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Aldous R, Roy R, Cannata A, Abdrazak M, Mohanan S, Beckley-Hoelscher N, Stahl D, Kanyal R, Kordis P, Sunderland N, Parczewska A, Kirresh A, Nevett J, Fothergill R, Webb I, Dworakowski R, Melikian N, Kalra S, Johnson TW, Sinagra G, Rakar S, Noc M, Patel S, Auzinger G, Gruchala M, Shah AM, Byrne J, MacCarthy P, Pareek N. MIRACLE 2 Score Compared With Downtime and Current Selection Criterion for Invasive Cardiovascular Therapies After OHCA. JACC Cardiovasc Interv 2023; 16:2439-2450. [PMID: 37609699 DOI: 10.1016/j.jcin.2023.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 08/01/2023] [Accepted: 08/07/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND The MIRACLE2 score is the only risk score that does not incorporate and can be used for selection of therapies after out-of-hospital cardiac arrest (OHCA). OBJECTIVES This study sought to compare the discrimination performance of the MIRACLE2 score, downtime, and current randomized controlled trial (RCT) recruitment criteria in predicting poor neurologic outcome after out-of-hospital cardiac arrest (OHCA). METHODS We used the EUCAR (European Cardiac Arrest Registry), a retrospective cohort from 6 centers (May 2012-September 2022). The primary outcome was poor neurologic outcome on hospital discharge (cerebral performance category 3-5). RESULTS A total of 1,259 patients (total downtime = 25 minutes; IQR: 15-36 minutes) were included in the study. Poor outcome occurred in 41.8% with downtime <30 minutes and in 79.3% for those with downtime >30 minutes. In a multivariable logistic regression analysis, MIRACLE2 had a stronger association with outcome (OR: 2.23; 95% CI: 1.98-2.51; P < 0.0001) than zero flow (OR: 1.07; 95% CI: 1.01-1.13; P = 0.013), low flow (OR: 1.04; 95% CI: 0.99-1.09; P = 0.054), and total downtime (OR: 0.99; 95% CI: 0.95-1.03; P = 0.52). MIRACLE2 had substantially superior discrimination for the primary endpoint (AUC: 0.877; 95% CI: 0.854-0.897) than zero flow (AUC: 0.610; 95% CI: 0.577-0.642), low flow (AUC: 0.725; 95% CI: 0.695-0.754), and total downtime (AUC: 0.732; 95% CI: 0.701-0.760). For those modeled for exclusion from study recruitment, the positive predictive value of MIRACLE2 ≥5 for poor outcome was significantly higher (0.92) than the CULPRIT-SHOCK (Culprit lesion only PCI Versus Multivessel PCI in Cardiogenic Shock) (0.80), EUROSHOCK (Testing the value of Novel Strategy and Its Cost Efficacy In Order to Improve the Poor Outcomes in Cardiogenic Shock) (0.74) and ECLS-SHOCK (Extra-corporeal life support in Cardiogenic shock) criteria (0.81) (P < 0.001). CONCLUSIONS The MIRACLE2 score has superior prediction of outcome after OHCA than downtime and higher discrimination of poor outcome than the current RCT recruitment criteria. The potential for the MIRACLE2 score to improve the selection of OHCA patients should be evaluated formally in future RCTs.
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Affiliation(s)
- Robert Aldous
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Roman Roy
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Antonio Cannata
- King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular and Metabolic Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, London, United Kingdom
| | - Muhamad Abdrazak
- King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular and Metabolic Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, London, United Kingdom
| | - Shamika Mohanan
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | | | - Daniel Stahl
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Ritesh Kanyal
- School of Cardiovascular and Metabolic Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, London, United Kingdom
| | - Peter Kordis
- Centre for Intensive Internal Medicine, University Medical Center, Ljubljana, Slovenia
| | - Nicholas Sunderland
- Bristol Heart Institute, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
| | | | - Ali Kirresh
- Royal Free Hospital NHS Foundation Trust, London, United Kingdom
| | - Joanne Nevett
- London Ambulance Service NHS Trust, London, United Kingdom
| | | | - Ian Webb
- King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular and Metabolic Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, London, United Kingdom
| | - Rafal Dworakowski
- King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular and Metabolic Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, London, United Kingdom
| | - Narbeh Melikian
- King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular and Metabolic Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, London, United Kingdom
| | - Sundeep Kalra
- Royal Free Hospital NHS Foundation Trust, London, United Kingdom
| | - Thomas W Johnson
- Bristol Heart Institute, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
| | | | - Serena Rakar
- Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Marko Noc
- Centre for Intensive Internal Medicine, University Medical Center, Ljubljana, Slovenia
| | - Sameer Patel
- Faculty of Life Science and Medicine, King's College London, London, United Kingdom
| | - Georg Auzinger
- Faculty of Life Science and Medicine, King's College London, London, United Kingdom
| | - Marcin Gruchala
- Department of Cardiology, Medical University of Gdańsk, Gdańsk, Poland
| | - Ajay M Shah
- King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular and Metabolic Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, London, United Kingdom
| | - Jonathan Byrne
- King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular and Metabolic Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, London, United Kingdom
| | - Philip MacCarthy
- King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular and Metabolic Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, London, United Kingdom
| | - Nilesh Pareek
- King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular and Metabolic Medicine and Sciences, British Heart Foundation Centre of Excellence, King's College London, London, United Kingdom.
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Sharma S, Raman P, Sinha M, Deo AS. Factors Affecting Outcomes of Cardiopulmonary Resuscitation in a Nephro-Urology Unit: A Retrospective Analysis. Indian J Crit Care Med 2022; 26:322-326. [PMID: 35519930 PMCID: PMC9015917 DOI: 10.5005/jp-journals-10071-24146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Availability of cardiopulmonary resuscitation (CPR) data from India is limited in published literature and data on patients with renal disease even more so. Documented survival-to-discharge rates worldwide range from 8 to 15% in renal disease as compared to 25% in the general population. Methods An institution-wide format for collection of cardiac arrest data was introduced in late 2015. We have analyzed all adult onsite cardiac arrests from January 2016 to December 2019. Patient characteristics and CPR parameters were both studied in detail. Primary endpoint was defined as survival to discharge. Association between patient and treatment characteristics and survival to discharge was studied. Results Successful CPR resulting in patient discharge occurred in 28 (31.4%) out of 89 patients. A very strong association was found between mortality and prolonged CPR (p <0.00001). Events occurring out of hours (p = 0.0029), patients admitted in the intensive care unit (ICU) (p = 0.03), initiated on inotropes (p = 0.003), and patients already on a ventilator (p = 0.0018) had poorer outcomes. Sepsis as the etiology emerged as the most significant association with mortality (p = 0.0007). Patient characteristics such as age, sex, presence or absence of chronic kidney disease, type of dialysis treatment, and vintage were found to be insignificant. Conclusion Analysis revealed survival to discharge of 31.4%. Sepsis in association with renal disease has been found to be consistent with higher risk for mortality. Other factors such as an out of hours event, admission to ICU, early intubation and inotrope initiation were associated with worse outcomes. How to cite this article Sharma S, Raman P, Sinha M, Deo AS. Factors Affecting Outcomes of Cardiopulmonary Resuscitation in a Nephro-Urology Unit: A Retrospective Analysis. Indian J Crit Care Med 2022;26(3):322–326.
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Affiliation(s)
- Sadhvi Sharma
- Department of Anaesthesiology and Critical Care, NU Hospitals, Bengaluru, Karnataka, India
- Sadhvi Sharma, Department of Anaesthesiology and Critical Care, NU Hospitals, Bengaluru, Karnataka, India, Phone: +91 8939138561, e-mail:
| | - Padmalatha Raman
- Department of Anaesthesiology and Critical Care, NU Hospitals, Bengaluru, Karnataka, India
| | - Maneesh Sinha
- Department of Urology, NU Hospitals, Bengaluru, Karnataka, India
| | - Alka S Deo
- Department of Anaesthesiology and Critical Care, NU Hospitals, Bengaluru, Karnataka, India
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Saeed F, Murad HF, Wing RE, Li J, Schold JD, Fiscella KA. Outcomes Following In-Hospital Cardiopulmonary Resuscitation in People Receiving Maintenance Dialysis. Kidney Med 2022; 4:100380. [PMID: 35072044 PMCID: PMC8767126 DOI: 10.1016/j.xkme.2021.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Rationale & Objective Previous studies showing poor cardiopulmonary resuscitation (CPR) outcomes in the dialysis population have largely been derived from claims data and are somewhat limited by a lack of detailed characterization of CPR events. We aimed to analyze CPR-related outcomes in individuals receiving maintenance dialysis. Study Design Retrospective chart review. Setting & Participants Using electronic medical records from a single academic health care system, we identified all hospitalized adult patients receiving maintenance dialysis who had undergone in-hospital CPR between 2006 and 2014. Exposure Initial in-hospital CPR. Outcomes Overall survival, predictors of unsuccessful CPR, predictors of death during the same hospitalization among initial survivors, predictors of discharge-to-home status. Analytical Approach We provide descriptive statistics for the study variables and used t tests, χ2 tests, or Fisher exact tests to compare differences between the groups. We built multivariable logistic regression models to examine the CPR-related outcomes. Results A total of 184 patients received in-hospital CPR: 51 (28%) did not survive the initial CPR event, and 77 CPR survivors died (additional 42%) later during the same hospitalization (overall mortality 70%). Only 18 (10%) were discharged home, with the remaining 32 (17%) discharged to a rehabilitation facility or a nursing home. In the multivariable model, the only predictor of unsuccessful CPR was CPR duration (OR, 1.41; 95% CI, 1.24-1.61; P < 0.001). Predictors of death during the same hospitalization after surviving the initial CPR event were CPR duration (OR, 1.15; 95% CI 1.04-1.27; P = 0.007) and older age (OR, 1.64; 95% CI, 1.23-2.2; P < 0.001). Older people also had lower odds of discharge-to-home status (OR, 0.25; 95% CI, 0.11-0.54; P < 0.001). Limitations Retrospective study design, single-center study, no information on functional status. Conclusions Patients receiving maintenance dialysis experience high mortality following in-hospital CPR and only 10% are discharged home. These data may help clinicians provide useful prognostic information while engaging in goals of care conversations.
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Marinacci LX, Mihatov N, D'Alessandro DA, Villavicencio MA, Roy N, Raz Y, Thomas SS. Extracorporeal cardiopulmonary resuscitation (ECPR) survival: A quaternary center analysis. J Card Surg 2021; 36:2300-2307. [PMID: 33797800 DOI: 10.1111/jocs.15550] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/08/2021] [Accepted: 03/22/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Extracorporeal cardiopulmonary resuscitation (ECPR) has emerged as a rescue strategy for nonresponders to conventional CPR (CCPR) in cardiac arrest. Definitive guidelines for ECPR deployment do not exist. Prior studies suggest that arrest rhythm and cardiac origin of arrest may be variables used to assess candidacy for ECPR. AIM To describe a single-center experience with ECPR and to assess associations between survival and physician-adjudicated origin of arrest and arrest rhythm. METHODS A retrospective review of all patients who underwent ECPR at a quaternary care center over a 7-year period was performed. Demographic and clinical characteristics were extracted from the medical record and used to adjudicate the origin of cardiac arrest, etiology, rhythm, survival, and outcomes. Univariate analysis was performed to determine the association of patient and arrest characteristics with survival. RESULTS Between 2010 and 2017, 47 cardiac arrest patients were initiated on extracorporeal membrane oxygenation (ECMO) at the time of active CPR. ECPR patient survival to hospital discharge was 25.5% (n = 12). Twenty-six patients died on ECMO (55.3%) while nine patients (19.1%) survived decannulation but died before discharge. Neither physician-adjudicated arrest rhythm nor underlying origin were significantly associated with survival to discharge, either alone or in combination. Younger age was significantly associated with survival. Nearly all survivors experienced myocardial recovery and left the hospital with a good neurological status. CONCLUSIONS Arrest rhythm and etiology may be insufficient predictors of survival in ECPR utilization. Further multiinstitutional studies are needed to determine evidenced-based criteria for ECPR deployment.
