One-year survival after in-hospital cardiac arrest: A systematic review and meta-analysis

Incidence, outcome and trends of in-hospital cardiac arrest over a ten-year period in a Swiss tertiary hospital

BACKGROUND

Although in-hospital cardiac arrest (IHCA) occurs frequently, it is less well described in the literature and data is rare compared to out-of-hospital cardiac arrest (OHCA), especially with regard to incidence and outcomes.

OBJECTIVE

The aim of this retrospective study was to analyze the incidence, characteristics, outcomes and potential predictors of outcome of IHCA occurring from 2012 to 2022 at a tertiary hospital in Switzerland.

METHODS

All in-hospital cardiac arrest missions over a ten-year period were retrospectively analyzed. Subsequently, statistical analysis was conducted to identify variables influencing the outcome (outcomes of interest were return of spontaneous circulation (ROSC) and survival after 6 and 12 months).

RESULTS

Over a ten-year period, there were 364 resuscitations, resulting in an overall incidence of 1.87 resuscitation per 1000 hospitalizations. ROSC was achieved in 63.4 % and 37.4 % were alive at 12 months. In 71.2 % the initial rhythm was non-shockable. Observed cardiac arrest and continuous ECG monitoring were significant positive predictors for ROSC and improved survival. Older age was associated with worse survival throughout the study period. Over the ten-year study period both incidence and outcomes of IHCA were unchanged.

CONCLUSION

HCA was infrequent but associated with high mortality rates. Continuous ECG monitoring emerged as a robust predictor for achieving ROSC and for improved survival following IHCA.

Individual and shared situational awareness in in-hospital cardiac arrest: insights from a real-world observational study

BACKGROUND

Individual and shared situational awareness (SA) are crucial for team performance in high-pressure emergencies like cardiopulmonary resuscitation (CPR). While SA has been extensively studied in simulations, little research has examined its role in real-world in-hospital cardiac arrest (IHCA) settings. This study assessed individual and shared SA among medical emergency team (MET) members during CPR and explored its influence on team structure, communication and outcomes.

METHODS

A cross-sectional observational study was conducted in real-world clinical settings, involving seven METs (n = 40). Individual SA was measured using the Situation Awareness Global Assessment Technique (SAGAT), while shared SA was assessed via a similarity index reflecting the alignment of team members' responses. Associations between SA, team structure, stress levels and clinical performance were analysed.

RESULTS

Findings showed substantial variability in individual SA, with only 25% achieving full SA. Shared SA scores ranged from 0.95 ± 0.046 to 0.78 ± 0.144, with higher scores significantly associated with improved team structure (P = 0.034) and resuscitation success (P = 0.048). Mental work stress during CPR was linked to lower individual SA (P = 0.004), highlighting cognitive overload's impact on SA.

CONCLUSIONS

This study identifies critical SA gaps, affecting both individual performance and team coordination. Shared SA is a key predictor of resuscitation success and should be enhanced through structured SA training, high-frequency simulations and algorithm-driven protocols to improve team synchronisation, decision-making and patient outcomes in IHCA settings.

The Heart Team approach to cardiac arrest

Cardiac arrest is a critical emergency in cardiovascular medicine, requiring rapid, multidisciplinary interventions to enhance patient survival and neurological outcomes. This review explores the unique challenges of managing out-of-hospital (OHCA) and in-hospital cardiac arrest (IHCA), with a focus on mechanical circulatory support (MCS) and extracorporeal cardiopulmonary resuscitation for selected patients. While OHCA management should prioritize rapid transport to specialized centres, IHCA may allow for immediate, patient-tailored interventions. Post-cardiac arrest syndrome adds complexity, often requiring nuanced MCS escalation and weaning. Standardized protocols, ethical considerations, and further research are essential to refine patient selection and improve outcomes, ultimately advancing cardiac arrest care.

Temporal trends in the incidence and outcomes of cardiopulmonary arrest events treated in the emergency department at a tertiary hospital in Jordan

Objective

This study aimed to estimate the incidence and outcomes of cardiac arrest treated in the emergency department (ED), and identify factors associated with survival to hospital discharge.

Methods

This was a single-center observational study of all adult cardiac arrest patients treated in the ED between 2015 and 2022. Patients were categorized into out-of-hospital cardiac arrest (OHCA) and in-ED events based on whether the patients arrived at the ED in cardiac arrest or developed during the ED visit. Annual incidence rates were calculated per 10,000 ED visits. Changes in the temporal trend for incidence were assessed using Poisson regression and factors associated with survival to hospital discharge among admitted patients were identified using logistic regression models.

Results

A total of 613 patients received cardiopulmonary resuscitation in the ED, resulting in an incidence rate of 9.3 per 10,000 visits with an annual incidence decreasing by 3.9% (95% CI: 0.7%─7.1%). Compared to OHCA events (n = 373), in-ED events (n = 240) had a lower and decreasing incidence rate (6.1 vs. 3.2 per 10,000 visits) and had higher rates of return of spontaneous circulation (19.3% vs. 47.1%), survived to hospital admission (17.2% vs. 37.5%), and survived to hospital discharge (1.9% vs. 7.9%). Among admitted patients, predictors of survival to hospital discharge included in-ED event, younger age, cardiac etiology, receiving defibrillation, and fewer epinephrine doses.

Conclusions

Clinical outcomes following OHCA and in-ED cardiac arrests were poor in Jordan. Efforts should be directed toward improving the performance of community and healthcare practitioners with significant emphasis on prehospital emergency care.

Prevalence, outcome and conduct of in-hospital cardiopulmonary resuscitation in government hospitals of Nepal

INTRODUCTION

Cardiopulmonary resuscitation (CPR) is an evidence-based intervention that saves lives. In low- and middle-income countries like Nepal, the occurrence of the problem and its outcome are seldom studied. The study aims to highlight the prevalence, performance, and outcome of CPR in government hospitals of Nepal.

METHODS

A mixed method study was done for two months in central and provincial government hospitals of Nepal. A total of 80 resuscitations were evaluated using a questionnaire based on the American Heart Association 2020 guidelines for cardiopulmonary resuscitation. An in-depth interview was conducted with 15 active participants of the resuscitation in different sites. Thematic analysis was done using the framework of the chain of survival of arrest victims.

RESULTS

The overall prevalence of CPR was found to be 1.92% [95% CI: 0.01,0.02] with 5.4% in central hospitals and 0.65% in provincial hospitals with 60% cardiac arrests occurring in the intensive care unit. Estimated time from recognition of the arrest to initiating CPR was 1.9 ±1.4 minutes. Asystole 66.25% was the commonest arrest rhythm and 21.25% had difficulty interpreting rhythm. Only 11.25% of the victims had return of spontaneous circulation and were subsequently transferred for post-arrest care. The qualitative analysis highlighted the lack of trained staff, a dedicated system, feedback mechanism, and provision of post-arrest care.

CONCLUSION

Across various level of Nepal's healthcare system, cardiopulmonary resuscitation is prevalent with poor performance and outcome. To improve outcomes, it is essential to implement standardized procedures and ensure high quality resuscitation delivery before and after the event supported by well-trained healthcare personnel and adequate infrastructure.

Understanding Code Blue Activations: Insights From Early Warning and Palliative Scores in a Tertiary Hospital

Background

In-hospital cardiac arrest (IHCA) is a critical emergency, occurring at rates of 1-6 events per 1000 hospital admissions, necessitating immediate and efficient resuscitation efforts. This study aims to determine the frequency, demographic characteristics, and outcomes of Code Blue activations in a tertiary teaching hospital in a low-middle-income country.

Methods

This retrospective observational study was conducted at in National Referral and Teaching Hospital in a middle income country in Asia, covering data from January 1, 2017, to December 31, 2023. The study included 2184 Code Blue activations, with data on Early Warning Scores (EWS) and palliative scores available from 2021 onwards. Statistical analyses were performed to evaluate the relationship between these scores and patient outcomes.

Results

Out of 2184 Code Blue activations, 713 cases included both EWS and palliative scores. The highest number of activations was recorded in 2019 (535 cases), and the lowest in 2021 (152 cases). Calculated incidence where 5.46 per 1000 visits. The return of spontaneous circulation (ROSC) rates ranged from 11% to 27.6%, with an average of 17.7% per year. The mean EWS and palliative scores for Code Blue activations were 9.2 (SD ± 2.3) and 7.8 (SD ± 1.9), respectively.

Discussion

The findings highlight trends in IHCA incidence, causes, and outcomes, emphasizing the importance of early identification and management of patients at risk. The study underscores the need for continuous monitoring and early intervention, particularly for patients with high EWS. Additionally, the integration of palliative care considerations into hospital protocols is crucial for improving patient outcomes and resource allocation.

Conclusion

Early warning system and palliative care scoring may predict code blue activation and if managed can reduce its number.

Longitudinal analysis of in-hospital cardiac arrest: trends in the incidence, mortality, and long-term survival of a nationwide cohort

BACKGROUND

In-hospital cardiac arrest (IHCA) poses a considerable threat to hospitalized patients, leading to high mortality rates and severe neurological deficits among survivors. Despite the advancements in resuscitation practices, the prognosis of IHCA remains poor, and comprehensive studies exploring nationwide trends and long-term survival are scarce, particularly in the Asian populations.

METHODS

Utilizing data from the Taiwan National Health Insurance Research Database, we conducted a nationwide cohort study to analyze the IHCA events among adult patients between 2003 and 2020. The outcomes of interest in this study included the temporal trend in the IHCA incidence, in-hospital mortality, and median survival after discharge for overall hospitalizations.

