Post-cardiac Arrest Syndrome Patients Research Articles

Abstract 18785: Prognostication of Neurological Outcomes in Cardiac Arrest Patients Based on Novel Serum Biomarkers

Introduction and Hypothesis: Patients with post-cardiac arrest syndrome (PCAS) rely on precise and timely diagnosis for good clinical outcomes. Our study sought to evaluate novel serum parameters' diagnostic and clinical efficacy in prognosticating neurological outcomes in post-cardiac arrest syndrome patients. Methods: 345 patients with cardiac arrest treated with target temperature management were enrolled in this retrospective, multicenter study. Blood samples were drawn and evaluated at a period of 0, 1, 2, and 3 days. Samples were analyzed for conventional biomarkers; S100 calcium-binding protein (S-100B) and neuron-specific enolase, and for novel biomarkers; ubiquitin carboxy-terminal hydrolase L1 (UCH-L1), glial fibrillary acidic protein (GFAP), neurofilament light chain (NFL), and tau load. Patients were followed up for neurological outcomes over 6 months period Results: 328 patients completed the study in which the mean age was 68.4 years, and 23% were female. Normal values for NFL, UCH-L1, and tau proteins showed the highest sensitivity (91.8-96% of patients with poor neurological outcomes had abnormal values) and negative predictive value (90-94.5% with good neurological outcomes had normal values). Overall, all the novel biomarkers had independent statistically significant values for the diagnosis of clinical outcome (p<0.005). The area under the curves of the novel serum biomarkers was highest at 72 h post-cardiac arrest (0.913 for NFL, 0.88 for tau, 0.961 for GFAP, and 0.947 for UCH-L1). Conclusions: Our study concluded that low levels of novel serum biomarkers are associated with good neurological outcomes. The reliability of these novel biomarkers highlights that they should be included in baseline laboratory investigation for better prognostication of neurological outcomes in patients with PCAS.

Comparison of Clinical Outcomes between Rebound Hyperthermia and Non-Rebound Hypertherma Groups in Postcardiac Arrest Syndrome Patients Undergoing Targeted Temperature Management

Purpose : This retrospective study aims to provide basic data for intervention to improve clinical outcomes and identify the characteristics of the rebound hyperthermia (RHG) and non-rebound hyperthermia (NRHG) groups by checking body temperature in patients with post-cardiac arrest syndrome.Method : The study involved 118 patients who completed target temperature management (TTM) in an acute-care unit. Data were analyzed for frequency, percentages, mean, standard deviation, median, and quartiles, and compared using the chi-squared test and Mann–Whitney U-test.Results : Rebound hyperthermia (RH) was observed in 74 (62.7%) patients, predominantly male (69.5%), with an average age of 64.54 ± 15.98, and a body mass index of 23.22 ± 4.75kg/m<sup>2</sup> (overweight). Hypertension (50%) was the most common co-morbidity, followed by diabetes and heart disease (33.1%). Neuron-specific enolase levels were higher in the NRHG 24, 48, and 72 hours after recovery of spontaneous circulation (p = .037, <i>p</i>＜ .001, <i>p</i>= .008). The APHCHE Ⅳ was also higher in the NRHG (<i>p</i>＜ .001). RH occurred 25.49 (7.28–52.96) hours after TTM completion, lasting for 2 (1–3) hours. Temperature reduction strategies included notifying doctors, administering antipyretics, and nursing intervention, with the latter being the most common at 94.6%. Half of the subjects in the RHG and 77.3% in the NRHG fell into cerebral performance categories 3, 4, and 5 (<i>p</i>= .003).Conclusion : RH is more likely a body mechanism related to CPR and TTM than a result of pathogenic infection. Therefore, we require an active intervention for hyperthermia, and a patient-specific nursing intervention protocol.

Rapid rewarming rate associated with favorable neurological outcomes in patients with post-cardiac arrest syndrome patients treated with targeted temperature management.

