The impact of severe acidemia on neurologic outcome of cardiac arrest survivors undergoing therapeutic hypothermia

Introduction

Therapeutic Hypothermia (TH) has become a standard of care in improving neurological outcomes in cardiac arrest (CA) survivors. Previous studies have defined severe acidemia as plasma pH < 7.20. We investigated the influence of severe acidemia at the time of initiation of TH on neurological outcome in CA survivors.

Methods

A retrospective analysis was performed on 196 consecutive CA survivors (out-of-hospital CA and in-hospital CA) who underwent TH with endovascular cooling between January 2007 and October 2012. Arterial blood gas drawn prior to initiation of TH was utilized to measure pH in all patients. Shockable and non-shockable CA patients were divided into two sub-groups based on pH (pH < 7.2 and pH ≥ 7.2). The primary end-point was measured using the Pittsburgh Cerebral Performance Category (CPC) scale prior to discharge from the hospital: good (CPC 1 and 2) and poor (CPC 3 to 5) neurologic outcome.

Results

Sixty-two percent of shockable CA patients with pH ≥ 7.20 had good neurological outcome as compared to 34% patients with pH < 7.20. Shockable CA patients with pH ≥ 7.20 were 3.3 times more likely to have better neurological outcome when compared to those with pH <7.20 [p = 0.013, OR 3.3, 95% CI (1.28–8.45)]. In comparison, non-shockable CA patients with p ≥ 7.20 did not have a significantly different neurological outcome as compared to those with pH < 7.20 [p = 0.97, OR 1.02, 95% CI (0.31–3.3)].

Conclusion

Presence of severe acidemia at initiation of TH in shockable CA survivors is significantly associated with poor neurological outcomes. This effect was not observed in the non-shockable CA survivors.     

Level of consciousness on admission to a Heart Attack Centre is a predictor of survival from out-of-hospital cardiac arrest

Introduction

The relationship between the neurological status at the time of handover from the ambulance crew to a Heart Attack Centre (HAC) in patients who have achieved return of spontaneous circulation (ROSC) and subsequent outcome, in the context of current treatment standards, is unknown.

Methods

A retrospective review of all patients treated by London Ambulance Service (LAS) from 1^st April 2011 to 31^st March 2013 admitted to a HAC in Greater London was undertaken. Neurological status (A - alert; V - responding to voice; P - responding to pain; U - unresponsive) recorded by the ambulance crew on handover was compared with length of hospital stay and survival to hospital discharge.

Results

A total of 475 sequential adult cardiac arrests of presumed cardiac origin, achieving ROSC on admission to a HAC were identified. Outcome data was available for 452 patients, of whom 253 (56.0%) survived to discharge. Level of consciousness on admission to the HAC was a predictor of duration of hospital stay (P < 0.0001) and survival to hospital discharge (P < 0.0001). Of those presenting with a shockable rhythm, 32.3% (120/371) were ‘A’ or ‘V’, compared with 9.1% (9/99) of those with non-shockable rhythms (P < 0.001).

Conclusion

Patients with shockable rhythms achieving ROSC are more likely to be conscious (A or V) compared with those with non-shockable rhythms. Most patients who are conscious on admission to the HAC will survive, compared with approximately half of those who are unconscious (P or U), suggesting that critical care is generally appropriate at all levels of consciousness if ROSC has been achieved.     

Survival after avalanche-induced cardiac arrest

Aim

Criteria to prolong resuscitation after cardiac arrest (CA) induced by complete avalanche burial are critical since profound hypothermia could be involved. We sought parameters associated with survival in a cohort of victims of complete avalanche burial.

Methods

Retrospective observational study of patients suffering CA on-scene after avalanche burial in the Northern French Alps between 1994 and 2013. Criteria associated with survival at discharge from the intensive care unit (ICU) were collected on scene and upon admission to Level-1 trauma center. Neurological outcome was assessed at 3 months using cerebral performance category score.

