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Jesper Kjaergaard - One of the best experts on this subject based on the ideXlab platform.

  • highly malignant routine eeg predicts poor prognosis after cardiac arrest in the Target Temperature management trial
    Resuscitation, 2018
    Co-Authors: Sofia Backman, Niklas Nielsen, Hans Friberg, Christian Hassager, Janneke Horn, Jesper Kjaergaard, Susann Ullen, Tobias Cronberg, M Wanscher, Erik Westhall
    Abstract:

    Introduction: Routine EEG is widely used and accessible for post arrest neuroprognostication. Recent studies, using standardised EEG terminology, have proposed highly malignant EEG patterns with promising predictive ability. Objectives: To validate the performance of standardised routine EEG patterns to predict neurological outcome after cardiac arrest. Methods: In the prospective multicenter Target Temperature Management trial, comatose cardiac arrest patients were randomised to different Temperature levels (950 patients, 36 sites). According to the prospective protocol a routine EEG was performed in patients who remained comatose after the 36 h Temperature control intervention. EEGs were retrospectively reviewed blinded to outcome using the standardised American Clinical Neurophysiology Society terminology. Highly malignant, malignant and benign EEG patterns were correlated to poor and good outcome, defined by best achieved Cerebral Performance Category up to 180 days. Results: At 20 sites 207 patients had a routine EEG performed at median 76 h after cardiac arrest. Highly malignant patterns (suppression or burst-suppression with or without discharges) had a high specificity for poor outcome (98%, CI 92–100), but with limited sensitivity (31%, CI 24–39). Our false positive patient had a burst-suppression pattern during ongoing sedation. A benign EEG, i.e. continuous normal-voltage background without malignant features, identified patients with good outcome with 77% (CI 66–86) sensitivity and 80% (CI 73–86) specificity. Conclusion: Highly malignant routine EEG after Targeted Temperature management is a strong predictor of poor outcome. A benign EEG is an important indicator of a good outcome for patients remaining in coma.

  • carbon dioxide dynamics in relation to neurological outcome in resuscitated out of hospital cardiac arrest patients an exploratory Target Temperature management trial substudy
    Critical Care, 2018
    Co-Authors: Florian Ebner, Hans Friberg, Anders Aneman, Christian Hassager, Jesper Kjaergaard, Michael A Kuiper, Tobias Cronberg, Matthew B A Harmon, Nicole P Juffermans, Niklas Mattsson
    Abstract:

    Dyscarbia is common in out-of-hospital cardiac arrest (OHCA) patients and its association to neurological outcome is undetermined. This is an exploratory post-hoc substudy of the Target Temperature Management (TTM) trial, including resuscitated OHCA patients, investigating the association between serial measurements of arterial partial carbon dioxide pressure (PaCO2) and neurological outcome at 6 months, defined by the Cerebral Performance Category (CPC) scale, dichotomized to good outcome (CPC 1 and 2) and poor outcome (CPC 3–5). The effects of hypercapnia and hypocapnia, and the time-weighted mean PaCO2 and absolute PaCO2 difference were analyzed. Additionally, the association between mild hypercapnia (6.0–7.30 kPa) and neurological outcome, its interaction with Target Temperature (33 °C and 36 °C), and the association between PaCO2 and peak serum-Tau were evaluated. Of the 939 patients in the TTM trial, 869 were eligible for analysis. Ninety-six percent of patients were exposed to hypocapnia or hypercapnia. None of the analyses indicated a statistical significant association between PaCO2 and neurological outcome (P = 0.13–0.96). Mild hypercapnia was not associated with neurological outcome (P = 0.78) and there was no statistically significant interaction with Target Temperature (Pinteraction = 0.95). There was no association between PaCO2 and peak serum-Tau levels 48 or 72 h after return of spontaneous circulation (ROSC). Dyscarbia is common after ROSC. No statistically significant association between PaCO2 in the post-cardiac arrest phase and neurological outcome at 6 months after cardiac arrest was detected. There was no significant interaction between mild hypercapnia and Temperature in relation to neurological outcome.

  • time to awakening after cardiac arrest and the association with Target Temperature management
    Resuscitation, 2018
    Co-Authors: Anna Lybeck, Anders Aneman, Christian Hassager, Janneke Horn, Jesper Kjaergaard, Michael A Kuiper, Tobias Cronberg, Jan Hovdenes, Michael Wanscher, Pascal Stammet
    Abstract:

    Aim: Target Temperature management (TTM) at 32-36 °C is recommended in unconscious survivors of cardiac arrest. This study reports awakening in the TTM-trial. Our predefined hypotheses were that time until awakening correlates with long-term neurological outcome and is not affected by level of TTM. Methods: Post-hoc analysis of time until awakening after cardiac arrest, its association with long-term (180-days) neurological outcome and predictors of late awakening (day 5 or later. ). The trial randomized 939 comatose survivors to TTM at 33 °C or 36 °C with strict criteria for withdrawal of life-sustaining therapies. Administered sedation in the treatment groups was compared. Awakening was defined as a Glasgow Coma Scale motor score 6. Results: 496 patients had registered day of awakening in the ICU, another 43 awoke after ICU discharge. Good neurological outcome was more common in early (275/308, 89%) vs late awakening (142/188, 76%), p < 0.001. Awakening occurred later in TTM33 than in TTM36 (p = 0.002) with no difference in neurological outcome, or cumulative doses of sedative drugs at 12, 24 or 48 h. TTM33 (p = 0.006), clinical seizures (p = 0.004), and lower GCS-M on admission (p = 0.03) were independent predictors of late awakening. Conclusion: Late awakening is common and often has a good neurological outcome. Time to awakening was longer in TTM33 than in TTM36, this difference could not be attributed to differences in sedative drugs administered during the first 48 h.

