Prediction of good functional outcome decreases diagnostic uncertainty in unconscious survivors after out-of-hospital cardiac arrest.
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Lagebrant Alice, Sandroni Claudio, Nolan Jerry P, Bělohlávek Jan, Cariou Alain, Carrai Riccardo, Dankiewicz Josef, Grejs Anders Morten, Grippo Antonello, Hassager Christian, Horn Janneke, Haenggi Matthias, Jakobsen Janus C, Keeble Thomas R, Kirkegaard Hans, Kjaergaard Jesper, Kuiper Michael A, Lee Byung Kook, Lee Dong Hun, Levin Helena, Lilja Gisela, Lundin Andreas, Nielsen Niklas, Oh Sang Hoon, Park Kyu Nam, Pellis Tommaso, Robba Chiara, Rylander Christian, Ryu Seok Jin, Saxena Manoxj, Scarpino Maenia, Schrag Claudia, Stammet Pascal, Storm Christian, Taccone Fabio Silvio, Thomas Matthew, Westhall Erik, Wise Matt P, Youn Chun Song, Young Paul, Cronberg Tobias, Moseby-Knappe Marion
Аннотация
METHODS: Post-hoc analysis of four prospective multicentre studies (TTM, TTM2, KORHN and ProNeCA). We raised the Glasgow Coma Scale motor (GCS-M) inclusion threshold at 72 h after cardiac arrest from the current GCS-M < 4 to GCS-M < 6 (all unconscious patients). Secondly, we included good outcome predictors (GCS-M 4-5, neuron-specific enolase < 17 µg/L, benign electroencephalography patterns ≤ 72 h post-arrest and normal magnetic resonance imaging at 72-168 h post-arrest) in the algorithm. Functional outcome was assessed dichotomously at six months, including modified Rankin Scale 0-3, Cerebral Performance Category 1-2 or Glasgow Outcome Scale 4-5 (no symptoms to moderate disability) as good outcome.
RESULTS: We analysed 3,388 patients, of whom 2,079 had GCS-M < 4 at ≥ 72 h. Of the 874 patients identified by the 2021 ERC/ESICM poor outcome criteria, 870 had poor functional outcome (specificity: 99.6% [95%CI 99.0-99.9]). Using the GCS-M < 6 threshold, 366 more patients entered the algorithm (N = 2,445). Seven more patients with poor outcomes were identified, with close to identical specificity. Good outcome predictors thereafter identified 673 patients with potential recovery, of whom 411 (61%) had a good functional outcome at six months. With the updated algorithm, the number of prognosticated patients with an indeterminate prognosis decreased from 1,205/2,079 (58%) to 891/2,445 (36%).
CONCLUSION: Raising the GCS-M inclusion threshold and adding favourable predictors to the 2021 ERC/ESICM prognostication algorithm reduced prognostic uncertainty without increasing falsely pessimistic predictions.