Abstract Details

Title Early withdrawal of life-sustaining treatments after out-of-hospital cardiac arrest: a sub-analysis of a randomized trial of prehospital hypothermia

Topic Cerebrovascular Disease and Interventional Neurology

Presentation(s) S17 - Cerebrovascular Disease: Clinical Trials and Outcomes Studies (4:18 PM-4:30 PM)

Poster/Presentation
Number 005

Background N/A

Objective To describe incidence and factors associated with early withdrawal of life sustaining therapies based on presumed poor neurologic prognosis (WLST-N) after out-of-hospital cardiac arrest (OHCA).

Design/Methods We performed a sub-analysis of a randomized control trial assessing pre-hospital hypothermia in adult patients with non-traumatic OHCA between 2007-2012. Patients who underwent tracheal intubation and were unconscious following return of spontaneous circulation were included. Our primary outcome was the incidence of WLST-N within <72 hours (early WLST-N). Secondary outcomes included clinical characteristics associated with early WLST-N compared to patients who remained comatose at 72 hours, utilization of multimodal prognostication, and use of sedative medications for patients with early WLST-N. Analysis included descriptive statistics and multivariable logistic regression.

Results We included 1040 OHCA patients (mean age 65 years, 37% female, 41% Caucasian, 44% presented in ventricular fibrillation). Early WLST-N accounted for 24% (n=154) of patient deaths and 51% of WLST-N. Factors associated with early WLST-N were age (OR 1.02, 95%CI:1.01-1.03), DNAR before hospitalization (OR 4.67, 95%CI:1.55-14.01), bilateral absent pupillary reflexes (OR 2.4, 95%CI:1.42-4.10), and lack of neurological consultation (OR 2.60, 95%CI:1.52-4.46). Most patients (72%, n=112) with early WLST-N did not undergo any prognostic tests beyond a neurological exam and computed tomography of the brain. Most patients with early WLST-N received sedating medications (90%) within 24 hours before WLST-N, including opioids (77%), benzodiazepines (68%), propofol/dexmedetomidine (31%), and neuromuscular blocking agents (28%). The median time from last sedation dose to WLST-N was 4.2 hours (IQR 0.4-15); 38% (n=42) received sedation between their last neurological exam and initiation of comfort care.

Conclusions Nearly one quarter of deaths after OHCA were due to early WLST-N, which is discordant with current guidelines. Prognostic tests were underutilized and sedating medications were often co-administered in patients with early WLST-N. Standardizing prognostication and restricting early WLST-N might improve outcome after OHCA.

Authors/Disclosures
Sarah Wahlster, MD PRESENTER	Dr. Wahlster has nothing to disclose.
	No disclosure on file
	No disclosure on file
Nassim Matin, MD (Barrow Neurological Institute)	Dr. Matin has nothing to disclose.
	No disclosure on file
Vasisht Srinivasan (University of Washington)	No disclosure on file
	No disclosure on file
	No disclosure on file
	No disclosure on file
David L. Tirschwell, MD, FAAN (Harborview Medical Center)	Dr. Tirschwell has received personal compensation in the range of $0-$499 for serving on a Scientific Advisory or Data Safety Monitoring board for CARMAT. Dr. Tirschwell has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for AbbVie. The institution of Dr. Tirschwell has received research support from Abbott. The institution of Dr. Tirschwell has received research support from NIH.