Abstract 10: Early Neuroprognostication After Refractory VF/VT Cardiac Arrest Requiring ECPR

Background: Extracorporeal cardiopulmonary resuscitation (ECPR) can improve survival for refractory ventricular fibrillation (VF) cardiac arrest. Early prognostication will be critical to focus this resource-intensive care to patients likely to benefit. Objectives: The aim of this study is to examine the efficacy of current neuroprognostication tools early in the setting of ECPR for refractory VF. Methods: Consecutive patients transported for the University of Minnesota ECPR program and surviving to hospital admission between December 2015 and May 2019 were assessed. All patients received neurologic assessment with head CT, continuous EEG, cerebral near-infrared spectroscopy (NIRS), biomarkers including S100B and neuron specific enolase (NSE), and neurologic exam. All patients were considered viable unless they developed refractory shock, devastating brain injury, or family requested cessation of efforts. For this analysis, patients were divided into two groups: 1) neurologically favorable survival (CPC 1-2) and 2) those who died or had CPC 3-4. Data from the first 24 hours of hospital admission were used. Results: Of 168 patients, 130 patients survived to hospital admission. Of these, 42% (54/130) survived neurologically favorable. Abnormalities on admission head CT were predictive of poor outcomes; cerebral edema was 100% specific and 30% sensitive for poor outcomes while anoxic injury provided 98% specificity and 39% sensitivity. Admission NSE levels greater than three times the upper limit of normal were predictive with 98% specificity and 26% sensitivity for poor outcome. Admission S100B was highly variable failing to discriminate patient outcome. Absence of brainstem reflexes at 24 hours had 100% specificity and 32% sensitivity. An isoelectric EEG at 24 hours had 100% specificity and 20% sensitivity. NIRS did not predict poor outcomes. When combined, ≥ 1 of the following: anoxic injury on CT, edema on CT, NSE, absence of brainstem reflexes, isoelectric EEG have a specificity of 96% and sensitivity of 67% for poor outcome. Conclusions: Neuroprognostication after 24 hours of hospital admission may be possible in the refractory VF population requiring ECPR. High specificity is possible but sensitivity is limited. Further study is needed.

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Comparison of Prognostic Performance between Neuron-Specific Enolase and S100 Calcium-Binding Protein B Obtained from the Cerebrospinal Fluid of Out-Of-Hospital Cardiac Arrest Survivors Who Underwent Targeted Temperature Management

Journal of Clinical Medicine ◽

10.3390/jcm10071531 ◽

2021 ◽

Vol 10 (7) ◽

pp. 1531

Author(s):

Changshin Kang ◽

Wonjoon Jeong ◽

Jung Soo Park ◽

Yeonho You ◽

Jin Hong Min ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Cardiac Arrest ◽

Calcium Binding ◽

Neuron Specific Enolase ◽

Poor Outcome ◽

The Poor ◽

S100 Calcium Binding Protein ◽

Poor Outcome Group ◽

Outcome Group ◽

Hospital Cardiac Arrest

We compared the prognostic performances of serum neuron-specific enolase (sNSE), cerebrospinal fluid (CSF) NSE (cNSE), and CSF S100 calcium-binding protein B (cS100B) in out-of-hospital cardiac arrest (OHCA) survivors. This prospective observational study enrolled 45 patients. All samples were obtained immediately and at 24 h intervals until 72 h after the return of spontaneous circulation. The inter- and intragroup differences in biomarker levels, categorized by 3 month neurological outcome, were analyzed. The prognostic performances were evaluated with receiver operating characteristic curves. Twenty-two patients (48.9%) showed poor outcome. At all-time points, sNSE, cNSE, and cS100B were significantly higher in the poor outcome group than in the good outcome group. cNSE and cS100B significantly increased over time (baseline vs. 24, 48, and 72 h) in the poor outcome group than in the good outcome group. sNSE at 24, 48, and 72 h showed significantly lower sensitivity than cNSE or cS100B. The sensitivities associated with 0 false-positive rate (FPR) for cNSE and cS100B were 66.6% vs. 45.5% at baseline, 80.0% vs. 80.0% at 24 h, 84.2% vs. 94.7% at 48 h, and 88.2% (FPR, 5.0%) vs. 94.1% at 72 h. High cNSE and cS100B are strong predictors of poor neurological outcome in OHCA survivors. Multicenter prospective studies may determine the generalizability of these results.

