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BACKGROUND: This study aimed to validate apparent diffusion coefficient (ADC) values and thresholds to predict poor neurological outcomes in out-of-hospital cardiac arrest (OHCA) survivors by quantitatively analysing the ADC values via brain magnetic resonance imaging (MRI). METHODS: This observational study used prospectively collected data from two tertiary academic hospitals. The derivation cohort comprised 70% of the patients randomly selected from one hospital, whereas the internal validation cohort comprised the remaining 30%. The external validation cohort used the data from another hospital, and the MRI data were restricted to scans conducted at 3 T within 72-96 h after an OHCA experience. We analysed the percentage of brain volume below a specific ADC value at 50-step intervals ranging from 200 to 1200 × 10-6 mm2/s, identifying thresholds that differentiate between good and poor outcomes. Poor neurological outcomes were defined as cerebral performance categories 3-5, 6 months after experiencing an OHCA. RESULTS: A total of 448 brain MRI scans were evaluated, including a derivation cohort (n = 224) and internal/external validation cohorts (n = 96/128, respectively). The proportion of brain volume with ADC values below 450, 500, 550, 600, and 650 × 10-6 mm2/s demonstrated good to excellent performance in predicting poor neurological outcomes in the derivation group (area under the curve [AUC] 0.89-0.91), and there were no statistically significant differences in performances among the derivation, internal validation, and external validation groups (all P > 0.5). Among these, the proportion of brain volume with an ADC below 600 × 10-6 mm2/s predicted a poor outcome with a 0% false-positive rate (FPR) and 76% (95% confidence interval [CI] 68-83) sensitivity at a threshold of > 13.2% in the derivation cohort. In both the internal and external validation cohorts, when using the same threshold, a specificity of 100% corresponded to sensitivities of 71% (95% CI 58-81) and 78% (95% CI 66-87), respectively. CONCLUSIONS: In this validation study, by consistently restricting the MRI types and timing during quantitative analysis of ADC values in brain MRI, we observed high reproducibility and sensitivity at a 0% FPR. Prospective multicentre studies are necessary to validate these findings.
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Paro Cardíaco Extrahospitalario , Humanos , Femenino , Masculino , Persona de Mediana Edad , Anciano , Paro Cardíaco Extrahospitalario/diagnóstico por imagen , Estudios Prospectivos , Pronóstico , Sobrevivientes/estadística & datos numéricos , Estudios de Cohortes , Imagen por Resonancia Magnética/métodos , Imagen de Difusión por Resonancia Magnética/métodos , Valor Predictivo de las Pruebas , Encéfalo/diagnóstico por imagen , Encéfalo/fisiopatologíaRESUMEN
BACKGROUND: To determine if the density distribution proportion of Hounsfield unit (HUdp) in head computed tomography (HCT) images can be used to quantitatively measure cerebral edema in survivors of out-of-hospital cardiac arrest (OHCA). METHODS: This retrospective observational study included adult comatose OHCA survivors who underwent HCT within 6 h (first) and 72-96 h (second), all performed using the same CT scanner. Semi-automated quantitative analysis was used to identify differences in HUdp at specific HU ranges across the intracranial component based on neurological outcome. Cerebral edema was defined as the increased displacement of the sum of HUdp values (ΔHUdp) at a specific range between two HCT scans. Poor neurological outcome was defined as cerebral performance categories 3-5 at 6 months after OHCA. RESULTS: Twenty-three (42%) out of 55 patients had poor neurological outcome. Significant HUdp differences were observed between good and poor neurological outcomes in the second HCT scan at HU = 1-14, 23-35, and 39-56 (all P < 0.05). Only the ΔHUdp = 23-35 range showed a significant increase and correlation in the poor neurological outcome group (4.90 vs. -0.72, P < 0.001) with the sum of decreases in the other two ranges (r = 0.97, P < 0.001). Multivariate logistic regression analysis demonstrated a significant association between ΔHUdp = 23-35 range and poor neurological outcomes (adjusted OR, 1.12; 95% CI: 1.02-1.24; P = 0.02). CONCLUSION: In this cohort study, the increased displacement in ΔHUdp = 23-35 range is independently associated with poor neurological outcome and provides a quantitative assessment of cerebral edema formation in OHCA survivors.
