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15.11.2022 | Original work

Factors Associated with Early Withdrawal of Life-Sustaining Treatments After Out-of-Hospital Cardiac Arrest: A Subanalysis of a Randomized Trial of Prehospital Therapeutic Hypothermia

verfasst von: Sarah Wahlster, Kyle Danielson, Lindy Craft, Nassim Matin, James A. Town, Vasisht Srinivasan, Glenn Schubert, David Carlbom, Francis Kim, Nicholas J. Johnson, David Tirschwell

Erschienen in: Neurocritical Care | Ausgabe 3/2023

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Abstract

Background

The objective of this study is to describe incidence and factors associated with early withdrawal of life-sustaining therapies based on presumed poor neurologic prognosis (WLST-N) and practices around multimodal prognostication after out-of-hospital cardiac arrest (OHCA).

Methods

We performed a subanalysis of a randomized controlled trial assessing prehospital therapeutic hypothermia in adult patients admitted to nine hospitals in King County with nontraumatic OHCA between 2007 and 2012. Patients who underwent tracheal intubation and were unconscious following return of spontaneous circulation were included. Our outcomes were (1) incidence of early WLST-N (WLST-N within < 72 h from return of spontaneous circulation), (2) factors associated with early WLST-N compared with patients who remained comatose at 72 h without WLST-N, (3) institutional variation in early WLST-N, (4) use of multimodal prognostication, and (5) use of sedative medications in patients with early WLST-N. Analysis included descriptive statistics and multivariable logistic regression.

Results

We included 1,040 patients (mean age was 65 years, 37% were female, 41% were White, and 44% presented with arrest due to ventricular fibrillation) admitted to nine hospitals. Early WLST-N accounted for 24% (n = 154) of patient deaths and occurred in half (51%) of patients with WLST-N. Factors associated with early WLST-N in multivariate regressions were older age (odds ratio [OR] 1.02, 95% confidence interval [CI]: 1.01–1.03), preexisting do-not-attempt-resuscitation orders (OR 4.67, 95% CI: 1.55–14.01), bilateral absent pupillary reflexes (OR 2.4, 95% CI: 1.42–4.10), and lack of neurological consultation (OR 2.60, 95% CI: 1.52–4.46). The proportion of patients with early WLST-N among all OHCA admissions ranged from 19–60% between institutions. A head computed tomography scan was obtained in 54% (n = 84) of patients with early WLST-N; 22% (n = 34) and 5% (n = 8) underwent ≥ 1 and ≥ 2 additional prognostic tests, respectively. Prognostic tests were more frequently performed when neurological consultation occurred. Most patients received sedating medications (90%) within 24 h before early WLST-N; the median time from last sedation to early WLST-N was 4.2 h (interquartile range 0.4–15).

Conclusions

Nearly one quarter of deaths after OHCA were due to early WLST-N. The presence of concerning neurological examination findings appeared to impact early WLST-N decisions, even though these are not fully reliable in this time frame. Lack of neurological consultation was associated with early WLST-N and resulted in underuse of guideline-concordant multimodal prognostication. Sedating medications were often coadministered prior to early WLST-N and may have further confounded the neurological examination. Standardizing prognostication, restricting early WLST-N, and a multidisciplinary approach including neurological consultation might improve outcomes after OHCA.

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Tsao CW, Aday AW, Almarzooq ZI, et al. Heart disease and stroke statistics-2022 update: a report from the American heart association. Circulation. 2022;145(8):e153–639. https://doi.org/10.1161/CIR.0000000000001052.CrossRefPubMed

Fugate JE, Brinjikji W, Mandrekar JN, et al. Post-cardiac arrest mortality is declining: a study of the US National Inpatient Sample 2001 to 2009. Circulation. 2012;126(5):546–50. https://doi.org/10.1161/CIRCULATIONAHA.111.088807.CrossRefPubMed

Yan S, Gan Y, Jiang N, et al. The global survival rate among adult out-of-hospital cardiac arrest patients who received cardiopulmonary resuscitation: a systematic review and meta-analysis. Crit Care. 2020;24(1):61. https://doi.org/10.1186/s13054-020-2773-2.CrossRefPubMedPubMedCentral

Geocadin RG, Callaway CW, Fink EL, et al. Standards for studies of neurological prognostication in comatose survivors of cardiac arrest: a scientific statement from the American heart association. Circulation. 2019;140(9):e517–42. https://doi.org/10.1161/CIR.0000000000000702.CrossRefPubMed

