[en] [en] PURPOSE: To explore modifications of the 2021 European Resuscitation Council/European Society of Intensive Care Medicine (ERC/ESICM) guideline algorithm for neuroprognostication after cardiac arrest to improve its prognostic accuracy.
METHODS: Post-hoc analysis of four prospective multicentre studies (TTM, TTM2, KORHN and ProNeCA). We raised the Glasgow Coma Scale motor (GCS-M) inclusion threshold at 72 hours after cardiac arrest from the current GCS-M<4 to GCS-M<6 (all unconscious patients). Secondly, we included good outcome predictors (GCS-M 4-5, neuron-specific enolase <17 µg/L, benign electroencephalography patterns ≤72 hours post-arrest and normal magnetic resonance imaging at 72-168 hours post-arrest) in the algorithm. Functional outcome was assessed dichotomously at six months, including modified Rankin Scale 0-3, Cerebral Performance Category 1-2 or Glasgow Outcome Scale 4-5 (no symptoms to moderate disability) as good outcome.
RESULTS: We analysed 3,388 patients, of whom 2,079 had GCS-M<4 at ≥72 hours. Of the 874 patients identified by the 2021 ERC/ESICM poor outcome criteria, 870 had poor functional outcome (specificity: 99.6% [95%CI 99.0-99.9]). Using the GCS-M<6 threshold, 366 more patients entered the algorithm (N=2,445). Seven more patients with poor outcomes were identified, with close to identical specificity. Good outcome predictors thereafter identified 673 patients with potential recovery, of whom 411 (61%) had a good functional outcome at six months. With the updated algorithm, the number of prognosticated patients with an indeterminate prognosis decreased from 1,205/2,079 (58%) to 891/2,445 (36%).
CONCLUSION: Raising the GCS-M inclusion threshold and adding favourable predictors to the 2021 ERC/ESICM prognostication algorithm reduced prognostic uncertainty without increasing falsely pessimistic predictions.
Disciplines :
Anesthesia & intensive care
Author, co-author :
Lagebrant, Alice ; Department of Clinical Sciences Lund, Lund University, Lund, Sweden, Department of Neurology, Skåne University Hospital, Malmö, Sweden. Electronic address: alice.lagebrant@med.lu.se
Sandroni, Claudio; Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario "Agostino Gemelli"-IRCCS, Largo Francesco Vito, 1, Rome, Italy, Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
Nolan, Jerry P; Warwick Clinical Trials Unit, University of Warwick, UK, Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK
Bělohlávek, Jan; Department of Internal Medicine II, Cardiovascular Medicine, General University, 1st Faculty of Medicine, Charles University Prague, Czech Republic, Institute for Heart Diseases, Wroclaw Medical University, Wrocław, Poland Hospital
Cariou, Alain; Medical Intensive Care unit, Cochin University Hospital, AP-HP Centre Université Paris Cité, Paris, France
Dankiewicz, Josef; Department of Clinical Sciences Lund, Lund University, Lund, Sweden, Department of Cardiology, Skåne University Hospital, Lund, Sweden
Grejs, Anders Morten; Department of Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
Hassager, Christian; Department of Cardiology, Rigshospitalet, Copenhagen, Denmark, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
Horn, Janneke; Department of Intensive Care, Amsterdam Neurosciences, Academic Medical Center, Amsterdam, The Netherlands
Haenggi, Matthias; Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
Jakobsen, Janus C; Copenhagen Trial Unit, Centre for Clinical Intervention Research, Capital Region of Denmark, Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Denmark
Keeble, Thomas R; Essex Cardiothoracic Centre, Nethermayne, Basildon, Essex, UK, ARU School of Medicine & MTRC, Chelmsford, Essex, UK
Kirkegaard, Hans; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark, Research Center for Emergency Medicine, Emergency Department, Aarhus University Hospital, Denmark
Kjaergaard, Jesper; Department of Cardiology, Rigshospitalet, Copenhagen, Denmark, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
Kuiper, Michael A; Department of Intensive Care, Frisius Medical Center Leeuwarden, The Netherlands
Lee, Byung Kook; Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea, Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
Lee, Dong Hun; Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea, Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
Levin, Helena; Department of Clinical Sciences Lund, Lund University, Lund, Sweden, Department of Research, Development, Education and Innovation, Skåne University Hospital, Lund, Sweden
Lilja, Gisela; Department of Clinical Sciences Lund, Lund University, Lund, Sweden, Department of Neurology, Skåne University Hospital, Lund, Sweden
Lundin, Andreas; Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
Nielsen, Niklas; Department of Clinical Sciences Lund, Lund University, Lund, Sweden, Department of Anesthesia and Intensive Care, Intensive Care Unit, Helsingborg Hospital, Helsingborg, Sweden
