Neurological Survival Research Articles

Cardiac arrest centres: what, who, when, and where?

Cardiac arrest centres (CACs) may play a key role in providing postresuscitation care, thereby improving outcomes in out-of-hospital cardiac arrest (OHCA). There is no consensus on CAC definitions or the optimal CAC transport strategy despite advances in research. This review provides an updated overview of CACs, highlighting evidence gaps and future research directions. CAC definitions vary worldwide but often feature 24/7 percutaneous coronary intervention capability, targeted temperature management, neuroprognostication, intensive care, education, and research within a centralized, high-volume hospital. Significant evidence exists for benefits of CACs related to regionalization. A recent meta-analysis demonstrated clearly improved survival with favourable neurological outcome and survival among patients transported to CACs with conclusions robust to sensitivity analyses. However, scarce data exists regarding 'who', 'when', and 'where' for CAC transport strategies. Evidence for OHCA patients without ST elevation postresuscitation to be transported to CACs remains unclear. Preliminary evidence demonstrated greater benefit from CACs among patients with shockable rhythms. Randomized controlled trials should evaluate specific strategies, such as bypassing nearest hospitals and interhospital transfer. Real-world study designs evaluating CAC transport strategies are needed. OHCA patients with underlying culprit lesions, such as those with ST-elevation myocardial infarction (STEMI) or initial shockable rhythms, will likely benefit the most from CACs.

Cost-Effectiveness Analysis of Intravascular Targeted Temperature Management after Cardiac Arrest in England.

BackgroundTargeted temperature management (TTM) has been shown to improve neurological outcomes and survival in patients resuscitated from cardiac arrest; however, the cost effectiveness of multiple TTM methods is not well studied.ObjectiveThis study aimed to evaluate the cost effectiveness of intravascular temperature management (IVTM) using Thermogard XP compared with surface cooling methods after cardiac arrest in the England from the perspectives of the UK national health service and Personal Social Services.MethodsWe developed a multi-state Markov model that evaluated IVTM (Thermogard XP) compared with surface cooling using two different devices (Blanketrol III and Arctic Sun 5000) over a short-term and lifetime time horizon. Model input parameters were obtained from the literature and local databases. We assumed a hypothetical cohort of 1000 patients who required TTM after cardiac arrest per year in the England. The outcomes were costs (in £, year 2019 values) and quality-adjusted life-years (QALYs), discounted at 3.5% annually. Deterministic and probabilistic sensitivity analyses were undertaken to examine the effect of alternative assumptions and uncertainty in model parameters on the results.ResultsThe cost-effectiveness analysis determined that Thermogard XP resulted in direct cost savings of £2339 and £2925 (per patient) compared with Blanketrol III and Arctic Sun 5000, respectively, and a gain of 0.98 QALYs over the patient lifetime. The probabilistic sensitivity analysis demonstrated that the probability of Thermogard XP being cost saving would be 69.2% and 65.3% versus the Arctic Sun 5000 and Blanketrol III, respectively.ConclusionImplementation of IVTM using Thermogard XP can lead to cost savings and improved patient quality of life versus surface cooling methods.Supplementary InformationThe online version contains supplementary material available at 10.1007/s41669-022-00333-7.

Neurological intact survival with rescue mechanical circulatory support for refractory out-of-hospital cardiac arrest despite long low-flow times

Abstract Funding Acknowledgements Type of funding sources: None. Background The potential window for using mechanical circulatory support (MCS) for refractory out-of-hospital cardiac arrest (OHCA) remain unsettled. It has been proposed that a cut-off limit defined as the golden hour may produce higher survival with good neurological outcome. Purpose The present study analyzed the association of low-flow time and neurological intact survival (Cerebral Performance Categories 1-2) at discharge between patients receiving conventional cardiopulmonary resuscitation (CCPR) and MCS. Methods The present retrospective, observational, single centre study from 2015-2019 included all consecutive OHCA patients, who were treated with MCS for refractory OHCA or received CCPR. Low-flow time was defined as the time from CPR to deployment of either veno-arterial extracorporeal membrane oxygenation or Impella support for the MCS group. Time from CPR to return of spontaneous circulation or termination of treatment was recorded for the CCPR group. Rate of neurological intact survival at discharge were analyzed for both groups. Results A total of 101 patients were treated with MCS and 914 patients received CCPR. The MCS group was significantly younger with a median age of 56 (IQR, 46-62) years compared to 67 (IQR, 57-74) years, p < 0.001. In the CCPR group, short low-flow times (0-20 minutes) were associated with high survival with good neurological outcome at discharge. There were no survivors with low-flow times exceeding 70 minutes. All patients receiving MCS survived at low-flow times 31-60 minutes, however neurological intact survival dropped to 21% at low-flow times > 80 minutes. Conclusion Patients treated with MCS with low-flow time 70-80 minutes did show similar favorable neurological outcome at discharge as patients receiving CCPR with low-flow < 10 minutes. Despite, low-flow times exceeding 80 minutes, patients treated with MCS still presented high survival rate of 21%. Hence, the data in this study does not support a golden hour for MCS.

