Cerebral Performance Category Scale Research Articles

Ghrelin for Neuroprotection in Post–Cardiac Arrest Coma

Out-of-hospital cardiac arrest survival rates have markedly risen in the last decades, but neurological outcome only improved marginally. Despite research on more than 20 neuroprotective strategies involving patients in comas after cardiac arrest, none have demonstrated unequivocal evidence of efficacy; however, treatment with acyl-ghrelin has shown improved functional and histological brain recovery in experimental models of cardiac arrest and was safe in a wide variety of human study populations. To determine safety and potential efficacy of intravenous acyl-ghrelin to improve neurological outcome in patients in a coma after cardiac arrest. A phase 2, double-blind, placebo-controlled, multicenter, randomized clinical trial, Ghrelin Treatment of Comatose Patients After Cardiac Arrest: A Clinical Trial to Promote Cerebral Recovery (GRECO), was conducted between January 18, 2019, and October 17, 2022. Adult patients 18 years or older who were in a comatose state after cardiac arrest were assessed for eligibility; patients were from 3 intensive care units in the Netherlands. Expected death within 48 hours or unfeasibility of treatment initiation within 12 hours were exclusion criteria. Patients were randomized to receive intravenous acyl-ghrelin, 600 μg (intervention group), or placebo (control group) within 12 hours after cardiac arrest, continued for 7 days, twice daily, in addition to standard care. Primary outcome was the score on the Cerebral Performance Categories (CPC) scale at 6 months. Safety outcomes included any serious adverse events. Secondary outcomes were mortality and neuron-specific enolase (NSE) levels on days 1 and 3. A total of 783 adult patients in a coma after cardiac arrest were assessed for eligibility, and 160 patients (median [IQR] age, 68 [57-75] years; 120 male [75%]) were enrolled. A total of 81 patients (51%) were assigned to the intervention group, and 79 (49%) were assigned to the control group. The common odds ratio (OR) for any CPC improvement in the intervention group was 1.78 (95% CI, 0.98-3.22; P = .06). This was consistent over all CPC categories. Mean (SD) NSE levels on day 1 after cardiac arrest were significantly lower in the intervention group (34 [6] μg/L vs 56 [13] μg/L; P = .04) and on day 3 (28 [6] μg/L vs 52 [14] μg/L; P = .08). Serious adverse events were comparable in incidence and type between the groups. Mortality was 37% (30 of 81) in the intervention group vs 51% (40 of 79) in the control group (absolute risk reduction, 14%; 95% CI, -2% to 29%; P = .08). In patients in a coma after cardiac arrest, intravenous treatment with acyl-ghrelin was safe and potentially effective to improve neurological outcome. Phase 3 trials are needed for conclusive evidence. Clinicaltrialsregister.eu: EUCTR2018-000005-23-NL.

Regional Brain Net Water Uptake in Computed Tomography after Cardiac Arrest – A Novel Biomarker for Neuroprognostication

BackgroundSelective 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. MethodsWe 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. ResultsWe 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%). ConclusionThis 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.

Neurological outcome of cardiac arrest patients in mountain areas: An analysis of the Northern French Alps Emergency Network

BackgroundMountainous areas pose a challenge for the out-of-hospital cardiac arrest (OHCA) chain of survival. Survival rates for OHCAs in mountainous areas may differ depending on the location. Increased survival has been observed compared to standard location when OHCA occurred on ski slopes. Limited data is available about OHCA in other mountainous areas. The objective was to compare the survival rates with a good neurological outcome of OHCAs occurring on ski slopes (On-S) and off the ski slopes (OffS) compared to other locations (OL). MethodsAnalysis of prospectively collected data from the cardiac arrest registry of the Northern French Alps Emergency Network (RENAU) from 2015 to 2021. The RENAU corresponding to an Emergency Medicine Network between all Emergency Medical Services and hospitals of 3 counties (Isère, Savoie, Haute-Savoie). The primary outcome was survival at 30 days with a Cerebral Performance Category scale (CPC) of 1 or 2 (1: Good Cerebral Performance, 2: Moderate Cerebral Disability). ResultsA total of 9589 OHCAs were included: 213 in the On-S group, 141 in the Off-S group, and 9235 in the OL group. Cardiac etiology was more common in On-S conditions (On-S: 68.9% vs OffS: 51.1% vs OL: 66.7%, p < 0.001), while Off-S cardiac arrests were more often due to traumatic circumstances (OffS: 39.7% vs On-S: 21.7% vs OL: 7.7%, p < 0.001). Automated external defibrillator (AED) use before rescuers' arrival was lower in the Off-S group than in the other two groups (On-S: 15.2% vs OL: 4.5% vs OffS: 3.7%; p < 0.002). The first AED shock was longer in the Off-S group (median time in minutes: OffS: 22.0 (9.5–35.5) vs On-S: 10.0 (3.0–19.5) vs OL: 16.0 (11.0–27.0), p = 0.03). In multivariate analysis, on-slope OHCA remained a positive factor for 30-day survival with a CPC score of 1 or 2 with a 1.96 adjusted odds ratio (95% confidence interval (CI), 1.02–3.75, p = 0.04), whereas off-slope OHCA had an 0.88 adjusted odds ratio (95% CI, 0.28–2.72, p = 0.82). ConclusionsOHCAs in ski-slopes conditions were associated with an improvement in neurological outcomes at 30 days, whereas off-slopes OHCAs were not. Ski-slopes rescue patrols are efficient in improving outcomes.

