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Delayed awakening after cardiac arrest: prevalence and risk factors in the Parisian registry

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Abstract

Purpose

Although prolonged unconsciousness after cardiac arrest (CA) is a sign of poor neurological outcome, limited evidence shows that a late recovery may occur in a minority of patients. We investigated the prevalence and the predictive factors of delayed awakening in comatose CA survivors treated with targeted temperature management (TTM).

Methods

Retrospective analysis of the Parisian Region Out-of-Hospital CA Registry (2008–2013). In adult comatose CA survivors treated with TTM, sedated with midazolam and fentanyl, time to awakening was measured starting from discontinuation of sedation at the end of rewarming. Awakening was defined as delayed when it occurred after more than 48 h.

Results

A total of 326 patients (71 % male, mean age 59 ± 16 years) were included, among whom 194 awoke. Delayed awakening occurred in 56/194 (29 %) patients, at a median time of 93 h (IQR 70–117) from discontinuation of sedation. In 5/56 (9 %) late awakeners, pupillary reflex and motor response were both absent 48 h after sedation discontinuation. In multivariate analysis, age over 59 years (OR 2.1, 95 % CI 1.0–4.3), post-resuscitation shock (OR 2.6 [1.3–5.2]), and renal insufficiency at admission (OR 3.1 [1.4–6.8]) were associated with significantly higher rates of delayed awakening.

Conclusions

Delayed awakening is common among patients recovering from coma after CA. Renal insufficiency, older age, and post-resuscitation shock were independent predictors of delayed awakening. Presence of unfavorable neurological signs at 48 h after rewarming from TTM and discontinuation of sedation did not rule out recovery of consciousness in late awakeners.

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Abbreviations

CA:

Cardiac arrest

CPC:

Cerebral performance category

CPR:

Cardiopulmonary resuscitation

EEG:

Electroencephalography

ESM:

Electronic supplementary material

GCS:

Glasgow coma scale

GFR:

Glomerular filtration rate

ICU:

Intensive care unit

IQR:

Interquartile range

RASS:

Richmond agitation-sedation scale

ROSC:

Return of spontaneous circulation

SD:

Standard deviation

SSEP:

Short-latency somatosensory evoked potentials

TTM:

Targeted temperature management

WLST:

Withdrawal of life-sustaining treatments

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Acknowledgments

We thank Nancy Kentish-Barnes for her help in preparing the manuscript.

Author information

Author notes

    Authors and Affiliations

    1. Medical ICU, Cochin Hospital, AP-HP, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France

      Marine Paul, Wulfran Bougouin, Guillaume Geri, Benoit Champigneulle, Julien Charpentier, Jean-Paul Mira & Alain Cariou

    2. Paris Cardiovascular Research Center, INSERM U970, Paris, France

      Wulfran Bougouin, Guillaume Geri, Florence Dumas, Stéphane Legriel & Alain Cariou

    3. Université Paris-Descartes-Sorbonne-Paris-Cité, Paris, France

      Wulfran Bougouin, Guillaume Geri, Florence Dumas, Benoit Champigneulle, Julien Charpentier, Jean-Paul Mira & Alain Cariou

    4. Paris Sudden Death Expertise Center, Paris, France

      Wulfran Bougouin, Guillaume Geri, Florence Dumas, Stéphane Legriel & Alain Cariou

    5. Emergency Department, Cochin-Hotel-Dieu Hospital, APHP, Paris, France

      Florence Dumas

    6. Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy

      Claudio Sandroni

    7. ICU, Mignot Hospital, Le Chesnay, France

      Stéphane Legriel

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    1. Marine Paul
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    Correspondence to Alain Cariou.

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    On behalf of all authors, the corresponding author states that there is no conflict of interest.

    Additional information

    Marine Paul and Wulfran Bougouin contributed equally to this work; Claudio Sandroni and Alain Cariou contributed equally to this work.

    Take-home message: Delayed awakening from coma after cardiac arrest is frequent, occurring in almost one-third of patients; renal insufficiency, older age. and post-resuscitation shock are independent predictors of delayed awakening. In patients presenting one or more of these factors, an observation period longer than the minimum recommended should be respected before neuroprognostication assessment.

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    Paul, M., Bougouin, W., Geri, G. et al. Delayed awakening after cardiac arrest: prevalence and risk factors in the Parisian registry. Intensive Care Med 42, 1128–1136 (2016). https://doi.org/10.1007/s00134-016-4349-9

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