Response to “Comment on ‘Predictive Effects of the Lactate/Albumin Ratio on Neurological Outcomes in Patients After Out‐Of‐Hospital Cardiac Arrest’”

Cerebral oximetry – The holy grail of non-invasive cerebral perfusion monitoring in cardiac arrest or just a false dawn?

Bystander-initiated cardiopulmonary resuscitation can curb the deterioration of regional cerebral oxygen saturation on hospital arrival in patients with cardiac arrest

Fever after therapeutic hypothermia – Does rebound pyrexia matter?

The contributors to this statement were selected to ensure expertise in all the disciplines relevant to post–cardiac arrest care. In an attempt to make this document universally applicable and generalizable, the authorship comprised clinicians and scientists who represent many specialties in many regions of the world. Several major professional groups whose practice is relevant to post–cardiac arrest care were asked and agreed to provide representative contributors. Planning and invitations took place initially by e-mail, followed a series of telephone conferences and face-to-face meetings of the cochairs and writing group members. International writing teams were formed to generate the content of each section, which corresponded to the major subheadings of the final document. Two team leaders from different countries led each writing team. Individual contributors were assigned by the writing group cochairs to work on 1 or more writing teams, which generally reflected their areas of expertise. Relevant articles were identified with PubMed, EMBASE, and an American Heart Association EndNote master resuscitation reference library, supplemented by hand searches of key papers. Drafts of each section were written and agreed on by the writing team authors and then sent to the cochairs for editing and amalgamation into a single document. The first draft of the complete document was circulated among writing team leaders for initial comment and editing. A revised version of the document was circulated among all contributors, and consensus was achieved before submission of the final version for independent peer review and approval for publication. This scientific statement outlines current understanding and identifies knowledge gaps in the pathophysiology, treatment, and prognosis of patients who regain spontaneous circulation after cardiac arrest. The purpose is to provide a resource for optimization of post–cardiac arrest care and to pinpoint the need for research focused on gaps in knowledge that would potentially improve outcomes …

Risk factors for neurological disability outcomes in patients under extracorporeal membrane oxygenation following cardiac arrest: An observational study

Public-access defibrillation and neurological outcomes in patients with out-of-hospital cardiac arrest in Japan: a population-based cohort study

Latest in Resuscitation Research: Highlights From the 2021 American Heart Association's Resuscitation Science Symposium.

IntroductionSeveral methods have been proposed to evaluate neurological outcome in out-of-hospital cardiac arrest (OHCA) patients. Blood lactate has been recognized as a reliable prognostic marker for trauma, sepsis, or cardiac arrest. The objective of this study was to examine the association between initial lactate level or lactate clearance and neurologic outcome in OHCA survivors who were treated with therapeutic hypothermia.MethodsThis retrospective cohort study included patients who underwent protocol-based 24-hour therapeutic hypothermia after OHCA between January 2010 and March 2012. Serum lactate levels were measured at the start of therapy (0 hours), and after 6 hours, 12 hours, 24 hours, 48 hours and 72 hours. The 6 hour and 12 hour lactate clearance were calculated afterwards. Patients’ neurologic outcome was assessed at one month after cardiac arrest; good neurological outcome was defined as Cerebral Performance Category one or two. The primary outcome was an association between initial lactate level and good neurologic outcome. The secondary outcome was an association between lactate clearance and good neurologic outcome in patients with initial lactate level >2.5 mmol/l.ResultsOut of the 76 patients enrolled, 34 (44.7%) had a good neurologic outcome. The initial lactate level showed no significant difference between good and poor neurologic outcome groups (6.07 ±4 .09 mmol/L vs 7.13 ± 3.99 mmol/L, P = 0.42), However, lactate levels at 6 hours, 12 hours, 24 hours, and 48 hours in the good neurologic outcome group were lower than in the poor neurologic outcome group (3.81 ± 2.81 vs 6.00 ± 3.22 P <0.01, 2.95 ± 2.07 vs 5.00 ± 3.49 P <0.01, 2.17 ± 1.24 vs 3.86 ± 3.92 P <0.01, 1.57 ± 1.02 vs 2.21 ± 1.35 P = 0.03, respectively). The secondary analysis showed that the 6-hour and 12-hour lactate clearance was higher for good neurologic outcome patients (35.3 ± 34.6% vs 6.89 ± 47.4% P = 0.01, 54.5 ± 23.7% vs 25.6 ± 43.7% P <0.01, respectively). After adjusting for potential confounding variables, the 12-hour lactate clearance still showed a statistically significant difference (P = 0.02).ConclusionThe lactate clearance rate, and not the initial lactate level, was associated with neurological outcome in OHCA patients after therapeutic hypothermia.