To determine whether the rewarming rate is associated with neurological outcomes in patients with post-cardiac arrest syndrome treated with targeted temperature management (TTM) at 34°C. We conducted a retrospective analysis of a nationwide cohort study of out-of-hospital cardiac arrest in Japan. Adult patients who experienced a return of spontaneous circulation and completed TTM at 34°C between June 2014 and December 2019 were divided equally into three groups (slow, moderate, and rapid) according to their rewarming rates from 34°C to 36°C. The rates of favorable neurological outcomes (Cerebral Performance Category of 1-2 after 30 days) were compared among the groups, and the adjusted odds ratios for a favorable neurological outcome were calculated for the groups. We analyzed 348, 357, and 358 patients in the slow, moderate, and rapid groups, respectively. The periods of rewarming from 34°C to 36°C were 41.9 ± 10.5, 22.4 ± 1.8, and 12.2 ± 3.6 h, respectively. The number of favorable neurological outcomes after 30 days was 121 (34.8%), 125 (35.0%), and 147 (41.1%), respectively, with no significant differences among the three groups (p = 0.145). Rapid rewarming was independently associated with a favorable neurological outcome compared with slow rewarming (adjusted odds ratio 1.57 [95% confidence interval 1.04-2.37]; p = 0.031). Rapid rewarming after TTM at 34°C was associated with a more favorable neurological outcome than slow rewarming.

Predictive value of sequential organ failure assessment on 28-day mortality in patients with post-cardiac arrest syndrome

To evaluate the predictive value of sequential organ failure assessment (SOFA) for 28-day mortality in patients with post-cardiac arrest syndrome (PCAS). Retrospective analysis of 125 patients with PCAS who were treated in Emergency Intensive Care Unit (EICU) of Wenzhou People's Hospital from July 2016 to July 2021. Clinical data were collected, including age, gender, underlying diseases, acute physiology and chronic health evaluation II (APACHE II), SOFA score on admission to EICU and 28-day mortality. Univariate and multivariate Logistic regression model was constructed to analyze the influencing factors of PCAS patients, which was used to examine the independent correlation between SOFA score and 28-day mortality. Receiver operator characteristic curve (ROC curve) was used to determine the best predictive value of SOFA score and 28-day mortality in PCAS patients. Among the 125 PCAS patients, there were 91 males and 34 females with an average age of (58.7±15.1) years old, and 97 died and 28 survived within 28 days. The overall SOFA score ranged from 7 to 15 points, with an average of 10.9 (10.0, 12.0) points. The SOFA score of non-survival group was significantly higher than that of the survival group [points: 11.0 (10.0, 12.0) vs. 9.5 (9.0, 10.0), P < 0.05]. This difference between SOFA score mainly caused by the neurological and cardiovascular systems. After excluding neurological factors, the SOFA score of the non-survival group was still significantly higher than that of the survival group [points: 8.0 (6.0, 8.0) vs. 6.5 (6.0, 7.0), P < 0.05]. SOFA score was found to be an independent risk factor for 28-day mortality in PCAS patients by multifactorial Logistic regression analysis [odds ratio (OR) = 1.97, 95% confidence interval (95%CI) was 1.24-3.04]. The correlation between neurological score and mortality was the highest in subgroups (OR = 3.47, 95%CI was 1.04-11.52). The area under the ROC curve (AUC) predicted by SOFA score was 0.81 (95%CI was 0.73-0.89). When SOFA score cut-off value was 10.5 points (10 or 11 points), the sensitivity and specificity of SOFA score for predicting 28-day mortality in patients with PCAS were 67.0% and 82.1%, respectively. The SOFA score is quite accurate in predicting 28-day mortality in patients with PCAS.

Association of Histones With Coagulofibrinolytic Responses and Organ Dysfunction in Adult Post-cardiac Arrest Syndrome.

