Fifth link to complete chain for cardiac arrest care?

By Piriya Mahendra, MedWire News Reporter

Adding a fifth link to the "Chain of Survival" concept for management of patients with out-of-hospital cardiac arrest (OHCA) significantly improves their survival and positive neurologic outcome chances, a study suggests.

Takashi Tagami (Nippon Medical School, Tokyo, Japan) and colleagues found that adding a multidisciplinary and regional postresuscitation system to standard OHCA care, as recommended by the American Heart Association (AHA) in 2010, increased 1-month survival from 0.5% to 3.0% (p<0.001).

Indeed, individuals were nearly eightfold more likely to survive at 1 month after the fifth link to the OHCA model of care was introduced to the Aizu region of Fukushima, Japan.

The number of patients with favorable neurologic outcome (Cerebral Performance Scale score of 1 or 2), at 1 month increased significantly from 4 (19%) of 21 patients in 2006-2008, before the fifth link was introduced, to 21 (51%) of 41 patients afterwards, in the period January 2009 to December 2010. This corresponded to a 10-fold increase in the chance of a favorable neurologic outcome upon the introduction of the fifth link (p=0.02).

Survival-to-hospital discharge also improved significantly after the intervention, from 18 (2.3%) of 770 patients to 30 (4.2%) of 712, corresponding to an OR of 1.8 (p=0.04).

In addition, significantly more patients whose heartbeat was restored received therapeutic hypothermia after the intervention than before, at 76% versus 11%. Moreover, all intensive care unit (ICU) patients received appropriate hemodynamic management using an advanced hemodynamic monitoring system after the fifth link was introduced versus none before the intervention.

"Although there were concerns that the proportion of survivors with severe neurologic disability would increase, this did not occur," commented Tagami in a press statement. "These findings suggest that the 'fifth link' is associated with an increase in survival rate as well as improvement of quality of life among survivors."

The four-link Chain of Survival, which was developed by the AHA in 2010, includes calling 911 for early access to medical care, early cardiopulmonary resuscitation, early defibrillation, and early advanced cardiovascular life support.

The Association added the fifth link after resuscitation experts called for a regional and multidisciplinary approach, due to difficulties encountered by non-tertiary hospitals when trying to deliver bundles of postresuscitation care.

"Post-cardiac arrest care requires a multidisciplinary approach to intensive care that is difficult to implement in a non-specialized hospital," explained Tagami. "This study indicates that the introduction of the regional resuscitation system of care, the 'fifth link,' made it possible to treat all potential survivors in the ICU of a specialized hospital."

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