Kleinman ME, Perkins GD, Bhanji F, et al. ILCOR scientific knowledge gaps and clinical research priorities for cardiopulmonary resuscitation and emergency cardiovascular care: a consensus statement. Circulation. 2018;137(22):e802–19. https://doi.org/10.1161/CIR.0000000000000561.CrossRefPubMed

Bernard SA, Gray TW, Buist MD, et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med. 2002;346(8):557–63. https://doi.org/10.1056/NEJMoa003289.CrossRefPubMed

Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med. 2002;346(8):549–56. https://doi.org/10.1056/NEJMoa012689.CrossRef

Ruijter BJ, Keijzer HM, Tjepkema-Cloostermans MC, et al. Treating rhythmic and periodic EEG patterns in comatose survivors of cardiac arrest. N Engl J Med. 2022;386(8):724–34. https://doi.org/10.1056/NEJMoa2115998.CrossRefPubMed

Nolan JP, Sandroni C, Böttiger BW, et al. European resuscitation council and European society of intensive care medicine guidelines 2021: post-resuscitation care. Intensive Care Med. 2021;47(4):369–421. https://doi.org/10.1007/s00134-021-06368-4.CrossRefPubMedPubMedCentral

10.

Sandroni C, Cariou A, Cavallaro F, et al. Prognostication in comatose survivors of cardiac arrest: an advisory statement from the European Resuscitation Council and the European Society of Intensive Care Medicine. Resuscitation. 2014;85(12):1779–89. https://doi.org/10.1016/j.resuscitation.2014.08.011.CrossRefPubMed

11.

Panchal AR, Bartos JA, Cabañas JG, et al. Part 3: adult basic and advanced life support: 2020 American heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2020;142(16_suppl_2):S366–468. https://doi.org/10.1161/CIR.0000000000000916.CrossRefPubMed

12.

Albaeni A, Chandra-Strobos N, Vaidya D, Eid SM. Predictors of early care withdrawal following out-of-hospital cardiac arrest. Resuscitation. 2014;85(11):1455–61. https://doi.org/10.1016/j.resuscitation.2014.08.030.CrossRefPubMed

13.

Elmer J, Torres C, Aufderheide TP, et al. Association of early withdrawal of life-sustaining therapy for perceived neurological prognosis with mortality after cardiac arrest. Resuscitation. 2016;102:127–35. https://doi.org/10.1016/j.resuscitation.2016.01.016.CrossRefPubMedPubMedCentral

14.

Kim F, Nichol G, Maynard C, et al. Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest: a randomized clinical trial. JAMA. 2014;311(1):45–52. https://doi.org/10.1001/jama.2013.282173.CrossRefPubMed

15.

von Elm E, Altman DG, Egger M, et al. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007;370(9596):1453–7. https://doi.org/10.1016/S0140-6736(07)61602-X.CrossRef

16.

Keijzer HM, Hoedemaekers CWE, Meijer FJA, Tonino BAR, Klijn CJM, Hofmeijer J. Brain imaging in comatose survivors of cardiac arrest: Pathophysiological correlates and prognostic properties. Resuscitation. 2018;133:124–36. https://doi.org/10.1016/j.resuscitation.2018.09.012.CrossRefPubMed

17.

Jeon CH, Park JS, Lee JH, et al. Comparison of brain computed tomography and diffusion-weighted magnetic resonance imaging to predict early neurologic outcome before target temperature management comatose cardiac arrest survivors. Resuscitation. 2017;118:21–6. https://doi.org/10.1016/j.resuscitation.2017.06.021.CrossRefPubMed

18.

Hirsch KG, Fischbein N, Mlynash M, et al. Prognostic value of diffusion-weighted MRI for post-cardiac arrest coma. Neurology. 2020;94(16):e1684–92. https://doi.org/10.1212/WNL.0000000000009289.CrossRefPubMedPubMedCentral

19.

Cloostermans MC, van Meulen FB, Eertman CJ, Hom HW, van Putten MJAM. Continuous electroencephalography monitoring for early prediction of neurological outcome in postanoxic patients after cardiac arrest: a prospective cohort study. Crit Care Med. 2012;40(10):2867–75. https://doi.org/10.1097/CCM.0b013e31825b94f0.CrossRefPubMed

20.

