Scientific statement on prediction of survival of survivors of cardiac arrest

In order to facilitate research on the appropriate prognosis after cardiac arrest and to develop better treatments for the recovery from brain injury, a working group consisting of a Johns Hopkins Medicine doctor and 39; experts from the American Heart Association (AHA) released a scientific release How to Predict Recovery in Comatose Survivors. The statement was published in the July 11 issue of circulation.

At the present time, there are no rules or criteria defining how to conduct a study to predict recovery. Due to the quality and quality of the research, policy decisions may lead to predictive errors that may indicate a poor outcome for patients who may have a good outcome, or vice versa. In addition, the lack of standards for predicting results has made it impossible to study therapies that can heal the brain and the rest of the body after cardiac resuscitation.

To develop this scientific statement, the AHA Scientific Subcommittee on Cardiovascular Emergency Care has established an international group of experts in the specialties for adults and children of neurology, cardiology, emergency medicine, intensive medicine and nursing. The group's goal is for the clinical research community to develop an accurate clinical test for most patients after resuscitation following cardiac arrest to determine the likely prognosis.

"We need to help patients and their families do their best not to prolong their unnecessary suffering while ensuring that they do not interrupt their care too early if the person has the potential to recover with a relatively good quality of life", said Romergryko Geocadin. , MD, Chair of the Expert Panel and Professor of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine at the Johns Hopkins University School of Medicine. "In the current state of affairs, we must recognize the limits of our practices in this area because we do not have high quality scientific data to support our decision-making process."

According to the release, about 8% of the more than 320,000 people who experience cardiac arrest outside a health facility in the United States are coming out of the hospital with a positive outcome, while the vast majority of Resuscitated patients end up in coma or another state of consciousness due to brain injury. Most deaths are reported as brain damage, but only 10% of these patients have clinical signs of brain death. Most die after being removed from the survival system because it is predicted that they will have poor brain function and that they will probably not recover.

Currently, many doctors wait 48 hours after a cardiac arrest that the patient wakes up from coma, and some even opt to wait 72 hours. However, because of the limitations of tests and other confounders, such as therapeutic hypothermia, the forecast of a result may be biased and premature.

During a cardiac arrest, there are two phases of brain injury: one is due to lack of oxygen and the other occurs, ironically, after the return of blood. Healing may not begin until the patient has cleared this barrier, which may take at least a week after cardiac arrest. This further complicates the decision as to how long a patient will wait for him to wake up. Sedatives can also affect some of the diagnoses that determine brain function. The authors generally recommend waiting seven days or until the patient has finished taking sedatives, depending on what happens later.

"One of the possible reasons for the failure of each drug tested in clinical trials to cure a brain injury after cardiac arrest is that studies are designed to look for these drug effects 30 or 90 days after successful resuscitation after cardiac arrest, but we do not give most patients time to recover for this period, but early recovery predictions (within 72 hours) based on quality studies mediocre, "said Geocadin. "By providing this statement, health care providers can use it as a guide to developing more rigorous, high quality studies that can inform how to undertake better clinical studies leading to better practice." medicine and the development of useful treatments for our patients. "

The authors examined currently available diagnoses and their limitations for testing brain function, such as evaluation of reflexes, stimulation of sensory nerves in the arm, measurement of pupil dilation after illuminating a lamp. pen in the eye, the use of an electroencephalogram to badess seizures, the application of MRI and computed tomography. brain imaging, and more. By properly using existing tools or developing them in better designed studies, they hope that researchers will be able to adopt or improve these procedures to create better diagnoses that predict long-term brain function.

The declaration provides clinical researchers with parameters for setting up their studies, such as the number of people they have to register, the statistical methods to use, the opportune time to re-evaluate the function of patients recovering, the means to avoid bias and consistent application of protocols.

The last section of the statement addresses ethical issues such as respecting the wishes of the patient or family regarding life support and non-resuscitation orders. The authors point out that quality of life is an important factor and point out that there is currently little data on long-term outcomes after waking up and much more needs to be done.