Is this patient dead, vegetative, or severely neurologically impaired? Assessing outcome for comatose survivors of cardiac arrest
Is this patient dead, vegetative, or severely neurologically impaired? Assessing outcome for comatose survivors of cardiac arrest
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DOI：
10.1001/jama.291.7.870
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发表时间：
2004-02-18
影响因子：
120.7
通讯作者：
Detsky, AS
中科院分区：
文献类型：
--
作者：
Booth, CM;Boone, RH;Detsky, AS
背景：大多数心脏骤停的幸存者在复苏后处于昏迷状态，有意义的神经系统恢复发生在一小部分病例中。治疗时间长、费用高，而且对家庭和护理人员来说往往很困难。在这种临床情况下，体格检查可能是有用的，获得的信息可以帮助医生和家属做出准确的治疗和/或退出护理的决定。目的探讨临床检查预测心脏骤停后昏迷不良预后的准确性和精确性。资料来源和研究选择我们使用昏迷、心脏骤停、预后、体格检查、敏感性和特异性以及观察者变异等术语在MEDLINE检索英语文章（1966-2003）。其他来源来自检索文章的参考书目和体检教科书。如果评估成人心脏骤停后昏迷预后的临床检查的精确性和准确性，则纳入研究。11项研究，涉及1914名患者，符合我们的纳入标准。两位作者独立审查了每项研究，以确定合格性，抽象数据，并使用预定的标准对方法质量进行分类。分歧以一致意见解决了。摘要似然比（LRs）由随机效应模型计算。发现有5种临床体征可强烈预测死亡或神经预后不良：24小时无角膜反射（LR, 12.9； 95%可信区间[CI]， 2.0-68.7）， 24小时无瞳孔反应（LR, 10.2; 95% CI, 1.8-48.6）， 24小时无疼痛戒断反应（LR, 4.7; 95% CI, 2.2-9.8）， 24小时无运动反应（LR, 4.9; 95% CI, 1.6-13.0）， 72小时无运动反应（LR, 9.2; 95% CI, 2.1-49.4）。通过汇总11项研究（n=1914）的结果数据来计算个体死亡或神经预后不良的比例，并将其用作预后不良的预测概率的估计。不良结果的随机效应估计为77% （95% CI, 72%-80%）。最高LR使测前概率从77%增加到测后概率97% （95% CI, 87%-100%）。没有临床发现LRs能强烈预测良好的神经预后。结论简单的体格检查能有效预测心脏骤停昏迷幸存者的死亡或预后不良。最有用的体征出现在心脏骤停后24小时，早期预后不应仅凭临床检查。这些数据提供了预后信息，而不是治疗建议，治疗建议必须在结合许多其他变量的个人基础上提出。
Context Most survivors of cardiac arrest are comatose after resuscitation, and meaningful neurological recovery occurs in a small proportion of cases. Treatment can be lengthy, expensive, and often difficult for families and caregivers. Physical examination is potentially useful in this clinical scenario, and the information obtained may help physicians and families make accurate decisions about treatment and/or withdrawal of care.Objective To determine the precision and accuracy of the clinical examination in predicting poor outcome in post-cardiac arrest coma.Data Sources and Study Selection We searched MEDLINE for English-language articles (1966-2003) using the terms coma, cardiac arrest, prognosis, physical examination, sensitivity and specificity, and observer variation. Other sources came from bibliographies of retrieved articles and physical examination textbooks. Studies were included if they assessed the precision and accuracy of the clinical examination in prognosis of post-cardiac arrest coma in adults. Eleven studies, involving 1914 patients, met our inclusion criteria.Data Extraction Two authors independently reviewed each study to determine eligibility, abstract data, and classify methodological quality Using predetermined criteria. Disagreement was resolved by consensus.Data Synthesis Summary likelihood ratios (LRs) were calculated from random effects models. Five clinical signs were found to strongly predict death or poor neurological outcome: absent corneal reflexes at 24 hours (LR, 12.9; 95% confidence interval [CI], 2.0-68.7), absent pupillary response at 24 hours (LR, 10.2; 95% CI, 1.8-48.6), absent withdrawal response to pain at 24 hours (LR, 4.7; 95% CI, 2.2-9.8), no motor response at 24 hours (LR, 4.9; 95% CI, 1.6-13.0), and no motor response at 72 hours (LR, 9.2; 95% CI, 2.1-49.4). The proportion of individuals' dying or having a poor neurological outcome was calculated by pooling the outcome data from the 11 studies (n=1914) and used as an estimate of the pretest probability of poor outcome. The random effects estimate of poor outcome was 77% (95% CI, 72%-80%). The highest LR increases the pretest probability of 77% to a posttest probability of 97% (95% CI, 87%-100%). No clinical findings were found to have LRs that strongly predicted good neurological outcome.Conclusions Simple physical examination maneuvers strongly predict death or poor outcome in comatose survivors of cardiac arrest. The most useful signs occur at 24 hours after cardiac arrest, and earlier prognosis should not be made by clinical examination alone. These data provide prognostic information, rather than treatment recommendations, which must be made on an individual basis incorporating many other variables.