Early prediction of individual outcome after cardiopulmonary resuscitation

doi:10.1016/0140-6736(93)93061-5

The Lancet

Volume 341, Issue 8849, 3 April 1993, Pages 855-858

https://doi.org/10.1016/0140-6736(93)93061-5 Get rights and content

Abstract

Prediction of individual outcome after cardiopulmonary resuscitation is of major medical, ethical, and socioeconomic interest but uncertain. We studied the early predictive potency of evoked potential recording after cardiac arrest in 66 resuscitated patients who returned to spontaneous circulation but were unconscious and mechanically ventilated. Detailed long-latency and short-latency sensory evoked potentials were recorded and neurological evaluations were done 4-48 h after admission to intensive care.

In all 17 patients with favourable outcome (cerebral performance categories 1 and 2) the cortical evoked potential N70 peak, a reliable measure of cortical function, was detected between 74 and 116 ms. In 49 patients with bad outcome (categories 4 and 5) the N70 peak was absent in 35 or found with a delay between 121 and 171 ms in 14 (p<0·05 vs favourable outcome). Thus the predictive ability was 100% with cutoff of 118 ms. To confirm reproducibility and validity, repeated tracings, and linked-earlobe referenced techniques were done and gave similar results.

Early recording of long-latency evoked potentials after cardiopulmonary resuscitation is highly predictive of outcome.

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Cited by (158)

