Hospitalized patients' attitudes towards participating in a randomized control trial in case of a cardiac arrest.

Background: No previous study has evaluated patients attitudes towards inclusion in an ongoing cardiac arrest clinical trial. The aim of this study was to assess patients willingness and motives to participate in the ongoing randomized controlled drug trial "Vasopressin and Steroids in addition to Adrenaline in cardiac arrest" (VAST-A trial) in case of an in-hospital cardiac arrest (IHCA). Objectives: Hospitalized patients, men ≥ 18 and women ≥ 50 years, were asked for informed consent for inclusion in the VAST-A trial in case of an IHCA, the reason for approving or declining inclusion in the trial and baseline characteristics. Methods: Patients admitted to hospital were asked to give informed consent of inclusion in VAST-A in case of an IHCA during their hospital stay. Patients were also asked why they approved or declined inclusion as well as baseline characteristics questions. Results: 1,064 patients were asked about willingness to participate in the VAST-A trial, of these 902 (84.8%) patients approved inclusion. A subgroup of 411 patients were, except willingness, also asked about motives to participate or not and basic characteristics. The main reason for approving inclusion was to contribute to research (n = 328, 83.9%). The main reason for declining inclusion was concerns regarding testing the drug treatment (n = 6, 30%). Conclusion: Among hospitalized patients the vast majority gave informed consent to inclusion in an ongoing randomized cardiac arrest drug trial. The main reason for approving inclusion was to contribute to research.

The capacity of neurological pupil index to predict the absence of somatosensory evoked potentials after cardiac arrest - An observational study.

Background: In neurologic prognostication of comatose survivors from cardiac arrest, two independent predictors of poor outcome are the loss of the Pupillary light reflex (PLR) and the loss of the N20 response from Somatosensory Evoked potentials (SSEP). The PLR can be quantitatively assessed by pupillometry. Both tests depend on the midbrain, in which a dysfunction reflects a severe hypoxic injury. We reasoned that a certain level of defective PLR would be predictive of a bilaterally absent SSEP N20 response. Method: Neurological Pupil index (NPi) from the pupillometry and the SSEP N20 response were registered >48 h after cardiac arrest in comatose survivors. Clinical data were retrospectively analyzed. A receiver operating characteristic curve was used to evaluate the capacity of NPi to predict bilaterally absent SSEP N20 response. An NPi threshold value resulting in <5% false positive rate (FPR) for bilaterally absent N20 response was identified. Results: From February 2020 to August 2022, we included 54 patients out of which 49 had conclusive pupillometry and SSEP examinations. The NPi threshold value with FPR < 5% was 3.4, yielding 36% sensitivity (95% CI 18-55) and significantly discriminated between respective groups with preserved and bilaterally absent N20 response to SSEP (p-value <0.01). Conclusion: In this limited cohort, NPi < 3.4 in patients remaining comatose >48 hours after cardiac arrest predicted bilateral loss of the SSEP N20 response with a FPR < 5%. If validated in a larger cohort, an NPi threshold may be clinically applied in settings where SSEP is unavailable.

Aetiology and outcome in hospitalized cardiac arrest patients.

Aims: To study aetiologies of in-hospital cardiac arrests (IHCAs) and their association with 30-day survival. Methods and results: Observational study with data from national registries. Specific aetiologies (n = 22) of IHCA patients between April 2018 and December 2020 were categorized into cardiac vs. non-cardiac and six main aetiology categories: myocardial ischemia, other cardiac causes, pulmonary causes, infection, haemorrhage, and other non-cardiac causes. Main endpoints were proportions in each aetiology, 30-day survival, and favourable neurological outcome (Cerebral Performance Category scale 1-2) at discharge. Among, 4320 included IHCA patients (median age 74 years, 63.1% were men), approximate 50% had cardiac causes with a 30-day survival of 48.4% compared to 18.7% among non-cardiac causes (P < 0.001). The proportion in each category were: myocardial ischemia 29.9%, pulmonary 21.4%, other cardiac causes 19.6%, other non-cardiac causes 11.6%, infection 9%, and haemorrhage 8.5%. The odds ratio (OR) for 30-day survival compared to myocardial ischemia for each category were: other cardiac causes OR 1.48 (CI 1.24-1.76); pulmonary causes OR 0.36 (CI 0.3-0.44); infection OR 0.25 (CI 0.18-0.33); haemorrhage OR 0.22 (CI 0.16-0.3); and other non-cardiac causes OR 0.56 (CI 0.45-0.69). IHCA caused by myocardial ischemia had the best favourable neurological outcome while those caused by infection had the lowest OR 0.06 (CI 0.03-0.13). Conclusion: In this nationwide observational study, aetiologies with cardiac and non-cardiac causes of IHCA were evenly distributed. IHCA caused by myocardial ischemia and other cardiac causes had the strongest associations with 30-day survival and neurological outcome.

