Cerebral Performance Category Scale Research Articles

Near-infrared spectroscopy after out-of-hospital cardiac arrest

BackgroundCerebral hypoperfusion may aggravate neurological damage after cardiac arrest. Near-infrared spectroscopy (NIRS) provides information on cerebral oxygenation but its relevance during post-resuscitation care is undefined. We investigated whether cerebral oxygen saturation (rSO2) measured with NIRS correlates with the serum concentration of neuron-specific enolase (NSE), a marker of neurological injury, and with clinical outcome in out-of-hospital cardiac arrest (OHCA) patients.MethodsWe performed a post hoc analysis of a randomised clinical trial (COMACARE, NCT02698917) comparing two different levels of carbon dioxide, oxygen and arterial pressure after resuscitation from OHCA with ventricular fibrillation as the initial rhythm. We measured rSO2 in 118 OHCA patients with NIRS during the first 36 h of intensive care. We determined the NSE concentrations from serum samples at 48 h after cardiac arrest and assessed neurological outcome with the Cerebral Performance Category (CPC) scale at 6 months. We evaluated the association between rSO2 and serum NSE concentrations and the association between rSO2 and good (CPC 1–2) and poor (CPC 3–5) neurological outcome.ResultsThe median (inter-quartile range (IQR)) NSE concentration at 48 h was 17.5 (13.4–25.0) μg/l in patients with good neurological outcome and 35.2 (22.6–95.8) μg/l in those with poor outcome, p < 0.001. We found no significant correlation between median rSO2 and NSE at 48 h, rs = − 0.08, p = 0.392. The median (IQR) rSO2 during the first 36 h of intensive care was 70.0% (63.5–77.0%) in patients with good outcome and 71.8% (63.3–74.0%) in patients with poor outcome, p = 0.943. There was no significant association between rSO2 over time and neurological outcome. In a binary logistic regression model, rSO2 was not a statistically significant predictor of good neurological outcome (odds ratio 0.99, 95% confidence interval 0.94–1.04, p = 0.635).ConclusionsWe found no association between cerebral oxygenation measured with NIRS and NSE concentrations or outcome in patients resuscitated from OHCA.Trial registrationClinicalTrials.gov, NCT02698917. Registered on 26 January 2016.

Effectiveness and safety of nimodipine in preventing cerebral vasospasm after subarachnoid hemorrhage in children

Objective: To evaluate the effect of prophylactic nimodipine in vasospasm prevention and outcome improvement in children with subarachnoid hemorrhage (SAH). Methods: A prospective, randomized controlled clinical trial which enrolled children with SAH who were admitted to pediatric intensive care unit (PICU) of Beijing Children's Hospital from January 2015 to October 2018 was conducted. A total of 43 patients were randomly divided into nimodipine group (24 patients) and control group (19 patients) according to random number table. Transcranial Doppler (TCD) was used to dynamically monitor blood flow velocity and spectrum monography of bilateral middle cerebral artery (MCA) for vasospasm evaluation. Pediatric cerebral performance category (PCPC) scale was used to evaluate patients' brain function on 28(th) day after discharge. Data were analyzed by t test, Mann-Whitney U test, χ(2) test. Results: Except heart rate ((157±26) vs. (137±34) beats/min, t=2.079, P=0.045), no significant differences existed between the two groups in basic demographic characteristics, primary diseases, and clinical manifestations (all P>0.05). The peak velocities of bilateral MCA on the 5(th) day after admission were significantly lower in nimodipine group (left MCA (136±34) vs. (158±23) cm/s, t=-2.890, P=0.006; right MCA (129±34) vs. (176±27) cm/s, t=-3.717, P=0.001). Likewise, a lower peak velocity of left MCA was observed on the 7(th) day after admission in nimodipine group ((127±45) vs. (152±13) cm/s, t=-2.903, P=0.007), but no significant difference existed in that of right MCA ((131±48) vs. (150±22) cm/s, t=-1.760, P=0.090). Eleven patients suffered from vasospasm, 25% (6/24) in nimodipine group and 26% (5/19) in control group (χ(2)=0.010, P=1.000), within whom 8 patients had complete remission after continuing nimodipine treatment, one died in hospital and the other two's vasospasm still existed at the time of discharge. No significant differences were found between the two groups in mean length of hospitalization, proportion of mechanical ventilation, Glasgow coma scale at discharge, survival rate at discharge or survival rate on 28(t)h day after discharge (all P>0.05). However, nimodipine group had a higher proportion of favorable PCPC brain function (92% (22/24) vs. 63% (12/19), χ(2)=5.208, P=0.030). No side effects such as hypotension, rash or injection site erythema were observed. Conclusion: Prophylactic nimodipine cannot reduce vasospasm incidence in children with SAH but may improve short-term brain function, without any significant safety issues.

Hyponatremia in Children With Bacterial Meningitis.