Results

Forty-eight patients were studied. They were buried for a median time of 43 min (25–76 min; 25–75th percentiles) and had a pre-hospital body core temperature of 28.0 °C (26.0–30.7). Eighteen patients (37.5%) had pre-hospital return of spontaneous circulation and 30 had refractory CA. Rewarming of 21 patients (43.7%) was performed using extracorporeal life support. Eight patients (16.7%) survived and were discharged from the ICU, three (6.3%) had favorable neurological outcome at 3 months. Pre-hospital parameters associated with survival were the presence of an air pocket and rescue collapse. On admission, survivors had lower serum potassium concentrations than non-survivors: 3.2 mmol/L (2.7–4.0) versus 5.6 mmol/L (4.2–8.0), respectively (P < 0.01). They also had normal values for prothrombin and activated partial thromboplastin compared to non-survivors.

Conclusions

Our findings indicate that survival after avalanche burial and on-scene CA is rarely associated with favorable neurological outcome. Among criteria associated with survival, normal blood coagulation on admission warrants further investigation.     

Procalcitonin after cardiac arrest – An indicator of severity of illness,ischemia-reperfusion injury and outcome

Aim

To investigate serial serum concentrations of procalcitonin (PCT) and C-reactive protein (CRP) in patients treated with mild hypothermia after cardiac arrest, and to study their association to severe infections, post cardiac arrest syndrome (PCAS) and long-term outcome.

Methods

Serum samples from cardiac arrest patients treated with mild hypothermia were collected serially at admission, 2, 6, 12, 24, 36, 48 and 72 h after cardiac arrest. PCT and CRP concentrations were determined and tested for association with three definitions of infection, two surrogate markers of PCAS (circulation-SOFA and time to return of spontaneous circulation (ROSC)) and cerebral performance category (CPC) at six months.

Results

Eighty-four patients were included. PCT displayed an earlier release pattern than CRP with a significant increase within 2 h, increasing further at 6 h and onwards in patients with poor outcome. CRP increased later and continued to rise during the study period. PCT was strongly associated with circulation-SOFA and time to ROSC, and predicted a poor neurologic outcome with high accuracy (area under the receiver operating characteristic curve of 0.88, 0.86 and 0.87 at 12, 24 and 48 h respectively). No association of PCT or CRP to infection was observed.

Conclusion

Our results suggest that PCT is released early after resuscitation following cardiac arrest, is associated with markers of PCAS but not with infection, and is an accurate predictor of poor outcome. Validation of these findings in larger studies is warranted.     

NSE and S-100B are not sufficiently predictive of neurologic outcome after therapeutic hypothermia for cardiac arrest

Introduction

Prognostication of cardiac arrest survivors is challenging since therapeutic hypothermia (TH) has been introduced. We evaluated serum biomarkers and motor response.

Methods

This was a retrospective data analysis including patients in the years 2007–2012. Blood was drawn and a neurological examination was performed on admission and every morning. Outcomes were evaluated 6 months after discharge and dichotomized into good (cerebral performance category (CPC) = 1 or 2) and poor (CPC = 3, 4 or 5).

Results

123 patients (79.7% male, 63 ± 14 years) received TH; 50% had a good outcome. On admission, S-100B (P = 0.004) was significantly associated with the outcome, as well as neuron-specific enolase (NSE; P = 0.020) and S-100B (P = 0.004) on day 1 after admission. NSE on day 2, NSE progression from day 1 to 2 and motor response on day 3 also predicted the outcome (all P < 0.001).NSE > 33 μg l⁻¹ only predicted a poor outcome with a specificity of 76%. An absent motor response on day 3 was the most sensitive marker (94%). NSE > 41.1 μg l⁻¹ combined with S-100B > 0.461 μg l⁻¹ on day 1 was the most specific marker (96%).

Conclusion

Although NSE and S-100B levels are associated with the outcome, the use of previously described cut-off values was insufficiently predictive of neurologic outcome. Caution should be exercised in the use of these tests to provide neuroprognostication.     

