Practice Parameter: Prediction Practice Parameter: Prediction of Outcome in comatose of Outcome in comatose

survivors after cardiopulmonary survivors after cardiopulmonary resuscitationresuscitation

(an evidence-based review)(an evidence-based review)

RiRi 朱健銘朱健銘

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

ReferenceReference

• Prediction of poor outcome within the firPrediction of poor outcome within the first 3 days of postanoxic comast 3 days of postanoxic coma– Neurology. 66(1):62-68, January 10, 2006Neurology. 66(1):62-68, January 10, 2006

• Early prediction of individual outcome folEarly prediction of individual outcome following cardiopulmonary resuscitation: sylowing cardiopulmonary resuscitation: systematic reviewstematic review– Emerg Med J 2005;22:700–705Emerg Med J 2005;22:700–705

• Clinical Neurophysiologic Monitoring and Clinical Neurophysiologic Monitoring and Brain Injury from Cardiac ArrestBrain Injury from Cardiac Arrest– Neurol Clin 24 (2006) 89–106Neurol Clin 24 (2006) 89–106

IntroductionIntroduction

• Out-hospital CPR successful rate <10 %Out-hospital CPR successful rate <10 %• In-hospital CPR survival to discharge < 20%In-hospital CPR survival to discharge < 20%

• Parameters: Parameters: – Circumstances surrounding CPR, Circumstances surrounding CPR, – Elevated body temperatureElevated body temperature– Neurologic examination, Neurologic examination, – Electrophysiologic studies, Electrophysiologic studies, – Biochemical markers, Biochemical markers, – Monitoring of brain function, Monitoring of brain function, – Neuroimaging studies.Neuroimaging studies.

Study designStudy design

• January 1966 to January 2006.January 1966 to January 2006.• Search titlesSearch titles: cardiorespiratory resuscitation: “: cardiorespiratory resuscitation: “

coma,” “anoxic encephalopathy,” “prognocoma,” “anoxic encephalopathy,” “prognosis,” “electrophysiological studies,” and “bisis,” “electrophysiological studies,” and “biochemical markers.”ochemical markers.”

• InclusionInclusion: documented cardiac arrest, age : documented cardiac arrest, age ≥ ≥ 1717• ExclusionExclusion: coma was not adequate described, si: coma was not adequate described, si

ngle case report, language other than English, ngle case report, language other than English, German, French, or Italian or when an English trGerman, French, or Italian or when an English translation was not available.anslation was not available.

Study designStudy design

• Definitions of coma: Definitions of coma: – Glasgow Coma Scale score sum score Glasgow Coma Scale score sum score ≤ ≤ 8,8,– ““Persistent unresponsiveness,” Persistent unresponsiveness,” – ““Not regaining consciousness.”Not regaining consciousness.”

• Definition of poor outcome:Definition of poor outcome:– Death or persisting unconsciousness after 1 month Death or persisting unconsciousness after 1 month

or or – Death, persisting unconsciousness, or severe disabiDeath, persisting unconsciousness, or severe disabi

lity requiring full nursing care after 6 months.lity requiring full nursing care after 6 months.

Rating and assessment of Rating and assessment of studiesstudies

Class IClass I Class IIClass II Class Class IIIIII

Class Class IVIV

Circumstances surrounding Circumstances surrounding CPR and clinical featuresCPR and clinical features 44 33 55

Electrophysiologic studiesElectrophysiologic studies 11 11 99

Biochemical markersBiochemical markers 11 1111 33

Brain function and neuroimagiBrain function and neuroimagingng 1010

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)

Results and Results and recommendationsrecommendations

Circumstances surrounding Circumstances surrounding CPRCPR

• Anoxia time, duration of CPR, and cause of cardAnoxia time, duration of CPR, and cause of cardiac arrest are related to poor outcome after CPiac arrest are related to poor outcome after CPR (class I).R (class I).– Age is Age is NOTNOT a predictor of poor outcome. a predictor of poor outcome.– The PAM index and PAR score predict survival but The PAM index and PAR score predict survival but NN

OTOT neurologic status after resuscitation . neurologic status after resuscitation .• Duration.Duration.• Pulseless VT/VF, PEA, asystolePulseless VT/VF, PEA, asystole

• Prognosis can Prognosis can NOTNOT be based on the circumstan be based on the circumstances of CPR (level B)ces of CPR (level B)

HyperthermiaHyperthermia

• For each degree Celsius above 37 °C, For each degree Celsius above 37 °C, patients were 2.26 times more likely patients were 2.26 times more likely to die or remain in a vegetative state to die or remain in a vegetative state after 6 months (class II).after 6 months (class II).

• Prognosis can Prognosis can NOTNOT be based on be based on elevated body temperature alone elevated body temperature alone (level C)(level C)

Neurologic examinationNeurologic examination• The motor component of the GCS score is more uThe motor component of the GCS score is more u

seful and accurate than the GCS sum score.seful and accurate than the GCS sum score.– False positive rate (FPR) of predictions of poor outcomFalse positive rate (FPR) of predictions of poor outcom

e may occur with a e may occur with a GCS motor score ≦ 2GCS motor score ≦ 2 within 24-48 h within 24-48 hoursours

• FPR=0 for poor prognosis in patient FPR=0 for poor prognosis in patient – Absent pupillary Absent pupillary light reflexeslight reflexes 24 to 72 hours after CPR, 24 to 72 hours after CPR, – Absent Absent corneal reflexescorneal reflexes after 3 days, after 3 days,– Absent Absent eye movementseye movements after 3 days. after 3 days.

