Irina Dragancea1, Matthew P Wise2, Nawaf Al-Subaie3, Julius Cranshaw4, Hans Friberg5, Guy Glover6, Tommaso Pellis7, Rebecca Rylance8, Andrew Walden9, Niklas Nielsen10, Tobias Cronberg11. 1. Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Neurology, Lund, Sweden. Electronic address: irina.dragancea@med.lu.se. 2. Adult Critical Care, University of Wales, Cardiff, UK. 3. Department of Intensive Care, St. George's University Hospital, London, UK. 4. Department of Intensive Care, Royal Bournemouth Hospital, Bournemouth, UK. 5. Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Anesthesia & Intensive Care, Lund, Sweden. 6. Department of Intensive Care, Guy's and St. Thomas NHS Trust, King's College Hospital, London, UK. 7. Intensive Care Unit, Santa Maria degli Angeli, Pordenone, Italy. 8. R&D Centre Skåne, Skåne University Hospital, Lund, Sweden. 9. Department of Intensive Care, Royal Berkshire Hospital, Reading, UK. 10. Lund University, Helsingborg Hospital, Department of Clinical Sciences Lund, Anesthesia & Intensive Care, Lund, Sweden. 11. Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Neurology, Lund, Sweden.
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. RESULTS:Of 939 patients, 452 (48%) woke and 139 (15%) died, mostly for non-neurological reasons, before a scheduled time point for neurological prognostication (72h 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.
RCT Entities:
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 (72h 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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