Abstract P143: A Rush to Judgment: Timing of Prognostication in Post-arrest Therapeutic Hypothermia
Background: Early assessment of neurologic recovery is often challenging in survivors of cardiac arrest. Little is known about when to assess neurologic status in comatose post-arrest patients receiving therapeutic hypothermia (TH). We sought to evaluate timing of prognostication in patients with cardiac arrest who then received TH.
Methods: This study was a retrospective chart review of 29 consecutive patients who were cooled post arrest (hypothermia protocol: 24 hours cooling, average 8 hours rewarming) at one academic institution between 2005–2008. We abstracted data from the first 96 hours post-arrest including timing of neurology consultation, use of diagnostic testing, prognosis documentation by primary service or neurology consultants and outcome at discharge.
Results: Of our sample, 62% (18/29) were male, mean age 56, and 52% (15/29) presented in ventricular fibrillation. Of these cases, initial neurology consultation occurred post-arrest on day 1 in 35% (10/29), day 2 in 17% (5/29), day 3 in 14% (4/29), and after day 3 in 14% (4/29). Neurology was not consulted in 21% (6/29) of cases. In the first 96 hours: 97% (28/29) received a head CT, 93% (27/29) received electroencephalography, 1(3%) received somatosensory evoked potential testing, and none received neuron specific enolase testing. Early documentation of “poor” or “grave” prognosis occurred during cooling/rewarming or soon after in 48% (14/29) of cases. Poor prognosis was specifically documented during cooling (less than 24 hours post-arrest) in 7% (2/29), during rewarming (less than 48 hours) in 7% (2/29), and within 15 hours of rewarming and discontinuation of paralytics in 34% (10/29). Of the patients with early documentation of poor prognosis, 36% (5/14) had care withdrawn within 72 hours post-arrest, and 21% (3/14) survived to discharge with favorable neurologic recovery (cerebral performance category 1 or 2).
Conclusion: Documentation of poor prognosis occurred prematurely in post-arrest patients undergoing TH. The extent to which premature documentation of poor prognosis led to the actual withdrawal of care is unknown. Future guidelines should establish when to best prognosticate in post-arrest patients receiving neuroprotective hypothermia and sedation/paralytics.