Cardiac arrest is associated with a high mortality rate (Mozaffarian et al., 2015). The introduction of therapeutic hypothermia has improved outcomes and increased the likelihood of earlier discharge to home or a rehabilitation center (Taccone et al., 2014). This case report examined how the use of sedatives negatively influenced the clinical examination and prognostication for a patient who was recovering from hypoxic-ischemic encephalopathy after therapeutic hypothermia. It also showed how agitation was evidence of early signs of neurological recovery that would benefit from rehabilitation rather than pharmacological sedation. In this case, the occupational therapist played a key role in shifting the clinical care plan from palliation to rehabilitation.
According to Deckard and Ebright (2011), therapeutic hypothermia is “deliberate reduction of the core body temperature, typically to a range of about 32° to 34°C (89.6° to 93.2°F) in patients who don't regain consciousness after return of spontaneous circulation following a cardiac arrest” (p. 23). The use of therapeutic hypothermia has challenged the practice parameters recommended by the American Academy of Neurology as prognostic predictors after cardiac arrest, which were based on data obtained before the introduction of this therapy (Fugate, Wijdicks, White, & Rabinstein, 2011). Because therapeutic hypothermia is associated with delayed recovery, applying the 2006 American Academy of Neurology guidelines may be inappropriate in this clinical setting (Bigham, Bigham, & Martin, 2018). Several studies discussed the effect of therapeutic hypothermia on established neurological assessment, prognostic predictors, and time to recovery (Bro-Jeppesen et al., 2009; Che et al., 2011; Ganga et al., 2013; Terman, Hume, Meurer, & Silbergleit, 2014; Yokoyama et al., 2011). Determining an accurate and reliable prognosis for patients who experience hypoxic-ischemic encephalopathy after cardiac arrest is both challenging and critical because the decision to withdraw life-sustaining therapy depends on the expected prognosis (Taccone et al., 2014).
There is concern that, in some cases, life-sustaining treatments may have been withdrawn prematurely. The duration of coma after cardiac arrest depends on many factors, such as complications of critical systemic illness, persistent pharmacological interventions, and the use of sedatives (Fugate et al., 2011). Some patients who are treated with therapeutic hypothermia may regain consciousness at a slower rate than previously expected. For patients who are treated with therapeutic hypothermia, sedation likely persists longer and may be unpredictable. Thus, prognostication should be delayed to ensure that the effect of medication has been eliminated. Further, the predictive value of a neurological examination is insufficient at day 3 and must be delayed at least until day 5 and possibly beyond (Matthews et al., 2018). The withdrawal of life-sustaining therapies based on current predictive models may have an inherent self-fulfilling prophecy effect because clinicians rely on current prognostic variables to inform the family of the likelihood of meaningful functional recovery (Bigham et al., 2018; Fugate et al., 2011).
Thus, an optimal clinical outcome requires interdisciplinary teamwork and effective communication. Interdisciplinary and multimodal approaches are needed to improve the reliability and quality of prognostic assessment (Taccone et al., 2014).
Ethical approval to write this article was obtained from the ethics review board of Jewish General Hospital, Montréal, Québec, Canada.
A 43-year-old man experienced a nontraumatic cardiac arrest and was treated with therapeutic hypothermia in 2013. The patient lost consciousness in public, and cardio-pulmonary resuscitation commenced immediately. Emergency medical services (EMS) arrived on site in 3 minutes. The patient was transported to the emergency department, where the Glasgow Coma Scale score was 3, blood pressure was 150/100 mmHg, heart rate was 115 beats/min, oxygen saturation was 100%, and intubation was performed. Computed tomography scan of the cervical spine showed normal results, with no sign of acute trauma. Therapeutic hypothermia was initiated 3 hours after the cardiac arrest and lasted for 24 hours. The patient had no relevant medical history. Computed tomography scan of the head showed severe brain anoxia with diffused disturbance of the cerebral background. The patient had seizure activity that was treated with levetiracetam 1000 mg bid. He was admitted to the coronary care unit, where he continued to be intubated and was sedated with propofol 15 mg/hr. Sedation was discontinued on the fourth day, and Ativan 4 mg was administered every 3 hours as needed. The next day, the neurology team reassessed the patient and reported that he did not meet the criteria for neurological determination of death, based on the Canadian medical standards (Shemie et al., 2006). For example, he had a positive gag reflex, a cough reflex, and reactive pupils. On the sixth day, the patient did not respond to commands but randomly opened and closed his eyes. The pupils were normal and reactive. On day 7, he showed pain response, rapidly contracting pupil, and spontaneous decorticate. Treatment with propofol 15 mg drip was resumed, and the patient underwent weaning trials.
