Extracorporeal cardiopulmonary resuscitation (ECPR) refers to use of extracorporeal membrane oxygenation (ECMO) in cardiopulmonary arrest. Although ECPR can increase survival rates after cardiac arrest, it can also result in poor post-resuscitation neurological status. Thus, we investigated predictors of good neurological outcomes after successful ECPR. A total of 227 patients underwent ECPR from May 2004 to June 2013 at Samsung Medical Center. Successful ECPR was defined as survival more than 24 hours after ECPR. Neurological outcomes were assessed at discharge using the Glasgow-Pittsburgh Cerebral Performance Categories scale (CPC). CPC 1 and 2 were classified as good and CPC 3 to 5 were classified as poor neurological outcomes. Excluded were 22 patients who did not survive more than 24 hours after ECPR and 90 patients who died from unknown causes or causes other than brain death or whose neurological status could not be assessed at discharge. Multiple logistic regression analysis was used to identify independent predictors of neurological outcomes. Included were 115 patients with a mean age of 58 (range 45–66) years and 80 men (70%). Cardiopulmonary resuscitation (CPR) was performed at non-hospital sites for 19 (17%) patients and bystander CPR was performed in 9 of 19 cases (47%). Cardiac etiology was verified in 74 (64%) patients and therapeutic hypothermia was performed in 9 patients (8%); 68 (59%) had good neurological outcomes and 47 (41%) did not and 24 patients died from brain death. Neurological outcomes were affected by hemoglobin levels before ECMO (P = 0.02), serum lactic acid (P < 0.001) before ECMO insertion, and interval from cardiac arrest to ECMO (P = 0.04). Low hemoglobin or high serum lactic acid levels before ECMO, and prolonged interval from cardiac arrest to ECMO predicted poor neurological outcomes after successful ECPR. Early institution of ECMO and a low threshold for blood transfusion might improve neurological outcomes for patients who survive ECPR.

Sepsis is a major cause of mortality and morbidity in critically ill patients. Procalcitonin (PCT) and C-reactive protein (CRP) are the most frequently used biomarkers in sepsis. We investigated changes in PCT and CRP concentrations in critically ill patients with sepsis to determine which biochemical marker better predicts outcome. We retrospectively analyzed 171 episodes in 157 patients with severe sepsis and septic shock who were admitted to the Samsung Medical Center intensive care unit from March 2013 to February 2014. The primary endpoint was patient outcome within 7 days from ICU admission (treatment failure). The secondary endpoint was 28-day mortality. Severe sepsis was observed in 42 (25%) episodes from 41 patients, and septic shock was observed in 129 (75%) episodes from 120 patients. Fifty-five (32%) episodes from 42 patients had clinically-documented infection, and 116 (68%) episodes from 99 patients had microbiologically-documented infection. Initial peak PCT and CRP levels were not associated with treatment failure and 28-day mortality. However, PCT clearance (PCTc) and CRP (CRPc) clearance were significantly associated with treatment failure (p = 0.027 and p = 0.030, respectively) and marginally significant with 28-day mortality (p = 0.064 and p = 0.062, respectively). The AUC for prediction of treatment success was 0.71 (95% CI, 0.61–0.82) for PCTc and 0.71 (95% CI, 0.61–0.81) for CRPc. The AUC for survival prediction was 0.77 (95% CI, 0.66–0.88) for PCTc and 0.77 (95% CI, 0.67–0.88) for CRPc. Changes in PCT and CRP concentrations were associated with outcomes of critically ill septic patients. CRP may not be inferior to PCT in predicting outcome in these patients.

Limited data are available on imaging predictors of neurological outcomes after extracorporeal cardiopulmonary resuscitation (ECPR). We investigated the association of initial brain computed tomography (CT) findings with neurological outcomes following ECPR. Between February 2005 and December 2015, a total of 42 patients who underwent brain CT scans within 48 h after ECPR were analyzed. Loss of the boundary between gray matter and white matter (LOB) or cortical sulcal effacement (SE), gray-to-white matter ratio (GWR), and optic nerve sheath diameter (ONSD) were measured on initial brain CT. The primary outcome was the Cerebral Performance Categories (CPC) scale at discharge. Of the 42 adult ECPR patients, 23 (54.8%) patients survived to discharge and 19 (45.2%) patients had good neurological outcomes (CPC 1 and 2). The area under the curve (AUC) of GWR in the basal ganglia (GWR-BG) was 0.792 (95% confidence interval (CI), 0.639–0.901, p = 0.001). ONSD (AUC 0.745; 95% CI, 0.587 – 0.867, p = 0.007) was 5.57 (interquartile range (IQR) 5.14 – 5.98) mm in the good neurological outcome group versus 6.07 (IQR 5.71 – 6.64) mm in the poor outcome group. LOB or SE were more often detected in the poor neurological outcome group (AUC 0.817; 95% CI, 0.682–0.952, p <0.001). The predictive performance of poor neurological outcomes of a composite of GWR-BG, ONSD, and LOB/SE was significantly improved (AUC 0.904; 95% CI, 0.773–0.973) compared to when each brain CT marker was considered separately (GWR-BG, p = 0.048; ONSD, p = 0.026; LOB/SE, p = 0.028). GWR, ONSD, and LOB/SE on initial brain CT scans are associated with neurological prognosis in patients who underwent ECPR. The new risk prediction model, which uses a composite of GWR, ONCD, and LOB/SE, could provide better information on neurologic outcomes in patients underwent ECPR.

