Feasibility of Magnetic Resonance-Based Conductivity Imaging as a Tool to Estimate the Severity of Hypoxic-Ischemic Brain Injury in the First Hours After Cardiac Arrest.

BACKGROUND: Early identification of the severity of hypoxic-ischemic brain injury (HIBI) after cardiac arrest can be used to help plan appropriate subsequent therapy. We evaluated whether conductivity of cerebral tissue measured using magnetic resonance-based conductivity imaging (MRCI), which provides contrast derived from the concentration and mobility of ions within the imaged tissue, can reflect the severity of HIBI in the early hours after cardiac arrest. METHODS: Fourteen minipigs were resuscitated after 5 min or 12 min of untreated cardiac arrest. MRCI was performed at baseline and at 1 h and 3.5 h after return of spontaneous circulation (ROSC). RESULTS: In both groups, the conductivity of cerebral tissue significantly increased at 1 h after ROSC compared with that at baseline (P = 0.031 and 0.016 in the 5-min and 12-min groups, respectively). The increase was greater in the 12-min group, resulting in significantly higher conductivity values in the 12-min group (P = 0.030). At 3.5 h after ROSC, the conductivity of cerebral tissue in the 12-min group remained increased (P = 0.022), whereas that in the 5-min group returned to its baseline level. CONCLUSIONS: The conductivity of cerebral tissue was increased in the first hours after ROSC, and the increase was more prominent and lasted longer in the 12-min group than in the 5-min group. Our findings suggest the promising potential of MRCI as a tool to estimate the severity of HIBI in the early hours after cardiac arrest.

Late Awakening Is Common in Settings Without Withdrawal of Life-Sustaining Therapy in Out-of-Hospital Cardiac Arrest Survivors Who Undergo Targeted Temperature Management.

OBJECTIVES: We investigated awakening time and characteristics of awakening compared nonawakening and factors contributing to poor neurologic outcomes in out-of-hospital cardiac arrest survivors in no withdrawal of life-sustaining therapy settings. DESIGN: Retrospective analysis of the Korean Hypothermia Network Pro registry. SETTING: Multicenter ICU. PATIENTS: Adult (≥ 18 yr) comatose out-of-hospital cardiac arrest survivors who underwent targeted temperature management at 33-36°C between October 2015 and December 2018. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We measured the time from the end of rewarming to awakening, defined as a total Glasgow Coma Scale score greater than or equal to 9 or Glasgow Coma Scale motor score equals to 6. The primary outcome was awakening time. The secondary outcome was 6-month neurologic outcomes (poor outcome: Cerebral Performance Category 3-5). Among 1,145 out-of-hospital cardiac arrest survivors, 477 patients (41.7%) regained consciousness 30 hours (6-71 hr) later, and 116 patients (24.3%) awakened late (72 hr after the end of rewarming). Young age, witnessed arrest, shockable rhythm, cardiac etiology, shorter time to return of spontaneous circulation, lower serum lactate level, absence of seizures, and multisedative requirement were associated with awakening. Of the 477 who woke up, 74 (15.5%) had poor neurologic outcomes. Older age, liver cirrhosis, nonshockable rhythm, noncardiac etiology, a higher Sequential Organ Failure Assessment score, and higher serum lactate levels were associated with poor neurologic outcomes. Late awakeners were more common in the poor than in the good neurologic outcome group (38/74 [51.4%] vs 78/403 [19.4%]; p < 0.001). The awakening time (odds ratio, 1.005; 95% CIs, 1.003-1.008) and late awakening (odds ratio, 3.194; 95% CIs, 1.776-5.746) were independently associated with poor neurologic outcomes. CONCLUSIONS: Late awakening after out-of-hospital cardiac arrest was common in no withdrawal of life-sustaining therapy settings and the probability of awakening decreased over time.

External validation of the 2020 ERC/ESICM prognostication strategy algorithm after cardiac arrest.

