Different neuroprognostication thresholds of neuron-specific enolase in shockable and non-shockable out-of-hospital cardiac arrest: a prospective multicenter observational study in Korea (the KORHN-PRO registry).

BACKGROUND: Serum neuron-specific enolase (NSE) is the only recommended biomarker for multimodal prognostication in postcardiac arrest patients, but low sensitivity of absolute NSE threshold limits its utility. This study aimed to evaluate the prognostic performance of serum NSE for poor neurologic outcome in out-of-hospital cardiac arrest (OHCA) survivors based on their initial rhythm and to determine the NSE cutoff values with false positive rate (FPR) < 1% for each group. METHODS: This study included OHCA survivors who received targeted temperature management (TTM) and had serum NSE levels measured at 48 h after return of spontaneous circulation in the Korean Hypothermia Network, a prospective multicenter registry from 22 university-affiliated teaching hospitals in South Korea between October 2015 and December 2018. The primary outcome was poor outcome at 6 month, defined as a cerebral performance category of 3-5. RESULTS: Of 623 patients who underwent TTM with NSE measured 48 h after the return of spontaneous circulation, 245 had an initial shockable rhythm. Median NSE level was significantly higher in the non-shockable group than in the shockable group (104.6 [40.6-228.4] vs. 25.9 [16.7-53.4] ng/mL, P < 0.001). Prognostic performance of NSE assessed by area under the receiver operating characteristic curve to predict poor outcome was significantly higher in the non-shockable group than in the shockable group (0.92 vs 0.86). NSE cutoff values with an FPR < 1% in the non-shockable and shockable groups were 69.3 (sensitivity of 42.1%) and 102.7 ng/mL (sensitivity of 76%), respectively. CONCLUSION: NSE prognostic performance and its cutoff values with FPR < 1% for predicting poor outcome in OHCA survivors who underwent TTM differed between shockable and non-shockable rhythms, suggesting postcardiac arrest survivor heterogeneity. Trial registration KORHN-PRO, NCT02827422. Registered 11 September 2016-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT02827422.

Coagulation measures after cardiac arrest (CMACA).

BACKGROUND: During cardiac arrest (CA) and after cardiopulmonary resuscitation, activation of blood coagulation and inadequate endogenous fibrinolysis occur. The aim of this study was to describe the time course of coagulation abnormalities after out-of-hospital CA (OHCA) and to examine the association with clinical outcomes in patients undergoing targeted temperature management (TTM) after OHCA. METHODS: This prospective, multicenter, observational cohort study was performed in eight emergency departments in Korea between September 2018 and September 2019. Laboratory findings from hospital admission and 24 hours after return of spontaneous circulation (ROSC) were analyzed. The primary outcome was cerebral performance category (CPC) at discharge, and the secondary outcome was in-hospital mortality. RESULTS: A total of 170 patients were included in this study. The lactic acid, prothrombin time (PT), activated partial thrombin time (aPTT), international normalized ratio (INR), and D-dimer levels were higher in patients with poor neurological outcomes at admission and 24 h after ROSC. The lactic acid and D-dimer levels decreased over time, while fibrinogen increased over time. PT, aPTT, and INR did not change over time. The PT at admission and D-dimer levels 24 h after ROSC were associated with neurological outcomes at hospital discharge. Coagulation-related factors were moderately correlated with the duration of time from collapse to ROSC. CONCLUSION: The time-dependent changes in coagulation-related factors are diverse. Among coagulation-related factors, PT at admission and D-dimer levels 24 h after ROSC were associated with poor neurological outcomes at hospital discharge in patients treated with TTM.

Stem cell laden nano and micro collagen/PLGA bimodal fibrous patches for myocardial regeneration.

