Cerebral Performance Category Research Articles

The impact of door to extracorporeal cardiopulmonary resuscitation time on mortality and neurological outcomes among out-of-hospital cardiac arrest acute myocardial infarction patients treated by primary percutaneous coronary intervention

BackgroundFew previous studies evaluated the impact of time from the hospital arrival to the implementation of extracorporeal cardiopulmonary resuscitation (ECPR) (door to ECPR time) on outcomes among out-of-hospital cardiac arrest (OHCA) acute myocardial infarction (MI) patients. Methods50 patients with OHCA who received both ECPR and percutaneous coronary intervention (PCI) at Cardiovascular Division, NHO Osaka National Hospital were analyzed. Patients were divided into 2 groups according to the median of door to ECPR time. The primary outcome was all-cause death. Survival analyses were conducted to compare all-cause mortality at 90 days between 2 groups. Neurological outcome at 30 days was also compared between 2 groups using the Cerebral Performance Category (CPC). ResultsThe multivariable Cox proportional-hazards model showed that all-cause mortality at 90 days was significantly higher among patients with door to ECPR time ≥ 25 min compared with those with door to ECPR time < 25 min (adjusted hazard ratio [HR]: 3.14; 95 % confidence interval [CI]: 1.21–8.18). The proportion of patients with CPC at 30 days ≤ 2 was significantly higher among patients with shorter door to ECPR time (P = 0.048). ConclusionAmong patients with OHCA due to acute MI who received ECPR and PCI, the shorter door to ECPR time was associated with the lower mortality and favorable neurological outcomes.

Higher blood glucose within the first 72 hours after prolonged cardiac arrest predict poor prognosis: a post-hoc analysis of Prague OHCA trial

Abstract Background and purpose Both low and higher glucose levels and their tight control were associated with worse prognosis of critically ill patients. We performed a post-hoc analysis of treated Prague OHCA trial population of patients subjected to extracorporeal cardiopulmonary resuscitation (ECPR) vs. standard approach for refractory cardiac arrest, aimed to assess relationship of glucose levels in the first 72 hours after admission to the neurological outcome. Methods Prague OHCA trial enrolled adults with a witnessed refractory OHCA of presumed cardiac origin. In this post-hoc analysis, the effects blood glucose on the best cerebral performance category (CPC) within 180 days was examined. Blood samples for glycemia evaluation were drawn at admission and then every 3 hours within the first 3 days. Fischer exact test was used to analyze the impact on the prognosis (CPC 1-2 = good and CPC 3-5 = poor prognosis). Results Patients with CPC 1-2 did not differ in blood glucose on admission from patients with CPC 3-5. However, patients with type 2 diabetes mellitus had significantly worse prognosis (83 vs. 60% of diabetics vs. non-diabetics had poor prognosis, p = 0.007). Glycemia on admission was slightly but significantly related to the amount of given epinephrine and to the serum triglycerides. Patients having at least 3 glucose levels &amp;gt;10 mmol/L within the first 72 hours had worse neurological prognosis: CPC 1-2 was reached in 61.4% of patients with less than 3 levels &amp;gt;10 mmol/L, but only in 24% of patients that fulfilled this criterion (p=0.000004). Conclusions Repeatedly higher blood glucose within the first 72 hours after admission for prolonged cardiac arrest are related to worse prognosis.

Increased miRNA-related inflammation markers and pro-inflammatory circulating cell profile in patients with poor neurological outcome after out-of-hospital cardiac arrest

