Post-cardiac Arrest Research Articles

External validation of cardiac arrest-specific prognostication scores developed for early prognosis estimation after out-of-hospital cardiac arrest in a Korean multicenter cohort

We evaluated the performance of cardiac arrest-specific prognostication scores developed for outcome prediction in the early hours after out-of-hospital cardiac arrest (OHCA) in predicting long-term outcomes using independent data. The following scores were calculated for 1,163 OHCA patients who were treated with targeted temperature management (TTM) at 21 hospitals in South Korea: OHCA, cardiac arrest hospital prognosis (CAHP), C-GRApH (named on the basis of its variables), TTM risk, 5-R, NULL-PLEASE (named on the basis of its variables), Serbian quality of life long-term (SR-QOLl), cardiac arrest survival, revised post-cardiac arrest syndrome for therapeutic hypothermia (rCAST), Polish hypothermia registry (PHR) risk, and PROgnostication using LOGistic regression model for Unselected adult cardiac arrest patients in the Early stages (PROLOGUE) scores and prediction score by Aschauer et al. Their accuracies in predicting poor outcome at 6 months after OHCA were determined using the area under the receiver operating characteristic curve (AUC) and calibration belt. In the complete-case analyses, the PROLOGUE score showed the highest AUC (0.923; 95% confidence interval [CI], 0.904-0.941), whereas the SR-QOLl score had the lowest AUC (0.749; 95% CI, 0.711-0.786). The discrimination performances were similar in the analyses after multiple imputation. The PROLOGUE, TTM risk, CAHP, NULL-PLEASE, 5-R, and cardiac arrest survival scores were well calibrated. The rCAST and PHR risk scores showed acceptable overall calibration, although they showed miscalibration under the 80% CI level at extreme prediction values. The OHCA score, C-GRApH score, prediction score by Aschauer et al., and SR-QOLl score showed significant miscalibration in both complete-case (P = 0.026, 0.013, 0.005, and < 0.001, respectively) and multiple-imputation analyses (P = 0.007, 0.018, < 0.001, and < 0.001, respectively). In conclusion, the discrimination performances of the prognostication scores were all acceptable, but some showed significant miscalibration.

TCTAP C-139 Successful Bailout From Blow-Out Bleeding From Descending Branch of Left Lateral Circumflex Femoral Artery by Balloon Inflation via Trans-Radial R2P System and Polytetrafluoroethylene-Covered Viabahn Stent Placement via Ipsilateral RIKISHI, a Side-grooved Guiding Sheath, System After Successful Recanalization of Left Main Coronary Artery in a Patient With Post-cardiac Arrest Syndrome Under PCPS Support

TCTAP C-139 Successful Bailout From Blow-Out Bleeding From Descending Branch of Left Lateral Circumflex Femoral Artery by Balloon Inflation via Trans-Radial R2P System and Polytetrafluoroethylene-Covered Viabahn Stent Placement via Ipsilateral RIKISHI, a Side-grooved Guiding Sheath, System After Successful Recanalization of Left Main Coronary Artery in a Patient With Post-cardiac Arrest Syndrome Under PCPS Support

Palliative Care Consultation and Cost of Stay in out of Hospital Cardiac Arrest.

Background: Cardiac arrest is a critical condition with high clinical, economic, and emotional burden. The role of palliative medicine in the management of critical patients has grown and, in some areas, has shown reduced cost of stay. This study set out to examine the association of palliative care involvement in out of hospital post cardiac arrest patients and cost of stay. Methods: This is a single center retrospective analysis of all patients ≥18 years of age who were admitted at our institution from March 2018 to June 2019 with out of hospital cardiac arrest. Patients who immediately died in the emergency department were excluded. Patients were then classified according to whether palliative care was consulted. Total charges were obtained from the billing records and compared between those with palliative care compared to those without using Mann-Whitney U test. Results: A final sample of 98 patients that were included in the analysis. The mean age was 61.2 ± 17.3, 46% were female, and 61% were African American. Palliative care consultation was present in 27 (28%) of patients. There were no significant differences among age, gender, ethnicity, BMI, SOFA scores, and common comorbidities among those who did and did not have palliative care consultation. While there was a significantly longer ICU length of stay and mechanical ventilation days among patients with palliative care involvement P < .0001, the charges among patients with palliative care involvement were not statistically significantly different $59,245 ($3744-148,492) (median IQR) compared to those without palliative care $79,521 ($6540-157,952) P = .762. Conclusion: Length of stay increased with palliative care consultation which may relate more to the inherent clinical scenario. Cost of stay was not statistically significantly different.

