Neurological prognostication after cardiac arrest.
OBJECTIVE
Prediction of neurological prognosis in patients who are comatose after successful resuscitation from cardiac arrest remains difficult. Previous guidelines recommended ocular reflexes, somatosensory evoked potentials and serum biomarkers for predicting poor outcome within 72  h from cardiac arrest. However, these guidelines were based on patients not treated with targeted temperature management and did not appropriately address important biases in literature.


RESULTS
Recent evidence reviews detected important limitations in prognostication studies, such as low precision and, most importantly, lack of blinding, which may have caused a self-fulfilling prophecy and overestimated the specificity of index tests. Maintenance of targeted temperature using sedatives and muscle relaxants may interfere with clinical examination, making assessment of neurological status before 72  h or more after cardiac arrest unreliable.


CONCLUSIONS
No index predicts poor neurological outcome after cardiac arrest with absolute certainty. Prognostic evaluation should start not earlier than 72  h after ROSC and only after major confounders have been excluded so that reliable clinical examination can be made. Multimodality appears to be the most reasonable approach for prognostication after cardiac arrest.
aDepartment of Anesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy bDepartments of Neurology and Neurosurgery, Division of Neurosciences Critical Care Medicine cDepartment of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
Claudio
C
Sandroni
Romergryko G
RG
Geocadin
D015415:Biomarkers / Q000097:blood; D001927:Brain Diseases / Q000209:etiology*; D003128:Coma / Q000209:etiology / Q000503:physiopathology; D003131:Combined Modality Therapy; D004569:Electroencephalography; D005073:Evoked Potentials, Somatosensory; D006323:Heart Arrest / Q000150:complications*; D006801:Humans; D007036:Hypothermia, Induced / Q000009:adverse effects; D009460:Neurologic Examination; D011379:Prognosis
D015415:Biomarkers