Neurocit Carehttps:/dol1.org/10.1007s12028-023-01688-3NEURCRITICALCARE SOCIETYNCS GUIDELINEGuidelines for Neuroprognosticationin Comatose Adult Survivors of Cardiac ArrestVenkatakrishna Rajajee,Susanne Muehlschlegel2,Katja E.Wartenberg3,Sheila A.AlexanderKatharina M.Busl5,Sherry H.Y.Chous,Claire J.Creutzfeldt?,Gabriel V.Fontaine,Herbert Fried,Sara E.Hocker,David Y.Hwang11,Keri S.Kim12,Dominik Madzar3,Dea Mahanes14,Shraddha Mainali15,Juergen Meixensberger16,Felipe Montellano17,Oliver W.Sakowitz18,Christian Weimar.20Thomas Westermaier21 and Panayiotis N.Varelas222023 The Author(s)AbstractBackground:Among cardiac arrest survivors,about half remain comatose 72 h following return of spontaneouscirculation (ROSC).Prognostication of poor neurological outcome in this population may result in withdrawal of life-sustaining therapy and death.The objective of this article is to provide recommendations on the reliability of selectclinical predictors that serve as the basis of neuroprognostication and provide guidance to clinicians counseling sur-rogates of comatose cardiac arrest survivors.Methods:A narrative systematic review was completed using Grading of Recommendations Assessment,Develop-ment and Evaluation(GRADE)methodology.Candidate predictors,which included clinical variables and predictionmodels,were selected based on clinical relevance and the presence of an appropriate body of evidence.The Popula-tion,Intervention,Comparator,Outcome,Timing,Setting(PICOTS)question was framed as follows:"When counselingsurrogates of comatose adult survivors of cardiac arrest,should [predictor,with time of assessment if appropriate]beconsidered a reliable predictor of poor functional outcome assessed at 3 months or later?"Additional full-text screen-ing criteria were used to exclude small and lower-quality studies.Following construction of the evidence profile andsummary of findings,recommendations were based on four GRADE criteria:quality of evidence,balance of desirableand undesirable consequences,values and preferences,and resource use.In addition,good practice recommenda-tions addressed essential principles of neuroprognostication that could not be framed in PICOTS format.Results:Eleven candidate clinical variables and three prediction models were selected based on clinical relevanceand the presence of an appropriate body of literature.A total of 72 articles met our eligibility criteria to guide recom-mendations.Good practice recommendations include waiting 72 h following ROSC/rewarming prior to neuroprog-nostication,avoiding sedation or other confounders,the use of multimodal assessment,and an extended period ofobservation for awakening in patients with an indeterminate prognosis,if consistent with goals of care.The bilateralabsence of pupillary light response 72 h from ROSC and the bilateral absence of N20 response on somatosensoryevoked potential testing were identified as reliable predictors.Computed tomography or magnetic resonance imag-ing of the brain >48 h
