早期测定血清神经元特异性烯醇化酶水平对心跳呼吸骤停复苏后住院患儿转归以及神经学预后的预测作用

目的探讨早期检测血清神经元特异性烯醇化酶（NSE）水平对发生心跳呼吸骤停（CRA）住院患儿复苏后转归以及神经学预后的预测作用。方法选择2006年1月至2008年12月发生CRA的住院患儿,分为死亡组和存活组,对存活患儿随访6个月,分为神经学预后不良组和预后良好组。比较患儿年龄、性别、骤停类型、CPR时间、ROSC后Glasgow昏迷评分（CCS）、瞳孔对光反射恢复、需要镇静与否;在复苏后24～36h随机测定外周静脉血清NSE浓度,比较组间采样时间以及血清NSE水平。利用受试者工作特征（ROC）曲线,分别取NSE对复苏后死亡和6月时神经学不良预后诊断特异度（Sp）为100％、敏感度（se）最高的点为截断（cutt-off）值,并计算阳性预测值（PPV）、阴性预测值（NPV）和正确度。结果最终纳入病例87例,ROSC43例,存活出院19例,死亡24例;随访6月后,神经学预后不良12例,预后良好7例。死亡组与存活组以及神经学预后不良组与良好组间比较,CPR时间、GCS、瞳孔对光反射恢复、需要镇静与否以及NSE血清水平存在显著统计学差异（P均〈0．05）。NSE水平与CPR时间呈显著正相关（r=0．901,P=0．00）;与GCS呈显著负相关（r=-0．813,P=0．00）。NSE对复苏后ROSC患儿转归的ROC曲线下面积为0．846±0．065（95％CI：0．720-0．973,P=0．oo）,截断值为90．6ng／ml,Se、Sp、PPV、NPV、准确度分别为20．8％、100％、100％、50％、53．5％;NSE对神经学预后的ROC曲线下面积为0．929±0．072（95％CI：0．788—1．069,P=0．002）,截断值为50．7ng／ml,se、Sp、PPV、NPV、准确度分别为50％、100％、100％、53．8％、68．4％。结论ROSC后早期血清NSE水平对复苏后患儿转归和神经学预后有预测意义。     

Serum levels of the brain-derived proteins S-100 and NSE predict long-term outcome after cardiac arrest

Background and purpose: patients with cardiac arrest have a high mortality and the long-term outcome is doubtful. The prognosis is mainly dependent on clinical parameters. S-100 and neurone specific enolase (NSE) are established biochemical markers of central nervous system (CNS) injury. The purpose of this study was to validate the use of serum determinations of S-100 and NSE with neurological investigations in regard to brain damage and long-term outcome after cardiac arrest. Methods: neurological examinations were performed on 66 patients after cardiac arrest. Serum levels of S-100 and NSE were determined during the first 3 days of post arrest, using commercial luminescent immunoassays (LIAs). The main outcome variable was the Glasgow Outcome Scale (GOS), while secondary variables were the activity of daily living (ADL) index and mini mental state examination (MMSE). Outcome was determined at 1 year. Results: the serum levels of S-100 and NSE were increased during the first 3 days after the arrest and were related to coma depth, time of anoxia and abnormal brain stem reflexes. High levels predicted a poor outcome, according to the GOS (death, vegetative state and severe disability). The prognostic value of the brain damage markers was comparable with that of traditional clinical parameters. None of the secondary outcome variables (ADL and MMSE) was strongly associated with S-100 or NSE. Discussion: the serum levels of S-100 and NSE increased after cardiac arrest due to the anoxic brain damage. The determination of S-100 and NSE can be used as an adjunct to predict long-term outcome after cardiac arrest.     

