Outcomes In Post-cardiac Arrest Patients Research Articles

Optimal Timing of the Neutrophil-to-Lymphocyte Ratio and Platelet-to-Lymphocyte Ratio as Early Predictors of Neurological Outcomes in Postcardiac Arrest Patients

The neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) have been recognized as predictors of various critical illnesses. Our study aimed to investigate whether the NLR and PLR measured at different timepoints could predict poor neurological outcomes at 6 months. This observational retrospective cohort study included adults who had experienced out-of-hospital cardiac arrest (OHCA) and received targeted temperature management between November 2015 and December 2020. Patients with an active infection, as confirmed by an initial blood culture, were excluded. Multivariate logistic regression models were used to determine the association between the NLR and PLR at 0, 24, and 48 h after return of spontaneous circulation and poor neurological outcomes, defined as a Cerebral Performance Category score of ≥3 at 6 months. The NLR at 24 h, but not the NLR or PLR at other timepoints, was significantly associated with poor neurological outcomes (odds ratio: 1.05; 95% CI: 1.01–1.09; p = 0.018). The NLR at 24 h showed moderate accuracy in predicting poor neurological outcomes, with an AUC of 0.619. A cutoff value of 9.0 achieved 72.5% sensitivity and 47.7% specificity. The NLR measured at 24 h after ROCS could be used for early neuroprognostication given its low cost and widespread availability.

Prediction performance of scoring systems after out-of-hospital cardiac arrest: A systematic review and meta-analysis.

Ongoing changes in post resuscitation medicine and society create a range of ethical challenges for clinicians. Withdrawal of life-sustaining treatment is a very sensitive, complex decision to be made by the treatment team and the relatives together. According to the guidelines, prognostication after cardiopulmonary resuscitation should be based on a combination of clinical examination, biomarkers, imaging, and electrophysiological testing. Several prognostic scores exist to predict neurological and mortality outcome in post-cardiac arrest patients. We aimed to perform a meta-analysis and systematic review of current scoring systems used after out-of-hospital cardiac arrest (OHCA). Our systematic search was conducted in four databases: Medline, Embase, Central and Scopus on 24th April 2023. The patient population consisted of successfully resuscitated adult patients after OHCA. We included all prognostic scoring systems in our analysis suitable to estimate neurologic function as the primary outcome and mortality as the secondary outcome. For each score and outcome, we collected the AUC (area under curve) values and their CIs (confidence iterval) and performed a random-effects meta-analysis to obtain pooled AUC estimates with 95% CI. To visualize the trade-off between sensitivity and specificity achieved using different thresholds, we created the Summary Receiver Operating Characteristic (SROC) curves. 24,479 records were identified, 51 of which met the selection criteria and were included in the qualitative analysis. Of these, 24 studies were included in the quantitative synthesis. The performance of CAHP (Cardiac Arrest Hospital Prognosis) (0.876 [0.853-0.898]) and OHCA (0.840 [0.824-0.856]) was good to predict neurological outcome at hospital discharge, and TTM (Targeted Temperature Management) (0.880 [0.844-0.916]), CAHP (0.843 [0.771-0.915]) and OHCA (0.811 [0.759-0.863]) scores predicted good the 6-month neurological outcome. We were able to confirm the superiority of the CAHP score especially in the high specificity range based on our sensitivity and specificity analysis. Based on our results CAHP is the most accurate scoring system for predicting the neurological outcome at hospital discharge and is a bit less accurate than TTM score for the 6-month outcome. We recommend the use of the CAHP scoring system in everyday clinical practice not only because of its accuracy and the best performance concerning specificity but also because of the rapid and easy availability of the necessary clinical data for the calculation.

Hemoglobin as a prognostic marker for neurological outcomes in post-cardiac arrest patients: a meta-analysis

The aim of this study was to investigate the relationship between serum level of hemoglobin and neurological outcomes following cardiac arrest. Relevant studies were identified by searching electronic databases including PubMed, Web of Science, Cochrane Library, and Embase from June 2012 through April 2023. Articles were rigorously reviewed for their study inclusion and exclusion criteria. Pooled effect date was determined using the standardized mean difference (SMD) and 95% confidence intervals (CI). The Newcastle–Ottawa Scale was used to evaluate study quality. Subgroup analyses were conducted to determine confounding factors affecting patient outcomes. Study heterogeneity, sensitivity, and publication bias were also determined.This meta-analysis included 11 studies involving 2519 patients. Our results suggest that high serum level of hemoglobin may improve neurological prognosis(SMD = 0.60, 95%CI = 0.49–0.71, I2 = 10.85). The findings of this study indicate that serum level of hemoglobin may be associated with better neurological prognosis, perhaps an appropriate increase in serum haemoglobin levels can improve the neurological prognosis of patients in cardiac arrest.