We evaluated the role of optic nerve sheath diameter (ONSD) using brain computed tomography (CT) in predicting neurological outcomes of patients with subarachnoid hemorrhage (SAH). This was a retrospective, multicenter, observational study of adult patients with SAH admitted between January 2012 and June 2017. Initial brain CT was performed within 12 h from onset of SAH, and follow-up brain CT was performed within 24 h from treatment of a ruptured aneurysm. Primary outcome was neurological status at 6-month follow-up assessed with the Glasgow Outcome Scale (GOS, 1 to 5). Among 223 SAH patients, 202 (90.6%) survived until discharge. Of these survivors, 186 (83.4%) manifested favorable neurological outcomes (GOS of 3, 4, or 5). In this study, the ONSDs in the group of patients with poor neurological outcome were significantly greater than those in the favorable neurological outcome group (all p < 0.01). Intracranial pressure (ICP) was monitored in 21 (9.4%) patients during the follow-up CT. A linear correlation existed between the average ONSD and ICP in simple correlation analysis (r = 0.525, p = 0.036). Analysis of the receiver operating characteristic curve for prediction of poor neurological outcome showed that ONSD had considerable predictive value (C-statistics, 0.735 to 0.812). In addition, the performance of a composite of Hunt and Hess grade and ONSD was increasingly associated with poor neurological outcomes than the use of each marker alone. ONSD measured with CT may be used in combination with clinical grading scales to improve prognostic accuracy in SAH patients.

Background: The purpose of this study was to evaluate the role of C-reactive protein (CRP) in predicting neurological outcomes of patients with subarachnoid hemorrhage (SAH). Methods: In this retrospective, observational study of adult patients with SAH treated between January 2012 and June 2017. Initial CRP levels collected within 24 h from the onset of SAH, the follow-up CRP levels were measured. The primary outcome was neurological status at six-month follow-up assessed with the Glasgow Outcome Scale (GOS, 1 to 5). Results: Among 156 patients with SAH, 145 (92.9%) survived until discharge. Of these survivors, 109 (69.9%) manifested favorable neurological outcomes (GOS of 4 or 5). Initial CRP levels on admission and maximal CRP levels within four days were significantly higher in the group with poor neurological outcome compared with those manifesting favorable neurological outcomes (P = 0.022, P < 0.001, respectively). However, the clearance of CRPs did not differ significantly between the two groups (P = 0.785). Analysis of the receiver operating characteristic curve for prediction of poor neurological outcome showed that the performance of the maximal CRP was significantly better compared with the initial CRP or the clearance of CRP (P = 0.007, P < 0.001, respectively). In this study, the effect of CRP on neurological outcomes differed according to surgical clipping. The maximal CRP levels within four days facilitate the prediction of neurological outcomes of SAH patients without surgical clipping (C-statistic: 0.856, 95% confidence interval [CI]: 0.767–0.921). However, they were poorly associated with neurological prognoses in SAH patients who underwent surgical clipping (C-statistic: 0.562, 95% CI: 0.399–0.716). Multivariable logistic regression analysis revealed that age (adjusted odds ratio [OR]: 1.10, 95% CI: 1.052–1.158), initial Glasgow Coma Scale (adjusted OR: 0.74, 95% CI: 0.647–0.837), and maximal CRP without surgical clipping (adjusted OR: 1.27, 95% CI: 1.066–1.516) were significantly associated with poor neurological outcomes in SAH patients. Conclusions: Early serial measurements of CRP may be used to predict neurological outcomes of SAH patients. Furthermore, maximal CRP levels within four days post-SAH are significantly correlated with poor neurological outcomes.

Ryu JA, et al. J Korean Med Sci. 2017 Jun;32(6):1024-1030. https://doi.org/10.3346/jkms.2017.32.6.1024