Abstracts

RATIONALE: Neurological prognostication in patients resuscitated from cardiac arrest is commonly sought by intensive care unit (ICU) physicians. We studied the impact of neurological prognostication by clinical examination, CEP and EEG on the decision by ICU physicians and patients[ssquote] families on the withdrawal of life sustaining therapies (WLST) in patients after cardiac arrest.
METHODS: All patients who were resuscitated from cardiac arrest (CA) and referred for neurological consultation at the Johns Hopkins Bayview Medical Center for a period of 3 years were included in the study. Serial evaluation by clinical examinations and Glasgow Coma Score (GCS) was undertaken. EEG and CEP were performed during the first 72 period after CA and prospectively graded as benign, uncertain and malignant based on established protocols. Neurological prognostication based on the clinical evaluation and tests was given to the ICU team. The desicion to WLST was made by the patient[ssquote]s family with the help of the ICU team. Clinical outcomes include: alive at discharge (Group A), brain or cardiac death (Group D), and death from WLST (Group W). Group W was further divided into subgroups by EEG/CEP grades and clinical condition at the time of WLST. The duration from EEG/CEP testing to WLST was compared between subgroups.
RESULTS: Forty six patients were included in the study. Group A had 7 (15%), group D had 7 (15%) and group W had 32 (70%) patients. No significant difference in age range and place of CA was noted. For all groups, benign EEG was noted in 85% of A, 0% of D and 18% of W. Benign CEP was noted in 85% of A, 66% of D and 42% of W. Focusing on the subgroups of Group W and time from CEP/EEG testing to WLST, those with benign CEP were provided aggressive life-support and observed for 10.5[plusminus]2 days, those with uncertain CEP were observed for 3.1[plusminus]1 days and those with malignant CEP had 1.1[plusminus]0.3 days to WLST. Good grade CEP correlated strongly with longer period of aggressive support and clinical observation to WLST (Spearman Coefficient=0.80, p[lt]0.001). EEG grade did not correlate with the period of observation to WLST. GCS (range 3-4) was not significantly different for the subgroups of W immediately prior to the time of WLST.
CONCLUSIONS: Neurological prognostication based on grades of CEP significantly correlated with the duration of observation prior to WLST. A benign CEP correlated with more days of aggressive support by the ICU team and families before deciding on WLST. Low GCS noted immediately prior to WLST may have also influenced the decision to WLST.
[Supported by: Dr. Geocadin is supported in part by the Corporate Roundtable Clinical Research Training Fellowship Award of the American Academy of Neurology-Educational and Research Foundation.]