BackgroundPatients successfully resuscitated from cardiac arrest often develop organ dysfunction caused by systemic inflammation and increased coagulation, leading to disseminated intravascular coagulation (DIC). The involvement of histones in DIC and organ dysfunction in patients with sepsis and trauma has been previously reported, raising the probability that histones may also be associated with pathophysiology in patients after cardiac arrest and resuscitation. This study evaluated the relationship between histones and organ dysfunction related to coagulofibrinolytic changes in patients with post-cardiac arrest syndrome (PCAS).MethodsThis prospective single-center observational study assessed 35 adult patients with PCAS who were divided into two groups, i.e., 15 patients with multiple organ dysfunction syndrome (MODS) and 20 patients without MODS. MODS was defined as a sequential organ failure assessment score of ≥12. The plasma levels of histones and coagulofibrinolytic markers, including soluble fibrin, tissue-type plasminogen activator, plasminogen activator inhibitor-1, plasmin-alpha 2-plasmin inhibitor complex (PIC), and soluble thrombomodulin, were measured in patients with PCAS immediately after admission to the emergency department, and 3 and 24 h after arriving at the hospital.ResultsPCAS patients with MODS had higher DIC scores [4 (3.0–5.0) vs. 1 (0.0–3.0), p = 0.012] and higher mortality rates (66.7% vs. 20.0%, p = 0.013) than those without MODS. Moreover, patients with MODS exhibited higher histone levels than those without MODS during the early phase of the post-resuscitation period. Severe endothelial injury and higher thrombin and plasmin generation were observed in the MODS group. Plasma levels of histones were positively correlated with those of soluble fibrin immediately after resuscitation (rho = 0.367, p = 0.030) and PIC 3 h after arriving at the hospital (rho = 0.480, p = 0.005). This correlation was prominent in the patient population with MODS (soluble fibrin: rho = 0.681, p = 0.005, PIC: rho = 0.742, p = 0.002).ConclusionsThis study demonstrated that elevated histone levels were associated with increased levels of thrombin, and subsequent plasmin generation in PCAS patients, especially those with MODS. Further studies are required to elucidate the causal relationship between histones and organ dysfunction related to DIC in PCAS.

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.

Differential Effectiveness of Hypothermic Targeted Temperature Management According to the Severity of Post-Cardiac Arrest Syndrome.

International guidelines recommend targeted temperature management (TTM) to improve the neurological outcomes in adult patients with post-cardiac arrest syndrome (PCAS). However, it still remains unclear if the lower temperature setting (hypothermic TTM) or higher temperature setting (normothermic TTM) is superior for TTM. According to the most recent large randomized controlled trial (RCT), hypothermic TTM was not found to be associated with superior neurological outcomes than normothermic TTM in PCAS patients. Even though this represents high-quality evidence obtained from a well-designed large RCT, we believe that we still need to continue investigating the potential benefits of hypothermic TTM. In fact, several studies have indicated that the beneficial effect of hypothermic TTM differs according to the severity of PCAS, suggesting that there may be a subgroup of PCAS patients that is especially likely to benefit from hypothermic TTM. Herein, we summarize the results of major RCTs conducted to evaluate the beneficial effects of hypothermic TTM, review the recent literature suggesting the possibility that the therapeutic effect of hypothermic TTM differs according to the severity of PCAS, and discuss the potential of individualized TTM.

Effect of Shenfu Injection () on Lactate and Lactate Clearance in Patients with Post-cardiac Arrest Syndrome: A Post Hoc Analysis of a Multicenter Randomized Controlled Trial.

