Impact of Structured Pathways for Postcardiac Arrest Care: A Systematic Review and Meta-Analysis

Pro: All Cardiac Arrest Patients Should Be Transferred To a Cardiac Arrest Center

Out-of-hospital cardiac arrest (OHCA) is characterized by a high prevalence and is burdened by significant mortality and morbidity. While underlying atherosclerotic coronary artery disease accounts for the majority of the cases in the Western world owing to lifestyle and dietary customs, several other conditions and diseases can lead to OHCA. Although patient survival rates have doubled over the past 3 decades, only marginal improvements in terms of overall survival and neurologic outcomes have been observed over the last decade. A growing body of evidence suggests that regional differences in OHCA outcomes may be attributable to differences in hospital infrastructure and healthcare provider expertise, thus contributing to increased awareness of the importance of cardiac arrest centers (CACs). CACs are centers of excellence for post-cardiac arrest care, which provide dedicated, continuous access to specialized multidisciplinary facilities and expert physicians (eg, emergency department, cardiac intensive care unit, coronary angiography laboratory, rehabilitation departments), ultimately seeking to optimize patient management and improve their survival rates and functional outcomes. Here we provide an overview of the complex management of OHCA patients and outline evidence-based benefits that can result from the treatment of OHCA patients in dedicated CACs.

Post-Cardiopulmonary Arrest Care and Functional Outcomes in Dogs and Cats Surviving to Hospital Discharge Since Publication of the RECOVER Guidelines: 2012-2022

OBJECTIVE

To describe the in-hospital postcardiac arrest (PCA) care and short- and long-term functional outcomes of dogs and cats surviving to hospital discharge after naturally occurring cardiopulmonary arrest (CPA) and CPR.

DESIGN

Multicenter retrospective observational study.

SETTING

Three veterinary teaching hospitals.

ANIMALS

Client-owned dogs (n = 25) and cats (n = 15).

MEASUREMENTS AND MAIN RESULTS

Medical records of animals that underwent CPR and survived to discharge were retrospectively reviewed, and information was recorded regarding CPR event, PCA hospitalization, and short- and long-term outcomes. Ninety-two percent of CPA events occurred in hospital and were witnessed, and 8% occurred out of hospital. Eighty-five percent of events occurred during general anesthesia or sedation. CPR efforts ranged from <1 to 18 min, and animals remained hospitalized between 0.5 and 15.5 days after return of spontaneous circulation. Seventy-three percent of animals required supplemental oxygen, 13% required mechanical ventilation, and 20% required vasopressor, positive inotropic, or glucocorticoid therapy. Hyperosmolar therapies were administered to 38% of animals, anticonvulsants were given to 18%, and 8% of animals developed new-onset PCA seizures. The median (range) modified Glasgow Coma Scale score before CPA was 18 (11-18), 12 h PCA was 16 (6-18), and 72 h PCA was 17.5 (14-18). Median survival time was 455 days (range: 11-2650 days). Twenty-five percent of owners perceived a persistent disability in their pets, from behavioral changes to required nutritional and recumbent care. Nonetheless, all owners reported their pet's PCA quality of life to be good.

CONCLUSIONS

Good short- and long-term functional outcomes post-CPA can be achieved in dogs and cats. Functional survival remains possible in some cases of out-of-hospital CPA and after prolonged CPR, suggesting a benefit of high-quality CPR in all scenarios. Patient stabilization and neurological improvement may take 48-72 h, and early discouraging findings should not prevent continuation of PCA care.

Postcardiac Arrest Care Delivery in Pediatric Intensive Care Units: A Plan and Call to Action

Background

Despite national pediatric postcardiac arrest care (PCAC) guidelines to improve neurological outcomes and survival, there are limited studies describing PCAC delivery in pediatric institutions. This study aimed to describe PCAC delivery in centers belonging to a resuscitation quality collaborative.

Methods

An institutional review board-approved REDCap survey was distributed electronically to the lead resuscitation investigator at each institution in the international Pediatric Resuscitation Quality Improvement Collaborative. Data were summarized using descriptive statistics. A chi-square test was used to compare categorical data.

Results

Twenty-four of 47 centers (51%) completed the survey. Most respondents (58%) belonged to large centers (>1,000 annual pediatric intensive care unit admissions). Sixty-seven percent of centers reported no specific process to initiate PCAC with the other third employing order sets, paper forms, or institutional guidelines. Common PCAC targets included temperature (96%), age-based blood pressure (88%), and glucose (75%). Most PCAC included electroencephalogram (75%), but neuroimaging was only included at 46% of centers. Duration of PCAC was either tailored to clinical improvement and neurological examination (54%) or time-based (45%). Only 25% of centers reported having a mechanism for evaluating PCAC adherence. Common barriers to effective PCAC implementation included lack of time and limited training opportunities.