Serum neuron-specific enolase predicts outcome in post-anoxic coma: a prospective cohort study

OBJECTIVE: The aim of this study was to investigate whether serial serum neuron-specific enolase (NSE) can be used to predict neurological prognosis in patients remaining comatose after cardiopulmonary resuscitation (CPR). DESIGN. Observational cohort study. Clinicians were blinded to NSE results. SETTING: Eighteen-bed general ICU. PATIENTS: Comatose patients admitted to the ICU after CPR. INTERVENTIONS: Serum NSE was measured at admission and daily for 5 days. MEASUREMENTS AND RESULTS: Patients received full intensive treatment until recovery or until absence of cortical response to somatosensory evoked potentials more than 48 h after CPR proved irreversible coma. Of the 110 patients included (mean GCS at ICU admission 3, range 3--9), 34 regained consciousness, five of whom died in hospital. Seventy-six patients did not regain consciousness, 72 of whom died in hospital. Serum NSE at 24 h and at 48 h after CPR was significantly higher in patients who did not regain consciousness than in patients who regained consciousness (at 24 h: median NSE 29.9 microg/l, range 1.8-250 vs 9.9 microg/l, range 4.5-21.5, P<0.001; at 48 h: median 37.8 microg/l, range 4.4-411 vs 9.5 microg/l, range 6.2-22.4, P= 0.001). No patient with a serum NSE level >25.0 microg/l at any time regained consciousness. Addition of NSE to GCS and somatosensory evoked potentials increased predictability of poor neurological outcome from 64% to 76%. CONCLUSIONS: High serum NSE levels in comatose patients at 24 h and 48 h after CPR predict a poor neurological outcome. Addition of NSE to GCS and somatosensory evoked potentials increases predictability of neurological outcome.     

Serum S-100B is superior to neuron-specific enolase as an early prognostic biomarker for neurological outcome following cardiopulmonary resuscitation

IntroductionMost patients with cardiac arrest (CA) admitted to hospitals after successful cardiopulmonary resuscitation (CPR) are discharged with various degree of neurological deficits. To determine predictor of neurological outcome early and accurately, and to determine cutoff values, serum levels of protein S-100B and neuron-specific enolase (NSE) within 24 h after CA were assessed.Methods and resultsA multicenter prospective observational study was conducted between May 2007 and April 2008 at three medical institutions in Japan on 107 consecutive non-traumatic CA patients with return of spontaneous circulation after CPR. Based on “best-ever achieved” Glasgow-Pittsburgh cerebral performance categories (CPC) score within 6 months after CA, patients were classified into a “poor neurological outcome” group (CPC3 to CPC5) (n = 67) and “favorable neurological outcome” group (CPC1 and CPC2) (n = 13). Blood was sampled on admission, at 6 and 24 h after CA. Serum S-100B and NSE in “poor outcome” group were higher than those in “favorable outcome” group (P < 0.01). On ROC analysis, area under the curve of S-100B was 0.85, 0.94 and 1.0, respectively. These were greater than those of NSE at all sampling points. The “100%-specific” cutoff values of S-100B predictive of poor neurological outcome were 1.41, 0.21, and 0.05 ng/mL, respectively. These values corresponded to sensitivities of 20.9%, 62.8%, and 100%, respectively, each of which was higher than those of NSE.ConclusionsS-100B is more reliable as an early predictor of poor neurological outcome within 24 h after CA than NSE and can be applied clinically.     

Diagnostic pitfalls in patients with hypoxic brain damage: three case reports

OBJECTIVE: Our aim was to assess the possible diagnostic pitfalls in three patients with hypoxic brain damage who had partly conflicting clinical, biochemical, and electrophysiological data and were in a persistent vegetative state (PVS) following cardiac arrest (CA). METHODS: Serum concentrations of the destruction proteins, neuron-specific enolase (NSE) and protein S-100B (S-100B), were measured on days 1-3, and 7; somatosensory evoked potentials (SEPs) were recorded within 48 h and on day 7 after CA. RESULTS: Two patients had significantly increased concentrations of NSE and S-100B during the first 3 days after CA, a finding that indicates ongoing neuronal destruction. In contrast, the SEPs of these patients were normal or showed only a diminished amplitude configuration. In the third patient the SEPs demonstrated a bilateral loss of cortical responses repeatedly, but both destruction proteins were only slightly above the upper normal values on all study days. CONCLUSION: Our findings demonstrate that a poor prognosis can only be established if either SEPs, NSE, or S-100B are very abnormal. The conflicting results in our patients indicate that variable values may reflect different patterns of neuropathological damage caused by diffuse hypoxia. We, therefore, favour a multi-modal approach with a combination of clinical, biochemical, and electrophysiological investigations in order to predict neurological outcome after CA reliably.     

