Survival From In-hospital Cardiac Arrest on the Internal Medicine Clinical Teaching Unit

Characteristics, therapies, and outcomes of In-Hospital vs Out-of-Hospital cardiac arrest in patients presenting to cardiac intensive care units: From the critical care Cardiology trials network (CCCTN)

BACKGROUND

Cardiac arrest (CA) is a common reason for admission to the cardiac intensive care unit (CICU), though the relative burden of morbidity, mortality, and resource use between admissions with in-hospital (IH) and out-of-hospital (OH) CA is unknown. We compared characteristics, care patterns, and outcomes of admissions to contemporary CICUs after IHCA or OHCA.

METHODS

The Critical Care Cardiology Trials Network is a multicenter network of tertiary CICUs in the US and Canada. Participating centers contributed data from consecutive admissions during 2-month annual snapshots from 2017 to 2021. We analyzed characteristics and outcomes of admissions by IHCA vs OHCA.

RESULTS

We analyzed 2,075 admissions across 29 centers (50.3% IHCA, 49.7% OHCA). Admissions with IHCA were older (median 66 vs 62 years), more commonly had coronary disease (38.3% vs 29.7%), atrial fibrillation (26.7% vs 15.6%), and heart failure (36.3% vs 22.1%), and were less commonly comatose on CICU arrival (34.2% vs 71.7%), p < 0.001 for all. IHCA admissions had lower lactate (median 4.3 vs 5.9) but greater utilization of invasive hemodynamics (34.3% vs 23.6%), mechanical circulatory support (28.4% vs 16.8%), and renal replacement therapy (15.5% vs 9.4%); p < 0.001 for all. Comatose IHCA patients underwent targeted temperature management less frequently than OHCA patients (63.3% vs 84.9%, p < 0.001). IHCA admissions had lower unadjusted CICU (30.8% vs 39.0%, p < 0.001) and in-hospital mortality (36.1% vs 44.1%, p < 0.001).

CONCLUSION

Despite a greater burden of comorbidities, CICU admissions after IHCA have lower lactate, greater invasive therapy utilization, and lower crude mortality than admissions after OHCA.

Efficacy and cost-feasibility of the Timely Chest Compression Training (T-CCT): a contextualized cardiopulmonary resuscitation training for personal support workers participating during in-hospital cardiac arrests

OBJECTIVES

The Timely Chest Compression Training (T-CCT) was created to promote more frequent training in chest compressions for personal support workers. This study aims to assess the efficacy of the T-CCT on the chest compression performance and to examine costs related to this intervention.

METHODS

A prospective single group, before-after study was conducted at a university-affiliated hospital. The T-CCT is adapted for support workers and lasts 20 min during working hours. Guided by peer trainers, live feedback devices and mannikins, the T-CCT targets chest compression training. Using an algorithm, chest compression performance scores were gathered before and after the intervention.

RESULTS

Of 875 employed support workers, 573 were trained in 5 days. Prior to the intervention, the median performance score was 72%. Participants significantly improved after the intervention (p < 0.001) and the median of the differences was 32% (95% CI 28.5-36.0). Support workers in critical care units and those with an active basic life support (BLS) certification performed better at baseline and were less inclined to have large changes in performance scores after the intervention. When compared to basic life support training, the T-CCT is over three times less expensive.

CONCLUSIONS

The T-CCT was an effective and low-cost initiative that allowed to train a large group of support workers in a short amount of time. Since they are actively involved in resuscitation efforts in Quebec (Canada), it may promote the delivery of high-quality compressions during in-hospital cardiac arrests. Our inquiry can incite and guide other organizations in the implementation of similar interventions.

One-Year Survival after Inhospital Cardiac Arrest-Does Prearrest Sepsis Matter?

AIM

Cardiac arrest is not a common complication of sepsis, although sepsis has been recognized as one condition behind cardiac arrest. Our aim was to evaluate the prevalence of sepsis among patients with inhospital cardiac arrest (IHCA), and to determine if sepsis is associated with inferior outcome after IHCA.