  • prognostic significance of clinical seizures after cardiac arrest and Target Temperature management
    Resuscitation, 2017
    Co-Authors: Anna Lybeck, Niklas Nielsen, Hans Friberg, Anders Aneman, Christian Hassager, Janneke Horn, Jesper Kjaergaard, Michael A Kuiper, Susann Ullen, Matt P Wise
    Abstract:

    Abstract Aim Clinical seizures are common after cardiac arrest and predictive of a poor neurological outcome. Seizures may be myoclonic, tonic-clonic or a combination of seizure types. This study reports the incidence and prognostic significance of clinical seizures in the Target Temperature management (TTM) after cardiac arrest trial. Our hypotheses were that seizures are associated with a poor prognosis and that the incidence of seizures is not affected by the Target Temperature. Methods Post-hoc analysis of reported clinical seizures during day 1–7 in the TTM-trial including their treatment, EEG-findings, and long-term neurological outcome. The trial randomised 939 comatose survivors to TTM at 33°C or 36°C with strict criteria for withdrawal of life-sustaining therapies. Sensitivity, specificity and false positive rate for poor outcome were reported for different types of seizures. Results Clinical seizures were registered in 268 patients (29%), similarly distributed in both intervention arms. Early and late seizures were equally predictive of poor outcome. Myoclonic seizures were the most common (240 patients, 26%) and the most predictive of a poor outcome (sensitivity 36.1%, false positive rate 4.3%). Two patients with status myoclonus regained consciousness, one with a good neurological outcome, generating a false positive rate of poor outcome of 0.2% (95%CI 0.0–1.0). Conclusion Clinical seizures are common after cardiac arrest and indicate poor outcome with limited specificity. Prolonged seizures are a very grave sign but occasional patients may have a good outcome. The level of the Target Temperature does not affect the prevalence or prognostic significance of seizures.

  • cognitive function in survivors of out of hospital cardiac arrest after Target Temperature management at 33 c versus 36 c
    Circulation, 2015
    Co-Authors: Gisela Lilja, Niklas Nielsen, Tommaso Pellis, Hans Friberg, Janneke Horn, Jesper Kjaergaard, Matt P Wise, Jørn Wetterslev, Fredrik Nilsson, Frank H Bosch
    Abstract:

    Background—Target Temperature management is recommended as a neuroprotective strategy after out-of-hospital cardiac arrest. Potential effects of different Target Temperatures on cognitive impairment commonly described in survivors have not been investigated sufficiently. The primary aim of this study was to evaluate whether a Target Temperature of 33°C compared with 36°C was favorable for cognitive function; the secondary aim was to describe cognitive impairment in cardiac arrest survivors in general. Methods and Results—Study sites included 652 cardiac arrest survivors originally randomized and stratified for site to Temperature control at 33°C or 36°C within the Target Temperature Management trial. Survival until 180 days after the arrest was 52% (33°C, n=178/328; 36°C, n=164/324). Survivors were invited to a face-to-face follow-up, and 287 cardiac arrest survivors (33°C, n=148/36°C, n=139) were assessed with tests for memory (Rivermead Behavioural Memory Test), executive functions (Frontal Assessment B...

Niklas Nielsen - One of the best experts on this subject based on the ideXlab platform.

  • highly malignant routine eeg predicts poor prognosis after cardiac arrest in the Target Temperature management trial
    Resuscitation, 2018
    Co-Authors: Sofia Backman, Niklas Nielsen, Hans Friberg, Christian Hassager, Janneke Horn, Jesper Kjaergaard, Susann Ullen, Tobias Cronberg, M Wanscher, Erik Westhall
    Abstract:

    Introduction: Routine EEG is widely used and accessible for post arrest neuroprognostication. Recent studies, using standardised EEG terminology, have proposed highly malignant EEG patterns with promising predictive ability. Objectives: To validate the performance of standardised routine EEG patterns to predict neurological outcome after cardiac arrest. Methods: In the prospective multicenter Target Temperature Management trial, comatose cardiac arrest patients were randomised to different Temperature levels (950 patients, 36 sites). According to the prospective protocol a routine EEG was performed in patients who remained comatose after the 36 h Temperature control intervention. EEGs were retrospectively reviewed blinded to outcome using the standardised American Clinical Neurophysiology Society terminology. Highly malignant, malignant and benign EEG patterns were correlated to poor and good outcome, defined by best achieved Cerebral Performance Category up to 180 days. Results: At 20 sites 207 patients had a routine EEG performed at median 76 h after cardiac arrest. Highly malignant patterns (suppression or burst-suppression with or without discharges) had a high specificity for poor outcome (98%, CI 92–100), but with limited sensitivity (31%, CI 24–39). Our false positive patient had a burst-suppression pattern during ongoing sedation. A benign EEG, i.e. continuous normal-voltage background without malignant features, identified patients with good outcome with 77% (CI 66–86) sensitivity and 80% (CI 73–86) specificity. Conclusion: Highly malignant routine EEG after Targeted Temperature management is a strong predictor of poor outcome. A benign EEG is an important indicator of a good outcome for patients remaining in coma.