A national multi centre pre-hospital ECPR stepped wedge study; design and rationale of the ON-SCENE study

BackgroundThe likelihood of return of spontaneous circulation with conventional advanced life support is known to have an exponential decline and therefore neurological outcome after 20 min in patients with a cardiac arrest is poor. Initiation of venoarterial ExtraCorporeal Membrane Oxygenation (ECMO) during resuscitation might improve outcomes if used in time and in a selected patient category. However, previous studies have failed to significantly reduce the time from cardiac arrest to ECMO flow to less than 60 min. We hypothesize that the initiation of Extracorporeal Cardiopulmonary Resuscitation (ECPR) by a Helicopter Emergency Medical Services System (HEMS) will reduce the low flow time and improve outcomes in refractory Out of Hospital Cardiac Arrest (OHCA) patients.MethodsThe ON-SCENE study will use a non-randomised stepped wedge design to implement ECPR in patients with witnessed OHCA between the ages of 18–50 years old, with an initial presentation of shockable rhythm or pulseless electrical activity with a high suspicion of pulmonary embolism, lasting more than 20, but less than 45 min. Patients will be treated by the ambulance crew and HEMS with prehospital ECPR capabilities and will be compared with treatment by ambulance crew and HEMS without prehospital ECPR capabilities. The primary outcome measure will be survival at hospital discharge. The secondary outcome measure will be good neurological outcome defined as a cerebral performance categories scale score of 1 or 2 at 6 and 12 months.DiscussionThe ON-SCENE study focuses on initiating ECPR at the scene of OHCA using HEMS. The current in-hospital ECPR for OHCA obstacles encompassing low survival rates in refractory arrests, extended low-flow durations during transportation, and the critical time sensitivity of initiating ECPR, which could potentially be addressed through the implementation of the HEMS system. When successful, implementing on-scene ECPR could significantly enhance survival rates and minimize neurological impairment.Trial registrationClinicaltyrials.gov under NCT04620070, registration date 3 November 2020.

Non-linear association between the time required to reaching temperature targets and the neurological outcome in patients undergoing targeted temperature management after out-of-hospital cardiac arrest: Observational multicentre cohort study

PurposeWe evaluated associations between outcomes and time to achieving temperature targets during targeted temperature management of out-of-hospital cardiac arrest. MethodsUsing Comprehensive Registry of Intensive Care for out-of-hospital cardiac arrest Survival (CRITICAL) study, we enrolled all patients transported to participating hospitals from 1 July 2012 through 31 December 2017 aged ≥ 18 years with out-of-hospital cardiac arrest of cardiac aetiology and who received targeted temperature management in Osaka, Japan. Primary outcome was Cerebral Performance Category scale of 1 or 2 one month after cardiac arrest, designated as “one-month favourable neurological outcome”. Non-linear multivariable logistic regression analyses assessed the primary outcome based on time to reaching temperature targets. In patients subdivided into quintiles based on time to achieving temperature targets, multivariable logistic regression calculated adjusted odds ratios and 95% confidence intervals. ResultsWe analysed 473 patients. In non-linear multivariable logistic regression analysis, p value for non-linearity was < 0.01. In the first quintile (< 26.7 minutes), second quintile (26.8–89.9 minutes), third quintile (90.0–175.1 minutes), fourth quintile (175.2–352.1 minutes), and fifth quintile (≥ 352.2 minutes), one-month favourable neurological outcome was 32.6% (31/95), 40.0% (36/90), 53.5% (53/99), 57.4% (54/94), and 37.9% (36/95), respectively. Adjusted odds ratios with 95% confidence intervals for one-month favourable neurological outcome in the first, second, third, and fifth quintiles compared with the fourth quintile were 0.38 (0.20 to 0.72), 0.43 (0.23 to 0.81), 0.77 (0.41 to 1.44), and 0.46 (0.25 to 0.87), respectively. ConclusionNon-linear multivariable logistic regression analysis could clearly describe the association between neurological outcome in patients with out-of-hospital cardiac arrest and the time from the introduction of targeted temperature management to reaching the temperature targets.

A Comparison of Prognostic Factors in a Large Cohort of In-Hospital and Out-of-Hospital Cardiac Arrest Patients.

