Cerebral Performance Category Research Articles

Effects of the 2020 COVID-19 pandemic on outcomes of out-of-hospital cardiac arrest and bystander resuscitation efforts: a nationwide cohort study in Japan.

Background and importance There is limited knowledge about the nationwide impact of the 2020 COVID-19 pandemic in Japan on out-of -hospital cardiac arrest (OHCA) outcomes.Objectives The aim of this study was to investigate the impact of the 2020 COVID-19 pandemic on OHCA outcomes and bystander resuscitation efforts in Japan. Design Retrospective analysis of a nationwide population-based registry of OHCA cases. Settings and participants To conduct this study, we created a comprehensive database comprising 821 665 OHCA cases by combining and reconciling the OHCA database for 835 197 OHCA cases between 2017 and 2020 with another database, including location and time records. After applying exclusion and inclusion criteria, we analysed 751 617 cases.Outcome measures and analysis The primary outcome measure for this study was survival with neurologically favourable outcome (cerebral performance category 1 or 2). We compare OHCA characteristics and outcomes between prepandemic and pandemic years, and also investigated differences in factors associated with outcomes. Results We found that survival with neurologically favourable outcome and the rates of bystander cardiopulmonary resuscitation (CPR) slightly increased in the pandemic year [2.8% vs. 2.9%; crude odds ratio (OR), 1.07; 95% confidence interval (CI), 1.03-1.10; 54.1% vs. 55.3%, 1.05 (1.04-1.06), respectively], although the incidence of public access defibrillation (PAD) slightly decreased [1.8% vs. 1.6%, 0.89 (0.86-0.93)]. Calls for hospital selection by emergency medical service (EMS) increased during the pandemic. Subgroup analysis showed that the incidence of neurologically favourable outcome increased in 2020 for OHCA cases that occurred on nonstate of emergency days, in unaffected prefectures, with noncardiac cause, nonshockable initial rhythm, and during daytime hours. Conclusions During the 2020 COVID-19 pandemic in Japan, survival with neurologically favourable outcome of OHCA patients and bystander CPR rate did not negatively change, despite the decrement in PAD incidence. However, these effects varied with the state of emergency, region, and characteristics of OHCA, suggesting an imbalance between medical demand and supply, and raising concerns about the pandemic.

Early Extracorporeal CPR for Refractory Out-of-Hospital Cardiac Arrest

BackgroundExtracorporeal cardiopulmonary resuscitation (CPR) restores perfusion and oxygenation in a patient who does not have spontaneous circulation. The evidence with regard to the effect of extracorporeal CPR on survival with a favorable neurologic outcome in refractory out-of-hospital cardiac arrest is inconclusive.MethodsIn this multicenter, randomized, controlled trial conducted in the Netherlands, we assigned patients with an out-of-hospital cardiac arrest to receive extracorporeal CPR or conventional CPR (standard advanced cardiac life support). Eligible patients were between 18 and 70 years of age, had received bystander CPR, had an initial ventricular arrhythmia, and did not have a return of spontaneous circulation within 15 minutes after CPR had been initiated. The primary outcome was survival with a favorable neurologic outcome, defined as a Cerebral Performance Category score of 1 or 2 (range, 1 to 5, with higher scores indicating more severe disability) at 30 days. Analyses were performed on an intention-to-treat basis.ResultsOf the 160 patients who underwent randomization, 70 were assigned to receive extracorporeal CPR and 64 to receive conventional CPR; 26 patients who did not meet the inclusion criteria at hospital admission were excluded. At 30 days, 14 patients (20%) in the extracorporeal-CPR group were alive with a favorable neurologic outcome, as compared with 10 patients (16%) in the conventional-CPR group (odds ratio, 1.4; 95% confidence interval, 0.5 to 3.5; P=0.52). The number of serious adverse events per patient was similar in the two groups.ConclusionsIn patients with refractory out-of-hospital cardiac arrest, extracorporeal CPR and conventional CPR had similar effects on survival with a favorable neurologic outcome. (Funded by the Netherlands Organization for Health Research and Development and Maquet Cardiopulmonary [Getinge]; INCEPTION ClinicalTrials.gov number, NCT03101787.)

A novel cardiac arrest severity score for the early prediction of hypoxic-ischemic brain injury and in-hospital death

