Short- and long-term survival after cardiopulmonary resuscitation

Impact of age on survival for patients receiving ECPR for refractory out-of-hospital VT/VF cardiac arrest

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (ECPR) has been shown to improve neurologically favorable survival for patients with refractory ventricular tachycardia (VT)/ventricular fibrillation (VF) out-of-hospital cardiac arrest. Prior studies of the impact of age on outcomes in ECPR have demonstrated mixed results and we aim to investigate this relationship.

METHODS

Patients treated with ECPR at the University of Minnesota Medical Center for refractory out-of-hospital VT/VF arrest from December 2015 to February 2023 were included. The primary endpoints included neurologically favorable survival to discharge. A receiver operating characteristic curve was used to determine an optimal predictive age limit with the highest accuracy for neurologically favorable survival.

RESULTS

391 consecutive patients were included: 22% (n = 86) were female and the mean age was 56.9 ± 11.8 years. Age was independently associated with neurologically favorable survival to discharge, with a 30% decrease in survival with every 10-year increase in age (OR 0.7 (0.57-0.87), p = 0.001. Among those with neurologically favorable survival to discharge, older patients had longer length of hospital stay compared to younger age groups (p = 0.002) while patients who failed to achieve neurologically favorable survival to discharge had similar length of stay independent of age (p = 0.51).

CONCLUSIONS

Age is associated with neurologically favorable survival to discharge for patients receiving ECPR for refractory out-of-the-hospital VT/VF cardiac arrest. However, with a survival rate of 23% in the oldest age group, caution should be used when choosing age criteria for patient selection.

Frailty and Survival After In-Hospital Cardiopulmonary Resuscitation

BACKGROUND

Older adults face high mortality following resuscitation efforts for in-hospital cardiac arrest. Less is known about the role of frailty in survival to discharge after in-hospital cardiopulmonary resuscitation.

OBJECTIVE

To investigate whether frailty, measured by the Clinical Frailty Scale, is associated with mortality after cardiopulmonary resuscitation following in-hospital cardiac arrest in older adults in the USA.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Patients ≥ 65 years who had undergone cardiopulmonary resuscitation during an inpatient admission at two urban academic hospitals and three suburban community hospitals within a Boston area healthcare system from January 2018-January 2020. Patients with Clinical Frailty Scale scores 1-3 were considered not frail, 4-6 were considered very mildly, mildly, and moderately frail, respectively, and 7-9 were considered severely frail.

MAIN MEASURES

In-hospital mortality after cardiopulmonary resuscitation.

KEY RESULTS

Among 324 patients who underwent cardiopulmonary resuscitation following in-hospital cardiac arrest, 73.1% experienced in-hospital mortality. Patients with a Clinical Frailty Scale score of 1-3 had 54% in-hospital mortality, which increased to 66%, 78%, 84%, and 84% for those with a Clinical Frailty Scale score of 4, 5, 6, and 7-9, respectively (p = 0.001). After adjusting for age, sex, race, and Charlson Comorbidity Index, higher frailty scores were significantly associated with higher odds of in-hospital mortality. Compared to those with a Clinical Frailty Scale score of 1-3, odds ratios (95% CI) for in-hospital mortality for patients with a Clinical Frailty Scale score of 4, 5, 6, and 7-9 were 1.6 (0.8-3.3), 3.0 (1.3-7.1), 4.4 (1.9-9.9), and 4.6 (1.8-11.8), respectively (p = 0.001).

CONCLUSIONS

Higher levels of frailty are associated with increased mortality after in-hospital cardiopulmonary resuscitation in older adults. Clinicians may consider using the Clinical Frailty Scale to help guide goals of care conversations, including discussion of code status, in this patient population.

Factors associated with prolonged cardiopulmonary resuscitation attempts in out-of-hospital cardiac arrest patients presenting to the emergency department

BACKGROUND

There is high variability among clinicians' decision of appropriate cardiopulmonary resuscitation (CPR) duration before deciding for termination of resuscitation. This study attempted to investigate factors associated with the decision to prolong resuscitation attempts in cardiac arrest patients treated in an emergencydepartment (ED).

METHODS

A retrospective study that evaluated two years of mortality registry starting in 2015 was conducted in the ED of University Kebangsaan Malaysia Medical Centre (UKMMC), Kuala Lumpur, Malaysia. Adult out-hospital cardiac arrest (OHCA) patients treated in the ED were included. Multivariate logistic regression analysis was utilized for the exploration of factors associated with prolonged CPR attempts (> 30min).

RESULTS

The median CPR duration was 24min (range 2-68min). Four variables were independently associated with prolonged CPR attempts: younger age (OR, 0.97; 95% CI, 0.95-0.99; p<0.001), pre-existing heart disease (OR, 1.97; 95% CI, 1.07-3.65; p=0.031), occurrence of transient return of spontaneous circulation (ROSC) (OR, 2.38; 95% CI, 1.05-5.36; p=0.037), and access to the ED by nonemergency medical services (EMS) transport (OR, 1.92; 95% CI, 1.09-3.37; p=0.024).

CONCLUSION

Patient-related and access-related factors were associated with prolonged CPR attempts among OHCA patients resuscitated in the ED.

Pre-arrest and intra-arrest prognostic factors associated with survival after in-hospital cardiac arrest: systematic review and meta-analysis

OBJECTIVE

To determine associations between important pre-arrest and intra-arrest prognostic factors and survival after in-hospital cardiac arrest.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Medline, PubMed, Embase, Scopus, Web of Science, and the Cochrane Database of Systematic Reviews from inception to 4 February 2019. Primary, unpublished data from the United Kingdom National Cardiac Arrest Audit database.

STUDY SELECTION CRITERIA

English language studies that investigated pre-arrest and intra-arrest prognostic factors and survival after in-hospital cardiac arrest.

DATA EXTRACTION

PROGRESS (prognosis research strategy group) recommendations and the CHARMS (critical appraisal and data extraction for systematic reviews of prediction modelling studies) checklist were followed. Risk of bias was assessed by using the QUIPS tool (quality in prognosis studies). The primary analysis pooled associations only if they were adjusted for relevant confounders. The GRADE approach (grading of recommendations assessment, development, and evaluation) was used to rate certainty in the evidence.

RESULTS

The primary analysis included 23 cohort studies. Of the pre-arrest factors, male sex (odds ratio 0.84, 95% confidence interval 0.73 to 0.95, moderate certainty), age 60 or older (0.50, 0.40 to 0.62, low certainty), active malignancy (0.57, 0.45 to 0.71, high certainty), and history of chronic kidney disease (0.56, 0.40 to 0.78, high certainty) were associated with reduced odds of survival after in-hospital cardiac arrest. Of the intra-arrest factors, witnessed arrest (2.71, 2.17 to 3.38, high certainty), monitored arrest (2.23, 1.41 to 3.52, high certainty), arrest during daytime hours (1.41, 1.20 to 1.66, high certainty), and initial shockable rhythm (5.28, 3.78 to 7.39, high certainty) were associated with increased odds of survival. Intubation during arrest (0.54, 0.42 to 0.70, moderate certainty) and duration of resuscitation of at least 15 minutes (0.12, 0.07 to 0.19, high certainty) were associated with reduced odds of survival.

CONCLUSION

Moderate to high certainty evidence was found for associations of pre-arrest and intra-arrest prognostic factors with survival after in-hospital cardiac arrest.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018104795.

