Guidelines for Neuroprognostication in Comatose Adult Survivors of Cardiac Arrest

Neurocritical Care Society · 2023 · USA

Source and licence

Authors: Venkatakrishna Rajajee, Susanne Muehlschlegel, Katja E Wartenberg et al.
Title: Guidelines for Neuroprognostication in Comatose Adult Survivors of Cardiac Arrest
Journal: Neurocritical Care, 2023
DOI: 10.1007/s12028-023-01688-3
Licence: CC BY 4.0
Changes: Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC10241762

Licence statement of the original publication

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Recommendations

Verbatim, with grade of recommendation or strength of consensus where given.

Good Practice Statement 1

We recommend deferral of assessment of the neurological prognosis of comatose survivors of cardiac arrest for at least 72 h following ROSC in patients not treated with therapeutic hypothermia (goal temperature < 36.5 °C) and at least 72 h following rewarming in patients treated with hypothermia. However, persistence of coma beyond this period in the ICU must not be equated with a poor neurological prognosisstrong recommendation, evidence cannot be graded

Good Practice Statement 2

We recommend that assessment of the neurological prognosis of comatose survivors of cardiac arrest be performed in the absence of sedation or other potential confoundersstrong recommendation, evidence cannot be graded

Good Practice Statement 3

We recommend that factors that impact overall prognosis, such as a poor baseline level of functioning, preexisting illness associated with limited life-expectancy, and multiorgan failure, be considered prior to, and distinct from, assessment of the neurological prognosis of comatose survivors of cardiac arreststrong recommendation, evidence cannot be graded

Good Practice Statement 4

We recommend that assessment of the neurological prognosis of comatose survivors of cardiac arrest be multimodal, with consideration of the complete clinical scenario, and never based on a single variablestrong recommendation, evidence cannot be graded

Good Practice Statement 5

We recommend that in the absence of reliable (or multiple moderately reliable) predictors of outcome, surrogates of cardiac arrest survivors who remain comatose at the time of neuroprognostication should be counseled that the likelihood, extent, and time course of neurological recovery is uncertain. Surrogates should also be counseled that the timeline of any functional recovery that does occur may extend from several days to several monthsstrong recommendation, evidence cannot be graded

Good Practice Statement 6

We recommend an extended period of observation for signs of neurological recovery in comatose survivors of cardiac arrest with an indeterminate prognosis, if consistent with the goals of care as established through discussions with patient surrogatesstrong recommendation, evidence cannot be graded

Question 4

When counseling surrogates of comatose adult survivors of cardiac arrest, should the bilateral absence of a pupillary light response, assessed at least 72 h from ROSC, be considered a reliable predictor of functional outcome assessed at 3 months or later?
When counseling surrogates of comatose adult survivors of cardiac arrest, should the bilateral absence of a corneal reflex, assessed at least 72 h from ROSC, be considered a reliable predictor of functional outcome assessed at 3 months or later?

Recommendation

When counseling family members and/or surrogates of comatose survivors of cardiac arrest, we suggest the bilateral absence of a pupillary light response, assessed at least 72 h from ROSC, be considered a reliable predictor of poor functional outcome assessed at 3 months or later. This recommendation is conditional on accurate assessment without confounding by medication, hypothermia, or prior surgery and an overall clinical picture consistent with severe, widespread neurological injuryweak recommendation; moderate quality evidence
When counseling family members and/or surrogates of comatose survivors of cardiac arrest, we suggest the bilateral absence of the corneal reflex alone, assessed at least 72 h from ROSC, not be considered a reliable predictor of poor functional outcome assessed at 3 months or laterweak recommendation; moderate quality evidence

Abstract

Background: Among cardiac arrest survivors, about half remain comatose 72 h following return of spontaneous circulation (ROSC). Prognostication of poor neurological outcome in this population may result in withdrawal of life-sustaining therapy and death. The objective of this article is to provide recommendations on the reliability of select clinical predictors that serve as the basis of neuroprognostication and provide guidance to clinicians counseling surrogates of comatose cardiac arrest survivors.

Methods: A narrative systematic review was completed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Candidate predictors, which included clinical variables and prediction models, were selected based on clinical relevance and the presence of an appropriate body of evidence. The Population, Intervention, Comparator, Outcome, Timing, Setting (PICOTS) question was framed as follows: “When counseling surrogates of comatose adult survivors of cardiac arrest, should [predictor, with time of assessment if appropriate] be considered a reliable predictor of poor functional outcome assessed at 3 months or later?” Additional full-text screening criteria were used to exclude small and lower-quality studies. Following construction of the evidence profile and summary of findings, recommendations were based on four GRADE criteria: quality of evidence, balance of desirable and undesirable consequences, values and preferences, and resource use. In addition, good practice recommendations addressed essential principles of neuroprognostication that could not be framed in PICOTS format.

Results: Eleven candidate clinical variables and three prediction models were selected based on clinical relevance and the presence of an appropriate body of literature. A total of 72 articles met our eligibility criteria to guide recommendations. Good practice recommendations include waiting 72 h following ROSC/rewarming prior to neuroprognostication, avoiding sedation or other confounders, the use of multimodal assessment, and an extended period of observation for awakening in patients with an indeterminate prognosis, if consistent with goals of care. The bilateral absence of pupillary light response > 72 h from ROSC and the bilateral absence of N20 response on somatosensory evoked potential testing were identified as reliable predictors. Computed tomography or magnetic resonance imaging of the brain > 48 h from ROSC and electroencephalography > 72 h from ROSC were identified as moderately reliable predictors.

Conclusions: These guidelines provide recommendations on the reliability of predictors of poor outcome in the context of counseling surrogates of comatose survivors of cardiac arrest and suggest broad principles of neuroprognostication. Few predictors were considered reliable or moderately reliable based on the available body of evidence.

Supplementary Information: The online version contains supplementary material available at 10.1007/s12028-023-01688-3.

Contents of the original publication

The section headings of the original.

Introduction
Scope, Purpose, and Target Audience
How to Use These Guidelines
Methods
Selection of Guideline Questions
Selection of Outcomes
Systematic Review Methodology
Effect Size (Predictor Accuracy)
Evidence to Recommendation Criteria
Good Practice Statements
Good Practice Statement 1
Rationale
Good Practice Statement 2
Rationale
Good Practice Statement 3
Rationale
Good Practice Statement 4
Rationale
Good Practice Statement 5
Rationale
Good Practice Statement 6
Rationale
Recommendations: Clinical Variables as Predictors
Recommendations: Clinical Prediction Models
Outcome: Functional Outcome
Approach to Neuroprognostication in Comatose Survivors of Cardiac Arrest
Future Directions
Conclusions
Endorsements
Source of Support
Ethical Approval/Informed Consent

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