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NCS Currents June 2016

MOCHA Study Aims to Address Biases in Cardiac Arrest Prognostication By David Matthew Greer, MD, MA, FNCS The MOCHA (Multimodal Outcome CHAracterization in Cardiac Arrest) study is a prospective, multicenter, international study of prognostication after cardiac arrest that will innovatively approach neurologic outcome assessment by reducing the impact of the self-fulfilling prophecy. MOCHA has three main objectives: • To standardize the evaluation of post-cardiac arrest patients with validated tests (clinical, electrophysiologic, biochemical markers, and imaging) at appropriate time points • To encourage more time to allow for delayed recovery in patients with an uncertain prognosis • To establish a network for future prospective studies evaluating therapeutic interventions in defined subpopulations of cardiac arrest survivors Cardiac arrest affects millions worldwide every year, and survivors are often initially comatose with an uncertain prognosis. The neurointensivist has the greatest experience in neurological prognostication and is the best positioned individual to evaluate these patients. Cardiac arrest prognostication research has been mired by the self-fulfilling prophesy of premature withdrawal of life sustaining therapy, a bias created when the methods being investigated for prognostic value are also used to guide decisions of limiting medical interventions. By creating a large registry of cardiac arrest patients in this worldwide study, we hope to achieve several important goals. The overarching goal is to develop a reliable prediction model for prognostication in initially unresponsive post-cardiac arrest patients. Another goal is the comparison of guidelines currently in use for prognostication in different countries and regions to see how accurately they predict outcome. Furthermore, tests that have yet to be validated but are commonly in use, such as neuroimaging, will have an opportunity to be validated prospectively. It is important to note several key features of the study. First, centers are not expected to perform testing that is outside the scope of their standard care. However, guidance will be provided as to how to perform specific tests, as well as the appropriate timing of their performance. Second, centers will be encouraged to allow additional time for recovery, especially in cases in which the outcome is uncertain, or in patients in whom there are no overwhelming systemic comorbidities that might sway toward early withdrawal of life sustaining treatments. Third, the study is international, and will include many centers in countries that traditionally have very little early withdrawal of life sustaining treatments. We are currently recruiting sites for MOCHA and anticipate sites will start enrolling in the fall of 2016. We project that the study will run for two to three years and will enroll 2,500-3,000 patients worldwide. We are particularly interested in sites where a conservative approach is common, with caution frequently exercised to avoid premature withdrawal of life sustaining treatments. The study is being conducted at Yale University with the Yale Center for Clinical Investigation (YCCI). Sites will be expected to include data regarding the patients’ demographics and comorbidities, peri-arrest information, post-arrest treatment (including targeted temperature management), diagnostic work up, and outcomes. There will be central blinded analysis of specific data, including neuroimaging and electrophysiology. Authorship for publications from this large-scale project will be determined based on site enrolment and quality of data. Interested investigators are encouraged to contact Dave Greer at david.greer@yale.edu. Neuroprognostication is one of the core functions of neurointensivists and prognostication after cardiac arrest is perhaps the most homogenous and best studied of all major cerebral injuries. However, based on limitations in the data thus far, prognostication of patients with hypoxic-ischemic encephalopathy is potentially inaccurate, biased, and commonly premature. There is much to be gained by studying this disease well, as the tools utilized and lessons learned may translate into better methods of prognostication in many other disease states in neurocritical care. 10


NCS Currents June 2016
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