The response time threshold for predicting favourable neurological outcomes in patients with bystander-witnessed out-of-hospital cardiac arrest

IntroductionProlonged conventional cardiopulmonary resuscitation (CCPR) is associated with a poor prognosis in out-of-hospital cardiac arrest (OHCA) patients. Alternative methods can be needed to improve the outcome in patients with prolonged CCPR and extracorporeal cardiopulmonary resuscitation (ECPR) can be considered as an alternative method. The objectives of this study were to estimate the optimal duration of CPR to consider ECPR as an alternative resuscitation method in patients with CCPR, and to find the indications for predicting good neurologic outcome in OHCA patients who received ECPR.MethodsThis study is a retrospective analysis based on a prospective cohort. We included patients ≥ 18 years of age without suspected or confirmed trauma and who experienced an OHCA from May 2006 to December 2013. First, we determined the appropriate cut-off duration for CPR based on the discrimination of good and poor neurological outcomes in the patients who received only CCPR, and then we compared the outcome between the CCPR group and ECPR group by using propensity score matching. Second, we compared CPR related data according to the neurologic outcome in matched ECPR group.ResultsOf 499 patients suitable for inclusion, 444 and 55 patients were enrolled in the CCPR and ECPR group, respectively. The predicted duration for a favorable neurologic outcome (CPC1, 2) is < 21 minutes of CPR in only CCPR patients. The matched ECPR group with ≥ 21 minutes of CPR duration had a more favorable neurological outcome than the matched CCPR group at 3 months post-arrest. In matched ECPR group, younger age, witnessed arrest without initial asystole rhythm, early achievement of mean arterial pressure ≥ 60 mmHg, low rate of ECPR-related complications, and therapeutic hypothermia were significant factors for expecting good neurologic outcome.ConclusionsECPR should be considered as an alternative method for attaining good neurological outcomes in OHCA patients who required prolonged CPR, especially of ≥ 21 minutes. Younger or witnessed arrest patients without initial asystole were good candidates for ECPR. After implantation of ECPR, early hemodynamic stabilization, prevention of ECPR-related complications, and application of therapeutic hypothermia may improve the neurological outcome.

Global cerebral ischemia occurs due to reduced blood supply to the brain. This is commonly caused by a cessation of myocardial activity associated with cardiac arrest and cardiac surgery. Survival is not the only important outcome because neurological dysfunction impacts on quality of life, reducing independent living. Magnesium has been identified as a potential neuroprotective agent; however, its role in this context is not yet clear. The objective of this review was to present the best currently available evidence related to the neuroprotective effects of magnesium during a period of global cerebral ischemia in adults with cardiac arrest or cardiac surgery. The current review considered adults aged over 18 years who were at risk of global cerebral ischemia associated with cardiac arrest or cardiac surgery. Studies of patients with existing neurological deficits or under the age of 18 years were excluded from the review. The intervention of interest was magnesium administered in doses of at least of 2 g compared to placebo to adult patients within 24 hours of cardiac arrest or cardiac surgery. The current review considered experimental designs including randomized controlled trials, non-randomized controlled trials and quasi-experimental designs. The outcome of interest were neurological recovery post-cardiac arrest or cardiac surgery, as measured by objective scales, such as but not limited to, cerebral performance category, brain stem reflexes, Glasgow Coma Score and independent living or dependent living status. To enable assessment of the available data, neuroprotection was examined by breaking down neurological outcomes into three domains - functional neurological outcomes, neurophysiological outcomes and neuropsychological outcomes. The search strategy aimed to find both published and unpublished studies between January 1980 and August 2014, utilizing the Joanna Briggs Institute (JBI) three-step search strategy. Databases searched included PubMed, Embase, CINAHL, Cochrane Central Register of Controlled Trials, Australian Clinical Trials Register, Australian and New Zealand Clinical Trials Register, Clinical Trials, European Clinical Trials Register and ISRCTN Registry. The studies included in this review were of moderate-to-good-quality randomized controlled trials. Studies included measured neurological outcome using functional neurological assessment, neuropsychiatric assessment or neurophysiological assessment. Data were extracted using standardized templates provided by the JBI Meta-analysis of Statistics Assessment and Review Instrument software. Quantitative data were, where possible, pooled in statistical meta-analysis using Review Manager 5.3 (The Nordic Cochrane Centre, Cochrane; Copenhagen, Denmark). Where statistical pooling was not possible, the findings were presented in narrative form, including tables and figures, to aid in data presentation, where appropriate. Seven studies with a total of 1164 participants were included in this review. Neurological outcome was categorized into three domains: functional neurological, neurophysiological and neuropsychological outcomes. Meta-analysis of three studies assessing the neuroprotective properties of magnesium administration post cardiac arrest found improved functional neurological outcome (odds ratio 0.44; 95% confidence interval 0.24-0.81). Magnesium may improve functional neurological outcome in patients who suffer global cerebral ischemia associated with cardiac surgery and cardiac arrest. Magnesium does not decrease neuropsychological decline.Further testing of neurological outcomes in the domains of functional outcomes, neurophysiological markers and neuropsychological tests are required to further understanding of the neuroprotective effects of magnesium. Suitable dosing regimens should be investigated prior to introduction into clinical practice. Further research is required to investigate the optimal magnesium dose.