山莨菪碱对心肺复苏后患者血清NSE和S100蛋白水平及神经功能的影响

目的 探讨山莨菪碱对心肺复苏(CPR)后患者血清神经元特异性烯醇酶(NSE)、S100蛋白水平及神经功能的影响.方法 53例心搏骤停后经心肺复苏心搏恢复≥72h、需要进一步生命支持的患者,随机分为山莨菪碱组27例(山莨菪碱+常规综合治疗)和常规组26例(单纯常规综合治疗).分别于治疗后不同时间点检测血清NSE、S100蛋白水平,并以格拉斯哥昏迷评分(GCS)和神经功能缺损评分(NFI)判断临床疗效.结果 与常规组比较,山莨菪碱组治疗后血清NSE、S100蛋白水平显著降低(P<0.05或P<0.01),GCS评分显著增高(P<0.05或P<0.01),NFI评分显著降低(P<0.05或P<0.01).结论 山莨菪碱通过降低血清NSE、S100蛋白水平对心肺复苏后脑损伤起到一定保护作用.     

Prognostication of neurologic outcome in cardiac arrest patients after mild therapeutic hypothermia: a meta-analysis of the current literature

Purpose

To assess the sensitivity and false positive rate (FPR) of neurological examination and somatosensory evoked potentials (SSEPs) to predict poor outcome in adult patients treated with therapeutic hypothermia after cardiopulmonary resuscitation (CPR).

Methods

MEDLINE and EMBASE were searched for cohort studies describing the association of clinical neurological examination or SSEPs after return of spontaneous circulation with neurological outcome. Poor outcome was defined as severe disability, vegetative state and death. Sensitivity and FPR were determined.

Results

A total of 1,153 patients from ten studies were included. The FPR of a bilaterally absent cortical N20 response of the SSEP could be calculated from nine studies including 492 patients. The SSEP had an FPR of 0.007 (confidence interval, CI, 0.001–0.047) to predict poor outcome. The Glasgow coma score (GCS) motor response was assessed in 811 patients from nine studies. A GCS motor score of 1–2 at 72 h had a high FPR of 0.21 (CI 0.08–0.43). Corneal reflex and pupillary reactivity at 72 h after the arrest were available in 429 and 566 patients, respectively. Bilaterally absent corneal reflexes had an FPR of 0.02 (CI 0.002–0.13). Bilaterally absent pupillary reflexes had an FPR of 0.004 (CI 0.001–0.03).

Conclusions

At 72 h after the arrest the motor response to painful stimuli and the corneal reflexes are not a reliable tool for the early prediction of poor outcome in patients treated with hypothermia. The reliability of the pupillary response to light and the SSEP is comparable to that in patients not treated with hypothermia.     