Abstract Funding Acknowledgements Type of funding sources: None. Background Out-of-hospital cardiac arrest (OHCA) outcomes are unsatisfactory despite postcardiac arrest care. Early prediction of prognoses might help stratify patients and provide tailored therapy. Purpose In this study, we derived and validated a novel scoring system to predict hypoxic-ischaemic brain injury (HIBI) and in-hospital death (IHD). Methods We retrospectively analysed Korean Hypothermia Network prospective registry data collected from in Korea between 2015 and 2018. Patients without neuroprognostication data were excluded, and the remaining patients were randomly divided into derivation and validation cohorts. HIBI was defined when at least one prognostication predicted a poor outcome. IHD meant all deaths regardless of cause. In the derivation cohort, stepwise multivariate logistic regression was conducted for HIBI and IHD scores, and model performance was assessed. We then classified patients into four categories and analysed associations between the categories and cerebral performance categories (CPCs) at hospital discharge. Finally, we validated our models in the internal validation cohort. Results Among 1373 patients, 240 were excluded, and 1133 were randomised into derivation (n=754) and validation cohorts (n=379). In the derivation cohort, 7 and 8 predictors were selected for HIBI (0–8) and IHD scores (0–11), respectively, and the area under the curve (AUC) was 0.85 (95% CI 0.82–0.87) and 0.80 (95% CI 0.77–0.82), respectively. Applying optimum cutoff values of ≥6 points for HIBI and ≥7 points for IHD, patients were classified as follows: HIBI (-)/IHD (-), Category 1 (n=424); HIBI (-)/IHD (+), Category 2 (n=100); HIBI (+)/IHD (-), Category 3 (n=21); and HIBI (+)/IHD (+), Category 4 (n=209). CPCs at discharge were significantly different in each category (p<0.001). In the validation cohort, the model showed moderate discrimination (AUC 0.83, 95% CI 0.79–0.87 for HIBI and AUC 0.77, 95% CI 0.72–0.81 for IHD) with good calibration. Each category of the validation cohort showed a significant difference in discharge outcomes (p<0.001) and a similar trend to the derivation cohort. Conclusions We presented a novel approach for assessing illness severity after OHCA. Although external prospective studies are warranted, risk stratification for HIBI and IHD could help provide OHCA patients with appropriate treatment.

A nationwide survey of human metapneumovirus-associated encephalitis/encephalopathy in Japan

BackgroundAs there have been no comprehensive reports of human metapneumovirus-associated encephalopathy (hMPVE), this study examined the clinical features of hMPVE in children in Japan. MethodA nationwide survey of children with hMPVE was conducted using a structured research form. An initial survey asked pediatricians about children with hMPVE treated between 2014 and 2018. A second survey obtained patient information from hospitals that responded to the initial survey and those identified as having treated cases from a literature search. We collected demographic data, symptoms of hMPV infection, neurological symptoms, laboratory data, treatment, and outcomes. Outcomes were determined using the Pediatric Cerebral Performance Category Score. ResultClinical information was available for 16 children. Their median age was 37 months. Six had preexisting neurological disorders. The interval between the onsets of infection and hMPVE was 4 days. Outcomes were good in 11 patients and poor in 5. There were no significant differences in demographic data, neurological symptoms, or laboratory data between the patients with good and poor outcomes. The encephalopathy subtypes were acute encephalopathy with biphasic seizures and late reduced diffusion in 3, clinically mild encephalitis/encephalopathy with a reversible splenial lesion in 3, hemorrhagic shock and encephalopathy syndrome in 2, and others in 8. ConclusionThe outcomes of children with hMPVE were not very different from those of acute encephalopathy due to other viruses. We found no factors associated with poor outcomes.

Association of ultra-early diffusion-weighted magnetic resonance imaging with neurological outcomes after out-of-hospital cardiac arrest

BackgroundThis study aimed to investigate the association between ultra-early (within 6 h after return of spontaneous circulation [ROSC]) brain diffusion-weighted magnetic resonance imaging (DW-MRI) and neurological outcomes in comatose survivors after out-of-hospital cardiac arrest.MethodsWe conducted a registry-based observational study from May 2018 to February 2022 at a Chungnam national university hospital in Daejeon, Korea. Presence of high-signal intensity (HSI) (PHSI) was defined as a HSI on DW-MRI with corresponding hypoattenuation on the apparent diffusion coefficient map irrespective of volume after hypoxic ischemic brain injury; absence of HSI was defined as AHSI. The primary outcome was the dichotomized cerebral performance category (CPC) at 6 months, defined as good (CPC 1–2) or poor (CPC 3–5).ResultsOf the 110 patients (30 women [27.3%]; median (interquartile range [IQR]) age, 58 [38–69] years), 48 (43.6%) had a good neurological outcome, time from ROSC to MRI scan was 2.8 h (IQR 2.0–4.0 h), and the PHSI on DW-MRI was observed in 46 (41.8%) patients. No patients in the PHSI group had a good neurological outcome compared with 48 (75%) patients in the AHSI group. In the AHSI group, cerebrospinal fluid (CSF) neuron-specific enolase (NSE) levels were significantly lower in the group with good neurological outcome compared to the group with poor neurological outcome (20.1 [14.4–30.7] ng/mL vs. 84.3 [32.4–167.0] ng/mL, P < 0.001). The area under the curve for PHSI on DW-MRI was 0.87 (95% confidence interval [CI] 0.80–0.93), and the specificity and sensitivity for predicting a poor neurological outcome were 100% (95% CI 91.2%–100%) and 74.2% (95% CI 62.0–83.5%), respectively. A higher sensitivity was observed when CSF NSE levels were combined (88.7% [95% CI 77.1–95.1%]; 100% specificity).ConclusionsIn this cohort study, PHSI findings on ultra-early DW-MRI were associated with poor neurological outcomes 6 months following the cardiac arrest. The combined CSF NSE levels showed higher sensitivity at 100% specificity than on DW-MRI alone. Prospective multicenter studies are required to confirm these results.