Effects of brain tissue oxygen (PbtO2) guided management on patient outcomes following severe traumatic brain injury: A systematic review and meta-analysis

Monitoring and optimisation of brain tissue oxygen tension (PbtO2) has been associated with improved neurological outcome and survival in observational studies of severe traumatic brain injury (TBI). We carried out a systematic review of randomized controlled trials to determine if PbtO2-guided management is associated with differential neurological outcomes, survival, and adverse events. Searches were carried out to 10 February 2022 in Medline (OvidSP), 11 February in EMBASE (OvidSP) and 8 February in Cochrane library. Randomized controlled trials comparing PbtO2 and ICP-guided management to ICP-guided management alone were included. The primary outcome was survival with favourable neurological outcome at 6-months post injury. Data were extracted by two independent authors and GRADE certainty of evidence assessed. There was no difference in the proportion of patients with favourable neurological outcomes with PbtO2-guided management (relative risk [RR] 1.42, 95% CI 0.97 to 2.08; p = 0.07; I2 = 0%, very low certainty evidence) but PbtO2-guided management was associated with reduced mortality (RR 0.54, 95% CI 0.31 to 0.93; p = 0.03; I2 = 42%; very low certainty evidence) and ICP (mean difference (MD) − 4.62, 95% CI − 8.27 to − 0.98; p = 0.01; I2 = 63%; very low certainty evidence). There was no significant difference in the risk of adverse respiratory or cardiovascular events. PbtO2-guided management in addition to ICP-based care was not significantly associated with increased favourable neurological outcomes, but was associated with increased survival and reduced ICP, with no difference in respiratory or cardiovascular adverse events. However, based on GRADE criteria, the certainty of evidence provided by this meta-analysis was consistently very low.MESH:Brain Ischemia; Intensive Care; Glasgow Outcome Scale; Randomized Controlled Trial; Craniocerebral Trauma.

Direct Transport to Cardiac Arrest Center and Survival Outcomes after Out-of-Hospital Cardiac Arrest by Urbanization Level.

Current guidelines for post-resuscitation care recommend regionalized care at a cardiac arrest center (CAC). Our objectives were to evaluate the effect of direct transport to a CAC on survival outcomes of out-of-hospital cardiac arrests (OHCAs), and to assess interaction effects between CAC and urbanization levels. Adult EMS-treated OHCAs with presumed cardiac etiology between 2015 and 2019 were enrolled. The main exposure was the hospital where OHCA patients were transported by EMS (CAC or non-CAC). The outcomes were good neurological recovery and survival to discharge. Multivariable logistic regression analyses were conducted. Interaction analysis between the urbanization level of the location of arrest (metropolitan or urban/rural area) and the exposure variable was performed. Among the 95,931 study population, 23,292 (24.3%) OHCA patients were transported directly to CACs. Patients in the CAC group had significantly higher likelihood of good neurological recovery and survival to discharge than the non-CAC group (both p < 0.01, aORs (95% CIs): 1.75 (1.63–1.89) and 1.70 (1.60–1.80), respectively). There were interaction effects between CAC and the urbanization level for good neurological recovery and survival to discharge. Direct transport to CAC was associated with significantly better clinical outcomes compared to non-CAC, and the findings were strengthened in OHCAs occurring in nonmetropolitan areas.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Autophagy inhibitors alleviate Japanese encephalitis virus-induced cerebral inflammation in mice.

Japanese encephalitis (JE) is a zoonotic epidemic disease caused by Japanese encephalitis virus (JEV), and currently, no medicines are available to treat this disease. Autophagy modulators play an important role in the treatment of tumors, heart disease, and some viral diseases. The aim of this study was to investigate the effects of autophagy modulators on JEV infection and the host response in mice. The experimental mice were grouped as follows: DMEM (control), JEV, JEV+rapamycin (JEV+Rapa), JEV+wortmannin (JEV+Wort), JEV+chloroquine (JEV+CQ), Rapa, Wort, and CQ. The control group was treated with DMEM. The mice in other groups were infected with 105 PFU of JEV, and Rapa, Wort, and CQ were administered 2 h prior to JEV challenge and then administered daily for 10 consecutive days. All mice were monitored for neurological signs and survival. The damage of subcellular structures in the mouse brain was evaluated by transmission electron microscopy. The distribution of virus in the mouse brain was determined by RNAScope staining and immunohistochemical staining. The neuroinflammatory responses in the brain were examined via quantitative real-time PCR, and the signal pathways involved in neuroinflammation were identified by Western blot. The mice in the JEV+Wort and JEV+CQ groups showed milder neurological symptoms, less damage to the mitochondria in the brain tissue, and a higher survival rate than those in the JEV+Rapa and JEV groups. Compared with the JEV+Rapa and JEV groups, the distribution of JEV in the brain of mice in the JEV+Wort and JEV+CQ groups was lower, and the inflammatory response was weaker. No significant difference was observed in the expression of the PI3K/AKT/NF-κB pathway in mouse brain among the different groups. Our study suggests that the autophagy inhibitors Wort and CQ reduce JEV infection and weaken the inflammatory response, which does not depend on the PI3K/AKT/NF-κB pathway in mouse brain.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00705-021-05283-9.

