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Chen CB, Wang MF, Seak CJ, Chien LT, Chaou CH, Chang YT, Ng CJ, Tsai LH, Huang CH, Cheng TH, Yen CC, Chung PL, Chien CY. Installation of Public Access Defibrillators for Out-of-Hospital Cardiac Arrests: Identifying Suitable Locations by Using a Geographic Information System. J Am Heart Assoc 2024:e034045. [PMID: 39377202 DOI: 10.1161/jaha.123.034045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 08/29/2024] [Indexed: 10/09/2024]
Abstract
BACKGROUND Survival following an out-of-hospital cardiac arrest depends on prompt defibrillation. Despite the efforts made to install automated external defibrillators (AEDs) in crowded areas, their usage rate remains suboptimal. This study evaluated the efficiency of installing AEDs at key landmarks in Taoyuan City to enhance accessibility and usage. METHODS AND RESULTS This retrospective cohort study analyzed nontraumatic public out-of-hospital cardiac arrest cases in Taoyuan City from 2017 to 2021, using data from the Taoyuan Fire Department and a regional registry. AED data were collected for 1163 devices. A geographic information system mapped target locations within the city, and real-world walking routes were examined to assess coverage. The primary outcome was actual coverage and the coverage efficiency ratio, calculated as the actual coverage divided by the number of facilities at a location. The coverage efficiency ratio compared the coverage efficiency of target locations with existing public access defibrillators (PADs). Top locations for superior coverage in both downtown and outside downtown areas were bus stops and convenience stores (7-Eleven and FamilyMart), which outperformed existing PADs. Convenience stores had a higher coverage efficiency ratio than the public service sector. Bus stops showed high AED usage rates before ambulance arrival. CONCLUSIONS The current PAD locations in Taoyuan City offer limited coverage, which highlights the need for strategically installed AEDs, particularly in convenience stores. Policymakers should consider using the cultural relevance and accessibility of convenience stores, particularly 7-Eleven branches, to enhance AED usage rates.
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Affiliation(s)
- Chen-Bin Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou and College of Medicine Chang Gung University Taoyuan Taiwan
- Department of Emergency Medicine New Taipei Municipal TuCheng Hospital and Chang Gung University New Taipei City Taiwan
| | - Ming-Fang Wang
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou and College of Medicine Chang Gung University Taoyuan Taiwan
- Department of Emergency Medicine Chang Gung Memorial Hospital Taipei Branch Taipei Taiwan
| | - Chen-June Seak
- Department of Emergency Medicine New Taipei Municipal TuCheng Hospital and Chang Gung University New Taipei City Taiwan
- Department of Emergency Medicine Chang Gung Memorial Hospital Taipei Branch Taipei Taiwan
| | - Liang-Tien Chien
- Graduate Institute of Management, College of Management, Chang Gung University Taoyuan Taiwan
- Taoyuan Fire Department Taoyuan Taiwan
| | - Chung-Hsien Chaou
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou and College of Medicine Chang Gung University Taoyuan Taiwan
| | - Yu-Tung Chang
- College of Health Technology National Taipei University of Nursing and Health Sciences Taipei Taiwan
| | - Chip-Jin Ng
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou and College of Medicine Chang Gung University Taoyuan Taiwan
- Department of Nursing Chang Gung University of Science and Technology Taoyuan Taiwan
- Department of Emergency Medicine New Taipei City Hospital New Taipei City Taiwan
| | - Li-Heng Tsai
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou and College of Medicine Chang Gung University Taoyuan Taiwan
| | - Chien-Hsiung Huang
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou and College of Medicine Chang Gung University Taoyuan Taiwan
- Graduate Institute of Management, College of Management, Chang Gung University Taoyuan Taiwan
| | - Tzu-Heng Cheng
- Department of Emergency Medicine New Taipei Municipal TuCheng Hospital and Chang Gung University New Taipei City Taiwan
| | - Chieh-Ching Yen
- Department of Emergency Medicine New Taipei Municipal TuCheng Hospital and Chang Gung University New Taipei City Taiwan
| | - Pei-Li Chung
- Department of Emergency Medicine Ton-Yen General Hospital Zhubei Taiwan
| | - Cheng-Yu Chien
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou and College of Medicine Chang Gung University Taoyuan Taiwan
- Department of Emergency Medicine Chang Gung Memorial Hospital Taipei Branch Taipei Taiwan
- Department of Emergency Medicine Ton-Yen General Hospital Zhubei Taiwan
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University Taipei Taiwan
- Department of Senior Service Industry Management Minghsin University of Science and Technology Hsinchu Taiwan
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Khan MS, Kennedy KF, Chan PS. In-hospital cardiac arrest survival before and after the COVID-19 pandemic: Have higher performing hospitals stayed high-performing? Resuscitation 2024; 203:110374. [PMID: 39174001 PMCID: PMC11466693 DOI: 10.1016/j.resuscitation.2024.110374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Revised: 08/10/2024] [Accepted: 08/17/2024] [Indexed: 08/24/2024]
Abstract
BACKGROUND Survival for in-hospital cardiac arrest (IHCA) has declined since the COVID-19 pandemic. Because the burden of COVID-19 was uneven throughout the U.S., it remains unknown if top-performer hospitals in IHCA survival have remained top-performers since the pandemic. METHODS Within Get With The Guidelines®-Resuscitation, we identified hospitals with at least 2 years of registry participation pre-pandemic (2017-2019) and post-pandemic (July 2020-2022) and with at least 20 IHCA cases in both periods. Using multivariable hierarchical models with hospital as a random effect and adjusting for patient and arrest characteristics, we calculated risk-standardized survival rates to discharge (RSSR) for IHCA at each hospital during the pre- and post-pandemic periods. We then assessed the correlation between a hospital's pre-pandemic and post-pandemic RSSR for IHCA, and whether the correlation differed by the proportion of Black or Hispanic IHCA patients at each hospital. RESULTS A total of 243 hospitals were included, comprising 122,561 IHCAs (pre-pandemic: 57,601; post-pandemic: 64,960). Pre-pandemic, the mean RSSR was 26.8% (SD, 5.2%) whereas the mean RSSR post-pandemic was 21.7% (SD, 5.5%). There was good correlation between a hospital's pre- and post-pandemic RSSR: correlation of 0.55. When hospitals were categorized into tertiles based on the proportion of their IHCA patients who were Black or Hispanic, this correlation remained similar: 0.48, 0.68, and 0.45 (interaction P-value: 0.69) for hospitals in the upper, middle and lower tertiles, respectively. CONCLUSION Although the COVID-19 pandemic affected the U.S. unevenly, there was good correlation in a hospital's performance for IHCA survival before and after the pandemic, even at hospitals caring for a larger proportion of Black and Hispanic patients. Future studies are needed to understand what characteristics of high-performing hospitals pre-pandemic allowed many to continue to excel in the post-pandemic period.
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Affiliation(s)
- Mirza S Khan
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA; University of Missouri-Kansas City, Kansas City, MO, USA.
| | - Kevin F Kennedy
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | - Paul S Chan
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA; University of Missouri-Kansas City, Kansas City, MO, USA
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Sim JH, Kim SM, Kim HR, Kang PJ, Kim HJ, Lee D, Lee SW, Choi IC. Time to initiation of extracorporeal membrane oxygenation in conventional cardiopulmonary resuscitation affects the patient survival prognosis. J Intern Med 2024; 296:350-361. [PMID: 39073177 DOI: 10.1111/joim.20002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/30/2024]
Abstract
BACKGROUND Cardiopulmonary resuscitation (CPR) is the cornerstone intervention for cardiac arrest, with extracorporeal CPR (ECPR) demonstrating enhanced survival and neurologic outcomes in in-hospital cardiac arrest. This study explores the time interval between CPR initiation and the onset of extracorporeal membrane oxygenation (ECMO) in ECPR recipients, investigating its impact on survival outcomes. METHODS This retrospective analysis included 1950 adults who received CPR at a single medical center between March 2019 and April 2023. Data from 198 adult patients who had ECMO inserted during CPR were analyzed. The interval from CPR initiation to ECMO initiation was quantified and categorized as ≤20, 20-40, and >40 min. Cox regression analysis assessed associations between CPR-to-ECMO time and short- and long-term mortalities. RESULTS Among the 198 patients who underwent ECPR, 116 (58.6%) experienced 30-day mortality. Initiation of ECMO within 20 min occurred in 46 (23.2%), whereas 74 (37.4%) had ECMO initiated after 40 min. Cox regression revealed a significant association between time from CPR to ECMO initiation and 30-day mortality (adjusted hazard ratio [HR]: 2.20 in >40 min, HR: 2.63 in 20-40 min, p = 0.006) and 6-month mortality (HR: 1.81, in >40 min, HR: 1.99 in 20-40 min, p = 0.021). CONCLUSIONS This study revealed that, in ECPR recipients, a shorter duration between CPR initiation and ECMO flow commencement is associated with improved short- and long-term patient prognoses. These findings emphasize the critical role of timely ECMO application in optimizing outcomes for patients undergoing ECPR.
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Affiliation(s)
- Ji-Hoon Sim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Min Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hong-Rae Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Pil-Je Kang
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hwa Jung Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Donghee Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Wook Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - In-Cheol Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Khera R, Aminorroaya A, Kennedy KF, Chan PS. Correlation between hospital rates of survival to discharge and long-term survival for in-hospital cardiac arrest: Insights from Get With The Guidelines®-Resuscitation registry. Resuscitation 2024; 202:110322. [PMID: 39029583 PMCID: PMC11390317 DOI: 10.1016/j.resuscitation.2024.110322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 07/05/2024] [Accepted: 07/10/2024] [Indexed: 07/21/2024]
Abstract
AIM Given challenges in collecting long-term outcomes for survivors of in-hospital cardiac arrest (IHCA), most studies have focused on in-hospital survival. We evaluated the correlation between a hospital's risk-standardized survival rate (RSSR) at hospital discharge for IHCA with its RSSR for long-term survival. METHODS We identified patients ≥65 years of age with IHCA at 472 hospitals in Get With The Guidelines®-Resuscitation registry during 2000-2012, who could be linked to Medicare files to obtain post-discharge survival data. We constructed hierarchical logistic regression models to compute RSSR at discharge, and 30-day, 1-year, and 3-year RSSRs for each hospital. The association between in-hospital and long-term RSSR was evaluated with weighted Kappa coefficients. RESULTS Among 56,231 Medicare beneficiaries (age 77.2 ± 7.5 years and 25,206 [44.8%] women), 10,536 (18.7%) survived to discharge and 8,485 (15.1%) survived to 30 days after discharge. Median in-hospital, 30-day, 1-year, and 3-year RSSRs were 18.6% (IQR, 16.7-20.4%), 14.9% (13.2-16.7%), 10.3% (9.1-12.1%), and 7.6% (6.8-8.8%), respectively. The weighted Kappa coefficient for the association between a hospital's RSSR at discharge with its 30-day, 1-year, and 3-year RSSRs were 0.72 (95% CI, 0.68-0.76), 0.56 (0.50-0.61), and 0.47 (0.41-0.53), respectively. CONCLUSIONS There was a strong correlation between a hospital's RSSR at discharge and its 30-day RSSR for IHCA, although this correlation weakens over time. Our findings suggest that a hospital's RSSR at discharge for IHCA may be a reasonable surrogate of its 30-day post-discharge survival and could be used by Medicare to benchmark hospital performance for this condition without collecting 30-day survival data.
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Affiliation(s)
- Rohan Khera
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA; Section of Health Informatics, Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
| | - Arya Aminorroaya
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Kevin F Kennedy
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | - Paul S Chan
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA; University of Missouri-Kansas City, Kansas City, MO, USA.