Abstract Background Out-of-Hospital Cardiac Arrest (OHCA) supposes a main cause of disability and mortality worldwide. Between patients suffering OHCA, only a 10-20% can be successfully resuscitated and, between them, a 50% suffers of neurological sequelae. Mechanisms underlying brain damage seems to be strongly related with neuroinflammation, mediated by classical (PCR, NLR) and novel (miRNAs) agents at play. Even there are studies suggesting the relevance of miRNA-mediated inflammatory response in ECA, no consistent conclusions about its role in ECA outcomes have been obtained. Purpose The aim of the present investigation is to study the temporal patterns of classical (PCR, NLR) and novel (miRNAs) inflammation markers during hospitalization of ECA patients and to correlate them with neurological outcome. Methods Consecutive OHCA patients were prospectively recruited at the Acute Cardiac Care Unit (ACCU) of the hospital Clinic of Barcelona from March 2019 to December 2023. Serum samples were obtained at 0, 24 and 72 hours after hospital admission. Patients were grouped according to their neurological outcome, measured by Cerebral Performance Category (CPC), at hospital discharge. Classical inflammation markers (PCR and NLR) were measured and in silico pre-targeted serum circulating-miRNAs were analysed by qPCR. Results A total of 120 patients (60 ± 13 years, 20% female) were included for the analysis. At hospital discharge, 55 (45%) patients survived with good NO (GNO; CPC 1-2) and 65 (55%) patients presented a poor NO (PNO; CPC 3-5). Classical inflammation markers such as PCR and NLR were significant higher in PNO than in GNO Group (P-value = 0.0042 and p-ANOVA = 0.0444, respectively) (Figure 1A). 11 inflammation-related miRNAs with strong correlation with OHCA-related conditions such as cardiovascular and coronary artery disease, hypoxic encephalopathy and neuro-inflammation were pre-targeted by in silico analysis. Five of the pre-targetedmiRNAs (miR-21-5p, miR-23a-3p, miR-146-5p, miR-155-5p and miR-181a-5p) presented significant differences between GNO and PNO groups (p-ANOVA = 0.0001, 0.0027, 0.0001, 0.0023 and 0.0002 respectively) in at least one time point, with an reduced expression in all cases in the PNO respect the GNO group (Figure 1B). Conclusions Patients with PNO after OHCA presents a downregulation of inflammation-regulatory miRNAs that leads an increase of clinical inflammation-related mediators such as PCR and NLR, with potential neuro-inflammatory consequences.

The severity of metabolic derangement predicts survival of out-of-hospital cardiac arrest and the benefit of extracorporeal life support

Abstract Aims This study aimed to develop Metabolic Derangement score and validate its prognostic performance in patients with out-of-Hospital Cardiac Arrest (OHCA) and also its discriminative performance in guiding the application of extracorporeal life support (ECLS). Methods and Results From 5,100 patients (average age 67 years, 69% male), Metabolic Derangement score was developed to predict primary outcome (death or poor neurologic outcome, cerebral performance category ≥ 3 at day 30) from initial blood laboratory test including pH, PaCO2, PaO2, potassium, haemoglobin, lactate, and creatinine. It was created using machine learning algorithms and a training set (60%), and validated with a test set (40%). The risk of primary outcome consistently increased from 34% to 100% as the Metabolic Derangement score ranged from 0 to 7. Patients with Metabolic Derangement score ≤ 2 showed no difference in the primary outcome risk between those with or without ECLS. Conversely, those with a Metabolic Derangement score ≥3 had a lower risk with ECLS (difference of restricted mean survival time=6.5 days, 95% CI=3.3-9.6 days, ratio of restricted mean time lost=0.76, 95%CI=0.65-0.88, all p&amp;lt;0.001). Clinical subgroup analyses showed generally consistent results. Metabolic Derangement score also outperformed OHCA-, CAHP-, and NULL-PLEASE-scores in prediction the primary outcome (p&amp;lt;0.05, all). Conclusions The severity of metabolic derangement predicted the clinical outcome of OHCA, and could also identify patients likely to benefit from ECLS.Metabolic Derangement score

Therapeutic hypothermia after out-of-hospital cardiac arrest in comatose patients with acute myocardial infarction

Abstract Background Comatous survivors of out-of-hospital cardiac arrest (OHCA) have a high risk of death or poor neurological outcome. Therapeutic hypothermia is recommended for these patients after OHCA. However, there is a lack of data regarding outcomes of therapeutic hypothermia after OHCA in comatose patients with acute myocardial infarction (AMI). Purpose This study aimed to investigate the impact of therapeutic hypothermia on clinical outcomes in comatose patients who underwent primary percutaneous coronary intervention (PCI) for AMI after OHCA. Methods Using a prospective nationwide registry from 2016 to 2021, we examined 2,925 consecutive comatose patients experiencing OHCA in patients with AMI. These patients were categorized into groups receiving hypothermia treatment (n=624) and those without hypothermia treatment (n=2,301). The primary endpoint was the mortality rate upon discharge. The secondary endpoints were mortality rates at 6 or 24 hours, and neurological outcomes at hospital discharge. Results Overall, 624 (21.3%) patients were classified into the hypothermia group. This group showed a notably reduced mortality rate (hazard ratio [HR]: 0.68, 95% confidence interval [CI]: 0.58-0.78, p&amp;lt;0.001) after IPTW analysis (Figure 1). While the worse neurological outcome (as indicated by cerebral performance category [CPC] category 3-5) at hospital discharge was not significantly different between groups after IPTW analysis (odds ratio [OR]: 1.04, 95% CI: 0.93-1.15, p=0.499), early hypothermia within 180 minutes after hospital arrival showed significantly lower mortality rates (HR: 0.64, 95% CI: 0.44-0.95, p=0.027) and reduced occurrence of worse neurological outcome (OR: 0.75, 95% CI: 0.59-0.96, p=0.021) after IPTW analysis (Figure 2). Detailed hypothermia protocol including a targeted temperature of 33°C vs. 36°C or hypothermia duration of 48 hours vs. 24 hours did not significantly reduce the rate of death or poor neurological outcome at discharge. Conclusions Therapeutic hypothermia in OHCA patients complicating AMI was associated with lower mortality rates and comparable neurologic outcomes. However, early hypothermia within 180 minutes after hospital arrival showed significantly improved the mortality and neurological outcomes.all-cause deathAll-cause death and neurological outcome

