Prognostication in comatose survivors of cardiac arrest. An Advisory Statement from the European Resuscitation Council and the European Society of Intensive Care Medicine
Intensive Care Medicine, 2014.
Claudio Sandroni, Alain Cariou, Fabio Cavallaro, Tobias Cronberg, Hans Friberg, Cornelia Hoedemaekers, Janneke Horn, Jerry P. Nolan, Andrea O. Rossetti and Jasmeet Soar
Corresponding author:
Claudio Sandroni
Department of Anaesthesiology and Intensive Care
Catholic University School of Medicine,
Largo Gemelli, 8 - 00168 Rome, Italy [email protected] ESM Table 5. Blinding of treating team and criteria for treatment suspension in included studies.
Blinding Minimal duration Author, year Indexes Criteria for treatment suspension or limitation of care (treating team) of support
Clinical Examination
Al Thenayan 2008 PLR, CR, MR, Status No - - myoclonus Bertini 1989 PLR, MR - - - Bouwes BMC 2012 Status myoclonus Yes (1) At discretion of treating physician; in most cases, based on - absent N20 SSEP after rewarming Earnest 1979 PLR, OCR, MR - - - Greer 2013 PLR, CR, MR No At discretion of treating team - Hui 2005 Status myoclonus - - - Krumholz 1988 Status myoclonus - - - Okada 2012 PLR, MR No - - Pfeifer 2005 GCS - - - Thomke 2005 Myoclonus No Clinical examination, EEG, NSE 3-4 d Withdrawal of life support reported but the criteria are not Wijdicks 1994 No - Status myoclonus specified Wu 2011 PLR, CR, MR - - - Young 1990 Status myoclonus - - - Electrophysiology Treatment and management “were not influenced by the Bauer 2003 SSEPs - - results of the SEP recordings” Berkhoff 2000 Alpha coma - - - Cloostermans 2012 cEEG Yes, partial (2) Absent N20 SSEP at 72h - Kawai 2011 EEG No - - Leary 2010 BIS No Perception of moribund condition - Leithner 2010 SSEP No - - Oh 2012 aEEG No - - “In no patient was a decision to abandon medical support Rothstein 2000 - - SSEPs based on the results of SSEPs” Rundgren 2010 aEEG No M≤2 and absent N20 SSEP after rewarming 3 d Seder 2010 BIS, SR No - - Stammet 2009 BIS No No PLR on day 3, seizures or M=1 on day 5 and/or absent 5 d after N20 SSEP and/or signs of brain damage on CT or MRI suspension of sedation Stelzl 1995 SSEPs - - - Tiainen 2005 SSEPs Yes Clinical status (not on electrophysiological tests) 3-7 d Zanatta 2012 EEG, SSEP No - -
Biomarkers
Hachimi-Idrissi 2002 S-100 Yes - - Mortberg 2011 NSE, S-100B No - - Mussack 2002 S-100B - - - Oksanen 2009 NSE No Clinical status, absent N20 SSEP, myoclonus, nonreactive 3-5 d EEG, brain damage on CT Reisinger 2007 NSE No Irreversible multiple organ failure or brain death - Rosen 1998 S-100 - - - Rosen 2001 NSE, S-100B - - - Rundgren 2009 NSE No GCS 3 d after RW Steffen 2010 NSE No SSEP, PLR, MR, NSE 3 d Storm 2012 NSE No SSEP, PLR, MR, NSE - Tiainen 2003 NSE, S-100B No - 3-7 d (3)
Imaging
Choi 2008 Brain CT - - - Choi 2010 Brain MRI No No withdrawal unlimited Els 2004 Brain MRI - - - Inamasu 2010 Brain CT - - - Patients in whom intensive care was withdrawn were Kim 2013 - - Brain CT excluded
4 Mlynash 2010 Brain MRI - ( ) No withdrawal unlimited Morimoto 1993 Brain CT - - - Withdrawal of life support reported but the criteria are not Wijdicks 2001 - - Brain MRI specified Wijman 2009 Brain MRI Yes Based on the AAN 2006 review - Withdrawal of life support reported but the criteria are not Wu 2009 No - Brain MRI specified
Multimodal