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.

Efficacy of Quantitative Pupillary Light Reflex for Predicting Neurological Outcomes in Patients Treated with Targeted Temperature Management after Cardiac Arrest: A Systematic Review and Meta-Analysis.

Background and objectives: This study aims to evaluate the usefulness of the quantitative pupillary light reflex as a prognostic tool for neurological outcomes in post-cardiac arrest patients treated with targeted temperature management (TTM). Material and Methods: We systematically searched MEDLINE, EMBASE, and the Cochrane Library (search date: 9 July 2021) for studies on post-cardiac arrest patients treated with TTM that had measured the percent constriction of pupillary light reflex (%PLR) with quantitative pupillometry as well as assessed the neurological outcome. For an assessment of the methodological quality of the included studies, two authors utilized the prognosis study tool independently. Results: A total of 618 patients from four studies were included in this study. Standardized mean differences (SMDs) were calculated to compare patients with good or poor neurological outcomes. A higher %PLR measured at 0–24 h after hospital admission was related to good neurological outcomes at 3 months in post-cardiac arrest patients treated with TTM (SMD 0.87; 95% confidence interval 0.70–1.05; I2 = 0%). A higher %PLR amplitude measured at 24–48 h after hospital admission was also associated with a good neurological outcome at 3 months in post-cardiac arrest patients treated with TTM, but with high heterogeneity (standardized mean difference 0.86; 95% confidence interval 0.40–1.32; I2 = 70%). The evidence supporting these findings was of poor quality. For poor neurological outcome, the prognosis accuracy of %PLR was 9.19 (pooled diagnostic odds ratio, I2 = 0%) and 0.75 (area under the curve). Conclusions: The present meta-analysis could not reveal that change of %PLR was an effective tool in predicting neurological outcomes for post-cardiac arrest patients treated with TTM owing to a paucity of included studies and the poor quality of the evidence.

The Early Prognostic Value and Optimal Time of Measuring Serum and Cerebrospinal Fluid Tau Protein for Neurologic Outcomes in Postcardiac Arrest Patients Treated with Targeted Temperature Management.

Neuroprognostication of cardiac arrest patients remains a challenge. We evaluated the early prognostic value and optimal time of measuring serum and cerebrospinal fluid (CSF) tau protein levels to predict neurologic outcome in postcardiac arrest patients treated with targeted temperature management (TTM). We also evaluated the cutoff values in predicting poor outcomes. Patients treated with TTM following cardiac arrest, from May 2018 to June 2019, were included in the study. Serum and CSF tau levels were obtained and compared immediately, at 24, 48, and 72 hours after return of spontaneous circulation (ROSC). The area under the receiver-operating characteristic curve (AUROC) and the Delong method were used to identify the cutoff values of serum and CSF tau protein levels in predicting poor outcomes at each interval. Of 38 patients enrolled, 16 experienced poor outcomes. Both serum and CSF tau levels were consistently higher in the poor outcome group than in the good outcome group. The AUROCs of serum and CSF tau protein were not significantly different at each time point. Immediately after ROSC, sensitivities of both serum and CSF tau protein levels were 31.25% at 100% specificity and increased to 86.6% and 73.3%, respectively, at 72 hours. This study demonstrates that serum and CSF tau protein levels could be used as valuable predictors of neurologic outcomes in postcardiac arrest patients treated with TTM. The early optimal time for measuring the serum and CSF tau protein levels was determined to be 72 hours after ROSC.

Targeted Temperature Management Experience of an Academic Emergency Department: A 5-Year Retrospective Study.

