Unfavorable Neurological Outcome Research Articles

321 Severe Metabolic Acidosis Was Associated With Unfavorable Neurological Outcome in Patients With Out-of-Hospital Cardiac Arrest

321 Severe Metabolic Acidosis Was Associated With Unfavorable Neurological Outcome in Patients With Out-of-Hospital Cardiac Arrest

The Impact of Heart Rate Response During 48-Hour Rewarming Phase of Therapeutic Hypothermia on Neurologic Outcomes in Out-of-Hospital Cardiac Arrest Patients.

Bradycardia during therapeutic hypothermia has been reported to be a predictor of favorable neurologic outcomes in out-of-hospital cardiac arrests. However, bradycardia occurrence rate may be influenced by the target body temperature. During therapeutic hypothermia, as part of the normal physiologic response, heart rate decreases in the cooling phase and increases during the rewarming phase. We hypothesized that increased heart rate during the rewarming phase is another predictor of favorable neurologic outcomes. To address this hypothesis, the study aimed to examine the association between heart rate response during the rewarming phase and neurologic outcomes in patients having return of spontaneous circulation after out-of-hospital cardiac arrest. A secondary analysis of the Japanese Population-based Utstein style study with defibrillation and basic/advanced Life Support Education and implementation-Hypothermia registry, which was a multicenter prospective cohort study. Fourteen hospitals throughout Japan. Patients suffering from out-of-hospital cardiac arrest who received therapeutic hypothermia after the return of spontaneous circulation from 2005 to 2011. None. This study enrolled 452 out-of-hospital cardiac arrest patients, of which 354 were analyzed, and 80.2% survived to hospital discharge, of which 57.3% had a good neurologic outcome. Heart rate response was calculated using heart rate data recorded during therapeutic hypothermia in the abovementioned registry. Heart rate response in the rewarming phase (heart rate response-rewarming) was calculated as follows: (heart rate [post rewarming]-heart rate [pre rewarming])/heart rate (pre rewarming) × 100. The primary outcome was an unfavorable neurologic outcome at hospital discharge, that is, a Cerebral Performance Category of 3-5. Multivariable logistic regression analysis was performed to determine the association between heart rate response-rewarming and unfavorable neurologic outcomes. Multivariable logistic regression analysis showed that heart rate response-rewarming was independently associated with unfavorable outcomes (odds ratio [per 10% change], 0.86; 95% CI, 0.78-0.96; p = 0.004). Increased heart rate in the approximately 48-hour rewarming phase during therapeutic hypothermia was significantly associated with and was an independent predictor of favorable neurologic outcomes during out-of-hospital cardiac arrest.

Incomplete revascularization of coronary artery in cardiac arrest survivors is associated increased mortality and unfavorable neurological outcome

Incomplete revascularization of coronary artery in cardiac arrest survivors is associated increased mortality and unfavorable neurological outcome

The Importance of the Time that Elapses Before Spontaneous Circulation is Established Following an Out-of-Hospital Cardiac Arrest

Objective: In order to clarify indications for therapeutic hypothermia, we retrospectively examined patients resuscitated after Out-of-Hospital Cardiac Arrest (OHCA) who recorded an Auditory Brainstem Response (ABR) wave V according to the Utstein-style guidelines. Methods: Patients who recorded an ABR wave V immediately after resuscitation from OHCA were kept at 34 °C for 48 hours. The cohort was divided into two groups: A favorable neurological outcome group (F group: N=12) and an unfavorable neurological outcome group (U group: N=14). Favorable neurological outcome was defined as Pittsburgh Cerebral-Performance Scale (CPC) 1 or 2 and unfavorable as CPC 3-5. Data used to compare the groups included whether CA was witnessed, if a bystander initiated cardiopulmonary resuscitation, presence of cardiac etiology, initial cardiac rhythm and elapsed time from emergency call receipt until Return of Spontaneous Circulation (ROSC). Results: Elapsed time from receipt of the emergency call until ROSC was significantly shorter in the F group than in the U group. ROC curve analysis indicated that the cut-off duration was 28 minutes for a favorable neurological outcome. Conclusion: For OHCA patients with an ABR wave V, elapsed time from receipt of emergency call until ROSC may be an important parameter within the Utstein-style guidelines to determine the usefulness of therapeutic hypothermia.