BACKGROUND: Although the use of cardiac patches is still controversial, cardiac patch has the significance in the field of the tissue engineered cardiac regeneration because it overcomes several shortcomings of intra-myocardial injection by providing a template for cells to form a cohesive sheet. So far, fibrous scaffolds fabricated using electrospinning technique have been increasingly explored for preparation of cardiac patches. One of the problems with the use of electrospinning is that nanofibrous structures hardly allow the infiltration of cells for development of 3D tissue construct. In this respect, we have prepared novel bi-modal electrospun scaffolds as a feasible strategy to address the challenges in cardiac tissue engineering . METHODS: Nano/micro bimodal composite fibrous patch composed of collagen and poly (D, L-lactic-co-glycolic acid) (Col/PLGA) was fabricated using an independent nozzle control multi-electrospinning apparatus, and its feasibility as the stem cell laden cardiac patch was systemically investigated. RESULTS: Nano/micro bimodal distributions of Col/PLGA patches without beaded fibers were obtained in the range of the 4-6% collagen concentration. The poor mechanical properties of collagen and the hydrophobic property of PLGA were improved by co-electrospinning. In vitro experiments using bone marrow-derived mesenchymal stem cells (BMSCs) revealed that Col/PLGA showed improved cyto-compatibility and proliferation capacity compared to PLGA, and their extent increased with increase in collagen content. The results of tracing nanoparticle-labeled as well as GFP transfected BMSCs strongly support that Col/PLGA possesses the long-term stem cells retention capability, thereby allowing stem cells to directly function as myocardial and vascular endothelial cells or to secrete the recovery factors, which in turn leads to improved heart function proved by histological and echocardiographic findings. CONCLUSION: Col/PLGA bimodal cardiac patch could significantly attenuate cardiac remodeling and fully recover the cardiac function, as a consequence of their potent long term stem cell engraftment capability.

Background frequency can enhance the prognostication power of EEG patterns categories in comatose cardiac arrest survivors: a prospective, multicenter, observational cohort study.

BACKGROUND: We assessed the prognostic accuracy of the standardized electroencephalography (EEG) patterns ("highly malignant," "malignant," and "benign") according to the EEG timing (early vs. late) and investigated the EEG features to enhance the predictive power for poor neurologic outcome at 1 month after cardiac arrest. METHODS: This prospective, multicenter, observational, cohort study using data from Korean Hypothermia Network prospective registry included adult patients with out-of-hospital cardiac arrest (OHCA) treated with targeted temperature management (TTM) and underwent standard EEG within 7 days after cardiac arrest from 14 university-affiliated teaching hospitals in South Korea between October 2015 and December 2018. Early EEG was defined as EEG performed within 72 h after cardiac arrest. The primary outcome was poor neurological outcome (Cerebral Performance Category score 3-5) at 1 month. RESULTS: Among 489 comatose OHCA survivors with a median EEG time of 46.6 h, the "highly malignant" pattern (40.7%) was most prevalent, followed by the "benign" (33.9%) and "malignant" (25.4%) patterns. All patients with the highly malignant EEG pattern had poor neurologic outcomes, with 100% specificity in both groups but 59.3% and 56.1% sensitivity in the early and late EEG groups, respectively. However, for patients with "malignant" patterns, 84.8% sensitivity, 77.0% specificity, and 89.5% positive predictive value for poor neurologic outcome were observed. Only 3.5% (9/256) of patients with background EEG frequency of predominant delta waves or undetermined had good neurologic survival. The combination of "highly malignant" or "malignant" EEG pattern with background frequency of delta waves or undetermined increased specificity and positive predictive value, respectively, to up to 98.0% and 98.7%. CONCLUSIONS: The "highly malignant" patterns predicted poor neurologic outcome with a high specificity regardless of EEG measurement time. The assessment of predominant background frequency in addition to EEG patterns can increase the prognostic value of OHCA survivors. Trial registration KORHN-PRO, NCT02827422 . Registered 11 September 2016-Retrospectively registered.

Prognostic Value of P25/30 Cortical Somatosensory Evoked Potential Amplitude After Cardiac Arrest.

