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Neuroprognostication Practices in Postcardiac Arrest Patients

An International Survey of Critical Care Providers

Maciel, Carolina B. MD, MSCR1,2; Barden, Mary M. MD1; Youn, Teddy S. MD2; Dhakar, Monica B. MD, MS3; Greer, David M. MD, MA1,4

doi: 10.1097/CCM.0000000000004107
Online Clinical Investigation: PDF Only

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.

1Department of Neurology, Yale University School of Medicine, New Haven, CT.

2Department of Neurology, UF-Health Shands Hospital, University of Florida College of Medicine, Gainesville, FL.

3Department of Neurology, Emory University School of Medicine, Atlanta, GA.

4Department of Neurology, Boston University School of Medicine, Boston, MA.

Drs. Maciel and Barden contributed equally for this article and shared first authorship.

This study was conducted at Yale University School of Medicine.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (

Dr. Maciel received funding from Claude D. Pepper Older Americans Independence Center Junior Scholar award that supports preclinical studies of mechanisms of secondary brain injury in a rodent cardiac arrest model. Dr. Dhakar received funding from Adamas Pharmaceuticals and research support from Marinus Pharmaceuticals and UCB Biopharma for clinical trials. Dr. Greer’s institution received funding from National Institutes of Neurological Disorders and Stroke/National Institutes of Health, he received funding form medical-legal consultation, and he serves as Editor-in-Chief of Seminars in Neurology and has received compensation for medico-legal consultation. The remaining authors have disclosed that they do not have any potential conflicts of interest.

ORCID 0000-0002-8763-5839 (to Dr. Maciel), ORCID 0000-0002-4901-4177 (to Dr. Barden), ORCID 0000-0002-7325-1148 (to Dr. Youn), ORCID 0000-0001-9275-2784 (to Dr. Dhakar), and ORCID 0000-0002-2026-8333 (to Dr. Gree).

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