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

Abstract

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...

ILCOR Scientific Knowledge Gaps and Clinical Research Priorities for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: A Consensus Statement

“…In some settings, life-sustaining treatments are limited when the treating team believes favorable functional recovery is not possible 67 ; the use of postarrest hypothermia added another layer of complexity. 68,69 The 2015 Consensus on Science identified multiple methods of patient assessment for estimating prognosis: clinical examination, neurophysiologic studies, blood biomarkers, and imaging studies. 36,37 There were specific knowledge gaps regarding prognostic tests as well as global concerns related to the design of prognosis studies.…”

Independent Functional Outcomes after Prolonged Coma following Cardiac Arrest: A Mechanistic Hypothesis

“…The importance of these patients is underlined by the fact that in present clinical practice, withdrawal of life‐sustaining therapy in comatose post–cardiac arrest patients most typically occurs within 5 to 7 days and rarely exceeds 2 weeks, even in the setting of some favorable prognostic factors . As a result, most studies are hindered by self‐fulfilling prophecy, as withdrawal of life‐sustaining therapy practices in post–cardiac arrest patients with prolonged coma limit the evaluation of the natural course of their recovery potential or cellular survival mechanisms. Furthermore, the marked change in clinical outcomes generally associated with TTM of post–cardiac arrest coma indicates that such therapies can significantly shift the probabilities of permanent neuronal death or dysfunction after cardiac arrest and hence the possibility of favorable outcomes.…”

Targeted temperature management and neuroprognostication after cardiac arrest: A survey in Belgium

“…All these issues explain why up to 30% of CA patients treated with TTM will regain consciousness after 72 h from arrest [12]. In one study (n = 163), mean time of awakening for these patients was 3.8 days and 21% of them regained neurological responsiveness after 5 days from arrest, in particular if cooled at lower target temperatures (32-33°C) [21].…”

“…Among all potential therapeutic interventions, only the use of targeted temperature management (TTM) provided significant benefits in terms of neurological recovery among CA survivors [9][10][11], although the evidence supporting this approach is not the same according to the type and location of arrest. Nevertheless, the need of sedatives and analgesic drugs during TTM may delay the accuracy of neurological examination to assess prognosis of such patients [12]. International recommendations underline that a multimodal prognostication approach should be initiated in CA patients who remain comatose at C72 h from arrest [13].…”