In-hospital cardiopulmonary resuscitation of patients with cirrhosis: A population-based analysis

Objective

To examine the epidemiology and outcomes of in-hospital cardiopulmonary resuscitation (CPR) among patients with cirrhosis.

Methods

We used the Texas Inpatient Public Use Data File to identify hospitalizations aged ≥ 18 years with and without cirrhosis during 2009–2014 and those in each group who have undergone in-hospital CPR. Short-term survival (defined as absence of hospital mortality or discharge to hospice) following in-hospital CPR was examined. Multivariate logistic regression modeling was used to assess the prognostic impact of cirrhosis following in-hospital CPR and predictors of short-term survival among cirrhosis hospitalizations.

Results

In-hospital CPR was reported in 2,511 and 51,969 hospitalizations with and without cirrhosis, respectively. The rate of in-hospital CPR (per 1,000 hospitalizations) was 7.6 and 4.0 among hospitalizations with and without cirrhosis, respectively. The corresponding rate of in-hospital CPR among decedents was 10.7% and 13.4%, respectively. Short-term survival following in-hospital CPR among hospitalizations with and without cirrhosis was 14.9% and 27.3%, respectively, and remained unchanged over time on adjusted analyses among the former (p = 0.1753), while increasing among the latter (p = 0.0404). Cirrhosis was associated with lower odds of short-term survival following in-hospital CPR (adjusted odds ratio [aOR] 0.55 [95% CI: 0.49–0.62]). Lack of health insurance (vs. Medicare) (aOR] 0.47 [95% CI: 0.34–0.67]) and sepsis ([aOR] 0.67 [95% CI: 0.53–85]) were associated with lower odds of short-term survival following in-hospital CPR among cirrhosis hospitalizations.

Conclusions

The rate of in-hospital CPR was nearly 2-fold higher among hospitalizations with cirrhosis than among those without it, though it was used more selectively among the former. Short-term survival following in-hospital CPR remained markedly lower among cirrhosis hospitalizations, while progressively improving among those without cirrhosis. Strategies to increase access to health insurance and improve early identification and control of infection should be explored in future preventive and interventional efforts.

Survival after in-hospital cardiac arrest among cerebrovascular disease patients

Stroke is a leading cause of death and disability, and while preferences for cardiopulmonary resuscitation (CPR) are frequently discussed, there is limited evidence detailing outcomes after CPR among acute cerebrovascular neurology (inclusive of stroke, subarachnoid hemorrhage (SAH)) patients. Systematic review and meta-analysis of PubMed and Cochrane libraries from January 1990 to December 2016 was conducted among stroke patients undergoing in-hospital CPR. Primary data from studies meeting inclusion criteria at two levels were extracted: 1) studies reporting survival to hospital discharge after CPR with cerebrovascular primary admitting diagnosis, and 2) studies reporting survival to hospital discharge after CPR with cerebrovascular comorbidity. Meta-analysis generated weighted, pooled survival estimates for each population. Of 818 articles screened, there were 176 articles (22%) that underwent full review. Three articles met primary inclusion criteria, with an estimated 8% (95% Confidence Interval (CI) 0.01, 0.14) rate of survival to hospital discharge from a pooled sample of 561 cerebrovascular patients after in-hospital CPR. Twenty articles met secondary inclusion criteria, listing a cerebrovascular comorbidity, with an estimated rate of survival to hospital discharge of 16% (95% CI 0.14, 0.19). All studies demonstrated wide variability in adherence to Utstein guidelines, and neurological outcomes were detailed in only 6 (26%) studies. Among the few studies reporting survival to hospital discharge after CPR among acute cerebrovascular patients, survival is lower than general inpatient populations. These findings synthesize the limited empirical basis for discussions about resuscitation among stroke patients, and highlight the need for more disease stratified reporting of outcomes after inpatient CPR.

Morbidity of cardiac arrest in the very elderly

The objective of this retrospective cohort study was to assess mortality and morbidity after cardiac arrest in hospital inpatients aged 80 years or older, in an Australian tertiary hospital. We studied patients aged 80 years or older who suffered an in-hospital cardiac arrest from 1 January 2000 to 31 December 2016. The main outcome measures were one-year survival and narrative morbidity. Two hundred and eighty-five patients were identified. Absolute one-year survival after cardiac arrest was, at best, 12.6%. Narrative descriptions of morbidity demonstrate high healthcare utilisation, dependency or residential care, and significant impairments of physical and social function. In conclusion, one-year survival after cardiac arrest in the very elderly is poor. In those who survive, significant morbidity is present.

Trends in in-hospital cardiopulmonary resuscitation and survival in adults receiving maintenance dialysis

IMPORTANCE

Understanding cardiopulmonary resuscitation (CPR) practices and outcomes can help to support advance care planning in patients receiving maintenance dialysis.

OBJECTIVE

To characterize patterns and outcomes of in-hospital CPR in US adults receiving maintenance dialysis.

DESIGN, SETTING, AND PARTICIPANTS

This national retrospective cohort study studied 663,734 Medicare beneficiaries 18 years or older from a comprehensive national registry for end-stage renal disease who initiated maintenance dialysis from January 1, 2000, through December 31, 2010.

EXPOSURES

Receipt of in-hospital CPR from 91 days after dialysis initiation through the time of death, first kidney transplantation, or end of follow-up on December 31, 2011.

MAIN OUTCOMES AND MEASURES

Incidence of CPR and survival after the first episode of CPR recorded in Medicare claims during follow-up.

RESULTS

The annual incidence of CPR for the overall cohort was 1.4 events per 1000 in-hospital days (95% CI, 1.3-1.4). A total of 21.9% CPR recipients (95% CI, 21.4%-22.3%) survived to hospital discharge, with a median postdischarge survival of 5.0 months (interquartile range, 0.7-16.8 months). Among patients who died in the hospital, 14.9% (95% CI, 14.8%-15.1%) received CPR during their terminal admission. From 2000 to 2011, there was an increase in the incidence of CPR (1.0 events per 1000 in-hospital days; 95% CI, 0.9-1.1; to 1.6 events per 1000 in-hospital days; 95% CI, 1.6-1.7; P for trend <.001), the proportion of CPR recipients who survived to discharge (15.2%; 95% CI, 11.1%-20.5%; to 28%; 95% CI, 26.7%-29.4%; P for trend <.001), and the proportion of in-hospital deaths preceded by CPR (9.5%; 95% CI, 8.4%-10.8%; to 19.8%; 95% CI, 19.2%-20.4%; P for trend <.001), with no substantial change in duration of postdischarge survival.

CONCLUSIONS AND RELEVANCE

Among a national cohort of patients receiving maintenance dialysis, the incidence of CPR was higher and long-term survival worse than reported for other populations.

Long-term outcomes after in-hospital CPR in older adults with chronic illness

BACKGROUND

Outcomes after in-hospital CPR in older adults with chronic illness are unclear.

METHODS

We examined inpatient Medicare data from 1994 through 2005 to identify CPR recipients. We grouped beneficiaries aged ≥ 67 years by severity of six chronic diseases-COPD, congestive heart failure (CHF), chronic kidney disease (CKD), malignancy, diabetes, and cirrhosis-and investigated survival to discharge, discharge destination, rehospitalizations, and long-term survival.

