The predictive value of highly malignant EEG patterns after cardiac arrest: evaluation of the ERC-ESICM recommendations.

PURPOSE: The 2021 guidelines endorsed by the European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) recommend using highly malignant electroencephalogram (EEG) patterns (HMEP; suppression or burst-suppression) at > 24 h after cardiac arrest (CA) in combination with at least one other concordant predictor to prognosticate poor neurological outcome. We evaluated the prognostic accuracy of HMEP in a large multicentre cohort and investigated the added value of absent EEG reactivity. METHODS: This is a pre-planned prognostic substudy of the Targeted Temperature Management trial 2. The presence of HMEP and background reactivity to external stimuli on EEG recorded > 24 h after CA was prospectively reported. Poor outcome was measured at 6 months and defined as a modified Rankin Scale score of 4-6. Prognostication was multimodal, and withdrawal of life-sustaining therapy (WLST) was not allowed before 96 h after CA. RESULTS: 845 patients at 59 sites were included. Of these, 579 (69%) had poor outcome, including 304 (36%) with WLST due to poor neurological prognosis. EEG was recorded at a median of 71 h (interquartile range [IQR] 52-93) after CA. HMEP at > 24 h from CA had 50% [95% confidence interval [CI] 46-54] sensitivity and 93% [90-96] specificity to predict poor outcome. Specificity was similar (93%) in 541 patients without WLST. When HMEP were unreactive, specificity improved to 97% [94-99] (p = 0.008). CONCLUSION: The specificity of the ERC-ESICM-recommended EEG patterns for predicting poor outcome after CA exceeds 90% but is lower than in previous studies, suggesting that large-scale implementation may reduce their accuracy. Combining HMEP with an unreactive EEG background significantly improved specificity. As in other prognostication studies, a self-fulfilling prophecy bias may have contributed to observed results.

Extracorporeal Life Support Organization Center of Excellence recognition is associated with improved failure to rescue after cardiac arrest.

OBJECTIVE: The influence of Extracorporeal Life Support Organization (ELSO) center of excellence (CoE) recognition on failure to rescue after cardiac surgery is unknown. We hypothesized that ELSO CoE would be associated with improved failure to rescue. METHODS: Patients undergoing a Society of Thoracic Surgeons index operation in a regional collaborative (2011-2021) were included. Patients were stratified by whether or not their operation was performed at an ELSO CoE. Hierarchical logistic regression analyzed the association between ELSO CoE recognition and failure to rescue. RESULTS: A total of 43,641 patients were included across 17 centers. In total, 807 developed cardiac arrest with 444 (55%) experiencing failure to rescue after cardiac arrest. Three centers received ELSO CoE recognition, and accounted for 4238 patients (9.71%). Before adjustment, operative mortality was equivalent between ELSO CoE and non-ELSO CoE centers (2.08% vs 2.36%; P = .25), as was the rate of any complication (34.5% vs 33.8%; P = .35) and cardiac arrest (1.49% vs 1.89%; P = .07). After adjustment, patients undergoing surgery at an ELSO CoE facility were observed to have 44% decreased odds of failure to rescue after cardiac arrest, relative to patients at non-ELSO CoE facility (odds ratio, 0.56; 95% CI, 0.316-0.993; P = .047). CONCLUSIONS: ELSO CoE status is associated with improved failure to rescue following cardiac arrest for patients undergoing cardiac surgery. These findings highlight the important role that comprehensive quality programs serve in improving perioperative outcomes in cardiac surgery.

Ventricular Fibrillation Is a Sign of Life.

Ventricular fibrillation (VF) is a deadly rhythm problem. With asystole, it represents one of the most extreme emergencies that may engage vital prognosis within only few minutes if appropriated treatment is not instituted. It is learned in all medical schools worldwide that VF is not compatible with consciousness and sustained life. Moreover, at 37°C, and without restauration of cardiac flow, VF may be responsible for severe and most often irreversible brain damage after 3 minutes.

Predicting Risk of Cardiac Arrest in Young Asian Americans: Insights from an Artificial Neural Network Analysis of the Nationwide Cohort.

