Outcomes In Post-cardiac Arrest Patients Research Articles

Optimal timing to measure optic nerve sheath diameter as a prognostic predictor in post-cardiac arrest patients treated with targeted temperature management

AimWe evaluated the optimal timing of optic nerve sheath diameter (ONSD) measurement to predict neurologic outcome in post-cardiac arrest patients treated with target temperature management (TTM). MethodsThis was a prospective single-centre observational study from April 2018 to March 2019. Good outcome was defined as the Glasgow-Pittsburgh cerebral performance categories (CPC) 1 or 2, and poor outcome as a CPC between 3 and 5. ONSD was measured initially after return of spontaneous circulation (ROSC) (ONSDinitial), at 24 h (ONSD24), 48 h (ONSD48), and 72 h (ONSD72) using ultrasonography. The receiver operating characteristic (ROC) curves and DeLong method were used to compare the values for predicting neurologic outcomes. ResultsOut of the 36 patients enrolled, 18 had a good outcome. ONSD24, ONSD48, and ONSD72 were higher in the poor outcome group. The area under ROC curve of ONSD24 was 0.91 (95% confidence interval 0.77–0.98) in predicting poor neurologic outcomes. With a cut off value of 4.90 mm, ONSD24 had a sensitivity of 83.3% and a specificity of 94.4% in predicting poor neurologic outcomes. ConclusionOur findings demonstrate ONSD24 as a valuable tool to predict the neurologic outcome in post-cardiac arrest patients treated with TTM. Therefore, we recommend performing ONSD measurement using ultrasonography at 24 h after ROSC, rather than immediately after ROSC, to predict neurologic outcome in post-cardiac arrest patients treated with TTM.

Relative tachycardia is associated with poor outcomes in post-cardiac arrest patients regardless of therapeutic hypothermia

BackgroundTo investigate whether the relationship between heart rate and neurological outcome is independent of therapeutic hypothermia (TH) and whether heart rate is related to hemodynamic instability post-cardiac arrest. MethodsRetrospective review of an out-of-hospital cardiac arrest registry was performed. The primary exposure was heart rate quartiles at 24 h post-cardiac arrest. The primary outcome was a poor neurological outcome, which was defined as having a cerebral performance category (CPC) of 3–5 at 28 days. Secondary outcomes were mean blood pressure and serum lactate at 24 h and Sequential Organ Failure Assessment (SOFA) scores at admission. ResultsIn total, 155 patients were enrolled. The proportion of patients with a poor CPC was significantly greater in higher heart rate quartiles; similar results were observed in patients who did and did not undergo TH. Serum lactate levels at 24 h were significantly higher in the 3rd and 4th quartile groups than in the 1st quartile group. Additionally, SOFA scores were significantly higher in the 4th quartile group than in the 1st and 3rd quartile groups. ConclusionsRelative tachycardia is associated with poor neurological outcomes in post-cardiac arrest patients, independent of TH, and with higher serum lactate levels and admission SOFA scores.

Dynamic regimes of neocortical activity linked to corticothalamic integrity correlate with outcomes in acute anoxic brain injury after cardiac arrest.

ObjectiveRecognition of potential for neurological recovery in patients who remain comatose after cardiac arrest is challenging and strains clinical decision making. Here, we utilize an approach that is based on physiological principles underlying recovery of consciousness and show correlation with clinical recovery after acute anoxic brain injury.MethodsA cohort study of 54 patients admitted to an Intensive Care Unit after cardiac arrest who underwent standardized bedside behavioral testing (Coma Recovery Scale – Revised [CRS‐R]) during EEG monitoring. Blinded to all clinical variables, artifact‐free EEG segments were selected around maximally aroused states and analyzed using a multi‐taper method to assess frequency spectral content. EEG spectral features were assessed based on pre‐defined categories that are linked to anterior forebrain corticothalamic integrity. Clinical outcomes were determined at the time of hospital discharge, using Cerebral Performance Categories (CPC).ResultsTen patients with ongoing seizures, myogenic artifacts or technical limitations obscuring recognition of underlying cortical dynamic activity were excluded from primary analysis. Of the 44 remaining patients with distinct EEG spectral features, 39 (88%) fit into our predefined categories. In these patients, spectral features corresponding to higher levels of anterior forebrain corticothalamic integrity correlated with higher levels of consciousness and favorable clinical outcome at the time of hospital discharge (P = 0.014).InterpretationPredicted transitions of neocortical dynamics that indicate functional integrity of anterior forebrain corticothalamic circuitry correlate with clinical outcomes in postcardiac‐arrest patients. Our results support a new biologically driven approach toward better understanding of neurological recovery after cardiac arrest.