Intravascular Versus Surface Cooling in Patients Resuscitated From Cardiac Arrest: A Systematic Review and Network Meta-Analysis With Focus on Temperature Feedback.

OBJECTIVE:The aim of the study was to compare the effect of intravascular cooling (IC), surface cooling with temperature feedback (SCF), and surface cooling without temperature feedback (SCnoF) on neurologic outcome and survival in patients successfully resuscitated from cardiac arrest (CA) and treated with targeted temperature management (TTM) at 32–34°C.DATA SOURCES:We performed a systematic review on Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, MEDLINE, SCOPUS, CINAHL, Web of Science, and Clinical Trials up to June 30, 2021.STUDY SELECTION:We included randomized and nonrandomized studies on IC, SCF, and SCnoF in adult humans resuscitated from CA undergoing TTM, reporting neurologic outcome or survival.DATA EXTRACTION:We performed a network meta-analysis to assess the comparative effects of IC, SCF, and SCnoF. The overall effect between two cooling methods included the effect of direct and indirect comparisons. Results are given as odds ratios (OR) and 95% CIs. Rankograms estimated the probability of TTM methods being ranked first, second, and third best interventions.DATA SYNTHESIS:A total of 14 studies involving 4,062 patients met the inclusion criteria. Four studies were randomized controlled studies, and 10 studies were nonrandomized observational studies. IC compared with SCnoF was significantly associated with better neurologic outcome (OR, 0.6; 95% CI, 0.49–0.74) and survival (OR, 0.8; 95% CI, 0.66–0.96). IC compared with SCF, and SCF compared with SCnoF did not show significant differences in neurologic outcome and survival. The rankogram showed that IC had the highest probability to be the most beneficial cooling method, followed by SCF and SCnoF.CONCLUSIONS:Our results suggest that in patients resuscitated from CA and treated with TTM at 32–34°C, IC has the highest probability of being the most beneficial cooling method for survival and neurologic outcome.

The feasibility of extracorporeal cardiopulmonary resuscitation for patients with active cancer who undergo in-hospital cardiac arrest

Indications of extracorporeal cardiopulmonary resuscitation (ECPR) are still debatable, particularly in patients with cancer. Prediction of the prognosis of in-hospital cardiac arrest (IHCA) in patients with cancer receiving ECPR is important given the increasing prevalence and survival rate of cancer. We compared the neurologic outcomes and survival rates of IHCA patients with and without cancer receiving ECPR. Data from the extracorporeal membrane oxygenation registry between 2015 and 2019 were used in a retrospective manner. The primary outcome was 6-month good neurologic outcome, defined as a Cerebral performance category score of 1 or 2. The secondary outcomes were 1- and 3-month good neurologic outcome, and 6-month survival. Among 247 IHCA patients with ECPR, 43 had active cancer. The 6-month good neurologic outcome rate was 27.9% and 32.4% in patients with and without active cancer, respectively (P > 0.05). Good neurologic outcomes at 1-month (30.2% vs. 20.6%) and 3-month (30.2% vs. 28.4%), and the survival rate at 6-month (39.5% vs. 36.5%) were not significantly different (all P > 0.05) Active cancer was not associated with 6-month good neurologic outcome by logistic regression analyses. Therefore, patients with IHCA should not be excluded from ECPR solely for the presence of cancer itself.

Inflow cannula position as risk factor for stroke in patients with HeartMate 3 left ventricular assist devices.

