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Kovach CP, Leonard J, Messenger JC, Waldo SW, Perman SM. Impact of Time to Initiation of Targeted Temperature Management Among Patients with Out-of-Hospital Cardiac Arrest Undergoing Percutaneous Coronary Intervention. Ther Hypothermia Temp Manag 2025; 15:74-81. [PMID: 39311798 DOI: 10.1089/ther.2024.0030] [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: 05/29/2025] Open
Abstract
Delays in initiation of targeted temperature management (TTM) have been observed in randomized trials evaluating immediate or delayed coronary angiography among survivors of ventricular tachycardia (VT) or ventricular fibrillation (VF) out-of-hospital cardiac arrest (OHCA), but whether delays are associated with adverse clinical outcomes is unknown. Resuscitated survivors of VT/VF OHCA who received TTM between April 2011 and June 2015 were identified and time to TTM initiation was described. The association between TTM initiation <2 versus ≥2 hours, neurologically favorable, and overall survival to hospital discharge was assessed. In a propensity-weighted analysis of 2954 patients, a significantly larger proportion of patients undergoing percutaneous coronary intervention (PCI) had TTM initiation ≥2 hours (48.6%) as compared to patients undergoing angiography (41.4%) or those who did not undergo a procedure (33.0%; p < 0.001 for all comparisons). In this cohort, the odds of neurologically favorable survival (odds ratios [OR]: 0.88, 95% confidence intervals [CI] = 0.75-1.02) and overall survival (OR: 0.92, 95% CI = 0.83-1.03) to hospital discharge were similar among ST-elevation myocardial infarction (STEMI) patients who underwent PCI with TTM initiation <2 versus ≥2 hours. Patients without STEMI who underwent PCI with TTM initiation ≥2 hours and did not have a "do not resuscitate" order or withdrawal of life-sustaining care had decreased odds of neurologically favorable survival to hospital discharge (OR: 0.45, 95% CI = 0.22-0.93) compared to TTM initiation <2 hours. PCI was associated with delays in TTM initiation ≥2 hours among resuscitated survivors of VT/VF OHCA. Delays in TTM initiation ≥2 hours were associated with decreased odds of neurologically favorable survival among patients without STEMI who underwent PCI.
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Affiliation(s)
- Christopher P Kovach
- Colorado Springs Cardiology, Colorado Springs, Colorado, USA
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Jan Leonard
- Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado, USA
| | - John C Messenger
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Stephen W Waldo
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora, Colorado, USA
- Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA
| | - Sarah M Perman
- Department of Emergency Medicine, University of Colorado, Aurora, Colorado, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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Wang Z, Kulpanowski AM, Copen WA, Rosenthal ES, Dodelson JA, McCrory DE, Edlow BL, Kimberly WT, Amorim E, Westover MB, Ning M, Zabihi M, Schaefer PW, Malhotra R, Giacino JT, Greer DM, Wu O. Automated Detection of Severe Cerebral Edema Using Explainable Deep Transfer Learning after Hypoxic Ischemic Brain Injury. Resuscitation 2025:110652. [PMID: 40414341 DOI: 10.1016/j.resuscitation.2025.110652] [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: 03/10/2025] [Revised: 05/13/2025] [Accepted: 05/14/2025] [Indexed: 05/27/2025]
Abstract
BACKGROUND Substantial gaps exist in the neuroprognostication of cardiac arrest patients who remain comatose after the restoration of spontaneous circulation. Most studies focus on predicting survival, a measure confounded by the withdrawal of life-sustaining treatment decisions. Severe cerebral edema (SCE) may serve as an objective proximal imaging-based surrogate of neurologic injury. METHODS We retrospectively analyzed data from 288 patients to automate SCE detection with machine learning (ML) and to test the hypothesis that the quantitative values produced by these algorithms (ML_SCE) can improve predictions of neurologic outcomes. Ground-truth SCE (GT_SCE) classification was based on radiology reports. RESULTS The model attained a cross-validated testing accuracy of 87% [95% CI: 84%, 89%] for detecting SCE. Attention maps explaining SCE classification focused on cisternal regions (p<0.05). Multivariable analyses showed that older age (p<0.001), non-shockable initial cardiac rhythm (p=0.004), and greater ML_SCE values (p<0.001) were significant predictors of poor neurologic outcomes, with GT_SCE (p=0.064) as a non-significant covariate. CONCLUSION Our results support the feasibility of automated SCE detection. Future prospective studies with standardized neurologic assessments are needed to substantiate the utility of quantitative ML_SCE values to improve neuroprognostication.
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Affiliation(s)
- Zihao Wang
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA 02129, USA
| | - Annelise M Kulpanowski
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA 02129, USA
| | - William A Copen
- Department of Radiology, Neuroradiology Division, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Eric S Rosenthal
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Jacob A Dodelson
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA 02129, USA
| | - David E McCrory
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA 02129, USA
| | - Brian L Edlow
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - W Taylor Kimberly
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Edilberto Amorim
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA; Department of Neurology, University of California, San Francisco, San Francisco, CA 94143, USA
| | - MBrandon Westover
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA; Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - MingMing Ning
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Morteza Zabihi
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Pamela W Schaefer
- Department of Radiology, Neuroradiology Division, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Rajeev Malhotra
- Department of Medicine, Cardiology Division, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA 02129, USA
| | - David M Greer
- Department of Neurology, Boston University Chobanian and Avedisian School of Medicine, Boston Medical Center, Boston, MA 02118, USA
| | - Ona Wu
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA 02129, USA.
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3
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Czimmeck C, Nee J, Hinrichs C, Endisch C, Körtvélyessy P, Ploner CJ, Leithner C, Kenda M. Serum neurofilament light chain and multimodal neuroprognostication after cardiac arrest - a retrospective cohort study. Resuscitation 2025:110650. [PMID: 40409670 DOI: 10.1016/j.resuscitation.2025.110650] [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: 03/21/2025] [Revised: 04/26/2025] [Accepted: 05/05/2025] [Indexed: 05/25/2025]
Abstract
BACKGROUND AND PURPOSE Most patients remain comatose within the first days after cardiac arrest (CA) and resuscitation. Guidelines recommend multimodal neuroprognostication including neuron specific enolase (NSE) as serum biomarker. Neurofilament light-chain (NFL) may have higher prognostic accuracy earlier after cardiac arrest and a lower risk of confounders. This study investigates the prognostic value of serum NFL in clinical routine compared to established prognostic tests. METHODS Monocentric retrospective observational study of patients with serum NFL between 24-96 hours after CA. Neurological outcome was evaluated at hospital discharge via the Cerebral Performance Category score (CPC), dichotomized as good (CPC 1-3) and poor (CPC 4-5). Prognostic performance for good and poor neurological outcome prediction was analysed for NFL, NSE, electroencephalography (EEG), somatosensory evoked potentials (SSEP), and head computed tomography (CT). NFL was measured using the SIMOA Quanterix assay. RESULTS 152 patients were included, median age was 61 years, 24% were female. 10 patients were discharged in vegetative state or comatose (7%), and 78 died before discharge (51%). NFL >2000pg/ml predicted poor outcome with 53% (43-63%) sensitivity and 100% (94-100%) specificity. Most patients (69%) with NFL <55pg/ml had a good outcome. Predictive accuracy was similar to other neuroprognostic tests (AUC 0.89, 0.84-0.94). In head-to-head comparisons with established neuroprognostic tests, NFL identified 16-41% additional poor outcome patients. CONCLUSION NFL (SIMOA) >2000pg/ml predicts poor neurological outcome with high specificity, while low concentrations strongly argue against severe HIE. Adding NFL to established neuroprognostication increases sensitivity of poor outcome prediction.
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Affiliation(s)
- Constanze Czimmeck
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology and Experimental Neurology, 13353 Berlin, Germany
| | - Jens Nee
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Nephrology and Intensive Care Medicine, Circulatory Arrest Center Berlin, Berlin, Germany
| | - Carl Hinrichs
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Nephrology and Intensive Care Medicine, Circulatory Arrest Center Berlin, Berlin, Germany
| | - Christian Endisch
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology and Experimental Neurology, 13353 Berlin, Germany
| | - Péter Körtvélyessy
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology and Experimental Neurology, 13353 Berlin, Germany; Deutsches Zentrum für Neurodegenerative Erkrankungen, Research Site Magdeburg,39120 Magdeburg, Germany; Labor Berlin, Innovation Lab, Labor Berlin 13353 Berlin, Germany
| | - Christoph J Ploner
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology and Experimental Neurology, 13353 Berlin, Germany
| | - Christoph Leithner
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology and Experimental Neurology, 13353 Berlin, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Clinical Fellow Program, 10117 Berlin, Germany
| | - Martin Kenda
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology and Experimental Neurology, 13353 Berlin, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Junior Digital Clinician Scientist Program, 10117 Berlin, Germany.
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4
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Ceric A, Dankiewicz J, Hästbacka J, Young P, Niemelä VH, Bass F, Skrifvars MB, Hammond N, Saxena M, Levin H, Lilja G, Moseby‐Knappe M, Tiainen M, Reinikainen M, Holgersson J, Kamp CB, Wise MP, McGuigan PJ, White J, Sweet K, Keeble TR, Glover G, Hopkins P, Remmington C, Cole JM, Gorgoraptis N, Pogson DG, Jackson P, Düring J, Lybeck A, Johnsson J, Unden J, Lundin A, Kåhlin J, Grip J, Lotman EM, Romundstad L, Seidel P, Stammet P, Graf T, Mengel A, Leithner C, Nee J, Druwé P, Ameloot K, Nichol A, Haenggi M, Hilty MP, Iten M, Schrag C, Nafi M, Joannidis M, Robba C, Pellis T, Belohlavek J, Rob D, Arabi YM, Buabbas S, Yew Woon C, Aneman A, Stewart A, Reade M, Delcourt C, Delaney A, Ramanan M, Venkatesh B, Navarra L, Crichton B, Williams A, Knight D, Tirkkonen J, Oksanen T, Kaakinen T, Bendel S, Friberg H, Cronberg T, Jakobsen JC, Nielsen N. Continuous deep sedation versus minimal sedation after cardiac arrest and resuscitation (SED-CARE): A protocol for a randomized clinical trial. Acta Anaesthesiol Scand 2025; 69:e70022. [PMID: 40178107 PMCID: PMC11967157 DOI: 10.1111/aas.70022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2025] [Accepted: 03/04/2025] [Indexed: 04/05/2025]
Abstract
BACKGROUND Sedation is often provided to resuscitated out-of-hospital cardiac arrest (OHCA) patients to tolerate post-cardiac arrest care, including temperature management. However, the evidence of benefit or harm from routinely administered deep sedation after cardiac arrest is limited. The aim of this trial is to investigate the effects of continuous deep sedation compared to minimal sedation on patient-important outcomes in resuscitated OHCA patients in a large clinical trial. METHODS The SED-CARE trial is part of the 2 × 2 × 2 factorial Sedation, Temperature and Pressure after Cardiac Arrest and Resuscitation (STEPCARE) trial, a randomized international, multicentre, parallel-group, investigator-initiated, superiority trial with three simultaneous intervention arms. In the SED-CARE trial, adults with sustained return of spontaneous circulation (ROSC) who are comatose following resuscitation from OHCA will be randomized within 4 hours to continuous deep sedation (Richmond agitation and sedation scale (RASS) -4/-5) (intervention) or minimal sedation (RASS 0 to -2) (comparator), for 36 h after ROSC. The primary outcome will be all-cause mortality at 6 months after randomization. The two other components of the STEPCARE trial evaluate sedation and temperature control strategies. Apart from the STEPCARE trial interventions, all other aspects of general intensive care will be according to the local practices of the participating site. Neurological prognostication will be performed according to European Resuscitation Council and European Society of Intensive Care Medicine guidelines by a physician blinded to the allocation group. To detect an absolute risk reduction of 5.6% with an alpha of 0.05, 90% power, 3500 participants will be enrolled. The secondary outcomes will be the proportion of participants with poor functional outcomes 6 months after randomization, serious adverse events in the intensive care unit, and patient-reported overall health status 6 months after randomization. CONCLUSION The SED-CARE trial will investigate if continuous deep sedation (RASS -4/-5) for 36 h confers a mortality benefit compared to minimal sedation (RASS 0 to -2) after cardiac arrest.
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Affiliation(s)
- A. Ceric
- Anesthesia and Intensive Care, Department of Clinical SciencesLund University, Skane University HospitalMalmöSweden
| | - J. Dankiewicz
- Department of Clinical Sciences Lund, Section of CardiologySkåne University HospitalMalmöSweden
| | - J. Hästbacka
- Faculty of Medicine and Health Technology, Tampere University HospitalWellbeing Services County of Pirkanmaa and Tampere UniversityTampereFinland
| | - P. Young
- Intensive Care UnitWellington HospitalWellingtonNew Zealand
- Medical Research Institute of New ZealandWellingtonNew Zealand
- Australian and New Zealand Intensive Care Research CentreMonash UniversityMelbourneVictoriaAustralia
- Department of Critical CareUniversity of MelbourneMelbourneVictoriaAustralia
| | - V. H. Niemelä
- Department of Anaesthesia and Intensive CareHelsinki University Hospital and University of HelsinkiHelsinkiFinland
| | - F. Bass
- The George Institute for Global HealthSydneyAustralia
- Royal North Shore HospitalSydneyAustralia
| | - M. B. Skrifvars
- Department of Anaesthesia and Intensive CareHelsinki University Hospital and University of HelsinkiHelsinkiFinland
| | - N. Hammond
- Critical Care ProgramThe George Institute for Global Health, UNSWSydneyAustralia
- Malcolm Fisher Department of Intensive CareRoyal North Shore HospitalSt LeonardsAustralia
| | - M. Saxena
- Critical Care Division and Department of Intensive Care Medicine, The George Institute for Global Health and St George Hospital Clinical SchoolUniversity of New South WalesSydneyAustralia
| | - H. Levin
- Department of Clinical Sciences LundLund UniversityLundSweden
- Department of Research, Development, Education and InnovationSkåne University HospitalLundSweden
| | - G. Lilja
- Neurology, Department of Clinical Sciences LundLund UniversityLundSweden
- Department of NeurologySkåne University HospitalLundSweden
| | - M. Moseby‐Knappe
- Department of Clinical Sciences LundLund UniversityLundSweden
- Department of Neurology and RehabilitationSkåne University HospitalLundSweden
| | - M. Tiainen
- Department of NeurologyHelsinki University Hospital and University of HelsinkiHelsinkiFinland
| | - M. Reinikainen
- Institute of Clinical MedicineUniversity of Eastern FinlandKuopioFinland
- Department of Anaesthesiology and Intensive CareKuopio University HospitalKuopioFinland
| | - J. Holgersson
- Department of Clinical Sciences Lund, Anesthesia and Intensive CareLund UniversityLundSweden
- Department of Anesthesia and Intensive CareHelsingborg HospitalHelsingborgSweden
| | - C. B. Kamp
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital RegionCopenhagen University Hospital—RigshospitaletCopenhagenDenmark
- Department of Regional Health Research, The Faculty of Health SciencesUniversity of Southern DenmarkOdenseDenmark
| | - M. P. Wise
- Adult Critical CareUniversity Hospital of WalesCardiffUK
| | - P. J. McGuigan
- Wellcome‐Wolfson Institute for Experimental MedicineQueen's University BelfastBelfastUK
- Regional Intensive care UnitRoyal Victoria HospitalBelfastUnited Kingdom
| | - J. White
- Adult Critical CareUniversity Hospital of WalesCardiffUK
| | - K. Sweet
- University Hospitals Bristol and Weston NHS Foundation TrustBristolUK
| | - T. R. Keeble
- Essex Cardiothoracic CentreMSE NHSFTEssexUK
- Anglia Ruskin School of Medicine & MTRC, ARUChelmsford, EssexUnited Kingdom
| | - G. Glover
- Department of Critical CareGuy's and St Thomas NHS Foundation TrustLondonUK
| | - P. Hopkins
- Faculty of Life, Sciences and Medicine, King's College, Intensive Care Medicine, Centre for Human and Applied Physiological SciencesSchool of Basic and Medical BiosciencesLondonUK
- Intensive Care Medicine, King's Critical CareKing's College Hospital, NHS Foundation TrustLondonUK
| | - C. Remmington
- Department of Pharmacy and Adult Critical Care, Guy's and St Thomas' NHS Foundation TrustLondonUK
- Institute of Pharmaceutical Sciences, School of Cancer & Pharmaceutical SciencesKing's College LondonLondonUK
| | - J. M. Cole
- Critical CareUniversity Hospital of WalesCardiffUK
| | | | - D. G. Pogson
- Department of Critical CarePortsmouth University Hospitals TrustPortsmouthUK
| | - P. Jackson
- Leeds Teaching Hospitals NHS TrustLeedsUK
| | - J. Düring
- Department of Clinical Sciences, Anesthesia and Intensive Care, Lund UniversitySkåne University HospitalMalmöSweden
| | - A. Lybeck
- Anesthesia and Intensive Care, Department of Clinical Sciences LundLund University, Skane University HospitalLundSweden
| | - J. Johnsson
- Department of Anaesthesiology and Intensive CareHelsingborg HospitalHelsingborgSweden
| | - J. Unden
- Department of Operation and Intensive CareHallands HospitalHalmstadSweden
- Department of Intensive and Perioperative Care, Skåne University HospitalLund UniversityLundSweden
| | - A. Lundin
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - J. Kåhlin
- Perioperative Medicine and Intensive Care (PMI)Karolinska University HospitalStockholmSweden
- Department of Physiology and PharmacologyKarolinska InstitutetStockholmSweden
| | - J. Grip
- Function Perioperative Medicine and Intensive CareKarolinska University HospitalStockholmSweden
- Department of Clinical Science, Interventionand TechnologyKarolinska InstituteStockholmSweden
| | | | - L. Romundstad
- Department of Anesthesia and Intensive Care medicine, Division of Emergencies and Critical careOslo University HospitalOsloNorway
- Lovisenberg Diaconal University CollegeOsloNorway
| | - P. Seidel
- Department of Intensive Care MedicineStavanger University HospitalStavangerNorway
| | - P. Stammet
- Department of Anaesthesia and Intensive Care MedicineCentre Hospitalier de LuxembourgLuxembourgLuxembourg
- Department of Life Sciences and Medicine, Faculty of Science, Technology and MedicineUniversity of LuxembourgEsch‐sur AlzetteLuxembourg
| | - T. Graf
- University Heart Center LübeckUniversity Hospital Schleswig‐HolsteinSchleswig‐HolsteinGermany
- German Center for Cardiovascular Research (DZHK)Hamburg/Lübeck/KielGermany
| | - A. Mengel
- Department of Neurology and StrokeUniversity Hospital Tuebingen, Hertie Institute of Clinical Brain ResearchTuebingenGermany
| | - C. Leithner
- Charité—Universitätsmedizin Berlin, Department of NeurologyFreie Universität and Humboldt‐Universität zu BerlinBerlinGermany
| | - J. Nee
- Department of Nephrology and Medical Intensive CareCharité—Universitaetsmedizin BerlinBerlinGermany
| | - P. Druwé
- Department of Intensive Care MedicineGhent University HospitalGhentBelgium
| | - K. Ameloot
- Department of Cardiology, Ziekenhuis Oost‐GenkLimburgBelgium
| | - A. Nichol
- University College Dublin Clinical Research Centre at St Vincent's University HospitalUniversity College DublinDublinIreland
- The Australian and New Zealand Intensive Care Research CentreMonash UniversityMelbourneAustralia
- The Alfred HospitalMelbourneAustralia
| | - M. Haenggi
- Institute of Intensive Care Medicine University Hospital ZurichZurichSwitzerland
| | - M. P. Hilty
- Institute of Intensive Care MedicineUniversity Hospital ZurichZurichSwitzerland
| | - M. Iten
- Department of Intensive Care MedicineInselspital University Hospital BernBernSwitzerland
| | - C. Schrag
- Klinik für Intensivmedizin, Kantonsspital St. GallenSt. GallenSwitzerland
| | - M. Nafi
- Istituto Cardiocentro TicinoLuganoSwitzerland
| | - M. Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal MedicineMedical University InsbruckInnsbruckAustria
| | - C. Robba
- IRCCS Policlinico San Martino, Genova, Italy. Dipartimento di Scienze Chirurgiche Diagnostiche IntegrateUniversity of GenovaGenovaItaly
| | - T. Pellis
- Anaesthesia and Intensive CarePordenone Hospital, Azienda Sanitaria Friuli OccidentalePordenoneItaly
| | - J. Belohlavek
- First Faculty of MedicineCharles University in Prague, Institute for Heart DiseasesPraugeCzech Republic
- Second Department of Internal Medicine, Cardiovascular MedicineGeneral University Hospital, Wroclaw Medical UniversityWroclawPoland
| | - D. Rob
- Second Department of Medicine, Department of Cardiovascular Medicine, First Faculty of MedicineCharles University in Prague and General University Hospital in PraguePragueCzech Republic
| | - Y. M. Arabi
- King Abdullah International Medical Research CenterKing Saud bin Abdulaziz University for Health SciencesRiyadhSaudi Arabia
| | - S. Buabbas
- Department of Anestesia, Critical Care and Pain MedicineJaber Alahmad Alsabah HospitalKuwait CityKuwait
| | - C. Yew Woon
- Tan Tock Seng HospitalSingaporeSingapore
- Yong Loo Lin School of MedicineNational University of SingaporeSingaporeSingapore
- Lee Kong Chian School of MedicineNanyang Technological UniversitySingaporeSingapore
| | - A. Aneman
- Intensive Care UnitLiverpool Hospital, South Western Sydney Local Health DistrictSydneyNew South WalesAustralia
- South Western Clinical SchoolUniversity of New South WalesSydneyNew South WalesAustralia
- The Ingham Institute for Applied Medical ResearchSydneyNew South WalesAustralia
| | | | - M. Reade
- Medical SchoolUniversity of Queensland, Level 9, Health Sciences Building, Royal Brisbane and Women's HospitalBrisbaneAustralia
| | - C. Delcourt
- The George Institute for Global Health, Faculty of MedicineUniversity of New South WalesSydneyAustralia
- Department of Clinical Medicine, Faculty of Medicine, Health and Human SciencesMacquarie UniversitySydneyAustralia
| | - A. Delaney
- Critical Care Program, The George Institute for Global Health. Malcolm Fisher Depratment of Intensive Care Medicine, Royal North Shore Hospital. Northern Clinical School, Sydney Medical SchoolUniversity of SydneySydneyAustralia
| | - M. Ramanan
- Caboolture and Royal Brisbane and Women's HospitalsMetro North Hospital and Health ServiceBrisbaneQueenslandAustralia
- School of Clinical MedicineQueensland University of TechnologyBrisbaneQueenslandAustralia
- Critical Care Division, The George Institute for Global HealthUniversity of New South WalesSydneyNew South WalesAustralia
| | - B. Venkatesh
- The George Institute for Global HealthSydneyAustralia
| | - L. Navarra
- Medical Research Institute of New ZealandWellingtonNew Zealand
| | - B. Crichton
- Medical Research Institute of New ZealandWellingtonNew Zealand
| | | | - D. Knight
- Department of Intensive CareChristchurch HospitalChristchurch Central CityNew Zealand
| | - J. Tirkkonen
- Intensive Care UnitTampere University HospitalTampereFinland
| | - T. Oksanen
- Department of Anaesthesia and Intensive CareJorvi Hospital, University Hospital of Helsinki and University of HelsinkiEspooFinland
| | - T. Kaakinen
- Research Unit of Translational Medicine, Research Group of Anaesthesiology, Medical Research Center OuluOulu University Hospital and University of OuluOuluFinland
- OYS Heart, Oulu University Hospital, MRC Oulu and University of OuluOuluFinland
| | - S. Bendel
- Institute of Clinical MedicineUniversity of Eastern FinlandKuopioFinland
- Department of Anaesthesiology and Intensive CareKuopio University HospitalKuopioFinland
| | - H. Friberg
- Anesthesia and Intensive Care, Department of Clinical Sciences LundLund UniversityLundSweden
- Intensive and Perioperative CareSkåne University HospitalMalmöSweden
| | - T. Cronberg
- Neurology, Department of Clinical Sciences LundLund UniversityLundSweden
- Department of NeurologySkåne University HospitalLundSweden
| | - J. C. Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention ResearchCopenhagen University Hospital—RigshospitaletCopenhagenDenmark
- Department of Regional Health Research, Faculty of Health SciencesUniversity of Southern DenmarkOdenseDenmark
| | - N. Nielsen
- Department of Clinical Sciences Lund, Anesthesia and Intensive CareLund UniversityLundSweden
- Department of Anesthesia and Intensive CareHelsingborg HospitalHelsingborgSweden
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5
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Endisch C, Millard K, Preuß S, Stenzel W, Nee J, Storm C, Ploner CJ, Leithner C. Duration of resuscitation, regain of consciousness and histopathological severity of hypoxic-ischemic encephalopathy after cardiac arrest. Resusc Plus 2025; 23:100945. [PMID: 40235929 PMCID: PMC11999640 DOI: 10.1016/j.resplu.2025.100945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2025] [Revised: 03/08/2025] [Accepted: 03/20/2025] [Indexed: 04/17/2025] Open
Abstract
Purpose To study the histopathologically quantified severity of hypoxic-ischemic encephalopathy (HIE) in deceased cardiac arrest unbiased by death causes and correlated with demographic parameters. Methods We conducted a retrospective, single-centre study including cardiac arrest patients with postmortem brain autopsies. Using the selective eosinophilic neuronal death (SEND), the histopathological severity of HIE was quantified in the cerebral neocortex, hippocampus, basal ganglia, cerebellum, and brainstem, and correlated with demographic parameters. Results We included 319 patients with a median time of return from cardiac arrest to spontaneous circulation (tROSC) of 10 min, of whom 62(19.4%) had a regain of consciousness (RoC) before death. The tROSC was significantly correlated with the SEND in all brain regions (p < 0.05, Spearman's rho = 0.14 to 0.29). The SEND in the neocortex, hippocampus, and basal ganglia was significantly correlated with RoC (p < 0.05, Spearman's rho = -0.25 to -0.11). In 9 patients with tROSCs less than 1 min, all had a brainstem SEND less than 30%, and 8(88.9%) had neocortical SEND less than 30%. Among 69 patients with tROSCs greater than 20 min, 47.8-82.6% showed a SEND less than 30% across brain regions. Conclusions We found less SEND and RoC was more likely in patients with shorter tROSCs. A tROSC less than 1 min was mostly associated with SEND less than 30% in all brain regions. Prolonged resuscitations with tROSCs greater than 20 min did not exclude a SEND less than 30% in a relevant proportion of patients. Future histopathological studies are warranted to investigate the impact of modifiable clinical parameters on the severity of HIE.
