Incidence and Outcomes of Cardiopulmonary Resuscitation in ICUs: Retrospective Cohort Analysis

COMPLICATED CARDIAC ARREST AND ITS RESUSCITATION CHARACTERISTICS IN PATIENTS WITH INTRACEREBRAL HEMORRHAGE: CHINESE STROKE CENTER ALLIANCE

ABSTRACT

Objective: Cardiac arrest (CA) is one of the most severe complications in patients with intracerebral hemorrhage (ICH), increasing the risk of death. This study explored the factors influencing CA occurrence and its resuscitation characteristics in ICH patients. Methods: Data were retrieved from the Chinese Stroke Center Alliance database. The primary outcome was CA, and the secondary outcomes were in-hospital death and survival post- CA. Absolute standardized and rate differences were utilized for intergroup comparisons, while logistic regression was employed for correlation analysis. Results: A total of 85,105 patients were enrolled in this study. Among them, 1651 (1.9%) patients experienced CA, of whom 1032 (62.5%) died in hospital. At baseline, prehospital notification from the emergency medical service system was a co-factor influencing CA occurrence and the presence of a death outcome (OR: 1.71, 95% CI: 1.47-1.98, P < 0.001; OR: 0.50, 95% CI: 0.41-0.62, P < 0.001). In terms of complications, posthospital hematoma expansion and swallowing dysfunction were co-factors influencing CA occurrence and the presence of a death outcome (OR: 3.78, 95% CI: 3.20-4.47, P < 0.001, OR: 1.39, 95% CI: 1.11-1.76; P < 0.001; OR: 7.66, 95% CI: 5.48-10.70, P < 0.001, OR: 1.66, 95% CI: 1.08-2.57, P < 0.001). The incidence of CA in ICH patients decreased annually from 2015 to 2019, while survival after CA increased annually ( P < 0.001). Conclusions: Prehospital notification from the emergency medical service system, posthospital hematoma expansion, and swallowing dysfunction were identified as co-factors contributing to CA occurrence and post-CA mortality following ICH. The proportion of CA patients following ICH decreased, while survival rates improved annually from 2015 to 2019.

Intensive care unit cardiac arrest among very elderly critically ill patients - is cardiopulmonary resuscitation justified?

INTRODUCTION

The proportion of very elderly patients in the intensive care unit (ICU) is expected to rise. Furthermore, patients are likely more prone to suffer a cardiac arrest (CA) event within the ICU. The occurrence of intensive care unit cardiac arrest (ICU-CA) is associated with high mortality. To date, the incidence of ICU-CA and its clinical impact on outcome in the very old (≥ 90 years) patients treated is unknown.

METHODS

Retrospective analysis of all consecutive critically ill patients ≥ 90 years admitted to the ICU of a tertiary care university hospital in Hamburg (Germany). All patients suffering ICU-CA were included and CA characteristics and functional outcome was assessed. Clinical course and outcome were assessed and compared between the subgroups of patients with and without ICU-CA.

RESULTS

1,108 critically ill patients aged ≥ 90 years were admitted during the study period. The median age was 92.3 (91.0-94.2) years and 67% (n = 747) were female. 2% (n = 25) of this cohort suffered ICU-CA after a median duration 0.5 (0.2-3.2) days of ICU admission. The presumed cause of ICU-CA was cardiac in 64% (n = 16). The median resuscitation time was 10 (2-15) minutes and the initial rhythm was shockable in 20% (n = 5). Return of spontaneous circulation (ROSC) could be achieved in 68% (n = 17). The cause of ICU admission was primarily medical in the total cohort (ICU-CA: 48% vs. No ICU-CA: 34%, p = 0.13), surgical - planned (ICU-CA: 32% vs. No ICU-CA: 37%, p = 0.61) and surgical - unplanned/emergency (ICU-CA: 43% vs. No ICU-CA: 28%, p = 0.34). The median Charlson Comorbidity Index (CCI) was 2 (1-3) points for patients with ICU-CA and 1 (0-2) for patients without ICU-CA (p = 0.54). Patients with ICU-CA had a higher disease severity according to SAPS II (ICU-CA: 54 vs. No ICU-CA: 36 points, p < 0.001). Patients with ICU-CA had a higher rate of mechanically ventilation (ICU-CA: 64% vs. No ICU-CA: 34%, p < 0.01) and required vasopressor therapy more often (ICU-CA: 88% vs. No ICU-CA: 41%, p < 0.001). The ICU and in-hospital mortality was 88% (n = 22) and 100% (n = 25) in patients with ICU-CA compared to 17% (n = 179) and 28% (n = 306) in patients without ICU-CA. The mortality rate for patients with ICU-CA was observed to be 88% (n = 22) in the ICU and 100% (n = 25) in-hospital. In contrast, patients without ICU-CA had an in-ICU mortality rate of 17% (n = 179) and an in-hospital mortality rate of 28% (n = 306) (both p < 0.001).