The impact of diastolic blood pressure values on the neurological outcome of cardiac arrest patients

AimWhich haemodynamic variable is the best predictor of neurological outcome remains unclear. We investigated the association of several haemodynamic variables with neurological outcome in CA patients. MethodsRetrospective analysis of adult comatose survivors of CA admitted to the intensive care unit (ICU) of a University Hospital. Exclusion criteria were early death due to withdrawal of care, missing haemodynamic data and use of intra-aortic balloon pump or extracorporeal membrane oxygenation. We retrieved CA characteristics; lactate concentration and cardiovascular sequential organ failure assessment (cSOFA) score on admission; systolic (SAP), diastolic (DAP), mean arterial pressure (MAP), and the use of vasopressors and inotropic agents during the first 6 h of ICU stay. Unfavourable neurological outcome (UO) was defined as a 3-month cerebral performance category score of 3–5. ResultsAmong the 170 patients (median age 63 years, 67% male, 60% out-of-hospital CA), 106 (63%) had UO. Admission lactate was higher in patients with UO than in those with favourable neurological outcome (4.0[2.4–7.3] vs. 2.5[1.4–6.0] mEq/L; p = 0.003) as was the cSOFA (3 [1–4] vs. 2[0–3]; p = 0.007). The lowest DAP during the first 6 h after ICU admission was significantly lower in patients with unfavourable neurological outcome, notably in patients with high cSOFA scores. In multivariable analysis, high adrenaline doses and the lowest value of DAP during the first 6 h after ICU admission was significantly associated with unfavourable neurological outcome. ConclusionsIn CA patients admitted to the ICU, low DAP during the first 6 h is an independent predictor of unfavourable neurological outcome at 3 months.

Quantitative assessment of pupillary light reflex for early prediction of outcomes after out-of-hospital cardiac arrest: A multicentre prospective observational study

AimTo clarify whether quantitative assessment of pupillary light reflexes (PLR) can predict the outcome of post-cardiac arrest (CA) patients during the first 72 h after the return of spontaneous circulation (ROSC). MethodsFifty adults resuscitated after non-traumatic out-of-hospital CA (OHCA) (mean age 64.1 years old, 36 males) were enrolled in four emergency hospitals. PLR was sequentially measured at 0, 6, 12, 24, 48, and 72 h after ROSC by an automated portable infrared pupillometry. PLR values for each time point were compared between both survivors and non-survivors, and patients with either favourable (Cerebral Performance Category (CPC) 1 or 2) or unfavourable neurological outcomes. ResultsTwenty-three patients survived for 90 days after CA, and 13 patients achieved favourable neurological outcomes. The PLR values of the survivors and patients with favourable neurological outcomes were consistently greater than those of non-survivors (P < 0.001) and those with unfavourable neurological outcomes (P < 0.001), respectively. The change in PLR over time was not statistically different between the outcome groups. The 0-hour PLR best predicted both 90-day survival (AUC = 0.82, cutoff 3%, sensitivity 0.87, specificity 0.80) and favourable neurological outcomes (AUC = 0.84, cutoff 6%, sensitivity 0.92, specificity 0.74). No patient with a 6-hour PLR less than 3% survived for 90 days after CA. ConclusionsQuantitatively measured PLR was consistently greater in survivors and patients with favourable neurological outcomes during the 72 h after ROSC. Quantitative assessment of PLR at as early as 0 h has a potential role for prognostication in post-CA patients.