BackgroundA relation between the left ventricular assist device inflow cannula (IC) malposition and pump thrombus has been reported. This study aimed to investigate if the pump position, derived from chest X‐rays in HeartMate 3 (HM3) patients, correlates with neurological dysfunction (ND), ischemic stroke (IS), hemorrhagic stroke (HS) and survival.MethodsThis analysis was performed on routinely acquired X‐rays of 42 patients implanted with a HM3 between 2014 and 2017. Device position was quantified in patients with and without ND from frontal and lateral X‐rays characterizing the IC and pump in relation to spine, diaphragm or horizontal line. The primary end‐point was freedom from stroke and survival one‐year after HM3 implantation stratified by pump position.ResultsThe analysis of X‐rays, 33.5 (41.0) days postoperative, revealed a significant smaller IC angle of HM3 patients with ND versus no ND (0.1° ± 14.0° vs. 12.9° ± 10.1°, p = 0.005). Additionally, the IC angle in the frontal view, IS: 4.1 (20.9)° versus no IS: 13.8 (7.5)°, p = 0.004 was significantly smaller for HM3 patients with IS. Using receiver operating characteristics derived cut‐off, IC angle <10° provided 75% sensitivity and 100% specificity (C‐statistic = 0.85) for predicting IS. Stratified by IC angle, freedom from IS at 12 months was 100% (>10°) and 60% (<10°) respectively (p = 0.002). No significant differences were found in any end‐point between patients with and without HS. One‐year survival was significantly higher in patients with IC angle >10° versus <10° (100% vs. 71.8%, p = 0.012).ConclusionsIC malposition derived from standard chest X‐rays serves as a risk factor for ND, IS and worse survival in HM3 patients.

The effects of ultra-early clipping on survival and neurological outcome in poor-grade aneurysmal subarachnoid haemorrhage

European Stroke Organisation guidelines advise treating aneurysmal subarachnoid haemorrhage (aSAH) as early as possible. However, the optimum timing along with its beneficial effects is controversial. Therefore, we aimed to investigate the effects of ultra-early clipping on neurological outcomes and survival in poor-grade aneurysmal subarachnoid haemorrhages. This retrospective study included all poor-grade aneurysmal subarachnoid haemorrhage patients treated by ultra-early surgical clipping at Trakya University Hospital between January 1, 2001, and December 31, 2020. We analysed the outcome and mortality data of these patients. Specifically, we evaluated the effects of ultra-early clipping on outcomes, defined as within six hours of the onset of symptoms. From 813 records, 212 met our inclusion criteria. Of these, 117 (55.2%) were female and 95 (44.8%) male. The mean age was 58.3 ± 13.7 years. Glasgow Outcome Scale scores differed significantly between age groups, subarachnoid haemorrhage grades, those who did and did not rebleed, and those who did or did not suffer from vasospasms. A beneficiary relationship was found between ultra-early clipping and mortality among patients. Furthermore, favourable outcomes were significantly more frequent in the ultra-early clipping group. The aSAH patients treated at our hospital who received ultra-early clipping had significantly lower mortality rates and more favourable outcomes. The difference was significant among those treated during the last decade and among patients younger than 50.

The role of blood lnc-ZFAS1 in acute ischemic stroke: correlation with neurological impairment, inflammation, and survival profiles.

BackgroundLong non‐coding RNA zinc finger antisense 1 (lnc‐ZFAS1) has been reported to inhibit neuronal damage in acute ischemic stroke (AIS). However, the role of lnc‐ZFAS1 in AIS patients remains unclear. Therefore, we assessed the relationship of lnc‐ZFAS1 with neurological impairment, inflammation, and prognosis in AIS patients.MethodsTotally, 241 AIS patients and 120 controls were enrolled. lnc‐ZFAS1 in peripheral blood mononuclear cells was evaluated using reverse transcription‐quantitative polymerase chain reaction. Besides, a 3‐year follow‐up was conducted to assess recurrence‐free survival (RFS) and overall survival (OS) in AIS patients.Resultslnc‐ZFAS1 was reduced in AIS patients compared to that in controls (Z = −10.693, p < 0.001). In AIS patients, lnc‐ZFAS1 was negatively correlated with National Institutes of Health Stroke Scale score (r s = −0.335, p < 0.001), C‐reactive protein (r s = −0.284, p < 0.001), tumor necrosis factor‐alpha (r s = −0.293, p < 0.001), interleukin‐1β (r s = −0.149, p = 0.021), and interleukin‐6 (r s = −0.161, p = 0.012), but not underlying diseases (all p > 0.05). Besides, lnc‐ZFAS1 was divided into high and low levels based on the median expression in AIS patients. Indeed, high lnc‐ZFAS1 predicted better RFS (χ 2 = 6.222, p = 0.013); the 1‐year, 2‐year, and 3‐year RFS rates were 94.2%, 88.3%, and 85.5%, respectively, in patients with high lnc‐ZFAS1, then 87.5%, 79.2%, and 71.6%, respectively, in those with low lnc‐ZFAS1. However, lnc‐ZFAS1 was not correlated with OS (χ 2 = 1.404, p = 0.236); the 1‐year, 2‐year, and 3‐year OS rates were 98.3%, 95.8%, and 94.0%, respectively, in patients with high lnc‐ZFAS1, then 96.7%, 93.9%, and 89.6%, respectively, in those with low lnc‐ZFAS1.ConclusionLower lnc‐ZFAS1 expression is connected with increased neurological impairment and inflammation as well as worse RFS in AIS patients.