OBJECTIVES: The aim of this study was to evaluate the prognostic performance of the peak amplitude of P25/30 cortical somatosensory evoked potentials in predicting nonawakening in targeted temperature management-treated cardiac arrest patients. DESIGN: Prospective analysis. SETTING: Four academic tertiary care hospitals. PATIENTS: Eighty-seven cardiac arrest survivors after targeted temperature management. INTERVENTIONS: Analysis of the amplitude of P25/30. MEASUREMENTS AND MAIN RESULTS: In all participants, somatosensory evoked potentials were recorded after rewarming, and bilaterally absent pupillary and corneal reflexes were evaluated at 72 hours after the return of spontaneous circulation. We analyzed the amplitudes of the N20 and P25/30 peaks and the N20-P25/30 complex in cortical somatosensory evoked potentials. Upon hospital discharge, 87 patients were dichotomized into the awakening and nonawakening groups. The lowest amplitudes of N20, P25/30, and N20-P25/30 in the awakening patients were 0.17, 0.45, and 0.73 µV, respectively, and these thresholds showed a sensitivity of 70.5% (95% CI, 54.8-83.2%), 86.4% (95% CI, 72.7-94.8%), and 75.0% (95% CI, 59.7-86.8%), respectively, for nonawakening. The area under the curve of the P25/30 amplitude was significantly higher than that of the N20 amplitude (0.955 [95% CI, 0.912-0.998] vs 0.894 [95% CI, 0.819-0.969]; p = 0.036) and was comparable with that of the N20-P25/30 amplitude (0.931 [95% CI, 0.873-0.989]). Additionally, adding resuscitation variables or an absent brainstem reflex to the P25/30 amplitude showed a trend toward improving prognostic performance compared with the use of other somatosensory evoked potential amplitudes (area under the curve, 0.958; 95% CI, 0.917-0.999 and area under the curve, 0.974; 95% CI, 0.914-0.996, respectively). CONCLUSIONS: Our results provide evidence that the absence of the P25/30 peak and a reduction in the P25/30 amplitude may be considered prognostic indicators in these patients.

Renal replacement therapy is independently associated with a lower risk of death in patients with severe acute kidney injury treated with targeted temperature management after out-of-hospital cardiac arrest.

BACKGROUND: The effect of renal replacement therapy (RRT) on the outcomes of severe acute kidney injury (AKI) after out-of-hospital cardiac arrest (OHCA) is uncertain. This study aimed to evaluate the association of RRT with 6-month mortality in patients with severe AKI treated with targeted temperature management (TTM) after OHCA. METHODS: This was a retrospective analysis of a prospectively collected multicentre observational cohort study that included adult OHCA patients treated with TTM across 22 hospitals in South Korea between October 2015 and December 2018. AKI was diagnosed using the Kidney Disease: Improving Global Outcomes criteria. The primary outcome was 6-month mortality and the secondary outcome was cerebral performance category (CPC) at 6 months. Multivariate Cox regression analysis was performed to define the role of RRT in stage 3 AKI. RESULTS: Among 10,426 patients with OHCA, 1373 were treated with TTM. After excluding those who died within 48 h of return of spontaneous circulation (ROSC) and those with pre-arrest chronic kidney disease, our study cohort comprised 1063 patients. AKI developed in 590 (55.5%) patients and 223 (21.0%) had stage 3 AKI. Among them, 115 (51.6%) were treated with RRT. The most common treatment modality among RRT patients was continuous renal replacement therapy (111 [96.5%]), followed by intermittent haemodialysis (4 [3.5%]). The distributions of CPC (1-5) at 6 months for the non-RRT vs. the RRT group were 3/108 (2.8%) vs. 12/115 (10.4%) for CPC 1, 0/108 (0.0%) vs. 1/115 (0.9%) for CPC 2, 1/108 (0.9%) vs. 3/115 (2.6%) for CPC 3, 6/108 (5.6%) vs. 6/115 (5.2%) for CPC 4, and 98/108 (90.7%) vs. 93/115 (80.9%) for CPC 5, respectively (P = 0.01). The RRT group had significantly lower 6-month mortality than the non-RRT group (93/115 [81%] vs. 98/108 [91%], P = 0.04). Multivariate Cox regression analyses showed that RRT was independently associated with a lower risk of death in patients with stage 3 AKI (hazard ratio, 0.569 [95% confidence interval, 0.377-0.857, P = 0.01]). CONCLUSION: Dialysis interventions were independently associated with a lower risk of death in patients with stage 3 AKI treated with TTM after OHCA.

Association between acute kidney injury and neurological outcome or death at 6 months in out-of-hospital cardiac arrest: A prospective, multicenter, observational cohort study.

