Abstract 11617: Personalizing Outcomes After Child Cardiac Arrest (POCCA): A Preliminary Biomarker Report

Circulation ◽  
2021 ◽  
Vol 144 (Suppl_2) ◽  
Author(s):  
Ericka L Fink ◽  
Patrick M Kochanek ◽  
Ashok Panigrahy ◽  
Sue R Beers ◽  
Rachel P Berger ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Brain Injury ◽  
Cerebral Performance Category ◽  
Pediatric Intensive Care ◽  
Early Brain Injury ◽  
Unfavorable Outcome ◽  
Neurofilament Light ◽  
Multicenter Observational Study ◽  
Child Centered ◽  
One Year

Blood-based brain injury biomarkers show promise to prognosticate outcome for children resuscitated from cardiac arrest. The objective of this multicenter, observational study was to validate promising biomarkers to accurately prognosticate outcome at 1 year. Early brain injury biomarkers will be associated with outcome at one year for children with cardiac arrest. Fourteen centers in the US enrolled children aged < 18 years with in- or out-of-hospital cardiac arrest and pediatric intensive care unit admission if pre-cardiac arrest Pediatric Cerebral Performance Category score was 1-3. Glial fibrillary acidic protein (GFAP), ubiquitin carboxyl-terminal esterase L1 (UCHL1), neurofilament light (NfL), and Tau protein concentrations were measured in samples drawn post-arrest day 1 using Quanterix Simoa 4-Plex assay. The primary outcome was unfavorable outcome at one year (Vineland Adaptive Behavioral Scale < 70). Of 164 children enrolled, 120 children had evaluable data (n=50 with unfavorable outcome). Children were median (interquartile range) 1 (0-8.5) years of age, 41% female, and 60% had asphyxia etiology. Of children with unfavorable outcome, 93% had unwitnessed arrests and 43 died. While all 4 day 1 biomarkers were increased in children with unfavorable vs. favorable outcome at 1-year post-arrest, NfL had the best univariate area under the receiver operator curve to predict 1 year outcome at 0.731. In a multivariate logistic regression, NfL concentration trended toward significance on day 1 and was associated with unfavorable outcome at 1-year on days 2 and 3 (day 1: Odds Ratio [95% Confidence Interval] 1.004 [1.000-1.008], p=.062; day 2: 1.005 [1.002-1.008], p=.003, and day 3: 1.002 [1.001-1.004], p=.003, respectively). UCHL1 was associated with outcome on days 2: 1.005 [1.002-1.009], p=.003 and 3: 1.001 [1.000-1.002], p=.019) and Tau trended toward association with outcome on days 2: 1.003 [1.000-1.005], p=.08) and 3: 1.001 [1.000-1.002], p=.077. Brain injury biomarkers predict unfavorable outcome post-pediatric cardiac arrest. Accuracy of biomarkers alone and together with other prognostication tools should be evaluated to predict long term child centered outcomes post-cardiac arrest.

Abstract 15636: Percutaneous Intervention (PCI) Improves Outcomes in Out of Hospital Cardiac Arrest (OHCA) Patients Receiving Coronary Angiography

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Michael G Scutella ◽  
Francis Pike ◽  
James Fitzgibbon ◽  
Lindsey Kowalski ◽  
Clifton Callaway ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Brain Injury ◽  
Coronary Angiography ◽  
Treatment Effect ◽  
Cerebral Performance Category ◽  
Early Brain Injury ◽  
Average Treatment Effect ◽  
Severe Brain Injury ◽  
Acute Coronary Occlusion ◽  
Improved Outcomes