  • Changes in Temperature Management of Cardiac Arrest Patients Following Publication of the Target Temperature Management Trial
    Critical Care Medicine, 2018
    Co-Authors: Ryan Salter, Michael Bailey, Rinaldo Bellomo, Glenn M Eastwood, Andrew Goodwin, Niklas Nielsen, David Pilcher, Alistair Nichol, Manoj Saxena, Yahya Shehabi
    Abstract:

    Objectives:To evaluate knowledge translation after publication of the Target Temperature management 33°C versus 36°C after out-of-hospital cardiac arrest trial and associated patient outcomes. Our primary hypothesis was that Target Temperature management at 36°C was rapidly adopted in Australian and

  • prognostic significance of clinical seizures after cardiac arrest and Target Temperature management
    Resuscitation, 2017
    Co-Authors: Anna Lybeck, Niklas Nielsen, Hans Friberg, Anders Aneman, Christian Hassager, Janneke Horn, Jesper Kjaergaard, Michael A Kuiper, Susann Ullen, Matt P Wise
    Abstract:

    Abstract Aim Clinical seizures are common after cardiac arrest and predictive of a poor neurological outcome. Seizures may be myoclonic, tonic-clonic or a combination of seizure types. This study reports the incidence and prognostic significance of clinical seizures in the Target Temperature management (TTM) after cardiac arrest trial. Our hypotheses were that seizures are associated with a poor prognosis and that the incidence of seizures is not affected by the Target Temperature. Methods Post-hoc analysis of reported clinical seizures during day 1–7 in the TTM-trial including their treatment, EEG-findings, and long-term neurological outcome. The trial randomised 939 comatose survivors to TTM at 33°C or 36°C with strict criteria for withdrawal of life-sustaining therapies. Sensitivity, specificity and false positive rate for poor outcome were reported for different types of seizures. Results Clinical seizures were registered in 268 patients (29%), similarly distributed in both intervention arms. Early and late seizures were equally predictive of poor outcome. Myoclonic seizures were the most common (240 patients, 26%) and the most predictive of a poor outcome (sensitivity 36.1%, false positive rate 4.3%). Two patients with status myoclonus regained consciousness, one with a good neurological outcome, generating a false positive rate of poor outcome of 0.2% (95%CI 0.0–1.0). Conclusion Clinical seizures are common after cardiac arrest and indicate poor outcome with limited specificity. Prolonged seizures are a very grave sign but occasional patients may have a good outcome. The level of the Target Temperature does not affect the prevalence or prognostic significance of seizures.

  • Infectious complications after out-of-hospital cardiac arrest-A comparison between two Target Temperatures.
    Resuscitation, 2016
    Co-Authors: Josef Dankiewicz, Niklas Nielsen, Michael A Kuiper, Matt P Wise, Tobias Cronberg, David Erlinge, Yvan Gasche, Matthew B A Harmon, Adam Linder, Christian Hassager
    Abstract:

    Abstract Background It has been suggested that Target Temperature management (TTM) increases the probability of infectious complications after cardiac arrest. We aimed to compare the incidence of pneumonia, severe sepsis and septic shock after out-of-hospital cardiac arrest (OHCA) in patients with two Target Temperatures and to describe changes in biomarkers and possible mortality associated with these infectious complications. Methods Post-hoc analysis of the TTM-trial which randomized patients resuscitated from OHCA to a Target Temperature of 33 °C or 36 °C. Prospective data on infectious complications were recorded daily during the ICU-stay. Pneumonia, severe sepsis and septic shock were considered infectious complications. Procalcitonin (PCT) and C-reactive-protein (CRP) levels were measured at 24 h, 48 h and 72 h after cardiac arrest. Results There were 939 patients in the modified intention-to-treat population. Five-hundred patients (53%) developed pneumonia, severe sepsis or septic shock which was associated with mortality in multivariate analysis (Hazard ratio [HR] 1.39; 95%CI 1.13–1.70; p = 0.001). There was no statistically significant difference in the incidence of infectious complications between Temperature groups (sub-distribution hazard ratio [SHR] 0.88; 95%CI 0.75–1.03; p = 0.12). PCT and CRP were significantly higher for patients with infections at all times (p  Conclusions Patients who develop pneumonia, severe sepsis or septic shock after OHCA might have an increased mortality. A Target Temperature of 33 °C after OHCA was not associated with an increased risk of infectious complications compared to a Target Temperature of 36 °C. PCT and CRP are of limited value for diagnosing infectious complications after cardiac arrest.

  • cognitive function in survivors of out of hospital cardiac arrest after Target Temperature management at 33 c versus 36 c
    Circulation, 2015
    Co-Authors: Gisela Lilja, Niklas Nielsen, Tommaso Pellis, Hans Friberg, Janneke Horn, Jesper Kjaergaard, Matt P Wise, Jørn Wetterslev, Fredrik Nilsson, Frank H Bosch
    Abstract:

    Background—Target Temperature management is recommended as a neuroprotective strategy after out-of-hospital cardiac arrest. Potential effects of different Target Temperatures on cognitive impairment commonly described in survivors have not been investigated sufficiently. The primary aim of this study was to evaluate whether a Target Temperature of 33°C compared with 36°C was favorable for cognitive function; the secondary aim was to describe cognitive impairment in cardiac arrest survivors in general. Methods and Results—Study sites included 652 cardiac arrest survivors originally randomized and stratified for site to Temperature control at 33°C or 36°C within the Target Temperature Management trial. Survival until 180 days after the arrest was 52% (33°C, n=178/328; 36°C, n=164/324). Survivors were invited to a face-to-face follow-up, and 287 cardiac arrest survivors (33°C, n=148/36°C, n=139) were assessed with tests for memory (Rivermead Behavioural Memory Test), executive functions (Frontal Assessment B...