A novel cardiac arrest severity score for the early prediction of hypoxic-ischemic brain injury and in-hospital death

IntroductionOut-of-hospital cardiac arrest (OHCA) outcomes are unsatisfactory despite postcardiac arrest care. Early prediction of prognoses might help stratify patients and provide tailored therapy. In this study, we derived and validated a novel scoring system to predict hypoxic-ischemic brain injury (HIBI) and in-hospital death (IHD). MethodsWe retrospectively analyzed Korean Hypothermia Network prospective registry data collected from in Korea between 2015 and 2018. Patients without neuroprognostication data were excluded, and the remaining patients were randomly divided into derivation and validation cohorts. HIBI was defined when at least one prognostication predicted a poor outcome. IHD meant all deaths regardless of cause. In the derivation cohort, stepwise multivariate logistic regression was conducted for the HIBI and IHD scores, and model performance was assessed. We then classified the patients into four categories and analyzed the associations between the categories and cerebral performance categories (CPCs) at hospital discharge. Finally, we validated our models in an internal validation cohort. ResultsAmong 1373 patients, 240 were excluded, and 1133 were randomized into the derivation (n = 754) and validation cohorts (n = 379). In the derivation cohort, 7 and 8 predictors were selected for HIBI (0–8) and IHD scores (0−11), respectively, and the area under the curves (AUC) were 0.85 (95% CI 0.82–0.87) and 0.80 (95% CI 0.77–0.82), respectively. Applying optimum cutoff values of ≥6 points for HIBI and ≥7 points for IHD, the patients were classified as follows: HIBI (−)/IHD (−), Category 1 (n = 424); HIBI (−)/IHD (+), Category 2 (n = 100); HIBI (+)/IHD (−), Category 3 (n = 21); and HIBI (+)/IHD (+), Category 4 (n = 209). The CPCs at discharge were significantly different in each category (p < 0.001). In the validation cohort, the model showed moderate discrimination (AUC 0.83, 95% CI 0.79–0.87 for HIBI and AUC 0.77, 95% CI 0.72–0.81 for IHD) with good calibration. Each category of the validation cohort showed a significant difference in discharge outcomes (p < 0.001) and a similar trend to the derivation cohort. ConclusionsWe presented a novel approach for assessing illness severity after OHCA. Although external prospective studies are warranted, risk stratification for HIBI and IHD could help provide OHCA patients with appropriate treatment.

Clinical characteristics and outcomes after extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest patients with an initial asystole rhythm

AimThis study aimed to describe the characteristics of cases of out-of-hospital cardiac arrest (OHCA) with an initial asystole rhythm in which extracorporeal cardiopulmonary resuscitation (ECPR) was introduced and discuss the clinical indications for ECPR in such patients. MethodsThis was a secondary analysis of the SAVE-J II study, a retrospective, multicentre, registry study involving 36 participating institutions in Japan. Patients with an initial asystole rhythm were selected. Favourable neurological outcomes (cerebral performance categories 1–2) constituted the primary outcome. ResultsIn total, 202 patients met the inclusion criteria, with favourable neurological outcomes at hospital discharge in 12 patients (5.9%). Causes of cardiac arrest with favourable neurological outcomes were hypothermia (7 cases), acute coronary syndrome (2 cases), arrhythmia (2 cases), and pulmonary embolism (1 case). Among patients with non-hypothermia (temperature ≥32 °C) on hospital arrival with the cardiac rhythm of asystole or pulseless electrical activity (PEA) on arrival, all 107 patients (66 asystole, 41 PEA) who lacked one or more of the requirements (witness; bystander CPR; signs of life or pupil < 5 mm) had unfavourable neurological outcomes. All 5 cases with favourable neurological outcomes, except for 1 case with a short duration of no-flow time that was highly suspected based on the patient’s history, met all the requirements on hospital arrival. ConclusionsA total of 202 ECPR cases with an initial asystole rhythm, including 12 patients with favourable neurological outcomes, were described. Even if the initial cardiac rhythm is asystole, ECPR could be considered if certain conditions are met.

