Cerebrospinal fluid creatine kinase BB isoenzyme activity and neurologic prognosis after cardiac arrest.

OBJECTIVE: To assess the relationship between CSF creatine kinase BB isoenzyme activity (CSF CKBB) and neurologic outcome after cardiac arrest in clinical practice. BACKGROUND: CSF CKBB reflects the extent of brain damage following cardiac arrest. METHODS: To help with prognosis, treating physicians ordered CSF CKBB tests on 474 patients over 7.5 years; 351 of these patients had experienced a cardiac arrest. Assays were performed in one laboratory using agarose electrophoresis. By chart review, we determined awakening status for all patients, defined as the patient having comprehensible speech or following commands. RESULTS: CSF CKBB was usually sampled 48 to 72 hours after cardiac arrest and was strongly associated with awakening (p < < 0.001). The median was 4 U/l for 61 patients who awakened and 191 U/l for 290 who never awakened. For those who awakened, 75% of CKBB levels were < 24 U/l, and for those who never awakened, 75% were > 86 U/l. The highest value in a patient who awakened was 204 U/l, a cutoff that yielded a specificity of 100% of never awakening but a sensitivity of forty-eight percent. Only nine patients who awakened had CSF CKBB values greater than 50 U/l, and none regained independence in activities of daily living. Only three unconscious patients were still alive at last contact, with follow-up of 63, 107, and 109 months. Using logistic regression, the probability of never awakening given a CSF CKBB result can be estimated as: 1/(1 + L), where L = e raised to (0.1267 - 0.0211 x CSF CKBB [U/l]). CONCLUSION: CSF CKBB measurement helps to estimate degree of brain damage and thus neurologic prognosis after cardiac arrest. However, results of this retrospective study could reflect in part a self-fulfilling prophecy.

Intravenous glucose after out-of-hospital cardiopulmonary arrest: a community-based randomized trial.

QUESTION: Does the common practice of infusing small amounts of glucose after cardiopulmonary arrest worsen neurologic outcome? DESIGN AND SETTING: A community-based randomized trial in Seattle, WA. Paramedics treated all patients with out-of-hospital cardiac arrest in a standard fashion except that the intravenous infusion did or did not contain glucose; ie, patients received either usual treatment, with 5% dextrose in water (D5W), or alternative, with half normal saline (0.45S). OUTCOMES: The main outcome was awakening, defined as the patient having comprehensible speech or following commands as determined by chart review. Other outcomes were survival to hospital admission and to discharge. RESULTS: Over 2 years, paramedics randomized 748 patients. The type of fluid administered was not significantly related to awakening (16.7% for D5W versus 14.6% for 0.45S), admission (38.0% for D5W versus 39.8% for 0.45S), or discharge (15.1% for D5W versus 13.3% for 0.45S). As in previous studies, patients whose arrest had likely been on a cardiac basis with initial rhythms of ventricular fibrillation or asystole had admission blood glucose levels significantly related to awakening: mean = 309 mg/dl for never awakening and 251 mg/dl for awakening. Of note, the relation between glucose and awakening was reversed in the remaining patients, who had electromechanical dissociation or noncardiac mechanisms of arrest. CONCLUSION: Current practices of using limited amounts of glucose-containing solutions after cardiopulmonary arrest do not need to be changed. Blood glucose level on admission is a prognostic indicator but depends on the type of arrest.