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Gul F, Abid S, Khalid S, Khalid S, Shad I, Saleem S, Qayyum SN, Noori S. A quality improvement project to enhance the knowledge, skills, and attitude of healthcare workers regarding the use of defibrillators. Ann Med Surg (Lond) 2024; 86:5206-5210. [PMID: 39239006 PMCID: PMC11374289 DOI: 10.1097/ms9.0000000000002417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 07/05/2024] [Indexed: 09/07/2024] Open
Abstract
Introduction Defibrillation is a critical intervention in managing cardiac emergencies, yet healthcare workers (HCWs) preparation for utilizing defibrillators remains inadequate, particularly in low and middle-income countries. This quality improvement project aimed to assess and enhance HCWs' knowledge, skills, and attitudes toward defibrillator use in the emergency department (ED) through a 1-h defibrillator workshop. Methodology An observational clinical audit was conducted within the ED of a tertiary care hospital. Pre- and post-workshop data were collected from the participants using structured questionnaires for demographics, knowledge assessment (20 multiple-choice questions), skills assessment (10-step checklist), and attitude evaluation (Likert-scale statements). The workshop included theoretical instruction and hands-on practice, with a post-workshop assessment conducted one week later. Data analysis employed descriptive statistics and paired t-tests, while ethical considerations ensured confidentiality and consent. Results The study included 38 participants, demonstrating significant gaps in defibrillator knowledge, skills, and attitudes pre-workshop. Post-workshop assessments revealed a marked improvement in knowledge scores (P<0.05), attitudes (P<0.05), and practical skills (P<0.05). Participants' confidence and preparation for managing cardiac emergencies notably increased, indicating the workshop's efficacy in addressing the identified deficiencies. Conclusion The 1-h defibrillator workshop effectively enhanced HCWs' competence and readiness to utilize ED defibrillators. The observed improvements underscore the importance of targeted educational interventions in bridging knowledge gaps and fostering proactive attitudes toward emergency management. Regular training sessions should be conducted to sustain these enhancements and improve patient outcomes in the ED.
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Affiliation(s)
- Fahad Gul
- Department of Medicine, Holy Family Hospital
| | - Seemab Abid
- Department of Medicine, Holy Family Hospital
| | | | | | - Iram Shad
- Department of Medicine, Benazir Bhutto Hospital
| | - Samar Saleem
- Department of Medicine, Rawalpindi Teaching Hospital, Rawalpindi
| | | | - Samim Noori
- Nangarhar University, Faculty of Medicine, Nangarhar, Afghanistan
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O’Halloran A, Morgan RW, Kennedy K, Berg RA, Gathers CA, Naim MY, Nadkarni V, Reeder R, Topjian A, Wolfe H, Kleinman M, Chan PS, Sutton RM. Characteristics of Pediatric In-Hospital Cardiac Arrests and Resuscitation Duration. JAMA Netw Open 2024; 7:e2424670. [PMID: 39078626 PMCID: PMC11289702 DOI: 10.1001/jamanetworkopen.2024.24670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 05/30/2024] [Indexed: 07/31/2024] Open
Abstract
Importance Cardiopulmonary resuscitation (CPR) duration is associated with cardiac arrest survival. Objectives To describe characteristics associated with CPR duration among hospitalized children without return of circulation (ROC) (patient-level analysis) and determine whether hospital median CPR duration in patients without ROC is associated with survival (hospital-level analysis). Design, Setting, and Participants This retrospective cohort study of patients undergoing pediatric in-hospital CPR between January 1, 2000, and December 31, 2021, used data from the Get With the Guidelines-Resuscitation registry. Children receiving chest compressions for at least 2 minutes and/or defibrillation were included in the patient-level analysis. For the hospital-level analysis, sites with at least 20 total events and at least 5 events without ROC were included. Data were analyzed from December 1, 2022, to November 15, 2023. Exposures For the patient-level analysis, the exposure was CPR duration in patients without ROC. For the hospital-level analysis, the exposure was quartile of median CPR duration in events without ROC at each hospital. Main Outcomes and Measures For the patient-level analysis, outcomes were patient and event factors, including race and ethnicity and event location; we used a multivariable hierarchical linear regression model to assess factors associated with CPR duration in patients without ROC. For the hospital-level analysis, the main outcome was survival to discharge among all site events; we used a random intercept multivariable hierarchical logistic regression model to examine the association between hospital quartile of CPR duration and survival to discharge. Results Of 13 899 events, 3859 patients did not have ROC (median age, 7 months [IQR, 0 months to 7 years]; 2175 boys [56%]). Among event nonsurvivors, median CPR duration was longer in those with initial rhythms of bradycardia with poor perfusion (8.37 [95% CI, 5.70-11.03] minutes; P < .001), pulseless electrical activity (8.22 [95% CI, 5.44-11.00] minutes; P < .001), and pulseless ventricular tachycardia (6.17 [95% CI, 0.09-12.26] minutes; P = .047) (vs asystole). Shorter median CPR duration was associated with neonates compared with older children (-4.86 [95% CI, -8.88 to -0.84] minutes; P = .02), emergency department compared with pediatric intensive car7 e unit location (-4.02 [95% CI, -7.48 to -0.57] minutes; P = .02), and members of racial or ethnic minority groups compared with White patients (-3.67 [95% CI, -6.18 to -1.17]; P = .004). Among all CPR events, the adjusted odds of survival to discharge differed based on hospital quartile of median CPR duration among events without ROC; compared with quartile 1 (15.0-25.9 minutes), the adjusted odds ratio for quartile 2 (26.0-29.4 minutes) was 1.22 (95% CI, 1.09-1.36; P < .001); for quartile 3 (29.5-32.9 minutes), 1.23 (95% CI, 1.08-1.39; P = .002); and for quartile 4 (33.0-53.0 minutes), 1.04 (95% CI, 0.91-1.19; P = .58). Conclusions and Relevance In this retrospective cohort study of pediatric in-hospital CPR, several factors, including age and event location, were associated with CPR duration in event nonsurvivors. The odds of survival to discharge were lower for patients at hospitals with the shortest and longest median CPR durations among events without ROC. Further studies are needed to determine the optimal duration of CPR during pediatric in-hospital cardiac arrest and to provide training guidelines for resuscitation teams to eliminate disparities in resuscitation care.
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Affiliation(s)
- Amanda O’Halloran
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Ryan W. Morgan
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia, Philadelphia
| | - Kevin Kennedy
- Saint Luke’s Mid America Heart Institute, Kansas City, Missouri
| | - Robert A. Berg
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia, Philadelphia
| | - Cody-Aaron Gathers
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Maryam Y. Naim
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia, Philadelphia
| | - Vinay Nadkarni
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia, Philadelphia
| | - Ron Reeder
- Department of Pediatrics, University of Utah, Salt Lake City
| | - Alexis Topjian
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia, Philadelphia
| | - Heather Wolfe
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Monica Kleinman
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School and Boston Children’s Hospital, Boston, Massachusetts
| | - Paul S. Chan
- Saint Luke’s Mid America Heart Institute, Kansas City, Missouri
| | - Robert M. Sutton
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia, Philadelphia
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Kim JH, Lee J, Shin H, Lim TH, Jang BH, Cho Y, Kim W, Choi KS, Kim JG, Ahn C, Lee H, Namgung M, Na MK, Kwon SM. Association Between QRS Characteristics in Pulseless Electrical Activity and Survival Outcome in Cardiac Arrest Patients: A Systematic Review and Meta-Analysis. PREHOSP EMERG CARE 2024:1-8. [PMID: 38787646 DOI: 10.1080/10903127.2024.2360139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 05/13/2024] [Indexed: 05/26/2024]
Abstract
OBJECTIVE Recent studies have shown inconsistent results regarding the association between QRS characteristics and survival outcomes in patients with cardiac arrest and pulseless electrical activity (PEA) rhythms. This meta-analysis aimed to identify the usefulness of QRS width and frequency as prognostic tools for outcomes in patients with cardiac arrest and PEA rhythm. METHODS Extensive searches were conducted using Medline, Embase, and the Cochrane Library to find articles published from database inception to 4 June 2023. Studies that assessed the association between the QRS characteristics of cardiac arrest patients with PEA rhythm and survival outcomes were included. The Newcastle-Ottawa Scale was used to assess the methodological quality of the included studies. RESULTS A total of 9727 patients from seven observational studies were included in this systematic review and meta-analysis. The wide QRS group (QRS ≥ 120 ms) was associated with significantly higher odds of mortality than the narrow QRS group (QRS < 120 ms) (odds ratio (OR) = 1.86, 95% confidence interval (CI) = 1.11-3.11, I2 = 58%). The pooled OR for mortality was significantly higher in patients with a QRS frequency of < 60/min than in those with a QRS frequency of ≥ 60/min (OR = 1.90, 95% CI = 1.19-3.02, I2 = 65%). CONCLUSIONS Wide QRS width or low QRS frequency is associated with increased odds of mortality in patients with PEA cardiac arrest. These findings may be beneficial to guide the disposition of cardiac arrest patients with PEA during resuscitation.
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Affiliation(s)
- Jae Hwan Kim
- Department of Emergency Medicine, College of Medicine, Chung-Ang University, Seoul, Republic of Korea
| | - Juncheol Lee
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Hyungoo Shin
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Tae Ho Lim
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Bo-Hyoung Jang
- Department of Preventive Medicine, College of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Youngsuk Cho
- Department of Emergency Medicine, Hallym University, Kangdong Sacred Heart Hospital, Seoul, Republic of Korea
| | - Wonhee Kim
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Kyu-Sun Choi
- Department of Neurosurgery, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Jae Guk Kim
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Chiwon Ahn
- Department of Emergency Medicine, College of Medicine, Chung-Ang University, Seoul, Republic of Korea
| | - Heekyung Lee
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Myeong Namgung
- Department of Emergency Medicine, College of Medicine, Chung-Ang University Gwangmyeong Hospital, Gyeonggi-do, Republic of Korea
| | - Min Kyun Na
- Department of Neurosurgery, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Sae Min Kwon
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Republic of Korea
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Stewart C, Chan PS, Kennedy K, Swanson MB, Girotra S. Hospital Variation in Epinephrine Administration Before Defibrillation for Cardiac Arrest Due to Shockable Rhythm. Crit Care Med 2024; 52:878-886. [PMID: 38502800 DOI: 10.1097/ccm.0000000000006203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
OBJECTIVES Contrary to advanced cardiac life support guidelines that recommend immediate defibrillation for shockable in-hospital cardiac arrest (IHCA), epinephrine administration before first defibrillation is common and associated with lower survival at a "patient-level." Whether this practice varies across hospitals and its association with "hospital-level" IHCA survival remains unknown. The purpose of this study was to determine hospital variation in rates of epinephrine administration before defibrillation for shockable IHCA and its association with IHCA survival. DESIGN Observational cohort study. SETTING Five hundred thirteen hospitals participating in the Get With The Guidelines Resuscitation Registry. PATIENTS A total of 37,668 adult patients with IHCA due to an initial shockable rhythm from 2000 to 2019. INTERVENTIONS Epinephrine before first defibrillation. MEASUREMENTS AND MAIN RESULTS Using multivariable hierarchical regression, we examined hospital variation in epinephrine administration before first defibrillation and its association with hospital-level rates of risk-adjusted survival. The median hospital rate of epinephrine administration before defibrillation was 18.8%, with large variation across sites (range, 0-68.8%; median odds ratio: 1.54; 95% CI, 1.47-1.61). Major teaching status and annual IHCA volume were associated with hospital rate of epinephrine administration before defibrillation. Compared with hospitals with the lowest rate of epinephrine administration before defibrillation (Q1), there was a stepwise decline in risk-adjusted survival at hospitals with higher rates of epinephrine administration before defibrillation (Q1: 44.3%, Q2: 43.4%; Q3: 41.9%; Q4: 40.3%; p for trend < 0.001). CONCLUSIONS Administration of epinephrine before defibrillation in shockable IHCA is common and varies markedly across U.S. hospitals. Hospital rates of epinephrine administration before defibrillation were associated with a significant stepwise decrease in hospital rates of risk-adjusted survival. Efforts to prioritize immediate defibrillation for patients with shockable IHCA and avoid early epinephrine administration are urgently needed.
