Abstract
Background
Hypoxic brain injury is the leading cause of death in comatose patients following resuscitation from cardiac arrest. Neurological outcome can be difficult to prognosticate following resuscitation, and goals of care discussions are often informed by multiple prognostic tools. One tool that has shown promise is the SLANT score, which encompasses five metrics including initial nonshockable rhythm, leukocyte count after targeted temperature management, total adrenaline dose during resuscitation, lack of bystander cardiopulmonary resuscitation, and time to return of spontaneous circulation. This cohort study aimed to provide an external validation of this score by using a database of comatose cardiac arrest survivors from our institution.
Methods
We retrospectively queried our database of cardiac arrest survivors, selecting for patients with coma, sustained return of spontaneous circulation, and use of targeted temperature management to have a comparable sample to the index study. We calculated SLANT scores for each patient and separated them into risk levels, both according to the original study and according to a Youden index analysis. The primary outcome was poor neurologic outcome (defined by a cerebral performance category score of 3 or greater at discharge), and the secondary outcome was in-hospital mortality. Univariable and multivariable analyses, as well as a receiver operator characteristic curve, were used to assess the SLANT score for independent predictability and diagnostic accuracy for poor outcomes.
Results
We demonstrate significant association between a SLANT group with increased risk and poor neurologic outcome on univariable (p = 0.005) and multivariable analysis (odds ratio 1.162, 95% confidence interval 1.003–1.346, p = 0.046). A receiver operating characteristic analysis indicates that SLANT scoring is a fair prognostic test for poor neurologic outcome (area under the curve 0.708, 95% confidence interval 0.536–0.879, p = 0.024). Among this cohort, the most frequent SLANT elements were initial nonshockable rhythm (84.5%) and total adrenaline dose ≥ 5 mg (63.9%). There was no significant association between SLANT score and in-hospital mortality (p = 0.064).
Conclusions
The SLANT score may independently predict poor neurologic outcome but not in-hospital mortality. Including the SLANT score as part of a multimodal approach may improve our ability to accurately prognosticate comatose survivors of cardiac arrest.
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References
Sekhon MS, Ainslie PN, Griesdale DE. Clinical pathophysiology of hypoxic ischemic brain injury after cardiac arrest: a “two-hit” model. Crit Care. 2017;21:90.
Grasner JT, Lefering R, Koster RW, et al. EuReCa ONE-27 Nations, ONE Europe, ONE Registry: A prospective one month analysis of out-of-hospital cardiac arrest outcomes in 27 countries in Europe. Resuscitation. 2016;105:188–95.
Bernard SA, Gray TW, Buist MD, et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med. 2002;346:557–63.
Nielsen N, Wetterslev J, Cronberg T, et al. Targeted temperature management at 33 degrees C versus 36 degrees C after cardiac arrest. N Engl J Med. 2013;369:2197–206.
Geocadin RG, Callaway CW, Fink EL, et al. Standards for studies of neurological prognostication in comatose survivors of Cardiac arrest: A scientific statement from the American heart association. Circulation. 2019;140:e517–42.
Golan E, Barrett K, Alali AS, et al. Predicting neurologic outcome after targeted temperature management for cardiac arrest: systematic review and meta-analysis. Crit Care Med. 2014;42:1919–30.
Sandroni C, Cavallaro F, Callaway CW, et al. Predictors of poor neurological outcome in adult comatose survivors of cardiac arrest: a systematic review and meta-analysis. Part 2: Patients treated with therapeutic hypothermia. Resuscitation. 2013;84:1324–38.
Sandroni C, Cavallaro F, Callaway CW, et al. Predictors of poor neurological outcome in adult comatose survivors of cardiac arrest: a systematic review and meta-analysis. Part 1: patients not treated with therapeutic hypothermia. Resuscitation. 2013;84:1310–23.
Chen CT, Lin JW, Wu CH, et al. A simple risk score for predicting neurologic Outcome in Out-of-Hospital Cardiac arrest patients after targeted temperature management. Crit Care Med. 2021. https://doi.org/10.1097/CCM.0000000000005266.