Useful Computed Tomography Score for Estimation of Early Neurologic Outcome in Post-Cardiac Arrest Patients With Therapeutic Hypothermia.

The Alberta Stroke Program Early CT Score (ASPECTS) is used to assess early ischemic stroke damage. This study compared bilateral ASPECTS (ASPECTS-b) with the gray:white matter ratio (GWR) and quantitative regional abnormality (QRA) to evaluate the prognostic utility of early computed tomography (CT) findings in post-cardiac arrest patients.Methods and Results:Out-of-hospital cardiac arrest patients with return of spontaneous circulation (ROSC) who underwent brain CT (<6 h after onset) and therapeutic hypothermia were recruited from a university hospital over a 2-year period. General demographics, ROSC characteristics, ASPECTS-b (total score=20 points), GWR, and QRA were assessed. Multivariate logistic regression analysis was used to predict neurologic outcome using cerebral performance category (CPC) at 1 month. The study population was divided into good (n=20; CPC 1-2) and poor (n=47; CPC 3-5) outcome groups. The good (vs. poor) outcome group was younger (mean [±SD] age 46.7±11.8 vs. 60.3±17.2 years; P=0.002) and had more initial shockable rhythms (40.0% vs. 8.5%; P=0.002). In addition, the good outcome group had a higher mean ASPECTS-b score (15.3±2.7 vs. 9.0±4.9; P<0.001), despite no differences in QRA and mean GWR. Age and ASPECTS-b were independent predictors of outcome after adjusting for potential confounders. These findings suggest that an initial CT score (ASPECTS-b) could help estimate early neurologic outcomes in post-cardiac arrest patients treated with therapeutic hypothermia.

Time to Awakening Is Often Delayed in Patients Who Receive Targeted Temperature Management After Cardiac Arrest.

Post cardiac arrest, neuroprognostication remains a complex and clinically challenging issue for critical care providers. For this reason, our primary objective in this study was to determine the frequency of survival and favorable neurological outcomes in post-cardiac arrest patients with delayed time to awakening. To assess whether early withdrawal of care may adversely impact survival, we also sought to describe the time to withdrawal of care of non-surviving patients. We performed a retrospective study of patients resuscitated after cardiac arrest in two large academic community hospitals. We performed a structured chart review of patients treated with therapeutic hypothermia (TH) at one hospital from 2009 to 2015 and at a second hospital from 2013 to 2015. Demographics and Utstein style variables were recorded on all patients, as well as temporal variables to characterize the time interval from Return of Spontaneous Circulation (ROSC) to awakening as recorded by ICU nurses and defined as Glasgow Coma Scale (GCS) of >8. Descriptive data were also captured regarding time to withdrawal of care. We pre-hoc defined delayed awakening as >72 hours post ROSC or >72 hours post rewarming. Our primary outcome was survival to hospital discharge with a secondary outcome of a favorable cerebral performance category of 1 or 2. During this study period, 321 patients received TH, with 111 (34.6%) discharged alive and, of these, 67 (68.5%) experienced a good neurological outcome. Awakening more than 72 hours after return of circulation was common with 31 patients surviving to discharge. Of these, 16 of 31 (51.6%) were found to have a good neurological outcome on hospital discharge. Of the patients who died before discharge, 54 (29.5%) had care withdrawn less than 72 hours after ROSC. A delayed time to awakening is not infrequently associated with a good neurological outcome after TH in patients resuscitated from cardiac arrest.

The Outcomes of Targeted Temperature Management After Cardiac Arrest at Emergency Department: A Real-World Experience in a Developing Country.