PURPOSE: To assess the performance of the post-cardiac arrest (CA) prognostication strategy algorithm recommended by the European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) in 2020. METHODS: This was a retrospective analysis of the Korean Hypothermia Network Prospective Registry 1.0. Unconscious patients without confounders at day 4 (72-96 h) after return of spontaneous circulation (ROSC) were included. The association between the prognostic factors included in the prognostication strategy algorithm, except status myoclonus and the neurological outcome, was investigated, and finally, the prognostic performance of the prognostication strategy algorithm was evaluated. Poor outcome was defined as cerebral performance categories 3-5 at 6 months after ROSC. RESULTS: A total of 660 patients were included in the final analysis. Of those, 108 (16.4%) patients had a good neurological outcome at 6 months after CA. The 2020 ERC/ESICM prognostication strategy algorithm identified patients with poor neurological outcome with 60.2% sensitivity (95% CI 55.9-64.4) and 100% specificity (95% CI 93.9-100) among patients who were unconscious or had a GCS_M score ≤ 3 and with 58.2% sensitivity (95% CI 53.9-62.3) and 100% specificity (95% CI 96.6-100) among unconscious patients. When two prognostic factors were combined, any combination of prognostic factors had a false positive rate (FPR) of 0 (95% CI 0-5.6 for combination of no PR/CR and poor CT, 0-30.8 for combination of No SSEP N20 and NSE 60). CONCLUSION: The 2020 ERC/ESICM prognostication strategy algorithm predicted poor outcome without an FPR and with sensitivities of 58.2-60.2%. Any combinations of two predictors recommended by ERC/ESICM showed 0% of FPR.

Supranormal arterial oxygen tension only during the first six hours after cardiac arrest is associated with unfavourable outcomes.

BACKGROUND: Multiple studies have investigated the association between hyperoxaemia following cardiac arrest (CA) and unfavourable outcomes; however, they have yielded inconsistent results. Most previous studies quantified oxygen exposure without considering its timing or duration. We investigated the relationship between unfavourable outcomes and supranormal arterial oxygen tension (PaO2 ), commonly defined as PaO2 > 100 mmHg, at specific time intervals within 24 h following CA. METHODS: This retrospective observational study included 838 adult non-traumatic patients with CA. The first 24 h following CA were divided into four 6-h time intervals, and the first 6-h period was further divided into three 2-h segments. Multivariable logistic regression analyses were conducted to assess associations of the highest PaO2 and time-weighted average PaO2 (TWA-PaO2 ) values at each time interval with unfavourable outcomes at hospital discharge (cerebral performance categories 3-5). RESULTS: The highest PaO2 (p = .028) and TWA-PaO2 (p = .022) values during the 0-6-h time interval were significantly associated with unfavourable outcomes, whereas those at time intervals beyond 6 h were not. The association was the strongest at supranormal PaO2 values within the 0-2-h time interval, becoming significant at PaO2 values ≥ 150 mmHg. During the first 6 h, longer time spent at ≥150 mmHg of PaO2 was associated with an increased risk of unfavourable outcomes (p = .038). The results were consistent across several sensitivity analyses. CONCLUSION: Supranormal PaO2 during but not after the first 6 h following cardiac arrest was independently associated with unfavourable outcomes.

Pralidoxime-Induced Potentiation of the Pressor Effect of Adrenaline and Hastened Successful Resuscitation by Pralidoxime in a Porcine Cardiac Arrest Model.

PURPOSE: Pralidoxime potentiated the pressor effect of adrenaline and facilitated restoration of spontaneous circulation (ROSC) after prolonged cardiac arrest. In this study, we hypothesised that pralidoxime would hasten ROSC in a model with a short duration of untreated ventricular fibrillation (VF). We also hypothesised that potentiation of the pressor effect of adrenaline by pralidoxime would not be accompanied by worsening of the adverse effects of adrenaline. METHODS: After 5 min of VF, 20 pigs randomly received either pralidoxime (40 mg/kg) or saline, in combination with adrenaline, during cardiopulmonary resuscitation (CPR). Coronary perfusion pressure (CPP) during CPR, and ease of resuscitation were compared between the groups. Additionally, haemodynamic data, severity of ventricular arrhythmias, and cerebral microcirculation were measured during the 1-h post-resuscitation period. Cerebral microcirculatory blood flow and brain tissue oxygen tension (PbtO2) were measured on parietal cortices exposed through burr holes. RESULTS: All animals achieved ROSC. The pralidoxime group had higher CPP during CPR (P = 0.014) and required a shorter duration of CPR (P = 0.024) and smaller number of adrenaline doses (P = 0.024). During the post-resuscitation period, heart rate increased over time in the control group, and decreased steadily in the pralidoxime group. No inter-group differences were observed in the incidences of ventricular arrhythmias, cerebral microcirculatory blood flow, and PbtO2. CONCLUSION: Pralidoxime improved CPP and hastened ROSC in a model with a short duration of untreated VF. The potentiation of the pressor effect of adrenaline was not accompanied by the worsening of the adverse effects of adrenaline.

