Post-cardiac arrest evaluation and care

---is a long neglected topic in terms of formal systematic recommendations. Publication of this ILCOR Consensus Statement is a welcome development. While we might think we know all this stuff there’s tremendous variation in post-arrest care. Moreover, in the past 50 years survival has improved very little in patients who achieve return of spontaneous circulation (ROSC).

Regarding treatment, the Statement says (italics mine):

Given the complex nature of post–cardiac arrest care, it is optimal to have a multidisciplinary team develop and execute a comprehensive clinical pathway tailored to available resources. Treatment plans for post–cardiac arrest care must accommodate a spectrum of patients, ranging from the awake, hemodynamically stable survivor to the unstable comatose patient with persistent precipitating pathology. In all cases, treatment must focus on reversing the pathophysiological manifestations of the post–cardiac arrest syndrome with proper prioritization and timely execution. Such a plan enables physicians, nurses, and other healthcare professionals to optimize post–cardiac arrest care and prevents premature withdrawal of care before long-term prognosis can be established. This approach improved outcomes at individual institutions compared with historical controls.

That sounds like a worthwhile project for any hospitalist program. While the concepts outlined in this report are straightforward there are substantial barriers, mainly administrative and institutional, to their implementation.

How evidence based are the recommendations? Randomized controlled trials support therapeutic hypothermia. A meta-analysis indicates an impressive NNT of 6 for improvement in neurologic outcome. Most of the other recommendations are supported by lower levels of evidence and pathophysiologic rationale. The entire report, however, is consistent with the principles of EBM, which require that the best available evidence be applied to each question, not that every intervention must be supported by RCTs.