Comment on “Mode of death after admission to an intensive care unit following cardiac arrest” by Laver et al.

Excerpt

Sir: Laver and colleagues [1] claim to report “cause” of death following ICU admission after cardiac arrest and suggest that their findings support the study of induced hypothermia in comatose survivors of cardiac arrest from arrhythmias other than ventricular fibrillation (VF). I would submit, however, that the most common antecedent to death in this patient population is withdrawal of ventilatory support and withholding of active treatment. It would be of interest to know how many patients in each of the groups had treatment withdrawn or withheld, and the time that this occurred in relation to admission. In patients suffering out-of-hospital cardiac arrest where the presenting rhythm was pulseless electrical activity or asystole 90% died (only three survivors), 74% with neurological failure and 22% with multiple organ failure (which, according to their definition, included the possibility of neurological failure). Only one of the survivors had a good neurological outcome. Although experimental therapies such as induced hypothermia may reduce the incidence of post-resuscitation neurological injury and therefore impact on survival [2, 3], for the average intensive care physician this is likely to impact on far fewer patients than are affected by the predominant issue of deciding for whom and when is withdrawal of therapy the appropriate measure. When we come to embrace a complex and expensive new treatment, such as induced hypothermia, we must ensure that there is appropriate triage such that those patients who have no hope of benefit are not inappropriately burdened. Improved ability to prognosticate early following resuscitation from non-VF rhythms would be likely to have a more beneficial impact on practice than extending the use of hypothermia to these patients. …