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Withdrawal of life-sustaining therapy in intensive care unit patients following out-of-hospital cardiac arrest: An Australian metropolitan ICU experience

      Highlights

      • Early withdrawal of life-sustaining therapy was a significant contributor to out-of-hospital cardiac arrest.
      • Following multivariable logistic regression analysis, status myoclonus had the strongest association with early withdrawal of life-sustaining therapy.
      • Within the cohort of patients presenting with status myoclonus, 52 patients underwent withdrawal and subsequently died, whereas three patients who didn't undergo withdrawal survived their ICU and hospital stay.
      • Status myoclonus must no longer be viewed as an agonal phenomenon and used as the sole determinant for withdrawal. We strongly advocate objective assessment and stratification with EEG.

      Abstract

      Background

      Withdrawal of life-sustaining therapy is a common phenomenon following out-of-hospital cardiac arrest. The clinical practices surrounding withdrawal of life-sustaining therapy remain unclear and warrant further inspection due to their reported impact on post-cardiac arrest mortality.

      Objectives

      To determine factors associated with withdrawal of life-sustaining therapy (WLST) in intensive care unit (ICU) patients following out-of-hospital cardiac arrest (OHCA).

      Methods

      A retrospective review of ICU patients’ clinical records following OHCA was conducted from January 2010 to December 2015. Demographic features, cardiac arrest characteristics, and targeted temperature management practices were compared between patients with and without WLST. We dichotomised WLST into early (ICU length of stay <72 h) and late (ICU length of stay ≥72 h). Factors independently associated with WLST were determined by multivariable binary logistic regression.

      Results

      The study cohort included 260 post-OHCA ICU patients. The mean age was 58 years, and majority were males (178, 68%); 145 (56%) underwent WLST, with the majority undergoing early WLST (89, 61%). Status myoclonus was the strongest independent factor associated with early WLST (OR 42.53, 95% CI 4.97–363.60; p < 0.001). Glasgow Coma Scale (GCS) motor response of <4 on day three post-OHCA was the strongest factor associated with delayed WLST (OR 48.76, 95% CI 11.87–200.27; p < 0.0001).

      Conclusion

      The majority of deaths in ICU patients post-OHCA occurred following early WLST. Status myoclonus and a GCS motor response of <4 on day three post-OHCA are independently associated with WLST.

      Keywords

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