We investigated independent factors predicting neurological outcome and death, comparing in-hospital (IHCA) and out-of-hospital cardiac arrest (OHCA) patients. The study was conducted in the mixed 34-bed Intensive Care Department at the Hôpital Universitaire de Bruxelles (HUB), Belgium. All adult consecutive cardiac arrest (CA) survivors were included between 2004 and 2022. For all patients, demographic data, medical comorbidities, CA baseline characteristics, treatments received during Intensive Care Unit stay, in-hospital major complications, and neurological outcome at three months after CA, using the Cerebral Performance Category (CPC) scale, were collected. In the multivariable analysis, in the IHCA group (n = 540), time to return of spontaneous circulation (ROSC), older age, unwitnessed CA, higher lactate on admission, asystole as initial rhythm, a non-cardiac cause of CA, the occurrence of shock, the occurrence of acute kidney injury (AKI), and the presence of previous neurological disease and of liver cirrhosis were independent predictors of an unfavorable neurological outcome. Among patients with OHCA (n = 567), time to ROSC, older age, higher lactate level on admission, unwitnessed CA, asystole or pulseless electrical activity (PEA) as initial rhythm, the occurrence of shock, a non-cardiac cause of CA, and a previous neurological disease were independent predictors of an unfavorable neurological outcome. To conclude, in our large cohort of mixed IHCA and OHCA patients, we observed numerous factors independently associated with a poor neurological outcome, with minimal differences between the two groups, reflecting the greater vulnerability of hospitalized patients.

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

ObjectivesThis study aimed to identify factors associated with neurological and disability outcomes in patients who underwent ECMO following cardiac arrest. MethodsThis retrospective, single-center, observational study included adult patients who received ECMO treatment for in-hospital cardiac arrest (IHCA) or out-of-hospital cardiac arrest (OHCA) between February 2016 and March 2020. Factors associated with neurological and disability outcomes in these patients who underwent ECMO were assessed. SettingHamad General Hospital, Qatar. Main outcome measuresNeurological disability outcomes were assessed using the Modified Rankin Scale (mRS) and the Cerebral Performance Category (CPC) scale. ResultsAmong the 48 patients included, 37 (77 %) experienced OHCA, and 11 (23 %) had IHCA. The 28-day survival rate was 14 (29.2 %). Of the survivors, 9 (64.3 %) achieved a good neurological outcome, while 5 (35.7 %) experienced poor neurological outcomes. Regarding disability, 5 (35.7 %) of survivors had no disability, while 9 (64.3 %) had some form of disability. The results showed significantly shorter median time intervals in minutes, including collapse to cardiopulmonary resuscitation (CPR) (3 vs. 6, P = 0.001), CPR duration (12 vs. 35, P = 0.001), CPR to extracorporeal cardiopulmonary resuscitation (ECPR) (20 vs. 40, P = 0.001), and collapse-to-ECPR (23 vs. 45, P = 0.001), in the good outcome group compared to the poor outcome group. ConclusionThis study emphasizes the importance of minimizing the time between collapse and CPR/ECMO initiation to improve neurological outcomes and reduce disability in cardiac arrest patients. However, no significant associations were found between outcomes and other demographic or clinical variables in this study. Further research with a larger sample size is needed to validate these findings. Implications for clinical practiceThe study underscores the significance of reducing the time between collapse and the initiation of CPR and ECMO. Shorter time intervals were associated with improved neurological outcomes and reduced disability in cardiac arrest patients.

Factors influencing the development of infantile traumatic brain injury with a biphasic clinical course and late reduced diffusion

BackgroundInfantile traumatic brain injury (TBI) with a biphasic clinical course and late reduced diffusion (TBIRD) has been reported as a type of TBI. However, it remains uncertain which pediatric patients with TBI develop TBIRD. MethodsPatients with TBI who were admitted to our hospital and underwent magnetic resonance imaging (MRI) between December 2006 and October 2022 were included in this study. A diagnosis of TBIRD was made in patients with or suspected TBI, with initial symptoms being convulsions or disturbance of consciousness and late-onset subcortical reduced diffusion, the so-called bright tree appearance. Clinical features, neuroimaging (computed tomography (CT) and MRI) findings, laboratory data, and Tada score were retrospectively compared between TBIRD and non-TBIRD patients. Neurological prognosis was assessed using the Pediatric Cerebral Performance Category scale. ResultsOf 21 patients who met the inclusion criteria, a diagnosis of TBIRD was made in 7 patients (median age: 8 months). The factors contributing to TBIRD development were seizures lasting over 30 min as the initial symptom (5/7 in TBIRD vs. 0/14 in non-TBIRD), tracheal intubation during initial treatment (5/7 vs. 0/14), and brain parenchymal lesions on CT (3/7 vs. 0/14), suggesting that severe TBI may progress to TBIRD. The Tada score was more positive in patients with TBIRD (6/7) than in those without (0/14). ConclusionsIt is important to monitor infant patients with severe TBI for the development of TBIRD. The Tada score can be a useful tool for TBIRD prediction.