Targeted temperature management (TTM) for postcardiac arrest syndrome patients is a cornerstone therapy to reduce mortality and neurological morbidity. The care of critical patients is provided in the emergency department (ED) when intensive care units (ICUs) are unavailable. This study aimed to determine the characteristics and mortality outcomes of postcardiac arrest patients who underwent TTM in an academic ED. Postcardiac arrest patients who underwent TTM between January 1, 2014, to November 1, 2018, at a tertiary care academic ED in Turkey were examined retrospectively. The mean age of 24 patients in whom TTM was initiated in the ED was 60.7 ± 19.2 years. Five (20.8%) of the patients who underwent TTM were discharged. Four (80%) of the discharged patients were in out-of-hospital cardiac arrest (OHCA). All patients with a total cardiopulmonary resuscitation duration of >25 minutes died. Mortality was significantly higher in patients without light reflexes (p = 0.006). Two patients who underwent TTM in the ED became organ donors after neurological determination of death. If the ICU cannot meet the needs, early initiation of TTM in the ED may contribute to good neurological outcomes. In this study, 80% of the patients who have positive neurological outcomes are OHCA. Lack of light reflex may be an evidence of poor neurological outcomes in postcardiac arrest patients. Emergency physicians should be encouraged to apply TTM.

Abstract 11652: Long-Term Outcomes in Post-Cardiac Arrest Patients With Severe Functional Disability at Hospital Discharge

Background: In patients resuscitated from out of hospital cardiac arrest (OHCA) with severe functional disability, life support is often limited. However, long-term outcomes in such patients are largely unknown, leaving little data to guide this decision. Methods: We performed a retrospective cohort study of OHCA survivors ≥ 18 years of age, treated at a single center in Western Pennsylvania from 01/01/2010-05/20/2021, with a modified Rankin scale (mRS) of 5 and cerebral performance category (CPC) of 4 at hospital discharge. We recorded demographics, arrest characteristics, and neurological exam at hospital discharge. We reviewed records from index hospitalization to the present to determine the date and type of subsequent healthcare encounters and whether or not subjects followed commands in subsequent neurological exams. National Death Index query and internet search for obituary until 5/20/2021. Survival time and hazard ratios were estimated using Kaplan-Meier curves. Results: Among 2,460 OHCA patients treated, 857 (35%) survived to hospital discharge. Of survivors, 83 (9.6%) had mRS 5 and CPC 4, and 69 (85%) did not follow commands. One year mortality was 59% (n=48) with median survival time of 166 days (IQR 77-1083). Age ≥ 65 years was not associated with survival [HR 1.51, 95%CI 0.79 - 2.89]. We found 361 subsequent medical encounters (median per patient =1, IQR 0-4), most often ED visits (n=131, 41%). Visits comprised 87 (28%) well patient visit/medication refills, 60 (22%) infections, and 38 (12%) tracheostomy/feeding tube issues. Average frequency of healthcare encounters was about once every 3 months (.30 encounters per month, SD .799). Of subjects who did not follow commands at hospital discharge, 4 (6%) followed commands on subsequent encounters. Conclusions: About 10% of OHCA survivors were discharged from the hospital with severe functional disability. They had a 59% 1-year mortality and frequent visits to the ED. Few (6%) patients regained the ability to follow commands.

Derivation and validation of the CANP scoring model for predicting the neurological outcome in post-cardiac arrest patients.

Objectives:To establish and validate a prognostic scoring model in a Chinese population to predict the neurological outcome among comatose survivors of cardiac arrest (CA).Methods:159 CA patients between January 2016 and November 2020 were recruited in this retrospective study. In the derivation cohort, prognostic factors available from arrest circumstances and early in-hospital indicators were measured. The Cardiac Arrest Neurological Prognosis (CANP) score was then constructed to predict unfavorable outcomes at 30 days after CA. The assessment of predictive effectiveness of this scoring model was conducted in both derivation and validation cohorts.Results:Witnessed status, bystander cardiopulmonary resuscitation, initial rhythm, duration of resuscitation, Glasgow Coma Scale motor score, pupillary/corneal reflex, gray-white matter ratio and neuron-specific enolase exhibit strong correlations with the neurological outcomes in the derivation cohort (all p<0.05), and a risk scoring model for the prediction of an unfavorable outcome was created using these factors. In the validation cohort, significantly higher CANP scores were noted in the unfavorable outcome group. A CANP score ≥5 was associated with unfavorable neurological outcomes (sensitivity 68.8%, specificity 100%).Conclusion:The CANP score was established and validated for predicting the possible neurological prognosis in comatose post-CA survivors.