On day 12, the neurology team completed a neurological assessment between the intermittent halting and resumption of propofol administration. A percutaneous endoscopic gastrostomy and a tracheostomy tube were placed, according to the family's wishes. The family and the medical team discussed the patient's code level and decided on nonaggressive measures, including no cardiac resuscitation, approximately 20 days after admission. The medical team suggested palliative care, with the possibility of harvesting the organs.
To prevent self-harm during episodes of agitation, 17 days after admission, an occupational therapist was consulted to assist with positioning. The physiotherapist had already been involved; however, it was difficult to intervene effectively because of the patient's sedation level or episodes of agitation when he was not sedated. On analyzing the patient's information and clinical status, the occupational therapist saw that a more comprehensive occupational therapy assessment was required. Based on chart review and discussion with the team, the initial impression was that the patient's clinical picture and the subsequent care plan were not adequate because of the continuous use of sedatives. Because the patient was exhibiting episodes of agitation, the occupational therapist suspected that he might be experiencing early stages of recovery from brain injury (Bogner & Corrigan, 1995; Fleminger, Greenwood, & Oliver, 2006; Lemke, 2004; McNett, Sarver, & Wilczewski, 2012; Riker, Fugate, & Participants in the International Multi-disciplinary Consensus Conference on Multimodality, 2014). Sedation had to be withdrawn for an extended period to confirm the hypothesis and allow reliable assessment and interpretation of his neurological behavior.
Physicians performed assessment with the Glasgow Coma Scale, which has questionable predictive validity, according to Balestreri et al. (2004). Nurses performed routine neurological assessment. Interprofessional team members used the manual muscle test to assess muscle strength (Cuthbert & Goodheart, 2007). The manual muscle test has adequate to excellent interrater reliability for the muscles of the upper and lower extremities (intraclass correlation coefficient = 0.45–1.00 and intraclass correlation coefficient = 0.66–1.00), respectively, according to Fan et al. (2010).
The occupational therapist used the Rancho Los Amigos Cognitive Recovery Scale-Revised (RLA) to assess the patient's neurobehavioral recovery. This cognitive scale is used to assess individuals with brain injury, based on cognitive and behavioral presentation. This 10-level scale describes the stages of cognitive and functional evolution after a brain injury (Hagen, Malkmus, & Durham, 1979). It has excellent test-retest reliability, (Spearman rho = 0.82) (Gouvier, Blanton, LaPorte, & Nepomuceno, 1987). The occupational therapist used the Functional Independence Measure in a nonstandardized way to assess activities of daily living (ADLs) (Ottenbacher, Hsu, Granger, & Fiedler, 1996). It has median interrater reliability of 0.95. Because the Functional Independence Measure was conducted in a nonstandardized fashion, the test results were likely compromised.
The neurological-rehabilitation treatment approach was derived from the Neuro-Integrative Functional Rehabilitation and Habilitation (Neuro-IFRAH) and neurodevelopmental treatment methods. These two methods use a holistic and integrative clinical approach when treating patients with neurological pathophysiology, such as brain injury, including stroke and anoxic brain injury. Both methods emphasize the importance of individualizing therapy and interventions in diverse clinical settings to maximize the potential for habilitation and rehabilitation.