Factors associated with survival and neurologic outcome after in-hospital cardiac arrest in children: A cohort study

AimIn-hospital paediatric cardiopulmonary resuscitation (CPR) survival has been improving in high-income countries. This study aimed to analyse factors associated with survival and neurological outcome after paediatric CPR in a middle-income country. MethodsThis observational study of in-hospital cardiac arrest using Utstein-style registry included patients <18 years old submitted to CPR between 2015 and 2020, at a high-complexity hospital. Outcomes were survival and neurological status assessed using Paediatric Cerebral Performance Categories score at prearrest, discharge, and after 180 days. ResultsOf 323 patients who underwent CPR, 108 (33.4%) survived to discharge and 93 (28.8%) after 180 days. In multivariable analysis, lower survival at discharge was associated with liver disease (OR 0.060, CI 0.007–0.510, p = 0.010); vasoactive drug infusion before cardiac arrest (OR 0.145, CI 0.065–0.325, p < 0.001); shock as the immediate cause (OR 0.183, CI 0.069–0.486, p = 0.001); resuscitation > 30 min (OR 0.070, CI 0.014–0.344, p = 0.001); and bicarbonate administration during CPR (OR 0.318, CI 0.130–0.780, p = 0.01). The same factors remained associated with lower survival after 180 days. Neurological outcome was analysed in the 93 survivors after 180 days following CPR. Prearrest neurological dysfunction was observed in 31.4%, and neurological prognosis was favourable in 79.7% at discharge and similar after 180 days. ConclusionIn-hospital paediatric cardiac arrest patients with complex chronic conditions had lower survival associated with liver disease, shock as cause of cardiac arrest, vasoactive drug infusion before cardiac arrest, bicarbonate administration during CPR, and prolonged resuscitation. Most survivors had favourable neurological outcome.

Functional changes in the hypothalamic-pituitary-adrenal axis after successful cardiopulmonary resuscitation

Abstract Background Cardiac arrest (CA) is a terminal event that results in a range of pathophysiological changes in the body, most notably, systemic ischemia-reperfusion injury. The hypothalamic-pituitary-adrenal (HPA) axis is an important neuroendocrine system that modulates adrenocortical hormone release. This study was designed to investigate the changes in HPA-related hormone levels after successful cardiopulmonary resuscitation (CPR) and to explore possible etiologies to provide a basis for relevant clinical research. Methods We collected the clinical data of 96 patients with CA admitted to the Emergency Department of Beijing Chaoyang Hospital, Capital Medical University, between January 2016 and May 2017. Serum samples were collected 6, 24, and 72 hours after restoring spontaneous circulation (ROSC). The data were compared with those of the healthy control group (n = 50). An enzyme-linked immunosorbent assay (ELISA) was performed to measure copeptin, adrenocorticotropic hormone (ACTH), corticotropin-releasing hormone (CRH), and total cortisol. Demographic data were collected for both groups. For the CPR group, clinical data and the end-of-study cerebral performance category (CPC) were analyzed. Patients were followed up through day 28. Death or survival after day 28 was used as the study endpoint. Simple values were expressed as medians and quartiles or ratios (%) for statistical analysis. Continuous variables are expressed as mean ± standard deviation. Categorical variables were expressed as frequencies and percentages. The mean values of normally distributed measurement data were analyzed using 1-way analysis of variance (ANOVA) for among-group comparisons and the least significant difference (LSD) test for between-group comparisons. SPSS v17 (SPSS, Chicago, IL, USA) was used for statistical analysis, and P &lt; 0.05 was considered statistically significant. Results No significant between-group differences were observed in terms of age or sex. The 28-day mortality rate in the CPR group was 71%. ACTH and CRH levels were significantly lower in the CPR group than in the healthy control group (P &lt; 0.001). Copeptin and cortisol levels 6 hours after ROSC were significantly higher in the CPR group than in the healthy control group (P &lt; 0.001). No significant changes in any indicator were observed over time (6, 24, and 72 hours after ROSC) (P &gt; 0.05). The CPC score was 1–2 (good cerebral performance group) in 13 patients, 3–4 (poor cerebral performance group) in 17 patients, and 5 (brain death or clinical death) in 66 patients. Patients with significantly declining ACTH and CRH levels had higher CPC scores (P &lt; 0.05); however, no significant differences were found in other indicators (P &gt; 0.05). Conclusion After post-CA ROSC, ischemia-reperfusion injury may cause brain damage and HPA axis damage and dysfunction, the severity of which is associated with CPC score.

Effect of video laryngoscopy for non-trauma out-of-hospital cardiac arrest on clinical outcome: A registry-based analysis

AimVideolaryngoscopy (VL) is a promising tool to provide a safe airway during cardiopulmonary resuscitation (CPR) and to ensure early reoxygenation. Using data from the German Resuscitation Registry, we investigated the outcome of non-traumatic out-of-hospital cardiac arrest (OHCA) patients treated with VL versus direct laryngoscopy (DL) for airway management. MethodsWe analysed retrospective data of 14,387 patients from 1 January 2018 until 31 December 2021 (VL group, n = 2201; DL group, n = 12186). Primary endpoint was discharge with cerebral performance categories one and two (CPC1/2). Secondary endpoints were the rate of return of spontaneous circulation (ROSC), hospital admission, hospital admission with ongoing cardiopulmonary resuscitation, 30-day survival/ hospital discharge and airway management complications. We used multivariate binary logistic regression analysis to identify the effects on outcome of known influencing variables and of VL vs DL. ResultsThe multivariate regression model revealed that VL was an independent predictor of CPC1/2 survival (OR = 1.34, 95% CI = 1.12–1.61, p = 0.002) and of hospital discharge/30-day survival (OR = 1.26, 95% CI = 1.08–1.47, p = 0,004). ConclusionVL for endotracheal intubation (ETI) at OHCA was associated with better neurological outcome in patients with ROSC. Therefore, the use of VL for OHCA offers a promising perspective. Further prospective studies are required.