RESULTS

We identified 358,682 CPR recipients. Most patients with chronic disease were less likely to survive to discharge (eg, 14.8% in the advanced COPD group [P < .001] and 11.3% in the advanced malignancy group [P < .001]) than patients without chronic illness (17.3%). Among discharge survivors, the median long-term survival was shorter in patients with chronic illness (eg, 5.0, 3.5, and 2.8 months in the advanced COPD, malignancy, and cirrhosis groups, respectively; P < .001 for all) than without (26.7 months). Although 7.2% of CPR recipients without chronic disease were discharged home and survived at least 6 months without readmission, ≤ 2.0% of recipients with advanced COPD, CHF, malignancy, and cirrhosis (P < .001 for all) met these criteria. Adjusted analyses confirmed that most subgroups with chronic illness had lower hospital discharge survival, and among discharge survivors, most were discharged home less often, experienced more hospital readmissions, and had worse long-term survival.

CONCLUSIONS

Older CPR recipients with any of the six underlying chronic diseases investigated generally have much worse outcomes than CPR recipients without chronic disease. These findings may substantially affect decisions about CPR in patients with chronic illness.

Cerebral performance category at hospital discharge predicts long-term survival of cardiac arrest survivors receiving targeted temperature management*

OBJECTIVE

Despite recent advancements in post-cardiac arrest resuscitation, the optimal measurement of postarrest outcome remains unclear. We hypothesized that Cerebral Performance Category score can predict the long-term outcome of postarrest survivors who received targeted temperature management during their postarrest hospital care.

DESIGN

Retrospective chart review.

SETTING

Two academic medical centers from May 2005 to December 2012.

PATIENTS

The medical records of 2,417 out-of-hospital and in-hospital patients post cardiac arrest were reviewed to identify 140 of 582 survivors who received targeted temperature management.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The Cerebral Performance Category scores at hospital discharge were determined by three independent abstractors. The 1-month, 6-month, and 12-month survival of these patients was determined by reviewing hospital records and querying the Social Security Death Index and by follow-up telephone calls. The association of unadjusted long-term survival and adjusted survival with Cerebral Performance Category was calculated. Of the 2,417 patients who were identified to have undergone cardiac arrest, 24.1% (582/2,417) were successfully resuscitated, of whom 24.1% (140/582) received postarrest targeted temperature management. Overall, 42.9% of patients (60/140) were discharged with Cerebral Performance Category 1, 27.1% (38/140) with Cerebral Performance Category 2, 18.6% (26/140) with Cerebral Performance Category 3, and 11.4% (16/140) with Cerebral Performance Category 4. Cerebral Performance Category 1 survivors had the highest long-term survival followed by Cerebral Performance Categories 2 and 3, with Cerebral Performance Category 4 having the lowest long-term survival (p < 0.001, log-rank test). We found that Cerebral Performance Category 3 (hazard ratio = 3.62, p < 0.05) and Cerebral Performance Category 4 (hazard ratio = 12.73, p < 0.001) remained associated with worse survival after adjusting for age, gender, race, shockable rhythm, time to targeted temperature management initiation, total duration of resuscitation, withdrawal of care, and location of arrest.

CONCLUSION

Patients with different Cerebral Performance Category scores at discharge have significantly different survival trajectories. Favorable Cerebral Performance Category at hospital discharge predicts better long-term outcomes of survivors of cardiac arrest who received targeted temperature management than those with less favorable Cerebral Performance Category scores.

Study of survival rate after cardiopulmonary resuscitation (CPR) in hospitals of Kermanshah in 2013

BACKGROUND

After CPR, the follow-up of survival rate and caused complications are the most important practices of the medical group. This study was performed aimed at determining the follow-up results after CPR in patients of university hospitals in Kermanshah in 2014.

METHODS

In this prospective study, 320 samples were examined. A purposive sampling method was used, and data was collected using a researcher-made information form with content and face validity and reliability of r= 0.79. Data was analyzed with STATA9 software and statistical tests, including calculation of the success rate, relative risk (RR), chi-square and Fisher at significance level of P < 0.05.

RESULTS

The initial success rate of cardiopulmonary resuscitation was equal to 15.3%, while the ultimate success rate (discharged alive from the hospital) was as 10.6%. The six-month success rate after resuscitation was 8.78% than those who were discharged alive. There were no significant statistical differences between different age groups regarding the initial success rate of resuscitation (P = 0.14), and the initial resuscitation success rate was higher in patients in morning shift (P = 0.02).

CONCLUSION

By the results of study, it is recommended to increase the medical - nursing knowledge and techniques for personnel in the evening and night shifts. Also, an appropriate dissemination of health care staff in working shifts should be done to increase the success rate of CPR procedure.

Cardiopulmonary resuscitation among mechanically ventilated patients

PURPOSE

To evaluate the outcomes, including long-term survival, after cardiopulmonary resuscitation (CPR) in mechanically ventilated patients.

METHODS

We analyzed Medicare data from 1994 to 2005 to identify beneficiaries who underwent in-hospital CPR. We then identified a subgroup receiving CPR one or more days after mechanical ventilation was initiated [defined by ICD-9 procedure code for intubation (96.04) or mechanical ventilation (96.7x) one or more days prior to procedure code for CPR (99.60 or 99.63)].

RESULTS

We identified 471,962 patients who received in-hospital CPR with an overall survival to hospital discharge of 18.4 % [95 % confidence interval (CI) 18.3-18.5 %]. Of those, 42,163 received CPR one or more days after mechanical ventilation initiation. Survival to hospital discharge after CPR in ventilated patients was 10.1 % (95 % CI 9.8-10.4 %), compared to 19.2 % (95 % CI 19.1-19.3 %) in non-ventilated patients (p < 0.001). Among this group, older age, race other than white, higher burden of chronic illness, and admission from a nursing facility were associated with decreased survival in multivariable analyses. Among all CPR recipients, those who were ventilated had 52 % lower odds of survival (OR 0.48, 95 % CI 0.46-0.49, p < 0.001). Median long-term survival in ventilated patients receiving CPR who survived to hospital discharge was 6.0 months (95 % CI 5.3-6.8 months), compared to 19.0 months (95 % CI 18.6-19.5 months) among the non-ventilated survivors (p < 0.001 by logrank test). Of all patients receiving CPR while ventilated, only 4.1 % were alive at 1 year.

CONCLUSIONS

Survival after in-hospital CPR is decreased among ventilated patients compared to those who are not ventilated. This information is important for clinicians, patients, and family members when discussing CPR in critically ill patients.

Active chest compression-decompression for cardiopulmonary resuscitation

BACKGROUND

Active compression-decompression cardiopulmonary resuscitation (ACDR CPR) uses a hand-held suction device, applied mid-sternum, to compress the chest then actively decompress the chest after each compression. Randomised controlled trials testing this device have shown discordant results.

OBJECTIVES

To determine the effect of active chest compression-decompression CPR compared to standard chest compression CPR on mortality and neurological function in adults with cardiac arrest treated either in-hospital or out-of-hospital.

SEARCH METHODS

We updated the searches of CENTRAL in The Cochrane Library (Issue 12 of 12, 2012), MEDLINE (OVID, 1946 to January week 1 2013), and EMBASE (OVID, 1980 to week 1 2013) on 14 January 2013. We checked the reference list of retrieved articles, contacted experts in the field, and searched ClinicalTrials.gov.

SELECTION CRITERIA

All randomised or quasi-randomised studies comparing active compression-decompression with standard manual chest compression in adults with a cardiac arrest who received cardiopulmonary resuscitation by a trained medical or paramedical team.