成人体外心肺复苏患者神经功能预后相关指标的预测价值研究

目的探讨成人体外心肺复苏（ECPR）患者神经功能预后相关指标的判断价值。 方法回顾性分析2018年1月至2021年4月于南京医科大学第一附属医院急诊科接受ECPR治疗的69例心脏骤停患者。根据患者出院时脑功能表现分级（CPC）评分将69例患者分为预后良好组（26例,CPC评分1 ~ 2分）和预后不良组（43例,CPC评分3 ~ 5分）。所有患者均于体外生命支持建立后24 h内接受头颅CT检查,测定其灰质/白质比例（GWR）。记录所有患者的一般资料及72 h内血清神经元特异性烯醇化酶（NSE）峰值水平。采用Spearman相关分析探讨基底节GWR与NSE水平的相关性,并采用受试者工作特征（ROC）曲线评价相关指标对ECPR患者神经功能预后的判断价值。 结果预后不良组心脏骤停患者基底节GWR [1.15（1.10,1.22）vs. 1.26 （1.22,1.28）,Z = 4.576,P < 0.001]较预后良好组显著降低,而体外膜肺氧合建立后72 h内血清NSE峰值[205.80（105.00,370.00）μg/L vs. 41.25（31.96,52.07）μg/L,Z = 5.910,P < 0.001]显著升高。Spearman相关分析结果显示,基底节GWR与NSE水平呈显著负相关（r = -0.685,P < 0.001）。ROC曲线分析结果显示,基底节GWR [曲线下面积（AUC）= 0.831,95%置信区间（CI）（0.735,0.926）,P < 0.001]及NSE 72 h内峰值[AUC = 0.926,95%CI（0.859,0.992）,P < 0.001]均对心脏骤停患者神经功能不良预后具有预测价值。基底节GWR < 1.18时,其预测神经功能不良预后的敏感度和特异度分别为62.8%和92.3%。ECMO建立后72 h内NSE峰值> 79.49 μg/L时,其预测不良预后的敏感度为83.7%,特异度为100%。 结论ECPR患者24 h内头颅CT提示GWR降低、72 h内NSE水平升高可作为预测神经功能预后不良的有效手段。     

Immediate S-100B and neuron-specific enolase plasma measurements for rapid evaluation of primary brain damage in alcohol-intoxicated,minor head-injured patients

The neuroproteins S-100B and neuron-specific enolase (NSE) released into the circulation are suggested to be reliable markers for primary brain damage. However, safe identification of relevant post-traumatic complications after minor head injury (MHI) is often hampered by acute intoxication of the patients. The objective of this study was to determine the diagnostic validity of immediate plasma measurements of S-100B and NSE in comparison with neurological examinations and cerebral computed tomography (CCT) findings in alcohol-intoxicated MHI patients. One hundered thrity-nine MHI individuals were enrolled in this prospective study during Munich's Oktoberfest 2000. Plasma levels of S-100B and NSE as well as serum alcohol and glucose values were determined by fully automated assays immediately after admission. The results were compared with Glasgow Coma Scale score, a brief neurological examination, and the CCT findings. Without being influenced by alcohol, median S-100B levels of the CCT+ group were significantly increased compared with those of the CCT- group (P < 0.001). NSE, alcohol, and glucose levels showed no significant group differences. As calculated by the ROC analysis, a cutoff value of 0.21 ng/mL with an area under the curve of 0.864 clearly differentiates between CCT+ and CCT- patients at a sensitivity of 100%, a specificity of 50.0%, and a positive likelihood ratio of 2.0. Although acute alcohol intoxication did not confound plasma measurements of S-100B and NSE, only S-100B levels below the cutoff level of 0.21 ng/mL seem to indicate absence of primary brain damage. Thus, in addition to routine neurological examinations, S-100B measurements immediately after admission might help to reduce CCT scans in alcohol-intoxicated patients early after MHI.     

Neuron specific enolase and S-100B as predictors of outcome after cardiac arrest and induced hypothermia

Aim

To assess the prognostic value of repetitive serum samples of neuron specific enolase (NSE) and S-100B in cardiac arrest patients treated with hypothermia.

Methods

In a three-centre study, comatose patients after cardiac arrest were treated with hypothermia at 33 °C for 24 h, regardless of cause or the initial rhythm. Serum samples were collected at 2, 24, 48 and 72 h after the arrest and analysed for NSE and S-100B in a non-blinded way. The cerebral performance categories scale (CPC) was used as the outcome measure; a best CPC of 1–2 during 6 months was regarded as a good outcome, a best CPC of 3–5 a poor outcome.