The RLA was used to determine the patient's baseline and monitor his progress. It helped to guide the discussion about the appropriate care plan with the interdisciplinary team, which included cardiac physicians and residents, a neurologist, a nurse from the coronary care unit, a clinical nurse educator, an occupational therapist, a physical therapist, a speech and language pathologist, a dietician, and a social worker, in addition to the family. Sedation was removed gradually over 17 days. At that time, occupational therapy evaluation showed that the patient was at RLA II, which was a generalized response, and the patient required total assistance (Table 1). At this level, patients can move around, although their movements appear to be without purpose. Patients do not seem to be able to focus on anything in particular (Hagen et al., 1979). The patient's physical impairments included an increase in extensor tone in four limbs, poor sitting balance, and inability to stand.
Patient's Assessment and Progress
While observing other clinicians interact with the patient, the occupational therapist noticed that the patient reacted more suddenly and abruptly when handled without sufficient forewarning. In addition, a nurse reported that the patient responded positively to his son's voice and gentle touch.
The medical team introduced the option of initiating palliative care to the family before occupational therapy was able to complete an evaluation. The occupational therapist inquired about such a decision with the nurse educator and suggested postponing the palliative care option until the assessment was completed and the patient was no longer sedated. An interdisciplinary meeting was necessary to share perspectives and explain what occupational therapy could offer once an accurate baseline was obtained without sedation. A team meeting was held with the cardiology team, the pharmacist, the physiotherapist, nurses, the nutritionist, and the occupational therapist. The medical team explained that propofol was used primarily to control agitation because the nurses were concerned for the patient's safety. The occupational therapist educated the team about the stages of recovery from brain injury, using the RLA as a guide, and noted that agitation could be considered an early sign of recovery. Consequently, suppressing such neurological behavior with pharmaceutical agents was contraindicated. The medical team and the pharmacist discussed pharmaceutical options to manage hyperactivity without complete sedation. They decided to initiate treatment with Seroquel 50 mg/day, which the patient tolerated. The cardiologist consulted and updated the neurologist about the outcomes of the interdisciplinary team meeting.
The occupational therapist used different treatment methods to address the complex rehabilitation. The RLA scale was used to assess and guide the rehabilitation approach during recovery.
Interventions during RLA levels II to V. When the patient was at RLA level II to III, the occupational therapist met with the interdisciplinary team and the family and recommended sensitizing the patient to external stimuli through predictable handling accompanied by a simple explanation of the upcoming activity. For example, if more than one person was working with the patient, one team member was designated as the lead voice in providing commands for the activity while minimizing distractions. Occupational therapy treatment focused on providing and recommending stimuli that calmed the patient, desensitized him to touch, and offered simple step-by-step explanations with predictable physical touch. For example, basic self-care activities, such as face washing, were structured to facilitate the patient's capacity to consistently follow simple one-step verbal or tactile commands. The occupational therapist would face the patient, place a warm washcloth in his hand, and provide the verbal command “wash your face,” followed by hand-over-hand assistance to perform the activity when the patient could not initiate or complete the task. Slowly the patient started to show improvement on the RLA scale (Hagen et al., 1979).
As the patient progressed through RLA levels III to V, some nurses reported that he seemed to be following verbal commands. As his behavior became more predictable and showed a more purposeful pattern (e.g., turning to voice stimuli), some nurses and the occupational therapist wondered whether his vision was compromised. He could not speak because he had a tracheostomy. When the tracheostomy tube was removed, he stated his name, and eventually he regained speech. The patient reported that he could not see. He gradually regained some vision while maintaining visual field cut deficits.
The environment was modified to facilitate alertness and encourage safe and active engagement with his surroundings. The patient was seated in a protective reclining chair that allowed him to safely adjust the position on his own; his bed was padded to prevent possible self-injury during episodes of agitation. The approach to cognitive rehabilitation focused on ameliorating impairments at each stage of recovery. For example, a structured schedule for routine ADLs was established. A progressive calendar was used to improve orientation and self-organization when he was at RLA level V. Initially, the occupational therapist worked with the patient on using a daily calendar, followed by a weekly calendar, and then a monthly calendar, as his cognitive abilities improved. He was at RLA level V when he agreed to be discharged to a neurological rehabilitation center. Almost a year after discharge, he visited the hospital and reported that he was back home and working part time. He denied much recollection of his stay in the coronary care unit.