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Affiliation(s)
- Lucas X Marinacci
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nino Mihatov
- Division of Cardiology, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, New York, USA
| | - David A D'Alessandro
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Nathalie Roy
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Yuval Raz
- Division of Pulmonary and Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sunu S Thomas
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts, USA
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Wang W, Liu X, Yang Z, Shen H, Liu L, Yu Y, Zhang T. Levodopa Improves Cognitive Function and the Deficits of Structural Synaptic Plasticity in Hippocampus Induced by Global Cerebral Ischemia/Reperfusion Injury in Rats. Front Neurosci 2020; 14:586321. [PMID: 33328857 PMCID: PMC7734175 DOI: 10.3389/fnins.2020.586321] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 10/27/2020] [Indexed: 12/16/2022] Open
Abstract
The cognitive impairment caused by cerebral ischemia/reperfusion is an unsolved problem in the field of international neural rehabilitation. Not only ameliorates the consciousness level of certain patients who suffered from ischemia-reperfusion injury and were comatose for a long time period after cerebral resuscitation treatment, but levodopa also improves the symptoms of neurological deficits in rats with global cerebral ischemia-reperfusion injury. However, Levodopa has not been widely used as a brain protection drug after cardiopulmonary resuscitation, because of its unclear repair mechanism. Levodopa was used to study the neuroplasticity in the hippocampus of global cerebral ischemia/reperfusion injury rat model, established by Pulsinelli's four-vessel occlusion method. Levodopa was injected intraperitoneally at 50 mg/kg/d for 7 consecutive days after 1st day of surgery. The modified neurological function score, Morris water maze, magnetic resonance imaging, Nissl and TH staining, electron microscopy and western blot were used in the present study. The results showed that levodopa improved the neurological function and learning and memory of rats after global cerebral ischemia/reperfusion injury, improved the integrity of white matter, and density of gray matter in the hippocampus, increased the number of synapses, reduced the delayed neuronal death, and increased the expression of synaptic plasticity-related proteins (BDNF, TrkB, PSD95, and Drebrin) in the hippocampus. In conclusion, levodopa can improve cognitive function after global cerebral ischemia/reperfusion injury by enhancing the synaptic plasticity in the hippocampus.
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Affiliation(s)
- Wenzhu Wang
- Chinese Institute of Rehabilitation Science, China Rehabilitation Science Institute, Beijing, China.,Beijing Key Laboratory of Neural Injury and Rehabilitation, China Rehabilitation Research Center, Beijing, China
| | - Xu Liu
- School of Rehabilitation Medicine, Capital Medical University, Beijing, China
| | - Zhengyi Yang
- Institute of Automation, Chinese Academy of Sciences, Beijing, China
| | - Hui Shen
- School of Biomedical Engineering, Tianjin Medical University, Tianjin, China
| | - Lixu Liu
- School of Rehabilitation Medicine, Capital Medical University, Beijing, China.,Beijing Bo'ai Hospital, China Rehabilitation Research Center, Beijing, China
| | - Yan Yu
- Chinese Institute of Rehabilitation Science, China Rehabilitation Science Institute, Beijing, China.,Beijing Key Laboratory of Neural Injury and Rehabilitation, China Rehabilitation Research Center, Beijing, China.,Center of Neural Injury and Repair, Beijing Institute for Brain Disorders, Beijing, China
| | - Tong Zhang
- Chinese Institute of Rehabilitation Science, China Rehabilitation Science Institute, Beijing, China.,Beijing Key Laboratory of Neural Injury and Rehabilitation, China Rehabilitation Research Center, Beijing, China.,Institute of Automation, Chinese Academy of Sciences, Beijing, China
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6
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Carr C, Carson KA, Millin MG. Acidemia Detected on Venous Blood Gas After Out-of-Hospital Cardiac Arrest Predicts Likelihood to Survive to Hospital Discharge. J Emerg Med 2020; 59:e105-e111. [PMID: 32684378 DOI: 10.1016/j.jemermed.2020.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 05/04/2020] [Accepted: 06/01/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Sudden cardiac arrest is the most common cause of death worldwide, and prognostication after survival remains challenging. Decisions regarding prognosis can be fraught with error in the immediate postarrest period, with guidelines recommending the use of various tests, including blood gas pH, to determine which interventions to perform. Despite these recommendations, the prognostic utility of blood gas pH remains unclear. OBJECTIVES In this retrospective cohort study, we aimed to demonstrate the prognostic utility of emergency department blood gas pH after return of spontaneous circulation (ROSC) in out-of-hospital cardiac arrest. METHODS A retrospective cohort study was performed, including all adult survivors of out-of-hospital cardiac arrest (n = 79). Primary disease-oriented outcome was venous blood pH after ROSC and survival to hospital discharge. RESULTS In patients with out-of-hospital cardiac arrest, pH < 7.2 was associated with decreased likelihood of survival to hospital discharge (odds ratio 0.06), with every 0.1-unit increase in pH being associated with an increased likelihood of survival (1.98). Based on the area under the receiver curve, the pH that optimizes sensitivity and specificity for predicting survival was 7.04. CONCLUSION Both presence and degree of acidemia on initial blood gas after ROSC was associated with a decreased likelihood of survival to hospital discharge. The optimal cutoff for prediction in this cohort of patients was 7.04. Using a higher pH cutoff would result in fewer patients receiving intervention that would otherwise have survived.
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Affiliation(s)
- Casey Carr
- Departments of Emergency Medicine and Critical Care, University of Florida - Shands Hospital, Gainesville, Florida
| | - Kathryn A Carson
- Department of Emergency Medicine, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Michael G Millin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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7
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Surgical outcomes of acute type A aortic dissection in patients undergoing cardiopulmonary resuscitation. J Thorac Cardiovasc Surg 2020; 161:1173-1180. [PMID: 32008759 DOI: 10.1016/j.jtcvs.2019.11.135] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 11/24/2019] [Accepted: 11/27/2019] [Indexed: 01/24/2023]
Abstract
OBJECTIVES The surgical indications for acute type A aortic dissection (AAAD) in patients in cardiopulmonary arrest remain controversial. Outcomes of AAAD for patients who underwent cardiopulmonary resuscitation (CPR) were evaluated. METHODS Between 2004 and 2018, of the 519 patients who underwent AAAD repair, 34 (6.6%) required CPR before or on starting AAAD repair. The patients were divided into 2 groups, survivors (n = 13) and nonsurvivors (n = 21), to compare the early operative outcomes, including mortality and neurological events. RESULTS The major cause of cardiovascular collapse requiring CPR was aortic rupture/cardiac tamponade (n = 21 [61.8%]), followed by coronary malperfusion (n = 12 [35.3%]) and acute aortic valve regurgitation (n = 3 [8.8%]). There were 3 (23.1%) patients in the survivors group and 11 (52.4%) in the nonsurvivors group who required ongoing CPR at the beginning of AAAD repair (P = .039). Of these patients, 1 survivor and 6 nonsurvivors could not achieve return of spontaneous circulation after pericardiotomy (P = .045). Although the duration from onset or arrival to the operating room was similar (P = .35 and P = .49, respectively), overall duration of CPR was shorter in survivors (10 minutes [range, 7.5-16 minutes] vs 16.5 minutes [range, 15-20 minutes]; P = .044). All survivors without any neurological deficits showed return of spontaneous circulation after pericardiotomy. Multivariate regression modeling showed that CPR duration >15 minutes was a significant risk factor for in-hospital mortality (P = .0040). CONCLUSIONS CPR duration beyond 15 minutes may be a contraindication for AAAD repair. Moreover, we should reconsider surgery for patients who cannot achieve return of spontaneous circulation after pericardiotomy.
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Abstract
BACKGROUND This study was designed to evaluate the patient characteristics and outcomes of in-hospital cardiac arrest (IHCA). MATERIALS AND METHODS We carried out a single-center, 5-year, retrospective chart review and analysis of resuscitation data for age, gender, body mass index (BMI), length of stay (LOS) until cardiac arrest, survival of initial IHCA, survival to hospital discharge, primary medical service, and determination of the etiology of cardiac arrest. RESULTS A total of 500 cases occurred with a mean LOS of 8.5 days until the initial IHCA. Overall, 79.5% survived the initial IHCA and 32.4% survived to discharge. As LOS increased, there was an increase in the proportion of pulmonary and metabolic etiologies. Logistic regression analysis adjusting for BMI, gender, age, LOS, and primary medical service were on a surgical service significant for survival to discharge (p = 0.0007) and LOS <9 days significant for survival of IHCA (p = 0.018). CONCLUSION There are a number of causes of IHCA, and the incidence of death and respiratory related IHCA etiologies increase with LOS. Length of stay carries the highest weight when predicting survival of IHCA. Also, there is a higher rate of survival to discharge when on a primary surgical service. HOW TO CITE THIS ARTICLE Riley LE, Mehta HJ, Lascano J. Single-center In-hospital Cardiac Arrest Outcomes. Indian J Crit Care Med 2020;24(1):44-48.
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Affiliation(s)
- Leonard E Riley
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, Florida, USA
| | - Hiren J Mehta
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, Florida, USA
| | - Jorge Lascano
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, Florida, USA
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Fernando SM, Tran A, Cheng W, Rochwerg B, Taljaard M, Vaillancourt C, Rowan KM, Harrison DA, Nolan JP, Kyeremanteng K, McIsaac DI, Guyatt GH, Perry JJ. Pre-arrest and intra-arrest prognostic factors associated with survival after in-hospital cardiac arrest: systematic review and meta-analysis. BMJ 2019; 367:l6373. [PMID: 31801749 PMCID: PMC6891802 DOI: 10.1136/bmj.l6373] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Shannon M Fernando
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Alexandre Tran
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Wei Cheng
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Bram Rochwerg
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Monica Taljaard
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Christian Vaillancourt
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Kathryn M Rowan
- Intensive Care National Audit and Research Centre, London, UK
| | | | - Jerry P Nolan
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Kwadwo Kyeremanteng
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Daniel I McIsaac
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jeffrey J Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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Kiehl EL, Amuthan R, Adams MP, Love TE, Enfield KB, Gimple LW, Cantillon DJ, Menon V. Initial arterial pH as a predictor of neurologic outcome after out-of-hospital cardiac arrest: A propensity-adjusted analysis. Resuscitation 2019; 139:76-83. [PMID: 30946922 DOI: 10.1016/j.resuscitation.2019.03.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 02/09/2019] [Accepted: 03/25/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Lower pH after out-of-hospital cardiac arrest (OHCA) has been associated with worsening neurologic outcome, with <7.2 identified as an "unfavorable resuscitation feature" in consensus treatment algorithms despite conflicting data. This study aimed to describe the relationship between decremental post-resuscitation pH and neurologic outcomes after OHCA. METHODS Consecutive OHCA patients treated with targeted temperature management (TTM) at multiple US centers from 2008 to 2017 were evaluated. Poor neurologic outcome at hospital discharge was defined as cerebral performance category ≥3. The exposure was initial arterial pH after return of spontaneous circulation (ROSC) analyzed in decremental 0.05 thresholds. Potential confounders (demographics, history, resuscitation characteristics, initial studies) were defined a priori and controlled for via ATT-weighting on the inverse propensity score plus direct adjustment for the linear propensity score. RESULTS Of 723 patients, 589 (80%) experienced poor neurologic outcome at hospital discharge. After propensity-adjustment with excellent covariate balance, the adjusted odds ratios for poor neurologic outcome by pH threshold were: ≤7.3: 2.0 (1.0-4.0); ≤7.25: 1.9 (1.2-3.1); ≤7.2: 2.1 (1.3-3.3); ≤7.15: 1.9 (1.2-3.1); ≤7.1: 2.4 (1.4-4.1); ≤7.05: 3.1 (1.5-6.3); ≤7.0: 4.5 (1.8-12). CONCLUSIONS No increased hazard of progressively poor neurologic outcomes was observed in resuscitated OHCA patients treated with TTM until the initial post-ROSC arterial pH was at least ≤7.1. This threshold is more acidic than in current guidelines, suggesting the possibility that post-arrest pH may be utilized presently as an inappropriately-pessimistic prognosticator.