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Out of hospital cardiac arrest in Western Sydney - an analysis of outcomes and estimation of future eCPR eligibility

10.21203/rs.3.rs-1083706/v1 ◽

2021 ◽

Author(s):

Pramod Chandru ◽

Tatum Priyambada Mitra ◽

Nitesh Dutt Dhanekula ◽

Mark Dennis ◽

Adam Eslick ◽

...

Keyword(s):

Cardiac Arrest ◽

Life Support ◽

Rescue Therapy ◽

A Priori ◽

Advanced Life Support ◽

Spontaneous Circulation ◽

Eligibility Criteria ◽

Extracorporeal Cardiopulmonary Resuscitation ◽

Poor Outcomes ◽

Hospital Cardiac Arrest

Abstract Background Refractory out of hospital cardiac arrest (OHCA) is associated with extremely poor outcomes. However, in selected patients extracorporeal cardiopulmonary resuscitation (eCPR) may be an effective rescue therapy, allowing time treat reversible causes. The primary goal was to estimate the potential future caseload of eCPR at historically 'low-volume' extracorporeal membrane oxygenation (ECMO) centres. Methods A 3-year observational study of OHCA presenting to the Emergency Department (ED of an urban referral centre without historical protocolised use of eCPR. Demographics and standard Utstein outcomes are reported. Further, an a priori analysis of each case for potential eCPR eligibility was conducted. A current eCPR selection criteria (from the 2-CHEER study) was used to determine eligibly. Results In the study window 248 eligible cardiac arrest cases were included in the OHCA registry. 30-day survival was 23.4% (n=58). The mean age of survivors was 55.4 years. 17 (6.8%) cases were deemed true refractory arrests and fulfilled the 2-CHEER eligibility criteria. The majority of these cases presented within “office hours” and no case obtained a return of spontaneous circulation standard advanced life support. Conclusions In this contemporary OHCA registry a significant number of refractory cases were deemed potential eCPR candidates reflecting a need for future interdisciplinary work to support delivery of this therapy.

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Abstract 3752: Performance Of Color ADC Maps As A Prognostic Tool In Comatose Post-cardiac Arrest Patients

Stroke ◽

10.1161/str.43.suppl_1.a3752 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Michael Mlynash ◽

Jonathan T Kleinman ◽

Anna Finley Caulfield ◽

Chitra Ventkatasubramanian ◽

Marion Buckwalter ◽

...

Keyword(s):

