Practice parameter: prediction of outcome in comatose survivors after cardiopulmonary resuscitation (an evidenc

e-based review)

Author: Wijdicks, E F.M. MD; Hijdra, A MD; Young, G B. MD; Bassetti, C L. MD; Wiebe, S MD

Neurology. 67(2):203-210, July 25, 2006

Ri 胡哲源 / VS王植賢

Seven variables to predict poor outcome

Circumstances surrounding CPR

Elevated body tempertature

Neurologic examination

Electrophysiologic studies

Biochemical markers

Neuroimaging studies

Rating and assessment of studies

Class IClass

IIClass

IIIClass

IV

Circumstances surrounding CPR and clinical features

4 3 5

Electrophysiologic studies 1 1 9

Biochemical markers 1 11 3

Brain function and neuroimaging

10

Recommendation levels:- Level A: Established as effective, ineffective, or harmful for the given conditionin the specified population (at least two consistent class I studies)- Level B: Probably effective, ineffective, or harmful for the given condition in thespecified population (at least one class I or two consistent class II studies)- Level C: Possibly effective, ineffective, or harmful for the given condition in thespecified population (one class II studies or two consistent class III studies)

Are the circumstances surrounding CPR predictive of outcome?

Discussion

Anoxia time

Duration of CPR

Cause of cardiac arrest

Type of cardiac arrhythmia

FPR: ranging from 20 to 27%

Recommendations

Prognosis cannot be based on the circumstances of CPR (recommendation level B)

Is hyperthermia predictive of outcome?

Discussion

For each degree Celsius above 37oC, patients were 2.26 times more likely to die or remain in a vegetative state after 6 months

Patients with poor outcome can’t be identified with body temperature measurements alone

Recommendations

Prognosis cannot be based on elevated body temperature alone (recommendation level C)

Which features of the neurologic examination of the comatose patient are predictive of outcome?

Discussion

The motor component of the GCS score > GCS sum score

GCS motor score ≤ 2

In 24~48 hr, false-positive predictions may occur

After 72 hr, FPR=0

Absent pupillary light reflexs 24~72 hr after CPR

Discussion

Absent corneal reflexes after 3 days

Absent eye movements (spontaneous eye movements and absent oculocephalic reflexes) after 3 days

Myoclonus status epilepticus

Myoclonus status epilepticus

May be only present on the day of CPR

Severe ischemic brain, brainstem, and spinal cord damage

Good recovery presents in circulatory arrest was secondary to respiratory failure

Recommentdations

The prognosis is invariably poor in above conditions (recommendation level B)

Which electrophysiologic studies are helpful in determining outcome?

Discussion

EEG

Generalized suppression to ≤ 20 μV

Burst suppression

α and θ pattern coma

Generalized periodic complexes

Discussion

Serial or continuous EEGs may appear more accurate and valid than single EEGs

Not invariably herald a poor outcome

The FPR for poor outcome was 3%

Recommentdations

Burst suppression on EEG predicted poor outcomes but with insufficient prognostic accuracy (recommendation level C)

Discussion

Somatosensory evoked potentials (SSEPs)

Much less influenced by drugs and metabolic derangements

Bilateral absence of N20 response

FPR: 0.7%

Discussion

Uncertainty about the optimal timing of SSEP testing

Vary widely among studies (from hours to days), but all were done in 3 days

Presence of N20 response is not helpful in predicting good outcome

Recommentdations

The assessment of poor prognosis can be guided by the bilateral absence of cortical SSEPs (N20 response) within 1 to 3 days (recommendation level B)

Do biochemical markers accurately predict outcome?

Discussion

Neuron specific enolase (NSE):

located in neurons and neuroectodermal cells

60% of 231 patients had NSE> 33μg/L at day 1 to 3 after CPR (In a class I study) all had poor outcome (FPR: 0)

Discussion

S100

calcium-binding astroglial protein

Median FPR: 2% in 4 class III studies

FPR: 5% in one class I study

Discussion

Creatine kinase brain isoenzyme (CKBB)

Present in neurons and astrocytes

Median FPR: 15% in 6 class III studies

Discussion

Neurofilament in CSF

FPR: 10% in one class IV study

Recommentdations

Serum NSE accurately predict poor outcome (recommendation level B)

Does monitoring of intracranial pressure predict outcome?

Discussion

ICP > 20mmHg had poor outcome in one class IV study

Recommentdations

There are inadequate data to support or refute the prognostic value of ICP monitoring (recommendation level U)

Are neuroimaging studies indicative of outcome?

Discussion

CT: 1.normal soon after CPR 2.diffuse brain swelling 3 days after CPR in 7 class IV studies 3. brain swelling on CT scanning may occur, but its predictive value for poor outcome is not known

MRI: 1.no value of conventional MRI 2.poor prognosis with diffuse cortical signal changes on DWI or FLAIR

Recommentdations

There are inadequate data to support or refute the prognostic value of neuroimaging (recommendation level U)

Reference

Prediction of poor outcome within the first 3 days of postanoxic coma

Neurology. 66(1):62-68, January 10, 2006

Early prediction of individual outcome following cardiopulmonary resuscitation: systematic review

Emerg Med J 2005;22:700–705

Clinical Neurophysiologic Monitoring and Brain Injury from Cardiac Arrest

Neurol Clin 24 (2006) 89–106

Thank you for your attention