Impact of controlled normothermia following hypothermic targeted temperature management for post-rewarming fever and outcomes in post-cardiac arrest patients: A propensity score-matched analysis from a multicentre registry

Aim of the studyWe investigated whether controlled normothermia (CN) after the rewarming phase of targeted temperature management (TTM) is associated with preventing post-rewarming fever and outcomes 6 months after out-of-hospital cardiac arrest (OHCA). MethodsThis was an analysis of a prospective registry comprising OHCA patients treated with TTM at 22 academic hospitals between October 2015 and December 2018. We calculated the incremental area under the curve (iAUC) for body temperature greater than or equal to 37.5 °C for each patient during the first 24 h after the end of rewarming. The relationships among CN and iAUC, 6-month survival and good neurological outcome were analysed. To minimize differences in the baseline characteristics of the patients, we used propensity score-matched analysis. ResultsIn total, 1144 patients were enrolled. After propensity score matching, 646 patients (comprising 323 pairs) were obtained. In the unmatched cohort, post-rewarming CN was significantly associated with a lower iAUC (0.34 [1.38] vs. 1.19 [2.27]; p < 0.001) but not 6-month survival (adjusted odds ratio (OR): 1.121; 95% confidence interval (CI): 0.836−1.504; p = 0.446) and good neurological outcome (adjusted OR: 1.030; 95% CI: 0.734−1.446; p = 0.863). The results were similar in the propensity score-matched cohort (0.38 [1.56] vs. 1.03 [2.21], p < 0.001, OR: 1.347, 95% CI: 0.989−1.835, p = 0.059 and OR: 1.280, 95% CI 0.925−1.772, p = 0.137, respectively). ConclusionPost-rewarming CN prevents high fever in the normothermia phase of TTM. However, our data suggest the lack of association between CN and the patient’s 6-month survival and good neurological outcome.

Predictive Value of Estimated Lean Body Mass for Neurological Outcomes after Out-of-Hospital Cardiac Arrest.

Background: Postcardiac arrest patients with a return of spontaneous circulation (ROSC) are critically ill, and high body mass index (BMI) is ascertained to be associated with good prognosis in patients with a critically ill condition. However, the exact mechanism has been unknown. To assess the effectiveness of skeletal muscles in reducing neuronal injury after the initial damage owing to cardiac arrest, we investigated the relationship between estimated lean body mass (LBM) and the prognosis of postcardiac arrest patients. Methods: This retrospective cohort study included adult patients with ROSC after out-of-hospital cardiac arrest from January 2015 to March 2020. The enrolled patients were allocated into good- and poor-outcome groups (cerebral performance category (CPC) scores 1–2 and 3–5, respectively). Estimated LBM was categorized into quartiles. Multivariate regression models were used to evaluate the association between LBM and a good CPC score. The area under the receiver operating characteristic curve (AUROC) was assessed. Results: In total, 155 patients were analyzed (CPC score 1–2 vs. 3–5, n = 70 vs. n = 85). Patients’ age, first monitored rhythm, no-flow time, presumed cause of arrest, BMI, and LBM were different (p < 0.05). Fourth-quartile LBM (≥48.98 kg) was associated with good neurological outcome of postcardiac arrest patients (odds ratio = 4.81, 95% confidence interval (CI), 1.10–25.55, p = 0.04). Initial high LBM was also a predictor of good neurological outcomes (AUROC of multivariate regression model including LBM: 0.918). Conclusions: Initial LBM above 48.98kg is a feasible prognostic factor for good neurological outcomes in postcardiac arrest patients.

Prognostic Role of Optic Nerve Sheath Diameter for Neurological Outcomes in Post-Cardiac Arrest Patients: A Systematic Review and Meta-Analysis.