Cardiac Arrest ◽

Therapeutic Hypothermia ◽

Predictive Performance ◽

Post Processing ◽

Poor Outcome ◽

Apparent Diffusion ◽

Predicting Outcome ◽

Poor Outcomes ◽

Predictive Rate ◽

A Prospective Study

Background: Predicting outcome for comatose post-cardiac arrest survivors is challenging and compounded by the use of therapeutic hypothermia and sedative agents in recent years. Previous studies suggest that brain abnormalities on MRI are predictive for poor outcome. MRI based predictive factors are attractive because they are not affected by drugs or metabolic derangements; however, most of the methods proposed require image post-processing with specialized software. We assessed the prognostic value of color apparent diffusion coefficient (ADC) maps in a prospective study. Methods: Consecutive patients who remained comatose after cardiac arrest were prospectively enrolled. Color ADC maps were created by assigning computed ADC values to 8 colors of spectrum ranging from red to blue ( Figure ). The color ADC maps were not available to the clinical teams caring for the patient. Two raters (a neurocritical care/stroke neurologist and a medical student) independently and blinded reviewed the color ADC maps and predicted 3 month outcome as poor (Glasgow Outcome Scale (GOS) 1 or 2), impaired (GOS=3) or good (GOS of 4 or 5). Both raters were “trained” by viewing 4 examples of patients with good, impaired and poor outcomes. A 3 month GOS of 3-5 was considered a favorable outcome. The agreement between raters and the predictive performance of the color ADC maps were assessed. Results: 112 color ADC maps of 94 patients (56% with poor, 12% with impaired, and 32% with good outcome) were reviewed: age 59±15 years, 36% females, 69% underwent therapeutic hypothermia, median (IQR) arrest duration 20min (14-30), and time between the arrest and MRI 82hours (60-141). Kappa with quadratic weighting for agreement on predicting all 3 levels of outcomes was 0.74, while kappa for favorable vs. unfavorable outcome was 0.76. For the two reviewers, the sensitivity for predicting poor outcome was 0.85 (95%CI 0.73-0.92) and 0.78 (0.66-0.87), the specificity 0.81(0.66-0.90) and 0.74(0.59-0.86), and the true positive predictive rate 86% (74-93%) and 81% (69-89%), respectively. After excluding early (≤24 hours) and late (>120 hours) scans (ADC changes are time dependent and most apparent after day 1 and before day 6), the specificity improved to 0.87 (0.68-0.96) and 0.77 (0.57-0.89), respectively. Conclusion: MRI color ADC maps hold promise as a useful and easy to interpret adjunct for predicting outcome of comatose post-cardiac arrest patients in the first few days after the arrest. Since these maps do not require post-processing and can be created in real-time, they can easily be implemented in the clinical setting.

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Prognostic value of diffusion-weighted MRI for post-cardiac arrest coma

Neurology ◽

10.1212/wnl.0000000000009289 ◽

2020 ◽

Vol 94 (16) ◽

pp. e1684-e1692 ◽

Cited By ~ 4

Author(s):

Karen G. Hirsch ◽

Nancy Fischbein ◽

Michael Mlynash ◽

Stephanie Kemp ◽

Roland Bammer ◽

...

Keyword(s):

Cardiac Arrest ◽

Brain Tissue ◽

Characteristic Curve ◽

Area Under The Curve ◽

Poor Outcome ◽

Diffusion Weighted ◽

Blinded Study ◽

Apparent Diffusion ◽

Adc Values ◽

Poor Outcomes

ObjectiveTo validate quantitative diffusion-weighted imaging (DWI) MRI thresholds that correlate with poor outcome in comatose cardiac arrest survivors, we conducted a clinician-blinded study and prospectively obtained MRIs from comatose patients after cardiac arrest.MethodsConsecutive comatose post-cardiac arrest adult patients were prospectively enrolled. MRIs obtained within 7 days after arrest were evaluated. The clinical team was blinded to the DWI MRI results and followed a prescribed prognostication algorithm. Apparent diffusion coefficient (ADC) values and thresholds differentiating good and poor outcome were analyzed. Poor outcome was defined as a Glasgow Outcome Scale score of ≤2 at 6 months after arrest.ResultsNinety-seven patients were included, and 75 patients (77%) had MRIs. In 51 patients with MRI completed by postarrest day 7, the prespecified threshold of >10% of brain tissue with an ADC <650 ×10−6 mm2/s was highly predictive for poor outcome with a sensitivity of 0.63 (95% confidence interval [CI] 0.42–0.80), a specificity of 0.96 (95% CI 0.77–0.998), and a positive predictive value (PPV) of 0.94 (95% CI 0.71–0.997). The mean whole-brain ADC was higher among patients with good outcomes. Receiver operating characteristic curve analysis showed that ADC <650 ×10−6 mm2/s had an area under the curve of 0.79 (95% CI 0.65–0.93, p < 0.001). Quantitative DWI MRI data improved prognostication of both good and poor outcomes.ConclusionsThis prospective, clinician-blinded study validates previous research showing that an ADC <650 ×10−6 mm2/s in >10% of brain tissue in an MRI obtained by postarrest day 7 is highly specific for poor outcome in comatose patients after cardiac arrest.

