Evaluation of serum biomarkers and electroencephalogram to determine survival outcomes in pediatric post-cardiac arrest patients

Abstract Background Cardiac arrest causes primary and secondary brain injuries. We aimed to evaluate the association between neuron-specific enolase (NSE), serum S-100B (S100B), electroencephalogram (EEG) patterns, and post-cardiac arrest outcomes, including arrest duration and survival, in pediatric patients. Methods This prospective observational study was conducted in the pediatric intensive care unit of our hospital from January 2017 to December 2019 and included 41 post-cardiac arrest patients with different etiologies who underwent EEG and serum sampling for NSE and S100B. The participants were aged 1 month to 18 years who experienced cardiac arrest and underwent cardiopulmonary resuscitation after a sustained return of spontaneous circulation for ≥48 hours. We excluded immunocompromised patients, those with neurological diseases, hematological malignancies or solid tumors, or a history of head trauma. Results Approximately 19.5% (n=8) of patients survived until hospital discharge. Convulsions and sepsis—observed in 21.9% (n=9) and 82.9% (n=34) of patients, respectively—were significantly associated with higher mortality (relative risk: 1.33 [95% CI=1.09–1.6] and 1.99 [95% CI=0.8–4.7], respectively). Serum NSE and S100B levels were not statistically associated with outcome (P=0.278 and 0.693, respectively). NSE levels were positively correlated with arrest duration. EEG patterns were significantly associated with outcome (P=0.01). Non-epileptogenic EEG activity was associated with the highest survival rate. No patient with burst suppression survived. Conclusion Post-cardiac arrest syndrome is a serious condition with a high mortality rate. Management of sepsis and convulsions affects prognosis. NSE and S100B have no benefit in survival evaluation. EEG is recommended for all post-cardiac arrest patients.

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Neuron-Specific Enolase, Serum-100B, Electroencephalogram as Indicators of Extent of Brain Damage in Post Cardiac Arrest Patients

QJM ◽

10.1093/qjmed/hcaa063.009 ◽

2020 ◽

Vol 113 (Supplement_1) ◽

Author(s):

M Y Elseify ◽

A R Ahmed ◽

M O Shattah ◽

S A Salaheldin

Keyword(s):

Cardiac Arrest ◽

Prospective Observational Study ◽

Pediatric Patients ◽

Neuron Specific Enolase ◽

Pediatric Intensive Care ◽

P Value ◽

Study Group ◽

Significant Relation ◽

Mortality And Morbidity ◽

Risk Of Mortality

Abstract Background Post cardiac arrest patients have high risk of mortality and morbidity. Brain injury plays an important role in determining patients’ outcome. Aim of the Work: To correlate the levels of Neuron-specific enolase (NSE), Serum-100B (S100B) and Electroencephalogarm patterns in post cardiac arrest pediatric patients with cardiac arrest circumstances and patients’ outcome. Patients and Methods: This prospective observational study was conducted in Pediatric Intensive Care Unit, Ain Shams University. It included 41 post cardiac arrest patients who underwent serum sampling for NSE, Serum 100B and Electroencephalogram. Results: In our study, 19.5% of patients survived to hospital discharge. Convulsions and sepsis were present in 21.9% and 82.9% of the study group respectively. Convulsions and sepsis were associated with higher mortality with relative risk 1.33 and 1.99 respectively. Serum NSE and serum 100B showed no statistically significant relation with outcome. NSE levels were positively correlated with duration of arrest. EEG patterns showed statistically significant differences when related to outcome with p value of 0.01. Conclusion: Post cardiac arrest patients need intense care especially regarding sepsis and convulsions. NSE levels are related to duration of arrest but not survival. S100B levels aren’t related to survival or duration of arrest. Different EEG Patterns are related to patients’ outcome.

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Loperamide Induced Recurrent Torsades de Pointes: A Case Report

Journal of Pharmacy Practice ◽

10.1177/08971900211004832 ◽

2021 ◽

pp. 089719002110048

Author(s):

Gregory G. Jackson ◽

Christine R. Lopez ◽

Elizabeth S. Bermudez ◽

Nina E. Hill ◽

Dan M. Roden ◽

...

