![]() ![]() Post-cardiac arrest careĪll patients received standard intensive care according to our institutional intensive care unit protocol based on the 2021 international guidelines for post-CA care 5. ![]() Among them, patients who underwent extracorporeal membrane oxygenation (ECMO) and only one prognostic test were excluded from this study. Comatose adult patients (> 18 years old) treated with post-CA care after OHCA between May 2018 and June 2022 were included in this study. The requirement for informed consent was waived by the Institutional Review Board of Chungnam National University Hospital (CNUH IRB 6) owing to the retrospective study design. We collected data from a tertiary-care hospital registry on patients with post-CA care after out-of-hospital cardiac arrest (OHCA). This was a single-center, retrospective, observational, registry-based study. Therefore, the aims of this study were (1) to investigate the prognostic performance of post-CA care in an environment where WLST is infrequently performed, not only for single predictors but also for combination strategies, including a significant number of imaging studies, and (2) suggest an optimal combination strategy to improve prognostic performance with limited medical resources. Particularly, among the six prognostic tests, imaging techniques, such as computed tomography (CT) and magnetic resonance imaging (MRI), have shown high accuracy as prognostic tests in previous studies 11, 12, 13 however, they are not readily available in all countries. Therefore, finding and optimizing an effective combination strategy for prognostication given the limited medical resources in each facility is essential. There are six prognostic tests, and they cannot all be performed in clinical practice because not every facility has sufficient resources 9, 10. This has been described in some studies conducted in countries or communities where treatment limitations are not accepted due to cultural, legal or religious reasons 6, 7.Īnother limitation of the current prognostic algorithm is the insufficient evidence on how to combine predictors to effectively maximize prognostic accuracy 8. A special condition limiting the risk of self-fulfilling prophecy bias is the absence of an active WLST policy. However, a major bias from self-fulfilling prophecy having a potential for WLST can affect this algorithm for prognostication in the patients with CA 5. Over the past decades, outcome prediction after CA has progressed towards a multimodal approach to ensure high accuracy, and the European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have recently published a prognostication strategy algorithm combining at least two abnormal predictors of any of six tests 5. Therefore, in patients who are comatose after resuscitation from cardiac arrest, the prognostication should be performed to both inform patient’s relatives and to help clinicians to target treatments based on the patient’s chances of achieving a neurological recovery 5. A withdrawal of life-sustaining treatment (WLST) based on a predicted poor neurological outcome is the most common cause of death in patients undergoing post-resuscitation care after CA 2, 3, 4. Similar content being viewed by othersĬardiac arrest (CA) occurs annually in approximately 50–110 per 100,000 people worldwide 1. Combining three of the predictors may improve prognostic performance and be more efficient than adding all tests indiscriminately, given limited medical resources. The best prognostic performance was observed with the combination of absent PR/CR, high NSE, and diffuse injury on DWI, whereas the combination strategy of all available predictors did not improve prognostic performance (87.8%, 95% CI 73.8–95.9). Of these, 68 (52.3%) patients had poor outcomes. A total of 130 patients were included in the analysis. The prognostic performances for poor outcomes were analyzed for sensitivity and specificity. Predictors of poor outcome were absence of ocular reflexes (PR/CR) without confounding factors, a highly malignant pattern on the most recent electroencephalography, defined as suppressed background with or without periodic discharges and burst-suppression, high neuron-specific enolase (NSE) after 48 h, and diffuse injury on imaging studies (computed tomography or diffusion-weighted imaging ) at 72–96 h. ![]() Poor outcome was defined as a cerebral performance category of 3–5 at 6 months. Prospectively collected registry data were used for this retrospective analysis. This study investigated the prognostic performance of combination strategies using a multimodal approach in patients treated after cardiac arrest.
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