RESULTS

Over the 18-year period, the IHCA incidence in Taiwan declined by 70%, from an annual incidence of 7.1 per 1,000 admissions to a lower rate in 2020, accompanied by a 14% reduction in the in-hospital mortality rate, with an average of 86.5%. The overall long-term survival rate for discharged survivors was 63.9%. We observed a substantial 125% increase in the median survival duration of discharged survivors, rising from 1.56 years in 2003 to 3.51 years in 2015. Favorable in-hospital survival rates and extended life expectancy were notably seen in the patients with shockable rhythms, those with a cardiac primary diagnosis, women, and younger patients.

CONCLUSIONS

Our study data revealed significant declines in the IHCA incidence and in-hospital mortality in Taiwan, along with improved long-term survival among survivors, particularly among specific subgroups. Women exhibited significantly better long-term survival as compared to men, underscoring the need to avoid sex-based treatment biases. Improvements in discharge survival rates and life expectancy were less pronounced in older survivors, indicating that age alone may not be sufficient to guide IHCA management decisions. Proactive resuscitation should be carefully considered for older patients, particularly those with mild frailty and potentially reversible conditions. Trial registration the institutional review board of Chang Gung Memorial Hospital approved all data usage and the study protocol (Registration number: 202301625B0, Registered 7 November 2023).

GYY4137 ameliorates blood brain barrier damage by inhibiting autophagy mediated occludin degradation in cardiac arrest and resuscitation

Cardiopulmonary resuscitation (CPR) after cardiac arrest (CA) is an important cause of neurological impairment and leads to considerable morbidity and mortality. The stability of the blood-brain barrier (BBB) is crucial for minimizing secondary neurological damage and improving long-term prognosis. However, the precise mechanisms and regulatory pathways that contribute to BBB dysfunction after CPR remain elusive. GYY4137 is an innovative hydrogen sulfide slow-release agent with excellent properties as a hydrogen sulfide substitute. The aim of this study was to investigate the protective effects of GYY4137 on CA/CPR and the underlying mechanisms of BBB protection. The effects of GYY4137 on systemic inflammation, BBB integrity, and autophagy were evaluated using a mouse CA/CPR model. The underlying mechanisms of occludin changes associated with GYY4137 were investigated using oxygen-glucose deprivation / reoxygenation (OGD/R) model. ELISA, neurological function and other tests showed that GYY4137 ameliorates systemic inflammation and neurological prognosis. Western blotting, transwell migration and tube formation assays showed that GYY4137 improves BBB function both in vivo and in vitro. The detection of autophagy flow and protein degradation pathways showed the inhibition of occludin reduction by GYY4137 was mainly achieved by suppressing autophagy mediated degradation. Taken together, GYY4137 may improve BBB dysfunction following CPR by increasing occludin content. This effect was achieved by inhibiting autophagic degradation rather than promoting synthesis. GYY4137 also mitigated systemic inflammation and improved neurological outcomes after CA/CPR. In summary, our study provides valuable insights into protecting the integrity of BBB and improving neurological outcomes after CPR.

Short- and long-term outcomes of patients with acute myocardial infarction complicated by cardiac arrest: a nationwide cohort study 2013-22

AIMS

To assess short- and long-term outcomes of acute myocardial infarction (AMI) complicated by out-of-hospital cardiac arrest (OHCA) or in-hospital cardiac arrest (IHCA) in a nationwide cohort.

METHODS AND RESULTS

Cohort study of AMI patients admitted to hospitals in Norway 2013-22 registered in the Norwegian Myocardial Infarction Registry. Outcomes were in-hospital and long-term mortality. Cumulative mortality was assessed with the Kaplan-Meier and the life-table methods. Cox regression was used for risk comparisons. Among 105 439 AMI patients (35% women), we identified 3638 (3.5%) patients with OHCA and 2559 (2.4%) with IHCA. The mean age was 65.7 (13.2), 70.9 (12.6), and 70.7 (13.6) years for OHCA, IHCA, and AMI without cardiac arrest (CA), respectively. The median follow-up time was 3.3 (25th, 75th percentile: 1.1, 6.3) years. In-hospital mortality was 28, 49, and 5%, in OHCA, IHCA, and AMI without CA, and the estimated 5-year cumulative mortality was 48% [95% confidence interval (CI) 46-50%], 69% (95% CI 67-71%), and 35% (95% CI 34-35%), respectively. Among patients surviving to hospital discharge, no significant difference in mortality during follow-up was found between OHCA and AMI without CA [adjusted hazard ratio (HR) 1.04, 95% CI 0.96-1.13], while the long-term mortality of AMI patients with IHCA was higher (age-adjusted HR 1.31, 95% CI 1.19-1.45).

CONCLUSION

In this large, contemporary cohort of AMI patients, in-hospital mortality of patients with OHCA or IHCA was still high. Among patients surviving to hospital discharge, long-term mortality was comparable between OHCA and AMI without CA, while the outcome of patients with IHCA was significantly worse.

In-hospital cardiac arrest in middle-income settings: A comprehensive analysis of clinical profiles and outcomes of both adults and pediatrics

Background

In hospital cardiac arrest is associated with poor survival despite basic and advanced life support measures. This study aimed to identify the clinical characteristics and outcomes of cardiac arrests occurring during in-hospital admission to the tertiary care center in Pakistan.

Method

A retrospective, cross-sectional study at Aga Khan University Hospital from 2021 to 2023 analyzed 230 cardiac arrest cases. Data included demographics, arrest type, timing, initial rhythm, resuscitation duration, and arrest location. American Heart Association guidelines were adhered to for life support. The main outcomes focused on the return of spontaneous circulation survival to hospital discharge.

Results

During the study, 230 cardiac arrests were observed: 152 in adults (mean age 57.8, 142 shockable cases, ROSC 52.6 %, alive at discharge 28.3 %) and 78 in pediatric patients (mean age 4.99, non-shockable rhythm 85.9 %, ROSC 51.3 %, alive at discharge 17.9 %). Adult Charles comorbidity index: 2.88 (SD±2.08), pediatric index: 0.610 (SD±0.88). Survival rates were lower with a high comorbidity index and code duration > 20 min.

Conclusion

The study provides valuable observational data that challenges global survival rates for in-hospital cardiac arrest. It highlights how factors like being in monitored units and the presence of rapid response teams can lead to higher survival rates. The research underscores the influence of comorbidities, initial rhythms, and the duration of resuscitation efforts on patient outcomes, emphasizing the need for more research, especially in settings with limited resources.

The impact of the SARS-CoV-2 pandemic on in-hospital cardiac arrest: A systematic review and meta-analysis

Background

There is an emerging concern regarding the indirect effect the Covid-19 pandemic has had on the care provided to patients. New resuscitation guidance including the donning of Personal Protective Equipment before commencing resuscitation efforts, the avoidance of bag-mask ventilation, limiting the number of responders and stopping resuscitation efforts earlier could have led to worse outcomes following in-hospital cardiac arrest (IHCA) when compared to the non-pandemic period. The primary objective was to understand the impact of the pandemic on patient outcomes following IHCA by comparing the pandemic and non-pandemic periods.

Methods

Our systematic search was conducted on the 13th of September 2022 in three databases: Medline, Embase and Central. Randomised or non-randomised clinical trials and observational studies were included. The search was repeated on 31st December 2023 and there were no new studies appropriate for inclusion which had been published in the interim. The patient population consisted of adult patients who suffered IHCA due to any cause. The primary outcome was survival to hospital discharge (SHD). The secondary outcomes were return of spontaneous circulation (ROSC) and length of resuscitation.

Results

We identified 1873 studies, 9 were included in our qualitative analysis. SHD was reported in 8 studies with no difference between the two periods (OR 0.69; 95% CI 0.47-1.03) along with resuscitation (MD: 0.74; 95% CI: -0.67 to 2.14; p = 0.153. ROSC was included in all studies and showed significant difference between the two periods (OR 0.75; 95% 0.60-0.95).

Conclusion

Although SHD was similar between the two periods, ROSC was significantly lower during the pandemic with longer resuscitation times highlighting a substantial impact of the pandemic on patient outcomes.

Early mNGS testing for diagnose and prognostic prediction of early onset pneumonia among in-hospital cardiac arrest patients undergoing extracorporeal cardiopulmonary resuscitation

Objectives

Metagenomic next-generation sequencing (mNGS) is emerging as a novel diagnostic technology for various infectious diseases; however, limited studies have investigated its application in etiological diagnosis of early onset pneumonia (EOP) among patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR) following in-hospital cardiac arrest (IHCA), The clinical significance of early mNGS in predicting short-term prognosis of IHCA patients after ECPR remains unclear.

Methods

This retrospective study included 76 patients with IHCA who underwent ECPR at the First Affiliated Hospital of Zhengzhou University from January 2018 to December 2022. Baseline characteristics and etiological data of all patients during their hospitalization were collected and statistically analyzed. The primary outcome of this study was the diagnosis of EOP, while the secondary outcomes included successful extracorporeal membrane oxygenation (ECMO) weaning and survival at discharge. Additionally, the characteristics of bronchoalveolar lavage fluid (BALF) flora in these patients were compared by analyzing both mNGS results and culture results.