We used the Artificial Neural Network (ANN) model to identify predictors of Sudden Cardiac Arrest (SCA) in a national cohort of young Asian patients in the United States. The National Inpatient Sample (2019) was used to identify young Asians (18-44-year-old) who were hospitalized with SCA. The neural network's predicted criteria for SCA were selected. After eliminating missing data, young Asians (n = 65,413) were randomly divided into training (n = 45,094) and testing (n = 19347) groups. Training data (70%) was used to calibrate ANN while testing data (30%) was utilized to assess the algorithm's accuracy. To determine ANN's performance in predicting SCA, we compared the frequency of incorrect prediction between training and testing data and measured the area under the Receiver Operating Curve (AUC). The 2019 young Asian cohort had 327,065 admissions (median age 32 years; 84.2% female), with SCA accounting for 0.21%. The exact rate of error in predictions vs. tests was shown by training data (0.2% vs 0.2%). In descending order, the normalized importance of predictors to accurately predict SCA in young adults included prior history of cardiac arrest, sex, age, diabetes, anxiety disorders, prior coronary artery bypass grafting, hypertension, congenital heart disease, income, peripheral vascular disease, and cancer. The AUC was 0.821, indicating an excellent ANN model for SCA prediction. Our ANN models performed excellently in revealing the order of important predictors of SCA in young Asian American patients. These findings could have a considerable impact on clinical practice to develop risk prediction models to improve the survival outcome in high-risk patients.

Kidney-specific biomarkers for predicting acute kidney injury following cardiac arrest.

AIM: To evaluate the performance of kidney-specific biomarkers (neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), and cystatin-C) in early detection of acute kidney injury (AKI) following cardiac arrest (CA) when compared to serum creatinine. METHODS: Adult CA patients who had kidney-specific biomarkers of AKI collected within 12 h of return of spontaneous circulation (ROSC) were included. The association between renal biomarker levels post-ROSC and the development of KDIGO stage III AKI within 7 days of enrollment were assessed as well as their predictive value of future AKI development, neurological outcomes, and survival to discharge. RESULTS: Of 153 patients, 54 (35%) developed stage III AKI within 7 days, and 98 (64%) died prior to hospital discharge. Patients who developed stage III AKI, compared to those who did not, had higher median levels of creatinine, NGAL, and cystatin-C (p < 0.001 for all). There was no statistically significant difference in KIM-1 between groups. No biomarker outperformed creatinine in the ability to predict stage III AKI, neurological outcomes, or survival outcomes (p > 0.05 for all). However, NGAL, cystatin-C, and creatinine all performed better than KIM-1 in their ability to predict AKI development (p < 0.01 for all). CONCLUSION: In post-CA patients, creatinine, NGAL, and cystatin-C (but not KIM-1) measured shortly after ROSC were higher in patients who subsequently developed AKI. No biomarker was statistically superior to creatinine on its own for predicting the development of post-arrest AKI.

Incidences and outcomes of intra-operative vs. postoperative paediatric cardiac arrest: A retrospective cohort study of 42 776 anaesthetics in children who underwent noncardiac surgery in a Thai tertiary care hospital.

BACKGROUND: The reported incidence of paediatric perioperative cardiac arrest (PPOCA) in most developing countries ranges from 2.7 to 22.9 per 10 000 anaesthetics, resulting in mortality rates of 2.0 to 10.7 per 10 000 anaesthetics. The definitions of 'peri-operative' cardiac arrest often include the intra-operative period and extends from 60 min to 48 h after anaesthesia completion. However, the characteristics of cardiac arrests, care settings, and resuscitation quality may differ between intra-operative and early postoperative cardiac arrests. OBJECTIVE: To compare the mortality rates between intraoperative and early postoperative cardiac arrests (<24 h) following anaesthesia for paediatric noncardiac surgery. DESIGN: A retrospective cohort study. SETTING: In a tertiary care centre in Thailand during 2014 to 2019, the peri-operative period was defined as from the beginning of anaesthesia care until 24 h after anaesthesia completion. PATIENTS: Paediatric patients aged 0 to 17 years who underwent anaesthesia for noncardiac surgery. MAIN OUTCOME MEASURES: Mortality rates. RESULTS: A total of 42 776 anaesthetics were identified, with 63 PPOCAs and 23 deaths (36.5%). The incidence (95% confidence interval) of PPOCAs and mortality were 14.7 (11.5 to 18.8) and 5.4 (3.6 to 8.1) per 10 000 anaesthetics, respectively. Among 63 PPOCAs, 41 (65%) and 22 (35%) occurred during the intra-operative and postoperative periods, respectively. The median [min to max] time of postoperative cardiac arrest was 3.84 [0.05 to 19.47] h after anaesthesia completion. Mortalities (mortality rate) of postoperative cardiac arrest were significantly higher than that of intra-operative cardiac arrest at 14 (63.6%) vs. 9 (22.0%, P = 0.001). Multivariate analysis of risk factors for mortality included emergency status and duration of cardiopulmonary resuscitation with adjusted odds ratio 5.388 (95% confidence interval (1.031 to 28.160) and 1.067 (1.016 to 1.120). CONCLUSIONS: Postoperative cardiac arrest resulted in a higher mortality rate than intra-operative cardiac arrest. A high level of care should be provided for at least 24 h after the completion of anaesthesia. TRIAL REGISTRATION: None. CLINICAL TRIAL NUMBER AND REGISTRY URL: NA.

