Predictors of poor neurologic outcome after induced mild hypothermia following cardiac arrest

Laval University, Quebec City, Quebec, Canada
Neurology (Impact Factor: 8.3). 12/2008; 71(19):1535-7. DOI: 10.1212/01.wnl.0000334205.81148.31
Source: PubMed

ABSTRACT 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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    ABSTRACT: Objective: To assess the value of electroencephalogram for prediction of outcome of comatose patients after cardiac arrest treated with mild therapeutic hypothermia. Design: Prospective cohort study. Setting: Medical ICU. Patients: One hundred forty-two patients with postanoxic encephalopathy after cardiac arrest, who were treated with mild therapeutic hypothermia. Measurements and Main Results: Continuous electroencephalogram was recorded during the first 5 days of ICU admission. Visual classification of electroencephalogram patterns was performed in 5-minute epochs at 12 and 24 hours after cardiac arrest by two independent observers, blinded for patients' conditions and outcomes. Patterns were classified as isoelectric, low voltage, epileptiform, burst-suppression, diffusely slowed, or normal. Burst-suppression was subdivided into patterns with and without identical bursts. Primary outcome measure was the neurologic outcome based on each patient's best achieved Cerebral Performance Category score within 6 months after inclusion. 67 patients (47%) had favorable outcome (Cerebral Performance Category, 1-2). In patients with favorable outcome, electroencephalogram patterns improved within 24 hours after cardiac arrest, mostly toward diffusely slowed or normal. At 24 hours after cardiac arrest, the combined group of isoelectric, low voltage, and "burst-suppression with identical bursts" was associated with poor outcome with a sensitivity of 48% (95% CI, 35-61) and a specificity of 100% (95% CI, 94-100). At 12 hours, normal or diffusely slowed electroencephalogram patterns were associated with good outcome with a sensitivity of 56% (95% CI, 41-70) and a specificity of 96% (95% CI, 86-100). Conclusions: Electroencephalogram allows reliable prediction of both good and poor neurologic outcome of patients with postanoxic encephalopathy treated with mild therapeutic hypothermia within 24 hours after cardiac arrest.
    Critical Care Medicine 09/2014; 43(1). DOI:10.1097/CCM.0000000000000626 · 6.15 Impact Factor
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    ABSTRACT: Objectives To review and update the evidence on predictors of poor outcome (death, persistent vegetative state or severe neurological disability) in adult comatose survivors of cardiac arrest, either treated or not treated with controlled temperature, to identify knowledge gaps and to suggest a reliable prognostication strategy. Methods GRADE-based systematic review followed by expert consensus achieved using Web-based Delphi methodology, conference calls and face-to-face meetings. Predictors based on clinical examination, electrophysiology, biomarkers and imaging were included. Results and conclusions Evidence from a total of 73 studies was reviewed. The quality of evidence was low or very low for almost all studies. In patients who are comatose with absent or extensor motor response at ≥72 h from arrest, either treated or not treated with controlled temperature, bilateral absence of either pupillary and corneal reflexes or N20 wave of short-latency somatosensory evoked potentials were identified as the most robust predictors. Early status myoclonus, elevated values of neuron-specific enolase at 48–72 h from arrest, unreactive malignant EEG patterns after rewarming, and presence of diffuse signs of postanoxic injury on either computed tomography or magnetic resonance imaging were identified as useful but less robust predictors. Prolonged observation and repeated assessments should be considered when results of initial assessment are inconclusive. Although no specific combination of predictors is sufficiently supported by available evidence, a multimodal prognostication approach is recommended in all patients.
    Intensive Care Medicine 11/2014; 40(12). DOI:10.1007/s00134-014-3470-x · 5.54 Impact Factor
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    ABSTRACT: We analysed the relationship between serum levels of lactate within 1 h of return of spontaneous circulation (ROSC) and survival and neurological outcomes in patients who underwent therapeutic hypothermia (TH).Methods This was a multi-centre retrospective and observational study that examined data from the first Korean Hypothermia Network (KORHN) registry from 2007 to 2012. The inclusion criteria were out-of-hospital cardiac arrest (OHCA) and examination of serum levels of lactate within 1 h after ROSC, taken from KORHN registry data. The primary endpoint was survival outcome at hospital discharge, and the secondary endpoint was poor neurological outcome (Cerebral Performance Category, CPC, 3–5) at hospital discharge. Initial lactate levels and other variables collected within 1 h of ROSC were analysed via multivariable logistic regression.ResultsData from 930 cardiac arrest patients who underwent TH were collected from the KORHN registry. In a total of 443 patients, serum levels of lactate were examined within 1 h of ROSC. In-hospital mortality was 289/443 (65.24%), and 347/443 (78.33%) of the patients had CPCs of 3–5 upon hospital discharge. The odds ratios of lactate levels for CPC and in-hospital mortality were 1.072 (95% confidence interval (CI) 1.026–1.121) and 1.087 (95% CI = 1.031–1.147), respectively, based on multivariate ordinal logistic regression analyses.Conclusion High levels of lactate in serum measured within 1 h of ROSC are associated with hospital mortality and CPC scores of 3–5 in cardiac arrest patients treated with TH.
    Resuscitation 11/2014; 88. DOI:10.1016/j.resuscitation.2014.11.005 · 3.96 Impact Factor

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