Emergency Department, Chelsea and Westminster Hospital, 369 Fulham Road, Chelsea, London, SW10 9NH, England.
Kings College London, Room No 213, St Thomas' House, Westminster Bridge Road, London, SE1 7EH, England.
Syst Rev. 2019 Nov 25;8(1):286. doi: 10.1186/s13643-019-1209-z.
Despite advances in resuscitation care, mortality rates following cardiac arrest (CA) remain high. Between one-quarter (in-hospital CA) and two-thirds (out of hospital CA) of patients admitted comatose to intensive care die of neurological injury. Neuroprognostication determines an informed and timely withdrawal of life sustaining treatment (WLST), sparing the patient unnecessary suffering, alleviating family distress and allowing a more utilitarian use of resources. The latest Resuscitation Council UK (2015) guidance on post-resuscitation care provides the current multi-modal neuroprognostication strategy to predict neurological outcome. Its modalities include neurological examination, neurophysiological tests, biomarkers and radiology. Despite each of the current strategy's predictive modalities exhibiting limitations, meta-analyses show that three, namely PLR (pupillary light reflex), CR (corneal reflex) and N20 SSEP (somatosensory-evoked potential), accurately predict poor neurological outcome with low false positive rates. However, the quality of evidence is low, reducing confidence in the strategy's results. While infrared pupillometry (IRP) is not currently used as a prognostication modality, it can provide a quantitative and objective measure of pupillary size and PLR, giving a definitive view of the second and third cranial nerve activity, a predictor of neurological outcome.
The proposed study will test the hypothesis, "in those patients who remain comatose following return of spontaneous circulation (ROSC) after CA, IRP can be used early to help predict poor neurological outcome". A comprehensive review of the evidence using a PRISMA-P (2015) compliant methodology will be underpinned by systematic searching of electronic databases and the two authors selecting and screening eligible studies using the Cochrane data extraction and assessment template. Randomised controlled trials and retrospective and prospective studies will be included, and the quality and strength of evidence will be assessed using the Grading of Recommendation, Assessment and Evaluation (GRADE) approach.
IRP requires rudimentary skill and is objective and repeatable. As a clinical prognostication modality, it may be utilised early, when the strategy's other modalities are not recommended. Corroboration in the evidence would promote early use of IRP and a reduction in ICU bed days.
PROSPERO CRD42018118180.
尽管复苏护理取得了进展，但心脏骤停（CA）后的死亡率仍然很高。四分之一（院内 CA）至三分之二（院外 CA）昏迷后入住重症监护病房的患者因神经损伤而死亡。神经预后判断决定了及时停止维持生命的治疗（WLST），使患者免受不必要的痛苦，减轻家庭痛苦，并更有效地利用资源。英国复苏委员会（2015 年）最新的复苏后护理指南提供了目前多模式神经预后判断策略来预测神经结局。其模式包括神经系统检查、神经生理学测试、生物标志物和影像学。尽管当前策略的每种预测模式都存在局限性，但荟萃分析表明，其中三种模式，即 PLR（瞳孔光反射）、CR（角膜反射）和 N20 SSEP（体感诱发电位），可以以低假阳性率准确预测不良神经结局。然而，证据质量较低，降低了对该策略结果的信心。虽然红外瞳孔测量（IRP）目前不作为预后判断模式使用，但它可以提供瞳孔大小和 PLR 的定量和客观测量，全面观察第二和第三颅神经活动，这是神经结局的预测指标。
拟议的研究将检验假设，“在 CA 后自主循环恢复（ROSC）后仍处于昏迷状态的患者中，早期使用 IRP 可帮助预测不良神经结局”。使用符合 PRISMA-P（2015 年）的综合审查方法，对证据进行全面审查，系统搜索电子数据库，两名作者使用 Cochrane 数据提取和评估模板选择和筛选合格研究。将纳入随机对照试验以及回顾性和前瞻性研究，并使用推荐评估、制定与评价（GRADE）方法评估证据的质量和强度。
IRP 需要基本技能，具有客观性和可重复性。作为一种临床预后判断模式，它可以在其他模式不推荐使用时尽早使用。证据的佐证将促进 IRP 的早期使用和减少 ICU 住院天数。
PROSPERO CRD42018118180。
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