Heparin-Induced Thrombocytopenia in Patients Undergoing Venoarterial Extracorporeal Membrane Oxygenation.

Background: Heparin-induced thrombocytopenia (HIT) is a serious, immune-mediated adverse drug reaction to unfractionated heparin (UFH) affecting also patients undergoing venoarterial extracorporeal membrane oxygenation (VA-ECMO). Although the association between VA-ECMO support and the development of thrombocytopenia has long been known and discussed, HIT as one underlying cause is still insufficiently understood. Therefore, the purpose of this study was to further investigate the epidemiology, mortality, diagnosis, and clinical management of HIT occurring in VA-ECMO patients treated with UFH. Methods: We conducted a retrospective single-center study including adult patients (≥18 years) with VA-ECMO support in the cardiac intensive care unit (ICU) of the University Hospital of Munich (LMU) between January 2013 and May 2022, excluding patients with a known history of HIT upon admission. Differences in baseline characteristics and clinical outcome between excluded HIT (positive anti-platelet factor 4 (PF4)/heparin antibody test but negative functional assay) and confirmed HIT (positive anti-PF4/heparin antibody test and positive functional assay) VA-ECMO patients as well as diagnosis and clinical management of HIT were analysed. Results: Among the 373 patients included, anti-PF4/heparin antibodies were detected in 53/373 (14.2%) patients. Functional HIT testing confirmed HIT in 13 cases (3.5%) and excluded HIT in 40 cases (10.7%), corresponding to a prevalence of confirmed HIT of 13/373 (3.5%) [1.6, 5.3] and a positive predictive value (PPV) of 24.5% for the antibody screening test. The platelet course including platelet recovery following argatroban initiation was similar between all groups. One-month mortality in patients with excluded HIT was 14/40 (35%) and 3-month mortality 17/40 (43%), compared to 5/13 (38%) (p > 0.999), and 6/13 (46%) (p > 0.999) in patients with confirmed HIT. Neurological outcome in both groups measured by the cerebral performance category of survivors on hospital discharge was similar, as well as adverse events during VA-ECMO therapy. Conclusions: With a prevalence of 3.5%, HIT is a non-frequent complication in patients on VA-ECMO and was not associated with a higher mortality rate. HIT was ultimately excluded by functional essay in 75% of VA-ECMO patients with clinical suspicion of HIT and positive anti-PF4/heparin antibody test. Argatroban seems to be an appropriate and safe therapeutic option for confirmed HIT-positive patients on VA-ECMO support.

Effect of prehospital advanced airway management on out-of-hospital cardiac arrest due to asphyxia: A JAAM-OHCA registry-based observational study in Japan.

To investigate the relationship between prehospital advanced airway management (AAM) and neurological outcomes in patients with asphyxia-related out-of-hospital cardiac arrest (OHCA). We retrospectively analyzed data from the Japanese Association for Acute Medicine OHCA registry between June 2014 and December 2017. Patients with asphyxia-related cardiac arrest aged ≥18 years were included. The primary outcome was a 1-month favorable neurological outcome (cerebral performance category [CPC] 1-2). Of the 34,754 patients in the 2014-2017 JAAM-OHCA Registry, 1956 were included in our analysis. Cerebral performance category 1-2 was observed in 31 patients (1.6%), while CPC 3-5 was observed in 1925 patients (98.4%). Although prehospital AAM was associated with unfavorable neurological outcomes (odds ratio [OR], 0.269; 95% confidence interval [CI], 0.114-0.633; p = 0.003) in the univariate analysis, the association was not significant in the multivariate analysis. Compared with the AAM group, the non-AAM group showed increased rates of cardiac arrest after emergency medical service contact (4.3 vs. 7.2%, p = 0.009) and Glasgow Coma Scale ≥4 at hospital admission (1.9% vs. 4.7%, p = 0.004). Among the 903 patients for whom the time to return of spontaneous circulation (ROSC) could be calculated, the time from witnessed cardiac arrest to ROSC was significantly shorter (median, 8.5 vs. 37.0 min; p < 0.001) for those with favorable neurological outcomes than for those without. Prehospital AAM is not associated with improved neurological outcomes among those with asphyxia-related OHCA. However, the time from cardiac arrest to the first ROSC was significantly shorter among those with favorable outcomes.