Heparin-binding protein: An early indicator of critical illness and predictor of outcome in cardiac arrest

Aim

To investigate plasma levels of the neutrophil-borne heparin-binding protein (HBP) in patients with induced hypothermia after cardiac arrest (CA), and to study any association to severity of organ failure, incidence of infection and neurological outcome.

Methods

This study included 84 patients with CA of mixed origin who were treated with hypothermia. Plasma samples from 7 time points during the first 72 h after return of spontaneous circulation (ROSC) were collected and analyzed for HBP with an ELISA. Outcomes were dichotomized: a cerebral performance category scale (CPC) of 1–2 at 6 months follow-up was considered a good outcome, a CPC of 3–5, a poor outcome. Patient data, including APACHE II and SOFA-scores were retrieved from the computerized system for quality assurance for intensive care.

Results

At 6 h and 12 h after CA, plasma levels of HBP were significantly higher among patients with a poor outcome. A receiver operated characteristics (ROC)-analysis yielded respective areas under curve (AUC) values of 0.68 and 0.70. This was similar to APACHE II and SOFA-score AUC values. There was a significant correlation between early elevated HBP-values and time to ROSC. HBP-levels were not higher in patients with infections at any time.

Conclusions

Elevated HBP is an early indicator of organ failure and poor neurological outcome after CA, independent of microbial infection, and should be further evaluated in prospective trials. The temporal profile of HBP is suggestive of a role in the pathogenesis of critical illness after CA.     

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.     

Duplex sonography of cerebral blood flow after cardiac arrest—A prospective observational study

Aim

Despite successful resuscitation, cardiac arrest (CA) often has a poor clinical prognosis. Different diagnostic tools have been established to predict patients’ outcome. However, their sensitivity remains low. Assessment of cerebral perfusion by duplex ultrasound might provide additional information regarding the extent of neuronal damage. The aim of the present study was to analyse the changes of global cerebral blood flow (CBF) and intracranial blood flow parameters in the acute stage after CA and its correlation with patients’ outcome.

Methods

We investigated 54 patients (17–85 years, mean age: 63 ± 17 years) after CA with return of spontaneous circulation on an intensive care unit. All patients received therapeutic hypothermia (TH) for 24 h after CA and reanimation. Serial measurements of CBF as well as intracranial blood flow velocities and pulsatility indices of the middle cerebral artery and the basal vein of Rosenthal were performed within the first 10 days using duplex ultrasound. Clinical outcome was measured using the Cerebral Performance Category.

Results

Measurements were successful in 53 patients. CBF values differed between 210 and 1100 ml/min. 24 patients (45%) attained a good outcome. No correlation between CBF or intracranial blood flow characteristics and outcome was found. Neither cerebral hypo- nor hyperperfusion was associated with a fatal outcome.

Conclusion

Cerebral perfusion varies widely after CA. Neither hypo- nor hyperperfusion seems to be an independent risk factor for poor outcome. Duplex ultrasound of cerebral haemodynamics after CA is suitable but probably of limited prognostic value.     

Evaluation of ischemia-modified albumin in myocardial infarction and prostatic diseases

Background

Ischemia-modified albumin (IMA) has been shown to be a rapidly rising and sensitive biochemical marker for the diagnosis of myocardial ischemia. In this study, we evaluated the levels of IMA in myocardial infarction and prostate diseases, as well as the influence of HDL cholesterol levels on C-reactive protein (CRP) and IMA levels.

Methods

A total of 27 patients with myocardial infarction (MI), 102 patients with benign prostatic hyperplasia (BPH), 84 patients with prostate cancer (PCA), and 21 healthy subjects were enrolled in this study. IMA levels were measured in whole studied patients. Cardiac troponin I (cTnI), cholesterol, HDL cholesterol, and CRP were measured in MI and control groups.