Christian Hassager - One of the best experts on this subject based on the ideXlab platform.

  • highly malignant routine eeg predicts poor prognosis after cardiac arrest in the Target Temperature management trial
    Resuscitation, 2018
    Co-Authors: Sofia Backman, Niklas Nielsen, Hans Friberg, Christian Hassager, Janneke Horn, Jesper Kjaergaard, Susann Ullen, Tobias Cronberg, M Wanscher, Erik Westhall
    Abstract:

    Introduction: Routine EEG is widely used and accessible for post arrest neuroprognostication. Recent studies, using standardised EEG terminology, have proposed highly malignant EEG patterns with promising predictive ability. Objectives: To validate the performance of standardised routine EEG patterns to predict neurological outcome after cardiac arrest. Methods: In the prospective multicenter Target Temperature Management trial, comatose cardiac arrest patients were randomised to different Temperature levels (950 patients, 36 sites). According to the prospective protocol a routine EEG was performed in patients who remained comatose after the 36 h Temperature control intervention. EEGs were retrospectively reviewed blinded to outcome using the standardised American Clinical Neurophysiology Society terminology. Highly malignant, malignant and benign EEG patterns were correlated to poor and good outcome, defined by best achieved Cerebral Performance Category up to 180 days. Results: At 20 sites 207 patients had a routine EEG performed at median 76 h after cardiac arrest. Highly malignant patterns (suppression or burst-suppression with or without discharges) had a high specificity for poor outcome (98%, CI 92–100), but with limited sensitivity (31%, CI 24–39). Our false positive patient had a burst-suppression pattern during ongoing sedation. A benign EEG, i.e. continuous normal-voltage background without malignant features, identified patients with good outcome with 77% (CI 66–86) sensitivity and 80% (CI 73–86) specificity. Conclusion: Highly malignant routine EEG after Targeted Temperature management is a strong predictor of poor outcome. A benign EEG is an important indicator of a good outcome for patients remaining in coma.

  • carbon dioxide dynamics in relation to neurological outcome in resuscitated out of hospital cardiac arrest patients an exploratory Target Temperature management trial substudy
    Critical Care, 2018
    Co-Authors: Florian Ebner, Hans Friberg, Anders Aneman, Christian Hassager, Jesper Kjaergaard, Michael A Kuiper, Tobias Cronberg, Matthew B A Harmon, Nicole P Juffermans, Niklas Mattsson
    Abstract:

    Dyscarbia is common in out-of-hospital cardiac arrest (OHCA) patients and its association to neurological outcome is undetermined. This is an exploratory post-hoc substudy of the Target Temperature Management (TTM) trial, including resuscitated OHCA patients, investigating the association between serial measurements of arterial partial carbon dioxide pressure (PaCO2) and neurological outcome at 6 months, defined by the Cerebral Performance Category (CPC) scale, dichotomized to good outcome (CPC 1 and 2) and poor outcome (CPC 3–5). The effects of hypercapnia and hypocapnia, and the time-weighted mean PaCO2 and absolute PaCO2 difference were analyzed. Additionally, the association between mild hypercapnia (6.0–7.30 kPa) and neurological outcome, its interaction with Target Temperature (33 °C and 36 °C), and the association between PaCO2 and peak serum-Tau were evaluated. Of the 939 patients in the TTM trial, 869 were eligible for analysis. Ninety-six percent of patients were exposed to hypocapnia or hypercapnia. None of the analyses indicated a statistical significant association between PaCO2 and neurological outcome (P = 0.13–0.96). Mild hypercapnia was not associated with neurological outcome (P = 0.78) and there was no statistically significant interaction with Target Temperature (Pinteraction = 0.95). There was no association between PaCO2 and peak serum-Tau levels 48 or 72 h after return of spontaneous circulation (ROSC). Dyscarbia is common after ROSC. No statistically significant association between PaCO2 in the post-cardiac arrest phase and neurological outcome at 6 months after cardiac arrest was detected. There was no significant interaction between mild hypercapnia and Temperature in relation to neurological outcome.

  • time to awakening after cardiac arrest and the association with Target Temperature management
    Resuscitation, 2018
    Co-Authors: Anna Lybeck, Anders Aneman, Christian Hassager, Janneke Horn, Jesper Kjaergaard, Michael A Kuiper, Tobias Cronberg, Jan Hovdenes, Michael Wanscher, Pascal Stammet
    Abstract:

    Aim: Target Temperature management (TTM) at 32-36 °C is recommended in unconscious survivors of cardiac arrest. This study reports awakening in the TTM-trial. Our predefined hypotheses were that time until awakening correlates with long-term neurological outcome and is not affected by level of TTM. Methods: Post-hoc analysis of time until awakening after cardiac arrest, its association with long-term (180-days) neurological outcome and predictors of late awakening (day 5 or later. ). The trial randomized 939 comatose survivors to TTM at 33 °C or 36 °C with strict criteria for withdrawal of life-sustaining therapies. Administered sedation in the treatment groups was compared. Awakening was defined as a Glasgow Coma Scale motor score 6. Results: 496 patients had registered day of awakening in the ICU, another 43 awoke after ICU discharge. Good neurological outcome was more common in early (275/308, 89%) vs late awakening (142/188, 76%), p < 0.001. Awakening occurred later in TTM33 than in TTM36 (p = 0.002) with no difference in neurological outcome, or cumulative doses of sedative drugs at 12, 24 or 48 h. TTM33 (p = 0.006), clinical seizures (p = 0.004), and lower GCS-M on admission (p = 0.03) were independent predictors of late awakening. Conclusion: Late awakening is common and often has a good neurological outcome. Time to awakening was longer in TTM33 than in TTM36, this difference could not be attributed to differences in sedative drugs administered during the first 48 h.