Pralidoxime administered during cardiopulmonary resuscitation facilitates successful resuscitation in a pig model of cardiac arrest.

Pralidoxime is a common antidote for organophosphate poisoning; however, studies have also reported pralidoxime's pressor effect, which may facilitate the restoration of spontaneous circulation (ROSC) after cardiac arrest by improving coronary perfusion pressure (CPP). We investigated the immediate cardiovascular effects of pralidoxime in anaesthetised normal rats and the effects of pralidoxime administration during cardiopulmonary resuscitation (CPR) in a pig model of cardiac arrest. To evaluate the immediate cardiovascular effects of pralidoxime, seven anaesthetised normal rats received saline or pralidoxime (20 mg/kg) in a randomised crossover design, and the responses were determined using the conductance catheter technique. To evaluate the effects of pralidoxime administration during CPR, 22 pigs randomly received either 80 mg/kg of pralidoxime or an equivalent volume of saline during CPR. In the rats, pralidoxime significantly increased arterial pressure than saline (P = .044). The peak effect on arterial pressure was observed in the first minute. In a pig model of cardiac arrest, CPP during CPR was higher in the pralidoxime group than in the control group (P = .002). ROSC was attained in three animals (27.3%) in the control group and nine animals (81.8%) in the pralidoxime group (P = .010). Three animals (27.3%) in the control group and eight animals (72.2%) in the pralidoxime group survived the 6-hour period (P = .033). In conclusion, pralidoxime had a rapid onset of pressor effect. Pralidoxime administered during CPR led to significantly higher rates of ROSC and 6-hour survival by improving CPP in a pig model.

Glycated Hemoglobin is Associated with Glycemic Control and 6-Month Neurologic Outcome in Cardiac Arrest Survivors Undergoing Therapeutic Hypothermia.

BACKGROUND: Glucose control status after cardiac arrest depending on chronic glycemic status and the association between chronic glycemic status and outcome in cardiac arrest survivors are not well known. We investigated the association between glycated hemoglobin (HbA1c) and 6-month neurologic outcome in cardiac arrest survivors undergoing therapeutic hypothermia (TH) and whether mean glucose, area under curve (AUC) of glucose during TH, and neuron-specific enolase (NSE) are different between normal and high HbA1c groups. METHODS: This retrospective single-center study included adult comatose cardiac arrest survivors who underwent TH from September 2011 to December 2017. HbA1c and glucose were measured after return of spontaneous circulation (ROSC), and normal or high HbA1c was defined using cutoff value of 6.4% of HbA1c. Blood glucose was measured at least every 4 h and treated with a written protocol to maintain the range of 80-200 mg/dL. Hypoglycemia and hyperglycemia were defined with glucose < 70 or > 180 mg/dL. Mean glucose during induction and rewarming phase and AUC of glucose during every 6 h of maintenance were calculated, and NSE at 48 h after cardiac arrest was recorded. The primary outcome was unfavorable neurologic outcome, defined as Glasgow Pittsburgh Cerebral Performance Category scale 3-5 at 6 months after cardiac arrest. RESULTS: Of 384 included patients, 81 (21.1%) had high HbA1c and 247 (64.3%) had an unfavorable neurologic outcome. Patients with high HbA1c were more common in the unfavorable group than in favorable group (27.5% vs 9.5%, p < 0.001), and the unfavorable group had significantly higher HbA1c level (5.8% [5.4-6.8%] vs 5.6% [5.3-6.0%], p = 0.007). HbA1c level was independently associated with worse neurologic outcome (odds ratio 1.414; 95% confidence interval 1.051-1.903). High HbA1c group had higher glucose after ROSC, glucose AUC during maintenance, and rewarming phase than normal HbA1c group. High HbA1c group had significantly higher incidence of hyperglycemia throughout the TH, while normal HbA1c group had significantly higher incidence of normoglycemia. However, no glucose parameter remained as an independent predictor of neurologic outcome after adjustment, irrespective of HbA1c level. NSE showed good prognostic performance (area under curve 0.892; cutoff value 26.3 ng/mL). Although NSE level was not different between HbA1c groups, high HbA1c group had higher proportion of patient having NSE over cutoff. CONCLUSIONS: Higher HbA1c was independently associated with unfavorable neurologic outcome. Glycemic status during TH was different between normal and high HbA1c groups.

