Life-sustaining Therapy Research Articles

Novel serum biomarkers for predicting neurological outcomes in postcardiac arrest patients treated with targeted temperature management

ObjectiveTo determine the clinical feasibility of novel serum biomarkers in out-of-hospital cardiac arrest (OHCA) patients treated with target temperature management (TTM).MethodsThis study was a prospective observational study conducted on OHCA patients who underwent TTM. We measured conventional biomarkers, neuron‑specific enolase and S100 calcium-binding protein (S-100B), as well as novel biomarkers, including tau protein, neurofilament light chain (NFL), glial fibrillary acidic protein (GFAP), and ubiquitin C-terminal hydrolase-L1 (UCH-L1), at 0, 24, 48, and 72 h after the return of spontaneous circulation identified by SIMOA immunoassay. The primary outcome was poor neurological outcome at 6 months after OHCA.ResultsA 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 at 6 months after OHCA. All conventional and novel serum biomarkers had the ability to discriminate between the good and poor neurological outcome groups (p < 0.001). The area under the curves of the novel serum biomarkers were highest at 72 h after cardiac arrest (CA) (0.906 for Tau, 0.946 for NFL, 0.875 for GFAP, and 0.935 for UCH-L1). The NFL at 72 h after CA had the highest sensitivity (77.1%, 95% CI 59.9–89.6) in predicting poor neurological outcomes while maintaining 100% specificity.ConclusionNovel serum biomarkers reliably predicted poor neurological outcomes for patients with OHCA treated with TTM when life-sustaining therapy was not withdrawn. Cutoffs from two large existing studies (TTM and COMACARE substudy) were externally validated in our study. The predictive power of the novel biomarkers was the highest at 72 h after CA.

End-of-life practices: An ethical framework for clinicians

Most hospitalized patients die following a decision to forgo life-sustaining treatment and/or focus on comfort care. Since “Do not kill” is a general ethical norm, many healthcare professionals (HCPs) are uncertain or troubled by such decisions.We propose an ethical framework to help clinicians to understand better their own ethical perspectives about four end-of-life practices: lethal injections, the withdrawal of life-sustaining therapies, the withholding of life-sustaining therapies, and the injection of sedatives and/or analgesics for comfort care. This framework identifies three broad ethical perspectives that may permit HCPs to examine their own attitudes and intentions.According to moral perspective A (absolutist), it is never morally permissible to be causally involved in the occurrence of death. According to moral perspective B (agential), it may be morally permissible to be causally involved in the occurrence of death, if HCPs do not have the intention to terminate the patient’s life and if, among other conditions, they ensure respect for the person. Three of the four end-of-life practices, but not lethal injection, may be morally permitted. According to moral perspective C (consequentialist), all four end-of-life practices may be morally permissible if, among other conditions, respect for persons is ensured, even if one intends to hasten the dying process. This structured ethical framework may help to mitigate moral distress among HCPs by helping them to understand better their own fundamental ethical perspectives, as well as those of their patients and colleagues.

Paucity of neuroprognostic testing after cardiac arrest in the United States

BackgroundWithdrawal of life-sustaining therapies for perceived poor neurological prognosis is the most common cause of death for patients hospitalized after resuscitation from cardiac arrest. Accurate neuroprognostication is challenging and high stakes, so guidelines recommend multimodality testing. We quantified the frequency and timing with which guideline recommended diagnostics were acquired prior to in-hospital death after cardiac arrest. MethodsWe performed a retrospective cohort study using the Optum® deidentified Electronic Health Record dataset for 2010 to 2021. We included in-hospital decedents admitted after resuscitation from non-traumatic cardiac arrest. We quantified the number of decedents who underwent head computed tomographic imaging, electroencephalography, somatosensory evoked potentials, brain magnetic resonance imaging, or evaluation by a neurologist, as well as the timing of these tests. ResultsOf 34,585 included patients, median age was 66 [interquartile range 53 – 79] years and 13,609 (39%) were female. Median hospital length of stay was 0 days [0–1] days, and only 16% of deaths occurred on or after day three. Only 3,245 patients (9%) had at least one neurodiagnostic test acquired and only 1,708 (5%) were evaluated by a neurologist. The most common neurological diagnostic test to be obtained was CT imaging, acquired in 3,004 (9%) of the overall cohort. Only 852 patients (2%) of patients had at least two diagnostic modalities obtained. DiscussionIn this retrospective cohort, we found few patients hospitalized after out-of-hospital cardiac arrest underwent guideline-recommended prognostic testing. If validated in prospective cohorts with more granular clinical information, better guideline adherence and more frequent use of multimodality neuroprognostication offer an opportunity to improve quality of post-arrest care.