To assess the effects of Shenfu Injection (, SFI) on blood lactate, and secondarily its effect on the lactate clearance (LC) in patients with post cardiac arrest syndrome (PCAS). The present study is a post hoc study of a randomized, assessor-blinded, controlled trial. Patients experienced in-hospital cardiac arrest between 2012 and 2015 were included in the predefined post hoc analyses. Of 1,022 patients enrolled, a total of 978 patients were allocated to the control group (486 cases) and SFI (492 cases) group, receiving standardized post-resuscitation care bundle (PRCB) treatment or PRCB combined with SFI (100 mL/d), respectively. Patients' serum lactate was measured simultaneously with artery blood gas, lactate clearance (LC) was calculated on days 1, 3, and 7 after admission and compared between groups. Lactate and LC were also compared between the survivors and non-survivors according to the 28-d mortality, as well as the survivors and non-survivors subgroups both in the SFI and control groups. In both groups, compared with pre-treatment levels, mean arterial pressure (MAP) and PaO2 were significantly improved on 1, 3, 7 d after treatment (P<0.05), while heart rate (HR) and blood glucose levels were significantly decreased on 1, 3 and 7 d after treatment (P<0.05). compared with control group, SFI treatment improved the values of MAP and PaO2 (P<0.05), and significantly decreased the levels of HR and the blood glucose level on 3 and 7 d after treatment (P<0.05). Compared with the control group, lactate levels decreased faster in the SFI group versus the control group on 3 and 7 d (P<0.05). From initiation of treatment and the following 3 and 7 d, SFI treatment greatly increased the LC compared with that in the control group (P<0.05). Compared with survivors, non-survivors had higher admission lactate levels (7.3 ±1.1 mmol/L vs. 5.5 ±2.3 mmol/L; P<0.01), higher lactate levels on days 1, 3 and 7 (P<0.05), and LC were decreased significantly on 3 and 7 d after treatment (P<0.05). Similar results were also found both in the SFI and control groups between survivors and non-survivors subgroups. SFI in combination with PRCB treatment is effective at lowering lactate level and resulted in increasing LC in a targeted population of PCAS patients.

The rCAST score is useful for estimating the neurological prognosis in pediatric patients with post-cardiac arrest syndrome before ICU admission: External validation study using a nationwide prospective registry

IntroductionThe objective of this cohort study was to investigate whether the revised post-Cardiac Arrest Syndrome for Therapeutic hypothermia score (rCAST), which we previously developed as a prognostic score for adult patients with post-cardiac arrest syndrome (PCAS), is also applicable to pediatric patients. MethodsPediatric PCAS patients were included from an out-of-hospital cardiac arrest (OHCA) registry of the Japanese Association for Acute Medicine (JAAM). We validated the predictive accuracy of the rCAST for the neurological outcomes at 30 and 90 days. We also evaluated the probability of a good neurological outcome in each of the three specified severity categories based on the rCAST (low severity: ≤5.5; moderate severity: 6.0–14.0; high severity: ≥14.5). ResultsAmong the 737 pediatric patients with OHCA, the data of 179 pediatric PCAS patients in whom return of spontaneous circulation was achieved were analyzed. The areas under the curve (AUC) of the rCAST for predicting the neurological outcomes at 30 days and 90 days were 0.95 (95% CI: 0.90–0.99) and 0.96 (0.91–1.00), respectively. The proportions of patients with a good neurological outcome at 30 days were 100% (12/12) in the low severity group, 36.1% (13/36) in the moderate severity group, and 2.3% (3/131) in the high severity group. ConclusionsThe AUC of the rCAST for pediatric PCAS patients was found to be greater than 0.9 in the external validation, which corresponds to excellent predictive accuracy. There was no patient with good neurological outcome among the patients with more than 17.0 points (extremely high severity group).

Outcome Related to Level of Targeted Temperature Management in Postcardiac Arrest Syndrome of Low, Moderate, and High Severities: A Nationwide Multicenter Prospective Registry.