Background: Hyponatremia has frequently been described as a common complication associated with bacterial meningitis, though its frequency and clinical course in children with bacterial meningitis are unclear. The present study aimed to investigate the frequency, clinical characteristics, and prognosis associated with pediatric hyponatremia due to bacterial meningitis.Methods: We performed a retrospective review of children with bacterial meningitis provided with standard care. One hundred seventy-five children were included. We documented all participants' symptoms and signs, laboratory and microbiological data, radiological findings, and complications that occurred during their hospital admission. Disease severity was determined using the maximum Pediatric Cerebral Performance Category (PCPC) and minimum Glasgow Coma Scale (GCS). Residual deficits were assessed using PCPC at discharge.Results: Hyponatremia (<135 mmol/L) was seen in 116 (66.4%) of the patients assessed and was classified as mild (130–135 mmol/L) in 77, moderate (125–129 mmol/L) in 26, and severe (<125 mmol/L) in 13. Hyponatremia was associated with a shorter duration of symptoms before admission, higher CSF white cell counts, and a longer duration of hospitalization. Moderate and severe hyponatremia were associated with an increase in convulsions, impaired consciousness, altered CSF protein levels, higher maximum PCPC scores, and lower minimum GCS scores. Severe hyponatremia was further associated with the development of systemic complications including shock, multiple organ dysfunction syndrome, respiratory failure requiring mechanical ventilation, and an increase in poor outcome (PCPC ≥ 2). Hyponatremia was not associated with the development of neurologic complications. Logistic regression analyses revealed that convulsions (OR 12.09, 95% CI 2.63–56.84) and blood glucose levels > 6.1 mmol/L (OR 8.28, 95% CI 1.65–41.60) predicted severe hyponatremia.Conclusion: Hyponatremia occurred in 66.4% of the assessed pediatric bacterial meningitis patients. Moderate and severe hyponatremia affected the severity of pediatric bacterial meningitis. Only severe hyponatremia affected the short-term prognosis of patients with pediatric bacterial meningitis. We recommend that patients with pediatric bacterial meningitis who exhibit convulsions and increased blood glucose levels should be checked for severe hyponatremia. Further studies are needed to evaluate the effectiveness of treatment of hyponatremia.

Use of systemic thrombolytic therapy in patients with non-traumatic cardiac arrest: A systematic review and meta-analysis

Objective: To better delineate the benefits and risks of systemic thrombolytic therapy inpatients with cardiac arrest from non-traumatic etiologies.Data sources: MEDLINE, EMBASE, and SCOPUS were systematically searched up toNovember of 2017.Study Selection: All retrospective and prospective studies in which systemic thrombolytictherapy was used during the sequence of cardiopulmonary resuscitation (CPR) or shortly afterachieving return of spontaneous circulation (ROSC) were included.Data extraction: The following variable results were extracted from intervention and controlgroups if available: rate of ROSC, survival after 24 hours, survival at discharge, neurologicalperformance at 6 months based on a favorable Cerebral Performance Categories Scale (1 or 2)and major bleeding events.Data Synthesis: Eight retrospective studies and 6 prospective studies were included in thequalitative analysis. Research synthesis was conducted when at least 4 studies were availablefor an outcome, which limited the analysis of major bleeding events and neurologic outcomes.Benefit of thrombolytic therapy in survival to discharge showed a moderate beneficial effect(OR = 2.79, 2.11–3.69) in the retrospective study analysis while in the prospective study analysisno statistically significant benefit was found (OR = 1.27, 0.77–2.10). Benefit of thrombolysis inthe rate of ROSC was not statistically significant in the prospective analysis (OR = 1.59, 0.92–2.76, p = 0.138) as well as survival at 24 hours (OR = 1.17, 0.72–1.71).Conclusions: The widespread use of thrombolytics in patients with non-traumatic cardiacarrest does not seem to improve major outcomes, including survival to discharge. However,the modest benefit found in the retrospective study analysis suggests a subgroup of patientsthat may benefit from this therapy.

Neurologic Outcomes in Patients Who Undergo Extracorporeal Cardiopulmonary Resuscitation

This study aimed to develop a risk prediction model for neurologic outcomes in patients who underwent extracorporeal cardiopulmonary resuscitation (ECPR). Between May 2004 and April 2016, a total of 274 patients who underwent ECPR were included in this analysis. The primary outcome was neurologic status on discharge from the hospital, as assessed by Cerebral Performance Categories (CPC) scale. To develop a new predictive scoring system, backward stepwise elimination and a z-score-based scoring scheme were used on the basis of logistic regression analyses. A total of 95 patients (34.7%) survived until discharge. Of these, 78 patients (28.5%) had favorable neurologic outcomes (CPC scores of 1 or 2). In the multivariable logistic regression analysis, significant predictors of poor neurologic outcome included age older than 65 years, initial Sequential Organ Failure Assessment score greater than 13 points, first monitored arrest rhythm, low-flow time longer than 30 minutes, initial pulse pressure less than 25 mm Hg, initial mean arterial pressure less than 70 mm Hg, and serum glucose level greater than 300 mg/dL. There was also a significant interaction between age and low-flow time. The newly developed neurologic outcome score after ECPR (nECPR) more effectively predicted poor neurologic outcome (C-statistic, 0.867; 95% confidence interval, 0.823 to 0.912) than the former ECPR score (p= 0.019) and the survival after venoarterial ECMO score (p < 0.001). The investigators created a risk prediction model for neurologic outcomes using independent predictors and the interaction between age and low-flow time, and this new scoring system could predict early neurologic prognosis more effectively in ECPR-treated patients. It may be help guide decisions in ECPR management for intensivists, cardiovascular surgeons, or cardiologists.

