Hours Of Return Of Spontaneous Circulation Research Articles

Association of blood pressure with neurologic outcome at hospital discharge after pediatric cardiac arrest resuscitation

BackgroundPoor outcomes are associated with post cardiac arrest blood pressures <5th percentile for age. We aimed to study the relationship of mean arterial pressure (MAP) with favorable neurologic outcome following cardiac arrest and return of spontaneous circulation (ROSC). MethodsThis retrospective, multi-center, observational study analyzed data from the Pediatric Resuscitation Quality Collaborative (pediRES-Q). Children (<18 years) who achieved ROSC following index in-hospital or out-of-hospital cardiac arrest and survived ≥6 hours were included. Lowest documented MAP within the first 6 hours of ROSC was percentile adjusted for age and categorized into six groups – Group I: <5th, II: 5–24th, III: 25–49th, IV: 50–74th, V: 75–94th; and VI: 95–100th percentile. Primary outcome was favorable neurologic status at hospital discharge, defined as PCPC score 1, 2, or no change from pre-arrest baseline. Multivariable logistic regression was performed to analyze the association of MAP group with favorable outcome, controlling for illness category (surgical-cardiac), initial rhythm (shockable), arrest time (weekend or overnight), age, CPR duration, and clustering by site. Results787 patients were included: median [Q1,Q3] age 17.9 [4.8,90.6] months; male 58%; OHCA 21%; shockable rhythm 13%; CPR duration 7 [3,16] min; favorable neurologic outcome 54%. Median lowest documented MAP percentile for the favorable outcome group was 13 [3,43] versus 8 [1,37] for the unfavorable group. The distribution of blood pressures by MAP group was I: 37%, II: 28%, III: 13%, IV: 11%, V: 7%, and VI: 4%. Compared with patients in Group I (<5%ile), Groups II, III, and IV had higher odds of favorable outcome (aOR, 1.84 [95% CI, 1.24, 2.73]; 2.20 [95% CI, 1.32, 3.68]; 1.90 [95% CI, 1.12, 3.25]). There was no association between Groups V or VI and favorable outcome (aOR, 1.44 [95% CI, 0.75, 2.80]; 1.11 [95% CI, 0.47, 2.59]). ConclusionIn the first 6-hours post-ROSC, a lowest documented MAP between the 5th−74th percentile for age was associated with favorable neurologic outcome compared to MAP <5th percentile for age.

Novel serum biomarkers for predicting prognosis in post cardiac arrest patients

Abstract Funding Acknowledgements Type of funding sources: None. Objective To determine the clinical feasibility of novel serum biomarkers by comparing them with conventional serum biomarkers in out-of-hospital cardiac arrest (OHCA) patients treated with target temperature management (TTM). Methods This study was a prospective observational study conducted on OHCA patients who underwent TTM. We measured serum biomarker Neuron‑Specific Enolase (NSE), S-100B (S100 calcium-binding protein), Tau protein, Glial Fibrillary Acidic Protein (GFAP), Neurofilament Light Chain (NFL), and Ubiquitin C-terminal hydrolase-L1 (UCH-L1) at 0, 24, 48, and 72 hours after return of spontaneous circulation (ROSC). Conventional biomarkers include NSE and S-100B. The primary outcome was good neurologic outcome at 6 months after OHCA. Results A total of 100 patients were included in this study from August 2018 to May 2020. Among the included patients, 46 patients had good neurologic outcomes. As for the biomarker's AUC value measured immediately after ROSC, GFAP had the highest value (0.850), and among the values measured 24 hours after ROSC, S100B showed the highest value (0.901). The AUC values of biomarkers measured after 48 hours and 72 hours after ROSC, were the highest in NFL (0.921, 0.946). AUC values measured after 72 hours of ROSC showed higher values in novel biomarkers than in conventional biomarkers. Conclusion After 72 hours of ROSC, the Novel biomarkers showed a higher AUC value than the conventional biomarkers. Among them, NFL showed the highest AUC values than other biomarkers at 48 and 72 hours of ROSC.

Nonconvulsive status epilepticus following cardiac arrest—are we missing the beginning?

