Prognostication of neurologic outcome using gray-white-matter-ratio in comatose patients after cardiac arrest

Background This study aimed to assess the prognostic value regarding neurologic outcome of CT neuroimaging based Gray-White-Matter-Ratio measurement in patients after resuscitation from cardiac arrest. Methods We retrospectively evaluated CT neuroimaging studies of 91 comatose patients resuscitated from cardiac arrest and 46 non-comatose controls. We tested the diagnostic performance of Gray-White-Matter-Ratio compared with established morphologic signs of hypoxic-ischaemic brain injury, e. g. loss of distinction between gray and white matter, and laboratory parameters, i. e. neuron-specific enolase, for the prediction of poor neurologic outcomes after resuscitated cardiac arrest. Primary endpoint was neurologic function assessed with cerebral performance category score 30 days after the index event. Results Gray-White-Matter-Ratio showed encouraging interobserver variability (ICC 0.670 [95% CI: 0.592–0.741] compared to assessment of established morphologic signs of hypoxic-ischaemic brain injury (Fleiss kappa 0.389 [95% CI: 0.320–0.457]) in CT neuroimaging studies. It correlated with cerebral performance category score with lower Gray-White-Matter-Ratios associated with unfavourable neurologic outcomes. A cut-off of 1.17 derived from the control population predicted unfavourable neurologic outcomes in adult survivors of cardiac arrest with 100% specificity, 50.3% sensitivity, 100% positive predictive value, and 39.3% negative predictive value. Gray-White-Matter-Ratio prognostic power depended on the time interval between circulatory arrest and CT imaging, with increasing sensitivity the later the image acquisition was executed. Conclusions A reduced Gray-White-Matter-Ratio is a highly specific prognostic marker of poor neurologic outcomes early after resuscitation from cardiac arrest. Sensitivity seems to be dependent on the time interval between circulatory arrest and image acquisition, with limited value within the first 12 h.

Αξιολόγηση οργανικών βλαβών μετά από ενδονοσοκομειακή καρδιακή ανακοπή

Σκοπός: Η χαμηλή δόση στεροειδών μπορεί να φανεί ωφέλιμη σε βαρέως πάσχοντες ασθενείς με σηπτική καταπληξία. Οι ασθενείς με καρδιακή ανακοπή είναι επηρρεπείς σε νοσοκομειακές λοιμώξεις, οι οποίες συμβάλλουν στη μετά την αναζωογώνηση θνησιμότητα. Υποθέσαμε ότι στρες-δόση στεροειδών κατά τη διάρκεια και/ή μετά την ανάταξη μπορεί να συσχετίζεται με μειωμένο κίνδυνο θανάτου εξ αιτίας μετά της ανακοπής λοιμώξεων που οδηγούν σε σηπτική καταπληξία. Μέθοδοι: Διεξάγαμε μια επανανάλυση [cumulative incidence competing risks (CICR)] στοιχείων από 2 προηγούμενες, τυχαιοποιημένες κλινικές μελέτες. Οι μελέτες αυτές αξιολογούσαν τη βαζοπρεσσίνη, τα στεροειδή και την επινεφρίνη [vasopressin, steroids, and epinephrine (VSE)] κατά τη διάρκεια της αναζωογώνησης και τη στρες-δόση στεροειδών μετά την αναζωογώνηση σε ασθενείς που είχαν υποστεί ενδονοσοκομειακή ανακοπή. Στις πρωτογενείς αναλύσεις, οι ασθενείς με μετά την ανάταξη καταπληξία χωρίστηκαν σε μια ομάδα που έλαβε Στεροειδή (n=118) ή στην ομάδα Μη Στεροειδή (n=73) , σύμφωνα με την αρχή «as treated». Εφαρμόσαμε CICR Cox ανάλυση παλινδρόμησης ώστε να καθορίσουμε σχετικές με την αιτία αναλογίες κινδύνου [cause-specific hazard ratios (CSHRs)] για προκαθορισμένους προγνωστικούς παράγοντες μοιραίας σηπτικής καταπληξίας (πρωτογενής έκβαση), θάνατο από μη λοιμώδη αίτια και πτωχή ενδονοσοκομειακή έκβαση outcome (cerebral performance category score ≥3). Στις αναλύσεις ευαισθησίας, τα δεδομένα επεξεργάστηκαν σύμφωνα με την αρχή intention-to-treat (ITT) (ομάδα VSE, n=103; Ομάδα ελέγχου, n=88). Αποτελέσματα: Η μοιραία σηπτική καταπληξία ήταν λιγότερο πιθανή στην ομάδα Στεροειδή έναντι στην ομάδα Μη Στεροειδή [CSHR, 0.40, 95% confidence interval (CI), 0.20-0.82; p=0.012]. Ο θάνατος από μη λοιμώδη αίτια και η πτωχή ενδονοσοκομειακή έκβαση προβλέφθηκαν από την ομάδα και από τη σχετιζόμενη με την αναζωογώνηση δόση διττανθρακικών. Τα αποτελέσματα της ανάλυσης ΙΤΤ για τη μοιραία σηπτική καταπληξία και την πτωχή ενδονοσοκομειακή έκβαση ήταν παρόμοια. Η ομάδα Στεροειδή σε σχέση με την ομάδα ΜηΣτεροειδή είχε περισσότερες ημέρες ελεύθερες οργανικής ανεπάρκειας και εκτός αναπνευστήρα, καθώς και χωρίς επεισόδια υπεργλυκαιμίας/ χρήσης ινσουλίνης. Συμπέρασμα: Σε αυτήν την επανανάλυση, η στρες-δόση στεροειδών συσχετίστηκε με χαμηλότερο κίνδυνο μετά την αναζωογώνηση μοιραίας σηπτικής καταπληξίας. Η απόδειξη της αιτιότητας απαιτεί επιβεβαιώση από μελλοντικές τυχαιοποιημένες μελέτες.