Limitation of life-sustaining therapies in critically ill patients with COVID-19: a descriptive epidemiological investigation from the COVID-ICU study

BackgroundLimitations of life-sustaining therapies (LST) practices are frequent and vary among intensive care units (ICUs). However, scarce data were available during the COVID-19 pandemic when ICUs were under intense pressure. We aimed to investigate the prevalence, cumulative incidence, timing, modalities, and factors associated with LST decisions in critically ill COVID-19 patients.MethodsWe did an ancillary analysis of the European multicentre COVID-ICU study, which collected data from 163 ICUs in France, Belgium and Switzerland. ICU load, a parameter reflecting stress on ICU capacities, was calculated at the patient level using daily ICU bed occupancy data from official country epidemiological reports. Mixed effects logistic regression was used to assess the association of variables with LST limitation decisions.ResultsAmong 4671 severe COVID-19 patients admitted from February 25 to May 4, 2020, the prevalence of in-ICU LST limitations was 14.5%, with a nearly six-fold variability between centres. Overall 28-day cumulative incidence of LST limitations was 12.4%, which occurred at a median of 8 days (3–21). Median ICU load at the patient level was 126%. Age, clinical frailty scale score, and respiratory severity were associated with LST limitations, while ICU load was not. In-ICU death occurred in 74% and 95% of patients, respectively, after LST withholding and withdrawal, while median survival time was 3 days (1–11) after LST limitations.ConclusionsIn this study, LST limitations frequently preceded death, with a major impact on time of death. In contrast to ICU load, older age, frailty, and the severity of respiratory failure during the first 24 h were the main factors associated with decisions of LST limitations.

Using Normalisation Process Theory to explore an interprofessional approach to Goals of Care: a qualitative study of stakeholders’ perspectives

ABSTRACT Goals of Care (GOC) is a longitudinal, multi-setting, and interprofessional practise aiming to guide the use of life-sustaining therapies. We documented the perspectives of different stakeholders regarding their roles in GOC intervention and explored the possibility of implementing an interprofessional approach in a healthcare and social services institution. We interviewed nurses, social workers, and relatives of deceased persons and analyzed the results using an analytical framework based on the 16 mechanisms of the Normalization Process Theory. We identified barriers to implementing a sustainable interprofessional approach to GOC, such as the lack of designated leaders responsible for supporting the day-to-day provision of this rather complex intervention, the difficulty of access to physicians in two of the three care settings under study, and the lack of a robust informational system. We also demonstrated that the GOC intervention is postponed until there is no uncertainty to deal with, i.e., at the end of life. Our study adds to an emerging body of literature criticising the concept of making advance medical directives itself. We advocated for the promotion of tools that would enable lay people to select and empower a supportive decision maker to better represent them in serious illness decision making.

Benefits of dexamethasone on early outcomes in patients with acute myeloid leukemia with hyperleukocytosis: a propensity score matched analysis.