Change in neuron specific enolase levels in out-of-hospital cardiopulmonary arrest survivors as a simple and useful tool to predict neurological prognosis.

Neuron-specific enolase (NSE) is a prognostic marker in out-of-hospital cardiopulmonary arrest (OHCA) survivors treated with mild therapeutic hypothermia (MTH). The objectives were to analyze the correlation between dynamic changes in NSE and outcomes and to determine the measurement timing that best predicts neurological status. Multicenter cohort study including patients admitted after shockable rhythm OHCA and treated with MTH. Serum NSE was sampled at 2 different times and Δ-NSE (%) was calculated as 100 x (NSE2-NSE1)/NSE1. In-hospital mortality and neurological outcome, as assessed by the Cerebral Performance Category (CPC) scale, were evaluated during admission and after a 6-month follow-up. We included 166 patients admitted to 4 hospitals. In-hospital mortality was 31.9%. Almost 60% of patients had a good neurological recovery (CPC 1-2). On univariate and multivariate logistic regression analyses, an increase in NSE levels was associated with higher in-hospital mortality and worse CPC on discharge and after 6-months (P<.001). Positive Δ-NSE showed an OR=9.28 (95% CI 4.40-19.57) for mortality, OR=11.23 (95% CI 5.24-24.11) for CPC 3-5 at discharge and OR=11.14 (95% CI 5.05-24.55) for CPC 3-5 after 6-months' follow-up (P<.001). The first NSE measurement, conducted at 18 to 24hours, and the second measurement at 69 to 77hours after OHCA showed a high area under the curve in predicting CPC at discharge (0.9389 and 0.9909, respectively; 0.8096 for the whole cohort). Dynamic changes in NSE serum levels are good markers of hard clinical outcomes after an OHCA due to shockable rhythm in an MTH-treated cohort. NSE measurements at specific intervals after OHCA may predict events even more precisely.

Relationships between three and twelve month outcomes in children enrolled in the therapeutic hypothermia after pediatric cardiac arrest trials

AimTo inform design aspects of future trials by comparing 3 and 12-month neurobehavioural outcomes in children enrolled in Therapeutic Hypothermia After Pediatric Cardiac Arrest Out-Of-Hospital and In-Hospital (THAPCA-OH, THAPCA-IH) trials. MethodsThe THAPCA trials evaluated two targeted temperature management interventions (hypothermia, 32.0–34.0 °C; normothermia, 36.0–37.5 °C). Children, aged 2 days to <18 years, were enrolled from 2009–2015. Three and 12-month post-cardiac arrest (CA) outcomes included the Vineland Adaptive Behavior Scales, Second Edition (VABS-II) (population mean = 100, SD = 15) and the pediatric cerebral performance category (PCPC) scale. Children without significant pre-existing neurodevelopmental deficits were included in primary outcome analyses. Among survivors, favorable 12-month outcome was defined as VABS-II ≥ 70. ResultsVABS-II and PCPC were available at 3 and 12 months in 204 of 222 eligible survivors (THAPCA-OH, n = 82; THAPCA-IH, n = 122). Relative to THAPCA-IH, THAPCA-OH had significantly less pre-CA disability and significantly greater 12-month CA impairment, based on both VABS-II and PCPC. Correlations between 3 and 12-month VABS-II scores were strong for THAPCA-OH (r = 0.95) and THAPCA-IH (r = 0.72), and lower (p ≤ 0.001) in THAPCA-IH. Between time-points correlations were lower, but still significant in children <1 year at CA (p < 0.001). In both cohorts, 3-month VABS-II and PCPC categorical outcomes had high sensitivity (≥70%) for predicting favorable 12-month VABS-II outcomes, but specificity was lower for THAPCA-IH (68–89%) relative to THAPCA-OH (≥95%). Overall, 12-month diagnostic accuracy was ≥80% for both VABS-II and PCPC in both cohorts. ConclusionsIn future paediatric cardiac arrest clinical trials that enroll similar cohorts, integration of 3-month neurobehavioral outcome measures should be considered.

Role of Extracorporeal Membrane Oxygenation Support as a Bridge to Medical Therapy in Decompensated Pulmonary Hypertension