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Affiliation(s)
- Erich L Kiehl
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ram Amuthan
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Mark P Adams
- Department of Cardiovascular Medicine, University of Virginia, Charlottesville, VA, USA
| | - Thomas E Love
- Departments of Medicine and of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA; Center for Health Care Research and Policy, MetroHealth Medical Center, Cleveland, OH, USA
| | - Kyle B Enfield
- Department of Pulmonary and Critical Care Medicine, University of Virginia, Charlottesville, VA, USA
| | - Lawrence W Gimple
- Department of Cardiovascular Medicine, University of Virginia, Charlottesville, VA, USA
| | - Daniel J Cantillon
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Venu Menon
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA.
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11
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Moosajee US, Saleem SG, Iftikhar S, Samad L. Outcomes following cardiopulmonary resuscitation in an emergency department of a low- and middle-income country. Int J Emerg Med 2018; 11:40. [PMID: 31179917 PMCID: PMC6326149 DOI: 10.1186/s12245-018-0200-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 09/17/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cardiopulmonary resuscitation (CPR) is a key component of emergency care following cardiac arrest. A better understanding of factors that influence CPR outcomes and their prognostic implications would help guide care. A retrospective analysis of 800 adult patients that sustained an in- or out-of-hospital cardiac arrest and underwent CPR in the emergency department of a tertiary care facility in Karachi, Pakistan, between 2008 and 15 was conducted. METHODS Patient demographics, clinical history, and CPR characteristics data were collected. Logistic regression model was applied to assess predictors of return of spontaneous circulation and survival to discharge. Analysis was conducted using SPSS v.21.0. RESULTS Four hundred sixty-eight patients met the study's inclusion criteria, and overall return of spontaneous circulation and survival to discharge were achieved in 128 (27.4%) and 35 (7.5%) patients respectively. Mean age of patients sustaining return of spontaneous circulation was 52 years and that of survival to discharge was 49 years. The independent predictors of return of spontaneous circulation included age ≤ 49 years, witnessed arrest, ≤ 30 min interval between collapse-to-start, and 1-4 shocks given during CPR (aOR (95% CI) 2.2 (1.3-3.6), 1.9 (1.0-3.7), 14.6 (4.9-43.4), and 3.0 (1.4-6.4) respectively), whereas, age ≤ 52 years, bystander resuscitation, and initial rhythm documented (pulseless electrical activity and ventricular fibrillation) were independent predictors of survival to discharge (aOR (95% CI) 2.5 (0.9-6.5), 1.4 (0.5-3.8), 5.3 (1.5-18.4), and 3.1 (1.0-10.2) respectively). CONCLUSION Our study notes that while the majority of arrests occur out of the hospital, only a small proportion of those arrests receive on-site CPR, which is a key contributor to unfavorable outcomes in this group. It is recommended that effective pre-hospital emergency care systems be established in developing countries which could potentially improve post-arrest outcomes. Younger patients, CPR initiation soon after arrest, presenting rhythm of pulseless ventricular tachycardia and ventricular fibrillation, and those requiring up to four shocks to revive are more likely to achieve favorable outcomes.
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Affiliation(s)
- Umme Salama Moosajee
- Center for Essential Surgical and Acute Care, Global Health Directorate, Indus Health Network, 5th Floor, Woodcraft Building, Sector 47, Korangi Creek Road, Karachi, 75300 Pakistan
| | | | - Sundus Iftikhar
- Indus Hospital Research Center, The Indus Hospital, Karachi, Pakistan
| | - Lubna Samad
- Center for Essential Surgical and Acute Care, Global Health Directorate, Indus Health Network, 5th Floor, Woodcraft Building, Sector 47, Korangi Creek Road, Karachi, 75300 Pakistan
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12
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Day E, Hort JR. Out-of-hospital arrests attending an Australian tertiary paediatric emergency department over 13 years: An observational study. Emerg Med Australas 2018; 30:687-693. [DOI: 10.1111/1742-6723.13127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 03/31/2018] [Accepted: 05/30/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Elisabeth Day
- Children's Hospital at Westmead; Sydney New South Wales Australia
| | - Jason R Hort
- Children's Hospital at Westmead; Sydney New South Wales Australia
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13
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Cardiac arrests within the emergency department: an Utstein style report, causation and survival factors. Eur J Emerg Med 2018; 25:12-17. [PMID: 27749378 DOI: 10.1097/mej.0000000000000427] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Emergency Department Cardiac Arrests are typically classified with in-hospital cardiac arrests, but are yet to be well described as a distinct clinical entity. This study provides an Utstein style report on Emergency Department Cardiac Arrests, and identifies factors associated with survival. PATIENTS AND METHODS Patients who experienced a cardiac arrest in the Emergency Department of the National University Hospital, Singapore, between January 2010 and August 2012 were studied. Data were collected retrospectively and potential survival factors were assessed with a multivariate logistic regression. RESULTS One hundred and six cases were identified for analysis. Most patients were male and 43.4% had a presumed cardiac diagnosis. All arrests were witnessed and received Advanced Cardiac Life Support interventions immediately. Out of the total, 31.1% of arrests occurred during or immediately after intubation. Overall, 48.1% of patients survived to hospital discharge. Patients with a shockable rhythm had the highest survival rate (70.8%), followed by asytole (20.8%) and pulseless electrical activity (15.1%). In all, 91.3% of survivors with a premorbid Cerebral Performance Category score of 1 were discharged with a similar Cerebral Performance Category score.Variables associated with survival to hospital discharge were a shockable initial rhythm (odds ratio 12.1; 95% confidence interval, 3.1-47.6) and a time to return of spontaneous circulation of less than 10 min (odds ratio 4.1; 95% confidence interval, 1.0-16.9). CONCLUSION This is the first Utstein style report on Emergency Department Cardiac Arrests. A high survival rate with good neurological outcomes was found in this population. The initial rhythm and time to return of spontaneous circulation have been identified as survival factors and may be used to guide decision-making during resuscitation.
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Au WK, Tsui KL, Tang YH, Lui CT. Predictors of Outcome in Out-Of-Hospital Cardiac Arrest Survived to Hospital Admission. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791402100301] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective To identify the independent predictors of survival to hospital discharge in the group of patients admitted to hospital with out-of-hospital cardiac arrest. Design Prospective cohort study. Setting Two public hospitals in a cluster in Hong Kong. Methods Data were reported to local Cardiac Arrest Registry using Utstein style template from 1st August 2010 to 31st October 2012. The post cardiac arrest care and outcome, premorbid mobility, activities of daily living (ADL) and medical illnesses were traced from medical records. Independent predictors were calculated using logistic regression model. Results A total of 323 patients were recruited in this study. Patients' age (Odds raio [OR]=0.966; 95% confidence interval [CI]=0.937-0.996), total down time (OR=0.897; 95% CI=0.858-0.938), pre-hospital defibrillation (OR=5.649; 95% CI=1.673-19.07), post-cardiac arrest intensive care (OR=3.674; 95% CI=1.001-13.951) were independent predictors of survival to hospital discharge. Conclusions Younger age, shorter down time, prehospital defibrillation for shockable rhythm, post-cardiac arrest intensive care are independent predictors of survival to discharge for patients admitted to hospital after out-of-hospital cardiac arrest. Premorbid health conditions, ADL and mobility are not predictors to patient's survival. (Hong Kong j.emerg.med. 2014;21:131-139)
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15
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Zhang Z. Echocardiography for patients undergoing extracorporeal cardiopulmonary resuscitation: a primer for intensive care physicians. J Intensive Care 2017; 5:15. [PMID: 28168038 PMCID: PMC5288871 DOI: 10.1186/s40560-017-0211-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 01/26/2017] [Indexed: 02/07/2023] Open
Abstract
Echocardiography is an invaluable tool in the management of patients with extracorporeal cardiopulmonary resuscitation (ECPR) and subsequent extracorporeal membrane oxygenation (ECMO) support and weaning. At the very beginning, echocardiography can identify the etiology of cardiac arrest, such as massive pulmonary embolism and cardiac tamponade. Eliminating these culprits saves life and may avoid the initiation of extracorporeal cardiopulmonary resuscitation. If the underlying causes are not identified or intrinsic to the heart (e.g., such as those caused by cardiomyopathy and myocarditis), conventional cardiopulmonary resuscitation (CCPR) will continue to maintain cardiac output. The quality of CCPR can be monitored, and if cardiac output cannot be maintained, early institution of extracorporeal cardiopulmonary resuscitation may be reasonable. Cannulation is sometimes challenging for extracorporeal cardiopulmonary resuscitation patients. Fortunately, with the help of ultrasonography procedures including localization of vessels, selecting a cannula of appropriate size and confirmation of catheter tip may become easy under sophisticated hand. Monitoring of cardiac function and complications during extracorporeal membrane oxygenation support can be done with echocardiography. However, the cardiac parameters should be interpreted with understanding of hemodynamic configuration of extracorporeal membrane oxygenation. Thrombus and blood stasis can be identified with ultrasound, which may prompt mechanical and pharmacological interventions. The final step is extracorporeal membrane oxygenation weaning. A number of studies investigated the accuracy of some echocardiographic parameters in predicting success rate and demonstrated promising results. Parameters and threshold for successful weaning include aortic VTI ≥ 10 cm, LVEF > 20-25%, and lateral mitral annulus peak systolic velocity >6 cm/s. However, the effectiveness of echocardiography in ECPR patients cannot be determined in observational studies and requires randomized controlled trials in the future. The contents in this review are well known to echocardiography specialists; thus, it should be used as an educational material for emergency or intensive care physicians. There is a trend that focused echocardiography is performed by intensivists and emergency physicians.
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Affiliation(s)
- Zhongheng Zhang
- 0000 0004 1759 700Xgrid.13402.34Department of Emergency Medicine, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, No 3, East Qingchun Road, Hangzhou, 310016 Zhejiang Province China
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16
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Bradley SM, Liu W, Chan PS, Girotra S, Goldberger ZD, Valle JA, Perman SM, Nallamothu BK. Duration of resuscitation efforts for in-hospital cardiac arrest by predicted outcomes: Insights from Get With The Guidelines - Resuscitation. Resuscitation 2016; 113:128-134. [PMID: 28039064 DOI: 10.1016/j.resuscitation.2016.12.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 12/08/2016] [Accepted: 12/13/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND The duration of resuscitation efforts has implications for patient survival of in-hospital cardiac arrest (IHCA). It is unknown if patients with better predicted survival of IHCA receive longer attempts at resuscitation. METHODS In a multicenter observational cohort of 40,563 adult non-survivors of resuscitation efforts for IHCA between 2000 and 2012, we determined the pre-arrest predicted probability of survival to discharge with good neurologic status, categorized into very low (<1%), low (1-3%), average (>3%-15%), and above average (>15%). We then determined the association between predicted arrest survival probability and the duration of resuscitation efforts. RESULTS The median duration of resuscitation efforts among all non-survivors was 19min (interquartile range 13-28min). Overall, the median duration of resuscitation efforts was longer in non-survivors with a higher predicted probability of survival with good neurologic status (median of 16, 17, 20, and 23min among the groups predicted to have very low, low, average, and above probabilities, respectively; P<0.001). However, the duration of resuscitation was often discordant with predicted survival, including longer than median duration of resuscitation efforts in 40.4% of patients with very low predicted survival and shorter than median duration of resuscitation efforts in 31.9% of patients with above average predicted survival. CONCLUSIONS The duration of resuscitation efforts in patients with IHCA was generally consistent with their predicted survival. However, nearly a third of patients with above average predicted outcomes received shorter than average (less than 19min) duration of resuscitation efforts.
