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Gap Analysis Regarding Prognostication in Neurocritical Care: a Joint Statement from the German Neurocritical Care Society and the Neurocritical Care Society Katja E

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Gap Analysis Regarding Prognostication in Neurocritical Care: a Joint Statement from the German Neurocritical Care Society and the Neurocritical Care Society Katja E Neurocrit Care https://doi.org/10.1007/s12028-019-00769-6 SPECIAL ARTICLE Gap Analysis Regarding Prognostication in Neurocritical Care: A Joint Statement from the German Neurocritical Care Society and the Neurocritical Care Society Katja E. Wartenberg1*, David Y. Hwang2, Karl Georg Haeusler3, Susanne Muehlschlegel4, Oliver W. Sakowitz5, Dominik Madžar6, Hajo M. Hamer6, Alejandro A. Rabinstein7, David M. Greer8, J. Claude Hemphill III9, Juergen Meixensberger10 and Panayiotis N. Varelas11 © 2019 The Author(s), corrected publication 2019 Abstract Background/Objective: Prognostication is a routine part of the delivery of neurocritical care for most patients with acute neurocritical illnesses. Numerous prognostic models exist for many diferent conditions. However, there are concerns about signifcant gaps in knowledge regarding optimal methods of prognostication. Methods: As part of the Arbeitstagung NeuroIntensivMedizin meeting in February 2018 in Würzburg, Germany, a joint session on prognostication was held between the German NeuroIntensive Care Society and the Neurocritical Care Society. The purpose of this session was to provide presentations and open discussion regarding existing prog- nostic models for eight common neurocritical care conditions (aneurysmal subarachnoid hemorrhage, intracerebral hemorrhage, acute ischemic stroke, traumatic brain injury, traumatic spinal cord injury, status epilepticus, Guillain– Barré Syndrome, and global cerebral ischemia from cardiac arrest). The goal was to develop a qualitative gap analysis regarding prognostication that could help inform a future framework for clinical studies and guidelines. Results: Prognostic models exist for all of the conditions presented. However, there are signifcant gaps in prognosti- cation in each condition. Furthermore, several themes emerged that crossed across several or all diseases presented. Specifcally, the self-fulflling prophecy, lack of accounting for medical comorbidities, and absence of integration of in-hospital care parameters were identifed as major gaps in most prognostic models. Conclusions: Prognostication in neurocritical care is important, and current prognostic models are limited. This gap analysis provides a summary assessment of issues that could be addressed in future studies and evidence-based guidelines in order to improve the process of prognostication. Keywords: Prognostication, Self-fulflling prophecy, Outcome predictors, Comorbidities *Correspondence: [email protected] 1 Neurocritical Care and Stroke Unit, Department of Neurology, University of Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany Full list of author information is available at the end of the article Introduction Members of DGNI and NCS who were recognized as Te word prognostication derives from the ancient Greek experts in prognostication or clinical care of these con- ο word πρόγνωσις (πρ [pro-; before] + γνώσις [gnosis; ditions (one expert per condition) were selected by the knowledge] or γιγνώσκειν [verb; come to know). Prog- session organizing committee. Tey were instructed to nostication involves an attempt to predict the future or, undertake a general literature search regarding prognos- specifcally in medicine, the course of a disease. Although tication models for their assigned condition, to present no person can always predict the future with perfect an oral 15 min-summary, and to moderate and integrate accuracy, prognostic attempts for various diseases are feedback from the audience into a brief written summary. based on empiric knowledge from the past. Tat is, how Formal defned literature searches or systematic reviews specifc patient populations diagnosed with the disease with utilization of a librarian were not undertaken nor in question fared over times. Of course this depends on was there specifc grading of the literature using an estab- the length of time and on the specifc outcome of inter- lished methodological approach. Rather, the intent was est. In medicine, length of follow-up extends either from to provide an overview for discussion in order to identify symptom onset or hospital admission to discharge or gaps in current prognostication models as well as themes few months or years later and specifc outcomes range that might cross over between diferent conditions. Rec- from mortality to cognitive or physical status (depend- ognizing that prognostication paradigms involve broader ence or independence). In neurocritical care, prognos- aspects than just prognostication models, this focus was tication takes on a high priority because