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Optimal Time of Collapse to Return of Spontaneous Circulation to Apply Targeted Temperature Management for Cardiac Arrest: A Bayesian Network Meta-Analysis.

ABSTRACT: Background: Both the American Heart Association (AHA) and European Resuscitation Council (ERC) have strongly recommended targeted temperature management (TTM) for patients who remain in coma after return of spontaneous circulation (ROSC). However, the role of TTM, especially hypothermia, in cardiac arrest patients after TTM2 trials has become much uncertain. Methods: We searched four online databases (PubMed, Embase, CENTRAL, and Web of Science) and conducted a Bayesian network meta-analysis. Based on the time of collapse to ROSC and whether the patient received TTM or not, we divided this analysis into eight groups (<20 min + TTM, <20 min, 20-39 min + TTM, 20-39 min, 40-59 min + TTM, 40-59 min, ≥60 min + TTM and ≥60 min) to compare their 30-day and at-discharge survival and neurologic outcomes. Results: From an initial search of 3,023 articles, a total of 9,005 patients from 42 trials were eligible and were included in this network meta-analysis. Compared with other groups, patients in the <20 min + TTM group were more likely to have better survival and good neurologic outcomes (probability = 46.1 and 52.5%, respectively). In comparing the same time groups with and without TTM, only the survival and neurologic outcome of the 20-39 min + TTM group was significantly better than that of the 20-39 min group [odds ratio = 1.41, 95% confidence interval (1.04-1.91); OR = 1.46, 95% CI (1.07-2.00) respectively]. Applying TTM with <20 min or more than 40 min of collapse to ROSC did not improve survival or neurologic outcome [ <20 min vs. <20 min + TTM: OR = 1.02, 95% CI (0.61-1.71)/OR = 1.03, 95% CI (0.61-1.75); 40-59 min vs. 40-59 min + TTM: OR = 1.50, 95% CI (0.97-2.32)/OR = 1.40, 95% CI (0.81-2.44); ≧60 min vs. ≧60 min + TTM: OR = 2.09, 95% CI (0.70-6.24)/OR = 4.14, 95% CI (0.91-18.74), respectively]. Both survival and good neurologic outcome were closely related to the time from collapse to ROSC. Conclusion: Survival and good neurologic outcome are closely associated with the time of collapse to ROSC. These findings supported that 20-40 min of collapse to ROSC should be a more suitable indication for TTM for cardiac arrest patients. Moreover, the future trials should pay more attention to these patients who suffer from moderate injury. Systematic Review Registration: [https://inplasy.com/?s=202180027], identifier [INPLASY202180027].

SUBMITTER: Duan J

PROVIDER: S-EPMC8777010 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BACKGROUND:Continuous electroencephalography (cEEG), interpreted by an experienced neurologist, has been reported to be useful in predicting neurological outcome in adult patients post cardiac arrest. Amplitude-integrated electroencephalography (aEEG) is a type of quantitative EEG and is easily interpreted by a non-neurologist. A few studies have shown the effectiveness of aEEG in prognostication among adult patients post cardiac arrest. In this study, we hypothesized that the pattern of aEEG after return of spontaneous circulation (ROSC) could successfully categorize patients post cardiac arrest according to their expected neurological outcome. METHODS:We assessed the comatose survivors of out-of-hospital cardiac arrest who received targeted temperature management with midazolam-based sedation and were monitored with aEEG at our tertiary emergency care center from January 2013 to June 2017. We categorized the patients into categories 1 (C1) to 4 (C4). C1 included patients who regained continuous normal voltage (CNV) within 12 h post ROSC, C2 included those who recovered CNV 12-36 h post ROSC, C3 included those who did not recover CNV before 36 h post ROSC, and C4 included those who had burst suppression at any time post ROSC. We evaluated the outcomes of neurological function for each category at hospital discharge. A good outcome was defined as a cerebral performance category of 1 or 2. RESULTS:A total of 61 patients were assessed (median age, 60 years), among whom 42 (70%) had an initial shockable rhythm, and 52 (85%) had cardiac etiology. Of all 61 patients, 40 (66%) survived to hospital discharge and 27 (44%) had a good neurological outcome. Of 20 patients in C1, 19 (95%) had a good outcome, while the percentage dropped to 57% among C2 patients. No patients in C3 or C4 had a good outcome. Three patients could not be classified into any category. CONCLUSIONS:The pattern of aEEG during the early post-cardiac-arrest period can successfully categorize patients according to their neurological prognoses and could be used as a potential guide to customize post-cardiac-arrest care for each patient.

Project description:BACKGROUND:Despite advances in resuscitation care, mortality rates following cardiac arrest (CA) remain high. Between one-quarter (in-hospital CA) and two-thirds (out of hospital CA) of patients admitted comatose to intensive care die of neurological injury. Neuroprognostication determines an informed and timely withdrawal of life sustaining treatment (WLST), sparing the patient unnecessary suffering, alleviating family distress and allowing a more utilitarian use of resources. The latest Resuscitation Council UK (2015) guidance on post-resuscitation care provides the current multi-modal neuroprognostication strategy to predict neurological outcome. Its modalities include neurological examination, neurophysiological tests, biomarkers and radiology. Despite each of the current strategy's predictive modalities exhibiting limitations, meta-analyses show that three, namely PLR (pupillary light reflex), CR (corneal reflex) and N20 SSEP (somatosensory-evoked potential), accurately predict poor neurological outcome with low false positive rates. However, the quality of evidence is low, reducing confidence in the strategy's results. While infrared pupillometry (IRP) is not currently used as a prognostication modality, it can provide a quantitative and objective measure of pupillary size and PLR, giving a definitive view of the second and third cranial nerve activity, a predictor of neurological outcome. METHODS:The proposed study will test the hypothesis, "in those patients who remain comatose following return of spontaneous circulation (ROSC) after CA, IRP can be used early to help predict poor neurological outcome". A comprehensive review of the evidence using a PRISMA-P (2015) compliant methodology will be underpinned by systematic searching of electronic databases and the two authors selecting and screening eligible studies using the Cochrane data extraction and assessment template. Randomised controlled trials and retrospective and prospective studies will be included, and the quality and strength of evidence will be assessed using the Grading of Recommendation, Assessment and Evaluation (GRADE) approach. DISCUSSION:IRP requires rudimentary skill and is objective and repeatable. As a clinical prognostication modality, it may be utilised early, when the strategy's other modalities are not recommended. Corroboration in the evidence would promote early use of IRP and a reduction in ICU bed days. SYSTEMATIC REVIEW REGISTRATION:PROSPERO CRD42018118180.

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Optimal Time of Collapse to Return of Spontaneous Circulation to Apply Targeted Temperature Management for Cardiac Arrest: A Bayesian Network Meta-Analysis.

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