PURPOSE: This study aimed to evaluate the association between acute kidney injury (AKI) and 6 months neurological outcome after out-of-hospital cardiac arrest (OHCA). MATERIALS AND METHODS: Prospective multi-center observational cohort included adult OHCA patients treated with targeted temperature management (TTM) across 20 hospitals in the South Korea between October 2015 and October 2017. The diagnosis of AKI was made using the Kidney Disease: Improving Global Outcomes criteria. The outcome was neurological outcome at 6 months evaluated using the modified Rankin scale (MRS). RESULTS: Among 5676 patients with OHCA, 583 patients were enrolled. AKI developed in 348 (60%) patients. Significantly more non-AKI patients had good neurological outcome at 6 months (MRS 0-3) than AKI patients (134/235 [57%] vs. 69/348 [20%], P < .001). AKI was associated with poor neurological outcome at six months in multivariate logistic regression analysis (adjusted odds ratio: 0.206 [95% confidence interval: 0.099-0.426], P < .001]). Cox regression analysis with time-varying covariate of AKI showed that patients with AKI had a higher risk of death than those without AKI (hazard ratio: 2.223; 95% confidence interval: 1.630-3.030, P < .001). CONCLUSIONS: AKI is associated with poor neurological outcome (MRS 4-6) at 6 months in OHCA patients treated with TTM. TRIAL REGISTRATION: NCT02827422.

Identifying Potentially Avoidable Emergency Department Visits of Long-Term Care Hospital Residents in Korea: A Multicenter Retrospective Cohort Study.

The aims of this study were to investigate the reasons of transfers from long-term care hospitals (LTCHs) to emergency departments (EDs) of university hospitals in geriatric patients and to categorize the avoidable causes of these transfers. This retrospective multicenter study involved patients aged 65 years and older who were transferred from LTCHs to 5 EDs of university hospitals located in the metropolitan area of South Korea between January 2017 and December 2017. The expert panel reviewed and categorized the reason of transfers as avoidable or not. Moreover, we also investigated the number of patients with do-not-resuscitate (DNR) documents and the date these DNR documents were written. A total of 255,543 patients visited 5 EDs during the study period. Of these, 1,131 patients were from LTCHs. The number of potentially avoidable transfers was 168/1,131 (14.9%). The most common reason of avoidable transfers was noncritical diagnoses that could be assessed and managed in LTCHs (57.1%). There were 162 patients with DNR orders; of these, 12 had approved the DNR order before transfer. In conclusion, in Korea, potentially avoidable transfers could be reduced by managing noncritical diseases in LTCH and preparing advance care directives, including DNR orders, during admission to LTCH.

Characteristics of Elderly Long-Term Care Residents Who Were Injured and Transferred to Hospital Emergency Departments in Korea: A Retrospective Multicenter Study.

The objective of this retrospective multicenter study was to investigate the mechanism and characteristics of trauma experienced by patients aged ≥65 years who were transferred from a long-term care hospital to one of five university hospital emergency departments. Of 255,543 patients seen in one of the five emergency departments, 79 were transferred from a long-term care hospital because of trauma. The most common trauma mechanism was slipping down, with 33 (58.9%) patients, followed by falling from a bed (17.9%), striking an object such as a wall or corner (10.7%), overextending a joint (8.9%), and unknown mechanisms (3.6%). Many cases of slip (39.4%) occurred in relation to the bathroom. Comparing slip and fall from a bed, we found more hip fractures (95.2%) because of slipping down than falling from a bed (57.1%); traumatic brain injury only occurred in slip cases. These traumas cause significant morbidity in elderly patients; therefore, we sought to identify strategies that prevent slip in long-term care hospitals.

Assessment of serum biomarkers and coagulation/fibrinolysis markers for prediction of neurological outcomes of out of cardiac arrest patients treated with therapeutic hypothermia.