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Edema Encefálico , Paro Cardíaco Extrahospitalario , Adulto , Humanos , Edema Encefálico/etiología , Edema Encefálico/complicaciones , Estudios de Cohortes , Pronóstico , Paro Cardíaco Extrahospitalario/diagnóstico por imagen , Paro Cardíaco Extrahospitalario/terapia , Paro Cardíaco Extrahospitalario/complicaciones , Tomografía Computarizada por Rayos X/métodos , Estudios Retrospectivos , SobrevivientesRESUMEN
BACKGROUND: This study aimed to investigate the association between ultra-early (within 6 h after return of spontaneous circulation [ROSC]) brain diffusion-weighted magnetic resonance imaging (DW-MRI) and neurological outcomes in comatose survivors after out-of-hospital cardiac arrest. METHODS: We conducted a registry-based observational study from May 2018 to February 2022 at a Chungnam national university hospital in Daejeon, Korea. Presence of high-signal intensity (HSI) (PHSI) was defined as a HSI on DW-MRI with corresponding hypoattenuation on the apparent diffusion coefficient map irrespective of volume after hypoxic ischemic brain injury; absence of HSI was defined as AHSI. The primary outcome was the dichotomized cerebral performance category (CPC) at 6 months, defined as good (CPC 1-2) or poor (CPC 3-5). RESULTS: Of the 110 patients (30 women [27.3%]; median (interquartile range [IQR]) age, 58 [38-69] years), 48 (43.6%) had a good neurological outcome, time from ROSC to MRI scan was 2.8 h (IQR 2.0-4.0 h), and the PHSI on DW-MRI was observed in 46 (41.8%) patients. No patients in the PHSI group had a good neurological outcome compared with 48 (75%) patients in the AHSI group. In the AHSI group, cerebrospinal fluid (CSF) neuron-specific enolase (NSE) levels were significantly lower in the group with good neurological outcome compared to the group with poor neurological outcome (20.1 [14.4-30.7] ng/mL vs. 84.3 [32.4-167.0] ng/mL, P < 0.001). The area under the curve for PHSI on DW-MRI was 0.87 (95% confidence interval [CI] 0.80-0.93), and the specificity and sensitivity for predicting a poor neurological outcome were 100% (95% CI 91.2%-100%) and 74.2% (95% CI 62.0-83.5%), respectively. A higher sensitivity was observed when CSF NSE levels were combined (88.7% [95% CI 77.1-95.1%]; 100% specificity). CONCLUSIONS: In this cohort study, PHSI findings on ultra-early DW-MRI were associated with poor neurological outcomes 6 months following the cardiac arrest. The combined CSF NSE levels showed higher sensitivity at 100% specificity than on DW-MRI alone. Prospective multicenter studies are required to confirm these results.
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Paro Cardíaco Extrahospitalario , Femenino , Humanos , Persona de Mediana Edad , Encéfalo , Estudios de Cohortes , Imagen de Difusión por Resonancia Magnética/métodos , Paro Cardíaco Extrahospitalario/complicaciones , Paro Cardíaco Extrahospitalario/diagnóstico por imagen , Fosfopiruvato Hidratasa , Pronóstico , Estudios Prospectivos , Masculino , Adulto , AncianoRESUMEN
BACKGROUND: This study aimed to quantitatively analyse ultra-early brain diffusion-weighted magnetic resonance imaging (DW-MRI) findings to determine the apparent diffusion coefficient (ADC) threshold associated with neurological outcomes in comatose survivors of out-of-hospital cardiac arrest (OHCA). METHODS: This retrospective study included adult survivors of comatose OHCA who underwent DW-MRI imaging scans using a 3-T MRI scanner within 6 h of the return of spontaneous circulation (ROSC). We investigated the association between neurological outcomes and ADC values obtained through voxel-based analysis on DW-MRI. Additionally, we constructed multivariable logistic regression models with pupillary light reflex (PLR), serum neuron-specific enolase (NSE), and ADC values as independent variables to predict poor neurological outcomes. The primary outcome was poor neurological outcome 6 months after ROSC, determined by the Cerebral Performance Category 3-5. RESULTS: Overall, 131 patients (26% female) were analysed, of whom 74 (57%) showed poor neurological outcomes. The group with a poor neurological outcome had lower mean whole brain ADC values (739.1 vs. 787.1 × 10-6 mm/s) and higher percentages of voxels with ADC below threshold in all ranges (250-1150) (all P < 0.001). The mean whole brain ADC values (area under the receiver operating characteristic curve [AUC] 0.83) and the percentage of voxels with ADC below 600 (AUC 0.81) had the highest sensitivity of 51% (95% confidence interval [CI] 39.4-63.1; cut-off value ≤ 739.2 × 10-6 mm2/s and > 17.2%, respectively) when the false positive rate (FPR) was 0%. In the multivariable model, which also included PLR, NSE, and mean whole brain ADC values, poor neurological outcome was predicted with the highest accuracy (AUC 0.91; 51% sensitivity). This model showed more accurate prediction and sensitivity at an FPR of 0% than did the combination of PLR and NSE (AUC 0.86; 30% sensitivity; P = 0.03). CONCLUSIONS: In this cohort study, early voxel-based quantitative ADC analysis after ROSC was associated with poor neurological outcomes 6 months after cardiac arrest. The mean whole brain ADC value demonstrated the highest sensitivity when the FPR was 0%, and including it in the multivariable model improved the prediction of poor neurological outcomes.