Targeted temperature management (TTM) is indicated for comatose survivors of cardiac arrest to improve outcomes. However, the benefit of TTM was verified by rigid controlled clinical trials. This study aimed at evaluating its effects in real-world practices. A prospective observational study was done at the emergency department of tertiary care, Thammasat Hospital, from March 2012 until October 2015. We included all who did not obey verbal commands after being resuscitated from cardiac arrest regardless of initial cardiac rhythm. We excluded patients with traumatic arrest, uncontrolled bleeding, younger than 15 years old, and of poor neurological status (Glasgow coma scale below 14) before cardiac arrest. Primary and secondary outcomes were survival to hospital discharge and favorable neurological outcome (Cerebral Performance Categories 1 or 2 within 30 days). We used the logistic regression model to estimate the propensity score (PS) that will be used as a weight in the analysis. To analyze outcomes, the PS was introduced as a factor in the final logistic regression model in conjunction with other factors. A total of 192 cases, 61 and 131 patients, were enrolled in TTM and non-TTM groups, respectively. Characteristics believed to be related to initiation of TTM: gender, age, cardiac etiology, out-of-hospital cardiac arrest, witness arrest, collapse time, initial rhythm, received defibrillation, and advanced airway insertion, were included in multivariable analysis and estimated PS. After adjusted regression analysis with PS, the TTM group had a better result in survival to hospital discharge (34.43% vs. 12.21%; adjusted incidence risk ratio (IRR), 2.95; 95% confidence interval (CI), 1.49-5.84; p = 0.002). For neurological outcome, the TTM group had a higher number of favorable neurological outcomes (24.59% vs. 6.87%; IRR, 3.96; 95% CI, 1.67-9.36; p = 0.002). In real-world practices without a strictly controlled environment, TTM can improve survival and favorable neurological outcome in postcardiac arrest patients regardless of initial rhythm.

Prognostic value of the recovery time of continuous normal voltage in amplitude-integrated electroencephalography in out-of-hospital cardiac arrest patients treated with therapeutic hypothermia: a retrospective study.

BackgroundThe early prediction of neurological outcomes in postcardiac arrest patients treated with therapeutic hypothermia (TH) remains challenging. Amplitude-integrated electroencephalography (aEEG) is a type of quantitative EEG. A particular cutoff time from the return of spontaneous circulation (ROSC) to the recovery of a normal aEEG trace for predicting a good neurological outcome has not yet been established. The purpose of the present study was to examine the relation between neurological outcomes and the continuous normal voltage (CNV) recovery time in adult comatose survivors of cardiac arrest treated with TH and identify the recovery time cutoff for predicting a good neurological outcome.MethodsWe retrospectively evaluated adult survivors of cardiac arrest with initial shockable rhythm treated with TH and monitored with aEEG. A good outcome was defined as a cerebral performance category (CPC) of 1 or 2 at hospital discharge. A CNV trace was considered as the normal aEEG trace, and the CNV recovery time was defined as the time from ROSC to the initial CNV trace.ResultsThe study included 30 patients, and of these patients, 22 had recovery of CNV trace. The median CNV recovery time was shorter among patients with a good outcome than that among those with a poor outcome (10.7 h [interquartile range (IQR), 7.4–15.8 h] vs. 28.6 h [IQR, 26.9–29.3 h]; p = 0.003). The area under the receiver operating characteristic curve of the CNV recovery time for predicting a good neurological outcome was 0.95 (95 % CI 0.86–1; p = 0.003), and the optimal cutoff was 23 h. The recovery of CNV trace within 23 h had a sensitivity of 89 %, specificity of 100 %, positive predictive value of 100 %, and negative predictive value of 86 % for predicting a good neurological outcome in all the patients, including the eight patients without recovery of CNV trace.ConclusionsA CNV recovery time cutoff of 23 h might help predict a good neurological outcome in adult survivors of cardiac arrest treated with TH.

Relationship between optic nerve sheath diameter on initial brain computed tomography and neurologic outcome in post-cardiac arrest patients with therapeutic hypothermia

Relationship between optic nerve sheath diameter on initial brain computed tomography and neurologic outcome in post-cardiac arrest patients with therapeutic hypothermia

Ventilation and gas exchange management after cardiac arrest.

