Neuroprognostication Practices in Postcardiac Arrest Patients: An International Survey of Critical Care Providers.
Crit Care Med. 2020 02;48(2):e107-e114
Authors: Maciel CB, Barden MM, Youn TS, Dhakar MB, Greer DM
OBJECTIVES: To characterize approaches to neurologic outcome prediction by practitioners who assess prognosis in unconscious cardiac arrest individuals, and assess compliance to available guidelines.
DESIGN: International cross-sectional study.
SETTING: We administered a web-based survey to members of Neurocritical Care Society, Society of Critical Care Medicine, and American Academy of Neurology who manage unconscious cardiac arrest patients to characterize practitioner demographics and current neuroprognostic practice patterns.
SUBJECTS: Physicians that are members of aforementioned societies who care for successfully resuscitated cardiac arrest individuals.
INTERVENTIONS: Not applicable.
MEASUREMENTS AND MAIN RESULTS: A total of 762 physicians from 22 countries responses were obtained. A significant proportion of respondents used absent corneal reflexes (33.5%) and absent pupillary reflexes (36.2%) at 24 hours, which is earlier than the recommended 72 hours in the standard guidelines. Certain components of the neurologic examination may be overvalued, such as absent motor response or extensor posturing, which 87% of respondents considered being very or critically important prognostic indicators. Respondents continue to rely on myoclonic status epilepticus and neuroimaging, which were favored over median nerve somatosensory evoked potentials for prognostication, although the latter has been demonstrated to have a higher predictive value. Regarding definitive recommendations based on poor neurologic prognosis, most physicians seem to wait until the postarrest timepoints proposed by current guidelines, but up to 25% use premature time windows.
CONCLUSIONS: Neuroprognostic approaches to hypoxic-ischemic encephalopathy vary among physicians and are often not consistent with current guidelines. The overall inconsistency in approaches and deviation from evidence-based recommendations are concerning in this disease state where mortality is so integrally related to outcome prediction.
PMID: 31939809 [PubMed - indexed for MEDLINE]