Intensive Care Medicine, Cardiac Arrest Center of Excellence Berlin, Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Christoph Leithner
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Christian Endisch
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
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Pandiyan P, Cvetkovic M, Antonini MV, Shappley RKH, Karmakar SA, Raman L. Clinical Guidelines for Routine Neuromonitoring in Neonatal and Pediatric Patients Supported on Extracorporeal Membrane Oxygenation. ASAIO J 2023; 69:895-900. [PMID: 37603797 DOI: 10.1097/mat.0000000000001896] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023] Open
Abstract
DISCLAIMER These guidelines for routine neuromonitoring in neonatal and pediatric patients supported on extracorporeal membrane oxygenation (ECMO) are intended for educational use to build the knowledge of physicians and other health professionals in assessing the conditions and managing the treatment of patients undergoing extracorporeal life support (ECLS)/ECMO and describe what are believed to be useful and safe practice for ECLS and ECMO but these are not necessarily consensus recommendations. The aim of clinical guidelines was to help clinicians to make informed decisions about their patients. However, adherence to a guideline does not guarantee a successful outcome. Healthcare professionals must make their own treatment decisions about care on a case-by-case basis, after consultation with their patients, using their clinical judgment, knowledge, and expertise. These guidelines do not take the place of physicians' and other health professionals' judgment in diagnosing and treatment of patients. These guidelines are not intended to and should not be interpreted as setting a standard of care or being deemed inclusive of all proper methods of care nor exclusive of other methods of care directed at obtaining the same results. The ultimate judgment must be made by the physician and other health professionals and the patient considering all the circumstances presented by the individual patient, and the known variability and biologic behavior of the clinical condition. These guidelines reflect the data at the time the guidelines were prepared; the results of subsequent studies or other information may cause revisions to the recommendations in these guidelines to be prudent to reflect new data, but ELSO is under no obligation to provide updates. In no event will ELSO be liable for any decision made or action taken in reliance upon the information provided through these guidelines.
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Affiliation(s)
- Poornima Pandiyan
- From the Department of Pediatrics, Division of Medical Critical Care, Boston Children's Hospital, Tufts University School of Medicine, Boston, Massachusetts
| | - Mirjana Cvetkovic
- Cardiac Critical Care Division, Heart and Lung Directorate, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Marta Velia Antonini
- Anesthesia and Intensive Care Unit, Bufalini Hospital - AUSL della Romagna, Cesena, Italy
- Department of Biomedical, Metabolic and Neural Science, University of Modena and Reggio Emilia, Modena, Italy
| | - Rebekah K H Shappley
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Swati A Karmakar
- Department of Pediatrics, Baylor College of Medicine, Neurology and Developmental Neuroscience Section, Texas Children's Hospital, Houston, Texas
| | - Lakshmi Raman
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
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Kromm J, Bencsik C, Soo A, Ainsworth C, Savard M, van Diepen S, Kramer A. Somatosensory evoked potential for post-arrest neuroprognostication. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:532-539. [PMID: 37283039 DOI: 10.1093/ehjacc/zuad060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 06/01/2023] [Indexed: 06/08/2023]
Affiliation(s)
- Julie Kromm
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Alberta Health Services, Alberta, Canada
| | - Caralyn Bencsik
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Alberta Health Services, Alberta, Canada
| | - Andrea Soo
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Alberta Health Services, Alberta, Canada
| | - Craig Ainsworth
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Martin Savard
- Département de Médecine, Université Laval, Quebec City, Quebec, Canada
| | - Sean van Diepen
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
- Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Andreas Kramer
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Alberta Health Services, Alberta, Canada
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5