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Cost-effectiveness analysis of multimodal prognostication in cardiac arrest with EEG monitoring

Neurology ◽

10.1212/wnl.0000000000009916 ◽

2020 ◽

Vol 95 (5) ◽

pp. e563-e575 ◽

Cited By ~ 1

Author(s):

Edilberto Amorim ◽

Shirley S. Mo ◽

Sebastian Palacios ◽

Mohammad M. Ghassemi ◽

Wei-Hung Weng ◽

...

Keyword(s):

Cardiac Arrest ◽

Cost Effectiveness ◽

Cost Effective ◽

Eeg Monitoring ◽

Monitoring Cost ◽

Poor Outcome ◽

Continuous Eeg ◽

Continuous Eeg Monitoring ◽

Increased Sensitivity ◽

The Cost

ObjectiveTo determine cost-effectiveness parameters for EEG monitoring in cardiac arrest prognostication.MethodsWe conducted a cost-effectiveness analysis to estimate the cost per quality-adjusted life-year (QALY) gained by adding continuous EEG monitoring to standard cardiac arrest prognostication using the American Academy of Neurology Practice Parameter (AANPP) decision algorithm: neurologic examination, somatosensory evoked potentials, and neuron-specific enolase. We explored lifetime cost-effectiveness in a closed system that incorporates revenue back into the medical system (return) from payers who survive a cardiac arrest with good outcome and contribute to the health system during the remaining years of life. Good outcome was defined as a Cerebral Performance Category (CPC) score of 1–2 and poor outcome as CPC of 3–5.ResultsAn improvement in specificity for poor outcome prediction of 4.2% would be sufficient to make continuous EEG monitoring cost-effective (baseline AANPP specificity = 83.9%). In sensitivity analysis, the effect of increased sensitivity on the cost-effectiveness of EEG depends on the utility (u) assigned to a poor outcome. For patients who regard surviving with a poor outcome (CPC 3–4) worse than death (u = −0.34), an increased sensitivity for poor outcome prediction of 13.8% would make AANPP + EEG monitoring cost-effective (baseline AANPP sensitivity = 76.3%). In the closed system, an improvement in sensitivity of 1.8% together with an improvement in specificity of 3% was sufficient to make AANPP + EEG monitoring cost-effective, assuming lifetime return of 50% (USD $70,687).ConclusionIncorporating continuous EEG monitoring into cardiac arrest prognostication is cost-effective if relatively small improvements in sensitivity and specificity are achieved.

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Predictive Modeling of Poor Outcome in Severe COVID-19: A Single-Center Observational Study Based on Clinical, Cytokine and Laboratory Profiles

Journal of Clinical Medicine ◽

10.3390/jcm10225431 ◽

2021 ◽

Vol 10 (22) ◽

pp. 5431

Author(s):

Óscar Gorgojo-Galindo ◽

Marta Martín-Fernández ◽

María Jesús Peñarrubia-Ponce ◽

Francisco Javier Álvarez ◽

Christian Ortega-Loubon ◽

...

Keyword(s):

Hospital Admission ◽

Predictive Model ◽

Blood Group ◽

Clinical Laboratory ◽

Area Under The Curve ◽

Abo Blood Group ◽

Poor Outcome ◽

Emergency Room Admission ◽

Poor Outcomes

Pneumonia is the main cause of hospital admission in COVID-19 patients. We aimed to perform an extensive characterization of clinical, laboratory, and cytokine profiles in order to identify poor outcomes in COVID-19 patients. Methods: A prospective and consecutive study involving 108 COVID-19 patients was conducted between March and April 2020 at Hospital Clínico Universitario de Valladolid (Spain). Plasma samples from each patient were collected after emergency room admission. Forty-five serum cytokines were measured in duplicate, and clinical data were analyzed using SPPS version 25.0. Results: A multivariate predictive model showed high hepatocyte growth factor (HGF) plasma levels as the only cytokine related to intubation or death risk at hospital admission (OR = 7.38, 95%CI—(1.28–42.4), p = 0.025). There were no comorbidities included in the model except for the ABO blood group, in which the O blood group was associated with a 14-fold lower risk of a poor outcome. Other clinical variables were also included in the predictive model. The predictive model was internally validated by the receiver operating characteristic (ROC) curve with an area under the curve (AUC) of 0.94, a sensitivity of 91.7% and a specificity of 95%. The use of a bootstrapping method confirmed these results. Conclusions: A simple, robust, and quick predictive model, based on the ABO blood group, four common laboratory values, and one specific cytokine (HGF), could be used in order to predict poor outcomes in COVID-19 patients.