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Affiliation(s)
- Colten Stewart
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Paul S Chan
- Division of Cardiology, Department of Medicine, University of Missouri, Kansas City, MO
- Saint Luke's Mid-America Heart Institute, Kansas City, MO
| | - Kevin Kennedy
- Division of Cardiology, Department of Medicine, University of Missouri, Kansas City, MO
| | - Morgan B Swanson
- Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Saket Girotra
- Division of Cardiovascular Medicine, University of Texas Southwestern Medical Center, Dallas, TX
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Haskell SE, Hoyme D, Zimmerman MB, Reeder R, Girotra S, Raymond TT, Samson RA, Berg M, Berg RA, Nadkarni V, Atkins DL. Association between survival and number of shocks for pulseless ventricular arrhythmias during pediatric in-hospital cardiac arrest in a national registry. Resuscitation 2024; 198:110200. [PMID: 38582444 DOI: 10.1016/j.resuscitation.2024.110200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 03/13/2024] [Accepted: 03/30/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Annually 15,200 children suffer an in-hospital cardiac arrest (IHCA) in the US. Ventricular fibrillation or pulseless ventricular tachycardia (VF/pVT) is the initial rhythm in 10-15% of these arrests. We sought to evaluate the association of number of shocks and early dose escalation with survival for initial VF/pVT in pediatric IHCA. METHODS Using 2000-2020 data from the American Heart Association's (AHA) Get with the Guidelines®-Resuscitation (GWTG-R) registry, we identified children >48 hours of life and ≤18 years who had an IHCA from initial VF/pVT and received defibrillation. RESULTS There were 251 subjects (37.7%) who received a single shock and 415 subjects (62.3%) who received multiple shocks. Baseline and cardiac arrest characteristics did not differ between those who received a single shock versus multiple shocks except for duration of arrest and calendar year. The median first shock dose was consistent with AHA dosing recommendations and not different between those who received a single shock versus multiple shocks. Survival was improved for those who received a single shock compared to multiple shocks. However, no difference in survival was noted between those who received 2, 3, or ≥4 shocks. Of those receiving multiple shocks, no difference was observed with early dose escalation. CONCLUSIONS In pediatric IHCA, most patients with initial VF/pVT require more than one shock. No distinctions in patient or pre-arrest characteristics were identified between those who received a single shock versus multiple shocks. Subjects who received a single shock were more likely to survive to hospital discharge even after adjusting for duration of resuscitation.
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Affiliation(s)
- Sarah E Haskell
- University of Iowa Carver College of Medicine, Iowa City, IA, United States.
| | - Derek Hoyme
- University of Wisconsin Madison School of Medicine, Madison, WI, United States
| | | | - Ron Reeder
- University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Saket Girotra
- UT Southwestern Medical Center, Dallas, TX, United States
| | - Tia T Raymond
- Medical City Children's Hospital, Dallas, TX, United States
| | | | - Marc Berg
- Stanford School of Medicine, Palo Alto, CA, United States
| | - Robert A Berg
- Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Vinay Nadkarni
- Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Dianne L Atkins
- University of Iowa Carver College of Medicine, Iowa City, IA, United States
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10
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Vaillancourt C, Charette M, Lanos C, Godbout J, Buhariwalla H, Dale-Tam J, Nemnom MJ, Brehaut J, Wells G, Stiell I. Multi-phase implementation of automated external defibrillator use by nurses during in-hospital cardiac arrest and its impact on survival. Resuscitation 2024; 197:110148. [PMID: 38382874 DOI: 10.1016/j.resuscitation.2024.110148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/26/2024] [Accepted: 02/13/2024] [Indexed: 02/23/2024]
Abstract
OBJECTIVE We sought to evaluate the impact of a medical directive allowing nurses to use defibrillators in automated external defibrillator-mode (AED) on in-hospital cardiac arrest (IHCA) outcomes. METHODS We completed a health record review of consecutive IHCA for which resuscitation was attempted using a pragmatic multi-phase before-after cohort design. We report Utstein outcomes before (Jan.2012-Aug.2013;Control) the implementation of the AED medical directive following usual practice (Sept.2013-Aug.2016;Phase 1), and following the addition of a theory-based educational video (Sept.2016-Dec.2017;Phase 2). RESULTS There were 753 IHCA with the following characteristics (Before n = 195; Phase 1n = 372; Phase 2n = 186): mean age 66, 60.0% male, 79.3% witnessed, 29.1% noncardiac-monitored medical ward, 23.9% cardiac cause, and initial ventricular fibrillation/tachycardia (VF/VT) 27.2%. Comparing the Before, Phase 1 and 2: an AED was used 0 time (0.0%), 21 times (5.7%), 15 times (8.1%); mean times to 1st analysis were 7 min, 3 min and 1 min (p < 0.0001); mean times to 1st shock were 12 min, 10 min and 8 min (p = 0.32); return of spontaneous circulation (ROSC) was 63.6%, 59.4% and 58.1% (p = 0.77); survival was 24.6%, 21.0% and 25.8% (p = 0.37). Among IHCA in VF/VT (n = 165), time to 1st analysis and 1st shock decreased by 5 min (p = 0.01) and 6 min (p = 0.23), and ROSC and survival increased by 3.0% (p = 0.80) and 15.6% (p = 0.31). There was no survival benefit overall (1.2%; p = 0.37) or within noncardiac-monitored areas (-7.2%; p = 0.24). CONCLUSIONS The implementation of a medical directive allowing for AED use by nurses successfully improved key outcomes for IHCA victims, particularly following the theory-based education video and among the VF/VT group.
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Affiliation(s)
- Christian Vaillancourt
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, ON, Canada.
| | - Manya Charette
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Chelsea Lanos
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Justin Godbout
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Hannah Buhariwalla
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Marie-Joe Nemnom
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Jamie Brehaut
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, ON, Canada
| | - George Wells
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, ON, Canada; University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Ian Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, ON, Canada
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11
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DeMasi S, Donohue M, Merck L, Mosier J. Extracorporeal cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest: Lessons learned from recent clinical trials. J Am Coll Emerg Physicians Open 2024; 5:e13129. [PMID: 38434097 PMCID: PMC10904351 DOI: 10.1002/emp2.13129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 01/23/2024] [Accepted: 01/24/2024] [Indexed: 03/05/2024] Open
Abstract
Cardiac arrest is a leading contributor to morbidity and mortality in the United States. Survival has been historically dependent on high-quality cardiopulmonary resuscitation (CPR) and rapid defibrillation. However, a large percentage of patients remain in refractory cardiac arrest despite adherence to structured advanced cardiac life support algorithms in which these factors are emphasized. Veno-arterial extracorporeal membrane oxygenation is becoming an increasingly used rescue therapy for patients in refractory cardiac arrest to restore oxygen delivery by extracorporeal CPR (ECPR). Recently published clinical trials have provided new insights into ECPR for patients who sustain an outside hospital cardiac arrest (OHCA). In this narrative review, we summarize the rationale for, results of, and remaining questions from these recently published clinical trials. The existing observational data combined with the latest clinical trials suggest ECPR improves mortality in patients in refractory arrest. However, a mixed methods trial is essential to understand the complexity, context, and effectiveness of implementing an ECPR program.
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Affiliation(s)
- Stephanie DeMasi
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Megan Donohue
- Department of Emergency MedicineVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Lisa Merck
- Department of Emergency MedicineVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Jarrod Mosier
- Department of Emergency MedicineThe University of Arizona College of MedicineTucsonArizonaUSA
- Division of Pulmonary, Allergy, Critical Care, and SleepDepartment of MedicineThe University of Arizona College of MedicineTucsonArizonaUSA
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12
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Liu Y, Yo CH, Hu JR, Hsu WT, Hsiung JC, Chang YH, Chen SC, Lee CC. Sepsis increases the risk of in-hospital cardiac arrest: a population-based analysis. Intern Emerg Med 2024; 19:353-363. [PMID: 38141118 DOI: 10.1007/s11739-023-03475-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 10/19/2023] [Indexed: 12/24/2023]
Abstract
Sepsis patients have a high risk of developing in-hospital cardiac arrest (IHCA), which portends poor survival. However, little is known about whether the increased incidence of IHCA is due to sepsis itself or to comorbidities harbored by sepsis patients. We conducted a retrospective population-based cohort study comprising 20,022 patients admitted with sepsis to hospitals in Taiwan using the National Health Insurance Research Database (NHIRD). We constructed three non-sepsis comparison cohorts using risk set sampling and propensity score (PS) matching. We used univariate conditional logistic regression to evaluate the risk of IHCA and associated mortality. We identified 12,790 inpatients without infection (matched cohort 1), 12,789 inpatients with infection but without sepsis (matched cohort 2), and 10,536 inpatients with end-organ dysfunction but without sepsis (matched cohort 3). In the three PS-matched cohorts, the odds ratios (OR) for developing ICHA were 21.17 (95% CI 17.19, 26.06), 18.96 (95% CI: 15.56, 23.10), and 1.23 (95% CI: 1.13, 1.33), respectively (p < 0.001 for all ORs). In conclusion, in our study of inpatients across Taiwan, sepsis was independently associated with an increased risk of IHCA. Further studies should focus on identifying the proxy causes of IHCA using real-time monitoring data to further reduce the incidence of cardiopulmonary insufficiency in patients with sepsis.
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Affiliation(s)
- Ye Liu
- Department of Health Policy and Organization, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Chia-Hung Yo
- Department of Emergency Medicine, Far Eastern Memorial Hospital, Taipei, Taiwan
| | - Jiun-Ruey Hu
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Wan-Ting Hsu
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Jo-Ching Hsiung
- Department of Pediatrics, Jefferson Einstein Hospital, Philadelphia, PA, USA
| | - Yung-Han Chang
- Department of Biostatistics, University of California, Los Angeles, Los Angeles, USA
| | - Shyr-Chyr Chen
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chien-Chang Lee
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan.
- The Centre for Intelligent Healthcare, College of Medicine, National Taiwan University Hospital, National Taiwan University, No.7, Chung Shan S. Rd., Zhongzheng Dist., Taipei City, 100, Taiwan.
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13
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Low CJW, Ling RR, Ramanathan K, Chen Y, Rochwerg B, Kitamura T, Iwami T, Ong MEH, Okada Y. Extracorporeal cardiopulmonary resuscitation versus conventional CPR in cardiac arrest: an updated meta-analysis and trial sequential analysis. Crit Care 2024; 28:57. [PMID: 38383506 PMCID: PMC10882798 DOI: 10.1186/s13054-024-04830-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 02/10/2024] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND Extracorporeal cardiopulmonary resuscitation (ECPR) may reduce mortality and improve neurological outcomes in patients with cardiac arrest. We updated our existing meta-analysis and trial sequential analysis to further evaluate ECPR compared to conventional CPR (CCPR). METHODS We searched three international databases from 1 January 2000 through 1 November 2023, for randomised controlled trials or propensity score matched studies (PSMs) comparing ECPR to CCPR in both out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA). We conducted an updated random-effects meta-analysis, with the primary outcome being in-hospital mortality. Secondary outcomes included short- and long-term favourable neurological outcome and survival (30 days-1 year). We also conducted a trial sequential analysis to evaluate the required information size in the meta-analysis to detect a clinically relevant reduction in mortality. RESULTS We included 13 studies with 14 pairwise comparisons (6336 ECPR and 7712 CCPR) in our updated meta-analysis. ECPR was associated with greater precision in reducing overall in-hospital mortality (OR 0.63, 95% CI 0.50-0.79, high certainty), to which the trial sequential analysis was concordant. The addition of recent studies revealed a newly significant decrease in mortality in OHCA (OR 0.62, 95% CI 0.45-0.84). Re-analysis of relevant secondary outcomes reaffirmed our initial findings of favourable short-term neurological outcomes and survival up to 30 days. Estimates for long-term neurological outcome and 90-day-1-year survival remained unchanged. CONCLUSIONS We found that ECPR reduces in-hospital mortality, improves neurological outcome, and 30-day survival. We additionally found a newly significant benefit in OHCA, suggesting that ECPR may be considered in both IHCA and OHCA.
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Affiliation(s)
- Christopher Jer Wei Low
- Yong Loo Lin School of Medicine, National University of Singapore, National Unviersity Health System, Singapore, Singapore
| | - Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, National Unviersity Health System, Singapore, Singapore
| | - Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, National Unviersity Health System, Singapore, Singapore
- Cardiothoracic Intensive Care Unit, National University Heart Centre Singapore, National University Health System, Singapore, Singapore
| | - Ying Chen
- Genome Institute of Singapore, Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
| | - 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
| | - Tetsuhisa Kitamura
- Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Taku Iwami
- Preventive Services, Graduate School of Medicine, School of Public Health, Kyoto University, Kyoto, Japan
| | - Marcus Eng Hock Ong
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Yohei Okada
- Preventive Services, Graduate School of Medicine, School of Public Health, Kyoto University, Kyoto, Japan.
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore.