The optimal target temperature during targeted temperature management for patients after cardiac arrest remains under debate. The aim of this study was to evaluate the association between targeted temperature management at lower target temperatures and the neurologic outcomes among patients classified by the severity of postcardiac arrest syndrome. A multicenter observational study from the out-of-hospital cardiac arrest registry of the Japanese Association for Acute Medicine, which is a nationwide prospective registry of out-of-hospital cardiac arrest patients. A total of 125 critical care medical centers or hospitals with an emergency care department across Japan. A total of 1,111 out-of-hospital cardiac arrest patients who had received targeted temperature management. We divided all 1,111 postcardiac arrest syndrome patients treated with targeted temperature management into two groups: those who received targeted temperature management at a lower target temperature (33-34°C) and those who received targeted temperature management at a higher target temperature (35-36°C). In regard to classification of the patients, we divided the patients into three categories of severity (low, moderate, and high severities) using the risk classification tool, post-Cardiac Arrest Syndrome for Therapeutic hypothermia, which was previously validated. The primary outcome was the percentage of patients with a good neurologic outcome at 30 days, and the secondary outcome was the survival rate at 30 days. Multivariate analysis showed that targeted temperature management at 33-34°C was significantly associated with a good neurologic outcome and survival at 30 days in the moderate severity (odds ratio, 1.70 [95% CI, 1.03-2.83] and 1.90 [95% CI, 1.15-3.16], respectively), but not in the patients of low or high severity (pinteraction = 0.033). Propensity score analysis also showed that targeted temperature management at 33-34°C was associated with a good neurologic outcome in the moderate-severity group (p = 0.022). Targeted temperature management at 33-34°C was associated with a significantly higher rate of a good neurologic outcome in the moderate-severity postcardiac arrest syndrome group, but not in the low- or high-severity group.

Neurologic Prognostication by QEEG in Post Cardiac Arrest Patients with Therapeutic Hypothermia

Background: Post-cardiac arrest syndrome (PCAS) is one of the critical conditions which can result in a more serious brain injury. Early and accurate prognostication is crucial for deciding the patient’s therapeutic plan and setting the treatment goal. This study aimed to establish the prognostication values of quantitative electroencephalography (QEEG) in PCAS patients.Methods: We recruited 183 PCAS patients treated with therapeutic hypothermia. Electroencephalography (EEG) data within 72 hours after cardiac arrest (CA) and clinical data were collected. QEEG analysis including power spectral density (PSD) and connectivity analysis of default mode network (DMN) with imaginary coherence were performed.Results: There were significantly different patterns of PSD between neurologic good and poor outcome groups; absolute and relative power of the alpha 2 and beta 1 frequency (10-15 Hz) bands were increased in all brain regions of good outcome group. However, the relative power of the delta band and higher frequency bands over fast alpha (beta 3 and gamma bands over 20 Hz) were poor outcome markers. We found out that connectivity of DMN were significantly decreased in the poor outcome group compared with the good outcome group.Conclusions: These findings suggest that QEEG analysis could quantify and automate the interpretation of EEG. Furthermore, they can improve the prognostic values for neurologic outcomes relatively accurately and objectively in PCAS patients treated with hypothermia compared with traditional visual grading.

Precision and Safety of an Intravascular Temperature Management System for Postcardiac Arrest Syndrome Patients: A Multicenter Clinical Trial (COOL-ARREST JP).

Rapid induction and maintaining a target temperature of 32.0–36.0°C within a narrow range for <24 hours are essential, but those are very hard to perform in postcardiac arrest syndrome (PCAS) patients. We investigated the usability of an intravascular temperature management (IVTM) system with neurolept-anesthesia (NLA; droperidol and fentanyl). Single-arm, prospective multicenter trial was carried out in the seven university and the three affiliated hospitals. In the 24 comatose PCAS patients, the target temperature (33.0°C) was rapidly induced and maintained for 24 hours using an IVTM system with NLA. The rewarming speed was 0.1°C/h until 36.5°C and was maintained for 24 hours. The primary end point was the ability to achieve ≤34.0°C for <3 hours after starting cooling, and the secondary end points were the cooling rate, deviation from the target temperature, and adverse events. Cerebral Performance Category (CPC) score at 14 days was also evaluated. Statistical analyses were performed by SPSS software, using the intention-to-treat data sets. The target temperature of ≤34.0°C was reached by 45 minutes (35–73 minutes) and was within 3 hours in all patients. The cooling rate from 36.4°C to 33.0°C was 2.7°C/h (2.4–3.6°C/h). The temperature of 33.1°C (33.1–33.1°C) and 36.7°C (36.6–36.9°C) for 24 hours each was held during the maintenance and the after rewarming phases, respectively. Temperature deviations >0.2°C from 33.0°C in the maintenance phase occurred once each in two patients. The favorable neurological outcomes (CPC1, 2) were relatively good (50%). Five patients experienced serious adverse events; none was device related. We rapidly achieved therapeutic hypothermia within a narrow temperature range without major complications using the IVTM system with NLA in PCAS patients.

