Full neurological recovery, Cerebral Performance Category (CPC) 1, after 65-minute cardiac arrest using percutaneous cardiopulmonary system and therapeutic hypothermia

Introduction: Several small studies have reported variable outcomes following in-hospital cardiac arrest (IHCA) in patients with COVID-19. A clear estimate is important in prognostication and guiding resuscitation efforts and policies for these patients. Methods: A search of PubMed, Embase, and Scopus databases was conducted to identify studies reporting outcomes after IHCA in adult patients with confirmed COVID-19. The cumulative characteristics of the patients were described. The primary outcome studied was survival at 30 days or at hospital discharge (short term survival). Additional outcomes of interest were proportional prevalence of the initial rhythm at arrest, return of spontaneous circulation (ROSC), and neurological recovery (defined as Cerebral Performance Category Score of 1-2 ). Metanalysis of proportions was performed utilizing the Metaprop command. A random effects model was chosen to account for interstudy variance. Results: A total of 13 eligible studies were identified and included in the analyses. Out of all the hospitalized patients with COVID-19, 1,618 underwent advanced cardiac resuscitation after an IHCA. Patients who had a cardiac arrest had a median age between 50-69 years. IHCA occurred predominantly in men, and in the ICU setting. Shockable rhythms were identified in 8% (95% CI 5-10%, I2; 56%) and non-shockable rhythms in 89% (95% CI 85-94% I2; 84%) of patients (Fig. 1a). ROSC was achieved in 40% (95% CI 31-48% I2; 90%) (Fig. 1b). Only 7 % ( 95% CI 3-12% I2; 86%) of patients survived at 30 days/hospital discharge (Fig. 1c). Neurological recovery was seen in 5% (95% CI 3-9% I2; 67%) of patients who suffered a IHCA (Fig. 1d). Conclusions: Our meta-analysis demonstrates the majority of the cardiac arrests in patients with COVID-19 have non-shockable rhythms. Survival rate in these patients is low, and neurological recovery is unfavorable. This study provides further insight in guiding resuscitation efforts in these patients.

Download Full-text

Abstract 12120: Intracranial Pressure Increases Both During Mild Therapeutic Hypothermia and During Rewarming Period in Post Cardiac Arrest Patients

Circulation ◽

10.1161/circ.132.suppl_3.12120 ◽

2015 ◽

Vol 132 (suppl_3) ◽

Author(s):

Hiromichi Naito ◽

Eiji Isotani ◽

Clifton W Callaway ◽

Shingo Hagioka ◽

Naoki Morimoto

Keyword(s):

Cardiac Arrest ◽

Brain Injury ◽

Intracranial Pressure ◽

Therapeutic Hypothermia ◽

Perfusion Pressure ◽

Cerebral Performance Category ◽

Secondary Brain Injury ◽

Surface Cooling ◽

Cooling Device ◽

Performance Category

Introduction: Elevation of intracranial pressure (ICP) may induce secondary brain injury and worsen the neurological outcome. Some studies on traumatic brain injury show that rapid rewarming can result in poorer outcomes contributory due to elevation of ICP. However, little is known about ICP during therapeutic hypothermia (TH) and rewarming period in post cardiac arrest patients. Hypothesis: We tested if there is occurrence of increased ICP during mild TH and rewarming period and whether it is related to outcome in patients resuscitated after cardiac arrest. Methods: Comatose patients resuscitated from cardiac arrest, treated with TH and ICP monitored were enrolled in the study. Surface cooling device was used for TH. Patients were maintained in target core temperature of 34 °C for 24 hrs. Thereafter, the temperature was regulated to increase to normothermia (37.0 °C) at the rate of 0.25 °C/hr. ICP and cerebral perfusion pressure (CPP) were monitored during the period. Cerebral Performance Category (CPC) scale was obtained 28 days later. Results: Data of 9 patients were analyzed (8 [89 %] men, age: 62 ± 17 years, cardiac origin 3 [33 %]/non-cardiac origin: 6 [67 %], CPC 1: 2 patients; CPC 2: 1 patient; CPC 3: 1 patient; CPC 4: 2 patients; CPC 5: 3 patients). ICP was 7.7 ± 4.4 mmHg at the beginning of TH and significantly elevated to 17.4 ± 13.3 mmHg at the end of TH (p = 0.03). ICP was 23.6 ± 19.1 mmHg at the end of rewarming which was higher than the end of TH (p = 0.04). At the end of rewarming, ICP value ranged in variety from 10 mmHg (CPC 1) to 68 mmHg (CPC 5). CPP was 81.3 ± 15.6 mmHg at the beginning of TH and was 72.1 ± 22.7 mmHg (p = 0.22) at the end of rewarming. All the cases with CPP less than 40 mmHg within 48 hrs died. Conclusions: ICP is increasing both during TH of target temperature 34°C and during rewarming at speed of 0.25 °C/hr in patients after cardiac arrest. Increment of ICP seems to be greater in cases with poorer outcome. CPP decrease was not usually observed and was limited to fatal cases.