Results

One centre was omitted in the NSE analysis due to missing 24 and 48 h samples. Two partially overlapping groups were studied, the NSE group (n = 102) and the S-100B group (n = 107). NSE at 48 h >28 μg/l (specificity 100%, sensitivity 67%) and S-100B >0.51 μg/l at 24 h (specificity 96%, sensitivity 62%) correlated with a poor outcome, and so did a rise in NSE of >2 μg/l between 24 and 48 h (odds ratio 9.8, CI 3.5–27.7). A majority of missing samples (n = 123) were from the 2 h sampling time (n = 56) due to referral from other hospitals or inter-hospital transfer.

Conclusion

NSE was a better marker than S-100B for predicting outcome after cardiac arrest and induced hypothermia. NSE above 28 μg/l at 48 h and a rise in NSE of more than 2 μg/l between 24 and 48 h were markers for a poor outcome.     

神经元烯醇化酶和脑电双频指数评估心肺复苏患者预后

目的：探讨神经元特异度烯醇化酶和脑电双频指数对心肺复苏成功后接受亚低温治疗患者预后的评估价值。方法选择心搏骤停复苏成功自主循环恢复后的昏迷患者46例,所有患者均接受亚低温治疗,测定自主循环恢复后24、48、72 h患者血清神经元特异度烯醇化酶和脑电双频指数。3个月后进行大脑功能评分（ cerebral-performance category CPC）, CPC1-3分,为预后良好, CPC 4-5分,为预后不良。结果3个月后,预后良好（CPC1-3分）14例,预后不良（CPC4-5分）32例,预后不良组患者48、72 h血清NSE水平高于预后良好组[48 h：（90.1±42.7） ng／mL vs ．（33.2±17.5） ng／mL;72 h：（95.4±37.0） ng／mL vs．（29.2±17.0） ng／mL, P＜0.05]。预后不良组患者NSE在48h和72h均出现升高趋势,而预后良好组均出现降低趋势[△NSE 24 h-48 h：（37.3±28.7） ng／mL vs．（-10.7±12.1） ng／mL;△NSE 48 h-72h：（5.3±13.2） ng／mL vs．（-4.0±4.5） ng／mL, P＜0.05],两组变化出现显著性差异。预后不良组48、72 h BIS值低于预后良好组[48h：（39.2±24.1） vs．（78.0±12.4）;72 h：（45.7±26.4） vs．（89.0±7.3）, P＜0.05]。结论神经元特异度烯醇化酶（NSE）和脑电双频指数（ BIS ）可评估接受亚低温治疗的心搏骤停后患者的神经功能预后,为临床决策提供依据。     

S-100B and neuron-specific enolase as predictors of neurological outcome in patients after cardiac arrest and return of spontaneous circulation: a systematic review

Introduction  

Neurological prognostic factors after cardiopulmonary resuscitation (CPR) in patients with cardiac arrest (CA) as early and accurately as possible are urgently needed to determine therapeutic strategies after successful CPR. In particular, serum levels of protein neuron-specific enolase (NSE) and S-100B are considered promising candidates for neurological predictors, and many investigations on the clinical usefulness of these markers have been published. However, the design adopted varied from study to study, making a systematic literature review extremely difficult. The present review focuses on the following three respects for the study design: definitions of outcome, value of specificity and time points of blood sampling.     

亚低温治疗在脑复苏中的应用及影响预后因素分析

目的 探讨影响心肺复苏(CPR)术后亚低温治疗患者预后的因素及动态脑电波监测对预后的价值.方法 对42例循环稳定的CPR术后患者在全身治疗的基础上进行亚低温治疗,体温(颈静脉球温度)控制在31～34℃,维持3～6 d后复温.治疗期间行各项常规检查,同时监测脑电波并进行Hockday分级,对于存活3个月者通过格拉斯哥预后评分(GOS)评估神经系统功能.结果 良好转归组(包括恢复良好、中度残疾,19例)与不良转归组(包括严重残疾、植物状态、死亡,23例)间停跳后至开始CPR时间及复苏后格拉斯哥昏迷评分(GCS)、血中剩余碱、乳酸浓度均存在不同程度差异[停跳后至开始CPR时间(min):4.11±1.80比13.08±11.37,GCS(分):5.48±1.32比4.13±1.61,剩余碱(mmol/L):-10.27±6.23比-13.18±7.29,乳酸(mmol/L):6.82±3.12比8.47±4.14,P＜0.05或P＜0.01];37例患者行动态脑电波监测,Hockday分级Ⅱ级与Ⅲ级间的良好预后率比较差异有统计学意义[85.7%(12/14)比37.5%(3/8),P＜0.05].结论 停跳后至开始CPR时间及复苏后GCS、血中剩余碱、乳酸浓度有助于判定亚低温治疗后患者的预后;脑电波监测对判定亚低温治疗后患者神经功能转归有较大帮助.     