Relationship between serum neuron-specific enolase and EEG after cardiac arrest: A reappraisal.

OBJECTIVE: Electroencephalogram (EEG) and serum neuron specific enolase (NSE) are frequently used prognosticators after cardiac arrest (CA). This study explored the association between NSE and EEG, considering the role of EEG timing, its background continuity, reactivity, occurrence of epileptiform discharges, and pre-defined malignancy degree. METHODS: Retrospective analysis including 445 consecutive adults from a prospective registry, surviving the first 24 hours after CA and undergoing multimodal evaluation. EEG were interpreted blinded to NSE results. RESULTS: Higher NSE was associated with poor EEG prognosticators, such as increasing malignancy, repetitive epileptiform discharges and lack of background reactivity, independently of EEG timing (including sedation and temperature). When stratified for background continuity, NSE was higher with repetitive epileptiform discharges, except in the case of suppressed EEGs. This relationship showed some variation according to the recording time. CONCLUSIONS: Neuronal injury after CA, reflected by NSE, correlates with several EEG features: increasing EEG malignancy, lack of background reactivity, and presence of repetitive epileptiform discharges. The correlation between epileptiform discharges and NSE is influenced by underlying EEG background and timing. SIGNIFICANCE: This study, describing the complex interplay between serum NSE and epileptiform features, suggests that epileptiform discharges reflect neuronal injury particularly in non-suppressed EEG.

Cardiac arrest in the perioperative period: a consensus guideline for identification, treatment, and prevention from the European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery.

INTRODUCTION: Cardiac arrest in the operating room is a rare but potentially life-threatening event with mortality rates of more than 50%. Contributing factors are often known, and the event is recognised rapidly as patients are usually under full monitoring. This guideline covers the perioperative period and is complementary to the European Resuscitation Council (ERC) guidelines. MATERIAL AND METHODS: The European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery jointly nominated a panel of experts to develop guidelines for the recognition, treatment and prevention of cardiac arrest in the perioperative period. A literature search was conducted in MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials. All searches were restricted to publications from 1980 to 2019 inclusive and to the English, French, Italian and Spanish languages. The authors also contributed individual, independent literature searches. RESULTS: This guideline contains background information and recommendation for the treatment of cardiac arrest in the operating room environment, and addresses controversial topics such as open chest cardiac massage (OCCM), resuscitative endovascular balloon occlusion (REBOA) and resuscitative thoracotomy, pericardiocentesis, needle decompression and thoracostomy. CONCLUSION: Successful prevention and management of cardiac arrest during anaesthesia and surgery requires anticipation, early recognition and a clear treatment plan. The ready availability of expert staff and equipment must also be taken into consideration. Success not only depends on medical knowledge, technical skills and a well organised team using crew resource management but also on an institutional safety culture embedded in everyday practice through continuous education, training and multidisciplinary co-operation.

Prevalence of asystole during tilt test-induced vasovagal syncope may depend on test methodology.