many diseases chosen specifcally in order to frame the gap analysis and are either fatal or lead to substantial disability. Patients, conform to available program time. Tis report involves a families, and healthcare providers want to know what to summary of the individual presentations which were syn- expect and these expectations often infuence decisions thesized into this single document by the session mod- regarding acute care and long-term support. Further- erators. It is hoped that this gap analysis can provide a more, prognostication is often considered in relation to framework for DGNI and NCS members as well as the a specifc time point, but may be relevant across a con- neurocritical care community worldwide to improve the tinuum of outcomes and time points. Prognosis for early study of prognostication tools and methods and guide- mortality and long-term functional independence may be lines for their use. important for diferent types of decisions such as whether to continue aggressive neurointensive care or whether Subarachnoid Hemorrhage arrangements should be made regarding job prospects Outcome Predictors and Prognostic Models and family fnancial planning. Te plateau of functional Te long-term outcome after aneurysmal subarachnoid status and the time course and trajectory to get there may hemorrhage (SAH) has improved over the last decades be the most important prospect to patients and fami- [1–4]. Te original grading scales of clinical severity, lies. However, most studies assess a formal outcome at Hunt and Hess scale [5], and World Federations of Neu- an arbitrary snapshot in time such as hospital discharge, rosurgical Societies (WFNS) scale [6], are still the most 3 months, 6 months, or 1 year. Prognosis assessment can widely used and remain the most important predictors of vary between diferent disease states and between avail- long-term poor functional outcome and mortality [7, 8]. able variables, scores, and scales defned by the literature. In comparative research, there was no diference in the In February 2018, the Arbeitstagung NeuroIntensiv- precision of outcome prediction between the Hunt and Medizin (ANIM) meeting took place in Würzburg, Ger- Hess grade and the WFNS using the modifed Rankin many, and involved substantial collaboration between the scale (mRS) and the Glasgow Outcome scale (GOS) at German Neurocritical Care Society (DGNI) and the Neu- discharge, 6 months and 12 months [9–11]. However, in rocritical Care Society (NCS). Because of the recognized the WFNS scale there was substantial overlap between importance of prognostication in neurocritical care, this grade II and III, III and IV with similar outcomes for the collaboration included a special joint session focusing on assigned grades [9, 12]. gaps in current prognostication paradigms and models in Te original scales, Hunt and Hess and WFNS, were neurocritical care. Te purpose of this session was to pro- modifed to enable more precise and reliable distinction vide a forum for presentation and discussion regarding between the grades. Most of them are based on the Glas- existing formal prediction models across eight diferent gow Coma scale (GCS) [13]. Te modifed WFNS scale common neurocritical care conditions (aneurysmal suba- was better able to distinguish between grades I, II, and III rachnoid hemorrhage, intracerebral hemorrhage, acute as well as IV and V when predicting the mean GOS and ischemic stroke, traumatic brain injury, traumatic spinal mRS at 90 days [14]. Another GCS-based scale (“Prog- cord injury, status epilepticus, Guillain–Barré Syndrome nosis on Admission of Aneurysmal Subarachnoid Hem- (GBS) and global cerebral ischemia from cardiac arrest). orrhage-PAASH scale”) clearly distinguished 6-month outcome based on the GOS and mRS [15, 16]. Te Table 1 FRESH score [26] Revised GCS-based scale on four signifcant breakpoints FRESH function of the admission GCS predicted long-term outcome Age 70 > 70 (mRS at 3 and 12 months) better in poor grade patients ≤ compared to GCS, WFNS, and Hunt–Hess scales [17]. Hunt–Hess scale I–V Te Full Outline of UnResponsiveness (FOUR) score Apache II physiologic score Middle arterial pressure Heartrate Respiratory rate Tempera- with four scoring items: eye opening, eye and eyelid ture movements (E), motor examination (M), brain stem White blood cell count Hematocrit refexes (B), and respiratory patterns (R) were designed Sodium Potassium for more detailed assessment of the level of conscious- Aa gradient (if FiO 50%) pH or HCO 2 ≥ 3 ness [18]. Te total, eye, motor, and respiratory FOUR or paO2 scores obtained on day 0 and 7 after SAH were associ- Creatinine ated with mortality and functional outcome (mRS and Rebleeding within 48 h Yes No GOS) at 1 and 6 months [19]. Tis score obtained on day FRESH-Cog Years of education up to 14 was also associated with functional outcome (GOS) at 24 years 6 months [19]. Te SAH Physiologic Derangement score FRESH-Quol Premorbid glasgow
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