RAeccceeipvteedd:: 2202 AAuugguusstt 22001144 ICNn.itjeHmnoseiegvdeeenmCMaaereekd,eicrRsaaldCbeonutdreU,nNiivjemrseigtyen,, iecmloenaccgtlriuonspgihowynssei:roeloiEngvcyli,dubedineocdme. afRrroekmseurlsatstaonatdanldof The Author(s) 2014. This article is The Netherlands 73 studies was reviewed. The quality of pSupbrilnisgheerdlinwki.tcho mopen access at IJn.tHenosrinve Care, Academic Medical Center, ealvlisdteundcieesw.Ians ploawtieonrtsvewrhyoloawrefcoormalamtoosset This statement has been endorsed by the Amsterdam, The Netherlands with absent or extensor motor response European Resuscitation Council (ERC) and at C72 h from arrest, either treated or not tpRCMhueaeebsrduleEiisscucMhirineoteeadpdteii(icoaEninnSnRIe[SCe.dosoMOuciis:r)e1citgi0aytin.an1odta0iflo1ilsnIy6n/btapje.enurniedbnsslgiuIivsnsejhtcoeeiCintdnasattiilrivnyeoen. JCBD.aaePtrphe.a,NrMtUmoeKledannictinoef,ARnoayeaslthUesniiateadndHoInspteintasli,ve tlcbraoietlreaanntteeecrdayalwlsraoeibtflmhseaexctnoeocsnseetornoorsflNoleer2idyt0hteeewvrmoapkvpueeepdroialpftluaosrrhteyeo,nar-tn-d s2Ci0oo1nm4mo.0fe8Er.0cli1sae1lv]R;iepirguhIbrtlesilsaRhneeddseLwrvtdiet.hdA.klilnd permis- DA.epOa.rtRmoesnstetotif Clinical Neurosciences, tpiraelsdiwcteorres.idEeanrtliyfisetdatausstmheymocolostnruosb,uesletCHUV and University of Lausanne, vated values of neuron-specific enolase Electronic supplementary material Lausanne, Switzerland at 48-72 h from arrest, unreactive (sTduhopeip:lo1en0m.l1ien0ne0ta7vr/eysr0sm0io1an3te4or-fi0a1tlh,4iw-s3ha4ir7ct0ihc-lxies) acvoanitlaaibnlse JD.eSpoaartrment of Anaesthesia and Intensive imngal,iagnndanptrEesEeGncpeaottfedrnifsfuasfetesrirgenws aorfmto authorized users. Care Medicine, Southmead Hospital, postanoxic injury on either computed Bristol, UK tomography or magnetic resonance imaging were identified as useful but C. Sandroni ()) F. Cavallaro less robust predictors. Prolonged obserDepartment of Anaesthesiology and Abstract Objectives: To review vation and repeated assessments should Intensive Care, Catholic University School and update the evidence on predictors be considered when results of initial Ieot-famlMyaeild:icsainned,
[email protected],t00168 Rome, covafelgpedotioastraibvoieulitstcytoa)mteineoa(rddseuealvtthecr,oepmnearestuoirssoteelongti- sanusosffiespscseimecniefitnlcyt casouremppibnoicnrotaentdicolbnuysoiavfvepa.riAeladlbitchletoouergvshii-s A. Cariou survivors of cardiac arrest, either dence, a multimodal prognostication Medical ICU, Cochin Hospital (APHP), treated or not treated with controlled approach is recommended in all patients. Paris Descartes University, Paris, France temperature, to identify knowledge gaps and to suggest a reliable prog- Keywords Heart arrest Coma oSTDfw.eNCepdreaoeurnntrmobleeornggtyo,fLCunlidniUcanlivSecriseintyc,esL,uDnidv,ision anMtoiesctthircoeadvtsiieo:wn sGftorRlalAtoewDgyeE.d-bbayseedxpseyrsttem- PSNroeomugranotonossisespnescoCirfilyicneiecvnaoolkleeaxdseapmoitCneTanttiisoacnlasn consensus achieved using Web-based Magnetic resonance H. Friberg Delphi methodology, conference calls Anaesthesiology and Intensive Care and face-to-face meetings. Predictors Medicine, Skane University Hospital, Lund based on clinical examination, University, Lund, Sweden
1 Introduction 2. Provide practical recommendations on the most reli
1. The AAN 2006 review was based on studies conducted
before the advent of therapeutic hypothermia (TH) for
post-resuscitation care. Both TH itself and sedatives or 2.2 Group process
neuromuscular blocking drugs used to maintain it may
potentially interfere with prognostication indices, Following an initial conference call and a face-to-face
especially clinical examination [3]. The predictive meeting, the panel members agreed on criteria for study
value of those indices therefore needs to be re- inclusion, grading methods, and the process timeline.
evaluated in TH-treated patients. Subsequent consensus on the evidence and the
recom2. Studies conducted both before [4] and after [5, 6] the mendations was achieved using a Web-based Delphi
AAN 2006 review showed that the previously recom- method. The document was written using a Web-based
mended thresholds for outcome prediction using collaborative process and collectively reviewed for
conbiomarkers were inconsistent [7]. tent and wording. A final face-to-face meeting was held to
3. Evidence for some prognostic tools such as EEG [8] finalize the statements.
and imaging studies was limited at the time of the 2006
AAN review, and needs re-evaluation.
4. The AAN 2006 review and previous reviews did not 2.3 Inclusion criteria and definitions
adequately address some important limitations of
prognostication studies, such as the risk of self- Given the paucity of evidence on neurological
prognosfulfilling prophecy, which is a bias occurring when tication in children with coma after cardiac arrest, the
the treating physicians are not blinded to the results of evidence evaluation was restricted to adults. Inclusion
the outcome predictor and use it to make a decision to criteria are described in detail elsewhere [12]. Briefly, all
withdraw life-sustaining treatment (WLST) [9]. studies on adult (C16 years) patients who were comatose
following resuscitation from cardiac arrest and were
Given the limitations of the current literature and the treated with TH were considered for inclusion. Patients
need for up-to-date clinical guidance, members of the defined as unconscious, unresponsive, or having a
GlasEuropean Resuscitation Council (ERC) and the Trauma gow Coma Scale score (GCS) [13] B8, were considered
and Emergency Medicine (TEM) Section of the European as comatose. Studies including non-comatose patients or
Society of Intensive Care Medicine (ESICM) planned an patients in hypoxic coma from causes other than cardiac
Advisory Statement on Neurological Prognostication in arrest (e.g., respiratory arrest, carbon monoxide
intoxicomatose survivors of cardiac arrest. The aims of this cation, drowning, and hanging) were excluded, except
statement are to: when a subpopulation of cardiac arrest patients could be
evaluated separately.
1. Update and summarize the available evidence on this Studies were considered for inclusion regardless of
topic, including that on TH-treated patients; both the cause of arrest and treatment with TH. Pooling of
2.4 Data source of the strategy under evaluation.
Results from three recent systematic reviews [7, 12, 17]
on post-arrest prognostication were used as a data source.
One of these [7] included 50 studies on 2,828 patients not
treated with TH, the two other reviews [12, 17] included a 3 Clinical examination
total of 39 studies in 2,564 TH-treated patients. In order to 3.1 Evidence (ESM Table 1)
identify further studies published during the grading and
consensus process, the automatic alert system of PubMed 3.1.1 Ocular reflexes
was maintained active and the tables of contents of
relevant journals were screened. This led to the inclusion of
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