Predicting Outcome from Hypoxic-Ischemic Coma

JAMA The Journal of the American Medical Association (Impact Factor: 35.29). 04/1985; 253(10):1420-6. DOI: 10.1097/00132586-198604000-00038
Source: PubMed
Outcome from coma caused by cerebral hypoxia-ischemia (eg, cardiac arrest) was compared with serial neurological findings in 210 patients. Thirteen percent of patients regained independent function at some point during the first postarrest year. Computer application of new multivariate techniques to the prospectively observed findings generated easily utilized rules that classified patients by likely outcome. At the time of initial examination, 52 patients (one fourth of the total population) had absent pupillary light reflexes, and none of these patients ever regained independent daily function. By contrast, the initial presence of pupillary light reflexes, the development of spontaneous eye movements that were roving conjugate or better, and the findings of extensor, flexor, or withdrawal responses to pain identified a smaller group of 27 patients, 11 (41%) of whom regained independence in their daily lives. By 24 hours after onset, 93 poor-outcome patients were identified by motor responses that were absent, extensor, or flexor and by spontaneous eye movements that were neither orienting nor roving conjugate; only one regained independent function. This contrasts with recovery in 19 (63%) of 30 patients who at that time showed improvement in their eye-opening responses and obeyed commands or had motor responses that were withdrawal or localizing. Similarly simple rules distinguished between good- and poor-prognosis patients on postarrest days 3, 7, and 14.


Available from: Halina Frydman
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    • "However, this presents two dilemmas-objectively defining meaningful recovery and prognosticating which patients would make such recovery. Prediction of outcomes in comatose survivors after cardiac arrests requiring CPR has been described in several studies25262728. Results from these studies are varied, yet important, and much further research is needed before definitive recommendations guide clinical care. "
    [Show abstract] [Hide abstract] ABSTRACT: Introduction: Current prevalence estimates of gastrostomy tube (GT)/tracheostomy placement in hospitalized patients with anoxic/hypoxic ischemic encephalopathic injury (AHIE) post cardiopulmonary resuscitation (CPR) are unknown. We sought, to estimate the prevalence of AHIE in hospitalized patients who had CPR and to identify patient/hospital level factors that predict the performance of GT/tracheostomy in those with AHIE. Methods: We performed a retrospective analysis of the Nationwide Inpatient Sample (years 2004-2010). All patients who developed AHIE following CPR were included. In this cohort the odds of having GT and tracheostomy was computed by multivariable logistic regression analysis. Patient and hospital level factors were the independent variables. Results: During the study period, a total of 686,578 CPR events occurred in hospitalized patients. Of these, 94,336 (13.7%) patients developed AHIE. In this AHIE cohort, 6.8% received GT and 8.3% tracheostomy. When compared to the 40-49 yrs age group, those aged >70 yrs were associated with lower odds for GT (OR = 0.65, 95% CI:0.53-0.80, p<0.0001). Those aged <18 years & those >60 years were associated with lower odds for having tracheostomy when compared to the 40-49 years group (p<0.0001). Each one unit increase in co-morbid burden was associated with higher odds for having GT (OR = 1.23,p<0.0001) or tracheostomy (OR = 1.17, p<0.0001). Blacks, Hispanics, Asians/Pacific Islanders, and other races were associated with higher odds for having GT or tracheostomy when compared to whites (p<0.05). Hospitals located in northeastern regions were associated with higher odds for performing GT (OR = 1.48, p<0.0001) or tracheostomy (OR = 1.63, p<0.0001) when compared to those in Western regions. Teaching hospitals (TH) were associated with higher odds for performing tracheostomy when compared to non-TH (OR = 1.36, 1.20-1.54, p<0.0001). Conclusions: AHIE injury occurs in a significant number of in-hospital arrests requiring CPR. Certain predictors of GT/ Tracheostomy placement are identified. Patients in teaching hospitals were more likely to receive tracheostomy than their counterparts.
