Estimating the False Positive Rate of Absent Somatosensory Evoked Potentials in Cardiac Arrest Prognostication

Objectives: Absence of somatosensory evoked potentials ("absent somatosensory evoked potentials") is considered a nearly perfect predictor of poor outcome after cardiac arrest. However, reports of good outcomes despite absent somatosensory evoked potentials and high rates of withdrawal of life-sustaining therapies have raised concerns that estimates of the prognostic value of absent somatosensory evoked potentials may be biased by self-fulfilling prophecies. We aimed to develop an unbiased estimate of the false positive rate of absent somatosensory evoked potentials as a predictor of poor outcome after cardiac arrest. Data Sources: PubMed. Study Selection: We selected 35 studies in cardiac arrest prognostication that reported somatosensory evoked potentials. Data Extraction: In each study, we identified rates of withdrawal of life-sustaining therapies and good outcomes despite absent somatosensory evoked potentials. We appraised studies for potential biases using the Quality in Prognosis Studies tool. Using these data, we developed a statistical model to estimate the false positive rate of absent somatosensory evoked potentials adjusted for withdrawal of life-sustaining therapies rate. Data Synthesis: Two-thousand one-hundred thirty-three subjects underwent somatosensory evoked potential testing. Five-hundred ninety-four had absent somatosensory evoked potentials; of these, 14 had good functional outcomes. The rate of withdrawal of life-sustaining therapies for subjects with absent somatosensory evoked potential could be estimated in 14 of the 35 studies (mean 80%, median 100%). The false positive rate for absent somatosensory evoked potential in predicting poor neurologic outcome, adjusted for a withdrawal of life-sustaining therapies rate of 80%, is 7.7% (95% CI, 4–13%). Conclusions: Absent cortical somatosensory evoked potentials do not infallibly predict poor outcome in patients with coma following cardiac arrest. The chances of survival in subjects with absent somatosensory evoked potentials, though low, may be substantially higher than generally believed. The content is solely the responsibility of the authors and does not necessarily represent the official views of Harvard Catalyst, Harvard University and its affiliated academic healthcare centers, or the National Institutes of Health. Drs. Bianchi and Westover are co-senior authors. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (https://ift.tt/29S62lw). Supported, in part, by National Institutes of Health 1K23NS090900, T32HL007901, T90DA22759, T32EB001680; Neurocritical Care Society research training fellowship; American Heart Association postdoctoral fellowship; Andrew David Heitman Neuroendovascular Research Fund; Rappaport Foundation; and Salerno foundation. Dr. Amorim is supported by the Neurocritical Care Society and the American Heart Association. Dr. Amorim's institution received funding from the National Institutes of Health (NIH), Neurocritical Care Society, and the American Heart Association; he disclosed he is supported by the Andrew David Heitman Neuroendovascular Research Fund, Rappaport Foundation, and Salerno foundation. Dr. Ghassemi is supported by the Salerno foundation. Dr. Lee's institution received funding from the NIH-NINDS (R03NS091864), and he received funding from SleepMed/DigiTrace and Advance Medical. Dr. Greer received funding from Bard Medical (research grant), and he received funding from medical-legal consultation. Dr. Kaplan received funding from Wiley Blackwell (royalties), Cadwell, and Lundbeck; and as an expert witness on quantitative electroencephalogram. Dr. Cash received support from NIH-National Institute of Neurological Diseases and Stroke (NINDS) NINDS RO1-NS062092, and NINDS-K24-NS088568). Dr. Westover received support from the NIH (1K23NS090900, 1R01NS102190, 1R01NS102574, 1R01NS107291), Andrew David Heitman Neuroendovascular Research Fund, and Rappaport Foundation. Drs. Amorim, Ghassemi, Cole, and Westover received support for article research from the NIH. Dr. Bianchi received support from the Massachusetts General Hospital, the Center for Integration of Medicine and Innovative Technology, the Milton Family Foundation, and the American Sleep Medicine Foundation; he has a patent pending on a home sleep monitoring device; he has received travel funding from Servier; has consulting and research contracts with Foramis, MC10, Insomnisolv, International Flavors and Fragrances, and GrandRounds; and has provided expert testimony in sleep medicine. For information regarding this article, E-mail: edilbertoamorim@gmail.com Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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