The prognostic value of bispectral index and suppression ratio monitoring after out-of-hospital cardiac arrest: a prospective observational study

Ward Eertmans, Cornelia Genbrugge, Margot Vander Laenen, Willem Boer, Dieter Mesotten, Jo Dens, Frank Jans, Cathy De Deyne, Ward Eertmans, Cornelia Genbrugge, Margot Vander Laenen, Willem Boer, Dieter Mesotten, Jo Dens, Frank Jans, Cathy De Deyne

Abstract

Background: We investigated the ability of bispectral index (BIS) monitoring to predict poor neurological outcome in out-of-hospital cardiac arrest (OHCA) patients fully treated according to guidelines.

Results: In this prospective, observational study, 77 successfully resuscitated OHCA patients were enrolled in whom BIS, suppression ratio (SR) and electromyographic (EMG) values were continuously monitored during the first 36 h after the initiation of targeted temperature management at 33 °C. The Cerebral Performance Category (CPC) scale was used to define patients' outcome at 180 days after OHCA (CPC 1-2: good-CPC 3-5: poor neurological outcome). Using mean BIS and SR values calculated per hour, receiver operator characteristics curves were constructed to determine the optimal time point and threshold to predict poor neurological outcome. At 180 days post-cardiac arrest, 39 patients (51%) had a poor neurological outcome. A mean BIS value ≤ 25 at hour 12 predicted poor neurological outcome with a sensitivity of 49% (95% CI 30-65%), a specificity of 97% (95% CI 85-100%) and false positive rate (FPR) of 6% (95% CI 0-29%) [AUC: 0.722 (0.570-0.875); p = 0.006]. A mean SR value ≥ 3 at hour 23 predicted poor neurological with a sensitivity of 74% (95% CI 56-87%), a specificity of 92% (95% CI 78-98%) and FPR of 11% (95% CI 3-29%) [AUC: 0.836 (0.717-0.955); p < 0.001]. No relationship was found between mean EMG and BIS < 25 (R2 = 0.004; p = 0.209).

Conclusion: This study found that mean BIS ≤ 25 at hour 12 and mean SR ≥ 3 at hour 23 might be used to predict poor neurological outcome in an OHCA population with a presumed cardiac cause. Since no correlation was observed between EMG and BIS < 25, our calculated BIS threshold might assist with poor outcome prognostication following OHCA.

Keywords: Bispectral index; Neurological outcome; Neuromonitoring; Out-of-hospital cardiac arrest; Prognostication; Suppression ratio.

Figures

Fig. 1
Fig. 1
Evolution of mean BIS and SR during targeted temperature management. Hourly mean BIS (a) and SR values (b) are shown with their 95% CI in patients with a good and poor neurological outcome. Patients with a poor neurological outcome had significantly higher BIS and lower SR values during (1) the induction phase (p = 0.002 and p < 0.001, respectively), (2) the hypothermic phase (p < 0.001 and p < 0.001, respectively) and (3) rewarming phase (p < 0.001 and p < 0.001, respectively)
Fig. 2
Fig. 2
Forest plots. Relative risk ratios for poor neurological outcome at 180 days post-cardiac arrest are presented for the presence between given BIS (a) and SR (b) ranges at hour 12 and 23, respectively
Fig. 3
Fig. 3
Correlation between EMG and BIS. The overall relationship between mean EMG and BIS is best described by a quadratic regression curve. No correlation is present between mean EMG and BIS below 25
Fig. 4
Fig. 4
Survival analyses. Kaplan–Meier curves showing survival with a good neurological outcome according to BIS monitoring at hour 12 (a), SR monitoring at hour 23 (b) or both (c)

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