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Rajajee V, Muehlschlegel S, Wartenberg KE, Alexander SA, Busl KM, Chou SHY, Creutzfeldt CJ, Fontaine GV, Fried H, Hocker SE, Hwang DY, Kim KS, Madzar D, Mahanes D, Mainali S, Meixensberger J, Montellano F, Sakowitz OW, Weimar C, Westermaier T, Varelas PN. Guidelines for Neuroprognostication in Comatose Adult Survivors of Cardiac Arrest. Neurocrit Care 2023; 38:533-563. [PMID: 36949360 PMCID: PMC10241762 DOI: 10.1007/s12028-023-01688-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 01/30/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND Among cardiac arrest survivors, about half remain comatose 72 h following return of spontaneous circulation (ROSC). Prognostication of poor neurological outcome in this population may result in withdrawal of life-sustaining therapy and death. The objective of this article is to provide recommendations on the reliability of select clinical predictors that serve as the basis of neuroprognostication and provide guidance to clinicians counseling surrogates of comatose cardiac arrest survivors. METHODS A narrative systematic review was completed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Candidate predictors, which included clinical variables and prediction models, were selected based on clinical relevance and the presence of an appropriate body of evidence. The Population, Intervention, Comparator, Outcome, Timing, Setting (PICOTS) question was framed as follows: "When counseling surrogates of comatose adult survivors of cardiac arrest, should [predictor, with time of assessment if appropriate] be considered a reliable predictor of poor functional outcome assessed at 3 months or later?" Additional full-text screening criteria were used to exclude small and lower-quality studies. Following construction of the evidence profile and summary of findings, recommendations were based on four GRADE criteria: quality of evidence, balance of desirable and undesirable consequences, values and preferences, and resource use. In addition, good practice recommendations addressed essential principles of neuroprognostication that could not be framed in PICOTS format. RESULTS Eleven candidate clinical variables and three prediction models were selected based on clinical relevance and the presence of an appropriate body of literature. A total of 72 articles met our eligibility criteria to guide recommendations. Good practice recommendations include waiting 72 h following ROSC/rewarming prior to neuroprognostication, avoiding sedation or other confounders, the use of multimodal assessment, and an extended period of observation for awakening in patients with an indeterminate prognosis, if consistent with goals of care. The bilateral absence of pupillary light response > 72 h from ROSC and the bilateral absence of N20 response on somatosensory evoked potential testing were identified as reliable predictors. Computed tomography or magnetic resonance imaging of the brain > 48 h from ROSC and electroencephalography > 72 h from ROSC were identified as moderately reliable predictors. CONCLUSIONS These guidelines provide recommendations on the reliability of predictors of poor outcome in the context of counseling surrogates of comatose survivors of cardiac arrest and suggest broad principles of neuroprognostication. Few predictors were considered reliable or moderately reliable based on the available body of evidence.
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Affiliation(s)
- Venkatakrishna Rajajee
- Departments of Neurology and Neurosurgery, 3552 Taubman Health Care Center, SPC 5338, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109-5338, USA.
| | - Susanne Muehlschlegel
- Departments of Neurology, Anesthesiology, and Surgery, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | | | | | - Katharina M Busl
- Departments of Neurology and Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Sherry H Y Chou
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Gabriel V Fontaine
- Departments of Pharmacy and Neurosciences, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Herbert Fried
- Department of Neurosurgery, Denver Health Medical Center, Denver, CO, USA
| | - Sara E Hocker
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - David Y Hwang
- Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Keri S Kim
- Pharmacy Practice, University of Illinois, Chicago, IL, USA
| | - Dominik Madzar
- Department of Neurology, University of Erlangen, Erlangen, Germany
| | - Dea Mahanes
- Departments of Neurology and Neurosurgery, University of Virginia Health, Charlottesville, VA, USA
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | | | | | - Oliver W Sakowitz
- Department of Neurosurgery, Neurosurgery Center Ludwigsburg-Heilbronn, Ludwigsburg, Germany
| | - Christian Weimar
- Institute of Medical Informatics, Biometry, and Epidemiology, University Hospital Essen, Essen, Germany
- BDH-Clinic Elzach, Elzach, Germany
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Oishi T, Triplett JD, Laughlin RS, Hocker SE, Berini SE, Hoffman EM. Short-Acting Neuromuscular Blockade Improves Inter-rater Reliability of Median Somatosensory Evoked Potentials in Post-cardiac arrest Prognostication. Neurocrit Care 2023; 38:600-611. [PMID: 36123569 DOI: 10.1007/s12028-022-01601-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 08/29/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although median nerve somatosensory evoked potentials are routinely used for prognostication in comatose cardiac arrest survivors, myogenic artifact can reduce inter-rater reliability, leading to unreliable or inaccurate results. To minimize this risk, we determined the benefit of neuromuscular blockade agents in improving the inter-rater reliability and signal-to-noise ratio of SSEPs in the context of prognostication. METHODS Thirty comatose