• Single seizures and sporadic focal myoclonus do Single seizures and sporadic focal myoclonus do NOT predict poor outcome, but NOT predict poor outcome, but myoclonus status myoclonus status epilepticusepilepticus do. do.

Stagnation of recoveryStagnation of recovery

• Recovery of spontaneous ventilationRecovery of spontaneous ventilation• Pupillary light responsePupillary light response• Coughing/swallowingCoughing/swallowing• Ciliospinal reflexCiliospinal reflex

Recommendations for Recommendations for neurologic examination neurologic examination • Poor prognosis factor: (level A) Poor prognosis factor: (level A)

– Absent Absent pupillarypupillary or or corneal reflexescorneal reflexes, or , or exteextensor motor responsesnsor motor responses 3 days after cardiac ar 3 days after cardiac arrest rest

• Myoclonus status epilepticus Myoclonus status epilepticus within thewithin the first dayfirst day after a primary circulatory arres after a primary circulatory arrest have a poor prognosis (level B)t have a poor prognosis (level B)

EEGEEG

• Malignant categories:Malignant categories:– SuppressionSuppression– Burst-suppression, Burst-suppression, – Generalized periodic complexes on a flat backgroundGeneralized periodic complexes on a flat background– Alpha and theta pattern ComaAlpha and theta pattern Coma

• Single, Series or continue EEG ?Single, Series or continue EEG ?• Timing of EEG remain unclear.Timing of EEG remain unclear.• Burst suppressionBurst suppression or or generalized epileptiform digeneralized epileptiform di

schargesscharges on EEG predicted poor outcomes but w on EEG predicted poor outcomes but with insufficient prognostic accuracy. (level C)ith insufficient prognostic accuracy. (level C)

Somatosensory evoked potentialSomatosensory evoked potentials (SSEP)s (SSEP)• Bilateral Bilateral absence of theabsence of the N20 componentN20 component of of

the SSEP with median nerve stimulationthe SSEP with median nerve stimulation– The optimal timing of SSEP testing remain The optimal timing of SSEP testing remain

uncertain (hours to days, but mostly within 3 uncertain (hours to days, but mostly within 3 days).days).

– The N20 responses may disappear on repeat The N20 responses may disappear on repeat teststests

– Regain of N20 responseRegain of N20 response– Preserved N20 response didn’t predict good Preserved N20 response didn’t predict good

outcomeoutcome

NEUROLOGY 2006;66:62–68

RecommendationRecommendation

• The assessment of poor prognosis can bThe assessment of poor prognosis can be guided by the bilateral absence of cortie guided by the bilateral absence of cortical SSEPs (cal SSEPs (N2O responseN2O response) within ) within 1 to 3 d1 to 3 daysays (level B) (level B)

Biochemical markersBiochemical markers

• Neuron-specific enolase (Neuron-specific enolase (NSENSE))– > 33 g/L> 33 g/L at day 1 to 3 after CPR. at day 1 to 3 after CPR.– The cutoff points for a 0 FPR value vary greatly (20 to The cutoff points for a 0 FPR value vary greatly (20 to

65 g/L).65 g/L).• High levels of serum High levels of serum lactatelactate (16 mmol/L) after R (16 mmol/L) after R

OSC correlate with poor neurological outcomeOSC correlate with poor neurological outcome• Serum S100: FPR: 2-5%Serum S100: FPR: 2-5%• CK-BB: FPR: 15%CK-BB: FPR: 15%• Neurofilament: FPR:10%,Neurofilament: FPR:10%,

NEUROLOGY 2006;66:62–68

RecommendationRecommendation

• Serum Serum NSE levels ≧ 33 g/LNSE levels ≧ 33 g/L at days 1 at days 1 to 3 post-CPR accurately predict poor to 3 post-CPR accurately predict poor outcome (level B).outcome (level B).

IICP and brain oxygenationIICP and brain oxygenation

• The prognostic usefulness of The prognostic usefulness of monitoring of brain oxygenation and monitoring of brain oxygenation and ICP is ICP is inconclusiveinconclusive (level U). (level U).– Increased Increased jugular bulb venous oxygen jugular bulb venous oxygen

saturation (SjO2)saturation (SjO2) compared to mixed compared to mixed venous oxygenation (SmvO2) venous oxygenation (SmvO2)

NeuroimagingNeuroimaging

• A noncontrast CT scan is often used to exclude a A noncontrast CT scan is often used to exclude a primary catastrophic brain injury that could resulprimary catastrophic brain injury that could result in cardiac arrest and coma.t in cardiac arrest and coma.

• Brain swelling on CT scanning may occur, but its Brain swelling on CT scanning may occur, but its predictive value for poor outcome is predictive value for poor outcome is NOTNOT known known (level U).(level U).

• NoNo value of conventional MRIvalue of conventional MRI but suggested poor but suggested poor prognosis in patients with diffuse cortical signal cprognosis in patients with diffuse cortical signal changes on diffusion-weighted imaging (hanges on diffusion-weighted imaging (DWIDWI) or fl) or fluidattenuated inversion recovery (uidattenuated inversion recovery (FLAIRFLAIR) (level ) (level U).U).

Thanks for your attentionThanks for your attention