Awakening after cardiac arrest and post resuscitation hypothermia: Are we pulling the plug too early?

Gold, B.; Puertas, Laura; Davis, Scott; Metzger, Anja; Yannopoulos, Demetri; Oakes, Dana A; Lick, Charles; Gillquist, Debbie L; Holm, Susie Y Osaki; Olsen, John D.; Jain, Sandeep; Lurie, Keith G.

doi:10.1016/j.resuscitation.2013.10.030

Cited by 121 publications

(89 citation statements)

References 15 publications

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“…Guidelines currently used in many centers to determine prognosis after cardiac arrest are still based on the 2006 AAN Practice Parameters intended for patients not treated with TH despite recent evidence and new guidelines that advocate for delaying prognostication beyond 72 hours (31,32,39,44,45). Our results indicate that making WLST decisions at 72 hours postarrest could deprive as many as 36% of comatose survivors treated with TH of the opportunity to potentially achieve good neurological outcomes.…”

Section: Discussionmentioning

confidence: 84%

Section: Discussionmentioning

confidence: 99%

“…The high rate and early timing of WLST in the TH group render comparisons between the two groups very difficult; however, the aim of the present study is not to compare these groups but rather to highlight the inadequacies of prognostication at 72 hours after TH. This study is also one of the few to describe the time to awakening of patients treated with and without TH, as well as the proportion of patients who progress to brain death, and one of the first to describe time to withdrawal of care (28,31,32,40,42,43).This study and the majority of clinical trials and studies on the subject have been unable to accurately account for the multiple effects of TH in postcardiac arrest-be it the mechanisms of neuroprotection or the delay in awakening. It is important for the resuscitation community to consider that without a solid physiopathologic understanding of the effects of the intervention on our patients, many of these questions are unlikely to be answered satisfactorily.…”

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confidence: 99%

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Awakening and Withdrawal of Life-Sustaining Treatment in Cardiac Arrest Survivors Treated With Therapeutic Hypothermia

Mulder

Gibbs

Smith

et al. 2015

Survey of Anesthesiology

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Objectives-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.Design-Single center, prospective observational cohort study of consecutive patients with outof-hospital cardiopulmonary arrests. Setting-Academic HHS Public Access Author Manuscript Author ManuscriptAuthor Manuscript Author ManuscriptPatients-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. Interventions-None.Measurements and Main 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 lifesustaining 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. Keywordsbrain death; cardiac arrest; outcome; prognostication; therapeutic hypothermia; withdrawal of lifesustaining treatmentOut-of-hospital cardiopulmonary arrests (OHCA) pose a significant public health burden, with an estimated annual prevalence of over 380,000 arrests evaluated by emergency medical services in the United States alone (1-4). In the decade following the 2002 landmark trials of therapeutic hypothermia (TH) to improve outcomes in comatose cardiac arrest survivors, little additional progress has been made in finding and implementing successful new neuroprotective interventions (5, 6). Therefore, TH remains the only proven neuroprotective strategy available and the focus of the resuscitation community. A number of factors explain this lack of progress: a lack of understanding of the mechanisms and circumstances leading to poor outcomes, lead time and selection biases, as well as funding and ethical co...

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Section: Discussionmentioning

confidence: 84%

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

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Awakening and Withdrawal of Life-Sustaining Treatment in Cardiac Arrest Survivors Treated With Therapeutic Hypothermia

Mulder

Gibbs

Smith

et al. 2015

Survey of Anesthesiology

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“…6 Despite this finding, there are concerns that many survivors are substantially disabled with poor long-term quality of life. 7,8 Given that there is significant investment in improving the emergency response to OHCA patients 9,10 and reported improvements in short-term survival outcomes, the long-term neurological state and quality of life of survivors is of growing significance.…”

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confidence: 99%

Quality of Life and Functional Outcomes 12 Months After Out-of-Hospital Cardiac Arrest

et al. 2015

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Background-Out-of-hospital cardiac arrest (OHCA) is a significant global health problem. There has been considerable investment in improving the emergency medical response to OHCA, with associated improvements in survival. However, concern remains that survivors have a poor quality of life. This study describes the quality of life of OHCA survivors at 1-year postarrest in Victoria, Australia. Methods and Results-Adult OHCA patients who arrested between 2010 and 2012 were identified from the Victorian Ambulance Cardiac Arrest Registry. Paramedics attended 15 113 OHCA patients of which 46.3% received an attempted resuscitation. Nine hundred and twenty-seven (13.2%) survived to hospital discharge of which 76 (8.2%) died within 12 months. Interviews were conducted with 697 (80.7%) patients or proxies, who were followed-up via telephone interview, including the Glasgow Outcome Scale-Extended, the 12-item short form health survey, and the EuroQol. The majority (55.6%) of respondents had a good recovery via the Glasgow Outcome Scale-Extended≥7 (41.1% if patients who died postdischarge were included and nonrespondents were assumed to have poor recovery

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“…6,7 More recent guidelines suggest delaying prognostic assessments when TTM is used 4,8 ; however, time to awakening in HIBI varies and up to 1 in 7 patients may experience a delayed awakening with favorable neurologic outcome. 9 DISCUSSION Given the complex relationship between TTM and neurologic prognosis, it is important to reevaluate previously ascribed indicators of poor prognosis. A meta-analysis of 37 studies of neuroprognostic tools used within 7 days from CA demonstrated that even predictors with a high positive predictive value were subject to a self-fulfilling prophecy bias.…”

Section: Sectionmentioning

confidence: 99%

Clinical Reasoning: Prognostication after cardiac arrest

et al. 2017

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Awakening after cardiac arrest and post resuscitation hypothermia: Are we pulling the plug too early?

Cited by 121 publications

References 15 publications

Awakening and Withdrawal of Life-Sustaining Treatment in Cardiac Arrest Survivors Treated With Therapeutic Hypothermia

Awakening and Withdrawal of Life-Sustaining Treatment in Cardiac Arrest Survivors Treated With Therapeutic Hypothermia

Quality of Life and Functional Outcomes 12 Months After Out-of-Hospital Cardiac Arrest

Clinical Reasoning: Prognostication after cardiac arrest

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