Prognostic Value of the Neurological Examination in Cardiac Arrest Patients After Therapeutic Hypothermia

Overview

Journal Neurohospitalist

Publisher Sage Publications

Date 2018 Apr 7

PMID 29623156

Citations 5

Authors

Elizabeth A Matthews

Jessica Magid-Bernstein

Evie Sobczak

Angela Velazquez

Cristina Maria Falo

Soojin Park

Jan Claassen

Sachin Agarwal

Affiliations

Soon will be listed here.

Abstract

Objectives: Current prognostication guidelines for cardiac arrest (CA) survivors predate the use of therapeutic hypothermia (TH). The prognostic value and ideal timing of the neurological examination remain unknown in the setting of TH.

Design: Patients (N = 291) admitted between 2007 and 2015 to Columbia University intensive care units for TH following CA had neurological examinations performed on days 1, 3, 5, and 7 postarrest. Absent pupillary light response (PLR), absent corneal reflexes (CRs), and Glasgow coma scores motor (GCS-M) no better than extension were considered poor examinations. Poor outcome was recorded as cerebral performance category score ≥3 at discharge and 1 year. Predictive values of examination maneuvers were calculated for each time point.

Main Results: Among the 137 survivors to day 7, sensitivities and negative predictive values were low at all time points. The PLR had false positive rates (FPRs) of 0% and positive predictive values (PPV) of 100% from day 3 onward. For the CR and GCS-M, the FPRs decreased from day 3 to 5 (9% vs 3%; 21% vs 9%), while PPVs increased (91% vs 96%; 90% vs 95%). Excluding patients who died due to withdrawal of life-sustaining therapy (WLST) did not significantly affect FPRs or PPVs, nor did assessing outcome at 1 year.

Conclusions: A poor neurological examination remains a strong predictor of poor outcome, both at hospital discharge and at 1 year, independent of WLST. Following TH, the predictive value of the examination is insufficient at day 3 and should be delayed until at least day 5, with some additional benefit beyond day 5.

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References

Wijdicks E, Hijdra A, Young G, Bassetti C, Wiebe S . Practice parameter: prediction of outcome in comatose survivors after cardiopulmonary resuscitation (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2006; 67(2):203-10. DOI: 10.1212/01.wnl.0000227183.21314.cd. View

Wijdicks E, Bamlet W, Maramattom B, Manno E, McClelland R . Validation of a new coma scale: The FOUR score. Ann Neurol. 2005; 58(4):585-93. DOI: 10.1002/ana.20611. View

Kamps M, Horn J, Oddo M, Fugate J, Storm C, Cronberg T . Prognostication of neurologic outcome in cardiac arrest patients after mild therapeutic hypothermia: a meta-analysis of the current literature. Intensive Care Med. 2013; 39(10):1671-82. DOI: 10.1007/s00134-013-3004-y. View

Buanes E, Heltne J . Comparison of in-hospital and out-of-hospital cardiac arrest outcomes in a Scandinavian community. Acta Anaesthesiol Scand. 2014; 58(3):316-22. DOI: 10.1111/aas.12258. View

Tortorici M, Kochanek P, Poloyac S . Effects of hypothermia on drug disposition, metabolism, and response: A focus of hypothermia-mediated alterations on the cytochrome P450 enzyme system. Crit Care Med. 2007; 35(9):2196-204. DOI: 10.1097/01.ccm.0000281517.97507.6e. View

Fukuoka N, Aibiki M, Tsukamoto T, Seki K, Morita S . Biphasic concentration change during continuous midazolam administration in brain-injured patients undergoing therapeutic moderate hypothermia. Resuscitation. 2004; 60(2):225-30. DOI: 10.1016/j.resuscitation.2003.09.017. View

Samaniego E, Mlynash M, Finley Caulfield A, Eyngorn I, Wijman C . Sedation confounds outcome prediction in cardiac arrest survivors treated with hypothermia. Neurocrit Care. 2010; 15(1):113-9. PMC: 3153345. DOI: 10.1007/s12028-010-9412-8. View