Results

IMA values were significantly higher in patients with MI (0.5215 ± 0.0241 ABSU) and BPH (0.4150 ± 0.0156 ABSU) in comparison to control subjects (0.3381 ± 0.0194 ABSU). IMA and CRP were higher in MI group, especially in patients with HDL cholesterol levels lower than 38 mg/dL. The ability of IMA to discriminate myocardial infarction was higher than CRP. Significant correlations between CRP and HDL, CRP and IMA, and HDL and IMA were reported.

Conclusions

IMA and CRP increase in myocardial damage, and the decrease of HDL cholesterol appears to enhance the inflammatory response. IMA also increase in benign prostate hyperplasia and this finding suggests that the diagnosis of prostate diseases must be considered on evaluation of IMA as a marker of cardiac ischemia.     

Survival in out-of-hospital cardiac arrests with initial asystole or pulseless electrical activity and subsequent shockable rhythms

Background

Non-shockable arrest rhythms (pulseless electrical activity and asystole) represent an increasing proportion of reported cases of out-of-hospital cardiac arrest (OHCA). The prognostic significance of conversion from non-shockable to shockable rhythms during the course of resuscitation remains unclear.

Objective

To evaluate whether out-of-hospital cardiac arrest survival with initially non-shockable arrest rhythms is improved with subsequent conversion to shockable rhythms.

Methods

Secondary analysis of data in Epistry – Cardiac Arrest, an epidemiologic registry maintained by the Resuscitation Outcomes Consortium (ROC). This analysis includes OHCA events from December 1, 2005 through May 31, 2007 contributed by six US and two Canadian sites. For all EMS-treated adult (18 and older) cardiac arrest patients who presented with non-shockable cardiac arrest, we compared survival to hospital discharge between patients who did develop a shockable rhythm and those who did not based on receipt of subsequent defibrillation. Missing data were handled using multiple imputation. Multivariable logistic regression was used to adjust for potentially confounding variables.

Results

A total of 6556 EMS treated adult cardiac arrest cases presented in non-shockable rhythms. Survival to discharge in patients who converted to a shockable rhythm was 2.77% while survival in those who did not was 2.72% (p = 0.92). After adjusting for confounders, conversion to a shockable rhythm was not associated with improved survival (OR 0.88, 95% CI: 0.60–1.30).

Conclusion

For OHCA patients presenting in PEA/asystole, survival to hospital discharge was not associated with conversion to a shockable rhythm during EMS resuscitation efforts.     

The role of pentraxin 3 as diagnostic value in classification of patients with heart failure

Objective

Pentraxin 3 (PTX3) is a new inflammatory marker that is the prototype of the long pentraxin group, while C-reactive protein (CRP) is the short pentraxin group. The aim of the present study was to investigate the clinical significance of plasma PTX3 and CRP levels in heart failure (HF).

Materials and methods

The study included 22 male and 37 female patients with HF, and 23 healthy volunteers as the control group. Patients were divided into 4 groups (class I, II, III and IV) according to New York Heart Association functional class.

Results

Plasma PTX3 and CRP levels were significantly elevated in HF patients compared to healthy controls. Comparing PTX3 levels in patient groups, statistically significant difference was found between class-I and class-II, class-III and class-IV patients (p = 0.009, p = 0.001, p < 0.001, respectively). There was a positive correlation between PTX3 and CRP levels (r = 0.369, p = 0.004). In receiver-operating characteristic (ROC) curves, area under the curve (AUC) values for PTX3 and CRP were 0.928 (p = 0.001) and 0.834 (p = 0.001), respectively.

Conclusions

Plasma PTX3 levels are elevated in HF and might be used as diagnostic value in classification of patients with HF. It is still debated whether inflammation may be just a cause or a consequence of the disease. Therefore further work is needed to better understand in large populations of patients with HF.     