DATA COLLECTION AND ANALYSIS

We independently extracted data on an intention-to-treat basis. When needed, we contacted the authors of the primary studies. If appropriate, we cumulated studies and pooled relative risk (RR) estimates. We predefined subgroup analyses according to setting (out-of-hospital or in-hospital) and attending team composition (with physician or paramedic only).

MAIN RESULTS

In this update, 27 new related publications were found, but they did not all fulfil inclusion criteria or concerned participants already reported in previous publications. In the end, we included 10 trials in this review: Eight were in out-of-hospital settings; one was set in-hospital only; and one had both in-hospital and out-of-hospital components. Allocation concealment was adequate in four studies. The two in-hospital studies were different in quality and size (773 and 53 participants). Both found no differences between ACDR CPR and STR in any outcome.Out-of-hospital trials cumulated 4162 participants. There were no differences between ACDR CPR and STR for mortality either immediately (RR 0.98, 95% confidence interval (CI) 0.94 to 1.03) or at hospital discharge (RR 0.99, 95% CI 0.98 to 1.01). The pooled RR of neurological impairment of any severity was 1.71 (95% CI 0.90 to 3.25), with a non-significant trend to more frequent severe neurological damage in survivors of ACDR CPR (RR 3.11, 95% CI 0.98 to 9.83). However, assessment of neurological outcome was limited, and few participants had neurological damage.There was no difference between ACDR CPR and STR with regard to complications such as rib or sternal fractures, pneumothorax, or haemothorax (RR 1.09, 95% CI 0.86 to 1.38). Skin trauma and ecchymosis were more frequent with ACDR CPR.

AUTHORS' CONCLUSIONS

Active chest compression-decompression in people with cardiac arrest is not associated with any clear benefit.

Long-term outcomes in elderly survivors of in-hospital cardiac arrest

BACKGROUND

Little is known about the long-term outcomes in elderly survivors of in-hospital cardiac arrest. We determined rates of long-term survival and readmission among survivors of in-hospital cardiac arrest and examined whether these outcomes differed according to demographic characteristics and neurologic status at discharge.

METHODS

We linked data from a national registry of inpatient cardiac arrests with Medicare files and identified 6972 adults, 65 years of age or older, who were discharged from the hospital after surviving an in-hospital cardiac arrest between 2000 and 2008. Predictors of 1-year survival and of readmission to the hospital were examined.

RESULTS

One year after hospital discharge, 58.5% of the patients were alive, and 34.4% had not been readmitted to the hospital. The risk-adjusted rate of 1-year survival was lower among older patients than among younger patients (63.7%, 58.6%, and 49.7% among patients 65 to 74, 75 to 84, and ≥85 years of age, respectively; P<0.001), among men than among women (58.6% vs. 60.9%, P=0.03), and among black patients than among white patients (52.5% vs. 60.4%, P=0.001). The risk-adjusted rate of 1-year survival was 72.8% among patients with mild or no neurologic disability at discharge, as compared with 61.1% among patients with moderate neurologic disability, 42.2% among those with severe neurologic disability, and 10.2% among those in a coma or vegetative state (P<0.001 for all comparisons). Moreover, 1-year readmission rates were higher among patients who were black, those who were women, and those who had substantial neurologic disability (P<0.05 for all comparisons). These differences in survival and readmission rates persisted at 2 years. At 3 years, the rate of survival among survivors of in-hospital cardiac arrest was similar to that of patients who had been hospitalized with heart failure and were discharged alive (43.5% and 44.9%, respectively; risk ratio, 0.98; 95% confidence interval, 0.95 to 1.02; P=0.35).

CONCLUSIONS

Among elderly survivors of in-hospital cardiac arrest, nearly 60% were alive at 1 year, and the rate of 3-year survival was similar to that among patients with heart failure. Survival and readmission rates differed according to the demographic characteristics of the patients and neurologic status at discharge. (Funded by the American Heart Association and the National Heart, Lung, and Blood Institute.).

Impact of advanced cardiac life support training program on the outcome of cardiopulmonary resuscitation in a tertiary care hospital

Background:

Guidelines on performing cardiopulmonary resuscitation (CPR) have been published from time to time, and formal training programs are conducted based on these guidelines. Very few data are available in world literature highlighting the impact of these trainings on CPR outcome.

Aim:

The aim of our study was to evaluate the impact of the American Heart Association (AHA)-certified basic life support (BLS) and advanced cardiac life support (ACLS) provider course on the outcomes of CPR in our hospital.

Materials and Methods:

An AHA-certified BLS and ACLS provider training programme was conducted in our hospital in the first week of October 2009, in which all doctors in the code blue team and intensive care units were given training. The retrospective study was performed over an 18-month period. All in-hospital adult cardiac arrest victims in the pre-BLS/ACLS training period (January 2009 to September 2009) and the post-BLS/ACLS training period (October 2009 to June 2010) were included in the study. We compared the outcomes of CPR between these two study periods.

Results:

There were a total of 627 in-hospital cardiac arrests, 284 during the pre-BLS/ACLS training period and 343 during the post-BLS/ACLS training period. In the pre-BLS/ACLS training period, 52 patients (18.3%) had return of spontaneous circulation, compared with 97 patients (28.3%) in the post-BLS/ACLS training period (P < 0.005). Survival to hospital discharge was also significantly higher in the post-BLS/ACLS training period (67 patients, 69.1%) than in the pre-BLS/ACLS training period (12 patients, 23.1%) (P < 0.0001).

Conclusion:

Formal certified BLS and ACLS training of healthcare professionals leads to definitive improvement in the outcome of CPR.

Survival after in-hospital cardiopulmonary resuscitation in a major referral center

Aim:

This study was undertaken to assess the demographics, clinical parameters and outcomes of patients undergoing cardiopulmonary resuscitation (CPR), by the code blue team at our center to compare with other centers.

Materials and Methods:

Data were collected retrospectively from all adult patients who underwent CPR at our hospital from 2007 to 2008. CPR was performed on 290 patients and it was given 313 times. Clinical outcomes of interest were survival at the end of CPR and survival at discharge from the hospital. Factors associated with survival were evaluated via binomial and chi square-tests.

Results:

Of the 290 patients included, 95 patients (30.4%) had successful CPR. However, only 35 patients (12%) were alive at discharge. The majority requiring CPR were above 60 years of age (61.7%). Males required CPR more than females. There were 125 women (43.1%) and 165 males (56.9%) aged 3 to 78 (average 59.6) years. Majority (179) of the cases (61.7%) were above 60 years of age. Regarding the various wards, 54 cases (17.3%) were in the internal medicine ward, 63 cases (20.1%) in the surgery ward, 1 case (0.3%) in the clinic, 11 cases (3.5%) in the paraclinic, 116 cases (37.1%) in the emergency (ER), 55 cases (17.5%) in the Intensive Care Unit (ICU) and Coronary Care Unit (CCU), and 13 cases (4.2%) were in other wards. Cardiac massage was done in 133 cases (42.5%), defibrillation only via electroshock 3 cases (1%), and both were used in177 cases (56.5%). The ER had the most cases of CPR. Both cardiac massage and electroshock defibrillation were needed in most cases.

Conclusion:

In-hospital CPR for cardiopulmonary arrest was associated with 30.4% success at our center at the end of CPR but only 12% were alive at discharge. Duration of CPR >10 minutes was predictive of significantly decreased survival to discharge.