Abstract Background Status epilepticus (SE) is a common complication in patients surviving a cardiac arrest, but little is known about the frequency of nonconvulsive status epilepticus (NCSE). Objectives To compile the first the evidence from the literature of the overall frequency of NCSE in adults with persistent coma following cardiac arrest. Secondarily, to assess the emergence of NCSE in comatose resuscitated patients within the first hours of the return of spontaneous circulation (ROSC) and before inducing target temperature management. Material and methods The medical search engine PubMed was screened to identify prospective and retrospective studies in English reporting on the frequency of NCSE in comatose post-resuscitated patients. Study design, time of EEG performance, detection of SE and NCSE, outcomes, and targeted temperature management were assessed. Results Only three cohort studies (one prospective and two retrospective) reported on the EEG evaluation describing NCSE during ongoing sedation and target temperature management. Overall, we identified 213 patients with SE in 18–38% and NCSE in 5–12%. Our review found no study reporting NCSE in resuscitated adult patients remaining in coma within the first hours of ROSC and prior to targeted temperature management and sedation. Conclusion Studies of NCSE after ROSC in adults are rare and mostly nonsystematic. This and the low proportion of patients reported having NCSE following ROSC suggest that NCSE before target temperature management and sedation is often overlooked. The limited quality of the data does not allow firm conclusions to be drawn regarding the effects of NCSE on outcome calling for further investigations. Clinicians should suspect NCSE in patients with persistent coma before starting sedation and targeted temperature management.

Acute respiratory distress syndrome after in-hospital cardiac arrest

ObjectiveAcute respiratory distress syndrome (ARDS) after out-of-hospital cardiac arrest is common and associated with worse outcomes. In the hospital setting, there are many potential risk factors for post-arrest ARDS, such as aspiration, sepsis, and shock. ARDS after in-hospital cardiac arrest (IHCA) has not been characterized. MethodsWe performed a single-center retrospective study of adult patients admitted to the hospital between 2014–2018 who suffered an IHCA, achieved return of spontaneous circulation (ROSC), and were either already intubated at the time of arrest or within 2 hours of ROSC. Post-IHCA ARDS was defined as meeting the Berlin criteria in the first 3 days following ROSC. Outcomes included alive-and-ventilator free days across 28 days, hospital length-of-stay, hospital mortality, and hospital disposition. ResultsOf 203 patients included, 146 (71.9%) developed ARDS. In unadjusted analysis, patients with ARDS had fewer alive-and-ventilator-free days over 28 days with a median of 1 (IQR: 0, 21) day, compared to 18 (IQR: 0, 25) days in patients without ARDS (p = 0.03). However, this association was not significant after multivariate adjustment. There was also a non-significant longer hospital length-of-stay (15 [IQR: 7, 26] vs 10 [IQR: 7, 22] days, p = 0.25; median adjusted increase in ARDS patients: 3 [95% CI: −2 to 8] days, p = 0.27) and higher hospital mortality (53% vs 44%, p = 0.26; aOR 1.6 [95% CI: 0.8–2.9], p = 0.17) in the ARDS group. ConclusionAmong IHCA patients, almost three-quarters developed ARDS within 3 days of ROSC. As in out of hospital cardiac arrest, post-IHCA ARDS is common.

Determining consistency of care after resuscitation from in-hospital cardiac arrest, a retrospective analysis at a tertiary care academic medical center

BackgroundFew guidelines have focused on the care delivered after return of spontaneous circulation (ROSC). Post ROSC best practice guidelines lack clarity about important tasks to accomplish in the first hours after ROSC. Objectives and methodsWe conducted a retrospective cohort analysis of adults who had suffered an in hospital cardiac arrest (IHCA) with ROSC over a two-year period to determine the completion rate of critical tasks in the immediate post-ROSC period: ECG within one hour, ABG within one hour, physician documentation within six hours, and surrogate communication within six hours. ResultsIn the 113 reviewed cases, there was significant variance between completion of all four (19.4%), three (35.3%), two (32.7%), one (20.6%) and none (1.7%) of these critical post ROSC tasks. We observed that 62.8% of IHCA with ROSC had an ECG obtained within one hour of ROSC. The rate of obtaining an ABG within one hour of ROSC was 76.9%. 49.5% of cases had physician documentation of the resuscitation within six hours of ROSC. The rate of documenting surrogate communication within six hours of ROSC was 69.9%. ConclusionsOur study demonstrated that the completion rates of critical tasks in the post ROSC setting were suboptimal within our patient cohort. This provides a baseline for the development of future best practice guidelines and clinical decision-making aids for post ROSC care after IHCA. This can lead to future research in coupling specific care tasks to post ROSC patient outcomes.

Association of hypoxic ischemic brain injury on early CT after out of hospital cardiac arrest with neurologic outcome