OBJECTIVE: Despite increased survival in patients with cardiac arrest, it remains difficult to determine patient prognosis at the early stage. This study evaluated the prognosis of cardiac arrest patients using brain injury, inflammation, cardiovascular ischemic events, and coagulation/fibrinolysis markers collected 24, 48, and 72 hours after return of spontaneous circulation (ROSC). METHODS: From January 2011 to December 2016, we retrospectively observed patients who underwent therapeutic hypothermia. Blood samples were collected immediately and 24, 48, and 72 hours after ROSC. Neuron-specific enolase (NSE), S100-B protein, procalcitonin, troponin I, creatine kinase-MB, pro-brain natriuretic protein, D-dimer, fibrin degradation product, antithrombin-III, fibrinogen, and lactate levels were measured. Prognosis was evaluated using GlasgowPittsburgh cerebral performance categories and the predictive accuracy of each marker was evaluated. The secondary outcome was whether the presence of multiple markers improved prediction accuracy. RESULTS: A total of 102 patients were included in the study: 39 with good neurologic outcomes and 63 with poor neurologic outcomes. The mean NSE level of good outcomes measured 72 hours after ROSC was 18.50 ng/mL. The area under the curve calculated on receiver operating characteristic analysis was 0.92, which showed the best predictive power among all markers included in the study analysis. The relative integrated discrimination improvement and categoryfree net reclassification improvement models showed no improvement in prognostic value when combined with all other markers and NSE (72 hours). CONCLUSION: Although biomarker combinations did not improve prognostic accuracy, NSE (72 hours) showed the best predictive power for neurological prognosis in patients who received therapeutic hypothermia.

Inter-scanner variability in Hounsfield unit measured by CT of the brain and effect on gray-to-white matter ratio.

PURPOSE: The density ratio of gray matter (GM) to white matter (WM) on brain computed tomography (CT) (gray-to-white matter ratio, GWR) helps predict the prognosis of comatose patients after cardiac arrest. However, Hounsfield units (HU) are not an absolute value and can change based on imaging parameters and CT scanners. We compared the density of brain GM and WM and the GWR by using images scanned with different types of CT machines. METHOD: 102 patients with normal readings who were scanned using three types of CT scanners were included in the study. HU were measured at the basal ganglia level by two observers with circular regions of interest. RESULT: The difference in GM was 0.98-10.30 HU and WM was 1.05-7.55 HU. The mean value of measured HU and GWR were different for each CT group. The ANOVA test showed significant difference all variables. The post hoc test for GWR, which was used to compare the differences between each scanner, was statistically significant. Interclass correlation coefficients of measured GM and WM between the two observers were very high (Cronbach's α=0.995 and 0.990, respectively) and GWR was showed good confidence level (0.798). CONCLUSION: In this study, the HU values of GM and WM in the normal adult brain differed up to 23% among scanners. Unfortunately, the GWR may not compensate for the HU difference between GM and WM occurring between scanners. Therefore, rather than applying consistent GWR cut-offs, the protocol or manufacturer differences between imaging scanners should be considered.

Elderly patients visiting the emergency department for deliberate self-poisoning: do they present a more severe poisoning severity score than the nonelderly patients in the initial 24 h?

PURPOSE: Many elderly patients arrive at the emergency department (ED) complaining of deliberate self-poisoning (DSP). This study determined the poisoning severity of elderly patients who committed DSP. METHODS: A study was performed with 1329 patients (> 15 years of age) who were treated for DSP at two EDs between January 2010 and December 2016. We classified these patients into two groups based on age (an elderly group ≥ 65 years of age and a nonelderly group). Information was collected on age, sex, cause, ingestion time, drug type, suicide attempt history, initial poisoning severity score (PSS), final PSS, outcome, etc. RESULTS: In total, 242 (18.2%) patients were included in the elderly group, of whom 211 (86.9%) were treated for a first suicide attempt. Admission to the intensive-care unit (ICU) (43.8% vs. 25.5%) and endotracheal intubation (16.1% vs. 4.9%) occurred more frequently in the elderly group than in the nonelderly group (p < 0.001). The frequencies of initial severe PSSs (3 and 4) in the elderly group were 9.1% (N = 22) and 1.2% (N = 3), respectively. Multivariate logistic regression analysis showed that the ICU admission of DSP patients was significantly associated with being elderly (OR of 1.47, 95% CI 1.04-2.09, p = 0.029) and with having a GCS of < 13 (OR of 2.67, 95% CI 1.99-3.57, p < 0.001) and an initial PSS of (3,4) (OR of 3.66, 95% CI 2.14-6.26, p < 0.001). In addition, the presence of underlying diseases (coronary heart disease and cerebrovascular disease) yielded high ORs [(OR of 13.13, 95% CI 2.80-61.57, p = 0.001), (OR of 7.34, 95% CI 1.38-39.09, p = 0.020)]. CONCLUSION: Elderly patients who visited the ED for DSP exhibited overall more severe PSSs and poorer in-hospital prognosis than did nonelderly DSP patients.