Hyperleukocytosis is associated with a significant early mortality rate in patients with acute myeloid leukemia (AML). To date, no controlled trial has ever evaluated a strategy to reduce this risk, and the initial management of these patients remains heterogeneous worldwide. The aim of the present study was to evaluate the influence of a short course of intravenous dexamethasone on the early outcomes of patients with hyperleukocytic AML with white blood cell (WBC) count above 50 × 109/L. Clinical and biological data of all consecutive patients (1997-2017) eligible for intensive chemotherapy from a single center were retrospectively collected. A total of 251 patients with a median age of 51years and a median WBC count of 120 × 109/L were included, 95 of whom received dexamethasone. Patients treated with dexamethasone had higher WBC count and a more severe disease compared with those who did not, and they presented more often with leukostasis and hypoxemia, resulting in a more frequent need for life-sustaining therapies (p < 0.001). To account for these imbalances, patients were compared after adjusting for a propensity score, which included all variables with a prognostic influence in the overall cohort. In the matched cohort, dexamethasone was associated with lower early death (OR = 0.34, p = 0.0026) and induction failure rate (OR = 0.44, p = 0.02) and better overall survival (HR = 0.60, p = 0.011), with no impact on relapse risk (cHR = 0.73, p = 0.39). The overall survival benefit was confirmed among all tested subgroups. This study suggests that dexamethasone administration is safe and associated with a lower risk of induction mortality in patients with hyperleukocytic AML and deserves prospective evaluation.

Assessment of parental decision making in congenital heart disease, cardiomyopathy and heart transplantation: an observational study analysing decisional characteristics and preferences

ObjectiveWe explore shared decision making (DM) in guardians of children with heart disease by assessing the desired weight of influence on DM and factors that may alter the relative weight...

Abstract 14: Determinants Of Withdrawal Of Life-sustaining Therapy After Acute Stroke

Introduction: The decision to withhold or withdraw life-sustaining therapy (WLST) is common after acute stroke. Factors that may influence the decision are not well determined. We aimed to investigate factors associated with WLST in hospitalized acute stroke patients. Methods: Patients with acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH) were included across 152 Florida hospitals participating in the prospective Florida Stroke Registry from 2008-2021. Importance plots were performed to generate the predictive factors associated with WLST. AUC-ROC curves were generated for the performance of logistic regression (LR) and random forest (RF) models. We used 75/15/15 for training/testing/validation. Results: Among 309,393 AIS patients, 47,485 ICH patients, and 16,694 SAH patients; 9%, 28%, and 19% subsequently had WLST during hospitalization. Patients who had WLST were older (77 vs. 69 years), more women (57% vs. 49%), more White (76% vs. 67%), greater stroke severity at presentation NIHSS ≥ 5 (29% vs.19%), more likely to be treated in comprehensive stroke centers (52% vs. 44%), more likely to have Medicare insurance (53% vs. 44%), less likely to be uninsured (8% vs. 13%), more likely to undergo surgical treatments (1.2% vs 0.3%), and more likely to have impaired level of consciousness (38% vs. 12%). The most predictive factors associated with the decision to WLST in AIS were age, stroke severity, state region, insurance status, stroke center type, race, and level of consciousness (RF AUC of .93 and LR AUC of .85). The most predictive factors in ICH were age, impaired level of consciousness, state region, race, insurance status, stroke center type, and ambulation status at baseline (RF AUC of .76 and LR AUC of .71). Most predictive factors in SAH were age, impaired level of consciousness, state region, insurance status, race, and stroke center type (RF AUC of .82 and LR AUC of .72). Conclusion: Among acute hospitalized stroke patients; age, level of consciousness, state region, race, insurance status, ambulation status at baseline, and stroke center type could contribute to the decision to WLST.

Donation after circulatory death heart transplantation using normothermic regional perfusion:The NYU Protocol.