Purpose For patients with decompensated pulmonary hypertension (PH) who require extracorporeal membrane oxygenation (ECMO) support, limited literatures showed possibilities of ECMO support as a bridge to medical therapy without lung transplant. We analyzed the short and mid-term outcomes of ECMO bridge-to-recovery (BTR) strategy for decompensated PH. Methods From 2009 to 2018, 18 patients who underwent veno-arterial ECMO for decompensated PH were retrospectively reviewed. The mean age was 45.7 ± 12.2 years. Male to female ratio was 1:2. 8 patients who underwent extracorporeal cardiopulmonary resuscitation (ECPR) were compared with the 10 patients who did not. The predictors of hospital mortality and mid-term survival were analyzed. Results The ECPR and non-ECPR group were similar in age, sex, comorbidities, and baseline systolic pulmonary artery pressure (sPAP, 91.5 ± 40 vs 97.9 ± 25.2 mmHg, p = 0.37). Before ECMO implantation, the ECPR group had worse blood pressure (30.9 ± 34.3 vs 59.9 ± 33.7 mmHg, p = 0.04) and base excess (-12.2 ± 10.1 vs -1.9 ± 7.4 mEq/L, p = 0.02). At 24 hours post-ECMO, the two groups had similar blood pressure, gas and biochemistry data, except the higher PaO2/FiO2 ratio from right brachial artery in ECPR group (433.6±252.2 vs208.6±105, p = 0.03), suggesting a worse ventricular contractility. The sPAP at post-ECMO 24hrs was marginally higher in the ECPR group (82 ± 16.1 vs 50.8 ± 21.8 mmHg, p = 0.07). The combination of anti-PH medications tended to be less in the ECPR group throughout the course (2.2 ± 1.6 vs 3.5 ± 1.5 at post-ECMO day 3, p = 0.09). The rate of ECMO weaned-off was higher in the non-ECPR group (80% vs 25%, p = 0.05), but there was no difference in hospital mortality (50% vs 87.5%, p = 0.15). Central venous pressure after ECMO (OR 1.68, p = 0.03) and requirement of dialysis (OR 25, p = 0.02) were risk factors for mortality. The survival of discharged patients was 80% at 1 year and 60% at 5 year. The cerebral performance category scale (HR 7.23 if scale > 2, p = 0.04) and NYHA functional class at discharge (HR 7.0 if class > 2, p = 0.046) were predictors for midterm mortality. Conclusion ECMO with BTR strategy remains an option for decompensated PH. ECMO support before circulatory collapse might lead to better outcome. Medical and fluid optimization is the key to survive BTR. Neurological and functional outcomes are crucial for mid-term survival.

Poison severity score and sequential organ failure assessment score: Carbon monoxide poisoning prognosis.

PurposeWe aimed to examine the utility of the Poison Severity Score (PSS) and Sequential Organ Failure Assessment (SOFA) score as early prognostic predictors of short-term outcomes in patients with carbon monoxide (CO) poisoning. We hypothesized that both the PSS and the SOFA score would be useful prognostic tools.MethodsThis was retrospective observational study of patients with CO poisoning who presented to the emergency department and were admitted for more than 24 hours. We calculated PSS, the initial SOFA score, a second (2nd) SOFA score, and a 24-hour delta SOFA score. The primary outcome was reported as the cerebral performance category (CPC) scale score at discharge. We classified those with CPC 1–2 as the good outcome group and those with CPC 3–5 as the poor outcome group.ResultsThis study included 192 patients: 174 (90.6%) belonged to the good outcome group, whereas 18 (9.4%) belonged to the poor outcome group. The PSS (1.00 [0.00, 1.00] vs 3.00 [3.00, 3.00], p < 0.001), initial SOFA (1.00 [0.00, 2.00] vs 4.00 [3.25, 6.00], p < 0.001), 2nd SOFA score (0.00 [0.00, 1.00] vs 4.00 [3.00, 7.00], p < 0.001), and 24-hour delta SOFA score (-1.00 [-1.00, 0.00] vs 0.00 [-1.00, 1.00], p = 0.047) of the good outcome group were significantly higher than those of the poor outcome group. The areas under the receiver operating characteristic curve for PSS and the initial SOFA and 2nd SOFA scores were 0.977 (95% confidence interval [CI] 0.944–0.993), 0.945 (95% CI 0.903–0.973), and 0.978 (95% CI 0.947–0.994), respectively.ConclusionThe PSS, initial SOFA score, and 2nd SOFA score predict acute poor outcome accurately in patients with CO poisoning.

Multimodal assessment using early brain CT and blood pH improve prediction of neurologic outcomes after pediatric cardiac arrest

BackgroundEarly prediction of neurologic prognosis in children resuscitated from cardiac arrest is a major challenge. This study aimed to investigate the usefulness of a combined model based on brain computed tomography (CT) and initial blood gas analysis to predict neurologic prognoses in pediatric patients after cardiac arrest. MethodsWe retrospectively analyzed the medical records of patients resuscitated after cardiac arrest from 2000 to 2018. Patients aged one month to 18 years were included. Gray to white matter ratio (GWR), ambient cistern effacement (ACE), and blood gas analysis were studied. The primary outcome was neurological prognosis, which was evaluated using the Pediatric Cerebral Performance Category (PCPC) scale at discharge. ResultsOf 97 resuscitated patients, 64 brain CT images were available. Fourteen patients had a good neurologic outcome (PCPC 1–3) and 50 patients a poor neurologic outcome (PCPC 4–6). The multimodal model (AUC 0.897) containing GWR of basal ganglia (BG), ACE, and blood pH was found to be superior for predicting poor neurologic prognosis than single variable models (AUC of GWR-BG: 0.744, ACE: 0.804, pH: 0.747). Interestingly, we found the GWR-BG cutoff value for specificity 100% differed significantly between patients <4 years (cutoff value: 1.08, p = 0.04) and ≥4 years (cutoff value: 1.18, p = 0.004). ConclusionsThe combination of GWR-BG, ambient cistern effacement, and blood pH was found to usefully predict neurological outcome in children resuscitated from cardiac arrest. In addition, the cutoff value of GWR-BG for the prediction of neurologic outcome was found to increase with age.