Bongiovanni F, Romagnosi F, Barbella G, et al. Standardized EEG analysis to reduce the uncertainty of outcome prognostication after cardiac arrest. Intensive Care Med. 2020;46(5):963–72. https://doi.org/10.1007/s00134-019-05921-6.CrossRefPubMed

21.

Westhall E, Rosén I, Rundgren M, et al. Time to epileptiform activity and EEG background recovery are independent predictors after cardiac arrest. Clin Neurophysiol. 2018;129(8):1660–8. https://doi.org/10.1016/j.clinph.2018.05.016.CrossRefPubMed

22.

Horn J, Tjepkema-Cloostermans MC. Somatosensory evoked potentials in patients with hypoxic-ischemic brain injury. Semin Neurol. 2017;37(1):60–5. https://doi.org/10.1055/s-0036-1594252.CrossRefPubMed

23.

Lachance B, Wang Z, Badjatia N, Jia X. Somatosensory evoked potentials and neuroprognostication after cardiac arrest. Neurocrit Care. 2020;32(3):847–57. https://doi.org/10.1007/s12028-019-00903-4.CrossRefPubMed

24.

Tirschwell DL, Longstreth WT, Rauch-Matthews ME, et al. Cerebrospinal fluid creatine kinase BB isoenzyme activity and neurologic prognosis after cardiac arrest. Neurology. 1997;48(2):352–7. https://doi.org/10.1212/wnl.48.2.352.CrossRefPubMed

25.

Targeted Temperature Management at 33 °C versus 36 °C after Cardiac Arrest | NEJM. Accessed January 2, 2022. https://doi.org/10.1056/nejmoa1310519.

26.

Dankiewicz J, Cronberg T, Lilja G, et al. Hypothermia versus normothermia after out-of-hospital cardiac arrest. N Engl J Med. 2021;384(24):2283–94. https://doi.org/10.1056/NEJMoa2100591.CrossRefPubMed

27.

Tsai MS, Chen WJ, Chen WT, et al. Should we prolong the observation period for neurological recovery after cardiac arrest? Crit Care Med. 2022;50(3):389–97. https://doi.org/10.1097/CCM.0000000000005264.CrossRefPubMed

28.

Choi SP, Park KN, Wee JH, et al. Can somatosensory and visual evoked potentials predict neurological outcome during targeted temperature management in post cardiac arrest patients? Resuscitation. 2017;119:70–5. https://doi.org/10.1016/j.resuscitation.2017.06.022.CrossRefPubMed

29.

Javaudin F, Leclere B, Segard J, et al. Prognostic performance of early absence of pupillary light reaction after recovery of out of hospital cardiac arrest. Resuscitation. 2018;127:8–13. https://doi.org/10.1016/j.resuscitation.2018.03.020.CrossRefPubMed

30.

Hofmeijer J, Beernink TMJ, Bosch FH, Beishuizen A, Tjepkema-Cloostermans MC, van Putten MJAM. Early EEG contributes to multimodal outcome prediction of postanoxic coma. Neurology. 2015;85(2):137–43. https://doi.org/10.1212/WNL.0000000000001742.CrossRefPubMedPubMedCentral

31.

Oddo M, Sandroni C, Citerio G, et al. Quantitative versus standard pupillary light reflex for early prognostication in comatose cardiac arrest patients: an international prospective multicenter double-blinded study. Intensive Care Med. 2018;44(12):2102–11. https://doi.org/10.1007/s00134-018-5448-6.CrossRefPubMedPubMedCentral

32.

Zhou SE, Maciel CB, Ormseth CH, Beekman R, Gilmore EJ, Greer DM. Distinct predictive values of current neuroprognostic guidelines in post-cardiac arrest patients. Resuscitation. 2019;139:343–50. https://doi.org/10.1016/j.resuscitation.2019.03.035.CrossRefPubMedPubMedCentral

33.

Nakstad ER, Stær-Jensen H, Wimmer H, et al. Late awakening, prognostic factors and long-term outcome in out-of-hospital cardiac arrest—results of the prospective Norwegian Cardio-Respiratory Arrest Study (NORCAST). Resuscitation. 2020;149:170–9. https://doi.org/10.1016/j.resuscitation.2019.12.031.CrossRefPubMed

34.

Chung-Esaki HM, Mui G, Mlynash M, Eyngorn I, Catabay K, Hirsch KG. The neuron specific enolase (NSE) ratio offers benefits over absolute value thresholds in post-cardiac arrest coma prognosis. J Clin Neurosci. 2018;57:99–104. https://doi.org/10.1016/j.jocn.2018.08.020.CrossRefPubMedPubMedCentral

35.