Effect of nelonemdaz for patients with out-of-hospital cardiac arrest: the AWAKE phase II randomised clinical trial

Abstract Background Hypoxic brain injury is a major hurdle that limits the survival of out-of-hospital cardiac arrest (OHCA). Nelonemdaz is a dual-target neuroprotectant, serving as a moderate NR2B-selective N-methyl-D-aspartate (NMDA) receptor antagonist while also exhibiting potent free radical scavenger properties. This dual neuroprotective action of nelonemdaz has the potential to reduce hypoxic brain injury in OHCA. We investigated the efficacy and safety of nelonemdaz for patients with OHCA. Methods AWAKE trial was a double-blind, placebo-controlled, randomised, multicentre phase II trial at 5 sites in South Korea. OHCA patients undergoing targeted temperature management were randomly assigned to high-dose (5250 mg), low-dose (3250 mg), and placebo groups at a 1:1:1 ratio. The primary outcome was the blood level of neuron-specific enolase (NSE) after 4th administration of drug. Secondary outcomes comprised blood biomarkers including neuron specific enolase (NSE) and S100beta, brain magnetic resonance imaging (MRI), and Cerebral Performance Category (CPC) and Modified Rankin Scale (mRS) up to day 90. Safety is assessed by serious adverse event. Findings: A total of 105 patients were enrolled between November 18, 2018 to February 23, 2023. Patients with a median age of 61 years and 82% male were assigned to the high-dose (N=37), low-dose (N=35), and placebo (N=33) groups. Primary outcome was evaluated in 93 patients. There was no difference of neuron specific enolase (NSE, ng/mL), which served as the primary endpoint, between high-dose (median and interquartile range; 23·7, 15·0–69·9) and placebo (17·5, 13·6–113·0) groups and also between low-dose (26·6, 16·2–83·4) versus placebo groups (all p&amp;gt;0·05). Among secondary outcomes, fractional anisotropy of brain MRI was significantly higher in high-dose group compared to placebo group (0·465, 0·449–0·485 versus 0·441, 0·431–0·464; p=0·028), and was not different between low-dose (0·462, 0·439–0·480) and placebo groups (p&amp;gt;0·05). At day 90, the common odds ratio (95% confidence interval) indicating a favourable shift in the modified Rankin Scale was 1·25 (0·48–3·24) and 1·22 (0·47–3·20) in the high-dose and low-dose groups respectively, compared to placebo group (all p&amp;gt;0·05). No serious adverse events were reported. Interpretation: Nelonemdaz did not reduced blood NSE level of OHCA patients. However, patients treated with high-dose nelonemdaz showed better fractional anisotropy that suggests reduced cerebral white matter damage. Patients treated with nelonemdaz also showed a favourable tendency of neurological recovery at day 90 without significant adverse effects. These results justify the initiation of a large-scale phase III trial.Neurological function up to day 90

Cardiovascular etiologies and risk factors of survival outcomes after resuscitation for out-of-hospital cardiac arrest: data from the KoCARC registry

Abstract Background The outcomes and characteristics of out-of-hospital cardiac arrest (OHCA) vary across geographic regions. The etiologies and prognoses of OHCA in Asian populations remain less established. This study aimed to investigate the etiologies and clinical characteristics of patients successfully resuscitated after OHCA and identify predictors of survival outcomes. Methods Data were extracted from a South Korean multicenter prospective registry of OHCA that included 64 tertiary hospitals from 2015 to 2018 (n=7577). The primary outcome was in-hospital mortality, and secondary outcome was the grade-1 cerebral performance category (CPC) score at discharge. Results Of the 7577 patients, 2066 achieved return of spontaneous circulation (ROSC) and were hospitalized and 915 (44·2%) presented with ventricular arrhythmia (VA) as their initial rhythm or on admission. The leading cause was obstructive coronary artery disease (n=413; 20·0%). Sudden unexplained death syndrome (SUDS) accounted for 67·5% of survivors, which were significantly lower with VA (82·7% vs. 48·3%, p&amp;lt;0.001). VA was an independent predictor of in-hospital mortality (adjusted hazard ratio [aHR] 0·72, 95% confidence interval 0·60–0·87) and the grade-1 CPC score at discharge (aHR 3·63, 95% CI 2·56–5·15). Other predictors of the primary outcome included age, ROSC on arrival, total arrest time, alertness on admission, extracorporeal membrane oxygenation use, targeted temperature management, implantable cardioverter defibrillator use, and coronary vasospasm. Conclusions SUDS was common in patients with ROSC after OHCA and thus needs to be evaluated comprehensively. VA was independently associated with favorable survival outcomes at discharge. Further management may improve clinical outcomes in patients with OHCA, particularly those with VA.