Oh, Sang Hoon; Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
Park, Kyu Nam; Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
Pellis, Tommaso; Department of Anesthesia and Intensive Care, Pordenone Hospital, Azienda Sanitaria Friuli Occidentale, Italy
Robba, Chiara; IRCCS Policlinico San Martino Genova Italy, Dipartimento di Scienze Chirurgiche Diagnostiche e Integrate, University of Genoa, Italy
Rylander, Christian; Department of Surgical Sciences, Anaesthesiology and Intensive Care, Uppsala University, Uppsala, Sweden
Ryu, Seok Jin; Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea, Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
Saxena, Manoxj; Division of Critical Care and Trauma, George Institute for Global Health, Sydney, NSW, Australia, Intensive Care Unit, St George Hospital, Sydney, Australia
Schrag, Claudia; Clinic for Intensive Care Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
STAMMET, Pascal ; University of Luxembourg > Faculty of Science, Technology and Medicine (FSTM) > Department of Life Sciences and Medicine (DLSM) > Medical Education
Storm, Christian; Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Berlin
Taccone, Fabio Silvio; Université Libre de Bruxelles, Brussels, Belgium, Department of Intensive Care, Hôpital Universitaire de Bruxelles, Brussels, Belgium
Thomas, Matthew; Dept of Intensive Care, University Hospitals Bristol and Weston, UK
Westhall, Erik; Department of Clinical Sciences Lund, Lund University, Lund, Sweden, Department of Clinical Neurophysiology, Skåne University Hospital, Lund, Sweden
Wise, Matt P; Adult Critical Care, University Hospital of Wales, Cardiff, UK
Youn, Chun Song; Department of Emergency Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
Young, Paul; Medical Research Institute of New Zealand, Wellington, New Zealand, Intensive Care Unit, Wellington Regional Hospital, Wellington, New Zealand, Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia, Department of Critical Care, University of Melbourne, Parkville, VIC, Australia
Cronberg, Tobias; Department of Clinical Sciences Lund, Lund University, Lund, Sweden, Department of Neurology, Skåne University Hospital, Lund, Sweden
Moseby-Knappe, Marion; Department of Clinical Sciences Lund, Lund University, Lund, Sweden, Department of Rehabilitation, Skåne University Hospital, Lund, Sweden
Nolan, J.P., Cariou, A., Post-resuscitation care: ERC–ESICM guidelines 2015. Intensive Care Med 41:12 (2015), 2204–2206.
Nolan, J.P., Sandroni, C., Böttiger, B.W., et al. European resuscitation council and European society of intensive care medicine guidelines 2021: post-resuscitation care. Intensive Care Med 47:4 (2021), 369–421.
Perkins, G.D., Callaway, C.W., Haywood, K., et al. Brain injury after cardiac arrest. Lancet 398:10307 (2021), 1269–1278.
Moseby-Knappe, M., Pellis, T., Dragancea, I., et al. Head computed tomography for prognostication of poor outcome in comatose patients after cardiac arrest and targeted temperature management. Resuscitation 119 (2017), 89–94.
Youn, C.S., Park, K.N., Kim, S.H., et al. External validation of the 2020 ERC/ESICM prognostication strategy algorithm after cardiac arrest. Crit Care, 26(1), 2022, 95.
Moseby-Knappe, M., Westhall, E., Backman, S., et al. Performance of a guideline-recommended algorithm for prognostication of poor neurological outcome after cardiac arrest. Intensive Care Med 46:10 (2020), 1852–1862.
Arctaedius, I., Levin, H., Larsson, M., et al. 2021 European resuscitation council/european society of intensive care medicine algorithm for prognostication of poor neurological outcome after cardiac arrest-can entry criteria be broadened?. Crit Care Med 52:4 (2024), 531–541.
Bongiovanni, F., Romagnosi, F., Barbella, G., et al. Standardized EEG analysis to reduce the uncertainty of outcome prognostication after cardiac arrest. Intensive Care Med 46:5 (2020), 963–972.
Bougouin, W., Lascarrou, J.B., Chelly, J., et al. Performance of the ERC/ESICM-recommendations for neuroprognostication after cardiac arrest: Insights from a prospective multicenter cohort. Resuscitation, 202, 2024, 110362.
Sandroni, C., D'Arrigo, S., Cacciola, S., et al. Prediction of good neurological outcome in comatose survivors of cardiac arrest: a systematic review. Intensive Care Med 48:4 (2022), 389–413.
Berg, K.M., Bray, J.E., Ng, K.C., et al. 2023 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations: summary from the basic life support; advanced life support; pediatric life support; neonatal life support; education, implementation, and teams; and first aid task forces. Circulation 148:24 (2023), e187–e280.
Nielsen, N., Wetterslev, J., Cronberg, T., et al. Targeted temperature management at 33°C versus 36°C after cardiac arrest. N Engl J Med 369:23 (2013), 2197–2206.
Dankiewicz, J., Cronberg, T., Lilja, G., et al. Hypothermia versus normothermia after out-of-hospital cardiac arrest. N Engl J Med 384:24 (2021), 2283–2294.