Association of response time interval with neurological outcomes after out-of-hospital cardiac arrest according to bystander CPR

BackgroundThis study intended to find out how association between response time interval (RTI) and good neurological outcome is affected by bystander CPR. We hypothesized that bystander CPR will ensure positive effect in relationship between RTI and clinical outcome.MethodsA retrospective, observational study was made with Pan-Asian Resuscitation Outcome Study data from January 2009 to December 2016. Six cities from four Asian countries were selected. EMS-treated, non-traumatic witnessed out-of-hospital cardiac arrest (OHCA) cases were included. General demographic data, prehospital cardiac arrest details and clinical outcome were collected and analyzed according to whether bystander CPR was performed. Good neurological outcome and survival discharge were primary and secondary outcomes.ResultsA total of 13,245 OHCA cases were analyzed. Median EMS response time intervals were 6 min, regardless of bystander CPR. Dividing into RTI time range by 3 min, good neurological outcome and survival discharge were only significant in 3 to 6 minutes group (adjusted odds ratio [AOR] 1.42, 1.17–1.73 95% confidence interval [CI] and AOR 1.31, 1.15–1.51 95% CI) in non-bystander CPR group but in bystander CPR group significant RTI time range was 3 to 9 min (AOR 2.02, 1.82, 1.62–2.52, 1.48–2.25 95% CI for primary, AOR 1.66, 1.43, 1.41–1.96, 1.22–1.67 95% CI for secondary).ConclusionsAs response time interval increased, slower deterioration of good neurological outcome and survival discharge was shown in cardiac arrest patients with bystander CPR performed. If bystander CPR is provided, RTI time range showing significant neurological outcome and survival improvement seems to be relatively lengthened.     

S-100B is superior to NSE, BDNF and GFAP in predicting outcome of resuscitation from cardiac arrest with hypothermia treatment

Objective

To conduct a pilot study to evaluate the blood levels of brain derived neurotrophic factor (BDNF), glial fibrillary acidic protein (GFAP), neuron specific enolase (NSE) and S-100B as prognostic markers for neurological outcome 6 months after hypothermia treatment following resuscitation from cardiac arrest.

Design

Prospective observational study.

Setting

One intensive care unit at Uppsala University Hospital.

Patients

Thirty-one unconscious patients resuscitated after cardiac arrest.

Interventions

None.

Measurements and main results

Unconscious patients after cardiac arrest with restoration of spontaneous circulation (ROSC) were treated with mild hypothermia to 32-34 °C for 26 h. Time from cardiac arrest to target temperature was measured. Blood samples were collected at intervals of 1-108 h after ROSC. Neurological outcome was assessed with Glasgow-Pittsburgh cerebral performance category (CPC) scale at discharge from intensive care and again 6 months later, when 15/31 patients were alive, of whom 14 had a good outcome (CPC 1-2). Among the predictive biomarkers, S-100B at 24 h after ROSC was the best, predicting poor outcome (CPC 3-5) with a sensitivity of 87% and a specificity of 100%. NSE at 96 h after ROSC predicted poor outcome, with sensitivity of 57% and specificity of 93%. BDNF and GFAP levels did not predict outcome. The time from cardiac arrest to target temperature was shorter for those with poor outcome.

