小儿心脏骤停后的神经预后评估
Neuroprognostication after pediatric cardiac arrest.
作者信息
Kirschen Matthew P, Topjian Alexis A, Hammond Rachel, Illes Judy, Abend Nicholas S
机构信息
Division of Neurology, Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Anesthesia and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
Department of Anesthesia and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
出版信息
Pediatr Neurol. 2014 Nov;51(5):663-668.e2. doi: 10.1016/j.pediatrneurol.2014.07.026. Epub 2014 Jul 24.
BACKGROUND
Management decisions and parental counseling after pediatric cardiac arrest depend on the ability of physicians to make accurate and timely predictions regarding neurological recovery. We evaluated neurologists and intensivists performing neuroprognostication after cardiac arrest to determine prediction agreement, accuracy, and confidence.
METHODS
Pediatric neurologists (n = 10) and intensivists (n = 9) reviewed 18 cases of children successfully resuscitated from a cardiac arrest and managed in the pediatric intensive care unit. Cases were sequentially presented (after arrest day 1, days 2-4, and days 5-7), with updated examinations, neurophysiologic data, and neuroimaging data. At each time period, physicians predicted outcome by Pediatric Cerebral Performance Category and specified prediction confidence.
RESULTS
Predicted discharge Pediatric Cerebral Performance Category versus actual hospital discharge Pediatric Cerebral Performance Category outcomes were compared. Exact (Predicted Pediatric Cerebral Performance Category - Actual Pediatric Cerebral Performance Category = 0) and close (Predicted Pediatric Cerebral Performance Category - Actual Pediatric Cerebral Performance Category = ±1) outcome prediction accuracies for all physicians improved over successive periods (P < 0.05). Prediction accuracy did not differ significantly between physician groups at any period or overall. Agreement improved over time among neurologists (day 1 Kappa [κ], 0.28; days 2-4 κ, 0.43; days 5-7 κ, 0.68) and among intensivists (day 1 κ, 0.30; days 2-4 κ, 0.44; days 5-7 κ, 0.57). Prediction confidence increased over time (P < 0.001) and did not differ between physician groups.
CONCLUSIONS
Inter-rater agreement among neurologists and among intensivists improved over time and reached moderate levels. For all physicians, prediction accuracy and confidence improved over time. Further prospective research is needed to better characterize how physicians objectively and subjectively estimate neurological recovery after acute brain injury.
背景
小儿心脏骤停后的管理决策及对家长的咨询取决于医生对神经功能恢复做出准确、及时预测的能力。我们评估了在心脏骤停后进行神经预后评估的神经科医生和重症监护医生，以确定预测的一致性、准确性和可信度。
方法
小儿神经科医生（n = 10）和重症监护医生（n = 9）回顾了18例成功从心脏骤停中复苏并在儿科重症监护病房接受治疗的儿童病例。病例按顺序呈现（心脏骤停后第1天、第2 - 4天和第5 - 7天），同时提供更新的检查、神经生理学数据和神经影像学数据。在每个时间段，医生根据小儿脑功能表现分类预测结果，并指定预测可信度。
结果
比较预测出院时的小儿脑功能表现分类与实际出院时的小儿脑功能表现分类结果。所有医生在连续时间段内的精确（预测小儿脑功能表现分类 - 实际小儿脑功能表现分类 = 0）和接近（预测小儿脑功能表现分类 - 实际小儿脑功能表现分类 = ±1）结果预测准确性均有所提高（P < 0.05）。在任何时间段或总体上，医生组之间的预测准确性无显著差异。随着时间的推移，神经科医生之间（第1天卡方值[κ]，0.28；第2 - 4天κ，0.43；第5 - 7天κ，0.68）和重症监护医生之间（第1天κ，0.30；第2 - 4天κ，0.44；第5 - 7天κ，0.57）的一致性有所提高。预测可信度随时间增加（P < 0.001），且医生组之间无差异。
结论
神经科医生之间和重症监护医生之间的评分者间一致性随时间提高并达到中等水平。对于所有医生而言，预测准确性和可信度随时间提高。需要进一步的前瞻性研究，以更好地描述医生如何客观和主观地评估急性脑损伤后的神经功能恢复情况。
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