Multi-dimensional assessment of long-term outcomes in patients treated with extracorporeal cardiopulmonary resuscitation during refractory cardiac arrest

Abstract Background Recent randomised controlled trials showed short-term survival benefits with extracorporeal cardiopulmonary resuscitation (ECPR) compared to standard cardiac arrest treatment in selected patients with refractory cardiac arrest. Only limited data exist on multi-dimensional long-term outcomes after ECPR. Purpose To investigate multi-dimensional long-term outcomes of ECPR survivors, that is general health status, as well as cardiac, cognitive and psychological functions. Methods This is a multicenter, mixed-method clinical study conducted by cardiologists, neurologists and psychologists between May 2021 and December 2023. Adult patients who survived ECPR with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) or "ECMELLA" (i.e., VA-ECMO plus percutaneous left-ventricular assist device) in two German tertiary care centers were included. A comprehensive set of functional outcomes across multiple dimensions were assessed at approximately 18 months after the index cardiac arrest event (see Figure for stations A to E and explanation of abbreviations). Results Long-term outcomes were assessed in 32 ECPR survivors, out of whom 15 patients (46%) had received VA-ECMO and 18 (54%) ECMELLA treatment. 23 patients (70%) were male and the average age was 55 years (±13). Vital signs and laboratory markers were unremarkable. Most patients denied heart failure symptoms although the average EQ-5D-5L score was 52 (±8). The left-ventricular ejection fraction was 51% (±9), which improved by 14% (±11) in the ECMO group and 31% (±15) in the ECMELLA group since the index cardiac arrest event. Bicycle exercise (on average 6 minutes duration with a power of up to 100 Watts) and 6-minute walk test (average distance of 394 meters ±145) revealed physical impairments. 29 patients (88%) had a good cerebral performance (i.e., Cerebral Performance Category scale of 1) and the average mental status was good (mini–mental state examination score 29 ±1). 22 patients (56%) perceived (partial) impairments in activities of daily living although the average Barthel index was 100 (±5) and modified Rankin scale was 1 (±1). 12 patients (36%) were unable to return to their jobs. Remarkably, 17 (51%) and 4 (12%) patients reported depressive symptoms and suicidal thoughts, respectively. Conclusion Although ECPR remains a highly complex procedure, cardiac and neurologic functions in survivors have almost recovered, while physical and psychological impairments still persisted at 18 months after cardiac arrest. Physical rehabilitation and psychological care appear to be important measures for ECPR survivors.

NSE and S100β as serum alarmins in predicting neurological outcomes after cardiac arrest

Cardiac arrest (CA) is a serious health concern that often results in mortality or severe neurological dysfunction in the case of survival. Our aim was to explore the neurological prognostic factors in patients with CA. This retrospective observational study included adult patients with CA. We investigated serum neuron-specific enolase (NSE), S100 calcium-binding protein β (S100β), and indices and parameters at 1, 3, 5, 7 and intensive care unit (ICU) discharge days after CA. The primary study endpoint was the Cerebral Performance Category (CPC) scale score at ICU discharge, which was dichotomized as good neurological outcome (CPC 1–2: full recovery or moderate disability) and poor neurological outcome (CPC 3–5: severe disability, vegetative state, or death). Of the 191 adult patients with CA, 42 (22%) had good neurological outcomes, and 149 (78%) had poor neurological outcomes. NSE at 1,3,5,7 and ICU discharge days showed excellent predictive accuracy for neurological outcomes (area under the curve [AUC]: 0.666, 0.716, 0.870, 0.739, and 0.901, respectively). However, S100β exhibited general predictive power (AUC: 0.666, 0.573, 0.607, 0.594, 0.727). Finally, the early warning model, which combined day 1 NSE, day 1 S100β, cardiac arrest time, SOFA scores, APACHE II scores, and age, was used to screen CA patients with poor neurological prognosis at early stages and had an AUC of 0.792. Serum concentrations of NSE and S100β were significantly elevated in CA patients and could be prognostic biomarkers to predict neurological outcomes. Day 1 NSE and S100β combined with multiple indicators could be a decent early warning model for poor neurological prognosis in patients with CA.