Prehospital emergency treatment of palliative care patients with cardiac arrest: a retrolective investigation

BACKGROUND

Today, prehospital emergency medical teams (EMTs) are confronted with emergent situations of cardiac arrest in palliative care patients. However, little is known about the out-of-hospital approach in this situation and the long-term survival rate of this specific patient type. The aim of the present investigation was to provide information about the strategic and therapeutic approach employed by EMTs in outpatient palliative care patients in cardiac arrest.

METHODS

During a period of 2 years, we retrolectively analysed emergency medical calls with regard to palliative care emergency situations dealing with cardiac arrest. We evaluated the numbers of patients who were resuscitated, the prevalence of an advance directive or other end-of-life protocol, the first responder on cardiac arrest, the return of spontaneous circulation (ROSC) and the survival rate.

RESULTS

Eighty-eight palliative care patients in cardiac arrest were analysed. In 19 patients (22%), no resuscitation was started. Paramedics and prehospital emergency physicians began resuscitation in 61 cases (69%) and in 8 cases (9%), respectively. A total of 10 patients (11%) showed a ROSC; none survived after 48 h. Advance directives were available in 43% of cases. The start of resuscitation was independent of the presence of an advance directive or other end-of-life protocol.

CONCLUSIONS

Strategic and therapeutic approaches in outpatient palliative care patients with cardiac arrest differ depending on medical qualification. Although many of these patients do not wish to be resuscitated, resuscitation was started independent of the presence of advance directive. To reduce legal insecurity and to avoid resuscitation and a possible lengthening of the dying process, advance directives and/or "Do not attempt resuscitation" orders should be more readily available and should be adhered to more closely.

The triad that matters: palliative medicine, code status, and health care costs

INTRODUCTION

Delayed discussion of a patient's code status can lead to shortsighted care plans that increase hospital length of stay (LOS) and costs.

METHODS

Retrospective study compared intensive care unit (ICU) patients who accepted verses rejected palliation and examined the relationships between 5 predictor variables with the outcome variables ICU LOS and total hospital LOS, and total direct and variable hospital cost.

RESULTS

A significant number of patients who accepted palliative care agreed to a hospice referral or expired in the hospital. The relationships between days until a family conference, do-not-resuscitate (DNR) order, and the number of invasive procedures were significant.

CONCLUSIONS

The amount of time that expires until the issue of code status was settled to clearly related to utilization of hospital resources.

Reviving the conversation around CPR/DNR

This paper examines the historical rise of both cardiopulmonary resuscitation (CPR) and the do-not-resuscitate (DNR) order and the wisdom of their continuing status in U.S. hospital practice and policy. The practice of universal presumed consent to CPR and the resulting DNR policy are the products of a particular time and were responses to particular problems. In order to keep the excesses of technology in check, the DNR policies emerged as a response to the in-hospital universal presumed consent to CPR. We live with this historical concretion, which seems to perpetuate a false culture that the patient's wishes must be followed. The authors are critical of the current U.S. climate, where CPR and DNR are viewed as two among a panoply of patient choices, and point to UK practice as an alternative. They conclude that physicians in the United States should radically rethink approaches to CPR and DNR.

Cardiopulmonary resuscitation and do-not-resuscitate orders: a guide for clinicians

The do-not-resuscitate order, introduced nearly a half century ago, continues to raise questions and controversy among health care providers and patients. In today's society, the expectation and availability of medical interventions, including at the end of life, have rendered the do-not-resuscitate order particularly relevant. The do-not-resuscitate order is the only order that requires patient consent to prevent a medical procedure from being performed; therefore, informed code status discussions between physicians and patients are especially important. Epidemiologic studies have informed our understanding of resuscitation outcomes; however, patient, provider, and institutional characteristics account for great variability in the prevalence of do-not-resuscitate orders. Specific strategies can improve the quality of code status conversations and enhance end-of-life care planning. In this article, we review the history, epidemiology, and determinants of do-not-resuscitate orders, as well as frequently encountered questions and recommended strategies for discussing this important topic with patients.

Informed consent and the ethical management of the older patient

Informed consent in elderly patients presents many ethical and legal challenges. Most aging patients are competent to provide consent for medical care. The purpose of informed consent is to promote autonomy, to protect a patient from undesired treatment, and to help the patient to make appropriate medical care decisions that correlate with his or her personal values. A surrogate decision-maker should be sought for an incompetent patient. Advance directives are legally and ethically binding tools by which patients can express their decisions regarding medical care before they lose capacity to do so. Discussion of do-not-resuscitate orders is part of informed consent, and patients' wishes regarding resuscitation in the operating room should be respected. Surrogate consent for participation in research is not necessarily allowed by IRB approval and research protocols.

Prognostic indicators for dogs and cats with cardiopulmonary arrest treated by cardiopulmonary cerebral resuscitation at a university teaching hospital

OBJECTIVE

To determine the association among signalment, health status, other clinical variables, and treatments and events during cardiopulmonary cerebral resuscitation (CPCR) with the return of spontaneous circulation (ROSC) for animals with cardiopulmonary arrest (CPA) in a veterinary teaching hospital.

DESIGN

Cross-sectional study.

ANIMALS

161 dogs and 43 cats with CPA.

PROCEDURES

Data were gathered during a 60-month period on animals that had CPA and underwent CPCR. Logistic regression was used to evaluate effects of multiple predictors for ROSC.

RESULTS

56 (35%) dogs and 19 (44%) cats had successful CPCR. Twelve (6%) animals (9 dogs and 3 cats) were discharged from the hospital. Successfully resuscitated dogs were significantly more likely to have been treated with mannitol, lidocaine, fluids, dopamine, corticosteroids, or vasopressin; had CPA while anesthetized; received chest compressions while positioned in lateral recumbency; and had a suspected cause of CPA other than hemorrhage or anemia, shock, hypoxemia, multiple organ dysfunction syndrome, cerebral trauma, malignant arrhythmia, or an anaphylactoid reaction and were less likely to have been treated with multiple doses of epinephrine, had a longer duration of CPA, or had multiple disease conditions, compared with findings in dogs that were not successfully resuscitated. Successfully resuscitated cats were significantly more likely to have had more people participate in CPCR and less likely to have had shock as the suspected cause of CPA, compared with findings in cats that were not successfully resuscitated.

CONCLUSIONS AND CLINICAL RELEVANCE

The prognosis was grave for animals with CPA, except for those that had CPA while anesthetized.

Survival after in-hospital cardiopulmonary resuscitation

BACKGROUND

The use of postarrest variables to predict survival after discharge following in-hospital cardiopulmonary resuscitation has not been definitive. This study evaluates whether the duration of cardiopulmonary resuscitation (CPR) and other variables affect discharge rates and survival rates after discharge.

METHODS

Prospective cohort survival data and arrest variables were collected, including initial observed rhythm, duration of CPR, time of arrest, and number of arrests. Arrests on unmonitored general medical units, monitored telemetry units, and critical care units were included. Outcome measures were: survival after CPR, 24 hours post-CPR, survival to discharge, and to six months postdischarge.

RESULTS

At both discharge and six months after discharge, ventricular fibrillation and ventricular tachycardia were associated with better survival rates than other initial rhythms (P < 0.001). There were significantly higher survival rates (P < 0.001) for those receiving CPR for < or =10 minutes as compared with those receiving CPR >10 minutes. Multiple versus single arrests and monitored versus unmonitored arrests approached significance. The time of day of the arrest was not a significant factor.