  • prognostic significance of clinical seizures after cardiac arrest and Target Temperature management
    Resuscitation, 2017
    Co-Authors: Anna Lybeck, Niklas Nielsen, Hans Friberg, Anders Aneman, Christian Hassager, Janneke Horn, Jesper Kjaergaard, Michael A Kuiper, Susann Ullen, Matt P Wise
    Abstract:

    Abstract Aim Clinical seizures are common after cardiac arrest and predictive of a poor neurological outcome. Seizures may be myoclonic, tonic-clonic or a combination of seizure types. This study reports the incidence and prognostic significance of clinical seizures in the Target Temperature management (TTM) after cardiac arrest trial. Our hypotheses were that seizures are associated with a poor prognosis and that the incidence of seizures is not affected by the Target Temperature. Methods Post-hoc analysis of reported clinical seizures during day 1–7 in the TTM-trial including their treatment, EEG-findings, and long-term neurological outcome. The trial randomised 939 comatose survivors to TTM at 33°C or 36°C with strict criteria for withdrawal of life-sustaining therapies. Sensitivity, specificity and false positive rate for poor outcome were reported for different types of seizures. Results Clinical seizures were registered in 268 patients (29%), similarly distributed in both intervention arms. Early and late seizures were equally predictive of poor outcome. Myoclonic seizures were the most common (240 patients, 26%) and the most predictive of a poor outcome (sensitivity 36.1%, false positive rate 4.3%). Two patients with status myoclonus regained consciousness, one with a good neurological outcome, generating a false positive rate of poor outcome of 0.2% (95%CI 0.0–1.0). Conclusion Clinical seizures are common after cardiac arrest and indicate poor outcome with limited specificity. Prolonged seizures are a very grave sign but occasional patients may have a good outcome. The level of the Target Temperature does not affect the prevalence or prognostic significance of seizures.

  • Infectious complications after out-of-hospital cardiac arrest-A comparison between two Target Temperatures.
    Resuscitation, 2016
    Co-Authors: Josef Dankiewicz, Niklas Nielsen, Michael A Kuiper, Matt P Wise, Tobias Cronberg, David Erlinge, Yvan Gasche, Matthew B A Harmon, Adam Linder, Christian Hassager
    Abstract:

    Abstract Background It has been suggested that Target Temperature management (TTM) increases the probability of infectious complications after cardiac arrest. We aimed to compare the incidence of pneumonia, severe sepsis and septic shock after out-of-hospital cardiac arrest (OHCA) in patients with two Target Temperatures and to describe changes in biomarkers and possible mortality associated with these infectious complications. Methods Post-hoc analysis of the TTM-trial which randomized patients resuscitated from OHCA to a Target Temperature of 33 °C or 36 °C. Prospective data on infectious complications were recorded daily during the ICU-stay. Pneumonia, severe sepsis and septic shock were considered infectious complications. Procalcitonin (PCT) and C-reactive-protein (CRP) levels were measured at 24 h, 48 h and 72 h after cardiac arrest. Results There were 939 patients in the modified intention-to-treat population. Five-hundred patients (53%) developed pneumonia, severe sepsis or septic shock which was associated with mortality in multivariate analysis (Hazard ratio [HR] 1.39; 95%CI 1.13–1.70; p = 0.001). There was no statistically significant difference in the incidence of infectious complications between Temperature groups (sub-distribution hazard ratio [SHR] 0.88; 95%CI 0.75–1.03; p = 0.12). PCT and CRP were significantly higher for patients with infections at all times (p  Conclusions Patients who develop pneumonia, severe sepsis or septic shock after OHCA might have an increased mortality. A Target Temperature of 33 °C after OHCA was not associated with an increased risk of infectious complications compared to a Target Temperature of 36 °C. PCT and CRP are of limited value for diagnosing infectious complications after cardiac arrest.

Hans Friberg - One of the best experts on this subject based on the ideXlab platform.