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Affiliation(s)
- Christian Endisch
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Katharina Millard
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Sandra Preuß
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
- Department of Cardiology and Angiology, Charité Campus Mitte, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Werner Stenzel
- Department of Neuropathology, Charité Campus Mitte, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Jens Nee
- Telehealth Competence Center GmbH, Humboldtstraße 67a, 22083 Hamburg, Germany
| | - Christian Storm
- Telehealth Competence Center GmbH, Humboldtstraße 67a, 22083 Hamburg, 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
| | - Christoph Leithner
- 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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Niu Y, Chen X, Fan J, Liu C, Fang M, Liu Z, Meng X, Liu Y, Lu L, Fan H. Explainable machine learning model based on EEG, ECG, and clinical features for predicting neurological outcomes in cardiac arrest patient. Sci Rep 2025; 15:11498. [PMID: 40181037 PMCID: PMC11968807 DOI: 10.1038/s41598-025-93579-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2024] [Accepted: 03/07/2025] [Indexed: 04/05/2025] Open
Abstract
Early and accurate prediction of neurological outcomes in comatose patients following cardiac arrest is critical for informed clinical decision-making. Existing studies have predominantly focused on EEG for assessing brain injury, with some exploring ECG data. However, the integration of EEG, ECG, and clinical features remains insufficiently investigated, and its potential to enhance predictive accuracy has not been fully established. Moreover, the limited interpretability of current models poses significant barriers to clinical application. Using the I-CARE database, we analyzed EEG, ECG, and clinical data from comatose cardiac arrest patients. After rigorous preprocessing and feature engineering, machine learning models (Logistic Regression, SVM, Random Forest, and Gradient Boosting) were developed. Performance was evaluated through AUC-ROC, accuracy, sensitivity, and specificity, with SHAP applied to interpret feature contributions. Our multi-modal model outperformed single-modality models, achieving AUC values from 0.75 to 1.0. Notably, the model's accuracy peaked at a critical point within the 12-24 h window (e.g., 18 h, AUC = 1.0), surpassing EEG-only (AUC 0.7-0.8) and ECG-only (AUC < 0.6) models. SHAP identified Shockable Rhythm as the most influential feature (mean SHAP value 0.17), emphasizing its role in predictive accuracy. This study presents a novel multi-modal approach that significantly enhances early neurological outcome prediction in critical care. SHAP-based interpretability further supports clinical applicability, paving the way for more personalized patient management post-cardiac arrest.
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Affiliation(s)
- Yanxiang Niu
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, 325000, China
| | - Xin Chen
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, 325000, China
| | - Jianqi Fan
- College Of Intelligence and Computing, Tianjin University, Tianjin, China
| | - Chunli Liu
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, 325000, China
| | - Menghao Fang
- School of Cyber Science and Engineering, University of International Relations, Beijing, China
| | - Ziquan Liu
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, 325000, China
| | - Xiangyan Meng
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, 325000, China
| | - Yanqing Liu
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, 325000, China
| | - Lu Lu
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China.
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, 325000, China.
| | - Haojun Fan
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China.
- Wenzhou Safety (Emergency) Institute, Tianjin University, Wenzhou, 325000, China.
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Elfassy MD, Gewarges M, Fan S, McLean B, Tanaka D, Bagga A, Bennett SA, Janusonis I, Nadarajah S, Osei-Yeboah C, Rosh J, Teitelbaum D, Sklar JC, Basuita M, Scales DC, Luk AC, Dorian P. Factors Associated With Withdrawal of Life-Sustaining Therapy After Out-of-Hospital Cardiac Arrest. CJC Open 2025; 7:449-455. [PMID: 40433137 PMCID: PMC12105735 DOI: 10.1016/j.cjco.2024.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2024] [Accepted: 11/14/2024] [Indexed: 05/29/2025] Open
Abstract
Background Out-of-hospital cardiac arrest (OHCA) is a leading cause of global mortality. Most patients get hypoxic brain injury, which often leads to the withdrawal of life-sustaining therapy (WLST) because of concerns of poor neurologic prognosis. This study describes the rates and reasons for WLST and identifies factors associated with early WLST, defined as occurring within 72 hours of admission. Methods We conducted a multicentered, retrospective cohort study of adult OHCA patients admitted to 3 large academic hospitals in Toronto from January 2012 to December 2019. Data were extracted from medical records and analyzed using descriptive statistics and cause-specific hazards regression models to identify factors associated with WLST and documented goals of care (GOC) discussions. Results Among 264 patients (median age 66 years, 76.5% male), the in-hospital mortality rate was 62.1%. Of the nonsurvivors, 67.1% died following WLST (90% of cases because of concern of poor neurologic prognosis), with 50% of WLST occurring <72 hours from admission. Formal declaration of brain death only occurred 9.8% of the time. Older age significantly increased the risk of early WLST. GOC discussions were documented only 56.4% of the time in the overall cohort and significantly associated with WLST across all time periods. Conclusions This study highlights the high incidence of WLST, and specifically early WLST, in OHCA patients. GOC discussions are routinely undocumented and is associated with a higher likelihood of WLST. These findings underscore heterogeneity of practice, and the influence of GOC discussions in education and shared decision making.
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Affiliation(s)
- Michael D. Elfassy
- Division of Cardiology, St. Michael’s Hospital, Toronto, Ontario, Canada
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mena Gewarges
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Steve Fan
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Bianca McLean
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Dustin Tanaka
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Amrita Bagga
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Stephen A. Bennett
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Isabella Janusonis
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Shamara Nadarajah
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Clara Osei-Yeboah
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jeremy Rosh
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Daniel Teitelbaum
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jaime C. Sklar
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Manpreet Basuita
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Damon C. Scales
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre; Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Adriana C. Luk
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Paul Dorian
- Division of Cardiology, St. Michael’s Hospital, Toronto, Ontario, Canada
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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8
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Naas CJ, Saleh HO, Engel TW, Gutterman DD, Szabo A, Grawey T, Weston BW, Monti CE, Baker JE, Labinski J, Tang L, Jasti J, Bartos JA, Kalra R, Yannopoulos D, Riccardo Colella M, Aufderheide TP. Associations with resolution of ST-segment elevation myocardial infarction criteria on out-of-hospital 12-lead electrocardiograms following resuscitation from cardiac arrest. Resuscitation 2025; 209:110567. [PMID: 40057016 DOI: 10.1016/j.resuscitation.2025.110567] [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: 01/24/2025] [Revised: 02/24/2025] [Accepted: 02/25/2025] [Indexed: 03/25/2025]
Abstract
INTRODUCTION A previous study found that following out-of-hospital cardiac arrest (OHCA), 67% of out-of-hospital 12-lead electrocardiograms (ECGs) diagnostic for ST-segment elevation myocardial infarction (STEMI) changed to non-STEMI on repeat emergency department (ED) ECG. Here we evaluated associations with resolution of STEMI on ED ECG. METHODS In this secondary analysis of a previous retrospective study, adults (≥18 years) with return of spontaneous circulation (ROSC) following OHCA, at least 1 out-of-hospital and ED ECG and transport to the study hospital were entered. We analyzed variables suspected of influencing ischemic changes on ECG including arrest characteristics, treatment interventions, resuscitation duration, and out-of-hospital and ED ECG acquisition times. RESULTS Forty-nine of 176 patients entered had out-of-hospital ECGs diagnostic for STEMI, and 33/49 (67%) had resolved STEMI upon ED evaluation. Shorter resuscitation time (13 [interquartile range 5-18] vs 21 [14-28] minutes), p = 0.007), less epinephrine (3 [1-4] vs 5 [2-10] milligrams, p = 0.018), lower incidence of norepinephrine (5/33 (15%) vs 11/16 (69%), p ≤ 0.001), less time from ROSC to out-of-hospital ECG acquisition (5.5 [1-8] vs 8.5 [7-14] minutes, p = 0.044), and more time between out-of-hospital and ED ECG acquisition (34 [25-52] vs 21 [14-27] minutes, p = 0.001) were associated with resolution of out-of-hospital STEMI on ED evaluation. More defibrillations were associated with increased ischemia on ED ECG for patients with non-STEMI out-of-hospital ECGs. CONCLUSION ROSC patients with STEMI on out-of-hospital ECG commonly resolve in the ED (67%). These identified associations may better inform clinical decision making. Post-ROSC out-of-hospital 12-lead ECGs should be repeated on arrival in the ED.
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Affiliation(s)
- Christopher J Naas
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee WI, United States.
| | - Hadi O Saleh
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee WI, United States.
| | - Thomas W Engel
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee WI, United States.
| | - David D Gutterman
- Division of Cardiovascular Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee WI, United States.
| | - Aniko Szabo
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee WI, United States.
| | - Thomas Grawey
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee WI, United States.
| | - Benjamin W Weston
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee WI, United States.
| | - Christopher E Monti
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee WI, United States.
| | - John E Baker
- Division of Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee WI, United States.
| | - Jacob Labinski
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee WI, United States.
| | - Lujia Tang
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee WI, United States.
| | - Jamie Jasti
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee WI, United States.
| | - Jason A Bartos
- Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States.
| | - Rajat Kalra
- Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States.
| | - Demetris Yannopoulos
- Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States.
| | - M Riccardo Colella
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee WI, United States.
| | - Tom P Aufderheide
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee WI, United States.
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Long B, Gottlieb M. Emergency medicine updates: Managing the patient with return of spontaneous circulation. Am J Emerg Med 2025; 93:26-36. [PMID: 40133018 DOI: 10.1016/j.ajem.2025.03.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2025] [Revised: 03/16/2025] [Accepted: 03/18/2025] [Indexed: 03/27/2025] Open
Abstract
INTRODUCTION Patients with return of spontaneous circulation (ROSC) following cardiac arrest are a critically important population requiring close monitoring and targeted interventions in the emergency department (ED). Therefore, it is important for emergency clinicians to be aware of the current evidence regarding the management of this condition. OBJECTIVE This paper provides evidence-based updates concerning the management of the post-ROSC patient. DISCUSSION The patient with ROSC following cardiac arrest is critically ill, including a post-cardiac arrest syndrome which may include hypoxic brain injury, myocardial dysfunction, systemic ischemia and reperfusion injury, and persistent precipitating pathophysiology. Initial priorities in the ED setting in the post-ROSC patient include supporting cardiopulmonary function, addressing and managing the underlying cause of arrest, minimizing secondary cerebral injury, and correcting physiologic derangements. Testing including laboratory assessment, electrocardiogram (ECG), and imaging are necessary, aiming to evaluate for the precipitating cause and assess end-organ injury. Computed tomography head-to-pelvis may be helpful in the post-ROSC patient, particularly when the etiology of arrest is unclear. There are several important components of management, including targeting a mean arterial pressure of at least 65 mmHg, preferably >80 mmHg, to improve end-organ and cerebral perfusion pressure. An oxygenation target of 92-98 % is recommended using ARDSnet protocol, along with carbon dioxide partial pressure values of 35-55 mmHg. Antibiotics should be reserved for those with evidence of infection but may be considered if the patient is comatose, intubated, and undergoing hypothermic targeted temperature management (TTM). Corticosteroids should not be routinely administered. While the majority of cardiac arrests in adults are associated with cardiovascular disease, not all post-ROSC patients require emergent coronary angiography. However, if the patient has ST-segment elevation on ECG following ROSC, emergent angiography and catheterization is recommended. This should also be considered if the patient had an initial history concerning for acute coronary syndrome or a presenting arrhythmia of ventricular fibrillation or pulseless ventricular tachycardia. TTM at 32-34° C does not appear to demonstrate improved outcomes compared with targeted normothermia, but fever should be avoided. CONCLUSIONS An understanding of literature updates can improve the ED care of patients post-ROSC.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, University of Virginia Medical School, Charlottesville, VA, USA.
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
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Kreinbrook JA, Kimbrell JM, Rodriguez D, Stebel J, Rampersaud M, Kalosza B, Poke D, Shekhar AC, Miele A, Grunau B, Vega J. Measuring intra-arrest transport in out-of-hospital cardiac arrest: A methodological study of registry-compatible definitions. Resuscitation 2025; 208:110529. [PMID: 39914622 DOI: 10.1016/j.resuscitation.2025.110529] [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: 11/19/2024] [Revised: 01/17/2025] [Accepted: 01/29/2025] [Indexed: 03/16/2025]
Abstract
INTRODUCTION For out-of-hospital cardiac arrest (OHCA) with refractory arrest, transport to hospital with ongoing cardiopulmonary resuscitation (CPR)-"intra-arrest transport (IAT)"-is a treatment option, however it may reduce resuscitation quality. Unfortunately, international registries do not measure IAT directly, but other variables may be used to estimate IAT. We compared three indirect definitions to a direct measurement of IAT. METHODS We included advanced life support-treated adult non-traumatic OHCA from a large metropolitan emergency medical services network (2021-2023). We reviewed prehospital records and cardiac monitor files to identify IAT, defined as CPR in progress at time of transport. We compared this to three indirect definitions, including transport prior to: (1) "Any ROSC"; (2)"Sustained ROSC" (≥20 min or present at ED); or, (3) "Post-ROSC Vitals" (1st blood pressure/12-lead ECG.) RESULTS: Of 1,269 cases, the median age was 71 years (IQR: 60-81), 523 (41%) were female, 128 (10%) had initial shockable rhythms, 336 (26%) achieved ROSC on scene and were transported (75 of 200 [38%] with available data experienced rearrest on scene). Overall, 472 (37%, 95% CI: 34-40%) received IAT (direct definition). Indirect definitions of "Any ROSC", "Sustained ROSC", and "Post-ROSC Vitals" demonstrated sensitivity and specificities of 78.0%/100.0%, 98.5%/97.0%, and 82.4%/97.6%, respectively. CONCLUSION Compared to a direct measurement of IAT, the indirect definition using "Any ROSC" demonstrated the lowest sensitivity; however, the definition using "Sustained ROSC" showed the highest sensitivity and specificity. These indirect definitions may support estimation of IAT within future research and quality initiatives.