Objective The present study investigated whether optic nerve sheath diameter (ONSD) could be used to predict neurological outcomes in post-cardiac arrest (CA) patients. Methods We performed a comprehensive literature search in the Cochrane Library, ScienceDirect, PubMed, and Web of Science from inception to June 2020 for eligible articles. Stata 14.0 software was used to calculate the pooled odds ratios (ORs) and 95% confidence intervals (95% CIs), sensitivity, specificity, summary receiver operating characteristic (SROC) curve, subgroup analysis, sensitivity analysis, and publication bias. Results Eight studies involving 473 patients were considered eligible for this meta-analysis. The pooled result using a random-effects model showed that broadened ONSD is associated with poor neurological outcomes in post-CA patients (OR = 15.62, 95% CI: 5.50–44.34, P < 0.001; I2 = 58.4%, P = 0.018), with a sensibility of 0.60 (95% CI: 0.45–0.73) and specificity of 0.94 (95% CI: 0.83–0.98). The area under the curve of the SROC curve for ONSD was 0.87 (95% CI: 0.84–0.90). Subgroup analysis revealed that sample size and time of ONSD measurement may be the source of heterogeneity. Sensitivity analysis demonstrated the stability of the results of this meta-analysis. No publication bias using Deeks' funnel plot was noted across the studies (P = 0.23). Conclusion This meta-analysis confirmed that ONSD can be used to predict neurological outcomes in post-CA patients.

Abstract 369: Noninvasive Cerebral Perfusion Pressure and Neurologic Outcome in Post-cardiac Arrest Patients with Targeted Temperature Management

Introduction: Hypoxic ischemic brain injury (HIBI) is the leading cause of mortality and long-term neurologic disability in survivors of cardiac arrest. Recently, the role of cerebral monitoring is emphasized for individualizing therapy and mitigating secondary brain injury in HIBI patients after return of spontaneous circulation (ROSC). The first step of cerebral monitoring is checking the driving force by cerebral perfusion pressure (CPP). However, as CPP is calculated by mean arterial pressure (MAP) minus intracranial pressure (ICP), the process of obtaining ICP is invasive. Noninvasive CPP can be estimated by parameters obtained from transcranial doppler (TCD). Therefore, we aimed to investigate non-invasively measured CPP from TCD and its association with neurologic outcome in post cardiac arrest patients that underwent targeted temperature management (TTM). Methods: This retrospective single-center study included patients who had been treated with TTM following cardiac arrest and who underwent TCD evaluation between July 2017 and July 2019. We aimed to perform TCD evaluation within 48h of ROSC, but sometimes this could not be achieved due to limited resources. Patients with TCD that was performed after 72 hours were excluded. The MFV was calculated using the peak systolic flow velocity (PSV) and the end-diastolic flow velocity (EDV) as below. Two methods of estimating CPP non-invasively was calculated as below.MFV = PSV+(EDVх2) / 3 eCPP_A= MAP*diastolic FVmca/MFVmca + 14eCPP_B= MFVmca*(MAP-DBP)/FVmean-FVdia Results: Table 1. Baseline characteristics of study population Data are presented as mean (standard deviation), number (%) or median (interquartile range).OHCA, out of hospital cardiac arrest; CPR, cardiopulmonary resuscitation; AED, automated external defibrillator; TCD, transcranial doppler; CPP, cerebral perfusion pressure. Table 2. Cut off values and diagnostic values in predicting poor neurologic outcome with 100% specificityCPP, cerebral perfusion pressure. Conclusion: eCPP cut off values of &lt;50 mmHg and &lt;60mmHg predicted poor neurological outcome with high specificity. This study suggests that eCPP obtained from TCD may be feasible to predict neurologic outcome.

The Sequential Organ Failure Assessment (SOFA) score predicts mortality and neurological outcome in patients with post-cardiac arrest syndrome