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Abstract 375: Utility of Routine Early Head Computed Tomography Following Non-Traumatic Out-Of Hospital Cardiac Arrest

Circulation ◽

10.1161/circ.140.suppl_2.375 ◽

2019 ◽

Vol 140 (Suppl_2) ◽

Author(s):

Bradley J Petek ◽

David E Hamilton ◽

Lindsay G Panah ◽

Philip E Dormish ◽

Sean R Mendez ◽

...

Keyword(s):

Computed Tomography ◽

Cardiac Arrest ◽

Clinical Utility ◽

Spontaneous Circulation ◽

Head Ct ◽

Shockable Rhythm ◽

Baseline Characteristics ◽

Poor Outcomes ◽

Head Computed Tomography ◽

Hospital Cardiac Arrest

Introduction: Head computed tomography (CT) is frequently performed in survivors of out-of-hospital cardiac arrest (OHCA). However, the clinical utility of routine, early head CT in these patients is not well understood. We sought to characterize the associations between findings on early head CT with presenting characteristics and outcomes in survivors of OHCA. Hypothesis: Presence of early intracranial swelling is associated with poor outcomes. Methods: This is a retrospective analysis from a multicenter cohort of 432 patients with non-traumatic OHCA between 2/1/17 through 4/1/19. Patients were included if they underwent head CT <24 hrs after return of spontaneous circulation. Head CT findings were based on reads performed by local radiologists. Intracranial swelling was defined as loss of gray-white matter differentiation, sulcal effacement, and/or cerebral edema. Underlying cause of OHCA was adjudicated by trained physicians. Baseline characteristics and outcomes were compared between those with and without intracranial swelling. Result: Early head CT (<24 hrs) was performed in 378 (87.5%) patients with OHCA. Intracranial swelling was present in 97 (25.7%) patients with early head CT, and 14 (3.7%) had evidence of intracranial hemorrhage (ICH, Table). Of the patients presenting with ICH, 3/14 (21.4%) had shockable rhythms, 7/14 (50%) had subarachnoid hemorrhage, and ICH was the adjudicated cause of arrest in 10/14 (71.4%) patients. Patients with intracranial swelling were younger, less likely to have presented with a shockable rhythm, cardiac etiology, and witnessed OHCA. They were more likely to have a suppressed EEG, anoxia on MRI, and were less likely to survive to hospital discharge. Conclusions: In survivors of non-traumatic OHCA, routine, early (<24 hrs) head CT identified ICH in 3.7% of patients, and ICH was the adjudicated cause of arrest in 2.6% of patients. Intracranial swelling was present in more than 1/4 of patients, and associated with poor outcomes.

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The Surgical Safety Huddle: Novel Quality Improvement Patient Safety Initiative

Patient Safety ◽

10.33940/data/2021.6.5 ◽

2021 ◽

pp. 66-77

Author(s):

Carolyn Cullinane ◽

Catharina Healy ◽

Mary Doyle ◽

Helen McCarthy ◽

Claire Costigan ◽

...

Keyword(s):