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Affiliation(s)
| | - Joshua M Kimbrell
- Department of Pre-Hospital Care, Jamaica Hospital Medical Center Queens NY USA; Albert Einstein College of MedicineThe Bronx, NY USA.
| | - Dheuris Rodriguez
- Department of Pre-Hospital Care, Jamaica Hospital Medical Center Queens NY USA
| | - Jacob Stebel
- Department of Pre-Hospital Care, Jamaica Hospital Medical Center Queens NY USA
| | - Maria Rampersaud
- Department of Pre-Hospital Care, Jamaica Hospital Medical Center Queens NY USA
| | - Brittany Kalosza
- Department of Pre-Hospital Care, Jamaica Hospital Medical Center Queens NY USA
| | - Dana Poke
- Department of Pre-Hospital Care, Jamaica Hospital Medical Center Queens NY USA
| | | | - Andrew Miele
- Department of Pre-Hospital Care, Jamaica Hospital Medical Center Queens NY USA
| | - Brian Grunau
- Department of Emergency Medicine, University of British Columbia Vancouver Canada
| | - John Vega
- Department of Pre-Hospital Care, Jamaica Hospital Medical Center Queens NY USA
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Huang SS, Huang CH, Hsu NT, Ong HN, Lin JJ, Wu YW, Chen WT, Chen WJ, Chang WT, Tsai MS. Application of Phosphorylated Tau for Predicting Outcomes Among Sudden Cardiac Arrest Survivors. Neurocrit Care 2025; 42:142-151. [PMID: 38982004 DOI: 10.1007/s12028-024-02055-6] [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: 03/19/2024] [Accepted: 06/21/2024] [Indexed: 07/11/2024]
Abstract
BACKGROUND Phosphorylated Tau (p-Tau), an early biomarker of neuronal damage, has emerged as a promising candidate for predicting neurological outcomes in cardiac arrest (CA) survivors. Despite its potential, the correlation of p-Tau with other clinical indicators remains underexplored. This study assesses the predictive capability of p-Tau and its effectiveness when used in conjunction with other predictors. METHODS In this single-center retrospective study, 230 CA survivors had plasma and brain computed tomography scans collected within 24 h after the return of spontaneous circulation (ROSC) from January 2016 to June 2023. The patients with prearrest Cerebral Performance Category scores ≥ 3 were excluded (n = 33). The neurological outcomes at discharge with Cerebral Performance Category scores 1-2 indicated favorable outcomes. Plasma p-Tau levels were measured using an enzyme-linked immunosorbent assay, diastolic blood pressure (DBP) was recorded after ROSC, and the gray-to-white matter ratio (GWR) was calculated from brain computed tomography scans within 24 h after ROSC. RESULTS Of 197 patients enrolled in the study, 54 (27.4%) had favorable outcomes. Regression analysis showed that higher p-Tau levels correlated with unfavorable neurological outcomes. The levels of p-Tau were significantly correlated with DBP and GWR. For p-Tau to differentiate between neurological outcomes, an optimal cutoff of 456 pg/mL yielded an area under the receiver operating characteristic curve of 0.71. Combining p-Tau, GWR, and DBP improved predictive accuracy (area under the receiver operating characteristic curve = 0.80 vs. 0.71, p = 0.008). CONCLUSIONS Plasma p-Tau levels measured within 24 h following ROSC, particularly when combined with GWR and DBP, may serve as a promising biomarker of neurological outcomes in CA survivors, with higher levels predicting unfavorable outcomes.
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Affiliation(s)
- Sih-Shiang Huang
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | - Chien-Hua Huang
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | | | - Hooi-Nee Ong
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | - Jr-Jiun Lin
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | | | - Wei-Ting Chen
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | - Wen-Jone Chen
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
- Cardiology Division, Department of Internal Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
- Department of Internal Medicine, Min-Shen General Hospital, Taoyuan, Taiwan
| | - Wei-Tien Chang
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan
| | - Min-Shan Tsai
- Department of Emergency Medicine, National Taiwan University Medical College and Hospital, Taipei, Taiwan.
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12
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Nadir A, Kara D, Turkoz A. The effect of thermoelectric craniocerebral cooling device on protecting brain functions in post-cardiac arrest syndrome. Front Cardiovasc Med 2025; 11:1502173. [PMID: 39850380 PMCID: PMC11754288 DOI: 10.3389/fcvm.2024.1502173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2024] [Accepted: 12/17/2024] [Indexed: 01/25/2025] Open
Abstract
Aim This study aimed to protect brain functions in patients who experienced in-hospital cardiac arrest through the application of local cerebral hypothermia. By utilizing a specialized thermal hypothermia device, this approach sought to mitigate ischemic brain injury associated with post-cardiac arrest syndrome, enhance survival rates, and improve neurological outcomes as measured by standardized scales. Methods A prospective, single-center cohort study was conducted involving patients aged ≥18 years who experienced in-hospital cardiac arrest and achieved return of spontaneous circulation (ROSC). Patients were cooled using a hypothermia helmet to achieve a target temperature of 32°C-34°C, maintained for 36-72 h, followed by controlled rewarming and normothermia for 72 h. Neurological recovery was assessed using the Cerebral Performance Category (CPC) scale, where CPC 1-2 denotes good recovery and CPC 3-5 indicates poor outcomes. Body temperature, hemodynamic parameters, biochemical changes, and survival data were meticulously recorded and analyzed. Statistical analysis included paired t-tests to compare pre- and post-treatment data. Results Of 116 cardiac arrest cases, 30 (25.86%) were in-hospital, and 16 (53.33%) of these achieved ROSC. Among the patients, 62.5% underwent emergency coronary angiography due to ST-elevation myocardial infarction (STEMI). The mean time to hypothermia initiation was 32.9 ± 13.5 min, with hypothermia maintained for 58 ± 6.4 h. Neurological outcomes were favorable, with 62.5% of patients achieving CPC scores of 1 or 2, indicating functional recovery and independence. In contrast, CPC scores of 3 or higher were observed in 37.5% of patients, reflecting varying degrees of disability. Biochemical analysis revealed significant decreases in sodium, potassium, calcium, and magnesium levels, alongside increased urea and creatinine concentrations. Hemodynamic improvements included elevated systolic blood pressure and heart rate, while left ventricular ejection fraction remained stable. Overall survival was 75%, and the majority (62.5%) of survivors were discharged without significant neurological deficits. Conclusion The findings suggest that early and targeted application of craniocerebral thermal hypothermia has the potential to improve survival and preserve neurological function in post-cardiac arrest syndrome. The high rates of favorable outcomes, as reflected by CPC scores, underscore the neuroprotective effects of localized hypothermia. Further large-scale, multicenter trials are recommended to validate these promising results and refine protocols for optimal clinical application.
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Affiliation(s)
- Aydın Nadir
- Department of Cardiology, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Türkiye
| | - Deniz Kara
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Türkiye
| | - Ayda Turkoz
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Türkiye
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Gupta R, Behnoush AH, Khalaji A, Malik AH, Goel A, Sreenivasan J, Bandyopadhyay D, Agrawal A, Frishman WH, Aronow WS, Vyas AV, Patel NC. Early Coronary Angiography in Patients With Out-of-Hospital Cardiac Arrest Without ST-Segment Elevation: A Systematic Review, Meta-Analysis, and Comparative Analysis of Studies. Cardiol Rev 2025; 33:27-35. [PMID: 37071117 DOI: 10.1097/crd.0000000000000551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
Abstract
Out-of-hospital cardiac arrest has a high mortality rate. Unlike ST-elevation myocardial infarction, the results of performing early coronary angiography (CAG) in non-ST-elevation myocardial infarction patients are controversial. This study aimed to compare early and nonearly CAG in this population, in addition to the identification of differences between randomized controlled trials (RCTs) and observational studies conducted in this regard. A systematic search in PubMed, Embase, and Cochrane library was performed to identify the relevant studies. Random-effect meta-analysis was done to calculate the pooled effect size of early versus nonearly CAG outcomes in all studies in addition to each of the RCT and observational subgroups of the studies. The relative risk ratio (RR), along with its 95% confidence interval (CI), was used as a measure of difference. A total of 16 studies including 5234 cases were included in our analyses. Compared with observational cohorts, RCT studies had patients with higher baseline comorbidities (older age, hypertension, diabetes, and coronary artery disease). Random-effect analysis revealed a lower rate of in-hospital mortality in the early-CAG group (RR, 0.79; 95% CI, 0.65-0.97; P = 0.02); however, RCT studies did not find a statistical difference in this outcome (RR, 1.01; 95% CI, 0.83-1.23; P = 0.91). Moreover, mid-term mortality rates were lower in the early-CAG group (RR, 0.87; 95% CI, 0.78-0.98; P = 0.02), mostly due to observational studies. There was no significant difference between the groups in other efficacy and safety outcomes. Although early CAG was associated with lower in-hospital and mid-term mortality in overall analyses, no such difference was confirmed by the results obtained from RCTs. Current evidence from RCTs may not be representative of real-world patients and should be interpreted within its limitation.
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Affiliation(s)
- Rahul Gupta
- From the Lehigh Valley Heart Institute, Lehigh Valley Health Network, Allentown, PA
| | - Amir Hossein Behnoush
- Universal Scientific Education and Research Network, Tehran University of Medical Sciences, Tehran, Iran
| | - Amirmohammad Khalaji
- Universal Scientific Education and Research Network, Tehran University of Medical Sciences, Tehran, Iran
| | - Aaqib H Malik
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Akshay Goel
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Jayakumar Sreenivasan
- Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| | | | - Ankit Agrawal
- Department of Hospital Medicine, Cleveland Clinic, Cleveland, OH
| | - William H Frishman
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
- Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Apurva V Vyas
- From the Lehigh Valley Heart Institute, Lehigh Valley Health Network, Allentown, PA
| | - Nainesh C Patel
- From the Lehigh Valley Heart Institute, Lehigh Valley Health Network, Allentown, PA
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14
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Biyani S, Chang H, Shah VA. Neurologic prognostication in coma and disorders of consciousness. HANDBOOK OF CLINICAL NEUROLOGY 2025; 207:237-264. [PMID: 39986724 DOI: 10.1016/b978-0-443-13408-1.00017-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/24/2025]
Abstract
Coma and disorders of consciousness (DoC) are clinical syndromes primarily resulting from severe acute brain injury, with uncertain recovery trajectories that often necessitate prolonged supportive care. This imposes significant socioeconomic burdens on patients, caregivers, and society. Predicting recovery in comatose patients is a critical aspect of neurocritical care, and while current prognostication heavily relies on clinical assessments, such as pupillary responses and motor movements, which are far from precise, contemporary prognostication has integrated more advanced technologies like neuroimaging and electroencephalogram (EEG). Nonetheless, neurologic prognostication remains fraught with uncertainty and significant inaccuracies and is impacted by several forms of prognostication biases, including self-fulfilling prophecy bias, affective forecasting, and clinician treatment biases, among others. However, neurologic prognostication in patients with disorders of consciousness impacts life-altering decisions including continuation of treatment interventions vs withdrawal of life-sustaining therapies (WLST), which have a direct influence on survival and recovery after severe acute brain injury. In recent years, advancements in neuro-monitoring technologies, artificial intelligence (AI), and machine learning (ML) have transformed the field of prognostication. These technologies have the potential to process vast amounts of clinical data and identify reliable prognostic markers, enhancing prediction accuracy in conditions such as cardiac arrest, intracerebral hemorrhage, and traumatic brain injury (TBI). For example, AI/ML modeling has led to the identification of new states of consciousness such as covert consciousness and cognitive motor dissociation, which may have important prognostic significance after severe brain injury. This chapter reviews the evolving landscape of neurologic prognostication in coma and DoC, highlights current pitfalls and biases, and summarizes the integration of clinical examination, neuroimaging, biomarkers, and neurophysiologic tools for prognostication in specific disease states. We will further discuss the future of neurologic prognostication, focusing on the integration of AI and ML techniques to deliver more individualized and accurate prognostication, ultimately improving patient outcomes and decision-making process in neurocritical care.
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Affiliation(s)
- Shubham Biyani
- Departments of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Henry Chang
- Department of Neurology, TriHealth Hospital, Cincinnati, OH, United States
| | - Vishank A Shah
- Departments of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
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Xia W, Ai M, Ma X, Hu C, Peng Q, Zhao C, Liu Q, He S, Huang L, Zhang L. Application of high-quality targeted temperature management guided by multimodal brain monitoring in brain protection of patients with cardiac arrest: A case series. Medicine (Baltimore) 2024; 103:e40943. [PMID: 39705417 PMCID: PMC11666168 DOI: 10.1097/md.0000000000040943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2024] [Accepted: 11/25/2024] [Indexed: 12/22/2024] Open
Abstract
RATIONALE Cardiac arrest (CA) is an acute emergency with high mortality and is closely associated with the risk of brain damage or systemic ischemia-reperfusion injury, post-traumatic stress symptoms. PATIENT CONCERNS Targeted temperature management in the intensive care unit can improve the neurological outcomes of patients who are comatose after resuscitation from CA. However, there is often a lack of specific evaluation methods for optimal target temperature settings. DIAGNOSES From November 2021 to October 2022, 9 CA patients received prompt cardiopulmonary resuscitation and return of spontaneous circulation after approximately 10 to 30 minutes of cardiopulmonary resuscitation in Xiangya Hospital, Central South University. INTERVENTIONS We retrospectively reviewed 9 CA patients' medical data, including demographic characteristics, hemodynamic change, clinically relevant score, imageological examination, transcranial Doppler ultrasonography, electroencephalogram (EEG), somatosensory-evoked potential, and laboratory data. OUTCOMES According to the result of each patient's transcranial Doppler ultrasonography, somatosensory-evoked potential, and EEG to formulate an individualized target temperature. Contrary to the internationally recommended target of hypothermia, we found that not all patients require hypothermia therapy to maintain normal cerebrovascular autonomic regulation function. And neuron-specific enolase and S100β in patients showed a downward trend after hypothermia therapy. Compared with before hypothermia treatment, clinically relevant scores were reduced in patients with good prognosis. Intracranial congestion or ischemia was improved and intracranial pressure was reduced in all patients during hypothermia treatment. For patients with good EEG response, the ratio of gray matter in the brain increased and the neurological prognosis was significantly improved. Finally, after 6 months of follow-up, we found 3 patients died and 1 patient had a long-term vegetative state, the other patients had a good prognosis. LESSONS Individualized targeted temperature management under the guidance of multimodal brain monitoring plays an important role in brain protection of patients with CA.
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Affiliation(s)
- Weiping Xia
- Department of Intensive Care Medicine, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Meiling Ai
- Department of Intensive Care Medicine, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Xinhua Ma
- Department of Intensive Care Medicine, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Chenhuan Hu
- Department of Intensive Care Medicine, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Qianyi Peng
- Department of Intensive Care Medicine, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Chunguang Zhao
- Department of Intensive Care Medicine, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Qi Liu
- Department of Intensive Care Medicine, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Shixiong He
- Department of Intensive Care Medicine, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Li Huang
- Department of Intensive Care Medicine, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Lina Zhang
- Department of Intensive Care Medicine, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
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16
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Inoue Y, Okamura K, Shimada H, Watakabe S, Hirayama S, Hirata M, Kusuda A, Matsumoto A, Inoue M, Matsuishi E, Yamada M, Iwanaga S, Narumi S, Nakayama S, Sako H, Udo A, Taniguchi K, Morisaki S, Ide S, Nomoto Y, Miura SI, Imakyure O, Imamura I. The Impact on Patient Prognosis of Changes to the Method of Notifying Staff About Accepting Patients With Out-of-Hospital Cardiac Arrest. J Clin Med Res 2024; 16:578-588. [PMID: 39759487 PMCID: PMC11699870 DOI: 10.14740/jocmr6111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2024] [Accepted: 12/11/2024] [Indexed: 01/07/2025] Open
Abstract
Background Our hospital is a designated emergency hospital and accepts many patients with out-of-hospital cardiac arrest (OHCA). Previously, after receiving a direct call from emergency services to request acceptance of an OHCA patient, the emergency room (ER) chief nurse notified medical staff. However, this method delayed ER preparations, so a Code Blue system (CB) was introduced in which the pending arrival of an OHCA patient was broadcast throughout the hospital. Methods In this study, we retrospectively analyzed the impact of introducing CB at our hospital on OHCA patient prognosis to examine whether the introduction of CB is clinically meaningful. We compared consecutive cases treated before introduction of the CB (March 3, 2022, to March 22, 2023) with those treated afterwards (March 23, 2023, to July 23, 2024). Results A total of 30 cases per group were included. The mean number of medical staff present at admissions increased significantly from 5.4 ± 0.6 to 15.0 ± 3.0 (P < 0.001). Although not statistically significant, the introduction of the CB increased the return of spontaneous circulation (ROSC) rate from 20% to 30%, survival to discharge rate from 3% to 10%, and social reintegration rate from 0% to 3%. ROSC occurred in 15 patients. Among OHCA patients with cardiac disease, the ROSC rate tended to increase from 0% to 43% (P = 0.055). In addition, in OHCA patients with cardiac disease whose electrocardiogram initially showed ventricular fibrillation or pulseless electrical activity, the ROSC rate increased from 0% to 100%. ROSC tended to be influenced by the total number of staff and physicians present and the number of staff such as medical clerks, clinical engineers, and radiology technicians (P = 0.095, 0.076, 0.088, respectively). Conclusions Introduction of a CB may increase the ROSC rate and the number of patients surviving to discharge. It also appears to improve the quality of medical care by quickly gathering all necessary medical staff so that they can perform their predefined roles.
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Affiliation(s)
- Youichi Inoue
- Emergency Room, Imamura Hospital, Tosu, Saga, Japan
- These authors contributed equally to this work
| | - Keisuke Okamura
- Department of Cardiology and Cardiovascular Center, Imamura Hospital, Tosu, Saga, Japan
- Department of Cardiology, Fukuoka University School of Medicine, Fukuoka, Fukuoka, Japan
- These authors contributed equally to this work
| | - Hideaki Shimada
- Clinical Research Support Center, Fukuoka University Chikushi Hospital, Chikushino, Fukuoka, Japan
| | | | | | | | - Ayaka Kusuda
- Emergency Room, Imamura Hospital, Tosu, Saga, Japan
| | | | - Miki Inoue
- Emergency Room, Imamura Hospital, Tosu, Saga, Japan
| | | | | | - Sachiko Iwanaga
- Saga University Hospital Trauma and Resuscitation, Saga, Saga, Japan
| | - Shogo Narumi
- Saga University Hospital Trauma and Resuscitation, Saga, Saga, Japan
| | - Shiki Nakayama
- Department of Emergency, Takagi Hospital, Ookawa, Fukuoka, Japan
| | - Hideto Sako
- Department of Cardiology and Cardiovascular Center, Imamura Hospital, Tosu, Saga, Japan
- Department of Cardiology, Fukuoka University School of Medicine, Fukuoka, Fukuoka, Japan
| | - Akihiro Udo
- Department of Cardiology and Cardiovascular Center, Imamura Hospital, Tosu, Saga, Japan
| | - Kenichiro Taniguchi
- Department of Cardiology and Cardiovascular Center, Imamura Hospital, Tosu, Saga, Japan
| | - Shogo Morisaki
- Department of Cardiology and Cardiovascular Center, Imamura Hospital, Tosu, Saga, Japan
| | - Souichiro Ide
- Department of Respiratory Medicine, Imamura Hospital, Tosu, Saga, Japan
| | - Yasuyuki Nomoto
- Department of Neurosurgery, Imamura Hospital, Tosu, Saga, Japan
| | - Shin-ichiro Miura
- Department of Cardiology, Fukuoka University School of Medicine, Fukuoka, Fukuoka, Japan
| | - Osamu Imakyure
- Clinical Research Support Center, Fukuoka University Chikushi Hospital, Chikushino, Fukuoka, Japan
| | - Ichiro Imamura
- Department of Surgery, Imamura Hospital, Tosu, Saga, Japan
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17
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Hwang J, Cho SM, Geocadin R, Ritzl EK. Methods of Evaluating EEG Reactivity in Adult Intensive Care Units: A Review. J Clin Neurophysiol 2024; 41:577-588. [PMID: 38857365 DOI: 10.1097/wnp.0000000000001078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2024] Open
Abstract
PURPOSE EEG reactivity (EEG-R) has become widely used in intensive care units for diagnosing and prognosticating patients with disorders of consciousness. Despite efforts toward standardization, including the establishment of terminology for critical care EEG in 2012, the processes of testing and interpreting EEG-R remain inconsistent. METHODS A review was conducted on PubMed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Inclusion criteria consisted of articles published between January 2012, and November 2022, testing EEG-R on adult intensive care unit patients. Exclusion criteria included articles focused on highly specialized stimulation equipment or animal, basic science, or small case report studies. The Quality In Prognostic Studies tool was used to assess risk of bias. RESULTS One hundred and five articles were identified, with 26 variables collected for each. EEG-R testing varied greatly, including the number of stimuli (range: 1-8; 26 total described), stimulus length (range: 2-30 seconds), length between stimuli (range: 10 seconds-5 minutes), frequency of stimulus application (range: 1-9), frequency of EEG-R testing (range: 1-3 times daily), EEG electrodes (range: 4-64), personnel testing EEG-R (range: neurophysiologists to nonexperts), and sedation protocols (range: discontinuing all sedation to no attempt). EEG-R interpretation widely varied, including EEG-R definitions and grading scales, personnel interpreting EEG-R (range: EEG specialists to nonneurologists), use of quantitative methods, EEG filters, and time to detect EEG-R poststimulation (range: 1-30 seconds). CONCLUSIONS This study demonstrates the persistent heterogeneity of testing and interpreting EEG-R over the past decade, and contributing components were identified. Further many institutional efforts must be made toward standardization, focusing on the reproducibility and unification of these methods, and detailed documentation in the published literature.