BackgroundPatients experiencing out-of-hospital cardiac arrest (OHCA) and subsequent post-cardiac arrest syndrome are often compromised by multi-organ failure. The Sequential Organ Failure Assessment (SOFA) score has been used to predict clinical outcome of patients requiring intensive care for multi-organ failure. Thus, the assessment of SOFA score is recommended as a criterion for sepsis. Although post-cardiac arrest patients frequently develop sepsis-like status in ICU, there are limited reports evaluating the SOFA score in post-cardiac arrest patients. We investigated the predictive value of the SOFA score in survival and neurological outcomes in patients with post-cardiac arrest syndrome. MethodsA total of 231 cardiovascular arrest patients achieving return of spontaneous circulation (ROSC) were finally extracted from the institutional consecutive database comprised of 1218 OHCA patients transferred to the institution between January 2015 and July 2018. The SOFA score was calculated on admission and after 48h. Predictors of survival and neurological outcome defined as having cerebral-performance-category (CPC) 1 or 2 at 30 days were determined. ResultsSOFA score was lower in survived patients (5.0 vs 10.0, p<0.001) and those with favorable neurological outcome (5.0 vs 8.0, p<0.001) as compared with the counterparts. The SOFA score on admission was an independent predictor of survival (OR 0.68, 95% confidence interval [CI] 0.59–0.78; p<0.001) and favorable neurological performance (OR 0.79; 95% CI 0.69–0.90; p<0.001) at 30 days. Furthermore, a change in SOFA score (48–0h) was predictive of favorable 30-day neurological outcome (OR 0.71, 95% CI 0.60–0.85; p<0.001). ConclusionsEvaluation of the SOFA score in the ICU is useful to predict survival and neurological outcome in post-cardiac arrest patients.

The value of cerebrospinal fluid ubiquitin C-terminal hydrolase-L1 protein as a prognostic predictor of neurologic outcome in post-cardiac arrest patients treated with targeted temperature management

AimWe evaluated the prognostic value of serum- and cerebrospinal fluid (CSF)-ubiquitin carboxyl-terminal esterase L1 protein (UCHL1) measurements in post- post-out of hospital cardiac arrest (OHCA) patients treated with target temperature management (TTM), to predict neurologic outcome. MethodsThis was a prospective single-centre observational cohort study, conducted from April 2018 to September 2019. Serum- and CSF-UCHL1 were obtained immediately (UCHL1initial), 24 h (UCHL124), 48 h (UCHL148), and 72 h (UCHL172) after return of spontaneous circulation (ROSC). The area under the receiver operating characteristic curves (AUROC) and Delong method were used to identify cut-off values of serum- and CSF-UCHL1initial, UCHL124, UCHL148, UCHL172 for predicting neurologic outcomes. ResultsOf 38 patients enrolled, 16 comprised the poor outcome group. The AUROCs for serum- and CSF-UCHL1initial were 0.71 and 0.93 in predicting poor neurological outcomes, respectively (p = 0.01). The AUROCs for serum- and CSF-UCHL124 were 0.85 and 0.91 (p = 0.24). The AUROCs for serum- and CSF-UCHL148 were 0.90 and 0.97 (p = 0.07). The AUROCs for serum- and CSF-UCHL172 were 0.94 and 0.98 (p = 0.25). ConclusionFindings of this study demonstrate that CSF-UCHL1 measured immediately, 24, 48, and 72 h after ROSC is a valuable predictor for evaluating neurologic outcomes, whereas serum-UCHL1 measured at 24, 48, and 72 h after ROSC showed a significant performance in the prognostication of poor outcomes in post-OHCA patients treated with TTM.

Prognostic factors for neurological outcomes in Korean targeted temperature management recipients with return of spontaneous circulation after out-of-hospital cardiac arrests: A nationwide observational study.

Targeted temperature management (TTM) is recommended for comatose patients after out-of-hospital cardiac arrests (OHCAs). Even after successful TTM, several factors could influence the neuroprotective effect of TTM. The aim of this study is to identify prognostic factors associated with good neurological outcomes in TTM recipients.This study used nationwide data during 2012 to 2016 to investigate prognostic factors associated with good neurological outcomes in patients who received TTM after the return of spontaneous circulation (ROSC). Multivariate logistic regression analysis was conducted to analyse the factors that may affect the neurological outcomes in the TTM recipients.The study included 1578 eligible patients, comprising 767 with good and 811 with poor neurological outcomes. Multivariable analyses showed that OHCA in public places (OR, 1.599; 95% CI, 1.100–2.323, P = .014), initial shockable rhythms (OR, 1.721; 95% CI, 1.191–2.486, P = .004), pre-hospital ROSCs (OR, 6.748; 95% CI, 4.703–9.682, P < .001), bystander cardiopulmonary resuscitation (CPR) (OR, 1.715; 95% CI, 1.200–2.450, P = .003), and primary coronary interventions (PCIs) (OR, 2.488; 95% CI, 1.639–3.778, P < .001) were statistically significantly associated with good neurological outcomes. Whereas, increase of age (OR, 0.962; 95% CI, 0.950–0.974, P < .001) and conventional cooling (OR, 0.478; 95% CI, 0.255–0.895, P = .021) were statistically significantly associated with poor neurological outcome.This study suggests that being younger, experiencing OHCA in public places, having initial shockable rhythm, pre-hospital ROSC, and bystander CPR, implementing PCIs and applying intravascular or surface cooling devices compared to conventional cooling method could predict good neurological outcomes in post-cardiac arrest patients who received TTM.