The Cumulative Partial Pressure of Arterial Oxygen Is Associated With Neurological Outcomes After Cardiac Arrest Treated With Targeted Temperature Management.

OBJECTIVE: Hyperoxia could lead to a worse outcome after cardiac arrest. The aim of this study was to investigate the relationship between the cumulative partial pressure of arterial oxygen (PaO2) and neurological outcomes after cardiac arrest treated with targeted temperature management. DESIGN: Retrospective analysis of a prospective cohort. SETTING: An academic tertiary care hospital. PATIENTS: A total of 187 consecutive patients treated with targeted temperature management after cardiac arrest. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The area under the curve of PaO2 for different cutoff values of hyperoxia (≥ 100, ≥ 150, ≥ 200, ≥ 250, and ≥ 300 mm Hg) with different time intervals (0-24, 0-6, and 6-24 hr after return of spontaneous circulation) was calculated for each patient using the trapezoidal method. The primary outcome was the neurologic outcome, as defined by the cerebral performance category, at 6 months after cardiac arrest. Of 187 subjects, 77 (41%) had a good neurologic outcome at 6 months after cardiac arrest. The median age was 54 (43-69) years, and 128 (68%) were male. The area under the curve of PaO2 with cutoff values of greater than or equal to 200, greater than or equal to 250, and greater than or equal to 300 was higher in the poor outcome group at 0-6 and 0-24 hours. The adjusted odds ratios of area under the curve of PaO2 greater than or equal to 200 mm Hg were 1.659 (95% CI, 1.194-2.305) for 0-24 hours after return of spontaneous circulation and 1.548 (95% CI, 1.086-2.208) for 0-6 hours after return of spontaneous circulation. With a higher cumulative exposure to oxygen tension, we found significant increasing trends in the adjusted odds ratio for poor neurologic outcomes. CONCLUSION: In a new method for PaO2 analysis, cumulative exposure to hyperoxia was associated with neurologic outcomes in a dose-dependent manner. Greater attention to oxygen supply during the first 6 hours appears to be important for outcome after cardiac arrest.

Association of plasma neutrophil gelatinase-associated lipocalin with acute kidney injury and clinical outcome in cardiac arrest survivors depends on the time of measurement.

PURPOSE: The optimal timing for measurement of neutrophil gelatinase-associated lipocalin (NGAL) level to predict acute kidney injury (AKI) and prognosis in cardiac arrest (CA) survivors has not been elucidated. We aimed to compare the diagnostic and prognostic performance of NGAL levels after return of spontaneous circulation (ROSC) and at 48 h after CA. METHODS: We included 231 adult cardiac arrest survivors who underwent targeted temperature management between May 2013 and December 2016. The primary outcome was stage 2 and 3 AKI (high stage AKI), and the secondary outcomes were in-hospital mortality and neurologic outcome. Sixty-one (26.4%) developed high stage AKI, 50 (21.6%) died, and 152 (65.8%) had a poor neurologic outcome. RESULTS: NGAL level at 48 h (0.876; 95% confidence interval [CI], 0.826-0.916) had a higher area under receiver operating characteristic curve than NGAL level after ROSC (0.694; 95% CI, 0.631-0.753). Both NGAL levels were independently associated with high stage AKI. NGAL level at 48 h (1.001; 95% CI, 1.000-1.002) remained a significant predictor for in-hospital mortality, while neither of the NGAL levels were independently associated with neurologic outcome. CONCLUSIONS: NGAL at 48 h after CA seems to be a robust predictor for high stage AKI and in-hospital mortality.