Conclusions

The blood concentration of S-100B at 24 h after ROSC is highly predictive of outcome in patients treated with mild hypothermia after cardiac arrest.     

Post-cardiac arrest serum levels of glial fibrillary acidic protein for predicting neurological outcome

Aim of the study

To investigate serum levels of glial fibrillary acidic protein (GFAP) for evaluation of neurological outcome in cardiac arrest (CA) patients and compare GFAP sensitivity and specificity to that of more studied biomarkers neuron-specific enolas (NSE) and S100B.

Method

A prospective observational study was performed in three hospitals in Sweden during 2008-2012. The participants were 125 CA patients treated with therapeutic hypothermia (TH) to 32-34 °C for 24 hours. Samples were collected from peripheral blood (n = 125) and the jugular bulb (n = 47) up to 108 hours post-CA. GFAP serum levels were quantified using a novel, fully automated immunochemical method. Other biomarkers investigated were NSE and S100B. Neurological outcome was assessed using the Cerebral Performance Categories scale (CPC) and dichotomized into good and poor outcome.

Results

GFAP predicted poor neurological outcome with 100% specificity and 14-23% sensitivity at 24, 48 and 72 hours post-CA. The corresponding values for NSE were 27-50% sensitivity and for S100B 21-30% sensitivity when specificity was set to 100%. A logistic regression with stepwise combination of the investigated biomarkers, GFAP, did not increase the ability to predict neurological outcome. No differences were found in GFAP, NSE and S100B levels when peripheral and jugular bulb blood samples were compared.

Conclusion

Serum GFAP increase in patients with poor outcome but did not show sufficient sensitivity to predict neurological outcome after CA. Both NSE and S100B were shown to be better predictors. The ability to predict neurological outcome did not increased when combining the three biomarkers.     

The Modified Glasgow Outcome Score for the prediction of outcome in patients after cardiac arrest: a prospective clinical proof of concept study

The Glasgow-Pittsburgh cerebral performance categories (GP-CPC) and the Glasgow Outcome Score (GOS) have been used to categorize patients according to their neurological outcome for prognostic predictors in patients after cardiac arrest (CA). We postulated that inclusion of deaths without knowing the cerebral status into the group of patients with poor outcome after CA using the GP-CPC and GOS will lead to dilution of the prognostic power of the investigated biochemical marker. The present study was conducted to verify this issue by employing a modified outcome score, which we termed as Modified Glasgow Outcome Score (MGOS). In the present study, 97 patients were enrolled in a prospective manner. Serum NSE and S100B levels were measured daily for 7 days after admission to the intensive care unit. Neurological outcome was assessed by employing the GOS and MGOS after 6 months. By employing the GOS, 46 patients were categorized into the group of patients with poor outcome and 51 patients survived with good neurological outcome. Patients who died without certified brain damage or with unknown cerebral status after CA (n = 20) were separated from patients with poor outcome in the MGOS. The magnitude of NSE (S100B) elevation in patients with poor outcome categorized by the MGOS was approximately 1.7-fold (1.5) higher as compared with patients divided by the GOS. The mean calculated sensitivities and area under the curve values of NSE and S100B predicting poor outcome classified by the MGOS were significantly higher as compared with the GOS. Conclusively, inclusion of deaths without certified brain damage or with unknown cerebral status into the group of patients with poor outcome will lead to underestimation of the prognostic power of investigated biochemical markers such as NSE and S100B. The MGOS will help to avoid this bias.     

Efficacy of vasopressin during cardio-pulmonary resuscitation in adult patients: A meta-analysis

Background

Experimental and animal studies suggested that vasopressin may have a favorable survival profile during CPR. This meta-analysis aimed to determine the efficacy of vasopressin in adult cardiac patients.

Methodology

Meta-analysis of randomized control trials (RCTs) comparing the efficacy of vasopressin containing regimen during CPR in adult cardiac arrest population with an epinephrine only regimen.