Keyword(s):

Cardiac Arrest ◽

Torsades De Pointes ◽

Altered Mental Status ◽

Spontaneous Circulation ◽

Prior History ◽

Common Phenomenon ◽

Medical Providers ◽

Return Of Spontaneous Circulation ◽

History Of ◽

Overdrive Pacing

Purpose: A case of loperamide-induced recurrent torsades de pointes is reported to raise awareness of an increasingly common phenomenon that could be encountered by medical providers during the current opioid epidemic. Summary: A 40 year-old-man with a prior history of opioid abuse who presented to the emergency department after taking up to 100 tablets of loperamide 2 mg daily for 5 years to blunt opioid withdrawal symptoms and was subsequently admitted to the intensive care unit for altered mental status and hyperthermia. The patient had prolonged QTc and 2 episodes of torsades de pointes (TdP) that resulted in cardiac arrest with return of spontaneous circulation. He was managed with isoproterenol, overdrive pacing, and methylnatrexone with no other events of TdP or cardiac arrest. Conclusion: A 40-year-old male who developed torsades de pointes from loperamide overdose effectively treated with overdrive pacing, isoproterenol, and methylnatrexone.

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Abstract P82: Implementation Of New Resuscitation Guidelines Takes One-and-a-half Year

Circulation ◽

10.1161/circ.118.suppl_18.s_1463 ◽

2008 ◽

Vol 118 (suppl_18) ◽

Author(s):

Jocelyn Berdowski ◽

Andra Schmohl ◽

Rudolph W Koster

Keyword(s):

Cardiac Arrest ◽

World Wide ◽

Prospective Observational Study ◽

Spontaneous Circulation ◽

Chest Compressions ◽

Return Of Spontaneous Circulation ◽

Resuscitation Guidelines ◽

Rhythm Analysis ◽

New Guidelines ◽

Hospital Cardiac Arrest

Objective- In November 2005, updated resuscitation guidelines were introduced world-wide, and will be revised again in 2010. This study aims to determine how long it takes to implement new guidelines. Methods- This was a prospective observational study. From July 2005 to January 2008, we included all patients with a non traumatic out-of-hospital cardiac arrest. Ambulance paramedics sent all continuous ECG registrations with impedance signal by modem. We excluded ECGs from patients with Return Of Spontaneous Circulation at arrival, incomplete ECG registrations, ECGs with technical deficits or with continuous chest compressions. The same guidelines needed to be used in over 75% of the registration time in order to be labeled. We classified ECGs as guidelines 2000 if the c:v ratio was 15:2, shock blocks were present and there was rhythm analysis after each shock; guidelines 2005 if the c:v ratio was 30:2, a single shock protocol was used and chest compressions was immediately resumed after shock or rhythm analysis in a no shock scenario. We accepted 10% deviations in the amount of compressions (13–17 for 2000 guidelines, 27–33 for 2005). Results- Of the 1703 analyzable ECGs, we classified 827 (48.6%) as guidelines 2000 and 624 (36.6%) as guidelines 2005. In the remaining 252 ECGs (14.8%) 31 used guidelines 1992, 137 applied guidelines 2000 with c:v ratio of 30:2 and 84 did not show distinguishable guideline usage. Since the introduction in November 2005, it took 17 months to apply new guidelines in over 80% of the cases (figure 1 ). Conclusion- Guideline changes are slowly implemented by professionals. This needs to be taken in consideration when new guideline revisions are considered.