Out-of-Hospital Cardiac Arrest Following the COVID-19 Pandemic

Out-of-hospital cardiac arrest (OHCA) health care provision may be a good indicator of the recovery of the health care system involved in OHCA care following the COVID-19 pandemic. There is a lack of data regarding outcomes capable of verifying this recovery. To determine whether return to spontaneous circulation, overall survival, and survival with good neurological outcome increased in patients with OHCA since the COVID-19 pandemic was brought under control in 2022 compared with prepandemic and pandemic levels. This observational cohort study was conducted to examine health care response and survival with good neurological outcome at hospital discharge in patients treated following OHCA. A 3-month period, including the first wave of the pandemic (February 1 to April 30, 2020), was compared with 2 periods before (April 1, 2017, to March 31, 2018) and after (January 1 to December 31, 2022) the pandemic. Data analysis was performed in July 2023. Emergency medical services (EMS) serving a population of more than 28 million inhabitants across 10 Spanish regions participated. Patients with OHCA were included if participating EMS initiated resuscitation or continued resuscitation initiated by a first responder. The pandemic was considered to be under control following the official declaration that infection with SARS-CoV-2 was to be considered another acute respiratory infection. The main outcomes were return of spontaneous circulation, overall survival, and survival at hospital discharge with good neurological outcome, expressed as unimpaired or minimally impaired cerebral performance. A total of 14 732 patients (mean [SD] age, 64.2 [17.2] years; 10 451 [71.2%] male) were included, with 6372 OHCAs occurring during the prepandemic period, 1409 OHCAs during the pandemic period, and 6951 OHCAs during the postpandemic period. There was a higher incidence of OHCAs with a resuscitation attempt in the postpandemic period compared with the pandemic period (rate ratio, 4.93; 95% CI, 4.66-5.22; P < .001), with lower incidence of futile resuscitation for OHCAs (2.1 per 100 000 person-years vs 1.3 per 100 000 person-years; rate ratio, 0.81; 95% CI, 0.71-0.92; P < .001). Recovery of spontaneous circulation at hospital admission increased from 20.5% in the pandemic period to 30.5% in the postpandemic period (relative risk [RR], 1.08; 95% CI, 1.06-1.10; P < .001). In the same way, overall survival at discharge increased from 7.6% to 11.2% (RR, 1.45; 95% CI, 1.21-1.75; P < .001), with 6.6% of patients being discharged with good neurological status (Cerebral Performance Category Scale categories 1-2) in the pandemic period compared with 9.6% of patients in the postpandemic period (RR, 1.07; 95% CI, 1.04-1.10; P < .001). In this cohort study, survival with good neurological outcome at hospital discharge following OHCA increased significantly after the COVID-19 pandemic.

Ferritin as an Effective Predictor of Neurological Outcomes in Children With Acute Necrotizing Encephalopathy

BackgroundAcute necrotizing encephalopathy (ANE) is a fulminant disease with poor prognosis. Cytokine storm is the important phenomenon of ANE that affects the brain and multiple organs. The study aimed to identify whether hyperferritinemia was associated with poor prognosis in patients with ANE. MethodsAll patients with ANE had multiple symmetric lesions located in the bilateral thalami and other regions such as brainstem tegmentum, cerebral white matter, and cerebellum. Neurological outcome at discharge was evaluated by pediatric neurologists using the Pediatric Cerebral Performance Category Scale. All risk factors associated with poor prognosis were further analyzed using receiver operating characteristic curve analysis. ResultsTwenty-nine patients with ANE were enrolled in the current study. Nine (31%) patients achieved a favorable neurological outcome, and 20 (69%) patients had poor neurological outcomes. results The group of poor neurological outcome had significantly higher proportion of shock on admission and brainstem involvement. Based on multivariate logistic regression analysis, ferritin, aspartate aminotransferase (AST), and ANE severity score (ANE-SS) were the predictors associated with outcomes. The appropriate cutoff value for predicting neurological outcomes in patients with ANE was 1823 ng/mL for ferritin, 78 U/L for AST, and 4.5 for ANE-SS. Besides, comparison analyses showed that higher level of ferritin and ANE-SS were significantly correlated with brainstem involvement (P < 0.05). ConclusionsFerritin may potentially be a prognostic factor in patients with ANE. Hyperferritinemia is associated with poor neurological outcomes in patients with ANE and ferritin levels more than 1823 ng/mL have about eightfold increased risk of poor neurological outcome.

Impact of clinical variables on outcomes in refractory cardiac arrest patients undergoing extracorporeal cardiopulmonary resuscitation.

In the past two decades, extracorporeal resuscitation (ECPR) has been increasingly used in the management of refractory cardiac arrest (CA) patients. Decision algorithms have been used to guide the care such patients, but the effectiveness of such decision-making tools is not well described. The aim of this study was to compare the rate of survival with a good neurologic outcome of patients treated with ECPR meeting all criteria of a clinical decision-making tool for the initiation of ECPR to those for whom ECPR was implemented outside of the algorithm. All patients who underwent E-CPR between January 2014 and December 2021 at the Montreal Heart Institute were included in this retrospective analysis. We dichotomized the cohort according to adherence or non-adherence with the ECPR decision-making tool, which included the following criteria: age ≤65 years, initial shockable rhythm, no-flow time <5 min, serum lactate <13 mmol/L. Patients were included in the "IN" group when they met all criteria of the decision-making tool and in the "OUT" group when at least one criterion was not met. The primary outcome was survival with intact neurological status at 30 days, defined by a Cerebral Performance Category (CPC) Scale 1 and 2. A total of 41 patients (IN group, n = 11; OUT group, n = 30) were included. A total of 4 (36%) patients met the primary outcome in the IN group and 7 (23%) in the OUT group [odds ratio (OR): 1.88 (95% CI, 0.42-8.34); P = 0.45]. However, survival with a favorable outcome decreased steadily with 2 or more deviations from the decision-making tool [2 deviations: 1 (11%); 3 deviations: 0 (0%)]. Most patients supported with ECPR fell outside of the criteria encompassed in a clinical decision-making tool, which highlights the challenge of optimal selection of ECPR candidates. Survival rate with a good neurologic outcome did not differ between the IN and OUT groups. However, survival with favorable outcome decreased steadily after one deviation from the decision-making tool. More studies are needed to help select proper candidates with refractory CA patients for ECPR.