Targeted temperature management evolving over time-A local process analysis.

BACKGROUND: Post-resuscitation care of comatose survivors from cardiac arrest includes target temperature management (TTM) to mitigate cerebral reperfusion injury. High-quality TTM requires protocols enhancing good precision. This study explored how the quality of TTM may have evolved with increasing experience from clinical trial protocols and standard operating procedures. We hypothesized that there would be a positive effect over time, detectable between trial periods and between trial periods and later everyday practice. METHODS: Three TTM quality parameters were defined: time to target, temperature variability, and fever incidence. Data from 181 patients treated during three different time periods in a tertiary center were analyzed; 45 from Period 1 (local trial cohort 2011-2013) targeting 33°C or 36°C; 76 from Period 2 (local trial cohort 2018-2020) targeting 33 or <37.5°C; 60 from Period 3 (current standard operating procedure 2020-2021) targeting 36°C. Groups of similar target temperatures from different time periods were compared using ordinary group statistics. RESULTS: TTM quality in all three parameters increased between trial periods. There were no differences in TTM quality as to temperature variability or fever incidence between the <37.5°C Period 2 and the 36°C Period 3 groups. A 33°C target temperature was associated with lower fever incidence than 36°C and <37.5°C target regimes. CONCLUSION: The observed increase in TTM quality in this single-center study may be a result of increased competence through learning and training in different strict TTM protocols. If so, the results of this study further support the protocolization of post-cardiac arrest intensive care.

The association between signs of medical distress preceding in-hospital cardiac arrest and 30-day survival - A register-based cohort study.

Background: Identifying signs of medical distress prior to in-hospital cardiac arrest (IHCA) is important to prevent IHCA and improve survival. The primary objective of this study was to investigate the association between signs of medical distress present within 60 minutes prior to cardiac arrest and survival after cardiac arrest. Methods: The register-based cohort study included adult patients (≥18 years) with IHCA in the Swedish Registry of Cardiopulmonary Resuscitation (SRCR) from 2017-01-01 to 2020-07-15. Signs of distress prior to IHCA were defined as the medical signs arrhythmia, pulmonary oedema, hypotension, hypoxia or seizures present within 60 minutes prior to cardiac arrest (pre-arrest signs). Using multivariable logistic regression, the association between these pre-arrest signs and 30-day survival was analysed in both unadjusted and adjusted models. The covariates used were demographics, comorbidities, characteristics and treatment of cardiac arrest. Results: In total, 8525 patients were included. After adjusting for covariates, patients with arrhythmia had a 58% higher probability of 30-day survival. The adjusted probability of 30-day survival was 41% and 52% lower for patients with hypotension and hypoxia prior to IHCA, respectively. Pulmonary oedema and seizures were not associated with any change in 30-day survival. Conclusions: Among signs of medical distress prior to in-hospital cardiac arrest, arrhythmia was associated with a higher 30-day survival. Hypotension and hypoxia were associated with lower survival after IHCA. These findings indicate that future research on survival after cardiac arrest should take pre-arrest signs into account as it impacts the prerequisites for survival.

Impact of obesity on intensive care outcomes in patients with COVID-19 in Sweden-A cohort study.

BACKGROUND: Previous studies have shown that a high body mass index (BMI) is a risk factor for severe COVID-19. The aim of the present study was to assess whether a high BMI affects the risk of death or prolonged length of stay (LOS) in patients with COVID-19 during intensive care in Sweden. METHODS AND FINDINGS: In this observational, register-based study, we included patients with COVID-19 from the Swedish Intensive Care Registry admitted to intensive care units (ICUs) in Sweden. Outcomes assessed were death during intensive care and ICU LOS ≥14 days. We used logistic regression models to evaluate the association (odds ratio [OR] and 95% confidence interval [CI]) between BMI and the outcomes. Valid weight and height information could be retrieved in 1,649 patients (1,227 (74.4%) males) with COVID-19. We found a significant association between BMI and the risk of the composite outcome death or LOS ≥14 days in survivors (OR per standard deviation [SD] increase 1.30, 95%CI 1.16-1.44, adjusted for sex, age and comorbidities), and this association remained after further adjustment for severity of illness (simplified acute physiology score; SAPS3) at ICU admission (OR 1.30 per SD, 95%CI 1.17-1.45). Individuals with a BMI ≥ 35 kg/m2 had a doubled risk of the composite outcome. A high BMI was also associated with death during intensive care and a prolonged LOS in survivors assessed as separate outcomes. The main limitations were the restriction to the first wave of the pandemic, and the lack of information on socioeconomic status as well as smoking. CONCLUSIONS: In this large cohort of Swedish ICU patients with COVID-19, a high BMI was associated with increasing risk of death and prolonged length of stay in the ICU. Based on our findings, we suggest that individuals with obesity should be more closely monitored when hospitalized for COVID-19.