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Affiliation(s)
| | - Wenhui Liu
- VA Eastern Colorado Health Care System, Denver, CO, United States; University of Colorado School of Public Health, Aurora, CO, United States
| | - Paul S Chan
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, MO, United States
| | - Saket Girotra
- University of Iowa Carver College of Medicine, Iowa City, IA, United States
| | | | - Javier A Valle
- University of Colorado School of Medicine, Aurora, CO, United States
| | - Sarah M Perman
- University of Colorado School of Medicine, Aurora, CO, United States
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17
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Olasveengen T. Challenging our current concept of futility. Resuscitation 2016; 105:A6-7. [DOI: 10.1016/j.resuscitation.2016.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 05/04/2016] [Indexed: 11/24/2022]
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18
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Rajan S, Folke F, Kragholm K, Hansen CM, Granger CB, Hansen SM, Peterson ED, Lippert FK, Søndergaard KB, Køber L, Gislason GH, Torp-Pedersen C, Wissenberg M. Prolonged cardiopulmonary resuscitation and outcomes after out-of-hospital cardiac arrest. Resuscitation 2016; 105:45-51. [DOI: 10.1016/j.resuscitation.2016.05.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 04/20/2016] [Accepted: 05/04/2016] [Indexed: 11/15/2022]
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Price RJ, Garrioch A. Prospective Observational Survey of the Utilisation of Anaesthetists and the Outcome following Cardiac Arrest Calls. Scott Med J 2016; 50:13-4. [PMID: 15792380 DOI: 10.1177/003693300505000105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background and Aims: We wanted to determine whether the practice of routinely sending an anaesthetist to cardiac arrests is common within Scotland. We also wished to evaluate the interventions performed by our intensive care anaesthetist when responding to cardiac arrest calls. Methods: We performed a telephone survey of the 26 Scottish hospitals with an intensive care unit. We conducted a prospective observational survey over a period of six months in one Scottish teaching hospital. Structured interviews with the anaesthetist who responded to the cardiac arrest call were undertaken. Results: Routine attendance of an anaesthetist at cardiac arrests occurs in 25 of the 26 hospitals surveyed. We analysed 68 of 73 arrest calls. In 28 calls (41%) there was no requirement for anaesthetic intervention. In 40 (59%) the anaesthetist intervened. The interventions were for cardiac arrest procedures in 33 cases and ventilatory failure in the remaining 7 cases. One patient survived to hospital discharge: a mortality of 98%. Conclusions: Patients who remain in cardiac arrest upon the arrival of the anaesthetist have a very high mortality. The practice of routinely sending an anaesthetist to cardiac arrest calls is not justified.
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Affiliation(s)
- R J Price
- Department of Anaesthesia, Management Buildings, Southern General Hospital, 1345 Govan Road, Glasgow.
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20
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Momiyama Y, Yamada W, Miyata K, Miura K, Fukuda T, Fuse J, Kikuno T. Prognostic values of blood pH and lactate levels in patients resuscitated from out-of-hospital cardiac arrest. Acute Med Surg 2016; 4:25-30. [PMID: 28163922 PMCID: PMC5256427 DOI: 10.1002/ams2.217] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 04/19/2016] [Indexed: 11/11/2022] Open
Abstract
Aim Early prediction of prognosis after out‐of‐hospital cardiac arrest (OHCA) remains difficult. High blood lactate or low pH levels may be associated with poor prognosis in OHCA patients, but these associations remain controversial. We compared blood lactate and pH levels in OHCA patients transferred to our hospital to measure their prognostic performance. Methods We investigated the associations between blood lactate and pH levels on admission and neurological outcomes in 372 OHCA patients who had a return of spontaneous circulation. Results Of the 372 OHCA patients, 31 had a favorable neurological outcome. Blood lactate levels were lower in patients with a favorable outcome than in those with an unfavorable outcome, but this difference did not reach statistical significance (82 ± 49 vs. 96 ± 41 mg/dL). However, pH levels were significantly higher in patients with a favorable outcome than in those with an unfavorable outcome (7.26 ± 0.16 vs. 6.93 ± 0.19, P < 0.001). The relative cumulative frequency distribution curve analysis showed the optimal cut‐off points of lactate and pH to be approximately 80 mg/dL and 7.05, respectively. Sensitivity and specificity to predict a favorable outcome were 61% and 64% for lactate <80 mg/dL and 84% and 80% for pH >7.05, respectively. Areas under receiver–operating characteristic curves were significantly larger for pH than for lactate levels (P < 0.001). In multivariate analysis, pH >7.05 was an independent predictor for a favorable outcome. Conclusion After OHCA, patients with a favorable outcome had lower lactate and higher pH levels than those with an unfavorable outcome, but pH level was a much better predictor for neurological outcome than lactate levels.
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Affiliation(s)
- Yukihiko Momiyama
- Department of Cardiology National Hospital Organization Tokyo Medical Center Tokyo Japan
| | - Wataru Yamada
- Department of Cardiology National Hospital Organization Tokyo Medical Center Tokyo Japan
| | - Koutaro Miyata
- Department of Cardiology National Hospital Organization Tokyo Medical Center Tokyo Japan
| | - Koutarou Miura
- Department of Cardiology National Hospital Organization Tokyo Medical Center Tokyo Japan
| | - Tadashi Fukuda
- Department of Cardiology National Hospital Organization Tokyo Medical Center Tokyo Japan
| | - Jun Fuse
- Department of Cardiology National Hospital Organization Tokyo Medical Center Tokyo Japan
| | - Takaaki Kikuno
- Emergency and Critical Care Center National Hospital Organization Tokyo Medical Center Tokyo Japan
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21
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The impact of downtime on neurologic intact survival in patients with targeted temperature management after out-of-hospital cardiac arrest: National multicenter cohort study. Resuscitation 2016; 105:203-8. [PMID: 27060537 DOI: 10.1016/j.resuscitation.2016.03.020] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 03/14/2016] [Accepted: 03/17/2016] [Indexed: 11/22/2022]
Abstract
AIM OF STUDY The association between long duration of resuscitation efforts in out-of-hospital cardiac arrest (OHCA) and neurologic outcome is unclear and understudied with advancements in post-cardiac arrest care and high-quality cardiopulmonary resuscitation. We investigated how downtime, defined as the interval from collapse-to-return of spontaneous circulation (ROSC), impacts on neurologic outcome in OHCA patients treated with targeted temperature management (TTM). METHODS A multicenter, registry-based, retrospective cohort study was conducted using cases from 24 hospitals across South Korea. Of the 930 adults (≥18 years) non-traumatic OHCA patients treated with TTM between January 2007 and December 2012 at these hospitals, we included 858 patients who had sufficient data for calculating downtime. Good neurologic outcome was defined as a cerebral performance category score of 1 or 2. RESULTS Median downtime was 30.0 (22.0-41.0min) and 242 patients (28.2%) had good neurologic outcome. When downtime was divided by 10-min intervals (≤10min, 11-20min, 21-30min, 31-40min, 41-50min, 51-60min, and >60min), their neurologically intact survival rate were 48.2%, 51.6%, 29.2%, 22.1%, 16.1%, 14.8%, and 7.1%, respectively (p=0.01). Although downtime was associated with poor neurologic outcome [odds ratio 1.06 (1.05-1.08), p<0.01], the area under the receiver operating characteristic curve of downtime for outcome was only 0.67, 95% CI (0.63-0.71). Furthermore, even with downtime >20min, 22.2% (150/526) patients still had a good neurologic outcome, and this percentage increased to 50.3% (93/185) in patients with an initial shockable rhythm, and 31.1% (134/431) with age <65 years. CONCLUSIONS We found that neurologically intact survival can occur at prolonged downtimes and were unable to identify a downtime for which survivability was clearly futile. These data suggest that downtime should not be considered as a factor in determining whether to provide aggressive post-arrest care, especially in patients with young patients or those with an initially shockable rhythm.
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22
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Goto Y, Funada A, Goto Y. Relationship Between the Duration of Cardiopulmonary Resuscitation and Favorable Neurological Outcomes After Out-of-Hospital Cardiac Arrest: A Prospective, Nationwide, Population-Based Cohort Study. J Am Heart Assoc 2016; 5:e002819. [PMID: 26994129 PMCID: PMC4943259 DOI: 10.1161/jaha.115.002819] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 02/10/2016] [Indexed: 01/16/2023]
Abstract
BACKGROUND The determination of appropriate duration of in-the-field cardiopulmonary resuscitation (CPR) for out-of-hospital cardiac arrest (OHCA) patients is one of the biggest challenges for emergency medical service providers and clinicians. The appropriate CPR duration before termination of resuscitation remains unclear and may differ based on initial rhythm. We aimed to determine the relationship between CPR duration and post-OHCA outcomes. METHODS AND RESULTS We analyzed the records of 17 238 OHCA patients (age ≥18 years) who achieved prehospital return of spontaneous circulation. Data were prospectively recorded in a nationwide, Japanese database between 2011 and 2012. The time from CPR initiation to prehospital return of spontaneous circulation (CPR duration) was calculated. The primary end point was 1-month survival with favorable neurological outcomes (Cerebral Performance Category [CPC] scale; CPC 1-2). The 1-month CPC 1-2 rate was 21.8% (n=3771). CPR duration was inversely associated with 1-month CPC 1-2 (adjusted unit odds ratio: 0.95, 95% CI: 0.94-0.95). Among all patients, a cumulative proportion of >99% of 1-month CPC 1-2 was achieved with a CPR duration of 35 minutes. When sorted by the initial rhythm, the CPR duration producing more than 99% of survivors with CPC 1-2 was 35 minutes for shockable rhythms and pulseless electrical activity, and 42 minutes for asystole. CONCLUSIONS CPR duration was independently and inversely associated with favorable 1-month neurological outcomes. The critical prehospital CPR duration for OHCA was 35 minutes in patients with initial shockable rhythms and pulseless electrical activity, and 42 minutes in those with initial asystole.
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Affiliation(s)
- Yoshikazu Goto
- Department of Emergency and Critical Care Medicine, Kanazawa University Hospital, Kanazawa, Japan
| | - Akira Funada
- Department of Emergency and Critical Care Medicine, Kanazawa University Hospital, Kanazawa, Japan
| | - Yumiko Goto
- Department of Cardiology, Yawata Medical Center, Komatsu, Japan
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Kim SJ, Kim HJ, Lee HY, Ahn HS, Lee SW. Comparing extracorporeal cardiopulmonary resuscitation with conventional cardiopulmonary resuscitation: A meta-analysis. Resuscitation 2016; 103:106-116. [PMID: 26851058 DOI: 10.1016/j.resuscitation.2016.01.019] [Citation(s) in RCA: 171] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 12/19/2015] [Accepted: 01/19/2016] [Indexed: 10/22/2022]
Abstract
INTRODUCTION The objective was to determine whether extracorporeal cardiopulmonary resuscitation (ECPR), when compared with conventional cardiopulmonary resuscitation (CCPR), improves outcomes in adult patients, and to determine appropriate conditions that can predict good survival outcome in ECPR patients through a meta-analysis. METHODS We searched the relevant literature of comparative studies between ECPR and CCPR in adults, from the MEDLINE, EMBASE, and Cochrane databases. The baseline information and outcome data (survival, good neurologic outcome at discharge, at 3-6 months, and at 1 year after arrest) were extracted. Beneficial effect of ECPR on outcome was analyzed according to time interval, location of arrest (out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA)), and pre-defined population inclusion criteria (witnessed arrest, initial shockable rhythm, cardiac etiology of arrest and CPR duration) by using Review Manager 5.3. Cochran's Q test and I(2) were calculated. RESULTS 10 of 1583 publications were included. Although survival to discharge did not show clear superiority in OHCA, ECPR showed statistically improved survival and good neurologic outcome as compared to CCPR, especially at 3-6 months after arrest. In the subgroup of patients with pre-defined inclusion criteria, the pooled meta-analysis found similar results in studies with pre-defined criteria. CONCLUSION Survival and good neurologic outcome tended to be superior in the ECPR group at 3-6 months after arrest. The effect of ECPR on survival to discharge in OHCA was not clearly shown. As ECPR showed better outcomes than CCPR in studies with pre-defined criteria, strict indications criteria should be considered when implementation of ECPR.