This study aimed to evaluate the impact of cardiopulmonary bypass for thoraco-abdominal normothermic regional perfusion on the metabolic milieu of donation after cardiac death organ donors before transplantation. Local donation after cardiac death donor offers are assessed for suitability and willingness to participate. Withdrawal of life-sustaining therapy is performed in the operating room. After declaration of circulatory death and a 5-minute observation period, the cardiac team performs a median sternotomy, ligation of the aortic arch vessels, and initiation of thoraco-abdominal normothermic regional perfusion via central cardiopulmonary bypass at 37 °C. Three sodium chloride zero balance ultrafiltration bags containing 50 mEq sodium bicarbonate and 0.5g calcium carbonate are infused. Arterial blood gas measurements are obtained every 15 minutes after every zero balance ultrafiltration bag is infused, and blood is transfused as needed to maintain hemoglobin greater than 8 mg/dL. Cardiopulmonary bypass is weaned with concurrent hemodynamic and transesophageal echocardiogram evaluation of the donor heart. The remainder of the procurement, including the abdominal organs, proceeds in a similar controlled fashion as is performed for a standard donation after brain death donor. Between January 2020 and May 2022, 18 donation after cardiac death transplants using the thoraco-abdominal normothermic regional perfusion protocol were performed at our institution. The median donor age was 42.5 years (range, 20-51 years), and 88.9% (16/18) were male. The mean total donor cardiopulmonary bypass time was 88.8 ± 51.8 minutes. At the beginning of cardiopulmonary bypass, the average donor lactate was 9.4 ± 1.5 mmol/L compared with an average final lactate of 5.3 ± 2.7 mmol/L (P<.0001). The average beginning potassium was 6.5 ± 1.8 mmol/L compared with an average end potassium of 4.2 ± 0.4 mmol/L (P<.0001) . The average beginning hemoglobin was 6.8 ± 0.7 g/dL, and the average end hemoglobin was 8.2 ± 1.3 g/dL (P<.001) . On average, donation after cardiac death donors received transfusions of 2.3 ± 1.5 units of packed red blood cells. Of the 18 donors who underwent normothermic regional perfusion, all hearts were deemed suitable for recovery and successfully transplanted, a yield of 100%. Other organs successfully recovered and transplanted include kidneys (80.6% yield), livers (66.7% yield), and bilateral lungs (27.8% yield). The use of cardiopulmonary bypass for thoraco-abdominal normothermic regional perfusion is a burgeoning option for improving the quality of organs from donation after cardiac death donors. Meticulous intraoperative management of donation after cardiac death donors with a specific focus on improving their metabolic milieu may lead to improved graft function in transplant recipients.

Ethnic and sex-based differences in outcomes after out-of-hospital cardiac arrest: a glimpse of the largest municipal healthcare system in the United States.

Ethnic and sex-based disparity in outcomes after out-of-hospital cardiac arrest (OHCA) may exist and could be due to social factors and inequality in care. We aimed to study whether ethnic and sex-based differences in out-of-hospital cardiac arrest outcomes occurred in a safety net hospital within the largest municipal healthcare system in the United States. We conducted a retrospective cohort study of patients successfully resuscitated from an OHCA and brought to New York City Health + Hospitals/Jacobi, from January 2019 to September 2021. Out-of-hospital cardiac arrest characteristics, do not resuscitate and withdrawal of life-sustaining therapy orders, and disposition data were collected and analyzed using regression models. Out of 648 patients screened, 154 were included (48.1% women). On multivariable analysis, sex [odds ratio (OR): 0.84; 95% CI: 0.30-2.4; P=0.74] and ethnic background (OR: 0.80; 95% CI: 0.58-1.12; P=0.196) did not predict discharge survival. No significant sex difference in do not resuscitate (P=0.76) or withdrawal of life-sustaining therapy (P=0.39) orders was found. Younger age (OR: 0.96; P=0.04) and initial shockable rhythm (OR: 7.26; P=0.01) independently predicted survival, both at discharge and at one year. Among patients resuscitated after an out-of-hospital cardiac arrest, neither sex nor ethnic background predicted discharge survival and no sex differences in end-of-life preferences were found. These findings are distinct from those of previously published reports. Given the unique population studied, distinct from those of registry-based studies, socioeconomic factors likely served as bigger drivers of out-of-hospital cardiac arrest outcomes rather than ethnic background or sex.

Mechanical Thrombectomy for Ischemic Stroke Secondary to Large Vessel Occlusions in Patients on Extracorporeal Membrane Oxygenation