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Paro Cardíaco Extrahospitalario , Adulto , Humanos , Femenino , Masculino , Paro Cardíaco Extrahospitalario/complicaciones , Paro Cardíaco Extrahospitalario/diagnóstico por imagen , Imagen de Difusión por Resonancia Magnética/métodos , Coma , Estudios de Cohortes , Estudios Retrospectivos , Pronóstico , SobrevivientesRESUMEN
BACKGROUND/OBJECTIVE: Cerebrospinal fluid (CSF) and serum lactate levels were assessed to predict poor neurologic outcome 3 months after return of spontaneous circulation (ROSC). We compared arterio-CSF differences in the lactate (ACDL) levels between two neurologic outcome groups. METHODS: This retrospective observational study involved out-of-hospital cardiac arrest (OHCA) survivors who had undergone target temperature management. CSF and serum samples were obtained immediately (lactate0), and at 24 (lactate24), 48 (lactate48), and 72 (lactate72) h after ROSC, and ACDL was calculated at each time point. The primary outcome was poor 3-month neurologic outcome (cerebral performance categories 3-5). RESULTS: Of 45 patients, 27 (60.0%) showed poor neurologic outcome. At each time point, CSF lactate levels were significantly higher in the poor neurologic outcome group than in the good neurologic outcome group (6.97 vs. 3.37, 4.20 vs. 2.10, 3.50 vs. 2.00, and 2.79 vs. 2.06, respectively; all P < 0.05). CSF lactate's prognostic performance was higher than serum lactate at each time point, and lactate24 showed the highest AUC values (0.89, 95% confidence interval, 0.75-0.97). Over time, ACDL decreased from - 1.30 (- 2.70-0.77) to - 1.70 (- 3.2 to - 0.57) in the poor neurologic outcome group and increased from - 1.22 (- 2.42-0.32) to - 0.64 (- 2.31-0.15) in the good neurologic outcome group. CONCLUSIONS: At each time point, CSF lactate showed better prognostic performance than serum lactate. CSF lactate24 showed the highest prognostic performance for 3-month poor neurologic outcome. Over time, ACDL decreased in the poor neurologic outcome group and increased in the good neurologic outcome group.
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Hipotermia Inducida , Paro Cardíaco Extrahospitalario , Encéfalo , Humanos , Ácido Láctico , Paro Cardíaco Extrahospitalario/terapia , Pronóstico , Estudios RetrospectivosRESUMEN
BACKGROUND: A prior suicide attempt is known to be the most important risk factor for suicide. Case management programs provide psychosocial support and rehabilitation for suicide attempters. This study aimed to determine whether case management completion is associated with good clinical outcomes for suicide attempters visiting the emergency department (ED). METHODS: A cross-sectional observational study was conducted using risk assessment records for suicide attempters visiting the ED from October 2013 to December 2017. We created two groups according to completion of the case management program. The primary outcome was a decrease in suicide risk. The secondary and tertiary outcomes were untreated stressors and lack of a support system. We calculated the adjusted odds ratio (AOR) of the case management completion for study outcomes adjusting for potential confounders. RESULTS: Among 439 eligible suicide attempters, only 277 (63.1%) participants completed the case management program. Participants who completed the case management program were more likely to have decreased suicide risk (65.3% vs. 46.9%, AOR: 2.13 (1.42-3.20)) and less untreated stressors (49.8% vs. 61.1%, AOR: 0.64 (0.43-0.96)). However, there was no significant difference in lack of a support system (35.4% vs. 45.7%, AOR: 0.68 (0.45-1.03)). CONCLUSION: Completion of a case management program was associated with reduction of suicide risk. Multicomponent strategies to increase compliance with a case management program are needed to prevent suicide reattempt and reduce the health burden of suicide.