Somatosensory Evoked Potentials and Neuroprognostication After Cardiac Arrest.

Improved understanding of post-cardiac arrest syndrome and clinical practices such as targeted temperature management have led to improved mortality in this cohort. Attention has now been placed on development of tools to aid in predicting functional outcome in comatose cardiac arrest survivors. Current practice uses a multimodal approach including physical examination, neuroimaging, and electrophysiologic data, with a primary utility in predicting poor functional outcome. These modalities remain confounded by self-fulfilling prophecy and the withdrawal of life-sustaining therapies. To date, a reliable measure to predict good functional outcome has not been established or validated, but the use of quantitative somatosensory evoked potential (SSEP) shows potential for this use. MEDLINE and EMBASE search using words "Cardiac Arrest" and "SSEP," "Somato sensory evoked potentials," "qSSEP," "quantitative SSEP," "targeted temperature management in cardiac arrest" was conducted. Relevant recent studies on targeted temperature management in cardiac arrest, plus studies on SSEP in cardiac arrest in the setting of hypothermia and without hypothermia, were included. In addition, animal studies evaluating the role of different components of SSEP in cardiac arrest were reviewed. SSEP is a specific indicator of poor outcomes in post-cardiac arrest patients but lacks sensitivity and has not clinically been established to foresee good outcomes. Novel methods of analyzing quantitative SSEP (qSSEP) signals have shown potential to predict good outcomes in animal and human studies. In addition, qSSEP has potential to track cerebral recovery and guide treatment strategy in post-cardiac arrest patients. Lying beyond the current clinical practice of dichotomized absent/present N20 peaks, qSSEP has the potential to emerge as one of the earliest predictors of good outcome in comatose post-cardiac arrest patients. Validation of qSSEP markers in prospective studies to predict good and poor outcomes in the cardiac arrest population in the setting of hypothermia could advance care in cardiac arrest. It has the prospect to guide allocation of health care resources and reduce self-fulfilling prophecy.

Abstract 157: The Association Between Serum Magnesium Levels and Qt Interval Duration During Therapeutic Hypothermia and its Effects on Neurological Outcomes

Introduction: Sudden cardiac arrest is a major cause of mortality in the United States and globally. Therapeutic hypothermia (TH) has demonstrated success in improving neurological outcomes in post-cardiac arrest patients. TH causes several physiologic ECG changes, including QTc prolongation. TH also decreases serum magnesium levels. These changes may lead to malignant ventricular arrhythmia and poor neurological outcome. We aimed to evaluate the association between the QTc interval during TH, magnesium levels, and neurologic outcomes. Methods: We reviewed the electrocardiograms of 366 patients who underwent TH at various intervals corresponding to pre-cooling, maintenance of targeted temperature management, and rewarming periods. We reviewed the change in the corrected QT segment (QTc) and evaluated their relationship with the patients’ magnesium levels and neurologic outcomes. Results: 71.3% of the patients had a significant increase in QTc interval defined as &gt;60 ms or any QTc&gt;500 ms during TH. Patients with persistent prolongation of QTc after rewarming had poor neurological outcomes (p&lt;0.05). Magnesium level showed a positive correlation with QTc interval at presentation (R=0.240, p&lt;0.05) and at 48 hours (R=0.225, p= &lt;0.05). Patients who had poor neurological outcomes tended to have higher magnesium levels at presentation (p&lt;0.05). The majority of patients who received supplemental Mg did not have any significant change in their QTc. Conclusion: TH is independently associated with QTc prolongation. Patients with a persistent increase in QTc interval during the rewarming phase should be promptly evaluated for QTc-prolonging factors given its association with worse neurological outcomes. The inverse correlation between magnesium levels and poor neurological outcomes deserves further investigation.