AimThis study aimed to describe the prevalence of hypoxic-ischemic brain injury (HIBI) on head CT (HCT) obtained within two hours of return of spontaneous circulation (ROSC) care in the Emergency Department following out-of-hospital cardiac arrest (OHCA) and evaluate the association between early HIBI and neurologic outcome. MethodsRetrospective single center observational study of post-OHCA patients between 2009 and 2017. Two cohorts were analyzed: those who underwent non-contrast HCT within two hours of ROSC and all others who survived to ICU admission. HIBI was defined as the presence of cerebral edema and/or abnormal gray-white matter differentiation in the HCT interpretation by a neuroradiologist. The primary outcomes were the prevalence of HIBI on early HCT and the magnitude of the association between HIBI and survival with good neurologic outcome using multivariable logistic regression. ResultsFollowing OHCA, 333 of 520 patients (64%) underwent HCT within two hours of ROSC and HIBI was present in 96 of 333 patients (29%). Of the early HCT cohort, those with HIBI had a significantly lower hospital survival (2%) and favorable neurologic outcome (1%). In those without HIBI on imaging, 88 of 237 patients (37%) had a favorable outcome. After adjustment for confounding variables, HIBI on early HCT was independently associated with a decreased likelihood of good neurologic outcome (aOR 0.015, 95% CI 0.002–0.12). ConclusionHIBI was present on 29% of HCTs obtained within 2 h of ROSC in the patients selected for early imaging by emergency physicians and was strongly and inversely associated with survival with a good neurologic outcome.

THE EFFECT OF A CHECKLIST ON VARIABILITY OF CARE AFTER IN HOSPITAL CARDIAC ARREST AT A TERTIARY ACADEMIC MEDICAL CENTER

TOPIC: Critical Care TYPE: Original Investigations PURPOSE: There are approximately 290,000 in hospital cardiac arrests (IHCA) annually in the United States. Recent evidence suggests that post IHCA outcomes may be more related to post return of spontaneous circulation (ROSC) care than intra cardiac arrest resuscitation. The purpose of this study is to assess the effect of a post ROSC checklist on variability care after IHCA with ROSC. METHODS: We performed a retrospective analysis of inpatient adults with an IHCA with ROSC at Harborview Medical Center (HMC) between 1/1/2018-12/31/2019. Included patients had an ICHA on an acute care or intensive care unit (ICU), were over the age of 18, and not placed on extra corporeal membrane oxygenation. IHCA was defined as cardiopulmonary resuscitation delivered by healthcare personnel. Demographics, clinical variables, and process of care metrics were abstracted from the electronic medical record. We then developed a post ROSC checklist utilizing our retrospective data and expert opinion. The checklist was implemented at HMC in January 2020. We conducted a follow up analysis of post-ROSC care since checklist implementation between 1/1/2020-12/31/2020. Pre and post implementation results were compared. RESULTS: 125 IHCA were included in the pre implementation cohort and 47 were included in the post implementation cohort. The mean age of the pre implementation cohort was 55.1 versus 55.9 post implementation. Women comprised 36.8% in the pre implementation cohort and 37.0% in the post implementation cohort. The rate of obtaining an electrocardiogram within one hour of ROSC was 60.8% prior to checklist implementation, and 76.6% after implementation. The rate of obtaining a formal transthoracic echocardiogram within six hours of ROSC was 32.8% prior to checklist implementation, and 34.0% after implementation. The rate of physician documentation occurring within six hours of ROSC was 47.0% prior to checklist implementation, and 85.1% after implementation. The rate of documented notification of family within six hours of ROSC in 67.2% of cases prior to checklist implementation, and 80.8% after implementation. CONCLUSIONS: The introduction of a post ROSC checklist correlated with an increase in obtaining ECGs and completing documentation tasks after IHCA with ROSC at HMC. This study was limited by the small number patients included as well as being a single site study. Confounding circumstances in code blue management related to COVID-19 must be acknowledged. Further research is needed to assess the durability of these findings, and what impact this may have on post IHCA outcomes. CLINICAL IMPLICATIONS: While there will be differences in the management and evaluation of patients who suffer an IHCA, some interventions such as a timely ECG and documentation should be completed with little variance between patients. The use of a checklist decreased the rate of variance, by providing a cognitive aid to guide clinical decisions in a stressful scenario. The use of a post ROSC checklist has the potential to decrease variance in diagnostic and documentation tasks after IHCA. DISCLOSURES: No relevant relationships by David Carlbom, source=Web Response No relevant relationships by Stephen Ferraro, source=Web Response No relevant relationships by Vince Raikhel, source=Web Response No relevant relationships by Vera Schulte, source=Web Response No relevant relationships by James Town, source=Web Response

Post-Cardiac Arrest Hydrocortisone Use Ameliorates Cardiac Mitochondrial Injury in a Male Rat Model of Ventricular Fibrillation Cardiac Arrest.