Relationship Between Left Ventricle Position and Haemodynamic Parameters During Cardiopulmonary Resuscitation in a Pig Model.

BACKGROUND: From the viewpoint of cardiac pump theory, the area of the left ventricle (LV) subjected to compression increases as the LV lies closer to the sternum, possibly resulting in higher blood flow in patients with LV closer to the sternum. However, no study has evaluated LV position during cardiac arrest or its relationship with haemodynamic parameters during cardiopulmonary resuscitation (CPR). The objectives of this study were to determine whether the position of the LV relative to the anterior-posterior axis representing the direction of chest compression shifts during cardiac arrest and to examine the relationship between LV position and haemodynamic parameters during CPR. METHODS: Subcostal view echocardiograms were obtained from 15 pigs with the transducer parallel to the long axis of the sternum before inducing ventricular fibrillation (VF) and during cardiac arrest. Computed tomography was performed in three pigs to objectively observe LV position during cardiac arrest. LV position parameters including the shortest distance between the anterior-posterior axis and the mid-point of the LV chamber (DAP-MidLV), the shortest distance between the anterior-posterior axis and the LV apex (DAP-Apex), and the area fraction of the LV located on the right side of the anterior-posterior axis (LVARight/LVATotal) were measured. RESULTS: DAP-MidLV, DAP-Apex, and LVARight/LVATotal decreased progressively during untreated VF and basic life support (BLS), and then increased during advanced cardiovascular life support (ACLS). A repeated measures analysis of variance revealed significant time effects for these parameters. During BLS, the end-tidal carbon dioxide and systolic right atrial pressure were significantly correlated with the LV position parameters. During ACLS, systolic arterial pressure and systolic right atrial pressure were significantly correlated with DAP-MidLV and DAP-Apex. CONCLUSIONS: Left ventricular position changed significantly during cardiac arrest compared to the pre-arrest baseline. LV position during CPR had significant correlations with haemodynamic parameters.

The association of body mass index with outcomes and targeted temperature management practice in cardiac arrest survivors.

PURPOSE: Obesity is a well-known risk factor in various health conditions. We analyzed the association between obesity and clinical outcomes, and its effect on targeted temperature management (TTM) practice for cardiac arrest survivors by calculating and classifying their body mass indexes (BMIs). METHODS: We conducted a retrospective data analysis of adult comatose cardiac arrest survivors treated with TTM from 2008 to 2015. BMI was calculated and the cohort was divided into four categories based on the cut-off values of 18.5, 23.0, and 27.5kgm-2. The primary outcome was six-month mortality and the secondary outcomes were neurologic outcome at hospital discharge, cooling rate, and rewarming rate. RESULTS: The study included 468 patients. Poor neurologic outcome at discharge and six-month mortality were reported in 311 (66.5%) and 271 (57.9%) patients, respectively. A multivariate logistic analysis showed that an overweight compared to normal BMI was associated with lower probability of six-month mortality (odds ratio [OR], 0.481; 95% confidence interval [CI], 0.274-0.846; p=0.011) and poor neurologic outcome at discharge (OR, 0.482; 95% CI, 0.258-0.903; p=0.023). BMI correlated with cooling rate (B, -0.073; 95% CI, -0.108 to -0.039; p<0.001), but had no association with rewarming rate (B, 0.003; 95% CI, -0.001-0.008; p=0.058). CONCLUSION: Overweight BMI compared to normal BMI classification was found to be associated with lower six-month mortality and poor neurologic outcome at discharge in cardiac arrest survivors treated with TTM. Higher BMI correlated with a slower induction rate.

Disseminated intravascular coagulation is associated with the neurologic outcome of cardiac arrest survivors.

