Zhou Sonya E, Barden Mary M, Gilmore Emily J, Pontes-Neto Octavio M, Sampaio Silva Gisele, Kurtz Pedro, Oliveira-Filho Jamary, Cougo-Pinto Pedro Telles, Zampieri Fernando G, Napoli Nicholas J, Theriot Jeremy J, Greer David M, Maciel Carolina B
Department of Neurology, Yale University School of Medicine, New Haven, CT.
Stroke Service, Neurology Division, Department of Neuroscience and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil.
Crit Care Explor. 2021 Jan 11;3(1):e0321. doi: 10.1097/CCE.0000000000000321. eCollection 2021 Jan.
End-of-life care and decisions on withdrawal of life-sustaining therapies vary across countries, which may affect the feasibility of future multicenter cardiac arrest trials. In Brazil, withdrawal of life-sustaining therapy is reportedly uncommon, allowing the natural history of postcardiac arrest hypoxic-ischemic brain injury to present itself. We aimed to characterize approaches to neuroprognostication of cardiac arrest survivors among physicians in Brazil.
Cross-sectional study.
Between August 2, 2019, and July 31, 2020, we distributed a web-based survey to physicians practicing in Brazil.
Physicians practicing in Brazil and members of the Brazilian Association of Neurointensive Care, who care for patients resuscitated following cardiac arrest.
Not applicable.
Responses from 185 physicians were obtained. Pupillary reflexes, corneal reflexes, and motor responses were considered critical to prognostication, whereas neuroimaging and electroencephalography were also regarded as important. For patients without targeted temperature management, absent pupillary and corneal reflexes at 24 hours postarrest were considered strongly predictive of poor neurologic outcome by 31.8% and 33.0%, respectively. For targeted temperature management-treated patients, absent pupillary and corneal reflexes at 24-hour postrewarming were considered prognostic by 22.9% and 20.0%, respectively. Physicians felt comfortable making definitive prognostic recommendations at day 6 postarrest or later (34.2%) for nontargeted temperature management-treated patients, and at day 6 postrewarming (20.4%) for targeted temperature management-treated patients. Over 90% believed that improving neuroprognostic accuracy would affect end-of-life decision-making.
There is significant variability in neuroprognostic approaches to postcardiac arrest patients and timing of prognostic studies among Brazilian physicians, with practices frequently deviating from current guidelines, underscoring a need for greater neuroprognostic accuracy. Nearly all physicians believed that improving neuroprognostication will impact end-of-life decision-making. Given the tendency to delay prognostic recommendations while using similar neuroprognostic tools, Brazil offers a unique cohort in which to examine the natural history of hypoxic-ischemic brain injury in future studies.
临终关怀以及关于撤销维持生命治疗的决策在不同国家存在差异，这可能会影响未来多中心心脏骤停试验的可行性。在巴西，据报道撤销维持生命治疗的情况并不常见，使得心脏骤停后缺氧缺血性脑损伤的自然病程得以展现。我们旨在描述巴西医生对心脏骤停幸存者进行神经预后评估的方法。
横断面研究。
在2019年8月2日至2020年7月31日期间，我们向在巴西执业的医生发放了一份基于网络的调查问卷。
在巴西执业的医生以及巴西神经重症监护协会的成员，他们负责护理心脏骤停后复苏的患者。
不适用。
获得了185名医生的回复。瞳孔反射、角膜反射和运动反应被认为对预后评估至关重要，而神经影像学和脑电图检查也被视为重要手段。对于未进行目标体温管理的患者，心脏骤停后24小时瞳孔和角膜反射消失分别被31.8%和33.0%的医生认为强烈预示着不良神经结局。对于接受目标体温管理治疗的患者，复温后24小时瞳孔和角膜反射消失分别被22.9%和20.0%的医生认为具有预后意义。对于未进行目标体温管理治疗的患者，医生们对在心脏骤停后第6天或更晚做出明确的预后建议感到安心（34.2%），而对于接受目标体温管理治疗的患者，在复温后第6天（20.4%）感到安心。超过90%的医生认为提高神经预后评估的准确性会影响临终决策。
巴西医生对心脏骤停后患者的神经预后评估方法以及预后研究的时间存在显著差异，其做法常常偏离当前指南，这凸显了提高神经预后评估准确性的必要性。几乎所有医生都认为改善神经预后评估将影响临终决策。鉴于在使用类似神经预后评估工具时倾向于延迟预后建议，巴西为未来研究缺氧缺血性脑损伤的自然病程提供了一个独特的队列。