    Full-text · Article · Jul 2015 · PLoS ONE
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    • "Quite recently, several advances in cerebral imaging, in biochemical markers and in neurophysiological testing have been studied in OHCA [5] [6] [9] [10]. However, despite promising results, the neurological examination remains in most ICUs the cornerstone of the outcome assessment and relies on absent pupillary or corneal reflexes or absent or no better than extensor motor response at day 3 [5] [6] [11] [12]. The prognostic value of the Glasgow Coma Scale (GCS) has been previously studied [13] [14]. "
    [Show abstract] [Hide abstract] ABSTRACT: The accurate prediction of outcome after out-of-hospital cardiac arrest (OHCA) is of major importance. The recently described Full Outline of UnResponsiveness (FOUR) is well adapted to mechanically ventilated patients and does not depend on verbal response. To evaluate the ability of FOUR assessed by intensivists to accurately predict outcome in OHCA. We prospectively identified patients admitted for OHCA with a Glasgow Coma Scale below 8. Neurological assessment was performed daily. Outcome was evaluated at 6months using Glasgow-Pittsburgh Cerebral Performance Categories (GP-CPC). Eighty-five patients were included. At 6months, 19 patients (22%) had a favorable outcome, GP-CPC 1-2, and 66 (78%) had an unfavorable outcome, GP-CPC 3-5. Compared to both brainstem responses at day 3 and evolution of Glasgow Coma Scale, evolution of FOUR score over the three first days was able to predict unfavorable outcome more precisely. Thus, absence of improvement or worsening from day 1 to day 3 of FOUR had 0.88 (0.79-0.97) specificity, 0.71 (0.66-0.76) sensitivity, 0.94 (0.84-1.00) PPV and 0.54 (0.49-0.59) NPV to predict unfavorable outcome. Similarly, the brainstem response of FOUR score at 0 evaluated at day 3 had 0.94 (0.89-0.99) specificity, 0.60 (0.50-0.70) sensitivity, 0.96 (0.92-1.00) PPV and 0.47 (0.37-0.57) NPV to predict unfavorable outcome. The absence of improvement or worsening from day 1 to day 3 of FOUR evaluated by intensivists provides an accurate prognosis of poor neurological outcome in OHCA. Copyright © 2015 Elsevier Masson SAS. All rights reserved.
    Full-text · Article · Apr 2015 · Revue Neurologique
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    • "The latency of entering the dark compartment was recorded again as memory test (stepthrough latency). The maximum time that considered in this procedure were 300 seconds (Mahut et al., 1982; Levy et al., 1985; Lipton & Rosenberg, 1994). "
    [Show abstract] [Hide abstract] ABSTRACT: Objectives: Estrogen deficit following menopause results in cognitive behaviors impairment. This study aimed to evaluate the effects of pomegranate seed extract (PGSE) on avoidance memories after permanent bilateral common carotid arteries occlusion (2CCAO) in ovariectomized (OVX) rats. Materials and Methods: Adult female Wistar rats were divided randomly into eight groups with 8 rats in each group: 1) Sham-operated for ovaries and 2CCAO (ShO); 2) OVX and sham operated for ischemia (OShI); 3-7) OVX with 2CCAO (OI) received PGSE (100, 200, 400 and 800 mg/2ml/kg or normal saline, orally) for 14 days (OI+E100, 200, 400, 800 or OI+Veh); 8) OShI received most effective dose of PGSE (200 and 400 mg/kg for passive and active avoidance memories respectively). Active and passive avoidance tasks were measured in Y-maze and two-way shuttle box respectively. Data were analyzed with one-way and RM-ANOVA followed by HSD post-hoc test. Results: Sensorimotor impaired in OShI+Veh and OI+Veh (P<0.001 vs. ShO). PGSE improved it significantly in dose dependently manner (P<0.001 vs. OI+Veh). Both types of memories were significantly impaired in OVX rats before and after 2CCAO (P<0.001). PGSE treatment significantly improved memories in OI groups (P<0.05, P<0.01 and P<0.001) compared with OI+Veh. No toxicity was observed with PGSE consumption (800 mg/kg, 2 weeks, orally). Conclusion: PGSE exhibits therapeutic potential for avoidance memories, which is most likely related at least in part to its phytoestrogenic and also antioxidative actions.
    Full-text · Article · Mar 2015 · Avicenna Journal of Phytomedicine
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