BackgroundSteroid use after cardiac arrest has been reported to improve survival and neurological outcome in cardiac arrest survivors. The study aimed to evaluate the effect of post‐arrest hydrocortisone use on myocardial damage and cardiac mitochondrial injury in a rat model of ventricular fibrillation cardiac arrest.Methods and ResultsVentricular fibrillation cardiac arrest was induced and left untreated for 5 minutes in adult male Wistar rats. Cardiopulmonary resuscitation and electric shocks were then applied to achieve return of spontaneous circulation (ROSC). Successfully resuscitated animals were randomized into 3 groups: control, low‐dose hydrocortisone (2 mg/kg), and high‐dose hydrocortisone (8 mg/kg). The low‐dose hydrocortisone and high‐dose hydrocortisone (treatment) groups received intravenous hydrocortisone immediately after ROSC and the control group received saline as placebo. Each group consisted of 15 animals. Within 4 hours of ROSC, both treatment groups showed a higher cardiac output than the control group. At the fourth hour following ROSC, histological examination and transmission electron microscopy demonstrated less myocardial damage and mitochondrial injury in the animals treated with hydrocortisone. In the treatment groups, hydrocortisone mitigated the acceleration of Ca2+‐induced mitochondrial swelling and suppression of complex activity observed in the control group. At the 72nd hour after ROSC, a significantly higher proportion of animals treated with hydrocortisone survived and had good neurological recovery compared with those given a placebo.ConclusionsHydrocortisone use after cardiac arrest may mitigate myocardial injury and cardiac mitochondrial damage and thus improve survival, neurological and histological outcomes in a rat model of ventricular fibrillation cardiac arrest.

Intravascular Targeted Temperature Management: One Hospital's Experience.

Sudden cardiac arrest (SCA) is one of the leading causes of death in adults around the world. And in some patients, SCA is followed by a return of spontaneous circulation (ROSC) and remain unresponsive. International guidelines recommend therapeutic hypothermia within 4 hours of ROSC for patients' survival. A medium-sized tertiary teaching hospital in the Midwestern United States was not achieving the recommendations of therapeutic hypothermia therapy. A root cause analysis identified multiple factors contributed to therapy delay. In March 2019, this hospital embarked on a 6-month trial of an intravascular targeted temperature management (ITTM) system to meet the recommendations. Donabedian's model guided the trial and included patients who suffered an SCA, with ROSC and remained unresponsive. Descriptive analysis was completed to compare the patients before and after the trial. The trial included interprofessional education of the ITTM system, policies, orders, and new process for initiating the therapy. A total of nine patients were included in the trial and with an average time to target temperature was 3.28 hours compared with 8.81 hours before the trial. The trial demonstrated ITTM was successful in meeting the recommendations. Paired with the promising research on the system's effectiveness, we have demonstrated that intravascular cooling can be implemented to reach the international recommendations. These reductions in treatment delays may prompt improved outcomes for individuals in the post-SCA population.

Abstract 329: Predicting Survival from Out-of-hospital Cardiac Arrest

Introduction: Prognostication is a significant challenge early in the post-cardiac arrest period. Common prognostic factors for neurological survival are unreliable (high false positive rates) until 72 hours post-cardiac arrest. It is not known whether there are a combination of factors that can be utilized earlier in the post-cardiac arrest period to accurately predict patient outcome. Our objective was to predict neurological outcome utilizing a novel combination of patient factors early in the post-cardiac arrest period. Methods: We conducted a retrospective cohort study using data from our local registry. We included adult patients who obtained a return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest (OHCA). We excluded patients who did not survive for at least 24 hours post-ROSC and those who had a do not resuscitate (DNR) order within 2 hours of ROSC. We performed an ordinal regression analysis using the proportional odds model to predict neurological outcome (modified rankin score (mRS)). We included a good neurological outcome (mRS 0-2), poor neurological outcome (mRS 3-5), and dead (mRS 6) as an ordinal outcome. We included a number of patient demographics, intra- and post-cardiac arrest factors as covariates in our model. The predictive performance of our model was analyzed using receiver operating characteristic (ROC) curves for discrimination and Brier statistic for calibration. Results: We included 3448 patients in our analysis. We found that an initial shockable rhythm (odds ratio (OR) 4.1; 95% confidence interval (CI) 3.6, 5.4), the absence of pupillary reflexes (OR 3.5; 95% CI 2.4,4.8) and maximum motor score on the Glasgow Coma Scale (GCS) (OR 1.5; 95% CI 1.4,1.6) had the greatest association with improved neurologic outcome. Longer duration of resuscitation was associate with worse outcomes (OR 0.84, 95% CI 0.82,0.87). The overall performance of our model was excellent with an area under the ROC curve of 0.89 and a Brier statistic of 0.13. Conclusion: Our model predicted good neurological outcome with a high rate of accuracy, however external validation of the model is required. This model may be useful to provide risk stratification of patients in clinical practice and future research on post-cardiac arrest care.

Salvianolic Acid B Improves Postresuscitation Myocardial and Cerebral Outcomes in a Murine Model of Cardiac Arrest: Involvement of Nrf2 Signaling Pathway.

