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Timing of neuroprognostication in postcardiac arrest therapeutic hypothermia*

Perman, Sarah M. MD, MS; Kirkpatrick, James N. MD; Reitsma, Angelique M. MD; Gaieski, David F. MD; Lau, Bonnie MD; Smith, Thomas M. RN; Leary, Marion RN; Fuchs, Barry D. MD; Levine, Joshua M. MD; Abella, Benjamin S. MD, MPhil; Becker, Lance B. MD; Merchant, Raina M. MD, MS

doi: 10.1097/CCM.0b013e3182372f93
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Objective: Early assessment of neurologic recovery is often challenging in survivors of cardiac arrest. Further, little is known about when to assess neurologic status in comatose, postarrest patients receiving therapeutic hypothermia. We sought to evaluate timing of prognostication in cardiac arrest survivors who received therapeutic hypothermia.

Design: A retrospective chart review of consecutive postarrest patients receiving therapeutic hypothermia (protocol: 24-hr maintenance at target temperature followed by rewarming over 8 hrs). Data were abstracted from the medical chart, including documentation during the first 96 hrs post arrest of “poor” prognosis, diagnostic tests for neuroprognostication, consultations used for determination of prognosis, and outcome at discharge.

Setting: Two academic urban emergency departments.

Patients: A total of 55 consecutive patients who underwent therapeutic hypothermia were reviewed between September 2005 and April 2009.

Intervention: None.

Results: Of our cohort of comatose postarrest patients, 59% (29 of 49) were male, and the mean age was 56 ± 16 yrs. Chart documentation of “poor” or “grave” prognosis occurred “early”: during induction, maintenance of cooling, rewarming, or within 15 hrs after normothermia in 57% (28 of 49) of cases. Of patients with early documentation of poor prognosis, 25% (seven of 28) had care withdrawn within 72 hrs post arrest, and 21% (six of 28) survived to discharge with favorable neurologic recovery. In the first 96 hrs post arrest: 88% (43 of 49) of patients received a head computed tomography, 90% (44 of 49) received electroencephalography, 2% (one of 49) received somatosensory evoked potential testing, and 71% (35 of 49) received neurology consultation.

Conclusions: Documentation of “poor prognosis” occurred during therapeutic hypothermia in more than half of patients in our cohort. Premature documentation of poor prognosis may contribute to early decisions to withdraw care. Future guidelines should address when to best prognosticate in postarrest patients receiving therapeutic hypothermia.

From the Department of Emergency Medicine (SMP, DFG, BL, BSA, LBB, RMM); Center for Bioethics (JNK, AMR); Department of Medicine, Cardiovascular Division (JNK); Center for Resuscitation Science (DFG, TS, ML, BSA, LBB, RMM); Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine (BDF); Department of Neurology, Division of Neurocritical Care (JL); University of Pennsylvania School of Medicine, Philadelphia, PA.

* See also p. 979.

Dr. Gaieski is a consultant with Gaymar Industries and Inverness Medical. Dr. Levine received honoraria/speaking fees from Medivance Corporation. Dr. Abella received speaker honoraria/consultant fees from Philips Healthcare, Seattle, WA, and Medivance Corporation, Louisville, CO; institutional grant/research support from Philips Healthcare, Andover, MA, Doris Duke Foundation, New York, NY, the American Heart Association, Dallas, TX, and NIH, Bethesda, MD; and in-kind research support from Laerdal Medical Corp, Stavanger, Norway. Dr. Becker received speaker honoraria/consultant fees from Philips Healthcare, Seattle, WA, the Alleghany Medical Center, Zoll Medical, and Medtronic; received institutional grant/research support from Philips Medical Systems, Laerdal Medical, Cardiac Science, BeneChill, Zoll Medical Corp, Medtronic Foundation, and Abbott Point of Care; is a scientific consultant for Graymar Industries and the NIH Data Safety Monitoring Board and Protocol Committee; has potential royalties for hypothermia induction reperfusion techniques; and received inventor's equity and royalties from Cold Core Therapeutics, Inc. The remaining authors have not disclosed any potential conflicts of interest.

For information regarding this article, E-mail: sarah.perman@uphs.upenn.edu

© 2012 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins