Predictors of neurologic outcome in hypothermia after cardiac arrest

Fugate, Jennifer E.; Wijdicks, Eelco F. M.; Mandrekar, Jay; Claassen, Daniel O.; White, Roger D.; Bell, Malcolm R.; Rabinstein, Alejandro A.

doi:10.1002/ana.22133

Cited by 306 publications

(230 citation statements)

References 30 publications

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“…Prior to TTM, the “gold standard” for early prediction of neurologic outcomes was the 2006 American Academy of Neurology practice parameter, comprising 6 physical examination and diagnostic test findings on post‐arrest days 1 to 3, each with reported positive predictive value (PPV) of 100% for poor neurologic outcome 10. However, validity in the TTM population has been repeatedly questioned because of decreased individual and composite PPV 11, 12, 13. The current consensus recommendation is to delay prognosis ≥72 hours post‐arrest,14 consistent with a recent study reporting average time to awakening 3.2 days post‐arrest 15…”

Section: Introductionmentioning

confidence: 99%

C‐GRApH : A Validated Scoring System for Early Stratification of Neurologic Outcome After Out‐of‐Hospital Cardiac Arrest Treated With Targeted Temperature Management

Kiehl

Parker

Matar

et al. 2017

JAHA

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BackgroundOut‐of‐hospital cardiac arrest (OHCA) results in significant morbidity and mortality, primarily from neurologic injury. Predicting neurologic outcome early post‐OHCA remains difficult in patients receiving targeted temperature management.Methods and ResultsRetrospective analysis was performed on consecutive OHCA patients receiving targeted temperature management (32–34°C) for 24 hours at a tertiary‐care center from 2008 to 2012 (development cohort, n=122). The primary outcome was favorable neurologic outcome at hospital discharge, defined as cerebral performance category 1 to 2 (poor 3–5). Patient demographics, pre‐OHCA diagnoses, and initial laboratory studies post‐resuscitation were compared between favorable and poor neurologic outcomes with multivariable logistic regression used to develop a simple scoring system (C‐GRApH). The C‐GRApH score ranges 0 to 5 using equally weighted variables: (C): coronary artery disease, known pre‐OHCA; (G): glucose ≥200 mg/dL; (R): rhythm of arrest not ventricular tachycardia/fibrillation; (A): age >45; (pH): arterial pH ≤7.0. A validation cohort (n=344) included subsequent patients from the initial site (n=72) and an external quaternary‐care health system (n=272) from 2012 to 2014. The c‐statistic for predicting neurologic outcome was 0.82 (0.74–0.90, P<0.001) in the development cohort and 0.81 (0.76–0.87, P<0.001) in the validation cohort. When subdivided by C‐GRApH score, similar rates of favorable neurologic outcome were seen in both cohorts, 70% each for low (0–1, n=60), 22% versus 19% for medium (2–3, n=307), and 0% versus 2% for high (4–5, n=99) C‐GRApH scores in the development and validation cohorts, respectively.Conclusions C‐GRApH stratifies neurologic outcomes following OHCA in patients receiving targeted temperature management (32–34°C) using objective data available at hospital presentation, identifying patient subsets with disproportionally favorable (C‐GRApH ≤1) and poor (C‐GRApH ≥4) prognoses.

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Section: Introductionmentioning

confidence: 99%

C‐GRApH : A Validated Scoring System for Early Stratification of Neurologic Outcome After Out‐of‐Hospital Cardiac Arrest Treated With Targeted Temperature Management

Kiehl

Parker

Matar

et al. 2017

JAHA

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“…Clinicians may recognize abnormalities on imaging and restrict treatments, fostering a link between those findings and poor clinical outcome. 5,6 One prognostic factor on imaging that has received recent attention is the optic nerve sheath diameter (ONSD). The optic nerve sheath is an extension of the dura and contains cerebrospinal fluid (CSF) and the optic nerve.…”

Section: Introductionmentioning

confidence: 99%

Optic nerve sheath diameter on computed tomography not predictive of neurological status post-cardiac arrest

Rush

Wormsbecker

Berger

et al. 2016

CJEM

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Objective: Optic nerve sheath diameter (ONSD) measured on a head computed tomography (CT) has been suggested as a potential prognostic factor for poor neurological outcome after cardiac arrest. We performed a single centre retrospective cohort analysis to further investigate this relationship. Methods: All patients >18 years of age admitted to St. Paul's Hospital in Vancouver, Canada who survived a cardiac arrest and had a CT scan of the head within 48 hours were included in the analysis. Results: A total of 72 patients met inclusion criteria for the study; 54 (75.0%) of the patients had a poor neurological outcome, whereas 18 (25.0%) patients were discharged from the hospital with a good outcome. A CT head was obtained for patients in the good outcome group in a mean time of 9.3 hours (SD 10.0) compared to 10.2 hours (SD 11.2) for the poor outcome group (p = 0.75). There was no difference in average ONSD observed between the two outcome groups (6.66 mm SD 0.78 v. 6.60 mm SD 0.82, p = 0.77). Multiple logistic regression failed to show any association between ONSD and neurological outcome when adjusted for all other covariates (OR 1.32 95% CI 0.40-4.34, p = 0.65). Setting an ONSD threshold of >8 mm (OR 2.32, 95% CI 0.14-39.40, p = 0.55) or >7 mm (OR 0.28, 95% CI 0.03-2.77, p = 0.28) also failed to show any association on neurological outcome. Conclusion: There was no observed difference in ONSD between those with a good neurological outcome and those with a poor outcome. ONSD was not an independent predictor of poor neurological outcome. RÉSUMÉObjectifs : Certains sont d'avis que la mesure du diamètre de la gaine du nerf optique par une tomodensitométrie (TDM) de la tête pourrait se révéler un facteur pronostique possible de séquelles neurologiques graves à la suite d'un arrêt cardiaque. Les auteurs de l'étude ont donc procédé à une analyse rétrospective, unicentrique de cohorte afin d'approfondir l'existence de la relation. Méthode : Tous les patients âgés de plus de 18 ans, admis à l'hôpital St-Paul à Vancouver, au Canada, qui ont survécu à un arrêt cardiaque et qui ont subi une TDM de la tête dans les 48 heures ont été inclus dans l'analyse. Résultats : Soixante-douze patients respectaient les critères d'inclusion dans l'étude; sur ce nombre, 54 (75,0 %) ont connu des séquelles neurologiques graves, tandis que 18 (25,0 %) sont sortis de l'hôpital dans un bon état. Il s'est écoulé en moyenne 9,3 heures (écart-type [σ] : 10,0) avant que la TDM de la tête soit réalisée dans le groupe ayant connu une évolution favorable contre 10,2 heures (σ : 11,2) dans le groupe ayant connu une évolution défavorable (p = 0,75). Aucun écart n'a été relevé entre les deux groupes en ce qui concerne le diamètre moyen de la gaine du NO (6,66 mm; σ : 0,78 contre 6,60 mm; σ : 0,82; p = 0,77). Plusieurs analyses de régression logistique ont été réalisées, et aucune n'a démontré l'existence d'une relation entre le diamètre de la gaine du NO et l'état neurologique après rajustement de toutes les autres covariables (risque relatif ...