survivors of cardiac arrest were enrolled in the study, following the request from an intensivist to complete an SSEP for prognostication. Right and left median nerve SSEPs were obtained from each patient, before and after administration of an NMB agent. Clinical histories and outcomes were retrospectively reviewed. The SSEP recordings before and after NMB were randomized and reviewed by five blinded raters, who assessed the latency and amplitude of cortical and noncortical potentials (vs. absence of response) as well as the diagnostic quality of cortical recordings. The inter-rater reliability of SSEP interpretation before and after NMB was compared via Fleiss' κ score. RESULTS Following NMB administration, Fleiss' κ score for cortical SSEP interpretation significantly improved from 0.37 to 0.60, corresponding to greater agreement among raters. The raters were also less likely to report the cortical recordings as nondiagnostic following NMB (40.7% nondiagnostic SSEPs pre-NMB; 17% post-NMB). The SNR significantly improved following NMB, especially when the pre-NMB SNR was low (< 10 dB). Across the raters, there were three patients whose SSEP interpretation changed from bilaterally absent to bilaterally present after NMB was administered (potential false positives without NMB). CONCLUSIONS NMB significantly improves the inter-rater reliability and SNR of median SSEPs for prognostication among comatose cardiac arrest survivors. To ensure the most reliable prognostic information in comatose post-cardiac arrest survivors, pharmacologic paralysis should be consistently used before recording SSEPs.
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Affiliation(s)
- Tatsuya Oishi
- Department of Neurology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55902, USA.
| | - James D Triplett
- Department of Neurology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55902, USA
- Department of Neurology, Concord Repatriation General Hospital, Concord, NSW, Australia
| | - Ruple S Laughlin
- Department of Neurology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55902, USA
| | - Sara E Hocker
- Department of Neurology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55902, USA
| | - Sarah E Berini
- Department of Neurology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55902, USA
| | - Ernest M Hoffman
- Department of Neurology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55902, USA
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7
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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.
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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
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8
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Abstract
OBJECTIVES Critically ill patients are at high risk of acute brain injury. Bedside multimodality neuromonitoring techniques can provide a direct assessment of physiologic interactions between systemic derangements and intracranial processes and offer the potential for early detection of neurologic deterioration before clinically manifest signs occur. Neuromonitoring provides measurable parameters of new or evolving brain injury that can be used as a target for investigating various therapeutic interventions, monitoring treatment responses, and testing clinical paradigms that could reduce secondary brain injury and improve clinical outcomes. Further investigations may also reveal neuromonitoring markers that can assist in neuroprognostication. We provide an up-to-date summary of clinical applications, risks, benefits, and challenges of various invasive and noninvasive neuromonitoring modalities. DATA SOURCES English articles were retrieved using pertinent search terms related to invasive and noninvasive neuromonitoring techniques in PubMed and CINAHL. STUDY SELECTION Original research, review articles, commentaries, and guidelines. DATA EXTRACTION Syntheses of data retrieved from relevant publications are summarized into a narrative review. DATA SYNTHESIS A cascade of cerebral and systemic pathophysiological processes can compound neuronal damage in critically ill patients. Numerous neuromonitoring modalities and their clinical applications have been investigated in critically ill patients that monitor a range of neurologic physiologic processes, including clinical neurologic assessments, electrophysiology tests, cerebral blood flow, substrate delivery, substrate utilization, and cellular metabolism. Most studies in neuromonitoring have focused on traumatic brain injury, with a paucity of data on other clinical types of acute brain injury. We provide a concise summary of the most commonly used invasive and noninvasive neuromonitoring techniques, their associated risks, their bedside clinical application, and the implications of common findings to guide evaluation and management of critically ill patients. CONCLUSIONS Neuromonitoring techniques provide an essential tool to facilitate early detection and treatment of acute brain injury in critical care. Awareness of the nuances of their use and clinical applications can empower the intensive care team with tools to potentially reduce the burden of neurologic morbidity in critically ill patients.
