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Prognostication of neurologic outcome in cardiac arrest patients after mild therapeutic hypothermia: a meta-analysis of the current literature

M. J. A. Kamps| J. Horn| M. Oddo| J. E. Fugate| C. Storm| T. Cronberg| C. A. Wijman| O. Wu| J. M. Binnekade| C. W. E. Hoedemaekers
Systematic Review
Volume 39, Issue 10 / October , 2013

Pages 1671 - 1682

Abstract

Purpose

To assess the sensitivity and false positive rate (FPR) of neurological examination and somatosensory evoked potentials (SSEPs) to predict poor outcome in adult patients treated with therapeutic hypothermia after cardiopulmonary resuscitation (CPR).

Methods

MEDLINE and EMBASE were searched for cohort studies describing the association of clinical neurological examination or SSEPs after return of spontaneous circulation with neurological outcome. Poor outcome was defined as severe disability, vegetative state and death. Sensitivity and FPR were determined.

Results

A total of 1,153 patients from ten studies were included. The FPR of a bilaterally absent cortical N20 response of the SSEP could be calculated from nine studies including 492 patients. The SSEP had an FPR of 0.007 (confidence interval, CI, 0.001–0.047) to predict poor outcome. The Glasgow coma score (GCS) motor response was assessed in 811 patients from nine studies. A GCS motor score of 1–2 at 72 h had a high FPR of 0.21 (CI 0.08–0.43). Corneal reflex and pupillary reactivity at 72 h after the arrest were available in 429 and 566 patients, respectively. Bilaterally absent corneal reflexes had an FPR of 0.02 (CI 0.002–0.13). Bilaterally absent pupillary reflexes had an FPR of 0.004 (CI 0.001–0.03).

Conclusions

At 72 h after the arrest the motor response to painful stimuli and the corneal reflexes are not a reliable tool for the early prediction of poor outcome in patients treated with hypothermia. The reliability of the pupillary response to light and the SSEP is comparable to that in patients not treated with hypothermia.