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14
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Merchant RM, Becker LB, Brooks SC, Chan PS, Del Rios M, McBride ME, Neumar RW, Previdi JK, Uzendu A, Sasson C. The American Heart Association Emergency Cardiovascular Care 2030 Impact Goals and Call to Action to Improve Cardiac Arrest Outcomes: A Scientific Statement From the American Heart Association. Circulation 2024; 149:e914-e933. [PMID: 38250800 DOI: 10.1161/cir.0000000000001196] [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] [Indexed: 01/23/2024]
Abstract
Every 10 years, the American Heart Association (AHA) Emergency Cardiovascular Care Committee establishes goals to improve survival from cardiac arrest. These goals align with broader AHA Impact Goals and support the AHA's advocacy efforts and strategic investments in research, education, clinical care, and quality improvement programs. This scientific statement focuses on 2030 AHA emergency cardiovascular care priorities, with a specific focus on bystander cardiopulmonary resuscitation, early defibrillation, and neurologically intact survival. This scientific statement also includes aspirational goals, such as establishing cardiac arrest as a reportable disease and mandating reporting of standardized outcomes from different sources; advancing recognition of and knowledge about cardiac arrest; improving dispatch system response, availability, and access to resuscitation training in multiple settings and at multiple time points; improving availability, access, and affordability of defibrillators; providing a focus on early defibrillation, in-hospital programs, and establishing champions for debriefing and review of cardiac arrest events; and expanding measures to track outcomes beyond survival. The ability to track and report data from these broader aspirational targets will potentially require expansion of existing data sets, development of new data sets, and enhanced integration of technology to collect process and outcome data, as well as partnerships of the AHA with national, state, and local organizations. The COVID-19 (coronavirus disease 2019) pandemic, disparities in COVID-19 outcomes for historically excluded racial and ethnic groups, and the longstanding disparities in cardiac arrest treatment and outcomes for Black and Hispanic or Latino populations also contributed to an explicit focus and target on equity for the AHA Emergency Cardiovascular Care 2030 Impact Goals.
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15
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Okubo M, Komukai S, Andersen LW, Berg RA, Kurz MC, Morrison LJ, Callaway CW. Duration of cardiopulmonary resuscitation and outcomes for adults with in-hospital cardiac arrest: retrospective cohort study. BMJ 2024; 384:e076019. [PMID: 38325874 PMCID: PMC10847985 DOI: 10.1136/bmj-2023-076019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/05/2023] [Indexed: 02/09/2024]
Abstract
OBJECTIVE To quantify time dependent probabilities of outcomes in patients after in-hospital cardiac arrest as a function of duration of cardiopulmonary resuscitation, defined as the interval between start of chest compression and the first return of spontaneous circulation or termination of resuscitation. DESIGN Retrospective cohort study. SETTING Multicenter prospective in-hospital cardiac arrest registry in the United States. PARTICIPANTS 348 996 adult patients (≥18 years) with an index in-hospital cardiac arrest who received cardiopulmonary resuscitation from 2000 through 2021. MAIN OUTCOME MEASURES Survival to hospital discharge and favorable functional outcome at hospital discharge, defined as a cerebral performance category score of 1 (good cerebral performance) or 2 (moderate cerebral disability). Time dependent probabilities of subsequently surviving to hospital discharge or having favorable functional outcome if patients pending the first return of spontaneous circulation at each minute received further cardiopulmonary resuscitation beyond the time point were estimated, assuming that all decisions on termination of resuscitation were accurate (that is, all patients with termination of resuscitation would have invariably failed to survive if cardiopulmonary resuscitation had continued for a longer period of time). RESULTS Among 348 996 included patients, 233 551 (66.9%) achieved return of spontaneous circulation with a median interval of 7 (interquartile range 3-13) minutes between start of chest compressions and first return of spontaneous circulation, whereas 115 445 (33.1%) patients did not achieve return of spontaneous circulation with a median interval of 20 (14-30) minutes between start of chest compressions and termination of resuscitation. 78 799 (22.6%) patients survived to hospital discharge. The time dependent probabilities of survival and favorable functional outcome among patients pending return of spontaneous circulation at one minute's duration of cardiopulmonary resuscitation were 22.0% (75 645/343 866) and 15.1% (49 769/328 771), respectively. The probabilities decreased over time and were <1% for survival at 39 minutes and <1% for favorable functional outcome at 32 minutes' duration of cardiopulmonary resuscitation. CONCLUSIONS This analysis of a large multicenter registry of in-hospital cardiac arrest quantified the time dependent probabilities of patients' outcomes in each minute of duration of cardiopulmonary resuscitation. The findings provide resuscitation teams, patients, and their surrogates with insights into the likelihood of favorable outcomes if patients pending the first return of spontaneous circulation continue to receive further cardiopulmonary resuscitation.
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Affiliation(s)
- Masashi Okubo
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261, USA
| | - Sho Komukai
- Division of Biomedical Statistics, Department of Integrated Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Lars W Andersen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
- Prehospital Emergency Medical Services, Central Denmark Region, Denmark
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Michael C Kurz
- Section of Emergency Medicine, Department of Medicine, University of Chicago School of Medicine, Chicago, IL, USA
| | - Laurie J Morrison
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261, USA
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16
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Demers SP, Cournoyer A, Dagher O, Noly PE, Ducharme A, Ly H, Albert M, Serri K, Cavayas YA, Ben Ali W, Lamarche Y. Impact of clinical variables on outcomes in refractory cardiac arrest patients undergoing extracorporeal cardiopulmonary resuscitation. Front Cardiovasc Med 2024; 10:1315548. [PMID: 38250030 PMCID: PMC10799334 DOI: 10.3389/fcvm.2023.1315548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 12/14/2023] [Indexed: 01/23/2024] Open
Abstract
Background In the past two decades, extracorporeal resuscitation (ECPR) has been increasingly used in the management of refractory cardiac arrest (CA) patients. Decision algorithms have been used to guide the care such patients, but the effectiveness of such decision-making tools is not well described. The aim of this study was to compare the rate of survival with a good neurologic outcome of patients treated with ECPR meeting all criteria of a clinical decision-making tool for the initiation of ECPR to those for whom ECPR was implemented outside of the algorithm. Methods All patients who underwent E-CPR between January 2014 and December 2021 at the Montreal Heart Institute were included in this retrospective analysis. We dichotomized the cohort according to adherence or non-adherence with the ECPR decision-making tool, which included the following criteria: age ≤65 years, initial shockable rhythm, no-flow time <5 min, serum lactate <13 mmol/L. Patients were included in the "IN" group when they met all criteria of the decision-making tool and in the "OUT" group when at least one criterion was not met. Main outcomes and measures The primary outcome was survival with intact neurological status at 30 days, defined by a Cerebral Performance Category (CPC) Scale 1 and 2. Results A total of 41 patients (IN group, n = 11; OUT group, n = 30) were included. A total of 4 (36%) patients met the primary outcome in the IN group and 7 (23%) in the OUT group [odds ratio (OR): 1.88 (95% CI, 0.42-8.34); P = 0.45]. However, survival with a favorable outcome decreased steadily with 2 or more deviations from the decision-making tool [2 deviations: 1 (11%); 3 deviations: 0 (0%)]. Conclusion and relevance Most patients supported with ECPR fell outside of the criteria encompassed in a clinical decision-making tool, which highlights the challenge of optimal selection of ECPR candidates. Survival rate with a good neurologic outcome did not differ between the IN and OUT groups. However, survival with favorable outcome decreased steadily after one deviation from the decision-making tool. More studies are needed to help select proper candidates with refractory CA patients for ECPR.
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Affiliation(s)
- Simon-Pierre Demers
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
- Department of Cardiology, Montreal Heart Institute, Montreal, QC, Canada
| | - Alexis Cournoyer
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
- Department of Emergency Medicine, Hôpital du Sacré-Cœur de Montréal, Montreal, QC, Canada
| | - Olina Dagher
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
- Department of Surgery, Montreal Heart Institute, Montreal, QC, Canada
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Calgary, AB, Canada
| | - Pierre-Emmanuel Noly
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
- Department of Surgery, Montreal Heart Institute, Montreal, QC, Canada
- Research Center, Montreal Heart Institute, Montreal, QC, Canada
| | - Anique Ducharme
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
- Department of Cardiology, Montreal Heart Institute, Montreal, QC, Canada
- Research Center, Montreal Heart Institute, Montreal, QC, Canada
| | - Hung Ly
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
- Department of Cardiology, Montreal Heart Institute, Montreal, QC, Canada
- Research Center, Montreal Heart Institute, Montreal, QC, Canada
| | - Martin Albert
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
- Department of Surgery, Montreal Heart Institute, Montreal, QC, Canada
- Department of Medicine, Critical Care, Hôpital du Sacré-Cœur de Montréal and CIUSSS NIM Research Center, Montreal, QC, Canada
| | - Karim Serri
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
- Department of Surgery, Montreal Heart Institute, Montreal, QC, Canada
- Department of Medicine, Critical Care, Hôpital du Sacré-Cœur de Montréal and CIUSSS NIM Research Center, Montreal, QC, Canada
| | - Yiorgos Alexandros Cavayas
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
- Department of Surgery, Montreal Heart Institute, Montreal, QC, Canada
- Department of Medicine, Critical Care, Hôpital du Sacré-Cœur de Montréal and CIUSSS NIM Research Center, Montreal, QC, Canada
| | - Walid Ben Ali
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
- Research Center, Montreal Heart Institute, Montreal, QC, Canada
| | - Yoan Lamarche
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
- Research Center, Montreal Heart Institute, Montreal, QC, Canada
- Department of Medicine, Critical Care, Hôpital du Sacré-Cœur de Montréal and CIUSSS NIM Research Center, Montreal, QC, Canada
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17
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Piasecki RJ, Hunt EA, Perrin N, Spaulding EM, Winters B, Samuel L, Davidson PM, Chandra Strobos N, Churpek M, Himmelfarb CR. Using rapid response system trigger clusters to characterize patterns of clinical deterioration among hospitalized adult patients. Resuscitation 2024; 194:110041. [PMID: 37952578 PMCID: PMC10842078 DOI: 10.1016/j.resuscitation.2023.110041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 10/31/2023] [Accepted: 11/06/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Many rapid response system (RRS) events are activated using multiple triggers. However, the patterns in which multiple RRS triggers occur together to activate RRS events are unknown. The purpose of this study was to identify these patterns (RRS trigger clusters) and determine their association with outcomes among hospitalized adult patients. METHODS RRS events among adult patients from January 2015 to December 2019 in the Get With The Guidelines- Resuscitation registry's MET module were examined (n = 134,406). Cluster analysis methods were performed to identify RRS trigger clusters. Pearson's chi-squared and ANOVA tests were used to examine differences in patient characteristics across RRS trigger clusters. Multilevel logistic regressions were used to examine the associations between RRS trigger clusters and outcomes. RESULTS Six RRS trigger clusters were identified. Predominant RRS triggers for each cluster were: tachypnea, new onset difficulty in breathing, decreased oxygen saturation (Cluster 1); tachypnea, decreased oxygen saturation, staff concern (Cluster 2); respiratory depression, decreased oxygen saturation, mental status changes (Cluster 3); tachycardia, staff concern (Cluster 4); mental status changes (Cluster 5); hypotension, staff concern (Cluster 6). Significant differences in patient characteristics were observed across clusters. Patients in Clusters 3 and 6 had an increased likelihood of in-hospital cardiac arrest (p < 0.01). All clusters had an increased risk of mortality (p < 0.01). CONCLUSIONS We discovered six novel RRS trigger clusters with differing relationships to adverse patient outcomes. RRS trigger clusters may prove crucial in clarifying the associations between RRS events and adverse outcomes and aiding in clinician decision-making during RRS events.
