Postresuscitation care of OHCA patients lacks neuroprotection

A considerable variability exists in postresuscitation care of patients with return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest (OHCA) at the emergency department (ED), which suggests gaps between recommended guidelines and clinical practice, according to a Singapore study.

“Good quality postresuscitation care is required so that patients not just survive but obtain meaningful survival with intact neurology,” the researchers said. “However, postresuscitation care is a complex process, which starts in the ED but persists beyond the ED and requires a multidisciplinary approach.”

A total of 921 OHCA patients were included in this study, of whom 85 (9.2 percent) had sustained ROSC at the ED. Among those with sustained ROSC, 19 (22.4 percent) survived, but only 13 (15.3 percent) had intact neurology at discharge. [Singapore Med J 2025;66:66-72]

All OHCA patients underwent electrocardiogram and chest X-ray. CT scan was carried out inconsistently, with CT brain being the most common in 74 patients (87.1 percent), whereas CT pulmonary angiogram (n=6, 7.1 percent), abdomen and pelvis (n=4, 4.7 percent), and aortogram (n=2, 2.4 percent) were seldom performed.

Only four patients (4.7 percent) achieved all five neuroprotective goals (ie, normoxia, normocarbia, normotension, normothermia, and normoglycaemia) in the ED. Significantly more patients with neurologically intact survival (3/13, 23.1 percent) met all these neuroprotective goals (p=0.01) than those without (1/72, 1.4 percent).

"[A]chieving ROSC at the ED is the first shot at survival for OHCA patients,” the researchers said. “Postresuscitation care, centred on neuroprotection goals, needs to be initiated promptly at the ED.”

Resuscitation

OHCA cases has been increasing in Singapore. Efforts to train the public in performing cardiopulmonary resuscitation (CPR) and using automated external defibrillators have increased bystander CPR and public defibrillation and have improved survival outcomes. [https://www.myheart.org.sg/wp-content/uploads/2021/01/Singapore-OHCA-Data-Report-2011-2018.pdf]

Despite such efforts, however, the number of patients surviving with good-to-moderate neurological functioning on discharge has not improved.

"This calls to attention the need to focus on the optimization of in-hospital management of OHCA patients with sustained ROSC,” the researchers said. “Having survived the cardiac arrest, what happens next at the ED upon ROSC will play a paramount role in determining the patient’s recovery and ultimately, survival with intact neurology.”

Bundles of care

To standardize postresuscitation haemodynamic optimization with emphasis on neuroprotective goals, the researchers suggest the creation of bundles of care or using checklists. These interventions can also guide decision making for investigations and treatment options to be considered when managing the precipitating cause of cardiac arrest. [Resuscitation 2014;85:1142-1148]

“Until emergency teams can recite and implement recommendations for postresuscitation care like how they comply with CPR guidelines and advanced cardiac life support algorithms, bundles of care or checklists can be particularly useful as it can offload the cognitive burden of the attending team during such rare events involving very sick patients, thus allowing them to focus on delivering care based on evidence and best practices to these patients,” they said.

The current study involved a retrospective review of electronic medical records for OHCA patients with sustained ROSC at the ED. Analysis was done using data on demographics, prehospital resuscitation, ED resuscitation, postresuscitation care, and eventual outcomes.