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Manejo de Caso , Prevención del Suicidio , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Estudios Transversales , Servicio de Urgencia en Hospital , Femenino , Humanos , Masculino , Persona de Mediana Edad , Cooperación del Paciente , Factores de Riesgo , Intento de Suicidio , Resultado del Tratamiento , Adulto JovenRESUMEN
PURPOSE: The technical factors which improve cosmetic outcomes and which need to be emphasized in education of junior residents have yet to be described. We compared cases in which suturing was performed by either junior emergency medicine residents or experts, in order to determine the focus of future education and training. METHODS: Wound registry data was reviewed and retrospectively analyzed from September 2015 to February 2016. Only patients who visited the emergency room with facial lacerations were enrolled, and their wound registry data sheets were reviewed. Practitioners were divided into junior resident and expert groups. We assessed the progress using the Stony Brook Scar Evaluation Scale (SBSES) 5-10â¯days following suturing. RESULTS: Sixty-six patients were enrolled; 43 (65.2%) were men. The median (interquartile range) cosmetic scores (SBSES scale) for suturing performed by junior residents or experts were 3 (2-4) and 5 (4-5), respectively (pâ¯=â¯0.001). The percentage of maximum scores for each SBSES category was significantly lower in the junior resident group than in the expert group for width (68% vs. 86%), hatch marks (68% vs. 93%), and overall appearance (41% vs. 80%) (all pâ¯<â¯0.001). CONCLUSIONS: There were significant differences in scar widths and hatch marks, which were attributable to the skill level of the practitioner who performed the suturing of facial lacerations. Junior residents should be educated about maintenance of proper tension, atraumatic technique, and performing appropriate trimming or debridement.
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Cicatriz/prevención & control , Traumatismos Faciales/cirugía , Internado y Residencia , Laceraciones/cirugía , Técnicas de Sutura/educación , Adulto , Anciano , Competencia Clínica , Desbridamiento/educación , Medicina de Emergencia/educación , Servicio de Urgencia en Hospital/estadística & datos numéricos , Traumatismos Faciales/patología , Femenino , Humanos , Laceraciones/patología , Masculino , Persona de Mediana Edad , Sistema de Registros , Estudios RetrospectivosRESUMEN
BACKGROUND: This study aimed to explore the changes in blood-brain barrier (BBB) permeability and intracranial pressure (ICP) for the first 24 h after the return of spontaneous circulation (ROSC) and their association with injury severity of cardiac arrest. METHODS: This prospective study analysed the BBB permeability assessed using the albumin quotient (Qa) and ICP every 2 h for the first 24 h after ROSC. The injury severity of cardiac arrest was assessed using Pittsburgh Cardiac Arrest Category (PCAC) scores. The primary outcome was the time course of changes in the BBB permeability and ICP for the first 24 h after ROSC and their association with injury severity (PCAC scores of 1-4). RESULTS: Qa and ICP were measured 274 and 197 times, respectively, in 32 enrolled patients. Overall, the BBB permeability increased progressively over time after ROSC, and then it increased significantly at 18 h after ROSC compared with the baseline. In contrast, the ICP revealed non-significant changes for the first 24 h after ROSC. The Qa in the PCAC 2 group was < 0.01, indicating normal or mild BBB disruption at all time points, whereas the PCAC 3 and 4 groups showed a significant increase in BBB permeability at 14 and 22 h, and 12 and 14 h after ROSC, respectively. CONCLUSION: BBB permeability increased progressively over time for the first 24 h after ROSC despite post-resuscitation care, whereas ICP did not change over time. BBB permeability has an individual pattern when stratified by injury severity.