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Affiliation(s)
- Swarna Rajagopalan
- Department of Neurology, Cooper Medical School of Rowan University, Camden, NJ
| | - Aarti Sarwal
- Department of Neurology, Atrium Wake Forest School of Medicine, Winston-Salem, NC
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9
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Nawfal O, El Halabi T, Dib G, Dirani M, Beydoun A. Bilateral Reappearance of the N20 Potential in a Normothermic Young Woman Post-Anoxic Brain Injury. J Clin Neurophysiol 2022; 39:e21-e25. [PMID: 35239554 DOI: 10.1097/wnp.0000000000000928] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
SUMMARY Hypoxic-ischemic brain injury is a well-known consequence of cardiac arrest and providing an accurate prognostication remains a challenge, especially in decisions related to withdrawal of care. Bilateral absence of the cortical response (N20 potential) on median somatosensory evoked potentials, on days 1 to 3 after the return of spontaneous circulation, is widely considered as the most reliable predictor of poor outcome with a high specificity and a low false-positive rate. The authors describe the case of a young comatose woman after hypoxic injury because of cardiac arrest whose initial median somatosensory evoked potentials revealed bilateral absence of the N20 response associated with evidence of selective injury to both perirolandic cortices and basal ganglia on brain MRI. This patient made a substantial recovery associated with bilateral reappearance of the N20 potential and resolution of the neuroimaging abnormalities.This case revealed that an acute selective and reversible hypoxic injury to both perirolandic cortices may lead to a temporary loss of the N20 responses and an inaccurate prediction of poor outcome after cardiac arrest. It emphasizes on the importance of adopting a multimodal approach in the prognostic assessment of survivors of cardiac arrest.
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Affiliation(s)
- Omar Nawfal
- American University of Beirut Medical Center, Beirut, Lebanon
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10
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Clamping of the Aortic Arch Vessels During Normothermic Regional Perfusion After Circulatory Death Prevents the Return of Brain Activity in a Porcine Model. Transplantation 2022; 106:1763-1769. [PMID: 35066546 DOI: 10.1097/tp.0000000000004047] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The cerebral effect of clamping following normothermic regional perfusion (NRP) in donation after circulatory death (DCD) remains unknown. We investigated the effect of cerebral reperfusion during NRP and the preventive effect of clamping on brain function in a porcine model. METHODS In 16 pigs, intracranial physiological parameters were recorded, including pressure, cerebral blood perfusion (CBF), temperature, and oxygen. Additionally, electroencephalography (EEG) and somatosensory evoked potentials (SSEPs) were used to assess brain function. The animals were cannulated for the heart-lung machine, and baseline measurements were performed before withdrawal from life support. After 8 min of mechanical asystole, the animals were randomly allocated to clamp (n = 8) or nonclamp (n = 8) of the aortic arch vessels. After 30 min of NRP, the animals were monitored for 3 h after weaning (AW). RESULTS Intracranial measurements of CBF, oxygen, and temperature indicated successful occlusion of the arch vessels following NRP and AW in the clamp group versus the nonclamp group. In the clamp group, EEG was isoelectric and SSEPs were absent AW in all pigs. In the nonclamp group, EEG activity was observed in all 8 pigs, whereas SSEPs were observed in 6 of 8 pigs. Additionally, agonal respiratory movements in the form of gasping were observed in 6 of 8 pigs in the nonclamp group. CONCLUSIONS Reperfusion of the brain during NRP led to a return of brain activity. Conversely, clamping of the arch vessels halted cerebral circulation, ensuring the permanent cessation of brain function and maintaining the determination of death in DCD.
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Scarpino M, Lanzo G, Bonizzoli M, Troiano S, Baldanzi F, Lolli F, Grippo A. Bilateral reappearance of the cortical SEP in a comatose patient after cardiac arrest: pitfall or reality? Clin Neurophysiol 2022; 136:58-61. [DOI: 10.1016/j.clinph.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 01/10/2022] [Accepted: 01/11/2022] [Indexed: 11/28/2022]
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Pruvost-Robieux E, Marchi A, Martinelli I, Bouchereau E, Gavaret M. Evoked and Event-Related Potentials as Biomarkers of Consciousness State and Recovery. J Clin Neurophysiol 2022; 39:22-31. [PMID: 34474424 PMCID: PMC8715993 DOI: 10.1097/wnp.0000000000000762] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
SUMMARY The definition of consciousness has been the subject of great interest for many scientists and philosophers. To better understand how evoked potentials may be identified as biomarkers of consciousness and recovery, the different theoretical models sustaining neural correlates of consciousness are reviewed. A multimodal approach can help to better predict clinical outcome in patients presenting with disorders of consciousness. Evoked potentials are inexpensive and easy-to-implement bedside examination techniques. Evoked potentials are an integral part of prognostic evaluation, particularly in cases of cognitive motor dissociation. Prognostic criteria are well established in postanoxic disorders of consciousness, especially postcardiac arrest but are less well determined in other etiologies. In the early examination, bilateral absence of N20 in disorder of consciousness patients is strongly associated with unfavorable outcome (i.e., death or unresponsive wakefulness syndrome) especially in postanoxic etiologies. This predictive value is lower in other etiologies and probably also in children. Both N20 and mismatch negativity are proven outcome predictors for acute coma. Many studies have shown that mismatch negativity and P3a are characterized by a high prognostic value for awakening, but some patients presenting unresponsive wakefulness syndrome also process a P3a. The presence of long-latency event-related potential components in response to stimuli is indicative of a better recovery. All neurophysiological data must be integrated within a multimodal approach combining repeated clinical evaluation, neuroimaging, functional imaging, biology, and neurophysiology combining passive and active paradigms.
