Prognosis Following Cardiopulmonary Resuscitation: The Limits of Intensive Care

by Prof. Dr. med. Frank Thömke, Sacha L. Weilemann in volume 42/2007

In addition to the usual neurological examinations, the investigations under discussion (EEG/somatosensible evoked potentials [SEP]/neutron-specific enolase [NSE]/MRI) should have been the gold standard in intensive care medicine since the initial investigations of anoxic coma (1, 2) after cardiopulmonary resuscitation (as per Safar). This is the only way in which the limits of treatment of anoxic coma can be recognized under controlled conditions and in a timely fashion.
Timely prognosis in coma patients with severe cerebral damage requires intense interdisciplinary discussion. For example, in a patient with post-traumatic bulbar brain syndrome that is developing towards complete loss of cerebral function, diagnosis-based imaging, an isoelectric EEG, missing early SEP, and/or early acoustic evoked potentials hint at the limitations of intensive therapy – even before cerebral death is diagnosed. In this situation, which could be termed the "terminal coma phase," the constellation of findings described above will predict an irreversible course if treatment is continued: the proximity of brain death on the one hand, and the later, permanent, postanoxic apallic syndrome (or death) on the other. Responsible clinicians should not try to avoid challenging decisions if there are still gaps in their diagnostic skills or delay these by passing them over to care structures further down the line. Each justified uncertainty will have to be worked through and feed into extended observation and diagnostics. If the findings are completed and clear, a clear decision should be made at an early stage – including a decision about stopping treatment.
The article is published at a time where the limitations of intensive medical care are being redefined, which may limit access to the intensive care ward but are also intended to redefine the "exit" strategy, in order to formulate resource-adapted care pathways. Automatically basing crucial medical decisions on technical findings only is a serious danger. This contribution to
intensive care medicine from an experienced neurologist and physician of internal medicine does not conjure up this danger, but it points at the integration of relatives into syndrome specific palliative intensive care – which is really stating the obvious. DOI: 10.3238/arztebl.2008.0130

Conflict of interest statement
The author has been the study director of the German study "MMF in der Therapie der Myasthenia gravis (Mycophenolate mofetil in the therapy of Myasthenia gravis)“ conducted by Aspreva.

Prof. Dr. med. Rudolf Wilhelm Christian Janzen
ehem. Chefarzt Neurologische Klinik
Krankenhaus Nordwest
Landwehrweg 12c
61350 Bad Homburg, Germany

The authors of the review article have chosen not to reply.

References

1. Brierley JB, Adams JH, Graham C, Simpson JA: Neocortical death after cardiac arrest: a clinical, neurophysiological, and neuropathological report of two cases. Lancet 1971; 7724: 560–5.

2. Ingvar DH, Brun A, Johansson L: Survival after severe cerebral anoxia with destruction of the cerebral cortex: the apallic syndrome. Ann NY Acad Sci 1978; 315: 184–214.