Introduction: Acute coronary occlusion is common after OHCA. PCI may reduce subsequent cardiac death and improve cerebral perfusion thus improving outcomes. Recent studies suggest these benefits may be attenuated in patients with more severe brain injury. Hypothesis: PCI will more strongly associate with improved outcome than just coronary angiography (CA) after OHCA with loss of association in those with greatest brain injury. Methods: In subjects with OHCA with unclear arrest etiology, we examined the association between CA (with or without PCI) and PCI with 1) hospital survival; 2) discharge cerebral performance category (CPC); 3) discharge modified Rankin scale (mRS); 4) discharge destination. All outcomes were dichotomized and associations adjusted for propensity to perform 1) CA and 2) PCI based on associated pre-CA factors. This analysis was repeated after stratifying the cohort based on early brain injury as measured by Pittsburgh Cardiac Arrest Category (PCAC) dichotomized as PCAC 4 (severe injury) and PCAC 1-3 (mild to moderate). Results: Early (<24 h) CA was performed in 284/600 (47%) OHCA and PCI in 151/284 CA (53%). In unadjusted analysis, performance of both CA and PCI was strongly associated with improved outcomes (all p < 0.0001). Adjustment based on propensity to perform CA reduced the average treatment effect (ATE) to a non-significant 7-8% trend whereas adjustment based on propensity to perform PCI demonstrated a highly significant ATE of ~14-15% (p < 0.01) whereas those with less severe brain injury had trends to benefit with CA, which became significant (most p<0.01) with PCI. Conclusion: Early selection for CA of OHCA survivors likely to require PCI without severe brain injury is associated with substantial outcome benefits. The observed treatment effect is significantly reduced in patients with early signs of significant brain injury.

scholarly journals Quantitative EEG predicts outcomes in children after cardiac arrest

Neurology ◽  
2019 ◽  
Vol 92 (20) ◽  
pp. e2329-e2338 ◽  
Author(s):  
Seungha Lee ◽  
Xuelong Zhao ◽  
Kathryn A. Davis ◽  
Alexis A. Topjian ◽  
Brian Litt ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Predictive Value ◽  
Cross Validation ◽  
Characteristic Curve ◽  
Cerebral Performance Category ◽  
Pediatric Intensive Care ◽  
Quantitative Eeg ◽  
Line Length ◽  
Neurologic Outcomes ◽  
Fold Cross Validation

ObjectiveTo determine whether quantitative EEG (QEEG) features predict neurologic outcomes in children after cardiac arrest.MethodsWe performed a single-center prospective observational study of 87 consecutive children resuscitated and admitted to the pediatric intensive care unit after cardiac arrest. Full-array conventional EEG data were obtained as part of clinical management. We computed 8 QEEG features from 5-minute epochs every hour after return of circulation. We developed predictive models utilizing random forest classifiers trained on patient age and 8 QEEG features to predict outcome. The features included SD of each EEG channel, normalized band power in alpha, beta, theta, delta, and gamma wave frequencies, line length, and regularity function scores. We measured outcomes using Pediatric Cerebral Performance Category (PCPC) scores. We evaluated the models using 5-fold cross-validation and 1,000 bootstrap samples.ResultsThe best performing model had a 5-fold cross-validation accuracy of 0.8 (0.88 area under the receiver operating characteristic curve). It had a positive predictive value of 0.79 and a sensitivity of 0.84 in predicting patients with favorable outcomes (PCPC score of 1–3). It had a negative predictive value of 0.8 and a specificity of 0.75 in predicting patients with unfavorable outcomes (PCPC score of 4–6). The model also identified the relative importance of each feature. Analyses using only frontal electrodes did not differ in prediction performance compared to analyses using all electrodes.ConclusionsQEEG features can standardize EEG interpretation and predict neurologic outcomes in children after cardiac arrest.

scholarly journals Functional Outcomes: One Year after a Cardiac Arrest

2015 ◽  
Vol 2015 ◽  
pp. 1-8 ◽  
Author(s):  
Ketki D. Raina ◽  
Jon C. Rittenberger ◽  
Margo B. Holm ◽  
Clifton W. Callaway
Keyword(s):  
Quality Of Life ◽  
Cardiac Arrest ◽  
Time Course ◽  
Depressive Symptomatology ◽  
Cerebral Performance Category ◽  
Activity Limitations ◽  
Complete Representation ◽  
Participation Restrictions ◽  
One Year