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Affiliation(s)
- Jaeho Hwang
- Division of Epilepsy, Department of Neurology, Johns Hopkins Hospital, Baltimore, Maryland, U.S.A
| | - Sung-Min Cho
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine and Neurology, Johns Hopkins Hospital, Baltimore, Maryland, U.S.A.; and
| | - Romergryko Geocadin
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine and Neurology, Johns Hopkins Hospital, Baltimore, Maryland, U.S.A.; and
| | - Eva K Ritzl
- Division of Epilepsy, Department of Neurology, Johns Hopkins Hospital, Baltimore, Maryland, U.S.A
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine and Neurology, Johns Hopkins Hospital, Baltimore, Maryland, U.S.A.; and
- Division of Intraoperative Monitoring, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, U.S.A
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Tamura T, Narumiya H, Homma K, Suzuki M. Combination of Hydrogen Inhalation and Hypothermic Temperature Control After Out-of-Hospital Cardiac Arrest: A Post hoc Analysis of the Efficacy of Inhaled Hydrogen on Neurologic Outcome Following Brain Ischemia During PostCardiac Arrest Care II Trial. Crit Care Med 2024; 52:1567-1576. [PMID: 39133068 PMCID: PMC11392137 DOI: 10.1097/ccm.0000000000006395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2024]
Abstract
OBJECTIVE The Efficacy of Inhaled Hydrogen on Neurologic Outcome Following Brain Ischemia During Post-Cardiac Arrest Care (HYBRID) II trial (jRCTs031180352) suggested that hydrogen inhalation may reduce post-cardiac arrest brain injury (PCABI). However, the combination of hypothermic target temperature management (TTM) and hydrogen inhalation on outcomes is unclear. The aim of this study was to investigate the combined effect of hydrogen inhalation and hypothermic TTM on outcomes after out-of-hospital cardiac arrest (OHCA). DESIGN Post hoc analysis of a multicenter, randomized, controlled trial. SETTING Fifteen Japanese ICUs. PATIENTS Cardiogenic OHCA enrolled in the HYBRID II trial. INTERVENTIONS Hydrogen mixed oxygen (hydrogen group) versus oxygen alone (control group). MEASUREMENTS AND MAIN RESULTS TTM was performed at a target temperature of 32-34°C (TTM32-TTM34) or 35-36°C (TTM35-TTM36) per the institutional protocol. The association between hydrogen + TTM32-TTM34 and 90-day good neurologic outcomes was analyzed using generalized estimating equations. The 90-day survival was compared between the hydrogen and control groups under TTM32-TTM34 and TTM35-TTM36, respectively. The analysis included 72 patients (hydrogen [ n = 39] and control [ n = 33] groups) with outcome data. TTM32-TTM34 was implemented in 25 (64%) and 24 (73%) patients in the hydrogen and control groups, respectively ( p = 0.46). Under TTM32-TTM34, 17 (68%) and 9 (38%) patients achieved good neurologic outcomes in the hydrogen and control groups, respectively (relative risk: 1.81 [95% CI, 1.05-3.66], p < 0.05). Hydrogen + TTM32-TTM34 was independently associated with good neurologic outcomes (adjusted odds ratio 16.10 [95% CI, 1.88-138.17], p = 0.01). However, hydrogen + TTM32-TTM34 did not improve survival compared with TTM32-TTM34 alone (adjusted hazard ratio: 0.22 [95% CI, 0.05-1.06], p = 0.06). CONCLUSIONS Hydrogen + TTM32-TTM34 was associated with improved neurologic outcomes after cardiogenic OHCA compared with TTM32-TTM34 monotherapy. Hydrogen inhalation is a promising treatment option for reducing PCABI when combined with TTM32-TTM34.
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Affiliation(s)
- Tomoyoshi Tamura
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Shinjuku, Tokyo, Japan
- Center for Molecular Hydrogen Medicine, Keio University, Minato City, Tokyo, Japan
| | - Hiromichi Narumiya
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Kyoto Daini Hospital, Kamigyo Ward, Kyoto, Japan
| | - Koichiro Homma
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Shinjuku, Tokyo, Japan
- Center for Molecular Hydrogen Medicine, Keio University, Minato City, Tokyo, Japan
| | - Masaru Suzuki
- Department of Emergency Medicine, Tokyo Dental College Ichikawa General Hospital, Ichikawa, Chiba, Japan
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Hamilton DE, Kobe DS, Seth M, Sharma M, LaLonde T, Shah I, Gurm HS, Sukul D. Association Between Neurological Status and Outcomes in Cardiac Arrest Patients Undergoing PCI in Contemporary Practice: Insights From BMC2. Circ Cardiovasc Interv 2024; 17:e014189. [PMID: 39405370 DOI: 10.1161/circinterventions.124.014189] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 08/14/2024] [Indexed: 03/20/2025]
Abstract
BACKGROUND Coronary artery disease remains the largest contributor to cardiac arrests worldwide; yet, long-term outcomes are often driven by neurological status after resuscitation. We examined the association between pre-percutaneous coronary intervention (PCI) level of consciousness (LOC) and outcomes among patients with cardiac arrest who underwent PCI. METHODS The study cohort included patients undergoing PCI after cardiac arrest between April 2018 and March 2022 at 48 hospitals in the state of Michigan. Pre-PCI LOC was categorized as mentally alert, partially responsive, unresponsive, and unable to assess. In-hospital outcomes included mortality, bleeding, and acute kidney injury. RESULTS Among 3021 patients who underwent PCI after cardiac arrest, 1394 (49%) were mentally alert, 132 (5%) were partially responsive, 698 (24%) were unresponsive, and 631 (22%) were unable to assess. The mentally alert cohort had lower mortality (4.59%) compared with the partially responsive (17.42%), unresponsive (50.14%), and unable to assess cohorts (38.03%; P<0.001). After adjusting for baseline differences, compared with mentally alert patients, the odds of mortality were markedly elevated in patients who were partially responsive (adjusted odds ratio, 4.63 [95% CI, 2.67-8.04]; P<0.001), unable to assess (adjusted odds ratio, 13.95 [95% CI, 9.97-19.51]; P<0.001), and unresponsive (adjusted odds ratio, 24.36 [17.34-34.23]; P<0.001). After adjustment, patients with impaired LOC also had higher risks of acute kidney injury and bleeding compared with mentally alert patients. CONCLUSIONS Pre-PCI LOC is a strong predictor of in-hospital outcomes after PCI among cardiac arrest patients. A patient's pre-PCI LOC should be considered an important factor when weighing treatment options, designing clinical trials, and counseling patients and their families regarding prognosis after PCI.
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Affiliation(s)
- David E Hamilton
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor (D.E.H., D.S.K., M. Seth, H.S.G., D.S.)
| | - Daniel S Kobe
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor (D.E.H., D.S.K., M. Seth, H.S.G., D.S.)
| | - Milan Seth
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor (D.E.H., D.S.K., M. Seth, H.S.G., D.S.)
| | | | | | | | - Hitinder S Gurm
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor (D.E.H., D.S.K., M. Seth, H.S.G., D.S.)
| | - Devraj Sukul
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor (D.E.H., D.S.K., M. Seth, H.S.G., D.S.)
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VandenBerg J, Moss H, Wechsler C, Johnson C, McRae M, Sloan S, Dimitrijevski T, Kouyoumjian S, Kline JA, Messman A. The evaluation of video-assisted debriefing for improving performance in simulated medical student resuscitations. AEM EDUCATION AND TRAINING 2024; 8:e11029. [PMID: 39398865 PMCID: PMC11465287 DOI: 10.1002/aet2.11029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2024] [Revised: 09/10/2024] [Accepted: 09/18/2024] [Indexed: 10/15/2024]
Abstract
Objectives Simulation-based training is commonly used in medical education. However, there is a gap in knowledge regarding best practices in debriefing. We aimed to identify novel solutions to this by adapting video-assisted debriefing (VAD) methodologies used in athletic training. We hypothesized that utilizing VAD would lead to improvements in performance during advanced cardiac life support (ACLS)-based simulations compared to traditional verbal debriefing (VD). Methods The study was conducted at a single medical school. Participants were fourth-year medical students engaging in ACLS simulation-based training as part of their emergency medicine rotation. After completing an ACLS-based simulation, participants received either VD or VAD and then completed a second simulation scenario. Our primary outcome was ACLS performance, graded by blinded reviewers utilizing a previously developed modified checklist. Secondary outcomes included time from cardiac arrest to initiation of cardiopulmonary resuscitation (CPR) and first defibrillation. Measurements were made before and after the interventional debrief, referred to as pre- and postdebrief. A modified Likert-scale survey was used to subjectively assess the student's overall experience. Results Forty-six groups of 275 students were included in the study. Mean ACLS performance score for VD and VAD postdebrief were 85% and 82%, respectively (p = 0.27). Mean time from arrest to CPR initiation for VD and VAD postdebrief groups were 20 and 24 s, respectively (p = 0.46). Mean time from arrest to defibrillation for VD and VAD postdebrief groups were 50 and 59 s, respectively (p = 0.39). For the Likert surveys, 85% or more of participants in both groups indicated that the session was "very helpful" in all survey categories. Conclusions VD and VAD both led to improvements in ACLS performance, time to initiation of CPR, and defibrillation among fourth-year medical students. Though postdebrief results were not statistically significantly different by comparison, overall VD led to greater improvement overall across all outcomes.
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Affiliation(s)
- James VandenBerg
- Department of Emergency MedicineLewis Katz School of Medicine at Temple UniversityPhiladelphiaPennsylvaniaUSA
- Department of Emergency MedicineWayne State University School of MedicineDetroitMichiganUSA
| | - Henry Moss
- Department of Emergency MedicineWayne State University School of MedicineDetroitMichiganUSA
- Department of Emergency MedicineHenry Ford HospitalDetroitMichiganUSA
| | - Courtney Wechsler
- Department of Emergency MedicineWayne State University School of MedicineDetroitMichiganUSA
| | - Chelsea Johnson
- Department of Emergency MedicineWayne State University School of MedicineDetroitMichiganUSA
| | - Matthew McRae
- Department of Emergency MedicineWayne State University School of MedicineDetroitMichiganUSA
- Department of Emergency MedicineCovenant Emergency Care CenterSaginawMichiganUSA
| | - Shawn Sloan
- Department of Emergency MedicineWayne State University School of MedicineDetroitMichiganUSA
- Department of Emergency MedicineTrinity Health Oakland HospitalPontiacMichiganUSA
| | - Trifun Dimitrijevski
- Department of Emergency MedicineWayne State University School of MedicineDetroitMichiganUSA
| | - Sarkis Kouyoumjian
- Department of Emergency MedicineWayne State University School of MedicineDetroitMichiganUSA
| | - Jeffrey A. Kline
- Department of Emergency MedicineWayne State University School of MedicineDetroitMichiganUSA
| | - Anne Messman
- Department of Emergency MedicineWayne State University School of MedicineDetroitMichiganUSA
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21
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Murakami Y, Hongo T, Yumoto T, Kosaki Y, Iida A, Maeyama H, Inoue F, Ichiba T, Nakao A, Naito H. Prognostic value of grey-white matter ratio obtained within two hours after return of spontaneous circulation in out-of-hospital cardiac arrest survivors: A multicenter, observational study. Resusc Plus 2024; 19:100746. [PMID: 39238950 PMCID: PMC11375279 DOI: 10.1016/j.resplu.2024.100746] [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: 07/21/2024] [Revised: 07/28/2024] [Accepted: 08/02/2024] [Indexed: 09/07/2024] Open
Abstract
Background Grey-white matter ratio (GWR) measured by head computed tomography (CT) scan is known as a neurological prognostication tool for out-of-hospital cardiac arrest (OHCA) survivors. The prognostic value of GWR obtained early (within two hours after return of spontaneous circulation [ROSC]) remains a matter of debate. Methods We conducted a multicenter, retrospective, observational study at five hospitals. We included adult OHCA survivors who underwent head CT within two hours following ROSC. GWR values were measured using head CT. Average GWR values were calculated by the mean of the GWR-basal ganglia and GWR-Cerebrum. We divided the patients into poor or favorable neurological outcome groups defined by Glasgow-Pittsburgh Cerebral Performance Category scores. The predictive accuracy of GWR performance was assessed using the area under the curve (AUC). The sensitivities and specificities for predicting poor outcome were examined. Results Of 377 eligible patients, 281 (74.5%) showed poor neurological outcomes at one month after ROSC. Average GWR values of the poor neurological outcome group were significantly lower than those of the favorable neurological outcome. The average GWR value to predict neurological outcome with Youden index was 1.24 with AUC of 0.799. When average GWR values were 1.15 or lower, poor neurological outcomes could be predicted with 100% specificity. Conclusions GWR values measured by head CT scans early (within two hours after ROSC) demonstrated moderate predictive performance for overall ROSC patients. When limited to the patients with GWR values of 1.15 or lower, poor neurological outcomes could be predicted with high specificity.
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Affiliation(s)
- Yuya Murakami
- Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Department of Emergency, Critical Care, and Disaster Medicine, 2-5-1 Shikata, Kita, Okayama 700-8558, Japan
- Department of Emergency and Critical Care Medicine, Tsuyama Chuo Hospital, Tsuyama, 1756, Tsuyama, Okayama 708-0841, Japan
| | - Takashi Hongo
- Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Department of Emergency, Critical Care, and Disaster Medicine, 2-5-1 Shikata, Kita, Okayama 700-8558, Japan
- Department of Emergency, Okayama Saiseikai General Hospital, 2-25 Kokutai-cho, Okayama Kita-ku, Okayama, 700-8511, Japan
| | - Tetsuya Yumoto
- Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Department of Emergency, Critical Care, and Disaster Medicine, 2-5-1 Shikata, Kita, Okayama 700-8558, Japan
| | - Yoshinori Kosaki
- Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Department of Emergency, Critical Care, and Disaster Medicine, 2-5-1 Shikata, Kita, Okayama 700-8558, Japan
| | - Atsuyoshi Iida
- Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Department of Emergency, Critical Care, and Disaster Medicine, 2-5-1 Shikata, Kita, Okayama 700-8558, Japan
- Department of Emergency Medicine, Japanese Red Cross Okayama Hospital, 2-1-1 Aoe, Kita-ku, Okayama, Okayama, 700-8607 Japan
| | - Hiroki Maeyama
- Department of Emergency and Critical Care Medicine, Tsuyama Chuo Hospital, Tsuyama, 1756, Tsuyama, Okayama 708-0841, Japan
| | - Fumiya Inoue
- Department of Emergency Medicine, Hiroshima City Hospital, 7-33 Motomachi, Naka-Ku, Hiroshima City, Hiroshima 730-8518, Japan
| | - Toshihisa Ichiba
- Department of Emergency Medicine, Hiroshima City Hospital, 7-33 Motomachi, Naka-Ku, Hiroshima City, Hiroshima 730-8518, Japan
| | - Atsunori Nakao
- Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Department of Emergency, Critical Care, and Disaster Medicine, 2-5-1 Shikata, Kita, Okayama 700-8558, Japan
| | - Hiromichi Naito
- Okayama University Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Department of Emergency, Critical Care, and Disaster Medicine, 2-5-1 Shikata, Kita, Okayama 700-8558, Japan
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22
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Brown SR, Roberts JS, Killien EY, Brogan TV, Farris R, Di Gennaro JL, Barreto J, McMullan DM, Weiss NS. Factors Associated with Pediatric In-Hospital Recurrent Cardiac Arrest. J Pediatr Intensive Care 2024; 13:261-268. [PMID: 39629145 PMCID: PMC11379516 DOI: 10.1055/s-0041-1741404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 11/27/2021] [Indexed: 10/19/2022] Open
Abstract
The objective of this article was to identify demographic and clinical factors associated with early recurrent arrest (RA; <48 hours) and late RA (≥48 hours) among pediatric inpatients following an initial in-hospital cardiac arrest. A retrospective cohort study of inpatients was performed in a free-standing academic quaternary care children's hospital. All inpatients were <18 years old with a cardiac arrest event requiring ≥1 minute of cardiopulmonary resuscitation with the return of spontaneous circulation sustained for ≥20 minutes at Seattle Children's Hospital from February 1, 2012, to September 18, 2019. Of the 237 included patients, 20 (8%) patients had an early RA and 30 (13%) had a late RA. Older age and severe prearrest acidosis were associated with a higher risk of early RA, odds ratios (OR) = 1.2 (95% confidence interval [CI]: 1.1-1.3) per additional year and 4.6 (95% CI: 1.2-18.1), respectively. Prearrest organ dysfunction was also associated with a higher risk of early RA with an OR of 3.3 (95% CI: 1.1-9.4) for respiratory dysfunction, OR = 1.4 (95% CI: 1.1-1.9) for each additional dysfunctional organ system, and OR = 1.1 (95% CI: 1-1.2) for every one-point increase in PELOD2 score. The neonatal illness category was associated with a lower risk of late RA, OR 0.3 (95% CI: 0.1-0.97), and severe postarrest acidosis was associated with a higher risk of late RA, OR = 4.2 (95% CI: 1.1-15). Several demographic and clinical factors offer some ability to identify children who sustain a recurrent cardiac arrest, offering a potential opportunity for intervention to prevent early recurrent arrest.
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Affiliation(s)
- Stephanie R. Brown
- Division of Pediatric Critical Care Medicine, Oklahoma Children's Hospital, Oklahoma City, Oklahoma, United States
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Joan S. Roberts
- Division of Pediatric Critical Care Medicine, Seattle Children's Hospital, Seattle, Washington, United States
- Department of Pediatrics, University of Washington, Seattle, Washington, United States
| | - Elizabeth Y. Killien
- Division of Pediatric Critical Care Medicine, Seattle Children's Hospital, Seattle, Washington, United States
- Department of Pediatrics, University of Washington, Seattle, Washington, United States
| | - Thomas V. Brogan
- Division of Pediatric Critical Care Medicine, Seattle Children's Hospital, Seattle, Washington, United States
- Department of Pediatrics, University of Washington, Seattle, Washington, United States
| | - Reid Farris
- Division of Pediatric Critical Care Medicine, Seattle Children's Hospital, Seattle, Washington, United States
- Department of Pediatrics, University of Washington, Seattle, Washington, United States
| | - Jane L. Di Gennaro
- Division of Pediatric Critical Care Medicine, Seattle Children's Hospital, Seattle, Washington, United States
- Department of Pediatrics, University of Washington, Seattle, Washington, United States
| | - Jessica Barreto
- Division of Pediatric Critical Care Medicine, Seattle Children's Hospital, Seattle, Washington, United States
- Department of Pediatrics, University of Washington, Seattle, Washington, United States
| | - D. Michael McMullan
- Division of Congenital Cardiac Surgery, Seattle Children's Hospital, Seattle, Washington, United States
- Department of Surgery, University of Washington, Seattle, Washington, United States
| | - Noel S. Weiss
- Department of Epidemiology, University of Washington, Seattle, Washington, United States
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Matta A, Philippe J, Nader V, Levai L, Moussallem N, Kazzi AA, Ohlmann P. Predictors and rate of survival after Out-of-Hospital Cardiac Arrest. Curr Probl Cardiol 2024; 49:102719. [PMID: 38908728 DOI: 10.1016/j.cpcardiol.2024.102719] [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: 06/11/2024] [Accepted: 06/19/2024] [Indexed: 06/24/2024]
Abstract
BACKGROUND Out-of-hospital cardiac arrest (OHCA) is a major public health concern and encloses a wide spectrum of causes. The purpose of this study is to assess predictors and rate of survival at hospital discharge and long-term in the setting of OHCA. The secondary endpoint is to compare OHCA-survival outcomes of presumed ischemic versus non ischemic cause. METHODS A retrospective cohort was conducted on 318 consecutive patients admitted for OHCA at Civilian Hospitals of Colmar between 2010 and 2019. Data concerning baseline characteristics, EKG, biological parameters, and coronary angiograms were collected. We observed the living status (alive or dead) of each of study's participants by March 2023. RESULTS The observed survival rate was 34.3 % at hospital discharge and 26.7 % at 7.1-year follow up. The mean age of study population was 63 ± 16 years and 32.7 % were women. 65.7 % of OHCA-patients underwent coronary angiography that revealed a significant coronary artery disease (CAD) in half of study participants. Primary angioplasty was performed in 43.4 % of study population. The in-hospital mortality rate was significantly higher in those with RBBB (83.7 % vs. 62.5 %, p = 0.004), diabetes mellitus (84.2 % vs. 59.9 %, p < 0.001), arterial hypertension (72.2 % vs. 57.7 %, p = 0.007), peripheral arterial disease (79.2 % vs. 52.2 %, p = 0.031) whereas it was lower in case of anterior STEMI (43.9 % vs 71.4 %, p < 0.001), presence of obstructive CAD (52.2 % vs. 79.2 %, p < 0.001), primary angioplasty performance (48.6 % vs. 78.9 %, p < 0.001), initial shockable rhythm (43.8 % vs. 88.6 %, p < 0.001), initial chest pain (49.4 % vs. 71.5 %, p < 0.001). After adjusting on covariates, the Cox model only identified an initial shockable rhythm as independent predictor of survival at hospital discharge [HR = 0.185, 95 %CI (0.085-0.404), p < 0.001] and 7-year follow up [HR = 0.201, 95 %CI (0.082-0.492), p < 0.001]. The Kaplan-Meier and log Rank test showed a difference in survival outcomes between OHCA with versus without CAD (p < 0.001). CONCLUSION The proportion of OHCA-survivors is small despite the development of emergency health care system. Initial shockable rhythm is the strong predictor of survival. OHCA of presumed coronary cause is associated with a better long-term survival outcome.