Keywords

References

  1. Wijdicks EF, Hijdra A, Young GB, Bassetti CL, Wiebe S (2006) Practice parameter: prediction of outcome in comatose survivors after cardiopulmonary resuscitation (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 67:203–210
    • View reference on PubMed
    • View reference on publisher's website
  2. Nolan JP, Morley PT, Vanden Hoek TL, Hickey RW, Kloeck WG, Billi J, Bottiger BW, Okada K, Reyes C, Shuster M, Steen PA, Weil MH, Wenzel V, Carli P, Atkins D (2003) Therapeutic hypothermia after cardiac arrest: an advisory statement by the advanced life support task force of the International Liaison Committee on Resuscitation. Circulation 108:118–121
    • View reference on PubMed
    • View reference on publisher's website
  3. Polderman KH, Herold I (2009) Therapeutic hypothermia and controlled normothermia in the intensive care unit: practical considerations, side effects, and cooling methods. Crit Care Med 37:1101–1120
    • View reference on PubMed
    • View reference on publisher's website
  4. Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, Moher D, Becker BJ, Sipe TA, Thacker SB (2000) Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis of observational studies in epidemiology (MOOSE) group. JAMA 283:2008–2012
    • View reference on PubMed
    • View reference on publisher's website
  5. Reitsma JB, Glas AS, Rutjes AW, Scholten RJ, Bossuyt PM, Zwinderman AH (2005) Bivariate analysis of sensitivity and specificity produces informative summary measures in diagnostic reviews. J Clin Epidemiol 58:982–990
    • View reference on PubMed
    • View reference on publisher's website
  6. Higgins JP, Thompson SG (2002) Quantifying heterogeneity in a meta-analysis. Stat Med 21:1539–1558
    • View reference on PubMed
    • View reference on publisher's website
  7. Bisschops LL, van Alfen N, Bons S, van der Hoeven JG, Hoedemaekers CW (2011) Predictors of poor neurologic outcome in patients after cardiac arrest treated with hypothermia: a retrospective study. Resuscitation 82:696–701
    • View reference on PubMed
    • View reference on publisher's website
  8. Bouwes A, Binnekade JM, Kuiper MA, Bosch FH, Zandstra DF, Toornvliet AC, Biemond HS, Kors BM, Koelman JH, Verbeek MM, Weinstein HC, Hijdra A, Horn J (2012) Prognosis of coma after therapeutic hypothermia: a prospective cohort study. Ann Neurol 71:206–212
    • View reference on PubMed
    • View reference on publisher's website
  9. Bouwes A, Binnekade JM, Zandstra DF, Koelman JH, van Schaik IN, Hijdra A, Horn J (2009) Somatosensory evoked potentials during mild hypothermia after cardiopulmonary resuscitation. Neurology 73:1457–1461
    • View reference on PubMed
    • View reference on publisher's website
  10. Cronberg T, Rundgren M, Westhall E, Englund E, Siemund R, Rosen I, Widner H, Friberg H (2011) Neuron-specific enolase correlates with other prognostic markers after cardiac arrest. Neurology 77:623–630
    • View reference on PubMed
    • View reference on publisher's website
  11. Fugate JE, Wijdicks EF, Mandrekar J, Claassen DO, Manno EM, White RD, Bell MR, Rabinstein AA (2010) Predictors of neurologic outcome in hypothermia after cardiac arrest. Ann Neurol 68:907–914
    • View reference on PubMed
    • View reference on publisher's website
  12. Leithner C, Ploner CJ, Hasper D, Storm C (2010) Does hypothermia influence the predictive value of bilateral absent N20 after cardiac arrest? Neurology 74:965–969
    • View reference on PubMed
    • View reference on publisher's website
  13. Rossetti AO, Oddo M, Logroscino G, Kaplan PW (2010) Prognostication after cardiac arrest and hypothermia: a prospective study. Ann Neurol 67:301–307
    • View reference on PubMed
  14. Rossetti AO, Urbano LA, Delodder F, Kaplan PW, Oddo M (2010) Prognostic value of continuous EEG monitoring during therapeutic hypothermia after cardiac arrest. Crit Care 14:R173
    • View reference on PubMed
    • View reference on publisher's website
  15. Samaniego EA, Mlynash M, Caulfield AF, Eyngorn I, Wijman CA (2011) Sedation confounds outcome prediction in cardiac arrest survivors treated with hypothermia. Neurocrit Care 15:113–119
    • View reference on PubMed
    • View reference on publisher's website
  16. Wu O, Batista LM, Lima FO, Vangel MG, Furie KL, Greer DM (2011) Predicting clinical outcome in comatose cardiac arrest patients using early noncontrast computed tomography. Stroke 42:985–992
    • View reference on PubMed
    • View reference on publisher's website
  17. Fugate JE, Wijdicks EF, White RD, Rabinstein AA (2011) Does therapeutic hypothermia affect time to awakening in cardiac arrest survivors? Neurology 77:1346–1350
    • View reference on PubMed
    • View reference on publisher's website
  18. Polderman KH (2009) Mechanisms of action, physiological effects, and complications of hypothermia. Crit Care Med 37:S186–S202
    • View reference on PubMed
    • View reference on publisher's website
  19. Fukuoka N, Aibiki M, Tsukamoto T, Seki K, Morita S (2004) Biphasic concentration change during continuous midazolam administration in brain-injured patients undergoing therapeutic moderate hypothermia. Resuscitation 60:225–230
    • View reference on PubMed
    • View reference on publisher's website
  20. Tortorici MA, Kochanek PM, Poloyac SM (2007) Effects of hypothermia on drug disposition, metabolism, and response: a focus of hypothermia-mediated alterations on the cytochrome P450 enzyme system. Crit Care Med 35:2196–2204
    • View reference on PubMed
    • View reference on publisher's website
  21. Bjelland TW, Klepstad P, Haugen BO, Nilsen T, Dale O (2013) Effects of hypothermia on the disposition of morphine, midazolam, fentanyl, and propofol in intensive care unit patients. Drug Metab Dispos 41:214–223
    • View reference on PubMed
    • View reference on publisher's website
  22. Zandbergen EG, Hijdra A, de Haan RJ, van Dijk JG, Ongerboer de Visser BW, Spaans F, Tavy DL, Koelman JH (2006) Interobserver variation in the interpretation of SSEPs in anoxic-ischaemic coma. Clin Neurophysiol 117:1529–1535
    • View reference on PubMed
    • View reference on publisher's website

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