Department of Acute Medicine, Oslo University Hospital, Ullevål, Norway.
Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
Acta Anaesthesiol Scand. 2024 Feb;68(2):263-273. doi: 10.1111/aas.14337. Epub 2023 Oct 24.
Prognosis after out-of-hospital cardiac arrest (OHCA) is presumed poorer in patients with non-shockable than shockable rhythms, frequently leading to treatment withdrawal. Multimodal outcome prediction is recommended 72 h post-arrest in still comatose patients, not considering initial rhythms. We investigated accuracy of outcome predictors in all comatose OHCA survivors, with a particular focus on shockable vs. non-shockable rhythms.
In this observational NORCAST sub-study, patients still comatose 72 h post-arrest were stratified by shockable vs. non-shockable rhythms for outcome prediction analyzes. Good outcome was defined as cerebral performance category 1-2 within 6 months. False positive rate (FPR) was used for poor and sensitivity for good outcome prediction accuracy.
Overall, 72/128 (56%) patients with shockable and 12/50 (24%) with non-shockable rhythms had good outcome (p < .001). For poor outcome prediction, absent pupillary light reflexes (PLR) and corneal reflexes (clinical predictors) 72 h after sedation withdrawal, PLR 96 h post-arrest, and somatosensory evoked potentials (SSEP), all had FPR <0.1% in both groups. Unreactive EEG and neuron-specific enolase (NSE) >60 μg/L 24-72 h post-arrest had better precision in shockable patients. For good outcome, the clinical predictors, SSEP and CT, had 86%-100% sensitivity in both groups. For NSE, sensitivity varied from 22% to 69% 24-72 h post-arrest. The outcome predictors indicated severe brain injury proportionally more often in patients with non-shockable than with shockable rhythms. For all patients, clinical predictors, CT, and SSEP, predicted poor and good outcome with high accuracy.
Outcome prediction accuracy was comparable for shockable and non-shockable rhythms. PLR and corneal reflexes had best precision 72 h after sedation withdrawal and 96 h post-arrest.
院外心脏骤停（OHCA）后，非可电击性节律患者的预后被认为比可电击性节律患者更差，这经常导致治疗中止。在仍然昏迷的患者中，建议在心脏骤停后 72 小时进行多模态预后预测，而不考虑初始节律。我们调查了所有昏迷的 OHCA 幸存者中预后预测指标的准确性，特别关注可电击性与非可电击性节律。
在这项观察性 NORCAST 子研究中，根据心脏骤停后 72 小时的可电击性与非可电击性节律对昏迷患者进行分层以进行预后预测分析。良好的预后定义为 6 个月内脑功能分级 1-2。假阳性率（FPR）用于预测预后不良的准确性，而敏感性用于预测预后良好的准确性。
总体而言，72/128（56%）名具有可电击性节律的患者和 12/50（24%）名具有非可电击性节律的患者具有良好的预后（p<.001）。对于预后不良的预测，在镇静剂停药后 72 小时无瞳孔光反射（PLR）和角膜反射（临床预测因素）、心脏骤停后 96 小时的 PLR 以及体感诱发电位（SSEP）在两组中均具有低于 0.1%的 FPR。在可电击性患者中，昏迷后 24-72 小时的无反应性脑电图和神经元特异性烯醇化酶（NSE）>60μg/L 具有更好的准确性。对于良好的预后，临床预测因素、SSEP 和 CT 在两组中的敏感性均为 86%-100%。对于 NSE，在心脏骤停后 24-72 小时的敏感性从 22%到 69%不等。预后预测指标在非可电击性节律患者中更经常地表明存在严重的脑损伤，而在可电击性节律患者中则不然。对于所有患者，临床预测因素、CT 和 SSEP 均以较高的准确性预测了预后不良和良好。
可电击性与非可电击性节律的预后预测准确性相当。PLR 和角膜反射在镇静剂停药后 72 小时和心脏骤停后 96 小时具有最佳的准确性。