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Affiliation(s)
- Anthony Matta
- Department of cardiology, Civilian Hospitals of Colmar, Colmar, France; School of medicine and medical sciences, Holy Spirit University of Kaslik, P.O.Box 446, Jounieh, Lebanon.
| | - John Philippe
- Department of cardiology, Civilian Hospitals of Colmar, Colmar, France
| | - Vanessa Nader
- Department of cardiology, Civilian Hospitals of Colmar, Colmar, France
| | - Laszlo Levai
- Department of cardiology, Civilian Hospitals of Colmar, Colmar, France
| | - Nicolas Moussallem
- School of medicine and medical sciences, Holy Spirit University of Kaslik, P.O.Box 446, Jounieh, Lebanon
| | - Amin A Kazzi
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Patrick Ohlmann
- Department of cardiology, Strasbourg University Hospital, Strasbourg, France
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24
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Shinozaki K, Wong V, Aoki T, Hayashida K, Takegawa R, Endo Y, Nandurkar H, Diamond B, Robson SC, Becker LB. The role of pyruvate-induced enhancement of oxygen metabolism in extracellular purinergic signaling in the post-cardiac arrest rat model. Purinergic Signal 2024; 20:345-357. [PMID: 37507639 PMCID: PMC11303634 DOI: 10.1007/s11302-023-09958-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 07/07/2023] [Indexed: 07/30/2023] Open
Abstract
Purine nucleotide adenosine triphosphate (ATP) is a source of intracellular energy maintained by mitochondrial oxidative phosphorylation. However, when released from ischemic cells into the extracellular space, they act as death-signaling molecules (eATP). Despite there being potential benefit in using pyruvate to enhance mitochondria by inducing a highly oxidative metabolic state, its association with eATP levels is still poorly understood. Therefore, while we hypothesized that pyruvate could beneficially increase intracellular ATP with the enhancement of mitochondrial function after cardiac arrest (CA), our main focus was whether a proportion of the raised intracellular ATP would detrimentally leak out into the extracellular space. As indicated by the increased levels in systemic oxygen consumption, intravenous administrations of bolus (500 mg/kg) and continuous infusion (1000 mg/kg/h) of pyruvate successfully increased oxygen metabolism in post 10-min CA rats. Plasma ATP levels increased significantly from 67 ± 11 nM before CA to 227 ± 103 nM 2 h after the resuscitation; however, pyruvate administration did not affect post-CA ATP levels. Notably, pyruvate improved post-CA cardiac contraction and acidemia (low pH). We also found that pyruvate increased systemic CO2 production post-CA. These data support that pyruvate has therapeutic potential for improving CA outcomes by enhancing oxygen and energy metabolism in the brain and heart and attenuating intracellular hydrogen ion disorders, but does not exacerbate the death-signaling of eATP in the blood.
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Affiliation(s)
- Koichiro Shinozaki
- The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA.
- Department of Emergency Medicine, Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA.
- Department of Emergency Medicine, Kindai University Faculty of Medicine, Osaka, Japan.
| | - Vanessa Wong
- The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Tomoaki Aoki
- The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Kei Hayashida
- The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Ryosuke Takegawa
- The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Yusuke Endo
- The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Harshal Nandurkar
- Australian Centre for Blood Diseases, Monash University, Melbourne, Australia
| | - Betty Diamond
- The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Simon C Robson
- Department of Anesthesia: Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Lance B Becker
- The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
- Department of Emergency Medicine, Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
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25
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Pereira SJDS, Lee DH, Park JS, Kang C, Lee BK, Yoo IS, Lee IH, Kim M, Lee JG. Grey-to-White Matter Ratio Values in Early Head Computed Tomography (CT) as a Predictor of Neurologic Outcomes in Survivors of Out-of-Hospital Cardiac Arrest Based on Severity of Hypoxic-Ischemic Brain Injury. J Emerg Med 2024; 67:e177-e187. [PMID: 38851906 DOI: 10.1016/j.jemermed.2024.03.037] [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: 12/13/2023] [Revised: 03/10/2024] [Accepted: 03/23/2024] [Indexed: 06/10/2024]
Abstract
BACKGROUND Hypoxic-ischemic brain injury (HIBI) is a common complication of out-of-hospital cardiac arrest (OHCA). OBJECTIVES We investigated whether grey-to-white matter ratio (GWR) values, measured using early head computed tomography (HCT), were associated with neurologic outcomes based on the severity of HIBI in survivors of OHCA. METHODS This retrospective multicenter study included adult comatose OHCA survivors who underwent an HCT scan within 2 h after the return of spontaneous circulation. HIBI severity was assessed using the revised post-Cardiac Arrest Syndrome for Therapeutic hypothermia (rCAST) scale (low, moderate, and severe). Poor neurologic outcomes were defined as Cerebral Performance Categories 3 to 5 at 6 months after OHCA. RESULTS Among 354 patients, 27% were women and 224 (63.3%) had poor neurologic outcomes. The distribution of severity was 19.5% low, 47.5% moderate, and 33.1% severe. The area under the receiver operating curves of the GWR values for predicting rCAST severity (low, moderate, and severe) were 0.52, 0.62, and 0.79, respectively. The severe group had significantly higher predictive performance than the moderate group (p = 0.02). Multivariate logistic regression analysis revealed a significant association between GWR values and poor neurologic outcomes in the moderate group (adjusted odds ratio = 0.012, 95% CI 0.0-0.54, p = 0.02). CONCLUSIONS In this cohort study, GWR values measured using early HCT demonstrated variations in predicting neurologic outcomes based on HIBI severity. Furthermore, GWR in the moderate group was associated with poor neurologic outcomes.
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Affiliation(s)
- Sidonio J da Silva Pereira
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea; Emergency Department of Guido Valadares National Hospital, Avenida Dom. Martino Lopes, Culu Hun, Cristo Rey, Dili, Timor-Leste
| | - Dong Hoon Lee
- Department of Emergency Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Jung Soo Park
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea.
| | - Changshin Kang
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea; Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - In Sool Yoo
- Department of Emergency Medicine, College of Medicine, Chungnam National University, Daejeon, Republic of Korea; Department of Emergency Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - In Ho Lee
- Department of Radiology, College of Medicine, Chungnam National University, 266, Munhwa-ro, Jung-gu, Daejeon, Republic of Korea
| | - Mijoo Kim
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Jae Gwang Lee
- Department of Emergency Medicine, Konyang University Hospital, College of Medicine, Daejeon, Republic of Korea
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26
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Memenga F, Sinning C. Emerging Evidence in Out-of-Hospital Cardiac Arrest-A Critical Appraisal of the Cardiac Arrest Center. J Clin Med 2024; 13:3973. [PMID: 38999537 PMCID: PMC11242151 DOI: 10.3390/jcm13133973] [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: 06/02/2024] [Revised: 06/27/2024] [Accepted: 07/05/2024] [Indexed: 07/14/2024] Open
Abstract
The morbidity and mortality of out-of-hospital cardiac arrest (OHCA) due to presumed cardiac causes have remained unwaveringly high over the last few decades. Less than 10% of patients survive until hospital discharge. Treatment of OHCA patients has traditionally relied on expert opinions. However, there is growing evidence on managing OHCA patients favorably during the prehospital phase, coronary and intensive care, and even beyond hospital discharge. To improve outcomes in OHCA, experts have proposed the establishment of cardiac arrest centers (CACs) as pivotal elements. CACs are expert facilities that pool resources and staff, provide infrastructure, treatment pathways, and networks to deliver comprehensive and guideline-recommended post-cardiac arrest care, as well as promote research. This review aims to address knowledge gaps in the 2020 consensus on CACs of major European medical associations, considering novel evidence on critical issues in both pre- and in-hospital OHCA management, such as the timing of coronary angiography and the use of extracorporeal cardiopulmonary resuscitation (eCPR). The goal is to harmonize new evidence with the concept of CACs.
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Affiliation(s)
- Felix Memenga
- Department of Cardiology, University Heart & Vascular Center Hamburg, 20246 Hamburg, Germany
| | - Christoph Sinning
- Department of Cardiology, University Heart & Vascular Center Hamburg, 20246 Hamburg, Germany
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27
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Kramser N, Duse DA, Gröne M, Stücker B, Voß F, Tokhi U, Jung C, Horn P, Kelm M, Erkens R. Amiodarone Administration during Cardiopulmonary Resuscitation Is Not Associated with Changes in Short-Term Mortality or Neurological Outcomes in Cardiac Arrest Patients with Shockable Rhythms. J Clin Med 2024; 13:3931. [PMID: 38999496 PMCID: PMC11242294 DOI: 10.3390/jcm13133931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 07/02/2024] [Accepted: 07/03/2024] [Indexed: 07/14/2024] Open
Abstract
Background: The search for the best therapeutic approach in cardiopulmonary resuscitations (CPR) remains open to question. In this study, we evaluated if Amiodarone administration during CPR was associated with short-term mortality or neurological development. Methods: A total of 232 patients with sudden cardiac arrest (CA) with shockable rhythms were included in our analysis. Propensity score matching based on age, gender, type of CA, and CPR duration was used to stratify between patients with and without Amiodarone during CPR. Primary endpoints were short-term mortality (30-day) and neurological outcomes assessed by the cerebral performance category. Secondary endpoints were plasma lactate, phosphate levels at hospital admission, and the peak Neuron-specific enolase. Results: Propensity score matching was successful with a caliper size used for matching of 0.089 and a sample size of n = 82 per group. The 30-day mortality rates were similar between both groups (p = 0.24). There were no significant differences in lactate levels at hospital admission and during the following five days between the groups. Patients receiving Amiodarone showed slightly higher phosphate levels at hospital admission, while the levels decreased to a similar value during the following days. Among CA survivors to hospital discharge, no differences between the proportion of good neurological outcomes were detected between the two groups (p = 0.58), despite slightly higher peak neuron-specific enolase levels in CA patients receiving Amiodarone (p = 0.03). Conclusions: Amiodarone administration is not associated with short-term mortality or neurological outcomes in CA patients with shockable rhythms receiving CPR.
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Affiliation(s)
- Nicolas Kramser
- Department of Cardiology, Pulmonology and Angiology, Medical Faculty, Heinrich Heine University of Düsseldorf, 40225 Düsseldorf, Germany
| | - Dragos Andrei Duse
- Department of Cardiology, Pulmonology and Angiology, Medical Faculty, Heinrich Heine University of Düsseldorf, 40225 Düsseldorf, Germany
| | - Michael Gröne
- Department of Cardiology, Pulmonology and Angiology, Medical Faculty, Heinrich Heine University of Düsseldorf, 40225 Düsseldorf, Germany
| | - Bernd Stücker
- Department of Cardiology, Pulmonology and Angiology, Medical Faculty, Heinrich Heine University of Düsseldorf, 40225 Düsseldorf, Germany
| | - Fabian Voß
- Department of Cardiology, Pulmonology and Angiology, Medical Faculty, Heinrich Heine University of Düsseldorf, 40225 Düsseldorf, Germany
| | - Ursala Tokhi
- Department of Cardiology, Pulmonology and Angiology, Medical Faculty, Heinrich Heine University of Düsseldorf, 40225 Düsseldorf, Germany
| | - Christian Jung
- Department of Cardiology, Pulmonology and Angiology, Medical Faculty, Heinrich Heine University of Düsseldorf, 40225 Düsseldorf, Germany
- Cardiovascular Research Institute Düsseldorf (CARID), 40225 Düsseldorf, Germany
| | - Patrick Horn
- Department of Cardiology, Pulmonology and Angiology, Medical Faculty, Heinrich Heine University of Düsseldorf, 40225 Düsseldorf, Germany
| | - Malte Kelm
- Department of Cardiology, Pulmonology and Angiology, Medical Faculty, Heinrich Heine University of Düsseldorf, 40225 Düsseldorf, Germany
- Cardiovascular Research Institute Düsseldorf (CARID), 40225 Düsseldorf, Germany
| | - Ralf Erkens
- Department of Cardiology, Pulmonology and Angiology, Medical Faculty, Heinrich Heine University of Düsseldorf, 40225 Düsseldorf, Germany
- Department of Cardiology and Electrophysiology, St. Agnes-Hospital Bocholt, 46397 Bocholt, Germany
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28
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Kenda M, Lang M, Nee J, Hinrichs C, Dell'Orco A, Salih F, Kemmling A, Nielsen N, Wise M, Thomas M, Düring J, McGuigan P, Cronberg T, Scheel M, Moseby-Knappe M, Leithner C. Regional Brain Net Water Uptake in Computed Tomography after Cardiac Arrest - A Novel Biomarker for Neuroprognostication. Resuscitation 2024; 200:110243. [PMID: 38796092 DOI: 10.1016/j.resuscitation.2024.110243] [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: 03/19/2024] [Accepted: 05/10/2024] [Indexed: 05/28/2024]
Abstract
BACKGROUND Selective water uptake by neurons and glial cells and subsequent brain tissue oedema are key pathophysiological processes of hypoxic-ischemic encephalopathy (HIE) after cardiac arrest (CA). Although brain computed tomography (CT) is widely used to assess the severity of HIE, changes of brain radiodensity over time have not been investigated. These could be used to quantify regional brain net water uptake (NWU), a potential prognostic biomarker. METHODS We conducted an observational prognostic accuracy study including a derivation (single center cardiac arrest registry) and a validation (international multicenter TTM2 trial) cohort. Early (<6 h) and follow-up (>24 h) head CTs of CA patients were used to determine regional NWU for grey and white matter regions after co-registration with a brain atlas. Neurological outcome was dichotomized as good versus poor using the Cerebral Performance Category Scale (CPC) in the derivation cohort and Modified Rankin Scale (mRS) in the validation cohort. RESULTS We included 115 patients (81 derivation, 34 validation) with out-of-hospital (OHCA) and in-hospital cardiac arrest (IHCA). Regional brain water content remained unchanged in patients with good outcome. In patients with poor neurological outcome, we found considerable regional water uptake with the strongest effect in the basal ganglia. NWU >8% in the putamen and caudate nucleus predicted poor outcome with 100% specificity (95%-CI: 86-100%) and 43% (moderate) sensitivity (95%-CI: 31-56%). CONCLUSION This pilot study indicates that NWU derived from serial head CTs is a promising novel biomarker for outcome prediction after CA. NWU >8% in basal ganglia grey matter regions predicted poor outcome while absence of NWU indicated good outcome. NWU and follow-up CTs should be investigated in larger, prospective trials with standardized CT acquisition protocols.
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Affiliation(s)
- Martin Kenda
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology and Experimental Neurology, Augustenburger Platz 1, 13353 Berlin, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Junior Digital Clinician Scientist Program, Charitéplatz 1, 10117 Berlin, Germany.
| | - Margareta Lang
- Department of Clinical Sciences Lund, Radiology, Lund University, Helsingborg Hospital, Lund, Sweden
| | - Jens Nee
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Nephrology and Intensive Care Medicine, Circulatory Arrest Center Berlin, Berlin, Germany
| | - Carl Hinrichs
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Nephrology and Intensive Care Medicine, Circulatory Arrest Center Berlin, Berlin, Germany
| | - Andrea Dell'Orco
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Neuroradiology, Campus Charité, Mitte, Germany
| | - Farid Salih
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology and Experimental Neurology, Augustenburger Platz 1, 13353 Berlin, Germany
| | - André Kemmling
- Department of Neuroradiology, University Hospital Marburg, Marburg, Germany
| | - Niklas Nielsen
- Anaesthesiology and Intensive Care, Department of Clinical Sciences Lund, Helsingborg Hospital, Lund University, Lund, Sweden
| | - Matt Wise
- Adult Critical Care, University Hospital of Wales, Cardiff, UK
| | | | - Joachim Düring
- Department of Clinical Sciences, Anesthesia and Intensive Care, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Peter McGuigan
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK; Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, UK
| | - Tobias Cronberg
- Department of Neurology, Skane University Hospital, Lund, Sweden
| | - Michael Scheel
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Neuroradiology, Campus Charité, Mitte, Germany
| | - Marion Moseby-Knappe
- Department of Clinical Sciences Lund, Neurology and Rehabilitation, Lund University, Skåne University Hospital, Lund, Sweden
| | - Christoph Leithner
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology and Experimental Neurology, Augustenburger Platz 1, 13353 Berlin, Germany
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29
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Lang M, Kenda M, Scheel M, Martola J, Wheeler M, Owen S, Johnsson M, Annborn M, Dankiewicz J, Deye N, Düring J, Friberg H, Halliday T, Jakobsen JC, Lascarrou JB, Levin H, Lilja G, Lybeck A, McGuigan P, Rylander C, Sem V, Thomas M, Ullén S, Undén J, Wise MP, Cronberg T, Wassélius J, Nielsen N, Leithner C, Moseby-Knappe M. Standardised and automated assessment of head computed tomography reliably predicts poor functional outcome after cardiac arrest: a prospective multicentre study. Intensive Care Med 2024; 50:1096-1107. [PMID: 38900283 PMCID: PMC11245448 DOI: 10.1007/s00134-024-07497-2] [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: 03/13/2024] [Accepted: 05/21/2024] [Indexed: 06/21/2024]
Abstract
PURPOSE Application of standardised and automated assessments of head computed tomography (CT) for neuroprognostication after out-of-hospital cardiac arrest. METHODS Prospective, international, multicentre, observational study within the Targeted Hypothermia versus Targeted Normothermia after out-of-hospital cardiac arrest (TTM2) trial. Routine CTs from adult unconscious patients obtained > 48 h ≤ 7 days post-arrest were assessed qualitatively and quantitatively by seven international raters blinded to clinical information using a pre-published protocol. Grey-white-matter ratio (GWR) was calculated from four (GWR-4) and eight (GWR-8) regions of interest manually placed at the basal ganglia level. Additionally, GWR was obtained using an automated atlas-based approach. Prognostic accuracies for prediction of poor functional outcome (modified Rankin Scale 4-6) for the qualitative assessment and for the pre-defined GWR cutoff < 1.10 were calculated. RESULTS 140 unconscious patients were included; median age was 68 years (interquartile range [IQR] 59-76), 76% were male, and 75% had poor outcome. Standardised qualitative assessment and all GWR models predicted poor outcome with 100% specificity (95% confidence interval [CI] 90-100). Sensitivity in median was 37% for the standardised qualitative assessment, 39% for GWR-8, 30% for GWR-4 and 41% for automated GWR. GWR-8 was superior to GWR-4 regarding prognostic accuracies, intra- and interrater agreement. Overall prognostic accuracy for automated GWR (area under the curve [AUC] 0.84, 95% CI 0.77-0.91) did not significantly differ from manually obtained GWR. CONCLUSION Standardised qualitative and quantitative assessments of CT are reliable and feasible methods to predict poor functional outcome after cardiac arrest. Automated GWR has the potential to make CT quantification for neuroprognostication accessible to all centres treating cardiac arrest patients.
