The Curing Coma Campaign International Survey on Coma Epidemiology, Evaluation, and Therapy (COME TOGETHER)

Authors

Raimund Helbok, Department of Neurology, Neuro-Intensive Care Unit, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria. Raimund.helbok@tirol-kliniken.at.
Verena Rass, Department of Neurology, Neuro-Intensive Care Unit, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
Ettore Beghi, Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy.
Yelena G. Bodien, Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Harvard University, Boston, MA, USA.
Giuseppe Citerio, Neuro-Intensive Care, ASST Di Monza, Monza, Italy.
Joseph T. Giacino, Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Harvard University, Boston, MA, USA.
Daniel Kondziella, Department of Neurology, Rigshospitalet, Copenhagen University Hospital and Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
Stephan A. Mayer, Department of Neurology, New York Medical College, Valhalla, NY, USA.
David Menon, Division of Anaesthesia, University of Cambridge, Cambridge, UK.
Tarek Sharshar, Neuro-Intensive Care Medicine, Sainte-Anne Hospital, University of Paris, GHU-Psychiatry & Neurosciences, Paris, France.
Robert D. Stevens, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.
Hanno Ulmer, Director Department of Medical Statistic, Informatics and Health Economics, Medical University of Innsbruck, Innsbruck, Austria.
Chethan P. Venkatasubba Rao, Division of Vascular Neurology and Neurocritical Care, Baylor College of Medicine and CHI Baylor St Luke's Medical Center, Houston, TX, USA.
Paul Vespa, Departments of Neurology and Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA.
Molly McNett, College of Nursing, The Ohio State University, Columbus, OH, USA.
Jennifer Frontera, Department of Neurology, Grossman School of Medicine, New York University, New York, NY, USA.

Author Type(s)

Faculty

Journal Title

Neurocritical Care

First Page

47

Last Page

59

Document Type

Article

Publication Date

8-1-2022

Department

Neurology

Abstract

BACKGROUND: Although coma is commonly encountered in critical care, worldwide variability exists in diagnosis and management practices. We aimed to assess variability in coma definitions, etiologies, treatment strategies, and attitudes toward prognosis. METHODS: As part of the Neurocritical Care Society Curing Coma Campaign, between September 2020 and January 2021, we conducted an anonymous, international, cross-sectional global survey of health care professionals caring for patients with coma and disorders of consciousness in the acute, subacute, or chronic setting. Survey responses were solicited by sequential emails distributed by international neuroscience societies and social media. Fleiss κ values were calculated to assess agreement among respondents. RESULTS: The survey was completed by 258 health care professionals from 41 countries. Respondents predominantly were physicians (n = 213, 83%), were from the United States (n = 141, 55%), and represented academic centers (n = 231, 90%). Among eight predefined items, respondents identified the following cardinal features, in various combinations, that must be present to define coma: absence of wakefulness (81%, κ = 0.764); Glasgow Coma Score (GCS) ≤ 8 (64%, κ = 0.588); failure to respond purposefully to visual, verbal, or tactile stimuli (60%, κ = 0.552); and inability to follow commands (58%, κ = 0.529). Reported etiologies of coma encountered included medically induced coma (24%), traumatic brain injury (24%), intracerebral hemorrhage (21%), and cardiac arrest/hypoxic-ischemic encephalopathy (11%). The most common clinical assessment tools used for coma included the GCS (94%) and neurological examination (78%). Sixty-six percent of respondents routinely performed sedation interruption, in the absence of contraindications, for clinical coma assessments in the intensive care unit. Advanced neurological assessment techniques in comatose patients included quantitative electroencephalography (EEG)/connectivity analysis (16%), functional magnetic resonance imaging (7%), single-photon emission computerized tomography (6%), positron emission tomography (4%), invasive EEG (4%), and cerebral microdialysis (4%). The most commonly used neurostimulants included amantadine (51%), modafinil (37%), and methylphenidate (28%). The leading determinants for prognostication included etiology of coma, neurological examination findings, and neuroimaging. Fewer than 20% of respondents reported routine follow-up of coma survivors after hospital discharge; however, 86% indicated interest in future research initiatives that include postdischarge outcomes at six (85%) and 12 months (65%). CONCLUSIONS: There is wide heterogeneity among health care professionals regarding the clinical definition of coma and limited routine use of advanced coma assessment techniques in acute care settings. Coma management practices vary across sites, and mechanisms for coordinated and sustained follow-up after acute treatment are inconsistent. There is an urgent need for the development of evidence-based guidelines and a collaborative, coordinated approach to advance both the science and the practice of coma management globally.

Recommended Citation

Helbok, R., Rass, V., Beghi, E., Bodien, Y. G., Citerio, G., Giacino, J. T., Kondziella, D., Mayer, S. A., Menon, D., Sharshar, T., Stevens, R. D., Ulmer, H., Venkatasubba Rao, C. P., Vespa, P., McNett, M., & Frontera, J. (2022). The Curing Coma Campaign International Survey on Coma Epidemiology, Evaluation, and Therapy (COME TOGETHER). Neurocritical Care, 37 (1), 47-59. https://doi.org/10.1007/s12028-021-01425-8