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Abstract 421: Point of Care Ultrasound Sonography (POCUS) in Cardiac Arrest: Predicting Survivorship

Circulation ◽

10.1161/circ.140.suppl_2.421 ◽

2019 ◽

Vol 140 (Suppl_2) ◽

Author(s):

Ada Wong ◽

Hassan Patail ◽

Sahar Ahmad

Keyword(s):

Cardiac Arrest ◽

Tricuspid Valve ◽

Prospective Observational Study ◽

Thrombus Formation ◽

Point Of Care ◽

Spontaneous Circulation ◽

Point Of Care Ultrasound ◽

Short Term ◽

Flow Stasis

Introduction: Survival after in hospital (IH) cardiac arrest (CA) is at 17% suggesting that CA represents an arena of medical practice which deserves more attention. Ultrasound (US) may have a role in both intra-arrest management and peri-arrest prognosis. Very little is known about the role of ultrasound for IH CA. Hypothesis: Intra- arrest POCUS can provide prognostic value. Methods: This was a single center, prospective observational study and we included all IH CA which occurred when a provider was available to perform a standardized POCUS protocol. US and echocardiography imaging was collected during the intra- arrest period and compared with outcome measures of return of spontaneous circulation (ROSC) and survival to 24 hours post-ROSC. Results: Echocardiographic features which may reflect survivorship include cardiac standstill, right ventricle (RV) blood flow stasis, and the appearance of thrombus formation at or around the tricuspid valve. 10 of 16 (62.50%) patients with cardiac standstill alone and 1 of 3 (33.33%) RV stasis alone did not achieve ROSC. Of those that did achieve ROSC in these two groups, none of the patients survived beyond 24 hours of the CA. 11 of 19 (57.89%) patients with RV stasis in combination with cardiac standstill did not achieve ROSC, and of the remaining 8 patients that achieved ROSC, only 1 patient survived past 24 hours. The combination of cardiac standstill, RV stasis, and tricuspid valve thrombus had 2 of 3 (66.67%) patients fail to achieve ROSC, with the remaining 1 patient surviving only to 24 hours. The presence of cardiac standstill alone confers an association with death, with an odds ratio (OR) of 1.212. RV stasis plus cardiac standstill on intra-arrest POCUS confer a markedly higher OR 0.8250 in association with death. Conclusions: Our preliminary work brings to light the role of POCUS for predicting short term survivorship based on echocardiographic patient features. This may have implications for resource utilization in such events.

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Abstract 348: Impact of Low and High Partial Pressure of Carbon Dioxide on Neuron Specific Enolase Derived from Serum and Cerebrospinal Fluid in Patients Who Underwent Targeted Temperature Management After Out-of-hospital Cardiac Arrest: A Retrospective Study

Circulation ◽

10.1161/circ.142.suppl_4.348 ◽

2020 ◽

Vol 142 (Suppl_4) ◽

Author(s):

Changshin Kang

Keyword(s):

Carbon Dioxide ◽

Cerebrospinal Fluid ◽

Cardiac Arrest ◽

Retrospective Study ◽

Neuron Specific Enolase ◽

Weighted Average ◽

Carbon Dioxide Tension ◽

Spontaneous Circulation ◽

Temperature Management ◽

Multi Centre Study

Aim: In a previous study, low and high-normal arterial carbon dioxide tension (PaCO 2 ) were not associated with serum neuron specific enolase (NSE) in cardiac arrest survivors. We assessed the effect of PaCO 2 on NSE in cerebrospinal fluid (CSF) and serum. Methods: This was a retrospective study. PaCO 2 for the first 24 h was analysed in four means, qualitative exposure state (qES), time-weighted average (TWA), median, and minimum-maximum (Min-Max). These subgroups were divided into low (LCO 2 ) and high PaCO 2 (HCO 2 ) groups defined as PaCO 2 ≤35.3 and PaCO 2 >43.5 mmHg, respectively. NSE was measured at 24, 48, and 72 h (sNSE 24,48,72 and cNSE 24,48,72 ) from return of spontaneous circulation (ROSC). The primary outcome was the association between PaCO 2 and the NSE measured at 24 h after ROSC. Results: Forty-two subjects (male, 33; 78.6%) were included in total cohort. PaCO 2 in TWA subgroup was associated with cNSE 24,48,72 , while PaCO 2 in the other subgroup were only associated with cNSE 24 . PaCO 2 and cNSE in qES subgroup showed good correlation (r= -0.61; p< 0.01), and in TWA, Median, and Min-Max subgroup showed moderate correlations (r= -0.57, r= -0.48, and r= -0.60; p< 0.01). Contrastively, sNSE was not associated and correlated with PaCO 2 in all analysis. Poor neurological outcome in LCO 2 was significantly higher than HCO 2 in qES, TWA, and Median subgroups ( p< 0.01, p< 0.01, and p= 0.02). Conclusion: Association was found between NSE and PaCO 2 using CSF, despite including normocapnic ranges; TWA of PaCO 2 may be most strongly associated with CSF NSE levels. A prospective, multi-centre study is required to confirm our results.