CONCLUSION

The occurrence of ICU-CA in very elderly patients is rare but associated with high mortality. Providing CPR in this cohort did not lead to long-term survival at our centre. Very elderly patients admitted to the ICU likely benefit from supportive care only and should probably not be resuscitated due to poor chance of survival and ethical considerations. Providing personalized assurances that care will remain appropriate and in accordance with the patient's and family's wishes can optimise compassionate care while avoiding futile life-sustaining interventions.

Survival of In-Hospital Cardiopulmonary Arrest in Trauma Patients

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Intensive Care Admissions and Outcome of Cardiac Arrests; A National Cohort Study From the United States

OBJECTIVE

Outcomes of cardiac arrest among patients who had cardiopulmonary resuscitation (CPR) in intensive care units (ICU) has limited data on the national level basis in the United States. We aimed to study the outcomes of ICU CPRs.

METHODS

Data from the national readmissions database (NRD) sample that constitutes 49.1% of the stratified sample of all hospitals in the United States were analyzed for ICU-related hospitalizations for the years 2016 to 2019. ICU CPR was defined by procedure codes.

RESULTS

A total of 4,610,154 ICU encounters were reported for the years 2016 to 2019 in the NRD. Of these patients, 426,729 (9.26%) had CPR procedure recorded during the hospital encounter (mean age 65 ± 17.81; female 42.4%). And 167,597 (39.29%) patients had CPR on the day of admission, of which 63.16% died; while 64,752 (15.18%) patients had CPR on the day of ICU admission, of which 72.85% died. And 36,002 (8.44%) had CPR among patients with length of stay 2 days, of which 73.34% died. A total of 1,222,799 (26.5%) admitted to ICU died, and patients who had ICU CPR had higher mortality, 291,391(68.3%). Higher complication rates were observed among ICU CPR patients, especially who died. Over the years from 2016 to 2019, ICU CPR rates increased from 8.18% (2016) to 8.66% (2019); p-trend = 0.001. The mortality rates among patients admitted to ICU increased from 22.1% (2016) to 24.1% (2019); p-trend = 0.005.

CONCLUSION

The majority of ICU CPRs were done on the first day of ICU admission. The trend for ICU CPR was increasing. The mortality trend for overall ICU admissions has increased, which is concerning and would suggest further research to improve the high mortality rates in the CPR group.

Trends in Incidence and Outcomes of Cardiac Arrest Occurring in Swedish ICUs

OBJECTIVE

To determine temporal trends in the incidence of cardiac arrest occurring in the ICU (ICU-CA) and its associated long-term mortality.

DESIGN

Retrospective observational study.

SETTING

Swedish ICUs, between 2011 and 2017.

PATIENTS

Adult patients (≥18 yr old) recorded in the Swedish Intensive Care Registry (SIR).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

ICU-CA was defined as a first episode of cardiopulmonary resuscitation and/or defibrillation following an ICU admission, as recorded in SIR or the Swedish Cardiopulmonary Resuscitation Registry. Annual adjusted ICU-CA incidence trend (all admissions) was estimated using propensity score-weighted analysis. Six-month mortality trends (first admissions) were assessed using multivariable mixed-effects logistic regression. Analyses were adjusted for pre-admission characteristics (sex, age, socioeconomic status, comorbidities, medications, and healthcare utilization), illness severity on ICU admission, and admitting unit. We included 231,427 adult ICU admissions. Crude ICU-CA incidence was 16.1 per 1,000 admissions, with no significant annual trend in the propensity score-weighted analysis. Among 186,530 first admissions, crude 6-month mortality in ICU-CA patients was 74.7% (95% CI, 70.1-78.9) in 2011 and 68.8% (95% CI, 64.4-73.0) in 2017. When controlling for multiple potential confounders, the adjusted 6-month mortality odds of ICU-CA patients decreased by 6% per year (95% CI, 2-10). Patients admitted after out-of-hospital or in-hospital cardiac arrest had the highest ICU-CA incidence (136.1/1,000) and subsequent 6-month mortality (76.0% [95% CI, 73.6-78.4]).

CONCLUSIONS

In our nationwide Swedish cohort, the adjusted incidence of ICU-CA remained unchanged between 2011 and 2017. More than two-thirds of patients with ICU-CA did not survive to 6 months following admission, but a slight improvement appears to have occurred over time.