aDepartment of Intensive Care Medicine, University of Lausanne, CHUV-Lausanne University Hospital, Lausanne, Switzerland bDepartment of Clinical Sciences, Anesthesiology and Intensive Care Medicine, Lund University, Skåne University Hospital, Lund, Sweden.
Curr Opin Crit Care. 2017 Jun;23(3):244-250. doi: 10.1097/MCC.0000000000000406.
Delayed awakening after targeted temperature management (TTM) and sedation is frequent among cardiac arrest patients. Differentiating between prolonged coma and irreversible cerebral damage can be challenging, therefore the utilization of a multimodal approach is recommended by international guidelines. Here, we discuss indications and advantages/disadvantages of available modalities for coma prognostication and describe new tools to improve our accuracy for outcome prediction.
Studies from the TTM era confirmed that combining neurological examination with electrophysiological assessment [electroencephalography (EEG) and somato-sensory evoked potentials (SSEP)] greatly improves coma prognostication. This combination is nowadays recognized as the most useful by many clinicians and appears widely applicable as part of initial patient assessment. Additional tests (serum neuron specific enolase and neuroimaging) may be most useful to orient clinical decisions in patients with prolonged coma. Advanced analysis of EEG and SSEP recordings and the emergence of quantitative pupillometry hold great promise.
Multimodal prognostication offers a comprehensive approach of anoxic-ischemic encephalopathy and is increasingly used in postresuscitation care. Worldwide implementation and future advancements of available modalities, together with the increasing use of novel automated devices for quantitative neurological examination, may further optimize prognostic accuracy in the early ICU phase following cardiac arrest.
目标温度管理（TTM）和镇静后苏醒延迟在心脏骤停患者中很常见。区分长时间昏迷和不可逆的脑损伤具有挑战性，因此国际指南推荐采用多模态方法。在这里，我们讨论了用于昏迷预后评估的现有方法的适应证和优缺点，并描述了新的工具，以提高我们对预后预测的准确性。
TTM 时代的研究证实，将神经检查与电生理评估（脑电图（EEG）和体感诱发电位（SEP））相结合，极大地提高了昏迷的预后预测能力。这种组合现在被许多临床医生认为是最有用的，并且作为初始患者评估的一部分广泛适用。对于长时间昏迷的患者，其他测试（血清神经元特异性烯醇化酶和神经影像学）可能对指导临床决策最有用。脑电图和 SEP 记录的高级分析以及定量瞳孔测量的出现具有很大的前景。
多模态预后评估提供了一种全面的缺氧缺血性脑病评估方法，在心肺复苏后护理中越来越多地使用。现有方法的全球实施和未来的改进，以及新型自动定量神经检查设备的日益使用，可能会进一步优化心脏骤停后早期 ICU 阶段的预后准确性。