Associated Factors of Cardiopulmonary Resuscitation Outcomes; a Cohort Study on an Adult In-hospital Cardiac Arrest Registry.

In-hospital cardiac arrest (IHCA) remains a substantial cause of morbidity and mortality for hospitalized patients worldwide. This study aimed to identify associated factors of return of spontaneous circulation (ROSC) and survival with favorable neurological outcomes of IHCA patients. A two-year retrospective cohort study was conducted at a university-based tertiary care hospital in Bangkok, Thailand, studying adult patients aged ≥ 18 years with IHCA from January 2021 to December 2022. The primary endpoint was sustained ROSC, and the secondary endpoint was survival with favorable neurological outcomes defined as Cerebral Performance Categories (CPC) Scale of 1 or 2 at discharge. Pre-arrest and intra-arrest variables were collected and analyzed using multivariable logistic regression to identify independent factors associated with the outcomes. During the study period, 156 patients were included in the study. 105 (67.3%) patients achieved sustained ROSC after the CPR, 28 patients (18.0%) were discharged alive, and 15 patients (9.6%) survived with a favorable neurological outcome at hospital discharge. Overall, sustained ROSC was higher in patients who had IHCA during the day shift (odds ratio (OR): 4.11; 95% confidence interval (CI): 1.05-16.06) and electrocardiogram (ECG) monitoring prior to arrest (OR: 6.38; 95% CI: 1.18-34.54). In contrast, higher adrenaline doses administrated, and increased CPR duration reduced the odds of sustained ROSC (OR: 0.72; 95% CI: 0.54-0.94 and OR: 0.92; 95% CI: 0.85-0.98, respectively). Arrest due to cardiac etiology was associated with increased discharged survival with favorable neurological outcomes (OR: 13.43; 95% CI: 2.00-89.80), while a higher Good Outcome Following Attempted Resuscitation (GO-FAR) score reduced the odds of the secondary outcome (OR: 0.89; 95% CI: 0.81-0.98). The sustained ROSC was higher in IHCA during the daytime shift and under prior ECG monitoring. The administration of higher doses of adrenaline and prolonged CPR durations decreased the likelihood of achieving sustained ROSC. Furthermore, patients with cardiac-related causes of cardiac arrest exhibited a higher rate of survival to hospital discharge with favorable neurological outcomes.

Resting-State Functional Magnetic Resonance Imaging Network Association With Mortality, Epilepsy, Cognition, and Motor Two-Year Outcomes in Suspected Severe Neonatal Acute Brain Injury

Background and ObjectivesIn acute brain injury of neonates, resting-state functional magnetic resonance imaging (MRI) (RS) showed incremental association with consciousness, mortality, cognitive and motor development, and epilepsy, with correction for multiple comparisons, at six months postgestation in neonates with suspected acute brain injury (ABI). However, there are relatively few developmental milestones at six months to benchmark against, thus, we extended this cohort study to evaluate two-year outcomes. MethodsIn 40 consecutive neonates with ABI and RS, ordinal scores of resting-state networks; MRI, magnetic resonance spectroscopy, and electroencephalography; and up to 42-month outcomes of mortality, general and motor development, Pediatric Cerebral Performance Category Scale (PCPC), and epilepsy informed associations between tests and outcomes. ResultsMean gestational age was 37.8 weeks, 68% were male, and 60% had hypoxic-ischemic encephalopathy. Three died in-hospital, four at six to 42 months, and five were lost to follow-up. Associations included basal ganglia network with PCPC (P = 0.0003), all-mortality (P = 0.005), and motor (P = 0.0004); language/frontoparietal network with developmental delay (P = 0.009), PCPC (P = 0.006), and all-mortality (P = 0.01); default mode network with developmental delay (P = 0.003), PCPC (P = 0.004), neonatal intensive care unit mortality (P = 0.01), and motor (P = 0.009); RS seizure onset zone with epilepsy (P = 0.01); and anatomic MRI with epilepsy (P = 0.01). ConclusionFor the first time, at any age, resting state functional MRI in ABI is associated with long-term epilepsy and RSNs predicted mortality in neonates. Severity of RSN abnormality was associated with incrementally worsened neurodevelopment including cognition, language, and motor function over two years.

2021 European Resuscitation Council/European Society of Intensive Care Medicine Algorithm for Prognostication of Poor Neurological Outcome After Cardiac Arrest-Can Entry Criteria Be Broadened?