Introduction: The use of short-term mechanical circulatory support (MCS) devices and procedures for function- and life-sustaining therapy is becoming a routine practice at many centers. Concomitant with the increasing use of MCS is the increasing recognition of acute brain injuries, including acute ischemic stroke, which may be caused by a myriad of MCS-driven factors. The aim of this case series was to document our experience with mechanical thrombectomy (MT) for ischemic stroke in extracorporeal membrane oxygenation (ECMO) patients. Methods: We retrospectively reviewed a prospectively maintained database of patients undergoing endovascular thrombectomy for large vessel occlusion at our institution. We identified patients that were on ECMO and underwent thrombectomy. Baseline demographics and procedural and functional outcomes were collected. Results: Three patients on ECMO were identified to have a large vessel occlusion and underwent thrombectomy. Two patients had an internal carotid artery terminus occlusion and one had a basilar artery occlusion. An mTICI 3 recanalization was achieved in all patients without postoperative hemorrhagic complications. Two patients achieved a 3-month mRS of 1, while one had mRS 4. Conclusion: Ischemic stroke can be associated with significant morbidity in MCS patients. We demonstrate that MT can be safely performed in this patient population with good outcomes.

Strategies for organ preservation: Current prospective and challenges.

In current therapeutic approaches, transplantation of organs provides the best available treatment for a myriad of end-stage organ failures. However, shortage of organ donors, lacunae in preservation methods, and lack of a suitable match are the major constraints in advocating this life-sustaining therapy. There has been continuous progress in the strategies for organ preservation since its inception. Current strategies for organ preservation are based on the University of Wisconsin (UW) solution using the machine perfusion technique, which allows successful preservation of intra-abdominal organs (kidney and liver) but not intra-thoracic organs (lungs and heart). However, novel concepts with a wide range of adapted preservation technologies that can increase the shelf life of retrieved organs are still under investigation. The therapeutic interventions of in vitro-cultured stem cells could provide novel strategies for replacement of nonfunctional cells of damaged organs with that of functional ones. This review describes existing strategies, highlights recent advances, discusses challenges and innovative approaches for effective organ preservation, and describes application of stem cells to restore the functional activity of damaged organs for future clinical practices.

IMPROVE-PD Finder: A Web-Based Platform to Search and Share Peritoneal Dialysis Biobank, Registry, and Clinical Trial Metadata

Peritoneal dialysis (PD) is a life-sustaining kidney replacement therapy, for the increasing number of people suffering permanent kidney failure across all age groups worldwide. Although PD potentially offers socio-economic and performance benefits over haemodialysis (HD), both treatments severely accelerate complications of chronic kidney disease (CKD), in particular atherosclerotic disease progression that worsen outcomes when compared with non-dialysis patients 1. Improved understanding of the underlying molecular pathogenic mechanisms should help in the design of interventions that improve outcomes 2.

Addressing inadequate blood flow during normothermic regional perfusion for in-situ donation after circulatory death grafts preservation.

Donation after circulatory death (DCD) has emerged as attainable strategy to tackle the issue of organ shortage, expanding the donor pool. The DCD concept has been applied to the multiple declinations of circulatory arrest, as per the Modified Maastricht Classification. Notwithstanding, whichever the scenario, DCD donors experience a variable warm ischemia time whose correlation with graft dysfunction is ascertained. This applies to both "controlled" (cDCD) donors (i.e., the timespan from the withdrawal of life-sustaining therapies to the onset of in-situ perfusion), and "uncontrolled" DCD (uDCD) (i.e., the low-flow period during cardiopulmonary resuscitation - CPR). This sums up to the no-flow time from cardiac arrest to the start of CPR for uDCD donors, and to the no-touch period for both uDCDs and cDCDs. Static and hypothermic storage may not be appropriate for DCD grafts. In order to overcome this ischemic insult, extracorporeal membrane oxygenation devices are adopted to guarantee the in-situ grafts preservation by means of techniques such as the normothermic regional perfusion (NRP) which consists in a selective abdominal perfusion obtained via the endovascular or surgical occlusion of the thoracic aorta. The maintenance of an adequate pump flood throughout NRP is therefore a sine qua non to accomplish the DCD donation. The issue of insufficient pump flow during NRP is prevalent and clinically significant but its management remains technically challenging and not standardized. Hereby we propose a systematic algorithmic approach to address this relevant occurrence.