Tradução e adaptação transcultural da pediatric cerebral performance category (PCPC) e da pediatric overall performance category (POPC) para o português brasileiro

To translate and culturally adapt the scales Pediatric Cerebral Performance Category (PCPC) and Pediatric Overall Performance Category (POPC) to the Brazilian population. Two English language proficient professionals independently translated the original version of the scales into Brazilian Portuguese. After consensus, it was generated a translated version of each scale. These were back translated into English by two native English translators. A new consensus process resulted in an English version of each scale, which were compared with the originals and approved by the author. A committee of experts with clinical and academic experience in intensive care checked the validity of the content and produced the pre-final versions of the scales, which were tested by 25 professionals from a Pediatric Intensive Care Unit. An audit was conducted to verify the consistency of the methodological process. The pre-final versions were approved by 96% of the Brazilian professionals. No significant changes were made to the content of the instrument; however, it was identified the need of a guide with instructions on how to use the scales. The process of translation and cross-cultural adaptation of the scales was completed and resulted in PCPC-BR and POPC-BR scales.

The Japanese Pediatric Continuous Renal Replacement Therapy (jpCRRT) Registry: Study Protocol.

The use of continuous renal replacement therapy (CRRT) in critically ill children is rapidly increasing, but the standard of care has not yet been established and prognosis remains poor. To develop optimal CRRT strategies, we launched a research project generating the Japanese Pediatric CRRT registry, a multicenter registry of CRRT in Japanese pediatric intensive care units (PICUs), to investigate the actual status of CRRT in recent years in PICUs, where data are lacking. This manuscript presents a protocol for planning a multicenter prospective registry. As of April 2023, 15 Japanese PICUs are voluntarily participating. Patients enrolled are those <16 years of age who enter the PICUs of the collaborating institutions, require CRRT, and have the guardians' consent. CRRT is defined as anticipated to be required for >24 hours, and CRRT connected to extracorporeal membrane oxygenation is also included. The registry is an online registry system managed by the University Hospital Medical Information Network. The primary outcomes are Pediatric Cerebral Performance Category Scale at PICU discharge and 6 months post-discharge (deaths included), persistent need for dialysis, and PICU readmission within 6 months. The secondary outcomes are adverse events during and immediately after CRRT initiation, and initial circuit life span. This project will examine the differences in outcomes of CRRT in PICUs in specific patient and treatment groups and will be used to design future interventional studies. We will also aim to establish a platform for a multicenter registry study in Japanese PICUs, considering the current lack of such a platform.

Rapid rewarming rate associated with favorable neurological outcomes in patients with post-cardiac arrest syndrome patients treated with targeted temperature management.

To determine whether the rewarming rate is associated with neurological outcomes in patients with post-cardiac arrest syndrome treated with targeted temperature management (TTM) at 34°C. We conducted a retrospective analysis of a nationwide cohort study of out-of-hospital cardiac arrest in Japan. Adult patients who experienced a return of spontaneous circulation and completed TTM at 34°C between June 2014 and December 2019 were divided equally into three groups (slow, moderate, and rapid) according to their rewarming rates from 34°C to 36°C. The rates of favorable neurological outcomes (Cerebral Performance Category of 1-2 after 30 days) were compared among the groups, and the adjusted odds ratios for a favorable neurological outcome were calculated for the groups. We analyzed 348, 357, and 358 patients in the slow, moderate, and rapid groups, respectively. The periods of rewarming from 34°C to 36°C were 41.9 ± 10.5, 22.4 ± 1.8, and 12.2 ± 3.6 h, respectively. The number of favorable neurological outcomes after 30 days was 121 (34.8%), 125 (35.0%), and 147 (41.1%), respectively, with no significant differences among the three groups (p = 0.145). Rapid rewarming was independently associated with a favorable neurological outcome compared with slow rewarming (adjusted odds ratio 1.57 [95% confidence interval 1.04-2.37]; p = 0.031). Rapid rewarming after TTM at 34°C was associated with a more favorable neurological outcome than slow rewarming.

Effects of cardiopulmonary resuscitation instructions on the outcomes of out-of-hospital cardiac arrest: An analysis of the JAAM-OHCA registry.