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Barrera Hematoencefálica , Paro Cardíaco , Hipoxia-Isquemia Encefálica , Presión Intracraneal , Barrera Hematoencefálica/fisiopatología , Barrera Hematoencefálica/metabolismo , Humanos , Masculino , Femenino , Estudios Prospectivos , Persona de Mediana Edad , Hipoxia-Isquemia Encefálica/fisiopatología , Hipoxia-Isquemia Encefálica/etiología , Paro Cardíaco/fisiopatología , Paro Cardíaco/terapia , Paro Cardíaco/etiología , Anciano , Presión Intracraneal/fisiología , Factores de Tiempo , Retorno de la Circulación Espontánea , Reanimación Cardiopulmonar/métodos , Reanimación Cardiopulmonar/efectos adversos , Permeabilidad Capilar/fisiologíaRESUMEN
We investigated the agreement between the jugular bulb (JB) and cerebrospinal fluid (CSF) lactate levels. The study was conducted from July 2021 to June 2023 as a prospective observational cohort study at a single center. The right jugular vein was accessed, and the placement of JB catheter tip was confirmed using lateral cervical spine X-ray. A lumbar catheter was inserted between the 3rd and 4th lumbar spine of the patient. Lactate levels were measured immediately, 24 h, 48 h, and 72 h after ROSC. In patients with a good neurological prognosis, kappa between JB and CSF lactate levels measured immediately, at 24 h, 48 h, and 72 h after ROSC were 0.08, 0.36, 0.14, - 0.05 (p = 0.65, 0.06, 0.48, and 0.75, respectively). However, in patients with a poor neurological prognosis, kappa between JB and CSF lactate levels measured immediately, at 24 h, 48 h, and 72 h after ROSC were 0.38, 0.21, 0.22, 0.12 (p = 0.001, 0.04, 0.04, and 0.27, respectively). This study demonstrated that JB lactate levels exhibited significant agreement with arterial lactate levels, compared to CSF lactate levels. Therefore, this should be considered when using JB lactate to monitor cerebral metabolism.
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Venas Yugulares , Ácido Láctico , Paro Cardíaco Extrahospitalario , Humanos , Ácido Láctico/líquido cefalorraquídeo , Masculino , Femenino , Persona de Mediana Edad , Anciano , Paro Cardíaco Extrahospitalario/líquido cefalorraquídeo , Estudios Prospectivos , Pronóstico , Biomarcadores/líquido cefalorraquídeoRESUMEN
Changes in cerebrospinal fluid (CSF) dynamics can have adverse effects on neuronal function. We hypothesized that patients with hypoxic-ischemic brain injury (HIBI) showing poor neurological outcomes after cardiac arrest (CA) would exhibit changes in CSF dynamics, leading to abnormalities in gas diffusion within the CSF. Therefore, we investigated the prognostic value of the CSF partial pressure of carbon dioxide (PcsfCO2) in CA survivors who underwent targeted temperature management (TTM). We retrospectively analyzed the 6-month neurological outcomes, CSF, and arterial blood gas parameters of 67 CA survivors. Patients were divided into good and poor neurological outcome groups, and the predictive value of PcsfCO2 for poor neurological outcomes was assessed using receiver operating characteristic curve analysis. Among all patients, 39 (58.2%) had poor neurological outcomes. Significant differences in PcsfCO2 levels between the groups were observed, with lower PcsfCO2 levels on Day 1 showing the highest predictive value at a cutoff of 30 mmHg (area under the curve, sensitivity, and specificity were 0.823, 77.8%, and 79.0%, respectively). These results suggest that PcsfCO2 might serve not only as a unique marker for the severity of hypoxic-ischemic brain injury (HIBI), independent of extracorporeal CO2 levels, but also as an objective indicator of changes in CSF dynamics. This study highlights the potential prognostic and diagnostic utility of PcsfCO2 during TTM in CA survivors, emphasizing its importance in evaluating CSF dynamics and neurological recovery post CA. However, larger multicenter studies are warranted to address potential limitations associated with sample size and outcome assessment methods.
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Administration of sedatives for post-resuscitation care can complicate the determination of the optimal timing to avoid inappropriate, pessimistic prognostications. This prospective study aimed to investigate the distribution and elimination kinetics of midazolam (MDZ) and its metabolites, and their association with awakening time. The concentrations of MDZ and its seven metabolites were measured immediately and at 4, 8, 12, and 24 h after the discontinuation of MDZ infusion, using liquid chromatography-tandem mass spectrometry. The area under the time-plasma concentration curve from 0 to 24 h after MDZ discontinuation (AUClast) was calculated based on the trapezoidal rule. Of the 15 enrolled patients, seven awakened after the discontinuation of MDZ infusion. MDZ and three of its metabolites were major compounds and their elimination kinetics followed a first-order elimination profile. In the multivariable analysis, only MDZ was associated with awakening time (AUClast: R2 = 0.59, p = 0.03; AUCinf: R2 = 0.96, p < 0.001). Specifically, a 0.001% increase in MDZ AUC was associated with a 1% increase in awakening time. In the individual regression analysis between MDZ concentration and awakening time, the mean MDZ concentration at awakening time was 16.8 ng/mL. The AUC of MDZ is the only significant factor associated with the awakening time.
