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

Storm, Christian MD1,2; Leithner, Christoph MD3; Krannich, Alexander MSc1; Suarez, Jose I. MD2,4,5,6; Stevens, Robert D. MD2,4,5,6,7

doi: 10.1097/CCM.0000000000003827
Online Review Article

Objectives: Recent research has demonstrated value in selected therapeutic and prognostic interventions delivered to patients following cardiac arrest. The aim of this work was to determine if the implementation of a structured care pathway, which combines different interventions, could improve outcomes in survivors of cardiac arrest.

Data Sources: PubMed and review of citations in retrieved articles.

Study Selection: Randomized trials and prospective observational studies conducted in adult cardiac arrest patients, which evaluated the impact on outcome of a structured care pathway, defined as an organized set of interventions designed specifically for postcardiac arrest patients.

Data Extraction: Data collected included study characteristics and methodologic quality, populations enrolled, interventions that were part of the cardiac arrest structured care pathway, and outcomes. The principal outcome was favorable functional status defined as a Cerebral Performance Category score of 1–2 at or after hospital discharge.

Data Synthesis: The systematic search retrieved 481 articles of which nine (total, 1,994 patients) were selected for systematic review, and six (1,422 patients) met criteria for meta-analysis. Interventions in the care pathways included early coronary angiography with or without percutaneous coronary intervention (eight studies), targeted temperature management (nine studies), and protocolized management in the ICU (seven studies). Neurologic prognostication was not a part of any of the structured pathways. Meta-analysis found significantly higher odds of achieving a favorable functional outcome in patients who were treated in a structured care pathway, when compared with standard care (odds ratio, 2.35; 95% CI, 1.46–3.81).

Conclusions: Following cardiac arrest, patients treated in a structured care pathway may have a substantially higher likelihood of favorable functional outcome than those who receive standard care. These findings suggest benefit of a highly organized approach to postcardiac arrest care, in which a cluster of evidence-based interventions are delivered by a specialized interdisciplinary team. Given the overall low certainty of evidence, definitive recommendations will need confirmation in additional high-quality studies.

1Department of Nephrology and Intensive Care Medicine, Charité University, Berlin, Germany.

2Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD.

3Department of Neurology, Charité University, Berlin, Germany.

4Division of Neurosciences Critical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.

5Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.

6Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD.

7Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD.

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Dr. Storm has a relationship with C. R. Bard GmbH (Wachhausstrasse, Karlsruhe, Germany) by having received honoraria and taking expert witness and with Zoll GmbH (Emil-Hoffmann-Straße, Köln, Germany) by having received honoraria. Dr. Leithner has received honoraria from Bard Medical and Edwards Lifesciences GmbH (Edisonstraße, Unterschleißheim, Germany) for work in a Critical Event Committee. Dr. Krannich has no conflict of interest related to this publication but independent from this publication and the presented topic, however, Dr. Krannich has a financial relationship to Pfizer GmbH (Linkstraße, Berlin, Germany). Dr. Suarez is the Chair of the Data and Safety Monitoring Board of the Impact of Fever Prevention in brain Injured Patients (INTREPID) Study ( Identifier: NCT02996266) funded by C. R. Bard (Murray Hill, NJ). Dr. Stevens has disclosed that he does not have any potential conflicts of interest.

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