Addressing performance components and ADLs. As the patient started to follow commands, other team members, such as physical and speech therapists, intervened more successfully. Eventually, the patient was transferred to the cardiac unit. Pedretti (1996) indicated that improving performance components should be linked to a functional task. The occupational therapy intervention concentrated on retraining in ADLs through remedying the various performance components. Different techniques that were used to achieve this goal, such as neurodevelopmental treatment, were supported by the literature (Mikolajewska, 2012; Stevenson & Jarrett, 2006; Thibaut et al., 2013). Neurological re-education included managing muscle tone with different methods, such as weight-bearing techniques during therapeutic activities. Further, treatments focused on improving midline orientation, identifying right versus left body parts, and proprioception to enable the patient to engage in basic ADLs, such as dressing. For instance, initially, the occupational therapist identified the body part by stating “this is your right leg” or “this is your right arm” while stroking the full limb with a washcloth. Then the patient was asked to dress the upper or lower body, starting with the right side. The process was repeated for the left side. Tactile and verbal cues and assistance were graded to allow more independence with ADLs.
Careful and timely assessment of the neurological state was crucial in assessing functional recovery and prognosis. Occupational therapy assessment played a critical role as part of a multimodal interdisciplinary approach in evaluating neurological recovery, the potential for rehabilitation, and the overall functional clinical presentation. These interventions improved interprofessional communication and identified the effect of sedative drugs on recovery. Further, the occupational therapist assisted with outcome prediction and aided the patient's family and the interdisciplinary team in making life-sustaining decisions about treatment. The patient required more time than the conventional waiting period after therapeutic hypothermia before he started to show meaningful functional recovery. Continuous use of propofol limited the ability to obtain a reliable assessment of neurological behavior and proper evaluation by the rehabilitation team. The interdisciplinary team's understanding of the patient's neurological behavior as a possible sign of early recovery was a turning point for creating a shared clinical approach that focused on rehabilitation. The agitation started to be perceived as an indication of potential recovery that needed to be examined rather than suppressed through sedation.
Historically, patients who experience an out-of-hospital cardiac arrest have a mortality rate of more than 90% (Kozik, 2007). Patients who survive this type of cardiac arrest often have severe neurological impairment as a result of cerebral ischemia and hypoxia. However, the recent introduction of therapeutic hypothermia provided neuroprotection that may have challenged the reliability of the standard neurological examination before therapeutic hypothermia. The occupational therapy assessment and recommendations to the medical team, such as withholding sedative medication for an extended period before conducting neurological assessment, were consistent with literature reviews that questioned the reliability of the standard neurological assessment and suggested a multimodal approach (Rossetti & Koenig, 2011). Rossetti and Koenig (2011) recommended withholding sedative medication to allow neurological assessment when the patient was not sedated, especially because such medications could seriously confound the evaluation because of metabolic delay. Therefore, close coordination between the medical and allied health team was necessary to obtain an accurate assessment.
Understanding the different stages of neurological recovery after anoxic brain injury was important in establishing reasonable expectations for functional regains during the acute phase. Hence, because propofol was used to control agitation, the occupational therapist could not perform a functional evaluation and the validity of the neurological examination was questionable. Sharing such understanding with the interdisciplinary team helped to create a unified and comprehensive clinical picture. The occupational therapist's clinical reasoning was supported by the literature; for example, Taccone et al. (2014) reported that therapeutic hypothermia may prolong the metabolism of sedative agents and induce drug accumulation, which could alter neurological assessment and delay the recovery of motor response.
The occupational therapist provided both team education and early rehabilitation. The occupational therapist used the RLA scale (Hagen et al., 1979) to assess the evolution of neurological behavior and guide the rehabilitation care plan. In addition, the occupational therapist helped the team to understand the different stages of neurological recovery, especially during the agitation phase. Formisano et al. (2005) reported that restlessness and agitation in patients with severe brain injury who sustained prolonged disturbances of consciousness could be interpreted as purposeful interaction that may precede recovery of consciousness. The interprofessional team was informed about how behavioral observations, such as psychomotor agitation, could be helpful in detecting possible improvements in prognosis and encouraged to consider them as favorable prognostic factors (Formisano et al., 2005).