Results

Multivariate logistic regression were employed to analyze the predictors of ECMO weaning failure, mortality at discharge, and the incidence of EOP. Ultimately, patients with lower SOFA scores on admission [OR (95%CI): 1.447 (1.107-1.890), p=0.007] and those who underwent early mNGS testing within 48 hours after ECPR [OR (95%CI): 0.273 (0.086-0.865), p=0.027] demonstrated a higher probability of successful weaning from ECMO. Patients with higher SOFA scores on admission [OR (95%CI): 2.404 (1.422-4.064), p=0.001], and elevated lactate levels [OR (95%CI): 1.176 (1.017-1.361), p=0.029] exhibited an increased likelihood of mortality at discharge. Furthermore, early mNGS detection [OR (95%CI): 0.186 (0.035-0.979), p=0.047], and lower CRP levels (48h-7d after ECMO) [OR (95%CI):1.011 (1.003-1.019), p=0.006] were associated with a reduced incidence of EOP. In addition, the pathogens detected by mNGS within 48 hours after ECPR were mainly oral colonizing bacteria and viruses, and viruses were in the majority, while all BALF cultures were negative. In contrast, between 48 hours and 7 days after ECPR, BALF cultures were positive in all EOP patients.

Conclusions

Early mNGS testing to identify microbial flora facilitates timely adjustment of antibiotic regimens, thereby reducing the incidence of EOP and improving short-term prognosis in patients undergoing ECPR following IHCA.

Prediction model of in-hospital cardiac arrest using machine learning in the early phase of hospitalization

In hospitals, the deterioration of a patient's condition leading to death is often preceded by physiological abnormalities in the hours to days beforehand. Several risk-scoring systems have been developed to identify patients at risk of major adverse events; however, such systems often exhibit low sensitivity and specificity. To identify the risk factors associated with in-hospital cardiac arrest (IHCA), we conducted a retrospective cohort study at a tertiary medical center in Taiwan. Four machine learning algorithms were employed to identify the factors most predictive of IHCA. The support vector machine model was discovered to be the most effective at predicting IHCA. The ten most critical physiological parameters at 8 h prior to the event were pulse rate, age, white blood cell count, lymphocyte count, body temperature, body mass index, systolic and diastolic blood pressure, platelet count, and use of central nervous system-active medication. Using these parameters, we can enhance early warning and rapid response systems in our hospital, potentially reducing the incidence of IHCA in clinical practice.

Quality of life and performance status after cardiopulmonary resuscitation: A study in Cova da Beira University Hospital Center's intensive care unit

INTRODUCTION AND OBJECTIVES

Cardiac arrest (CA) is associated with high morbidity and mortality. Many studies focus on survival, but few explore the outcomes. The aim of this study is to analyze the survival curve, independence, quality of life, and performance status after CA.

METHODS

This retrospective study included adults admitted to the intensive care unit of Cova da Beira University Hospital Center after CA between 2015 and 2019. We analyzed patient records and applied a questionnaire including EuroQoL's EQ-5D-3L and ECOG performance status.

RESULTS

Ninety-seven patients were included (mean age 75.74 years). Thirty-one patients (32.0%) survived to hospital discharge. There was a significant loss of independence for activities of daily living, with 50.0% of those previously independent becoming dependent and 47.5% of those previously at home being institutionalized. Diabetes, female gender, and length of hospital stay were especially impactful on these findings. One year after CA, only 20.6% were alive and only 13.4% (65% of the one-year survivors) were independent. Nine patients answered our questionnaire. Mean EQ-5D quality of life index (0.528±0.297) and the most affected domains ('Pain/discomfort' and 'Anxiety/depression') were similar to the Portuguese population aged >30 years. However, 66.6% reported a decline in their quality of life. Lastly, seven respondents had a good performance status (ECOG 0-1).

CONCLUSIONS

There was a significant loss of independence after CA. Moreover, despite the acceptable performance status and the quality of life results being similar to the general population, there was a perceived deterioration post-CA. Ultimately, we emphasize the need to improve care for these patients.

The impact of frailty on survival times up to one year among patients admitted to ICU with in-hospital cardiac arrest

BACKGROUND

In-hospital cardiac arrest (IHCA) is a serious medical emergency. When IHCA occurs in patients with frailty, short-term survival is poor. However, the impact of frailty on long-term survival is unknown.

METHODS

We performed a retrospective multicentre study of all critically ill adult (age ≥ 16 years) patients admitted to Australian intensive care units (ICU) between 1st January 2018 to 31st March 2022. We included all patients who had an IHCA within the 24 h before ICU admission with a documented Clinical Frail Scale (CFS). The primary outcome was median survival up to one year following ICU admission. The effect of frailty on one-year survival was assessed using a Cox proportional hazards model, adjusting for age, sex, comorbidities, sequential organ failure assessment (SOFA) score, and hospital type.

RESULTS

We examined 3769 patients, of whom 30.8% (n = 1160) were frail (CFS ≥ 5). The median survival was significantly shorter for patients with frailty (median [IQR] days 19 [1-365] vs 302 [9-365]; p < 0.001). The overall one-year mortality was worse for the patients with frailty when compared to the non-frail group (64.8% [95%CI 61.9-67.5] vs 36.4% [95%CI 34.5-38.3], p < 0.001). Each unit increment in the CFS was associated with 22% worse survival outcome (adjusted Hazard ratio = 1.22, 95%-CI 1.19-1.26), after adjustment for confounders. The survival trend was similar among patients who survived the hospitalization.

CONCLUSION

In this retrospective multicentre study, frailty was associated with poorer one-year survival in patients admitted to Australian ICUs following an IHCA.

Long-term survival comparison of patients admitted to the intensive care unit following in-hospital cardiac arrest in perioperative and ward settings. A multicentre retrospective cohort study

PURPOSE

Perioperative in-hospital cardiac arrests (Perioperative IHCAs) may have better outcomes than IHCAs in the ward (Ward IHCAs), due to enhanced monitoring and faster response. However, quantitative comparisons of their long-term outcomes are lacking, posing challenges for prognostication.

METHODS

This retrospective multicentre study included adult intensive care unit (ICU) admissions from theatre/recovery or wards with a diagnosis of cardiac arrest between January 2018 and March 2022. We used data from 175 ICUs in the ANZICS adult patient database. The primary outcome was a survival time of up to 4 years. We used the Cox proportional hazards model adjusted for Sequential Organ Failure Assessment (SOFA) score, age, sex, comorbidities, hospital type, treatment limitation on admission to the ICU, and ICU treatments. Subgroup analyses examined age (≥ 65 years), intubation within the first 24 h, elective vs. emergency admission, and survival on discharge.

RESULTS

Of 702,675 ICU admissions, 5,659 IHCAs were included (Perioperative IHCA 38%; Ward IHCA 62%). Perioperative IHCA group were younger, less frail, and less comorbid. Perioperative IHCA were most frequent in patients admitted to ICU after cardiovascular, gastrointestinal, or trauma surgeries. Perioperative IHCA group had longer 4-year survival (59.9% vs. 33.0%, p < 0.001) than the Ward IHCA group, even after adjustments (adjusted hazard ratio [HR]: 0.63, 95% confidence interval [CI] 0.57-0.69). This was concordant across all subgroups. Of note, older patients with Perioperative IHCA survived longer than both younger and older patients with Ward IHCA.

CONCLUSION

Patients admitted to the ICU following Perioperative IHCA had longer survival than Ward IHCA. Future studies on IHCA should distinguish these patients.

In-hospital cardiac arrest after STEMI: prevention strategies and post-arrest care

INTRODUCTION

In-Hospital Cardiac Arrest (IHCA) after ST-segment Elevation Myocardial Infarction (STEMI) is a subset of IHCA with high morbidity. While information on this selected group of patients is limited, closer inspection reveals that this is a challenging patient population with certain risk factors for IHCA following treatment of STEMI.

AREAS COVERED

In this review article, strategies for prevention of IHCA post STEMI are reviewed, as well as best-practices for the care of STEMI patients post-IHCA.

EXPERT OPINION

Early and successful reperfusion is key for the prevention of IHCA and has a significant impact on in-hospital mortality. A number of pharmacological treatments have also been studied that can impact the progression to IHCA. Development of cardiogenic shock post-STEMI increases mortality and raises the risk of cardiac arrest. The treatment of IHCA follows the ACLS algorithm with some notable exceptions.

Does a Transition to Single-Occupancy Patient Rooms Affect the Incidence and Outcome of In-Hospital Cardiac Arrests?

BACKGROUND

It is proposed that patients in single-occupancy patient rooms (SPRs) carry a risk of less surveillance by nursing and medical staff and that resuscitation teams need longer to arrive in case of in-hospital cardiac arrest (IHCA). Higher incidences of IHCA and worse outcomes after cardiopulmonary resuscitation (CPR) may be the result.

OBJECTIVES

Our study examines whether there is a difference in incidence and outcomes of IHCA before and after the transition from a hospital with multibedded rooms to solely SPRs.

METHODS

In this prospective observational study in a Dutch university hospital, as a part of the Resuscitation Outcomes in the Netherlands study, we reviewed all cases of IHCA on general adult wards in a period of 16.5 months before to 16.5 months after the transition to SPRs.

RESULTS

During the study period, 102 CPR attempts were performed: 51 in the former hospital and 51 in the new hospital. Median time between last-seen-well and start basic life support did not differ significantly, nor did median time to arrival of the CPR team. Survival rates to hospital discharge were 30.0% versus 29.4% of resuscitated patients (p = 1.00), with comparable neurological outcomes: 86.7% of discharged patients in the new hospital had Cerebral Performance Category 1 (good cerebral performance) versus 46.7% in the former hospital (p = .067). When corrected for telemetry monitoring, these differences were still nonsignificant.

CONCLUSIONS

The transition to a 100% SPR hospital had no negative impact on incidence, survival rates, and neurological outcomes of IHCAs on general adult wards.