A potential termination of resuscitation rule for EMS to implement in the field for out-of-hospital cardiac arrest: An observational cohort study

IntroductionDespite international guidelines recommending termination of resuscitation (TOR) rules for out-of-hospital cardiac arrest (OHCA), their implementation remains low. We aimed to develop and validate a new TOR rule that could allow emergency medical service (EMS) personnel to immediately and objectively decide whether to withhold further resuscitation attempts after their arrival. MethodsThis observational study evaluated data from OHCA cases in a prospectively collected nationwide Utstein-style Japanese database (2008–2012). Patients were divided into a development cohort (2008–2010, n = 342,055) and a validation cohort (2011–2012, n = 247,283). A new TOR was developed based on multivariable logistic regression analysis of factors that were associated with unfavourable neurological outcomes. Validation was performed based on specificity, the positive predictive value (PPV), and the area under the receiver operating characteristic curve (AUC). ResultsThree factors were strongly associated with unfavourable neurological outcomes at one month after OHCA: unshockable initial rhythm (adjusted odds ratio [aOR]: 6.09, 95% confidence interval [CI]: 5.81–6.38), unwitnessed by bystanders (aOR: 5.27, 95% CI: 4.99–5.57), and age of ≥73 years (adjusted OR: 2.34, 95% CI: 2.24–2.45). In the validation cohort, the new TOR rule provided specificity of 0.955 (95% CI: 0.950–0.959), a PPV of 0.996 (95% CI: 0.996–0.997), and an AUC of 0.828 (95% CI: 0.824–0.833). ConclusionBased on three objective variables: unshockable initial rhythm, unwitnessed by bystanders, and age ≥73 years, which can be collected immediately after the arrival of EMS personnel at the scene, a new TOR can be developed. Our potential new TOR rule provided an excellent PPV (>99%) for unfavourable neurological outcomes at one month after OHCA.

Higher admission fasting plasma glucose levels are associated with a poorer short-term neurologic outcome in acute ischemic stroke patients with good collateral circulation

In this retrospective study, we sought to delineate the collateral circulation status of acute ischemic stroke patients by CT perfusion and evaluate 90-day modified Rankin Scale (mRS) scores of patients with good or poor collaterals and its correlation with admission fasting plasma glucose (FPG). We enrolled acute ischemic stroke patients who presented to our hospital 4.5h within an onset of the first episode between January 2009 and December 2015. Neurological assessment was performed using the 90-day mRS scores (0-2 for a favorable and 3-6 for an unfavorable neurologic outcome). Relative filling time delay (rFTD) was evaluated by CT perfusion scan. The primary outcomes were 90-day mRS scores stratified by good (rFTD ≤ 4s) versus poor collateral circulation (rFTD > 4s). Totally 270 patients were included, and 139 (51.5%) patients achieved a favorable neurologic outcome. One hundred eighty-five (68.5%) patients had good collateral circulation. Significantly greater portions of patients with good collateral circulation (60.5%, 112/185) achieved a favorable neurologic outcome compared to those with poor collateral circulation (31.8%, 27/85) (P < 0.05). Patients with good collateral circulation achieving a favorable neurologic outcome had significantly lower baseline FPG (6.6 ± 1.96) than those with good collateral circulation achieving an unfavorable neurologic outcome (8.12 ± 4.02; P = 0.002). Spearman correlation analysis showed that rFTD significantly correlated with 90-day mRS scores (adjusted r = 0.258; P < 0.001) and admission FPG (r = 0.286; P < 0.001). Higher admission FPG levels are associated with significantly higher rates of unfavorable neurologic outcome of acute ischemic stroke patients with good collateral circulation. FPG and rFTD may serve as useful predictors of short-term patient outcome and could be used for risk stratification in clinical decision making.

High serum uric acid levels are a protective factor against unfavourable neurological functional outcome in patients with ischaemic stroke.