For several decades, physicians had integrated several interventions aiming to improve the outcomes in post-cardiac arrest patients. However, the mortality rate after cardiac arrest is still as high as 50%. Post-cardiac arrest syndrome is associated with high morbidity and mortality due to not only poor neurological outcome and cardiovascular failure but also respiratory dysfunction. To minimize ventilator-associated lung injury, protective mechanical ventilation by using low tidal volume ventilation and driving pressure may decrease pulmonary complications and improve survival. Low level of positive end-expiratory pressure (PEEP) can be initiated and titrated with careful cardiac output and respiratory mechanics monitoring. Furthermore, optimizing gas exchange by avoiding hypoxia and hyperoxia as well as maintaining normocarbia may improve neurological and survival outcome. Early multidisciplinary cardiac rehabilitation intervention is recommended. Minimally invasive monitoring techniques, that is, echocardiography, transpulmonary thermodilution method measuring extravascular lung water, as well as transcranial Doppler ultrasound, might be useful to improve appropriate management of post-cardiac arrest patients.

Use of pentoxifylline for patients in the postcardiac arrest status

Background Postcardiac arrest syndrome has a unique pathophysiological process involving multiple organs. Pentoxifylline can modulate inflammation, oxidative stress, and endothelial function, and may thus reduce multiple organ dysfunction in postcardiac arrest patients and affect the outcome. The aim of this study was to evaluate the effect of intravenous pentoxifylline on organ functions and outcome in postcardiac arrest patients. Materials and methods Forty-two patients admitted to the ICU after inhospital cardiac arrest of both cardiac and noncardiac origin were included in this prospective double-blinded randomized two parallel-group study. Group P received a first dose of intravenous pentoxifylline 5 mg/kg over 5 min, followed by a 1.5 mg/kg/day infusion with a maximum of 1800 mg/day for 3 days, whereas group C received an equal volume of saline over 5 min and then infusion for 3 days as well. The primary outcome was the number of organ dysfunction-free and organ failure-free days, whereas the secondary outcome included time to initial acceptable blood pressure and systemic perfusion, number of acceptable blood pressure and systemic perfusion days, arterial lactate, Cerebral Performance Category score, duration of inotropic support, duration of mechanical ventilation, length of ICU stay, ICU survival, and adverse events. Results There was a significant increase in the number of organ dysfunction-free days [9 (3) vs. 6 (3), P = 0.003] and organ failure-free days [9 (3) vs. 7 (3), P = 0.008], accompanied by an increased number of acceptable blood pressure and systemic perfusion days [8 (3) vs. 6 (4), P = 0.01], with a shorter time to reach initial acceptable blood pressure and systemic perfusion [68 (51) vs. 38 (36), P = 0.03 ] and a significant improvement in the Cerebral Performance Category score on days 6, 7, and 14 in group P compared with group C. The arterial lactate level, duration of mechanical ventilation, duration of inotropic support, and ICU length of stay were significantly reduced in group P, along with an improvement in ICU survival that did not reach statistical significance. Conclusion We conclude that administration of intravenous pentoxifylline in postcardiac arrest patients improved organ function and decreased length of ICU stay, with no adverse effects.

Association between hemoglobin, cerebral oxygenation and neurologic outcome in postcardiac arrest patients

The safety of a restrictive transfusion threshold of 7 g/ dl applied in all critically ill patients can be questioned in postcardiac arrest (post-CA) patients since these are phenotypically clearly distinct. The aims of this study were to investigate the association between hemoglobin, cerebral oxygenation (SctO2) and outcome in post-CA patients.

Abstract 234: The Association Between Post--Cardiac Arrest Hemoglobin Levels and Neurological Outcome