  • highly malignant routine eeg predicts poor prognosis after cardiac arrest in the Target Temperature management trial
    Resuscitation, 2018
    Co-Authors: Sofia Backman, Niklas Nielsen, Hans Friberg, Christian Hassager, Janneke Horn, Jesper Kjaergaard, Susann Ullen, Tobias Cronberg, M Wanscher, Erik Westhall
    Abstract:

    Introduction: Routine EEG is widely used and accessible for post arrest neuroprognostication. Recent studies, using standardised EEG terminology, have proposed highly malignant EEG patterns with promising predictive ability. Objectives: To validate the performance of standardised routine EEG patterns to predict neurological outcome after cardiac arrest. Methods: In the prospective multicenter Target Temperature Management trial, comatose cardiac arrest patients were randomised to different Temperature levels (950 patients, 36 sites). According to the prospective protocol a routine EEG was performed in patients who remained comatose after the 36 h Temperature control intervention. EEGs were retrospectively reviewed blinded to outcome using the standardised American Clinical Neurophysiology Society terminology. Highly malignant, malignant and benign EEG patterns were correlated to poor and good outcome, defined by best achieved Cerebral Performance Category up to 180 days. Results: At 20 sites 207 patients had a routine EEG performed at median 76 h after cardiac arrest. Highly malignant patterns (suppression or burst-suppression with or without discharges) had a high specificity for poor outcome (98%, CI 92–100), but with limited sensitivity (31%, CI 24–39). Our false positive patient had a burst-suppression pattern during ongoing sedation. A benign EEG, i.e. continuous normal-voltage background without malignant features, identified patients with good outcome with 77% (CI 66–86) sensitivity and 80% (CI 73–86) specificity. Conclusion: Highly malignant routine EEG after Targeted Temperature management is a strong predictor of poor outcome. A benign EEG is an important indicator of a good outcome for patients remaining in coma.

  • carbon dioxide dynamics in relation to neurological outcome in resuscitated out of hospital cardiac arrest patients an exploratory Target Temperature management trial substudy
    Critical Care, 2018
    Co-Authors: Florian Ebner, Hans Friberg, Anders Aneman, Christian Hassager, Jesper Kjaergaard, Michael A Kuiper, Tobias Cronberg, Matthew B A Harmon, Nicole P Juffermans, Niklas Mattsson
    Abstract:

    Dyscarbia is common in out-of-hospital cardiac arrest (OHCA) patients and its association to neurological outcome is undetermined. This is an exploratory post-hoc substudy of the Target Temperature Management (TTM) trial, including resuscitated OHCA patients, investigating the association between serial measurements of arterial partial carbon dioxide pressure (PaCO2) and neurological outcome at 6 months, defined by the Cerebral Performance Category (CPC) scale, dichotomized to good outcome (CPC 1 and 2) and poor outcome (CPC 3–5). The effects of hypercapnia and hypocapnia, and the time-weighted mean PaCO2 and absolute PaCO2 difference were analyzed. Additionally, the association between mild hypercapnia (6.0–7.30 kPa) and neurological outcome, its interaction with Target Temperature (33 °C and 36 °C), and the association between PaCO2 and peak serum-Tau were evaluated. Of the 939 patients in the TTM trial, 869 were eligible for analysis. Ninety-six percent of patients were exposed to hypocapnia or hypercapnia. None of the analyses indicated a statistical significant association between PaCO2 and neurological outcome (P = 0.13–0.96). Mild hypercapnia was not associated with neurological outcome (P = 0.78) and there was no statistically significant interaction with Target Temperature (Pinteraction = 0.95). There was no association between PaCO2 and peak serum-Tau levels 48 or 72 h after return of spontaneous circulation (ROSC). Dyscarbia is common after ROSC. No statistically significant association between PaCO2 in the post-cardiac arrest phase and neurological outcome at 6 months after cardiac arrest was detected. There was no significant interaction between mild hypercapnia and Temperature in relation to neurological outcome.

  • prognostic significance of clinical seizures after cardiac arrest and Target Temperature management
    Resuscitation, 2017
    Co-Authors: Anna Lybeck, Niklas Nielsen, Hans Friberg, Anders Aneman, Christian Hassager, Janneke Horn, Jesper Kjaergaard, Michael A Kuiper, Susann Ullen, Matt P Wise
    Abstract:

    Abstract Aim Clinical seizures are common after cardiac arrest and predictive of a poor neurological outcome. Seizures may be myoclonic, tonic-clonic or a combination of seizure types. This study reports the incidence and prognostic significance of clinical seizures in the Target Temperature management (TTM) after cardiac arrest trial. Our hypotheses were that seizures are associated with a poor prognosis and that the incidence of seizures is not affected by the Target Temperature. Methods Post-hoc analysis of reported clinical seizures during day 1–7 in the TTM-trial including their treatment, EEG-findings, and long-term neurological outcome. The trial randomised 939 comatose survivors to TTM at 33°C or 36°C with strict criteria for withdrawal of life-sustaining therapies. Sensitivity, specificity and false positive rate for poor outcome were reported for different types of seizures. Results Clinical seizures were registered in 268 patients (29%), similarly distributed in both intervention arms. Early and late seizures were equally predictive of poor outcome. Myoclonic seizures were the most common (240 patients, 26%) and the most predictive of a poor outcome (sensitivity 36.1%, false positive rate 4.3%). Two patients with status myoclonus regained consciousness, one with a good neurological outcome, generating a false positive rate of poor outcome of 0.2% (95%CI 0.0–1.0). Conclusion Clinical seizures are common after cardiac arrest and indicate poor outcome with limited specificity. Prolonged seizures are a very grave sign but occasional patients may have a good outcome. The level of the Target Temperature does not affect the prevalence or prognostic significance of seizures.

