Elsevier

Resuscitation

Volume 90, May 2015, Pages 158-162
Resuscitation

Clinical paper
Survey on current practices for neurological prognostication after cardiac arrest

https://doi.org/10.1016/j.resuscitation.2015.01.018Get rights and content

Abstract

Purpose

To investigate current practices and timing of neurological prognostication in comatose cardiac arrest patients.

Methods

An anonymous questionnaire was distributed to the 8000 members of the European Society of Intensive Care Medicine during September and October 2012. The survey had 27 questions divided into three categories: background data, clinical data, decision-making and consequences.

Results

A total of 1025 respondents (13%) answered the survey with complete forms in more than 90%. Twenty per cent of respondents practiced outside of Europe. Overall, 22% answered that they had national recommendations, with the highest percentage in the Netherlands (>80%). Eighty-nine per cent used induced hypothermia (32–34 °C) for comatose cardiac arrest patients, while 11% did not. Twenty per cent had separate prognostication protocols for hypothermia patients. Seventy-nine per cent recognized that neurological examination alone is not enough to predict outcome and a similar number (76%) used additional methods. Intermittent electroencephalography (EEG), brain computed tomography (CT) scan and evoked potentials (EP) were considered most useful. Poor prognosis was defined as cerebral performance category (CPC) 3–5 (58%) or CPC 4–5 (39%) or other (3%). When prognosis was considered poor, 73% would actively withdraw intensive care while 20% would not and 7% were uncertain.

Conclusion

National recommendations for neurological prognostication after cardiac arrest are uncommon and only one physician out of five uses a separate protocol for hypothermia treated patients. A neurological examination alone was considered insufficient to predict outcome in comatose patients and most respondents advocated a multimodal approach: EEG, brain CT and EP were considered most useful. Uncertainty regarding neurological prognostication and decisions on level of care was substantial.

Introduction

Cardiac arrest is common and, in spite of improvements in care in recent years, only one of ten patients survives.1, 2 Most patients with return of spontaneous circulation (ROSC) who are admitted to a hospital are in coma and less than 50% eventually wake up.3, 4 Early clinical signs of a poor neurological prognosis, such as the absence of ocular reflexes on admission, cannot in general inform the clinician about survival chances for the individual patient.5, 6 The best prognostic sign after cardiac arrest is that of awakening but due to modern intensive care, including temperature management and coronary intervention of comatose survivors, most patients are pharmacologically affected and cannot be adequately assessed during the first days.7

Current American recommendations regarding neurological prognostication after cardiac arrest have been widely adopted but are not optimal since they are based on studies performed prior to the era of temperature management and coronary intervention.8 As a result, current practices for assessment of coma after cardiac arrest may differ between and within countries. National recommendations have been published in the Netherlands and in Sweden.9 Updated and evidence-based guidelines are requested and work is ongoing by several societies. Recently, an advisory statement from the European Resuscitation Council (ERC) and the European Society of Emergency Medicine (ESICM) was published.10 Most authors in the field recommend a multimodal approach using several independent methods in addition to a clinical neurological investigation, which remains the foundation.11, 12 Additional methods advocated include computed tomography (CT) scan of the brain, magnetic resonance imaging (MRI), electroencephalography (EEG), evoked potentials (EP) and biomarkers for brain damage.13, 14, 15

The aim of the present survey was to investigate current practices for neurological prognostication after cardiac arrest among members of the ESICM. In addition, data on the use of induced hypothermia were collected.

Section snippets

Methods

An anonymous questionnaire was generated by the authors and endorsed by the European Research Committee of the ESICM. A link to the electronic survey was distributed by e-mail through the ESICM membership database, consisting of approximately 8000 members, during September and October 2012. All replies were collected in a central database and saved. The survey consisted of 27 questions, 10 on background data, 11 on clinical data and 6 on decision-making and consequences (ESICM survey,

Results

A total of 1025 replies (13%) were collected and analyzed. Background data was complete in all surveys, clinical data was complete in 984 (96%) and decision-making and consequences was complete in 951 (93%).

Discussion

The main findings of this survey were that national recommendations for prognostication after cardiac arrest are uncommon and that only one of five physicians uses a separate protocol for hypothermia treated patients. A neurological examination alone was considered insufficient to predict outcome in comatose patients and most respondents used additional methods; EEG, brain CT and evoked potentials were considered most useful. Uncertainty regarding neurological prognostication and decisions on

Limitations

A group of ICU physicians, all members of the ESICM, were asked to complete the survey. Approximately one of eight answered the survey and the results may not represent the common view in Europe or abroad since physicians with a special interest in neurological prognostication after cardiac arrest may have been over-represented. In addition, our results represent above all the view of European colleagues. The survey was anonymous and we have no knowledge of whether some respondents were from

Conclusions

National recommendations are uncommon and only one of five physicians uses a separate protocol for hypothermia treated patients. Neurological examination alone was considered insufficient to predict outcome in comatose patients by the majority and most respondents advocated a multimodal approach using several additional methods: EEG, brain CT and SSEP were considered most useful. Uncertainty regarding neurological prognostication and decisions on level of care was substantial.

Conflict of interest statement

Hans Friberg has received lecture fees from Bard Medical and Natus Inc.

All other authors declare no conflict of interest.

Acknowledgement

No specific funding.

This project was endorsed by the European Research Committee of the European Society of Intensive Care Medicine.

References (29)

  • A. Stromsoe et al.

    Improved outcome in Sweden after out-of-hospital cardiac arrest and possible association with improvements in every link in the chain of survival

    Eur Heart J

    (2014)
  • N. Nielsen et al.

    Targeted temperature management at 33 degrees C versus 36 degrees C after cardiac arrest

    N Engl J Med

    (2013)
  • M.P. Earnest et al.

    Quality of survival after out-of-hospital cardiac arrest: predictive value of early neurologic evaluation

    Neurology

    (1979)
  • E.A. Samaniego et al.

    Sedation confounds outcome prediction in cardiac arrest survivors treated with hypothermia

    Neurocrit Care

    (2011)
  • Cited by (0)

    A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2015.01.018.

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