Background: Inadequate cerebral oxygenation is a risk factor for neurologic damage in successfully resuscitated cardiac arrest patients. One therapy to address this problem is early goal-directed hemodynamic optimization. However, the role of hemoglobin (Hgb) levels, a potential target for optimization, on outcomes in post-cardiac arrest patients is not known. Objective: To determine the association between Hgb levels in post-cardiac arrest patients and neurologic outcome (dichotomized into “good,” a Cerebral Performance Category (CPC) of 1 or 2 and “poor,” a CPC of 3, 4, or 5, at hospital discharge). The association between Hgb levels and survival to discharge was analyzed as a secondary outcome. Methods: A retrospective cohort study was conducted to compare patient demographics and Hgb levels. Hgb was analyzed as both a continuous and binary variable. To determine the association between Hgb levels and outcomes, multivariate logistic regression models controlling for gender, age, pulseless rhythm, and transfusion were used. Results: There were 598 eligible subjects from 21 hospitals in the US. Patients with ≤10 g/dL of Hgb had a higher percentage of subjects with good neurologic outcome than those with Hgb levels below 10 g/dL (41% vs. 26%; p &lt; 0.001). Patients with good neurologic outcome had higher median Hgb levels in the first six hours after arrest than those with a poor neurologic outcome (12.6 g/dL vs. 10.5 g/dL; p &lt; 0.001). Controlling for gender, age, pulseless rhythm, and transfusion, there was a significant relationship between Hgb levels within the first six hours after arrest and good neurologic outcome (OR: 1.21, 95% CI: 1.06 [[Unable to Display Character: &amp;#8211;]] 1.39) and the first 24 hours after arrest and good neurologic outcome (OR: 1.14, 95% CI: 1.01 [[Unable to Display Character: &amp;#8211;]] 1.28). There was a significant association between Hgb levels within the first six hours after arrest and survival to discharge (OR: 1.22, 95% CI: 1.07 [[Unable to Display Character: &amp;#8211;]] 1.39) and Hgb levels within the first 24 hours after arrest and survival to discharge (OR: 1.14, 95% CI: 1.02 [[Unable to Display Character: &amp;#8211;]] 1.28). Conclusions: Higher hemoglobin levels, particularly within the first six hours after cardiac arrest, are associated with better neurologic outcomes at hospital discharge in post-cardiac arrest patients admitted to the hospital.

Feasibility of optic nerve sheath diameter measured on initial brain computed tomography as an early neurologic outcome predictor after cardiac arrest.

Few parameters are available to predict neurologic outcome of post-cardiac arrest patients in the early stage of treatment. Optic nerve sheath diameter (ONSD) has been used to indirectly assess intracranial pressure. This study evaluated whether ONSD, an additional parameter in initial brain computed tomography (CT) scans, can be an early predictor of neurologic outcome in post-cardiac arrest patients. A total of 112 cardiac arrest patients between November 2012 and October 2013 were identified. Ninety-eight comatose cardiac arrest patients were evaluated with brain CT. Of these patients, after exclusion of patients whose brain CT scans were done too late or with poor baseline neurology (Cerebral Performance Category [CPC] ≥ 3), 91 patients were included for this study. The parameters of initial brain CT, i.e., gray matter-to-white matter ratio (GWR) and ONSD, were measured after clinical care as part of a retrospective reanalysis of images. ONSD on brain CT was bilaterally measured 3 mm behind the eyeball at fixed window width and level and averaged to yield the mean value. The performance of ONSD to predict poor neurologic outcome (CPC = 3 to 5) was analyzed using multiple logistic regression analysis, receiver operating characteristic (ROC) curve analysis, and cross-tabulations. Twenty-three patients showed good neurologic outcomes at hospital discharge. Mean (±SD) ONSD was 5.6 (±0.3) mm in the good outcome group versus 6.3 (±0.5) mm in the poor outcome group (p < 0.001). After basic clinical covariates were controlled for, i.e., age, Glasgow Coma Scale (GCS) score (3 vs. 4-15), and time from collapse to return of spontaneous circulation (ROSC), ONSD (odds ratio [OR] = 2.1; 95% confidence interval [CI] = 1.1 to 3.9) and GWR (OR = 0.6; 95% CI = 0.4 to 0.9) were found to be significant factors for predicting poor neurologic outcome. ROC curve analysis showed that ONSD and GWR had areas under the ROC curve of 0.931 (95% CI = 0.87 to 0.98) and 0.922 (95% CI = 0.86 to 0.97), respectively. Combining the cutoff values of ONSD (6.21 mm, sensitivity = 56%; 95% CI = 43% to 68%) and GWR (1.23, sensitivity = 84%; 95% CI = 73% to 92%) to have 100% specificities, the sensitivity was improved to 92% (95% CI = 84% to 98%). Intrarater and interrater intraclass correlation coefficients between the investigators measuring ONSD were 0.888 and 0.833, respectively. Optic nerve sheath diameter on initial brain CT correlated closely with the neurologic outcome of hypoxic ischemic encephalopathy and had good reliability. Additional prospective work may be justified evaluating the standardization and diagnostic performance in real time use as a predictive tool for neurologic outcome following cardiac arrest.