To explore broadened entry criteria of the 2021 European Resuscitation Council/European Society of Intensive Care Medicine (ERC/ESICM) algorithm for neuroprognostication including patients with ongoing sedation and Glasgow Coma Scale-Motor score (GCS-M) scores 4-5. Retrospective multicenter observational study. Four ICUs, Skane, Sweden. Postcardiac arrest patients managed at targeted temperature 36°C, 2014-2018. Neurologic outcome was assessed after 2-6 months according to the Cerebral Performance Category scale. None. In 794 included patients, median age was 69.5 years (interquartile range, 60.6-77.0 yr), 241 (30.4%) were female, 550 (69.3%) had an out-of-hospital cardiac arrest, and 314 (41.3%) had a shockable rhythm. Four hundred ninety-five patients were dead at follow-up, 330 of 495 died after a decision on withdrawal of life-sustaining therapies. At 72 hours after cardiac arrest 218 patients remained unconscious. The entry criteria of the original algorithm (GCS-M 1-3) was fulfilled by 163 patients and 115 patients with poor outcome were identified, with false positive rate (FPR) of 0% (95% CI, 0-79.4%) and sensitivity of 71.0% (95% CI, 63.6-77.4%). Inclusion of patients with ongoing sedation identified another 13 patients with poor outcome, generating FPR of 0% (95% CI, 0-65.8%) and sensitivity of 69.6% (95% CI, 62.6-75.8%). Inclusion of all unconscious patients (GCS-M 1-5), regardless of sedation, identified one additional patient, generating FPR of 0% (95% CI, 0-22.8) and sensitivity of 62.9% (95% CI, 56.1-69.2). The few patients with true negative prediction (patients with good outcome not fulfilling guideline criteria of a poor outcome) generated wide 95% CI for FPR. The 2021 ERC/ESICM algorithm for neuroprognostication predicted poor neurologic outcome with a FPR of 0%. Broadening inclusion criteria to include all unconscious patients regardless of ongoing sedation identified an additional small number of patients with poor outcome but did not affect the FPR. Results are limited by high rate of withdrawal of life-sustaining therapies and few patients with true negative prediction.

Temporal trends in neurologically intact survival after paediatric out-of-hospital cardiac arrest: a nationwide population-based observational study in Japan

Abstract Background/Introduction Out-of-hospital cardiac arrest (OHCA) in children is associated with poor outcomes. However, the temporal trends in survival, especially neurologically intact survival in paediatric patients with OHCA, remain unclear. Purpose To examine temporal trends in neurologically intact survival in paediatric patients with OHCA for over 16 years. Methods We reviewed the data of 27,202 children (age &amp;lt;18 years) who experienced OHCA and were treated by emergency medical service providers. Data were obtained from the All-Japan Utstein Registry from January 2005 to December 2020. We analysed the temporal trends in the 1-month neurologically intact survival (cerebral performance category scale 1 or 2: CPC 1–2) rate over time. Subgroup analyses for outcomes were performed by type of bystander cardiopulmonary resuscitation (CPR), dispatcher-assisted CPR, age group (infant [&amp;lt;1 year], child [1–11 years], adolescent [12–17 years]), witnessed status, and cause of arrest. The primary endpoint was the 1-month neurologically intact survival. Results The frequency of bystander CPR significantly increased from 50.0% in 2005 to 63.1% in 2020 and the frequency of dispatcher-assisted chest compression-only CPR (CC-CPR) significantly increased from 7.7% to 40.6% (both p for trend &amp;lt;0.0001). The rate of initial shockable rhythm significantly decreased from 5.0% to 3.4% (p for trend &amp;lt;0.0001). The multivariate logistic regression model showed that calendar year, age, witnessed arrest, presence of bystander CPR, initial shockable rhythm, and non-cardiac causes were associated with increased odds of CPC 1–2. The overall crude rates of 1-month CPC 1–2 significantly increased from 4.9% in 2005 to 11.0% in 2020 (p for trend &amp;lt;0.0001). In patients who received standard CPR with rescue breathing and CC-CPR, the 1-month CPC 1–2 rate significantly increased from 8.0% to 24.2% and 4.7% to 10.8% (p for trend &amp;lt;0.0001), respectively. The rate of CPC 1–2 in patients who underwent dispatcher-assisted CPR also increased from 4.4% to 9.2% (p for trend &amp;lt;0.0001). With regards to patient age groups, the rate of 1-month CPC 1–2 significantly increased from 2.4% in 2005 to 7.5% in 2020 for infants, 6.0% to 14.8% for children, and 6.5% to 11.4% for adolescents (all p for trend &amp;lt;0.0001). For witnessed arrest, the rate of 1-month CPC 1–2 significantly increased from 9.9% to 24.9% for witnessed arrest and 2.7% to 3.1% for unwitnessed arrest. The rate of 1-month CPC 1–2 significantly increased from 4.9% to 13.8% for presumed cardiac causes and 5.0% to 9.6% for non-cardiac causes. Conclusions The 1-month neurologically intact survival rate significantly increased from 2005 to 2020 for paediatric patients with OHCA in Japan, regardless of bystander CPR type, age, witnessed status, and cause of arrest. A frequency of dispatcher-assisted CC-CPR rate increase of almost five-fold over time was associated with a two-fold increase in the overall 1-month CPC 1–2 rate over time.

