ERC-ESICM guidelines for prognostication after cardiac arrest: time for an update
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EDITORIAL
ERC‑ESICM guidelines for prognostication after cardiac arrest: time for an update Claudio Sandroni1,2* , Antonello Grippo3,4 and Jerry P. Nolan5,6 © 2020 Springer-Verlag GmbH Germany, part of Springer Nature
About two-thirds of patients who are comatose after resuscitation from cardiac arrest die before hospital discharge, of whom two-thirds die from neurological injury [1]. In these patients, prognostication is crucial in informing clinicians and patient’s relatives so that appropriate care can be provided. In their 2015 guidelines on post-resuscitation care, the European Resuscitation Council and European Society of Intensive Care Medicine (ERC-ESICM) included a multimodal algorithm for predicting poor neurological outcome after cardiac arrest [2]. This algorithm is applicable to comatose, unsedated patients with a Glasgow Motor Score M ≤ 2 at ≥ 72 h after return of spontaneous circulation (ROSC) and includes bilateral absence of ocular reflexes and/or N20 waves of short-latency somatosensory evoked potentials (SSEPs) as first-line predictors, and a combination of second-line predictors including status myoclonus, high neuron-specific enolase (NSE) values, unreactive burst-suppression or status epilepticus on EEG, and signs of diffuse anoxic injury on brain CT or MRI. All these predictors individually had a high specificity and precision. However, their combination has yet to be prospectively validated. Recently, three studies from different groups of investigators have retrospectively assessed the accuracy of the 2015 ERC-ESICM prognostication algorithm. A singlecentre study from Zhou et al. [3] included 288 patients who remained unconscious for ≥ 24 h after ROSC. Among 207 survivors on day 3, the ERC-ESICM algorithm predicted an unfavourable 6-month outcome with
*Correspondence: [email protected] 1 Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario “Agostino Gemelli”-IRCCS, Largo Francesco Vito, 1, 00168 Rome, Italy Full author information is available at the end of the article
a 0% false-positive rate (FPR), compared with 15% FPR of an algorithm proposed in 2006 by the American Academy of Neurology [4]. The study was based on a retrospective chart review, which resulted in selection bias and missing data on several predictors. For instance, SSEPs and NSE were recorded in only 19% and 20% of patients, respectively, potentially underestimating their sensitivity. Among 174 patients who had poor outcome, only 48 (28%) were identified by the ERC-ESICM algorithm. A subsequent single-centre validation study published recently in this journal included 485 patients who were comatose on clinical examination performed off sedation between 48 and 72 h after ROSC [5]. Of these patients, 273 died or had severe neurological disability at 3 months, and the ERC-ESICM algorithm predicted poor outcome with 0% FPR in 155 (57%) of them. The study was conducted using prospectively collected data, which ensured a systematic use of progno
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