Outcomes of Gamma Knife Radiosurgery for Brain Metastases From Anaplastic Lymphoma Kinase Rearrangement-Positive and EGFR Mutation-Positive Non-Small Cell Lung Cancer.

IntroductionThe outcomes after gamma knife radiosurgery (GKRS) were retrospectively analysed in patients with brain metastases from anaplastic lymphoma kinase (ALK) rearrangement-positive and epidermal growth factor receptor (EGFR) mutation-positive non-small cell lung cancer (NSCLC) to evaluate the efficacy, safety and difference for overall survival and local tumor control.MethodsThe medical records were retrospectively reviewed of 607 patients (25 ALK-positive, 171 EGFR-positive, and 411 wild type) with 2959 tumors who had undergone GKRS.ResultsThe median overall survival time after initial GKRS was 14 months. Driver gene mutation-positive patients had significantly longer overall survival than wild type patients (p < 0.0001), and ALK-positive patients survived significantly longer than EGFR-positive patients (p = 0.04). Multivariate analysis showed the unfavorable factors significantly affecting overall survival outcomes were older age, lower Karnofsky Performance Status score, multiple intracranial metastases, uncontrolled primary cancer, uncontrolled extracranial metastases, no administration of immune checkpoint inhibitors, and driver gene mutation-negative cases. Seventy-three patients died of uncontrolled brain metastases at a median of 12 months. Driver gene mutations had no influence (p = 0.33), and ALK-positive and EGFR-positive patients showed no significant difference in neurological survival (p = 0.83). A total of 174 patients demonstrated distant brain control failure at a median of 15 months. ALK-positive type was significant compared with EGFR-positive type (p = 0.047), but driver gene mutation-positive and -negative types showed no significant difference in the development of new brain metastases (p = 0.2). The median tumor volume was 1.06 cm3 in the driver gene mutation-positive type and 1.85 cm3 in wild type. The median marginal dose was 20 Gy in both types. The 6-, 12-, and 24-month local tumor control rates were 97.3%, 96.1%, and 95.9%, respectively. Driver gene mutations had a significantly positive impact on local tumor control (p = 0.001), and ALK-positive and EGFR-positive types showed no significant difference (p = 0.95). A total of 193 tumors had radiation injury at a median of 12 months after GKRS. The 6-, 12-, and 24-month GKRS-related complication rates were 3.3%, 8.1%, and 8.7%, respectively. Driver gene mutations significantly induced radiation damage (p = 0.021), and the ALK-positive type was affected more than the EGFR-positive type (p = 0.02).ConclusionsALK rearrangement-positive NSCLC patients tended to have significantly longer survival, but had higher incidence of new intracranial metastases due to long-term survival after GKRS, compared with EGFR mutation-negative and driver gene mutation-negative NSCLC patients. GKRS induced significantly satisfactory local tumor control in driver gene mutation-positive tumors but GKRS-related complication frequency was higher, especially in ALK-positive NSCLC patients. Therefore, more careful imaging follow-up is necessary after GKRS for patients with driver gene mutation-positive NSCLC.

Dispatcher instructions for bystander cardiopulmonary resuscitation and neurologically intact survival after bystander-witnessed out-of-hospital cardiac arrests: a nationwide, population-based observational study

BackgroundThe International Liaison Committee on Resuscitation recommends that dispatchers provide instructions to perform compression-only cardiopulmonary resuscitation (CPR) to callers responding to adults with out-of-hospital cardiac arrest (OHCA). This study aimed to determine the optimal dispatcher-assisted CPR (DA-CPR) instructions for OHCA.MethodsWe analysed the records of 24,947 adult patients (aged ≥ 18 years) who received bystander DA-CPR after bystander-witnessed OHCA. Data were obtained from a prospectively recorded Japanese nationwide Utstein-style database for a 2-year period (2016–2017). Patients were divided into compression-only DA-CPR (n = 22,778) and conventional DA-CPR (with a compression-to-ventilation ratio of 30:2, n = 2169) groups. The primary outcome measure was 1-month neurological intact survival, defined as a cerebral performance category score of 1–2 (CPC 1–2).ResultsThe 1-month CPC 1–2 rate was significantly higher in the conventional DA-CPR group than in the compression-only DA-CPR group (before propensity score (PS) matching, 7.5% [162/2169] versus 5.8% [1309/22778], p < 0.01; after PS matching, 7.5% (162/2169) versus 5.7% (123/2169), p < 0.05). Compared with compression-only DA-CPR, conventional DA-CPR was associated with increased odds of 1-month CPC 1–2 (before PS matching, adjusted odds ratio 1.39, 95% confidence interval [CI] 1.14–1.70, p < 0.01; after PS matching, adjusted odds ratio 1.34, 95% CI 1.00–1.79, p < 0.05).ConclusionWithin the limitations of this retrospective observational study, conventional DA-CPR with a compression-to-ventilation ratio of 30:2 was preferable to compression-only DA-CPR as an optimal DA-CPR instruction for coaching callers to perform bystander CPR for adult patients with bystander-witnessed OHCAs.