Optimal timing of ultra-early diffusion-weighted MRI in out-of-hospital cardiac arrest patients based on a retrospective multicenter cohort study

Diffusion-weighted magnetic resonance imaging (DW-MRI) performed before target temperature management, within 6 h of return of spontaneous circulation (ROSC), is defined as ultra-early DW-MRI. In previous studies, high-signal intensity (HSI) on ultra-early DW-MRI can predict poor neurological outcomes (Cerebral Performance Category 3–5 at 6-months post-ROSC). We aimed to assess the optimal-timing for ultra-early DW-MRI to avoid false-negative outcomes post out-of-hospital cardiac arrest, considering cardiopulmonary resuscitation (CPR) factors. The primary outcomes were HSI in the cerebral cortex or deep gray matter on ultra-early DW-MRI. The impact of CPR factors and ROSC to DW-MRI scan-interval on HSI-presence was assessed. Of 206 included patients, 108 exhibited HSI-presence, exclusively associated with poor neurological outcomes. In multivariate regression analysis, ROSC to DW-MRI scan-interval (adjusted odds ratio [aOR], 1.509; 95% confidence interval (CI): 1.113–2.046; P = 0.008), low-flow time (aOR, 1.176; 95%CI: 1.121–1.233; P < 0.001), and non-shockable rhythm (aOR, 9.974; 95%CI: 3.363–29.578; P < 0.001) were independently associated with HSI-presence. ROSC to DW-MRI scan-interval cutoff of ≥ 2.2 h was particularly significant in low-flow time ≤ 21 min or shockable rhythm group. In conclusion, short low-flow time and shockable rhythm require a longer ROSC to DW-MRI scan-interval. Prolonged low-flow time and non-shockable rhythm reduce the need to consider scan-interval.

Factors associated with neurological outcomes in patients experiencing out-of-hospital cardiac arrest and severe acidaemia: retrospective analysis of a nation-wide registry

Background and objectiveAcidaemia is common among individuals who experience out-of-hospital cardiac arrest (OHCA). While severe acidaemia is a strong predictor of unfavourable outcomes, a subset of patients exhibits dramatic recovery. Despite these conflicting outcomes, little is known about the factors associated with neurological outcomes in those who experience OHCA with severe acidaemia. MethodsThis retrospective analysis used data from a Japanese multicentre nationwide database, the Japanese Association for Acute Medicine OHCA Registry. The analysis included data from adult patients with OHCA for whom blood pH data were available upon arrival to hospital. The primary outcome was 30-day survival with favourable neurological outcomes, defined as a Glasgow-Pittsburgh cerebral performance category score of 1 or 2. Patients were categorised with severe acidaemia if their blood pH was ≤ 6.8. Factors associated with favourable outcomes were investigated using multiple logistic regression analysis. ResultsData from 49,044 patients were included in the analysis, of whom 16,620 exhibited severe acidaemia with a median pH of 6.70 (interquartile range [IQR] 6.61–6.76], and 0.5% (86/16,620) experienced a neurologically favourable outcome. After adjustment for important prognostic factors, witnessed status exhibited a strong association with favourable neurological outcome (adjusted odds ratio [aOR] 6.46 [95% confidence interval (CI) 2.64–15.8]), while initial blood pH exhibited no significant association (aOR 0.90 with every 0.1 unit increase [95% CI 0.71–1.14]). ConclusionAlthough the number is small, a notable number of patients with severe acidaemia exhibited good neurological recovery. Witness status was critical for the prognosis of these patients.

Delays in Cardiopulmonary Resuscitation, Defibrillation, and Epinephrine Administration in Out-of-Hospital Cardiac Arrest - Composite Time-Dependent Effects of Prehospital Interventions on 30-Day Favorable Neurological Outcomes and Social Implications From a Prospective Nationwide Population-Based Cohort Study.

Our study investigated the prognostic impacts of the interval between collapse and the initiation of cardiopulmonary resuscitation (CPR), and subsequent intervals to defibrillation or epinephrine administration, on 30-day favorable neurological outcomes following out-of-hospital cardiac arrest (OHCA). This nationwide population-based cohort study used the All Japan Utstein Registry, encompassing OHCA patients in Japan between January 2006 and December 2021. The primary outcome was 30-day favorable neurological outcomes, defined as Cerebral Performance Category 1 or 2. Three-dimensional plots and multivariable logistic regression models were used to assess the time-dependent prognostic impacts of prehospital CPR interventions. In all, 184,731 OHCA patients (86,246 with shockable rhythm and 98,485 with non-shockable rhythm) were included in the study. Three-dimensional plots revealed that the interval between collapse and initiation of CPR, and subsequent intervals to defibrillation or epinephrine, were independently associated with 30-day favorable neurological outcomes in the groups with shockable and non-shockable rhythms, respectively (P<0.05 for all). Among patients with witnessed OHCA, there was a dose-response relationship between delays in the collapse-CPR initiation interval, and subsequent intervals to defibrillation or epinephrine administration, and 30-day favorable neurological outcomes. Our findings provide valuable insights into OHCA management.

