title: Awakening and withdrawal of life-sustaining treatment in cardiac arrest survivors treated with therapeutic hypothermia*.
abstract: OBJECTIVE
  To characterize the prevalence of withdrawal of life-sustaining treatment, as well as the time to awakening, short-term neurologic outcomes, and cause of death in comatose survivors of out-of-hospital resuscitated cardiopulmonary arrests treated with therapeutic hypothermia.
  
  
  METHODS
  Single center, prospective observational cohort study of consecutive patients with out-of-hospital cardiopulmonary arrests.
  
  
  METHODS
  Academic tertiary care hospital and level one trauma center in Minneapolis, MN.
  
  
  METHODS
  Adults with witnessed, nontraumatic, out-of-hospital cardiopulmonary arrests regardless of initial electrocardiographic rhythm with return of spontaneous circulation who were admitted to an ICU.
  
  
  METHODS
  None.
  
  
  RESULTS
  The study cohort included 154 comatose survivors of witnessed out-of-hospital cardiopulmonary arrests who were admitted to an ICU during the 54-month study period. One hundred eighteen patients (77%) were treated with therapeutic hypothermia. The mean age was 59 years, 104 (68%) were men, and 83 (54%) had an initial rhythm of ventricular tachycardia or fibrillation. Only eight of all 78 patients (10%) who died qualified as brain dead; and 81% of all patients (63 of 78) who died did so after withdrawal of life-sustaining treatment. Twenty of 56 comatose survivors (32%) treated with hypothermia who awoke (as defined by Glasgow Motor Score of 6) and had good neurologic outcomes (defined as Cerebral Performance Category 1-2) did so after 72 hours.
  
  
  CONCLUSIONS
  Our study supports delaying prognostication and withdrawal of life-sustaining treatment to beyond 72 hours in cases treated with therapeutic hypothermia. Larger multicenter prospective studies are needed to better define the most appropriate time frame for prognostication in comatose cardiac arrest survivors treated with therapeutic hypothermia. These data are also consistent with the notion that a majority of out-of-hospital cardiopulmonary arrest survivors die after a decision to withdrawal of life-sustaining treatment and that very few of these survivors progress to brain death.
authors.affiliation: 1Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD. 2Division of Neurosciences Critical Care, Department of Anesthesia and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. 3Department of Internal Medicine, Hennepin County Medical Center, Minneapolis, MN. 4Division of Pulmonary and Critical Care Medicine, Hennepin County Medical Center, Minneapolis, MN. 5Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD. 6Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN. 7Department of Emergency Medicine, University of Minnesota School Medicine, Minneapolis, MN. 8Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN. 9Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD. 10Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: Maximilian
authors.initials: M
authors.lastname: Mulder
authors.forename: Haley G
authors.initials: HG
authors.lastname: Gibbs
authors.forename: Stephen W
authors.initials: SW
authors.lastname: Smith
authors.forename: Ramnik
authors.initials: R
authors.lastname: Dhaliwal
authors.forename: Nathaniel L
authors.initials: NL
authors.lastname: Scott
authors.forename: Mark D
authors.initials: MD
authors.lastname: Sprenkle
authors.forename: Romergryko G
authors.initials: RG
authors.lastname: Geocadin
mesh_terms: D000046:Academic Medical Centers / Q000706:statistics & numerical data*; D000328:Adult; D000368:Aged; D001926:Brain Death; D003128:Coma / Q000209:etiology; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D007036:Hypothermia, Induced / Q000706:statistics & numerical data*; D007362:Intensive Care Units / Q000706:statistics & numerical data*; D008020:Life Support Care; D008297:Male; D058687:Out-of-Hospital Cardiac Arrest / Q000150:complications / Q000401:mortality* / Q000628:therapy*; D015995:Prevalence; D011446:Prospective Studies; D017741:Survivors; D013997:Time Factors; D028761:Withholding Treatment