Association between the simultaneous decrease in the levels of soluble vascular cell adhesion molecule-1 and S100 protein and good neurological outcomes in cardiac arrest survivors.

ObjectiveThis study aimed to determine whether simultaneous decreases in the serum levels of cell adhesion molecules (intracellular cell adhesion molecule-1 [ICAM-1], vascular cell adhesion molecule-1 [VCAM-1], and E-selectin) and S100 proteins within the first 24 hours after the return of spontaneous circulation were associated with good neurological outcomes in cardiac arrest survivors.MethodsThis retrospective observational study was based on prospectively collected data from a single emergency intensive care unit (ICU). Twenty-nine out-of-hospital cardiac arrest survivors who were admitted to the ICU for post-resuscitation care were enrolled. Blood samples were collected at 0 and 24 hours after ICU admission. According to the 6-month cerebral performance category (CPC) scale, the patients were divided into good (CPC 1 and 2, n=12) and poor (CPC 3 to 5, n=17) outcome groups.ResultsNo difference was observed between the two groups in terms of the serum levels of ICAM-1, VCAM-1, E-selectin, and S100 at 0 and 24 hours. A simultaneous decrease in the serum levels of VCAM-1 and S100 as well as E-selectin and S100 was associated with good neurological outcomes. When other variables were adjusted, a simultaneous decrease in the serum levels of VCAM-1 and S100 was independently associated with good neurological outcomes (odds ratio, 9.285; 95% confidence interval, 1.073 to 80.318; P=0.043).ConclusionA simultaneous decrease in the serum levels of soluble VCAM-1 and S100 within the first 24 hours after the return of spontaneous circulation was associated with a good neurological outcome in out-of-hospital cardiac arrest survivors.

Association between diabetes mellitus and poor patient outcomes after out-of-hospital cardiac arrest: A systematic review and meta-analysis

Diabetes mellitus (DM) serves as an important prognostic indicator in patients with cardiac-related illness. Our objective is to compare survival and neurological outcomes among diabetic and non-diabetic patients who were admitted to the hospital after an out-of-hospital cardiac arrest (OHCA). We searched MEDLINE and EMBASE for relevant articles from database inception to July 2018 without any language restriction. Studies were included if they evaluated patients who presented with OHCA, included mortality and neurological outcome data separately for DM patients and Non-DM patients and reported crude data, odds ratio (OR), relative risk (RR) or hazard ratio (HR). Two investigators independently reviewed the retrieved citations and assessed eligibility. The quality of included studies was evaluated using Newcastle-Ottawa quality assessment scale for cohort studies. Random-effect models using the generic variance method were used to create pooled odds ratios (OR) and 95% confidence intervals (CI). Heterogeneity was assessed using the I2 value. Survival and neurological outcomes (using modified rankin scale and cerebral performance category scale) after OHCA in hospitalized patients with DM compared with patients without DM. Out of 57 studies identified, six cohort studies met the inclusion criteria. In an analysis of unadjusted data, patients with DM had lower odds of survival, pooled OR 0.64; 95% CI, 0.52–0.78, [I2 = 90%]. When adjusted ORs were pooled, the association between DM and survival after OHCA was still significantly reduced, pooled OR 0.78, 95% CI, 0.68–0.89 [I2 = 55%]. Unadjusted pooled OR revealed poor neurological outcomes in patients with DM, pooled OR 0.55, 95% CI, 0.38–0.80 [I2 = 90%]. The result demonstrates significant poor outcomes of in-hospital survival and neurological outcomes among DM patients after OHCA.

Out-of-hospital cardiac arrest at place of residence is associated with worse outcomes in patients admitted to intensive care. A post-hoc analysis of the targeted temperature management trial

The majority of out-of-hospital cardiac arrests (OHCAs) occur at place of residence, which is associated with worse outcomes in unselected prehospital populations. Our aim was to investigate whether location of arrest was associated with outcome in a selected group of initial survivors admitted to intensive care. This is a post-hoc analysis of the Targeted Temperature Management After Cardiac Arrest (TTM) trial, a multicenter controlled trial, randomizing 950 OHCA patients to an intervention of 33 °C or 36 °C. The location of cardiac arrest was defined as place of residence versus public place or other. The outcome measures were mortality and neurological outcome, as defined by the Cerebral Performance Category Scale, at 180 days. Approximately half of 938 included patients arrested at place of residence (53%). Location groups did not differ with respect to age (P=0.11) or witnessed arrests (P=0.48) but bystander CPR was less common (P=0.02) at place of residence. OHCA at place of residence was associated with higher 180-day mortality (55% vs. 38%, P<0.001) and worse neurological outcome (61% vs. 43%, P<0.001) compared with a public place or other. After adjusting for known confounders, OHCA at place of residence remained an independent predictor of mortality (P=0.007). Half of all initial survivors after OHCA admitted to intensive care had an arrest at place of residence which was independently associated with poor outcomes. Actions to improve outcomes after OHCA at place of residence should be addressed in future trials.

Abstract 240: Are the Same Resuscitation Protocols Needed for Highly Aged Victims With Out-of-Hospital Cardiac Arrest as Middle or Younger Aged?