Objective. The study aim was to characterize the time-course of recovery in impairments, activity limitations, participation restrictions, disability, and quality of life during the first year after cardiac arrest. Secondarily, the study described the associations between the instruments used to measure each of these domains.Methods. Measures of global disability (Cerebral Performance Category, CPC, Modified Rankin Scale, mRS), quality of life, activity limitations, participation restrictions, and affective and cognitive impairments were administered to 29 participants 1, 6, and 12 months after cardiac arrest.Results. Global measures of disability indicated recovery between one month and one year after cardiac arrest (mean CPC: 2.1 versus 1.69,  P<0.05; mean mRS: 2.55 versus 1.83,P<0.05). While global measures of disability were moderately associated with participation, they were poorly associated with other measures. The cohort endorsed depressive symptomatology throughout the year but did not have detectable cognitive impairment.Conclusions. Recovery from cardiac arrest is multifaceted and recovery continues for months depending upon the measures being used. Measures of global disability, reintegration into the community, and quality of life yield different information. Future clinical trials should include a combination of measures to yield the most complete representation of recovery after cardiac arrest.

scholarly journals Clinical Trials in Cardiac Arrest and Subarachnoid Hemorrhage: Lessons from the Past and Ideas for the Future

2013 ◽  
Vol 2013 ◽  
pp. 1-42
Author(s):  
Jennifer A. Frontera
Keyword(s):  
Clinical Trials ◽  
Cardiac Arrest ◽  
Subarachnoid Hemorrhage ◽  
Brain Injury ◽  
Randomized Clinical Trials ◽  
Early Brain Injury ◽  
Aneurysm Rupture ◽  
Neurological Outcomes ◽  
Injury Research ◽  
The Brain

Introduction. Elevated intracranial pressure that occurs at the time of cerebral aneurysm rupture can lead to inadequate cerebral blood flow, which may mimic the brain injury cascade that occurs after cardiac arrest. Insights from clinical trials in cardiac arrest may provide direction for future early brain injury research after subarachnoid hemorrhage (SAH).Methods. A search of PubMed from 1980 to 2012 and clinicaltrials.gov was conducted to identify published and ongoing randomized clinical trials in aneurysmal SAH and cardiac arrest patients. Only English, adult, human studies with primary or secondary mortality or neurological outcomes were included.Results. A total of 142 trials (82 SAH, 60 cardiac arrest) met the review criteria (103 published, 39 ongoing). The majority of both published and ongoing SAH trials focus on delayed secondary insults after SAH (70%), while 100% of cardiac arrest trials tested interventions within the first few hours of ictus. No SAH trials addressing treatment of early brain injury were identified. Twenty-nine percent of SAH and 13% of cardiac arrest trials showed outcome benefit, though there is no overlap mechanistically.Conclusions. Clinical trials in SAH assessing acute brain injury are warranted and successful interventions identified by the cardiac arrest literature may be reasonable targets of the study.

scholarly journals Bedside microdialysis for detection of early brain injury after out-of-hospital cardiac arrest

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Simon Mölström ◽  
Troels Halfeld Nielsen ◽  
Carl H. Nordström ◽  
Axel Forsse ◽  
Sören Möller ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Continuous Monitoring ◽  
Venous Blood ◽  
Early Brain Injury ◽  
Jugular Bulb ◽  
Unfavorable Outcome ◽  
Monitoring Time ◽  
Lactate And Pyruvate ◽  
Hospital Cardiac Arrest ◽  
Pyruvate Ratio

AbstractBedside detection and early treatment of lasting cerebral ischemia may improve outcome after out-of-hospital cardiac arrest (OHCA). This feasibility study explores the possibilities to use microdialysis (MD) for continuous monitoring of cerebral energy metabolism by analyzing the draining cerebral venous blood. Eighteen comatose patients were continuously monitored with jugular bulb and radial artery (reference) MD following resuscitation. Median time from cardiac arrest to MD was 300 min (IQR 230–390) with median monitoring time 60 h (IQR 40–81). The lactate/pyruvate ratio in cerebral venous blood was increased during the first 20 h after OHCA, and significant differences in time-averaged mean MD metabolites between jugular venous and artery measurements, were documented (p < 0.02). In patients with unfavorable outcome (72%), cerebral venous lactate and pyruvate levels remained elevated during the study period. In conclusion, the study indicates that jugular bulb microdialysis (JBM) is feasible and safe. Biochemical signs of lasting ischemia and mitochondrial dysfunction are frequent and associated with unfavorable outcome. The technique may be used in comatose OHCA patients to monitor biochemical variables reflecting ongoing brain damage and support individualized treatment early after resuscitation.