The association between early hypotension and neurologic outcome after pediatric cardiac ECPR in children with cardiac disease

ObjectiveExplore the relationship between early hypotension after ECPR and survival to hospital discharge (SHD) with favorable neurologic outcome (FNO) in children with cardiac disease. MethodsRetrospective cohort study of patients undergoing ECPR at a single center pediatric cardiac intensive care unit. Hypotension was defined as MAP < 5th percentile for age. Primary and secondary exposure variables were presence and burden of hypotension respectively, during the first 6 h after ECPR. Our primary outcome was SHD with FNO defined by Pediatric Cerebral Performance Category score of 1–3 or no change from baseline. Secondary outcomes included acute central nervous system (CNS) injury via neuroimaging and EEG. Univariate and multivariable logistic regression analyses were performed. ResultsWe analyzed 82 index ECPR events from 2010 to 2022. Hypotension was observed for at least one MAP value in 36/82 (43.9%) of the cohort. The median [IQR] burden of hypotension was 0 [0,14.3]%. Patients with SHD with FNO had shorter CPR duration, lower number of epinephrine and calcium doses, and lower maximum lactate levels when compared to patients who died or had SHD without FNO. After controlling for potential confounders, there was no association between presence of hypotension or burden of hypotension and SHD, SHD with FNO, or acute CNS injury via neuroimaging and EEG. ConclusionIn children with cardiac disease, there was no association between early hypotension after ECPR and SHD with FNO. Multicenter studies are needed to better understand how early hypotension after ECPR affects neurologic outcomes in children with cardiac disease.

Validating the GO-FAR score: predicting in-hospital cardiac arrest outcomes in the Middle East

Introduction and aimExternal validations of the Good Outcome Following Attempted Resuscitation (GO-FAR) score have been in populations where Do Not Attempt Resuscitation (DNAR) is practised. We aim to externally validate the GO-FAR score in a population without a DNAR order.MethodsWe studied patients ≥ 18 years old who had an In-hospital cardiac arrest (IHCA) with known outcomes at Al Ain Hospital from January 2017 to December 2019, excluding those who died in the emergency department. Studied variables included demography, location, response time, code duration, initial rhythm, primary diagnosis, admission vital signs, GO FAR score variables, discharge status, and functional outcomes as determined by the cerebral performance category score ranging from 1 (good cerebral performance) to 5 (brain death).Results366 patients were studied; 66.7% were males. The median (IQR) age was 70 (55–81) years. Cardiac and respiratory causes were the primary diagnoses in 89 (24.6%) and 67 (18.5%), respectively. IHCA occurred in critical areas such as the intensive care unit, high dependency unit and coronary care unit in 206 (80.8%) patients. The majority, 308 (91.8%), had a non-shockable rhythm, and a return of spontaneous circulation was achieved in 159 (43.4%) of the patients. Thirty-one (8.5%) patients survived to hospital discharge, and 20 (5.5%) patients had cerebral performance category scores of 1 and 2. The area under the curve of the ROC for survival to discharge with good functional outcome was 0.74 (95% CI 0.59–0.88). The best cut-off point for predicting survival with a good neurological outcome was a GO-FAR score of < 4, having a sensitivity of 0.81, a specificity of 0.7, a positive likelihood ratio of 2.7 and a negative likelihood ratio of 0.27.ConclusionsA GO-FAR score of less than 4 predicts survival with a good neurological outcome in a healthcare system with an all-inclusive patient population with no DNAR practice.

Neurosurgical Procedures in Patients Requiring Extracorporeal Membrane Oxygenation.