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Affiliation(s)
- Su Jin Kim
- Department of Emergency Medicine, College of Medicine, Korea University Hospital, Seoul, Republic of Korea
| | - Hyun Jung Kim
- Institute for Evidence-based Medicine, The Korean Branch of Australasian Cochrane Center, Department of Preventive Medicine, College of Medicine, Korea University, Seoul, Republic of Korea
| | - Hee Young Lee
- Center for Preventive Medicine and Public Health, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Hyeong Sik Ahn
- Institute for Evidence-based Medicine, The Korean Branch of Australasian Cochrane Center, Department of Preventive Medicine, College of Medicine, Korea University, Seoul, Republic of Korea
| | - Sung Woo Lee
- Department of Emergency Medicine, College of Medicine, Korea University Hospital, Seoul, Republic of Korea.
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The duration of cardiopulmonary resuscitation in emergency departments after out-of-hospital cardiac arrest is associated with the outcome: A nationwide observational study. Resuscitation 2015; 96:323-7. [DOI: 10.1016/j.resuscitation.2015.05.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 05/02/2015] [Accepted: 05/08/2015] [Indexed: 01/31/2023]
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Khan AM, Kirkpatrick JN, Yang L, Groeneveld PW, Nadkarni VM, Merchant RM. Age, sex, and hospital factors are associated with the duration of cardiopulmonary resuscitation in hospitalized patients who do not experience sustained return of spontaneous circulation. J Am Heart Assoc 2015; 3:e001044. [PMID: 25520328 PMCID: PMC4338690 DOI: 10.1161/jaha.114.001044] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Variability in the duration of attempted in‐hospital cardiopulmonary resuscitation (CPR) is high, but the factors influencing termination of CPR efforts are unknown. METHODS AND RESULTS We examined the association between patient and hospital characteristics and CPR duration in 45 500 victims of in‐hospital cardiac arrest who did not experience return of spontaneous circulation (ROSC) and who were enrolled in the Get With the Guidelines registry between 2001 and 2010. In a secondary analysis, we performed analyses in 46 168 victims of in‐hospital cardiac arrest who experienced ROSC. We used ordered logistic regression to identify factors associated with CPR duration. Analyses were conducted by tertile of CPR duration (tertiles: ROSC group: 2 to 7, 8 to 17, and 18 to 120 minutes; no‐ROSC group: 2 to 16, 17 to 26, 27 to 120 minutes). In those without ROSC, younger age (aged 18 to 40 versus >65 years; odds ratio [OR] 1.81; 95% CI 1.69 to 1.95; P<0.001), female sex (OR 1.05; 95% CI 1.02 to 1.09; P=0.005), ventricular tachycardia or fibrillation (OR 1.50; 95% CI 1.42 to 1.58; P<0.001), and the need to place an invasive airway (OR 2.59; 95% CI 2.46 to 2.72; P<0.001) were associated with longer CPR duration. In those with ROSC, ventricular tachycardia or fibrillation (OR 0.89; 95% CI 0.85 to 0.93; P<0.001) and witnessed events (OR 0.87; 95% CI 0.82 to 0.91; P<0.001) were associated with shorter duration. CONCLUSIONS Age and sex were associated with attempted CPR duration in patients who do not experience ROSC after in‐hospital cardiac arrest but not in those who experience ROSC. Understanding the mechanism of these interactions may help explain variability in outcomes for in‐hospital cardiac arrest.
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Affiliation(s)
- Abigail M Khan
- Divisions of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA
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Mosca MS, Narotsky DL, Mochari-Greenberger H, Liao M, Mongero L, Beck J, Bacchetta M. Duration of conventional cardiopulmonary resuscitation prior to extracorporeal cardiopulmonary resuscitation and survival among adult cardiac arrest patients. Perfusion 2015; 31:200-6. [PMID: 26081930 DOI: 10.1177/0267659115589399] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the association between survival and the duration of conventional cardiopulmonary resuscitation (CCPR) prior to extracorporeal cardiopulmonary resuscitation (ECPR) and possible confounding factors. METHODS This was a retrospective analysis of 31 adults who received ECPR at an academic medical center between 2004 and 2013. Odds of 30-day survival and Kaplan Meier survival curves were compared among patients who received CCPR ⩾ 45 min (n=8, 26%) vs. <45 min (n=23, 74%). RESULTS There was a trend for greater survival up to 14 days in patients who received CCPR <45 vs. ⩾ 45 minutes (57% vs. 50%) with no significant difference at 30 days (OR 1.09, 95% CI 0.22-5.45) and survival did not differ by demographic factors. CONCLUSION More than half of all patients who received ECPR survived to 30 days. Longer duration CCPR was associated with reduced survival within 2 weeks, but not at 30 days.
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Affiliation(s)
- Matthew S Mosca
- SpecialtyCare Inc., University of Colorado Hospital, Aurora, CO, USA
| | - David L Narotsky
- Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | | | - Ming Liao
- Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - Linda Mongero
- Department of Cardiovascular Perfusion, Columbia University Medical Center/New York Presbyterian Hospital, New York, NY, USA
| | - James Beck
- Department of Cardiovascular Perfusion, Columbia University Medical Center/New York Presbyterian Hospital, New York, NY, USA
| | - Matthew Bacchetta
- Department of Cardiothoracic Surgery, Columbia University Medical Center, New York, NY, USA
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Quality of cardiopulmonary resuscitation of in-hospital cardiac arrest and its relation to clinical outcome: An Egyptian University Hospital Experience. Egypt Heart J 2015. [DOI: 10.1016/j.ehj.2014.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Mayo Registry for Telemetry Efficacy in Arrest (MR TEA) study: An analysis of code status change following cardiopulmonary arrest. Resuscitation 2015; 92:14-8. [PMID: 25891959 DOI: 10.1016/j.resuscitation.2015.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 03/27/2015] [Accepted: 04/09/2015] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Code status discussions are important during a hospitalization, yet variation in its practice exists. No data have assessed the likelihood of patients to change code status following a cardiopulmonary arrest. METHODS A retrospective review of all patients that experienced a cardiopulmonary arrest between May 1, 2008 and June 30, 2014 at an academic medical center was performed. The proportion of code status modifications to do not resuscitate (DNR) from full code was assessed. Baseline clinical characteristics, resuscitation factors, and 24-h post-resuscitation, hospital, and overall survival rates were compared between the two subsets. RESULTS A total of 157 patients survived the index event and were included. One hundred and fifteen (73.2%) patients did not have a change in code status following the index event, while 42 (26.8%) changed code status to DNR. Clinical characteristics were similar between subsets, although patients in the change to DNR subset were older (average age 67.7 years) compared to the full code subset (average age 59.2 years; p = 0.005). Patients in the DNR subset had longer overall resuscitation efforts with less attempts at defibrillation. Compared to the DNR subset, patients that remained full code demonstrated higher 24-h post-resuscitation (n = 108, 93.9% versus n = 32, 76.2%; p = 0.001) and hospital (n = 50, 43.5% versus n = 6, 14.3%; p = 0.001) survival rates. Patients in the DNR subset were more likely to have neurologic deficits on discharge and shorter overall survival. CONCLUSIONS Patient code status wishes do tend to change during critical periods within a hospitalization, adding emphasis for continued code status evaluation.
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Arima T, Nagata O, Sakaida K, Miura T, Kakuchi H, Ikeda K, Mizushima T, Takahashi A. Relationship between duration of prehospital resuscitation and favorable prognosis in ventricular fibrillation. Am J Emerg Med 2015; 33:677-81. [PMID: 25753293 DOI: 10.1016/j.ajem.2015.02.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 01/26/2015] [Accepted: 02/17/2015] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE There appears to be an optimal point in balancing the relative benefits of extending the resuscitation time to obtain return of spontaneous circulation in the prehospital setting and the initiation of therapies such as extracorporeal cardiopulmonary resuscitation (CPR). This study investigated how prehospital CPR duration is related to survival and neurologic outcome in ventricular fibrillation (VF) and tried to find the tolerable time for prehospital resuscitation. MATERIALS AND METHODS Out-of-hospital cardiac arrest patients with VF in Funabashi City, Japan, from January 2009 to December 2013 were reviewed. Resuscitation teams that included physicians were dispatched to incident sites. Survival rate at 24 hours and neurologic outcome at 30 days were analyzed with respect to prehospital CPR duration. RESULTS A total of 172 patients were evaluated. Seventy-three patients were alive at 24 hours. Thirty-four patients had favorable neurologic outcomes after 30 days. Of the 69 patients who required prolonged prehospital CPR (>30 minutes), 6 were alive at 24 hours, and only 1 had a favorable neurologic outcome at 30 days. Logistic regression model showed that both survival rate at 24 hours and neurologic outcome at 30 days deteriorated with the increase in prehospital CPR duration (both P < .001). CONCLUSION The prognosis of out-of-hospital cardiac arrest patients with VF deteriorated with the increase in prehospital CPR duration. Favorable results are less likely especially in cases of prolonged prehospital CPR (>30 minutes). Therefore, it may be necessary to consider transportation to a more definitive treatment facility rather than extending conventional CPR in the prehospital setting.
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Affiliation(s)
- Takahiro Arima
- Emergency Department, Funabashi Municipal Medical Center, Funabashi City, Chiba, Japan.
| | - Osamu Nagata
- Department of Anesthesiology, The Cancer Institute Hospital of JFCR, Koto Ward, Tokyo, Japan
| | - Koji Sakaida
- Emergency Department, Funabashi Municipal Medical Center, Funabashi City, Chiba, Japan
| | - Takeshi Miura
- Emergency Department, Funabashi Municipal Medical Center, Funabashi City, Chiba, Japan
| | - Hiroyuki Kakuchi
- Emergency Department, Funabashi Municipal Medical Center, Funabashi City, Chiba, Japan
| | - Katsuki Ikeda
- Emergency Department, Funabashi Municipal Medical Center, Funabashi City, Chiba, Japan
| | - Tomoya Mizushima
- Emergency Department, Funabashi Municipal Medical Center, Funabashi City, Chiba, Japan
| | - Azusa Takahashi
- Emergency Department, Funabashi Municipal Medical Center, Funabashi City, Chiba, Japan
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Kumagai K, Oda Y, Oshima C, Kaneko T, Kaneda K, Kawamura Y, Ogino Y, Yamashita S, Ichihara K, Maekawa T, Tsuruta R. Development of a prompt model for predicting neurological outcomes in patients with return of spontaneous circulation from out-of-hospital cardiac arrest. Acute Med Surg 2014; 2:176-182. [PMID: 29123717 DOI: 10.1002/ams2.96] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Accepted: 10/07/2014] [Indexed: 11/09/2022] Open
Abstract
Aim Early prediction of the neurological outcomes of patients with out-of-hospital cardiac arrest is important to select the optimal clinical management. We hypothesized that clinical data recorded at the site of cardiopulmonary resuscitation would be clinically useful. Methods This retrospective cohort study included patients with return of spontaneous circulation after cardiopulmonary resuscitation who were admitted to our university hospital between January 2000 and November 2013 or two affiliated hospitals between January 2006 and November 2013. Clinical parameters recorded on arrival included age (A), arterial blood pH (B), time from cardiopulmonary resuscitation to return of spontaneous circulation (C), pupil diameter (D), and initial rhythm (E). Glasgow Outcome Scale was recorded at 6 months and a favorable neurological outcome was defined as a score of 4-5 on the Glasgow Outcome Scale. Multiple logistic regression analysis was carried out to derive a formula to predict neurological outcomes based on basic clinical parameters. Results The regression equation was derived using a teaching dataset (total, n = 477; favourable outcome, n = 55): EP = 1/(1 + e-x ), where EP is the estimated probability of having a favorable outcome, and x = (-0.023 × A) + (3.296 × B) - (0.070 × C) - (1.006 × D) + (2.426 × E) - 19.489. The sensitivity, specificity, and accuracy were 80%, 92%, and 90%, respectively, for the validation dataset (total, n = 201; favourable outcome, n = 25). Conclusion The 6-month neurological outcomes can be predicted in patients resuscitated from out-of-hospital cardiac arrest using clinical parameters that can be easily recorded at the site of cardiopulmonary resuscitation.
