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Randomized clinical trial of magnesium, diazepam, or both after out-of-hospital cardiac arrest

To the Editor: Precise description of acute cardiac arrest management with medication by Longstreth et al. contrasts with their standard, but egregiously crude outcome data1: “The primary outcome was wakening at any time by three months after the cardiac arrest . . . Wakening was defined by the patient’s having comprehensible speech or following commands, and was based on review of medical records and telephone contact . . . secondary outcomes were days to awakening, days to death, being awake and independent at any time by three months, and being awake and independent at three months . . . Personnel conducted a telephone follow-up with the patient or surrogate at three months after the cardiac arrest. Patients or their surrogates were asked a number of questions to assess level of neurologic function and independence. Based on the responses to these questions, all patients who are discharged from the hospital were classified as being dead, alive but not awake, awake but dependent or awake and independent.” Beyond the medication failure is the calculated outcome estimate for the role model Seattle area. Of 2,714 candidate patients, 47% were dead; 32% were immediate treatment failures. At 3 months, 5% attained the telephone label “independent,” 1% “dependent,” and 0.1% “vegetative.” Of immediate survivors, 20% fewer were “awake” and 9% fewer “independent” at 3 months. This is the numerical window of humane hope and disappointment. The editorially cited Utstein categories of favorable outcome are as follows: “Moderate cerebral disability is Conscious. Sufficient cerebral function for part-time work in sheltered environment or independent activities of daily life (dressing, traveling by public transportation, and preparing food). May have hemiplegia, seizures, ataxia, dysarthria, dysphasia or permanent memory or mental changes .. . .Good cerebral performance is Conscious, alert, able to work and lead a normal life. May have minor psychological or neurological deficits (mild dysphasia, non incapacitating hemiparesis, or minor cranial nerve abnormalities).”2 Undefined are measures of work quality, normal life, memory, and complete recovery. The requirement of independent comprehensive neuropsychological measurement is established for valid research concerning cardiorespiratory and brain disease and cardiac surgery. Although patients with cardiac arrest enter treatment without informed consent, many do not want to suffer resuscitation.3 Precise stateof-the-art prognosis of anoxic encephalopathy treatment, ranging from rigorously defined total recovery to devastating disability, is a social and economic necessity for physicians, citizens, and their government.4,5 Beyond the casual Utstein guesswork, the ethical cost factors of public policy require reliable assessment and open public discussion.