Postarrest Neuroprognostication: Practices and Opinions of Canadian Physicians

Abstract

Background: Objective, evidence-based neuroprognostication of postarrest patients is crucial to avoid inappropriate withdrawal of life-sustaining therapies or prolonged, invasive, and costly therapies that could perpetuate suffering when there is no chance of an acceptable recovery. Postarrest prognostication guidelines exist; however, guideline adherence and practice variability are unknown. Objective: To investigate Canadian practices and opinions regarding assessment of neurological prognosis in postarrest patients. Methods: An anonymous electronic survey was distributed to physicians who care for adult postarrest patients. Results: Of the 134 physicians who responded to the survey, 63% had no institutional protocols for neuroprognostication. While the use of targeted temperature management did not affect the timing of neuroprognostication, an increasing number of clinical findings suggestive of a poor prognosis affected the timing of when physicians were comfortable concluding patients had a poor prognosis. Variability existed in what factors clinicians’ thought were confounders. Physicians identified bilaterally absent pupillary light reflexes (85%), bilaterally absent corneal reflexes (80%), and status myoclonus (75%) as useful in determining poor prognosis. Computed tomography, magnetic resonance imaging, and spot electroencephalography were the most useful and accessible tests. Somatosensory evoked potentials were useful, but logistically challenging. Serum biomarkers were unavailable at most centers. Most (79%) physicians agreed ≥2 definitive findings on neurologic exam, electrophysiologic tests, neuroimaging, and/or biomarkers are required to determine a poor prognosis with a high degree of certainty. Distress during the process of neuroprognostication was reported by 70% of physicians and 51% request a second opinion from an external expert. Conclusion: Significant variability exists in post-cardiac arrest neuroprognostication practices among Canadian physicians.

Predictive Performance of Neuron-Specific Enolase (NSE) for Survival after Resuscitation from Cardiac Arrest: A Systematic Review and Meta-Analysis

“…Despite the dissemination of knowledge about their predictive abilities, in the opinion of physicians, their measurement was still not common. Physicians are also skeptical about the possibility of basing the prognosis only on biomarker concentration values, and it is also necessary to perform electrophysiological tests and neuroimaging [120]. The need for an interdisciplinary approach in neuroprognostication has also also indicated in the Canadian Cardiovascular Society Position Statement, in which biomarkers are just one of many indicated aspects that should be taken into account when determining patient prognoses [121,122].…”