scholarly journals Proteomics-based Multimarker Model Improves Neurofilament Light Chain for Predicting Neurological Outcome after Cardiac Arrest

2020 ◽  
Author(s):  
Raphael Wurm ◽  
Henrike Arfsten ◽  
Besnik Muqaku ◽  
Markus Ponleitner ◽  
Andrea Bileck ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Single Molecule ◽  
Light Chain ◽  
Neurological Outcome ◽  
Cerebral Performance Category ◽  
Predictive Ability ◽  
Small Sample ◽  
Clinical Markers ◽  
Neurofilament Light Chain ◽  
Neurofilament Light

Abstract Background: Out of hospital cardiac arrest (OHCA) is a life-threatening event. Continuous advances in management increased initial survival, but the rate of favorable neurological outcome remains low. We have previously shown the usefulness of proteomics to identify novel biomarkers to predict this outcome. Neurofilament light chain (NfL), a marker of axonal damage, has since emerged as a promising single marker. The aim of this study was thus to assess the predictive value of NfL and compare it to our established model.Methods: NfL was measured in plasma samples from OHCA drawn at 48 hours after the event using single molecule assays. Neurological function at discharge from ICU was recorded on the cerebral performance category (CPC) scale. Predictive ability was assessed for NfL and compared to an established multimarker model.Results: Seventy patients were included into this analysis, of whom 21 (30%) showed a favorable outcome (CPC 1-2) compared to 49 (70%) with an unfavorable outcome (CPC 3 - 5). NfL increased from CPC 1 to 5 (16.5 pg/ml to 641 pg/ml, p<0.001). NfL alone performed moderately well with an area under the ROC (AUROC) of 79.4%. Prediction was significantly improved by combination of NfL with the established best performing model (F = 6.83, p = 0.01) with an AUROC to 89.7% (p for comparison = 0.017).Conclusion:The combination of NfL with other plasma and clinical markers is superior to that of either model alone and achieves a very good AUROC in this relatively small sample. Trial registration: ClinicalTrials.gov NCT01960699. Registered 08 October 2013.

scholarly journals One-year follow-up of neurological status of patients after cardiac arrest seen at the emergency room of a teaching hospital

2015 ◽  
Vol 13 (2) ◽  
pp. 183-188 ◽  
Author(s):  
Cássia Regina Vancini-Campanharo ◽  
Rodrigo Luiz Vancini ◽  
Claudio Andre Barbosa de Lira ◽  
Maria Carolina Barbosa Teixeira Lopes ◽  
Meiry Fernanda Pinto Okuno ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Cardiopulmonary Resuscitation ◽  
Emergency Room ◽  
Cerebral Performance Category ◽  
Neurological Status ◽  
Performance Category ◽  
Emergency Room Patients ◽  
Initial Rhythm ◽  
One Year

ABSTRACT Objective: To describe neurological status and associated factors of survivors after cardiac arrest, upon discharge, and at 6 and 12 month follow-up. Methods: A cohort, prospective, descriptive study conducted in an emergency room. Patients who suffered cardiac arrest and survived were included. A one-year consecutive sample, comprising 285 patients and survivors (n=16) followed up for one year after discharge. Neurological status was assessed by the Cerebral Performance Category before the cardiac arrest, upon discharge, and at 6 and 12 months after discharge. The following factors were investigated: comorbidities, presence of consciousness upon admission, previous cardiac arrest, witnessed cardiac arrest, location, cause and initial rhythm of cardiac arrest, number of cardiac arrests, interval between collapse and start of cardiopulmonary resuscitation, and between collapse and end of cardiopulmonary resuscitation, and duration of cardiopulmonary resuscitation. Results: Of the patients treated, 4.5% (n=13) survived after 6 and 12 months follow-up. Upon discharge, 50% of patients remained with previous Cerebral Performance Category of the cardiac arrest and 50% had worsening of Cerebral Performance Category. After 6 months, 53.8% remained in the same Cerebral Performance Category and 46.2% improved as compared to discharge. After 12 months, all patients remained in the same Cerebral Performance Category of the previous 6 months. There was no statistically significant association between neurological outcome during follow-up and the variables assessed. Conclusion: There was neurological worsening at discharge but improvement or stabilization in the course of a year. There was no association between Cerebral Performance Category and the variables assessed.