CONCLUSIONS

Duration of CPR >10 minutes was predictive of significantly decreased survival to discharge and six months postdischarge. Low six-month survival rates may reflect the relatively high proportion of initial rhythms other than ventricular in the study group.

Effect of decisions to withhold life support on prolonged survival

BACKGROUND

The effect on long-term mortality of decisions made to withhold life-supporting therapies (LST) for critically ill patients is unclear. We hypothesized that mortality 60 days after ICU admission is not influenced by a decision to withhold use of LST in the context of otherwise providing all indicated care.

METHODS

We studied 2,211 consecutive, initial admissions to the adult, medical ICU of a university-affiliated teaching hospital. To achieve balanced groups for comparing outcomes, we created a multivariable regression model for the probability (propensity score [PS]) of having an order initiated in the ICU to withhold LST. Each of the 201 patients with such an order was matched to the patient without such an order having the closest PS; mortality rates were compared between the matched pairs. Cox survival analysis was performed to extend the main analysis.

RESULTS

The matched pairs were well balanced with respect to all of the potentially confounding variables. Sixty days after ICU admission, 50.5% of patients who had an order initiated in the ICU to withhold life support had died, compared to 25.8% of those lacking such orders (risk ratio, 2.0; 95% confidence interval, 1.5 to 2.6). Survival analysis indicated that the difference in mortality between the two groups continued to increase for approximately 1 year.

CONCLUSION

Contrary to our hypothesis, decisions made in the ICU to withhold LST were associated with increased mortality rate to at least 60 days after ICU admission.

Simulation-Based Education Improves Quality of Care During Cardiac Arrest Team Responses at an Academic Teaching Hospital

BACKGROUND

Simulation technology is widely used in medical education. Linking educational outcomes achieved in a controlled environment to patient care improvement is a constant challenge.

METHODS

This was a retrospective case-control study of cardiac arrest team responses from January to June 2004 at a university-affiliated internal medicine residency program. Medical records of advanced cardiac life support (ACLS) events were reviewed to assess adherence to ACLS response quality indicators based on American Heart Association (AHA) guidelines. All residents received traditional ACLS education. Second-year residents (simulator-trained group) also attended an educational program featuring the deliberate practice of ACLS scenarios using a human patient simulator. Third-year residents (traditionally trained group) were not trained on the simulator. During the study period, both simulator-trained and traditionally trained residents responded to ACLS events. We evaluated the effects of simulation training on the quality of the ACLS care provided.

RESULTS

Simulator-trained residents showed significantly higher adherence to AHA standards (mean correct responses, 68%; SD, 20%) vs traditionally trained residents (mean correct responses, 44%; SD, 20%; p = 0.001). The odds ratio for an adherent ACLS response was 7.1 (95% confidence interval, 1.8 to 28.6) for simulator-trained residents compared to traditionally trained residents after controlling for patient age, ventilator, and telemetry status.

CONCLUSIONS

A simulation-based educational program significantly improved the quality of care provided by residents during actual ACLS events. There is a growing body of evidence indicating that simulation can be a useful adjunct to traditional methods of procedural training.

Variation in length of intensive care unit stay after cardiac arrest: where you are is as important as who you are

OBJECTIVE

To determine whether hospital site is independently associated with length of intensive care unit (ICU) stay in those patients who die in hospital after experiencing a cardiac arrest.

DESIGN

Retrospective cohort study.

SETTING

Thirty-one Canadian ICUs, all but one being members of the Critical Care Research Network.

PATIENTS

All patients admitted to these ICUs after resuscitation from a cardiac arrest.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Retrospective analysis of prospectively collected clinical data. Using gamma regression with ICU length of stay as the dependent variable, we found the following variables to be independently associated with ICU length of stay: age, gender, Acute Physiology and Chronic Health Evaluation II score, Glasgow Coma Scale score, hospital size, and hospital site.

CONCLUSIONS

In this cohort of patients admitted to ICU after cardiac arrest, hospital site was strongly associated with ICU length of stay after controlling for patient-specific factors. Variation in processes of care among ICUs may point to opportunities for improvement.

Factors associated with survival and neurological outcome after cardiopulmonary resuscitation of neurosurgical intensive care unit patients

OBJECTIVE

We investigated predictors of survival and the neurological outcomes of neurosurgical patients who experienced cardiac arrest and received cardiopulmonary resuscitation after being admitted to the neurosurgical intensive care unit.

METHODS

A retrospective study was conducted of adult patients in the neurosurgical intensive care unit who had experienced cardiac arrest and received cardiopulmonary resuscitation. Factors relevant to the cardiac arrest (before and after arrest) were used to study association with survival (immediate or short-term) and neurological outcome (unconscious or conscious) via statistical methods.

RESULTS

Immediate survival was seen in 105 patients (49%), 19 survived until hospital discharge, and 11 were still alive at the conclusion of this study. Of the immediate survivors, 41 patients were conscious and 64 were unconscious. Multivariate analysis showed increased mortality in patients with infection, asystole, or resuscitation time exceeding 30 minutes (P < 0.05). Additional factors associated with high in-hospital mortality included lack of spontaneous respiration, no caloric-vestibular reflex, and unconsciousness after resuscitation (P < 0.05). In addition, neurological recovery was poor in patients with infection, asystole, no caloric-vestibular reflex, conscious recovery, or resuscitation lasting more than 30 minutes (P < 0.05).

CONCLUSION

Even after initially successful resuscitation, survival and neurological recovery is quite dismal in patients with cerebral lesions. Prognostic factors for neurosurgical patients should be assessed on an individual basis to determine medical futility in the early post-resuscitation period.

Sudden cardiac death: Directing the scope of resuscitation towards the heart and brain

BACKGROUND

The fundamental goal of cardiopulmonary resuscitation (CPR) is recovery of the heart and the brain. This is best achieved by (1) immediate CPR for coronary and cerebral perfusion, (2) correction of the cause of cardiac arrest, and (3) controlled cardioplegic cardiac reperfusion. Failure of such an integrated therapy may cause permanent brain damage despite cardiac resuscitation.

METHODS

This strategy was applied at four centers to 34 sudden cardiac death patients (a) after acute myocardial infarction (n = 20), (b) "intraoperatively" following successful discontinuation of cardiopulmonary bypass (n = 4), and (c) "postoperatively" in the surgical ICU (n = 10). In each witnessed arrest the patient failed to respond to conventional CPR with ACLS interventions, including defibrillation. The cardiac arrest interval was 72 +/- 43 min (20-150 min). Compression and drugs maintained a BP > 60 mmHg to avoid cerebral hypoperfusion. Operating room (OR) transfer was delayed until the blood pressure was monitored. In four patients femoral bypass maintained perfusion while an angiographic diagnosis was made.

RESULTS

Management principles included no repeat defibrillation attempts after 10 min of unsuccessful CPR, catheter-monitored peak BP > 60 mmHg during diagnosis and transit to the operating room, left ventricular venting during cardiopulmonary bypass and 20 min global and graft substrate enriched blood cardioplegic reperfusion. Survival was 79.4% with two neurological complications (5.8%).

CONCLUSIONS

Recovery without adverse neurological outcomes is possible in a large number of cardiac arrest victims following prolonged manual CPR. Therapy is directed toward maintaining a monitored peak BP above 60 mmHg, determining the nature of the cardiac cause, and correcting it with controlled reperfusion to preserve function.

