Duration of Coma in Out-of-Hospital Cardiac Arrest Survivors Treated With Targeted Temperature Management

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

“…8 Nevertheless, reports of late recoveries from prolonged postcardiac arrest coma suggest that recovery of neuronal function can extend over much longer time periods. [11][12][13][14][15][16] The 3 patients with late recovery presented here all remained in coma for more than 2 weeks following cardiac arrest (17, 37, 30 days, respectively; see Fig 1 and Table 1) and yet achieved independent functional outcomes. In 2 patients (Patients 2 and 3), nonmedical reasons (ie, family wishes and logistical limitations of obtaining a legally authorized decision-maker) prohibited withdrawal of lifesustaining therapy; in the third patient (Patient 1), knowledge of the outcomes and clinical profiles of these first 2 patients provided the basis for the prolonged wait period to allow late emergence from coma (see Table 1).…”

“…However, following the widespread use of TTM, an increasing number of reports describe unexpected recoveries despite evidence of poor prognostic markers. [11][12][13][14][15][16] In addition, a lack of imaging-based evidence of anoxic cortical or white matter injuries after cardiac arrest may portend better outcomes, 17 even in patients remaining in coma for more than 7 days. 18 The poorly characterized physiological protective factors related to TTM 19 suggest the possibility that in comatose post-cardiac arrest patients with wide preservation of cerebral structure, some negative predictive markers may only indicate a sustained abnormal state of global neuronal functions without permanent loss of potential to recover integrative cerebral functions.…”

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

“…Moreover, renal insufficiency, older age and post-resuscitation shock were the most important determinants of delayed awakening in these patients [22]. Nevertheless, in the absence of confounders, the chance of neurological recovery remain unchanged after 7 days from arrest, with only 2% of comatose patients becoming responsive and being discharge with good neurological function after that time-point [23,24].…”

In search of consensus on ethics in airway research

“…Key elements of the framework are: to increase the number of patients who receive bystander CPR to more than the current 30-40% of all OHCA, by increasing recognition of cardiac arrest; increasing the number of people trained in resuscitation; increasing the availability and use of public access defibrillators; transfer of patients who have achieved ROSC to recognised centres of care that provide immediate access to echocardiography, CT scanning, a cardiac catheterisation laboratory and advanced circulatory support techniques; management of postresuscitation care in a general or cardiothoracic intensive care unit (ICU); and addressing the shortage of appropriate facilities for neurological and physical rehabilitation. The importance of delaying prognostication and decisions to withdraw treatment is further emphasised by reports of 2.5% of OHCA survivors becoming responsive more than 7 days after rewarming [9]. This is already routine practice in UK ICUs; data from the Intensive Care National Audit and Research Centre (ICNARC) shows that between 2004 and 2014 the proportion of patients admitted to UK ICUs after OHCA increased from 9% to 12%, and that over this time, both the length of stay in ICU and the time to the withdrawal of life-sustaining treatments have also increased [5].…”

“…While the ideal combination of tests needed for optimal prognostication remains unknown, cumulative experience with using these tools, coupled with careful audit, could lead to progressive refinement in the way we make decisions about WLST using objective scientific criteria. The importance of delaying prognostication and decisions to withdraw treatment is further emphasised by reports of 2.5% of OHCA survivors becoming responsive more than 7 days after rewarming [9]. The OHCA steering group stresses the importance of full discussions about withdrawal and its timing with the family, acknowledging the range of opinion about what constitutes an acceptable quality of life, and that some individuals or their families may be willing to accept survival with neurological disability.…”