Post-cardiac arrest intensive care in Sweden: A survey of current clinical practice.

BACKGROUND: European guidelines recommend targeted temperature management (TTM) in post-cardiac arrest care. A large multicentre clinical trial, however, showed no difference in mortality and neurological outcome when comparing hypothermia to normothermia with early treatment of fever. The study results were valid given a strict protocol for the assessment of prognosis using defined neurological examinations. With the current range of recommended TTM temperatures, and applicable neurological examinations, procedures may differ between hospitals and the variation of clinical practice in Sweden is not known. AIM: The aim of this study was to investigate current practice in post-resuscitation care after cardiac arrest as to temperature targets and assessment of neurological prognosis in Swedish intensive care units (ICUs). METHODS: A structured survey was conducted by telephone or e-mail in all Levels 2 and 3 (= 53) Swedish ICUs during the spring of 2022 with a secondary survey in April 2023. RESULTS: Five units were not providing post-cardiac arrest care and were excluded. The response rate was 43/48 (90%) of the eligible units. Among the responding ICUs, normothermia (36-37.7°C) was applied in all centres (2023). There was a detailed routine for the assessment of neurological prognosis in 38/43 (88%) ICUs. Neurological assessment was applied 72-96 h after return of spontaneous circulation in 32/38 (84%) units. Electroencephalogram and computed tomography and/or magnetic resonance imaging were the most common technical methods available. CONCLUSION: Swedish ICUs use normothermia including early treatment of fever in post-resuscitation care after cardiac arrest and almost all apply a detailed routine for the assessment of neurological prognosis. However, available methods for prognostic evaluation varies between hospitals.

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 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.

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.

Application of a standardized EEG pattern classification in the assessment of neurological prognosis after cardiac arrest: A retrospective analysis.

INTRODUCTION: Electroencephalogram (EEG) is used in the neurological prognostication after cardiac arrest. "Highly malignant" EEG patterns classified according to Westhall have a high specificity for poor neurological outcome when applied within protocols of recent studies. However, their predictive performance when applied in everyday clinical practice has not been investigated. We studied the prognostic accuracy and the interrater agreement when standardized EEG patterns were analysed and compared to neurological outcome in a patient cohort at a tertiary centre not involved in the original study of the standardized EEG pattern classification. METHODS: Comatose patients treated for out-of-hospital cardiac arrest were included. Poor outcome was defined as Cerebral Performance Category 3-5. Two senior consultants and one resident in clinical neurophysiology, blinded to clinical data and outcome, independently reviewed their EEG registrations and categorised the pattern as "highly malignant", "malignant" or "benign". These categories were compared to neurological outcome at hospital discharge. Interrater agreement was assessed using Cohen's Kappa. RESULTS: In total, 62 patients were included. The median (IQR) time to EEG was 59 (42-91) h after return of spontaneous circulation. Poor outcome was found in 52 (84%) patients. In 21 patients at least one of the raters considered the EEG to contain a "highly malignant" pattern, all with poor outcome (42% sensitivity, 100% specificity). The interrater agreement varied from kappa 0.62 to 0.29. CONCLUSION: "Highly malignant" patterns predict poor neurological outcome with a high specificity in everyday practice. However, interrater agreement may vary substantially even between experienced EEG interpreters.

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.