[Quality of life after in-hospital cardiac arrest : An 11-year experience from an university center]

BACKGROUND

Cardiac arrest is a life-threatening condition requiring urgent medical care and is one of the leading causes of death worldwide. Given that in-hospital cardiac arrest (IHCA) is still poorly investigated, data on health-associated quality of life thereafter remains scarce. The available evidence is mostly transferred from out-of-hospital cardiac arrest studies, but the epidemiology and determinants of success might be different. The aim of the study was to investigate the change in the quality of life after in-hospital cardiac arrest and to identify potential risk factors for a poor outcome.

MATERIAL AND METHODS

This retrospective analysis of data and prospective evaluation of quality of life included all patients surviving an IHCA and being treated by the emergency medical team between 2010 and 2020. The primary endpoint of the study was the quality of life after IHCA at the reference date. Secondary endpoints covered determination of risk factors and predictors of poor outcome after in-hospital cardiopulmonary resuscitation.

RESULTS

In total 604 patients were resuscitated within the period of 11 years and 61 (10%) patients survived until the interview took place. Finally, 48 (79%) patients fulfilled the inclusion criteria and 31 (65%) were included in the study. There was no significant difference in the quality of life before and after cardiac arrest (EQ-5D-5L utility 0.79 vs. 0.78, p = 0.567) and in the EQ-5D-5L visual analogue scale (VAS) score.

CONCLUSION

The quality of life before and after IHCA in survivors was good and comparable. The quality of life was mostly affected by reduced mobility and anxiety/depression. Future studies with larger patient samples should focus on potentially modifiable factors that could prevent, warn, and limit the consequences of in-hospital cardiac arrest. Moreover, research on outcomes of IHCA should include available tools for the quality of life assessment.

Wolf Creek XVII Part 6: Physiology-Guided CPR

Introduction

Physiology-guided cardiopulmonary resuscitation (CPR) offers the potential to optimize resuscitation and enable early prognosis.

Methods

Physiology-Guided CPR was one of six focus topic for the Wolf Creek XVII Conference held on June 14-17, 2023 in Ann Arbor, Michigan, USA. International thought leaders and scientists in the field of cardiac arrest resuscitation from academia and industry were invited. Participants submitted via online survey knowledge gaps, barriers to translation and research priorities for each focus topic. Expert panels used the survey results and their own perspectives and insights to create and present a preliminary unranked list for each category, which was then debated, revised and ranked by all attendees to identify the top 5 for each category.

Results

Top knowledge gaps include identifying optimal strategies for the evaluation of physiology-guided CPR and the optimal values for existing patients using patient outcomes. The main barriers to translation are the limited usability outside of critical care environments and the training and equipment required for monitoring. The top research priorities are the development of clinically feasible and reliable methods to continuously and non-invasively monitor physiology during CPR and prospective human studies proving targeting parameters during CPR improves outcomes.

Conclusion

Physiology-guided CPR has the potential to provide individualized resuscitation and move away from a one-size-fits-all approach. Current understanding is limited, and clinical trials are lacking. Future developments need to consider the clinical application and applicability of measurement to all healthcare settings. Therefore, clinical trials using physiology-guided CPR for individualisation of resuscitation efforts are needed.

The Effect of Cytokine Adsorption on Leukocyte and Platelet Activation after Extracorporeal Cardiopulmonary Resuscitation

BACKGROUND

 Post-cardiac arrest syndrome (PCAS) is a frequent complication following successful cardiopulmonary resuscitation and correlates with poor outcome. PCAS is characterized by an excessive inflammatory response to whole-body ischemia and reperfusion. Cytokine adsorption was suggested as an adjunctive treatment option for the removal of cytokines from the patients' blood to restore the physiological equilibrium of pro- and anti-inflammatory activity and thus mitigate hemodynamic instability and end-organ complications.

MATERIAL AND METHODS

 To better understand the cellular effects of cytokine adsorption in patients receiving extracorporeal cardiopulmonary resuscitation (ECPR) after in- and out-of-hospital cardiac arrest, we compared the activation status of neutrophils, monocytes, and platelets as well as the formation of platelet-leukocyte complexes in intravenous whole blood samples from an exploratory subgroup (n = 24) from the randomized CYTER study.

RESULT

 At 48 hours after initiation of ECPR, flow cytometry analyses did neither reveal significant differences in neutrophil (CD11b, CD66b, L-selectin, and PSGL-1) and monocyte (CD11b, L-selectin, and PSGL-1) surface molecule expression nor in circulating platelet-monocyte complexes between patients receiving cytokine adsorption and those without.

CONCLUSION

 Data did not show a relevant effect of cytokine adsorption on neutrophil and monocyte activation during the first 48 hours after initiation of ECPR.

Extracorporeal Versus Conventional Cardiopulmonary Resuscitation for In-Hospital Cardiac Arrest: A Propensity Score Matching Cohort Study

OBJECTIVE

Comparing the effects of extracorporeal cardiopulmonary resuscitation (ECPR) and conventional cardiopulmonary resuscitation (CCPR) on outcomes in patients with in-hospital cardiac arrest (IHCA) in China. The benefits of ECPR over CCPR in patients with IHCA remain controversial.

DESIGN

This article analyzed data from the BASeline Investigation of In-hospital Cardiac Arrest (BASIC-IHCA) study, which consecutively enrolled patients with IHCA from July 1, 2019, to December 31, 2020. Patients who received ECPR were selected as the case group and matched with patients who received CCPR as the control group by propensity score at a ratio of 1:4. A parallel questionnaire survey of participating hospitals was conducted, to collect data on ECPR cases from January 1, 2021 to November 30, 2021. The primary outcome was survival to discharge or 30-day survival.

SETTING

We included 39 hospitals across 31 provinces in China.

PATIENTS

Patients receiving cardiopulmonary resuscitation and without contraindications to ECPR were selected from the BASIC-IHCA database. Patients older than 75 years, not witnessed, or with cardiopulmonary resuscitation duration less than 10 min were excluded.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 4853 patients met the inclusion criteria before matching, with 34 undergoing ECPR (median age, 56.5 yr; 67.65% male) and 4819 underwent CCPR (median age, 59 yr; 64.52% male). There were 132 patients receiving CCPR and 33 patients receiving ECPR who were eventually matched. The ECPR group had significantly higher survival rates at discharge or 30-day survival (21.21% vs. 7.58%, p = 0.048). The ECPR group had significantly lower mortality rates (hazard ratio 0.57; 95% CI, 0.38-0.91) than the CCPR group at discharge or 30 days. Besides the BASIC-IHCA study, the volume of ECPR implementations and the survival rate of patients with ECPR (29.4% vs. 10.4%. p = 0.004) in participating hospitals significantly improved.

CONCLUSIONS

ECPR may be beneficial compared with CCPR for patient survival after IHCA and should be considered for eligible patients with IHCA.

Survival of In-Hospital Cardiopulmonary Arrest in Trauma Patients

INTRODUCTION

Relative to other hospitalized patients, trauma patients are younger with fewer comorbidities, but the incidence and outcomes of in-hospital cardiopulmonary arrest (IHCA) with cardiopulmonary resuscitation (CPR) in this population is unknown. Therefore, we aimed to investigate factors associated with survival in trauma patients after IHCA to test the hypothesis that compared to other hospitalized patients, trauma patients with IHCA have improved survival.

METHODS

Retrospective review of the Trauma Quality Improvement Program database 2017 to 2019 for patients who had IHCA with CPR. Primary outcome was survival to hospital discharge. Secondary outcomes were in-hospital complications, hospital length of stay, intensive care unit length of stay, and ventilator days. Data were compared with univariate and multivariate analyses at P < 0.05.

RESULTS

In 22,346,677 admitted trauma patients, 14,056 (0.6%) received CPR. Four thousand three hundred seventy-seven (31.1%) survived to discharge versus 26.4% in a national sample of all hospitalized patients (P < 0.001). In trauma patients, median age was 55 y, the majority were male (72.2%). Mortality was higher for females versus males (70.3% versus 68.3%, P = 0.026). Multivariate regression showed that older age 1.01 (95% confidence interval (CI) 1.01-1.02), Hispanic ethnicity 1.21 (95% CI 1.04-1.40), and penetrating trauma 1.51 (95% CI 1.32-1.72) were risk factors for mortality, while White race was a protective factor 0.36 (95% CI 0.14-0.89).

CONCLUSIONS

This is the first study to show that the incidence of IHCA with CPR is approximately six in 1000 trauma admissions and 31% survive to hospital discharge, which is higher than other hospitalized patients. Age, gender, racial, and ethnic disparities also influence survival.

Association of triglyceride glucose index and triglyceride glucose-body mass index with sudden cardiac arrest in the general population

BACKGROUND

Insulin resistance (IR) significantly contributes to cardiovascular disease (CVD) development. Triglyceride glucose (TyG) index and triglyceride glucose-body mass index (TyG-BMI) are recognised as convenient proxies for IR. However, their relationship with sudden cardiac arrest (SCA) remains unclear.

METHODS

This prospective cohort analysis included 355,242 UK Biobank participants with available TyG index and TyG-BMI data and no history of CVD. Cox proportional risk models assessed the association between the TyG index, TyG-BMI and SCA risk. Additionally, Accelerated Failure Time (AFT) models were employed to investigate the timing of SCA onset. The impact of dynamic increases in TyG index and TyG-BMI levels on SCA risk was examined using restricted cubic spline.