Optic Nerve Sheath Diameter for Predicting Outcomes in Post-Cardiac Arrest Syndrome: An Updated Systematic Review and Meta-Analysis.

We aimed to identify the efficacy of optic nerve sheath diameter (ONSD) in predicting mortality and poor neurological outcomes (PNO) in post-cardiac arrest syndrome (PCAS) by the measurement time of outcomes. We conducted an extensive literature search in EMBASE, MEDLINE, and Cochrane Library, which included studies on the prognostic accuracy of ONSD in predicting PNO and mortality in PCAS by the measured time of outcomes. A total of 791 patients from nine studies were included. Increased ONSD was weakly associated with PNO by a high heterogeneity (standardized mean difference with 95% confidence interval = 0.74 (0.22, 1.27); I2 = 87%). The analysis by the measurement time of PNO and mortality for ONSD had no significant difference due to insufficient articles or high heterogeneities. The prognostic accuracy of ONSD was 23.97 (pooled diagnostic odds ratio, I2 = 0%) and 0.94 (area under the curve) for short-term PNO. The pooled results showed low or very low quality and very low quality of evidence for PNO and mortality, respectively. ONSD measurement might be an effective predictor for short-term PNO in PCAS. An analysis by measurement time of outcomes showed no significant evidence for ONSD measurement effectiveness in predicting mortality and PNO.

Short-term effects of endotracheal suctioning in post-cardiac arrest patients: A prospective observational cohort study

BackgroundEndotracheal suctioning (ETS) is required in critically ill patients but may lead to adverse physiologic effects. The aim of this study was to investigate risk factors associated with adverse respiratory and circulatory effects of ETS, in post-cardiac arrest patients receiving controlled ventilation. MethodsPatients with return of spontaneous circulation after out-of-hospital cardiac arrest were followed the first five days in the intensive care unit (ICU). For each ETS procedure performed, data were extracted from the electronic ICU records 10 min before and until 30 min after the procedure. Adverse events were defined as heart rate > 120 beats/min, systolic blood pressure > 200 or < 80 mmHg or SpO2 < 85%. Multivariate logistic regression was applied with SpO2 < 85% and systolic blood pressure < 80 mmHg as primary outcomes. ResultsFor the 36 patients included in the study, the median number of ETS-procedures per patient was 13 (range 1–33). Oxygen desaturation occurred in 10.3% of procedures and severe hypotension in 6.6% of procedures. In the multivariate analysis, dose of noradrenaline, light sedation and oxygen desaturation prior to suctioning were associated with increased risk of oxygen desaturation. Doses of noradrenaline, suction with manual ventilation, suction in combination with patient repositioning, and first day of treatment in the ICU were significantly associated with severe hypotension. ConclusionsThe risk of circulatory and respiratory deterioration during ETS in post-cardiac arrest patients is increased the first day of ICU care, and related to sedation, dose of noradrenaline and pre-procedure hypoxemia.

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.

Deviations from PRx-derived optimal blood pressure are associated with mortality after cardiac arrest