Initial serum cholesterol level as a potential marker for post cardiac arrest patient outcomes

AimCholesterol and lipoproteins have many roles during systemic inflammation in critically ill patients. Many previous studies have reported that low levels of cholesterol are associated with poor outcomes in these patients. The aim of this study was to investigate the association of initial total cholesterol with predicting neurologic outcome of post-cardiac arrest patients. MethodsThis was a retrospective observational study of out-of-hospital-cardiac arrest (OHCA) survivors who had serum cholesterol levels at admission. Multivariate regression analysis was performed to investigate total cholesterol and its association with neurologic outcome. Area under receiver operator characteristic curve (AUROC) was assessed and cut off values for predicting good or poor neurologic outcomes were analysed. ResultsA total of 355 patients were analysed. Lower total cholesterol was significantly associated with poor neurologic outcome [OR: 0.99 (95% CI: 0.98–0.99), p < 0.01] in the multivariate analysis. Cholesterol was also useful to screening for poor neurologic outcome [AUROC: 0.70 (95%CI: 0.63–0.77)]. Patients with cholesterol lower than 71 mg/dL had poor neurologic outcome with a specificity of 100%. ConclusionsInitial cholesterol level is an easily obtained biomarker that showed association with neurologic outcomes of post cardiac arrest patients.

P6380The impact of coronary artery disease to predict mortality and neurological outcome in post-cardiac arrest patients

Abstract Background Some studies reported that performing coronary angiography (CAG) for patients with out-of-hospital cardiac arrest (OHCA) is effective for the prognosis and neurological outcome. However, the impact of complexity of coronary artery disease (CAD) on CAG findings has not been evaluated sufficiently. Purpose We sought to investigate the complexity of CAD to predict the prognosis and neurological outcome in patients with OHCA. Methods A total of 1382 out-of-hospital cardiac arrest patients were transferred to our critical care center, of which 252 cardiovascular arrest patients achieving the return of spontaneous circulation (ROSC) were extracted from the institutional consecutive database between January 2015 and December 2018. Among those patients, we performed CAG for 160 patients. To predict mortality in hospital and neurological outcome at 30 days, we investigated basic patients' characteristics, pre-hospital information, coronary anatomical angiographical findings. Results Ventricular fibrillation (VF) (P=0.001), younger age (P=0.007), pre-hospital ROSC (P&lt;0.001) and normal coronary artery on CAG findings (P=0.014) were associated with low 30-days mortality in hospital. VF (P=0.003), younger age (P=0.004), pre-hospital ROSC (P&lt;0.001), bystander cardiopulmonary resuscitation (CPR) (P=0.043) and normal coronary artery (P=0.001) were associated with good neurological outcome (cerebral-performance-category (CPC) =1 or 2) at 30 days. We further investigated 100 patients who had any coronary artery stenosis on CAG findings. Among these patients, 55 patients (55.0%) had multi-vessel coronary artery disease and 29 patients (29.0%) had at least a chronic total occlusion lesion. VF survivor (P=0.035), without previous history of CAD (P=0.008), pre-hospital ROSC (P=0.013), and Syntax score (P=0.002) were associated with low 30-days mortality. In multivariate analysis, Syntax score (OR 0.94; 95% confidence interval (CI) 0.88–0.99; P=0.042) was independent predictor of mortality. Bystander CPR (P=0.001), pre-hospital ROSC (P&lt;0.001) were associated with good neurological outcome at 30 days. Bystander CPR (OR 5.92; 95% CI 2.01–17.5; P&lt;0.001) and pre-hospital ROSC (OR 9.22; 95% CI 3.34–25.5; P&lt;0.001) were predictive for good neurological outcome. Conclusions OHCA patients with any coronary stenosis had high mortality and bad neurological outcome in comparison with those who had normal coronary arteries. OHCA patients with CAD had complex lesions such as multi-vessel disease or chronic total occlusion lesions. The coronary complexity in patients with OHCA was a predictor of in-hospital 30-days mortality. However, pre-hospital care such as bystander CPR and pre-hospital ROSC were the most important to achieve good neurological outcome at 30 days in the present study.