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Hipnóticos y Sedantes , Midazolam , Humanos , Estudios Prospectivos , Cromatografía LiquidaRESUMEN
BACKGROUND: No standard treatment guidelines have been established for postpartum hemorrhage (PPH). We aimed to assess the differences in outcomes and prognoses between patients with PPH who underwent surgical and non-surgical treatment. METHODS: This retrospective study included 230 patients diagnosed with PPH at two referral hospitals between August 2013 and October 2023. The patients were divided into non-surgical (group 1, n = 159) and surgical intervention groups (group 2, n = 71). A subgroup analysis was performed by dividing the surgical intervention group into immediate (n = 45) and delayed surgical intervention groups (n = 26). RESULTS: Initial lactic acid levels and shock index were significantly higher in group 2 (2.85 ± 1.37 vs. 4.54 ± 3.63 mmol/L, p = 0.001, and 0.83 ± 0.26 vs. 1.10 ± 0.51, p < 0.001, respectively). Conversely, initial heart rate and body temperature were significantly lower in group 2 (92.5 ± 21.0 vs. 109.0 ± 28.1 beat/min, p < 0.001, and 37.3 ± 0.8 °C vs. 37.0 ± 0.9 °C, p = 0.011, respectively). Logistic regression analysis identified low initial body temperature, high lactic acid level, and shock index as independent predictors of surgical intervention (p = 0.029, p = 0.027, and p = 0.049, respectively). Regarding the causes of PPH, tone was significantly more prevalent in group 1 (57.2% vs. 35.2%, p = 0.002), whereas trauma was significantly more prevalent in group 2 (24.5% vs. 39.4%, p = 0.030). Group 2 had worse overall outcomes and prognoses than group 1. The subgroup analysis showed significantly higher rates of uterine atony combined with other causes, hysterectomy, and disseminated intravascular coagulopathy in the delayed surgical intervention group than the immediate surgical intervention group (42.2% vs. 69.2%, p = 0.027; 51.1% vs. 73.1%, p = 0.049; and 17.8% vs. 46.2%, p = 0.018, respectively). CONCLUSIONS: Patients with PPH presenting with increased lactic acid levels and shock index and decreased body temperature may be surgical candidates. Additionally, immediate surgical intervention in patients with uterine atony combined with other causes of PPH could improve prognosis and reduce postoperative complications.
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Hemorragia Posparto , Humanos , Femenino , Estudios Retrospectivos , Adulto , Pronóstico , Embarazo , Ácido Láctico/sangreRESUMEN
The aim of this study was to investigate the differences in cerebral metabolism and the prognostic value of cerebrospinal fluid (CSF) lactate 24 h after the return of spontaneous circulation (ROSC) in patients with out-of-hospital cardiac arrest (OHCA). CSF lactate and pyruvate levels were measured immediately and every 2 h for 24 h after the ROSC. The distribution of cerebral mitochondrial dysfunction (MD) and cerebral ischemia was also evaluated. In the moderate-severity group, the absence of cerebral MD or ischemia was observed in six patients (40.0%) immediately after ROSC and in nine patients (60.0%) 24 h after the ROSC. In the high-severity group, the absence of cerebral MD or ischemia was observed in four patients (30.8%) immediately after ROSC and in three patients (23.1%) 24 h after the ROSC. The distribution of cerebral metabolism over time varied depending on the severity of the OHCA. The predictive value of CSF lactate levels for a poor neurological prognosis was better for patients in the moderate-severity group than for the overall patient cohort. Therefore, the severity in the patients with OHCA should be considered when studying cerebral metabolism or using CSF lactate as a prognostic tool.
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AIM: To understand the serum and cerebrospinal fluid (CSF) distribution of midazolam is important for proper timing of neurological prognostication of targeted temperature management(TTM) patients. Midazolam binds extensively to albumin in serum although non protein bound form exist in CSF. We investigated the time-course of CSF, serum concentrations of midazolam and albumin in patients with cardiac arrest who underwent TTM. METHODS: This prospective, single-center, observational study was conducted between May 2020 and April 2022. Midazolam and albumin concentrations in CSF and serum were quantified 0, 24, 48, and 72 h after the return of spontaneous circulation for comparison between the good (Cerebral Performance Category (CPC) 1 and 2) and poor (CPC 3, 4, and 5) neurologic outcome groups. The CSF/serum (C/S) ratios of midazolam and albumin concentrations were determined, along with their correlation coefficients. RESULTS: Of the 19 enrolled patients, 13 experienced poor outcomes. At 0 h, serum midazolam concentrations were the lowest, whereas serum albumin levels were the highest; in the CSF, the concentrations of both peaked at 24 h. There were no significant inter-group differences in midazolam concentrations in CSF or serum. The C/S ratios of midazolam and albumin significantly differed between the groups. Moderate to strong positive correlations were observed between the midazolam and albumin C/S ratios. CONCLUSION: In CSF, midazolam and albumin concentrations peaked 24 h post-cardiac arrest. Midazolam and albumin C/S ratios were significantly higher in the poor outcome group and positively correlated with each other, suggesting blood-brain barrier disruption 24 h post-cardiac arrest.