This review addresses tilt-testing methodology by searching the literature which reports timing of asystole and loss of consciousness (LOC). Despite the Italian protocol being the most widely adopted, its stipulations are not always followed to the letter of the European Society of Cardiology guidelines. The discrepancies permit reassessment of the incidence of asystole when tilt-down is early, impending syncope, compared with late, established LOC. Asystole is uncommon with early tilt down and diminishes with increasing age. However, if LOC is established as test-end, asystole is more common, and it is age-independent. Thus, the implications are that asystole is commonly under-diagnosed by early tilt-down. The prevalence of asystolic responses observed using the Italian protocol with a rigorous tilt down time is numerically close to that observed during spontaneous attacks by electrocardiogram loop recorder. Recently, tilt-testing has been questioned as to its validity but, in selection of pacemaker therapy in older highly symptomatic vasovagal syncope patients, the occurrence of asystole has been shown to be an effective guide for treatment. The use of head-up tilt test as an indication for cardiac pacing therapy requires pursuing the test until complete LOC. This review offers explanations for the findings and their applicability to practice. A novel interpretation is offered to explain why pacing induced earlier may combat vasodepression by raising the heart rate when sufficient blood remains in the heart.

Co-occurrence of Proteus syndrome and ventricular tachycardia cardiac arrest in a teenager.

Proteus syndrome is an extremely rare overgrowth condition caused by a somatic variant of the AKT1 gene. It can involve multiple organ systems though rarely is there symptomatic cardiac involvement. Fatty infiltration of the myocardium has been described but has not been reported to cause functional or conduction abnormalities. We present an individual with Proteus syndrome who suffered a sudden cardiac arrest.

Cardiac arrest as initial presentation of pheochromocytoma in a young.

We reported a case of pheochromocytoma with initial presentation of cardiac arrest. The patient underwent implantable cardioverter defibrillator for primary prevention but subsequently experienced repeated implantable cardioverter defibrillator shocks and syncopal episodes. A mass was found in the adrenal gland by CT, which was confirmed by anatomopathological analysis of the surgical specimen.

Benign EEG for prognostication of favorable outcome after cardiac arrest: A reappraisal.

AIM: The current EEG role for prognostication after cardiac arrest (CA) essentially aims at reliably identifying patients with poor prognosis ("highly malignant" patterns, defined by Westhall et al. in 2014). Conversely, "benign EEGs", defined by the absence of elements of "highly malignant" and "malignant" categories, has limited sensitivity in detecting good prognosis. We postulate that a less stringent "benign EEG" definition would improve sensitivity to detect patients with favorable outcomes. METHODS: Retrospectively assessing our registry of unconscious adults after CA (1.2018-8.2021), we scored EEGs within 72 h after CA using a modified "benign EEG" classification (allowing discontinuity, low-voltage, or reversed anterio-posterior amplitude development), versus Westhall's "benign EEG" classification (not allowing the former items). We compared predictive performances towards good outcome (Cerebral Performance Category 1-2 at 3 months), using 2x2 tables (and binomial 95% confidence intervals) and proportions comparisons. RESULTS: Among 381 patients (mean age 61.9 ± 15.4 years, 104 (27.2%) females, 240 (62.9%) having cardiac origin), the modified "benign EEG" definition identified a higher number of patients with potential good outcome (252, 66%, vs 163, 43%). Sensitivity of the modified EEG definition was 0.97 (95% CI: 0.92-0.97) vs 0.71 (95% CI: 0.62-0.78) (p < 0.001). Positive predictive values (PPV) were 0.53 (95% CI: 0.46-0.59) versus 0.59 (95% CI: 0.51-0.67; p = 0.17). Similar statistics were observed at definite recording times, and for survivors. DISCUSSION: The modified "benign EEG" classification demonstrated a markedly higher sensitivity towards favorable outcome, with minor impact on PPV. Adaptation of "benign EEG" criteria may improve efficient identification of patients who may reach a good outcome.

Outcomes of Cardiac Arrest with Valve Surgery Among Infective Endocarditis Patients: A United States National Cohort Study.