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Affiliation(s)
- Margareta Lang
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Radiology, Helsingborg Hospital, Helsingborg, Sweden
| | - Martin Kenda
- Berlin Institute of Health at Charité-Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Junior Digital Clinician Scientist Program, Universitätsmedizin Berlin, Berlin, Germany
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Michael Scheel
- Department of Neuroradiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Juha Martola
- HUS Medical Imaging Center, Radiology, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Matthew Wheeler
- University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, Wales, UK
| | - Stephanie Owen
- University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, Wales, UK
| | - Mikael Johnsson
- Department of Radiology, Helsingborg Hospital, Helsingborg, Sweden
| | - Martin Annborn
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Anaesthesia and Intensive Care, Helsingborg Hospital, Helsingborg, Sweden
| | - Josef Dankiewicz
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Cardiology, Skåne University Hospital, Lund, Sweden
| | - Nicolas Deye
- Department of Medical and Toxicological Intensive Care Unit, Inserm UMR-S 942, Assistance Publique des Hopitaux de Paris, Lariboisière University Hospital, Paris, France
| | - Joachim Düring
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Anaesthesia and Intensive Care, Skåne University Hospital, Malmö, Sweden
| | - Hans Friberg
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Anaesthesia and Intensive Care, Skåne University Hospital, Malmö, Sweden
| | - Thomas Halliday
- Department of Operation and Intensive Care, Linköping University Hospital, Linköping, Sweden
| | - Janus Christian Jakobsen
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jean-Baptiste Lascarrou
- Medecine Intensive Reanimation, Movement-Interactions-Performance,, Nantes Université, CHU Nantes, MIP, UR 4334, 44000, Nantes, France
| | - Helena Levin
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Research and Education, Skåne University Hospital, Lund, Sweden
| | - Gisela Lilja
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Neurology, Skåne University Hospital, Lund, Sweden
| | - Anna Lybeck
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Anaesthesia and Intensive Care, Skåne University Hospital, Lund, Sweden
| | - Peter McGuigan
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Christian Rylander
- Anaesthesia and Intensive Care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Victoria Sem
- Department of Anaesthesia and Intensive Care, Central Hospital of Karlstad, Karlstad, Sweden
| | - Matthew Thomas
- Intensive Care Unit, University Hospitals Bristol and Weston, Bristol, UK
| | - Susann Ullén
- Clinical Studies Sweden‑Forum South, Skåne University Hospital, Lund, Sweden
| | - Johan Undén
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Operation and Intensive Care, Hallands Hospital Halmstad, Halmstad, Sweden
| | - Matt P Wise
- Adult Critical Care, University Hospital of Wales, Cardiff, UK
| | - Tobias Cronberg
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Neurology, Skåne University Hospital, Lund, Sweden
| | - Johan Wassélius
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden
| | - Niklas Nielsen
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Anaesthesia and Intensive Care, Helsingborg Hospital, Helsingborg, Sweden
| | - Christoph Leithner
- Department of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Marion Moseby-Knappe
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden.
- Department of Neurology, Skåne University Hospital, Lund, Sweden.
- Department of Rehabilitation, Skåne University Hospital, 22185, Lund, Sweden.
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Liu G, Wang Y, Tian F, Chen W, Cui L, Jiang M, Zhang Y, Gao K, Su Y, Wang H. Quantitative EEG reactivity induced by electrical stimulation predicts good outcome in comatose patients after cardiac arrest. Ann Intensive Care 2024; 14:99. [PMID: 38935167 PMCID: PMC11211292 DOI: 10.1186/s13613-024-01339-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Accepted: 06/17/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND EEG reactivity is a predictor for neurological outcome in comatose patients after cardiac arrest (CA); however, its application is limited by variability in stimulus types and visual assessment. We aimed to evaluate the prognostic value of the quantitative analysis of EEG reactivity induced by standardized electrical stimulation and for early prognostication in this population. METHODS This prospective observational study recruited post-CA comatose patients in Xuanwu Hospital, Capital Medical University (Beijing, China) between January 2016 and June 2023. EEG reactivity to electrical or traditional pain stimulation was randomly performed via visual and quantitative analysis. Neurological outcome within 6 months was dichotomized as good (Cerebral Performance Categories, CPC 1-2) or poor (CPC 3-5). RESULTS Fifty-eight post-CA comatose patients were admitted, and 52 patients were included in the final analysis, of which 19 (36.5%) had good outcomes. EEG reactivity induced with the electrical stimulation had superior performance to the traditional pain stimulation for good outcome prediction (quantitative analysis: AUC 0.932 vs. 0.849, p = 0.048). When using the electrical stimulation, the AUC of EEG reactivity to predict good outcome by visual analysis was 0.838, increasing to 0.932 by quantitative analysis (p = 0.039). Comparing to the traditional pain stimulation by visual analysis, the AUC of EEG reactivity for good prognostication by the electrical stimulation with quantitative analysis was significantly improved (0.932 vs. 0.770, p = 0.004). CONCLUSIONS EEG reactivity induced by the standardized electrical stimulation in combination with quantitative analysis is a promising formula for post-CA comatose patients, with increased predictive accuracy.
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Affiliation(s)
- Gang Liu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing, 100053, China
| | - Yuan Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing, 100053, China
| | - Fei Tian
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing, 100053, China
| | - Weibi Chen
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing, 100053, China
| | - Lili Cui
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing, 100053, China
| | - Mengdi Jiang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing, 100053, China
| | - Yan Zhang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing, 100053, China
| | - Keming Gao
- Department of Psychiatry, Mood Disorders Program, University Hospitals Cleveland Medical Center/Case Western Reserve University, Cleveland, OH, 44106, USA
| | - Yingying Su
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing, 100053, China.
| | - Hongxing Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders, National Clinical Research Center for Geriatric Diseases, Beijing, 100053, China.
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Plante V, Basu M, Gettings JV, Luchette M, LaRovere KL. Update in Pediatric Neurocritical Care: What a Neurologist Caring for Critically Ill Children Needs to Know. Semin Neurol 2024; 44:362-388. [PMID: 38788765 DOI: 10.1055/s-0044-1787047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
Currently nearly one-quarter of admissions to pediatric intensive care units (PICUs) worldwide are for neurocritical care diagnoses that are associated with significant morbidity and mortality. Pediatric neurocritical care is a rapidly evolving field with unique challenges due to not only age-related responses to primary neurologic insults and their treatments but also the rarity of pediatric neurocritical care conditions at any given institution. The structure of pediatric neurocritical care services therefore is most commonly a collaborative model where critical care medicine physicians coordinate care and are supported by a multidisciplinary team of pediatric subspecialists, including neurologists. While pediatric neurocritical care lies at the intersection between critical care and the neurosciences, this narrative review focuses on the most common clinical scenarios encountered by pediatric neurologists as consultants in the PICU and synthesizes the recent evidence, best practices, and ongoing research in these cases. We provide an in-depth review of (1) the evaluation and management of abnormal movements (seizures/status epilepticus and status dystonicus); (2) acute weakness and paralysis (focusing on pediatric stroke and select pediatric neuroimmune conditions); (3) neuromonitoring modalities using a pathophysiology-driven approach; (4) neuroprotective strategies for which there is evidence (e.g., pediatric severe traumatic brain injury, post-cardiac arrest care, and ischemic stroke and hemorrhagic stroke); and (5) best practices for neuroprognostication in pediatric traumatic brain injury, cardiac arrest, and disorders of consciousness, with highlights of the 2023 updates on Brain Death/Death by Neurological Criteria. Our review of the current state of pediatric neurocritical care from the viewpoint of what a pediatric neurologist in the PICU needs to know is intended to improve knowledge for providers at the bedside with the goal of better patient care and outcomes.
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Affiliation(s)
- Virginie Plante
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Meera Basu
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | | | - Matthew Luchette
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Kerri L LaRovere
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
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Steinberg A, Yang Y, Fischhoff B, Callaway CW, Coppler P, Geocadin R, Silbergleit R, Meurer WJ, Ramakrishnan R, Yeatts SD, Elmer J. Clinicians' approach to predicting post-cardiac arrest outcomes for patients enrolled in a United States clinical trial. Resuscitation 2024; 199:110226. [PMID: 38685376 DOI: 10.1016/j.resuscitation.2024.110226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 04/16/2024] [Accepted: 04/20/2024] [Indexed: 05/02/2024]
Abstract
PURPOSE Perceived poor prognosis can lead to withdrawal of life-sustaining therapies (WLST) in patients who might otherwise recover. We characterized clinicians' approach to post-arrest prognostication in a multicenter clinical trial. METHODS Semi-structured interviews were conducted with clinicians who treated a comatose post-cardiac arrest patient enrolled in the Influence of Cooling Duration on Efficacy in Cardiac Arrest Patients (ICECAP) trial (NCT04217551). Two authors independently analyzed each interview using inductive and deductive coding. The clinician reported how they arrived at a prognosis for the specific patient. We summarized the frequency with which clinicians reported using objective diagnostics to formulate their prognosis, and compared the reported approaches to established guidelines. Each respondent provided demographic information and described local neuroprognostication practices. RESULTS We interviewed 30 clinicians at 19 US hospitals. Most claimed adherence to local hospital neuroprognostication protocols (n = 19). Prognostication led to WLST for perceived poor neurological prognosis in 15/30 patients, of whom most showed inconsistencies with guidelines or trial recommendations, respectively. In 10/15 WLST cases, clinicians reported relying on multimodal testing. A prevalent theme was the use of "clinical gestalt," defined as prognosticating based on a patient's overall appearance or a subjective impression in the absence of objective data. Many clinicians (21/30) reported using clinical gestalt for initial prognostication, with 9/21 expressing high confidence initially. CONCLUSION Clinicians in our study state they follow neuroprognostication guidelines in general but often do not do so in actual practice. They reported clinical gestalt frequently informed early, highly confident prognostic judgments, and few objective tests changed initial impressions. Subjective prognostication may undermine well-designed trials.
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Affiliation(s)
- Alexis Steinberg
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Yanran Yang
- Department of Engineering and Public Policy, Carnegie Mellon University, Pittsburgh, PA; Global Health Research Center, Duke Kunshan University, Suzhou, China
| | - Baruch Fischhoff
- Department of Engineering and Public Policy, Carnegie Mellon University, Pittsburgh, PA; Institute for Politics and Strategy, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Patrick Coppler
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Romergryko Geocadin
- Department of Neurology, Neurosurgery, Anesthesiology-Critical Care Medicine, Johns Hopkins University, Baltimore, MD. USA
| | - Robert Silbergleit
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI. USA
| | - William J Meurer
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI. USA; Department of Neurology, University of Michigan, Ann Arbor, MI. USA
| | - Ramesh Ramakrishnan
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC. USA
| | - Sharon D Yeatts
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC. USA
| | - Jonathan Elmer
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Steinberg A. Emergent Management of Hypoxic-Ischemic Brain Injury. Continuum (Minneap Minn) 2024; 30:588-610. [PMID: 38830064 DOI: 10.1212/con.0000000000001426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE This article outlines interventions used to improve outcomes for patients with hypoxic-ischemic brain injury after cardiac arrest. LATEST DEVELOPMENTS Emergent management of patients after cardiac arrest requires prevention and treatment of primary and secondary brain injury. Primary brain injury is minimized by excellent initial resuscitative efforts. Secondary brain injury prevention requires the detection and correction of many pathophysiologic processes that may develop in the hours to days after the initial arrest. Key physiologic parameters important to secondary brain injury prevention include optimization of mean arterial pressure, cerebral perfusion, oxygenation and ventilation, intracranial pressure, temperature, and cortical hyperexcitability. This article outlines recent data regarding the treatment and prevention of secondary brain injury. Different patients likely benefit from different treatment strategies, so an individualized approach to treatment and prevention of secondary brain injury is advisable. Clinicians must use multimodal sources of data to prognosticate outcomes after cardiac arrest while recognizing that all prognostic tools have shortcomings. ESSENTIAL POINTS Neurologists should be involved in the postarrest care of patients with hypoxic-ischemic brain injury to improve their outcomes. Postarrest care requires nuanced and patient-centered approaches to the prevention and treatment of primary and secondary brain injury and neuroprognostication.
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Herrmann JR, Fink EL, Fabio A, Berger RP, Janesko-Feldman K, Gorse K, Clark RSB, Kochanek PM, Jackson TC. Characterization of Circulating Cold Shock Proteins FGF21 and RBM3 in a Multi-Center Study of Pediatric Cardiac Arrest. Ther Hypothermia Temp Manag 2024; 14:99-109. [PMID: 37669029 PMCID: PMC11391889 DOI: 10.1089/ther.2023.0035] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2023] Open
Abstract
Fibroblast Growth Factor 21 (FGF21) is a neuroprotective hormone induced by cold exposure that targets the β-klotho co-receptor. β-klotho is abundant in the newborn brain but decreases rapidly with age. RNA-Binding Motif 3 (RBM3) is a potent neuroprotectant upregulated by FGF21 in hypothermic conditions. We characterized serum FGF21 and RBM3 levels in patients enrolled in a prospective multi-center study of pediatric cardiac arrest (CA) via a secondary analysis of samples collected to evaluate brain injury biomarkers. Patients (n = 111) with remnant serum samples available from at least two of three available timepoints (0-24, 24-48 or 48-72 hours post-resuscitation) were included. Serum samples from 20 healthy controls were used for comparison. FGF21 was measured by Luminex and internally validated enzyme-linked immunoassay (ELISA). RBM3 was measured by internally validated ELISA. Of postarrest patients, 98 were managed with normothermia, while 13 were treated with therapeutic hypothermia (TH). FGF21 increased >20-fold in the first 24 hours postarrest versus controls (681 pg/mL [200-1864] vs. 29 pg/mL [15-51], n = 99 vs. 19, respectively, p < 0.0001, median [interquartile range]) with no difference in RBM3. FGF21 did not differ by sex, while RBM3 was increased in females versus males at 48-72 hours postarrest (1866 pg/mL [873-5176] vs. 1045 pg/mL [535-2728], n = 40 vs. 54, respectively, p < 0.05). Patients requiring extracorporeal membrane oxygenation (ECMO) postresuscitation had increased FGF21 versus those who did not at 48-72 hours (6550 pg/mL [1455-66,781] vs. 1213 pg/mL [480-3117], n = 7 vs 74, respectively, p < 0.05). FGF21 and RBM3 did not correlate (Spearman's rho = 0.004, p = 0.97). We conclude that in a multi-center study of pediatric CA patients where normothermic targeted temperature management was largely used, FGF21 was markedly increased postarrest versus control and highest in patients requiring ECMO postresuscitation. RBM3 was sex-dependent. We provide a framework for future studies examining the effect of TH on FGF21 or use of FGF21 therapy after pediatric CA.
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Affiliation(s)
- Jeremy R Herrmann
- Safar Center for Resuscitation Research, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ericka L Fink
- Safar Center for Resuscitation Research, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Anthony Fabio
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Rachel P Berger
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Keri Janesko-Feldman
- Safar Center for Resuscitation Research, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kiersten Gorse
- Department of Molecular Pharmacology & Physiology, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Robert S B Clark
- Safar Center for Resuscitation Research, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Patrick M Kochanek
- Safar Center for Resuscitation Research, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Travis C Jackson
- Department of Molecular Pharmacology & Physiology, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
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Ando H, Sawano M, Kohsaka S, Ishii H, Tajima A, Suzuki W, Kunimura A, Nakano Y, Kozuma K, Amano T. Cardiac arrest and post-discharge mortality in patients with myocardial infarction: A large-scale nationwide registry analysis. Resusc Plus 2024; 18:100647. [PMID: 38737095 PMCID: PMC11088348 DOI: 10.1016/j.resplu.2024.100647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 03/12/2024] [Accepted: 04/12/2024] [Indexed: 05/14/2024] Open
Abstract
Background Cardiac arrest is a serious complication of acute myocardial infarction. The implementation of contemporary approaches to acute myocardial infarction management, including urgent revascularization procedures, has led to significant improvements in short-term outcomes. However, the extent of post-discharge mortality in patients experiencing cardiac arrest during acute myocardial infarction remains uncertain. This study aimed to determine the post-discharge outcomes of patients with cardiac arrest. Methods We analysed data from the J-PCI OUTCOME registry, a Japanese prospectively planed, observational, multicentre, national registry of percutaneous coronary intervention involving consecutive patients from 172 institutions who underwent percutaneous coronary intervention and were discharged. Patients who underwent percutaneous coronary intervention for acute myocardial infarction between January 2017 and December 2018 and survived for 30 days were included. Mortality in patients with and without cardiac arrest from 30 days to 1 year after percutaneous coronary intervention for acute myocardial infarction was compared. Results Of the 26,909 patients who survived for 30 days after percutaneous coronary intervention for acute myocardial infarction, 1,567 (5.8%) had cardiac arrest at the onset of acute myocardial infarction. Patients with cardiac arrest were younger and more likely to be males than patients without cardiac arrest. The 1-year all-cause mortality was significantly higher in patients with cardiac arrest than in those without (11.9% vs. 2.8%, p < 0.001) for all age groups. Multivariable analysis showed that cardiac arrest was an independent predictor of all-cause long-term mortality (hazard ratio: 2.94; 95% confidence interval: 2.29-3.76). Conclusions Patients with acute myocardial infarction and concomitant cardiac arrest have a worse prognosis for up to 1 year after percutaneous coronary intervention than patients without cardiac arrest.
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Affiliation(s)
- Hirohiko Ando
- Department of Cardiology, Aichi Medical University, Nagakute, Japan
| | - Mitsuaki Sawano
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, Yale New Haven Hospital Center of Outcomes Research and Evaluation, New Haven, CT, USA
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Hideki Ishii
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Atomu Tajima
- Department of Cardiology, Aichi Medical University, Nagakute, Japan
| | - Wataru Suzuki
- Department of Cardiology, Aichi Medical University, Nagakute, Japan
| | - Ayako Kunimura
- Department of Cardiology, Aichi Medical University, Nagakute, Japan
| | - Yusuke Nakano
- Department of Cardiology, Aichi Medical University, Nagakute, Japan
| | - Ken Kozuma
- Department of Cardiology, Teikyo University, Tokyo, Japan
| | - Tetsuya Amano
- Department of Cardiology, Aichi Medical University, Nagakute, Japan
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Preuß S, Multmeier J, Stenzel W, Major S, Ploner CJ, Storm C, Nee J, Leithner C, Endisch C. Survival, but not the severity of hypoxic-ischemic encephalopathy, is associated with higher mean arterial blood pressure after cardiac arrest: a retrospective cohort study. Front Cardiovasc Med 2024; 11:1337344. [PMID: 38774664 PMCID: PMC11106407 DOI: 10.3389/fcvm.2024.1337344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 04/15/2024] [Indexed: 05/24/2024] Open
Abstract
Background This study investigates the association between the mean arterial blood pressure (MAP), vasopressor requirement, and severity of hypoxic-ischemic encephalopathy (HIE) after cardiac arrest (CA). Methods Between 2008 and 2017, we retrospectively analyzed the MAP 200 h after CA and quantified the vasopressor requirements using the cumulative vasopressor index (CVI). Through a postmortem brain autopsy in non-survivors, the severity of the HIE was histopathologically dichotomized into no/mild and severe HIE. In survivors, we dichotomized the severity of HIE into no/mild cerebral performance category (CPC) 1 and severe HIE (CPC 4). We investigated the regain of consciousness, causes of death, and 5-day survival as hemodynamic confounders. Results Among the 350 non-survivors, 117 had histopathologically severe HIE while 233 had no/mild HIE, without differences observed in the MAP (73.1 vs. 72.0 mmHg, pgroup = 0.639). Compared to the non-survivors, 211 patients with CPC 1 and 57 patients with CPC 4 had higher MAP values that showed significant, but clinically non-relevant, MAP differences (81.2 vs. 82.3 mmHg, pgroup < 0.001). The no/mild HIE non-survivors (n = 54), who regained consciousness before death, had higher MAP values compared to those with no/mild HIE (n = 179), who remained persistently comatose (74.7 vs. 69.3 mmHg, pgroup < 0.001). The no/mild HIE non-survivors, who regained consciousness, required fewer vasopressors (CVI 2.1 vs. 3.6, pgroup < 0.001). Independent of the severity of HIE, the survivors were weaned faster from vasopressors (CVI 1.0). Conclusions Although a higher MAP was associated with survival in CA patients treated with a vasopressor-supported MAP target above 65 mmHg, the severity of HIE was not. Awakening from coma was associated with less vasopressor requirements. Our results provide no evidence for a MAP target above the current guideline recommendations that can decrease the severity of HIE.