scholarly journals Prognostic value of ‘late’ electroencephalography recordings in patients with cardiopulmonal resuscitation after cardiac arrest

2021 ◽  
Author(s):  
Jakob I. Doerrfuss ◽  
Alexander B. Kowski ◽  
Martin Holtkamp ◽  
Moritz Thinius ◽  
Christoph Leithner ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Prognostic Value ◽  
Background Activity ◽  
Cerebral Performance Category ◽  
Unfavorable Outcome ◽  
Continuous Administration ◽  
Time Period ◽  
Eeg Data ◽  
Continuous Eeg ◽  
Group A

Abstract Background Electroencephalography (EEG) significantly contributes to the neuroprognostication after resuscitation from cardiac arrest. Recent studies suggest that the prognostic value of EEG is highest for continuous recording within the first days after cardiac arrest. Early continuous EEG, however, is not available in all hospitals. In this observational study, we sought to evaluate the predictive value of a ‘late’ EEG recording 5–14 days after cardiac arrest without sedatives. Methods We retrospectively analyzed EEG data in consecutive adult patients treated at the medical intensive care units (ICU) of the Charité—Universitätsmedizin Berlin. Outcome was assessed as cerebral performance category (CPC) at discharge from ICU, with an unfavorable outcome being defined as CPC 4 and 5. Results In 187 patients, a ‘late’ EEG recording was performed. Of these patients, 127 were without continuous administration of sedative agents for at least 24 h before the EEG recording. In this patient group, a continuously suppressed background activity < 10 µV predicted an unfavorable outcome with a sensitivity of 31% (95% confidence interval (CI) 20–45) and a specificity of 99% (95% CI 91–100). In patients with suppressed background activity and generalized periodic discharges, sensitivity was 15% (95% CI 7–27) and specificity was 100% (95% CI 94–100). GPDs on unsuppressed background activity were associated with a sensitivity of 42% (95% CI 29–46) and a specificity of 92% (95% CI 82–97). Conclusions A ‘late’ EEG performed 5 to 14 days after resuscitation from cardiac arrest can aide in prognosticating functional outcome. A suppressed EEG background activity in this time period indicates poor outcome.

scholarly journals Association of deranged cerebrovascular reactivity with brain injury following cardiac arrest: a post-hoc analysis of the COMACARE trial

Critical Care ◽  
2021 ◽  
Vol 25 (1) ◽  
Author(s):  
Johanna Laurikkala ◽  
Anders Aneman ◽  
Alexander Peng ◽  
Matti Reinikainen ◽  
Paul Pham ◽  
...  
Keyword(s):  
Carbon Dioxide ◽  
Cardiac Arrest ◽  
Brain Injury ◽  
Cerebral Performance Category ◽  
Cerebrovascular Reactivity ◽  
Chronic Hypertension ◽  
Post Hoc Analysis ◽  
Poor Outcome ◽  
Arterial Blood ◽  
Post Hoc