Survival and outcome of cardiac arrest (CA) are dismal despite improvements in cardiopulmonary resuscitation (CPR). Salvianolic acid B (Sal B), extracted from Salvia miltiorrhiza, has been investigated for its cardioprotective properties in cardiac remodeling and ischemic heart disease, but less is known about its role in CA. The aim of this study was to learn whether Sal B improves cardiac and neurologic outcomes after CA/CPR in mice. Female C57BL/6 mice were subjected to eight minutes of CA induced by an intravenous injection of potassium chloride (KCl), followed by CPR. After 30 seconds of CPR, mice were blindly randomized to receive either Sal B (20 mg/kg) or vehicle (normal saline) intravenously. Hemodynamic variables and indices of left ventricular function were determined before CA and within three hours after CPR, the early postresuscitation period. Sal B administration resulted in a remarkable decrease in the time required for the return of spontaneous circulation (ROSC) in animals that successfully resuscitated compared to the vehicle-treated mice. Myocardial performance, including cardiac output and left ventricular systolic (dp/dtmax) and diastolic (dp/dtmin) function, was clearly ameliorated within three hours of ROSC in the Sal B-treated mice. Moreover, Sal B inhibited CA/CPR-induced cardiomyocyte apoptosis and preserved mitochondrial morphology and function. Mechanistically, Sal B dramatically promoted Nrf2 nuclear translocation through the downregulation of Keap1, which resulted in the expression of antioxidant enzymes, including HO-1 and NQO1, thereby counteracted the oxidative damage in response to CA/CPR. The aforementioned antiapoptotic and antioxidant effects of Sal B were impaired in the setting of gene silencing of Nrf2 with siRNA in vitro model. These improvements were associated with better neurological function and increased survival rate (75% vs. 40%, p < 0.05) up to 72 hours postresuscitation. Our findings suggest that the administration of Sal B improved cardiac function and neurological outcomes in a murine model of CA via activating the Nrf2 antioxidant signaling pathway, which may represent a novel therapeutic strategy for the treatment of CA.

LO16: Predicting survival from out-of-hospital cardiac arrest

Introduction: Prognostication is a significant challenge early in the post-cardiac arrest period. Common prognostic factors for neurological survival are unreliable (high false positive rates) until 72 hours post-cardiac arrest. It is not known whether there are a combination of factors that can be utilized earlier in the post-cardiac arrest period to accurately predict patient outcome. Our objective was to predict neurological outcome utilizing a novel combination of patient factors early in the post-cardiac arrest period. Methods: We conducted a retrospective cohort study using data from our local cardiac arrest registry. We included adult patients who obtained a return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest (OHCA). We excluded patients who did not survive for at least 24 hours post-ROSC and those who had a do not resuscitate (DNR) order within 2 hours of ROSC. We performed an ordinal regression analysis using the proportional odds model to predict neurological outcome (modified rankin score (mRS)). We included a good neurological outcome (mRS 0-2), poor neurological outcome (mRS 3-5), and dead (mRS 6) as an ordinal outcome. We included a number of patient demographics, intra- and post-cardiac arrest factors as covariates in our model. The predictive performance of our model was analyzed using receiver operating characteristic (ROC) curves for discrimination and Brier statistic for calibration. Results: We included 3448 patients in our analysis. We found that an initial shockable rhythm (odds ratio (OR) 4.1; 95% confidence interval (CI) 3.6, 5.4), the absence of pupillary reflexes (OR 3.5; 95% CI 2.4,4.8) and maximum motor score on the Glasgow Coma Scale (GCS) (OR 1.5; 95% CI 1.4,1.6) had the greatest association with improved neurologic outcome. Longer duration of resuscitation was associate with worse outcomes (OR 0.84, 95% CI 0.82,0.87). The overall performance of our model was excellent with an area under the ROC curve of 0.89 and a Brier statistic of 0.13. Conclusion: Our model predicted good neurological outcome with a high rate of accuracy, however external validation of the model is required. This model may be useful in providing initial risk stratification of patients in clinical practice and future research on post-cardiac arrest care.

Do Sex Differences Exist in the Establishment of "Do Not Attempt Resuscitation" Orders and Survival in Patients Successfully Resuscitated From In-Hospital Cardiac Arrest?