METHODS

All consecutive emergency team dispatches in Turku University Hospital in 2011 to 2014 (n = 607) were retrospectively reviewed to identify the patients undergoing cardiopulmonary resuscitation (CPR) for IHCA (n = 301). The patient records were reviewed for the criteria of severe sepsis, organ dysfunction, and chronic comorbidities before IHCA. Outcome was followed for 1 year.

RESULTS

The criteria for prearrest severe sepsis were met by 83/301 (28%) of the patients, and 93/301 (31%) had multiorgan dysfunction (3 or more organ systems). The patients with severe sepsis had higher mortality than those without severe sepsis, increasing from 30-day mortalities of 63/83 (76%) and 151/218 (69%), respectively (P = 0.256), to 1-year mortalities of 72/83 (87%) and 164/218 (75%), respectively (P = 0.030). Emergency admission, age, immunosuppression, DM, multiorgan dysfunction, and a nonshockable rhythm were independent predictors of 1-year mortality by multivariate logistic regression analysis. Six out of 83 patients with severe sepsis before IHCA (7%) survived 1 year with good neurological outcome (CPC scale 1).

CONCLUSIONS

A high proportion of patients with IHCA have sepsis and multiorgan dysfunction, and their prognosis is worse than the prognosis of patients with IHCA in general.

Perfusion parameters and target values during extracorporeal cardiopulmonary resuscitation: a scoping review protocol

INTRODUCTION

Extracorporeal cardiopulmonary resuscitation (eCPR) is increasingly applied in out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) patients. Treatment results are promising, but the efficacy and safety of the procedure are still unclear. Currently, there are no recommended target perfusion parameters during eCPR, the lack of which could result in inadequate (re)perfusion. We aim to perform a scoping review to explore the current literature addressing target perfusion parameters, target values, corresponding survival rates and neurologic outcomes in OHCA and IHCA patients treated with eCPR.

METHODS AND ANALYSIS

To identify relevant research, we will conduct searches in the electronic databases MEDLINE, EMBASE, Social Science Citation Index, Social Science Citation Index Expanded and the Cochrane library. We will also check references of relevant articles and perform a cited reference research (forward citation tracking).Two independent reviewers will screen titles and abstracts, check full texts for eligibility and perform data extraction. We will resolve dissent by consensus, moderated by a third reviewer. We will include observational and controlled studies addressing target perfusion parameters and outcomes such as survival rates and neurologic findings in OHCA and IHCA patients treated with eCPR. Data extraction tables will be set up, including study and patients' characteristics, aim of study, details on eCPR including target perfusion parameters and reported outcomes. We will summarise the data using tables and figures (ie, bubble plot) to present the research landscape and to describe potential clusters and/or gaps.

ETHICS AND DISSEMINATION

An ethical approval is not needed. We intend to publish the scoping review in a peer-reviewed journal and present results on a scientific meeting.

Real-time compression feedback for patients with in-hospital cardiac arrest: a multi-center randomized controlled clinical trial

Objective

To determine if real-time compression feedback using a non-automated hand-held device improves patient outcomes from in-hospital cardiac arrest (IHCA).

Methods

We conducted a prospective, randomized, controlled, parallel study (no crossover) of patients with IHCA in the mixed medical–surgical intensive care units (ICUs) of eight academic hospitals. Patients received either standard manual chest compressions or compressions performed with real-time feedback using the Cardio First Angel™ (CFA) device. The primary outcome was sustained return of spontaneous circulation (ROSC), and secondary outcomes were survival to ICU and hospital discharge.

Results

One thousand four hundred fifty-four subjects were randomized; 900 were included. Sustained ROSC was significantly improved in the CFA group (66.7% vs. 42.4%, P < 0.001), as was survival to ICU discharge (59.8% vs. 33.6%) and survival to hospital discharge (54% vs. 28.4%, P < 0.001). Outcomes were not affected by intra-group comparisons based on intubation status. ROSC, survival to ICU, and hospital discharge were noted to be improved in inter-group comparisons of non-intubated patients, but not intubated ones.