RESULTS

Over a median follow-up period of 165.4 months (interquartile range 156.5-174 months), 1,622 cases of SCA were recorded. Multivariate Cox regression analysis revealed a 9% increase in SCA risk per standard deviation increase in TyG index (adjusted hazard ratio (aHR) = 1.09, 95% confidence interval (CI) 1.04-1.15) and an 14% increase per standard deviation increase in TyG-BMI (aHR 1.14, 95% CI 1.09-1.2). AFT models indicated earlier median times to SCA occurrence with increasing quintiles of TyG index and TyG-BMI compared to the lowest quintile (P for trend < 0.05). SCA risk was linearly (P = 0.54) and non-linearly (P = 0.007) correlated with gradual increases in TyG index and TyG-BMI levels, respectively. Sex-stratified analyses showed stronger associations in women.

CONCLUSIONS

Higher TyG index and TyG-BMI levels are associated with an increased SCA risk and earlier onset, particularly in women.

Eligibility of cardiac arrest patients for extracorporeal cardiopulmonary resuscitation and their clinical characteristics: a retrospective two-centre study

BACKGROUND AND IMPORTANCE

Sudden cardiac arrest has a high incidence and often leads to death. A treatment option that might improve the outcomes in refractory cardiac arrest is Extracorporeal Cardiopulmonary Resuscitation (ECPR).

OBJECTIVES

This study investigates the number of in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA) patients eligible to ECPR and identifies clinical characteristics that may help to identify which patients benefit the most from ECPR.

DESIGN, SETTINGS AND PARTICIPANTS

A retrospective two-centre study was conducted in Rotterdam, the Netherlands. All IHCA and OHCA patients between 1 January 2017 and 1 January 2020 were screened for eligibility to ECPR. The primary outcome was the percentage of patients eligible to ECPR and patients treated with ECPR. The secondary outcome was the comparison of the clinical characteristics and outcomes of patients eligible to ECPR treated with conventional Cardiopulmonary Resuscitation (CCPR) vs. those of patients treated with ECPR.

MAIN RESULTS

Out of 1246 included patients, 412 were IHCA patients and 834 were OHCA patients. Of the IHCA patients, 41 (10.0%) were eligible to ECPR, of whom 20 (48.8%) patients were actually treated with ECPR. Of the OHCA patients, 83 (9.6%) were eligible to ECPR, of whom 23 (27.7%) were actually treated with ECPR. In the group IHCA patients eligible to ECPR, no statistically significant difference in survival was found between patients treated with CCPR and patients treated with ECPR (hospital survival 19.0% vs. 15.0% respectively, 4.0% survival difference 95% confidence interval -21.3 to 28.7%). In the group OHCA patients eligible to ECPR, no statistically significant difference in-hospital survival was found between patients treated with CCPR and patients treated with ECPR (13.3% vs. 21.7% respectively, 8.4% survival difference 95% confidence interval -30.3 to 10.2%).

CONCLUSION

This retrospective study shows that around 10% of cardiac arrest patients are eligible to ECPR. Less than half of these patients eligible to ECPR were actually treated with ECPR in both IHCA and OHCA.

Extracorporeal cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest: Lessons learned from recent clinical trials

Cardiac arrest is a leading contributor to morbidity and mortality in the United States. Survival has been historically dependent on high-quality cardiopulmonary resuscitation (CPR) and rapid defibrillation. However, a large percentage of patients remain in refractory cardiac arrest despite adherence to structured advanced cardiac life support algorithms in which these factors are emphasized. Veno-arterial extracorporeal membrane oxygenation is becoming an increasingly used rescue therapy for patients in refractory cardiac arrest to restore oxygen delivery by extracorporeal CPR (ECPR). Recently published clinical trials have provided new insights into ECPR for patients who sustain an outside hospital cardiac arrest (OHCA). In this narrative review, we summarize the rationale for, results of, and remaining questions from these recently published clinical trials. The existing observational data combined with the latest clinical trials suggest ECPR improves mortality in patients in refractory arrest. However, a mixed methods trial is essential to understand the complexity, context, and effectiveness of implementing an ECPR program.

Nurses' motivation for performing cardiopulmonary resuscitation: a cross-sectional study

BACKGROUND

Nurse motivation can have a significant impact on the quality of cardiopulmonary resuscitation and the patients' survival. Therefore, the present study aimed to examine nurses' motivation for performing cardiopulmonary resuscitation.

METHODS

This cross-sectional study focused on 217 nurses in a teaching hospital in Iran, in 2023. A random sample of nurses was selected from four hospital departments (emergency, critical care, medical, and surgery). These nurses completed the demographic information and motivation for cardiopulmonary resuscitation questionnaires. The data were analyzed using Mann-Whitney, Spearman coefficients, and Kruskal-Wallis and multiple linear regression tests.

RESULTS

The mean score of the dimension of the feeling of achievement (4.10 ± 0.50) was high in the nurses' motivation for performing cardiopulmonary resuscitation. There were more motivational factors in the emergency department compared to the other departments in terms of the feeling of achievement, high chance of success, low chances of success, recognition and appreciation, perceived importance, and beliefs (p < 0.05). The nurses who had participated in cardiopulmonary resuscitation workshops and had a bachelor's degree had a higher mean score in the dimension of perceived importance (p < 0.05). The correlation coefficient showed that there was a significant negative correlation between the nurses' frequency of participation in cardiopulmonary resuscitation and their motivation scores in the dimensions of the feeling of achievement(r=-0.170), low chances of success(r=-0.183), perceived importance (r = -0.302), and beliefs (r = -0.250; p < 0.05). The department variable predicted the motivation score in the dimensions of feeling of achievement, high chance of success, low chance of success, perceived importance, and beliefs. The sex variable predicted the motivation score in the dimensions of facilitator of resuscitation and high chance of success. Besides, the variable of years of membership in the CPR team predicted the motivation score in the feeling of achievement and high chance of success (p < 0.05).

CONCLUSION

Nurses would be more motivated to perform a quality cardiopulmonary resuscitation if they had a feeling of success. The nurses' motivation was affected by certain factors such as their department, sex, education level, years of membership in CPR team, number of participation in CPR, and participation in educational workshops.

The initiative for medical equity and global health (IMEGH) resuscitation training program: A model for resuscitation training courses in Africa

In high-income countries, outcomes following in hospital cardiac arrest have improved over the last two decades due to the introduction of rapid response teams, cardiac arrest teams, and advanced resuscitation training. However, in low-income countries, such as Rwanda, outcomes are still poor. This is due to multiple factors including lack of adequate resuscitation training, few trainers, and lack of equipment. To address this issue, the Initiative for Medical Equity and Global Health Equity (IMEGH), a training organization founded in 2018 by 5 local anesthesiologists has regularly taught resuscitation courses such as Basic Life Support, Advanced Cardiac Life Support, and Pediatric Advanced Life Support in hospitals throughout Rwanda. The aims of the organization include developing a sustainable model to offer context relevant resuscitation training courses, building a cadre of local instructors to teach on the courses, as well as engaging funding partners to help support the effort. From October 2018 until September 2022, 31 courses were run in 11 hospitals across Rwanda training 1,060 healthcare providers (mainly of non-physician anesthetists, nurses, midwives, and general practitioners). Ongoing challenges include lack of local protocols, inability to tracking resuscitation outcomes, and continued inaccessibility by many healthcare providers. Despite these challenges, the IMEGH program is an example of a successful context-relevant model and has potential to inform the design of resuscitation programs in other similar settings. This article describes the development of the IMEGH program, accomplishments as well as lessons learned, challenges, and next steps for expansion.

Mortality risk factors in patients receiving ECPR after cardiac arrest: Development and validation of a clinical prognostic prediction model

BACKGROUND

Previous studies have shown an increasing trend of extracorporeal cardiopulmonary resuscitation (ECPR) use in patients with cardiac arrest (CA). Although ECPR have been found to reduce mortality in patients with CA compared with conventional cardiopulmonary resuscitation (CCPR), the mortality remains high. This study was designed to identify the potential mortality risk factors for ECPR patients for further optimization of patient management and treatment selection.

METHODS

We conducted a prospective, multicentre study collecting 990 CA patients undergoing ECPR in 61 hospitals in China from January 2017 to May 2022 in CSECLS registry database. A clinical prediction model was developed using cox regression and validated with external data.

RESULTS

The data of 351 patients meeting the inclusion criteria before October 2021 was used to develop a prediction model and that of 68 patients after October 2021 for validation. Of the 351 patients with CA treated with ECPR, 227 (64.8%) patients died before hospital discharge. Multivariate analysis suggested that a medical history of cerebrovascular diseases, pulseless electrical activity (PEA)/asystole and higher Lactate (Lac) were risk factors for mortality while aged 45-60, higher pH and intra-aortic balloon pump (IABP) during ECPR have protective effects. Internal validation by bootstrap resampling was subsequently used to evaluate the stability of the model, showing moderate discrimination, especially in the early stage following ECPR, with a C statistic of 0.70 and adequate calibration with GOF chi-square = 10.4 (p = 0.50) for the entire cohort. Fair discrimination with c statistic of 0.65 and good calibration (GOF chi-square = 6.1, p = 0.809) in the external validation cohort demonstrating the model's ability to predict in-hospital death across a wide range of probabilities.

CONCLUSION

Risk factors have been identified among ECPR patients including a history of cerebrovascular diseases, higher Lac and presence of PEA or asystole. While factor such as age 45-60, higher pH and use of IABP have been found protective against in-hospital mortality. These factors can be used for risk prediction, thereby improving the management and treatment selection of patients for this resource-intensive therapy.

