Madl C, Kramer L, Yeganehfar W, Eisenhuber E, Kranz A, Ratheiser K, Zauner C, Schneider B, Grimm G
Department of Medicine IV, University Hospital of Vienna, Austria.
Arch Neurol. 1996 Jun;53(6):512-6. doi: 10.1001/archneur.1996.00550060054017.
To determine the predictive ability of sensory evoked potential recordings in nontraumatic comatose patients. To evaluate the hypothesis that patients with bilateral absent cortical responses ultimately die despite long-term intensive care treatment.
Prospective cohort study.
Medical intensive care unit (ICU) of a university hospital.
Four hundred forty-one adult nontraumatic comatose patients (unarousable unresponsiveness to external stimulation, Glasgow Coma Score < or = 7) from various causes. Six hundred seventy-six sensory evoked potential measurements were performed within 7 days after onset of coma.
Death or survival to hospital discharge.
Eighty-six patients (20%) had a bilateral loss of the cortical evoked potential N20 peak. Despite long-term intensive care treatment, all died without awakening from coma (mortality rate, 100%; 95% confidence interval, 96-100). The mean stay at the ICU after evoked potential measurement until death was 8.1 days (697 patient days). The overall cost of ICU management for these 86 patients accounted for approximately $1,324,300. In the remaining 355 comatose patients with preserved cortical N20 peak, 148 (42%) survived and 207 (58%) died. In this latter group of patients, cervicomedullary N13 to cortical N20 conduction time was prolonged in nonsurvivors (mean +/- SD, 6.7 +/- 1.3 milliseconds) compared with that in survivors (mean +/- SD, 6.4 +/- 1.2 milliseconds, P < .05) and healthy controls (mean +/- SD, 5.5 +/- 0.4 milliseconds, P < .05). Although this difference is statistically significant, a preserved N20 peak is not useful to discriminate whether the individual patient will survive (N13-N20 conduction time of > 7 milliseconds had a positive predictive value of correct prediction of death of 0.67).
Recording of sensory evoked potentials identifies a subgroup of adult nontraumatic comatose patients with a mortality rate of 100% in our sample. In these patients, advanced intensive care treatment should be withdrawn to provide limited ICU resources for patients with higher probability of favorable outcome. We emphasize that these results are not applicable to comatose patients following closed head trauma and particularly not to children.
确定感觉诱发电位记录对非创伤性昏迷患者的预测能力。评估双侧皮质反应缺失的患者尽管接受长期重症监护治疗最终仍会死亡这一假设。
前瞻性队列研究。
一所大学医院的内科重症监护病房（ICU）。
441例因各种原因导致的成年非创伤性昏迷患者（对外部刺激无反应、格拉斯哥昏迷评分≤7分）。在昏迷发作后7天内进行了676次感觉诱发电位测量。
死亡或存活至出院。
86例患者（20%）双侧皮质诱发电位N20波峰消失。尽管接受了长期重症监护治疗，所有患者均未苏醒而死亡（死亡率100%；95%置信区间，96 - 100）。从进行诱发电位测量到死亡，患者在ICU的平均停留时间为8.1天（共697个患者日）。这86例患者的ICU总体管理费用约为1324300美元。在其余355例皮质N20波峰保留的昏迷患者中，148例（42%）存活，207例（58%）死亡。在后者这组患者中，未存活者的颈髓N13至皮质N20的传导时间（平均±标准差，6.7±1.3毫秒）长于存活者（平均±标准差，6.4±1.2毫秒，P < 0.05）和健康对照者（平均±标准差，5.5±0.4毫秒，P < 0.05）。尽管这种差异具有统计学意义，但保留的N20波峰对于判断个体患者是否会存活并无帮助（N13 - N20传导时间>7毫秒时，正确预测死亡的阳性预测值为0.67）。
感觉诱发电位记录可识别出我们样本中死亡率为100%的成年非创伤性昏迷患者亚组。对于这些患者，应停止高级重症监护治疗，以便为预后较好可能性更高的患者提供有限的ICU资源。我们强调，这些结果不适用于闭合性颅脑损伤后的昏迷患者，尤其不适用于儿童。
