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The Influence of Therapeutics on Prognostication After Cardiac Arrest

  • Sachin AgarwalEmail author
  • Nicholas Morris
  • Caroline Der-Nigoghossian
  • Teresa May
  • Daniel Brodie
Critical Care Neurology (H Hinson, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Critical Care Neurology

Abstract

Purpose of review

The goal of this review is to highlight the influence of therapeutic maneuvers on neuro-prognostication measures administered to comatose survivors of cardiac arrest. We focus on the effect of sedation regimens in the setting of targeted temperature management (TTM), one of the principle interventions known to improve neurological recovery after cardiac arrest. Further, we discuss the critical need for novel markers, as well as refinement of existing markers, among patients receiving extracorporeal membrane oxygenation (ECMO) in the setting of failed conventional resuscitation, known as extracorporeal cardiopulmonary resuscitation (ECPR).

Recent findings

Automated pupillometry may have some advantage over standard pupillary examination for prognostication following TTM, sedation, or the use of ECMO after cardiac arrest. New serum biomarkers such as Neurofilament light chain have shown good predictive abilities and need further validation in these populations. There is a high-level uncertainty in brain death declaration protocols particularly related to apnea testing and appropriate ancillary tests in patients receiving ECMO.

Summary

Both sedation and TTM alone and in combination have been shown to affect prognostic markers to varying degrees. The optimal approach to analog-sedation is unknown, and requires further study. Moreover, validation of known prognostic markers, as well as brain death declaration processes in patients receiving ECMO is warranted. Data on the effects of TTM, sedation, and ECMO on biomarkers (e.g., neuron-specific enolase) and electrophysiology measures (e.g., somatosensory-evoked potentials) is sparse. The best approach may be one customized to the individual patient, a precision-medicine approach.

Keywords

Cardiac arrest Neuro-prognostication Analgo-sedation Targeted temperature management Extracorporeal membrane oxygenation 

Notes

Compliance with Ethical Standards

Conflict of Interest

Sachin Agarwal, Nicholas Morris, Caroline Der-Nigoghossian, and Teresa May each declare no potential conflicts of interest.

Daniel Brodie reports a grant from ALung Technologies, personal fees from Baxter, and serves and/or served as a member of the Medical Advisory Boards for ALung Technologies, Hemovent, BREETHE, and Xenios.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Supplementary material

11940_2019_602_MOESM1_ESM.docx (15 kb)
Supplementary Table 1 (DOCX 14 kb)

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Sachin Agarwal
    • 1
    Email author
  • Nicholas Morris
    • 2
  • Caroline Der-Nigoghossian
    • 3
  • Teresa May
    • 4
  • Daniel Brodie
    • 5
  1. 1.Division of Neurocritical Care and Hospitalist Neurology, Department of NeurologyNew York-Presbyterian Hospital/Columbia University Irving Medical CenterNew YorkUSA
  2. 2.Department of Neurology, Program in TraumaUniversity of Maryland Medical CenterBaltimoreUSA
  3. 3.Clinical PharmacyNew York-Presbyterian Hospital/Columbia University Irving Medical CenterNew YorkUSA
  4. 4.Division of Pulmonary and Critical Care MedicineMaine Medical CenterPortlandUSA
  5. 5.Division of Pulmonary, Allergy and Critical Care Medicine, Department of MedicineNew York-Presbyterian Hospital/Columbia University Irving Medical CenterNew YorkUSA

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