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Affiliation(s)
- Rebecca J Piasecki
- Johns Hopkins University, 3400 N. Charles St., Baltimore, MD 21218, United States.
| | - Elizabeth A Hunt
- Johns Hopkins University, 3400 N. Charles St., Baltimore, MD 21218, United States
| | - Nancy Perrin
- Johns Hopkins University, 3400 N. Charles St., Baltimore, MD 21218, United States
| | - Erin M Spaulding
- Johns Hopkins University, 3400 N. Charles St., Baltimore, MD 21218, United States
| | - Bradford Winters
- Johns Hopkins University, 3400 N. Charles St., Baltimore, MD 21218, United States
| | - Laura Samuel
- Johns Hopkins University, 3400 N. Charles St., Baltimore, MD 21218, United States
| | - Patricia M Davidson
- University of Wollongong Australia, Northfields Ave., Wollongong, NSW 2522, Australia
| | | | - Matthew Churpek
- University of Wisconsin-Madison, Union South, 1308 W. Dayton St., Madison, WI 53715, United States
| | - Cheryl R Himmelfarb
- Johns Hopkins University, 3400 N. Charles St., Baltimore, MD 21218, United States
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George N, Stephens K, Ball E, Crandall C, Ouchi K, Unruh M, Kamdar N, Myaskovsky L. Extracorporeal Membrane Oxygenation for Cardiac Arrest: Does Age Matter? Crit Care Med 2024; 52:20-30. [PMID: 37782526 PMCID: PMC11267242 DOI: 10.1097/ccm.0000000000006039] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
OBJECTIVES The impact of age on hospital survival for patients treated with extracorporeal cardiopulmonary resuscitation (ECPR) for cardiac arrest (CA) is unknown. We sought to characterize the association between older age and hospital survival after ECPR, using a large international database. DESIGN Retrospective analysis of the Extracorporeal Life Support Organization registry. PATIENTS Patients 18 years old or older who underwent ECPR for CA between December 1, 2016, and October 31, 2020. MEASUREMENTS AND MAIN RESULTS The primary outcome was adjusted odds ratio (aOR) of death after ECPR, analyzed by age group (18-49, 50-64, 65-74, and > 75 yr). A total of 5,120 patients met inclusion criteria. The median age was 57 years (interquartile range, 46-66 yr). There was a significantly lower aOR of survival for those 65-74 (0.68l 95% CI, 0.57-0.81) or those greater than 75 (0.54; 95% CI, 0.41-0.69), compared with 18-49. Patients 50-64 had a significantly higher aOR of survival compared with those 65-74 and greater than 75; however, there was no difference in survival between the two youngest groups (aOR, 0.91; 95% CI, 0.79-1.05). A sensitivity analysis using alternative age categories (18-64, 65-69, 70-74, and ≥ 75) demonstrated decreased odds of survival for age greater than or equal to 65 compared with patients younger than 65 (for age 65-69: odds ratio [OR], 0.71; 95% CI, 0.59-0.86; for age 70-74: OR, 0.84; 95% CI, 0.67-1.04; and for age ≥ 75: OR, 0.64; 95% CI, 0.50-0.81). CONCLUSIONS This investigation represents the largest analysis of the relationship of older age on ECPR outcomes. We found that the odds of hospital survival for patients with CA treated with ECPR diminishes with increasing age, with significantly decreased odds of survival after age 65, despite controlling for illness severity and comorbidities. However, findings from this observational data have significant limitations and further studies are needed to evaluate these findings prospectively.
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Affiliation(s)
- Naomi George
- Department of Emergency Medicine, Division of Critical Care, University of New Mexico School of Medicine, Albuquerque, NM
| | - Krista Stephens
- Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM
| | - Emily Ball
- Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM
| | - Cameron Crandall
- Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM
| | - Kei Ouchi
- Department of Emergency Medicine, Division of Critical Care, University of New Mexico School of Medicine, Albuquerque, NM
- Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA
- Department of Emergecy Medicine, Harvard Medical School, Boston, MA
- Serious Illness Care Program, Ariadne Labs, Boston, MA
- Department of Psychosocial Oncology and Palliative Care, Cancer Institute, Boston, MA
- Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC
- Department of Population Health Sciences, Stanford University, Stanford, CA
- Department of Emergency Medicine, Department of Family Medicine, Department of Surgery, Department of Obstetrics and Gynecology, Acute Care Research Unit, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM
- Center for Healthcare Equity in Kidney Disease, University of New Mexico School of Medicine, Albuquerque, NM
| | - Mark Unruh
- Department of Psychosocial Oncology and Palliative Care, Cancer Institute, Boston, MA
| | - Neil Kamdar
- Department of Emergency Medicine, Division of Critical Care, University of New Mexico School of Medicine, Albuquerque, NM
- Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA
- Department of Emergecy Medicine, Harvard Medical School, Boston, MA
- Serious Illness Care Program, Ariadne Labs, Boston, MA
- Department of Psychosocial Oncology and Palliative Care, Cancer Institute, Boston, MA
- Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC
- Department of Population Health Sciences, Stanford University, Stanford, CA
- Department of Emergency Medicine, Department of Family Medicine, Department of Surgery, Department of Obstetrics and Gynecology, Acute Care Research Unit, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM
- Center for Healthcare Equity in Kidney Disease, University of New Mexico School of Medicine, Albuquerque, NM
| | - Larissa Myaskovsky
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM
- Center for Healthcare Equity in Kidney Disease, University of New Mexico School of Medicine, Albuquerque, NM
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Cruz G, Pedroza S, Giraldo M, Peña AD, Calderón CA, Quintero IF. Intraoperative circulatory arrest secondary to high-risk pulmonary embolism. Case series and updated literature review. BMC Anesthesiol 2023; 23:415. [PMID: 38110877 PMCID: PMC10726619 DOI: 10.1186/s12871-023-02370-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 12/03/2023] [Indexed: 12/20/2023] Open
Abstract
BACKGROUND Intraoperative pulmonary embolism (PE) with cardiac arrest (CA) represents a critical and potentially fatal condition. Available treatments include systemic thrombolysis, catheter-based thrombus fragmentation or aspiration, and surgical embolectomy. However, limited studies are focused on the optimal treatment choice for this critical condition. We present a case series and an updated review of the management of intraoperative CA secondary to PE. METHODS A retrospective review of patients who developed high-risk intraoperative PE was performed between June 2012 and June 2022. For the updated review, a literature search on PubMed and Scopus was conducted which resulted in the inclusion of a total of 46 articles. RESULTS A total of 196 174 major non-cardiac surgeries were performed between 2012 and 2022. Eight cases of intraoperative CA secondary to high-risk PE were identified. We found a mortality rate of 75%. Anticoagulation therapy was administered to one patient (12.5%), while two patients (25%) underwent thrombolysis, and one case (12.5%) underwent mechanical thrombectomy combined with thrombus aspiration. Based on the literature review and our 10-year experience, we propose an algorithm for the management of intraoperative CA caused by PE. CONCLUSION The essential components for adequate management of intraoperative PE with CA include hemodynamic support, cardiopulmonary resuscitation, and the implementation of a primary perfusion intervention. The prompt identification of the criteria for each specific treatment modality, guided by the individual patient's characteristics, is necessary for an optimal approach.
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Affiliation(s)
- Gustavo Cruz
- Departamento de anestesiología, Fundación Valle del Lili, Cra 98 No. 18-49, Cali, 760032, Colombia.
| | - Santiago Pedroza
- Centro de investigaciones clínicas, Fundación Valle del Lili, Cra 98 No. 18-49, Cali, 760032, Colombia
| | - Miller Giraldo
- Departamento de cardiología y hemodinamia, Fundación Valle del Lili, Cra 98 No. 18-49, Cali, 760032, Colombia
| | - Alvaro D Peña
- Departamento de cirugía cardiovascular, Fundación Valle del Lili, Cra 98 No. 18-49, Cali, 760032, Colombia
| | - Camilo A Calderón
- Departamento de cardiología, Fundación Valle del Lili, Cra 98 No. 18-49, Cali, 760032, Colombia
| | - Ivan F Quintero
- Departamento de anestesiología, Fundación Valle del Lili, Cra 98 No. 18-49, Cali, 760032, Colombia
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20
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Akatsuka M, Tatsumi H, Masuda Y. Clinical features and outcomes of in-hospital cardiac arrest in code blue events: a retrospective observational study. Front Cardiovasc Med 2023; 10:1247340. [PMID: 38028464 PMCID: PMC10658708 DOI: 10.3389/fcvm.2023.1247340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 10/18/2023] [Indexed: 12/01/2023] Open
Abstract
Background In-hospital cardiac arrest (IHCA) is a critical medical event with outcomes less researched compared to out-of-hospital cardiac arrest. This retrospective observational study aimed to investigate key aspects of IHCA epidemiology and prognosis in patients with Code Blue activation. Methods This retrospective observational study enrolled patients with Code Blue events in our hospital between January 2010 and October 2019. Participant characteristics, including age and sex, and IHCA characteristics, including the time of cardiac arrest, witnessed event, bystander cardiopulmonary resuscitation (CPR), initial shockable rhythm, vital signs at 1 and 6 h before IHCA, survival to hospital discharge (SHD), and the cardiac arrest survival postresuscitation in-hospital (CASPRI) score were included in univariate and multivariate logistic regression analyses with SHD as the primary endpoint. Results From the 293 Code Blue events that were activated during the study period, 81 participants were enrolled. Overall, the SHD rate was 28.4%, the median CPR duration was 14 (interquartile range, 6-28) min, and the rate of initial shockable rhythm was 19.8%. There were significant intergroup differences between the SHD and non-SHD groups in the CPR duration, shockable rhythm, and CASPRI score on univariate logistic regression analysis. Multivariate logistic regression analysis showed that the CASPRI score was the most accurate predictive factor for SHD (OR = 0.98, p = 0.006). Conclusions The CASPRI score is associated with SHD in patients with IHCA during Code Blue events. Therefore, the CASPRI score of IHCA patients potentially constitutes a simple, useful adjunctive tool for the management of post-cardiac arrest syndrome.
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Affiliation(s)
- Masayuki Akatsuka
- Department of Intensive Care Medicine, School of Medicine, Sapporo Medical University, Sapporo, Japan
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21
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Caplin DM, Young S, Kassin M, Dowell JD, Makary MS, Metwalli ZA, Charalel RA, Halin NJ, Kleedehn M, Lewis PB, Ward TJ, Shah RP. A History and Modern Framework for Quality Improvement in Interventional Radiology. J Vasc Interv Radiol 2023; 34:2012-2019. [PMID: 37517464 DOI: 10.1016/j.jvir.2023.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 07/17/2023] [Accepted: 07/20/2023] [Indexed: 08/01/2023] Open
Abstract
Quality improvement (QI) initiatives have benefited patients as well as the broader practice of medicine. Large-scale QI has been facilitated by multi-institutional data registries, many of which were formed out of national or international medical society initiatives. With broad participation, QI registries have provided benefits that include but are not limited to establishing treatment guidelines, facilitating research related to uncommon procedures and conditions, and demonstrating the fiscal and clinical value of procedures for both medical providers and health systems. Because of the benefits offered by these databases, Society of Interventional Radiology (SIR) and SIR Foundation have committed to the development of an interventional radiology (IR) clinical data registry known as VIRTEX. A large IR database with participation from a multitude of practice environments has the potential to have a significant positive impact on the specialty through data-driven advances in patient safety and outcomes, clinical research, and reimbursement. This article reviews the current landscape of societal QI programs, presents a vision for a large-scale IR clinical data registry supported by SIR, and discusses the anticipated results that such a framework can produce.
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Affiliation(s)
- Drew M Caplin
- Division of Interventional Radiology, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, New Hyde Park, New York.
