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Contemporary Reviews in Critical Care Medicine |

Contemporary Approach to Neurologic Prognostication of Coma After Cardiac ArrestPrognostication After Cardiac Arrest

Nawfel Ben-Hamouda, MD; Fabio S. Taccone, MD, PhD; Andrea O. Rossetti, MD; Mauro Oddo, MD
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From the Department of Intensive Care Medicine (Drs Ben-Hamouda and Oddo) and Department of Clinical Neurosciences, Neurology Service (Dr Rossetti), Centre Hospitalier Universitaire Vaudois, University Hospital and Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland; and Department of Intensive Care (Dr Taccone), Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.

CORRESPONDENCE TO: Mauro Oddo, MD, Department of Intensive Care Medicine, Centre Hospitalier Universitaire Vaudois, University Hospital and Faculty of Biology and Medicine, Rue du Bugnon 46, CH-1011 Lausanne, Switzerland; e-mail: mauro.oddo@chuv.ch


FUNDING/SUPPORT: This study was supported by the Swiss National Science Foundation through research grants to Drs Oddo [Grant 320030_138191] and Rossetti [Grant CR32I3_143780].

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;146(5):1375-1386. doi:10.1378/chest.14-0523
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Coma after cardiac arrest (CA) is an important cause of admission to the ICU. Prognosis of post-CA coma has significantly improved over the past decade, particularly because of aggressive postresuscitation care and the use of therapeutic targeted temperature management (TTM). TTM and sedatives used to maintain controlled cooling might delay neurologic reflexes and reduce the accuracy of clinical examination. In the early ICU phase, patients’ good recovery may often be indistinguishable (based on neurologic examination alone) from patients who eventually will have a poor prognosis. Prognostication of post-CA coma, therefore, has evolved toward a multimodal approach that combines neurologic examination with EEG and evoked potentials. Blood biomarkers (eg, neuron-specific enolase [NSE] and soluble 100-β protein) are useful complements for coma prognostication; however, results vary among commercial laboratory assays, and applying one single cutoff level (eg, > 33 μg/L for NSE) for poor prognostication is not recommended. Neuroimaging, mainly diffusion MRI, is emerging as a promising tool for prognostication, but its precise role needs further study before it can be widely used. This multimodal approach might reduce false-positive rates of poor prognosis, thereby providing optimal prognostication of comatose CA survivors. The aim of this review is to summarize studies and the principal tools presently available for outcome prediction and to describe a practical approach to the multimodal prognostication of coma after CA, with a particular focus on neuromonitoring tools. We also propose an algorithm for the optimal use of such multimodal tools during the early ICU phase of post-CA coma.

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