Backgrounds: The population of elderly people aged 65 years or older in 2014 is 33 million, and the aging rate (proportion of the total population) is 26.0% in Japan. Victims facing to out of hospital cardiac arrest (OHCA) are getting older and older. Emergency medical system (EMS) in Japan must do the same resuscitation protocols once called to the patient with OHCA, even when he or she is very old and activity of daily life is very low. We need to clarify whether same resuscitation protocols are required to very highly aged patients with OHCA or not. Methods and Results: From January 2005 through December 2014, we conducted a prospective, population-based, observational study involving the consecutive patients across Japan who had OHCA (n= 1,299,784). The percentage of patients with OHCA aged more than 80 years old was increasing from 37.1% in 2005 to 47.8% in 2014 by 1% each year. Survival at one month after OHCA with cerebral performance category (CPC) scale 1 or 2 were 4,368 out of total 318,590 OHCA (1.4%) in 80’s, 1043 out of 126,546 (0.8%) in 90’s, and 35 out of 5,544 (0.6%) in aged more than 100 (from 100 to 114). Survival at one month after OHCA with CPC scale 1 or 2 was 11.084 out of 234,366 (4.7%) in 50- 60’s. Patients with witnessed OHCA with shockable rhythm and by-stander CPR survived to CPC 1 or 2 at one month after OHCA were 8.0% in 80’s, 4.1% in 90’s, 0 in aged more than 100, and 22.2% in 50-60’s respectably. Conclusion: Number of survivors with CPC 1 or 2 were very few in patients with OHCA aged more than 80 years old, but still existed. Although the same resuscitation protocols are needed for highly aged victims with OHCA, another system which arrow EMS to stop resuscitation should be established in the highly aging society.

Abstract 114: Association of Serum Potassium Levels With Favorable Neurological Outcome After Out-of-Hospital Cardiac Arrest: The CRITICAL Study in Osaka, Japan

Background: Little is known about the association between serum potassium levels on hospital arrival and favorable neurological outcome after out-of-hospital cardiac arrest. Objective: The purpose of this study was to assess whether serum potassium levels on hospital arrival had prognostic indications for patients with out-of-hospital cardiac arrest (OHCA). Methods: The prospective, multicenter observational study conducted in Osaka, Japan (the CRITICAL study) enrolled all consecutive OHCA patients transported to 14 participating institutions from July 2012 through December 2015. We included adult patients aged ≥ 18 years with OHCA of cardiac origin who achieved return of spontaneous circulation (ROSC) and whose serum potassium level on hospital arrival was available. Based on the serum potassium level on hospital arrival, patients were divided into five quintiles (Q1-Q5), namely, Q1 (&lt;3.7mEq/l), Q2 (3.7-4.2mEq/l), Q3 (4.2-5.0mEq/l), Q4 (5.0-6.1mEq/l), and Q5 (&gt;6.1mEq/l). The primary outcome was one-month survival with favorable neurological outcome, which was defined as cerebral performance category scale 1 or 2. Results: During the study period, a total of 7373 patients were registered and 1148 of them were eligible for our analyses. The highest proportion of favorable neurological outcome was 42.2% (113/268) in the Q1, followed by 37.6% (76/202), 20.6% (50/243), 6.9% (15/216), and 2.7% (6/219) in the Q2, Q3, Q4, and Q5 (p&lt;0.001). In the multivariable logistic regression analysis, the adjusted proportion of favorable neurological outcome decreased as serum potassium level increased (p for trend &lt;0.001). In the subgroup analyses stratified by the first documented rhythm and estimated glomerular filtration rate, the adjusted proportions of favorable neurological outcome indicated similar tendency with those in the main analysis. Conclusion: Higher serum potassium level was significantly and independently associated with poor neurological outcome. Serum potassium on hospital arrival may be effective as a prognostic indication for out-of-hospital cardiac arrest achieving ROSC.

Abstract 204: Conventional vs. Compression-Only Cardiopulmonary Resuscitation for Geriatric Out-of-Hospital Cardiac Arrest

Introduction: Compression-only cardiopulmonary resuscitation (CPR) and conventional CPR (30:2, chest compression and rescue breathing) performed by bystanders are known to have similar outcomes in adults. This study aimed to investigate if this difference is applicable in geriatric populations as well. Methods: We conducted a prospective observational study using the All-Japan Utstein Registry to enroll geriatric patients (≥75 years) who experienced out-of-hospital cardiac arrest that was witnessed by bystanders in Japan from January 1, 2009 to December 31, 2013. The primary outcome was favorable neurological function 1 month after the event, which was defined as a Cerebral Performance Category Scale score of 1 or 2. The secondary outcomes were return of spontaneous circulation (ROSC), 1-month survival, and favorable overall function 1 month after the event, which was defined as an Overall Performance Category Scale score of 1 or 2. Outcomes of compression-only CPR and conventional CPR were compared using multivariable logistic regression analyses. Results: Of the 58,072 enrolled patients, 13,248 (22.8%) received conventional CPR whereas 44,824 (77.2%) received compression-only CPR. Favorable neurological outcomes were achieved in 708 (5.3%) patients receiving CPR and 1799 (4.0%) patients receiving compression-only CPR. A crude analysis of neurologically favorable survival revealed superiority of conventional CPR [odds ratio (OR), 1.35; 95% confidence interval (CI), 1.24–1.48; P &lt; 0.001]], but it was no longer statistically significant after multivariable adjustment (OR, 1.09; 95% CI, 0.93–1.27; P = 0.29). Similarly, multivariable adjusted analysis of favorable overall function survival showed no significant difference (OR, 1.08; 95% CI, 0.92–1.26; P = 0.38) between conventional and compression-only CPR. Conventional CPR demonstrated better outcomes in multivariable adjusted analysis of ROSC and 1 month survival (OR, 1.30; 95% CI, 1.22–1.40; P &lt; 0.001 and OR, 1.13. 95% CI, 1.04–1.23; P = 0.003, respectively). Conclusions: The superiority of conventional CPR in geriatric populations was not proven. Thus, we conclude that compression-only CPR is an adequate means of resuscitation in geriatric populations.