Continuous Electroencephalogram in Comatose Postcardiac Arrest Syndrome Patients Treated With Therapeutic Hypothermia

Therapeutic Hypothermia (TH) is the only therapeutic intervention proven to significantly improve survival and neurologic outcome in comatose postcardiac arrest patients and is now considered standard of care. When we discuss prognostication with regard to comatose survivors postcardiac arrest, we should look for tools that are both reliable and accurate and that achieve a false-positive rate (FPR) equal to or very closely approaching zero. We retrospectively reviewed data that were prospectively collected on all cardiac arrest patients admitted to our ICU. Continuous electroencephalogram (cEEG) monitoring was performed as part of our protocol for therapeutic hypothermia in comatose postcardiac arrest patients. The primary outcome measure was the best score on hospital discharge on the 5-point Glasgow-Pittsburgh cerebral performance category (CPC) scores. A total of 58 patients were included in this study. Twenty five (43%) patients had a good neurologic outcome (CPC score of 1-2). Three (5.2%) patients had nonconvulsive status epilepticus, all of whom had poor outcome (CPC = 5). Seventeen (29%) patients had burst suppression (BS); all had poor outcome. Both nonconvuslsive seizures (NCS) and BS had a specificity of 100% (95% confidence interval [CI], 84%-100%), positive predictive values of 100% (95% CI, 31%-100%), and 100% (95% CI, 77%-100%), respectively. Both NCS and BS had FPRs of zero (95% CI, 0.0-0.69, and 0.0-0.23, respectively). In comatose postcardiac arrest patients treated with hypothermia, EEG during the maintenance and rewarming phase of hypothermia can contribute to prediction of neurologic outcome. Pending large multicenter prospective studies evaluating the role of cEEG in prognostication, our study adds to the existing evidence that cEEG can play a potential role in prediction of outcome in postcardiac arrest patients treated with hypothermia.

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Introduction: Post-cardiac arrest myocardial dysfunction (MD) is a well recognized and common phenomenon. Understanding this phenomenon and its effect on neurologic outcome is important to the successful management of post-cardiac arrest patients. There are no clinical studies evaluating the effect of MD on outcome in post-cardiac arrest patients treated with Therapeutic Hypothermia (TH). Hypothesis: The objective of this study was to determine whether MD in post-cardiac arrest patients treated with TH is associated with worse neurologic outcome. MD is defined as global dysfunction on echocardiogram with ejection fraction (EF) < 30% within 48 hours of cardiac arrest. Methods: Review of consecutive post-cardiac arrest comatose adult patients treated with TH between May 2009 and December 2010. Demographic data, time to return of spontaneous circulation (ROSC), time to target temperature (TTT), echocardiogram findings, survival, and neurologic outcomes using cerebral performance category (CPC) scale at hospital discharge were prospectively recorded. Results: A total of 71 patients were enrolled. All patients received TH, with a target temperature of 33 oC for 24 hours. Patients with MD (n = 13) were matched with control group (EF > 30%, n = 58) on baseline characteristics, age (63 +/- 17 vs 62 +/- 15, in years), time to ROSC (18.2 vs 19.2, in minutes), and TTT (566+/-331 vs 502+/-268, in minutes) respectively. A CPC score of 1–2 represents a good outcome and a CPC score of 3–5, a bad outcome. 84.6 % (11/13) of MD patients had poor outcome versus 51.7 % (30/58) of control patients had poor outcome (p = 0.05). Myocardial dysfunction had an odds ratio for poor outcome of 5.1 (95% confidence interval, 1.1-25.1, p=0.05). Conclusions: Among a small number of post-cardiac arrest comatose adult patients treated with therapeutic hypothermia, patients who developed myocardial dysfunction (EF<30%) had worse outcomes compared with patients who had EF > 30%. This provides scientific rationale for large prospective clinical trials evaluating the effect of myocardial dysfunction on outcome in post-cardiac arrest comatose patients treated with therapeutic hypothermia.