Cardiac Arrest ◽

Quality Improvement ◽

Early Recognition ◽

University Teaching ◽

Early Warning Score ◽

Surgical Safety ◽

Poor Outcome ◽

Surgical Ward ◽

Deteriorating Patient ◽

Poor Outcomes

Background: Acutely deteriorating patients are entitled to the best possible care which includes early recognition and timely appropriate intervention to reduce adverse events, unnecessary admissions to intensive care and/or cardiac arrest. Aim: To reduce the number of poor outcomes for surgical patients with a National Early Warning Score (NEWS) score ≥7 in our institution by 50%. A poor outcome was defined as: 1. Cardiac arrest 2. NEWS >7 not improving after 72 hours 3. Transfer to ICU >6 hours Methods: Surgical inpatients from a variety of surgical specialties (general, vascular, breast, colorectal, hepatobiliary, and plastic surgery) in a large university teaching hospital were included. Quality improvement tools were used to generate regular dialogue with the clinical teams, resulting in the concept of the surgical safety huddle being proposed. Deteriorating patients were highlighted at the daily huddle and a plan of early intervention was implemented. An incremental approach with continuous PDSA [Plan- Do-Study-Act] cycles and subsequent feedback was adopted on the surgical ward to develop the huddle. Poor patient outcomes were analysed prospectively via chart reviews. Results: Prior to the introduction of the “surgical huddle” 110 patients with NEWS >7 were audited. Twenty-eight of these patients had a poor outcome at 72 hours (25%). Following the introduction of the surgical huddle supported by the deteriorating patient team, 64 patients with NEWS >7 were reviewed. Three of these patients had a poor outcome at 72 hours (4.7%). The introduction of the surgical huddle increased the interval between cardiac arrests more than sixfold on the surgical ward. Discussion: The introduction of the surgical safety huddle supported by the deteriorating patient response team reduced the number of cardiac arrests and poor outcomes in a surgical inpatient cohort.

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Neuron-Specific Enolase Predicts Poor Outcome After Cardiac Arrest and Targeted Temperature Management

Critical Care Medicine ◽

10.1097/ccm.0000000000002335 ◽

2017 ◽

Vol 45 (7) ◽

pp. 1145-1151 ◽

Cited By ~ 35

Author(s):

Kaspar Josche Streitberger ◽

Christoph Leithner ◽

Michael Wattenberg ◽

Peter. H. Tonner ◽

Julia Hasslacher ◽

...

Keyword(s):

Cardiac Arrest ◽

Neuron Specific Enolase ◽

Targeted Temperature Management ◽

Temperature Management ◽

Poor Outcome

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Standards for Studies of Neurological Prognostication in Comatose Survivors of Cardiac Arrest: A Scientific Statement From the American Heart Association

Circulation ◽

10.1161/cir.0000000000000702 ◽

2019 ◽

Vol 140 (9) ◽

Cited By ~ 45

Author(s):

Romergryko G. Geocadin ◽

Clifton W. Callaway ◽

Ericka L. Fink ◽

Eyal Golan ◽

David M. Greer ◽

...

Keyword(s):

Cardiac Arrest ◽

Brain Injury ◽

American Heart Association ◽

American Heart ◽

Heart Association ◽

Poor Outcome ◽

Writing Group ◽

Life Sustaining Treatment ◽

Poor Outcomes

Significant improvements have been achieved in cardiac arrest resuscitation and postarrest resuscitation care, but mortality remains high. Most of the poor outcomes and deaths of cardiac arrest survivors have been attributed to widespread brain injury. This brain injury, commonly manifested as a comatose state, is a marker of poor outcome and a major basis for unfavorable neurological prognostication. Accurate prognostication is important to avoid pursuing futile treatments when poor outcome is inevitable but also to avoid an inappropriate withdrawal of life-sustaining treatment in patients who may otherwise have a chance of achieving meaningful neurological recovery. Inaccurate neurological prognostication leading to withdrawal of life-sustaining treatment and deaths may significantly bias clinical studies, leading to failure in detecting the true study outcomes. The American Heart Association Emergency Cardiovascular Care Science Subcommittee organized a writing group composed of adult and pediatric experts from neurology, cardiology, emergency medicine, intensive care medicine, and nursing to review existing neurological prognostication studies, the practice of neurological prognostication, and withdrawal of life-sustaining treatment. The writing group determined that the overall quality of existing neurological prognostication studies is low. As a consequence, the degree of confidence in the predictors and the subsequent outcomes is also low. Therefore, the writing group suggests that neurological prognostication parameters need to be approached as index tests based on relevant neurological functions that are directly related to the functional outcome and contribute to the quality of life of cardiac arrest survivors. Suggestions to improve the quality of adult and pediatric neurological prognostication studies are provided.

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