Prognosis In Comatose Survivors Research Articles

Assessing neurological prognosis in post-cardiac arrest patients from short vs plain text EEG reports: A survey among intensive care clinicians

BackgroundElectroencephalography (EEG) patterns are predictive of neurological prognosis in comatose survivors from cardiac arrest but intensive care clinicians are dependent of neurophysiologist reports to identify specific patterns. We hypothesized that the proportion of correct assessment of neurological prognosis would be higher from short statements confirming specific EEG patterns compared with descriptive plain text reports. MethodsVolunteering intensive care clinicians at two university hospitals were asked to assess the neurological prognosis of a fictional patient with high neuron specific enolase. They were presented with 17 authentic plain text reports and three short statements, confirming whether a “highly malignant”, “malignant” or “benign” EEG pattern was present. Primary outcome was the proportion of clinicians who correctly identified poor neurological prognosis from reports consistent with highly malignant EEG patterns. Secondary outcomes were how the prognosis was assessed from reports consistent with malignant and benign patterns. ResultsOut of 57 participants, poor prognosis was correctly identified by 61% from plain text reports and by 93% from the short statement “highly malignant” EEG patterns. Unaffected prognosis was correctly identified by 28% from plain text reports and by 40% from the short statement “malignant” patterns. Good prognosis was correctly identified by 64% from plain text reports and by 93% from the short statement “benign” pattern. ConclusionStandardized short statement, “highly malignant EEG pattern present”, as compared to plain text EEG descriptions in neurophysiologist reports, is associated with more accurate identification of poor neurological prognosis in comatose survivors of cardiac arrest.

Impact of resuscitation guidelines updates on global outcomes after cardiac arrest

Abstract Background Cardiopulmonary resuscitation (CPR) Guidelines are updated every five years in the light of new evidence. Recent major changes emphasized the importance of quality chest compressions during CPR and simplified recommendations for lay providers, but it is unknown whether these changes improved neurological outcomes. Purpose To analyse whether changes in CPR guidelines had an impact on the prognosis of comatose survivors after cardiac arrest (CA). Methods Prospective database of consecutive patients (pts) admitted to the acute cardiac care unit of a tertiary hospital after in-hospital and out-of-hospital CA (IHCA and OHCA) treated with targeted temperature management (32–34°) from August 2006 to January 2020. Patients were divided into three groups, each one representing the 5-year time frame of publication/implementation of CPR Guidelines: G1 (2006–2010); G2 (2011–2015); G3 (2016–2020). Results A total of 510 pts were included: G1 94 (18.4%), G2 243 (47.6%), G3 173 (33.9%). Mean age was 62.6±14.5 and 413 (81.0%) were men. Demographic characteristics and cardiovascular risk factors did not differ significantly among groups. Changes in CA features among the three analysed periods are shown in Table 1. On regards of prehospital care, CPR provided by lay bystanders (G1 51.6%; G2 63.3%, G3 69.8%) and the use of automated external defibrillators (AED) (G1 11.0%; G2 14.9%; G3 18.9%) progressively increased (p=0.01 and p=0.04, respectively) (Figure 1, A and B). After 2010, there was a higher proportion of CPR-related injuries: G1 12.7%, G2 23.5%, G3 22.7% (p=0.02). Global survival at discharge was 51.6% (263/510). Cerebral Performance Category (CPC) of 1–2 within a 3-month follow-up period significantly increased over time when comparing G1, G2, G3 groups (p=0.04) (Figure 1, D). Among all pts, those with CPR related injuries had a higher proportion of CPC 1–2 (71/109, 65.1% vs 168/389, 43.2%, p<0.01). Conclusions We found a progressive increase of lay bystander CPR and use of AED over the three time periods. Moreover, a higher proportion of CPR-related injuries was observed after publication of 2010 CPR Guidelines which recommended greater depth and higher rate of chest compressions. Survival and neurological outcomes improved significantly over time. Figure 1 Funding Acknowledgement Type of funding source: None

The potential role of auditory evoked potentials to assess prognosis in comatose survivors from cardiac arrest

AimFew data are available on the use of brainstem auditory evoked potentials (BAEPs) in combination with other electrophysiological tools to assess prognosis of comatose survivors from cardiac arrest (CA). MethodsRetrospective analysis of data from all adult patients (>18years of age) admitted to our Dept of Intensive Care after CA over a 6-year period who were comatose (Glasgow Coma Scale <9) on admission, had been treated with targeted temperature management and had BAEP testing. We collected variables related to CA, as well as electroencephalography (EEG) findings, N20 somatosensory evoked potentials, and the presence of I, III and/or V waves on BAEP testing. Outcome was assessed at 3 months using the Cerebral Performance Categories (3–5=poor outcome). ResultsWe studied 65 patients; 48 (74%) had a poor neurological outcome. BAEP assessment was performed day 3 [3,4] after the CA. At least one of the three waves was absent bilaterally in 34 patients (52%); of these patients, 29 (85%) had a poor neurological outcome (sensitivity 60%, specificity 71%, positive predictive value [PPV] 85% and negative predictive value [NPV] 39%). Three patients (5%) had bilateral absence of all three waves, all of whom had a poor neurological outcome. ConclusionsIn this series of patients after CA, at least one of the BAEP waves was absent bilaterally in half the survivors; however, their use for prediction of poor neurological outcome remains limited.