The occupational therapy approach that considers the whole person integrated different interventions and methods that helped to increase independence in performing functional tasks. For instance, ameliorating certain neurological deficits, such as decreased midline orientation, body part identification, ideomotor apraxia, right-left discrimination, and somatoagnosia, helped the patient to participate in ADLs. In this example, neuro-developmental treatment assisted in tone management, whereas the Neuro-IFRAH method of problem-solving, sequence, and facilitation techniques helped to improve midline orientation. Cognitive rehabilitation helped the patient to compensate for decreased short-term memory and increase insight and awareness of deficits, which facilitated discharge planning. Initially, the patient declined going to a rehabilitation center because of decreased insight regarding deficits. Many patients who experience cardiac arrest and are treated with therapeutic hypothermia may not show such severe global deficits. However, occupational therapists should consider screening these patients, on an inpatient or outpatient basis, to identify potential deficits in occupational performance.
Because this was a case report and thus the results could not be generalized, further research is indicated to examine the benefits of occupational therapy intervention on the clinical outcome of this patient population. Systematic replication of the described approach may be difficult. This was a case report, and some of the standardized tests were performed in a nonstandardized fashion, which could have compromised their validity. A longitudinal study would be valuable to assess the effect of therapeutic hypothermia on cognitive function and occupational performance, particularly work performance and instrumental ADLs.
Implications for Occupational Therapy
Patients who experience cardiac arrest and are treated with therapeutic hypothermia pose a new challenge for occupational therapists. We need to examine our scope of assessment and interventions to minimize possible deficits in occupational performance, roles, and quality of life as a result of neurological assault. Some impairments may affect higher cognitive functioning and the performance of instrumental ADLs. Occupational therapists can play a key role in assessment and intervention with this patient population. Establishing the role of occupational therapy at different stages of clinical evolution, especially in the critical acute phase, is recommended. However, many aspects of impairment may not be obvious in the acute phase. Therefore, occupational therapists should consider screening these patients, whether on an inpatient or outpatient basis, to identify potential deficits to occupational performance.
This report discussed how a patient with cardiac arrest who was treated with therapeutic hypothermia required an extended period to show meaningful recovery and challenged the early neurological assessment. Thus, early withdrawal of life support would have been contraindicated. Prolonged use of sedation played a role in masking neurological recovery. The occupational therapist played a critical role within the context of an interdisciplinary team to improve the clinical outcome. Further studies are needed to examine the effect of occupational therapy assessment and intervention at different stages of the care continuum on patients who received therapeutic hypothermia. In addition, longitudinal studies are needed to assess the possible long-term effect of therapeutic hypothermia on cognitive functioning and instrumental ADLs. With greater knowledge of this patient population, occupational therapists can better serve these patients and contribute to neurological assessment and recovery.
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Patient's Assessment and Progress
|Functional baseline||Assessment in the critical care unit (when propofol is withdrawn intermittently)||Assessment in the critical care unit (no sedation)||Functional status at discharge|
|Activities of daily living: independent.||Dependent||DependentNothing by mouth||Dressing upper/lower body: minimum to moderate assistance.Grooming: minimum assistance. Feeding: stand-by assistance.Main impairments: attention, body part identification, ideomotor apraxia, right-left discrimination, autopagnosia, and somatoagnosia.|
|Instrumental activities of daily living: independent (owns a business).||Dependent||Dependent||Not tested|
|Functional mobility: independent without an aid.||Neurobehavior: agitation||Sitting on edge of bed: maximum assistance of two persons.Bed mobility: dependent, with spontaneous movement.||Bed mobility: independent.Sitting on edge of bed: stand-by assistance. Transfers: minimum assistance. Ambulation: contact assistance to minimum assistance without an aid.|
|Physical components: moves all four limbs spontaneously (range of motion in four limbs = within functional limits).Cognitive components: does not follow commands.||Physical components: hypertonicity in four limbs, cortical blindness.Neurological behavior: hyperactive, not following commands.Cognitive components: Rancho level II.||Main impairments: decreased midline orientation, vision, and balance.Cognitive components: Rancho level V.|
|Psychosocial: divorced with two young children.|