Methodology and feasibility of neurofeedback to improve visual attention to letters in mild Alzheimer's disease

Background: Traumatic brain injury (TBI) is a leading cause of morbidity and mortality globally. Currently, the association between hyperoxia and outcomes in patients with TBI remains debatable. We assessed the effect of hyperoxia on the neurological outcomes and survival of critically ill patients with moderate-severe TBI. Methods: This was a retrospective cohort study of all adults with moderatesevere TBI admitted to the ICU between 1st January 2016 and 31st December 2019 who required invasive mechanical ventilation. We noted ABGs performed with the first 3 hours of intubation, then 6-12 hours and 24-48 hours. The patients were divided into two categories: normoxia (PaO2 60-99 mmHg) and hyeroxia (PaO2 >100 mmHg). Multivariable logistic regression was performed to assess predictors of hospital mortality and good neurologic outcome (Glasgow outcome score [GOS] ≥ 4). In a second analysis the patients were divided into survivors and non-survivors. Results: The study included 308 patients: 23.4% (n=72) in normoxia group and 76.6% (n=236) in hyeroxia group. Hyperoxia was not associated with increased hospital (43% vs. 18%, p=0.20) mortality. Further, the hospital discharge GCS (10 ± 5 vs. 11 ± 4, p=0.10) and GOS (3 ± 1 vs. 3 ± 1, p=0.35) were similar. In multivariable logistic regression analysis, hyperoxia was not associated with increased mortality (adjusted odds ratio [aOR] 0.99, 95% CI 0.99-1.00, p=0.11). PaO2 within different ranges was also not associated with mortality: 100-200 mmHg: aOR 0.60, 95% CI 0.29-1.52; 201-300 mmHg: aOR 0.66, 95% CI 0.29-1.52; 301-400 mmHg: aOR 0.80, 95% CI 0.31-2.09; and >400 mmHg: aOR 0.39, 95% CI 0.14-1.08; reference: PaO2 60-99 mmHg. The Kaplan-Meier survival curve for normoxia verses hyperoxia showed no significant difference for all-cause mortality. In the survivors verse nonsurvivors analysis, the PaO2 were (median, IQT) 199 mmHg (111-329) and 165 mmHg (84-252), respectively. Conclusion: Hyperoxia (PaO2 >100 mmHg) was not associated with increased mortality or poor neurological outcomes (determined by GOS) in moderatesevere TBI patients.

Background frequency can enhance the prognostication power of EEG patterns categories in comatose cardiac arrest survivors: a prospective, multicenter, observational cohort study

BackgroundWe assessed the prognostic accuracy of the standardized electroencephalography (EEG) patterns (“highly malignant,” “malignant,” and “benign”) according to the EEG timing (early vs. late) and investigated the EEG features to enhance the predictive power for poor neurologic outcome at 1 month after cardiac arrest.MethodsThis prospective, multicenter, observational, cohort study using data from Korean Hypothermia Network prospective registry included adult patients with out-of-hospital cardiac arrest (OHCA) treated with targeted temperature management (TTM) and underwent standard EEG within 7 days after cardiac arrest from 14 university-affiliated teaching hospitals in South Korea between October 2015 and December 2018. Early EEG was defined as EEG performed within 72 h after cardiac arrest. The primary outcome was poor neurological outcome (Cerebral Performance Category score 3–5) at 1 month.ResultsAmong 489 comatose OHCA survivors with a median EEG time of 46.6 h, the “highly malignant” pattern (40.7%) was most prevalent, followed by the “benign” (33.9%) and “malignant” (25.4%) patterns. All patients with the highly malignant EEG pattern had poor neurologic outcomes, with 100% specificity in both groups but 59.3% and 56.1% sensitivity in the early and late EEG groups, respectively. However, for patients with “malignant” patterns, 84.8% sensitivity, 77.0% specificity, and 89.5% positive predictive value for poor neurologic outcome were observed. Only 3.5% (9/256) of patients with background EEG frequency of predominant delta waves or undetermined had good neurologic survival. The combination of “highly malignant” or “malignant” EEG pattern with background frequency of delta waves or undetermined increased specificity and positive predictive value, respectively, to up to 98.0% and 98.7%.ConclusionsThe “highly malignant” patterns predicted poor neurologic outcome with a high specificity regardless of EEG measurement time. The assessment of predominant background frequency in addition to EEG patterns can increase the prognostic value of OHCA survivors.Trial registration KORHN-PRO, NCT02827422. Registered 11 September 2016—Retrospectively registered.