Conclusions

There is wide variation in PCAC delivery among surveyed pediatric institutions despite national guidelines to standardize and implement PCAC.

Mortality and Timing of Withdrawal of Life-Sustaining Therapies After Out-of-Hospital Cardiac Arrest: Two-Center Retrospective Pediatric Cohort Study

OBJECTIVES

Pediatric out-of-hospital cardiac arrest (OHCA) is associated with substantial morbidity and mortality. Limited data exist to guide timing and method of neurologic prognostication after pediatric OHCA, making counseling on withdrawal of life-sustaining therapies (WLSTs) challenging. This study investigates the timing and mode of death after pediatric OHCA and factors associated with mortality. Additionally, this study explores delayed recovery after comatose examination on day 3 postarrest.

DESIGN

This is a retrospective, observational study based on data collected from hospital databases and chart reviews.

SETTING

Data collection occurred in two pediatric academic hospitals between January 1, 2016, and December 31, 2020.

PATIENTS

Patients were identified from available databases and electronic medical record queries for the International Classification of Diseases , 10th Edition (ICD-10) code I46.9 (Cardiac Arrest). Patient inclusion criteria included age range greater than or equal to 48 hours to less than 18 years, OHCA within 24 hours of admission, greater than or equal to 1 min of cardiopulmonary resuscitation, and return-of-spontaneous circulation for greater than or equal to 20 min.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

One hundred thirty-five children (65% male) with a median age of 3 years (interquartile range 0.6-11.8) met inclusion criteria. Overall, 63 of 135 patients (47%) died before hospital discharge, including 34 of 63 patients (54%) after WLST. Among these, 20 of 34 patients underwent WLST less than or equal to 3 days postarrest, including 10 of 34 patients who underwent WLST within 1 day. WLST occurred because of poor perceived neurologic prognosis in all cases, although 7 of 34 also had poor perceived systemic prognosis. Delayed neurologic recovery from coma on day 3 postarrest was observed in 7 of 72 children (10%) who ultimately survived to discharge.

CONCLUSIONS

In our two centers between 2016 and 2020, more than half the deaths after pediatric OHCA occurred after WLST, and a majority of WLST occurred within 3 days postarrest. Additional research is warranted to determine optimal timing and predictors of neurologic prognosis after pediatric OHCA to better inform families during goals of care discussions.

Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement from the American Heart Association and Neurocritical Care Society

The critical care management of patients after cardiac arrest is burdened by a lack of high-quality clinical studies and the resultant lack of high-certainty evidence. This results in limited practice guideline recommendations, which may lead to uncertainty and variability in management. Critical care management is crucial in patients after cardiac arrest and affects outcome. Although guidelines address some relevant topics (including temperature control and neurological prognostication of comatose survivors, 2 topics for which there are more robust clinical studies), many important subject areas have limited or nonexistent clinical studies, leading to the absence of guidelines or low-certainty evidence. The American Heart Association Emergency Cardiovascular Care Committee and the Neurocritical Care Society collaborated to address this gap by organizing an expert consensus panel and conference. Twenty-four experienced practitioners (including physicians, nurses, pharmacists, and a respiratory therapist) from multiple medical specialties, levels, institutions, and countries made up the panel. Topics were identified and prioritized by the panel and arranged by organ system to facilitate discussion, debate, and consensus building. Statements related to postarrest management were generated, and 80% agreement was required to approve a statement. Voting was anonymous and web based. Topics addressed include neurological, cardiac, pulmonary, hematological, infectious, gastrointestinal, endocrine, and general critical care management. Areas of uncertainty, areas for which no consensus was reached, and future research directions are also included. Until high-quality studies that inform practice guidelines in these areas are available, the expert panel consensus statements that are provided can advise clinicians on the critical care management of patients after cardiac arrest.