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Affiliation(s)
- Sandra Preuß
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany
- Department of Cardiology and Angiology, Charité Campus Mitte, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jan Multmeier
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany
- Ada Health GmbH, Berlin, Germany
| | - Werner Stenzel
- Department of Neuropathology, Charité Campus Mitte, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Sebastian Major
- Center for Stroke Research, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph J. Ploner
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christian Storm
- Department of Nephrology and Intensive Care Medicine, Cardiac Arrest Center of Excellence Berlin, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jens Nee
- Department of Nephrology and Intensive Care Medicine, Cardiac Arrest Center of Excellence Berlin, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Leithner
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christian Endisch
- Department of Neurology, AG Emergency and Critical Care Neurology, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany
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Babkina AS, Lyubomudrov MA, Golubev MA, Pisarev MV, Golubev AM. Neuron-Specific Enolase-What Are We Measuring? Int J Mol Sci 2024; 25:5040. [PMID: 38732258 PMCID: PMC11084499 DOI: 10.3390/ijms25095040] [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: 04/03/2024] [Revised: 05/01/2024] [Accepted: 05/02/2024] [Indexed: 05/13/2024] Open
Abstract
Since the discovery of the neuron-specific protein by Moore and McGregor in 1965, tens of thousands of studies have investigated the basic and applied significance of neuron-specific enolase (NSE). This promising biomarker, according to many researchers, has not found widespread use in clinical practice, particularly in acute cerebrovascular accidents. Moreover, the several studies refuting the usefulness of serum NSE measurement in critically ill patients leads us to consider the reasons for such contradictory conclusions. In this article, we have analyzed the main directions in the study of NSE and expressed our perspective on the reasons for the contradictory results and the difficulties in implementing the results of these studies in clinical practice. In our opinion, the method of the enzyme-linked immunosorbent assay (ELISA) used in the majority of the studies is inappropriate for the evaluation of NSE as a marker of central nervous system damage, because it does not allow for the differentiation of heterodimers of enolases and the assessment of the enzymatic activity of this group of enzymatic proteins. Therefore, the methodological approach for the evaluation of NSE (γγ-enolase) as a biomarker needs to be elaborated and improved. Furthermore, the specificity of the applied research methods and the appropriateness of the continued use of the term "neuron-specific enolase" must be addressed.
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Affiliation(s)
- Anastasiya S. Babkina
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow 107031, Russia; (M.A.L.); (M.V.P.); (A.M.G.)
| | - Maxim A. Lyubomudrov
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow 107031, Russia; (M.A.L.); (M.V.P.); (A.M.G.)
| | | | - Mikhail V. Pisarev
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow 107031, Russia; (M.A.L.); (M.V.P.); (A.M.G.)
| | - Arkady M. Golubev
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow 107031, Russia; (M.A.L.); (M.V.P.); (A.M.G.)
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Li A, Hegazy AF, Vasquez LEM, Liu L, Durocher AM, Vucetic A, Patel A, Fleming C, Chui J. Characterizing the impact of thermoregulation in patients after cardiac arrest: a retrospective cohort study. Can J Anaesth 2024; 71:629-639. [PMID: 38514524 DOI: 10.1007/s12630-024-02737-x] [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: 03/21/2023] [Revised: 08/30/2023] [Accepted: 11/11/2023] [Indexed: 03/23/2024] Open
Abstract
PURPOSE Core body temperature has been extensively investigated as a thereuptic target in care after cardiac arrest. Nevertheless, the integrity of thermoregulation in patients after cardiac arrest has not been well studied. We sought to evaluate whether low spontaneous body temperature after cardiac arrest is associated with increased death and a worse neurologic outcome, and whether patients with low spontaneous body temperature exhibit features suggestive of impaired thermoregulation. METHODS We conducted a single-centre retrospective cohort study. We included all adult patients who underwent temperature control with hypothermia after cardiac arrest between 1 January 2014 and 30 June 2020. The primary exposure was low spontaneous core body temperature (< 35 °C) at initiation of hypothermia therapy. The primary outcome was in-hospital death and the secondary outcome was poor neurologic outcomes at discharge. RESULTS Five hundred and ninety-seven adult patients, comprising both in- and out-of-hospital cardiac arrests, were included. Patients with low spontaneous body temperature also had slightly lower average temperature, and more frequent transient but controlled breakthrough fever episodes in the first 24 hr. In the multivariable logistic regression analysis, low spontaneous body temperature was associated with higher odds of in-hospital death (odds ratio, 2.9; 95% confidence interval, 1.9 to 4.2; P < 0.001). CONCLUSION In this single-centre retrospective cohort study, low spontaneous core body temperature was associated with poor outcomes in patients after cardiac arrest. Patients with low spontaneous body temperature also exhibited features suggestive of impaired thermoregulation. Further research is needed to determine whether body temperature upon presentation reflects the robustness of the patient's underlying physiology and severity of brain insult after a cardiac arrest.
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Affiliation(s)
- Annie Li
- Department of Anesthesia & Perioperative Medicine, Schulich School Medicine & Dentistry, Western University, London, ON, Canada
| | - Ahmed F Hegazy
- Department of Anesthesia & Perioperative Medicine, Schulich School Medicine & Dentistry, Western University, London, ON, Canada
- Department of Critical Care, Schulich School Medicine & Dentistry, Western University, London, ON, Canada
| | - Luis E Mendoza Vasquez
- Department of Anesthesia & Perioperative Medicine, Schulich School Medicine & Dentistry, Western University, London, ON, Canada
| | - Lisa Liu
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Alexandra M Durocher
- Department of Anesthesia & Perioperative Medicine, Schulich School Medicine & Dentistry, Western University, London, ON, Canada
| | - Andrea Vucetic
- Department of Anesthesia & Perioperative Medicine, Schulich School Medicine & Dentistry, Western University, London, ON, Canada
| | - Arjun Patel
- Department of Anesthesia & Perioperative Medicine, Schulich School Medicine & Dentistry, Western University, London, ON, Canada
| | - Courtney Fleming
- Department of Anesthesia & Perioperative Medicine, Schulich School Medicine & Dentistry, Western University, London, ON, Canada
| | - Jason Chui
- Department of Anesthesia & Perioperative Medicine, Schulich School Medicine & Dentistry, Western University, London, ON, Canada.
- Department of Anesthesia & Perioperative Medicine, University of Western Ontario, C3-106, University Hospital, 339 Windermere Rd., London, ON, N6A 5A5, Canada.
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Zuyev Y, Hillock T, Islam R. Typical Exertional Angina With No Angiographic Coronary Artery Disease. Cureus 2024; 16:e61255. [PMID: 38939250 PMCID: PMC11210935 DOI: 10.7759/cureus.61255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 05/28/2024] [Indexed: 06/29/2024] Open
Abstract
Cardiac syndrome X (CSX) is a cardiac condition that is a diagnosis of exclusion. Patients usually present with terrible chest pains suggestive of myocardial infarction, but angiogram imaging shows no occlusion in the coronary vessels that would be suggestive of coronary artery disease. CSX is more commonly seen in women, but this case report demonstrates a different clinical presentation of CSX in a young, otherwise healthy male patient. The 38-year-old male patient presented to the emergency room with chest discomfort radiating to the left arm and to the left jaw. The chest pain started after the patient went for a jog, with the pain lasting for a couple of hours. The electrocardiogram (ECG) was abnormal, showing nonspecific ST changes and unremarkable troponin levels. The patient underwent a coronary angiogram, which was unremarkable. Three years later, the patient presented once more with chest heaviness that occurred again after going for a run. The patient's troponins were unremarkable, and an ECG test showed a new onset of AV block. Due to the ongoing chest pain, the patient received another coronary angiogram. This showed that the coronary vessels had no indications of occlusion. The patient was discharged and scheduled to follow up with their cardiologist for an extensive discussion about medications for their condition. This case report should bring awareness of the classical presentation of this disease in an uncommon population group and a way to identify this syndrome once exclusions have been made on previous hospitalizations.
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Affiliation(s)
- Yaroslav Zuyev
- Cardiology, Edward Via College of Osteopathic Medicine, Monroe, USA
| | - Tyson Hillock
- Cardiology, Edward Via College of Osteopathic Medicine, Monroe, USA
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Damarlapally N, Sinha T, Rawat A, Soe TM, Munawar G, Chaudhari SS, Wei CR, Ali N. Effects of Targeted Hypercapnia on Mortality and Length of Stay of Post-cardiac Arrest Patients: A Systematic Review and Meta-Analysis. Cureus 2024; 16:e60617. [PMID: 38894798 PMCID: PMC11185866 DOI: 10.7759/cureus.60617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2024] [Indexed: 06/21/2024] Open
Abstract
Therapeutic hypercapnia has been proposed as a potential strategy to enhance cerebral perfusion and improve outcomes in patients after cardiac arrest. However, the effects of targeted hypercapnia remain unclear. We conducted a systematic review and meta-analysis to evaluate the impact of hypercapnia compared to normocapnia on mortality and length of stay in post-cardiac arrest patients. We searched major databases for randomized controlled trials and observational studies comparing outcomes between hypercapnia and normocapnia in adult post-cardiac arrest patients. Data on in-hospital mortality and the ICU and hospital length of stay were extracted and pooled using random-effects meta-analysis. Five studies (two randomized controlled trials (RCTs) and three observational studies) with a total of 1,837 patients were included. Pooled analysis showed hypercapnia was associated with significantly higher in-hospital mortality compared to normocapnia (56.2% vs. 50.5%, OR 1.24, 95% CI 1.12-1.37, p<0.001). There was no significant heterogeneity (I2 = 25%, p = 0.26). No statistically significant differences were found for ICU length of stay (mean difference 0.72 days, 95% CI -0.51 to 1.95) or hospital length of stay (mean difference 1.13 days, 95% CI -0.67 to 2.93) between the groups. Sensitivity analysis restricted to mild hypercapnia studies did not alter the mortality findings. This meta-analysis did not find a mortality benefit with targeted hypercapnia compared to normocapnia in post-cardiac arrest patients. The results align with current guidelines recommending a normal partial pressure of arterial carbon dioxide (PaCO2) target range and do not support routinely targeting higher carbon dioxide levels in this setting.
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Affiliation(s)
| | - Tanya Sinha
- Medicine, Tribhuvan University, Kathmandu, NPL
| | - Anurag Rawat
- Interventional Cardiology, Himalayan Institute of Medical Sciences, Dehradun, IND
| | - Thin M Soe
- Medicine, University of Medicine 1, Yangon, MMR
| | - Ghazala Munawar
- Internal Medicine, Northwest General Hospital and Research Center, Peshawar, PAK
| | - Sandipkumar S Chaudhari
- Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, USA
- Family Medicine, University of North Dakota School of Medicine and Health Sciences, Fargo, USA
| | - Calvin R Wei
- Research and Development, Shing Huei Group, Taipei, TWN
| | - Neelum Ali
- Internal Medicine, University of Health Sciences, Lahore, PAK
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Kawakita K, Shishido H, Kuroda Y. Review of Temperature Management in Traumatic Brain Injuries. J Clin Med 2024; 13:2144. [PMID: 38610909 PMCID: PMC11012999 DOI: 10.3390/jcm13072144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/06/2024] [Accepted: 04/07/2024] [Indexed: 04/14/2024] Open
Abstract
Therapeutic hypothermia (TH) for severe traumatic brain injury has seen restricted application due to the outcomes of randomized controlled trials (RCTs) conducted since 2000. In contrast with earlier RCTs, recent trials have implemented active normothermia management in control groups, ensuring comparable intensities of non-temperature-related therapeutic interventions, such as neurointensive care. This change in approach may be a contributing factor to the inability to establish the efficacy of TH. Currently, an active temperature management method using temperature control devices is termed "targeted temperature management (TTM)". One of the goals of TTM for severe traumatic brain injury is the regulation of increased intracranial pressure, employing TTM as a methodology for intracranial pressure management. Additionally, fever in traumatic brain injury has been acknowledged as contributing to poor prognosis, underscoring the importance of proactively preventing fever. TTM is also employed for the preemptive prevention of fever in severe traumatic brain injury. As an integral component of current neurointensive care, it is crucial to precisely delineate the targets of TTM and to potentially apply them in the treatment of severe traumatic brain injury.
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Affiliation(s)
- Kenya Kawakita
- Emergency Medical Center, Kagawa University Hospital, Miki 761-0793, Japan;
| | - Hajime Shishido
- Emergency Medical Center, Kagawa University Hospital, Miki 761-0793, Japan;
| | - Yasuhiro Kuroda
- Department of Emergency, Disaster, and Critical Care Medicine, Faculty of Medicine, Kagawa University, Miki 760-0793, Japan;
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Nakamura E, Aoki T, Endo Y, Kazmi J, Hagiwara J, Kuschner CE, Yin T, Kim J, Becker LB, Hayashida K. Organ-Specific Mitochondrial Alterations Following Ischemia-Reperfusion Injury in Post-Cardiac Arrest Syndrome: A Comprehensive Review. Life (Basel) 2024; 14:477. [PMID: 38672748 PMCID: PMC11050834 DOI: 10.3390/life14040477] [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: 03/16/2024] [Revised: 04/01/2024] [Accepted: 04/03/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Mitochondrial dysfunction, which is triggered by systemic ischemia-reperfusion (IR) injury and affects various organs, is a key factor in the development of post-cardiac arrest syndrome (PCAS). Current research on PCAS primarily addresses generalized mitochondrial responses, resulting in a knowledge gap regarding organ-specific mitochondrial dynamics. This review focuses on the organ-specific mitochondrial responses to IR injury, particularly examining the brain, heart, and kidneys, to highlight potential therapeutic strategies targeting mitochondrial dysfunction to enhance outcomes post-IR injury. METHODS AND RESULTS We conducted a narrative review examining recent advancements in mitochondrial research related to IR injury. Mitochondrial responses to IR injury exhibit considerable variation across different organ systems, influenced by unique mitochondrial structures, bioenergetics, and antioxidative capacities. Each organ demonstrates distinct mitochondrial behaviors that have evolved to fulfill specific metabolic and functional needs. For example, cerebral mitochondria display dynamic responses that can be both protective and detrimental to neuronal activity and function during ischemic events. Cardiac mitochondria show vulnerability to IR-induced oxidative stress, while renal mitochondria exhibit a unique pattern of fission and fusion, closely linked to their susceptibility to acute kidney injury. This organ-specific heterogeneity in mitochondrial responses requires the development of tailored interventions. Progress in mitochondrial medicine, especially in the realms of genomics and metabolomics, is paving the way for innovative strategies to combat mitochondrial dysfunction. Emerging techniques such as mitochondrial transplantation hold the potential to revolutionize the management of IR injury in resuscitation science. CONCLUSIONS The investigation into organ-specific mitochondrial responses to IR injury is pivotal in the realm of resuscitation research, particularly within the context of PCAS. This nuanced understanding holds the promise of revolutionizing PCAS management, addressing the unique mitochondrial dysfunctions observed in critical organs affected by IR injury.
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Affiliation(s)
- Eriko Nakamura
- Laboratory for Critical Care Physiology, Feinstein Institutes for Medical Research, Northwell Health System, Manhasset, NY 11030, USA; (E.N.); (T.A.); (Y.E.); (J.K.); (J.H.); (C.E.K.); (T.Y.); (J.K.); (L.B.B.)
| | - Tomoaki Aoki
- Laboratory for Critical Care Physiology, Feinstein Institutes for Medical Research, Northwell Health System, Manhasset, NY 11030, USA; (E.N.); (T.A.); (Y.E.); (J.K.); (J.H.); (C.E.K.); (T.Y.); (J.K.); (L.B.B.)
| | - Yusuke Endo
- Laboratory for Critical Care Physiology, Feinstein Institutes for Medical Research, Northwell Health System, Manhasset, NY 11030, USA; (E.N.); (T.A.); (Y.E.); (J.K.); (J.H.); (C.E.K.); (T.Y.); (J.K.); (L.B.B.)
| | - Jacob Kazmi
- Laboratory for Critical Care Physiology, Feinstein Institutes for Medical Research, Northwell Health System, Manhasset, NY 11030, USA; (E.N.); (T.A.); (Y.E.); (J.K.); (J.H.); (C.E.K.); (T.Y.); (J.K.); (L.B.B.)
| | - Jun Hagiwara
- Laboratory for Critical Care Physiology, Feinstein Institutes for Medical Research, Northwell Health System, Manhasset, NY 11030, USA; (E.N.); (T.A.); (Y.E.); (J.K.); (J.H.); (C.E.K.); (T.Y.); (J.K.); (L.B.B.)
| | - Cyrus E. Kuschner
- Laboratory for Critical Care Physiology, Feinstein Institutes for Medical Research, Northwell Health System, Manhasset, NY 11030, USA; (E.N.); (T.A.); (Y.E.); (J.K.); (J.H.); (C.E.K.); (T.Y.); (J.K.); (L.B.B.)
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA
| | - Tai Yin
- Laboratory for Critical Care Physiology, Feinstein Institutes for Medical Research, Northwell Health System, Manhasset, NY 11030, USA; (E.N.); (T.A.); (Y.E.); (J.K.); (J.H.); (C.E.K.); (T.Y.); (J.K.); (L.B.B.)
| | - Junhwan Kim
- Laboratory for Critical Care Physiology, Feinstein Institutes for Medical Research, Northwell Health System, Manhasset, NY 11030, USA; (E.N.); (T.A.); (Y.E.); (J.K.); (J.H.); (C.E.K.); (T.Y.); (J.K.); (L.B.B.)
| | - Lance B. Becker
- Laboratory for Critical Care Physiology, Feinstein Institutes for Medical Research, Northwell Health System, Manhasset, NY 11030, USA; (E.N.); (T.A.); (Y.E.); (J.K.); (J.H.); (C.E.K.); (T.Y.); (J.K.); (L.B.B.)
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA
| | - Kei Hayashida
- Laboratory for Critical Care Physiology, Feinstein Institutes for Medical Research, Northwell Health System, Manhasset, NY 11030, USA; (E.N.); (T.A.); (Y.E.); (J.K.); (J.H.); (C.E.K.); (T.Y.); (J.K.); (L.B.B.)
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA
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Delignette MC, Stevic N, Lebossé F, Bonnefoy-Cudraz E, Argaud L, Cour M. Acute liver failure after out-of-hospital cardiac arrest: An observational study. Resuscitation 2024; 197:110136. [PMID: 38336284 DOI: 10.1016/j.resuscitation.2024.110136] [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: 11/01/2023] [Revised: 01/18/2024] [Accepted: 02/03/2024] [Indexed: 02/12/2024]
Abstract
RATIONALE Apart from hypoxic hepatitis (HH), the hepatic consequences of out-of-hospital cardiac arrest (OHCA) have been little studied. This cohort study aimed to investigate the characteristics of liver dysfunction resulting from OHCA and its association with outcomes. METHODS Among the conventional static liver function tests used to define acute liver failure (ALF), we determined which one correlated more closely with the reference indocyanine green (ICG) clearance test in a series of OHCA patients from the CYRUS trial (NCT01595958). Subsequently, we assessed whether ALF, in addition to HH (i.e., acute liver injury), was an independent risk factor for death in a large cohort of OHCA patients admitted to two intensive care units between 2007 and 2017. RESULTS ICG clearance, available for 22 patients, was impaired in 17 (77.3%) cases. Prothrombin time (PT) ratio was the only static liver function test that correlated significantly (r = -0.66, p < 0.01) with ICG clearance and was therefore used to define ALF, with the usual cutoff of < 50%. Of the 418 patients included in the analysis (sex ratio: 1.4; median age: 64 [53-75] years; non-shockable rhythm: 73%), 67 (16.0%) presented with ALF, and 61 (14.6%) had HH at admission. On day 28, 337 (80.6%) patients died. Following multivariate analysis, ALF at admission, OHCA occurring at home, absence of bystander, non-cardiac cause of OHCA, low-flow duration ≥ 20 min, and SOFA score excluding liver subscore at admission were independently associated with day 28 mortality. CONCLUSIONS ALF occurred frequently after OHCA and, unlike HH, was independently associated with day 28 mortality.
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Affiliation(s)
- Marie-Charlotte Delignette
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Médecine Intensive-Réanimation, Lyon, France; Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France.
| | - Neven Stevic
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Médecine Intensive-Réanimation, Lyon, France; Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France; INSERM U1060 CarMeN, IRIS, Lyon, France.
| | - Fanny Lebossé
- Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France; Hospices Civils de Lyon, Hôpital de la Croix-Rousse, Institut d'Hépatologie de Lyon, Lyon, France; INSERM U1052, Centre de Recherche en Cancérologie de Lyon (CRCL), Lyon, France.
| | - Eric Bonnefoy-Cudraz
- Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France; Hospices Civils de Lyon, Hôpital Louis Pradel, Unité de Soins Intensifs Cardiologiques, Bron, France.
| | - Laurent Argaud
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Médecine Intensive-Réanimation, Lyon, France; Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France; INSERM U1060 CarMeN, IRIS, Lyon, France.
| | - Martin Cour
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Médecine Intensive-Réanimation, Lyon, France; Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France; INSERM U1060 CarMeN, IRIS, Lyon, France.