Download Full-text

Impact of the cardiopulmonary resuscitation-related injuries on the prognosis after cardiac arrest

European Heart Journal ◽

10.1093/ehjci/ehaa946.1819 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

C Merino Argos ◽

I Marco Clement ◽

S.O Rosillo Rodriguez ◽

L Martin Polo ◽

E Arbas Redondo ◽

...

Keyword(s):

Cardiac Arrest ◽

Cardiopulmonary Resuscitation ◽

Cerebral Performance Category ◽

University Hospital ◽

Temperature Management ◽

Performance Category ◽

Neurological Outcomes ◽

Cardiac Care Unit ◽

Sternal Fractures

Abstract Background Cardiopulmonary resuscitation (CPR) manoeuvres involve vigorous compressions with the proper depth and rate in order to keep sufficient perfusion to organs, especially the brain. Accordingly, high incidences of CPR-related injuries (CPR-RI) have been observed in survivors after cardiac arrest (CA). Purpose To analyse whether CPR-related injuries have an impact on the survival and neurological outcomes of comatose survivors after CA. Methods Observational prospective database of consecutive patients (pts) admitted to the acute cardiac care unit of a tertiary university hospital after in-hospital and out-of-hospital CA (IHCA and OHCA) treated with targeted temperature management (TTM 32–34°) from August 2006 to December 2019. CPR-RI were diagnosed by reviewing medical records and analysing image studies during hospitalization. Results A total of 498 pts were included; mean age was 62.7±14.5 years and 393 (78.9%) were men. We found a total of 145 CPR-RI in 109 (21.9%) pts: 79 rib fractures, 20 sternal fractures, 5 hepatic, 5 gastrointestinal, 3 spleen, 1 kidney, 26 lung and 6 heart injuries. Demographic characteristics and cardiovascular risk factors did not differ between the non-CPR-RI group and CPR-RI group. Also, we did not find differences in CA features (Table 1). Survival at discharge was higher in the CPR-RI group [74 (67.8%) vs 188 (48.3%); p<0.001]. Moreover, Cerebral Performance Category (CPC) 1–2 within a 3-month follow-up was significantly higher in the CPR-RI group [(71 (65.1%) vs 168 (43.2%); p<0.001; Figure 1]. Finally, pts who recieved blood transfusions were proportionally higher in the CPR-RI group [34 (32.1%) vs 65 (16.7%)]; p=0.004). Conclusions In our cohort, the presence of CPR-RI was associated with higher survival at discharge and better neurological outcomes during follow-up. Figure 1 Funding Acknowledgement Type of funding source: None

Download Full-text

Abstract 115: One-Year Outcomes in Individual Domains of the Cerebral Performance Category Extended

Circulation ◽

10.1161/circ.138.suppl_2.115 ◽

2018 ◽

Vol 138 (Suppl_2) ◽

Author(s):

Katharyn L Flickinger ◽

Melissa J Repine ◽

Stephany Jaramillo ◽

Allison C Koller ◽

Margo Holm ◽

...