Abstract 121: The Influence of Age, Race, and Ethnicity on Public Automated External Defibrillator Use and Outcomes of Pediatric Out-of-Hospital Cardiac Arrest in the United States: An Analysis of the Cardiac Arrest Registry to Enhance Survival (CARES)

Introduction: Automated external defibrillators (AEDs) are an important link in the chain of survival following out-of-hospital cardiac arrest (OHCA). While the use of AEDs are clearly beneficial for OHCA in adults, there are few data on the overall use and outcomes of public AED use in children. Hypothesis: AED use is uncommon in children and associated with neurologically favorable survival. Methods: We conducted an analysis of the Cardiac Arrest Registry to Enhance Survival database. Inclusion criteria were age ≤ 18 years of age, public arrests, and non-traumatic OHCA from January 1, 2013 through December 31, 2017. Neurologically favorable survival was defined as a Cerebral Performance Category Scale of 1 or 2 at hospital discharge. Results: Of 971 public pediatric OHCA (66% male, 32% white), AEDs were used by bystanders in 117 (10.3%). AEDs were used among 2.3% of children aged ≤ 1 year (infants), 8.3% of 2-5 year-olds, 12.4% of 6-11 year-olds, and 18.2% of 12-18 year-olds (p&lt;0.001). AED use was similar among white (11.1%), black (9.1%), and Hispanic children (8.1%) (p=0.84). AED use was more common with the provision of bystander CPR (19.1%) vs no bystander CPR (0.9%), witnessed arrests (16.0%) vs unwitnessed arrests (4.7%), and arrests with a shockable rhythm (23.6%) vs a nonshockable rhythm (6.3%) (p&lt;0.001 for all). Overall, adjusted neurologically favorable survival was 29.1% (95% CI 22.7%, 35.5%) when a bystander used an AED compared to 23.7% (95% confidence interval [CI] 21.1%, 26.3%) for no bystander AED use (p=0.11). There was a significant interaction with age and race/ethnicity. AEDs were associated with neurologically favorable survival among children aged 12-18 years (p=0.04) but not associated with neurologically favorable survival in children ≤ 1 year (p=0.43), 1-5 years (p=0.16) or 6-11 years (0.41). AEDs were also associated with neurologically favorable survival in white children (p=0.01) but not with black (p=0.97) or Hispanic children (p=0.06). Conclusions: AED use is uncommon in children suffering OHCA but is associated with improved neurologically favorable survival. The benefit of AEDs was evident mostly for adolescents and white children. Further study is needed to understand these disparities in AED use and outcomes after AED use.

Abstract 118: The Epidemiology of Airway Management Following Pediatric Out-of-Hospital Cardiac Arrest in the United States

Introduction: Bag mask ventilation (BMV) has been associated with improved survival following out of hospital cardiac arrest (OHCA), however advanced airway placement remains part of pre-hospital protocols for many emergency medical services (EMS) agencies. Hypothesis: To characterize airway management for pediatric OHCA and assess whether BMV alone vs. BMV plus advanced airway (supraglottic airway or tracheal intubation) is associated with neurologically favorable survival. Methods: Analysis of the Cardiac Arrest Registry to Enhance Survival database. Inclusion criteria were age ≤ 18 years, non-traumatic OHCA from 2013 through 2017, resuscitated by EMS. To adjust for covariate imbalance, propensity score matching and entropy balancing were utilized; variables included age category, sex, bystander CPR, and shockable rhythm. The primary outcome was favorable neurologically favorable survival defined as a cerebral performance category scale of 1 or 2. Results: Of 5241 cardiac arrests, 2588 (49.3%) had BVM and 2653 (50.6%) had advanced airway placement. The majority 5118 (97.7%) were resuscitated by agencies using both BMV and advanced airways. Advanced airway placement was more common in older children compared to infants, arrests with bystander CPR, in white and Hispanic children, witnessed arrests, arrests with a shockable rhythm, and AED use (Table). Neurologically favorable survival was significantly higher with BMV compared to advanced airways in bivariate analysis (11.4% vs. 5.7%, p&lt;0.001). In multivariable analysis, advanced airway placement was associated with lower neurologically favorable survival (adjusted proportion 4.9% vs. 13.5% BVM, OR 0.21, 95% CI 0.17, 0.28). These results were robust on propensity analysis 3.0% advanced airway vs.11.9% BMV (OR 0.18, 95% CI 0.14, 0.25), and entropy balance 5.9% advanced airway, 15.0% for BMV (OR 0.28, 95% CI 0.22). Conclusion: In pediatric OHCA, advanced airways are placed in half of cardiac arrests where resuscitation is attempted. Advanced airway, compared to BMV alone management, is associated with lower neurologically favorable survival.