To determine whether dispatcher-provided cardiopulmonary resuscitation (CPR) instructions improve the outcomes of out-of-hospital cardiac arrest (OHCA). Cases registered in the Japanese Association for Acute Medicine Out-of-Hospital Cardiac Arrest (JAAM-OHCA) Registry between June 2014 and December 2019 were included. Cases in which the dispatcher provided CPR instructions to the bystander were included in the "Instructions" group", and cases without CPR instructions were included in the "No Instructions" group. The primary outcome was the proportion of patients with a favorable neurological outcome, defined as a Glasgow-Pittsburgh cerebral performance category scale of 1 to 2 at 1 month after OHCA. Overall, 51,199 patients with OHCA were registered in the JAAM-OHCA Registry during the study period. Of these, 33,745 were eligible for the study, with 16,509 in the Instructions group and 17,236 in the No Instructions group. The proportion of patients with a favorable neurological outcome at 1 month after OHCA was inferior in the Instructions group than in the No Instructions group (2.3% versus 3.0%, p < 0.001). After adjustment for patient background characteristics, no association was found between CPR instructions provided by a dispatcher and favorable neurological outcomes at 1 month after OHCA (adjusted odds ratio, 1.000; 95% confidence interval, 0.869-1.151, p = 0.996). The present study found no clear clinical benefit of dispatcher-provided CPR instructions on the neurological outcomes of cases with OHCA.

Association between insulin administration method and six-month neurological outcome in survivors of out-of-hospital cardiac arrest who underwent targeted temperature management.

We investigated the association of insulin administration method with the achievement of mean glucose ≤ 180 mg/dL and neurological outcomes in out-of-hospital cardiac arrest (OHCA) survivors who had hyperglycemia after the return of spontaneous circulation. From a multicenter prospective registry, we extracted the data of adult OHCA survivors who underwent targeted temperature management (TTM) between 2015 and 2018. Blood glucose levels every 4 h after initiating TTM were obtained for 72 h. We divided insulin administration methods into three categories: subcutaneous (SQI), intravenous bolus (IBI), and continuous intravenous (CII). We calculated the mean glucose and standard deviation (SD) of glucose. The primary outcome was the achievement of mean glucose ≤ 180 mg/dL. The secondary outcomes were the 6-month neurological outcome based on the Cerebral Performance Category (CPC) scale (good, CPC 1-2; poor, CPC 3-5), mean glucose, and SD of glucose. Of the 549 patients, 296 (53.9%) achieved mean glucose ≤ 180 mg/dL, and 438 (79.8%) had poor neurological outcomes, 134 (24.4%), 132 (24.0), and 283 (51.5%) were in the SQI, IBI, and CII groups, respectively. The SQI (adjusted odds ratio [aOR], 0.848; 95% confidence intervals [CIs], 0.493-1.461) and IBI (aOR, 0.673; 95% CIs, 0.415-1.091) groups were not associated with mean glucose ≤ 180 mg/dL and the SQI (aOR, 0.660; 95% CIs, 0.335-1.301) and IBI (aOR, 1.757; 95% CIs, 0.867-3.560) groups were not associated with poor neurological outcomes compared to the CII group. The CII (168 mg/dL [147-202]) group had the lowest mean glucose than the SQI (181 mg/dL [156-218]) and IBI (184 mg/dL [162-216]) groups. The CII (45.0[33.9-63.5]) group had a lower SD of glucose than the IBI (50.8 [39.1-72.0]) group. The insulin administration method was not associated with achieving mean glucose ≤ 180 mg/dL and 6-month neurological outcomes.

244: EPIDEMIOLOGY, ETIOLOGY, AND PROGNOSIS OF IN-HOSPITAL REFLEX-MEDIATED CARDIAC ARRESTS

Introduction: Reflex syncope is common; however, little is known about the epidemiology and prognosis of reflex-mediated (or vagal-mediated) cardiac arrest (RMCA). We evaluated the incidence of RMCA among hospitalized patients and compared their outcomes to those with in-hospital cardiac arrests (IHCAs) of all other causes. We hypothesized that in-hospital RMCA is common and has a higher rate of return of spontaneous circulation (ROSC) than other IHCAs. Methods: This is a retrospective cohort study of all adult IHCAs at two large academic medical centers from January 1, 2016 to June 30, 2022. Patients were included if they had a RMCA requiring cardiopulmonary resuscitation. A RMCA was defined as the absence of a palpable pulse with antecedent hypotension and bradycardia preceded by identifiable vagal triggers and/or a characteristic prodrome. We abstracted baseline demographics and reviewed charts to confirm the reflex-mediated etiology. The primary outcome was rate of ROSC. Secondary outcomes included survival to hospital discharge and cerebral performance category (CPC) scores of 2 or less. Student’s t-test and Pearson’s chi-squared test were used for comparisons. Results: Of 1,067 IHCA patients, 47 (4.4%) experienced RMCAs. The incidence of RMCA was 0.24 per 1,000 patients discharges while IHCA was 5.43 per 1,000 patients discharges. Compared to patients with IHCA of all other causes, RMCA patients were similar in age (mean years + SD 60.8 + 16.3 vs 58.6 + 16.2, p=0.3513) and sex (male 65.9% vs 53.2%, p=0.0739). RMCAs were most frequently triggered by defecating (29.8%) and turning (17.0%); they also frequently occurred peri-procedurally (14.9%). RMCA patients were less likely to arrest in the ICU compared to other IHCAs patients (40.4% vs 57.1%, p=0.0251). ROSC occurred in 100% and they were more likely to survive to hospital discharge (85.1% vs 36.2%, p< 0.00001) and have CPC scores of 2 or less (57.4% vs 27.0%, p< 0.00001). Conclusions: In-hospital RMCA is uncommon. Compared to patients with IHCA of all other causes, RMCA patients were less likely to arrest in the ICU, reflecting lower illness acuity and thus, increased rates of ROSC, survival to hospital discharge and good neurological outcomes. Future research should identify intervenable risk factors that predispose a patient to RMCA.