Hanging and asphyxia: Interventions, patient outcomes and resource utilisation in a UK tertiary intensive care unit

Introduction Suicide is increasing in the UK, and hanging is now the commonest mechanism. United Kingdom intensive care unit outcomes (including organ donation) after hanging have not been reported. Methods Retrospective analysis of cases admitted to a UK tertiary intensive care unit with a primary or secondary diagnosis of hanging/asphyxia. Case analysis divided between those with and without a history of cardiopulmonary resuscitation, and outcomes described using the cerebral performance category score. Results A total of 33 cases were reviewed, 19 with a history of cardiopulmonary resuscitation (three survivors with cerebral performance category of 1–2), 14 without history of cardiopulmonary resuscitation (14 survivors, 11 cerebral performance category score of 1, 3 cerebral performance category score of 3). Three cases went on to have a good neurological outcome with a cerebral performance category score of one, and 16 died. The three survivors only had bystander cardiopulmonary resuscitation and cardiac arrest was not independently confirmed. All three had a good neurological recovery despite two having hypoxic–ischaemic encephalopathy on computed tomography head. Of the three survivors, one received no temperature management and two received targeted temperature management. Median intensive care unit length of stay after hanging with cardiopulmonary resuscitation was 3.0 days (2.4–6.7 days). Fifteen patients were discussed with the organ donation specialist nurse, with six consenting to donation and six declining consent, with 18 solid organs donated. All 14 of those without a history of cardiopulmonary resuscitation survived, 11 with a cerebral performance category score of 1 and three having a cerebral performance category score of 3. No patients received active temperature management. Median intensive care unit length of stay in this group was 2.9 days (1.2–3.8). Conclusions Outcomes after confirmed cardiac arrest following hanging are poor, in keeping with existing international data, even in those surviving to intensive care unit admission. Despite low rates of consent to organ donation, the overall organ donation is high due to high referral rates. Despite the poor prognosis in this population, early initiation of full resuscitation should be offered to optimise survival and facilitate the possibility of donation.