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Affiliation(s)
- Estelle Pruvost-Robieux
- Neurophysiology Department, GHU Paris Psychiatry & Neurosciences, Sainte Anne, Paris, France
- Paris University, Paris, France
| | - Angela Marchi
- Neurophysiology Department, GHU Paris Psychiatry & Neurosciences, Sainte Anne, Paris, France
| | - Ilaria Martinelli
- Department of Neurosciences, St. Agostino-Estense Hospital, Azienda Ospedaliero, Universitaria di Modena, Modena, Italy;
| | - Eléonore Bouchereau
- Department of Anesthesiology and intensive care, GHU Paris Psychiatry & Neurosciences, Sainte Anne, Paris, France; and
| | - Martine Gavaret
- Neurophysiology Department, GHU Paris Psychiatry & Neurosciences, Sainte Anne, Paris, France
- Paris University, Paris, France
- INSERM UMR 1266, Paris, France
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Lilja L, Thuccani M, Joelsson S, Nilsson J, Redfors P, Lundgren P, Rylander C. The capacity of neurological pupil index to predict absence of somatosensory evoked potentials after cardiac arrest-A study protocol. Acta Anaesthesiol Scand 2021; 65:852-858. [PMID: 33735459 DOI: 10.1111/aas.13822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 03/12/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Anoxic-ischemic brain injury is the most common cause of death after cardiac arrest (CA). Robust methods to detect severe injury with a low false positive rate (FPR) for poor neurological outcome include the pupillary light reflex (PLR) and somatosensory evoked potentials (SSEP). The PLR can be assessed manually or with automated pupillometry which provides the neurological pupil index (NPi). We aim to describe the interrelation between NPi values and the absence of SSEP cortical response and to evaluate the capacity of NPi to predict the absence of cortical SSEP response in comatose patients after CA. METHODS A total of 50 patients will be included in an explorative, prospective, observational study of adult (>18 years) comatose survivors of CA admitted to intensive care in a university hospital. NPi assessed with a hand-held pupillometer will be compared to SSEP signals recorded >48 hours after CA. Primary outcomes are sensitivity, specificity, and odds ratio for NPi to predict bilateral absence of the SSEP N20 signal, with NPi values corresponding to <5% FPRs of SSEP absence. Secondary outcomes are the PLR and SSEP sensitivity, specificity, and odds ratio for poor neurological outcome at hospital discharge and death at 30 days. DISCUSSION The PLR and SSEP may have a systematic interrelation, and a certain NPi threshold could potentially predict the absence of cortical SSEP response. If this can be concluded from the present study, SSEP testing could be excluded in certain patients to save resources in the multimodal prognostication after CA. Editorial comment The interrelation between loss of the pupillary light reflex (PLR) and the loss of cortical response to a somatosensory evoked potential (SSEP) in comatose cardiac arrest patients is not known. This exploratory prospective study is designed to evaluate whether a specific degree of attenuated PLR, as measured by semiautomated pupillometry, can predict the bilateral loss of cortical SSEP response in severe anoxic/ischemic brain injury. Such an interrelation between the two methods would enable the use of pupillometry rather than the more resource demanding SSEP for neurologic prognostication in post cardiac arrest patients. TRIAL REGISTRATION ClinicalTrials.gov, NCT04720482, Registered 21 January 2021, retrospectively registered.