ObjectiveWe aimed to evaluate the association between serum uric acid levels at the onset and prognostic outcome in patients with acute ischaemic stroke.MethodsWe retrospectively analysed the outcomes of 1166 patients with ischaemic stroke who were hospitalized in our centre during August 2008 to November 2012. Correlations of serum uric acid levels and prognostic outcomes were analysed.ResultsMen had higher serum uric acid levels and better neurological functional outcomes compared with women. There was a strong negative correlation between serum uric acid levels and unfavourable neurological functional outcomes. Generalized estimated equation analysis showed that a higher serum uric acid level (>237 µmol/L) was a protective factor for neurological functional outcome in male, but not female, patients. Among five trial of ORG 10172 in acute stroke treatment classification subtypes, only patients with the large-artery atherosclerosis subtype had a significant protective effect of serum uric acid levels on neurological outcome.ConclusionsOur study shows that high serum uric acid levels are a significant protective factor in men and in the large-artery atherosclerosis subtype in patients with ischaemic stroke. This is helpful for determining the prognostic value of serum uric acid levels for neurological outcome of acute ischaemic stroke.

Time to Epinephrine Administration and Survival From Nonshockable Out-of-Hospital Cardiac Arrest Among Children and Adults.

Previous studies have demonstrated that earlier epinephrine administration is associated with improved survival from out-of-hospital cardiac arrest (OHCA) with shockable initial rhythms. However, the effect of epinephrine timing on patients with nonshockable initial rhythms is unclear. The objective of this study was to measure the association between time to epinephrine administration and survival in adults and children with emergency medical services (EMS)-treated OHCA with nonshockable initial rhythms. We performed a secondary analysis of OHCAs prospectively identified by the Resuscitation Outcomes Consortium network from June 4, 2011, to June 30, 2015. We included patients of all ages with an EMS-treated OHCA and an initial nonshockable rhythm. We excluded those with return of spontaneous circulation in <10 minutes. We conducted a subgroup analysis involving patients <18 years of age. The primary exposure was time (minutes) from arrival of the first EMS agency to the first dose of epinephrine. Secondary exposure was time to epinephrine dichotomized as early (<10 minutes) or late (≥10 minutes). The primary outcome was survival to hospital discharge. We adjusted for Utstein covariates and Resuscitation Outcomes Consortium study site. From 55 568 EMS-treated OHCAs, 32 101 patients with initial nonshockable rhythms were included. There were 12 238 in the early group, 14 517 in the late group, and 5346 not treated with epinephrine. After adjusting for potential confounders, each minute from EMS arrival to epinephrine administration was associated with a 4% decrease in odds of survival for adults, odds ratio=0.96 (95% confidence interval, 0.95-0.98). A subgroup analysis (n=13 290) examining neurological outcomes showed a similar association (adjusted odds ratio, 0.94 per minute; 95% confidence interval, 0.89-0.98). When epinephrine was given late in comparison with early, odds of survival were 18% lower (odds ratio, 0.82; 95% confidence interval, 0.68-0.98). In a pediatric analysis (n=595), odds of survival were 9% lower (odds ratio, 0.91; 95% confidence interval, 0.81-1.01) for each minute delay in epinephrine. Among OHCAs with nonshockable initial rhythms, the majority of patients were administered epinephrine >10 minutes after EMS arrival. Each minute delay in epinephrine administration was associated with decreased survival and unfavorable neurological outcomes. EMS agencies should consider strategies to reduce epinephrine administration times in patients with initial nonshockable rhythms.

Abstract WP157: Leukoaraiosis and Hemorrhagic Transformation After Intravenous Thrombolysis in Acute Ischemic Stroke