Predictors of Functional Outcome after Intraoperative Cardiac Arrest

Background: Few outcome data are available about intraoperative cardiac arrest (IOCA). The authors studied 90-day functional outcomes and their determinants in patients admitted to the intensive care unit after IOCA. Methods: Patients admitted to 11 intensive care units in a period of 2000–2013 were studied retrospectively. The main outcome measure was a day-90 Cerebral Performance Category score of 1 or 2. Results: Of the 140 patients (61 women and 79 men; median age, 60 yr [interquartile range, 46 to 70]), 131 patients (93.6%) had general anesthesia, 80 patients (57.1%) had emergent surgery, and 73 patients (52.1%) had IOCA during surgery. First recorded rhythms were asystole in 73 patients (52.1%), pulseless electrical activity in 44 patients (31.4%), and ventricular fibrillation/ventricular tachycardia in 23 patients (16.4%). Median times from collapse to cardiopulmonary resuscitation and return of spontaneous circulation were 0 min (0 to 0) and 10 min (5 to 20), respectively. Postcardiac arrest shock was identified in 114 patients (81.4%). Main causes of IOCA were preoperative complications (n = 46, 32.9%), complications of anesthesia (n = 39, 27.9%), and complications of surgical procedures (n = 36, 25.7%). On day 90, 63 patients (45.3%) were alive with Cerebral Performance Category score 1/2. Independent predictors of day-90 Cerebral Performance Category score 1/2 were day-1 Logistic Organ Dysfunction score (odds ratio, 0.78 per point; 95% CI, 0.71 to 0.87; P = 0.0001), ventricular fibrillation/tachycardia as first recorded rhythm (odds ratio, 4.78; 95% CI, 1.38 to 16.53; P = 0.013), and no epinephrine therapy during postcardiac arrest syndrome (odds ratio, 3.14; 95% CI, 1.29 to 7.65; P = 0.012). Conclusions: By day 90, 45% of IOCA survivors had good functional outcomes. The main outcome predictors were directly related to IOCA occurrence and postcardiac arrest syndrome; they suggest that the intensive care unit management of postcardiac arrest syndrome may be amenable to improvement.

The incidence of postoperative hyponatremia and associated neurological sequelae in children with intracranial neoplasms

Object Intracranial tumors are common pediatric neoplasms and account for substantial morbidity among children with cancer. Hyponatremia is a known complication of neurosurgical procedures and is associated with higher morbidity among neurosurgical patients. The authors aimed to estimate the incidence of hyponatremia, identify clinical characteristics associated with hyponatremia, and assess the association between hyponatremia and patient outcome among children undergoing surgery for intracranial tumors. Methods This is a retrospective cohort study of children ranging in age from 0 to 19 years who underwent an initial neurosurgical procedure for an intracranial tumor between January 2001 and February 2012. Hyponatremia was defined as serum sodium ≤ 130 mEq/L during admission. Results Hyponatremia during admission occurred in 39 (12%) of 319 patients and was associated with young age and obstructive hydrocephalus (relative risk [RR] 2.9 [95% CI 1.3–6.3]). Hyponatremic patients were frequently symptomatic; 21% had seizures and 41% had altered mental status. Hyponatremia was associated with complicated care including mechanical ventilation (RR 4.4 [95% CI 2.5–7.9]), physical therapy (RR 4 [95% CI 1.8–8.8]), supplemental nutrition (RR 5.7 [95% CI 3.3–9.8]), and infection (RR 5.7 [95% CI 3.3–9.5]). Hyponatremic patients had a 5-fold increased risk of moderate or severe disability on the basis of their Pediatric Cerebral Performance Category score at discharge (RR 5.3 [95% CI 2.9–9.8]). Obstructive hydrocephalus (adjusted odds ratio [aOR] 3.24 [95% CI 1.38–8.94]) and young age (aOR 0.92 [95% CI 0.85–0.99]) were independently associated with hyponatremia during admission. Hyponatremia was independently associated with moderate or worse disability by Pediatric Cerebral Performance Category score at discharge (aOR 6.2 [95% CI 3.0–13.03]). Conclusions Hyponatremia was common, particularly among younger children and those with hydrocephalus. Hyponatremia was frequently symptomatic and was associated with more complicated hospital courses. Hyponatremia was independently associated with worse neurological outcome when adjusted for age and tumor factors. This study serves as an exploratory analysis identifying important risk factors for hyponatremia and associated sequelae. Further research into the causes of hyponatremia and the association with poor outcome is needed to determine if prevention and treatment of hyponatremia can improve outcomes in these children.