AimPressure reactivity index (PRx) provides a surrogate measurement of cerebrovascular autoregulation (CAR). We determined whether deviations from PRx-derived optimal mean arterial pressure (MAPopt) were associated with in-hospital mortality after adult cardiac arrest. MethodsRetrospective analysis of post-cardiac arrest patients who had continuously recorded intracranial pressure (ICP) and MAP. PRx was calculated as a moving, linear correlation between ICP and MAP. Impaired CAR was defined as PRx ≥ 0.3. MAPopt was calculated using a multi-window weighted algorithm. The burdens of MAP < 5 mmHg below MAPopt (MAPopt-5) and > 5 mmHg above MAPopt (MAPopt + 5) were calculated by integrating the area between MAP and MAPopt-5 or MAPopt + 5 curves, respectively. Univariate logistic regression tested the association between burden of MAP < MAPopt-5 and outcome. ResultsTwenty-two patients were analyzed. Thirteen (59%) patients died before hospital discharge. Time (median [IQR]) between ROSC and monitoring initiation was 16 [14, 21] hours and duration of monitoring was 35 [22, 48] hours; neither differed between survivors and non-survivors. Median MAPopt was 89 [85, 97] mmHg and did not differ between survivors and non-survivors (89 [83, 94] vs. 91 [85, 105] mmHg, p = 0.64). Burden of MAP < MAPopt–5 was greater for non-survivors compared to survivors (OR 3.6 [95% CI 1.2–15.6]). Range of intact CAR (upper-lower limit) was narrower for non-survivors when compared to survivors (5 [0, 22] vs. 24 [7, 36] mmHg, p = 0.03). ConclusionA greater burden of MAP below PRx-derived MAPopt-5 was associated with mortality after cardiac arrest. Non-survivors had a narrower range of intact CAR than survivors.

A novel global ischemia-reperfusion rat model with asymmetric brain damage simulating post-cardiac arrest brain injury

BackgroundPost-cardiac arrest brain injury (PCABI) is a major cause of disability and death in patients with post-cardiac arrest syndrome (PCAS). However, there have been no suitable animal models with characteristic behaviors and cerebral damage adequately mimicking clinical PCABI. New methodWe established a chimeric model by increasing transient middle cerebral artery occlusion-mediated ipsilateral hemisphere damage in the 4-vessel occlusion (4VO) model, thereby inducing global forebrain asymmetric hemisphere ischemia. Severity of brain damage was then evaluated by behavioral and histological approaches. Neuroprotection was assessed by performing targeted temperature management (TTM) for two hours. ResultsComatose behaviors were observed in both groups. Compared to the 4VO group, the chimeric group exhibited a higher neurological deficit score (NDS) (70.5 ± 17.6 vs. 139.5 ± 16.8, p = 0.0002), decreased brain cell viability (88.6 ± 18.0% vs. 5.7 ± 2.7%, p < 0.0001), and increased inflammation in the cortex (10.3 ± 1.6% vs. 16.9 ± 1.1%, p = 0.0061). After TTM neuroprotection, the chimeric-TTM group showed improvement in NDS (139.5 ± 16.8 vs. 0.0 ± 0.0, p < 0.0001), cortex and hippocampus cell viability (5.7 ± 2.7% vs. 72.8 ± 10.0%, p < 0.0001; and 2.5 ± 1.5% vs. 75.5 ± 10.3%, p < 0.0001, respectively) and inflammation (16.9 ± 1.1% vs. 11.0 ± 2.3%, p = 0.190; and 30.9 ± 1.7% vs. 16.6 ± 1.2%, p < 0.0001, respectively) compared to the chimeric group. Comparison with existing methodUnlike the extensive brain damage found in clinical PCAS settings, the existing 4VO models showed only global forebrain damage involving CA1 lesions on both hippocampi. Our model induced global forebrain and additional asymmetric hemisphere ischemic damages, which resulted in simulating PCABI-specific clinical manifestations than conventional models. ConclusionsOur model adequately simulates clinical PCABI and reflects appropriate neuroprotective effects of TTM.

Ventilation management and outcomes in out-of-hospital cardiac arrest: a protocol for a preplanned secondary analysis of the TTM2 trial

IntroductionMechanical ventilation is a fundamental component in the management of patients post cardiac arrest. However, the ventilator settings and the gas-exchange targets used after cardiac arrest may not be optimal...

Does Physician Gender and Gender Composition of Clinical Teams Affect Guideline Concordance and Patient Outcomes in Out-of-Hospital Cardiac Arrest?

