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Protocol-driven neurological prognostication and withdrawal of life-sustaining therapy after cardiac arrest and targeted temperature management

Dragancea, Irina LU ; Wise, Matthew P; al-Subaie, Nawaf; Cranshaw, Julius; Friberg, Hans LU ; Glover, Guy; Pellis, Tommaso; Rylance, Rebecca LU ; Walden, Andrew and Nielsen, Niklas LU , et al. (2017) In Resuscitation 117. p.50-57
Abstract

Background Brain injury is reportedly the main cause of death for patients resuscitated after out-of-hospital cardiac arrest (OHCA). However, the majority may actually die following withdrawal of life-sustaining therapy (WLST) with a presumption of poor neurological recovery. We investigated how the protocol for neurological prognostication was used and how related treatment recommendations might have affected WLST decision-making and outcome after OHCA in the targeted temperature management (TTM) trial. Methods Analyses of prospectively recorded data: details of neurological prognostication; recommended level-of-care; WLST decisions; presumed cause of death; and cerebral performance category (CPC) 6 months following randomization.... (More)

Background Brain injury is reportedly the main cause of death for patients resuscitated after out-of-hospital cardiac arrest (OHCA). However, the majority may actually die following withdrawal of life-sustaining therapy (WLST) with a presumption of poor neurological recovery. We investigated how the protocol for neurological prognostication was used and how related treatment recommendations might have affected WLST decision-making and outcome after OHCA in the targeted temperature management (TTM) trial. Methods Analyses of prospectively recorded data: details of neurological prognostication; recommended level-of-care; WLST decisions; presumed cause of death; and cerebral performance category (CPC) 6 months following randomization. Results Of 939 patients, 452 (48%) woke and 139 (15%) died, mostly for non-neurological reasons, before a scheduled time point for neurological prognostication (72 h after the end of TTM). Three hundred and thirteen (33%) unconscious patients underwent prognostication at a median 117 (IQR 93–137) hours after arrest. Thirty-three (3%) unconscious patients were not neurologically prognosticated and for 2 patients (1%) data were missing. Related care recommendations were: continue in 117 (37%); not escalate in 55 (18%); and withdraw in 141 (45%). WLST eventually occurred in 196 (63%) at median day 6 (IQR 5–8). At 6 months, only 2 patients with WLST were alive and 248 (79%) of prognosticated patients had died. There were significant differences in time to WLST and death after the different recommendations (log rank <0.001). Conclusion Delayed prognostication was relevant for a minority of patients and related to subsequent decisions on level-of-care with effects on ICU length-of-stay, survival time and outcome.

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publication status
published
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keywords
Cardiac arrest, Neurological prognostication, Outcome, Target temperature management, Withdrawal of life-sustaining therapy
in
Resuscitation
volume
117
pages
8 pages
publisher
Elsevier
external identifiers
  • scopus:85020310539
  • wos:000405399300022
ISSN
0300-9572
DOI
10.1016/j.resuscitation.2017.05.014
language
English
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yes
id
b2f50050-48c2-4cfd-b2d1-2d4d154dcbf9
date added to LUP
2017-07-26 12:23:57
date last changed
2017-09-18 11:39:44
@article{b2f50050-48c2-4cfd-b2d1-2d4d154dcbf9,
  abstract     = {<p>Background Brain injury is reportedly the main cause of death for patients resuscitated after out-of-hospital cardiac arrest (OHCA). However, the majority may actually die following withdrawal of life-sustaining therapy (WLST) with a presumption of poor neurological recovery. We investigated how the protocol for neurological prognostication was used and how related treatment recommendations might have affected WLST decision-making and outcome after OHCA in the targeted temperature management (TTM) trial. Methods Analyses of prospectively recorded data: details of neurological prognostication; recommended level-of-care; WLST decisions; presumed cause of death; and cerebral performance category (CPC) 6 months following randomization. Results Of 939 patients, 452 (48%) woke and 139 (15%) died, mostly for non-neurological reasons, before a scheduled time point for neurological prognostication (72 h after the end of TTM). Three hundred and thirteen (33%) unconscious patients underwent prognostication at a median 117 (IQR 93–137) hours after arrest. Thirty-three (3%) unconscious patients were not neurologically prognosticated and for 2 patients (1%) data were missing. Related care recommendations were: continue in 117 (37%); not escalate in 55 (18%); and withdraw in 141 (45%). WLST eventually occurred in 196 (63%) at median day 6 (IQR 5–8). At 6 months, only 2 patients with WLST were alive and 248 (79%) of prognosticated patients had died. There were significant differences in time to WLST and death after the different recommendations (log rank &lt;0.001). Conclusion Delayed prognostication was relevant for a minority of patients and related to subsequent decisions on level-of-care with effects on ICU length-of-stay, survival time and outcome.</p>},
  author       = {Dragancea, Irina and Wise, Matthew P and al-Subaie, Nawaf and Cranshaw, Julius and Friberg, Hans and Glover, Guy and Pellis, Tommaso and Rylance, Rebecca and Walden, Andrew and Nielsen, Niklas and Cronberg, Tobias and , },
  issn         = {0300-9572},
  keyword      = {Cardiac arrest,Neurological prognostication,Outcome,Target temperature management,Withdrawal of life-sustaining therapy},
  language     = {eng},
  month        = {08},
  pages        = {50--57},
  publisher    = {Elsevier},
  series       = {Resuscitation},
  title        = {Protocol-driven neurological prognostication and withdrawal of life-sustaining therapy after cardiac arrest and targeted temperature management},
  url          = {http://dx.doi.org/10.1016/j.resuscitation.2017.05.014},
  volume       = {117},
  year         = {2017},
}