Early clinical prediction of neurological outcome following out of hospital cardiac arrest managed with therapeutic hypothermia
Mohammed Ishaq Ruknuddeen, V. Rajajee, Luke E. Grzeskowiak, Ram E. Rajagopalan
Neurological outcome, out of hospital cardiac arrest, therapeutic hypothermia
Citation Information :
Ruknuddeen MI, Rajajee V, Grzeskowiak LE, Rajagopalan RE. Early clinical prediction of neurological outcome following out of hospital cardiac arrest managed with therapeutic hypothermia. Indian J Crit Care Med 2015; 19 (6):304-310.
Background: Therapeutic hypothermia (TH) may improve neurological outcome in comatose patients following out of hospital cardiac arrest (OHCA). The reliability of clinical prediction of neurological outcome following TH remains unclear. In particular, there is very limited data on survival and predictors of neurological outcome following TH for OHCA from resource-constrained settings in general and South Asia in specific. Objective: The objective was to identify factors predicting unfavorable neurological outcome at hospital discharge in comatose survivors of OHCA treated with hypothermia. Design: Retrospective chart review. Setting: Urban 200-bed hospital in Chennai, India. Methods: Predictors of unfavorable neurological outcome (cerebral performance category score [3-5]) at hospital discharge were evaluated among patients admitted between January 2006 and December 2012 following OHCA treated with TH. Hypothermia was induced with cold intravenous saline bolus, ice packs and cold-water spray with bedside fan. Predictors of unfavorable neurological outcome were examined through multivariate exact logistic regression analysis. Results: A total of 121 patients were included with 106/121 (87%) experiencing the unfavorable neurological outcome. Independent predictors of unfavorable neurological outcome included: Status myoclonus <24 h (odds ratio [OR] 21.79, 95% confidence interval [CI] 2.89-Infinite), absent brainstem reflexes (OR 50.09, 6.55-Infinite), and motor response worse than flexion on day 3 (OR 99.41, 12.21-Infinite). All 3 variables had 100% specificity and positive predictive value. Conclusion: Status myoclonus within 24 h, absence of brainstem reflexes and motor response worse than flexion on day 3 reliably predict unfavorable neurological outcome in comatose patients with OHCA treated with TH.
Nolan JP, Lyon RM, Sasson C, Rossetti AO, Lansky AJ, Fox KA, et al. Advances in the hospital management of patients following an out of hospital cardiac arrest. Heart 2012;98:1201-6.
Sasson C, Rogers MA, Dahl J, Kellermann AL. Predictors of survival from out-of-hospital cardiac arrest: A systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes 2010;3:63-81.
American Heart Association Guidelines on Cardiopulmonary Resuscitation: Overview of CPR. Circulation 2005;112:12-8.
Travers AH, Rea TD, Bobrow BJ, Edelson DP, Berg RA, Sayre MR, et al. Part 4: CPR overview: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2010;122 18 Suppl 3:S676-84.
Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med 2002;346:549-56.
Bernard SA, Gray TW, Buist MD, Jones BM, Silvester W, Gutteridge G, et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med 2002;346:557-63.
Wijdicks EF, Hijdra A, Young GB, Bassetti CL, Wiebe S; Quality Standards Subcommittee of the American Academy of Neurology. Practice parameter: Prediction of outcome in comatose survivors after cardiopulmonary resuscitation (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2006;67:203-10.
Rossetti AO, Oddo M, Logroscino G, Kaplan PW. Prognostication after cardiac arrest and hypothermia: A prospective study. Ann Neurol 2010;67:301-7.
Bouwes A, Binnekade JM, Kuiper MA, Bosch FH, Zandstra DF, Toornvliet AC, et al. Prognosis of coma after therapeutic hypothermia: A prospective cohort study. Ann Neurol 2012;71:206-12.
Fugate JE, Wijdicks EF, Mandrekar J, Claassen DO, Manno EM, White RD, et al. Predictors of neurologic outcome in hypothermia after cardiac arrest. Ann Neurol 2010;68:907-14.
