Neuroprognostication after adult cardiac arrest treated with targeted temperature management: task force for Belgian recommendations

Abstract

The prognosis of patients who are admitted to the hospital after cardiac arrest often relies on neurological examination, which could be significantly influenced by the use of sedative drugs or the implementation of targeted temperature management. The need for early and accurate prognostication is crucial as up to 15-20% of patients could be considered as having a poor outcome and may undergo withdrawal of life-sustaining therapies while a complete neurological recovery is still possible. As current practice in Belgium is still based on a very early assessment of neurological function in these patients, the Belgian Society of Intensive Care Medicine created a multidisciplinary Task Force to provide an optimal approach for monitoring and refine prognosis of CA survivors. This Task Force underlined the importance to use a multimodal approach using several additional tools (e.g., electrophysiological tests, neuroimaging, biomarkers) and to refer cases with uncertain prognosis to specialized centers to better evaluate the extent of brain injury in these patients.

Early-SEPs’ amplitude reduction is reliable for poor-outcome prediction after cardiac arrest?

“…When evaluating the cortical responses of both hemispheres, the SEP amplitude was defined as the highest amplitude of N20/P25, as indicated by Endisch et al 14 The outcome was dichotomized between recovery of consciousness (GOS score [3][4][5] and no recovery of consciousness (GOS score 1-2). The mean values for SEP amplitude for different outcome groups and different EEG patterns were analysed by ANOVA followed by post-hoc analysis.…”

“…Furthermore, recent papers have reported that EEG markers can predict outcomes with relatively high specificity and sensitivity, 6 and that a multimodal approach incorporating more tools must always include EEG. 5 However, only a few papers have analysed the association between SEP and EEG in CA patients for prognostic purposes, 23 …”

“…Council, the European Society of Intensive Care Medicine 34 and the Task Force for Belgian recommendations 5 have suggested a multimodal approach for the neurological prognostic assessment of CA patients. Furthermore, recent papers have reported that EEG markers can predict outcomes with relatively high specificity and sensitivity, 6 and that a multimodal approach incorporating more tools must always include EEG.…”

“…Furthermore, recent papers have reported that EEG markers can predict outcomes with relatively high specificity and sensitivity, 6 and that a multimodal approach incorporating more tools must always include EEG. 5 However, only a few papers have analysed the association between SEP and EEG in CA patients for prognostic purposes, 23,24 and none have performed a detailed analysis of EEG patterns in patients with a marked reduction in SEPs. In addition, none of the previous two papers 13,14 reported the EEG patterns of patients with cortical SEPs of reduced amplitude.…”

Clinical Reasoning: Prognostication after cardiac arrest

“…In the setting of hypothermia, the variables used for neurologic prognostication have unacceptably high false-positive rates. 6,7 More recent guidelines suggest delaying prognostic assessments when TTM is used 4,8 ; however, time to awakening in HIBI varies and up to 1 in 7 patients may experience a delayed awakening with favorable neurologic outcome. 9 DISCUSSION Given the complex relationship between TTM and neurologic prognosis, it is important to reevaluate previously ascribed indicators of poor prognosis.…”