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Post–Cardiac Arrest Syndrome

AACN Advanced Critical Care ◽

10.4037/aacnacc2020535 ◽

2020 ◽

Vol 31 (4) ◽

pp. 383-393

Author(s):

Linda Dalessio

Keyword(s):

Cardiac Arrest ◽

Myocardial Dysfunction ◽

The United States ◽

Spontaneous Circulation ◽

Clinical State ◽

Precipitating Factors ◽

Patient Health ◽

Global Brain ◽

The Brain ◽

Post Cardiac Arrest Syndrome

More than 356 000 out-of-hospital cardiac arrests occur in the United States annually. Complications involving post–cardiac arrest syndrome occur because of ischemic-reperfusion injury to the brain, lungs, heart, and kidneys. Post–cardiac arrest syndrome is a clinical state that involves global brain injury, myocardial dysfunction, macrocirculatory dysfunction, increased vulnerability to infection, and persistent precipitating pathology (ie, the cause of the arrest). The severity of outcomes varies and depends on precipitating factors, patient health before cardiac arrest, duration of time to return of spontaneous circulation, and underlying comorbidities. In this article, the pathophysiology and treatment of post–cardiac arrest syndrome are reviewed and potential novel therapies are described.

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The post-cardiac arrest syndrome: A case for lung–brain coupling and opportunities for neuroprotection

Journal of Cerebral Blood Flow & Metabolism ◽

10.1177/0271678x19835552 ◽

2019 ◽

Vol 39 (6) ◽

pp. 939-958 ◽

Cited By ~ 5

Author(s):

Nguyen Mai ◽

Kathleen Miller-Rhodes ◽

Sara Knowlden ◽

Marc W Halterman

Keyword(s):

Cardiac Arrest ◽

Reperfusion Injury ◽

Systemic Inflammation ◽

Short Circuit ◽

Spontaneous Circulation ◽

Innate Immune ◽

Neurological Injury ◽

Temperature Management ◽

Immune Priming ◽

Post Cardiac Arrest Syndrome

Systemic inflammation and multi-organ failure represent hallmarks of the post-cardiac arrest syndrome (PCAS) and predict severe neurological injury and often fatal outcomes. Current interventions for cardiac arrest focus on the reversal of precipitating cardiac pathologies and the implementation of supportive measures with the goal of limiting damage to at-risk tissue. Despite the widespread use of targeted temperature management, there remain no proven approaches to manage reperfusion injury in the period following the return of spontaneous circulation. Recent evidence has implicated the lung as a moderator of systemic inflammation following remote somatic injury in part through effects on innate immune priming. In this review, we explore concepts related to lung-dependent innate immune priming and its potential role in PCAS. Specifically, we propose and investigate the conceptual model of lung–brain coupling drawing from the broader literature connecting tissue damage and acute lung injury with cerebral reperfusion injury. Subsequently, we consider the role that interventions designed to short-circuit lung-dependent immune priming might play in improving patient outcomes following cardiac arrest and possibly other acute neurological injuries.