Abstract Background Impaired cerebrovascular reactivity (CVR) is one feature of post cardiac arrest encephalopathy. We studied the incidence and features of CVR by near infrared spectroscopy (NIRS) and associations with outcome and biomarkers of brain injury. Methods A post-hoc analysis of 120 comatose OHCA patients continuously monitored with NIRS and randomised to low- or high-normal oxygen, carbon dioxide and mean arterial blood pressure (MAP) targets for 48 h. The tissue oximetry index (TOx) generated by the moving correlation coefficient between cerebral tissue oxygenation measured by NIRS and MAP was used as a dynamic index of CVR with TOx > 0 indicating impaired reactivity and TOx > 0.3 used to delineate the lower and upper MAP bounds for disrupted CVR. TOx was analysed in the 0–12, 12–24, 24–48 h time-periods and integrated over 0–48 h. The primary outcome was the association between TOx and six-month functional outcome dichotomised by the cerebral performance category (CPC1-2 good vs. 3–5 poor). Secondary outcomes included associations with MAP bounds for CVR and biomarkers of brain injury. Results In 108 patients with sufficient data to calculate TOx, 76 patients (70%) had impaired CVR and among these, chronic hypertension was more common (58% vs. 31%, p = 0.002). Integrated TOx for 0–48 h was higher in patients with poor outcome than in patients with good outcome (0.89 95% CI [− 1.17 to 2.94] vs. − 2.71 95% CI [− 4.16 to − 1.26], p = 0.05). Patients with poor outcomes had a decreased upper MAP bound of CVR over time (p = 0.001), including the high-normal oxygen (p = 0.002), carbon dioxide (p = 0.012) and MAP (p = 0.001) groups. The MAP range of maintained CVR was narrower in all time intervals and intervention groups (p < 0.05). NfL concentrations were higher in patients with impaired CVR compared to those with intact CVR (43 IQR [15–650] vs 20 IQR [13–199] pg/ml, p = 0.042). Conclusion Impaired CVR over 48 h was more common in patients with chronic hypertension and associated with poor outcome. Decreased upper MAP bound and a narrower MAP range for maintained CVR were associated with poor outcome and more severe brain injury assessed with NfL. Trial registration ClinicalTrials.gov, NCT02698917.

Early posttraumatic seizures in pediatric traumatic brain injury: a multicenter analysis

2021 ◽  
pp. 1-7
Author(s):  
Shu-Ling Chong ◽  
Suyun Qian ◽  
Sarah Hui Wen Yao ◽  
John Carson Allen ◽  
Hongxing Dang ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Functional Outcomes ◽  
Cerebral Performance Category ◽  
Secondary Analysis ◽  
Pediatric Intensive Care ◽  
Risk Of Death ◽  
Severe Tbi ◽  
Gcs Score ◽  
Posttraumatic Seizures

OBJECTIVE Early posttraumatic seizures (EPTSs) in children after traumatic brain injury (TBI) increase metabolic stress on the injured brain. The authors sought to study the demographic and radiographic predictors for EPTS, and to investigate the association between EPTS and death, and between EPTS and poor functional outcomes among children with moderate to severe TBI in Asia. METHODS A secondary analysis of a retrospective TBI cohort among participating centers of the Pediatric Acute & Critical Care Medicine Asian Network was performed. Children < 16 years of age with a Glasgow Coma Scale (GCS) score ≤ 13 who were admitted to pediatric intensive care units between January 2014 and October 2017 were included. Logistic regression analysis was performed to study risk factors for EPTS and to investigate the association between EPTS and death, and between EPTS and poor functional outcomes. Poor functional outcomes were defined as moderate disability, severe disability, and coma as defined by the Pediatric Cerebral Performance Category scale. RESULTS Overall, 313 children were analyzed, with a median age of 4.3 years (IQR 1.8–8.9 years); 162 children (51.8%) had severe TBI (GCS score < 8), and 76 children (24.3%) had EPTS. After adjusting for age, sex, and the presence of nonaccidental trauma (NAT), only younger age was significantly associated with EPTS (adjusted odds ratio [aOR] 0.85, 95% CI 0.78–0.92; p < 0.001). Forty-nine children (15.6%) in the cohort died, and 87 (32.9%) of the 264 surviving patients had poor functional outcomes. EPTS did not increase the risk of death. After adjusting for age, sex, TBI due to NAT, multiple traumas, and a GCS score < 8, the presence of EPTS was associated with poor functional outcomes (aOR 2.08, 95% CI 1.05–4.10; p = 0.036). CONCLUSIONS EPTSs were common among children with moderate to severe TBI in Asia and were associated with poor functional outcomes among children who survived TBI.

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