A void remains in the literature as far as addressing quality of life after ECPR.
Open in a separate window Generalized myoclonic seizures in face and extremities and continuous for a minimum of 30 min. Free use of further antiepileptic substances and combinations at the discretion of the attending physician.
Rationale for prognostication in the TTM-trial Since we believe that the process of neurological prognostication may have an effect on the results of the study, we decided to blind the assessor for treatment temperature. However, the decision to continue or withdraw intensive care is multi-disciplinary and blinding is difficult to maintain throughout the prognostication process.
However, as all recommendations and subsequent decisions are recorded, any systematic difference between the treatment arms will be detectable. By strictly regulating the time for prognostication and criteria allowing for WLST, we have aimed to avoid false and premature predictions.
The majority of patients with a favorable prognosis will wake up during the first three days after cardiac arrest [ 25 ] and we decided to postpone prognostication an extra 1. Recently published studies have shown that, although awakening itself may not be delayed by hypothermia [ 42 ], effects of sedation could explain why the clinical examination is less reliable [ 22 ].
Clinical examinations may still be unreliable at 4. Therefore, an extensor or absent motor response to pain at 4. If any of these two conditions is not fulfilled, at least an extra day of observation is demanded. Clearly, this is an area where more knowledge is urgently needed.
The TTM-protocol defines when WLST is allowed but the treating physician makes the decisions and continued intensive care is always an option. Many intensivists would consider it unethical to continue intensive care in a patient with early generalized and persistent myoclonus after cardiac arrest, but false predictions may occur both with [ 35 ] and without [ 43 ] hypothermia.
We therefore combined an early myoclonus status with another strong predictor, absent cortical responses on the SSEP, and allowed for SSEP to be performed immediately after rewarming in patients with status myoclonus. Early prognostication is also allowed for the small fraction of patients who become brain dead and these patients should be diagnosed according to national legislation.
Finally, strong ethical reasons for an early withdrawal of care may include generalized malignant disease or a clearly stated wish not to be resuscitated. Such reasons may become evident only after the patient has arrived in the ICU.
In the majority of the deceased patients, clinical, neurophysiological, biochemical neuron specific enolase NSE and neuroradiologic findings supported a massive brain injury and this was confirmed by post mortem examinations.
All these 8 patients had a generalized status epilepticus pattern on EEG and a lack of motor or extensor response to pain. Only one patient regained consciousness but was severely neurologically handicapped.
Discussion Despite international and national guidelines, the practice of neurological prognostication and WLST varies considerably and adheres poorly to recommendations [ 4445 ]. Early prognostication in hypothermia treated cardiac arrest patients is associated with a high rate of false predictions of poor outcome [ 44 ].
It has been suggested that prognostication protocols used in previous clinical intervention trials on cardiac arrest patients, or rather the lack of such protocols, may have introduced bias and thus may have led to skewed results, since a delayed recovery process might have been missed [ 39 ]. Several recently published reviews deal with the issue of neuroprognostication after cardiac arrest in the era of hypothermia treatment and detail the reliability of individual prognostic instruments [ 46 - 49 ].
However, very little comparative data exist and it is still unclear whether the reported false predictions in hypothermia-treated patients were directly caused by cooling or other treatment measures such as altered principles for sedation.
From the large amounts of comparative data in the TTM-trial, we will be able to learn how different prognostic instruments are affected by temperature. From a clinical trial perspective, the ideal strategy would be to refrain from prognostication and await the natural course of the post-anoxic encephalopathy but to our knowledge, this has never been done in a systematic way.
Such an approach would have practical and ethical limitations.
If a high level of care would be maintained and no treatment limitations implemented, many patients who remain in coma up to several days may risk surviving with a severe neurological handicap or in a chronic vegetative state.Unexpected cardiac arrest involves approximately to 5% of patients admitted in Intensive Care Unit (ICU).
Even if they have a technical environment conducive to prompt diagnosis and prompt treatment, patients hospitalized in ICU suffer from chronic illnesses and organ failure(s) that obscure the prognosis of cardiac arrest. The data relating to case mix, physiology, treatment, service delivery/organisation, activity and outcome for community cardiac arrest, in-hospital cardiac arrest (peri-operative) and in-hospital cardiac arrest (not peri-operative) are displayed in .
of intensive care unit cardiac arrest are few, and appear to be of a highly variable quality (Efendijev et al ).
which suffered a cardiac arrest during their stay in the ICU. This represents % of all admissions and a cal investigation and appropriate treatment initiated. 22 patients.
Patients with mild hypothermia received more fluids during the hour period after cardiac arrest than patients examination in the patients to the intensive care unit.
Nov 23, · Premature ventricular beats, atrial tachycardia, ventricular tachycardia, and cardiac arrest were described in these patients (14, 15). Left ventricular thrombus and thromboembolic events can be present (16), and in the worst clinical scenario, multiorgan failure can occur (17).
INTRODUCTION. Cardiac arrest results in over , deaths per year in North America alone .However, advances in cardiopulmonary resuscitation and post-cardiac arrest care have improved outcomes in select cohorts of patients .Among these advances are the use of therapeutic hypothermia (TH) and targeted temperature management (TTM), along with other interventions to improve the care .