Objective: To investigate the relationship between leukoaraiosis (LA)and hemorrhagic transformation(HT)and neurological outcome at 3 months after recombinant tissue plasminogen activator(rt-PA) treatment in patients with acute ischemic stroke. Methods: Prospective clinical,1aboratory, and radiological data from patients with acute ischemic stroke who had received intravenous rt-PA therapy in our hospital were retrospectively reviewed. The severity ratings of LA were evaluated by Age-related white matter changes scale (ARWMC) scale. In order to detect hemorrhagic transformation, all the patients in thrombolysis group had the second head CT scan at 24 h after thrombolysis. sICH was assessed according to the European Collaborative Acute Stroke Study II (ECASS II) criteria. Hemorrhagic transformation after thrombolytic therapy and clinical neurological outcome based on modified Rankin scale(mRS)at 3 months were also analyzed. Favorable outcome as mRS 0-1 and unfavorable outcome as mRS 2-6 were defined. Results: 584 patients receiving intravenous rt-PA treatment in this study were finally enrolled. The mean age was (63.1 ± 9.7) years and 250 cases (42.9%) in women. Door to needle time was (170.4 ± 44.4) min, pretreatment National Institutes of Health Stroke Scale score was 13.76 ± 6.18. Hemorrhagic transformation was found in 83 cases (14.2%). Logistic regression analysis showed that the severity of LA was associated with hemorrhagic transformation, the odds ratios ranged from 2.017(95% CI 1.419 ~ 2.915) to 2.541 (95% CI 1.714 ~ 3.368). Dicho-Logistic regression analysis showed that WMHs Score was the independent risk factor of unfavorable neurological outcome ( OR = 1.735, 95% CI 1.236 ~ 2.442). Conclusion: The severity of LA is associated with an increased risk of sICH and poor functional outcome after IV or intra-arterial thrombolysis for acute ischemic stroke.

Development and Validation of an Empiric Tool to Predict Favorable Neurologic Outcomes Among PICU Patients.

To create a novel tool to predict favorable neurologic outcomes during ICU stay among children with critical illness. Logistic regression models using adaptive lasso methodology were used to identify independent factors associated with favorable neurologic outcomes. A mixed effects logistic regression model was used to create the final prediction model including all predictors selected from the lasso model. Model validation was performed using a 10-fold internal cross-validation approach. Virtual Pediatric Systems (VPS, LLC, Los Angeles, CA) database. Patients less than 18 years old admitted to one of the participating ICUs in the Virtual Pediatric Systems database were included (2009-2015). None. A total of 160,570 patients from 90 hospitals qualified for inclusion. Of these, 1,675 patients (1.04%) were associated with a decline in Pediatric Cerebral Performance Category scale by at least 2 between ICU admission and ICU discharge (unfavorable neurologic outcome). The independent factors associated with unfavorable neurologic outcome included higher weight at ICU admission, higher Pediatric Index of Morality-2 score at ICU admission, cardiac arrest, stroke, seizures, head/nonhead trauma, use of conventional mechanical ventilation and high-frequency oscillatory ventilation, prolonged hospital length of ICU stay, and prolonged use of mechanical ventilation. The presence of chromosomal anomaly, cardiac surgery, and utilization of nitric oxide were associated with favorable neurologic outcome. The final online prediction tool can be accessed at https://soipredictiontool.shinyapps.io/GNOScore/. Our model predicted 139,688 patients with favorable neurologic outcomes in an internal validation sample when the observed number of patients with favorable neurologic outcomes was among 139,591 patients. The area under the receiver operating curve for the validation model was 0.90. This proposed prediction tool encompasses 20 risk factors into one probability to predict favorable neurologic outcome during ICU stay among children with critical illness. Future studies should seek external validation and improved discrimination of this prediction tool.

Inhalation of high concentration hydrogen gas improves short-term outcomes in a rat model of asphyxia induced-cardiac arrest.