Extracorporeal Cardiopulmonary Resuscitation: Prehospital or In-Hospital Cannulation?

The early change in pH values after out-of-hospital cardiac arrest is not associated with neurological outcome at hospital discharge

IntroductionNeuron specific enolase (NSE) has been proven effective in predicting neurological outcome after cardiac arrest with a current cut off recommendation of 33 μg/l. However, most of the corresponding studies were conducted before the introduction of mild therapeutic hypothermia (MTH). Therefore we conducted a study investigating the association between NSE and neurological outcome in patients treated with MTHMethodsIn this prospective observational cohort study the data of patients after cardiac arrest receiving MTH (n = 97) were consecutively collected and compared with a retrospective non-hypothermia (NH) group (n = 133). Serum NSE was measured 72 hours after admission to ICU. Neurological outcome was classified according to the Pittsburgh cerebral performance category (CPC 1 to 5) at ICU discharge.ResultsNSE serum levels were significantly lower under MTH compared to NH in univariate analysis. However, in a linear regression model NSE was affected significantly by time to return of spontaneous circulation (ROSC) and ventricular fibrillation rhythm but not by MTH. The model for neurological outcome identified NSE, NSE*MTH (interaction) as well as time to ROSC as significant predictors. Receiver Operating Characteristic (ROC) analysis revealed a higher cutoff value for unfavourable outcome (CPC 3 to 5) with a specificity of 100% in the hypothermia group (78.9 μg/l) compared to the NH group (26.9 μg/l).ConclusionsRecommended cutoff levels for NSE 72 hours after ROSC do not reliably predict poor neurological outcome in cardiac arrest patients treated with MTH. Prospective multicentre trials are required to re-evaluate NSE cutoff values for the prediction of neurological outcome in patients treated with MTH.

Background: Extracorporeal CPR (E-CPR) has been utilized as a rescue strategy for cardiac arrest (CA) patients unresponsive to conventional CPR. Although the time from cardiac arrest to starting extracorporeal membrane oxygenation (ECMO) is known as a predictor for a good outcome, the opportunities to establish the E-CPR initiation flow are limited. Objective: We developed a protocol for the E-CPR simulation program and investigated whether the faster deployment of ECMO improves the neurological outcome and mortality in patients with refractory CA. Methods: In this single-center observational study, we enrolled 140 consecutive patients who received E-CPR from January 2012 to May 2020. E-CPR simulation training was carried out twice a year with the participation of doctors and co-medicals using a mock vascular model to practice ECMO cannulation and initiation since October 2017. 86 patients received E-CPR in the pre-simulation period (from January 2012 to September 2017), and 54 received in the post-simulation period (October 2017 to May 2020). We assessed the 30-day survival rate and the rate of the Cerebral Performance Category grades 1 and 2 as favorable neurological prognosis. Results: No significant difference in age, the rate of the male sex, witnessed CA, by-stander CPR, shockable rhythm at the initial contact, acute coronary syndrome (ACS) as a cause of CA, and out of hospital CA (OHCA). The collapse to ECMO placement time (CTET) was significantly shorter in the post-simulation group compared to the pre-simulation group (44 min [IQR; 27-74] vs. 32 min [IQR; 15-46]; P&lt;0.01). The rate of 30-day survival and favorable neurological outcome was significantly higher in the Post-simulation group compared to the pre-simulation group (16% vs. 20%; P=0.02, 9% vs. 13%; p=0.03, respectively). Cox regression analysis including data on the age, male sex, OHCA, initial shockable rhythm, ACS, and CTET revealed that CTET was significantly associated with the 30-day mortality (HR for 5 minutes increase, 1.12 [95%CI; 1.07-1.16]; p&lt;0.01). Conclusion: A regular comprehensive simulation-based E-CPR training improves the 30-day mortality and the neurological outcome in patients with refractory CA as a result of the shortening of the ECMO deployment.