Post-resuscitation care: ERC/ESICM updated Guidelines

They also recommended some general guidelines which include,

• “In patients who are comatose after resuscitation from cardiac arrest, neurological prognostication should be performed using clinical examination, electrophysiology, biomarkers and imaging, to both inform patient’s relatives and to help clinicians to target treatments based on the patient’s chances of achieving a neurologically meaningful recovery.
• No single predictor is 100% accurate. Therefore, a multimodal neuroprognostication strategy is recommended.
• When predicting poor neurological outcome, a high specificity and precision are desirable, to avoid falsely pessimistic predictions.
• The clinical neurological examination is central to prognostication. To avoid falsely pessimistic predictions, clinicians should avoid potential confounding from sedatives and other drugs that may confound the results of the tests.
• When patients are treated with TTM, daily clinical examination is advocated but final prognostic assessment should be undertaken only after rewarming.
• Clinicians must be aware of the risk of a self-fulfilling prophecy bias, occurring when the results of an index test predicting poor outcome is used for treatment decisions, especially regarding life-sustaining therapies.
• Index tests for neurological prognostication are aimed at assessing the severity of hypoxic–ischaemic brain injury. The neurological prognosis is one of several aspects to consider in discussions around an individual’s potential for recovery.”

• “Start the prognostication assessment with an accurate clinical examination, to be performed only after major confounders (e.g. residual sedation, hypothermia) have been excluded.
• In a comatose patient with M ≤ 3 at ≥ 72 h from ROSC, in the absence of confounders, poor outcome is likely when two or more of the following predictors are present: no pupillary and corneal reflexes at ≥ 72 h, bilaterally absent N20 SSEP wave at ≥ 24 h, highly malignant EEG at > 24 h, neuron-specific enolase (NSE) > 60 µg L−1 at 48 h and/or 72 h, status myoclonus ≤ 72 h, or a diffuse and extensive anoxic injury on brain CT/MRI. Most of these signs can be recorded before 72 h from ROSC; however, their results will be evaluated only at the time of clinical prognostic assessment.
• Clinical examination is prone to interference from sedatives, opioids or muscle relaxants.”

• “A potential confounding from residual sedation should always be considered and excluded.
• A Glasgow Motor Score of ≤ 3 (abnormal flexion or worse in response to pain) at 72 h or later after ROSC may identify patients in whom neurological prognostication may be needed.
• In patients who remain comatose at 72 h or later after ROSC the following tests may predict a poor neurological outcome:
•          The bilateral absence of the standard pupillary light reflex.
•          Quantitative pupillometry
•          The bilateral absence of corneal reflex
•          The presence of myoclonus within 96 h and, in particular, status myoclonus within 72 h