Clinical characteristics of elderly drowning patients.

PURPOSE: Drowning is one of the major causes of traumatic death. The impact of drowning in the elderly and patients who were not elderly will be different because of physiological differences. We wanted to analyze the clinical differences such as mortality, incidence rate of complications, degree of hypothermia and rate of cardiac arrest between elderly and adult drowning patients. METHODS: This study included drowning patients over 18 years old who came to an emergency department (ED) located on a riverside from September 1997 to July 2016. Patients over the age of 65 years were classified as elderly, while those under the age of 65 years were classified as adults. Demographic data and clinical outcomes were surveyed. RESULTS: A total of 611 patients were included in this study. Sixty-one patients (9.9%) were elderly, and 550 patients (90.1%) were adults. There were 17 elderly patients (15.8%) and 87 adult patients (27.9%) who had cardiac arrest at the time of ED arrival (p = 0.017). The rate of body temperatures < 34 °C was higher in elderly patients than that in adult patients (27.9% vs 17.5%, respectively, p = 0.025). The rates of hospitalization in the intensive care unit (ICU) and mortality were higher in elderly group (23% vs. 15.1%, respectively, p = 0.01; 37.7% vs 21.8%, respectively, p = 0.01). There was no significant difference in suicidal intent between the elderly and adult patient groups (82.0% vs 78.9%, respectively, p = 0.421). CONCLUSIONS: Elderly drowning patients accounted for approximately 1/10 of all drowning cases and were more likely to experience a cardiac arrest, hypothermia, mortality, and ICU admission.

Differences in youngest-old, middle-old, and oldest-old patients who visit the emergency department.

OBJECTIVE: As aging progresses, clinical characteristics of elderly patients in the emergency department (ED) vary by age. We aimed to study differences among elderly patients in the ED by age group. METHODS: For 2 years, patients aged 65 and older were enrolled in the study and classified into three groups: youngest-old, ages 65 to 74 years; middle-old, 75 to 84 years; and oldest-old, ≥85 years. Participants' sex, reason for ED visit, transfer from another hospital, results of treatment, type of admission, admission department and length of stay were recorded. RESULTS: During the study period, a total 64,287 patients visited the ED; 11,236 (17.5%) were aged 65 and older, of whom 14.4% were 85 and older. With increased age, the female ratio (51.5% vs. 54.9% vs. 69.1%, P<0.001), medical causes (79.5% vs. 81.3% vs. 81.7%, P=0.045), and admission rate (35.3% vs. 42.8% vs. 48.5%, P<0.001) increased. Admissions to internal medicine (57.5% vs. 59.3% vs. 64.7%, P<0.001) and orthopedic surgery (8.5% vs. 11.6% vs. 13.8%, P< 0.001) also increased. The ratio of admission to intensive care unit showed no statistical significance (P=0.545). Patients over age 85 years had longer stays in the ED (330.9 vs. 378.9 vs. 407.2 minutes, P<0.001), were discharged home less (84.4% vs. 78.9% vs. 71.5%, P<0.001), and died more frequently (6.3% vs. 10.4% vs. 13.0%, P<0.001). CONCLUSION: With increased age, the proportion of female patients and medical causes increased. Rates of admission and death increased with age and older patients had longer ED and hospital stays.

Continuous neuromuscular blockade infusion for out-of-hospital cardiac arrest patients treated with targeted temperature management: A multicenter randomized controlled trial.

