Warwick Medical School, University of Warwick, Coventry, UK.
Faculty of Education Sciences and CLINURSID Research Group, Universidade de Santiago de Compostela, Santiago de Compostela, Spain; Simulation and Intensive Care Unit of Santiago (SICRUS) Research Group, Health Research Institute of Santiago, University Hospital of Santiago de Compostela-CHUS, Santiago de Compostela, Spain Research Group, Spain.
Resuscitation. 2024 Oct;203:110387. doi: 10.1016/j.resuscitation.2024.110387. Epub 2024 Sep 4.
Regionalisation and organised pathways of care using specialist centre hospitals can improve outcomes for critically ill patients. Cardiac arrest centre hospitals (CAC) may optimise the delivery of post-resuscitation care. The International Liaison Committee on Resuscitation (ILCOR) has called for a review of the current evidence base.
This systematic review aimed to assess the effect of cardiac arrest centres for patients with non-traumatic cardiac arrest.
Articles were included if they met the prospectively registered (PROSPERO) inclusion criteria. These followed the PICOST framework for ILCOR systematic reviews. A strict definition for a CAC was used, reflecting current position statements and clinical practice. MEDLINE, Embase and the Cochrane Library were searched using pre-determined criteria from inception to 31 December 2023. Risk of bias was assessed using Cochrane's Risk of Bias tool and ROBINS-I. The certainty of evidence for each outcome was assessed using the GRADE approach. Substantial heterogeneity precluded meta-analysis and a narrative synthesis with visualisation of effect estimates in forest plots was performed.
Sixteen studies met eligibility criteria, including data on over 145,000 patients. One was a randomised controlled trial (RCT) at low risk of bias and the remainder were observational studies, all at moderate or serious risk of bias. All studies included adults with out-of-hospital cardiac arrest. One study used initial shockable rhythm as an inclusion criterion and most studies (n = 12) included patients regardless of prehospital ROSC status. Two studies, including the RCT, excluded patients with ST elevation. Survival to hospital discharge with a favourable neurological outcome was reported by 11 studies and favoured CAC care in all observational studies, but the RCT showed no difference. Survival to 30 days with a favourable neurological outcome was reported by two observational studies and favoured CAC care in both. Survival to hospital discharge was reported by 13 observational studies and generally favoured CAC care. Survival to 30 days was reported by two studies, where the observational study favoured CAC care, but the RCT showed no difference.
This review supports a weak recommendation that adults with out-of-hospital cardiac arrest are cared for at CACs based on very low certainty of evidence. Randomised evidence has not confirmed the benefits of CACs found in observational studies, however this RCT was a single trial in a very specific setting and a population without ST elevation on post-ROSC ECG. The role of CACs in shockable and non-shockable subgroups, direct versus secondary transfer, as well as the impact of increased transport time and bypassing local hospitals remains unclear.
区域化和使用专科中心医院的有组织护理路径可以改善危重症患者的预后。心脏骤停中心医院 (CAC) 可以优化复苏后护理的实施。国际复苏联合会 (ILCOR) 呼吁对当前的证据基础进行审查。
本系统评价旨在评估心脏骤停中心对非创伤性心脏骤停患者的影响。
如果文章符合前瞻性注册 (PROSPERO) 的纳入标准，则将其纳入。这些标准遵循 ILCOR 系统评价的 PICOST 框架。严格定义 CAC，反映当前的立场声明和临床实践。使用预先确定的标准，从开始到 2023 年 12 月 31 日，在 MEDLINE、Embase 和 Cochrane 图书馆进行搜索。使用 Cochrane 的风险偏倚工具和 ROBINS-I 评估风险偏倚。使用 GRADE 方法评估每个结局的证据确定性。由于存在大量异质性，因此无法进行荟萃分析，而是进行了叙述性综合，并以森林图可视化效果估计值。
16 项研究符合纳入标准，包括超过 145000 名患者的数据。其中一项为低偏倚风险的随机对照试验 (RCT)，其余均为观察性研究，均存在中度或严重偏倚风险。所有研究均纳入院外心脏骤停的成年人。一项研究将初始可电击节律作为纳入标准，大多数研究（n=12）纳入了无论院前是否恢复自主循环 (ROSC) 状态的患者。两项研究（包括 RCT）排除了 ST 段抬高的患者。11 项研究报告了出院时具有良好神经功能结局的存活率，所有观察性研究均表明 CAC 护理有利，但 RCT 显示无差异。两项观察性研究报告了 30 天具有良好神经功能结局的存活率，并表明 CAC 护理有利。13 项观察性研究报告了出院存活率，通常表明 CAC 护理有利。两项研究报告了 30 天的存活率，其中观察性研究表明 CAC 护理有利，但 RCT 显示无差异。
本综述支持一项弱推荐，即基于极低确定性证据，将院外心脏骤停的成年人在 CAC 接受治疗。随机证据并未证实观察性研究中发现的 CAC 益处，但这项 RCT 是在一个非常特定的环境中进行的，并且是一个没有 ST 段抬高的人群，在 ROSC 后心电图上。CAC 在可电击和不可电击亚组、直接与二级转院、以及增加转运时间和绕过当地医院的影响方面的作用仍不清楚。