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Aoki T, Wong V, Yin T, Nakamura E, Endo Y, Hayashida K, Robson SC, Nandurkar H, Diamond B, Kim SJ, Murao A, Wang P, Becker LB, Shinozaki K. Immune cell expression patterns of CD39/CD73 ectonucleotidases in rodent models of cardiac arrest and resuscitation. Front Immunol 2024; 15:1362858. [PMID: 38545102 PMCID: PMC10967020 DOI: 10.3389/fimmu.2024.1362858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 03/01/2024] [Indexed: 04/04/2024] Open
Abstract
Background Cardiac arrest (CA) is a significant public health concern. There is the high imminent mortality and survival in those who are resuscitated is substantively compromised by the post-CA syndrome (PCAS), characterized by multiorgan ischemia-reperfusion injury (IRI). The inflammatory response in PCAS is complex and involves various immune cell types, including lymphocytes and myeloid cells that have been shown to exacerbate organ IRI, such as myocardial infarction. Purinergic signaling, as regulated by CD39 and CD73, has emerged as centrally important in the context of organ-specific IRI. Hence, comprehensive understanding of such purinergic responses may be likewise imperative for improving outcomes in PCAS. Methods We have investigated alterations of immune cell populations after CA by utilizing rodent models of PCAS. Blood and spleen were collected after CA and resuscitation and underwent flow cytometry analysis to evaluate shifts in CD3+CD4+ helper T cells, CD3+CD8a+ cytotoxic T cells, and CD4/CD8a ratios. We then examined the expression of CD39 and CD73 across diverse cell types, including myeloid cells, T lymphocytes, and B lymphocytes. Results In both rat and mouse models, there were significant increases in the frequency of CD3+CD4+ T lymphocytes in PCAS (rat, P < 0.01; mouse, P < 0.001), with consequently elevated CD4/CD8a ratios in whole blood (both, P < 0.001). Moreover, CD39 and CD73 expression on blood leukocytes were markedly increased (rat, P < 0.05; mouse, P < 0.01 at 24h). Further analysis in the experimental mouse model revealed that CD11b+ myeloid cells, with significant increase in their population (P < 0.01), had high level of CD39 (88.80 ± 2.05 %) and increased expression of CD73 (P < 0.05). CD19+ B lymphocytes showed slight increases of CD39 (P < 0.05 at 2h) and CD73 (P < 0.05 at 2h), while, CD3+ T lymphocytes had decreased levels of them. These findings suggested a distinct patterns of expression of CD39 and CD73 in these specific immune cell populations after CA. Conclusions These data have provided comprehensive insights into the immune response after CA, highlighting high-level expressions of CD39 and CD73 in myeloid cells.
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Affiliation(s)
- Tomoaki Aoki
- Department of Emergency Med-Cardiopulmonary, The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Vanessa Wong
- Department of Emergency Med-Cardiopulmonary, The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
- State University of New York Downstate Medical Center, NY, United States
| | - Tai Yin
- Department of Emergency Med-Cardiopulmonary, The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Eriko Nakamura
- Department of Emergency Med-Cardiopulmonary, The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Yusuke Endo
- Department of Emergency Med-Cardiopulmonary, The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Kei Hayashida
- Department of Emergency Med-Cardiopulmonary, The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Simon C. Robson
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Harshal Nandurkar
- Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia
| | - Betty Diamond
- Institutes of Molecular Medicine, The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Sun Jung Kim
- Institutes of Molecular Medicine, The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Atsushi Murao
- Center for Immunology and Inflammation, The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Ping Wang
- Center for Immunology and Inflammation, The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Lance B. Becker
- Department of Emergency Med-Cardiopulmonary, The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, NY, United States
| | - Koichiro Shinozaki
- Department of Emergency Med-Cardiopulmonary, The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
- Institutes of Molecular Medicine, The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, NY, United States
- Department of Emergency & Critical Care Medicine, Kindai University Faculty of Medicine, Osaka, Japan
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Hamaguchi T, Takiguchi T, Seki T, Tominaga N, Nakata J, Yamamoto T, Tagami T, Inoue A, Hifumi T, Sakamoto T, Kuroda Y, Yokobori S, Study Group TSJI. Association between pupillary examinations and prognosis in patients with out-of-hospital cardiac arrest who underwent extracorporeal cardiopulmonary resuscitation: a retrospective multicentre cohort study. Ann Intensive Care 2024; 14:35. [PMID: 38448746 PMCID: PMC10917711 DOI: 10.1186/s13613-024-01265-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 02/16/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND In some cases of patients with out-of-hospital cardiac arrest (OHCA) who underwent extracorporeal cardiopulmonary resuscitation (ECPR), negative pupillary light reflex (PLR) and mydriasis upon hospital arrival serve as common early indicator of poor prognosis. However, in certain patients with poor prognoses inferred by pupil findings upon hospital arrival, pupillary findings improve before and after the establishment of ECPR. The association between these changes in pupillary findings and prognosis remains unclear. This study aimed to clarify the association of pupillary examinations before and after the establishment of ECPR in patients with OHCA showing poor pupillary findings upon hospital arrival with their outcomes. To this end, we analysed retrospective multicentre registry data involving 36 institutions in Japan, including all adult patients with OHCA who underwent ECPR between January 2013 and December 2018. We selected patients with poor prognosis inferred by pupillary examinations, negative pupillary light reflex (PLR) and pupil mydriasis, upon hospital arrival. The primary outcome was favourable neurological outcome, defined as Cerebral Performance Category 1 or 2 at hospital discharge. Multivariable logistic regression analysis was performed to evaluate the association between favourable neurological outcome and pupillary examination after establishing ECPR. RESULTS Out of the 2,157 patients enrolled in the SAVE-J II study, 723 were analysed. Among the patients analysed, 74 (10.2%) demonstrated favourable neurological outcome at hospital discharge. Multivariable analysis revealed that a positive PLR at ICU admission (odds ration [OR] = 11.3, 95% confidence intervals [CI] = 5.17-24.7) was significantly associated with favourable neurological outcome. However, normal pupil diameter at ICU admission (OR = 1.10, 95%CI = 0.52-2.32) was not significantly associated with favourable neurological outcome. CONCLUSION Among the patients with OHCA who underwent ECPR and showed poor pupillary examination findings upon hospital arrival, 10.2% had favourable neurological outcome at hospital discharge. A positive PLR after the establishment of ECPR was significantly associated with favourable neurological outcome.
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Affiliation(s)
- Takuro Hamaguchi
- Department of Emergency and Critical Care Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, Japan
| | - Toru Takiguchi
- Department of Emergency and Critical Care Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, Japan.
- Department of Healthcare Information Management, The University of Tokyo Hospital, Tokyo, Japan.
| | - Tomohisa Seki
- Department of Healthcare Information Management, The University of Tokyo Hospital, Tokyo, Japan
| | - Naoki Tominaga
- Department of Emergency and Critical Care Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, Japan
| | - Jun Nakata
- Division of Cardiovascular Intensive Care, Department of Cardiovascular Medicine, Nippon Medical School Hospital, Tokyo, Japan
| | - Takeshi Yamamoto
- Division of Cardiovascular Intensive Care, Department of Cardiovascular Medicine, Nippon Medical School Hospital, Tokyo, Japan
| | - Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, Japan
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Akihiko Inoue
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Tetsuya Sakamoto
- Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Yasuhiro Kuroda
- Department of Emergency Medicine, Kagawa University School of Medicine, Kagawa, Japan
| | - Shoji Yokobori
- Department of Emergency and Critical Care Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, Japan
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46
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Heikkilä E, Setälä P, Jousi M, Nurmi J. Association among blood pressure, end-tidal carbon dioxide, peripheral oxygen saturation and mortality in prehospital post-resuscitation care. Resusc Plus 2024; 17:100577. [PMID: 38375443 PMCID: PMC10875297 DOI: 10.1016/j.resplu.2024.100577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 01/14/2024] [Accepted: 01/31/2024] [Indexed: 02/21/2024] Open
Abstract
Aim Post-resuscitation care is described as the fourth link in a chain of survival in resuscitation guidelines. However, data on prehospital post-resuscitation care is scarce. We aimed to examine the association among systolic blood pressure (SBP), peripheral oxygen saturation (SpO2) and end-tidal carbon dioxide (EtCO2) after prehospital stabilisation and outcome among patients resuscitated from out-of-hospital cardiac arrest (OHCA). Methods In this retrospective study, we evaluated association of the last measured prehospital SBP, SpO2 and EtCO2 before patient handover with 30-day and one-year mortality in 2,611 patients receiving prehospital post-resuscitation care by helicopter emergency medical services in Finland. Statistical analyses were completed through locally estimated scatterplot smoothing (LOESS) and multivariable logistic regression. The regression analyses were adjusted by sex, age, initial rhythm, bystander CPR, and time interval from collapse to the return of spontaneous circulation (ROSC). Results Mortality related to SBP and EtCO2 values were U-shaped and lowest at 135 mmHg and 4.7 kPa, respectively, whereas higher SpO2 shifted towards lower mortality. In adjusted analyses, increased 30-day mortality and one year mortality was observed in patients with SBP < 100 mmHg (OR 1.9 [95% CI 1.4-2.4]) and SBP < 100 (OR 1.8 [1.2-2.6]) or EtCO2 < 4.0 kPa (OR 1.4 [1.1-1.5]), respectively. SpO2 was not significantly associated with either 30-day or one year mortality. Conclusions After prehospital post-resuscitation stabilization, SBP < 100 mmHg and EtCO2 < 4.0 kPa were observed to be independently associated with higher mortality. The optimal targets for prehospital post-resuscitation care need to be established in the prospective studies.
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Affiliation(s)
- Elina Heikkilä
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, Finland
| | - Piritta Setälä
- Emergency Medical Services, Centre for Prehospital Emergency Care, Tampere University Hospital, Tampere, Finland
| | - Milla Jousi
- Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, Finland
| | - Jouni Nurmi
- Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, Finland
- FinnHEMS Research and Development Unit, Finland 4
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47
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Rashid K, Waheed MA, Ansar F, Makram AM, Hasan A, Ahmed S, Khan ST, Ubaid A, Ibad AA, Basri R, Makram OM, Khan Y, Rashad N, Elzouki A. Early coronary angioplasty fails to lower all-cause mortality in patients with out-of-hospital cardiac arrest without ST-segment elevation: A systematic review and meta-analysis. Health Sci Rep 2024; 7:e1379. [PMID: 38299209 PMCID: PMC10828130 DOI: 10.1002/hsr2.1379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 05/25/2023] [Accepted: 06/18/2023] [Indexed: 02/02/2024] Open
Abstract
Introduction Out-of-hospital cardiac arrest (OHCA) is defined as the loss of functional mechanical activity of the heart in association with an absence of systemic circulation, occurring outside of a hospital. Immediate coronary angiography (CAG) with percutaneous coronary intervention is recommended for OHCA with ST-elevation. We aimed to evaluate the effect of early CAG on mortality and neurological outcomes in OHCA patients without ST-elevation. Methods This meta-analysis and systemic review was conducted as per principles of Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) group. A protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO, Ref No. = CRD42022327833). A total of 674 studies were retrieved after scanning several databases (PubMed Central, EMBASE, Medline, and Cochrane Central Register of Controlled Trials). Results A total of 18 studies were selected for the final analysis, including 6 randomized control trials and 12 observational studies. Statistically, there was no significant difference in primary outcome, i.e., mortality, between early and delayed CAG. In terms of the grade of neurological recovery as a secondary outcome, early and delayed CAG groups also showed no statistically significant difference. Conclusion Early CAG has no survival benefits in patients with no ST elevations on ECG after OHCA.
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Affiliation(s)
- Khalid Rashid
- Internal MedicineJames Cook University HospitalMiddlesbroughUK
| | | | - Farrukh Ansar
- Department of MedicineQuaid e Azam International HospitalIslamabadPakistan
| | - Abdelrahman M. Makram
- Public health, School of Public HealthImperial College LondonLondonUK
- Department of Anesthesia and Intensive Care MedicineOctober 6 University HospitalGizaEgypt
| | - Ahmedyar Hasan
- Department of MedicineMohammed Bin Rashid University of Medicine and Health SciencesDubaiUAE
| | - Shahab Ahmed
- MedicineKing Abdullah Teaching HospitalMansehraPakistan
| | | | - Aamer Ubaid
- Internal MedicineUniversity of Missouri Kansas CityKansas CityMissouriUSA
| | | | - Rabia Basri
- Department of MedicineHamad Medical CorporationDohaQatar
| | - Omar Mohamed Makram
- Public health, Faculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
- Medicine, Center for Health & NatureHouston Methodist HospitalHoustonTexasUSA
- Department of CardiologyOctober 6 University HospitalGizaEgypt
| | | | - Nabhan Rashad
- Department of MedicineKhyber Teaching HospitalPeshawarPakistan
| | - Abdelnaser Elzouki
- Department of Medicine, Hamad General HospitalWeill Cornell MedicineAr‐RayyanQatar
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48
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Nikolovski SS, Lazic AD, Fiser ZZ, Obradovic IA, Tijanic JZ, Raffay V. Recovery and Survival of Patients After Out-of-Hospital Cardiac Arrest: A Literature Review Showcasing the Big Picture of Intensive Care Unit-Related Factors. Cureus 2024; 16:e54827. [PMID: 38529434 PMCID: PMC10962929 DOI: 10.7759/cureus.54827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2024] [Indexed: 03/27/2024] Open
Abstract
As an important public health issue, out-of-hospital cardiac arrest (OHCA) requires several stages of high quality medical care, both on-field and after hospital admission. Post-cardiac arrest shock can lead to severe neurological injury, resulting in poor recovery outcome and increased risk of death. These characteristics make this condition one of the most important issues to deal with in post-OHCA patients hospitalized in intensive care units (ICUs). Also, the majority of initial post-resuscitation survivors have underlying coronary diseases making revascularization procedure another crucial step in early management of these patients. Besides keeping myocardial blood flow at a satisfactory level, other tissues must not be neglected as well, and maintaining mean arterial pressure within optimal range is also preferable. All these procedures can be simplified to a certain level along with using targeted temperature management methods in order to decrease metabolic demands in ICU-hospitalized post-OHCA patients. Additionally, withdrawal of life-sustaining therapy as a controversial ethical topic is under constant re-evaluation due to its possible influence on overall mortality rates in patients initially surviving OHCA. Focusing on all of these important points in process of managing ICU patients is an imperative towards better survival and complete recovery rates.
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Affiliation(s)
- Srdjan S Nikolovski
- Pathology and Laboratory Medicine, Cardiovascular Research Institute, Loyola University Chicago Health Science Campus, Maywood, USA
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
| | - Aleksandra D Lazic
- Emergency Center, Clinical Center of Vojvodina, Novi Sad, SRB
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
| | - Zoran Z Fiser
- Emergency Medicine, Department of Emergency Medicine, Novi Sad, SRB
| | - Ivana A Obradovic
- Anesthesiology, Resuscitation, and Intensive Care, Sveti Vračevi Hospital, Bijeljina, BIH
| | - Jelena Z Tijanic
- Emergency Medicine, Municipal Institute of Emergency Medicine, Kragujevac, SRB
| | - Violetta Raffay
- School of Medicine, European University Cyprus, Nicosia, CYP
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
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49
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Ford VJ, Klein HG, Danner RL, Applefeld WN, Wang J, Cortes-Puch I, Eichacker PQ, Natanson C. Controls, comparator arms, and designs for critical care comparative effectiveness research: It's complicated. Clin Trials 2024; 21:124-135. [PMID: 37615179 PMCID: PMC10891304 DOI: 10.1177/17407745231195094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
BACKGROUND Comparative effectiveness research is meant to determine which commonly employed medical interventions are most beneficial, least harmful, and/or most costly in a real-world setting. While the objectives for comparative effectiveness research are clear, the field has failed to develop either a uniform definition of comparative effectiveness research or an appropriate set of recommendations to provide standards for the design of critical care comparative effectiveness research trials, spurring controversy in recent years. The insertion of non-representative control and/or comparator arm subjects into critical care comparative effectiveness research trials can threaten trial subjects' safety. Nonetheless, the broader scientific community does not always appreciate the importance of defining and maintaining critical care practices during a trial, especially when vulnerable, critically ill populations are studied. Consequently, critical care comparative effectiveness research trials sometimes lack properly constructed control or active comparator arms altogether and/or suffer from the inclusion of "unusual critical care" that may adversely affect groups enrolled in one or more arms. This oversight has led to critical care comparative effectiveness research trial designs that impair informed consent, confound interpretation of trial results, and increase the risk of harm for trial participants. METHODS/EXAMPLES We propose a novel approach to performing critical care comparative effectiveness research trials that mandates the documentation of critical care practices prior to trial initiation. We also classify the most common types of critical care comparative effectiveness research trials, as well as the most frequent errors in trial design. We present examples of these design flaws drawn from past and recently published trials as well as examples of trials that avoided those errors. Finally, we summarize strategies employed successfully in well-designed trials, in hopes of suggesting a comprehensive standard for the field. CONCLUSION Flawed critical care comparative effectiveness research trial designs can lead to unsound trial conclusions, compromise informed consent, and increase risks to research subjects, undermining the major goal of comparative effectiveness research: to inform current practice. Well-constructed control and comparator arms comprise indispensable elements of critical care comparative effectiveness research trials, key to improving the trials' safety and to generating trial results likely to improve patient outcomes in clinical practice.
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Affiliation(s)
- Verity J Ford
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Harvey G Klein
- Department of Transfusion Medicine, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Robert L Danner
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Willard N Applefeld
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey Wang
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Irene Cortes-Puch
- Division of Pulmonary, Critical Care and Sleep Medicine, UC Davis Medical Center, Sacramento, CA, USA
| | - Peter Q Eichacker
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Charles Natanson
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
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50
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Sznycer-Taub NR, Lowery R, Yu S, Owens G, Charpie JR. Reducing Hyperoxia Exposure in Infants Requiring Veno-Arterial Extracorporeal Membrane Oxygenation after Cardiac Surgery. Pediatr Cardiol 2024; 45:143-149. [PMID: 37698698 DOI: 10.1007/s00246-023-03277-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 08/12/2023] [Indexed: 09/13/2023]
Abstract
Recent studies have suggested worse outcomes in patients exposed to hyperoxia while supported on veno-arterial extracorporeal membrane oxygenation (VA-ECMO). However, there are no data regarding the effect of reducing hyperoxia exposure in this population by adjusting the fraction of inspired oxygen (FiO2) of the sweep gas of the ECMO circuit. A retrospective review of 143 patients less than 1 year of age requiring VA-ECMO following cardiac surgery from 2007 to 2018 was completed. 64 patients had a FiO2 of the sweep gas < 100% with an average PaO2 of 210 mm Hg in the first 48 h of support [vs 405 mm Hg in the group with a FiO2 = 100% (p < 0.0001)]. There was no difference in mortality at 30 days after surgery or other markers of end-organ injury with respect to whether the FiO2 was adjusted. At least one PaO2 value < 200 mm Hg in the first 24 h on ECMO in patients with a FiO2 < 100% trended toward a significant association (OR = 0.45, 95% CI = 0.21-1.01) with decreased risk of 30-day mortality when compared to those patients with a FiO2 = 100% and all PaO2 values > 200 mm Hg. Only 47% of patients with a FiO2 < 100% had an average PaO2 less than 200 mm Hg which indicates that the intervention of reducing the FiO2 of the sweep gas was not entirely effective at reducing hyperoxia exposure. Future research is needed for developing clinical protocols to avoid hyperoxia and to identify mechanisms for hyperoxia-induced injury on VA-ECMO.
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Affiliation(s)
- Nathaniel R Sznycer-Taub
- Division of Pediatric Cardiology, C.S. Mott Children's Hospital, University of Michigan, 1540 East Hospital Drive, Ann Arbor, MI, 48109-4204, USA.
| | - Ray Lowery
- Division of Pediatric Cardiology, C.S. Mott Children's Hospital, University of Michigan, 1540 East Hospital Drive, Ann Arbor, MI, 48109-4204, USA
| | - Sunkyung Yu
- Division of Pediatric Cardiology, C.S. Mott Children's Hospital, University of Michigan, 1540 East Hospital Drive, Ann Arbor, MI, 48109-4204, USA
| | - Gabe Owens
- Division of Pediatric Cardiology, C.S. Mott Children's Hospital, University of Michigan, 1540 East Hospital Drive, Ann Arbor, MI, 48109-4204, USA
| | - John R Charpie
- Division of Pediatric Cardiology, C.S. Mott Children's Hospital, University of Michigan, 1540 East Hospital Drive, Ann Arbor, MI, 48109-4204, USA
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