  • cognitive function in survivors of out of hospital cardiac arrest after Target Temperature management at 33 c versus 36 c
    Circulation, 2015
    Co-Authors: Gisela Lilja, Niklas Nielsen, Tommaso Pellis, Hans Friberg, Janneke Horn, Jesper Kjaergaard, Matt P Wise, Jørn Wetterslev, Fredrik Nilsson, Frank H Bosch
    Abstract:

    Background—Target Temperature management is recommended as a neuroprotective strategy after out-of-hospital cardiac arrest. Potential effects of different Target Temperatures on cognitive impairment commonly described in survivors have not been investigated sufficiently. The primary aim of this study was to evaluate whether a Target Temperature of 33°C compared with 36°C was favorable for cognitive function; the secondary aim was to describe cognitive impairment in cardiac arrest survivors in general. Methods and Results—Study sites included 652 cardiac arrest survivors originally randomized and stratified for site to Temperature control at 33°C or 36°C within the Target Temperature Management trial. Survival until 180 days after the arrest was 52% (33°C, n=178/328; 36°C, n=164/324). Survivors were invited to a face-to-face follow-up, and 287 cardiac arrest survivors (33°C, n=148/36°C, n=139) were assessed with tests for memory (Rivermead Behavioural Memory Test), executive functions (Frontal Assessment B...

  • Mortality and neurological outcome in the elderly after Target Temperature management for out-of-hospital cardiac arrest ☆
    Resuscitation, 2015
    Co-Authors: Matilde Winther-jensen, Niklas Nielsen, Tommaso Pellis, Christian Hassager, Michael A Kuiper, Matty Koopmans, Jørn Wetterslev, Tobias Cronberg, David Erlinge, Hans Friberg
    Abstract:

    To assess older age as a prognostic factor in patients resuscitated from out-of-hospital-cardiac arrest (OHCA) and the interaction between age and level of Target Temperature management.

Michael Wanscher - One of the best experts on this subject based on the ideXlab platform.

  • time to awakening after cardiac arrest and the association with Target Temperature management
    Resuscitation, 2018
    Co-Authors: Anna Lybeck, Anders Aneman, Christian Hassager, Janneke Horn, Jesper Kjaergaard, Michael A Kuiper, Tobias Cronberg, Jan Hovdenes, Michael Wanscher, Pascal Stammet
    Abstract:

    Aim: Target Temperature management (TTM) at 32-36 °C is recommended in unconscious survivors of cardiac arrest. This study reports awakening in the TTM-trial. Our predefined hypotheses were that time until awakening correlates with long-term neurological outcome and is not affected by level of TTM. Methods: Post-hoc analysis of time until awakening after cardiac arrest, its association with long-term (180-days) neurological outcome and predictors of late awakening (day 5 or later. ). The trial randomized 939 comatose survivors to TTM at 33 °C or 36 °C with strict criteria for withdrawal of life-sustaining therapies. Administered sedation in the treatment groups was compared. Awakening was defined as a Glasgow Coma Scale motor score 6. Results: 496 patients had registered day of awakening in the ICU, another 43 awoke after ICU discharge. Good neurological outcome was more common in early (275/308, 89%) vs late awakening (142/188, 76%), p < 0.001. Awakening occurred later in TTM33 than in TTM36 (p = 0.002) with no difference in neurological outcome, or cumulative doses of sedative drugs at 12, 24 or 48 h. TTM33 (p = 0.006), clinical seizures (p = 0.004), and lower GCS-M on admission (p = 0.03) were independent predictors of late awakening. Conclusion: Late awakening is common and often has a good neurological outcome. Time to awakening was longer in TTM33 than in TTM36, this difference could not be attributed to differences in sedative drugs administered during the first 48 h.

  • abstract 14644 impact of time to return of spontaneous circulation on neuro protective effect of Target Temperature management at 33 and 36 degrees in comatose survivors of out of hospital cardiac arrest
    Circulation, 2014
    Co-Authors: Jesper Kjaergaard, Niklas Nielsen, Anders Aneman, Jørn Wetterslev, Michael Wanscher, Matilde Wintherjensen, Wise P Matt, Stammet Pascal, Thomas Pellis, Michael A Kuiper
    Abstract:

    Introduction: Prolonged time to Return of Spontaneous Circulation (ttROSC) after Out of Hospital Cardiac Arrest (OHCA) has consistently been associated with adverse outcome by a plausible direct relation to severity of anoxic injury. Hypothesis: Target Temperature management (TTM) is assumed effective against anoxic brain injury and we hypothesized that TTM at 33 degrees would be more beneficial with prolonged time to ROSC compared to 36 degrees. Methods: In a post hoc analysis of the TTM trial, which showed no overall benefit of Targeting 33 °C over 36 in 939 patients (NEJM 2013), we investigated the relation of time to ROSC and mortality and neurological outcome as assessed by the Cerebral Performance Category (CPC) and Modified Ranking Scale (mRS) after 180 days. Results: Prolonged ttROSC was significantly and independently associated with increased mortality, p interaction =0.85. In survivors prolonged ttROSC was associated with increased odds of surviving with an unfavorable neurological outcome for CPC (p=0.008 for CPC 3-4) and a similar trend, albeit not statistically significant was observed for mRS (p=0.17, mRS 4-5). Odds for unfavorable neurological outcome (CPC>2, mRS>3) was not modified by levels of TTM overall. Conclusion: Time to ROSC remains a significant prognostic factor in comatose patients resuscitated from OHCA with regards to risk of death and risk of adverse neurological outcome in survivors. TTM at 33 degrees offers no advantage over Targeting 36 degrees with regards to mortality or neurological outcome in patients with prolonged time to ROSC. Figure: Mortality rates stratified by quartiles of tome to ROSC and by TTM level. Differences tested by log rank test in between TTM in strata