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“…[12][13][14][15][16][17][18]. These studies have several important flaws: a lack of blinding to the results of the prognostic markers being evaluated (13,16,(19)(20)(21)(22), the high proportion of patients who have withdrawal of life-sustaining therapy (WLST) (12,13,19,23), and a lack of understanding regarding the number of patients who die of a true neurologic cause defined brain death as opposed to WLST, cardiac, respiratory, infectious, or other causes. There are no adequate clinical data to prove or refute the notion that TH decreases the proportion of patients who progress to "brain death," and as such, our understanding of how TH improves mortality and neurologic outcomes remains inadequate.…”

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confidence: 99%

Awakening and Withdrawal of Life-Sustaining Treatment in Cardiac Arrest Survivors Treated With Therapeutic Hypothermia

Mulder

Gibbs

Smith

et al. 2015

Survey of Anesthesiology

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Objectives-To characterize the prevalence of withdrawal of life-sustaining treatment, as well as the time to awakening, short-term neurologic outcomes, and cause of death in comatose survivors of out-of-hospital resuscitated cardiopulmonary arrests treated with therapeutic hypothermia.Design-Single center, prospective observational cohort study of consecutive patients with outof-hospital cardiopulmonary arrests. Setting-Academic HHS Public Access Author Manuscript Author ManuscriptAuthor Manuscript Author ManuscriptPatients-Adults with witnessed, nontraumatic, out-of-hospital cardiopulmonary arrests regardless of initial electrocardiographic rhythm with return of spontaneous circulation who were admitted to an ICU. Interventions-None.Measurements and Main Results-The study cohort included 154 comatose survivors of witnessed out-of-hospital cardiopulmonary arrests who were admitted to an ICU during the 54-month study period. One hundred eighteen patients (77%) were treated with therapeutic hypothermia. The mean age was 59 years, 104 (68%) were men, and 83 (54%) had an initial rhythm of ventricular tachycardia or fibrillation. Only eight of all 78 patients (10%) who died qualified as brain dead; and 81% of all patients (63 of 78) who died did so after withdrawal of lifesustaining treatment. Twenty of 56 comatose survivors (32%) treated with hypothermia who awoke (as defined by Glasgow Motor Score of 6) and had good neurologic outcomes (defined as Cerebral Performance Category 1-2) did so after 72 hours.Conclusions-Our study supports delaying prognostication and withdrawal of life-sustaining treatment to beyond 72 hours in cases treated with therapeutic hypothermia. Larger multicenter prospective studies are needed to better define the most appropriate time frame for prognostication in comatose cardiac arrest survivors treated with therapeutic hypothermia. These data are also consistent with the notion that a majority of out-of-hospital cardiopulmonary arrest survivors die after a decision to withdrawal of life-sustaining treatment and that very few of these survivors progress to brain death. Keywordsbrain death; cardiac arrest; outcome; prognostication; therapeutic hypothermia; withdrawal of lifesustaining treatmentOut-of-hospital cardiopulmonary arrests (OHCA) pose a significant public health burden, with an estimated annual prevalence of over 380,000 arrests evaluated by emergency medical services in the United States alone (1-4). In the decade following the 2002 landmark trials of therapeutic hypothermia (TH) to improve outcomes in comatose cardiac arrest survivors, little additional progress has been made in finding and implementing successful new neuroprotective interventions (5, 6). Therefore, TH remains the only proven neuroprotective strategy available and the focus of the resuscitation community. A number of factors explain this lack of progress: a lack of understanding of the mechanisms and circumstances leading to poor outcomes, lead time and selection biases, as well as funding and ethical co...

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Predictors of neurologic outcome in hypothermia after cardiac arrest

Cited by 306 publications

References 30 publications

C‐GRApH : A Validated Scoring System for Early Stratification of Neurologic Outcome After Out‐of‐Hospital Cardiac Arrest Treated With Targeted Temperature Management

C‐GRApH : A Validated Scoring System for Early Stratification of Neurologic Outcome After Out‐of‐Hospital Cardiac Arrest Treated With Targeted Temperature Management

Optic nerve sheath diameter on computed tomography not predictive of neurological status post-cardiac arrest

Awakening and Withdrawal of Life-Sustaining Treatment in Cardiac Arrest Survivors Treated With Therapeutic Hypothermia

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