PURPOSE: We aimed to examine the serial changes in coagulofibrinolytic markers that occurred after the restoration of spontaneous circulation (ROSC) in cardiac arrest patients, who were treated with targeted temperature management (TTM). We also evaluated the association between the disseminated intravascular coagulation (DIC) score and clinical outcomes. METHODS: This was a single-centre, retrospective observational study that included cardiac arrest patients who were treated with TTM from May 2012 to December 2015. The prothrombin time (PT) and partial thromboplastin time (PTT), along with the levels of fibrinogen, fibrin degradation products (FDP), and D-dimer were obtained after ROSC and on day 1, 2, and 3. The DIC score was calculated after ROSC. The primary outcome was the neurologic outcome at discharge and the secondary outcome was the 6-month mortality. RESULTS: This study included 317 patients. Of these, 222 (70.0%) and 194 (61.2%) patients had a poor neurologic outcome at discharge and 6-month mortality, respectively. The PT, PTT, and fibrinogen level significantly increased over time, while the FDP and D-dimer levels decreased during first three days after ROSC. Multivariate logistic analyses revealed that the DIC score remained a significant predictor for poor neurologic outcome (odds ratio [OR], 1.800; 95% confidence interval [CI], 1.323-2.451) and 6-month mortality (OR, 1.773; 95% CI, 1.307-2.405). CONCLUSION: The activity of coagulation and fibrinolysis decreased over time. An increased DIC score was an independent prognostic factor for poor neurologic outcome and 6-month mortality.

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.

2,3-Butanedione monoxime facilitates successful resuscitation in a dose-dependent fashion in a pig model of cardiac arrest.

PURPOSE: Ischemic contracture compromises the hemodynamic effectiveness of cardiopulmonary resuscitation (CPR) and resuscitability from cardiac arrest. In a pig model of cardiac arrest, 2,3-butanedione monoxime (BDM) attenuated ischemic contracture. We investigated the effects of different doses of BDM to determine whether increasing the dose of BDM could improve the hemodynamic effectiveness of CPR further, thus ultimately improving resuscitability. METHODS: After 16minutes of untreated ventricular fibrillation and 8minutes of basic life support, 36 pigs were divided randomly into 3 groups that received 50mg/kg (low-dose group) of BDM, 100mg/kg (high-dose group) of BDM, or an equivalent volume of saline (control group) during advanced cardiovascular life support. RESULTS: During advanced cardiovascular life support, the control group showed an increase in left ventricular (LV) wall thickness and a decrease in LV chamber area. In contrast, the BDM-treated groups showed a decrease in the LV wall thickness and an increase in the LV chamber area in a dose-dependent fashion. Mixed-model analyses of the LV wall thickness and LV chamber area revealed significant group effects and group-time interactions. Central venous oxygen saturation at 3minutes after the drug administration was 21.6% (18.4-31.9), 39.2% (28.8-53.7), and 54.0% (47.5-69.4) in the control, low-dose, and high-dose groups, respectively (P<.001). Sustained restoration of spontaneous circulation was attained in 7 (58.3%), 10 (83.3%), and 12 animals (100%) in the control, low-dose, and high-dose groups, respectively (P=.046). CONCLUSION: 2,3-Butanedione monoxime administered during CPR attenuated ischemic contracture and improved the resuscitability in a dose-dependent fashion.

Prevalence and risk factors for central diabetes insipidus in cardiac arrest survivor treated with targeted temperature management.