  • Targeted Temperature management at 33 c versus 36 c and impact on systemic vascular resistance and myocardial function after out of hospital cardiac arrest a sub study of the Target Temperature management trial
    Circulation-cardiovascular Interventions, 2014
    Co-Authors: John Brojeppesen, Niklas Nielsen, Hans Friberg, Christian Hassager, David Erlinge, Michael Wanscher, Morten Ostergaard, Lars Kober, Jesper Kjaergaard
    Abstract:

    Background—Cardiovascular dysfunction is common after out-of-hospital cardiac arrest as part of the postcardiac arrest syndrome, and hypothermia may pose additional impact on hemodynamics. The aim was to investigate systemic vascular resistance index (SVRI), cardiac index, and myocardial performance at a Targeted Temperature management of 33°C (TTM33) versus 36°C (TTM36). Methods and Results—Single-center substudy of 171 patients included in the Target Temperature Management Trial (TTM Trial) randomly assigned to TTM33 or TTM36 for 24 hours after out-of-hospital cardiac arrest. Mean arterial pressure ≥65 mm Hg and central venous pressure of 10 to 15 mm Hg were hemodynamic treatment goals. Hemodynamic evaluation was performed by serial right heart catheterization and transthoracic echocardiography. Primary end point was SVRI after 24 hours of cooling and secondary end points included mean SVRI, cardiac index, systolic function, and lactate levels. The TTM33 group had a significant increase in SVRI compared...

  • The association of Targeted Temperature management at 33 and 36 °C with outcome in patients with moderate shock on admission after out-of-hospital cardiac arrest: a post hoc analysis of the Target Temperature Management trial
    Intensive Care Medicine, 2014
    Co-Authors: Martin Annborn, Niklas Nielsen, Tommaso Pellis, Christian Hassager, Jesper Kjaergaard, Susann Ullen, Jan Hovdenes, Michael Wanscher, John Bro-jeppesen, Paolo Pelosi
    Abstract:

    Purpose We hypothesized that a Targeted Temperature of 33 °C as compared to that of 36 °C would increase survival and reduce the severity of circulatory shock in patients with shock on admission after out-of-hospital cardiac arrest (OHCA). Methods The recently published Target Temperature Management trial (TTM-trial) randomized 939 OHCA patients with no difference in outcome between groups and no difference in mortality at the end of the trial in a predefined subgroup of patients with shock at admission. Shock was defined as a systolic blood pressure of 30 min or the need of supportive measures to maintain a blood pressure ≥90 mmHg and/or clinical signs of end-organ hypoperfusion. In this post hoc analysis reported here, we further analyzed the 139 patients with shock at admission; all had been randomized to receive intervention at 33 °C (TTM33; n  = 71) or 36 °C (TTM36; n  = 68). Primary outcome was 180-day mortality. Secondary outcomes were intensive care unit (ICU) and 30-day mortality, severity of circulatory shock assessed by mean arterial pressure, serum lactate, fluid balance and the extended Sequential Organ Failure assessment (SOFA) score. Results There was no significance difference between Targeted Temperature management at 33 °C or 36 °C on 180-day mortality [log-rank test, p  = 0.17, hazard ratio 1.33, 95 % confidence interval (CI) 0.88–1.98] or ICU mortality (61 vs. 44 %, p  = 0.06; relative risk 1.37, 95 % CI 0.99–1.91). Serum lactate and the extended cardiovascular SOFA score were higher in the TTM33 group ( p  

  • The association of Targeted Temperature management at 33 and 36 °C with outcome in patients with moderate shock on admission after out-of-hospital cardiac arrest: a post hoc analysis of the Target Temperature Management trial.
    Intensive Care Medicine, 2014
    Co-Authors: Martin Annborn, Niklas Nielsen, Tommaso Pellis, Christian Hassager, Jesper Kjaergaard, Susann Ullen, Jan Hovdenes, Michael Wanscher, John Bro-jeppesen, Paolo Pelosi
    Abstract:

    We hypothesized that a Targeted Temperature of 33 °C as compared to that of 36 °C would increase survival and reduce the severity of circulatory shock in patients with shock on admission after out-of-hospital cardiac arrest (OHCA). The recently published Target Temperature Management trial (TTM-trial) randomized 939 OHCA patients with no difference in outcome between groups and no difference in mortality at the end of the trial in a predefined subgroup of patients with shock at admission. Shock was defined as a systolic blood pressure of 30 min or the need of supportive measures to maintain a blood pressure ≥90 mmHg and/or clinical signs of end-organ hypoperfusion. In this post hoc analysis reported here, we further analyzed the 139 patients with shock at admission; all had been randomized to receive intervention at 33 °C (TTM33; n = 71) or 36 °C (TTM36; n = 68). Primary outcome was 180-day mortality. Secondary outcomes were intensive care unit (ICU) and 30-day mortality, severity of circulatory shock assessed by mean arterial pressure, serum lactate, fluid balance and the extended Sequential Organ Failure assessment (SOFA) score. There was no significance difference between Targeted Temperature management at 33 °C or 36 °C on 180-day mortality [log-rank test, p = 0.17, hazard ratio 1.33, 95 % confidence interval (CI) 0.88–1.98] or ICU mortality (61 vs. 44 %, p = 0.06; relative risk 1.37, 95 % CI 0.99–1.91). Serum lactate and the extended cardiovascular SOFA score were higher in the TTM33 group (p