Extracorporeal membrane oxygenation (ECMO) is often withheld in patients with significant neurologic injury or recent neurosurgical intervention due to perceived futility. Studies of neurosurgical interventions before or during ECMO are limited to case reports or single-center series, limiting generalizability, and outcomes in this population are unknown. We therefore sought to report the outcomes of ECMO patients with acute neurosurgical interventions at four high-volume ECMO and comprehensive stroke centers. Retrospective case series. Four academic tertiary referral hospitals in the United States. Adults (n = 24) having undergone neurosurgical procedures before or during ECMO. None. We retrospectively reviewed adults at four institutions who had undergone neurosurgical procedures immediately before or during ECMO from 2015 to 2023. The primary outcome was survival to hospital discharge. Secondary outcomes included favorable neurologic outcome (Cerebral Performance Category 1 or 2) and neurosurgical complications. Twenty-four of 2957 ECMO patients (0.8%) were included. Primary indications for neurosurgical intervention included traumatic brain (n = 8) or spinal (n = 3) injury, spontaneous intracranial hemorrhage (n = 6), and acute ischemic stroke (n = 5). Procedures included extraventricular drain (EVD) and/or intracranial pressure monitor placement (n = 10), craniectomy/craniotomy (n = 5), endovascular thrombectomy (n = 4), and spinal surgery (n = 3). Fifteen patients (63%) survived to hospital discharge, of whom 12 (80%) were discharged with favorable neurologic outcomes. Survival to discharge was similar for venoarterial and venovenous ECMO patients (8/12 vs. 7/12; p = 0.67) and those who had neurosurgery before vs. during ECMO (8/13 vs. 7/11; p = 0.92). One patient (4%) experienced a neurosurgical complication, a nonlethal tract hemorrhage from EVD placement. Survival to discharge was similar for neurosurgical and nonneurosurgical ECMO patients at participating institutions (63% vs. 57%; p = 0.58). Patients with acute neurologic injury can feasibly undergo neurosurgery during ECMO or can undergo ECMO after recent neurosurgery. Larger studies are needed to fully understand risks for bleeding and other procedure-related complications.

Effects of Perfusion, Coronary Artery Disease Burden, and Revascularization in Establishing Organized Cardiac Rhythm During Extracorporeal Cardiopulmonary Resuscitation for Shockable Refractory Out-of-Hospital Cardiac Arrest.

Two hundred eighty-nine consecutive patients in refractory shockable OHCA were placed on ECMO followed by coronary angiogram (n=289) and PCI (n=165). Patients were grouped based on the extracorporeal cardiopulmonary resuscitation stage where a sustained organized rhythm was achieved. Survival outcomes were evaluated by using the Cerebral Performance Category. Logistic regression analysis was performed to determine the relationship between Cerebral Performance Category and timing of organized rhythm. Standard advanced cardiac life support before hospital arrival resulted in 148 of 289 (51%) patients attaining an organized rhythm while 87 of 289 (30%) achieved an organized rhythm post ECMO cannulation but before PCI, and 37 of 289 (13%) achieved an organized rhythm following PCI. Obstructive coronary artery disease was observed in 192 of 289 (66%) patients. A total of 144 of 192 (75%) patients with obstructive coronary artery disease converted to an organized rhythm before PCI and 37 of 192 (19%) following PCI. Cerebral Performance Category score 1 or 2 was significantly more likely in patients with cardiac arrest and obstructive coronary artery disease who achieved an organized rhythm before PCI (odds ratio [OR], 3.9 [95% CI, 1.2-12.0], P=0.024). Most patients undergoing extracorporeal cardiopulmonary resuscitation for refractory OHCA due to shockable rhythms achieved an organized rhythm before PCI independent of coronary artery disease burden. Also, neurologically favorable survival was more prevalent in those attaining an organized rhythm before PCI.

Short-term neurologic outcomes in pediatric extracorporeal membrane oxygenation are proportional to bleeding severity graded by a novel bleeding scale.

This study aimed to characterize the severity of bleeding and its association with short-term neurologic outcomes in pediatric ECMO. Multicenter retrospective cohort study of pediatric ECMO patients at 10 centers utilizing the Pediatric ECMO Outcomes Registry (PEDECOR) database from December 2013-February 2019. Subjects excluded were post-cardiac surgery patients and those with neonatal pathologies. A novel ECMO bleeding scale was utilized to categorize daily bleeding events. Poor short-term neurologic outcome was defined as an unfavorable Pediatric Cerebral Performance Category (PCPC) or Pediatric Overall Performance Category (POPC) (score of >3) at hospital discharge. This study included 283 pediatric ECMO patients with a median (interquartile range [IQR]) age of 1.3years [0.1, 9.0], ECMO duration of 5days [3.0, 9.5], and 44.1% mortality. Unfavorable PCPC and POPC were observed in 48.4% and 51.3% of patients at discharge, respectively. Multivariable logistic regression analysis included patient's age, cannulation type, duration of ECMO, need for cardiopulmonary resuscitation, acute kidney injury, new infection, and vasoactive-inotropic score. As the severity of bleeding increased, there was a corresponding increase in the likelihood of poor neurologic recovery, shown by increasing odds of unfavorable neurologic outcome (PCPC), with an adjusted odds ratio (aOR) of 0.77 (confidence interval [CI] 0.36-1.62), 1.87 (0.54-6.45), 2.97 (1.32-6.69), and 5.56 (0.59-52.25) for increasing bleeding severity (grade 1 to 4 events, respectively). Similarly, unfavorable POPC aOR (CI) was 1.02 (0.48-2.17), 2.05 (0.63-6.70), 5.29 (2.12-13.23), and 5.11 (0.66-39.64) for bleeding grade 1 to 4 events. Short-term neurologic outcomes in pediatric ECMO are proportional to the severity of bleeding events. Strategies to mitigate bleeding events could improve neurologic recovery in pediatric ECMO.