Cronberg T, Greer DM, Lilja G, Moulaert V, Swindell P, Rossetti AO. Brain injury after cardiac arrest: from prognostication of comatose patients to rehabilitation. Lancet Neurol. 2020;19:611–22.
Greer DM, Yang J, Scripko PD, et al. Clinical examination for prognostication in comatose cardiac arrest patients. Resuscitation. 2013;84:1546–51.
Ramspek CL, Jager KJ, Dekker FW, Zoccali C, van Diepen M. External validation of prognostic models: what, why, how, when and where? Clin Kidney J. 2021;14:49–58.
Sharma K, John M, Zhang S, Gronseth G. Serum neuron-specific enolase thresholds for predicting postcardiac arrest outcome. Neurology. 2022;98: e62.
Ruopp MD, Perkins NJ, Whitcomb BW, Schisterman EF. Youden Index and optimal cut-point estimated from observations affected by a lower limit of detection. Biom J. 2008;50:419–30.
Steyerberg EW, Moons KG, van der Windt DA, et al. Prognosis Research Strategy (PROGRESS) 3: prognostic model research. PLoS Med. 2013;10: e1001381.
Wilkinson D. The self-fulfilling prophecy in intensive care. Theor Med Bioeth. 2009;30:401–10.
Wartenberg KE, Hwang DY, Haeusler KG, et al. Gap analysis regarding prognostication in neurocritical care: A joint statement from the german neurocritical care society and the neurocritical care society. Neurocrit Care. 2019;31:231–44.
Levy DE, Caronna JJ, Singer BH, Lapinski RH, Frydman H, Plum F. Predicting outcome from hypoxic-ischemic coma. JAMA. 1985;253:1420–6.
The Prognostic Value of Serum Neuron-Specific Enolase in Hypoxic Brain Damage. J Neurocrit Care 2009; 2: 6–11.
Daubin C, Guillotin D, Etard O, et al. A clinical and EEG scoring system that predicts early cortical response (N20) to somatosensory evoked potentials and outcome after cardiac arrest. BMC Cardiovasc Disord. 2008;8:35.
Hirsch KG, Mlynash M, Jansen S, et al. Prognostic value of a qualitative brain MRI scoring system after cardiac arrest. J Neuroimaging. 2015;25:430–7.
Callaway CW, Donnino MW, Fink EL, et al. Part 8: Post-Cardiac arrest care: 2015 American heart association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132:S465–82.
Nolan JP, Soar J, Cariou A, et al. European resuscitation council and european society of intensive care medicine 2015 guidelines for post-resuscitation care. Intensive Care Med. 2015;41:2039–56.
Zhou SE, Maciel CB, Ormseth CH, Beekman R, Gilmore EJ, Greer DM. Distinct predictive values of current neuroprognostic guidelines in post-cardiac arrest patients. Resuscitation. 2019;139:343–50.
Nielsen N, Wetterslev J, Cronberg T, et al. Targeted temperature management at 33°C versus 36°C after cardiac arrest. N Engl J Med. 2013;369:2197–206.
Dankiewicz J, Cronberg T, Lilja G, et al. Hypothermia versus Normothermia after Out-of-Hospital Cardiac arrest. N Engl J Med. 2021;384:2283–94.
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Trevor G. Luck: data acquisition and analysis, writing and editing the article. Katherine Locke: data acquisition, writing and editing the article. Benjamin Sherman: writing and editing the article. Matthew Vibbert: writing and editing the article. Sara Hefton: data acquisition, writing and editing the article. Syed Shah: data acquisition, writing and editing the article. The final manuscript has been approved by all authors.
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Luck, T.G., Locke, K., Sherman, B.C. et al. The SLANT Score Predicts Poor Neurologic Outcome in Comatose Survivors of Cardiac Arrest: An External Validation Using a Retrospective Cohort. Neurocrit Care 38, 129–137 (2023). https://doi.org/10.1007/s12028-022-01570-8
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DOI: https://doi.org/10.1007/s12028-022-01570-8