OBJECTIVE: Cardiac arrest can complicate infective endocarditis (IE) and is associated with significant in-hospital complications and mortality rates. We report the characteristics, outcomes, and readmission rates for IE patients with cardiac arrest in the United States. METHODS: We surveyed the Nationwide Readmission Database (NRD), a database designed to support national level readmission analyses, for patients admitted with IE and who had cardiac arrest during index admission between 2016 and 2019. Baseline demographics, comorbidities, surgical procedures, and outcomes were identified using their respective International Classification of Diseases (ICD) codes. RESULTS: There were 663 index admissions (mean age 55.87 ± 17.21 years;34.2 % females) for IE with cardiac arrest in the study period, with an overall mortality rate of 55.3 %. Of these, 270 (40.7 %) had surgical procedures performed during the hospitalization encounter. In patients who had a surgical procedure, 72 (26.8 %) patients had in-hospital mortality while 293 (74.9 %) patients without surgical procedures had in-hospital mortality (p < 0.001). After coarsened matching for baseline characteristics, surgical valve procedures were less likely to be associated with mortality (OR = 0.09, 95%CI 0.04-0.24; p < 0.001). Among the 295 alive discharges associated with cardiac arrest, 76 (38.57 %) were readmitted within 30-days, with a mortality rate of 22 % noted for readmissions. CONCLUSION: Among IE patients who had cardiac arrest, surgical procedures subgroup had low mortality despite having higher complication rates. However, due to chances of bias more randomized trials are needed evaluate the hypothesis.

Decision making and management of acute type-A dissection presenting with shock or cardiac arrest.

While the outcome of aortic repair for acute type-A aortic dissection has improved, overall mortality among patients who developed acute type-A aortic dissection remains extremely high. Hypotension in acute type-A aortic dissection patients is a critical condition that is associated with increased in-hospital mortality and neurologic events. The underlying causes of shock include acute aortic regurgitation, cardiac tamponade, and myocardial infarction. The most reasonable initial approach is to administer intravenous fluids to improve blood pressure, increase preload and cardiac output, and ensure adequate end-organ perfusion. Cardiac tamponade-induced hypotension associated with aortic rupture has been identified as a major risk factor for perioperative mortality in patients with acute type-A aortic dissection. In addition, the most serious complications of acute type-A aortic dissection include preoperative cardiopulmonary arrest, especially out-of-hospital cardiopulmonary arrest. Recent advances in rapid transportation and diagnosis, and the introduction of extracorporeal cardiopulmonary resuscitation, have resulted in an increase in the number of patients with cardiopulmonary arrest related to acute type-A aortic dissection. However, controversy continues to surround treatment strategies, surgical indications, and the timing of surgery on such patients. This review, therefore, discusses decision-making and the managerial issues surrounding acute type-A dissection presenting with shock, cardiac tamponade, and cardiac arrest.

A Case of Cardiac Arrest Caused by Air Embolism from Routine Root Canal Procedure.

Venous air embolism (VAE) occurs when air is introduced into the venous system and subsequently travels into the right heart and pulmonary circulation. VAE mainly occurs from air that is forced by positive pressure or drawn in by negative pressure. We present a rare case of fatal VAE that occurred during a routine dental root canal procedure. A 69-year-old male was undergoing a root canal procedure at an outpatient dental office under local anesthesia. During the procedure, he went into cardiopulmonary arrest. He was resuscitated, and return of spontaneous circulation was achieved. Thoracic computed tomography was performed and revealed large amounts of air within the right ventricle and portal venous system. VAE should be recognized as a potentially fatal complication resulting from routine dental procedures.

Incidence, Outcomes, and Risk Factors for Preincision Cardiac Arrest in Cardiac Surgery Patients.

