Golan Eyal, Barrett Kali, Alali Aziz S, Duggal Abhijit, Jichici Draga, Pinto Ruxandra, Morrison Laurie, Scales Damon C
1Interdepartmental Division of Critical Care and Department of Medicine, University of Toronto, Toronto, ON, Canada. 2Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada. 3Medical Intensive Care Unit, Respiratory Institute, Cleveland Clinic Foundation, Cleveland, OH. 4Division of Critical Care and Neurology, Department of Medicine, McMaster University, Hamilton, ON, Canada. 5Trauma, Emergency, and Critical Care Program, Sunnybrook Health Sciences Centre, Toronto, ON, Canada. 6Department of Emergency Medicine, St. Michael's Hospital, Toronto, ON, Canada. 7Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada. 8Rescu, Keenan Research Centre of the Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, ON, Canada. 9Department of Critical Care Medicine and Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada. 10Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.
Crit Care Med. 2014 Aug;42(8):1919-30. doi: 10.1097/CCM.0000000000000335.
Targeted temperature management improves survival and neurologic outcomes for adult out-of-hospital cardiac arrest survivors but may alter the accuracy of tests for predicting neurologic outcome after cardiac arrest.
We systematically searched Medline, Embase, CINAHL, and CENTRAL from database inception to September 2012.
Citations were screened for studies that examined diagnostic tests to predict poor neurologic outcome or death following targeted temperature management in adult cardiac arrest survivors.
Data on study outcomes and quality were abstracted in duplicate. We constructed contingency tables for each diagnostic test and calculated sensitivity, specificity, and positive and negative likelihood ratios.
Of 2,737 citations, 20 studies (n = 1,845) met inclusion criteria. Meta-analysis showed that three tests accurately predicted poor neurologic outcome with low false-positive rates: bilateral absence of pupillary reflexes more than 24 hours after a return of spontaneous circulation (false-positive rate, 0.02; 95% CI, 0.01-0.06; summary positive likelihood ratio, 10.45; 95% CI, 3.37-32.43), bilateral absence of corneal reflexes more than 24 hours (false-positive rate, 0.04; 95% CI, 0.01-0.09; positive likelihood ratio, 6.8; 95% CI, 2.52-18.38), and bilateral absence of somatosensory-evoked potentials between days 1 and 7 (false-positive rate, 0.03; 95% CI, 0.01-0.07; positive likelihood ratio, 12.79; 95% CI, 5.35-30.62). False-positive rates were higher for a Glasgow Coma Scale motor score showing extensor posturing or worse (false-positive rate, 0.09; 95% CI, 0.06-0.13; positive likelihood ratio, 7.11; 95% CI, 5.01-10.08), unfavorable electroencephalogram patterns (false-positive rate, 0.07; 95% CI, 0.04-0.12; positive likelihood ratio, 8.85; 95% CI, 4.87-16.08), myoclonic status epilepticus (false-positive rate, 0.05; 95% CI, 0.02-0.11; positive likelihood ratio, 5.58; 95% CI, 2.56-12.16), and elevated neuron-specific enolase (false-positive rate, 0.12; 95% CI, 0.06-0.23; positive likelihood ratio, 4.14; 95% CI, 1.82-9.42). The specificity of available tests improved when these were performed beyond 72 hours. Data on neuroimaging, biomarkers, or combination testing were limited and inconclusive.
Simple bedside tests and somatosensory-evoked potentials predict poor neurologic outcome for survivors of cardiac arrest treated with targeted temperature management, and specificity improves when performed beyond 72 hours. Clinicians should use caution with these predictors as they carry the inherent risk of becoming self-fulfilling.
目标温度管理可改善成年院外心脏骤停幸存者的生存率和神经功能结局，但可能会改变心脏骤停后预测神经功能结局的检测准确性。
我们系统检索了从数据库建立至2012年9月的Medline、Embase、CINAHL和CENTRAL数据库。
筛选文献，纳入那些对成年心脏骤停幸存者进行目标温度管理后预测神经功能不良结局或死亡的诊断检测的研究。
对研究结局和质量的数据进行双人提取。我们为每项诊断检测构建了列联表，并计算了敏感性、特异性以及阳性和阴性似然比。
在2737篇文献中，20项研究（n = 1845）符合纳入标准。荟萃分析表明，三项检测能够准确预测神经功能不良结局且假阳性率较低：自主循环恢复后24小时以上双侧瞳孔反射消失（假阳性率，0.02；95%可信区间，0.01 - 0.06；汇总阳性似然比，10.45；95%可信区间，3.37 - 32.43），24小时以上双侧角膜反射消失（假阳性率，0.04；95%可信区间，0.01 - 0.09；阳性似然比，6.8；95%可信区间，2.52 - 18.38），以及第1天至第7天双侧体感诱发电位消失（假阳性率，0.03；95%可信区间，0.01 - 0.07；阳性似然比，12.79；95%可信区间，5.35 - 30.62）。格拉斯哥昏迷量表运动评分显示伸展姿势或更差时假阳性率较高（假阳性率，0.09；95%可信区间，0.06 - 0.13；阳性似然比，7.11；95%可信区间，5.01 - 10.08），脑电图模式不良（假阳性率，0.07；95%可信区间，0.04 - 0.12；阳性似然比，8.85；95%可信区间，4.87 - 16.08），肌阵挛性癫痫持续状态（假阳性率，0.05；95%可信区间，0.02 - 0.11；阳性似然比，5.58；95%可信区间，2.56 - 12.16），以及神经元特异性烯醇化酶升高（假阳性率，0.12；95%可信区间，0.06 - 0.23；阳性似然比，4.14；95%可信区间，1.82 - 9.42）。当这些检测在72小时后进行时，现有检测的特异性有所提高。关于神经影像学、生物标志物或联合检测的数据有限且无定论。
简单的床旁检测和体感诱发电位可预测接受目标温度管理的心脏骤停幸存者的神经功能不良结局，且在72小时后进行时特异性会提高。临床医生在使用这些预测指标时应谨慎，因为它们存在自我实现的固有风险。
