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Post-resuscitation care: ERC/ESICM updated Guidelines - Page 3
PROGNOSTICATION:
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.”
With regard to Multimodal prognostication, they recommend,
- “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.”
Regarding Clinical examination, they recommend,
- “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
Article Source : Intensive Care Medicine
Dr Kartikeya Kohli is an Internal Medicine Consultant at Sitaram Bhartia Hospital in Delhi with super speciality training in Nephrology. He has worked with various eminent hospitals like Indraprastha Apollo Hospital, Sir Gangaram Hospital. He holds an MBBS from Kasturba Medical College Manipal, DNB Internal Medicine, Post Graduate Diploma in Clinical Research and Business Development, Fellow DNB Nephrology, MRCP and ECFMG Certification. He has been closely associated with India Medical Association South Delhi Branch and Delhi Medical Association and has been organising continuing medical education programs on their behalf from time to time. Further he has been contributing medical articles for their newsletters as well. He is also associated with electronic media and TV for conduction and presentation of health programs. He has been associated with Medical Dialogues for last 3 years and contributing articles on regular basis.
Dr Kamal Kant Kohli-MBBS, DTCD- a chest specialist with more than 30 years of practice and a flair for writing clinical articles, Dr Kamal Kant Kohli joined Medical Dialogues as a Chief Editor of Medical News. Besides writing articles, as an editor, he proofreads and verifies all the medical content published on Medical Dialogues including those coming from journals, studies,medical conferences,guidelines etc. Email: editorial@medicaldialogues.in. Contact no. 011-43720751