- Email: [email protected]
Reply to: Accurate neuroprognostication in cardiac arrest survivors: Details matter!
Resuscitation 115 (2017) e5–e6
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Letter to the Editor
Reply to: Accurate neuroprognostication in cardiac arrest survivors: Details matter! Sir, We appreciate Maciel et al’s interest [1] in our recently published letter [2]. We fully agree that both the technical details of test results, as well as the clinical details of a case, are of utmost importance when identifying whether a seemingly extraordinary recovery is truly an outlier that merits reporting or simply the result of unidentified confounders. Cortical SSEP response testing for neuroprognostication conforms to the standards cited by Maciel et al. for all patients at our institution, including our reported case. Responses were evoked by median nerve stimulation, and the appropriate stimulus intensity was confirmed by documenting consistent median motor responses. Stimulus duration, rate, and sweep window length were 0.2 ms, 5 Hz, and 50 ms, respectively. Notch filtering was off, and the signal was band pass filtered between 30 and 3000 Hz. We were unable to find the impedance of the recording electrodes used in this study; however, our standard practice is to use electrodes with impedance of less than 10,000 . The authors also highlight the important point that the averaged trace does not take rejected traces into account. Out of 2000 successive cortical responses on either hemisphere, only 17 traces on the right and 2 traces on the left were rejected. In terms of clinical confounders, we agree that sedation interferes with neuroprognostication after cardiac arrest. However, we strongly feel that sedation did not contribute to this patient’s overall unresponsiveness or her SSEP results. Except for lacosaminde and leviteracetam, all sedating medications (including benzodiazepines, propofol, and opiates) were stopped on post-arrest day (PAD) 17, 72 h prior to obtaining SSEPs, and were not administered for the rest of her hospitalization. Despite this, the patient remained completely unresponsive, with a Glasgow Coma Score of 3, for 12 more days until spontaneous eye opening was witnessed. This prolonged unresponsiveness, coupled with the known association between time to awakening and outcome [3], make this patient’s impressive recovery singularly unique. Finally, the presence of “malignant” EEG patterns is often regarded as a poor prognostic sign, and, contrary to the authors’ assertion, multiple retrospective studies demonstrate a clear association between ictal EEG patterns (including periodic discharges) and poor outcome [4,5]. While we certainly do not take this to mean that the presence of periodic discharges portends a uniformly poor prognosis, we do feel that this could reflect potential implicit biases within the medical community regarding the significance of EEG findings on outcome after cardiac arrest. Providing an accurate opinion on the capacity for neurologic recovery after cardiac arrest is a difficult and heavy burden for http://dx.doi.org/10.1016/j.resuscitation.2017.04.018 0300-9572/© 2017 Elsevier B.V. All rights reserved.
physicians. Even when a careful, multi-modal approach is adopted, we are frequently left with a fuzzy, unclear picture of what the future holds for patients. If presented with the same clinical details from this case for a different patient, our current state of knowledge would still lead us to assert that the capacity for meaningful recovery is infinitesimally small. That this assertion could destroy the very possibility of a meaningful recovery is a sobering thought. Conflict of interest statement The authors certify that they have NO affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript. Funding None Acknowledgement The authors report no disclosures. References [1].Maciel CB, Hirsch LJ, Greer DM, Alkawadri R. Accurate neuroprognostication in cardiac arrest survivors: details matter! Resuscitation 2017, http://dx.doi.org/10. 1016/j.resuscitation.2017.03.030. [2].Weinstein J, Mallela A, Abella BS, Levine JM, Balu R. Excellent neurologic recovery after prolonged coma in a cardiac arrest patient with multiple poor prognostic indicators. Resuscitation 2017, http://dx.doi.org/10.1016/j.resuscitation.2017.01. 022. [3].Grossestreuer AV, Abella BS, Leary M, Perman SM, Fuchs BD, Kolansky DM, et al. Time to awakening and neurologic outcome in therapeutic hypothermia-treated cardiac arrest patients. Resuscitation 2013;84(12):1741–6, http://dx.doi.org/10. 1016/j.resuscitation.2013.07.009. [4].Crepeau AZ, Rabinstein AA, Fugate JE, Mandrekar J, Wijdicks EF, White RD, et al. Continuous EEG in therapeutic hypothermia after cardiac arrest: prognostic and clinical value. Neurology 2013;80(4):339–44, http://dx.doi.org/10.1212/ WNL.0b013e31827f089d. [5].Westhall E, Rossetti AO, van Rootselaar AF, Wesenberg Kjaer T, Horn J, Ullén S, et al. Standardized EEG interpretation accurately predicts prognosis after cardiac arrest. Neurology 2016;86(16):1482–90, http://dx.doi.org/10.1212/ WNL0000000000002462.