Objective: Prior literature has shown improved outcomes in morbidity and mortality for admitted patients cared for by female physicians. One theory is that female physicians adhere closely to guideline recommendations. We sought to determine whether patients who have out-of-hospital cardiac arrest (OHCA) experience more guideline-concordant postcardiac arrest care and potentially better outcomes based on the gender of their treating physician and gender distribution of the treatment teams. Methods: This study is a retrospective cohort study from the Colorado Cardiac Arrest Registry, local registry of OHCA patients treated at one academic urban tertiary care hospital. We analyzed adult OHCA patients who survived to hospital admission but were comatose. Patient demographic data and arrest characteristics were abstracted for subjects, and the gender of the provider was abstracted from the medical record. Results: Patients were admitted by a female attending in 28.5% of the cohort. The difference in guideline-concordant care between male and female providers was not significant. No statistical difference was found between all-male or mixed gender teams in adherence to guideline-concordant care. No patient was cared for by an all-female team. Neither gender of the admitting physician nor gender of the physician who led the family meeting to discuss prognosis was associated with a survival difference. Conclusions: Prior literature has described differences in outcome based on gender of the treating physician. Our analysis targeted a similar question in a cohort of OHCA patients with survival to hospital admission. We determined that there was no difference in postcardiac arrest guideline concordance and survival to hospital discharge based on treating physician gender. This finding differs from the prior literature and supports the importance of diverse clinical teams in medicine.

Baclofen attenuates cognitive deficits in post-cardiac arrest brain injury

Between 30% and 50% of survivors of cardiac arrest (CA) suffer from cognitive deficits. However, no effective medical intervention is available to alleviate cognitive deficits. Baclofen is known to protect damaged neurons, but researchers have still not clearly whether baclofen alleviates CA-induced cognitive deficits. The present study aimed to investigate whether baclofen protects against post-CA cognitive deficits and to reveal the protective mechanism of baclofen. Rats underwent 10 min of asphyxia to establish CA models. Intriguingly, our results indicated that baclofen improved spatial memory 72 h after CA. Baclofen increased plasticity-related protein (PSD95, and GAP43) expression in the brain after CA. Baclofen reduced microglial number and the release of inflammatory factors (IL-1β and IL-18). Furthermore, baclofen significantly reduced the expression of pyroptosis-related molecules after CA. Notably, activation of NLRP3 abolished the anti-pyroptosis effect of baclofen and reduced the expression of synaptic plasticity-related proteins after CA. Taken together, this study first shows that baclofen attenuates cognitive deficits induced by brain injury after CA. The mechanism is at least partially attributed to baclofen regulating pyroptosis by inhibition of NLRP3 activation.

Olanzapine-Induced Therapeutic Hypothermia Attenuates Renal Injury in Rats after Asphyxial Cardiac Arrest and Resuscitation.

Return of spontaneous circulation (ROSC) through cardiopulmonary resuscitation (CPR) after cardiac arrest (CA) causes post-cardiac arrest syndrome (PCAS) due to dysfunction in various organs, which provokes acute kidney injury because of renal ischemia-reperfusion injury. Therapeutic hypothermia (TH) can reduce PCAS after CA and ROSC. However, it needs to be more sophisticated and effective. Hence, we aimed to elucidate the protective effects of olanzapine-induced TH against renal injury in asphyxial CA-induced rats. Every rat’s body temperature was maintained at 33 °C for 6 h after administering olanzapine post-CA and ROSC. Olanzapine-induced TH dramatically increased the survival rate of the rats and ameliorated renal tissue damage. Moreover, it suppressed oxidative stress responses through preservation of mitochondrial function and endoplasmic reticulum stress as the main contributor of oxidative stress. Notably, these actions of olanzapine-induced TH were mediated through the Sirt3-related signaling pathway, including the maintenance of Sirt3 and FOXO3a protein expression and the activation of AMPKα and superoxide dismutase 1 (SOD2, a mitochondrial antioxidant). This study is the first to disclose the protective effects of olanzapine-induced TH against renal injury after CA and ROSC, suggesting that olanzapine-induced TH could be utilized for treating CA followed by ROSC.

