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Localized Care Improves Cardiac Arrest Outcomes

Better regional systems of postresuscitation care for out-of-hospital cardiac arrest appeared to improve outcomes, a Japanese study showed.

A program to transport patients directly to centers for advanced care or move them there once the heart restarts boosted the proportion who survived with good neurological status at 1 month from 0.5% to 3.0% (P<0.001), Takashi Tagami, MD, PhD, of Nippon Medical School in Tokyo, and colleagues found.

Survivors were 10 times more likely to recover with minimal neurological impairment after the postresuscitation care program went into effect when adjusted for other factors (rate 51% versus 19%, P<0.001), they reported online in Circulation: Journal of the American Heart Association.

The findings are reassuring that aggressive postresuscitation care doesn’t increase the number of people surviving with poor neurological status, the group noted.

Regionalization of postresuscitation care has been added to the “chain of survival” with its guideline-recommended “links” of early access to emergency medical care, early CPR, early defibrillation, and early advanced cardiac life support.

After resuscitation, patients face life-threatening problems from reperfusion injury throughout the body that require “a multidisciplinary approach to intensive care that is difficult to implement in a nonspecialized hospital,” Tagami’s group explained.

Their prospective study included all 1,482 out-of-hospital cardiac arrest patients transported by emergency medical services during the study period in the suburban and rural region around Fukushima, Japan, best known for its nuclear power plant disaster after last year’s massive earthquake and tsunami.

Outcomes were compared before (January 2006-April 2008) and after (January 2009-December 2010) implementation of the program to transport all patients directly from the field to the tertiary-level hospital or from an outlying hospital after restoration of circulation.

Transport between hospitals was done by a physician-staffed ambulance capable of providing advanced care similar to that at the tertiary hospital, which meant intensive postresuscitation care with hemodynamic and respiratory management and therapeutic hypothermia for all patients.

Tertiary center care also included extracorporeal membrane oxygenation or intra-aortic balloon pump support, or both, and percutaneous coronary intervention as needed.

The campaign boosted hypothermia use from only 11% among patients whose heartbeat was restored before the program to 76% after. Also, advanced hemodynamic monitoring in the ICU was instituted for all patients compared with none before.

The improved aftercare was associated with significantly improved survival to discharge rates, though still low, at 4.2% versus 2.3% before the campaign (odds ratio 1.8, P=0.04).

The rate of favorable neurological outcome, defined as minimal neurological impairment with a Cerebral Performance Category score of 1 or 2, also improved significantly among patients with witnessed ventricular fibrillation (26.2% versus 7.9% before, OR 4.1, P=0.03).

These benefits appeared to be due to the intervention, since there were no differences in the other portions of the “chain of survival” (rates of witnessed arrest, bystander CPR, prehospital automated external defibrillator use, and time to start of early advanced care life support) between the study periods.

Nor did the proportion of patients resuming spontaneous circulation before arrival at the hospital change over the intervention period (14.5% before versus 16.5% after, P=0.62).

Primary source: Circulation: Journal of the American Heart Association           

Source reference: Tagami T, et al “Implementation of the fifth link of the chain of survival concept for out-of-hospital cardiac arrest” Circulation 2012; DOI: 10.1161/CIRCULATIONAHA.111.086173.

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