Factors associated with an unfavourable outcome in elderly intensive care traumatic brain injury patients. a retrospective multicentre study

BackgroundChanges in the epidemiology of traumatic brain injury (TBI) in older patients have received attention, but limited data are available on the outcome of these patients after admission to intensive care units (ICUs). The aim of this study was to evaluate the outcomes of patients over 65 years of age who were admitted to an ICU for TBI.MethodsThis was a multicentre, retrospective, observational study conducted from January 2013 to February 2019 in the surgical ICUs of 5 level 1 trauma centres in France. Patients aged ≥ 65 years who were hospitalized in the ICU for TBI with or without extracranial injuries were included. The main objective was to determine the risk factors for unfavourable neurological outcome at 3 months defined as an Extended Glasgow Outcome Scale (GOSE) score < 5.ResultsAmong the 349 intensive care patients analysed, the GOSE score at 3 months was ≤ 4 and ≥ 5 in 233 (67%) and 116 (33%) patients, respectively. The mortality rate at 3 months was 157/233 (67%), and only 7 patients (2%) fully recovered or had minor symptoms. Withdrawal or withholding of life-sustaining therapies in the ICU was identified in 140 patients (40.1%). Multivariate analysis showed that age (OR 1.09, CI 95% 1.04–1.14), male sex (OR 2.94, CI95% 1.70–5.11), baseline Glasgow Coma Scale score (OR 1.20, CI95% 1.13–1.29), injury severity score (ISS; OR 1.04, CI95% 1.02–1.06) and use of osmotherapy (OR 2.42, CI95% 1.26–4.65) were associated with unfavourable outcomes (AUC = 0.79, CI 95% [0.74–0.84]). According to multivariate analysis, the variables providing the best sensitivity and specificity were age ≥ 77 years, Glasgow Coma Scale score ≤ 9 and ISS ≥ 25 (AUC = 0.79, CI 95% [0.74–0.84]).ConclusionsAmong intensive care patients aged ≥ 65 years suffering from TBI, age (≥ 77 years), male sex, baseline Glasgow coma scale score (≤ 9), ISS (≥ 25) and use of osmotherapy were predictors of unfavourable neurological outcome.Trial registrationClinicalTrials.gov Identifier: NCT04651803. Registered 03/12/2020. Retrospectively registered.

956: MASSIVE FLASH PULMONARY EDEMA FOLLOWING ANTIBODY-MEDIATED REJECTION THERAPY POST-LUNG TRANSPLANT

Introduction: Antibody-mediated rejection (AMR) is a complication of orthotopic lung transplantation (OLT) leading to allograft dysfunction through immune activation. We report a patient with bilateral OLT who received daratumumab for AMR and subsequently developed flash pulmonary edema and multisystem organ failure (MSOF) resulting in death. Description: An 18-year-old male with pulmonary veno-occlusive disease status-post remote bilateral OLT presented to a quaternary-care hospital for respiratory distress. Biopsy revealed AMR with elevated donor-specific-antibodies (DSAs). He was started on our institution-specific AMR protocol: systemic steroids, rituximab, a 5–7-day course of plasmapheresis, mepolizumab, and daratumumab. Following daratumumab, the patient developed tachycardia, tachypnea, hypertension, and altered mental status. He was transferred to the PICU in extremis and was emergently intubated. He had massive flash pulmonary edema with copious production of proteinaceous fluid (>1L/hr) impairing ventilation and oxygenation. His arterial pH remained < 7 and pCO2 > 100 mmHg. Echocardiogram demonstrated normal biventricular function, eliminating a cardiogenic source. He continued to have profound hypoxemic and hypercapnic respiratory failure, pulmonary edema, uncompensated shock, acute kidney injury with anuria, disseminated intravascular coagulation, and acute encephalopathy. Due to progressive MSOF, life-sustaining therapies were withdrawn. A unifying diagnosis to explain his MSOF and acute decompensation were never identified. Discussion: There are no reports of flash pulmonary edema after daratumumab administration, however it has been described with other monoclonal antibodies, including muromonab-CD3 (OKT3) [1]. Edema from OKT3 has been attributed to cytokine release syndrome (CRS) [1]. We postulate a similar pathophysiology. Daratumumab, a human CD-38-targeting antibody, induces cell-death via complement and antibody-dependent cytotoxicity, apoptosis, and phagocytosis [2]. We suspect a massive response of the infused monoclonal antibody with the pulmonary DSAs, resulting in localized cell death and lysis, cytokine release, pulmonary vascular inflammation, and uncontrollable pulmonary edema. We hope to gain further insight with immunohistological data on autopsy.

