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Observational Study
, 21 (1), 221

Recorded Time Periods of Bispectral Index Values Equal to Zero Predict Neurological Outcome After Out-Of-Hospital Cardiac Arrest

Observational Study

Recorded Time Periods of Bispectral Index Values Equal to Zero Predict Neurological Outcome After Out-Of-Hospital Cardiac Arrest

Ward Eertmans et al. Crit Care.


Background: Prognostication in out-of-hospital cardiac arrest (OHCA) survivors is often difficult. Recent studies have shown the predictive ability of bispectral index (BIS) monitoring to assist with early neuroprognostication. The aim of this study was to investigate whether characteristics of BIS values equal to zero (BIS 0) (i.e. duration and/or uni- versus bilateral presence) instead of simply their occurrence are better indicators for poor neurological outcome after OHCA by aiming at a specificity of 100%.

Methods: Between 2011 and 2015, all successfully resuscitated OHCA patients were treated with targeted temperature management (TTM) at 33 °C for 24 hours followed by rewarming over 12 hours (0.3 °C/h). In total, BIS values were registered in 77 OHCA patients. The occurrence of unilateral (BIS 0 at one hemisphere) and bilateral (BIS 0 at both hemispheres) BIS 0 values as well as their total duration were calculated. Receiver operating characteristic (ROC) curves were constructed using the total duration with BIS 0 values calculated from the initiation of TTM onwards to determine poor neurological outcome.

Results: In 30 of 77 OHCA patients (39%), at least one BIS 0 value occurred during the first 48 hours after admission. Of these 30 patients, six (20%) had a good (cerebral performance category (CPC) 1-2) and 24 (80%) a poor neurological outcome (CPC3-5) at 180 days post-CA. Within these 30 patients, the incidence of bilateral BIS 0 values was higher in patients with poor neurological outcome (CPC1-2: 2 (33%) vs. CPC3-5: 19 (79%); p = 0.028). The presence of a BIS 0 value predicted poor neurological outcome with a sensitivity of 62% and specificity of 84% (AUC: 0.729; p = 0.001). With a ROC analysis, a total duration of 30,3 minutes with BIS 0 values calculated over the first 48 hours predicted poor neurological outcome with a sensitivity of 63% and specificity of 100% (AUC: 0.861; p = 0.007).

Conclusions: This study shows that a prolonged duration with (bilateral) BIS 0 values serves as a better outcome predictor after OHCA as compared to a single observation.

Keywords: Cardiac arrest; Neuromonitoring; Prognostication; Targeted temperature management.

Conflict of interest statement

Ethics approval and consent to participate

Ethical approval was obtained before study onset from the local medical ethics committee (Comité Medische Ethiek Ziekenhuis Oost-Limburg 11/066). Written informed consent was obtained from the patient’s next of kin.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.


Fig. 1
Fig. 1
Flowchart of enrolled study patients. CABG coronary-artery bypass graft surgery, IHCA in-hospital cardiac arrest, OHCA out-of-hospital cardiac arrest, TTM targeted temperature management
Fig. 2
Fig. 2
ROC curves of the presence and duration with BIS 0 values. The presence of a BIS 0 value predicted poor neurological outcome with a sensitivity of 62% (95% CI: 45–7) and specificity of 84% (95% CI: 45–77) (AUC: 0.729 (0.614–0.844)). The total duration with any BIS 0 values was calculated within the first 48 hours after TTM was initiated. A duration of 1820 seconds was associated with poor neurological outcome with a sensitivity of 62% (95% CI: 41–81) and specificity of 100% (95% CI: 54–100) (AUC: 0.861 (0.719–1.000))
Fig. 3
Fig. 3
Overview of the characteristics of BIS 0 values within specific time periods. In total, six patients with a good and 24 with a poor neurological outcome experienced at least one BIS 0 value within the first 48 hours following CCU admission. After subdividing this 48-hour time period into four equal time frames (denoted as 1–4 in the figure), the proportion of patients (a) with their respective mean duration of BIS 0 in minutes (b) was calculated per phase for both outcome groups. Additionally, the percentage of patients experiencing unilateral (BIS 0 at one hemisphere) or bilateral (BIS 0 at both hemispheres) BIS 0 values (c) is represented within each phase as well

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