High plasma levels of pro-inflammatory factors interleukin-17 and interleukin-23 are associated with poor outcome of cardiac-arrest patients: a single center experience

BackgroundSystemic inflammation is an important feature of post-cardiac arrest syndrome (PCAS). This study was designed to determine whether the plasma concentrations of some circulating pro-inflammatory cytokines (interleukin-17 [IL-8], IL-22, IL-23 and IL-33) are of value in predicting the outcome of patients after return of spontaneous circulation (ROSC) during the post–cardiac arrest period.MethodsThis was a prospective observational clinical study. In total, 21 patients (survivors, n = 10; non-survivors, n = 11) who experienced cardiac arrest and successful ROSC with expected survival of at least 7 days were consecutively enrolled from January 2016 to December 2017. Of the 21 enrolled patients, ten survived were designated “survivors”. The other eleven patients died between 2 days and 1 months post ROSC. Venous blood was drawn at three time-points: baseline (< 1 h post ROSC), 2 days post ROSC and 7 days post ROSC. Plasma IL-8, IL-22, IL-23 and IL-33 were determined using commercial enzyme-linked immunosorbent assays.ResultsPlasma creatinine levels, but aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels, were elevated in non-survivors compared with survivors. Plasma levels of IL-17, IL-22, IL-23 and IL-33 of the 21 total patients did not change at 2 or 7 days post ROSC compared to baseline. In survivors, the plasma levels of IL-17 and IL-23 at 2 or 7 days post ROSC were lower than baseline. In non-survivors, plasma levels of IL-17 increased compared with baseline. Receiver operating characteristic curve analysis showed that the plasma levels of IL-17 and IL-23 at 2 or 7 days post ROSC were able to predict the mortality of PCAS patients, and positively correlated with Acute Physiology and Chronic Health Evaluation (APACHE)-II score and time to ROSC.ConclusionThese results provide the first evidence that the elevated plasma IL-17 and IL-23 levels are associated with poor outcome in PCAS patients. The role of IL-17/IL-23 axis post ROSC is worth paying attention to in PCAS patients.Trial registrationClinicaltrial.govNCT02297776, 2014-11-21.

Parameters Influencing Brain Oxygen Measurement by Regional Oxygen Saturation in Postcardiac Arrest Patients with Targeted Temperature Management.

In several studies, regional cerebral oxygen saturation (rSO2) has been measured in patients with postcardiac arrest syndrome (PCAS) to analyze the brain's metabolic status. However, the significance of rSO2 in PCAS patients remains unclear. In the present study, we investigated the relationship between rSO2 and physiological parameters. Comatose survivors of out-of-hospital PCAS with targeted temperature management (TTM) at 34°C for 24 hours were included. All patients were monitored for their rSO2 and additional parameters (arterial oxygen saturation [SaO2], hemoglobin [Hb], mean arterial pressure [MAP], arterial carbon dioxide pressure [PaCO2], and body temperature]) measured at the start of monitoring and 24 and 48 hours after return of spontaneous circulation (ROSC). Patients were divided into favorable and unfavorable groups, and the correlation between rSO2 and these physiological parameters was evaluated by multiple regression analysis. Forty-nine patients were included in the study, with 15 in the favorable group and 34 in the unfavorable group. There was no significant difference in the rSO2 value between the two groups at any time point. The multiple regression analysis of the favorable group revealed a moderate correlation between rSO2 and SaO2, Hb, and PaCO2 only at 24 hours (coefficients: 0.482, 0.422, and 0.531, respectively), whereas that of the unfavorable group revealed moderate correlations between rSO2 and Hb values at all time points, PaCO2 at 24 hours and MAP at 24 and 48 hours. rSO2 was moderately correlated to MAP in unfavorable patients. To optimize brain oxygen metabolic balance for PCAS patients with TTM measuring rSO2, we suggest total evaluation of each parameters of SaO2, Hb, MAP, and PaCO2.