Cardiogenic global brain hypoxia-ischemia is a devastating medical problem that is associated with unfavorable neurologic outcomes. Low dose hydrogen gas (up to 2.9%) has been shown to be neuroprotective in a variety of brain diseases. In the present study, we investigated the protective effect of water by electrolysis-derived high concentration hydrogen gas (60%) in a rat model of asphyxia induced-cardiac arrest and global brain hypoxia-ischemia. High concentration hydrogen gas was either administered starting 1 hour prior to cardiac arrest for 1 hour and starting 1 hour post-resuscitation for 1 hour (pre- & post-treatment) or starting 1 hour post-resuscitation for 2 hours (post-treatment). In animals subjected to 9 minutes of asphyxia, both therapeutic regimens tended to reduce the incidence of seizures and neurological deficits within 3 days post-resuscitation. In rats subjected to 11 minutes of asphyxia, significantly worse neurological deficits were observed compared to 9 minutes asphyxia, and pre- & post-treatment had a tendency to improve the success rate of resuscitation and to reduce the seizure incidence within 3 days post-resuscitation. Findings of this preclinical study suggest that water electrolysis-derived 60% hydrogen gas may improve short-term outcomes in cardiogenic global brain hypoxia-ischemia.

Quality of life after intensive care unit discharge based on the GOLD classification

This study assesses the behavior of serial blood lactate measurements during intensive care unit (ICU) stay to identify prognostic factors of unfavorable neurological outcomes (UO) in patients with aneurysmal subarachnoid hemorrhage (SAH).We retrospectively reviewed all patients who were consecutively hospitalized with SAH between 2009 and 2016. Arterial blood lactate levels were routinely obtained on admission and every 6 h in the ICU. Univariate/multivariate analyses were performed to identify independent predictors of UO (modified Rankin scale of 3–6 upon hospital discharge).There were 145 patients with 46% of UO. Initially, increased lactate levels reached maximum levels during the first 24 h and then decreased to within the normal range. Then, the levels slightly increased again to within the normal range for the next 24 h, especially in UO. On multiple regression analysis, lactate levels measured at 24 h, and 48 h after admission were strong predictors of UO. Lactate level measured at 48 h after admission demonstrated the greatest accuracy and the highest specificity (area under the curve, 0.716; sensitivity, 40%; specificity, 92.1%).The lactate level at 48 h after admission was the most accurate predictor of UO with a high specificity in SAH patients.

The Prognostic Value of MRI in Moderate and Severe Traumatic Brain Injury: A Systematic Review and Meta-Analysis.

Traumatic brain injury is a major cause of death and disability, yet many predictors of outcome are not precise enough to guide initial clinical decision-making. Although increasingly used in the early phase following traumatic brain injury, the prognostic utility of MRI remains uncertain. We thus undertook a systematic review and meta-analysis of studies evaluating the predictive value of acute MRI lesion patterns for discriminating clinical outcome in traumatic brain injury. MEDLINE, EMBASE, BIOSIS, and CENTRAL from inception to November 2015. Studies of adults who had MRI in the acute phase following moderate or severe traumatic brain injury. Our primary outcomes were all-cause mortality and the Glasgow Outcome Scale. Two authors independently performed study selection and data extraction. We calculated pooled effect estimates with a random effects model, evaluated the risk of bias using a modified version of Quality in Prognostic Studies and determined the strength of evidence with the Grading of Recommendations, Assessment, Development, and Evaluation. We included 58 eligible studies, of which 27 (n = 1,652) contributed data to meta-analysis. Brainstem lesions were associated with all-cause mortality (risk ratio, 1.78; 95% CI, 1.01-3.15; I = 43%) and unfavorable Glasgow Outcome Scale (risk ratio, 2.49; 95% CI, 1.72-3.58; I = 81%) at greater than or equal to 6 months. Diffuse axonal injury patterns were associated with an increased risk of unfavorable Glasgow Outcome Scale (risk ratio, 2.46; 95% CI, 1.06-5.69; I = 74%). MRI scores based on lesion depth demonstrated increasing risk of unfavorable neurologic outcome as more caudal structures were affected. Most studies were at high risk of methodological bias. MRI following traumatic brain injury yields important prognostic information, with several lesion patterns significantly associated with long-term survival and neurologic outcome. Given the high risk of bias in the current body of literature, large well-controlled studies are necessary to better quantify the prognostic role of early MRI in moderate and severe traumatic brain injury.

