Protocol-driven neurological prognostication and withdrawal of life-sustaining therapy after cardiac arrest and targeted temperature management
| Autor: | Guy Glover, Tobias Cronberg, Matt P. Wise, Nawaf Al-Subaie, Andrew Walden, Hans Friberg, Rebecca Rylance, Julius Cranshaw, Tommaso Pellis, Irina Dragancea, Niklas Nielsen |
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| Rok vydání: | 2017 |
| Předmět: |
Male
medicine.medical_specialty Time Factors Randomization medicine.medical_treatment Decision Making Kaplan-Meier Estimate Emergency Nursing Targeted temperature management Hypothermia induced 03 medical and health sciences 0302 clinical medicine Hypothermia Induced medicine Humans Prospective Studies Cardiopulmonary resuscitation Intensive care medicine Prospective cohort study Aged Cause of death Withholding Treatment business.industry 030208 emergency & critical care medicine Middle Aged Prognosis Cardiopulmonary Resuscitation Log-rank test Emergency medicine Emergency Medicine Female Cardiology and Cardiovascular Medicine business Medical Futility Out-of-Hospital Cardiac Arrest 030217 neurology & neurosurgery |
| Zdroj: | Resuscitation. 117:50-57 |
| ISSN: | 0300-9572 |
| DOI: | 10.1016/j.resuscitation.2017.05.014 |
| Popis: | 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 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. |
| Databáze: | OpenAIRE |
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