Neurologic prognosis and withdrawal of life support after resuscitation from cardiac arrest.
OBJECTIVE
To study the impact of neurologic prognostication on the decision to withdraw life-sustaining therapies (LST) in comatose patients resuscitated after cardiac arrest.


METHODS
The authors prospectively studied a consecutive series of post-resuscitation comatose patients referred for neurologic prognostication at a single center for 4 years. For most patients, neurologic prognostication was not sought due to early death or rapid return to consciousness. Prognostication was based on Glasgow Coma Score (GCS) and Brainstem Reflex Score (BRS), with EEG and cortical evoked potentials (CEP), which were graded as benign, uncertain, and malignant. The outcomes were as follows: survivors (Group S), brain or cardiac death (Group D), and death from withdrawal of life sustaining therapy (Group W). In Group W, the time interval to withdrawal of LST was analyzed by EEG and CEP grades.


RESULTS
Of 58 patients studied, 10 were in Group S, 8 in Group D, and 40 in Group W. Initial median GCS and BRS was similar for all groups with significant improvement noted in Group S, but not in Group D or Group W. In Group W, CEP grade correlated with the median duration of continued therapy before a decision to withdraw LST: 7 days for benign CEP, 2 days for uncertain CEP, and 1 day for malignant CEP, p = 0.0004.


CONCLUSIONS
In patients with poor neurologic recovery early after resuscitation from cardiac arrest, physicians appear to use the cortical evoked potential grade to estimate prognosis. Cortical evoked potential grade correlated with the waiting time until life sustaining therapies were withdrawn after no improvement in neurologic examination was seen.
Geocadin
R G
RG
Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA. rgeocadi@jhmi.edi
Buitrago
M M
MM
Torbey
M T
MT
Chandra-Strobos
N
N
Williams
M A
MA
Kaplan
P W
PW
D000328:Adult; D022561:Advanced Cardiac Life Support / Q000379:methods*; D000368:Aged; D003128:Coma / Q000150:complications; D004558:Electric Stimulation / Q000379:methods; D004569:Electroencephalography / Q000379:methods; D005071:Evoked Potentials / Q000502:physiology*; D005260:Female; D015600:Glasgow Coma Scale / Q000706:statistics & numerical data; D006323:Heart Arrest / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009460:Neurologic Examination; D011379:Prognosis; D011446:Prospective Studies; D012189:Retrospective Studies; D013997:Time Factors