Predicting outcome after severe traumatic brain injury using the serum S100B biomarker: Results using a single (24 h) time-point

Background and objectives

In recent years, biochemical markers have been employed to predict the outcome of patients with traumatic brain injury (TBI). In mild TBI, S100B has shown the most promise as a marker of outcome. The objective of this study in patients with severe TBI was to: show the range of serum S100B levels during the acute phase after trauma: determine if S100B has potential to discriminate favourable from unfavourable outcome in patients with similar brain injury severity scores and to establish an S100B ‘cut-off’ predictive for death.

Methods

All patients with severe TBI, admitted to this neurointensive care unit within 24 h of injury were eligible for inclusion in the study. One serum blood sample was obtained from each patient at the 24 h post-injury time-point. S100B levels were measured using enzyme-linked immunosorbent assay. Injuries were coded using an internationally recognised injury severity scoring system (ISS). Three-month follow-up was undertaken with outcome assessed using the Glasgow outcome score (GOS).

Results

One hundred patients were recruited. Serum S100B levels ranged from 0.08 to 12.62 μg L⁻¹ S100B levels were significantly higher in patients with a GOS of 1 (death) 2 and 3 (unfavourable outcome) compared with those with GOS 4 and 5 (good recovery). In this study a cut-off point of 0.53 μg L⁻¹ has sensitivity of >80% and specificity of 60% to predict unfavourable outcome and 49% to predict death.

Conclusion

In 100 patients studied with similar brain injury severity scores, serum S100B measured at the 24-h time-point after injury is significantly associated with outcome but a cut-off 0.53 μg L⁻¹ does not have good prognostic performance.     

Increasing arterial oxygen partial pressure during cardiopulmonary resuscitation is associated with improved rates of hospital admission

Aim

As recent clinical data suggest a harmful effect of arterial hyperoxia on patients after resuscitation from cardiac arrest (CA), we aimed to investigate this association during cardiopulmonary resuscitation (CPR), the earliest and one of the most crucial phases of recirculation.

Methods

We analysed 1015 patients who from 2003 to 2010 underwent out-of-hospital CPR administered by emergency medical services serving 300,000 inhabitants. Inclusion criteria for further analysis were nontraumatic background of CA and patients >18 years of age. One hundred and forty-five arterial blood gas analyses including oxygen partial pressure (paO2) measurement were obtained during CPR.

Results

We observed a highly significant increase in hospital admission rates associated with increases in paO2 in steps of 100 mmHg (13.3 kPa).Subsequently, data were clustered according to previously described cutoffs (≤60 mmHg [8 kPa]], 61–300 mmHg [8.1–40 kPa], >300 mmHg [>40 kPa]). Baseline variables (age, sex, initial rhythm, rate of bystander CPR and collapse-to-CPR time) of the three compared groups did not differ significantly. Rates of hospital admission after CA were 18.8%, 50.6% and 83.3%, respectively. In a multivariate analysis, logistic regression revealed significant prognostic value for paO2 and the duration of CPR.

Conclusion

This study presents novel human data on the arterial paO2 during CPR in conjunction with the rate of hospital admission. We describe a significantly increased rate of hospital admission associated with increasing paO2. We found that the previously described potentially harmful effects of hyperoxia after return of spontaneous circulation were not reproduced for paO2 measured during CPR.Clinical trial registration: n/a.     

Haemodynamic variables and functional outcome in hypothermic patients following out-of-hospital cardiac arrest

Aim of the study

To evaluate the association between haemodynamic variables during the first 24 h after intensive care unit (ICU) admission and neurological outcome in out-of-hospital cardiac arrest (OHCA) victims undergoing therapeutic hypothermia.

Methods

In a multi-disciplinary ICU, records were reviewed for comatose OHCA patients undergoing therapeutic hypothermia. The hourly variable time integral of haemodynamic variables during the first 24 h after admission was calculated. Neurologic outcome was assessed at day 28 and graded as favourable or adverse based on the Cerebral Performance Category of 1–2 and 3–5. Bi- and multivariate regression models adjusted for confounding variables were used to evaluate the association between haemodynamic variables and functional outcome.