| | - Shamar Young
- Department of Medical Imaging, University of Arizona College of Medicine, Tucson, Arizona
| | - Michael Kassin
- National Institutes of Health Clinical Center, Center for Interventional Oncology, Bethesda, Maryland
| | | | - Mina S Makary
- Division of Vascular and Interventional Radiology, Department of Radiology, Ohio State University Columbus, Ohio
| | - Zeyad A Metwalli
- Department of Interventional Radiology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Resmi A Charalel
- Division of Interventional Radiology, Department of Radiology, and Department of Population Health Sciences (R.A.C.), New York Presbyterian Hospital/Weill Cornell Medicine, New York, New York
| | - Neil J Halin
- Department of Radiology, University of Wisconsin-Madison, Madison, Wisconsin
| | - Mark Kleedehn
- National Institutes of Health Clinical Center, Center for Interventional Oncology, Bethesda, Maryland
| | - Paul B Lewis
- Department of Radiology, University of Pittsburgh Physicians, Pittsburgh, Pennsylvania
| | - Thomas J Ward
- Department of Radiology, Advent Health Medical Group/Central Florida Division, Orlando, Florida
| | - Rajesh P Shah
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California; Department of Radiology, Stanford University, Stanford, California
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22
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Low CJW, Ramanathan K, Ling RR, Ho MJC, Chen Y, Lorusso R, MacLaren G, Shekar K, Brodie D. Extracorporeal cardiopulmonary resuscitation versus conventional cardiopulmonary resuscitation in adults with cardiac arrest: a comparative meta-analysis and trial sequential analysis. THE LANCET. RESPIRATORY MEDICINE 2023; 11:883-893. [PMID: 37230097 DOI: 10.1016/s2213-2600(23)00137-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/23/2023] [Accepted: 03/23/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Although outcomes of patients after cardiac arrest remain poor, studies have suggested that extracorporeal cardiopulmonary resuscitation (ECPR) might improve survival and neurological outcomes. We aimed to investigate any potential benefits of using ECPR over conventional cardiopulmonary resuscitation (CCPR) in patients with out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA). METHODS In this systematic review and meta-analysis, we searched MEDLINE via PubMed, Embase, and Scopus from Jan 1, 2000, to April 1, 2023, for randomised controlled trials and propensity-score matched studies. We included studies comparing ECPR with CCPR in adults (aged ≥18 years) with OHCA and IHCA. We extracted data from published reports using a prespecified data extraction form. We did random-effects (Mantel-Haenszel) meta-analyses and rated the certainty of evidence using the Grading of Recommendations, Assessments, Developments, and Evaluations (GRADE) approach. We rated the risk of bias of randomised controlled trials using the Cochrane risk-of-bias 2.0 tool, and that of observational studies using the Newcastle-Ottawa Scale. The primary outcome was in-hospital mortality. Secondary outcomes included complications during extracorporeal membrane oxygenation, short-term (from hospital discharge to 30 days after cardiac arrest) and long-term (≥90 days after cardiac arrest) survival with favourable neurological outcomes (defined as cerebral performance category scores 1 or 2), and survival at 30 days, 3 months, 6 months, and 1 year after cardiac arrest. We also did trial sequential analyses to evaluate the required information sizes in the meta-analyses to detect clinically relevant reductions in mortality. FINDINGS We included 11 studies (4595 patients receiving ECPR and 4597 patients receiving CCPR) in the meta-analysis. ECPR was associated with a significant reduction in overall in-hospital mortality (OR 0·67, 95% CI 0·51-0·87; p=0·0034; high certainty), without evidence of publication bias (pegger=0·19); the trial sequential analysis was concordant with the meta-analysis. When considering IHCA only, in-hospital mortality was lower in patients receiving ECPR than in those receiving CCPR (0·42, 0·25-0·70; p=0·0009), whereas when considering OHCA only, no differences were found (0·76, 0·54-1·07; p=0·12). Centre volume (ie, the number of ECPR runs done per year in each centre) was associated with reductions in odds of mortality (regression coefficient per doubling of centre volume -0·17, 95% CI -0·32 to -0·017; p=0·030). ECPR was also associated with an increased rate of short-term (OR 1·65, 95% CI 1·02-2·68; p=0·042; moderate certainty) and long-term (2·04, 1·41-2·94; p=0·0001; high certainty) survival with favourable neurological outcomes. Additionally, patients receiving ECPR had increased survival at 30-day (OR 1·45, 95% CI 1·08-1·96; p=0·015), 3-month (3·98, 1·12-14·16; p=0·033), 6-month (1·87, 1·36-2·57; p=0·0001), and 1-year (1·72, 1·52-1·95; p<0·0001) follow-ups. INTERPRETATION Compared with CCPR, ECPR reduced in-hospital mortality and improved long-term neurological outcomes and post-arrest survival, particularly in patients with IHCA. These findings suggest that ECPR could be considered for eligible patients with IHCA, although further research into patients with OHCA is warranted. FUNDING None.
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Affiliation(s)
- Christopher Jer Wei Low
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
| | - Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore; Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, National University Health System, Singapore.
| | - Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
| | - Maxz Jian Chen Ho
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
| | - Ying Chen
- Agency for Science, Technology, and Research (A*StaR), Singapore
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Graeme MacLaren
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore; Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, National University Health System, Singapore
| | - Kiran Shekar
- Adult Intensive Care Services, Prince Charles Hospital, Brisbane, QLD, Australia; Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia; School of Medicine, University of Queensland, Brisbane, QLD, Australia; Faculty of Medicine, Bond University, Gold Coast, QLD, Australia
| | - Daniel Brodie
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Holmberg MJ, Granfeldt A, Andersen LW. Bicarbonate, calcium, and magnesium for in-hospital cardiac arrest - An instrumental variable analysis. Resuscitation 2023; 191:109958. [PMID: 37661011 DOI: 10.1016/j.resuscitation.2023.109958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 08/10/2023] [Accepted: 08/23/2023] [Indexed: 09/05/2023]
Abstract
INTRODUCTION Bicarbonate, calcium, and magnesium are commonly used during in-hospital cardiac arrest. Whether these drugs are associated with survival in cardiac arrest patients is uncertain. METHODS This was an observational study using data from the Get With The Guidelines registry. Adult patients with an in-hospital cardiac arrest between January 2008 and December 2021 were included. An instrumental variable approach was used based on hospital preferences for bicarbonate, calcium, and magnesium, respectively. The primary outcome was survival to hospital discharge. RESULTS A total of 319,230 patients were included. The median age was 66 years, 59% patients were male, and 85% patients presented with a non-shockable rhythm. Bicarbonate was administered in 58% patients, calcium in 33% patients, and magnesium in 10% patients. When considering drug use in the previous cardiac arrest patient at a given hospital as an instrument, the absolute difference in survival to hospital discharge was estimated at -14.2% (95% CI, -19.9 to -8.6) for bicarbonate, -3.0% (95% CI, -8.6 to 2.6) for calcium, and 10.7% (95% CI, -0.8 to 22.2) for magnesium as compared to no drug. When considering the proportion of drug use within the past year at a given hospital as an instrument, the confidence intervals were very wide, making the results difficult to interpret. CONCLUSIONS In this analysis, the results for bicarbonate, calcium, and magnesium were inconclusive due to wide confidence intervals and inconsistencies in estimates across instrumental variables. Randomized trials are needed to investigate the effect of these drugs on patient outcomes.
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Affiliation(s)
- Mathias J Holmberg
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Cardiology, Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - Asger Granfeldt
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Lars W Andersen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark; Prehospital Emergency Medical Services, Central Region Denmark, Denmark.
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Colgan A, Swanson MB, Ahmed A, Harland K, Mohr NM. Documented Use of Emergency Medical Dispatch Protocols is Associated with Improved Survival in Out of Hospital Cardiac Arrest. PREHOSP EMERG CARE 2023; 28:160-167. [PMID: 37471458 DOI: 10.1080/10903127.2023.2239363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/17/2023] [Accepted: 07/18/2023] [Indexed: 07/22/2023]
Abstract
OBJECTIVE There are over 300,000 out-of-hospital cardiac arrests (OHCA) annually in the United States (US) and despite many scientific advances in the field, the survival rate remains low. We seek to determine if return of spontaneous circulation (ROSC) is higher when use of emergency medical dispatch (EMD) protocols is documented for OHCA calls compared to when no EMD protocol use is documented. We also seek identify care-related processes that differ in calls that use EMD protocols. METHODS This is a retrospective cohort study of U.S. adults with OHCA prior to emergency medical services (EMS) arrival using 2019 National EMS Information System data. The primary exposure was EMD usage during EMS call. The primary outcome was prehospital ROSC, and secondary outcomes included automated external defibrillator (AED) use before EMS arrival, bystander CPR, and end-of-event EMS survival (survival to the end of the EMS care at transport destination). Multivariable logistic regression adjusted for age, sex, race/ethnicity, primary insurance, rurality, initial rhythm, arrest etiology, and witnessed arrest. RESULTS Of the 96,269 OHCA cases included, EMD use was documented in 73%. Overall, 26% of subjects achieved ROSC in EMS care. EMD subjects were more likely to achieve ROSC (27.2% vs. 23.5%, uOR 1.22, 95%CI 1.18 - 1.26) even after adjusting for subject and arrest characteristics (aOR 1.13, 95%CI 1.08 - 1.17). EMD subjects also had higher end-of-event survival (19.1% vs. 16.4%, aOR 1.20, 95%CI 1.15 - 1.25). AED use before EMS arrival was more common in the EMD group (28.3% vs. 26.3% %diff 2.0, 95%CI 1.4 to 2.6), as was CPR before EMS arrival (63.8% vs. 55.1%, difference 8.6%, 95%CI 7.9 to 9.3%). CONCLUSIONS In this retrospective analysis, the rate of ROSC was higher in adult OHCA patients when EMD protocol use was reported compared to when it was not reported. The group with documented EMD use also experienced higher rates of bystander AED use, bystander CPR, and end-of-event survival.
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Affiliation(s)
- Alexander Colgan
- Department of Emergency Medicine, Banner Wyoming Medical Center, Casper, Wyoming
| | - Morgan B Swanson
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa
| | - Azeemuddin Ahmed
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Kari Harland
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa
| | - Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa
- Divison of Critical Care, Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa
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Santa Cruz Hernando AS, Nieves-Alonso JM, Mjertan A, Gutiérrez Martínez D, Planas Roca A. In-hospital cardiac arrest: Incidence, prognostic factors and results. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2023; 70:373-380. [PMID: 36940853 DOI: 10.1016/j.redare.2022.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 06/28/2022] [Indexed: 03/23/2023]
Abstract
BACKGROUND AND AIMS In-hospital cardiac arrest (CA) is a clinical entity with high morbidity and mortality that occurs in up to 2% of hospitalized patients. It is a public health problem with important economic, social, and medical repercussions, and as such its incidence needs to be reviewed and improved. The aim of this study was to determine the incidence of in-hospital CA, return of spontaneous circulation (ROSC), and survival rates at Hospital de la Princesa, and to define the clinical and demographic characteristics of patients with in-hospital CA. PATIENTS AND METHODS Retrospective observational chart review of patients presenting in-hospital CA and treated by anaesthesiologists from the hospital's rapid intervention team. Data were collected over 1 year. RESULTS Forty four patients were included in the study, of which 22 (50%) were women. Mean age was 75.7 years (±15.78 years), and incidence of in-hospital CA was 2.88 per 100,000 hospital admissions. Twenty two patients (50%) achieved ROSC and 11 patients (25%) survived until discharge home. The most prevalent comorbidity was arterial hypertension (63.64%); 66.7% of cases were not witnessed, and only 15.9% presented a shockable rhythm. CONCLUSIONS These results are similar to those reported in other larger studies. We recommend introducing immediate intervention teams and devoting time to training hospital staff in in-hospital CA.
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Affiliation(s)
- Alvar Santa Santa Cruz Hernando
- Servicio de Anestesiología y Reanimación, Médico Adjunto Servicio de Anestesiología y Reanimación del Hospital Clínico San Carlos, Hospital Universitario de La Princesa, Madrid, Spain.
| | - Jesús Manuel Nieves-Alonso
- Servicio de Anestesiología y Reanimación, Médico Adjunto Servicio de Anestesiología y Reanimación del Hospital Universitario de La Princesa, Hospital Universitario de La Princesa, Madrid, Spain
| | - Amadea Mjertan
- Servicio de Anestesiología y Reanimación, Médico Adjunto Servicio de Anestesiología y Reanimación del Hospital Universitario de La Princesa, Hospital Universitario de La Princesa, Madrid, Spain
| | - Diego Gutiérrez Martínez
- Servicio de Anestesiología y Reanimación, Médico Adjunto Servicio de Anestesiología y Reanimación del Hospital Universitario Puerta de Hierro, Hospital Universitario de La Princesa, Madrid, Spain
| | - Antonio Planas Roca
- Servicio de Anestesiología y Reanimación, Jefe de Servicio de Anestesiología y Reanimación del Hospital Universitario de La Princesa, Hospital Universitario de La Princesa, Madrid, Spain
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26
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Andrea L, Shiloh AL, Colvin M, Rahmanian M, Bangar M, Grossestreuer AV, Berg KM, Gong MN, Moskowitz A. Pulseless electrical activity and asystole during in-hospital cardiac arrest: Disentangling the 'nonshockable' rhythms. Resuscitation 2023; 189:109857. [PMID: 37270088 PMCID: PMC10527285 DOI: 10.1016/j.resuscitation.2023.109857] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 05/23/2023] [Accepted: 05/25/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND Pulseless electrical activity (PEA) and asystole account for 81% of initial in-hospital cardiac arrest (IHCA) rhythms in the U.S.A. These "non-shockable" rhythms are often grouped together in resuscitation research and practice. We hypothesized that PEA and asystole are distinct initial IHCA rhythms with distinguishing features. METHODS This was an observational cohort study using the prospectively collected nationwide Get With The Guidelines®-Resuscitation registry. Adult patients with an index IHCA and an initial rhythm of PEA or asystole between the years of 2006 and 2019 were included. Patients with PEA vs. asystole were compared with respect to pre-arrest characteristics, resuscitation practice, and outcomes. RESULTS We identified 147,377 (64.9%) PEA and 79,720 (35.1%) asystolic IHCA. Asystole had more arrests in non-telemetry wards (20,530/147,377 [13.9%] PEA vs. 17,618/79,720 [22.1%] asystole). Asystole had 3% lower adjusted odds of ROSC (91,007 [61.8%] PEA vs. 44,957 [56.4%] asystole, aOR 0.97, 95%CI 0.96-0.97, P < 0.01); there was no statistically significant difference in survival to discharge (28,075 [19.1%] PEA vs. 14,891 [18.7%] asystole, aOR 1.00, 95%CI 1.00-1.01, P = 0.63). Duration of resuscitation for those without ROSC were shorter for asystole (29.8 [±22.5] minutes in PEA vs. 26.2 [±21.5] minutes in asystole, adjusted mean difference -3.05 95%CI -3.36--2.74, P < 0.01). INTERPRETATION Patients suffering IHCA with an initial PEA rhythm had patient and resuscitation level differences from those with asystole. PEA arrests were more common in monitored settings and received longer resuscitations. Even though PEA was associated with higher rates of ROSC, there was no difference in survival to discharge.