Can red blood cell distribution width predict outcome after cardiac arrest?

In critically ill patients, high red blood cell distribution width (RDW) values have been associated with increased hospital mortality, but there are no data on the impact of RDW on outcomes of patients resuscitated from cardiac arrest (CA). The aim of this study was to investigate the relationship between RDW and long-term neurologic outcome in CA survivors. We performed a retrospective analysis of an institutional database including all unconscious adult patients admitted to the intensive care unit (ICU) after non-traumatic CA between January 2007 and January 2015. Patients who survived <24 hours were excluded. The RDW (normal values 10.9-13.4%) was obtained daily from the day of admission to day 3. Patients with a cerebral performance category (CPC) score of 3-5 at 3 months were considered to have an unfavourable neurological outcome. Three hundred and ninety patients were included. The ICU mortality rate was 56% (N.=220) and 64% of patients (N.=251) had an unfavorable 3-month neurological outcome. The median RDW on the day of admission was 14% (13.0-15.2%) and remained stable over the observation period. Two hundred and forty-five patients (63%) had a high RDW (>13.4%) on admission. In multivariable logistic regression analysis, older age, absence of bystander cardiopulmonary resuscitation (CPR), a non-cardiac etiology of the arrest, a non-shockable initial rhythm, high adrenaline dose during CPR and high admission RDW levels were independently associated with an unfavorable outcome at 3 months. High RDW values are associated with poor neurological outcome among CA survivors.

Lesions in deep gray nuclei after severe traumatic brain injury predict neurologic outcome.

PurposeThis study evaluates the correlation between injuries to deep gray matter nuclei, as quantitated by lesions in these nuclei on MR T2 Fast Spin Echo (T2 FSE) images, with 6-month neurological outcome after severe traumatic brain injury (TBI).Materials and methodsNinety-five patients (80 males, mean age = 36.7y) with severe TBI were prospectively enrolled. All patients underwent a MR scan within the 45 days after the trauma that included a T2 FSE acquisition. A 3D deformable atlas of the deep gray matter was registered to this sequence; deep gray matter lesions (DGML) were evaluated using a semi-quantitative classification scheme. The 6-month outcome was dichotomized into unfavorable (death, vegetative or minimally conscious state) or favorable (minimal or no neurologic deficit) outcome.ResultsSixty-six percent of the patients (63/95) had both satisfactory registration of the 3D atlas on T2 FSE and available clinical follow-up. Patients without DGML had an 89% chance (P = 0.0016) of favorable outcome while those with bilateral DGML had an 80% risk of unfavorable outcome (P = 0.00008). Multivariate analysis based on DGML accurately classified patients with unfavorable neurological outcome in 90.5% of the cases.ConclusionLesions in deep gray matter nuclei may predict long-term outcome after severe TBI with high sensitivity and specificity.

Target Serum Sodium Levels During Intensive Care Unit Management of Aneurysmal Subarachnoid Hemorrhage.

Dysnatremia commonly occur in the intensive care unit (ICU) management of patients with aneurysmal subarachnoid hemorrhage (SAH). However, detailed management strategies have not been provided even by current guidelines. The purposes of this study were to examine the association of abnormal serum sodium levels with unfavorable neurologic outcomes and to identify the target range of serum sodium in patients with SAH. We retrospectively reviewed all patients who were consecutively hospitalized with a confirmed diagnosis of SAH between January 2009 and December 2015. Univariate/multivariate analyses were performed to identify the independent predictors of an unfavorable neurologic outcome (modified Rankin scale of 3-6 upon hospital discharge). There were 131 patients included in this study. Unfavorable neurologic outcomes occurred in 45% of patients. On multiple regression analysis, age, Hunt and Kosnik grade, and serum sodium levels in the ICU at the maximum [odds ratio (OR), 1.18; 95% CI, 1.05-1.35; P < 0.01] and minimum (OR, 0.88; 95% CI, 0.77-0.99; P = 0.048) values were significantly associated with unfavorable neurologic outcomes. The receiver operating characteristic curve analysis showed that the cut-off serum sodium levels were 145 mmol/L for maximum value and 132 mmol/L for minimum value. Patients with hyponatremia and hypernatremia during the first 2 weeks in the ICU accounted for 88.2% of patients with an unfavorable neurologic outcome; whereas, those with normal sodium levels accounted for only 15.6%. In patients with SAH, both hyponatremia and hypernatremia during ICU management were significantly associated with unfavorable neurologic outcomes.