Kim, S.H., Park, K.N., Youn, C.S., et al. Outcome and status of postcardiac arrest care in Korea: results from the Korean Hypothermia Network prospective registry. Clin Exp Emerg Med 7:4 (2020), 250–258.
Scarpino, M., Lolli, F., Lanzo, G., et al. Neurophysiology and neuroimaging accurately predict poor neurological outcome within 24 hours after cardiac arrest: the ProNeCA prospective multicentre prognostication study. Resuscitation 143 (2019), 115–123.
Nielsen, N., Wetterslev, J., al-Subaie, N., Andersson, B., et al. Target Temperature Management after out-of-hospital cardiac arrest–a randomized, parallel-group, assessor-blinded clinical trial–rationale and design. Am. Heart J 163:4 (2012), 541–548.
Dankiewicz, J., Cronberg, T., Lilja, G., et al. Targeted hypothermia versus targeted Normothermia after out-of-hospital cardiac arrest (TTM2): a randomized clinical trial-rationale and design. Am Heart J 217 (2019), 23–31.
Teasdale, G., Jennett, B., Assessment of coma and impaired consciousness. A Practical Scale. Lancet 2:7872 (1974), 81–84.
Teasdale, G., Jennett, B., Assessment and prognosis of coma after head injury. Acta Neurochir (Wien) 34:1–4 (1976), 45–55.
Streitberger, K.J., Endisch, C., Ploner, C.J., et al. Timing of brain computed tomography and accuracy of outcome prediction after cardiac arrest. Resuscitation 145 (2019), 8–14.
Wang, G.N., Zhang, Z.M., Chen, W., Xu, X.Q., Zhang, J.S., Timing of brain computed tomography for predicting neurological prognosis in comatose cardiac arrest survivors: a retrospective observational study. World J Emerg Med 13:5 (2022), 349–354.
Greif, R., Bray, J.E., Djärv, T., et al. 2024 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations: summary from the basic life support; advanced life support; pediatric life support; neonatal life support; education, implementation, and teams; and first aid task forces. Circulation 150:24 (2024), e580–e687.
Haywood, K., Whitehead, L., Nadkarni, V.M., et al. COSCA (Core outcome set for cardiac arrest) in adults: an advisory statement from the international liaison committee on resuscitation. Circulation 137:22 (2018), e783–e801.
Rankin, J., Cerebral vascular accidents in patients over the age of 60. II. Prognosis. Scott Med J 2:5 (1957), 200–215.
Lemiale, V., Dumas, F., Mongardon, N., et al. Intensive care unit mortality after cardiac arrest: the relative contribution of shock and brain injury in a large cohort. Intensive Care Med 39:11 (2013), 1972–1980.
Sandroni, C., Cronberg, T., Sekhon, M., Brain injury after cardiac arrest: pathophysiology, treatment, and prognosis. Intensive Care Med 47:12 (2021), 1393–1414.
Dragancea, I., Wise, M.P., Al-Subaie, N., et al. Protocol-driven neurological prognostication and withdrawal of life-sustaining therapy after cardiac arrest and targeted temperature management. Resuscitation 117 (2017), 50–57.
Nobile, L., Taccone, F.S., Szakmany, T., et al. The impact of extracerebral organ failure on outcome of patients after cardiac arrest: an observational study from the ICON database. Crit Care, 20(1), 2016, 368.
Taccone, F.S., Horn, J., Storm, C., et al. Death after awakening from post-anoxic coma: the “Best CPC” project. Crit Care, 23(1), 2019, 107.
Steinberg, A., Callaway, C.W., Arnold, R.M., et al. Prognostication after cardiac arrest: results of an international, multi-professional survey. Resuscitation 138 (2019), 190–197.
Vlachos, S., Rubenfeld, G., Menon, D., Harrison, D., Rowan, K., Maharaj, R., Early and late withdrawal of life-sustaining treatment after out-of-hospital cardiac arrest in the United Kingdom: institutional variation and association with hospital mortality. Resuscitation, 193, 2023, 109956.
Elmer, J., Torres, C., Aufderheide, T.P., et al. Association of early withdrawal of life-sustaining therapy for perceived neurological prognosis with mortality after cardiac arrest. Resuscitation 102 (2016), 127–135.
May, T.L., Ruthazer, R., Riker, R.R., et al. Early withdrawal of life support after resuscitation from cardiac arrest is common and may result in additional deaths. Resuscitation 139 (2019), 308–313.
Lagebrant A, Lee BK, Youn CH et al. Effects of withdrawal of life-sustaining therapy on long-term neurological outcome after cardiac arrest - a multicentre matched cohort study. In review.
Bang, H.J., Youn, C.S., Sandroni, C., et al. Good outcome prediction after out-of-hospital cardiac arrest: a prospective multicenter observational study in Korea (the KORHN-PRO registry). Resuscitation, 199, 2024, 110207.