Samaniego EA, Mlynash M, Caulfield AF, Eyngorn I, Wijman CA. Sedation confounds outcome prediction in cardiac arrest survivors treated with hypothermia. Neurocrit Care 2011;15:113-9.
Rittenberger JC, Sangl J, Wheeler M, Guyette FX, Callaway CW. Association between clinical examination and outcome after cardiac arrest. Resuscitation 2010;81:1128-32.
Bisschops LL, van Alfen N, Bons S, van der Hoeven JG, Hoedemaekers CW. Predictors of poor neurologic outcome in patients after cardiac arrest treated with hypothermia: A retrospective study. Resuscitation 2011;82:696-701.
Berdowski J, Berg RA, Tijssen JG, Koster RW. Global incidences of out-of-hospital cardiac arrest and survival rates: Systematic review of 67 prospective studies. Resuscitation 2010;81:1479-87.
Rajaram R, Rajagopalan RE, Pai M, Mahendran S. Survival after cardiopulmonary resuscitation in an urban Indian hospital. Natl Med J India 1999;12:51-5.
Jacobs I, Nadkarni V, Bahr J, Berg RA, Billi JE, Bossaert L, et al. Cardiac arrest and cardiopulmonary resuscitation outcome reports: Update and simplification of the Utstein templates for resuscitation registries: A statement for healthcare professionals from a task force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada, Inter-American Heart Foundation, Resuscitation Councils of Southern Africa). Circulation 2004;110:3385-97.
Christensen S, Johansen MB, Christiansen CF, Jensen R, Lemeshow S. Comparison of Charlson comorbidity index with SAPS and APACHE scores for prediction of mortality following intensive care. Clin Epidemiol 2011;3:203-11.
NICE-SUGAR Study Investigators, Finfer S, Chittock DR, Su SY, Blair D, Foster D, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med 2009;360:1283-97.
Wijdicks EF, Parisi JE, Sharbrough FW. Prognostic value of myoclonus status in comatose survivors of cardiac arrest. Ann Neurol 1994;35:239-43.
Phelps R, Dumas F, Maynard C, Silver J, Rea T. Cerebral Performance Category and long-term prognosis following out-of-hospital cardiac arrest. Crit Care Med 2013;41:1252-7.
Mehta CR, Patel NR. Exact logistic regression: Theory and examples. Stat Med 1995;14:2143-60.
Nichol G, Thomas E, Callaway CW, Hedges J, Powell JL, Aufderheide TP, et al. Regional variation in out-of-hospital cardiac arrest incidence and outcome. JAMA 2008;300:1423-31.
Cheung W, Flynn M, Thanakrishnan G, Milliss DM, Fugaccia E. Survival after out-of-hospital cardiac arrest in Sydney, Australia. Crit Care Resusc 2006;8:321-7.
Jennings PA, Cameron P, Walker T, Bernard S, Smith K. Out-of-hospital cardiac arrest in Victoria: Rural and urban outcomes. Med J Aust 2006;185:135-9.
Kendal S, PHillipson A, Wright J. Out of Hospital Cardiac Arrest Registry: First Year of Data Report 2011. British Heart Foundation; 2011.
Grmec S, Gasparovic V. Comparison of APACHE II, MEES and Glasgow Coma Scale in patients with nontraumatic coma for prediction of mortality. Acute Physiology and Chronic Health Evaluation. Mainz Emergency Evaluation System. Crit Care 2001;5:19-23.
Deakin CD, Morrison LJ, Morley PT, Callaway CW, Kerber RE, Kronick SL, et al. 2010 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendation (ILCOR guidelines). Resuscitation 2010; 19:e93-174.
Perman SM, Kirkpatrick JN, Reitsma AM, Gaieski DF, Lau B, Smith TM, et al. Timing of neuroprognostication in postcardiac arrest therapeutic hypothermiaFNx01. Crit Care Med 2012;40:719-24.