INTRODUCTION: The aim of this trial was to investigate the effect of a continuous infusion of a neuromuscular blockade (NMB) in comatose out-of-hospital cardiac arrest (OHCA) subjects who underwent targeted temperature management (TTM). METHODS: In this open-label, multicenter trial, subjects resuscitated from OHCA were randomly assigned to receive either NMB (38 subjects) or placebo (43 subjects) for 24 hours. Sedatives and analgesics were given according to the protocol of each hospital during TTM. The primary outcome was serum lactate levels at 24 hours after drug infusion. The secondary outcomes included in-hospital mortality, a poor neurological outcome at hospital discharge, changes in lactate levels, changes in the PaO2:FiO2 ratio over time and muscle weakness as assessed by the Medical Research Council (MRC) scale. RESULTS: Eighty-one subjects (NMB group: median age, 65.5 years, 30 male patients; placebo group: median age, 61.0 years, 29 male patients) were enrolled in this trial. No difference in the serum lactate level at 24 hours was observed between the NMB (2.8 [1.2-4.0]) and placebo (3.6 [1.8-5.2]) groups (p = 0.238). In-hospital mortality and a poor neurologic outcome at discharge did not differ between the two groups. No significant difference in the PaO2:FiO2 ratio over time (p = 0.321) nor the MRC score (p = 0.474) was demonstrated. CONCLUSIONS: In OHCA subjects who underwent TTM, a continuous infusion of NMB did not reduce lactate levels and did not improve survival or neurological outcome at hospital discharge. Our results indicated a limited potential for the routine use of NMB during early TTM. However, this trial may be underpowered to detect clinical differences, and future research should be conducted.

Neurologic outcome after out-of-hospital cardiac arrest could be predicted with the help of bispectral-index during early targeted temperature management.

BACKGROUND: Outcome prediction is crucial for out-of-hospital cardiac arrest (OHCA) survivors. Several attempts have been made to use the bispectral index (BIS) for this purpose. We aimed to investigate the prognostic power of the BIS during the early stage of targeted temperature management (TTM) after OHCA. METHODS: From Jan 2014 to Feb 2017, the BIS was determined in OHCA patients as soon as possible after the start of TTM. We injected a neuro-muscular blocking agent and recoded the BIS value and the time when the electromyographic (EMG) factor reached zero. The primary outcome was the cerebral performance category scale (CPC) score at 6 months, and a poor outcome was defined as a CPC score of 3, 4, or 5. The exclusion criteria were age under 18 years, traumatic cardiac arrest, and BIS data with a non-zero EMG factor. RESULTS: Sixty-five patients were included in this study. Good outcomes were observed for 16 patients (24.6%), and poor outcomes were observed for 49 patients (75.4%). The mean time of BIS recording was 2.3 ± 1.0 h after return of spontaneous circulation (ROSC). The mean BIS values of the good outcome and poor outcome groups were 35.6 ± 13.1 and 5.5 ± 9.2, respectively (p < 0.001). The area under the curve was 0.961. Use of a cut-off value of 20.5 to predict a good outcome yielded a sensitivity of 87.5% and specificity of 93.9%. Use of a cut-off value of 10.5 to predict a poor outcome yielded a sensitivity of 87.8% and specificity of 100%. CONCLUSION: With the help of BIS, physicians could predict that a patient who has BIS value over 20.5 after ROSC could have a big chance to get good neurological outcome in less than three hours.

Short-Latency Positive Peak Following N20 Somatosensory Evoked Potential Is Superior to N20 in Predicting Neurologic Outcome After Out-of-Hospital Cardiac Arrest.

OBJECTIVES: The absence of N20 somatosensory evoked potential after cardiac arrest is related to poor outcome. However, discrimination between the low-amplitude and the absence of N20 is challenging. P25 and P30 are short-latency positive peaks with latencies between 25 and 30 ms following N20 (P25/30). P25/30 is evident even with an ambiguous N20 in patients with good outcome. Therefore, we evaluated the predictive value of P25/30 after cardiac arrest. DESIGN: A retrospective observational study. SETTING: University-affiliated hospital. SUBJECTS: Comatose survivors after out-of-hospital cardiac arrest treated by hypothermic targeted temperature management. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: The specificity and the positive predictive value of P25/30 and N20 in predicting poor outcome were the same, showing a rate of 100%. The sensitivity of P25/30 in predicting poor outcome (90.12% [95% CI, 81.5-95.6%]) was higher than that of N20 (70.37% [95% CI, 59.2-80%]). Also, the negative predictive value of P25/30 in predicting poor outcome (81.4% [95% CI, 69.4-89.4%]) was higher than that of N20 (59.3% [95% CI, 51-67.1%]). The P25/30-based adjusted model showed a larger area under the curve (0.98 [95% CI, 0.95-1]) compared with the N20-based adjusted model (0.95 [95% CI, 0.91-0.98]) (p = 0.02). CONCLUSIONS: The absence of P25/30 is related to poor outcome with a higher sensitivity, negative predictive value than the absence of N20.