Results

67/134 patients (50%) were classified as having favourable outcome. Patients with adverse outcome had a higher mean heart rate (73 [62–86] vs. 66 [60–78] bpm; p = 0.04) and received noradrenaline more frequently (n = 17 [25.4%] vs. n = 9 [6%]; p = 0.02) and at a higher dosage (128 [56–1004] vs. 13 [2–162] μg h⁻¹; p = 0.03) than patients with favourable outcome. The mean perfusion pressure (mean arterial blood pressure minus central venous blood pressure) (OR = 1.001, 95% CI  = 1–1.003; p = 0.04) and cardiac index time integral (OR = 1.055, 95% CI = 1.003–1.109; p = 0.04) were independently associated with adverse outcome at day 28.

Conclusion

Mean perfusion pressure and cardiac index during the first 24 h after ICU admission were weakly associated with neurological outcome in an OHCA population undergoing therapeutic hypothermia. Further studies need to elucidate whether norepinephrine-induced increases in perfusion pressure and cardiac index may contribute to adverse neurologic outcome following OHCA.     

Stent thrombosis: An increased adverse event after angioplasty following resuscitated cardiac arrest

Background

The leading cause of sudden cardiac death is myocardial ischemia. As for uncomplicated acute myocardial infarction (AMI), international guidelines plead for early coronary angiography with, in case of culprit lesion, angioplasty and stent implantation. However after cardiac arrest (CA), shock, hypothermia and changes in antiplatelet pharmacokinetic may promote stent thrombosis (ST). Incidence of ST in this situation has never been studied.

Objective

The aim of this study was to investigate incidence and determinants of ST after ischemic CA successfully revascularized.

Methods

We analyzed 208 consecutive patients admitted in our institution for AMI and who underwent PCI with stent implantation. Among these patients, 55 presented a resuscitated CA and were compared to 153 without CA (control group). All patients in the CA group received hypothermia (33 °C for 24 h) following resuscitation and PCI.

Results

There was no difference between the 2 groups for age, gender, cardiovascular risk factors, coronary lesions and type of stent. In the CA group, patients were less frequently pre-treated with heparin (50.9% vs 98.7%, p < 0.001) and aspirin (52.7% vs 99%, p < 0.001). In the CA group, we observed a significantly higher incidence of confirmed acute or subacute ST than in the control group: 10.9% vs 2.0% (p = 0.01). None of CA patients had received a dual antiplatelets therapy (0% vs 99%). LVEF at admission was lower in the CA group (40.3% vs 48%; p < 0.001), and shock was more frequent (83.6% vs 8.5%; p < 0.001). Survival at 28 days was 50.1% in CA group vs 98.0% (p < 0.001). In multivariate analysis, CA before stenting appears to be an independent risk factor for confirmed ST (OR = 12.9; 95%CI 1.3–124.6; p = 0.027).

Conclusion

In CA patients treated with cooling, stenting for AMI is associated with a high risk of ST. Shock, insufficient antithrombotic treatment, pharmacokinetic changes related to hypothermia may contribute to this higher risk. A strategy aiming to reduce this complication may probably improve prognosis of patients who underwent coronary sudden death.     

The inflammatory response after out-of-hospital cardiac arrest is not modified by targeted temperature management at 33 °C or 36 °C

Aim

Survivors after cardiac arrest (CA) exhibits a systemic inflammatory response as part of post-cardiac arrest syndrome (PCAS). We investigated the association between systemic inflammation and severity of PCAS and whether level of targeted temperature management (TTM) modifies level of the inflammatory response.

Methods

We studied 169 patients included at a single center in the TTM-trial, randomly assigned to TTM at 33 °C or 36 °C for 24 h. Plasma samples were analyzed for inflammatory markers including interleukin (IL) IL-1β,IL-4,IL-6,IL-10, tumor necrosis factor-α (TNF-α), C-reactive protein (CRP) and procalcitonin (PCT) at randomization and 24, 48 and 72 h after CA. Severity of PCAS was assessed by Sequential Organ Failure Assessment (SOFA) score.