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Affiliation(s)
- Luke Andrea
- Montefiore Medical Center, Department of Critical Care Medicine, 111 E 210th St, Bronx, NY 10467, United States.
| | - Ariel L Shiloh
- Montefiore Medical Center, Department of Critical Care Medicine, 111 E 210th St, Bronx, NY 10467, United States
| | - Mai Colvin
- Montefiore Medical Center, Department of Critical Care Medicine, 111 E 210th St, Bronx, NY 10467, United States
| | - Marjan Rahmanian
- Montefiore Medical Center, Department of Critical Care Medicine, 111 E 210th St, Bronx, NY 10467, United States
| | - Maneesha Bangar
- Montefiore Medical Center, Department of Critical Care Medicine, 111 E 210th St, Bronx, NY 10467, United States
| | - Anne V Grossestreuer
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, 330 Brookline Ave, Boston, MA 02215, United States
| | - Katherine M Berg
- Beth Israel Deaconess Medical Center, Department of Pulmonary and Critical Care Medicine, Boston, MA, United States
| | - Michelle N Gong
- Montefiore Medical Center, Department of Critical Care Medicine, 111 E 210th St, Bronx, NY 10467, United States
| | - Ari Moskowitz
- Montefiore Medical Center, Department of Critical Care Medicine, 111 E 210th St, Bronx, NY 10467, United States
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Cagino LM, Moskowitz A, Nallamothu BK, McSparron J, Iwashyna TJ. Trends in Return of Spontaneous Circulation and Survival to Hospital Discharge for In-Intensive Care Unit Cardiac Arrests. Ann Am Thorac Soc 2023; 20:1012-1019. [PMID: 36939838 DOI: 10.1513/annalsats.202205-393oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 03/17/2023] [Indexed: 03/21/2023] Open
Abstract
Rationale: Nearly 3 in 5 in-hospital cardiac arrests (IHCAs) occur in the intensive care unit (ICU), yet large-scale data on the outcomes of in-ICU cardiac arrests have not been published for over a decade. Objectives: We sought to examine outcomes of in-ICU cardiac arrests, evaluating both achievement of return of spontaneous circulation (ROSC) and subsequent survival to hospital discharge and how these have changed over time and by type of cardiac arrest. Methods: This was an observational study using the Get With The Guidelines-Resuscitation registry, an American Heart Association-sponsored, prospective, multisite registry of IHCAs in the United States, including adults 18 years of age and older with a confirmed initial cardiac arrest occurring in the ICU who underwent resuscitation. Outcomes included achievement of ROSC and survival to hospital discharge. Multivariable hierarchical logistic regression adjusting for patient-level factors and hospitals as random effects was used to evaluate ROSC and survival. Results: A total of 114,371 adult, in-ICU IHCAs from January 2006 to December 2018 were studied. The mean age was 63.8 years, 41.3% were women, and 82.1% had a nonshockable initial rhythm. Of the 114,371 ICU cardiac arrests, 70,610 (61.7%) achieved ROSC, and 21,747 (19.0%) survived until hospital discharge. The rate of ROSC improved from 2006 to 2018 (unadjusted rate, 55.0-65.4%; adjusted odds ratio [OR] per year, 1.04; 95% confidence interval [CI], 1.03-1.05). There was an increase in overall survival to discharge during this time (unadjusted rate, 16.7-20.5%; adjusted OR per year, 1.03; 95% CI, 1.03-1.04). The survival to discharge rate of the 70,610 patients who achieved ROSC increased slightly (unadjusted rate, 30.3-31.4%; adjusted OR per year, 1.02; 95% CI, 1.01, 1.02). Conclusions: There is an increase in survival to discharge for patients who experienced a cardiac arrest in the ICU between 2006 and 2018. There is an increase in achievement of ROSC and post-ROSC survival to discharge, although the increase in achievement of ROSC was greater than the increase in post-ROSC survival.
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Affiliation(s)
- Leigh M Cagino
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Ari Moskowitz
- Division of Critical Care Medicine, Montefiore Medical Center, Bronx, New York
| | - Brahmajee K Nallamothu
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
- VA Center for Clinical Management Research, Ann Arbor, Michigan; and
| | - Jakob McSparron
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Theodore J Iwashyna
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
- VA Center for Clinical Management Research, Ann Arbor, Michigan; and
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
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Ruangsomboon O, Surabenjawongse U, Jantataeme P, Chawaruechai T, Wangtawesap K, Chakorn T. Association between cardiopulmonary resuscitation audit results with in-situ simulation and in-hospital cardiac arrest outcomes and key performance indicators. BMC Cardiovasc Disord 2023; 23:299. [PMID: 37312018 DOI: 10.1186/s12872-023-03320-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 05/25/2023] [Indexed: 06/15/2023] Open
Abstract
INTRODUCTION In-situ simulation (ISS) is a method to evaluate the performance of hospital units in performing cardiopulmonary resuscitation (CPR). It is conducted by placing a high-fidelity mannequin at hospital units with simulated scenarios and having each unit's performance evaluated. However, little is known about its impact on actual patient outcomes. Therefore, we aimed to evaluate the association between the ISS results and actual outcomes of patients with in-hospital cardiac arrest (IHCA). METHODS This retrospective study was conducted by reviewing Siriraj Hospital's CPR ISS results in association with the data of IHCA patients between January 2012 and January 2019. Actual outcomes were determined by patients' outcomes (sustained return of spontaneous circulation (ROSC) and survival to hospital discharge) and arrest performance indicators (time-to-first-epinephrine and time-to-defibrillation). These outcomes were investigated for association with the ISS scores in multilevel regression models with hospital units as clusters. RESULTS There were 2146 cardiac arrests included with sustained ROSC rate of 65.3% and survival to hospital discharge rate of 12.9%. Higher ISS scores were significantly associated with improved sustained ROSC rate (adjusted odds ratio 1.32 (95%CI 1.04, 1.67); p = 0.01) and a decrease in time-to-defibrillation (-0.42 (95%CI -0.73, -0.11); p = 0.009). Although higher scores were also associated with better survival to hospital discharge and a decrease in time-to-first-epinephrine, most models for these outcomes failed to reach statistical significance. CONCLUSION CPR ISS results were associated with some important patient outcomes and arrest performance indicators. Therefore, it may be an appropriate performance evaluation method that can guide the direction of improvement.
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Affiliation(s)
- Onlak Ruangsomboon
- Department of Emergency Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Usapan Surabenjawongse
- Department of Emergency Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Pongthorn Jantataeme
- Department of Emergency Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Thanawin Chawaruechai
- Siriraj Medical Simulation for Education and Training (SiMSET), Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Khemchat Wangtawesap
- Siriraj Medical Simulation for Education and Training (SiMSET), Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Tipa Chakorn
- Department of Emergency Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand.
- Siriraj Medical Simulation for Education and Training (SiMSET), Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
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Pound G, Eastwood G, Jones D, Hodgson C. Potential role for extracorporeal membrane oxygenation cardiopulmonary resuscitation (E-CPR) during in-hospital cardiac arrest in Australia: A nested cohort study. CRIT CARE RESUSC 2023; 25:90-96. [PMID: 37876603 PMCID: PMC10581279 DOI: 10.1016/j.ccrj.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
Objective This study aims to evaluate the characteristics and outcomes of patients who fulfilled extracorporeal membrane oxygenation cardiopulmonary resuscitation (E-CPR) selection criteria during in-hospital cardiac arrest (IHCA). Design This is a nested cohort study. Setting Code blue data were collected across seven hospitals in Australia between July 2017 and August 2018. Participants Participants who fulfilled E-CPR selection criteria during IHCA were included. Main outcome measures Return of spontaneous circulation and survival and functional outcome at hospital discharge. Functional outcome was measured using the modified Rankin scale, with scores dichotomised into good and poor functional outcome. Results Twenty-three (23/144; 16%) patients fulfilled E-CPR selection criteria during IHCA, and 11/23 (47.8%) had a poor outcome. Patients with a poor outcome were more likely to have a non-shockable rhythm (81.8% vs. 16.7%; p = 0.002), and a longer duration of CPR (median 12.5 [5.5, 39.5] vs. 1.5 [0.3, 2.5] minutes; p < 0.001) compared to those with a good outcome. The majority of patients (18/19 [94.7%]) achieved sustained return of spontaneous circulation within 15 minutes of CPR. All five patients who had CPR >15 minutes had a poor outcome. Conclusion Approximately one in six IHCA patients fulfilled E-CPR selection criteria during IHCA, half of whom had a poor outcome. Non-shockable rhythm and longer duration of CPR were associated with poor outcome. Patients who had CPR for >15 minutes and a poor outcome may have benefited from E-CPR. The feasibility, effectiveness and risks of commencing E-CPR earlier in IHCA and among those with non-shockable rhythms requires further investigation.
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Affiliation(s)
- G. Pound
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - G.M. Eastwood
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Intensive Care Department, The Austin Hospital, Melbourne, Australia
| | - D. Jones
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Intensive Care Department, The Austin Hospital, Melbourne, Australia
| | - C.L. Hodgson
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Physiotherapy Department, The Alfred Hospital, Melbourne, Australia
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Coute RA, Nathanson BH, Kurz MC, Mader TJ, Jackson EA. Disability-Adjusted Life-Years After Adult In-Hospital Cardiac Arrest in the United States. Am J Cardiol 2023; 195:3-8. [PMID: 36989605 DOI: 10.1016/j.amjcard.2023.02.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 02/14/2023] [Accepted: 02/28/2023] [Indexed: 03/31/2023]
Abstract
We sought to estimate disability-adjusted life-years (DALYs) because of adult in-hospital cardiac arrest (IHCA) and to compare IHCA DALY to other leading causes of death and disability in the United States. DALY were calculated as the sum of years of life lost and years lived with disability. The years of life lost were calculated using all adult IHCA with complete data from the American Heart Association Get With The Guidelines-Resuscitation database for 2015 to 2019. Cerebral performance category scores and published disability weights were used to estimate the years lived with disability for survivors. The cohort's DALY were extrapolated to a national level to estimate the total United States DALY and were compared with a published ranking of the leading causes of DALY in the United States for 2018. Data were reported as DALY total and rate per 100,000. A total of 99,897 IHCA were included from 329 hospitals. The total IHCA DALY increased from 2,208,310 in 2015 to 2,225,722 in 2019. A modest decrease in the DALY rate was observed from 689 per 100,000 in 2015 to 678 per 100,000 in 2019. In 2018, the rate of IHCA DALY were 728 per 100,000, which represented the 11th leading cause of DALY. When combined with out-of-hospital cardiac arrest (1,322 per 100,000), sudden cardiac arrest (2,050 per 100,000) was found the be the 2nd leading cause of DALY after ischemic heart disease (2,681 per 100,000) in 2018. In conclusion, adult IHCA is a leading cause of DALY in the United States and has increased over time because of the expansion of the Get With The Guidelines-Resuscitation database.
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Affiliation(s)
- Ryan A Coute
- Department of Emergency Medicine, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama.
| | | | - Michael C Kurz
- Department of Emergency Medicine, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama; Center for Injury Science, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama
| | - Timothy J Mader
- Department of Emergency Medicine, UMass Chan Medical School-Baystate, Springfield, Massachusetts
| | - Elizabeth A Jackson
- Division of Cardiovascular Disease, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama
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Nakajima S, Matsuyama T, Okada N, Kandori K, Okada A, Okada Y, Kitamura T, Ohta B. Targeted temperature management on outcome of older adult patients after out-of-hospital cardiac arrest. Am J Emerg Med 2023; 66:61-66. [PMID: 36706483 DOI: 10.1016/j.ajem.2023.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 12/27/2022] [Accepted: 01/14/2023] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Targeted temperature management (TTM) can potentially improve the prognosis of patients with out-of-hospital cardiac arrest (OHCA). However, the effectiveness of TTM in older adults remains unknown. Therefore, this study aimed to assess the outcomes of older adult patients with OHCA who underwent TTM. METHODS This study was a multicenter, retrospective, nationwide observational analysis of the Japanese Association for Acute Medicine out-of-hospital cardiac arrest (JAAM-OHCA) registry. We included patients aged ≥18 years who had experienced OHCA and underwent TTM from June 1, 2014, to December 31, 2017, in Japan. The primary outcome was a 1-month neurological favorable outcome, and the secondary outcome was 1-month survival. RESULTS A total of 1847 patients were included in the analysis. 79 of 389 patients aged ≥75 years (20.3%) had a 1-month neurological favorable outcome compared with 369 of 959 patients aged 18-64 years (38.5%) (adjusted odds ratios, 0.31; 95% confidence interval [CI], 0.21-0.45; P for trend <0.001). With increasing age, 1-month mortality showed an increasing trend; however, there was no significant difference. CONCLUSION In this retrospective nationwide observational study in Japan, neurological outcomes worsened as age increased in patients with OHCA who underwent TTM.