Spectral analysis-based risk score enables early prediction of mortality and cerebral performance in patients undergoing therapeutic hypothermia for ventricular fibrillation and comatose status

BackgroundEarly prognosis in comatose survivors after cardiac arrest due to ventricular fibrillation (VF) is unreliable, especially in patients undergoing mild hypothermia. We aimed at developing a reliable risk-score to enable early prediction of cerebral performance and survival. MethodsSixty-one out of 239 consecutive patients undergoing mild hypothermia after cardiac arrest, with eventual return of spontaneous circulation (ROSC), and comatose status on admission fulfilled the inclusion criteria. Background clinical variables, VF time and frequency domain fundamental variables were considered. The primary and secondary outcomes were a favorable neurological performance (FNP) during hospitalization and survival to hospital discharge, respectively. The predictive model was developed in a retrospective cohort (n=32; September 2006–September 2011, 48.5±10.5months of follow-up) and further validated in a prospective cohort (n=29; October 2011–July 2013, 5±1.8months of follow-up). ResultsFNP was present in 16 (50.0%) and 21 patients (72.4%) in the retrospective and prospective cohorts, respectively. Seventeen (53.1%) and 21 patients (72.4%), respectively, survived to hospital discharge. Both outcomes were significantly associated (p<0.001). Retrospective multivariate analysis provided a prediction model (sensitivity=0.94, specificity=1) that included spectral dominant frequency, derived power density and peak ratios between high and low frequency bands, and the number of shocks delivered before ROSC. Validation on the prospective cohort showed sensitivity=0.88 and specificity=0.91. A model-derived risk-score properly predicted 93% of FNP. Testing the model on follow-up showed a c-statistic≥0.89. ConclusionsA spectral analysis-based model reliably correlates time-dependent VF spectral changes with acute cerebral injury in comatose survivors undergoing mild hypothermia after cardiac arrest.

Endovascular hypothermia after cardiac arrest in a Chilean ICU

For more than a decade, mild hypothermia has been a standard for enhancing the neurological prognosis in comatose survivors of cardiac arrest (CA). Despite this, in our country there are still few centers that apply hypothermia post CA regularly. We describe a Chilean experience with endovascular hypothermia post CA, in three ICUs of the same university clinical center [1-3].

Abstract 2054: Neuron-specific Enolase as a Prognostic Parameter in Patients Treated with Mild Hypothermia After Cardiopulmonary Resuscitation for Out-of-hospital Cardiac Arrest

Background: Overall prognosis in comatose survivors of Cardiopulmonary resuscitation is poor and the degree of hypoxic brain damage is usually the most important prognostic factor. Elevation of the neuron-specific enolase (NSE) as measured with 72 hours after admission has been identified as a predictor of neurologic outcome, and a threshold level of 33 ng/ml has been proposed as a highly specific cut-off value, above which neurologic outcome will be unfavourable. Therapeutic hypothermia is a new concept to improve neurologic outcome in patients after resuscitation, and the prognostic relevance of elevated NSE levels in patients treated by hypothermia has not yet been assessed. Methods: Mild therapeutic hypothermia (33–34°C) was applied via an intravenous cooling catheter for 24 hours in 38 consecutive patients admitted after successful on-site resuscitation following out-of-hospital cardiac arrest (28 male, 10 female, age 38 – 83 years, mean age 64.4±12.7 years). 72 hours after admission, NSE level was measured. Clinical and neurologic outcome was assessed at 1 and 4 weeks. Results: Out of 38 patients, 4 patients died within the first 72 hours. In 2 additional patients, NSE measurement was impossible because of haemolytic serum. NSE levels displayed a wide range (9.8 ng/ml − 720 ng/ml). Of the 32 patients available for analysis, 17 patients suffered severe ischemic brain damage or died during the further course (NSE 11.0 –720 ng/ml, mean 150.4±185.9 ng/ml). 15 patients recovered and had favourable neurologic outcome (NSE 9.8 – 47.9 ng/ml, mean 21.1±11.9 ng/ml). Using the recommended threshold value of 33 ng/ml, the sensitivity for ischemic brain damage was 76.5%, specificity was 80.0%, and the positive predictive value was 81.3%. Conclusions: Based on prior experience in patients without therapeutic hypothermia, a cut-off level of 33 ng/ml has been recommended as a highly specific threshold above which neurologic outcome in patients resuscitated for out-of-hospital cardiac arrest will be poor. Our data demonstrate, however, that favourable outcome can be achieved even for higher NSE levels in patients who are treated with therapeutic hypothermia. Thus, the prognostic value of NSE in these patients must be reconsidered.

Assessment of Neurological Prognosis in Comatose Survivors of Cardiac Arrest

EDGREN, ERIK; HEDSTRAND, ULF; KELSEY, SHERYL; SUTTON-TYRRELL, KIM; SAFER, PETER Author Information

Assessment of neurological prognosis in comatose survivors of cardiac arrest

When a patient resuscitated from cardiac arrest remains unconscious the clinician would like to have a reliable early method for predicting the outcome. The objective of our study was to predict cerebral outcome after cardiac arrest by clinical neurological examination. The data were drawn from an international multicentre controlled clinical trial of thiopentone. Twelve hospitals in nine countries took part. 262 comatose cardiac arrest survivors were followed up for one year. These patients were given advanced life support (American Heart Association guidelines) followed by intensive care to a standardised protocol. Glasgow and Glasgow-Pittsburgh coma scores and their constituent signs were recorded at fixed times. Outcome was taken to be the best cerebral performance at any time during follow-up, and for that purpose we used cerebral performance categories (CPC 1-5) of the Glasgow outcome categories. A poor outcome (CPC 3-5) could be predicted immediately after reperfusion (at entry into the study) with an accuracy ranging from 52% to 84% for various signs and scores. On the third day it was possible to identify severely disabled or permanently comatose survivors without false predictions using both coma scores and several of their constituent variables. The best predictor was absence of motor response to pain. This modelling exercise now needs to be repeated on a new series of patients but the results do suggest that, after 3 days, stringent ethical criteria can be met and used in decision-making about termination of care in comatose cardiac arrest survivors.