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Affiliation(s)
- Kazumi Kumagai
- Advanced Medical Emergency and Critical Care Center Yamaguchi University Hospital Ube Yamaguchi Japan
| | - Yasutaka Oda
- Department of Stress and Bio-response Medicine Yamaguchi University Graduate School of Medicine Ube Yamaguchi Japan
| | - Chiyomi Oshima
- Advanced Medical Emergency and Critical Care Center Yamaguchi University Hospital Ube Yamaguchi Japan
| | - Tadashi Kaneko
- Advanced Medical Emergency and Critical Care Center Yamaguchi University Hospital Ube Yamaguchi Japan
| | - Kotaro Kaneda
- Advanced Medical Emergency and Critical Care Center Yamaguchi University Hospital Ube Yamaguchi Japan
| | - Yoshikatsu Kawamura
- Advanced Medical Emergency and Critical Care Center Yamaguchi University Hospital Ube Yamaguchi Japan
| | - Yasuaki Ogino
- Advanced Medical Emergency and Critical Care Center Yamaguchi University Hospital Ube Yamaguchi Japan
| | - Susumu Yamashita
- Emergency and Critical Care Center Tokuyama Central Hospital Shunan Yamaguchi Japan
| | - Kiyoshi Ichihara
- Department of Clinical Laboratory Science Faculty of Health Sciences Yamaguchi University Graduate School of Medicine Ube Yamaguchi Japan
| | - Tsuyoshi Maekawa
- Advanced Medical Emergency and Critical Care Center Yamaguchi University Hospital Ube Yamaguchi Japan.,Department of Stress and Bio-response Medicine Yamaguchi University Graduate School of Medicine Ube Yamaguchi Japan
| | - Ryosuke Tsuruta
- Advanced Medical Emergency and Critical Care Center Yamaguchi University Hospital Ube Yamaguchi Japan.,Department of Stress and Bio-response Medicine Yamaguchi University Graduate School of Medicine Ube Yamaguchi Japan
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Park SB, Yang JH, Park TK, Cho YH, Sung K, Chung CR, Park CM, Jeon K, Song YB, Hahn JY, Choi JH, Choi SH, Gwon HC, Suh GY. Developing a risk prediction model for survival to discharge in cardiac arrest patients who undergo extracorporeal membrane oxygenation. Int J Cardiol 2014; 177:1031-5. [PMID: 25443259 DOI: 10.1016/j.ijcard.2014.09.124] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Accepted: 09/23/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Limited data are available on a risk model for survival to discharge after extracorporeal membrane oxygenation (ECMO)-assisted cardiopulmonary resuscitation (ECPR). We aimed to develop a risk prediction model for survival to discharge in cardiac arrest patients who undergo ECMO. METHODS Between January 2004 and December 2012, 505 patients supported by ECMO were enrolled in a retrospective, observational registry. Among those, we studied 152 adult patients with in-hospital cardiac arrest. The primary outcome was survival to discharge. A new predictive scoring system, named the ECPR score, was developed to monitor survival to discharge using the β coefficients of prognostic factors from the logistic model, which were internally validated. RESULTS In-hospital death occurred in 104 patients (68.4%). In multivariate logistic regression, age ≤ 66, shockable arrest rhythm, CPR to ECMO pump-on time ≤ 38 min, post-ECMO arterial pulse pressure > 24 mmHg, and post-ECMO Sequential Organ Failure Assessment score ≤ 14 were independent predictors for survival to discharge. Survival to discharge was predicted by the ECPR score with a c-statistics of 0.8595 (95% confidence interval [CI], 0.80-0.92; p<0.001) which was similar to the c-statistics obtained from internal validation (training vs. test set; c-statistics, 0.86 vs. 0.86005; 95% CI, 0.80-0.92 vs. 0.77-0.94). The sensitivity and specificity for prediction of survival to discharge were 89.6% and 75.0%, respectively, when the ECPR score was >10. CONCLUSIONS The new risk prediction model might be helpful for decisions about ECPR management and could provide better information regarding early prognosis.
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Affiliation(s)
- Sung Bum Park
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Department of Medicine, Korean Armed Forces Capital Hospital, Seongnam, South Korea
| | - Jeong Hoon Yang
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea.
| | - Taek Kyu Park
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea
| | - Yang Hyun Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Kiick Sung
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Chi Ryang Chung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Chi Min Park
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Kyeongman Jeon
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Young Bin Song
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea
| | - Joo-Yong Hahn
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea
| | - Jin-Ho Choi
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea
| | - Seung-Hyuk Choi
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea
| | - Hyeon-Cheol Gwon
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea
| | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Zhu BF, Chen HL, Shen JH, Xing JL, Chen JR. The relationship between patients’ age and prognosis outcome after cardiopulmonary resuscitation in adults: A meta-analysis. Eur Geriatr Med 2014. [DOI: 10.1016/j.eurger.2014.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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van Gijn MS, Frijns D, van de Glind EMM, C van Munster B, Hamaker ME. The chance of survival and the functional outcome after in-hospital cardiopulmonary resuscitation in older people: a systematic review. Age Ageing 2014; 43:456-63. [PMID: 24760957 DOI: 10.1093/ageing/afu035] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND physicians are frequently confronted with the question whether cardiopulmonary resuscitation (CPR) is a medically appropriate treatment for older people. For physicians, patients and relatives, it is important to know the chance of survival and the functional outcome after CPR in order to make an informed decision. METHODS a systematic search was performed in MEDLINE, Embase and Cochrane up to November 2012. Studies that were included described the chance of survival, the social status and functional outcome after in-hospital CPR in older people aged 70 years and above. RESULTS we identified 11,377 publications of which 29 were included in this review; 38.6% of the patients who were 70 years and older had a return of spontaneous circulation. More than half of the patients who initially survived resuscitation died in the hospital before hospital discharge. The pooled survival to discharge after in-hospital CPR was 18.7% for patients between 70 and 79 years old, 15.4% for patients between 80 and 89 years old and 11.6% for patients of 90 years and older. Data on social and functional outcome after surviving CPR were scarce and contradictory. CONCLUSIONS the chance of survival to hospital discharge for in-hospital CPR in older people is low to moderate (11.6-18.7%) and decreases with age. However, evidence about functional or social outcomes after surviving CPR is scarce. Prospective studies are needed to address this issue and to identify pre-arrest factors that can predict survival in the older people in order to define subgroups that could benefit from CPR.
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Affiliation(s)
- Myke S van Gijn
- Geriatric Medicine, Diakonessenhuis, Prof Lorentzlaan 76, Zeist, Utrecht 3707 HL, Netherlands
| | - Dionne Frijns
- Geriatric Medicine, Diakonessenhuis, Prof Lorentzlaan 76, Zeist, Utrecht 3707 HL, Netherlands
| | - Esther M M van de Glind
- Section of Geriatrics, Internal Medicine, Academic Medical Center, Amsterdam, Noord-Holland, Netherlands
| | - Barbara C van Munster
- Section of Geriatrics, Internal Medicine, Academic Medical Center, Amsterdam, Noord-Holland, Netherlands
| | - Marije E Hamaker
- Geriatric Medicine, Diakonessenhuis, Prof Lorentzlaan 76, Zeist, Utrecht 3707 HL, Netherlands
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Kim WY, Giberson TA, Uber A, Berg K, Cocchi MN, Donnino MW. Neurologic outcome in comatose patients resuscitated from out-of-hospital cardiac arrest with prolonged downtime and treated with therapeutic hypothermia. Resuscitation 2014; 85:1042-6. [PMID: 24746783 DOI: 10.1016/j.resuscitation.2014.04.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Revised: 03/29/2014] [Accepted: 04/07/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Previous reports have shown that prolonged duration of resuscitation efforts in out-of-hospital cardiac arrest (OHCA) is associated with poor neurologic outcome. This concept has recently been questioned with advancements in post-cardiac arrest care including the use of therapeutic hypothermia (TH). The aim of this study was to determine the rate of good neurologic outcome based on the duration of resuscitation efforts in OHCA patients treated with TH. METHODS This prospective, observational, study was conducted between January 2008 and September 2012. Inclusion criteria consisted of adult non-traumatic OHCA patients who were comatose after return of spontaneous circulation (ROSC) and received TH. The primary endpoint was good neurologic outcome defined as a cerebral performance category score of 1 or 2. Downtime was calculated as the length of time between the patient being recognized as pulseless and ROSC. RESULTS 105 patients were treated with TH and 19 were excluded due to unknown downtime, leaving 86 patients for analysis. The median downtime was 18.5 (10.0-32.3)min and 33 patients (38.0%) had a good neurologic outcome. When downtime was divided into four groups (≤10min, 11-20min, 21-30min, >30min), good neurologic outcomes were 62.5%, 37%, 25%, and 21.7%, respectively (p=0.02). However, even with downtime >20min, 22.9% had a good neurologic outcome, and this percentage increased to 37.5% in patients with an initial shockable rhythm. CONCLUSIONS Although longer downtime is associated with worse outcome in OHCA patients, we found that comatose patients who have been successfully resuscitated and treated with TH have neurologically intact survival rates of 23% even with downtime >20min.
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Affiliation(s)
- Won Young Kim
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States; Department of Emergency Medicine, Ulsan University College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Tyler A Giberson
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Amy Uber
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Katherine Berg
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States; Department of Medicine, Division of Pulmonary and Critical Care, Beth Israel Deaconess Medical Center, United States
| | - Michael N Cocchi
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States; Department of Anesthesia Critical Care, Division of Critical Care, Beth Israel Deaconess Medical Center, United States
| | - Michael W Donnino
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States; Department of Medicine, Division of Pulmonary and Critical Care, Beth Israel Deaconess Medical Center, United States.
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Abstract
In-hospital cardiac arrests are common and associated with poor outcomes. Predicting the likelihood of favorable neurological survival following resuscitation from an in-hospital cardiac arrest could provide important information for physicians and families. In this article, we review the literature regarding predictors of survival following in-hospital cardiac arrest. Specifically, we describe the Cardiac Arrest Survival Postresuscitation In-hospital (CASPRI) score that was recently developed and validated using data from the Get With the Guidelines-Resuscitation registry. The CASPRI score includes 11 predictor variables: age, initial cardiac arrest rhythm, defibrillation time, baseline neurological status, duration of resuscitation, mechanical ventilation, renal insufficiency, hepatic insufficiency, sepsis, malignancy, and hypotension. The score is simple to use at the bedside, has excellent discrimination and calibration, and provides robust estimates of the probability of favorable neurological survival after an in-hospital cardiac arrest. Thus, CASPRI may be valuable in establishing expectations by physicians and families in the critical period after these high-risk events.