1141: ANTIEPILEPTICS FOR PATIENTS AFTER CARDIAC ARREST: A SYSTEMATIC REVIEW AND META-ANALYSIS

Introduction: Epileptiform activity is common after cardiac arrest due to the hypoxic-ischemic lesion, resulting in increased morbidity (persistent coma states), and even mortality. Current guidelines for the treatment of status epilepticus after cardiac arrest encompass targeted temperature treatment and the use of antiepileptic drugs. Antiepileptic drugs may be used as primary prevention or treatment for patients with epileptiform activity. However, the exact protocol for the initiation of these drugs or the clinical outcome associated with seizure prophylaxis is not well understood or described. Therefore, this meta-analysis aims to analyze the role of antiepileptic drugs in reducing mortality and improving clinical outcomes in patients after cardiac arrest. Methods: Databases (PubMed, Scopus, and Cochrane) were systematically searched for studies directly comparing antiepileptics with standard care vs. standard care alone for comatose patients after cardiac arrest. Primary outcomes were all-cause mortality, Cerebral Performance Category (CPC), and electroencephalogram (EEG). Results: Four studies comprising 643 comatose patients who survived a cardiac arrest were included. In the pooled data, it was found no difference in cerebral performance (OR 0.69; 95%CI 0.43,1.13; P>0.05) or mortality (OR 1.38; 95%CI 0.51, 3.71; P< 0.0001) between the standard treatment and the intervention with antiepileptic drugs. Heterogeneity for mortality was considerably high (I2= 86%) mostly because of one study which shows a different design concerning the control and intervention groups. Regarding the EEGs, we were unable to do a statistical analysis because the studies used different parameters to evaluate EEGs, although all came to the same conclusion that AEDs improve status epilepticus momentarily but do not ameliorate neurological outcomes long-term. Conclusions: The use of antiepileptics for comatose patients after a cardiac arrest does not improve neurologic outcomes or mortality. There were many limiting factors to the comparison, including multiple drugs used and unstandardized protocol for EEG evaluation. However, the conclusion of the meta-analysis confirms the results of individual trials, showing no benefit in the usage of seizure prophylaxis in this population.

540: NEUROLOGIC OUTCOMES IN HOSPITALIZED CHILDREN WITH ACUTE SARS-COV-2 OR MIS-C

Introduction: We aimed to describe neurologic outcomes in hospitalized children diagnosed with acute SARS-CoV-2 infection or Multisystem Inflammatory Syndrome in Children (MIS-C). Methods: Multinational (n=50 centers), cross-sectional study of neurologic manifestations in children < 18 y old hospitalized with a positive SARS-CoV-2 test or clinical diagnosis of a SARS-CoV-2-related condition between January 2020-July 2021. Multivariable logistic regression to identify risk factors for unfavorable outcome at hospital discharge (Pediatric Cerebral Performance Category Score 3-6) was performed. Severe neurologic manifestation included those with univariate logistic regression significant to p< 0.05 for unfavorable outcome: dysautonomia, stroke, encephalopathy, cardiac arrest, meningitis/encephalitis, coma, seizures, weakness, and delirium. Results: Of 3,556 children (46% female), 3333 (94%) had acute SARS-CoV-2 and 223 (6%) had MIS-C. Unfavorable outcome occurred in 368 (11%) children and 39 (1.1%) died. Children with unfavorable outcome were older (median 9 interquartile range [4-14] vs. 8 [1-14] y, p< 0.001), and more likely to have neurologic comorbidity (72% vs. 10%, p< 0.001), worse Glasgow coma scale score (GCS) group (19% with combined GCS 9-15 vs. 1.7% with GCS< 9, p< 0.001), any neurologic manifestation (52% vs. 37%, p< 0.001), and severe neurologic manifestation (48% vs. 20%, p< 0.001) compared to children with favorable outcome. In multivariate logistic regression, older age (odds ratio 1.1 95% confidence interval [1.0, 1.1], total pre-existing conditions (2.1 [1.8, 2.5]), severe neurologic manifestation (3.4 [2.0, 6.0], and worse GCS group (4.0 [2.6, 5.9]) were associated with unfavorable outcome. Conclusions: Children with severe neurologic manifestation, pre-existing conditions, and children of older age hospitalized with acute SARS-CoV-2 infection or MIS-C have worse hospital discharge outcomes. Follow-up of these children is necessary to identify and manage neurologic and functional impairment.