Keyword(s):

Cardiac Arrest ◽

Return To Work ◽

Short Term Memory ◽

Demographic Data ◽

Cerebral Performance Category ◽

Logical Thinking ◽

Short Term ◽

Performance Category ◽

Term Memory

Introduction: Cognitive and physical impairments are common in cardiac arrest survivors. Global measures including the Modified Rankin Scale (mRS), Cerebral Performance Category (CPC) and the 10-domain CPC-Extended (CPC-E) tend to improve over 1 year. The CPC-E is scored from 1-5 with higher scores signifying greater impairment. However, with the CPC-E, individual functional domains (alertness, logical thinking, attention, motor skills, short-term memory, basic and complex activities of daily living (ADL), mood, fatigue, and return to work) may recover at different rates. Hypothesis: We hypothesized that patients would have recovery in all domains of the CPC-E at 1 year after index cardiac arrest. Methods: A prospective cohort study of cardiac arrest survivors was conducted between 2/1/16 and 5/31/17. Chart review was done for baseline demographic data. Outcome measures including mRS, CPC, and CPC-E scores were assessed at discharge, 3 months, 6 months, and 1 year. We defined recovery of a CPC-E domain when >90% of patients had scores of 1-2 in that domain. Results: Of 71 subjects, 35 completed the CPC-E at discharge, 35 at 3 months, 25 at 6 months and 31 at 1 year. The most common reasons for exclusion were patient declined or were lost to follow up. The majority (N=37; 52%) were female, with a mean (SD) age of 58(17) years. Most arrests occurred out of hospital (N= 49; 69%), 27 (38%) had a shockable rhythm and the majority (N=37; 54%) were discharged home. CPC-E domains of alertness (N=35, 100%) logical thinking (N=35; 100%), and attention (N=33; 94%) recovered by hospital discharge. BADLs were recovered by 3 months (N=33; 94%). The majority of patients (N=24;77%) experienced slight-to-no disability or symptoms (mRS 0-2 / CPC 1-2) at 1 year follow up. CPC-E short term memory (67%), motor (87%), mood (87%), fatigue (13%), complex ADL (74%), and return to work (55%) did not recover fully by 1 year. Conclusions: In survivors of cardiac arrest, CPC-E domains of alertness, logical thinking, and attention recover rapidly, while domains of short term memory, motor, mood, fatigue, complex ADL and ability to return to work are chronically impaired 1 year after arrest. Interventions to improve recovery in these domains are needed.

Download Full-text

The Overall Performance Category and Cerebral Performance Category to assess neurologic intact survival at discharge from a cardiac arrest. A good estimate of patients’ functioning?

Resuscitation ◽

10.1016/j.resuscitation.2013.08.138 ◽

2013 ◽

Vol 84 ◽

pp. S53

Author(s):

Stefanie Beesems ◽

Kim Wittebrood ◽

Rob de Haan ◽

Rudolph Koster

Keyword(s):

Cardiac Arrest ◽

Cerebral Performance Category ◽

Performance Category ◽

Overall Performance

Download Full-text

Our experiences with therapeutic hypothermia

Medicinski pregled ◽

10.2298/mpns0710431p ◽

2007 ◽

Vol 60 (9-10) ◽

pp. 431-435 ◽

Cited By ~ 1

Author(s):

Milovan Petrovic ◽

Ilija Srdanovic ◽

Gordana Panic ◽

Tibor Canji ◽

Tihomir Miljevic

Keyword(s):