Association between initial blood pressure measurements and outcome in post-cardiac arrest patients treated with therapeutic hypothermiaStatus: PendingCategory: Post Resuscitation Care

Association between initial blood pressure measurements and outcome in post-cardiac arrest patients treated with therapeutic hypothermiaStatus: PendingCategory: Post Resuscitation Care

Part 8: Advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations

Part 8: Advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations

Increase in plasma glucagon, a factor in hyperglycemia, is related to neurological outcome in postcardiac-arrest patients

Aim of the study In postcardiac-arrest (PCA) patients, hyperglycemia is a factor reflecting an unfavorable outcome, and might be caused by the inflammation and stress of “sepsis-like” syndrome. In this study, plasma glucagon, a representative glycogenolytic and gluconeogenic hormone, was measured and assessed the correlation for neurological outcome in PCA patients. Methods This study was a retrospective, single-medical-center analysis, conducted in the intensive care unit of a university hospital. Twenty-four sequential PCA patients were included. Plasma samples were collected from the patients on days 1, 2, and 3 after the return of spontaneous circulation (ROSC). Glucagon was compared in patients with favorable and unfavorable neurological outcomes. Results At all time points, plasma glucagon was significantly higher in patients with an unfavorable outcome ( P < 0.05). Glucagon on day 1 had remarkable sensitivity (88.2%) and specificity (85.8%) as an indicator of outcome, and correlated with the collapse–ROSC interval, the start of cardiopulmonary resuscitation (CPR)–ROSC interval, and the epinephrine dose during CPR. Conclusions Plasma glucagon reflects unfavorable outcomes in PCA patients, and might be related to ischemic and reperfusion stress.

Serum glial fibrillary acidic protein as a predictive biomarker of neurological outcome after cardiac arrest

Aim of the study Serum glial fibrillary acidic protein (GFAP) has recently been identified as a specific predictor of brain damage and neurological outcome in patients with head trauma. In this study, serum GFAP was assessed as a predictor of neurological outcome in post-cardiac-arrest (PCA) patients. Methods This study was a retrospective, single-medical-center analysis, conducted in the intensive care unit of a university hospital. Forty-four sequential PCA patients with cardiogenic or non-cardiogenic arrest were included. The patients were treated with or without therapeutic hypothermia (TH). Serum samples were collected from the patients at 12, 24, and 48 h after the return of spontaneous circulation (ROSC). Serum GFAP concentrations were measured by enzyme-linked immunosorbent assay and compared in patients with good and poor neurological outcomes, evaluated over a period of 6 months using Glasgow Outcome Scale. Results Serum GFAP was significantly higher in patients with a poor outcome at 12 and 24 h without TH and at 48 h with TH ( P < 0.05). GFAP (>0.1 ng dL −1) was a specific predictor of poor neurological outcome at 6 months with or without TH treatment. Conclusions Although this study is preliminary, serum GFAP after ROSC reflected a poor neurological outcome in PCA patients.

Effective lactate clearance is associated with improved outcome in post-cardiac arrest patients

Early, effective lactate clearance has been shown to be associated with improved mortality in patients with trauma, burns, and sepsis. We investigated whether early, high lactate clearance was associated with reduced mortality in post-cardiac arrest patients. We performed a retrospective analysis of post-cardiac arrest patients in an urban emergency department. Inclusion criteria included pre-hospital cardiac arrest patients over the age of 18. Exclusion criteria were traumatic arrest, successful resuscitation prior to the arrival of emergency medical services, and cardiac arrest in the presence of pre-hospital providers. Primary endpoints consisted of survival to 24h and survival to hospital discharge. A total of 79 patients were analyzed with a mean age of 64+/-17 and mean APACHE II score of 37.7+/-5. Of the 79 patients, 27 (34%) died within 24h and 66 (84%) died during the hospital course. The mean initial lactate level for the overall group was 15+/-5.2mmol/dl with a mean lactate of 14.4+/-5.1mmol/dl in the survivors and 16+/-5.3mmol/dl in the non-survivors (p>0.05). Lactate clearance at both 6 and 12h was significantly higher for both 24-h and overall in-hospital survival (p<0.05). A multivariable analysis showed that high lactate clearance at 12h was predictive of 24-h survival (p<0.05). Early, effective lactate clearance is associated with decreased early and overall in-hospital mortality in post-cardiac arrest patients. These findings suggest that post-arrest tissue hypo-perfusion plays in an important role in early as well as overall mortality.