Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
Alberta Health Services, Calgary, AB, Canada.
Can J Neurol Sci. 2024 May;51(3):404-415. doi: 10.1017/cjn.2023.261. Epub 2023 Jul 25.
Objective, evidence-based neuroprognostication of postarrest patients is crucial to avoid inappropriate withdrawal of life-sustaining therapies or prolonged, invasive, and costly therapies that could perpetuate suffering when there is no chance of an acceptable recovery. Postarrest prognostication guidelines exist; however, guideline adherence and practice variability are unknown.
To investigate Canadian practices and opinions regarding assessment of neurological prognosis in postarrest patients.
An anonymous electronic survey was distributed to physicians who care for adult postarrest patients.
Of the 134 physicians who responded to the survey, 63% had no institutional protocols for neuroprognostication. While the use of targeted temperature management did not affect the timing of neuroprognostication, an increasing number of clinical findings suggestive of a poor prognosis affected the timing of when physicians were comfortable concluding patients had a poor prognosis. Variability existed in what factors clinicians' thought were confounders. Physicians identified bilaterally absent pupillary light reflexes (85%), bilaterally absent corneal reflexes (80%), and status myoclonus (75%) as useful in determining poor prognosis. Computed tomography, magnetic resonance imaging, and spot electroencephalography were the most useful and accessible tests. Somatosensory evoked potentials were useful, but logistically challenging. Serum biomarkers were unavailable at most centers. Most (79%) physicians agreed ≥2 definitive findings on neurologic exam, electrophysiologic tests, neuroimaging, and/or biomarkers are required to determine a poor prognosis with a high degree of certainty. Distress during the process of neuroprognostication was reported by 70% of physicians and 51% request a second opinion from an external expert.
Significant variability exists in post-cardiac arrest neuroprognostication practices among Canadian physicians.
客观、基于证据的心脏停搏后患者神经预后评估对于避免不适当停止生命支持治疗或延长、侵入性和昂贵的治疗至关重要，这些治疗在没有可接受恢复机会的情况下可能会导致痛苦加剧。已经存在心脏停搏后预后预测指南；然而，指南的遵循情况和实践中的变异性尚不清楚。
调查加拿大医生在心脏停搏后患者神经预后评估方面的实践和观点。
对治疗成年心脏停搏后患者的医生进行了一项匿名电子调查。
在回答调查的 134 名医生中，63%的医生所在机构没有神经预后评估的协议。虽然目标温度管理的使用并不影响神经预后评估的时间，但越来越多的临床发现表明预后不良会影响医生得出患者预后不良的时间。临床医生认为哪些因素是混杂因素存在差异。医生认为双侧瞳孔光反射消失（85%）、双侧角膜反射消失（80%）和状态性肌阵挛（75%）有助于确定预后不良。计算机断层扫描、磁共振成像和点状脑电图是最有用和最容易获得的检查。体感诱发电位虽然有用，但在操作上具有挑战性。大多数中心都无法获得血清生物标志物。大多数（79%）医生同意需要≥2 项神经检查、电生理检查、神经影像学和/或生物标志物的明确发现，以确定预后不良的高度确定性。70%的医生报告在神经预后评估过程中感到痛苦，51%的医生要求外部专家进行第二次意见。
加拿大医生在心脏停搏后神经预后评估实践中存在显著的变异性。