Cardiac Arrest ◽

Therapeutic Hypothermia ◽

Neurological Outcome ◽

Mild Hypothermia ◽

Acute Myocarditis ◽

Neuroprotective Effect ◽

Sudden Cardiac Arrest ◽

Neurological Recovery ◽

Global Cerebral Ischemia ◽

Resuscitation Guidelines

Introduction. The single most important clinically relevant cause of global cerebral ischemia is cardiac arrest. The estimated rate of sudden cardiac arrest is between 40 and 130 cases per 100.000 people per year. Almost 80% of patients initially resuscitated from cardiac arrest remain comatose for more than one hour. One year after cardiac arrest only 10-30% of these patients survive with good neurological outcome. The ability to survive anoxic no-flow states is dramatically increased with protective and preservative hypothermia. The results of clinical studies show a marked neuroprotective effect of mild hypothermia in resuscitation. Material and Methods. In our clinic, 12 patients were treated with therapeutic hypothermia. A combination of intravascular and external method of cooling was used according to the ILCOR (International Liaison Committee on Resuscitation) guidelines. The target temperature was 33oC, while the duration of cooling was 24 hours. After that, passive rewarming was allowed. All patients also received other necessary therapy. Results. Six patients (50%) had a complete neurological recovery. Two patients (16.6%) had partial neurological recovery. Four patients (33.3%) remained comatose. Five patients (41.66%) survived, while 7 (58.33%) patients died. The main cause of cardiac arrest was acute myocardial infarction (91.6%). One patient had acute myocarditis. Conclusion. Mild resuscitative hypothermia after cardiac arrest improves neurological outcome and reduces mortality in comatose survivors. .

Download Full-text

Abstract 240: Are the Same Resuscitation Protocols Needed for Highly Aged Victims With Out-of-Hospital Cardiac Arrest as Middle or Younger Aged?

Circulation ◽

10.1161/circ.138.suppl_2.240 ◽

2018 ◽

Vol 138 (Suppl_2) ◽

Author(s):

Hiroyuki Hanada ◽

Yoshio Tahara ◽

Satoshi Yasuda ◽

Teruo Noguchi ◽

Kunihiro Nishimura ◽

...

Keyword(s):

Cardiac Arrest ◽

Total Population ◽

Cerebral Performance Category ◽

Population Based ◽

Aged Patients ◽

Performance Category ◽

Aging Society ◽

Shockable Rhythm ◽

Activity Of Daily Life ◽

Hospital Cardiac Arrest

Backgrounds: The population of elderly people aged 65 years or older in 2014 is 33 million, and the aging rate (proportion of the total population) is 26.0% in Japan. Victims facing to out of hospital cardiac arrest (OHCA) are getting older and older. Emergency medical system (EMS) in Japan must do the same resuscitation protocols once called to the patient with OHCA, even when he or she is very old and activity of daily life is very low. We need to clarify whether same resuscitation protocols are required to very highly aged patients with OHCA or not. Methods and Results: From January 2005 through December 2014, we conducted a prospective, population-based, observational study involving the consecutive patients across Japan who had OHCA (n= 1,299,784). The percentage of patients with OHCA aged more than 80 years old was increasing from 37.1% in 2005 to 47.8% in 2014 by 1% each year. Survival at one month after OHCA with cerebral performance category (CPC) scale 1 or 2 were 4,368 out of total 318,590 OHCA (1.4%) in 80’s, 1043 out of 126,546 (0.8%) in 90’s, and 35 out of 5,544 (0.6%) in aged more than 100 (from 100 to 114). Survival at one month after OHCA with CPC scale 1 or 2 was 11.084 out of 234,366 (4.7%) in 50- 60’s. Patients with witnessed OHCA with shockable rhythm and by-stander CPR survived to CPC 1 or 2 at one month after OHCA were 8.0% in 80’s, 4.1% in 90’s, 0 in aged more than 100, and 22.2% in 50-60’s respectably. Conclusion: Number of survivors with CPC 1 or 2 were very few in patients with OHCA aged more than 80 years old, but still existed. Although the same resuscitation protocols are needed for highly aged victims with OHCA, another system which arrow EMS to stop resuscitation should be established in the highly aging society.

Download Full-text

Targeted temperature management: beneficial or not?