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Affiliation(s)
- Saket Girotra
- Department of Internal Medicine, Division of Cardiovascular Diseases, University of Iowa Carver College of Medicine, 200 Hawkins Drive, Suite 4427 RCP, Iowa City, IA, 52246, USA,
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Schopka S, Philipp A, Lunz D, Camboni D, Zacher R, Rupprecht L, Zimmermann M, Lubnow M, Keyser A, Arlt M, Schmid C, Hilker M. Single-center experience with extracorporeal life support in 103 nonpostcardiotomy patients. Artif Organs 2013; 37:150-6. [PMID: 23379286 DOI: 10.1111/j.1525-1594.2012.01544.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) has been successfully used to support patients with cardiac arrest failing to respond to conventional cardiopulmonary resuscitation (CPR). Preimplant factors being indicative for success are unknown up to now. The study describes single center experience with special focus on differences between survivors and nonsurvivors. Between 2002 and 2009, 103 patients were supported within the scope of CPR by means of ECMO. Besides primary diagnosis, duration, and outcome, pH, lactate, mean arterial pressure, aspartate aminotransferase, bilirubin, catecholamine dosage, and oxygenation ratio before ECMO, after 2 h, 1 day, and at explantation were analyzed. One hundred three patients (51.2 ± 16 years, 35 women, 68 men) were analyzed. Primary cardiac failure led to CPR in 54%. Duration of support was 4.8 ± 0.6 days. Twenty-nine (28.1%) patients survived to hospital discharge. On ECMO support, pH, lactate, and mean arterial pressure improved significantly. Catecholamine dosage was significantly reduced after ECMO implantation. Demographic data and primary diagnosis revealed no significant influence on outcome. pH, lactate, creatinine, and bilirubin differed significantly between survivors and nonsurvivors in the course of ECMO support. ECMO support during CPR reliably improves the circulatory and respiratory situation. Considering observed survival critical patient selection is mandatory. Although there are several significant differences between surviving patients and patients with fatal outcome, patient selection turns out to be difficult as clinically relevant factors show only limited predictive value. Future research should focus on better defining a population that may be best of all suited for the use of ECMO support in CPR.
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Affiliation(s)
- Simon Schopka
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany.
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Trummer G, Foerster K, Buckberg GD, Benk C, Mader I, Heilmann C, Liakopoulos O, Beyersdorf F. Superior neurologic recovery after 15 minutes of normothermic cardiac arrest using an extracorporeal life support system for optimized blood pressure and flow. Perfusion 2013; 29:130-8. [PMID: 23885022 DOI: 10.1177/0267659113497776] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Sudden cardiac arrest is one of the leading causes of death. Conventional CPR techniques after cardiac arrest provide circulation with reduced and varying blood flow and pressure. We hypothesize that using pressure- and flow-controlled reperfusion of the whole body improves neurological recovery and survival after 15 min of normothermic cardiac arrest. METHODS Pigs were randomized in two experimental groups and exposed to 15 min of ventricular fibrillation (VF). After this period, the animals in the control group received conventional CPR with open chest compression (n=6), while circulation in the treatment group (n=6) was established with an extracorporeal life support system (ECLS) to control blood pressure and flow. Follow-up included the assessment of neurological recovery and magnetic resonance imaging (MRI) for up to 7 days. RESULTS Five of the six animals in the control group died, one animal was resuscitated successfully. In the treatment group, 1/6 could not be separated from ECLS. Five out of the six pigs survived and were transferred to the animal facility. One animal was unable to walk and had to be sacrificed 30 hours after ECLS. The remaining 4 animals of the treatment group and the surviving pig from the control group showed complete neurological recovery. Brain MRI revealed no pathological changes. CONCLUSION We were able to demonstrate a significant improvement in survival after 15 minutes of normothermic cardiac arrest. These results support our hypothesis that using an ECLS for pressure- and flow-controlled circulation after circulatory arrest is superior to conventional CPR.
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Affiliation(s)
- G Trummer
- 1Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany
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Blood pH is a useful indicator for initiation of therapeutic hypothermia in the early phase of resuscitation after comatose cardiac arrest: a retrospective study. J Emerg Med 2013; 45:57-64. [PMID: 23623286 DOI: 10.1016/j.jemermed.2012.11.095] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2012] [Revised: 07/10/2012] [Accepted: 11/04/2012] [Indexed: 10/26/2022]
Abstract
BACKGROUND Therapeutic hypothermia (TH) is one of the key treatments after cardiac arrest (CA). Selection of post-CA patients for TH remains problematic, as there are no clinically validated tools to determine who might benefit from the therapy. OBJECTIVE The aim of this study was to investigate retrospectively whether laboratory findings or other patient data obtained during the early phase of hospital admission could be correlated with neurological outcome after TH in comatose survivors of CA. METHODS Medical charts of witnessed CA patients admitted between June 2003 and July 2009 who were treated with TH were reviewed retrospectively. The subjects were grouped based on their cerebral performance category (CPC) 6 months after CA, as either good recovery (GR) for CPC 1-2 or non-good recovery (non-GR) for CPC 3-5. The following well-known determinants of outcome obtained during the early phase of hospital admission were evaluated: age, gender, body mass index, cardiac origin, presence of ventricular fibrillation (VF), time from collapse to cardiopulmonary resuscitation, time from collapse to return of spontaneous circulation, body temperature, arterial blood gases, and blood test results. RESULTS We analyzed a total of 50 (25 GR and 25 non-GR) patients. Multivariate logistic analysis showed that initial heart rhythm and pH levels were significantly higher in the GR group than in the non-GR group (ventricular tachycardia/VF rate: p = 0.055, 95% confidence interval [CI] 0.768-84.272, odds ratio [OR] 8.047; pH: 7.155 ± 0.139 vs. 6.895 ± 0.100, respectively, p < 0.001, 95% CI 1.838-25.827; OR 6.89). CONCLUSION These results imply that in addition to initial heart rhythm, pH level may be a good candidate for neurological outcome predictor even though previous research has found no correlation between initial pH value and neurological outcome.
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Khasawneh FA, Kamel MT, Abu-Zaid MI. Predictors of cardiopulmonary arrest outcome in a comprehensive cancer center intensive care unit. Scand J Trauma Resusc Emerg Med 2013; 21:18. [PMID: 23510300 PMCID: PMC3606609 DOI: 10.1186/1757-7241-21-18] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Accepted: 03/14/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Some comprehensive cancer centers in industrialized countries have reported improved outcomes in their cardiopulmonary arrest (CPA) patients. Little is known about the outcomes and predictors of CPA in cancer centers in other parts of the world. The objective of this study was to examine the predictors of CPA outcome in a comprehensive cancer center closed medical-surgical intensive care unit (ICU) located in Amman, Jordan. METHODS In this retrospective single-center cohort study, we identified 104 patients who had a CPA during their stay in the ICU between 1/1/2008 and 6/30/2009. Demographic data and CPA-related variables and outcome were extracted from medical records. Comparisons between different variables and CPA outcome were conducted using logistic regression. RESULTS The mean age of the group was 49.7 ± 15.3 years. The mean APACHE II score was 23.7 ± 8.0. Thirty six patients (34.6%) were resuscitated successfully but 8 of them (7.7% of the cohort) left the ICU alive and only 6 out of the 8 (5.8% of the cohort) left the hospital alive. The following variables predict resuscitation failure: acute kidney injury (OR 1.7, CI: 1.1-2.6), being on mechanical ventilation (OR 3.8, CI: 1.3-11), refractory shock (OR 4.7, CI: 1.8-12) and CPR duration (OR 1.1, CI: 1.1-1.2). CONCLUSION Survival among cancer patients who develop CPA in the ICU continues to be poor. Once cancer patients suffered a CPA in the ICU multiple factors predicted resuscitation failure but CPR duration was the only factor that predicted resuscitation failure and ICU as well as hospital mortality.
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Affiliation(s)
- Faisal A Khasawneh
- Section of Critical Care Medicine, Department of Internal Medicine, School of Medicine, Texas Tech University Health Sciences Center, Amarillo, Texas 79106, USA.
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Xue FS, Liao X, Cheng Y. Duration of resuscitation efforts and survival after in-hospital cardiac arrest. Lancet 2013; 381:445-6. [PMID: 23399062 DOI: 10.1016/s0140-6736(13)60237-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Jung JY, Kim Y, Kim JE. Usefulness of the bispectral index during cardiopulmonary resuscitation -A case report-. Korean J Anesthesiol 2013; 64:69-72. [PMID: 23372890 PMCID: PMC3558654 DOI: 10.4097/kjae.2013.64.1.69] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Revised: 03/26/2012] [Accepted: 03/29/2012] [Indexed: 12/03/2022] Open
Abstract
The usefulness of using the bispectral index (BIS) for monitoring during cardiopulmonary resuscitation (CPR) is not clearly understood. However, BIS has been a popular anesthetic monitoring device used during operations. The case presented is of a pregnant woman going into cardiac arrest due to an amniotic fluid embolism during a Cesarean section. CPR was performed, but neither the return of spontaneous circulation (ROSC) nor the return of consciousness was achieved, despite 50 min of effective CPR. However, CPR was continued based on BIS. ROSC was achieved, and an alert consciousness state was reached 1 day postoperation. This finding suggests that BIS be used as a basic monitoring device during CPR and that it may help in deciding to continue CPR.
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Affiliation(s)
- Jin Yong Jung
- Department of Anesthesiology and Pain Medicine, School of Medicine, Catholic University of Daegu, Daegu, Korea
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Chapman R, Watkins R, Bushby A, Combs S. Family-Witnessed Resuscitation: Perceptions of Nurses and Doctors Working in an Australian Emergency Department. ACTA ACUST UNITED AC 2012. [DOI: 10.5402/2012/369423] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Inconsistencies abound in the literature regarding staff attitudes and perceptions toward family-witnessed resuscitation. Our study builds on previous research by using a validated tool to investigate emergency department staff perceptions of family-witnessed resuscitation. A cross-sectional survey was distributed to 221 emergency department doctors' and nurses'. We found few differences between doctors and nurses perceptions toward family-witnessed resuscitation. Both nurses and doctors who held a specialty certification, who were more highly qualified, who had more experience with family presence during resuscitation, and who had a personal preference for having family members present during their own resuscitation perceived more benefits and fewer risks, as well as more confidence in their ability to manage these events. However, nurses more than doctors want patients to provide advanced directives for family presence. The findings will enable clinicians, educators, and hospital management to provide better support to all stakeholders through these events.
