• Defined as death, persistent vegetative state, or severe disability with dependence on others for activities of daily living

• Continuous EEG, initiated as soon as possible following ROSC, should be strongly considered to monitor for potentially treatable electrographic status epilepticus

• Neuroprognostication is performed ≥ 72 hours following ROSC

• Overall prognostication can be performed prior to this point in the setting of age, global medical condition, and co-morbidities; however this is distinct from prognostication regarding neurologic recovery from anoxic injury

Major confounders must be excluded prior to neuroprognostication

• Temperature (rewarming to normothermia must be complete)

• Sedation and Neuromuscular Blockade

  • Cessation of all sedative and paralytic medications for ≥ 12 hours (can consider longer duration based on clinical judgement and/or concern for intoxication outside of clinically administered sedation)

• Avoid hypotension

• Avoid hypoglycemia and other profound metabolic derangements

• Motor response of flexion or better at any time corresponds to a reasonable possibility of good neurologic recovery

  • Outcome is indeterminate and further neuroprognostication while in the ICU is unlikely to be beneficial

• Any sign of definitive neurological improvement over the course of evaluation should prompt reconsideration of neurologic prognosis

False positive rate < 3% with upper limit of 95% confidence interval < 10%

1. Absence of bilateral pupillary reflexes (confirmed with quantitative pupillometry, if available) and corneal reflexes, ideally assessed together

   • Isolated absence of either pupillary or corneal reflex should raise concern for confounders

2. Absence of bilateral N20 waves on SSEP

Poor neurologic outcome is very likely (>95% probability, based on available data) when bilateral pupillary and corneal reflexes are absent AND bilateral N20 waves are absent

• Strong predictors of poor outcome have high specificity but relatively poor sensitivity

• When only one of the strong predictors (absence of bilateral pupillary and corneal reflexes OR absence of bilateral N20 waves) is present, poor outcome remains quite likely; however, at least one moderate predictor should be present to support a poor prognosis

• If pupillary or corneal reflexes are present and at least one N20 wave is present, two or more moderate predictors, 24 hours after the initial assessment (i.e. ≥ 96 hours from ROSC) make a poor outcome likely (>80-90% probability) but this uncertainty should be acknowledged

Moderate Predictors:

1. 1. Myoclonic status epilepticus ≤ 48 hours from ROSC

      • Defined as generalized repetitive spontaneous myoclonic activity; myoclonus must occur at least once every 10 s for > 10 min or at least once a minute for > 30 min

   2. Absence of EEG reactivity to external stimuli or electrographic status epilepticus or burst suppression ≥ 72 hours from ROSC

   3. Diffuse loss of grey-white differentiation and sulcal effacement on head CT or presence of a diffuse restricted-diffusion pattern on MRI DWI.

• Should be given when none of the above criteria for poor neurologic prognosis are met

  1. Recovery is indeterminate

  2. If recovery occurs, it will likely be prolonged

  3. if recovery occurs, it will likely be incomplete