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Hipotermia Inducida , Paro Cardíaco Extrahospitalario , Humanos , Midazolam , Paro Cardíaco Extrahospitalario/terapia , Estudios Prospectivos , AlbúminasRESUMEN
We investigated prognostic strategies for predicting good outcomes in the early stage of post-cardiac-arrest care using multiple prognostic tests that are available until 24 h after the return of spontaneous circulation (ROSC). A retrospective analysis was conducted on 138 out-of-hospital cardiac-arrest patients who underwent prognostic tests, including the gray-white-matter ratio (GWR-BG), the Glasgow Coma Scale motor (GCS-M) score before sedative administration, and the neuron-specific enolase (NSE) level measured at 24 h after the ROSC. We investigated the prognostic performances of the tests as single predictors and in various combination strategies. Classification and regression-tree analysis were used to provide a reliable model for the risk stratification. Out of all the patients, 55 (44.0%) had good outcomes. The NSE level showed the highest prognostic performance as a single prognostic test and provided improved specificities (>70%) and sensitivities (>98%) when used in combination strategies. Low NSE levels (≤32.1 ng/mL) and high GCS-M (≥4) scores identified good outcomes without misclassification. The overall accuracy for good outcomes was 81.8%. In comatose patients with low NSE levels or high GCS-M scores, the premature withdrawal of life-sustaining therapy should be avoided, thereby complying with the formal prognostication-strategy algorithm after at least 72 h from the ROSC.
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This study investigated the prognostic performance of combination strategies using a multimodal approach in patients treated after cardiac arrest. Prospectively collected registry data were used for this retrospective analysis. Poor outcome was defined as a cerebral performance category of 3-5 at 6 months. Predictors of poor outcome were absence of ocular reflexes (PR/CR) without confounding factors, a highly malignant pattern on the most recent electroencephalography, defined as suppressed background with or without periodic discharges and burst-suppression, high neuron-specific enolase (NSE) after 48 h, and diffuse injury on imaging studies (computed tomography or diffusion-weighted imaging [DWI]) at 72-96 h. The prognostic performances for poor outcomes were analyzed for sensitivity and specificity. A total of 130 patients were included in the analysis. Of these, 68 (52.3%) patients had poor outcomes. The best prognostic performance was observed with the combination of absent PR/CR, high NSE, and diffuse injury on DWI [91.2%, 95% confidence interval (CI) 80.7-97.1], whereas the combination strategy of all available predictors did not improve prognostic performance (87.8%, 95% CI 73.8-95.9). Combining three of the predictors may improve prognostic performance and be more efficient than adding all tests indiscriminately, given limited medical resources.