BackgroundWomen have higher utilization of “do not attempt resuscitation” (DNAR) orders during treatment for critical illness. Occurrence of sex differences in the establishment of DNAR orders after resuscitation from in‐hospital cardiac arrest is unknown. Whether differences in DNAR use by sex lead to disparities in survival remains unclear.Methods and ResultsWe identified 71 820 patients with return of spontaneous circulation (ROSC) after in‐hospital cardiac arrest from the Get With The Guidelines–Resuscitation registry. Multivariable models evaluated the association between de novo DNAR (anytime after ROSC, within 12 hours of ROSC, or within 72 hours of ROSC) by sex and the association between sex and survival to discharge accounting for DNAR. All models accounted for clustering of patients within hospital and adjusted for demographic and cardiac arrest characteristics. The cohort included 30 454 (42.4%) women, who were slightly more likely than male participants to establish DNAR orders anytime after ROSC (45.0% versus 43.5%; adjusted relative risk: 1.15 [95% CI, 1.10–1.20]; P<0.0001). Of those with DNAR orders, women were more likely to be DNAR status within the first 12 hours (51.8% versus 46.5%; adjusted relative risk: 1.40 [95% CI, 1.30–1.52]; P<0.0001) and within 72 hours after ROSC (75.9% versus 70.9%; adjusted relative risk: 1.35 [95% CI, 1.26–1.45]; P<0.0001). However, no difference in survival to hospital discharge between women and men (34.5% versus 36.7%; adjusted relative risk: 1.00 [95% CI, 0.99–1.02]; P=0.74) was appreciated.ConclusionsIn patients successfully resuscitated from in‐hospital cardiac arrest, there was no survival difference between men and women while accounting for DNAR. However, women had a higher rate of DNAR status early after resuscitation (<12 and <72 hours) in comparison to men.

Abstract 418: Categorization of Post-Cardiac Arrest Patients According to the Pattern of Amplitude-Integrated Electroencephalography After Return of Spontaneous Circulation: Analysis of Long-Term Prognosis

Introduction: Amplitude-integrated electroencephalography (aEEG) is a type of quantitative EEG easily interpreted by emergency physicians and intensivists at the bedside. We previously reported that categorizing post-cardiac arrest patients according to the pattern of aEEG, after return of spontaneous circulation (ROSC), could help predict the neurological function at hospital discharge (Critical Care. 2018;20:226). In post-cardiac arrest patients, increasing importance is being placed on long-term prognosis. In this study we evaluated the neurological outcome of patients in each category from our previous study, one year after cardiac arrest. Methods: We assessed the outcomes of patients who received post-cardiac arrest care, including targeted temperature management (TTM) and aEEG monitoring, in our tertiary emergency center, between March 2013 and April 2017. The patients were divided into four categories: C1 included those who displayed continuous normal voltage (CNV), within 12 hours of ROSC, and the best aEEG pattern in post-cardiac arrest patients; C2 included those who recovered CNV between 12 and 36 hours after ROSC; C3 included those with no CNV up to 36 hours after ROSC; and C4 included those who revealed burst suppression any time after ROSC. A good outcome was defined as a cerebral performance category (CPC) of 1 or 2, one year after cardiac arrest. Results: A total of 60 patients, with a median age of 60 years, were assessed; of them, 41 (68%) had an initial shockable rhythm. A good outcome was recorded in 18/19 (95%) C1 patients, 8/14 (57%) C2 patients, 1/10 (10%) C3 patients, and 0/14 C4 patients. Three patients could not be categorized because the recording period was too short. Conclusion: The categorization of post-cardiac arrest patients according to the pattern of aEEG after ROSC may be useful to predict long-term neurological function. C1 patients had excellent prognosis, while C3 and C4 patients had poor prognosis. However, one patient in the C3 group had CPC 3 at hospital discharge and then recovered to CPC 2 within one year. Withdrawal of care should be considered cautiously, using a multimodal approach, for patients in this category. C2 patients have borderline prognosis and are targets for intensive post-cardiac neurological care.

