In-hospital cardiac arrest: evidence and specificities of perioperative cardiac arrest

To the Editor,

We read with great interest the article by Penketh and Nolan, which provides a comprehensive overview on in-hospital cardiac arrest (IHCA) [1]. We fully concur with the authors that guidelines for treatment of IHCA are lacking, and that several data are extrapolated from out-of-hospital cardiac arrest literature. Despite the extensive evidence from rigorous randomized controlled trials, professional guidelines reflect little tangible progress and a main contributing factor is the stagnation of resuscitation science due to our poor knowledge of the underlying pathophysiological mechanisms [2].

Regarding IHCA, this disheartening situation is more evident during the perioperative period as guidelines for treatment of perioperative cardiac arrest have been for long a major gap of knowledge. However, perioperative cardiac arrest has several specificities that are not detailed in Penketh’s review and that deserve considerations: potential neuroprotective effect of anesthesia drugs, immediate diagnosis in monitored patients, timely treatment by trained anesthesiologists, causes of cardiac arrest mostly related to preoperative complications, complications of anesthesia or complications of surgical procedures and finally, good long-term functional outcome [3].

In order to provide a scientific background for decision-making, as well as a guide for future research on perioperative cardiac arrest, the PERIOPCA Consortium recently published for the first time a consensus on 22 PICO questions specially formulated for the perioperative setting [4]. These recommendations (Table 1) are strengthened by a strict methodology including a modified Delphi consensus-building strategy and can be used in clinical practice.

Table 1 Summary of perioperative cardiac arrest (PERIOPCA) recommendations

Fortunately, the perioperative setting supports a physiology-guided treatment strategy to titrate the resuscitation efforts to patient’s physiological response. Therefore, translational research should be intensively used as a bridge between different areas of research to improve survival rates. Such an approach is currently investigated in the PERSEUS-PS randomized controlled trial (NCT04428060) [5].

We hope that the PERIOPCA recommendations and the results of the PERSEUS-PS trial will serve as a basis and would be of interest for the International Liaison Committee on Resuscitation or the scientist who wants to build upon the available evidence.