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Affiliation(s)
- Linus Lilja
- Department of Anaesthesiology and Intensive Care Medicine Institute of Clinical Sciences Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
| | - Meena Thuccani
- Department of Molecular and Clinical Medicine Institute of Medicine Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
| | - Sara Joelsson
- Department of Clinical Neurophysiology Institute of Neuroscience and Physiology Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
| | - Josefin Nilsson
- Department of Clinical Neurophysiology Institute of Neuroscience and Physiology Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
| | - Petra Redfors
- Department of Clinical Neuroscience Institute of Neuroscience and Physiology Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
| | - Peter Lundgren
- Department of Molecular and Clinical Medicine Institute of Medicine Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
- Prehospen—Centre for Prehospital Research University of Borås Borås Sweden
| | - Christian Rylander
- Department of Anaesthesiology and Intensive Care Medicine Institute of Clinical Sciences Sahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
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Lim JY, Oh SH, Park KN, Choi SP, Oh JS, Youn CS, Kim HJ, Kim HJ, Song H. Prognostic value of brainstem auditory and visual evoked potentials in cardiac arrest patients with targeted temperature management. Resuscitation 2021; 164:12-19. [PMID: 33964333 DOI: 10.1016/j.resuscitation.2021.04.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 03/26/2021] [Accepted: 04/26/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE We analysed the prognostic value of somatosensory, brainstem auditory and visual evoked potentials (SSEPs, BAEPs and VEPs, respectively) for outcome prediction in cardiac arrest patients with targeted temperature management (TTM) and assessed whether BAEP and VEP measurements conferred added value to SSEP measurements. METHODS Cases with SSEPs and VEPs or BAEPs were reviewed in a TTM registry. We focused on whether the following responses were clearly discernible: N20 for SSEPs, V for BAEPs, and P100 for VEPs. Each type of evoked potential was classified as absent, present or indeterminable. Neurological outcomes after 6 months were dichotomized as good (Cerebral Performance Category [CPC] 1-2) or poor (CPC 3-5). RESULTS From 185 patients, 185 SSEPs, 172 BAEPs and 178 VEPs were included. None of the patients with a good outcome had absent SSEP, BAEP or VEP responses. Absent SSEP, BAEP and VEP responses yielded sensitivities of 42.3% (95% confidence interval [CI], 33.7-51.3%), 9.4% (95% CI, 4.6-16.7%) and 54.4% (95% CI, 46.0-62.5%) for poor outcomes, respectively. For the overall cohort, the addition of VEP measurements improved the sensitivities of single SSEP measurements (65.8% [95% CI, 57.7-73.3%] versus 36.2% [95% CI, 28.6-44.4%] and multimodal prognostication using SSEPs, brainstem reflex and brain computed tomography (75.7% [95% CI, 68.0-82.3%] versus 60.5% [95% CI, 52.3-68.4%]). CONCLUSIONS The prognostic value of VEPs was comparable to that of SSEPs, but the use of BAEPs was limited due to their low sensitivity. Additional VEP measurements can reduce prognostic uncertainty.