PURPOSE: Central diabetes insipidus (CDI) is a marker of severe brain injury. Here we aimed to investigate the prevalence and risk factors of CDI in cardiac arrest survivors treated with targeted temperature management (TTM). METHODS: This retrospective observational study included consecutive adult cardiac arrest survivors treated with TTM between 2008 and 2014. Central diabetes insipidus was confirmed if all of the following criteria were met: urine volume >50 cc kg(-1) d(-1), serum osmolarity >300 mmol/L, urine osmolarity <300 mmol/L, and serum sodium >145 mEq/L. The primary outcome was the incidence of CDI. RESULTS: Of the 385 included patients, 45 (11.7%) had confirmed central CDI. Univariate analysis showed that younger age, nonwitness of collapse, nonshockable rhythm, a high incidence of asphyxia arrest, longer downtime, and lower initial core temperature were associated with CDI development. Patients with CDI had a higher incidence of poor neurologic outcomes at discharge and higher in-hospital mortality rate (20/45 vs 76/340, P= .001) as well as 180-day mortality (44/45 vs 174/340, P< .001). Multivariate analysis revealed that age (odds ratio [OR], 0.963; 95% confidence interval [CI], 0.942-0.984), shockable rhythm (OR, 0.077; 95% CI, 0.009-0.662), downtime (OR, 1.025; 95% CI, 1.006-1.044), and asphyxia etiology (OR, 6.815; 95% CI, 2.457-18.899) were independently associated with CDI development. CONCLUSION: Central diabetes insipidus developed in 12% of cardiac arrest survivors treated with TTM, and those with CDI showed poor neurologic outcomes and high mortality rates. Younger age, nonshockable rhythm, long downtime, and asphyxia arrest were significant risk factors for development of CDI.

An observational study of surface versus endovascular cooling techniques in cardiac arrest patients: a propensity-matched analysis.

INTRODUCTION: Various methods and devices have been described for cooling after cardiac arrest, but the ideal cooling method remains unclear. The aim of this study was to compare the neurological outcomes, efficacies and adverse events of surface and endovascular cooling techniques in cardiac arrest patients. METHODS: We performed a multicenter, retrospective, registry-based study of adult cardiac arrest patients treated with therapeutic hypothermia presenting to 24 hospitals across South Korea from 2007 to 2012. We included patients who received therapeutic hypothermia using overall surface or endovascular cooling devices and compared the neurological outcomes, efficacies and adverse events of both cooling techniques. To adjust for differences in the baseline characteristics of each cooling method, we performed one-to-one matching by the propensity score. RESULTS: In total, 803 patients were included in the analysis. Of these patients, 559 underwent surface cooling, and the remaining 244 patients underwent endovascular cooling. In the unmatched cohort, a greater number of adverse events occurred in the surface cooling group. Surface cooling was significantly associated with a poor neurological outcome (cerebral performance category 3-5) at hospital discharge (p = 0.01). After propensity score matching, surface cooling was not associated with poor neurological outcome and hospital mortality [odds ratio (OR): 1.26, 95% confidence interval (CI): 0.81-1.96, p = 0.31 and OR: 0.85, 95% CI: 0.55-1.30, p = 0.44, respectively]. Although surface cooling was associated with an increased incidence of adverse events (such as overcooling, rebound hyperthermia, rewarming related hypoglycemia and hypotension) compared with endovascular cooling, these complications were not associated with surface cooling using hydrogel pads. CONCLUSIONS: In the overall matched cohort, no significant difference in neurological outcomes and hospital morality was observed between the surface and endovascular cooling methods.

Adverse events associated with poor neurological outcome during targeted temperature management and advanced critical care after out-of-hospital cardiac arrest.