Results

Plasma levels of both IL-6 and IL-10 determined at randomization correlated with severity of PCAS at day 2 (r = 0.36 and r = 0.27, p < 0.001) and day 3 (r = 0.32 and r = 0.22, p < 0.001). IL-6 at randomization was an independent predictor of severity of PCAS at day 2 (p = 0.003) and day 3 (p < 0.0001) and was a significantly stronger predictor of severity of PCAS at day 3 compared to CRP (p = 0.04) and PCT (p = 0.03). Level of TTM did not modify level of the inflammatory markers IL-1β, IL-6, TNF-α, IL-4, IL-10, CRP and PCT, (p = NS for each inflammatory marker).

Conclusions

Level of inflammatory response was associated with severity of PCAS with IL-6 being consistently and more strongly associated with severity of PCAS than the inflammatory markers CRP and PCT. The systemic inflammatory response after CA was not modified by TTM at 33 °C or 36 °C.     

New treatment bundles improve survival in out-of-hospital cardiac arrest patients: A historical comparison

Introduction

Before the introduction of the new international cardiac arrest treatment guidelines in 2005, patients with out-of-hospital cardiac arrest (OHCA) of cardiac origin in Northern Italy had very poor prognosis. Since 2006, a new bundle of care comprising use of automated external defibrillators (AEDs) and therapeutic hypothermia (TH) was started, while extracorporeal CPR program (ECPR) for selected refractory CA and dispatcher-assisted cardio-pulmonary resuscitation (CPR) was started in January 2010.

Objectives

We hypothesized that a program of bundled care might improve outcome of OHCA patients.

Methods

We analyzed data collected in the OHCA registry of the MB area between September 2007 and August 2011 and compared this with data from 2000 to 2003.

Results

Between 2007 and 2011, 1128 OHCAs occurred in the MB area, 745 received CPR and 461 of these had a CA of presumed cardiac origin. Of these, 125 (27%) achieved sustained ROSC, 60 (13%) survived to 1 month, of whom 51 (11%) were discharged from hospital with a good neurological outcome (CPC ≤ 2), and 9 with a poor neurological outcome (CPC > 2).Compared with data from the 2000 to 2003 periods, survival increased from 5.6% to 13.01% (p < 0.0001). In the 2007–2011 group, low-flow time and bystander CPR were independent markers of survival.

Conclusions

OHCA survival has improved in our region. An increased bystander CPR rate associated with dispatcher-assisted CPR was the most significant cause of increased survival, but duration of CA remains critical for patient outcome.     

Prognostic value of electrographic postanoxic status epilepticus in comatose cardiac-arrest survivors in the therapeutic hypothermia era

Background

The independent prognostic significance of postanoxic status epilepticus (PSE) has not been evaluated prospectively since the introduction of therapeutic hypothermia. We studied 1-year functional outcomes and their determinants in comatose survivors of cardiac arrest (CA), with special attention to PSE.

Methods

106 comatose CA survivors admitted to the intensive care unit in 2005–2010 were included in a prospective observational study. The main outcome measure was a Cerebral Performance Category scale (CPC) of 1 or 2 (favorable outcome) 1 year after CA.

Results

CA occurred out-of-hospital in 89 (84%) patients and was witnessed from onset in 94 (89%). Median times were 6 min (IQR, 0–11) from CA to first-responder arrival and 23 min (14–40) from collapse to return of spontaneous circulation. PSE was diagnosed in 33 (31%) patients at a median of 39 h (4–49) after CA. PSE was refractory in 24 (22%) cases and malignant in 19 (20%). After 1 year, 31 (29.3%) patients had favorable outcomes including 2 (6.44%) with PSE. Factors independently associated with poor outcome (CPC ≥ 3) were PSE (odds ratio [OR], 14.28; 95% confidence interval [95% CI], 2.77–50.0; P = 0.001), time to restoration of spontaneous circulation (OR, 1.04/min; 95% CI, 1–1.07; P = 0.035), and LOD score on day 1 (OR, 1.28/point; 95% CI, 1.08–1.54; P = 0.003).