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Affiliation(s)
- Jee Yong Lim
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Sang Hoon Oh
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Kyu Nam Park
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Seung Pill Choi
- Department of Emergency Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Joo Suk Oh
- Department of Emergency Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Chun Song Youn
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Han Joon Kim
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Hyo Joon Kim
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Hwan Song
- Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
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Al Assil R, Singer J, Heidet M, Fordyce CB, Scheuermeyer F, Diepen SV, Sekhon M, Leung KHB, Stenstrom R, Christenson J, Grunau B. The association of pH values during the first 24 h with neurological status at hospital discharge and futility among patients with out-of-hospital cardiac arrest. Resuscitation 2020; 159:105-114. [PMID: 33385471 DOI: 10.1016/j.resuscitation.2020.12.017] [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: 08/02/2020] [Revised: 11/24/2020] [Accepted: 12/15/2020] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVE Post-resuscitation prognostic biomarkers for out-of-hospital cardiac arrest (OHCA) outcomes have not been fully elucidated. We examined the association of acid-base blood values (pH) with patient outcomes and calculated the pH test performance to predict prognosis. METHODS This was a post-hoc analysis of data from the continuous chest compression trial, which enrolled non-traumatic adult emergency medical system-treated OHCA in Canada and the United States. We examined cases who survived a minimum of 24 h post hospital arrival. The independent variables of interest were initial pH, final pH, and the change in pH (δpH). The primary outcome was neurological status at hospital discharge, with favorable status defined as modified Rankin Scale (mRS) ≤ 3. We reported adjusted odds ratios for favorable neurological outcome using multivariable logistic regression models. We calculated the test performance of increasing pH thresholds in 0.1 increments to predict unfavorable neurological status (defined as mRS >3) at hospital discharge. RESULTS We included 4189 patients. 32% survived to hospital discharge with favorable neurological status. In the adjusted analysis, higher initial pH (OR 6.82; 95% CI 3.71-12.52) and higher final pH (OR 7.99; 95% CI 3.26-19.62) were associated with higher odds of favorable neurological status. pH thresholds with highest positive predictive values were initial pH < 6.8 (92.5%; 95% CI 86.2 %-98.8%) and final pH < 7.0 (100%; 95% CI 95.2 %-100%). CONCLUSION In patients with OHCA, pH values were associated with patients' subsequent neurological status at hospital discharge. Final pH may be clinically useful to predict unfavorable neurological status at hospital discharge.
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Affiliation(s)
- Rahaf Al Assil
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada; Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Joel Singer
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Matthieu Heidet
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, SAMU 94 et Urgences, Créteil, France; Université Paris-Est Créteil (UPEC), EA-4390 (Analysis of Risks in Complex Health Systems - ARCHES), Créteil, France; Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christopher B Fordyce
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Frank Scheuermeyer
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada; Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sean van Diepen
- Department of Critical Care and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Mypinder Sekhon
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; BC Emergency Health Services, British Columbia, Canada
| | - K H Benjamin Leung
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Rob Stenstrom
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada; Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jim Christenson
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada; Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Brian Grunau
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada; Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada; BC Emergency Health Services, British Columbia, Canada
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Honore PM, Barreto Gutierrez L, Kugener L, Redant S, Attou R, Gallerani A, De Bels D. Early latency evoked potentials can no longer be considered an infallible predictor of neurologic outcome. Crit Care 2020; 24:322. [PMID: 32517720 PMCID: PMC7285431 DOI: 10.1186/s13054-020-03056-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 06/02/2020] [Indexed: 11/30/2022] Open
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Cronberg T, Greer DM, Lilja G, Moulaert V, Swindell P, Rossetti AO. Brain injury after cardiac arrest: from prognostication of comatose patients to rehabilitation. Lancet Neurol 2020; 19:611-622. [PMID: 32562686 DOI: 10.1016/s1474-4422(20)30117-4] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 03/30/2020] [Accepted: 04/01/2020] [Indexed: 02/08/2023]
Abstract
More patients are surviving cardiac arrest than ever before; however, the burden now lies with estimating neurological prognoses in a large number of patients who were initially comatose, in whom the ultimate outcome is unclear. Neurologists, neurointensivists, and clinical neurophysiologists must accurately balance the concern that overly conservative prognostication could leave patients in a severely disabled state, with the possibility that inaccurately pessimistic prognostication could lead to the withdrawal of life-sustaining treatment in patients who might otherwise have a good functional outcome. Prognostic tools have improved greatly, including electrophysiological tests, neuroimaging, and chemical biomarkers. Conclusions about the prognosis should be delayed at least 72 h after arrest to allow for the clearance of sedative drugs. Cognitive impairments, emotional problems, and fatigue are common among patients who have survived cardiac arrest, and often go unrecognised despite being related to caregiver burden and a decreased participation in society. Through simple screening, these problems can be identified, and patients can be provided with adequate information and rehabilitation.