Treatment of Refractory Cardiac Arrest by Controlled Reperfusion of the Whole Body: A Multicenter, Prospective Observational Study

Background: Survival following cardiac arrest (CA) remains poor after conventional cardiopulmonary resuscitation (CCPR) (6-26%), and the outcomes after extracorporeal cardiopulmonary resuscitation (ECPR) are often inconsistent. Poor survival is a consequence of CA, low-flow states during CCPR, multi-organ injury, insufficient monitoring, and delayed treatment of the causative condition. We developed a new strategy to address these issues. Methods: This all-comers, multicenter, prospective observational study (69 patients with in- and out-of-hospital CA (IHCA and OHCA) after prolonged refractory CCPR) focused on extracorporeal cardiopulmonary support, comprehensive monitoring, multi-organ repair, and the potential for out-of-hospital cannulation and treatment. Result: The overall survival rate at hospital discharge was 42.0%, and a favorable neurological outcome (CPC 1+2) at 90 days was achieved for 79.3% of survivors (CPC 1+2 survival 33%). IHCA survival was very favorable (51.7%), as was CPC 1+2 survival at 90 days (41%). Survival of OHCA patients was 35% and CPC 1+2 survival at 90 days was 28%. The subgroup of OHCA patients with pre-hospital cannulation showed a superior survival rate of 57.1%. Conclusions: This new strategy focusing on repairing damage to multiple organs appears to improve outcomes after CA, and these findings should provide a sound basis for further research in this area.

Outcomes in non-ST-segment elevation myocardial infarction complicated by in-hospital cardiac arrest based on management strategy

BACKGROUND

There are limited data on in-hospital cardiac arrest (IHCA) complicating non-ST-segment-elevation myocardial infarction (NSTEMI) based on management strategy.

METHODS

We used National Inpatient Sample (2000-2017) to identify adults with NSTEMI (not undergoing coronary artery bypass grafting) and concomitant IHCA. The cohort was stratified based on use of early (hospital day 0) or delayed (≥hospital day 1) coronary angiography (CAG), percutaneous coronary intervention (PCI), and medical management. Outcomes included incidence of IHCA, in-hospital mortality, adverse events, length of stay, and hospitalization costs.

RESULTS

Of 6,583,662 NSTEMI admissions, 375,873 (5.7 %) underwent early CAG, 1,133,143 (17.2 %) received delayed CAG, 2,326,391 (35.3 %) underwent PCI, and 2,748,255 (41.7 %) admissions were managed medically. The medical management cohort was older, predominantly female, and with higher comorbidities. Overall, 63,085 (1.0 %) admissions had IHCA, and incidence of IHCA was highest in the medical management group (1.4 % vs 1.1 % vs 0.7 % vs 0.6 %, p < 0.001) compared to early CAG, delayed CAG and PCI groups, respectively. In adjusted analysis, early CAG (adjusted OR [aOR] 0.67 [95 % confidence interval {CI} 0.65-0.69]; p < 0.001), delayed CAG (aOR 0.49 [95 % CI 0.48-0.50]; p < 0.001), and PCI (aOR 0.42 [95 % CI 0.41-0.43]; p < 0.001) were associated with lower incidence of IHCA compared to medical management. Compared to medical management, early CAG (adjusted OR 0.53, CI: 0.49-0.58), delayed CAG (adjusted OR 0.34, CI: 0.32-0.36) and PCI (adjusted OR 0.19, CI: 0.18-0.20) were associated with lower in-hospital mortality (all p < 0.001).

CONCLUSION

Early CAG and PCI in NSTEMI was associated with lower incidence of IHCA and lower mortality among NSTEMI-IHCA admissions.

Reduced mobility is associated with adverse outcomes after in-hospital cardiac arrest

OBJECTIVE

In-hospital cardiac arrest is a critical medical emergency. Knowledge of prognostic factors could assist in cardiopulmonary resuscitation decision-making. Frailty and functional status are emerging risk factors and may play a role in prognostication. The objective was to evaluate the association between reduced mobility and in-hospital cardiac arrest outcomes.

METHODS

This retrospective cohort study included patients over 18 years of age with in-hospital cardiac arrest in Botucatu, Brazil, from April 2018 to December 2021. Exclusion criteria were patients with a do-not-resuscitate order or patients with recurrent in-hospital cardiac arrest. Reduced mobility was defined as the need for a bed bath 48 h before in-hospital cardiac arrest. The outcomes of no return of spontaneous circulation and in-hospital mortality were evaluated.

RESULTS

A total of 387 patients were included in the analysis. The mean age was 65.4±14.8 years; 53.7% were males and 75.4% had reduced mobility. Among the evaluated outcomes, the no return of spontaneous circulation rate was 57.1%, and in-hospital mortality was 94.3%. In multivariate analysis, reduced mobility was associated with no return of spontaneous circulation when adjusted by age, gender, initial shockable rhythm, duration of cardiopulmonary resuscitation, and epinephrine administration. However, in multiple logistic regression, there was no association between reduced mobility and in-hospital mortality.

CONCLUSION

In patients with in-hospital cardiac arrest, reduced mobility is associated with no return of spontaneous circulation. However, there is no relation to in-hospital mortality.

Extracorporeal Cardiopulmonary Resuscitation

BACKGROUND

Around the world, survival rates after cardiac arrest range between <14% for in-hospital (IHCA) and <10% for outof- hospital cardiac arrest (OHCA). This situation could potentially be improved by using extracorporeal membrane oxygenation (ECMO) during cardiopulmonary resuscitation (CPR), i.e. by extracorporeal cardiopulmonary resuscitation (ECPR).

METHODS

A selective literature search of Pubmed and Embase using the searching string ((ECMO) OR (ECLS)) AND (ECPR)) was carried out in February 2023 to prepare an up-to-date review of published trials comparing the outcomes of ECPR with those of conventional CPR.

RESULTS

Out of 573 initial results, 12 studies were included in this review, among them three randomized controlled trials comparing ECPR with CPR, involving a total of 420 patients. The survival rates for ECPR ranged from 20% to 43% for OHCA and 20% to 30.4% for IHCA. Most of the publications were associated with a high degree of bias and a low level of evidence.

CONCLUSION

ECPR can potentially improve survival rates after cardiac arrest compared to conventional CPR when used in experienced, high-volume centers in highly selected patients (young age, initial shockable rhythm, witnessed cardiac arrest, therapy-refractory high-quality CPR). No general recommendation for the use of ECPR can be issued at present.

Attitudes toward End-of-Life Resuscitation: A Psychometric Evaluation of a Novel Attitude Scale

AIM

With the advent of an aging society and the development of end-of-life care, there is an increasing need to understand the older generation's attitude toward end-of-life resuscitation. The study aimed to develop and validate a novel attitude scale toward end-of-life resuscitation in older inpatients.

METHOD

Instrumental development and a psychometric evaluation were used. First, a new attitude scale toward end-of-life resuscitation was formulated from literature views, expert content validity, and face validity. Next, the new scale was evaluated using a principal component analysis and internal consistency reliability in a sample from 106 medical-surgical inpatients in a southern Taiwan hospital 1 enrolled through convenience sampling. Serving as an indicator of concurrent validity, a logistic regression analysis was performed to analyze the association between scores on the scale and intention to discuss end-of-life CPR issues.

RESULTS

After being validated by the expert content validity and face validity, a draft of a 20-item scale was created. Throughout the exploratory factor analysis, two items with low factor loadings were removed from the draft scale and an 18-item scale of attitude was generated. This 18-item scale had a three-factor structure that accounted for 64.1% of the total variance; the three components were named 'stress, avoidance, and ignorance', 'a peaceful death', and 'self-determination and ambivalence'. The Cronbach's alpha of the total scale and three components were 0.845, 0.885, 0.879, and 0.857, respectively, which indicated a favorable reliability. Scores on the scale were significantly associated with the intention to discuss end-of-life CPR issues, which also indicated a favorable concurrent validity.

CONCLUSIONS

A 18-item attitude scale with three factors is a valid scale to measure the attitude toward end-of-life resuscitation. The result provides preliminary evidence of the psychometric properties of the scale. Further research with larger samples or other populations is required.

Effects of Prolonged Serum Calcium Suppression during Extracorporeal Cardiopulmonary Resuscitation in Pigs

Controlled reperfusion by monitoring the blood pressure, blood flow, and specific blood parameters during extracorporeal reperfusion after cardiac arrest has the potential to limit ischemia-reperfusion injury. The intracellular calcium overload as part of the ischemia-reperfusion injury provides the possibility for the injury to be counteracted by the early suppression of serum calcium with the aim of improving survival and the neurological outcome. We investigated the effects of prolonged serum calcium suppression via sodium citrate during extracorporeal resuscitation using the CARL protocol (CARL-controlled automated reperfusion of the whole body) compared to a single-dose approach in a porcine model after prolonged cardiac arrest. A control group (N = 10) was resuscitated after a 20 min cardiac arrest, initially lowering the intravascular calcium with the help of a single dose of sodium citrate as part of the priming solution. Animals in the intervention group (N = 13) received additional sodium citrate for the first 15 min of reperfusion. In the control group, 9/10 (90.0%) animals survived until day 7 and 7/13 (53.8%) survived in the intervention group (p = 0.09). A favorable neurological outcome on day 7 after the cardiac arrest was observed in all the surviving animals using a species-specific neurological deficit score. The coronary perfusion pressure was significantly lower with a tendency towards more cardiac arrhythmias in the intervention group. In conclusion, a prolonged reduction in serum calcium levels over the first 15 min of reperfusion after prolonged cardiac arrest tended to be unfavorable regarding survival and hemodynamic variables compared to a single-dose approach in this animal model.