Abstract 159: Long-Term Survival and Neurological Follow-Up of Cardiac Arrest Survivors: Results From the French Multicentric Prospective Cohort the DESAC Study

Background: While short-term prognosis of cardiac arrest (CA) patients has been extensively studied, less is known regarding the mid- and long-term outcome of survivors. Aims: The aim of the DESAC study was to describe mid- and long-term survival and neurological status of CA survivors, and to assess the influence of pre- and intra-hospital therapeutic strategies on these outcomes. Methods: Between Jul 2015 and Oct 2018, patients over 18 years who were discharged alive from intensive care units in Paris and suburbs (France) after a non-traumatic CA were included and interviewed every 6 months during at least 24 months and up to 48 months in this multicentric study. Factors associated with Cerebral Performance Category (CPC) scale at 24 months were assessed with logistic regression, with CPC 1 or 2 level considered as a favorable neurological outcome. Trajectories of CPC were derived by mixed linear model in survivors with at least 3 evaluations. Results: Out of 593 survivors, 525 had a 24 months follow-up (mean age 57.6 +/-15.3, 79% men). CA occurred in public location in 251/525, with an initial shockable rhythm in 392/525. Prognostic factors independently associated with a favorable neurological outcome at 24 months were initial shockable rhythm (OR= 3.53 (1.65; 7.58)) and previous practice of sport (OR= 3.12 (1.20 ; 8.11)), whereas older age (OR per 10 years= 0.52 (0.40; 0.68)) and previous ischemic cardiomyopathy (OR= 0.34 (0.15 ; 0.77)) were poor prognostic factors. Therapeutic hypothermia or coronary procedures were not related to prognosis. Five trajectories of CPC could be derived among the 514 patients. Overall, 64% remained in CPC1, 13% in CPC2, 11% improved from CPC2 to CPC 12% died either early or lately (Figure 1). Conclusions: In this multicentric and prospective study, practice of sport and shockable rhythm were strongly associated with a favorable neurological recovery at 24 months. Furthermore, two thirds of the survivors remained in CPC 1 over time.

Abstract 150: Non-Linear Association Between the Time of Reaching the Targeted Temperature and the Neurological Outcome in Patients Undergoing Targeted Temperature Management After Out-of-Hospital Cardiac Arrest Observational Multicenter Cohort Study

Background: We aimed to identify the most favourable time from the introduction of targeted temperature management (TTM) to achieving the targeted temperature in patients experiencing out-of-hospital cardiac arrest. Methods: This multicenter cohort study was performed using the Comprehensive Registry of Intensive Care for OHCA Survival study, we collected patients’ information, including that on in-hospital care. We enrolled all consecutive patients transported to participating institutions in Osaka, Japan from 1 July 2012 through 31 December 2017. Eligible were persons aged ≥18 years whose cardiac arrest was of cardiac etiology and who received in-hospital TTM. Primary outcome was favourable neurological survival with a Cerebral Performance Category scale of 1 or 2 one-month after cardiac arrest, which was designated as “one-month favourable neurological survival”. After adjusting for several factors, a non-linear multivariable logistic regression analysis assessed the time from the introduction of TTM to reaching the targeted temperature and the probability of the primary outcome. Also, we subdivided patients according to five quintiles based on the time from the introduction of TTM to achieving the targeted temperature. To compare the probability of the primary outcome among quintiles, a multivariable logistic regression analysis calculated adjusted odds ratios and 95% confidence intervals. Results: We analyzed 483 patients. p for non-linearity was &lt;0.01 in the non-linear multivariable logistic regression analysis. In the first quintile (&lt;26.7 minutes), second quintile (26.8-89.9 minutes), third quintile (90.0-175.1 minutes), fourth quintile (175.2-352.1 minutes), and fifth quintile (≥352.2 minutes), one-month favourable neurological survival was 32.6% (31/95), 40.0% (36/90), 53.5% (53/99), 57.4% (54/94), and 37.9% (36/95), respectively. Adjusted odds ratios with 95% CI for the primary outcome in the first, second, third, and fifth quintiles, compared with the fourth quintile as the reference, were 0.38 (0.20 to 0.72), 0.43 (0.23 to 0.81), 0.77 (0.41 to 1.44), and 0.46 (0.25 to 0.87), respectively. Conclusions: Time to reaching the targeted temperature was associated with favourable outcome in patients with cardiac arrest.