Riker RR, Sawyer ME, Fischman VG, et al. Neurological pupil index and pupillary light reflex by pupillometry predict outcome early after cardiac arrest. Neurocrit Care. 2020;32(1):152–61. https://doi.org/10.1007/s12028-019-00717-4.CrossRefPubMed

36.

Hemphill JC, Greenberg SM, Anderson CS, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American heart association/American stroke association. Stroke. 2015;46(7):2032–60. https://doi.org/10.1161/STR.0000000000000069.CrossRefPubMed

37.

Madhok DY, Vitt JR, MacIsaac D, Hsia RY, Kim AS, Hemphill JC. Early do-not-resuscitate orders and outcome after intracerebral hemorrhage. Neurocrit Care. 2021;34(2):492–9. https://doi.org/10.1007/s12028-020-01014-1.CrossRefPubMed

38.

Curtis JR, Vincent JL. Ethics and end-of-life care for adults in the intensive care unit. Lancet. 2010;376(9749):1347–53. https://doi.org/10.1016/S0140-6736(10)60143-2.CrossRefPubMed

39.

Guterman EL, Kim AS, Josephson SA. Neurologic consultation and use of therapeutic hypothermia for cardiac arrest. Resuscitation. 2017;118:43–8. https://doi.org/10.1016/j.resuscitation.2017.06.025.CrossRefPubMed

40.

Amorim E, Ghassemi MM, Lee JW, et al. Estimating the false positive rate of absent somatosensory evoked potentials in cardiac arrest prognostication. Crit Care Med. 2018;46(12):e1213–21. https://doi.org/10.1097/CCM.0000000000003436.CrossRefPubMedPubMedCentral

41.

Dragancea I, Horn J, Kuiper M, et al. Neurological prognostication after cardiac arrest and targeted temperature management 33 °C versus 36 °C: Results from a randomised controlled clinical trial. Resuscitation. 2015;93:164–70. https://doi.org/10.1016/j.resuscitation.2015.04.013.CrossRefPubMed

42.

Leithner C, Ploner CJ, Hasper D, Storm C. Does hypothermia influence the predictive value of bilateral absent N20 after cardiac arrest? Neurology. 2010;74(12):965–9. https://doi.org/10.1212/WNL.0b013e3181d5a631.CrossRefPubMed

43.

Wijman CAC, Mlynash M, Caulfield AF, et al. Prognostic value of brain diffusion-weighted imaging after cardiac arrest. Ann Neurol. 2009;65(4):394–402. https://doi.org/10.1002/ana.21632.CrossRefPubMedPubMedCentral

44.

Samaniego EA, Mlynash M, Caulfield AF, Eyngorn I, Wijman CAC. Sedation confounds outcome prediction in cardiac arrest survivors treated with hypothermia. Neurocrit Care. 2011;15(1):113–9. https://doi.org/10.1007/s12028-010-9412-8.CrossRefPubMedPubMedCentral

45.

Wijdicks EFM, Hijdra A, Young GB, Bassetti CL, Wiebe S, Quality Standards Subcommittee of the American Academy of Neurology. Practice parameter: prediction of outcome in comatose survivors after cardiopulmonary resuscitation (an evidence-based review): report of the quality standards subcommittee of the American academy of neurology. Neurology. 2006;67(2):203–10. https://doi.org/10.1212/01.wnl.0000227183.21314.cd.CrossRefPubMed

Titel: Factors Associated with Early Withdrawal of Life-Sustaining Treatments After Out-of-Hospital Cardiac Arrest: A Subanalysis of a Randomized Trial of Prehospital Therapeutic Hypothermia
verfasst von: Sarah Wahlster
Kyle Danielson
Lindy Craft
Nassim Matin
James A. Town
Vasisht Srinivasan
Glenn Schubert
David Carlbom
Francis Kim
Nicholas J. Johnson
David Tirschwell
Publikationsdatum: 15.11.2022
Verlag: Springer US
Erschienen in: Neurocritical Care / Ausgabe 3/2023
Print ISSN: 1541-6933
Elektronische ISSN: 1556-0961
DOI: https://doi.org/10.1007/s12028-022-01636-7

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Factors Associated with Early Withdrawal of Life-Sustaining Treatments After Out-of-Hospital Cardiac Arrest: A Subanalysis of a Randomized Trial of Prehospital Therapeutic Hypothermia