Future shock: automatic external defibrillators

PURPOSE OF REVIEW

This review provides a practical overview of the performance capabilities of automatic external defibrillators (AEDs), and of advances in technology and dissemination programmes for these devices.

RECENT FINDINGS

Arrhythmia analysis by AEDs is extremely reliable in most settings (sensitivity 81-100%, specificity 99.9-97.6%). Accurate detection of arrhythmias has also been demonstrated in children, leading the US Food and Drug Administration to approve the use of several AEDs in children aged 8 years or younger. Factors that potentially may reduce the quality of arrhythmia detection are the presence of wide complex supraventricular tachycardia and location of an arrythmic event near to high-power lines. AED use by professional basic life support providers resulted in increased survival in the prehospital setting. However, provision of AEDs to nonmedical rescue services did not result in universal improvement in patient outcome. Public access defibrillation programmes have led to higher rates of survival from cardiac arrest. The role of AEDs in hospitals has yet to be elucidated, although in-hospital mortality from ventricular arrhythmias has been shown to decrease following AED deployment.

SUMMARY

Given the correct setting, AEDs can ensure that defibrillation is not limited by lack of medical knowledge or difficulties in decision making. However, event-related variables and operator-related factors, that are yet to be determined, can significantly affect the efficacy of automatic external defibrillation.

The use of amiodarone for in-hospital cardiac arrest at two tertiary care centres

BACKGROUND

Although amiodarone significantly increases survival to hospital admission when used in resuscitation of out-of-hospital pulseless ventricular tachycardia and fibrillation, there are limited data on its utility for in-hospital arrests.

OBJECTIVES

To determine whether the use of amiodarone, as recommended by the year 2000 American Heart Association Advanced Cardiac Life Support guidelines, improved survival following its introduction to the resuscitation algorithm at two tertiary care institutions.

METHODS

Charts of 374 cardiac resuscitations were retrospectively studied at the two institutions. Basic survival outcomes and demographic data were recorded for cardiac arrests with ventricular tachyarrhythmias qualifying for administration of antiarrhythmic agents.

RESULTS

Qualifying rhythms were present in 95 patients. Clinical uptake of amiodarone was limited. In the 36 patients who received amiodarone, survival of resuscitation was 67% versus 83% (P=0.07) in the 59 patients receiving only other antiarrhythmic agents (chiefly lidocaine [94%]), while survival to discharge was 36.1% and 55.9% (P=0.06) in these two groups, respectively.

CONCLUSIONS

Following two years' experience with the introduction of intravenous amiodarone for resuscitation in the institutions, use was less than 50% and no clinically observable survival benefit could be documented. Possible explanations for the difference between this experience and that found in out-of-hospital resuscitation trials include differing patient populations and operator bias during resuscitation. These results should provoke other institutions to question whether amiodarone has improved survival of cardiac arrest under the conditions prevailing in their hospitals. A patient registry or prospective, randomized trial will be required to assess what parameters affect the success of intravenous amiodarone for resuscitation in-hospital.

Performance of department staff in the window between discovery of collapse to cardiac arrest team arrival

INTRODUCTION

Guideline-directed therapy during the first minutes of resuscitation may be life saving. This study assessed the performance of American Heart Association (AHA) guidelines by trained departmental staff in the period between discovery of collapse and emergency team arrival.

METHODS

Over a period of 24 months, departmental performance prior to the arrival of the emergency team (median 180 s) was assessed by debriefings conducted within 24h of each event in a 740-bed tertiary hospital with a dedicated certified resuscitation team. Outcome measures were failure to meet AHA treatment recommendations (primary) and return of spontaneous circulation (ROSC)/survival to hospital discharge (secondary).

RESULTS

Two hundred and forty four events were included (216 patients). Mean age was 69+/-17 years; 45% were women. The underlying causes of collapse were mainly cardiac (39%) or respiratory (32%). Residents conducted most of the resuscitations (69%) prior to the arrival of the emergency team. Basic diagnostic measures such as assessments of pulse and rhythm were not performed in 19 and 33% of events. Therapeutic measures such as positive pressure ventilation, chest compressions and defibrillation were not provided according to the guidelines in 17, 12 and 44% of the events. ROSC occurred in 62% of events; 54% of VF/VT, 30% of asystole, 22% of PEA and 76% of bradyarrhythmias/severe bradycardias. Survival to hospital discharge was 37% overall and 41% for patients found in VF/VT (n=33).

CONCLUSIONS

Trained departmental staff performed poorly in the moments between patient discovery and arrival of the emergency team. Since patient outcomes were comparable to those described in the literature, poor resuscitation performance may be commonplace in hospitals where ward personnel are expected to deliver advanced life support prior to arrival of the emergency team.

Rapid cardiac ultrasound of inpatients suffering PEA arrest performed by nonexpert sonographers

Cardiac arrest presenting as pulseless electrical activity (PEA) currently has a very low survival rate. Many of the conditions underlying PEA (cardiac tamponade, hypovolemia, and pulmonary embolus) are associated with specific cardiac ultrasound findings. The aim of this study was to evaluate a rapid cardiac ultrasound assessment performed by trained nonexpert sonographers integrated into the ACLS response system at a major medical center.

METHODS

An emergency sonography system was created and deployed to each inpatient cardiac arrest occurring at Dartmouth Hitchcock Medical Center between November 1, 2003 and April 30, 2004. Thirteen internal medicine house officers received training to perform a limited subcostal cardiac ultrasound examination designed to diagnose cardiac tamponade, pulmonary embolus, severe hypovolemia, and lack of cardiac motion. Time from arrest alert to sonographic result, and correlation with over-reading by blinded echocardiography physicians were assessed.

RESULTS

A complete emergency ultrasound examination was performed in five PEA arrests. The average time from arrest alert to interpretation was 7.75 min. (95% CI 2.8-18.3 min). Three of these examinations (60%, 95% CI 14.7-94.7%) were adequate for interpretation. Agreement between the nonexpert sonographer and echocardiography physician occurred in four of five (kappa=0.706) cases.

CONCLUSION

Rapid cardiac sonography can be successfully integrated in the ACLS response. Nonexpert sonographers may be able to provide useful interpretive information when sufficiently trained.

Factors influencing survival after in-hospital cardiopulmonary resuscitation

INTRODUCTION

During recent years, in-hospital cardiopulmonary resuscitation (CPR) management has received much attention. However, the rate of survival after in-hospital resuscitation in Iran hospitals is not known. Therefore, a study was designed to evaluate the outcome of in-hospital cardiopulmonary resuscitation (CPR) in the city of Kashan, Iran, during a 6-month period during 2002.

MATERIAL AND METHODS

A prospective descriptive study was conducted on all cases of in-hospital cardiopulmonary resuscitation. Necessary data including the age and sex of patients, shift, time from cardiac arrest until initiating of CPR, time from cardiac arrest until defibrillation, duration and result of CPR, were recorded in a checklist. Descriptive statistics presented.

RESULTS

A total of 206 cases of CPR were attempted during the research period. The study population consisted of 59.2% males and 40.8% females. The survival rate was similar for both sexes. Short-term survival was observed in 19.9% of cases and only 5.3% survived to discharge. The key predictors of survival to hospital discharge were CPR duration, time of cardiac arrest, time from cardiac arrest to initiation of CPR, and defibrillation within the first few minutes of cardiac arrest.