The capacity of neurological pupil index to predict absence of somatosensory evoked potentials after cardiac arrest-A study protocol.

BACKGROUND: Anoxic-ischemic brain injury is the most common cause of death after cardiac arrest (CA). Robust methods to detect severe injury with a low false positive rate (FPR) for poor neurological outcome include the pupillary light reflex (PLR) and somatosensory evoked potentials (SSEP). The PLR can be assessed manually or with automated pupillometry which provides the neurological pupil index (NPi). We aim to describe the interrelation between NPi values and the absence of SSEP cortical response and to evaluate the capacity of NPi to predict the absence of cortical SSEP response in comatose patients after CA. METHODS: A total of 50 patients will be included in an explorative, prospective, observational study of adult (>18 years) comatose survivors of CA admitted to intensive care in a university hospital. NPi assessed with a hand-held pupillometer will be compared to SSEP signals recorded >48 hours after CA. Primary outcomes are sensitivity, specificity, and odds ratio for NPi to predict bilateral absence of the SSEP N20 signal, with NPi values corresponding to <5% FPRs of SSEP absence. Secondary outcomes are the PLR and SSEP sensitivity, specificity, and odds ratio for poor neurological outcome at hospital discharge and death at 30 days. DISCUSSION: The PLR and SSEP may have a systematic interrelation, and a certain NPi threshold could potentially predict the absence of cortical SSEP response. If this can be concluded from the present study, SSEP testing could be excluded in certain patients to save resources in the multimodal prognostication after CA. Editorial comment The interrelation between loss of the pupillary light reflex (PLR) and the loss of cortical response to a somatosensory evoked potential (SSEP) in comatose cardiac arrest patients is not known. This exploratory prospective study is designed to evaluate whether a specific degree of attenuated PLR, as measured by semiautomated pupillometry, can predict the bilateral loss of cortical SSEP response in severe anoxic/ischemic brain injury. Such an interrelation between the two methods would enable the use of pupillometry rather than the more resource demanding SSEP for neurologic prognostication in post cardiac arrest patients. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04720482, Registered 21 January 2021, retrospectively registered.

Assessing neurological prognosis in post-cardiac arrest patients from short vs plain text EEG reports: A survey among intensive care clinicians.

BACKGROUND: Electroencephalography (EEG) patterns are predictive of neurological prognosis in comatose survivors from cardiac arrest but intensive care clinicians are dependent of neurophysiologist reports to identify specific patterns. We hypothesized that the proportion of correct assessment of neurological prognosis would be higher from short statements confirming specific EEG patterns compared with descriptive plain text reports. METHODS: Volunteering intensive care clinicians at two university hospitals were asked to assess the neurological prognosis of a fictional patient with high neuron specific enolase. They were presented with 17 authentic plain text reports and three short statements, confirming whether a "highly malignant", "malignant" or "benign" EEG pattern was present. Primary outcome was the proportion of clinicians who correctly identified poor neurological prognosis from reports consistent with highly malignant EEG patterns. Secondary outcomes were how the prognosis was assessed from reports consistent with malignant and benign patterns. RESULTS: Out of 57 participants, poor prognosis was correctly identified by 61% from plain text reports and by 93% from the short statement "highly malignant" EEG patterns. Unaffected prognosis was correctly identified by 28% from plain text reports and by 40% from the short statement "malignant" patterns. Good prognosis was correctly identified by 64% from plain text reports and by 93% from the short statement "benign" pattern. CONCLUSION: Standardized short statement, "highly malignant EEG pattern present", as compared to plain text EEG descriptions in neurophysiologist reports, is associated with more accurate identification of poor neurological prognosis in comatose survivors of cardiac arrest.