Al Thenayan E, Savard M, Sharpe M, et al. Predictors of poor neurologic outcome after induced mild hypothermia following cardiac arrest

Laval University, Quebec City, Quebec, Canada
Neurology (Impact Factor: 8.29). 12/2008; 71(19):1535-7. DOI: 10.1212/01.wnl.0000334205.81148.31
Source: PubMed


Several predictors of poor neurologic outcome after cardiac arrest (CA) were proven to be valid. However, these studies preceded the advent of therapeutic induced mild hypothermia (TIMH), which may alter their validity. The objective of this study is to reassess the validity of these predictors in post-CA patients treated with TIMH.
Retrospective chart review of 37 consecutive adults who were comatose after resuscitation from CA and treated with TIMH.
None of six patients without pupillary reactivity, six without corneal reflexes on day 3, or eight with myoclonus status epilepticus recovered awareness. Two of 14 patients with motor responses no better than extension at day 3 recovered motor responses only after 6 days post-arrest (one at 5 and one at 6 days post-rewarming) and regained awareness.
Loss of motor responses better than extension on day 3 was not prognostically reliable after therapeutic induced mild hypothermia for comatose cardiac arrest survivors. None of the patients who lost pupillary or corneal reflexes on day 3 or developed myoclonus status epilepticus recovered awareness.

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Available from: Loretta Norton, May 29, 2014
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    • "From several recent studies on neurological prognostication after cardiac arrest it has become evident that the majority of deaths occur after a statement of a poor prognosis and withdrawal of life supportive treatment (WLST) [12,17-22]. Therefore, the routines for prognostication clearly have the power to affect survival rates in clinical trials. "
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    ABSTRACT: Brain injury is the dominant cause of death for cardiac arrest patients who are admitted to an intensive care unit, and the majority of patients die after withdrawal of life sustaining therapy (WLST) based on a presumed poor neurologic outcome. Mild induced hypothermia was found to decrease the reliability of several methods for neurological prognostication. Algorithms for prediction of outcome, that were developed before the introduction of mild hypothermia after cardiac arrest, may have affected the results of studies with hypothermia-treated patients. In previous trials on neuroprotection after cardiac arrest, including the pivotal hypothermia trials, the methods for prognostication and the reasons for WLST were not reported and may have had an effect on outcome. In the Target Temperature Management trial, in which 950 cardiac arrest patients have been randomized to treatment at 33[degree sign]C or 36[degree sign]C, neuroprognostication and WLST-decisions are strictly protocolized and registered. Prognostication is delayed to at least 72 hours after the end of the intervention period, thus a minimum of 4.5 days after the cardiac arrest, and is based on multiple parameters to account for the possible effects of hypothermia.
    Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 06/2013; 21(1):45. DOI:10.1186/1757-7241-21-45 · 2.03 Impact Factor
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    • "An increasing number of recent studies on outcome prognostication after cardiac arrest demonstrate that hypothermia treatment alters prognostic parameters that had been established in normothermic patients. For example, a level of neuron specific enolase (NSE) above 33 μg/L, obtained on day one to three after cardiac arrest, and motor reaction to painful stimuli not better than extension on day three, are associated with a substantial rate of false poor outcome predictions in these patients [1-8]. Individual patients have been reported who survived with good neurological outcome despite NSE levels of 97 μg/L [3], bilateral absent N20 of medianus somatosensory evoked potentials (SSEP) [4,5], absent pupillary light responses or corneal reflexes [6,7] and early status epilepticus [8]. "
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    ABSTRACT: Background Mild therapeutic hypothermia alters the validity of a number of parameters currently used to predict neurological outcome after cardiac arrest and resuscitation. Thus, additional parameters are needed to increase certainty of early prognosis in these patients. A promising new approach is the determination of the gray-white-matter ratio (GWR) in cranial computed tomography (CCT) obtained early after resuscitation. It is not known how GWR relates to established outcome parameters such as neuron specific enolase (NSE) or somatosensory evoked potentials (SSEP). Methods Cardiac arrest patients (n = 98) treated with hypothermia were retrospectively analyzed with respect to the prognostic value of GWR, NSE and SSEP. Results A GWR < 1.16 predicted poor outcome with 100% specificity and 38% sensitivity. In 62 patients NSE, SSEP and CCT were available. The sensitivity of poor outcome prediction by both NSE > 97 μg/L and bilateral absent SSEP was 43%. The sensitivity increased to 53% in a multi-parameter approach predicting poor outcome using at least two of the three parameters (GWR, NSE and SSEP). Conclusion Our results suggest a strong association of a low GWR with poor outcome following cardiac arrest. Determination of the GWR increases the sensitivity in a multi-parameter approach for prediction of poor outcome after cardiac arrest.
    Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 04/2013; 21(1):23. DOI:10.1186/1757-7241-21-23 · 2.03 Impact Factor
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    • "The use of induced hypothermia to improve outcomes has further complicated matters because it mandates sedation and intermittent use of muscle relaxants during the intervention. Moreover, hypothermia delays the metabolism of drugs [7] and makes a clinical neurological examination less reliable [8,9]. Therefore, we need to reassess and improve our prognostic instruments and explore novel and complementary methods of a clinical neurological examination [10]. "
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    ABSTRACT: Introduction Induced hypothermia has been shown to improve outcome after cardiac arrest, but early prognostication is hampered by the need for sedation. Here we tested whether a biomarker for neurodegeneration, the neurofilament heavy chain (NfH), may improve diagnostic accuracy in the first days after cardiac arrest. Methods This prospective study included 90 consecutive patients treated with hypothermia after cardiac arrest. Plasma levels of phosphorylated NfH (SMI35) were quantified using standard ELISA over a period of 72 h after cardiac arrest. The primary outcome was the dichotomized Cerebral Performance Categories scale (CPC). A best CPC 1-2 during 6 months follow-up was considered a good outcome, a best CPC of 3-4 a poor outcome. Receiver operator characteristics and area under the curve were calculated. Results The median age of the patients was 65 years, and 63 (70%) were male. A cardiac aetiology was identified in 62 cases (69%). 77 patients (86%) had out-of-hospital cardiac arrest. The outcome was good in 48 and poor in 42 patients. Plasma NfH levels were significantly higher 2 and 36 hours after cardiac arrest in patients with poor outcome (median 0.28 ng/mL and 0.5 ng/mL, respectively) compared to those with good outcome (0 ng/mL, p = 0.016, p < 0.005, respectively). The respective AUC were 0.72 and 0.71. Conclusions Plasma NfH levels correlate to neurological prognosis following cardiac arrest. In this study, 15 patients had neurological co-morbidities and there was a considerable overlap of data. As such, neurofilament should not be used for routine neuroprognostication until more data are available.
    Critical care (London, England) 03/2012; 16(2):R45. DOI:10.1186/cc11244 · 4.48 Impact Factor
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