Residual Psychomotor Skills of Orderlies After a Novel Chest Compression Training Intervention

BACKGROUND

High-quality chest compressions are essential to favorable patient outcomes after in-hospital cardiac arrest. Without frequent training, however, skill in performing compressions declines considerably. The Timely Chest Compression Training (T-CCT) intervention was introduced in 2019 as a quality improvement initiative to address this problem. The long-term impact of the T-CCT is unknown.

METHODS

A cohort study was conducted at a university-affiliated hospital in Quebec, Canada. Chest compression performance among orderlies was measured by using a subtractive scoring model and mannequins. The association of exposure to the T-CCT 10 months earlier with having an excellent chest compression performance (score ≥90 out of 100), after adjusting for potential confounders, was examined.

RESULTS

A total of 412 orderlies participated in the study. More than half (n = 232, 56%) had been exposed to the T-CCT, and the rest (n = 180, 44%) had not. Nearly half (n = 106, 46%) of orderlies exposed to the T-CCT had an excellent performance, compared with less than one-third (n = 53, 30%) of nonexposed orderlies. In univariable analysis, previous exposure to the T-CCT was associated with 1.53 times greater risk of having an excellent performance (risk ratio, 1.53; 95% CI, 1.17-1.99). This effect remained after adjustment for potential confounders (risk ratio, 1.57; 95% CI, 1.19-2.07).

CONCLUSION

The results of this study suggest that the T-CCT has a lasting effect on the psychomotor skills of orderlies 10 months after initial exposure. Further research should investigate the impact of the intervention on patient outcomes after in-hospital cardiac arrest.

Predicting the probability of good neurological outcome after in-hospital cardiac arrest based on prearrest factors: validation of the good outcome following attempted resuscitation 2 (GO-FAR 2) score

The Good Outcome Following Attempted Resuscitation (GO-FAR) 2 score is a prognostic tool developed to support decision-making for do-not-attempt-resuscitation (DNAR) orders by predicting neurological outcomes after in-hospital cardiac arrest (IHCA) based on prearrest variables. However, this scoring system requires further validation. We aimed to validate the GO-FAR 2 score for predicting good neurological outcome in Korean patients with IHCA. A single-centre registry of adult patients with IHCA from 2013 to 2017 was analysed. The primary outcome was discharge with good neurological outcome (Cerebral Performance Category score of 1 or 2). The patients were divided into four categories according to the GO-FAR 2 score: very poor (≥ 5), poor (2-4), average (- 3 to 1), and above-average (< - 3) likelihood of good neurological outcome. Of 1,011 patients (median age, 65 years), 63.1% were men. The rate of good neurological outcome was 16.0%. The proportions of patients categorised as having very poor, poor, average, and above-average probability of good neurological outcome were 3.9%, 18.3%, 70.2%, and 7.6%, respectively. In each category, good neurological outcome was observed in 0%, 1.1%, 16.8%, and 53.2%, respectively. Among patients in below-average categories (very poor + poor, GO-FAR 2 score ≥ 2), only 0.9% had good outcome. GO-FAR 2 score ≥ 2 showed a sensitivity of 98.8% and a negative predictive value of 99.1% in predicting good neurological outcome. The GO-FAR 2 score can predict neurological outcome after IHCA. In particular, GO-FAR 2 score ≥ 2 may support decision-making for DNAR orders.

Lactate to Albumin Ratio for Predicting Clinical Outcomes after In-Hospital Cardiac Arrest

In-hospital cardiac arrest (IHCA) is associated with high mortality and poor neurological outcomes. Our objective was to assess whether the lactate-to-albumin ratio (LAR) can predict the outcomes in patients after IHCA. We retrospectively screened 75,987 hospitalised patients at a university hospital between 2015 and 2019. The primary endpoint was survival at 30-days. Neurological outcomes were assessed at 30 days using the cerebral performance category scale. 244 patients with IHCA and return of spontaneous circulation (ROSC) were included in this study and divided into quartiles of LAR. Overall, there were no differences in key baseline characteristics or rates of pre-existing comorbidities among the LAR quartiles. Patients with higher LAR had poorer survival after IHCA compared to patients with lower LAR: Q1, 70.4% of the patients; Q2, 50.8% of the patients; Q3, 26.2% of the patients; Q4, 6.6% of the patients (p = 0.001). Across increasing quartiles, the probability of a favourable neurological outcome in patients with ROSC after IHCA decreased: Q1: 49.2% of the patients; Q2: 32.8% of the patients; Q3: 14.7% of the patients; Q4: 3.2% of the patients (p = 0.001). The AUCs for predicting 30-days survival using the LAR were higher as compared to using a single measurement of lactate or albumin. The prognostic performance of LAR was superior to that of a single measurement of lactate or albumin for predicting survival after IHCA.

Artificial Intelligence in Resuscitation: A Scoping Review

INTRODUCTION

Cardiac arrest is a significant cause of premature mortality and severe disability. Despite the death rate steadily decreasing over the previous decade, only 22% of survivors achieve good clinical status and only 25% of patients survive until their discharge from the hospital. The objective of this scoping review was to review relevant AI modalities and the main potential applications of AI in resuscitation.

METHODS

We conducted the literature search for related studies in PubMed, EMBASE, and Google Scholar. We included peer-reviewed publications and articles in the press, pooling and characterizing the data by their model types, goals, and benefits.

RESULTS

After identifying 268 original studies, we chose 59 original studies (reporting 1,817,419 patients) to include in the qualitative synthesis. AI-based methods appear to be superior to traditional methods in achieving high-level performance.

CONCLUSION

AI might be useful in predicting cardiac arrest, heart rhythm disorders, and post-cardiac arrest outcomes, as well as in the delivery of drone-delivered defibrillators and notification of dispatchers. AI-powered technologies could be valuable assistants to continuously track patient conditions. Healthcare professionals should assist in the research and development of AI-powered technologies as well as their implementation into clinical practice.

Survival after multiple episodes of cardiac arrest

BACKGROUND

Cardiopulmonary resuscitation (CPR) is widely used in response to cardiac arrest. However, little is known regarding outcomes for those who undergo multiple episodes of cardiac arrest while in the hospital.

OBJECTIVES

The purpose of this study was to evaluate the association of multiple cardiac events with in-hospital mortality for patients admitted to our tertiary care hospital who underwent multiple code events.

METHODS

We performed a retrospective cohort study on all patients who underwent cardiac arrest from 2012 to 2016. Primary outcome was survival to discharge. Secondary outcomes included post-cardiac-arrest neurologic events (PCANE), non-home discharge, and one-year mortality.

RESULTS

There were 622 patients with an overall mortality rate of 78.0%. Patients undergoing CPR for cardiac arrest once during their admission had lower in-hospital mortality rates compared to those that had multiple (68.9% versus 91.3%, p<.01). Subset analysis of those who had multiple episodes of CPR revealed that more than one event within a 24-hour period led to significantly higher in-hospital mortality rates (94.7% versus 74.4%, p<.01). Other variables associated with in-hospital mortality included body mass index, female sex, malignancy, and increased down time per code. Patients that had a non-home discharge were more likely to have sustained a PCANE than those that were discharged home (31.4% versus 3.9%, p<.01). A non-home discharge was associated with higher one-year mortality rates compared to a home discharge (78.4% versus 54.3%, p=.01).

CONCLUSION

Multiple codes within a 24-hour period and the average time per code were associated with in-hospital mortality in cardiac arrest patients.

Improving Time to Defibrillation Following Ventricular Tachycardia (VTach) and Ventricular Fibrillation (VFib) Cardiac Arrest: A Multicenter Retrospective and Prospective Quality Improvement Study

The goal of this study was to identify how often 2 independent centers defibrillated patients within the American Heart Association recommended 2-minute time interval following ventricular fibrillation/ventricular tachycardia arrest. A retrospective chart review revealed significant delays in defibrillation. Simulation sessions and modules were implemented to train nursing staff in a single nursing unit at a Philadelphia teaching hospital. Recruited nurses completed a code blue simulation session to establish a baseline time to defibrillation. They were then given 2 weeks to complete an online educational module. Upon completion, they participated in a second set of simulation sessions to assess improvement. First round simulations resulted in 33% with delayed defibrillation and 27% no defibrillation. Following the module, 77% of the second round of simulations ended in timely defibrillation, a statistically significant improvement ( P < 0.00001). Next steps involve prospective collection of the code blue data to analyze improvement in real code blue events.

Prognostic models for outcome prediction following in-hospital cardiac arrest using pre-arrest factors: a systematic review, meta-analysis and critical appraisal

BACKGROUND

Several prediction models of survival after in-hospital cardiac arrest (IHCA) have been published, but no overview of model performance and external validation exists. We performed a systematic review of the available prognostic models for outcome prediction of attempted resuscitation for IHCA using pre-arrest factors to enhance clinical decision-making through improved outcome prediction.

METHODS

This systematic review followed the CHARMS and PRISMA guidelines. Medline, Embase, Web of Science were searched up to October 2021. Studies developing, updating or validating a prediction model with pre-arrest factors for any potential clinical outcome of attempted resuscitation for IHCA were included. Studies were appraised critically according to the PROBAST checklist. A random-effects meta-analysis was performed to pool AUROC values of externally validated models.

