Neurological assessment
Neurological outcome as daily assessed by ICU physicians until death or ICU discharge
(fig 1 of ESM). Particularly, in difficult situations (i.e., patients with N20 potentials and/or
cranial reflexes preserved), decisions to withhold or withdraw life-support therapies were
systematically delayed in order to search for a confounding factor (sepsis, remaining
sedative drug effect, intercurrent disease process, other neurological disease). At this step, a
decision was proposed after discussion between all team members (intensivists, nurses,
neurologist, therapist), taking into account all prognostic variables. This decision could be
either to withhold or withdraw life-support therapies, or to wait for an additional follow-up
period.
According to guidelines and recent studies [4-7], life-sustaining treatments were
withdrawn in case of absence of pupillary responses, absence of corneal reflexes, absent or
extensor motor responses, and bilateral absence of the N20 component of the
somatosensory evoked potentials with median nerve stimulation recorded at minimum on
day 3 after CA. In patients who were treated by therapeutic hypothermia, this neurological
assessment was systematically delayed in order to wait for sedative drugs’ elimination. Lifesustaining therapies withdrawal was always decided after a collegial decision. All deaths
associated with such end-of-life decisions occurred during the ICU stay. If spontaneous
ventilation was present, the patient was extubated and kept in the ICU until death. No
patient was discharged from the ICU after terminal extubation. If there was no spontaneous
ventilation, vasoactive drugs were stopped, the inspired oxygen concentration was reduced
to 21%, and the end-expiratory pressure set to zero. Brain death was diagnosed according to
the current French legal framework [8], with the combination of clinical features (absence of
motor response, spontaneous ventilation and brainstem reflex) and the absence of
electroencephalographic activity or cerebral perfusion during cerebral CT scan.
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Figure 1 ESM : decision algorithm for post-CA patients.
EEG: electro-encephalogram; ICU: Intensive Care Unit.