Long-term outcomes of post-cardiac arrest patients with severe neurological and functional impairments at hospital discharge

BackgroundPatients resuscitated from cardiac arrest who have severe neurological or functional disability at discharge require high-intensity long-term support. However, few data describe the long-term survival and health-care utilization for these patients. MethodsWe identified a cohort of cardiac arrest survivors ≥ 18 years of age, treated at a single center in Western Pennsylvania from January 2010 to December 2019, with a modified Rankin scale (mRS) of 5 at hospital discharge. We recorded demographics, cardiac arrest characteristics, and neurological exam at hospital discharge. We characterized long term survival and mortality through December 31, 2020 through National Death Index query. We described survival time overall and in subgroups using Kaplan-Meier curves and compared using log-rank tests.We linked cases with administrative data to determine 30, 90 day, and one-year hospital readmission rate. For subjects unable to follow commands at discharge, we reviewed records from index hospitalization to the present to describe improvement in neurological status and return home. ResultsWe screened 2,687 patients of which 975 survived to discharge. We identified 190 subjects with mRS of 5 at hospital discharge who were sent to non-hospice settings. Of these, 43 (23%) did not follow commands at discharge. One-year mortality was 38% (n = 71) with a median survival time of 4.2 years (IQR 0.3–10.9). Duration of survival was shorter in older subjects but did not differ based on, sex, or ability to follow commands at hospital discharge. Within the first year of discharge, 58% (n = 111) of subjects had at least one hospitalization with a median length of stay of 8 days [IQR 3–19]. Of subjects who did not follow commands at hospital discharge, 5/43 (11%) followed commands and 9 (21%) were reportedly living at home on subsequent encounters. ConclusionsOf survivors treated over a decade at our institution, 20% (n = 190) were discharged from the hospital with severe functional disability. One-year mortality was 38%, and hospital readmissions were frequent. Few patients discharged unable to follow commands regained the ability over the period of observation, but many did return to living at home. These data can help inform decision maker expectations for patient trajectory and life expectancy.

Omecamtiv mecarbil treatment improves post-resuscitation cardiac function and neurological outcome in a rat model.

BackgroundMyocardial dysfunction is a major cause of poor outcomes in the post-cardiac arrest period. Omecamtiv mecarbil (OM) is a selective small molecule activator of cardiac myosin that prolongs myocardial systole and increases stroke volume without apparent effects on myocardial oxygen demand. OM administration is safe and improves cardiac function in patients with acute heart failure. Whether OM improves post-resuscitation myocardial dysfunction remains unclear. This study investigated the effect of OM treatment on post-resuscitation myocardial dysfunction and outcomes.Methods and resultsAdult male rats were resuscitated after 9.5 min of asphyxia-induced cardiac arrest. OM and normal saline was continuously intravenously infused after return of spontaneous circulation (ROSC) at 0.25 mg/kg/h for 4 h in the experimental group and control group, respectively (n = 20 in each group). Hemodynamic parameters were measured hourly and monitored for 4 h after cardiac arrest. Recovery of neurological function was evaluated by neurological functioning scores (0–12; favorable: 11–12) for rats 72 h after cardiac arrest. OM treatment prolonged left ventricular ejection time and improved post-resuscitation cardiac output. Post-resuscitation heart rate and left ventricular systolic function (dp/dt40) were not different between groups. Kaplan-Meier analysis showed non-statistically higher 72-h survival in the OM group (72.2% [13/18] and 58.8% [10/17], p = 0.386). The OM group had a higher chance of having favorable neurological outcomes in surviving rats 72 h after cardiac arrest (84.6% [11/13] vs. 40% [4/10], p = 0.026). The percentage of damaged neurons was lower in the OM group in a histology study at 72 h after cardiac arrest (55.5±2.3% vs. 76.2±10.2%, p = 0.004).ConclusionsOM treatment improved post-resuscitation myocardial dysfunction and neurological outcome in an animal model. These findings support further pre-clinical studies to improve outcomes in post-cardiac arrest care.

