Enhancing post-resuscitation care to optimise neurological outcomes: a call to action

Out-of-hospital cardiac arrest (OHCA) remains a formidable public health challenge, with neurologically intact survival remaining low in many communities globally, despite advances in resuscitation practices. Lam and Pek[1] reported a clinical audit study of OHCA patients with return of spontaneous circulation (ROSC) in the emergency department (ED) setting. Their findings highlight critical gaps between recommended guidelines and clinical practice, emphasising a need for improved post-resuscitation care protocols that are focused on neuroprotection. The study shows that among 921 OHCA patients treated at the single ED, only 9.2% achieved ROSC and a mere 1.4% survived with intact neurology. This proportion of neurologically intact survivors appears lower than that in the Pan-Asian Resuscitation Outcomes Study[2] (approximately 4%) and international studies[3] (potentially 7%–12%). The study by Lam and Pek[1] provides critical insights into this phenomenon, incriminating the potential gap in early arrival at neuroprotective targets. This highlights opportunities to improve post-resuscitative care and the importance of upstream implementation of neuroprotective strategies in the ED after ROSC. The study by Lam and Pek[1] also observed that patients who met all five neuroprotective targets studied were much more likely to survive neurologically intact. The authors meticulously examined the practice of five established neuroprotective goals, namely normoxia, normocarbia, normotension, normothermia and normoglycaemia. They strikingly found that only 4.7% of patients with sustained ROSC achieved these goals. The significant variability in post-resuscitation care underscores the real-world challenges in post-resuscitation management, where competing priorities such as obtaining an aetiological diagnosis, battling rearrests, negotiating mechanical circulatory support and facilitating high-risk transfers, make the task a complex one. Under these conditions, clear and evidence-based protocols and checklists that are supported by multiple stakeholders can lend method to the chaos and simplify the task of instituting a bundle of care.[4] The association between adherence to neuroprotective goals and favourable outcomes found in this study emphasises the potential benefits to be gained by optimising post-resuscitation care. Resuscitation guidelines have also reflected these priorities. The 2018–2023 International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support (ALS) Taskforce evidence reviews have informed contemporary guidelines that emphasise three aspects:[5] (1) immediate institution of post-resuscitation care, regardless of location; (2) early diagnosis of the cause of cardiac arrest by undertaking early coronary angiography or computed tomography; and (3) having a post-resuscitation bundle-of-care, incorporating specific multisystem clinical and parameter targets. These multisystem targets include: (a) oxygen control: target arterial oxygen saturation of 94%–98%; (b) ventilatory control: target normal arterial partial pressure of carbon dioxide (i.e., 4.5–6.0 kPa or 35–45 mmHg); (c) haemodynamic management: avoid hypotension, target mean arterial pressure of >65 mmHg to achieve adequate urine output (>0.5 mL kg−1 h-1) and normal or decreasing lactate; (d) temperature control: actively prevent fever (defined as a temperature >37.7°C) for at least 72 h; and (e) glucose control: target blood glucose of 7.8–10 mmol/L. The study by Lam and Pek[1] is a welcome addition to the resuscitation science literature. Fostering a culture of neuroprotection during the early post-resuscitation phase can positively impact our patients. It can transform what is traditionally a certain death, to an opportunity to return to the community as a productive member of our society and economy. A current limitation of resuscitation registries is the inability to capture data on the immediate post-resuscitation part of the patient journey.[6] Indeed, our understanding of post-resuscitation, as well as the long-term survivorship aspects of OHCA, lags behind what we know about the resuscitation process, but this is quickly gaining relevance as more patients achieve ROSC and survival to hospital discharge.[7] Therefore, we look forward to the ongoing work of the National Post-Cardiac Arrest and Survivorship Workgroup, in which a multidisciplinary team labours in quality improvement, research and education efforts to drive continuous improvements in cardiac arrest outcomes.[8,9] Additionally, we anticipate the findings of the National Medical Research Council-funded cohort study, Quality Cardiac Arrest Survivorship (QualiCAS), to provide one of the world’s first data on the long-term multidimensional survivorship experience of OHCA patients. These will surely pave the way to enable OHCA patients to not only survive, but also survive well.