Journal of Paramedic Practice ◽

10.12968/jpar.2020.12.6.235 ◽

2020 ◽

Vol 12 (6) ◽

pp. 235-241 ◽

Cited By ~ 1

Author(s):

Kelley Ricketts ◽

Bridie Jones

Keyword(s):

Cardiac Arrest ◽

Therapeutic Hypothermia ◽

Survival Rates ◽

Treatment Strategies ◽

Targeted Temperature Management ◽

Prehospital Setting ◽

Neurological Recovery ◽

Temperature Management ◽

Potential Treatment ◽

Potential Benefits

Targeted temperature management (TTM), formerly known as therapeutic hypothermia, has been shown to improve survival and neurological recovery in patients following cardiac arrest. Following successes with its in-hospital implementation, many guidelines now advocate its use in the prehospital domain for all out-of-hospital cardiac arrests (OHCAs). It has been suggested that patients presenting with shockable rhythms who receive early initiation of TTM have better survival rates. TTM can be initiated in the prehospital setting with minimal equipment. This article discusses and explores the potential benefits and pitfalls of targeted temperature management when initiated in the prehospital environment. Particular focus is given to potential treatment strategies that can be used by paramedics to adequately manage OHCA. It is proposed that prehospital TTM is advantageous to all patients in cardiac arrest and can be efficacious in a variety of prehospital environments, with its implementation requiring only minimal equipment.

Download Full-text

Prediction of regaining consciousness despite an early epileptiform EEG after cardiac arrest

Neurology ◽

10.1212/wnl.0000000000009283 ◽

2020 ◽

Vol 94 (16) ◽

pp. e1675-e1683 ◽

Cited By ~ 3

Author(s):

Giuseppina Barbella ◽

Jong Woo Lee ◽

Vincent Alvarez ◽

Jan Novy ◽

Mauro Oddo ◽

...

Keyword(s):

Cardiac Arrest ◽

Operating Characteristic ◽

Neuronal Damage ◽

Cerebral Performance Category ◽

Neuron Specific Enolase ◽

Area Under The Curve ◽

Performance Category ◽

Receiver Operating Characteristic Curves ◽

Normal Background ◽

Serum Neuron Specific Enolase

ObjectiveAfter cardiac arrest (CA), epileptiform EEG, occurring in about 1/3 of patients, often but not invariably heralds poor prognosis. We tested the hypothesis that a combination of specific EEG features identifies patients who may regain consciousness despite early epileptiform patterns.MethodsWe retrospectively analyzed a registry of comatose patients post-CA (2 Swiss centers), including those with epileptiform EEG. Background and epileptiform features in EEGs 12–36 hours or 36–72 hours from CA were scored according to the American Clinical Neurophysiology Society nomenclature. Best Cerebral Performance Category (CPC) score within 3 months (CPC 1–3 vs 4–5) was the primary outcome. Significant EEG variables were combined in a score assessed with receiver operating characteristic curves, and independently validated in a US cohort; its correlation with serum neuron-specific enolase (NSE) was also tested.ResultsOf 488 patients, 107 (21.9%) had epileptiform EEG <72 hours; 18 (17%) reached CPC 1–3. EEG 12–36 hours background continuity ≥50%, absence of epileptiform abnormalities (p < 0.00001 each), 12–36 and 36–72 hours reactivity (p < 0.0001 each), 36–72 hours normal background amplitude (p = 0.0004), and stimulus-induced discharges (p = 0.0001) correlated with favorable outcome. The combined 6-point score cutoff ≥2 was 100% sensitive (95% confidence interval [CI], 78%–100%) and 70% specific (95% CI, 59%–80%) for CPC 1–3 (area under the curve [AUC], 0.98; 95% CI, 0.94–1.00). Increasing score correlated with NSE (ρ = −0.46, p = 0.0001). In the validation cohort (41 patients), the score was 100% sensitive (95% CI, 60%–100%) and 88% specific (95% CI, 73%–97%) for CPC 1–3 (AUC, 0.96; 95% CI, 0.91–1.00).ConclusionPrognostic value of early epileptiform EEG after CA can be estimated combining timing, continuity, reactivity, and amplitude features in a score that correlates with neuronal damage.

Download Full-text