BACKGROUND: We examined the incidence, postoperative outcomes, and patient-related factors associated with preincision cardiac arrest in patients undergoing cardiac surgery. METHODS: We retrospectively examined adult patients undergoing elective or urgent cardiac surgery at the Cleveland Clinic between 2008 and 2019. The incidence of preincision cardiac arrest, defined as arrest between induction of general anesthesia and surgical incision, was reported. In a secondary analysis, we assessed the association between preincision cardiac arrest and major postoperative outcomes. In a tertiary analysis, we used adjusted linear regression models to explore the association between preincision cardiac arrest and prespecified patient risk factors, including severe left main coronary artery stenosis, left ventricular ejection fraction, moderate/severe right ventricular dysfunction, low-flow low-gradient aortic stenosis, and moderate/severe pulmonary hypertension. RESULTS: Preincision cardiac arrests occurred in 75 of 41,238 (incidence of 0.18%; 95% CI, 0.17-0.26) patients who had elective or urgent cardiac surgery. Successful cardiopulmonary resuscitation with return of spontaneous circulation or bridge to cardiopulmonary bypass occurred in 74 of 75 (98.6%) patients. Patients who experienced preincision cardiac arrest had significantly higher in-hospital mortality than those who did not (11% vs 2%; odds ratio [OR] (95% CI), 4.14 (1.94-8.84); P < .001). They were also more likely to suffer postoperative respiratory failure (46% vs 13%; OR [95% CI], 3.94 [2.40-6.47]; P < .001), requirement for renal replacement therapy (11% vs 2%; OR [95% CI], 3.90 [1.82-8.35]; P < .001), neurologic deficit (7% vs 2%; OR [95% CI], 2.49 (1.00-6.21); P = .05), and longer median hospital stay (15 vs 8 days; hazard ratio (HR) [95% CI], 0.68 [0.55-0.85]; P < .001). Reduced left ventricular ejection fraction (per 5% decrease) (OR [95% CI], 1.13 [1.03-1.22]; P = .006) and moderate/severe pulmonary hypertension (OR [95% CI], 3.40 [1.95-5.90]; P < .001) were identified as independent risk factors for cardiac arrest. CONCLUSIONS: Cardiac arrest after anesthetic induction is rare in cardiac surgical patients in our investigation. Though most patients are rescued, morbidity and mortality remain higher. Reduced left ventricular ejection fraction and moderate/severe pulmonary hypertension are associated with greater risk for preincision cardiac arrest.

Systematic review and meta-analysis comparing low-flow duration of extracorporeal and conventional cardiopulmonary resuscitation.

OBJECTIVES: After cardiac arrest, a key factor determining survival outcomes is low-flow duration. Our aims were to determine the relation of survival and low-flow duration of extracorporeal cardiopulmonary resuscitation (ECPR) and conventional cardiopulmonary resuscitation (CCPR) and if these 2 therapies have different short-term survival curves in relation to low-flow duration. METHODS: We searched Embase, Medline, Web of Science and Google Scholar from inception up to April 2021. A linear mixed-effect model was used to describe the course of survival over time, based on study-specific and time-specific aggregated survival data. RESULTS: We included 42 observational studies reporting on 1689 ECPR and 375 751 CCPR procedures. Of the included studies, 25 included adults, 13 included children and 4 included both. In adults, survival curves decline rapidly over time (ECPR 37.2%, 29.8%, 23.8% and 19.1% versus CCPR-shockable 36.8%, 7.2%, 1.4% and 0.3% for 15, 30, 45 and 60 min low-flow, respectively). ECPR was associated with a statistically significant slower decline in survival than CCPR with initial shockable rhythms (CCPR-shockable). In children, survival curves decline rapidly over time (ECPR 43.6%, 41.7%, 39.8% and 38.0% versus CCPR-shockable 48.6%, 20.5%, 8.6% and 3.6% for 15, 30, 45 and 60 min low-flow, respectively). ECPR was associated with a statistically significant slower decline in survival than CCPR-shockable. CONCLUSIONS: The short-term survival of ECPR and CCPR-shockable patients both decline rapidly over time, in adults as well as in children. This decline of short-term survival in relation to low-flow duration in ECPR was slower than in conventional cardiopulmonary resuscitation. TRIAL REGISTRATION: Prospero: CRD42020212480, 2 October 2020.

[Reflex syncope-or more? : Ictal asystole!] / Reflexsynkope ­ oder mehr? : Iktale Asystolie!

A 59-year-old male patient was admitted for possible reflex syncope following loss of consciousness during urination. During the visit, a malaise with unconsciousness occurred. Holter ECG at that time showed increasing sinus bradycardia with transition to a junctional escape rhythm (30/min); in addition, there were several sinus pauses > 2.0 s (the longest almost 10 s). This malaise occurred again during routine EEG, when a focal epileptic seizure on the right fronto-temporal with sinus bradycardia after 15 s was documented. Thus, the diagnosis of ictal asystole was made, anticonvulsant therapy was started, and a cardiac pacemaker was implanted.