Guidelines for Neuroprognostication in Critically Ill Adults with Status Epilepticus

BACKGROUND: Status epilepticus (SE) is a heterogeneous disorder with significant morbidity and mortality. This guideline provides broad principles of neuroprognostication and recommendations on the reliability of clinical predictors of outcome that clinicians may consider when counseling surrogate decision-makers of patients with SE. METHODS: This narrative systematic review used Grading of Recommendations Assessment, Development and Evaluation methodology. Good practice recommendations addressed essential principles of neuroprognostication. Candidate predictors, including clinical variables and prediction models, were selected based on clinical relevance and the availability of appropriate evidence. The question was: "When counseling surrogates of patients with SE, should [predictor, with time of assessment if appropriate] be considered a reliable predictor of [outcome] assessed at [time point]?" Outcomes were selected and rated by the panel. Screening criteria were used to exclude smaller and lower-quality studies. Following construction of the evidence profile and summary of findings, recommendations were based on four Grading of Recommendations Assessment, Development and Evaluation criteria: quality of evidence, balance of desirable and undesirable consequences, values and preferences, and resource use. RESULTS: Good practice recommendations include establishing appropriate long-term goals with surrogates of patients with SE that may extend beyond seizure control alone, setting expectations for recovery in patients with refractory/super-refractory SE, using predictors specific to underlying pathologies as a basis for neuroprognostication, considering potential confounders, and deferring neuroprognostication in cases of unclear etiology until appropriate diagnostic evaluation is performed. Nine clinical variables and two prediction models were selected. A sufficient body of evidence was available only for the prediction of mortality. Forty-two articles met the eligibility criteria for guiding recommendations. None of the variables and models selected were identified as reliable predictors of mortality in patients with SE. CONCLUSIONS: This guideline provides broad principles for neuroprognostication and recommendations on the reliability of predictors of in-hospital mortality in the context of counseling surrogates of patients with SE.