Critical Care Management of Patients After Cardiac Arrest: A Scientific Statement From the American Heart Association and Neurocritical Care Society

The critical care management of patients after cardiac arrest is burdened by a lack of high-quality clinical studies and the resultant lack of high-certainty evidence. This results in limited practice guideline recommendations, which may lead to uncertainty and variability in management. Critical care management is crucial in patients after cardiac arrest and affects outcome. Although guidelines address some relevant topics (including temperature control and neurological prognostication of comatose survivors, 2 topics for which there are more robust clinical studies), many important subject areas have limited or nonexistent clinical studies, leading to the absence of guidelines or low-certainty evidence. The American Heart Association Emergency Cardiovascular Care Committee and the Neurocritical Care Society collaborated to address this gap by organizing an expert consensus panel and conference. Twenty-four experienced practitioners (including physicians, nurses, pharmacists, and a respiratory therapist) from multiple medical specialties, levels, institutions, and countries made up the panel. Topics were identified and prioritized by the panel and arranged by organ system to facilitate discussion, debate, and consensus building. Statements related to postarrest management were generated, and 80% agreement was required to approve a statement. Voting was anonymous and web based. Topics addressed include neurological, cardiac, pulmonary, hematological, infectious, gastrointestinal, endocrine, and general critical care management. Areas of uncertainty, areas for which no consensus was reached, and future research directions are also included. Until high-quality studies that inform practice guidelines in these areas are available, the expert panel consensus statements that are provided can advise clinicians on the critical care management of patients after cardiac arrest.

Cardiac arrest centres: what do they add?

There are wide regional variations in outcome following resuscitated out of hospital cardiac arrest. These geographical differences appear to be due to hospital infrastructure and provider experience rather than baseline characteristics. It is proposed that post-arrest care be delivered in a systematic fashion by concentrating services in Cardiac Arrest Centres, with greater provider experience, 24-hour access to diagnostics, and specialist treatment to minimise the impact of ischaemia-reperfusion injury and treat the causative pathology. These cardiac arrest centres would provide access to targeted critical care, acute cardiac care, radiology services and appropriate neuro-prognostication. However implementation of cardiac arrest networks with specialist receiving hospitals is complex and requires alignment of pre-hospital care services with those delivered in hospital. Furthermore there are no randomised trial data currently supporting pre-hospital delivery to a Cardiac Arrest Centre and definitions are heterogeneous. In this review article, we propose a universal definition of a Cardiac Arrest Centre and review the current observational data evidence and the potential impact of the ARREST trial.

Cardiac arrest centres: what, who, when, and where?

PURPOSE OF REVIEW

Cardiac arrest centres (CACs) may play a key role in providing postresuscitation care, thereby improving outcomes in out-of-hospital cardiac arrest (OHCA). There is no consensus on CAC definitions or the optimal CAC transport strategy despite advances in research. This review provides an updated overview of CACs, highlighting evidence gaps and future research directions.

RECENT FINDINGS

CAC definitions vary worldwide but often feature 24/7 percutaneous coronary intervention capability, targeted temperature management, neuroprognostication, intensive care, education, and research within a centralized, high-volume hospital. Significant evidence exists for benefits of CACs related to regionalization. A recent meta-analysis demonstrated clearly improved survival with favourable neurological outcome and survival among patients transported to CACs with conclusions robust to sensitivity analyses. However, scarce data exists regarding 'who', 'when', and 'where' for CAC transport strategies. Evidence for OHCA patients without ST elevation postresuscitation to be transported to CACs remains unclear. Preliminary evidence demonstrated greater benefit from CACs among patients with shockable rhythms. Randomized controlled trials should evaluate specific strategies, such as bypassing nearest hospitals and interhospital transfer.

SUMMARY

Real-world study designs evaluating CAC transport strategies are needed. OHCA patients with underlying culprit lesions, such as those with ST-elevation myocardial infarction (STEMI) or initial shockable rhythms, will likely benefit the most from CACs.

Impact of Cardiac Arrest Centers on the Survival of Patients With Nontraumatic Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis

Background

The role of cardiac arrest centers (CACs) in out‐of‐hospital cardiac arrest care systems is continuously evolving. Interpretation of existing literature is limited by heterogeneity in CAC characteristics and types of patients transported to CACs. This study assesses the impact of CACs on survival in out‐of‐hospital cardiac arrest according to varying definitions of CAC and prespecified subgroups.

Methods and Results

Electronic databases were searched from inception to March 9, 2021 for relevant studies. Centers were considered CACs if self‐declared by study authors and capable of relevant interventions. Main outcomes were survival and neurologically favorable survival at hospital discharge or 30 days. Meta‐analyses were performed for adjusted odds ratio (aOR) and crude odds ratios. Thirty‐six studies were analyzed. Survival with favorable neurological outcome significantly improved with treatment at CACs (aOR, 1.85 [95% CI, 1.52–2.26]), even when including high‐volume centers (aOR, 1.50 [95% CI, 1.18–1.91]) or including improved‐care centers (aOR, 2.13 [95% CI, 1.75–2.59]) as CACs. Survival significantly increased with treatment at CACs (aOR, 1.92 [95% CI, 1.59–2.32]), even when including high‐volume centers (aOR, 1.74 [95% CI, 1.38–2.18]) or when including improved‐care centers (aOR, 1.97 [95% CI, 1.71–2.26]) as CACs. The treatment effect was more pronounced among patients with shockable rhythm (P=0.006) and without prehospital return of spontaneous circulation (P=0.005). Conclusions were robust to sensitivity analyses, with no publication bias detected.