Immediate Versus Delayed Cardiac Catheterization in Post-Arrest Patients Without ST Elevation Myocardial Infarction: Is Survivorship Bias an Important Influence?: March 2022 Annals of Emergency Medicine Journal Club

Immediate Versus Delayed Cardiac Catheterization in Post-Arrest Patients Without ST Elevation Myocardial Infarction: Is Survivorship Bias an Important Influence?: March 2022 Annals of Emergency Medicine Journal Club

The influence of timing of coronary angiography on acute kidney injury in out-of-hospital cardiac arrest patients: a retrospective cohort study

BackgroundAcute kidney injury (AKI) is a frequent complication in cardiac arrest survivors and associated with adverse outcome. It remains unclear whether the incidence of AKI increases after the post-cardiac arrest contrast administration for coronary angiography and whether this depends on timing of angiography. Aim of this study was to investigate whether early angiography is associated with increased development of AKI compared to deferred angiography in out-of-hospital cardiac arrest (OHCA) survivors.MethodsIn this retrospective multicenter cohort study, we investigated whether early angiography (within 2 h) after OHCA was non-inferior to deferred angiography regarding the development of AKI. We used an absolute difference of 5% as the non-inferiority margin. Primary non-inferiority analysis was done by calculating the risk difference with its 90% confidence interval (CI) using a generalized linear model for a binary outcome. As a sensitivity analysis, we repeated the primary analysis using propensity score matching. A multivariable model was built to identify predictors of acute kidney injury.ResultsA total of 2375 patients were included from 2009 until 2018, of which 1148 patients were treated with early coronary angiography and 1227 patients with delayed or no angiography. In the early angiography group 18.5% of patients developed AKI after OHCA and 24.1% in the deferred angiography group. Risk difference was − 3.7% with 90% CI ranging from − 6.7 to − 0.7%, indicating non-inferiority of early angiography. The sensitivity analysis using propensity score matching showed accordant results, but no longer non-inferiority of early angiography. The factors time to return of spontaneous circulation (odds ratio [OR] 1.12, 95% CI 1.06–1.19, p < 0.001), the (not) use of angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker (OR 0.20, 95% CI 0.04–0.91, p = 0.04) and baseline creatinine (OR 1.05, 95% CI 1.03–1.07, p < 0.001) were found to be independently associated with the development of AKI.ConclusionsAlthough AKI occurred in approximately 20% of OHCA patients, we found that early angiography was not associated with a higher AKI incidence than a deferred angiography strategy. The present results implicate that it is safe to perform early coronary angiography with respect to the risk of developing AKI after OHCA.

Myocardial dysfunction after cardiac arrest: tips and pitfalls.

Postcardiac arrest shock (PCAS) is defined by hemodynamic instability occurring in the first hours after cardiac arrest (CA) and is a major cause of mortality among patients hospitalized after CA. It includes vasoplegia and myocardial dysfunction. This postcardiac arrest myocardial dysfunction is supposed to recover within the 3 days. However, there are many unknowns regarding its definition, its prognosis value and its management. In this review dedicated to emergency physicians, we choose to address tips and pitfalls they should know regarding this prevalent syndrome.

Cytokine adsorption in patients with post-cardiac arrest syndrome after extracorporeal cardiopulmonary resuscitation (CYTER) – A single-centre, open-label, randomised, controlled trial

AimTo investigate the effect of cytokine adsorption in patients receiving extracorporeal cardiopulmonary resuscitation (ECPR) after cardiac arrest. MethodsCYTER was a single-centre, open-label, randomised, controlled trial. Patients selected for ECPR at the University Medical Center Freiburg (Freiburg, Germany) were assigned to extracorporeal membrane oxygenation (ECMO) support with or without cytokine adsorption (1:1) using the CytoSorb adsorber, incorporated into the ECMO, replaced every 24 hours, and removed after 72 hours. The primary endpoint was serum interleukin (IL)-6 concentration at 72 hours (intention-to-treat analysis). Secondary endpoints included 30-day survival, vasopressor support and biomarkers of end-organ injury. ResultsOf 50 patients enrolled in the trial, 26 (52%) were treated with cytokine adsorption and 24 (48%) without. Nine patients were excluded (informed consent could not be obtained); 41 patients were therefore included in the primary analysis. Median IL-6 levels (IQR) decreased from 408.0(93.4–906.5) to 324.0 (134.3–4617.3) pg/mL and increased from 133.0 (56.2–528.5) to 241.0 (132.8–718.0) pg/mL in the cytokine adsorption and control group, respectively (linear regression for treatment [cytokine adsorption vs control]: p = 0.48). Three (14%) of 22 patients treated with cytokine adsorption and 8 (42%) of 19 patients treated without cytokine adsorption survived to day 30 (HR = 1.85, 95% CI 0.86–4.01; p = 0.10). Vasopressor support and NSE, S100b, troponin T, CRP and PCT levels were similar between groups. ConclusionCytokine adsorption in patients receiving ECPR did not reduce serum IL–6 and had no significant effect on survival, vasopressor support, or biomarkers of injury. Clinical trial registrationClinicalTrials.gov: NCT03685383.