Conclusion

Use of the CFA compression feedback device improved event survival and survival to ICU and hospital discharge.

Trial registration

The study was registered with Clinicaltrials.gov (NCT02845011), registered retrospectively on July 21, 2016.

A Conceptual Framework to Reduce Inpatient Preventable Deaths

BACKGROUND

Efforts to reduce preventable deaths in the in-hospital setting should target both cardiopulmonary arrest (CPA) prevention and optimal resuscitation. This requires consideration of a broad range of clinical issues and processes. A comprehensive, integrated system of care (SOC) that links data collection with a modular education program to reduce preventable deaths has not been defined.

METHODS

This study was conducted in two urban university hospitals from 2005 to 2009. The Advanced Resuscitation Training (ART) program was implemented in 2007, incorporating hands-on resuscitative skills and in-hospital-specific training with an institutional resuscitation database. Linkage between the database and training modules occurs via the ART Matrix, which classifies all CPA events into the following etiologies: sepsis, hemorrhage, pulmonary embolus, heart failure, tachyarrhythmias, bradyarrhythmias, acute respiratory distress syndrome, non-intubated pulmonary disease, obstructive apnea, traumatic brain injury, ischemic brain injury, and intracranial mass lesions. This taxonomy was validated using descriptive statistics, before-and-after analysis evaluating CPA incidence, and multivariate logistic regression to predict CPA survival.

RESULTS

A total of 336 inpatients suffered a cardiopulmonary arrest during the study period-187 in the pre-ART period and 149 in the post-ART period. The vast majority of CPA events were categorized using the ART Matrix with high inter-observer reliability. As anticipated, changes in CPA incidence and survival were observed for some Matrix categories but not others following ART implementation. In addition, multivariate logistic regression revealed strong independent associations between taxonomy classifications and outcome.

CONCLUSION

A novel SOC using a unique taxonomy for arrest classification appears to be effective at reducing inpatient CPA incidence and outcome.

Adherence to advanced cardiovascular life support (ACLS) guidelines during in-hospital cardiac arrest is associated with improved outcomes

AIM OF THE STUDY

Identifying modifiable factors associated with survival following in-hospital cardiac arrest is crucial. The purpose of this study was to determine the extent to which adherence to the 2010 American Heart Association (AHA) Advanced Cardiac Life Support (ACLS) guidelines in their entirety affects patient outcomes. In addition, we explored the role of code leader training level on patient outcomes.

METHODS

We conducted a retrospective review of records for cardiac arrests that occurred on hospital wards and were run by the hospital code team, at three tertiary care centres over 2 to 4 years. Deviations from the ACLS guidelines were quantified using a standardized checklist. Primary outcomes included return of spontaneous circulation (ROSC) and survival to hospital discharge.

RESULTS

Of 160 resuscitation events, ROSC was achieved in 75 events (46.9%) and survival to hospital discharge in 20 patients (13.1%). On average, there were 2.3 deviations from ACLS guidelines during events that led to ROSC and 3.9 deviations during events that did not lead to ROSC (p < 0.0001). There were fewer deviations during events that led to survival to hospital discharge (2.1) compared to those where the patient did not survive to hospital discharge (3.1; p = 0.016). Code leader training level was not associated with patient outcomes. Multivariable logistic regression analysis confirmed an association between deviations from ACLS guidelines and ROSC, but not for survival to hospital discharge. The latter finding may reflect a very low survival rate.

CONCLUSION

We found that higher numbers of deviations from ACLS guidelines were associated with a lower likelihood of ROSC and survival to hospital discharge. These findings emphasize the importance of adherence to ACLS guidelines and the need for training healthcare personnel in resuscitation guidelines in order to improve outcomes for victims of in-hospital cardiac arrest.

Survival after in-hospital cardiac arrest among cerebrovascular disease patients

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