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Affiliation(s)
- Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden.
| | - David M Greer
- Department of Neurology, Boston University School of Medicine, Boston, MA, USA
| | - Gisela Lilja
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Véronique Moulaert
- Department of Rehabilitation Medicine, University of Groningen, University Medical Centre Groningen, Netherlands
| | | | - Andrea O Rossetti
- Department of Clinical Neurosciences, University Hospital and University of Lausanne, Lausanne, Switzerland
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Comanducci A, Boly M, Claassen J, De Lucia M, Gibson RM, Juan E, Laureys S, Naccache L, Owen AM, Rosanova M, Rossetti AO, Schnakers C, Sitt JD, Schiff ND, Massimini M. Clinical and advanced neurophysiology in the prognostic and diagnostic evaluation of disorders of consciousness: review of an IFCN-endorsed expert group. Clin Neurophysiol 2020; 131:2736-2765. [PMID: 32917521 DOI: 10.1016/j.clinph.2020.07.015] [Citation(s) in RCA: 91] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 07/06/2020] [Accepted: 07/26/2020] [Indexed: 12/13/2022]
Abstract
The analysis of spontaneous EEG activity and evoked potentialsis a cornerstone of the instrumental evaluation of patients with disorders of consciousness (DoC). Thepast few years have witnessed an unprecedented surge in EEG-related research applied to the prediction and detection of recovery of consciousness after severe brain injury,opening up the prospect that new concepts and tools may be available at the bedside. This paper provides a comprehensive, critical overview of bothconsolidated and investigational electrophysiological techniquesfor the prognostic and diagnostic assessment of DoC.We describe conventional clinical EEG approaches, then focus on evoked and event-related potentials, and finally we analyze the potential of novel research findings. In doing so, we (i) draw a distinction between acute, prolonged and chronic phases of DoC, (ii) attempt to relate both clinical and research findings to the underlying neuronal processes and (iii) discuss technical and conceptual caveats.The primary aim of this narrative review is to bridge the gap between standard and emerging electrophysiological measures for the detection and prediction of recovery of consciousness. The ultimate scope is to provide a reference and common ground for academic researchers active in the field of neurophysiology and clinicians engaged in intensive care unit and rehabilitation.
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Affiliation(s)
- A Comanducci
- IRCCS Fondazione Don Carlo Gnocchi, Milan, Italy
| | - M Boly
- Department of Neurology and Department of Psychiatry, University of Wisconsin, Madison, USA; Wisconsin Institute for Sleep and Consciousness, Department of Psychiatry, University of Wisconsin-Madison, Madison, USA
| | - J Claassen
- Department of Neurology, Columbia University Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - M De Lucia
- Laboratoire de Recherche en Neuroimagerie, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - R M Gibson
- The Brain and Mind Institute and the Department of Physiology and Pharmacology, Western Interdisciplinary Research Building, N6A 5B7 University of Western Ontario, London, Ontario, Canada
| | - E Juan
- Wisconsin Institute for Sleep and Consciousness, Department of Psychiatry, University of Wisconsin-Madison, Madison, USA; Amsterdam Brain and Cognition, Department of Psychology, University of Amsterdam, Amsterdam, the Netherlands
| | - S Laureys
- Coma Science Group, Centre du Cerveau, GIGA-Consciousness, University and University Hospital of Liège, 4000 Liège, Belgium; Fondazione Europea per la Ricerca Biomedica Onlus, Milan 20063, Italy
| | - L Naccache
- Inserm U 1127, CNRS UMR 7225, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France; Sorbonne Université, UPMC Université Paris 06, Faculté de Médecine Pitié-Salpêtrière, Paris, France
| | - A M Owen
- The Brain and Mind Institute and the Department of Physiology and Pharmacology, Western Interdisciplinary Research Building, N6A 5B7 University of Western Ontario, London, Ontario, Canada
| | - M Rosanova
- Department of Biomedical and Clinical Sciences "L. Sacco", University of Milan, Milan, Italy; Fondazione Europea per la Ricerca Biomedica Onlus, Milan 20063, Italy
| | - A O Rossetti
- Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - C Schnakers
- Research Institute, Casa Colina Hospital and Centers for Healthcare, Pomona, CA, USA
| | - J D Sitt
- Inserm U 1127, CNRS UMR 7225, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France
| | - N D Schiff
- Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, 1300 York Avenue, New York, NY 10065, USA
| | - M Massimini
- IRCCS Fondazione Don Carlo Gnocchi, Milan, Italy; Department of Biomedical and Clinical Sciences "L. Sacco", University of Milan, Milan, Italy
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Prognostic value of somatosensory evoked potential in cardiac arrest patients without withdrawal of life-sustaining therapy. Resuscitation 2020; 150:154-161. [DOI: 10.1016/j.resuscitation.2020.02.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 02/07/2020] [Accepted: 02/23/2020] [Indexed: 12/11/2022]
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