Abstract 10276: Impact of Time-to-Compression on Out-of-Hospital Cardiac Arrest Survival Outcomes: A National Registry Study

Introduction: Time To first Compression (TTC) in out-of-hospital cardiac arrests (OHCA) is thought to be an important predictor of survival outcomes. Guidelines such as the Journal of American College of Cardiology Scientific Expert Panel recommend that extracorporeal membrane oxygenation (ECMO) should not be used on OHCA patients with TTC &gt; 10 minutes. However, there is no literature validating this exclusion criterion on OHCA survival and neurological outcomes. This study aimed to evaluate the difference in neurological outcomes and survival to discharge of patients with CPR administered after 10 minutes, compared to within 10 minutes. Methodology: Data of OHCAs from 2012-2017 in Singapore were extracted from our national OHCA registry. We compared patients who received CPR within 10 minutes versus those who received CPR after 10 minutes. Primary outcomes were favorable cerebral performance (Glasgow-Pittsburgh Cerebral Performance Categories 1 and 2), and secondary were survival to hospital discharge or 30-day-survival. Results: There were 12,771 OHCAs analyzed, with 5,704 patients with TTC &lt;/=10 minutes and 7,067 with TTC &gt;10 minutes. Fewer patients survived to hospital discharge/30 th day with TTC &gt; 10 minutes (aOR 0.43, 95%CI: 0.32-0.58) and survival with good neurological outcomes was lower (aOR 0.51; 95%CI: 0.41-0.62). Other significant predictors of good neurological outcomes included age (aOR 0.98, 95%CI: 0.98 - 0.99), witnessed arrest (aOR 2.39, 95%CI: 1.69-3.40), bystander AED (aOR 1.55, 95%CI: 1.12-2.26), and presence of shockable rhythm (aOR 8.76, 95%CI: 7.12-10.78). A cut-off of 17.5 minutes (aOR 0.43, 95%CI:0.28-0.65) resulted in &lt;1% (127 out of 12,771) chance of survival with good neurological function based on the medical definition of Futility (specificity 0.84 sensitivity 0.84 ROC 0.91). Conclusion: Our study showed that there is a significant difference in survival and favourable neurological outcomes when TTC was &gt;10 minutes. However, more data-driven cut-off timings/criteria should be considered instead of the arbitrary 10 minutes for eligibility of ECMO therapy.

Abstract 12052: A Comprehensive Simulation-Based Training for E-CPR Improves the Neurological Outcome of Patients With Refractory Cardiac Arrest

Background: Extracorporeal cardiopulmonary resuscitation (E-CPR) has been utilized as a rescue strategy for patients with refractory cardiac arrest (CA). To improve the outcome of E-CPR, we developed a comprehensive simulation-based E-CPR training program. In the present study we assessed whether the E-CPR training improved the mortality and the neurological outcome. Methods: We have implemented the comprehensive E-CPR simulation training program twice a year to the medical team, which consists of emergency physicians, cardiologists, nurses, clinical engineers, and radiographers using a mock vascular model for E-CPR (ECMO cannulation). We assessed collapse to ECMO time, cumulative 30-day survival and good neurological outcome at hospital discharge defined as the cerebral performance categories (CPC) of 1 or 2. Results: Fifty-three consecutive patients received E-CPR for OHCA from January 2012 to December 2020 in which 31 patients were prior to (until September 2017) and 22 were after (from October 2017) the initiation of the E-CPR training. No differences were found in age, rates of witnessed and bystander-CPR, shockable rhythms, or acute coronary syndrome (ACS). Intra-aortic balloon pump was used in 87% patients prior to and 27% patients after the training (p&lt;0.001), and a microaxial Impella pump was used in 55% after the training. Collapse to ECMO time was significantly shorter after the training (p&lt;0.001). Cumulative 30-day survival and the rate of favorable neurological outcome were significantly higher after the training (p&lt;0.05). Multivariate cox proportional hazard analysis revealed that age (hazard ratio [HR], 1.38 (10 years increase), 95% confidence interval [CI], 1.12-1.73, p=0.002), Collapse to ECMO time (HR, 1.14, 95%CI, 1.04-1.23, p=0.006), and additional Impella use (HR, 0.23, 95% CI, 0.08-0.69, p=0.0009) were significantly associated with the 30-day survival. Conclusions: The E-CPR training significantly improved the collapse to ECMO time. The faster deployment of ECMO improves the neurological outcome and 30-day survival in patients with refractory CA. Additional use of Impella may improve the survival.