Abstract 106: Differential Effects of Mild Therapeutic Hypothermia Against Normothermia for Post-Cardiac Arrest Syndrome According to the Severity Scale

Introduction: There are few studies on the differential effects of mild therapeutic hypothermia (MTH) according to the risk class in post-cardiac arrest syndrome (PCAS) patients. Objective: The aim of this study was to evaluate the differential effects of MTH against therapeutic normothermia (TN) for PCAS patients according to our risk classification tool (rCAST). Methods: We used data from the out-of-hospital cardiac arrest (OHCA) registry of the Japanese Association for Acute Medicine (JAAM), which is a multi-center, prospective registry of OHCA patients who were transported to critical care medical centers or hospitals with an emergency care department across Japan. We classified eligible PCAS patients treated with MTH or TN on the basis of our rCAST score which was previously developed by us: low severity group (≤5.5), moderate severity group (6-14), and high severity group (≥14.5). The differential effects of MTH vs. TN for their neurological outcome in the 3 severity categories were evaluated by interaction analysis, and the effect of MTH vs. TN in each group was assessed by multivariate logistic regression analysis and propensity score analysis. The good neurological outcome was defined as a Cerebral Performance Categories score ≤2 at 30 days. Results: Among 12,024 OHCA patients in the registry, data of 460 PCAS patients treated by MTH or TN were analyzed (96 patients; the low score, 192; the moderate score, and 172; the high score group). There was a statistically significant interaction effect between MTH/TN and their neurological outcome at 30 days in the 3 categories (p = 0.022). MTH was significantly associated with good neurological outcome at 30 days in PCAS patients of moderate severity group both in the multivariate logistic regression analysis (adjusted odds ratio, 3.09; 95% confidence interval, 1.13-8.49; p = 0.029) and the propensity score analysis (p = 0.030), while it was not in low and high severity group. Conclusions: The effect of MTH in PCAS patients differed according to the severity of PCAS, and MTH was significantly associated with a good neurological outcome as compared to TN in the moderate severity group.

Target temperature in post-cardiac-arrest complex intensive care: arguments for mild therapeutic hypothermia

Long term survival of successfully resuscitated patients is primarily determined by their post-cardiac arrest neurological function. If the patient undergoes a long-term resuscitation or remains comatose as part of the post-cardiac arrest syndrome (PCAS), organ-specific intensive care is urged to aim hemodynamic stabilisation, normalisation of organ perfusion and prevention of injuries at cellular level. One of the basic measures of PCAS intensive care is to prevent hypoxic brain injury by mild therapeutic hypothermia (THT). The physiological changes of the human body at hypothermic conditions require high level monitoring and specially focused intensive care limiting its implementation. The multicentric, controlled, randomized targeted temperature management (TTM) trial published in 2013 compared the TTM against the THT in the treatment of PCAS patients. The equal outcome of the 2 methods has partly changed the practice of the intensivists in the treatment of such patients. This manuscript gives the pros and cons for each therapeutic method in post-resuscitation therapy. Nevertheless, the author shows the possible implementations and the DRG (diagnosis-related group) reimbursement of the method in Hungary. Orv Hetil. 2019; 160(46): 1840-1844.

Amplitude-Integrated Electroencephalography and Brain Oxygenation for Postcardiac Arrest Patients with Targeted Temperature Management.

Brain injury is the most common cause of death postcardiac arrest. Amplitude-integrated electroencephalography (aEEG) is suggested to be useful in the prognostication in cases of postcardiac arrest brain injury. However, combined monitoring with aEEG and regional oxygen saturation (rSO2) for postcardiac arrest syndrome (PCAS) patients to improve accuracy has not been reported. The purpose of this prospective observational study is to assess the usefulness of aEEG and rSO2 for PCAS patients with targeted temperature management (TTM) to predict neurological outcome and possibly identify the pathophysiology of postcardiac arrest brain injury. PCAS patients with TTM at 34°C were monitored by aEEG and rSO2 immediately after admission to the intensive care unit and evaluated at the start of monitoring, and 24 and 48 hours after return of spontaneous circulation (ROSC). Patients were divided into two groups according to electroencephalography (EEG) pattern: a continuous EEG (C) pattern group and a noncontinuous EEG (NC) pattern group. Patients with C pattern had a significantly more favorable neurologic outcome compared with patients with an NC pattern at each point in time. No significant difference in rSO2 values was observed between the C pattern and the NC pattern at any time point. Variation coefficient at rSO2 in the NC group was significantly greater than that in the C group from the start of the monitoring to 24 hours. aEEG is useful in predicting outcome for PCAS patients whereas rSO2 is not.