Abstract 164: Comparison of Tracheal Intubation vs. Supraglottic Airway Following Pediatric Out of Hospital Cardiac Arrest

Introduction: There are few data comparing Tracheal Intubation (TI) and SupraGlottic Airway (SGA) following pediatric out of hospital cardiac arrest (OHCA). Hypothesis: TI is associated with improved outcomes compared to SGA following pediatric OHCA. Methods: Analysis of the Cardiac Arrest Registry to Enhance Survival database. Inclusion criteria were age ≤ 18 years, non-traumatic OHCA from 2013 through 2017, resuscitated by Emergency Medical Services (EMS). To adjust for covariate imbalance, propensity score matching and entropy balancing were utilized; variables included age category, sex, bystander CPR, and initial rhythm. Primary outcome was neurologically favorable survival defined as a cerebral performance category scale of 1 or 2. Secondary outcome was survival to hospital discharge. Results: Of 2653 cardiac arrests evaluated, 2178 (82.1%) had TI and 475 (17.9%) had SGA placed during OHCA. 835 (31.2%) arrests were resuscitated by agencies used bag valve mask (BVM) and TI and 1818 (68.0%) arrests had agencies that used all 3 airway types (BVM/TI/SGA). Overall, unadjusted favorable neurological survival was 5.7% for TI and 5.3% for SGA, p=0.67 and survival to hospital discharge was 7.9% for TI and 7.5% for SGA, p=0.73. In multivariable analysis (adjusting for age, sex, race/ethnicity, bystander witness, bystander CPR, initial rhythm, AED use, year of arrest, and agency category), SGA was associated with lower neurologically favorable survival compared to TI (adjusted proportion 3.7% vs. 6.3%, OR 0.49, p=0.01), and lower survival to hospital discharge (5.5% vs. 8.5%, OR 0.57, 95% CI 0.36, 0.89). These results were robust on tests for unmeasured confounding and covariate balance; propensity analysis neurologically favorable survival 4.4% vs.7.6% (OR 0.54, 95% CI 0.30, 0.96), survival to hospital discharge 6.6% vs.10.5% (OR 0.58, 95% CI 0.35, 0.95); and entropy balance neurologically favorable survival 5.0 % vs. 9.7% for ETI (OR 0.44, 95% CI 0.27, 0.72), survival to hospital discharge 7.3% vs.12.5% (OR 0.51, 95% CI 0.34, 0.78). Conclusion: In pediatric OHCA, TI, compared with SGA advanced airway management is associated with improved neurologically favorable survival and survival to hospital discharge.

Serum Neurofilament Light Chain for Prognosis of Outcome After Cardiac Arrest

Prognostication of neurologic outcome after cardiac arrest is an important but challenging aspect of patient therapy management in critical care units. To determine whether serum neurofilament light chain (NFL) levels can be used for prognostication of neurologic outcome after cardiac arrest. Prospective clinical biobank study of data from the randomized Target Temperature Management After Cardiac Arrest trial, an international, multicenter study with 29 participating sites. Patients were included between November 11, 2010, and January 10, 2013. Serum NFL levels were analyzed between August 1 and August 23, 2017, after trial completion. A total of 782 unconscious patients with out-of-hospital cardiac arrest of presumed cardiac origin were eligible. Serum NFL concentrations analyzed at 24, 48, and 72 hours after cardiac arrest with an ultrasensitive immunoassay. Poor neurologic outcome at 6-month follow-up, defined according to the Cerebral Performance Category Scale as cerebral performance category 3 (severe cerebral disability), 4 (coma), or 5 (brain death). Of 782 eligible patients, 65 patients (8.3%) were excluded because of issues with aliquoting, missing sampling, missing outcome, or transport problems of samples. Of the 717 patients included (91.7%), 580 were men (80.9%) and median (interquartile range [IQR]) age was 65 (56-73) years. A total of 360 patients (50.2%) had poor neurologic outcome at 6 months. Median (IQR) serum NFL level was significantly increased in the patients with poor outcome vs good outcome at 24 hours (1426 [299-3577] vs 37 [20-70] pg/mL), 48 hours (3240 [623-8271] vs 46 [26-101] pg/mL), and 72 hours (3344 [845-7838] vs 54 [30-122] pg/mL) (P < .001 at all time points), with high overall performance (area under the curve, 0.94-0.95) and high sensitivities at high specificities (eg, 69% sensitivity with 98% specificity at 24 hours). Serum NFL levels had significantly greater performance than the other biochemical serum markers (ie, tau, neuron-specific enolase, and S100). At comparable specificities, serum NFL levels had greater sensitivity for poor outcome compared with routine electroencephalogram, somatosensory-evoked potentials, head computed tomography, and both pupillary and corneal reflexes (ranging from 29.2% to 49.0% greater for serum NFL level). Findings from this study suggest that the serum NFL level is a highly predictive marker of long-term poor neurologic outcome at 24 hours after cardiac arrest and may be a useful complement to currently available neurologic prognostication methods.