RESULTS

Out of 2678 initial articles screened, 33 studies were included in this systematic review: 16 model development studies, 5 model updating studies and 12 model validation studies. The most frequently included pre-arrest factors included age, functional status, (metastatic) malignancy, heart disease, cerebrovascular events, respiratory, renal or hepatic insufficiency, hypotension and sepsis. Only six of the developed models have been independently validated in external populations. The GO-FAR score showed the best performance with a pooled AUROC of 0.78 (95% CI 0.69-0.85), versus 0.59 (95%CI 0.50-0.68) for the PAM and 0.62 (95% CI 0.49-0.74) for the PAR.

CONCLUSIONS

Several prognostic models for clinical outcome after attempted resuscitation for IHCA have been published. Most have a moderate risk of bias and have not been validated externally. The GO-FAR score showed the most acceptable performance. Future research should focus on updating existing models for use in clinical settings, specifically pre-arrest counselling. Systematic review registration PROSPERO CRD42021269235. Registered 21 July 2021.

Clinical outcome and risk factors for acute fulminant myocarditis supported by venoarterial extracorporeal membrane oxygenation: An analysis of nationwide CSECLS database in China

BACKGROUND

To assess the outcomes and risk factors for adult patients with acute fulminant myocarditis (AFM) supported with venoarterial extracorporeal membrane oxygenation (VA ECMO) in China mainland.

METHODS

Data were extracted from Chinese Society of ExtraCorporeal Life Support (CSECLS) Registry database. Data from adult patients who were diagnosed with AFM and needed VA ECMO in the database were retrospectively analyzed. The primary outcome was 90-day mortality after ECMO initiation in patients with AFM supported with VA ECMO. Cox proportional hazard regression model was used to examine the risk factors associated with 90-day mortality.

RESULTS

Among 221 patients enrolled and followed up to 90 days, 186 (84.2%) patients weaned from ECMO and 159 (71.9%) patients survived and discharged home. The median age was 38 years (IQR 29-49) and males (n = 115) represented 52.0% of the total accounted patients. The median ECMO duration was 134 h (IQR 96-177 h). The main adverse event during ECMO course was bleeding (16.3%), followed by infection (15.4%). In the multivariate Cox model analysis, cardiac arrest prior to ECMO initiation (adjusted HR 2.529; 95%CI: 1.341-4.767, p = 0.004), lower pH value (adjusted HR 0.016; 95%CI: 0.010-0.059, p < 0.001) and higher lactate concentration at 24 h after ECMO initiation (adjusted HR 1.146; 95%CI: 1.075-1.221, p < 0.001) were associated with 90-day mortality.

CONCLUSIONS

71.9% patients with AFM (clinical diagnosed) supported with VA ECMO survived. Cardiac arrest prior to ECMO, lower pH and higher lactate concentration at 24 h after ECMO initiation were correlated with 90-day mortality of AFM patients supported with VA ECMO.

In-hospital cardiac arrest rhythm analysis by anesthesiologists: a diagnostic performance study

PURPOSE

In-hospital cardiac arrest is associated with high morbidity and mortality, with an overall survival rate at one year of approximately 13%. The first cardiac rhythm is often analyzed by anesthesiologist-intensivists. We aimed to determine the diagnostic performance of anesthesiologist-intensivists when distinguishing between shockable and nonshockable rhythms.

METHODS

We conducted a simulation-based, multicentre, prospective, observational study between May 2019 and March 2020. The responses of the participants were used to calculate individual sensitivity (defined as the proportion of decisions to shock for shockable rhythms) and individual specificity (defined as the proportion of decisions not to shock for nonshockable rhythms). The main outcome measure was the overall diagnostic performance, defined as the overall sensitivity and specificity. Secondary outcome measures were the sensitivity and specificity of participants' decisions for each type of cardiac arrest rhythm and their decision-making times.

RESULTS

Among the 267 physicians contacted, 179 (67%) completed the test. The median [interquartile range (IQR)] overall sensitivity was 88 [79-95]% and the median overall specificity was 86 [77-92]%. Among shockable rhythms, the median [IQR] sensitivity was 100 [100-100]% for ventricular tachycardia (VT), 100 [100-100]% for coarse ventricular fibrillation (VF), and 60 [20-100]% for fine VF. The median [IQR] specificities for nonshockable rhythms were 93 [86-100]% for asystole and 83 [72-86]% for pulseless electrical activity. The median decision times ranged from 2.0 to 3.5 sec.

CONCLUSION

Anesthesiologist-intensivists were quickly and effectively able to analyze rhythms in this simulation-based study. Participants' sensitivity in deciding to deliver shocks for VT and coarse VF was excellent, while specificity of their decisions for pulseless electrical activity was insufficient.

Clinical characteristics, causes and predictors of outcomes in patients with in-hospital cardiac arrest: results from the SURVIVE-ARREST study

INTRODUCTION

In-hospital cardiac arrest (IHCA) is acutely life-threatening and remains associated with high mortality and morbidity. Identifying predictors of mortality after IHCA would help to guide acute therapy.

METHODS

We determined patient characteristics and independent predictors of 30-day in-hospital mortality, neurological outcome, and discharge/referral pathways in patients experiencing IHCA in a large tertiary care hospital between January 2014 and April 2017. Multivariable Cox regression model was fitted to assess predictors of outcomes.

RESULTS

A total of 368 patients with IHCA were analysed (median age 73 years (interquartile range 65-78), 123 (33.4%) women). Most patients (45.9%) had an initial non-shockable rhythm and shockable rhythms were found in 20.9%; 23.6% of patients suffered from a recurrent episode of cardiac arrest. 172/368 patients died within 30 days (46.7%). Of 196/368 patients discharged alive after IHCA, the majority (72.9%, n = 143) had a good functional neurological outcome (modified Rankin Scale ≤ 3 points). In the multivariable analysis, return of spontaneous circulation without mechanical circulatory support (hazard ratio (HR) 0.36, 95% confidence interval (CI) 0.21-0.64), invasive coronary angiography and/or percutaneous intervention (HR 0.56, 95% CI 0.34-0.92), and antibiotic therapy (HR 0.87, 95% CI 0.83-0.92) were associated with a lower risk of 30-day in hospital mortality.

CONCLUSION

In the present study, IHCA was survived in ~ 50% in a tertiary care hospital, although only a minority of patients presented with shockable rhythms. The majority of IHCA survivors (~ 70%) had a good neurological outcome. Recovery of spontaneous circulation and presence of treatable acute causes of the arrest are associated with better survival. Clinical Characteristics, Causes and Predictors of Outcomes in Patients with In-Hospital Cardiac Arrest: Results from the SURVIVE-ARREST Study.

ABBREVIATIONS

CPR, cardiopulmonary resuscitation; IHCA, In-hospital cardiac arrest; MCS, mechanical circulatory support; PCI, percutaneous coronary intervention; ROSC, return of spontaneous circulation; SBP, systolic blood pressure.

Anemia before in-hospital cardiac arrest and survival from cardio-pulmonary resuscitation-a retrospective cohort study

BACKGROUND

Multiple patient-related variables have been associated with reduced rates of survival to hospital discharge (SHD) after in-hospital cardiac arrest (IHCA). As opposed to most of these, anemia may be reversible. This retrospective single-center study aims to examine the relationship between prearrest hemoglobin levels, comorbidities, and survival after cardiopulmonary resuscitation (CPR) among patients with non-traumatic IHCA. Patients were classified as anemic (hemoglobin < 10 g/dL) or non-anemic (hemoglobin ≥ 10 g/dL) based on their lowest hemoglobin measurement in the 48 h preceding the arrest. The primary outcome was SHD. The secondary outcome was return of spontaneous circulation (ROSC).

RESULTS

Of 1515 CPR reports screened, 773 patients were included. Half of the patients (50.5%, 390) were classified as anemic. Anemic patients had higher Charlson Comorbidity Indices (CCIs), less cardiac causes, and more metabolic causes for the arrest. An inverse association was found between CCI and lowest hemoglobin. Overall, 9.1% (70 patients) achieved SHD and 49.5% (383) achieved ROSC. Similar rates of SHD (7.3 vs. 10.7%, p = 0.118) and ROSC (49.5 vs. 51.0%, p = 0.688) were observed in anemic and non-anemic patients. These findings remained consistent after adjustment for comorbidities, in sensitivity analyses on the independent variable (i.e., hemoglobin) and on potential confounders and in subgroups based on sex or blood transfusion in the 72 h preceding the arrest.

CONCLUSIONS

Prearrest hemoglobin levels lower than 10 g/dL were not associated with lower rates of SHD or ROSC in IHCA patients after controlling for comorbidities. Further studies are required to confirm our findings and to establish whether post-arrest hemoglobin levels reflect the severity of the inflammatory post-resuscitation processes.

In-hospital cardiac arrest: the state of the art

In-hospital cardiac arrest (IHCA) is associated with a high risk of death, but mortality rates are decreasing. The latest epidemiological and outcome data from several cardiac arrest registries are helping to shape our understanding of IHCA. The introduction of rapid response teams has been associated with a downward trend in hospital mortality. Technology and access to defibrillators continues to progress. The optimal method of airway management during IHCA remains uncertain, but there is a trend for decreasing use of tracheal intubation and increased use of supraglottic airway devices. The first randomised clinical trial of airway management during IHCA is ongoing in the UK. Retrospective and observational studies have shown that several pre-arrest factors are strongly associated with outcome after IHCA, but the risk of bias in such studies makes prognostication of individual cases potentially unreliable. Shared decision making and advanced care planning will increase application of appropriate DNACPR decisions and decrease rates of resuscitation attempts following IHCA.