Conclusion

PSE strongly and independently predicts a poor outcome in comatose CA survivors receiving therapeutic hypothermia, but some patients with PSE survive with good functional outcomes. PSE alone is not sufficient to predict failure to awaken after CA in the era of therapeutic hypothermia.     

A multifaceted educational intervention to prevent delirium in older inpatients: A before and after study

Background

Systematically targeting modifiable risk factors for delirium may reduce its incidence. However, research interventions have not become part of routine clinical practice. Particular approaches to the education of clinical staff may improve their practice and patient outcomes.

Objectives

To evaluate the effectiveness of a multifaceted educational program in preventing delirium in hospitalised older patients and improving staff practice, knowledge and confidence.

Design

A before and after study.

Setting

A 22-bed general medical ward of a district hospital in Sydney, Australia.

Participants

Patients were aged 65 years and over and not delirious upon admission. Of 568 eligible patients, 129 were recruited pre-intervention (3 withdrew initial consent) and 129 patients post-intervention.

Methods

Prior to the intervention, in order to establish a baseline, patients were assessed early after admission and again at discharge. The intervention was a one-hour lecture on delirium focusing on prevention for medical and nursing staff followed by weekly interactive tutorials with delirium resource staff and ward modifications. Following the initial education session, data were gathered in a second group of medical ward patients at the same time-points to ascertain the effectiveness of the intervention. Pre and post-intervention data were analysed to determine change in staff objective knowledge and self-ratings of confidence and clinical practice in relation to delirium. The main outcome measures were incident delirium and change in staff practice, confidence and knowledge.

Results

The mean age of patients was 81. The pre and post-intervention groups were comparable, aside from greater co morbidity in the pre-intervention group (F(1, 253) = 9.20, p = 0.003). Post-intervention there was a significant reduction in incident delirium (19% vs. 10.1%, X² = 4.14, p = 0.042), and improved function on discharge (mean improvement 5.3 points, p < 0.001, SD 13.31, 95% CI −7.61 to −2.97). Staff objective knowledge of delirium improved post-intervention and their confidence assessing and managing delirious patients. Staff addressed more risk factors for delirium post-intervention (8.1 vs. 9.8, F(1, 253) = 73.44, p < 0.001).

Conclusions

A low-cost educational intervention reduced the incidence of delirium and improved function in older medical patients and staff knowledge and practice addressing risk factors for delirium. The program is readily transferable to other settings, but requires replication due to limitations of the before and after design.     

Serum level and prognostic value of neopterin in patients after ischemic stroke

Background

We hypothesized that serum level of neopterin is significantly predictive of prognostic outcome in patients after acute ischemic stroke (IS).

Methods

Between November 2008 and May 2010, serum levels of neopterin were prospectively collected at 48 h after acute IS in 157 patients.

Results

Serum neopterin levels were substantially higher in patients with severe neurological impairment [National institutes of Health Stroke Scale (NIHSS) score ≥ 12] than in those with NIHSS < 12 (p < 0.008). Furthermore, Spearman's test showed a strongly positive correlation between neopterin level and NIHSS (p = 0.003). Multiple logistic regression analysis demonstrated that serum neopterin level was strongly and independently predictive of NIHSS ≥ 12 (p = 0.002) at 48 h after acute IS and 90-day major adverse clinical outcome (defined as NIHSS ≥ 12, recurrent stroke or death) (p = 0.003).

Conclusion

Serum level of neopterin was notably increased after acute IS. This biomarker was strongly and independently predictive of 90-day unfavorable clinical outcome in patients after acute IS.