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Affiliation(s)
- Rose Chapman
- School of Nursing and Midwifery, Curtin University, GPO Box U1987, Perth, WA 6845, Australia
- Nursing Executive, Joondalup Health Campus, Shenton Avenue, Joondalup, WA 6027, Australia
| | - Rochelle Watkins
- Telethon Institute for Child Health Research, Centre for Child Health Research, The University of Western Australia, P.O. Box 855, West Perth, WA 6872, Australia
| | - Angela Bushby
- Department of Emergency, Joondalup Health Campus, Shenton Avenue, Joondalup, WA 6027, Australia
| | - Shane Combs
- Nursing Executive, Joondalup Health Campus, Shenton Avenue, Joondalup, WA 6027, Australia
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Goldberger ZD, Chan PS, Berg RA, Kronick SL, Cooke CR, Lu M, Banerjee M, Hayward RA, Krumholz HM, Nallamothu BK. Duration of resuscitation efforts and survival after in-hospital cardiac arrest: an observational study. Lancet 2012; 380:1473-81. [PMID: 22958912 PMCID: PMC3535188 DOI: 10.1016/s0140-6736(12)60862-9] [Citation(s) in RCA: 278] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND During in-hospital cardiac arrests, how long resuscitation attempts should be continued before termination of efforts is unknown. We investigated whether duration of resuscitation attempts varies between hospitals and whether patients at hospitals that attempt resuscitation for longer have higher survival rates than do those at hospitals with shorter durations of resuscitation efforts. METHODS Between 2000 and 2008, we identified 64,339 patients with cardiac arrests at 435 US hospitals within the Get With The Guidelines—Resuscitation registry. For each hospital, we calculated the median duration of resuscitation before termination of efforts in non-survivors as a measure of the hospital's overall tendency for longer attempts. We used multilevel regression models to assess the association between the length of resuscitation attempts and risk-adjusted survival. Our primary endpoints were immediate survival with return of spontaneous circulation during cardiac arrest and survival to hospital discharge. FINDINGS 31,198 of 64,339 (48·5%) patients achieved return of spontaneous circulation and 9912 (15·4%) survived to discharge. For patients achieving return of spontaneous circulation, the median duration of resuscitation was 12 min (IQR 6-21) compared with 20 min (14-30) for non-survivors. Compared with patients at hospitals in the quartile with the shortest median resuscitation attempts in non-survivors (16 min [IQR 15-17]), those at hospitals in the quartile with the longest attempts (25 min [25-28]) had a higher likelihood of return of spontaneous circulation (adjusted risk ratio 1·12, 95% CI 1·06-1·18; p<0·0001) and survival to discharge (1·12, 1·02-1·23; 0·021). INTERPRETATION Duration of resuscitation attempts varies between hospitals. Although we cannot define an optimum duration for resuscitation attempts on the basis of these observational data, our findings suggest that efforts to systematically increase the duration of resuscitation could improve survival in this high-risk population. FUNDING American Heart Association, Robert Wood Johnson Foundation Clinical Scholars Program, and the National Institutes of Health.
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Affiliation(s)
- Zachary D Goldberger
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI 48109-5869, USA
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Möhnle P, Huge V, Polasek J, Weig I, Atzinger R, Kreimeier U, Briegel J. Survival after cardiac arrest and changing task profile of the cardiac arrest team in a tertiary care center. ScientificWorldJournal 2012; 2012:294512. [PMID: 22654585 PMCID: PMC3361298 DOI: 10.1100/2012/294512] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Accepted: 01/10/2012] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND The characteristics of in-hospital emergency response systems, survival rates, and variables associated with survival after in-hospital cardiac arrest vary significantly among medical centers worldwide. Aiming to optimize in-hospital emergency response, we performed an analysis of survival after in-hospital cardiopulmonary resuscitation and the task profile of our cardiac arrest team. METHODS In-hospital emergencies handled by the cardiac arrest team in the years 2004 to 2006 were analyzed retrospectively, and patient and event characteristics were tested for their associations with survival after cardiopulmonary resuscitation. The results were compared to a similar prior analysis for the years 1995 to 1997. RESULTS After cardiopulmonary resuscitation, the survival rate to discharge was 30.2% for the years 2004 to 2006 compared to 25.1% for the years 1995 to 1997 (difference not statistically significant). Survival after one year was 18.5 %. An increasing percentage of emergency calls not corresponding to medical emergencies other than cardiac arrest was observed. CONCLUSIONS The observed survival rates are considerably high to published data. We suggest that for further improvement of in-hospital emergency response systems regular training of all hospital staff members in immediate life support is essential. Furthermore, future training of cardiac arrest team members must include basic emergency response to a variety of medical conditions besides cardiac arrest.
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Affiliation(s)
- Patrick Möhnle
- Klinik für Anaesthesiologie der Universität München, Marchioninistraße 15, 81377 München, Germany.
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Boller M, Boller EM, Oodegard S, Otto CM. Small animal cardiopulmonary resuscitation requires a continuum of care: proposal for a chain of survival for veterinary patients. J Am Vet Med Assoc 2012; 240:540-54. [DOI: 10.2460/javma.240.5.540] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Rajab TK, Pozner CN, Conrad C, Cohn LH, Schmitto JD. Technique for chest compressions in adult CPR. World J Emerg Surg 2011; 6:41. [PMID: 22152601 PMCID: PMC3261806 DOI: 10.1186/1749-7922-6-41] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2011] [Accepted: 12/10/2011] [Indexed: 11/18/2022] Open
Abstract
Chest compressions have saved the lives of countless patients in cardiac arrest as they generate a small but critical amount of blood flow to the heart and brain. This is achieved by direct cardiac massage as well as a thoracic pump mechanism. In order to optimize blood flow excellent chest compression technique is critical. Thus, the quality of the delivered chest compressions is a pivotal determinant of successful resuscitation. If a patient is found unresponsive without a definite pulse or normal breathing then the responder should assume that this patient is in cardiac arrest, activate the emergency response system and immediately start chest compressions. Contra-indications to starting chest compressions include a valid Do Not Attempt Resuscitation Order. Optimal technique for adult chest compressions includes positioning the patient supine, and pushing hard and fast over the center of the chest with the outstretched arms perpendicular to the patient's chest. The rate should be at least 100 compressions per minute and any interruptions should be minimized to achieve a minimum of 60 actually delivered compressions per minute. Aggressive rotation of compressors prevents decline of chest compression quality due to fatigue. Chest compressions are terminated following return of spontaneous circulation. Unconscious patients with normal breathing are placed in the recovery position. If there is no return of spontaneous circulation, then the decision to terminate chest compressions is based on the clinical judgment that the patient's cardiac arrest is unresponsive to treatment. Finally, it is important that family and patients' loved ones who witness chest compressions be treated with consideration and sensitivity.
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Affiliation(s)
- Taufiek K Rajab
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Palliative medicine consultation impacts DNR designation and length of stay for terminal medical MICU patients. Palliat Support Care 2011; 9:401-6. [DOI: 10.1017/s1478951511000423] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractObjective:The purpose of this study was to assess the impact of a palliative medicine consultation on medical intensive care unit (MICU) and hospital length of stay, Do Not Resuscitate (DNR) designation, and location of death for MICU patients who died during hospitalization.Method:A comparison of two retrospective cohorts in a 17-bed MICU in a tertiary care university-affiliated hospital was conducted. Patients admitted to the MICU between January 1, 2003 and June 30, 2004 (N = 515) were compared to MICU patients who had had a palliative medicine consultation between January 1, 2005 and June 1, 2009 (N = 693). To control for disease severity, only patients in both cohorts who died during their hospitalization were considered for this study.Results:Palliative medicine consultation reduced time until death during the entire hospitalization (log-rank test,p < 0.01). Time from MICU admission until death was also reduced (log-rank test,p < 0.01), further demonstrating the impact of the palliative care consultation on the duration of dying for hospitalized patients. The intervention group contained a significantly higher percentage of patients with a DNR designation at death than did the control group (86% vs. 68%, χ2test,p < 0.0001).Significance of results:Palliative medicine consultation is associated with an increased rate of DNR designation and reduced time until death. Patients in the intervention group were also more likely to die outside the MICU as compared to controls in the usual care group.
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Ebell MH, Afonso AM. Pre-arrest predictors of failure to survive after in-hospital cardiopulmonary resuscitation: a meta-analysis. Fam Pract 2011; 28:505-15. [PMID: 21596693 DOI: 10.1093/fampra/cmr023] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Our objective was to perform a systematic review of pre-arrest predictors of the outcome of in-hospital cardiopulmonary resuscitation (CPR) in adults. METHODS We searched PubMed for studies published since 1985 and bibliographies of previous meta-analyses. We included studies with predominantly adult patients, limited to in-hospital arrest, using an explicit definition of cardiopulmonary arrest and CPR and reporting survival to discharge by at least one pre-arrest variable. A total of 35 studies were included in the final analysis. Inclusion criteria, design elements and results were abstracted in parallel by both investigators. Discrepancies were resolved by consensus. RESULTS The rate of survival to discharge was 17.5%; we found a trend towards increasing survival in more recent studies. Metastatic malignancy [odds ratio (OR) 3.9] or haematologic malignancy (OR 3.9), age over 70, 75 or 80 years (OR 1.5, 2.8 and 2.7, respectively), black race (OR 2.1), altered mental status (OR 2.2), dependency for activities of daily living (range OR 3.2-7.0 depending on specific activity), impaired renal function (OR 1.9), hypotension on admission (OR 1.8) and admission for pneumonia (OR 1.7), trauma (OR 1.7) or medical non-cardiac diagnosis (OR 2.2) were significantly associated with failure to survive to discharge; cardiovascular diagnoses and co-morbidities were associated with improved survival (range OR 0.23-0.53). Elevated CPR risk scores predicted failure to survive but have not been validated consistently in different populations. CONCLUSIONS We identified several pre-arrest variables associated with failure to survive to discharge. This information should be shared with patients as part of a shared decision-making process regarding the use of do not resuscitate orders.
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Affiliation(s)
- Mark H Ebell
- Department of Epidemiology and Biostatistics, University of Georgia, Athens, GA 30602, USA.
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Sladjana A, Gordana P, Ana S. Emergency response time after out-of-hospital cardiac arrest. Eur J Intern Med 2011; 22:386-93. [PMID: 21767757 DOI: 10.1016/j.ejim.2011.04.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Revised: 02/20/2011] [Accepted: 04/08/2011] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To investigate the emergency response time after out-of-hospital cardiac arrest (OHCA) in four cities in Serbia. METHODS A prospective, two-year, multicenter study was designed. Using the Utstein template we recorded out-of-hospital CPR (OHCPR) and analyzed the time sequence segment of the variables in OHCA and CPR gold standards. Multivariable logistic regression models were developed using emergency response time as the primary independent variable and survival to return of spontaneous circulation (ROSC), survival to hospital discharge (HD), and one-year survival (1y) as the dependent variable. ROC curves represent cut off time dependent survival data. RESULTS During the study period, the median time of recognition OHCA was 5.5 min, call receipt was 1 min and the call-response interval was 7 min. The median time required to verify OHCA and ALS onset was 10 min. ALS was carried on for 30.5 min (SD=21.3). Abandonment of further CPR/death occurred after 29 min. The first defibrillation shock was performed after 13.3±9.0 min, endotracheal tube was placed after 16.8±9.4 min and the first adrenaline dose was injected after 18.9±9.3 min. Higher survival (ROSC, HD, 1y) rate was found when CPR is performed within the first 4 min after OHCA. CONCLUSION The emergency response time within 4 min was associated with improved survival to ROSC, HD and 1y after OHCA. Despite the fact that our results are in accordance with the findings published in other papers, there is still a need to take all appropriate measures in order to decrease the emergency response time after OHCA.
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Hospital do-not-resuscitate orders: why they have failed and how to fix them. J Gen Intern Med 2011; 26:791-7. [PMID: 21286839 PMCID: PMC3138592 DOI: 10.1007/s11606-011-1632-x] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Revised: 12/16/2010] [Accepted: 12/27/2010] [Indexed: 12/11/2022]
Abstract
Do-not-resuscitate (DNR) orders have been in use in hospitals nationwide for over 20 years. Nonetheless, as currently implemented, they fail to adequately fulfill their two intended purposes--to support patient autonomy and to prevent non-beneficial interventions. These failures lead to serious consequences. Patients are deprived of the opportunity to make informed decisions regarding resuscitation, and CPR is performed on patients who would have wanted it withheld or are harmed by the procedure. This article highlights the persistent problems with today's use of inpatient DNR orders, i.e., DNR discussions do not occur frequently enough and occur too late in the course of patients' illnesses to allow their participation in resuscitation decisions. Furthermore, many physicians fail to provide adequate information to allow patients or surrogates to make informed decisions and inappropriately extrapolate DNR orders to limit other treatments. Because these failings are primarily due to systemic factors that result in deficient physician behaviors, we propose strategies to target these factors including changing the hospital culture, reforming hospital policies on DNR discussions, mandating provider communication skills training, and using financial incentives. These strategies could help overcome existing barriers to proper DNR discussions and align the use of DNR orders closer to their intended purposes of supporting patient self-determination and avoiding non-beneficial interventions at the end of life.
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