A National Survey on Coma Epidemiology, Evaluation and Therapy in India – Revisiting The Curing Coma® Campaign COME TOGETHER Survey
Authors: Mahajan Charu , Prabhakar Hemanshu , Rass Verena , McNett Molly , Kapoor Indu , Helbok Raimund , Zirpe Kapil 
Published: April 2023

Abstract
Background The limited representation from developing countries in original COME TOGETEHER survey gave us an impetus to conduct this survey in the Indian subcontinent. The primary aim of carrying out this survey across various hospital settings in India was to assess variability of defining coma clinical features, it’s etiology and to identify the current practice for diagnosis, management, and prognostication of comatose patients.Methods This cross-sectional online survey was carried over the months from August through September, 2022. Participants were health care physicians caring for patients with coma and disorders of consciousness in the acute, subacute, or chronic setting. Survey responses were solicited by blast emails distributed by society of Neurocritical Care and social media. Fischer’s exact test or Mann Whitney U test were used to compare respondents who agreed or disagreed with the pre-established coma definition. Fleiss κ values were calculated to assess agreement among respondents. A value of p less than 0.05 was considered statistically significant.Results The survey was completed by 130 health care physicians, majority of them were trained in critical care medicine (70.8%) or neurocritical care (37.7%). When analyzing the agreement on individual features of coma, we found substantial interrater agreement on absence of wakefulness (71.54%, κ = 0.71), Glasgow Coma Score ≤ 8 (78.46%, κ = 0.78) and failure to respond purposefully to visual, verbal or tactile stimuli (66.15%, κ = 0.66). Reported common etiologies of coma include traumatic brain injury (50.76%), ischemic stroke (30%) and intracerebral hemorrhage (29.23%). The most common clinical assessment tools used for coma included GCS (92.3%) and neurological examination (60.8%). Eighty-one percent of respondents routinely performed sedation interruption, in the absence of contraindications, for clinical coma assessments. Neurological examination was the most common tool (100%), followed by magnetic resonance imaging (89.2%), basic laboratories studies (88.5%) and head computed tomography/angiography (86.9%). The common pharmacological interventions used to stimulate arousal in patients with coma was sedation vacation (91.5%), electrolyte/endocrine correction (65.4%), osmotic therapy with mannitol (60%), hypertonic saline (54.6%), modafinil (46.9%), and antidote for drugs (45.4%). Among the non-pharmacological interventions, sensory stimulation (57.7%) was commonest used modality. The most common discharge disposition for comatose patients who survived hospitalization were home with or without services (70.0%). Differences from global survey were noted regarding TBI being the commonest etiology of coma, more frequent practice of sedation interruption, less frequent use of EEG in India, rare use of pharmacological neuro-stimulants and common discharge disposition in India being home.Conclusion The LMIC’s face shortage in health resources, diagnostic facilities and trained specialists making it worthwhile to study the challenges and practices in these countries. Differences from global survey were noted regarding TBI being the commonest etiology of coma in India, more frequent practice of sedation interruption, less frequent use of EEG in India, rare use of pharmacological neuro-stimulants and common discharge disposition in India being home.