Heart rhythm at hospital admission: A factor for survival and neurological outcome among ECPR recipients?

BackgroundThe initial rhythm is a known predictor of survival in extracorporeal cardiopulmonary resuscitation (ECPR) patients. However, the effect of the rhythm at hospital admission on outcomes in these patients is less clear. MethodsThis observational, single-center study assessed the influence of the rhythm at hospital admission on 30-day survival and neurological outcomes at discharge in patients who underwent ECPR for out-of-hospital cardiac arrest (OHCA). ResultsBetween January 2012 and December 2023, 1,219 OHCA patients were admitted, and 210 received ECPR. Of these, 196 patients were analyzed. The average age was 52.9 years (±13), with 80.6 % male. The median time to ECPR initiation was 61 min (IQR 54–72). Patients with ventricular fibrillation as both the initial and admission rhythm had the highest 30-day survival rate (52 %: 35/67), while those with asystole in both instances had the lowest (6 %: 1/17, log-rank p < 0.00001). After adjusting for age, sex, initial rhythm, resuscitation time, location, bystander, and witnessed status, asystole at admission was linked to higher 30-day mortality (OR 4.03, 95 % CI 1.49–12.38, p = 0.009) and worse neurological outcomes (Cerebral Performance Category 3–5) at discharge (OR 4.61, 95 % CI 1.49–17.62, p = 0.013). ConclusionsThe rhythm at hospital admission affects ECPR outcomes. Patients presenting with and maintaining ventricular fibrillation have a higher chance of favorable neurological survival, whereas those presenting with or converting to asystole have poor outcomes. The rhythm at hospital admission appears to be a valuable criterion for deciding on ECPR initiation.

Prediction of poor prognosis using the peak systolic velocity and early diastolic velocity of the central retinal artery in patients with post‐cardiac arrest syndrome

AbstractIntroductionMonitoring intracranial pressure (ICP) in patients with post‐cardiac arrest syndrome (PCAS) is crucial for effective management and prognosis assessment. However, continuous ICP monitoring is rarely practiced. Increased ICP is often associated with the impairment of brain autoregulation. This study investigated whether central retinal artery (CRA) flow velocity, autoregulation status according to mean arterial pressure (MAP), and the optic nerve sheath diameter (ONSD)/eyeball transverse diameter (ETD) ratio could predict poor prognosis related to increased ICP in PCAS patients.MethodsIn this multicenter prospective observational study, transocular ultrasonography of the optic nerve sheath was performed on 38 PCAS patients treated with targeted temperature management from December 2021 to November 2022. CRA peak systolic velocity (PSV), early diastolic velocity (eDV), MAP, CRA‐PSV changes following MAP changes (autoregulation), and ONSD/ETD ratio were measured repeatedly from days 0 to 4 post‐admission.ResultsUnivariable analysis indicated that CRA‐PSV, nonpositive or flat CRA‐eDV, and disrupted autoregulation correlated with a poor prognosis (Cerebral Performance Category 4 or 5). In multivariable analysis, nonpositive CRA‐eDV or disrupted autoregulation was the most significant predictor of poor prognosis (odds ratio, 40.576; p = 0.002), with an area under the curve of 0.774. The ONSD/ETD ratio did not show a significant correlation.ConclusionsNonpositive CRA‐eDV, CRA‐PSV and disrupted autoregulation can predict poor prognosis in PCAS patients. Transocular Doppler ultrasonography of the CRA and autoregulation assessment may aid in ICP monitoring and management in PCAS patients.

Duration of prehospital and in-hospital cardiopulmonary resuscitation and neurological outcome in paediatric out-of-hospital cardiac arrest

BackgroundBecause of their young age and lack of known comorbidities, paediatric patients with out-of-hospital cardiac arrest (OHCA) often undergo prolonged cardiopulmonary resuscitation (CPR). We aimed to determine the association between...