External validation of a risk classification at the emergency department of post-cardiac arrest syndrome patients undergoing targeted temperature management

IntroductionThere are no established risk classification for post-cardiac arrest syndrome (PCAS) patients at the Emergency Department (ED) undergoing targeted temperature management (TTM). The aim of this study was to externally validate a simplified version of our prognostic score, the “post-Cardiac Arrest Syndrome for Therapeutic hypothermia score” (revised CAST [rCAST]) and estimate the predictive accuracy of the risk classification based on it. MethodsFor the external validation, we used data from an out-of-hospital cardiac arrest (OHCA) registry of the Japanese Association for Acute Medicine (JAAM), which is a multicenter, prospective registry of OHCA patients across Japan. Eligible patients were PCAS patients treated with TTM at 33–36 °C between June 2014 and December 2015. We validated the accuracy of rCAST for predicting the neurological outcomes at 30 and 90 days. ResultsAmong the 12,024 OHCA patients, the data of 460 PCAS patients treated by TTM were eligible for the validation. The areas under the curve of rCAST for predicting the neurological outcomes at 30 and 90 days were 0.892 and 0.895, respectively. The estimated sensitivity and specificity of the risk categories for the outcomes were as follows: 0.95 (95% CI: 0.92–0.98) and 0.47 (0.40–0.55) for the low (rCAST: ≤5.5), 0.62 (0.56–0.68) and 0.48 (0.40–0.55) for the moderate (rCAST: 6.0–14.0), and 0.57 (0.51–0.63) and 0.95 (0.91–0.98) for the high severity category (rCAST: ≥14.5). ConclusionsThe rCAST was useful for predicting the neurological outcomes with high accuracy in PCAS patients, and the three grades was developed for a risk classification based on the rCAST.

P2737The assessment of SOFA score predicts mortality and neurogenic outcome in Post-Cardiac Arrest Syndrome patients

P2737The assessment of SOFA score predicts mortality and neurogenic outcome in Post-Cardiac Arrest Syndrome patients

Accuracy of the first interpretation of early brain CT images for predicting the prognosis of post-cardiac arrest syndrome patients at the emergency department

BackgroundEarly brain CT is one of the most useful tools for estimating the prognosis in patients with post-cardiac arrest syndrome (PCAS) at the emergency department (ED). The aim of this study was to evaluate the prognosis-prediction accuracy of the emergency physicians’ interpretation of the findings on early brain CT in PCAS patients treated by targeted temperature management (TTM).MethodsThis was a double-center, retrospective, observational study. Eligible subjects were cardiac arrest patients admitted to the intensive care unit (ICU) for TTM between April 2011 and March 2017. We performed the McNemar test to compare the predictive accuracies of the interpretation by emergency physicians and radiologists and calculated the kappa statistic for determining the concordance rate between the interpretations by these two groups.ResultsOf the 122 eligible patients, 106 met the inclusion criteria for this study. The predictive accuracies (sensitivity, specificity) of the interpretations by the emergency physicians and radiologists were (0.34, 1.00) and (0.41, 0.93), respectively, with no significant difference in either the sensitivity or specificity as assessed by the McNemar test. The kappa statistic calculated to determine the concordance between the two interpretations was 0.66 (0.48–0.83), which showed a good conformity.ConclusionsThe emergency physicians’ interpretation of the early brain CT findings in PCAS patients treated by TTM was as reliable as that of radiologists, in terms of prediction of the prognosis.