CONCLUSIONS

Our study showed that it needs more attention to be paid to cardiopulmonary resuscitation management in Iran's hospitals. The results of this study could be an important first step toward a national study on the survival after cardiopulmonary resuscitation to provide accurate data on our performance with regards to the chain of survival.

Cardiopulmonary resuscitation in critically ill neurologic-neurosurgical patients

OBJECTIVES

To establish the rate of successful cardiopulmonary resuscitation (CPR) and to study outcome predictors in patients who experienced in-hospital cardiac arrest after being admitted to the neurologic-neurosurgical intensive care unit (ICU) with a primary neurologic diagnosis.

PATIENTS AND METHODS

We identified patients admitted to the neurologic-neurosurgical ICU between 1994 and 2001 who experienced in-hospital cardiac arrest and received CPR. Functional outcome was assessed using the modified Rankin scale.

RESULTS

During the study period, 38 consecutive patients experienced in-hospital cardiac arrest and received CPR. The median age of the patients was 65 years (range, 16-81 years), and the mean interval from admission to CPR was 12 days (range, 3 hours to 47 days). Acute intracranial disease was present in 32 patients (84%). Twenty-one patients (55%) were in the ICU at the time of the cardiac arrest; cardiac arrests in the wards occurred at a mean interval of 9 days (range, 1-45 days) after ICU discharge. Cardiopulmonary resuscitation achieved return of spontaneous circulation in 23 patients (61%). Seven patients (18%) were discharged from the hospital, 5 of whom later achieved a modified Rankin scale score of 2 or lower. Cardiac arrest after a deteriorating clinical course resulted in uniformly fatal outcomes. Duration of CPR shorter than 5 minutes and CPR in the ICU were associated with survival and good functional recovery.

CONCLUSIONS

Cardiopulmonary resuscitation is a worthwhile procedure in severely ill neurologic-neurosurgical patients, regardless of the patient's age. However, the outcome after CPR appears much worse in patients with a prior deteriorating clinical course.

A program encouraging early defibrillation results in improved in-hospital resuscitation efficacy

OBJECTIVES

The purpose of this study was to determine whether survival to discharge after in-hospital cardiopulmonary arrest could be improved by a program encouraging early defibrillation that included switching from monophasic to biphasic devices.

BACKGROUND

In-hospital resuscitation continues to have a low success rate. Biphasic waveform devices have demonstrated characteristics that might improve survival, and outside the hospital, automated external defibrillators (AEDs) have shown promise in improving survival of patients suffering cardiopulmonary arrest.

METHODS

A program including education and replacement of all manual monophasic defibrillators with a combination of manual biphasic defibrillators used in AED mode and AEDs in all outpatient clinics and chronic care units was implemented.

RESULTS

With program implementation, the percentage survival of all patients with resuscitation events improved 2.6-fold, from 4.9% to 12.8%. Factors independently predicting survival included event location outside an intensive care unit, younger age, an initial rhythm of pulseless ventricular tachycardia (VT) or ventricular fibrillation (VF), pre-arrest beta-blocker, and program initiation. The outcome was independent of gender, race, work shift, number of previous resuscitation attempts, body mass index, comorbidity index, presence of diabetes, presence of hypertension, or use of angiotensin-converting enzyme inhibitors. The improvement in mortality was attributable solely to an effect on patients presenting with VT/VF. Patients with these initial rhythms were 14-fold (odds ratio = 0.07 of death, confidence interval = 0.02 to 0.3) more likely to survive to discharge after program initiation. Automated external defibrillators performed similarly to biphasic manual defibrillators in AED mode.

CONCLUSIONS

A program including education and use of biphasic manual defibrillators in AED mode and selective use of AEDs improved survival to discharge in hospitalized patients suffering from cardiopulmonary arrest.

Active chest compression-decompression for cardiopulmonary resuscitation

BACKGROUND

Active compression-decompression cardiopulmonary resuscitation (ACDR CPR) uses a hand-held suction device, applied mid sternum, to compress the chest then actively decompress the chest after each compression. Randomised controlled trials on use of active compression decompression cardiopulmonary resuscitation have results which are discordant.

OBJECTIVES

To determine clinical effects and safety of active compression-decompression cardiopulmonary resuscitation compared with standard manual cardiopulmonary resuscitation (STR).

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE. Last search was conducted in January 2004. We checked the reference list of retrieved articles and contacted enterprises manufacturing the active decompression devices.

SELECTION CRITERIA

All randomised or quasi-randomised studies comparing active compression-decompression cardiopulmonary resuscitation compared with standard manual cardiopulmonary resuscitation in adults with a cardiac arrest who received cardiopulmonary resuscitation by a trained medical or paramedical team.

DATA COLLECTION AND ANALYSIS

Data were independently extracted. All data were analysed on an intention-to-treat basis. The authors of the primary studies were contacted for more information when needed. Studies were cumulated, if appropriate, and pooled relative risk (RR) estimated. Subgroup analysis according to setting (out of hospital or in hospital) and attending team composition (with physician or paramedic only) were predefined.

MAIN RESULTS

Ten trials were included: eight were in out-of-hospital settings, one set in-hospital only and one had both in-hospital and out-of-hospital components. Allocation concealment was adequate in 4 trials. The two in-hospital studies were very different in quality (A and C) and size (773 and 53 patients). Both found no differences between ACDR CPR and STR in any outcome. Trials conducted in out-of-hospital settings cumulated 4162 patients. There were no differences between ACDR CPR and STR for mortality either immediately (RR 0.98 [95% CI 0.94 - 1.03]) or at hospital discharge (RR 0.99 [95% CI 0.98 - 1.01]). The pooled RR of neurological impairment, any severity, was 1.71 [95% CI 0.90 - 3.25], with a non-significant trend to more frequent severe neurological damage in survivors of ACDR CPR (RR 3.11 [95% CI 0.98 - 9.83]). However, assessment of neurological outcome was limited and there were few patients with neurological damage. There was no difference between ACDR CPR and STR with regard complications such as rib or sternal fractures, pneumothorax or hemothorax (RR 1.09 [95% CI 0.86 - 1.38]). Skin trauma and ecchymosis were more frequent with ACDR CPR.

REVIEWERS' CONCLUSIONS

Active chest compression-decompression in patients with cardiac arrest is not associated with clear benefit.

Do-not-resuscitate order after 25 years

BACKGROUND

In 1976, the first hospital policies on orders not to resuscitate were published in the medical literature. Since that time, the concept has continued to evolve and evoke much debate. Indeed, few initials in medicine today evoke as much symbolism or controversy as the Do-Not-Resuscitate (DNR) order.

OBJECTIVE

To review the development, implementation, and present standing of the DNR order.

DESIGN

Review article.

MAIN RESULTS

The DNR order concept brought an open decision-making framework to the resuscitation decision and did much to put appropriate restraint on the universal application of cardiopulmonary resuscitation for the dying patient. Yet, even today, many of the early concerns remain.

CONCLUSIONS

After 25 yrs of DNR orders, it remains reasonable to presume consent and attempt resuscitation for people who suffer an unexpected cardiopulmonary arrest or for whom resuscitation may have physiologic effect and for whom no information is available at the time as to their wishes (or those of their surrogate). However, it is not reasonable to continue to rely on such a presumption without promptly and actively seeking to clarify the patient's (or surrogate's) wishes. The DNR order, then, remains an inducement to seek the informed patient's directive.