The impact of airway strategy on the patient outcome after out-of-hospital cardiac arrest: A propensity score matched analysis.

While guidelines mentioned supraglottic airway management in the case of out-of- hospital cardiac arrest, robust data of their impact on the patient outcome remain scare and results are inconclusive. To assess the impact of the airway strategy on the patient outcome we prospectively enrolled 2224 individuals suffering cardiac arrest who were treated by the Viennese municipal emergency medical service. To control for potential confounders, propensity score matching was performed. Patients were matched in four groups with a 1:1:1:1 ratio ( n=210/group) according to bag-mask-valve, laryngeal tube, endotracheal intubation and secondary endotracheal intubation after primary laryngeal tube ventilation. The laryngeal tube subgroup showed the lowest 30-day survival rate among all tested devices ( p<0.001). However, in the case of endotracheal intubation after primary laryngeal tube ventilation, survival rates were comparable to the primary endotracheal tube subgroup. The use of a laryngeal tube was independently and directly associated with mortality with an adjusted odds ratio of 1.97 (confidence interval: 1.14-3.39; p=0.015). Additionally, patients receiving laryngeal tube ventilation showed the lowest rate of good neurological performance (6.7%; p<0.001) among subgroups. However, if patients received endotracheal intubation after initial laryngeal tube ventilation, the outcome proved to be significantly better (9.5%; p<0.001). We found that the use of a laryngeal tube for airway management in cardiac arrest was significantly associated with poor 30-day survival rates and unfavourable neurological outcome. A primary endotracheal airway management needs to be considered at the scene, or an earliest possible secondary endotracheal intubation during both pre-hospital and in-hospital post-return of spontaneous circulation critical care seems crucial and most beneficial for the patient outcome.

Prognostic value of serum biomarkers of cerebral injury in classifying neurological outcome after paediatric resuscitation

AimTo investigate if the serum biomarkers of cerebral injury, neuron-specific enolase and S100b protein, may classify unfavourable neurological outcome after paediatric cardiac arrest. MethodsWe performed a retrospective study of neuron-specific enolase and S100b measurements from 95 children treated in our paediatric cardiac intensive care unit after cardiac arrest. Neurological outcome at discharge was evaluated using the paediatric cerebral performance category scale, with unfavourable outcome defined as a change of >1 compared to pre-arrest status or death. ResultsFifty-eight patients (61.1%) survived to discharge with 48 (50.5%) having a favourable neurological outcome. We observed significantly higher levels of both biomarkers in the unfavourable outcome group at designated time points (neuron-specific enolase at 24, 48, and 72h and S100b at 12, 24, and 48h after cardiac arrest, p<0.05). Receiver operating characteristic areas under the curve for neuron-specific enolase were 0.83, 0.80, and 0.73 at time points 24, 48, and 72h and 0.87, 0.81, and 0.82 for S100b at 12, 24, and 48h after cardiac arrest, respectively. Neuron-specific enolase measurement at 24h after cardiac arrest was an independent predictor of unfavourable outcome in a multivariable analysis. ConclusionsNeuron-specific enolase and S100b classify unfavourable neurological outcome in this large paediatric cardiac arrest cohort. Further multi-institutional prospective studies to comprehensively evaluate the diagnostic accuracy of these biomarkers under various clinical conditions and to determine reliable cut-off values in children are warranted.