Prognostication of post-cardiac arrest coma: early clinical and electroencephalographic predictors of outcome
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To determine the temporal evolution, clinical correlates, and prognostic significance of electroencephalographic (EEG) patterns in post-cardiac arrest comatose patients treated with hypothermia.
Prospective cohort study of consecutive post-anoxic patients receiving hypothermia and continuous EEG monitoring between May 2011 and June 2014 (n = 100). In addition to clinical variables, 5-min EEG clips at 6, 12, 24, 48, and 72 h after return of spontaneous circulation (ROSC) were reviewed. EEG background was classified according to the American Clinical Neurophysiological Society critical care EEG terminology. Clinical outcome at discharge was dichotomized as good [Glasgow outcome scale (GOS) 4–5, low to moderate disability] vs. poor (GOS 1–3, severe disability to death).
Non-ventricular fibrillation/tachycardia arrest, longer time to ROSC, absence of brainstem reflexes, extensor or no motor response, lower pH, higher lactate, hypotension requiring >2 vasopressors, and absence of reactivity on EEG were all associated with poor outcome (all p values ≤0.01). Suppression-burst at any time indicated a poor prognosis, with a 0 % false positive rate (FPR) [95 % confidence interval (CI) 0–10 %]. All patients (54/54) with suppression-burst or a low voltage (<20 µV) EEG at 24 h had a poor outcome, with an FPR of 0 % [95 % CI 0–8 %]. Normal background voltage ≥20 µV without epileptiform discharges at any time interval carried a positive predictive value >70 % for good outcome.
Suppression-burst or a low voltage at 24 h after ROSC was not compatible with good outcome in this series. Normal background voltage without epileptiform discharges predicted a good outcome.
KeywordsCardiac arrest Continuous EEG Prognostication Coma EEG reactivity Myoclonus
Conflicts of interest
The authors declare that they have no conflict of interest.
Adithya Sivaraju, MBBS, MHA: Dr. Sivaraju reports no disclosures. Emily Gilmore, MD: Dr. Gilmore is supported by Yale’s Center for Clinical Investigaton’s CTSA Grant (ULTR000142) and Yale’s Claude D. Pepper Older Americans Independence Center (P30AG021342 NIH/NIA). Charles R. Wira, MD: Dr. Wira reports no disclosures. Anna Stevens, MD, PhD: Dr. Stevens reports no disclosures. Nishi Rampal, MD: Dr. Rampal reports no disclosures. Jeremy J. Moeller, MD: Dr. Moeller has received royalties or payments from UpToDate, Inc., NeuroSeriesLive, QuantiaMD, and the Canadian Pharmacists’ Association. David M. Greer, MD: Dr. Greer reports no disclosures. Lawrence J. Hirsch, MD: Dr. Hirsch has received (a) research support to Yale for investigator-initiated studies from UCB-Pharma, Upsher-Smith, Lundbeck, Eisai, and Sunovion; consultation fees for advising from Lundbeck, Upsher-Smith, Neuropace, and Allergan; (b) honoraria for speaking from Natus and Neuropace; (c) royalties for authoring chapters for UpToDate-Neurology, and from Wiley for co-authoring the book Atlas of EEG in Critical Care, by Hirsch and Brenner, 2010.Nicolas Gaspard MD, PhD: Dr. Gaspard is a Clinical Master Specialist of the Belgian Fund for Scientific Research (FNRS) and received royalties for authoring chapters for UpToDate-Neurology. Dr. Sivaraju and Dr. Gaspard had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Selected findings of the manuscript were presented as a poster and platform presentation at the American Clinical Neurophysiological Society Meeting; February 7, 2015; Houston, Texas.
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