Postcardiac Arrest Neuroprognostication Practices: A Survey of Brazilian Physicians

Abstract

Objectives: End-of-life care and decisions on withdrawal of life-sustaining therapies vary across countries, which may affect the feasibility of future multicenter cardiac arrest trials. In Brazil, withdrawal of life-sustaining therapy is reportedly uncommon, allowing the natural history of postcardiac arrest hypoxic-ischemic brain injury to present itself. We aimed to characterize approaches to neuroprognostication of cardiac arrest survivors among physicians in Brazil. Design: Cross-sectional study. Setting: Between August 2, 2019, and July 31, 2020, we distributed a web-based survey to physicians practicing in Brazil. Subjects: Physicians practicing in Brazil and members of the Brazilian Association of Neurointensive Care, who care for patients resuscitated following cardiac arrest. Interventions: Not applicable. Measurements and Main Results: Responses from 185 physicians were obtained. Pupillary reflexes, corneal reflexes, and motor responses were considered critical to prognostication, whereas neuroimaging and electroencephalography were also regarded as important. For patients without targeted temperature management, absent pupillary and corneal reflexes at 24 hours postarrest were considered strongly predictive of poor neurologic outcome by 31.8% and 33.0%, respectively. For targeted temperature management-treated patients, absent pupillary and corneal reflexes at 24-hour postrewarming were considered prognostic by 22.9% and 20.0%, respectively. Physicians felt comfortable making definitive prognostic recommendations at day 6 postarrest or later (34.2%) for nontargeted temperature management-treated patients, and at day 6 postrewarming (20.4%) for targeted temperature management-treated patients. Over 90% believed that improving neuroprognostic accuracy would affect end-of-life decision-making. Conclusions: There is significant variability in neuroprognostic approaches to postcardiac arrest patients and timing of prognostic studies among Brazilian physicians, with practices frequently deviating from current guidelines, underscoring a need for greater neuroprognostic accuracy. Nearly all physicians believed that improving neuroprognostication will impact end-of-life decision-making. Given the tendency to delay prognostic recommendations while using similar neuroprognostic tools, Brazil offers a unique cohort in which to examine the natural history of hypoxic-ischemic brain injury in future studies.

Bedside monitoring of hypoxic ischemic brain injury using low-field, portable brain magnetic resonance imaging after cardiac arrest

“…Neuroimaging is a highly valued prognostic tool after CA, however, there is a discrepancy between the perceived importance of brain MRI and the frequency of use. 11,25 Large populations of critically ill CA patients are precluded from conventional MRI due to hospital resources or the inability to safely travel. 21,26 Critical events in ICU patients during transport are common, occurring at a rate of 1.6 events per patient transport.…”

“…9,10 Despite the high value clinicians place on MRI for neurologic prognostication after CA, it remains underutilized. 11 Conventional MRI systems operate at high magnetic field strength, which requires a strict access-controlled environment, expensive infrastructure, technicians, and transport out of the intensive care unit (ICU). In addition, there are risks of transporting critically ill patients to imaging suites, including compromise of venous or arterial access, endotracheal tube displacement, hypoxia, hypotension, increased intracranial pressure, and recurrent cardiac arrest.…”