Early head CT in post-cardiac arrest patients: A helpful tool or contributor to self-fulfilling prophecy?
Early head CT in post-cardiac arrest patients: A helpful tool or contributor to self-fulfilling prophecy?
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DOI：
10.1016/j.resuscitation.2021.06.004
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发表时间：
2021-06-23
期刊：
影响因子：
6.5
通讯作者：
Gilmore, Emily J.
中科院分区：
文献类型：
--
作者：
Beekman, Rachel;Maciel, Carolina B.;Gilmore, Emily J.
目的：神经系统诊断指南建议，早期头部计算机断层扫描（HCT）可能有助于评估心脏骤停（CA）患者恢复自主循环后。我们的目的是确定早期HCT的影响，在CA后的第一个6小时内进行，对recovery.Methods后的决策：我们确定了一个队列的最初无意识的CA后患者在三级保健学术医疗中心，从2012年至2017年。从电子病历中回顾性提取与人口统计学、CA详情、CA后护理（包括神经影像学和神经生理学检查）相关的变量。记录HCT结果导致的管理变更。经设盲委员会认证的神经重症监护医师裁定了与缺氧缺血性脑损伤（HIBI）负荷相关的HCT结果。结果：302例患者中，182例（60.2%）在CA后6小时内进行了HCT（早期HCT组）。约1/4的早期HCT异常（最常见的HIBI变化; 78.7%，n = 37），导致近一半病例（46.8%，n = 22）的管理发生变化。最常见的管理变化是护理降级[包括过渡到不复苏状态）、停止目标体温管理和停止生命维持治疗（WLST）]。在影像学HIBI病例中，平均[标准差] GWR较低（1.20 [0.10] vs 1.30 [0.09]，P < 0.001），进展至脑死亡的比例较高（44.4% vs 2.9%; P < 0.001）。早期HCT的评分者间可靠性（IRR），以确定放射科和三个neurointensivists之间的HIBI的存在有一个广泛的范围（K 0.13-0.66）。结论：早期HCT确定异常的情况下，25%，并经常影响治疗决策。放射科和神经重症监护医师之间的神经影像学解释差异很常见，早期HCT对HIBI严重程度的一致性较差（k 0.11）。
Objective: Neuroprognostication guidelines suggest that early head computed tomography (HCT) might be useful in the evaluation of cardiac arrest (CA) patients following return of spontaneous circulation. We aimed to determine the impact of early HCT, performed within the first 6 h following CA, on decision-making following resuscitation.Methods: We identified a cohort of initially unconscious post-CA patients at a tertiary care academic medical center from 2012 to 2017. Variables pertaining to demographics, CA details, post-CA care, including neuroimaging and neurophysiologic testing, were abstracted retrospectively from the electronic medical records. Changes in management resulting from HCT findings were recorded. Blinded board-certified neurointensivists adjudicated HCT findings related to hypoxic-ischemic brain injury (HIBI) burden. The gray-white matter ratio (GWR) was also calculated.Results: Of 302 patients, 182 (60.2%) underwent HCT within six hours of CA (early HCT group). Approximately 1 in 4 early HCTs were abnormal (most commonly HIBI changes; 78.7%, n = 37), which resulted in a change in management in nearly half of cases (46.8%, n = 22). The most common changes in management were de-escalation in care [including transition to do not resuscitate status), withholding targeted temperature management, and withdrawal of life sustaining therapy (WLST)]. In cases with radiographic HIBI, mean [standard deviation] GWR was lower (1.20 [0.10] vs 1.30 [0.09], P < 0.001) and progression to brain death was higher (44.4% vs 2.9%; P < 0.001). The inter-rater reliability (IRR) of early HCT to determine presence of HIBI between radiology and three neurointensivists had a wide range (K 0.13-0.66).Conclusion: Early HCT identified abnormalities in 25% of cases and frequently influenced therapeutic decisions. Neuroimaging interpretation discrepancies between radiology and neurointensivists are common and agreement on severity of HIBI on early HCT is poor (k 0.11).