Effects of targeted temperature management at 33 °C vs. 36 °C on comatose patients after cardiac arrest stratified by the severity of encephalopathy

ObjectivesTo assess neurological outcome after targeted temperature management (TTM) at 33 °C vs. 36 °C, stratified by the severity of encephalopathy based on EEG-patterns at 12 and 24 h. DesignPost hoc analysis of prospective cohort study. SettingFive Dutch Intensive Care units. Patients479 adult comatose post-cardiac arrest patients. InterventionsTTM at 33 °C (n = 270) or 36 °C (n = 209) and continuous EEG monitoring. Measurements and main resultsOutcome according to the cerebral performance category (CPC) score at 6 months post-cardiac arrest was similar after 33 °C and 36 °C. However, when stratified by the severity of encephalopathy based on EEG-patterns at 12 and 24 h after cardiac arrest, the proportion of good outcome (CPC 1–2) in patients with moderate encephalopathy was significantly larger after TTM at 33 °C (66% vs. 45%; Odds Ratios 2.38, 95% CI = 1.32–4.30; p = 0.004). In contrast, with mild encephalopathy, there was no statistically significant difference in the proportion of patients with good outcome between 33 °C and 36 °C (88% vs. 81%; OR 1.68, 95% CI = 0.65–4.38; p = 0.282). Ordinal regression analysis showed a shift towards higher CPC scores when treated with TTM 33 °C as compared with 36 °C in moderate encephalopathy (cOR 2.39; 95% CI = 1.40–4.08; p = 0.001), but not in mild encephalopathy (cOR 0.81 95% CI = 0.41–1.59; p = 0.537). Adjustment for initial cardiac rhythm and cause of arrest did not change this relationship. ConclusionsEffects of TTM probably depend on the severity of encephalopathy in comatose patients after cardiac arrest. These results support inclusion of predefined subgroup analyses based on EEG measures of the severity of encephalopathy in future clinical trials.

The Utility of a Point-of-Care Transcranial Doppler Ultrasound Management Algorithm on Outcomes in Pediatric Asphyxial Out-of-Hospital Cardiac Arrest - An Exploratory Investigation.

BackgroundTranscranial Doppler ultrasound is a sensitive, real time tool used for monitoring cerebral blood flow; it could provide additional information for cerebral perfusion in cerebral resuscitation during post cardiac arrest care. The aim of the current study was to evaluate the utility of a point-of-care transcranial Doppler ultrasound management algorithm on outcomes in pediatric asphyxial out-of-hospital cardiac arrest.MethodsThis retrospective cohort study was conducted in two tertiary pediatric intensive care units between January 2013 and June 2018. All children between 1 month and 18 years of age with asphyxial out-of-hospital cardiac arrest and a history of at least 3 min of chest compressions, who were treated with therapeutic hypothermia and survived for 12 h or more after the return of circulation were eligible for inclusion.ResultsTwenty-one patients met the eligibility criteria for the study. Sixteen (76.2%) of the 21 children were male, and the mean age was 2.8 ± 4.1 years. Seven (33.3%) of the children had underlying disorders. The overall 1-month survival rate was 52.4%. Twelve (57.1%) of the children received point-of-care transcranial Doppler ultrasound. The 1-month survival rate was significantly higher (p = 0.03) in the point-of-care transcranial Doppler ultrasound group (9/12, 75%) than in the non-point-of-care transcranial Doppler ultrasound group (2/9, 22.2%).ConclusionsPoint-of-care transcranial Doppler ultrasound group was associated with a significantly better 1-month survival rate compared with no point-of-care transcranial Doppler ultrasound group in pediatric asphyxial out-of-hospital cardiac arrest.