Ramani Balu ∗ Division of Neurocritical Care, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
e6
Letter to the Editor / Resuscitation 115 (2017) e5–e6
Jessica Weinstein Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States Arka Mallela Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States Benjamin S. Abella Center for Resuscitation Science, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
Joshua M. Levine Division of Neurocritical Care, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States ∗ Corresponding
author at: Division of Neurocritical Care, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, 3W Gates, 3600 Spruce Street, Philadelphia, PA, 19104, United States. E-mail address: [email protected] (R. Balu) 11 April 2017
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Letter to the Editor
Reply to: Accurate neuroprognostication in cardiac arrest survivors: Details matter! Sir, We appreciate Maciel et al’s interest [1] in our recently published letter [2]. We fully agree that both the technical details of test results, as well as the clinical details of a case, are of utmost importance when identifying whether a seemingly extraordinary recovery is truly an outlier that merits reporting or simply the result of unidentified confounders. Cortical SSEP response testing for neuroprognostication conforms to the standards cited by Maciel et al. for all patients at our institution, including our reported case. Responses were evoked by median nerve stimulation, and the appropriate stimulus intensity was confirmed by documenting consistent median motor responses. Stimulus duration, rate, and sweep window length were 0.2 ms, 5 Hz, and 50 ms, respectively. Notch filtering was off, and the signal was band pass filtered between 30 and 3000 Hz. We were unable to find the impedance of the recording electrodes used in this study; however, our standard practice is to use electrodes with impedance of less than 10,000 . The authors also highlight the important point that the averaged trace does not take rejected traces into account. Out of 2000 successive cortical responses on either hemisphere, only 17 traces on the right and 2 traces on the left were rejected. In terms of clinical confounders, we agree that sedation interferes with neuroprognostication after cardiac arrest. However, we strongly feel that sedation did not contribute to this patient’s overall unresponsiveness or her SSEP results. Except for lacosaminde and leviteracetam, all sedating medications (including benzodiazepines, propofol, and opiates) were stopped on post-arrest day (PAD) 17, 72 h prior to obtaining SSEPs, and were not administered for the rest of her hospitalization. Despite this, the patient remained completely unresponsive, with a Glasgow Coma Score of 3, for 12 more days until spontaneous eye opening was witnessed. This prolonged unresponsiveness, coupled with the known association between time to awakening and outcome [3], make this patient’s impressive recovery singularly unique. Finally, the presence of “malignant” EEG patterns is often regarded as a poor prognostic sign, and, contrary to the authors’ assertion, multiple retrospective studies demonstrate a clear association between ictal EEG patterns (including periodic discharges) and poor outcome [4,5]. While we certainly do not take this to mean that the presence of periodic discharges portends a uniformly poor prognosis, we do feel that this could reflect potential implicit biases within the medical community regarding the significance of EEG findings on outcome after cardiac arrest. Providing an accurate opinion on the capacity for neurologic recovery after cardiac arrest is a difficult and heavy burden for http://dx.doi.org/10.1016/j.resuscitation.2017.04.018 0300-9572/© 2017 Elsevier B.V. All rights reserved.
physicians. Even when a careful, multi-modal approach is adopted, we are frequently left with a fuzzy, unclear picture of what the future holds for patients. If presented with the same clinical details from this case for a different patient, our current state of knowledge would still lead us to assert that the capacity for meaningful recovery is infinitesimally small. That this assertion could destroy the very possibility of a meaningful recovery is a sobering thought. Conflict of interest statement The authors certify that they have NO affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript. Funding None Acknowledgement The authors report no disclosures. References [1].Maciel CB, Hirsch LJ, Greer DM, Alkawadri R. Accurate neuroprognostication in cardiac arrest survivors: details matter! Resuscitation 2017, http://dx.doi.org/10. 1016/j.resuscitation.2017.03.030. [2].Weinstein J, Mallela A, Abella BS, Levine JM, Balu R. Excellent neurologic recovery after prolonged coma in a cardiac arrest patient with multiple poor prognostic indicators. Resuscitation 2017, http://dx.doi.org/10.1016/j.resuscitation.2017.01. 022. [3].Grossestreuer AV, Abella BS, Leary M, Perman SM, Fuchs BD, Kolansky DM, et al. Time to awakening and neurologic outcome in therapeutic hypothermia-treated cardiac arrest patients. Resuscitation 2013;84(12):1741–6, http://dx.doi.org/10. 1016/j.resuscitation.2013.07.009. [4].Crepeau AZ, Rabinstein AA, Fugate JE, Mandrekar J, Wijdicks EF, White RD, et al. Continuous EEG in therapeutic hypothermia after cardiac arrest: prognostic and clinical value. Neurology 2013;80(4):339–44, http://dx.doi.org/10.1212/ WNL.0b013e31827f089d. [5].Westhall E, Rossetti AO, van Rootselaar AF, Wesenberg Kjaer T, Horn J, Ullén S, et al. Standardized EEG interpretation accurately predicts prognosis after cardiac arrest. Neurology 2016;86(16):1482–90, http://dx.doi.org/10.1212/ WNL0000000000002462.
Ramani Balu ∗ Division of Neurocritical Care, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
e6
Letter to the Editor / Resuscitation 115 (2017) e5–e6
Jessica Weinstein Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States Arka Mallela Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States Benjamin S. Abella Center for Resuscitation Science, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
Joshua M. Levine Division of Neurocritical Care, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States ∗ Corresponding
author at: Division of Neurocritical Care, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, 3W Gates, 3600 Spruce Street, Philadelphia, PA, 19104, United States. E-mail address: [email protected] (R. Balu) 11 April 2017