617: CANNABIDIOL GUMMY INGESTION LEADING TO CARDIAC ARREST IN A PEDIATRIC PATIENT

Introduction: Rising popularity and availability of cannabidiol (CBD) products have led to increased accessibility in homes. The resemblance of CBD gummies to candy has led to unintentional ingestions in pediatric patients. Toxic doses of CBD are unknown, and contamination with other cannabinoids and toxins can occur. Few reports describe CBD toxicity. Respiratory and neurologic depression are the main effects. Description: A 4-year-old 60kg male with a voracious appetite was found unresponsive at home. Parents report he ate half a 75mg CBD gummy approximately 6 hours prior to the event. At EMS arrival rhythm was a wide ventricular complex. At ED arrival the child remained pulseless with active cardiopulmonary resuscitation. Return of spontaneous circulation was obtained after approximately 20 minutes of downtime, though in a wide complex tachycardia. Labs demonstrated severe metabolic acidosis, hyperkalemia, and multiorgan dysfunction. Head CT showed diffuse cerebral edema and effacement of the sulci and basal cisterns. Shortly after transfer to our tertiary care center PICU he developed unequal pupils and received hyperosmolar therapies. He had no cough and no gag, corneal or pupillary reflexes. Electroencephalography demonstrated burst suppression pattern. Norepinephrine and epinephrine were started for hypotension. Echocardiogram showed poor biventricular function. Genetic testing for cardiomyopathies and arrhythmias was sent given the presenting rhythm. Given the neurologic exam and poor prognosis the family elected to withdraw life-sustaining therapies. A serum drug analysis was negative. A comprehensive urine drug analysis resulted 4 days later with carboxy-tetrahydrocannabinol (THC) >14,286 ng/mL, suggesting consumption of a substantial amount of CBD gummies containing THC. Discussion: The majority of CBD products are unregulated and can contain other cannabinoids, toxins, or synthetic equivalents, as shown in this case. CBD and synthetic equivalents do not result on traditional toxicology screens. Further testing may not be readily available, posing a diagnostic dilemma for practitioners. This case highlights the importance of considering CBD intoxication in patients who present with acute neurologic, respiratory, and cardiovascular depression.

267: PERFORMANCE STATUS AS A PREDICTOR OF ICU MORTALITY IN CRITICALLY ILL CANCER PATIENTS

Introduction: Frailty and poor performance status (PS) have been associated with low survival in the general intensive care units (ICUs). However, there is limited data focused on critically ill cancer patients. As demand for ICU admission among the cancer population rises, there is a need to prioritize access, especially in resource-limited settings. Therefore, we assessed the association between baseline PS to ICU mortality in critically ill cancer patients. Methods: A retrospective cohort of adult critically ill cancer patients admitted between 12/2020 and 07/2021 to an oncological hospital in Guayaquil, Ecuador. PS deterioration was measured with the Eastern Cooperative Oncology Group scale (ECOG) prior to hospital admission, and it was classified into mild (ECOG 0-1), moderate (ECOG 2), and poor (ECOG 3-4). We conducted a logistic regression to establish associations between characteristics and ICU mortality. Results: A total of 200 patients were included, with a mean age of 57.9 years (SD 16). Of them, there were 168 (84%) patients with solid tumors and 32 (16%) with hematological malignancies. Most patients were post-surgical (52%) and the rest were medical (48%). Regarding PS deterioration, we found 71 (35.5%) with mild PS, 95 (47.5%) with a moderate PS and 34 (17.0%) with a poor PS. Most patients in the poor PS group (70.6%) had a solid tumor. Overall, 96 (48%) patients required invasive mechanical ventilation (IMV) and 88 (44%) vasopressors. Patients with poor PS required more days on IMV (1.5 vs 1 vs 0; p=.001) and days on vasopressors (1vs 1 vs 0; p=.019) than the moderate and mild groups, respectively. The overall ICU mortality was 29%. Poor PS had higher risk of ICU mortality ratio (OR 5.013 [95% CI: 1.6–15.9]) than SOFA (OR 1.3 [95% CI: 1.1-1.6], APACHE II (OR 1.1 [95% CI: 1-1.2], and m-NUTRIC (OR 0.99 [95% CI: 0.7-1.3] scores. Conclusions: A poor performance status was associated with a 5-fold increased risk of ICU mortality. Additionally, poor PS implied a higher requirement of life-sustaining therapies like IMV and vasopressors. The association between ECOG and mortality was superior to the classic ICU scores such as, APACHE II, SOFA and m-NUTRIC. Future research should determine if the PS could be a triage tool in settings with low ICU capacity.