Conclusions

Care at CACs was associated with improved survival and neurological outcomes for patients with nontraumatic out‐of‐hospital cardiac arrest regardless of varying CAC definitions. Patients with shockable rhythms and those without prehospital return of spontaneous circulation benefited more from CACs. Evidence for bypassing hospitals or interhospital transfer remains inconclusive.

Clinical Characteristics and In-Hospital Mortality of Cardiac Arrest Survivors in Brazil: A Large Retrospective Multicenter Cohort Study

Supplemental Digital Content is available in the text.

Data on cardiac arrest survivors from developing countries are scarce. This study investigated clinical characteristics associated with in-hospital mortality in resuscitated patients following cardiac arrest in Brazil.

Care Does Not Stop Following ROSC: A Quality Improvement Approach to Postcardiac Arrest Care

Supplemental Digital Content is available in the text.

Pediatric cardiac arrests carry significant morbidity and mortality. With increasing rates of return of spontaneous circulation, it is vital to optimize recovery conditions to decrease morbidity.

Early risk stratification after resuscitation from cardiac arrest

Emergency clinicians often resuscitate cardiac arrest patients, and after acute resuscitation, clinicians face multiple decisions regarding disposition. Recent evidence suggests that out-of-hospital cardiac arrest patients with return of spontaneous circulation have higher odds of survival to hospital discharge, long-term survival, and improved functional outcomes when treated at centers that can provide advanced multidisciplinary care. For community clinicians, a high volume cardiac arrest center may be hours away. While current guidelines recommend against neurological prognostication in the first hours or days after return of spontaneous circulation, there are early findings suggestive of irrecoverable brain injury in which the patient would receive no benefit from transfer. In this Concepts article, we describe a simplified approach to quickly evaluate neurological status in cardiac arrest patients and identify findings concerning for irrecoverable brain injury. Characteristics of the arrest and resuscitation, initial neurological assessment, and brain computed tomography together can identify patients with high likelihood of irrecoverable anoxic injury. Patients who may benefit from centers with access to continuous electroencephalography are discussed. This approach can be used to identify patients who may benefit from rapid transfer to cardiac arrest centers versus those who may benefit from care close to home. Risk stratification also can provide realistic expectations for recovery to families.

Establishment of an extracorporeal cardio-pulmonary resuscitation program in Berlin - outcomes of 254 patients with refractory circulatory arrest

Objective

Optimal management of out of hospital circulatory arrest (OHCA) remains challenging, in particular in patients who do not develop rapid return of spontaneous circulation (ROSC). Extracorporeal cardiopulmonary resuscitation (eCPR) can be a life-saving bridging procedure. However its requirements and feasibility of implementation in patients with OHCA, appropriate inclusion criteria and achievable outcomes remain poorly defined.

Design

Prospective cohort study.

Setting

Tertiary referral university hospital center.

Patients

Here we report on characteristics, course and outcomes on the first consecutive 254 patients admitted between August 2014 and December 2017.

Intervention

eCPR program for OHCA.

Mesurements and main results

A structured clinical pathway was designed and implemented as 24/7 eCPR service at the Charité in Berlin. In total, 254 patients were transferred with ongoing CPR, including automated chest compression, of which 30 showed or developed ROSC after admission. Following hospital admission predefined in- and exclusion criteria for eCPR were checked; in the remaining 224, 126 were considered as eligible for eCPR.

State of the art postresuscitation therapy was applied and prognostication of neurological outcome was performed according to a standardized protocol.

Eighteen patients survived, with a good neurological outcome (cerebral performance category (CPC) 1 or 2) in 15 patients. Compared to non-survivors survivors had significantly shorter time between collaps and start of eCPR (58 min (IQR 12–85) vs. 90 min (IQR 74–114), p = 0.01), lower lactate levels on admission (95 mg/dL (IQR 44–130) vs. 143 mg/dL (IQR 111–178), p <  0.05), and less severe acidosis on admission (pH 7.2 (IQR 7.15–7.4) vs. 7.0 (IQR6.9–7.2), p <  0.05). Binary logistic regression analysis identified latency to eCPR and low pH as independent predictors for mortality.

Conclusion

An eCPR program can be life-saving for a subset of individuals with refractory circulatory arrest, with time to initiation of eCPR being a main determinant of survival.