| Part ? Prognostic factors in comatose patients after cardiopulmonary resuscitationObjective:In this study,we collected the clinical data of unconscious patients who achieved restoration of spontaneous circulation(ROSC)following cardiopulmonary resuscitation(CPR)from cardiac arrest(CA),and analyzed the factors related to the outcome of CA patients.Methods:The unconscious CA patients who achieved ROSC admitted to the Intensive Care Unit(ICU),the Second Affiliated Hospital of Soochow University between Jan.2009 and Jan.2018 were included in this study.Data sheets of cardiac arrest(CA)were established according to the Utstein standards.Then we collected the patients'information,including age,gender,pre-CA factors,resuscitation related factors,post-resuscitation factors,clinical score,blood test findings,ICU length stay,and hospital costs.The major study endpoint was neurologic status at the discharge of ICU,which was evaluated based on the Glasgow-Pittsburgh cerebral Performance Categories(CPC).A CPC of 1-2 was defined as good neurological outcome,while a score of 3-5 was defined as poor neurological outcome.Univariate analysis was used to investigate the outcome-related factors,and multi-variate Logistic regression analysis was performed to identify the independent prognostic factors.Results:In total,205 patients[male:137(66.8%),female:68(33.2%);average age:59.38±17.65 yrs]following CPR were included in this study.Thirty-two(17%)patients showed good neurological outcome when discharge from ICU,while the other 173(83%)showed poor neurological outcome.There were statistical differences in the age and CA location between the good neurological outcome group and the poor neurological outcome group(P<0.05).No statistical differences were noticed in the gender,basic disease,smoking and alcohol abuse(P>0.05).The ICU length stay in the patients with good neurological outcome significantly longer compared with those with poor neurological outcome(20.39±7.82 days vs.8.97±4.92 days,P<0.05).The hospital costs in the patients with good neurological outcome was significantly higher than those with poor neurological outcome(133831.81±113.68 CNY vs.68556.63±590.34 CNY,P<0.01).For the CPC score at discharge from ICU,22(10.73%)showed a score of 1,10(4.88%)showed a score of 2,33(16.10%)showed a score of 3,77(37.56%)showed a score of 4,and 63(30.73%)showed a score of 5,respectively.There were 132 deaths(64%).The major death-related cause was central nervous system injury(n=65,49.24%).Forty-one(31.06%)showed circulation system failure,and twenty-six(19.70%)showed multiple organ failure(MOF).The life support treatment was asked to withdraw by the kins of 70%patients for no improvement in the consciousness status.There were significant differences in the age,CA location,initial heart rate,bystander CPR,CA-CPR time,CPR-ROSC time,CA-start hypothermia time,papillary light reflex,corneal reflex,epilepsy,Acute physiology and chronic health score(APACHE-?),full outline of unresponsiveness score(FOUR),Glasgow coma scale(GCS),lactic acid(Lac),and neuron specific enolase(NSE)(P<0.05).Multi-variate Logistic regression analysis indicated that age,CA location,CA-CPR time,CPR-ROSC time,APACHE ?,FOUR,Lac and NSE were the independent risk factors for neurological outcome of unconscious patients after CPR(P<0.05).Conclusions:Age,duration of cardiac arrest,clinical score and blood markers were correlated with CA patients' neurological outcome.The main causes of death of comatose patients after CPR were central nervous system injury,circulatory system failure and multi-organ failure respectively,and the main reason of patients' family kin's request to withdraw life support treatment was that the patients' no improvement consciousness status.Part ? The role of brain multimodality monitoring in predicting the patients' neurological outcome after CPRObjective:To investigate the role of brain multimodality monitoring(MMM)in predicting the patients' neurological outcome after CPR.Methods:Patients with coma after CPR admitted to the ICU,the Second Affiliated Hospital of Soochow University between Jan.2012 and Dec.2018 were included in this study.The primary endpoint was neurological function after discharge from ICU.A CPC of 1-2 was defined as good neurological outcome,while a score of 3-5 was defined as poor neurological outcome.MMM methods were as follows:(?)FOUR and Glasgow coma scale-motor response(GCS-M);(?)near-infrared reflectance spectroscopy(NIRS)monitoring machine for regional cerebral oxygen saturation(rcSO2);(?)retrograde internal jugular vein catheter monitoring jugular bulb venous oxygen saturation(SjvO2):(?)Transcranial Doppler(TCD)monitoring on the systolic velocity(Vs),diastolic velocity(Vd),mean velocity(Vm),pulsatility index(PI),resistance index(RI);(?)blood NSE;(?)Amplitude-integrated electroencephalogram(aEEG);(?)Gray white matter ratio(GWR)was measured by CT scan,all of that be utilized to evaluate the neurological outcome.Normally distributed Data were presented as mean±standard deviation.Data that were non-normally distributed were presented as median interquartile.Student's t-test was carried out for the inter-group comparison,and then correlation analysis was performed.For the data that were not normally distributed,Wilcoxon rank test was performed.Chi square test was performed for the numeration data.Receiver operating characteristic(ROC)curve was utilized to compare the area under curve,sensitivity and specificity for the neurological outcome.P<0.05 was considered to be statistically significant.Results:(1)In total,81 cases(male:55,female:26;average age:67.5±8.9 yrs)were included,and were divided into good neurological outcome group(CPC:1-2;n=18)and poor neurological outcome group(CPC:3-5;n=63).Statistical differences were noticed in the age of the two groups(59.30± 17.65 yrs vs.62.09± 17.03 yrs,P<0.05).No statistical differences were noticed in the gender,underlying disease,baseline temperature,Mean arterial pressure(MAP)and hemoglobin between the two groups(P>0.05).Statistical differences were noticed in the out of hospital cardiac arrest(OHCA)/in hospital cardiac arrest(IHCA),shockable heart rate(%),bystander CPR(%),CA-CPR time,CPR-ROSC time,papillary reflex(%),corneal reflex(%),GSC-M of?2(%),FOUR,Lac,ICU length stay,and hospital costs(P<0.05).(2)Statistical differences were noticed in the rcSO2 at different time points between the two groups,in which the rcSO2 in the good neurological outcome was higher than that of the poor neurological outcome group(P<0.05).The SjvO2 after ROSC in the good neurological outcome group was lower than that of the poor neurological outcome group,however,no statistical differences were noticed(P>0.05).There were statistical differences in the mean SjvO2 among the patients(P<0.05).There were no statistical differences in the TCD findings between the two groups,including Vs,Vd,Vm,PI and RI.The NSE was significantly higher in the poor neurological outcome group compared with the good neurological outcome group(P=0.004).Twenty-one cases received aEEG monitoring,including 5 in good neurological outcome group and 16 in poor neurological outcome group.Among these patients,4 were classified into grade ?,2 into grade ?,9 into grade ?,and 6 into grade IV,respectively.Statistical differences were noticed in the basal ganglia GWR by CT scan(P=0.017).(3)The ROC Areas under curve(AUC)of the prognosis of neurological function in comatose patients after CA assessed by FOUR,GCS-M,rcSO2,SjvO2,aEEG,NSE and GWR,was 0.706,0.684,0.665,0.568,0.826,0.747 and 0.714,respectively,Among these parameters,SjvO2 could not be utilized to evaluate the prognosis(P=0.052).The area under curve in the presence of combined MMM methods prediction of neurological outcome was 0.947(P<0.001).Conclusions:Combination applicating of brain multimodality monitoring indicators could prognose neurological outcome after CPR more accurately.The prediction of neurological outcome in post-CPR comatose patients should combine with more methods available. |
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