Prognosis of Cardiac Arrest—Peri-arrest and Post-arrest Considerations
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Prognostic predictors in patients with cardiopulmonary arrest: A novel equation for evaluating the 30-day mortality
2023, Journal of Cardiology
Early prediction of outcomes after cardiopulmonary arrest (CPA) is important for considering the best support. Our purpose was to evaluate predictors of the 30-day mortality in patients with CPA after return of spontaneous circulation (ROSC) and to assess an equation for calculating the 30-day mortality using clinical parameters.
We retrospectively analyzed the data of 194 consecutive patients with CPA and ROSC in a derivation study (2015–2022). We compared clinical parameters between the survived (n = 78) and dead (n = 116) patients. We derived an equation for estimated probability of death based on clinical parameters, using multivariate logistic regression analysis. The reliability of the equation was validated in 80 additional patients with CPA.
The 30-day mortality was associated with sex, witnessed cardiac arrest, bystander cardiopulmonary resuscitation (CPR), CPA due to acute myocardial infarction, pupil diameter, Glasgow Coma Scale score (GCS), presence of light reflex, arterial or venous pH, lactate levels, initial ventricular fibrillation (VF), CPA time, and age. The derived logistic regression equation was as follows: Estimated probability of death = 1 / (1 + e^-x), x = (0.25 × bystander CPR) + (0.44 × pupil diameter) – (0.14 × GCS) + (0.09 × lactate) – (1.87 × initial VF) + (0.07 × CPA time) + (0.05 × age) - 7.03. The cut-off value for estimated probability of death calculated by this equation was 54.5 %, yielding a sensitivity, specificity, and accuracy of 86.2 %, 80.8 %, and 84.5 %, respectively. In the validation model, these values were 81.8 %, 85.7 %, and 82.5 %, respectively.
The 30-day mortality may be calculated after ROSC in patients with CPA using simple clinical parameters. This equation may facilitate further best support for patients with CPA.
Neurological Prognostication in Children After Cardiac Arrest
2020, Pediatric Neurology
Early after pediatric cardiac arrest, families and care providers struggle with the uncertainty of long-term neurological prognosis. Cardiac arrest characteristics such as location, intra-arrest factors, and postarrest events have been associated with outcome. We paid particular attention to postarrest modalities that have been shown to predict neurological outcome. These modalities include neurological examination, somatosensory evoked potentials, electroencephalography, and neuroimaging. There is no one modality that accurately predicts neurological prognosis. Thus, a multimodal approach should be undertaken by both neurologists and intensivists to present a clear and consistent message to families. Methods used for the prediction of long-term neurological prognosis need to be specific enough to identify indivuals with a poor outcome. We review the evidence evaluating children with coma, each with various etiologies of cardiac arrest, outcome measures, and timing of follow-up.
Added value of somato-sensory evoked potentials amplitude for prognostication after cardiac arrest
2020, Resuscitation
Bilateral absence of cortical somato-sensory evoked potentials (SSEPs) robustly predicts poor outcome after cardiac arrest (CA), but it is uncertain if SSEP amplitudes provide additional information. Here, we examined the prognostic value of cortical SSEP amplitude in comparison with other known outcome predictors.
We retrospectively determined SSEP amplitudes in a prospective CA registry, identified an amplitude cut-off for worst Cerebral Performance Category (CPC) within three months, and examined correlations of SSEP amplitude with pupillary light reflex (PLR), myoclonus, peak serum neuron specific enolase (NSE), and 24–36 h and 36–72 h EEG (reactivity, epileptiform features).
Among 158 patients, 54% awoke. Amplitudes correlated with EEG findings, present PLR, myoclonus, NSE. A cut-off for cortical SSEP ≤ 0.41 μV was 100% specific for poor outcome (95% CI: 96–100%); sensitivity increased marginally vs. SSEPs absence [47% (35–59%) vs 46% (34–58%)] for CPC 4–5. Adding SSEPs ≤0.41 μV to a multimodal prognostic model including EEG, clinical features, and NSE improved prediction for mortality, but not for CPC 3–5 at three months. No statistical correlation between amplitudes and good outcome was observed. SSEP amplitudes correlated inversely with CPC at three months in the overall cohort (r = −0.332; p < 0.0001) but not in the subgroup with present SSEPs (r = −0.102; p = 0.256).
Decreased SSEPs amplitudes are associated with poor outcome after cardiac arrest; however, adding this to a multimodal prognostic approach including EEG, clinical and blood biomarkers, improves slightly prediction of mortality, but not of poor or good outcome.
Therapeutic hypothermia does not diminish the vital and necessary role of SSEP in predicting unfavorable outcome in anoxic-ischemic coma
2014, Clinical Neurology and Neurosurgery
Rational medical management of patients who remain comatose following cardio-pulmonary resuscitation (CPR) due to anoxic-ischemic encephalopathy depends upon the early identification of those with a hopeless prognosis – regardless of how aggressively they are managed. Conversely, it is mandatory that we recognize those patients with the potential to recover in order to institute aggressive therapeutic measures. The bilateral absence of the N20 Cortical Somatosensory Evoked Potential has been identified as the most reliable predictor of an unfavorable prognosis in normothermic patients.
Two randomized trials have determined that mild therapeutic hypothermia (TH) delivered immediately after CPR improves neurologic outcomes. TH has now become the standard of care in the management of patients with cardio-pulmonary arrest. Eight studies targeting patients who were comatose following CPR, treated with TH, and using SSEP as an outcome predictor are reviewed. There is only one patient treated with TH who appears to have fully recovered following cardiac arrest who was initially found to have bilateral absent cortical potentials. This opinion paper will address whether the criteria that placed reliance upon SSEP to predict unfavorable outcome in post cardio-pulmonary arrest patients after receiving TH, still apply.
Investigation of the inter-observer variability effect on the prognostic value of somatosensory evoked potentials of the median nerve (SSEP) in cardiac arrest survivors using an SSEP classification
2013, Resuscitation
Citation Excerpt :
Patterns A–C are thus associated with favourable neurological prognosis following CPR in our assessment. Patients with pattern D (bilateral loss of the middle long latency potentials) either did not regain consciousness or died in previous investigations.9,15–17 Therefore, in our assessment, patterns D and E (E = bilateral loss of all cortical potentials) were both associated with unfavourable neurological outcome (Fig. 1 and Table 1).
We investigated the inter-observer variability in interpretation of median nerve SSEPs with regard to neurological prognosis in survivors of cardiac arrest (CA).
Four experienced neurologists analyzed 163 median nerve SSEPs on the basis of a pre-defined classification of SSEPs into five patterns (A–E), with consideration of cortical potentials up to a latency of 150 ms. Of these, 133 recordings were from CA survivors and 30 were from healthy volunteers. The experts were blinded to whether a SSEP finding was from a CA survivor or a healthy volunteer. They were also unaware of the neurological outcome for the resuscitated patients. Three categories were defined for decision making. These were “good neurological outcome” represented by patterns A–C, “poor neurological outcome” (patterns D and E), and “not evaluable”. Experts’ agreement was calculated using the kappa-coefficient.
The mean correct prediction by the experts was 81.8% (range 76.3–86.6%) in resuscitated patients with good neurological outcome. In those with poor neurological outcome, however, correct prediction was achieved in only 63% (60.5–66%). All SSEPs from healthy volunteers were classified as “good neurological outcome”. The kappa-coefficient (κ) for all decision-making classifications was 0.75; for patients with poor outcome it was 0.76 and for those with good outcome 0.88. The predictive value for poor neurological outcome of the SSEP pattern D achieved a specificity of 93.5% and that of E a specificity of 98.4%.
Our study demonstrates good inter-observer agreement in the interpretation of median nerve SSEPs in CA survivors on the basis of a pre-defined SSEP evaluation set. The strongest correlation with poor outcome was found for pattern E, bilateral absence of the N₂₀ peak.

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ARTICLESEarly prediction of individual outcome after cardiopulmonary resuscitation

Abstract

Electroenephalogr Clin Neurophysiol

Lancet

Kidney Int

Electroencephalogr Clin Neurophysiol

Lancet

Lancet

Electrocephalogr Clin Neurophysiol

Br J Anaesth

Lancet

Lancet

Unsuccessful emergency medical resuscitation-are continued efforts in the emergency department justified?

N Engl J Med

Coma following cardiac arrest: a review of the clincial features, management and prognosis

J Intensive Care Med

Central somatosensory conduction time: method and clinical applications

ARTICLES
Early prediction of individual outcome after cardiopulmonary resuscitation