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Association between Achievement of Estimated Average Glucose Level and 6-Month Neurologic Outcome in Comatose Cardiac Arrest Survivors: A Propensity Score-Matched Analysis

Journal of Clinical Medicine ◽

10.3390/jcm8091480 ◽

2019 ◽

Vol 8 (9) ◽

pp. 1480

Author(s):

Yong Hun Jung ◽

Byung Kook Lee ◽

Kyung Woon Jeung ◽

Dong Hun Lee ◽

Hyoung Youn Lee ◽

...

Keyword(s):

Cardiac Arrest ◽

Propensity Score ◽

Glucose Level ◽

Neuron Specific Enolase ◽

Spontaneous Circulation ◽

Neurologic Outcome ◽

Glucose Levels ◽

Neurologic Outcomes ◽

The Mean ◽

Average Glucose

We investigated whether achieving estimated average glucose (EAG) levels versus achieving standard glucose levels (180 mg/dL) was associated with neurologic outcome in cardiac arrest survivors. This single-center retrospective observational study included adult comatose cardiac arrest survivors undergoing therapeutic hypothermia (TH) from September 2011 to December 2017. EAG level was calculated using HbA1c obtained after the return of spontaneous circulation (ROSC), and the mean glucose level during TH was calculated. We designated patients to the EAG or standard glucose group according to whether the mean blood glucose level was closer to the EAG level or 180 mg/dL. Patients in the EAG and standard groups were propensity score- matched. The primary outcome was the 6-month neurologic outcome. The secondary outcomes were hypoglycemia (≤70 mg/dL) and serum neuron-specific enolase (NSE) at 48 h after ROSC. Of 384 included patients, 137 (35.7%) had a favorable neurologic outcome. The EAG group had a higher favorable neurologic outcome (104/248 versus 33/136), higher incidence of hypoglycemia (46/248 versus 11/136), and lower NSE level. After propensity score matching, both groups had similar favorable neurologic outcomes (24/93 versus 27/93) and NSE levels; the EAG group had a higher incidence of hypoglycemia (21/93 versus 6/93). Achieving EAG levels was associated with hypoglycemia but not neurologic outcome or serum NSE level.

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Post-cardiac arrest syndrome in adult hospitalized patients

Colombian Journal of Anesthesiology ◽

10.5554/22562087.e972 ◽

2021 ◽

Author(s):

Estivalis G. Acosta-Gutiérrez ◽

Andrés M. Alba-Amaya ◽

Santiago Roncancio-Rodríguez ◽

José Ricardo Navarro-Vargas

Keyword(s):

Cardiac Arrest ◽

Latin American ◽

Myocardial Dysfunction ◽

Spontaneous Circulation ◽

Neurologic Recovery ◽

One Year ◽

Meta Analyses ◽

Post Cardiac Arrest Syndrome ◽

Hospital Cardiac Arrest

Adult In-hospital Cardiac Arrest (IHCA) is defined as the loss of circulation of an in-patient. Following high-quality cardiopulmonary resuscitation (CPR), if the return of spontaneous circulation (ROSC) is achieved, the post-cardiac arrest syndrome develops (PCAS). This review is intended to discuss the current diagnosis and treatment of PCAS. To approach this topic, a bibliography search was conducted through direct digital access to the scientific literature published in English and Spanish between 2014 and 2020, in MedLine, SciELO, Embase and Cochrane. This search resulted in 248 articles from which original articles, systematic reviews, meta-analyses and clinical practice guidelines were selected for a total of 56 documents. The etiologies may be divided into 56% of in-hospital cardiac, and 44% of non-cardiac arrests. The incidence of this physiological collapse is up to 1.6 cases/1,000 patients admitted, and its frequency is higher in the intensive care units (ICU), with an overall survival rate of 13% at one year. The primary components of PCAS are brain injury, myocardial dysfunction and the persistence of the precipitating pathology. The mainstays for managing PCAS are the prevention of cardiac arrest, ventilation support, control of peri-cardiac arrest arrythmias, and interventions to optimize neurologic recovery. A knowledgeable healthcare staff in PCAS results in improved patient survival and future quality of life. Finally, there is clear need to do further research in the Latin American Population.

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