Performance of a guideline-recommended algorithm for prognostication of poor neurological outcome after cardiac arrest
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ORIGINAL
Performance of a guideline‑recommended algorithm for prognostication of poor neurological outcome after cardiac arrest Marion Moseby‑Knappe1* , Erik Westhall2, Sofia Backman2, Niklas Mattsson‑Carlgren1,3,4, Irina Dragancea1, Anna Lybeck5, Hans Friberg6, Pascal Stammet7, Gisela Lilja1, Janneke Horn8, Jesper Kjaergaard9, Christian Rylander10, Christian Hassager9, Susann Ullén11, Niklas Nielsen12 and Tobias Cronberg1 © 2020 The Author(s)
Abstract 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 Cat‑ egory 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 eno‑ lase, 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. Keywords: Cardiac arrest, Prognostication, Guideline algorithm, Prognostic accuracy, Coma
*Correspondence: [email protected] 1 Department of Clinical Sciences Lund, Neurology, Skåne University Hospital, Lund University, Getingevägen 4, 222 41 Lund, Sweden Full author information is available at the end of the article
Introduction The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) published joint guidelines for neurological prognostication after cardiac arrest (CA) in 2014 and 2015 [1, 2]. The included algorithm consists of 4 separate steps and was based on the current level of evidence for individual methods and expert opinions about combinations of methods. According to ERC/ESICM, prediction of neurolo
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