Results

A total of 6120 patients from 10 RCTs were included in this meta-analysis. Vasopressin use during CPR has no beneficial impact in an unselected population in ROSC [OR 1.19, 95% CI 0.93, 1.52], survival to hospital discharge [OR 1.13, 95% CI 0.89, 1.43], survival to hospital admission [OR 1.12, 95% CI 0.99, 1.27] and favorable neurological outcome [OR 1.02, 95% CI 0.75, 1.38]. ROSC in “in-hospital” cardiac arrest setting [OR 2.20, 95% CI 1.08, 4.47] is higher patients receiving vasopressin. Subgroup analyses revealed equal or higher chance of ROSC [OR 2.15, 95% CI 1.00, 4.61], higher possibility of survival to hospital discharge [OR 2.39, 95% CI 1.34, 4.27] and favorable neurological outcome [OR 2.58, 95% CI 1.39, 4.79] when vasopressin was used as repeated boluses of 4–5 times titrating desired effects during CPR.

Conclusion

ROSC in “in-hospital” cardiac arrest patients is significantly better when vasopressin was used. A subgroup analysis of this meta-analysis found that ROSC, survival to hospital admission and discharge and favorable neurological outcome may be better when vasopressin was used as repeated boluses of 4–5 times titrated to desired effects; however, overall no beneficial effect was noted in unselected cardiac arrest population.     

Association between clinical examination and outcome after cardiac arrest

Background

Neurologic prognostication after cardiac arrest relies on clinical examination findings derived before the advent of therapeutic hypothermia (TH). We measured the association between clinical examination findings at hospital arrival, 24, and 72 h after cardiac arrest in a modern intensive care unit setting.

Methods

Between 1/1/2005 and 3/31/2009, hospital charts were reviewed in 272 subjects for neurologic examination findings (Glasgow Coma Score - motor examination, pupil response, corneal response) at hospital arrival, 24, and 72 h following cardiac arrest. Primary outcome was survival to hospital discharge. Secondary outcome was “good outcome,” defined as discharge to home or acute rehabilitation facility.

Results

Mean age was 61 years; 155 (57%) were male. Most were treated with TH (N = 161; 59%) and 100 subjects (37%) were in ventricular fibrillation/ventricular tachycardia. Out-of-hospital cardiac arrest was common (N = 169; 62%). Ninety-one (33%) survived, with 54 (20%) experiencing a good outcome.In subjects with a GCS Motor score ≤3 at 24 and 72 h survival was 17% (13/76; 95% CI 7.9-26.2%) and 20% (6/27; 95% CI 6.3-33.6%), respectively. Subjects with a GCS Motor score ≤2 at 24 and 72 h survived in 14% (9/66; 95% CI 4.6-22.6%) and 18% (6/33; 95% CI 3.5-32.8%), respectively. Absent pupil reactivity on arrival did not exclude survival (7/65; 11%; 95% CI 2.4-19%). A lack of pupil reactivity or corneal response at 72 h was associated with death (pupil: 0/17; 95% CI 0, 2.9%; corneal: 0/21; 95% CI 0, 2.4%).

Conclusions

GCS Motor score ≤3 or ≤2 at 24 or 72 h following cardiac arrest does not exclude survival or good outcome. However, absent pupil or corneal response at 72 h appears to exclude survival and good outcome.     

Recovery from near death following cerebral anoxia: A case report demonstrating superiority of median somatosensory evoked potentials over EEG in predicting a favorable outcome after cardiopulmonary resuscitation

An electroencephalogram disclosing electrocerebral silence (ECS) after cardiopulmonary resuscitation (CPR) is usually considered an unfavorable prognostic indicator associated with brain death or persistent vegetative state. I report a case of a comatose patient following cardiac arrest, whose initial electroencphalography (EEG) was isoelectric taken 5 h after onset. Median somatosensory evoked potentials (SSEP) obtained immediately after the initial EEG were normal. He then underwent gradual recovery of neurologic function with incremental improvement on serial EEG study, and eventually achieved full neurological recovery. SSEP proved to be a more reliable predictor of a neurological outcome that was ultimately favorable.