Abstract 12933: Myocardial Dysfunction After In-Hospital Cardiac Arrest in COVID-19 Patients

Introduction: Post resuscitation myocardial dysfunction (PRMD) is common after out-of-hospital cardiac arrest. While PRMD is a known cause of post-resuscitation circulatory failure, few studies have reported associations between PRMD and neurologic outcome or survival. Further, little is known about PRMD after in-hospital cardiac arrest (IHCA) nor on the incidence and prognosis of PRMD in COVID-19 IHCA. We sought to evaluate the incidence of PRMD in a multicenter cohort of resuscitated COVID-19 IHCA patients. Study Population and Methods: We included adult patients (≥18 y) admitted to multiple hospitals of Cleveland Clinic Health System. Patients who attained ROSC with an initial echocardiogram (EC) in the 72 hours post-arrest were included. Data were extracted from a data registry and electronic medical records. Results: From 03/2020-10/2020, 58 patients with COVID-19 had IHCA. ROSC was noted in 35 patients (60.3%), 27 (46.6%) were alive at 24 h and 13 patients (22.4%) survived to hospital discharge. Of the 35 patients who had ROSC, 14 patients (40%) had an EC within 72 h. The median age of this cohort was 67 y (IQR 47 - 73); 71% were male, and median BMI of 28 (IQR 27 - 34), and admission APACHE II score was 13 (IQR 11 - 19). One third of the patients (36%) were mechanically ventilated before arrest and 43% were on vasopressors. Initial arrest rhythms were: PEA/Asystole, 79%; and VF/VT, 21%. Most patients (93%) received manual chest compression with median CPR duration of 5 min (IQR 2 - 10). The median time of obtaining first EC post-ROSC in these 14 patients was 22 hours (IQR 6 - 62). 7/14 (50%) of the patient had systolic dysfunction on initial EC (6 had global dysfunction, 1 with regional wall motion abnormality, and 4/7 had combined LV and RV systolic dysfunction). 5/14 patients had a follow up EC with a median time of 43 days. 2/5 had normal initial EC and 3 out of these 5 patients who initially had PMRD showed complete recovery in their LV and RV systolic function. Conclusion: We report a case series of PRMD in COVID-19 patients who experienced IHCA. We found that PMRD is seen in half of the patients. Most patients with PMRD recovered to normal RV and LV function, consistent with prior studies of non-COVID-19 arrest EC.

Abstract 10707: The Impact of the COVID-19 Pandemic on Incidence and Outcomes from Out-of-Hospital Cardiac Arrest (OHCA) in Texas

Introduction: Nationally, the COVID-19 pandemic was associated with worse OHCA outcomes. Whether these trends persist or were consistent between states is unclear. Purpose: To determine the impact of COVID-19 on OHCA incidence and outcomes in Texas between 2019-2020. Methods: We analyzed adult OHCAs in Texas from the Cardiac Arrest Registry to Enhance Survival (CARES) during a matched period (March 11-December 31 from 2019 through 2020). We excluded cases witnessed by 9-1-1 responders and arrests occurring at healthcare facilities. Outcomes were rates of BCPR, AED use, sustained ROSC, prehospital termination of resuscitation (TOR), survival to hospital, survival to hospital discharge, good neurological outcomes and Utstein bystander survival. We created a mixed effects logistic regression model analyzing the effect of the pandemic on outcomes, using EMS agency as the random intercept. We adjusted for age, gender, race/ethnicity, witnessed arrest, initial rhythm type and location type. Results: There were 8,070 OHCA cases, with 4,443 (55.1%) in the pandemic period (March 11 - December 31, 2020) and 3,627 (44.5%) from March 11 - December 31 2019, a relative 18.4% increase. There was a significantly decreased odds of BCPR (46.2% v 42.2%, aOR = 0.87, 95% CI 0.79-0.95), AED use (13.0% v 7.3%, aOR = 0.53, 95% CI 0.36-0.78), and sustained ROSC (28.8% v 21.2%, aOR = 0.67, 95% CI 0.60-0.74) during the pandemic. Survival to hospital (27.1% v 20.9%, aOR = 0.72, 95% CI 0.65-0.80) and survival to hospital discharge (10.0% v 7.4%, aOR = 0.71, 95% CI 0.64-0.89) also decreased. Prehospital TOR increased (37.3% v 46.7%, aOR = 1.51, 95% CI 1.35-1.67). The pandemic was associated with a lower Utstein bystander survival rate (58.5% v 52.5%, aOR = 0.79, 95% CI 0.6-0.97). Conclusion: In Texas during the COVID-19 pandemic, there was a greater number of OHCA events, with lower overall survival and increased prehospital TOR.