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Paro Cardíaco , Hipotermia Inducida , Paro Cardíaco Extrahospitalario , Humanos , Estudios Retrospectivos , Paro Cardíaco/terapia , Pronóstico , Resucitación , Sensibilidad y Especificidad , Fosfopiruvato Hidratasa , Hipotermia Inducida/métodos , Paro Cardíaco Extrahospitalario/terapiaRESUMEN
Surgical debridement is an essential step in treating complex facial lacerations (CFL). As the CFL severity increases, conventional surgical debridement (CSD) of wound edges becomes difficult and may be insufficient. Because the severity and shape of each CFL vary, it is necessary to tailor the customized pre-excisional design, that is, tailored surgical debridement (TSD), for each case before performing surgical debridement. The use of TSD can enable effective debridement of CFL with higher severity. This study aimed to compare the cosmetic outcomes and complication incidence of CSD versus TSD according to CFL severity. In this retrospective observational study, eligible patients with CFL who visited the emergency department between August 2020 and December 2021 were examined. CFL severity was graded as Grades I and II. The outcomes of CSD and TSD were compared using the scar cosmesis assessment and rating (SCAR) scale, wherein a good cosmetic outcome was defined as a SCAR score ofâ ≤â 2. The percentage of good cosmetic outcomes between the 2 groups was compared. The SCAR score and percentage of good cosmetic outcomes between the 2 groups were compared overall and by severity. For analyzing complication incidence, asymmetry, infection, and dehiscence incidence were compared. In total, 252 patients were enrolled [121 (48.0%) CSD and 131 (52.0%) TSD]. The median SCAR scores were 3 (1-5) and 1 (0-2) in all enrolled patients (Pâ <â .001), 2 (0-4), and 1 (0-1) in Grade I patients (Pâ <â .01), and 5 (4-6) and 1 (1-2) in Grade II patients (Pâ <â .001) in the CSD and TSD groups, respectively. The percentage of good cosmetic outcomes was 46.3% and 84.0% overall (Pâ <â .001), 59.6% and 85.0% in Grade I patients (Pâ <â .01), and 9.4% and 83.5% in Grade II patients (Pâ <â .001) in the CSD and TSD groups, respectively. The incidence of complications was significantly higher in the CSD group than in the TSD group, but this was limited to asymmetry. No significant difference was noted in infection or dehiscence. Compared with CSD, TSD can lead to an objectively good cosmetic prognosis at higher CFL severity and can reduce facial asymmetry occurrence.
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Traumatismos Faciales , Laceraciones , Humanos , Laceraciones/cirugía , Estudios Retrospectivos , Desbridamiento/efectos adversos , Resultado del Tratamiento , Cicatriz/etiología , Traumatismos Faciales/complicaciones , Servicio de Urgencia en HospitalRESUMEN
OBJECTIVE: In the present study, intracranial pressure (ICP) changes were investigated in out-ofhospital cardiac arrest (OHCA) patients with and without malignant blood-brain barrier (BBB) disruption who underwent target temperature management. METHODS: This prospective, single-center, observational study was conducted from June 2019 to December 2021. ICP and albumin quotient values were measured on days 1, 2, 3, and 4 of hospitalization. Malignant BBB disruption was defined as the sum of scores for the degree of BBB disruption ≥9 on days 1 to 4. RESULTS: ICP in OHCA patients without malignant BBB disruption on days 1, 2, 3, and 4 of hospitalization was 9.58±0.53, 12.32±0.65, 14.39±0.76, and 13.88±0.87 mmHg, respectively, and in OHCA patients with malignant BBB disruption 13.65±0.74, 15.72±0.67, 16.10±0.92, and 15.22±0.87 mmHg, respectively (P<0.001, P<0.001, P=0.150, and P=0.280, respectively). The P-values of changes in ICP between days 1 and 2, days 2 and 3, and days 3 and 4 of hospitalization in OHCA patients without malignant BBB disruption were P<0.001, P=0.001, and P=0.540, respectively, and in OHCA patients with malignant BBB disruption were P=0.002, P=0.550, and P=0.100, respectively. CONCLUSION: Among OHCA patients treated with target temperature management, ICP was higher on days 1 and 2 of hospitalization and an increase in ICP occurred earlier with malignant BBB disruption than without malignant BBB disruption.
RESUMEN
Neuroprognostication of cardiac arrest patients remains a challenge. We evaluated the early prognostic value and optimal time of measuring serum and cerebrospinal fluid (CSF) tau protein levels to predict neurologic outcome in postcardiac arrest patients treated with targeted temperature management (TTM). We also evaluated the cutoff values in predicting poor outcomes. Patients treated with TTM following cardiac arrest, from May 2018 to June 2019, were included in the study. Serum and CSF tau levels were obtained and compared immediately, at 24, 48, and 72 hours after return of spontaneous circulation (ROSC). The area under the receiver-operating characteristic curve (AUROC) and the Delong method were used to identify the cutoff values of serum and CSF tau protein levels in predicting poor outcomes at each interval. Of 38 patients enrolled, 16 experienced poor outcomes. Both serum and CSF tau levels were consistently higher in the poor outcome group than in the good outcome group. The AUROCs of serum and CSF tau protein were not significantly different at each time point. Immediately after ROSC, sensitivities of both serum and CSF tau protein levels were 31.25% at 100% specificity and increased to 86.6% and 73.3%, respectively, at 72 hours. This study demonstrates that serum and CSF tau protein levels could be used as valuable predictors of neurologic outcomes in postcardiac arrest patients treated with TTM. The early optimal time for measuring the serum and CSF tau protein levels was determined to be 72 hours after ROSC.