INTRODUCTION: The aim of this study was to investigate the association of adverse events (AEs) during targeted temperature management (TTM) and other AEs and concomitant treatments during the advanced critical care period with poor neurological outcome at hospital discharge in adult out-of-hospital cardiac arrest (OHCA) patients. METHODS: This was a retrospective study using Korean Hypothermia Network registry data of adult OHCA patients treated with TTM in 24 teaching hospitals throughout South Korea from 2007 to 2012. Demographic characteristics, resuscitation and post-resuscitation variables, AEs, and concomitant treatments during TTM and the advanced critical care were collected. The primary outcome was poor neurological outcome, defined as a cerebral performance category (CPC) score of 3-5 at hospital discharge. The AEs and concomitant treatments were individually entered into the best multivariable predictive model of poor neurological outcome to evaluate the associations between each variable and outcome. RESULTS: A total of 930 patients, including 704 for whom a complete dataset of AEs and covariates was available for multivariable modeling, were included in the analysis; 476 of these patients exhibited poor neurological outcome [CPC 3 = 50 (7.1%), CPC 4 = 214 (30.4%), and CPC 5 = 212 (30.1%)]. Common AEs included hyperglycemia (45.6%), hypokalemia (31.3%), arrhythmia (21.3%) and hypotension (29%) during cooling, and hypotension (21.6%) during rewarming. Bleeding (5%) during TTM was a rare AE. Common AEs during the advanced critical care included pneumonia (39.6%), myoclonus (21.9%), seizures (21.7%) and hypoglycemia within 72 hours (23%). After adjusting for independent predictors of outcome, cooling- and rewarming-related AEs were not significantly associated with poor neurological outcome. However, sepsis, myoclonus, seizure, hypoglycemia within 72 hours and anticonvulsant use during the advanced critical care were associated with poor neurological outcome [adjusted odds ratios (95% confidence intervals) of 3.12 (1.40-6.97), 3.72 (1.93-7.16), 4.02 (2.04-7.91), 2.03 (1.09-3.78), and 1.69 (1.03-2.77), respectively]. Alternatively, neuromuscular blocker use was inversely associated with poor neurological outcome (0.48 [0.28-0.84]). CONCLUSIONS: Cooling- and rewarming-related AEs were not associated with poor neurological outcome at hospital discharge. Sepsis, myoclonus, seizure, hypoglycemia within 72 hours and anticonvulsant use during the advanced critical care period were associated with poor neurological outcome at hospital discharge in our study.

Extracorporeal life support for cardiac arrest in a 13-year-old girl caused by Wolff-Parkinson-White syndrome.

Generally, Wolff-Parkinson-White (WPW) syndrome presents good prognosis. However, several case reports demonstrated malignant arrhythmia or sudden cardiac death as WPW syndrome's first presentation. Cardiopulmonary resuscitation using extracorporeal life support is a therapeutic option in refractory cardiac arrest. We present a WPW syndrome patient who had sudden cardiac arrest as the first presentation of the disease and treated it using extracorporeal life support with good neurologic outcome.

Safely completed therapeutic hypothermia in postpartum cardiac arrest survivors.

Recently, therapeutic hypothermia (TH) has been used as one of the most important treatments for post­cardiac arrest care. Although TH induces several complications, it is performed across various medical fields. The following series of case studies describes 2 cases of postpartum cardiac arrest, treated with TH without serious complications. Although 1 patient exhibited coagulopathy and bleeding tendencies, this report suggests further application for TH. Therefore, emergency physicians should consider TH for the treatment of postpartum cardiac arrest.

Impact of case volume on outcome and performance of targeted temperature management in out-of-hospital cardiac arrest survivors.

PURPOSE: This study aimed to determine the effect of case volume on targeted temperature management (TTM) performance, incidence of adverse events, and neurologic outcome in comatose out-of-hospital cardiac arrest (OHCA) survivors treated with TTM. METHODS: We used a Web-based, multicenter registry (Korean Hypothermia Network registry), to which 24 hospitals throughout the Republic of Korea participated to study adult (≥18 years) comatose out-of-hospital cardiac arrest patients treated with TTM between 2007 and 2012. The primary outcome was neurologic outcome at hospital discharge. The secondary outcomes were inhospital mortality, TTM performance, and adverse events. We extracted propensity-matched cohorts to control for bias. Multivariate logistic regression analysis was performed to assess independent risk factors for neurologic outcome. RESULTS: A total of 901 patients were included in this study; 544 (60.4%) survived to hospital discharge, and 248 (27.5%) were discharged with good neurologic outcome. The high-volume hospitals initiated TTM significantly earlier and had lower rates of hyperglycemia, bleeding, hypotension, and rebound hyperthermia. However, neurologic outcome and inhospital mortality were comparable between high-volume (27.7% and 44.6%, respectively) and low-volume hospitals (21.1% and 40.5%) in the propensity-matched cohorts. The adjusted odds ratio for the high-volume hospitals compared with low-volume hospitals was 1.506 (95% confidence interval, 0.875-2.592) for poor neurologic outcome. CONCLUSIONS: Higher TTM case volume was significantly associated with early initiation of TTM and lower incidence of adverse events. However, case volume had no association with neurologic outcome and inhospital mortality.