Can somatosensory and visual evoked potentials predict neurological outcome during targeted temperature management in post cardiac arrest patients?

PURPOSES: In cardiac arrest patients treated with targeted temperature management (TTM), it is not certain if somatosensory evoked potentials (SEPs) and visual evoked potentials (VEPs) can predict neurological outcomes during TTM. The aim of this study was to investigate the prognostic value of SEPs and VEPs during TTM and after rewarming. METHODS: This retrospective cohort study included comatose patients resuscitated from cardiac arrest and treated with TTM between March 2007 and July 2015. SEPs and VEPs were recorded during TTM and after rewarming in these patients. Neurological outcome was assessed at discharge by the Cerebral Performance Category (CPC) Scale. RESULTS: In total, 115 patients were included. A total of 175 SEPs and 150 VEPs were performed. Five SEPs during treated with TTM and nine SEPs after rewarming were excluded from outcome prediction by SEPs due to an indeterminable N20 response because of technical error. Using 80 SEPs and 85 VEPs during treated with TTM, absent SEPs yielded a sensitivity of 58% and a specificity of 100% for poor outcome (CPC 3-5), and absent VEPs predicted poor neurological outcome with a sensitivity of 44% and a specificity of 96%. The AUC of combination of SEPs and VEPs was superior to either test alone (0.788 for absent SEPs and 0.713 for absent VEPs compared with 0.838 for the combination). After rewarming, absent SEPs and absent VEPs predicted poor neurological outcome with a specificity of 100%. When SEPs and VEPs were combined, VEPs slightly increased the prognostic accuracy of SEPs alone. Although one patient with absent VEP during treated with TTM had a good neurological outcome, none of the patients with good neurological outcome had an absent VEP after rewarming. CONCLUSION: Absent SEPs could predict poor neurological outcome during TTM as well as after rewarming. Absent VEPs may predict poor neurological outcome in both periods and VEPs may provide additional prognostic value in outcome prediction.

Prognostic value of gray matter to white matter ratio in hypoxic and non-hypoxic cardiac arrest with non-cardiac etiology.

PURPOSE: This study evaluated the prognostic performance of the gray to white matter ratio (GWR) on brain computed tomography (CT) in out-of-hospital cardiac arrest (OHCA) survivors with a noncardiac etiology and compared the prognostic performance of GWR between hypoxic and nonhypoxic etiologies. METHODS: Using a multicenter retrospective registry of adult OHCA patients treated with targeted temperature management, we identified those with a noncardiac etiology who underwent brain CT within 24 hours after restoration of spontaneous circulation. Attenuation of the gray matter and white matter (at the level of the basal ganglia, centrum semiovale, and high convexity) were measured and GWRs were calculated. The primary outcome was neurologic outcome. RESULTS: Of 164 patients, 145 (88.4%) were discharged with a poor neurologic outcome. Lower GWR was associated with a poor neurologic outcome. The sensitivities of this marker were markedly low (9.7%-43.5%) at cutoff values, with 100% sensitivity. The cutoff values of the GWR for hypoxic arrest showed higher sensitivities than those for nonhypoxic arrest. The area under the curve (AUC) values of the GWR for the caudate nucleus/posterior limb of the internal capsule, putamen/corpus callosum, and basal ganglia were significant in the hypoxic group, whereas the AUC of the putamen/corpus callosum was the only significant GWR in the nonhypoxic group. CONCLUSION: A low GWR is associated with poor neurologic outcome in noncardiac etiology OHCA patients treated with targeted temperature management. Gray to white matter ratio can help to predict the neurologic outcome in a cardiac arrest with hypoxic etiology rather than a nonhypoxic etiology.