383 Neurofilament Light Chain as a Marker for Cerebral Anoxia in Out-of-Hospital Cardiac Arrest

Nationwide survival rates for out-of-hospital cardiac arrest (OHCA) approximate around 10-20% despite aggressive intervention. Approximately 90% of survivors will have moderate to severe neurological injury ranging from moderate cognitive impairment to brain death. There is a lack of early prognostic indicators. Traumatic brain injury studies have demonstrated that levels of blood biomarkers of neurological injury are reflective of degree of injury sustained. These biomarkers may be of prognostic value in OHCA patients where anoxic cerebral injury occurs. Non-traumatic OHCA patients ≥ 18 years old, with sustained return of spontaneous circulation (ROSC) for >1 hour were prospectively enrolled. Blood was collected within 59 minutes of ROSC, every 6 hours the first 24 hours, and then daily up to day 6. Patients were followed to day 6 post-OHCA, hospital discharge, or death, whichever occurred first. APACHE II and FOUR scores were recorded daily from time of ROSC (baseline) up to day 6. Five biomarkers of neuroinjury were analyzed: NF-L, GFAP, UCHL-1, Tau, and S100B. Cerebral Performance Category (CPC) was determined at 24 hours of ROSC and by death or within 24 hours before discharge. Primary outcomes were survival to discharge, and good versus poor (CPC 1-2 versus CPC 3-5) neurological outcome at 24 hours and discharge. The association between the biomarkers and other variables were assessed by using the Wilcoxon rank-sum test. Person correlation coefficient was used to assess the relationship between the biomarkers and continuous variables. All tests were performed with a 5% error rate. 13 OHCA patients were enrolled. Participants were mostly males (62%) with an average age of 60.5±9.6 (range 42-73) years. Their presenting rhythm was most often asystole (30.8%), VT/VF (46.2%), or PEA (23.1%). 38.5% of patients survived to discharge. Mean APACHE II at baseline did not significantly differ at 24 hours (26.38 versus 26.31). Of the biomarkers assayed, mean NF-L was significantly different between good versus poor outcome at 24 hours (1244.74 pg/mL versus 966.22 pg/mL, p=0.018), and remained consistently higher in poor outcome group at discharge (21.84 pg/mL versus 1556.46 pg/mL, p=0.012). NF-L levels also correlated with FOUR score at baseline and at 24 hours (p=0.026 and 0.027 respectively), as well as GCS at baseline and 24 hours (p=0.016). Early serum biomarker assays may be supportive in correlating with clinical outcomes and prognostication in out-of-hospital cardiac arrest. We report early pilot data demonstrating the promise of neurofilament light chain as a part of a strategy in supporting the clinical assessment of ischemic brain injury in post cardiac arrest patients.

2357 Lost and found: Detection of brain cardiolipins in plasma after cardiac arrest

OBJECTIVES/SPECIFIC AIMS: Neurological injury remains as the main limiting factor for overall recovery after cardiac arrest (CA). Currently available indicators of neurological injury are inadequate for early prognostication after return of spontaneous circulation (ROSC). High diversification of brain mitochondrial cardiolipins (CL) makes them unique candidates to quantify brain injury and to predict prognosis early after ROSC. METHODS/STUDY POPULATION: CL content in plasma in 39 patients within 6 hours of ROSC and 10 healthy subjects as well as CL content in human heart and brain specimens were quantified using a high-resolution liquid chromatography mass spectrometry method. The quantities of brain-type CL species were correlated with clinical parameters of brain injury severity permitting derivation of a cerebral CL score (C-score) using linear regression. C-score and a single CL species (70:5) were evaluated in patients with varying neurological injury and outcome. Using a rat model of CA, CL was quantified in the plasma and brain of rats using similar methods and results compared with the controls. RESULTS/ANTICIPATED RESULTS: We found that brain and the heart fell on extreme ends of the CL diversity spectrum with 26 species of CL exclusively present in human brain not heart. Nine of these 26 species were present in plasma within 6 hours of ROSC with quantities correlating with greater brain injury. The C-score correlated with early neurologic injury and predicted discharge neurologic/functional outcome. CL (70:5) emerged as a potential point-of-care marker that alone was predictive of injury severity and outcome nearly as well as C-score. Using a rat CA model we showed a significant reduction in hippocampal CL content corresponding to CL released from the brain into systemic circulation. C-score was significantly increased in 10 minute Versus 5 minute no-flow CA and naïve controls. DISCUSSION/SIGNIFICANCE OF IMPACT: CA results in appearance and accumulation of CL in plasma, proportional to injury severity. Quantitation of brain-type CL species in plasma can be used to prognosticate neurological injury within 6 hours after ROSC.

Patterns of Resuscitation Care and Survival After In-Hospital Cardiac Arrest in Patients With Advanced Cancer.

Little is known regarding patterns of resuscitation care in patients with advanced cancer who suffer in-hospital cardiac arrest (IHCA). In the Get With The Guidelines - Resuscitation registry, 47,157 adults with IHCA with and without advanced cancer (defined as the presence of metastatic or hematologic malignancy) were identified at 369 hospitals from April 2006 through June 2010. We compared rates of return of spontaneous circulation (ROSC) and survival to discharge between groups using multivariable models. We also compared duration of resuscitation effort and resuscitation quality measures. Overall, 6,585 patients with IHCA (14.0%) had advanced cancer. Patients with advanced cancer had lower multivariable-adjusted rates of ROSC (52.3% [95% CI, 49.5% to 55.3%] v 56.6% [95% CI, 53.8% to 59.5%]; P < .001) and survival to discharge (7.4% [95% CI, 6.6% to 8.4%] v 13.4% [95% CI, 12.1% to 14.8%]; P < .001). Among nonsurvivors who died during resuscitation, patients with advanced cancer had better performance on most resuscitation quality measures. Among patients with ROSC, patients with advanced cancer were made Do Not Attempt Resuscitation (DNAR) more frequently within 48 hours (adjusted relative risk, 1.30 [95% CI, 1.24 to 1.37]; P < .001). Adjustment for DNAR status explained some of the immediate effect of advanced cancer on survival; however, survival remained significantly lower in patients with cancer. Patients with advanced cancer can expect lower survival rates after IHCA compared with those without advanced cancer, and they are more frequently made DNAR within 48 hours of ROSC. These findings have important implications for discussions of resuscitation care wishes with patients and can better inform end-of-life discussions.

