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      How to assess prognosis after cardiac arrest and therapeutic hypothermia


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          The prognosis of patients who are admitted in a comatose state following successful resuscitation after cardiac arrest remains uncertain. Although the introduction of therapeutic hypothermia (TH) and improvements in post-resuscitation care have significantly increased the number of patients who are discharged home with minimal brain damage, short-term assessment of neurological outcome remains a challenge. The need for early and accurate prognostic predictors is crucial, especially since sedation and TH may alter the neurological examination and delay the recovery of motor response for several days. The development of additional tools, including electrophysiological examinations (electroencephalography and somatosensory evoked potentials), neuroimaging and chemical biomarkers, may help to evaluate the extent of brain injury in these patients. Given the extensive literature existing on this topic and the confounding effects of TH on the strength of these tools in outcome prognostication after cardiac arrest, the aim of this narrative review is to provide a practical approach to post-anoxic brain injury when TH is used. We also discuss when and how these tools could be combined with the neurological examination in a multimodal approach to improve outcome prediction in this population.

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          Therapeutic hypothermia after cardiac arrest: an advisory statement by the advanced life support task force of the International Liaison Committee on Resuscitation.

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              Sedation confounds outcome prediction in cardiac arrest survivors treated with hypothermia.

              Therapeutic hypothermia is commonly used in comatose survivors' post-cardiopulmonary resuscitation (CPR). It is unknown whether outcome predictors perform accurately after hypothermia treatment. Post-CPR comatose survivors were prospectively enrolled. Six outcome predictors [pupillary and corneal reflexes, motor response to pain, and somatosensory-evoked potentials (SSEP) >72 h; status myoclonus, and serum neuron-specific enolase (NSE) levels 72 h, and absent pupillary reflexes >72 h predicted poor outcome with a 100% specificity both in hypothermia and normothermia patients. In contrast, absent corneal reflexes >72 h, motor response extensor or absent >72 h, and peak NSE >33 ng/ml <72 h predicted poor outcome with 100% specificity only in non-sedated patients, irrespective of prior treatment with hypothermia. Sedative medications are commonly used in proximity of the 72-h neurological examination in comatose CPR survivors and are an important prognostication confounder. Patients treated with hypothermia are more likely to receive sedation than those who are not treated with hypothermia.

                Author and article information

                Crit Care
                Crit Care
                Critical Care
                BioMed Central
                14 January 2014
                14 January 2015
                : 18
                : 1
                : 202
                [1 ]Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
                [2 ]Department of Clinical Sciences, Section for Neurology, Skåne University Hospital, Lund University, 221 85, Lund, Sweden
                [3 ]Department of Intensive and Perioperative Care, Skåne University Hospital, Lund University, 221 85, Lund, Sweden
                [4 ]Department of Neurology, Temple Medical Center, 6C, New Haven, CT 06510, USA
                [5 ]Department of Intensive Care, Academisch Medisch Centrum Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
                [6 ]Department of Intensive Care Medicine, CHUV_Lausanne University Hospital, CH-1011, Lausanne, Switzerland
                [7 ]Department of Anesthesiology and Intensive Care, University of Siena, Viale Bracci 1, 53100, Siena, Italy
                Copyright © 2014 BioMed Central Ltd.

                Emergency medicine & Trauma
                Emergency medicine & Trauma


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