Abstract 18326: The Association of s Shockable Rhythm and Automated External Defibrillator Use With Outcomes in Infants With Out of Hospital Cardiac Arrest: A Study From the Cardiac Arrest Registry to Enhance Survival

Introduction: Defibrillation with an automated external defibrillator (AED) is critical in the chain of survival following a cardiac arrest caused by pulseless ventricular tachycardia and ventricular fibrillation. However, in 2022 the International Liaison Committee on Resuscitation could not make a recommendation for or against the use of AEDs in infants. Hypothesis: We aimed to describe the association of a shockable rhythm with outcomes in infants with out of hospital cardiac arrest (OHCA) and test the hypothesis that a shockable rhythm and AED use with defibrillation would be associated with improved neurologically favorable survival at hospital discharge by analyzing data from a large cardiac arrest registry in the United States Methods: We conducted an analysis of the Cardiac Arrest Registry to Enhance Survival database. Inclusion criteria were age &lt; 1 year of age and non-traumatic OHCA from January 1, 2013 through December 31, 2021. The primary outcome was neurologically favorable survival defined as a Cerebral Performance Category Scale of 1 or 2. Results: A total of 10,108 infants with OHCA were evaluated of which 308 (3%) had a shockable rhythm and 9,800 (97%) had a non-shockable rhythm. Compared to infants with non-shockable rhythms infants with shockable rhythms were more likely to be white (37.7% white, 25.6% black, 7.5% Hispanic), have a witnessed arrest (44.5% vs. 16%), a non-home/public arrest (16.9% vs. 6.7%), and bystander AED application with defibrillation (19.4% vs. 0.18%) (p&lt;0.05 for all). Neurologically favorable survival (19.2% shockable vs. 4.2% non-shockable was higher in arrests with a shockable rhythm compared to non-shockable arrests, p&lt;0.001). AEDs were applied by bystanders in 1479 (14.5%) arrests and were associated with neurologically favorable survival (11% AED with defibrillation vs. 3.5% AED without defibrillation, p=0.002) Conclusions: Although infants infrequently had an OHCA with a shockable rhythm survival outcomes were superior in arrests with a shockable rhythm and in arrests where there was bystander AED use with defibrillation. These results emphasize the importance of AED use in infants with shockable rhythms following an OHCA.

Abstract 212: Association of Glycocalyx Shedding and Outcomes in Patients After Cardiac Arrest: A Prospective Observational Study

Background: The glycocalyx sheds early after cardiac arrest (CA). However, the potential value of elevated serum glycocalyx components remains unknown. Methods: This prospective observational study included patients who suffered CA and survived over 24 hours in the ICU of the Affiliated Hospital of Xuzhou Medical University from September 2021 to October 2022. Serum samples were collected 24 hours post CA to assess the concentration of glycocalyx shedding, including Heparan Sulfate (HS), Hyaluronic Acid (HA) and Syndecan-1 (Sdc-1). Patients were followed for 30 days or until death after CA. Outcome measures were 30-day Cerebral Performance Categories scale (CPC≤2, good function group; CPC&gt;2, poor function group), and 30-day mortality. Logistic regression was used to assess the association of glycocalyx shedding with the 30-day CPC scale. COX regression was used to assess the association of glycocalyx shedding with 30-day mortality. Results: we included 71 patients. Compared with good function group (n=22), poor function group (n=49) had significantly higher levels of HS. Adjusted logistic regression showed that the high level of HS was associated with poor functional outcome (Figure1A, OR=0.41, 95% CI=0.21-0.79, p&lt;0.01). Compared with the survival group (n=39), non-survival group (n=32) had higher levels of HA. Adjusted Cox regression indicated that high levels of HA was associated with mortality (Figure1B,Figure2, HA: HR=1.69,95%, CI=1.13-2.56, p&lt;0.05). Conclusions: Elevated serum HS levels in the early stages post-CA have an association with poor functional outcomes. Increased levels of serum HA post-CA are associated with a higher 30-day mortality.

The Identification of Subsequent Events Following Out-of-Hospital Cardiac Arrests with Targeted Temperature Management.

Out-of-hospital cardiac arrest (OHCA) is a critical issue due to poor neurological outcomes and high mortality rate. Severe ischemia and reperfusion injury often occur after cardiopulmonary resuscitation (CPR) and return of spontaneous circulation (ROSC). Targeted temperature management (TTM) has been shown to reduce neurological complications among OHCA survivors. However, it is unclear how "time-to-cool" influences clinical outcomes. In this study, we investigated the optimal timing to reach target temperature after cardiac arrest and ROSC. A total of 568 adults with OHCA and ROSC were admitted for targeted hypothermia assessment. Several events were predicted, including pneumonia, septic shock, gastrointestinal (GI) bleeding, and death. One hundred and eighteen patients [70 men (59.32%); 48 women (40.68%)] were analyzed for clinical outcomes. The duration of CPR after ROSC was significantly associated with pneumonia, septic shock, GI bleeding, and mortality after TTM (all p < 0.001). The duration of CPR was also positively correlated with poor outcomes on the Elixhauser score (p = 0.001), APACHE II score (p = 0.008), Cerebral Performance Categories (CPC) scale (p < 0.001), and Glasgow Coma Scale (GCS) score (p < 0.001). There was a significant association between the duration of CPR and time-to-cool of TTM after ROSC (Pearson value = 0.447, p = 0.001). Pneumonia, septic shock, GI bleeding, and death were significantly higher in the patients who underwent TTM with a time-to-cool exceeding 360 minutes (all p < 0.001). For cardiac arrest patients, early cooling has clear benefits in reducing clinical sequelae. Clinical outcomes could be improved by improving the time to reach target temperature and feasibility for critically ill patients.