Performance of a guideline-recommended algorithm for prognostication of poor neurological outcome after cardiac arrest

• Published in: Intensive care medicine Vol. 46; no. 10; pp. 1852 - 1862
• Main Authors: Moseby-Knappe, Marion, Westhall, Erik, Backman, Sofia, Mattsson-Carlgren, Niklas, Dragancea, Irina, Lybeck, Anna, Friberg, Hans, Stammet, Pascal, Lilja, Gisela, Horn, Janneke, Kjaergaard, Jesper, Rylander, Christian, Hassager, Christian, Ullén, Susann, Nielsen, Niklas, Cronberg, Tobias
• Format: Journal Article
• Language: English
• Published: Berlin/Heidelberg Springer Berlin Heidelberg 01.10.2020; Springer; Springer Nature B.V
• Subjects: Algorithms; Anestesi och intensivvård; Anesthesiology; Anesthesiology and Intensive Care; Cardiac arrest; Cardiology and Cardiovascular Disease; Clinical Medicine; Clinical outcomes; Coma; Critical Care Medicine; EEG; Electroencephalography; Emergency Medicine; Guideline algorithm; Heart; Heart attacks; Humans; Hypothermia, Induced; Intensive; Intensive care; Kardiologi och kardiovaskulära sjukdomar; Klinisk medicin; Magnetic resonance imaging; Medical and Health Sciences; Medical prognosis; Medicin och hälsovetenskap; Medicine; Medicine & Public Health; Neuroimaging; Neurologi; Neurology; Neurophysiology; Original; Out-of-Hospital Cardiac Arrest - therapy; Pain Medicine; Pediatrics; Phosphopyruvate Hydratase; Pneumology/Respiratory System; Predictions; Prognosis; Prognostic accuracy; Prognostication; Resuscitation; Retrospective Studies; Sensitivity; Variation; Canada; United Kingdom; Sweden; Coma; Prognostication; Guideline algorithm; Cardiac arrest; Prognostic accuracy
• ISSN: 0342-4642; 1432-1238; 1432-1238
• DOI: 10.1007/s00134-020-06080-9

Purpose To assess the performance of a 4-step algorithm for neurological prognostication after cardiac arrest recommended by the European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM). Methods Retrospective descriptive analysis with data from the Target Temperature Management (TTM) Trial. Associations between predicted and actual neurological outcome were investigated for each step of the algorithm with results from clinical neurological examinations, neuroradiology (CT or MRI), neurophysiology (EEG and SSEP) and serum neuron-specific enolase. Patients examined with Glasgow Coma Scale Motor Score (GCS-M) on day 4 (72–96 h) post-arrest and available 6-month outcome were included. Poor outcome was defined as Cerebral Performance Category 3–5. Variations of the ERC/ESICM algorithm were explored within the same cohort. Results The ERC/ESICM algorithm identified poor outcome patients with 38.7% sensitivity (95% CI 33.1–44.7) and 100% specificity (95% CI 98.8–100) in a cohort of 585 patients. An alternative cut-off for serum neuron-specific enolase, an alternative EEG-classification and variations of the GCS-M had minor effects on the sensitivity without causing false positive predictions. The highest overall sensitivity, 42.5% (95% CI 36.7–48.5), was achieved when prognosticating patients irrespective of GCS-M score, with 100% specificity (95% CI 98.8–100) remaining. Conclusion The ERC/ESICM algorithm and all exploratory multimodal variations thereof investigated in this study predicted poor outcome without false positive predictions and with sensitivities 34.6–42.5%. Our results should be validated prospectively, preferably in patients where withdrawal of life-sustaining therapy is uncommon to exclude any confounding from self-fulfilling prophecies.