Sandroni Claudio, Geocadin Romergryko G
aDepartment of Anesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy bDepartments of Neurology and Neurosurgery, Division of Neurosciences Critical Care Medicine cDepartment of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
Curr Opin Crit Care. 2015 Jun;21(3):209-14. doi: 10.1097/MCC.0000000000000202.
Prediction of neurological prognosis in patients who are comatose after successful resuscitation from cardiac arrest remains difficult. Previous guidelines recommended ocular reflexes, somatosensory evoked potentials and serum biomarkers for predicting poor outcome within 72 h from cardiac arrest. However, these guidelines were based on patients not treated with targeted temperature management and did not appropriately address important biases in literature.
Recent evidence reviews detected important limitations in prognostication studies, such as low precision and, most importantly, lack of blinding, which may have caused a self-fulfilling prophecy and overestimated the specificity of index tests. Maintenance of targeted temperature using sedatives and muscle relaxants may interfere with clinical examination, making assessment of neurological status before 72 h or more after cardiac arrest unreliable.
No index predicts poor neurological outcome after cardiac arrest with absolute certainty. Prognostic evaluation should start not earlier than 72 h after ROSC and only after major confounders have been excluded so that reliable clinical examination can be made. Multimodality appears to be the most reasonable approach for prognostication after cardiac arrest.
对于心脏骤停成功复苏后昏迷患者的神经学预后预测仍然困难。既往指南推荐使用眼反射、体感诱发电位和血清生物标志物来预测心脏骤停后72小时内的不良预后。然而，这些指南是基于未接受目标温度管理治疗的患者制定的，且未适当解决文献中的重要偏倚问题。
近期的证据综述发现预后研究存在重要局限性，如准确性低，最重要的是缺乏盲法，这可能导致自我实现预言并高估了指标检测的特异性。使用镇静剂和肌肉松弛剂维持目标温度可能会干扰临床检查，使得在心脏骤停后72小时或更长时间之前评估神经状态不可靠。
没有任何指标能绝对确定地预测心脏骤停后的不良神经学结局。预后评估不应早于自主循环恢复后72小时，且只有在排除主要混杂因素后才能进行可靠的临床检查。多模式方法似乎是心脏骤停后预后评估最合理的方法。