Sandroni C, Cariou A, Cavallaro F, Cronberg T, Friberg H, Hoedemaekers C . Prognostication in comatose survivors of cardiac arrest: an advisory statement from the European Resuscitation Council and the European Society of Intensive Care Medicine. Resuscitation. 2014; 85(12):1779-89. DOI: 10.1016/j.resuscitation.2014.08.011. View

Bouwes A, Binnekade J, Verbaan B, Zandbergen E, Koelman J, Weinstein H . Predictive value of neurological examination for early cortical responses to somatosensory evoked potentials in patients with postanoxic coma. J Neurol. 2011; 259(3):537-41. PMC: 3296032. DOI: 10.1007/s00415-011-6224-5. View

10.

Bergman R, Hiemstra B, Nieuwland W, Lipsic E, Absalom A, van der Naalt J . Long-term outcome of patients after out-of-hospital cardiac arrest in relation to treatment: a single-centre study. Eur Heart J Acute Cardiovasc Care. 2015; 5(4):328-38. DOI: 10.1177/2048872615590144. View

11.

Greer D, Yang J, Scripko P, Sims J, Cash S, Wu O . Clinical examination for prognostication in comatose cardiac arrest patients. Resuscitation. 2013; 84(11):1546-51. PMC: 4041075. DOI: 10.1016/j.resuscitation.2013.07.028. View

12.

Choi H, Ko S, Presciutti M, Fernandez L, Carpenter A, Lesch C . Prevention of shivering during therapeutic temperature modulation: the Columbia anti-shivering protocol. Neurocrit Care. 2011; 14(3):389-94. DOI: 10.1007/s12028-010-9474-7. View

13.

Perkins G, Jacobs I, Nadkarni V, Berg R, Bhanji F, Biarent D . Cardiac Arrest and Cardiopulmonary Resuscitation Outcome Reports: Update of the Utstein Resuscitation Registry Templates for Out-of-Hospital Cardiac Arrest: A Statement for Healthcare Professionals From a Task Force of the International Liaison.... Resuscitation. 2014; 96:328-40. DOI: 10.1016/j.resuscitation.2014.11.002. View

14.

Mashiko K, Otsuka T, Shimazaki S, Kohama A, Kamishima G, Katsurada K . An outcome study of out-of-hospital cardiac arrest using the Utstein template--a Japanese experience. Resuscitation. 2002; 55(3):241-6. DOI: 10.1016/s0300-9572(02)00207-1. View

15.

Sessler D . Complications and treatment of mild hypothermia. Anesthesiology. 2001; 95(2):531-43. DOI: 10.1097/00000542-200108000-00040. View

16.

Bernard S, Gray T, Buist M, Jones B, Silvester W, Gutteridge G . Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med. 2002; 346(8):557-63. DOI: 10.1056/NEJMoa003289. View

17.

Zandbergen E, de Haan R, Reitsma J, Hijdra A . Survival and recovery of consciousness in anoxic-ischemic coma after cardiopulmonary resuscitation. Intensive Care Med. 2003; 29(11):1911-5. DOI: 10.1007/s00134-003-1951-4. View

18.

Teasdale G, Jennett B . Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974; 2(7872):81-4. DOI: 10.1016/s0140-6736(74)91639-0. View

19.

Badjatia N, Strongilis E, Gordon E, Prescutti M, Fernandez L, Fernandez A . Metabolic impact of shivering during therapeutic temperature modulation: the Bedside Shivering Assessment Scale. Stroke. 2008; 39(12):3242-7. DOI: 10.1161/STROKEAHA.108.523654. View

20.

Rossetti A, Oddo M, Logroscino G, Kaplan P . Prognostication after cardiac arrest and hypothermia: a prospective study. Ann Neurol. 2010; 67(3):301-7. DOI: 10.1002/ana.21984. View