Trial of Therapy on Trial: Inconsistent Thresholds for Discussing Withdrawal of Life-Sustaining Therapies in the Neonatal Intensive Care Unit.

This study aimed to establish the degree of variability in thresholds for discussing withdrawal of life-sustaining therapies (WLST) in periviable infants among neonatal intensive care unit (NICU) personnel. A vignette-style survey was administered to NICU personnel at two urban NICUs assessing likelihood of discussing WLST or support for discussing WLST (on a scale from 1, not at all likely/supportive to 10, extremely likely/supportive) in 10 clinical scenarios. Response rates ranged by clinical role from 26 to 89%. Participant responses ranged from 1 to 10 in 5 out of 10 vignettes for NICU attendings, and 9 out of 10 vignettes for bedside nurses. Lower gestational age (22-23 vs. 24-25 weeks) was associated with increased likelihood to discuss WLST in some but not all scenarios. NICU personnel have widely variable criteria for discussing WLST which threatens the informed consent process surrounding resuscitation decisions in a "trial of therapy" framework. · NICU personnel have variable criteria for WLST.. · Parents have little say in whether WLST is offered.. · Disclosure of variable criteria is not routine..

Long-Term Outcomes of Patients with Stroke Predicted by Clinicians to have no Chance of Meaningful Recovery: A Japanese Cohort Study.

Little is known about the natural history of comatose patients with brain injury, as in many countries most of these patients die in the context of withdrawal of life-sustaining therapies (WLSTs). The accuracy of predicting recovery that is used to guide goals-of-care decisions is uncertain. We examined long-term outcomes of patients with ischemic or hemorrhagic stroke predicted by experienced clinicians to have no chance of meaningful recovery in Japan, where WLST in patients with isolated neurological disease is uncommon. We retrospectively reviewed the medical records of all patients admitted with acute ischemic stroke, intracerebral hemorrhage, or nontraumatic subarachnoid hemorrhage between January 2018 and December 2020 to a neurocritical care unit at Toda Medical Group Asaka Medical Center in Saitama, Japan. We screened for patients who were predicted by the attending physician on postinjury day 1-4 to have no chance of meaningful recovery. Primary outcome measures were disposition at hospital discharge and the ability to follow commands and functional outcomes measured by the Glasgow Outcome Scale-Extended (GOS-E), which was assessed 6months after injury. From 860 screened patients, we identified 40 patients (14 with acute ischemic stroke, 19 with intracerebral hemorrhage, and 7 with subarachnoid hemorrhage) who were predicted to have no chance of meaningful recovery. Median age was 77years (interquartile range 64-85), 53% (n = 21) were women, and 80% (n = 32) had no functional deficits prior to hospitalization. Six months after injury, 17 patients were dead, 14 lived in a long-term care hospital, 3 lived at home, 2 lived in a rehabilitation center, and 2 lived in a nursing home. Three patients reliably followed commands, two were in a vegetative state (GOS-E 2), four fully depended on others and required constant assistance (GOS-E 3), one could be left alone independently for 8h per day but remained dependent (GOS-E 4), and one was independent and able to return to work-like activities (GOS-E 5). In the absence of WLST, almost half of the patients predicted shortly after the injury to have no chance of meaningful recovery were dead 6months after the injury. A small minority of patients had good functional recovery, highlighting the need for more accurate neurological prognostication.