Time to Cooling Is Associated with Resuscitation Outcomes.

Our purpose was to analyze evidence related to timing of cooling from studies of targeted temperature management (TTM) after return of spontaneous circulation (ROSC) after cardiac arrest and to recommend directions for future therapy optimization. We conducted a preliminary review of studies of both animals and patients treated with post-ROSC TTM and hypothesized that a more rapid cooling strategy in the absence of volume-adding cold infusions would provide improved outcomes in comparison with slower cooling. We defined rapid cooling as the achievement of 34°C within 3.5 hours of ROSC without the use of volume-adding cold infusions, with a ≥3.0°C/hour rate of cooling. Using the PubMed database and a previously published systematic review, we identified clinical studies published from 2002 through 2014 related to TTM. Analysis included studies with time from collapse to ROSC of 20–30 minutes, reporting of time from ROSC to target temperature and rate of patients in ventricular tachycardia or ventricular fibrillation, and hypothermia maintained for 20–24 hours. The use of cardiopulmonary bypass as a cooling method was an exclusion criterion for this analysis. We compared all rapid cooling studies with all slower cooling studies of ≥100 patients. Eleven studies were initially identified for analysis, comprising 4091 patients. Two additional studies totaling 609 patients were added based on availability of unpublished data, bringing the total to 13 studies of 4700 patients. Outcomes for patients, dichotomized into faster and slower cooling approaches, were determined using weighted linear regression using IBM SPSS Statistics software. Rapid cooling without volume-adding cold infusions yielded a higher rate of good neurological recovery than slower cooling methods. Attainment of a temperature below 34°C within 3.5 hours of ROSC and using a cooling rate of more than 3°C/hour appear to be beneficial.

ROLE OF BISPECTRAL INDEX AND SUPPRESSION RATIO MONITORING WITHIN THE EMERGENCY DEPARTMENT AFTER RETURN OF SPONTANEOUS CIRCULATION FOLLOWING CARDIAC ARREST?: A META-ANALYSIS

Objectives & BackgroundPrognostication following return of spontaneous circulation (ROSC) after cardiac arrest (CA) is of growing interest. Several studies have shown early use of the bispectral index (BIS) monitor to...

Alignment of Do-Not-Resuscitate Status With Patients' Likelihood of Favorable Neurological Survival After In-Hospital Cardiac Arrest.

After patients survive an in-hospital cardiac arrest, discussions should occur about prognosis and preferences for future resuscitative efforts. To assess whether patients' decisions for do-not-resuscitate (DNR) orders after a successful resuscitation from in-hospital cardiac arrest are aligned with their expected prognosis. Within Get With The Guidelines-Resuscitation, we identified 26,327 patients with return of spontaneous circulation (ROSC) after in-hospital cardiac arrest between April 2006 and September 2012 at 406 US hospitals. Using a previously validated prognostic tool, each patient's likelihood of favorable neurological survival (ie, without severe neurological disability) was calculated. The proportion of patients with DNR orders within each prognosis score decile and the association between DNR status and actual favorable neurological survival were examined. Do-not-resuscitate orders within 12 hours of ROSC. Likelihood of favorable neurological survival. Overall, 5944 (22.6% [95% CI, 22.1%-23.1%]) patients had DNR orders within 12 hours of ROSC. This group was older and had higher rates of comorbidities (all P < .05) than patients without DNR orders. Among patients with the best prognosis (decile 1), 7.1% (95% CI, 6.1%-8.1%) had DNR orders even though their predicted rate of favorable neurological survival was 64.7% (95% CI, 62.8%-66.6%). Among patients with the worst expected prognosis (decile 10), 36.0% (95% CI, 34.2%-37.8%) had DNR orders even though their predicted rate for favorable neurological survival was 4.0% (95% CI, 3.3%-4.7%) (P for both trends <.001). This pattern was similar when DNR orders were redefined as within 24 hours, 72 hours, and 5 days of ROSC. The actual rate of favorable neurological survival was higher for patients without DNR orders (30.5% [95% CI, 29.9%-31.1%]) than it was for those with DNR orders (1.8% [95% CI, 1.6%-2.0%]). This pattern of lower survival among patients with DNR orders was seen in every decile of expected prognosis. Although DNR orders after in-hospital cardiac arrest were generally aligned with patients' likelihood of favorable neurological survival, only one-third of patients with the worst prognosis had DNR orders. Patients with DNR orders had lower survival than those without DNR orders, including those with the best prognosis.