Bassetti 1996 BR, GCS, MR, EEG, SSEPs No Withdrawal of life support reported but the criteria are not 3 d specified Bisschops 2011 Myoclonus, PLR, MR, No N20 SSEP absent after rewarming or absent CR and PLR + 3 d SSEP, EEG M≤2 Yes (1) At discretion of treating physician; in most cases, based on - Bouwes 2009 PLR, CR, MR, SSEP absent N20 SSEP after rewarming Bouwes AN 2012 PLR, CR, MR, NSE, SSEP Yes (1) At discretion of treating physician; in most cases, based on - N20 SSEP absent after RW Choi 2012 MRI, SSEP No - - Crepeau 2013 Myoclonus, cEEG No Family request in some cases. < 2 days Cronberg 2011 PLR, CR, MRI, SSEP, EEG, No M≤2 or absent PLR or absent N20 SSEP on day 3 3 d NSE (5) Edgren 1987 BR, MR, EEG No Severe brain damage and no improvement 3 d Fugate 2010 PLR, CR, MR, SSEP No Neurologic assessment, critical illness state - Kim 2012 NSE, MRI No At the discretion of the treating physicians - Lee 2013 NSE, brain CT No No withdrawal - Legriel 2013 Myoclonus, PSE No Bilaterally absent PLR or CR or MR or bilaterally absent N20 7 d 2 criteria in normothermia: unreactive EEG (7), treatment- Oddo 2014 BR, Myoclonus, EEG, No resistant myoclonus, N20 bilaterally absent (8), incomplete 3 d SSEP, NSE brainstem reflexes Rittenberger 2012 EEG, Status myoclonus No - - Rossetti AN 2010 Myoclonus, BR, MR, No AAN criteria (2006) (6), based on BR, EEG (7), SSEP at ≥24h 3 d EEG, SSEP after weaning from sedation Incomplete recovery of brainstem reflexes, bilaterally Rossetti CC 2010 - 3 d MR, SSEP absent N20 Rossetti 2012 BR, MR, myoclonus, No At least 2 of the following: 1) incomplete recovery of BR; 2) 3 d after RW SSEP, EEG, NSE early myoclonus; 3) unreactive EEG; 4) absent N20 SSEP.(8). Samaniego 2011 PLR, CR, MR, status No Multiple clinical and neurophysiological testing "In 3 d myoclonus, NSE, SSEP accordance with patient's next of kin" Stammet 2013 BIS, S-100B Yes clinical signs of brain death 5 days after suspension of sedation
Topcuoglu 2009 GCS, FOUR score, brain No No withdrawal unlimited MRI Wennervirta 2009 NSE, EEG No - -
Young 2005 PLR, CR, OVR, MR, - - - myoclonus, SSEPs, EEG BR, MR, status 9 Zandbergen 2006 (a) myoclonus, NSE, S-100B, Yes ( ) SSEPs, EEG, PLR, MR 1-2 d SSEPs, EEG Decision was taken together with the family and the Zellner 2013 No - MR, S100B neurological consultation service Zingler 2003 NSE, S-100B, SSEPs - - -
Indexes used for treatment suspension are in bold.
Abbreviations BAEPs = Brain stem Auditory Evoked Potentials; BIS = Bispectral Index; BR: Brain Reflexes; CR = Corneal Reflex; CT = Computed tomography; d = days; EEG = Electroencephalogram; GCS= Glasgow Coma Score; M= GCS motor score; MR = Motor Response; MRI = Magnetic Resonance Imaging; N/A = Not Available; NSE = Neuron- Specific Enolase; OVR = Oculo-vestibular reflex PLR = Pupillary Light Response; RW: rewarming; SR = Suppression Ratio; SSEPs = Short-latency Somatosensory Evoked Potentials; TH = Therapeutic Hypothermia.
Notes (1) Results of SSEP recorded during normothermia were not disclosed to the treating physician. In patients who remained in coma after rewarming, a second SSEP was performed and its results were disclosed to the treating physician. (2) The treating physicians were not completely blinded to the EEG to allow treatment of epileptiform discharges, and also had access to SSEP results (3) Life support was maintained for at least 3 days in all patients and at least 7 days in patients responding to pain in any manner (4) An unspecified number of patients underwent withdrawal of life support and were excluded from the study. The study included only patients who were alive at 6 months or died while meeting the following criteria: absent PLR or motor response on day 3, and/or bilaterally absent SSEP cortical response on day 2, and/or vegetative after 1 month. (5) This is a retrospective study aimed to investigate the correlation among NSE and other prognostic markers. (6) Wijdicks EF et al. Neurology 2006; 67:203-10. SSEP and a routine EEG were obtained at 72 ± 8 hours following resuscitation. (7) “EEG reactivity did not influence the decision” on termination of life support. (8) Criteria were assessed at NT ≥48–72 hours after CA. Results of EEG during HT and NSE did not influence decisions on withdrawal. (9) The treating physicians were blinded to the SSEP only for 48 h. At 72h SSEP results were disclosed. Treatment limitations were based, among others, on SSEP results.