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Affiliation(s)
- Satoshi Nakajima
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kaji-cho 465, Kamigyo-ku, Kyoto 6028566, Japan
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kaji-cho 465, Kamigyo-ku, Kyoto 6028566, Japan.
| | - Nobunaga Okada
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Kyoto Daiichi Hospital, Honmachi 15-749, Higashiyama-ku, Kyoto 6050981, Japan
| | - Kenji Kandori
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Society, Kyoto Daini Hospital, Haruobi-cho 355-5, Kamigyo-ku, Kyoto 6020826, Japan
| | - Asami Okada
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Society, Kyoto Daini Hospital, Haruobi-cho 355-5, Kamigyo-ku, Kyoto 6020826, Japan
| | - Yohei Okada
- Health Services and Systems Research, Duke-NUS Medical School, National University of Singapore, 8 College Road, Singapore 169857, Singapore
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka 5650871, Japan
| | - Bon Ohta
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kaji-cho 465, Kamigyo-ku, Kyoto 6028566, Japan
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Rusnak J, Schupp T, Weidner K, Ruka M, Egner-Walter S, Forner J, Bertsch T, Kittel M, Mashayekhi K, Tajti P, Ayoub M, Behnes M, Akin I. Differences in Outcome of Patients with Cardiogenic Shock Associated with In-Hospital or Out-of-Hospital Cardiac Arrest. J Clin Med 2023; 12:jcm12052064. [PMID: 36902851 PMCID: PMC10004576 DOI: 10.3390/jcm12052064] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 02/18/2023] [Accepted: 02/22/2023] [Indexed: 03/08/2023] Open
Abstract
Cardiogenic Shock (CS) complicated by in-hospital (IHCA) or out-of-hospital cardiac arrest (OHCA) has a poor outcome. However, studies regarding the prognostic differences between IHCA and OHCA in CS are limited. In this prospective, observational study, consecutive patients with CS were included in a monocentric registry from June 2019 to May 2021. The prognostic impact of IHCA and OHCA on 30-day all-cause mortality was tested within the entire group and in the subgroups of patients with acute myocardial infarction (AMI) and coronary artery disease (CAD). Statistical analyses included univariable t-test, Spearman's correlation, Kaplan-Meier analyses, as well as uni- and multivariable Cox regression analyses. A total of 151 patients with CS and cardiac arrest were included. IHCA on ICU admission was associated with higher 30-day all-cause mortality compared to OHCA in univariable COX regression and Kaplan-Meier analyses. However, this association was solely driven by patients with AMI (77% vs. 63%; log rank p = 0.023), whereas IHCA was not associated with 30-day all-cause mortality in non-AMI patients (65% vs. 66%; log rank p = 0.780). This finding was confirmed in multivariable COX regression, in which IHCA was solely associated with higher 30-day all-cause mortality in patients with AMI (HR = 2.477; 95% CI 1.258-4.879; p = 0.009), whereas no significant association could be seen in the non-AMI group and in the subgroups of patients with and CAD. CS patients with IHCA showed significantly higher all-cause mortality at 30 days compared to patients with OHCA. This finding was primarily driven by a significant increase in all-cause mortality at 30 days in CS patients with AMI and IHCA, whereas no difference could be seen when differentiated by CAD.
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Affiliation(s)
- Jonas Rusnak
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
- Correspondence:
| | - Tobias Schupp
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Kathrin Weidner
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Marinela Ruka
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Sascha Egner-Walter
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Jan Forner
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Thomas Bertsch
- Institute of Clinical Chemistry, Laboratory Medicine and Transfusion Medicine, Nuremberg General Hospital, Paracelsus Medical University, 90419 Nuremberg, Germany
| | - Maximilian Kittel
- Institute for Clinical Chemistry, Faculty of Medicine Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Kambis Mashayekhi
- Department of Internal Medicine and Cardiology, Mediclin Heart Centre Lahr, 77933 Lahr, Germany
| | - Péter Tajti
- Gottsegen György National Cardiovascular Center, 1096 Budapest, Hungary
| | - Mohamed Ayoub
- Division of Cardiology and Angiology, Heart Center University of Bochum—Bad Oeynhausen, 32545 Bad Oeynhausen, Germany
| | - Michael Behnes
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
| | - Ibrahim Akin
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167 Mannheim, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, 68167 Mannheim, Germany
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Lu TC, Wang CH, Chou FY, Sun JT, Chou EH, Huang EPC, Tsai CL, Ma MHM, Fang CC, Huang CH. Machine learning to predict in-hospital cardiac arrest from patients presenting to the emergency department. Intern Emerg Med 2023; 18:595-605. [PMID: 36335518 DOI: 10.1007/s11739-022-03143-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 10/18/2022] [Indexed: 11/08/2022]
Abstract
In-hospital cardiac arrest (IHCA) in the emergency department (ED) is not uncommon but often fatal. Using the machine learning (ML) approach, we sought to predict ED-based IHCA (EDCA) in patients presenting to the ED based on triage data. We retrieved 733,398 ED records from a tertiary teaching hospital over a 7 year period (Jan. 1, 2009-Dec. 31, 2015). We included only adult patients (≥ 18 y) and excluded cases presenting as out-of-hospital cardiac arrest. Primary outcome (EDCA) was identified via a resuscitation code. Patient demographics, triage data, and structured chief complaints (CCs), were extracted. Stratified split was used to divide the dataset into the training and testing cohort at a 3-to-1 ratio. Three supervised ML models were trained and performances were evaluated and compared to the National Early Warning Score 2 (NEWS2) and logistic regression (LR) model by the area under the receiver operating characteristic curve (AUC). We included 316,465 adult ED records for analysis. Of them, 636 (0.2%) developed EDCA. Of the constructed ML models, Random Forest outperformed the others with the best AUC result (0.931, 95% CI 0.911-0.949), followed by Gradient Boosting (0.930, 95% CI 0.909-0.948) and Extra Trees classifier (0.915, 95% CI 0.892-0.936). Although the differences between each of ML models and LR (AUC: 0.905, 95% CI 0.882-0.926) were not significant, all constructed ML models performed significantly better than using the NEWS2 scoring system (AUC 0.678, 95% CI 0.635-0.722). Our ML models showed excellent discriminatory performance to identify EDCA based only on the triage information. This ML approach has the potential to reduce unexpected resuscitation events if successfully implemented in the ED information system.
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Affiliation(s)
- Tsung-Chien Lu
- Department of Emergency Medicine, National Taiwan University Hospital, 7, Zhongshan S. Rd, Taipei City, 100, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chih-Hung Wang
- Department of Emergency Medicine, National Taiwan University Hospital, 7, Zhongshan S. Rd, Taipei City, 100, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Fan-Ya Chou
- Department of Emergency Medicine, National Taiwan University Hospital, 7, Zhongshan S. Rd, Taipei City, 100, Taiwan
| | - Jen-Tang Sun
- Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Eric H Chou
- Department of Emergency Medicine, Baylor Scott and White All Saints Medical Center, Fort Worth, TX, USA
| | - Edward Pei-Chuan Huang
- Department of Emergency Medicine, National Taiwan University Hospital, 7, Zhongshan S. Rd, Taipei City, 100, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Emergency Medicine, National Taiwan University Hsinchu Branch, Hsinchu, Taiwan
| | - Chu-Lin Tsai
- Department of Emergency Medicine, National Taiwan University Hospital, 7, Zhongshan S. Rd, Taipei City, 100, Taiwan.
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.
| | - Matthew Huei-Ming Ma
- Department of Emergency Medicine, National Taiwan University Hospital, 7, Zhongshan S. Rd, Taipei City, 100, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Emergency Medicine, National Taiwan University Yunlin Branch, Yunlin, Taiwan
| | - Cheng-Chung Fang
- Department of Emergency Medicine, National Taiwan University Hospital, 7, Zhongshan S. Rd, Taipei City, 100, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chien-Hua Huang
- Department of Emergency Medicine, National Taiwan University Hospital, 7, Zhongshan S. Rd, Taipei City, 100, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
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Piasecki RJ, Hunt EA, Perrin N, Spaulding EM, Winters B, Samuel L, Davidson PM, Strobos NC, Churpek M, Himmelfarb CR. Using rapid response system trigger clusters to characterize patterns of clinical deterioration among hospitalized adult patients. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.02.06.23285560. [PMID: 36798369 PMCID: PMC9934794 DOI: 10.1101/2023.02.06.23285560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Background Many rapid response system (RRS) events are activated using multiple triggers. However, the patterns in which RRS triggers co-occur to activate the medical emergency team (MET) to respond to RRS events is unknown. The purpose of this study was to identify and describe the patterns (RRS trigger clusters) in which RRS triggers co-occur when used to activate the MET and determine the association of these clusters with outcomes using a sample of hospitalized adult patients. Methods RRS events among adult patients from January 2015 to December 2019 in the Get With The Guidelines- Resuscitation registry's MET module were examined (n=134,406). A combination of cluster analyses methods was performed to group patients into RRS trigger clusters based on the triggers used to activate their RRS events. Pearson's chi-squared and ANOVA tests were used to examine differences in patient characteristics across RRS trigger clusters. Multilevel logistic regression was used to examine the associations between RRS trigger clusters and outcomes following RRS events. Results Six RRS trigger clusters were identified in the study sample. The RRS triggers that predominantly identified each cluster were as follows: tachypnea, new onset difficulty in breathing, and decreased oxygen saturation (Cluster 1); tachypnea, decreased oxygen saturation, and staff concern (Cluster 2); respiratory depression, decreased oxygen saturation, and mental status changes (Cluster 3); tachycardia and staff concern (Cluster 4); mental status changes (Cluster 5); hypotension and staff concern (Cluster 6). Significant differences in patient characteristics were observed across RRS trigger clusters. Patients in Clusters 3 and 6 were associated with an increased likelihood of in-hospital cardiac arrest (IHCA [p<0.01]), while Cluster 4 was associated with a decreased likelihood of IHCA (p<0.01). All clusters were associated with an increased risk of mortality (p<0.01). Conclusions We discovered six novel RRS trigger clusters with differing relationships to adverse patient outcomes following RRS events. RRS trigger clusters may prove crucial in clarifying the associations between RRS events and adverse outcomes and may aid in clinician decision-making during RRS events.
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Chan PS, Kennedy KF, Girotra S. Updating the model for Risk-Standardizing survival for In-Hospital cardiac arrest to facilitate hospital comparisons. Resuscitation 2023; 183:109686. [PMID: 36610502 PMCID: PMC9811915 DOI: 10.1016/j.resuscitation.2022.109686] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 12/28/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Risk-standardized survival rates (RSSR) for in-hospital cardiac arrest (IHCA) have been widely used for hospital benchmarking and research. The novel coronavirus 2019 (COVID-19) pandemic has led to a substantial decline in IHCA survival as COVID-19 infection is associated with markedly lower survival. Therefore, there is a need to update the model for computing RSSRs for IHCA given the COVID-19 pandemic. METHODS Within Get With The Guidelines®-Resuscitation, we identified 53,922 adult patients with IHCA from March, 2020 to December, 2021 (the COVID-19 era). Using hierarchical logistic regression, we derived and validated an updated model for survival to hospital discharge and compared the performance of this updated RSSR model with the previous model. RESULTS The survival rate was 21.0% and 20.8% for the derivation and validation cohorts, respectively. The model had good discrimination (C-statistic 0.72) and excellent calibration. The updated parsimonious model comprised 13 variables-all 9 predictors in the original model as well as 4 additional predictors, including COVID-19 infection status. When applied to data from the pre-pandemic period of 2018-2019, there was a strong correlation (r = 0.993) between RSSRs obtained from the updated and the previous models. CONCLUSION We have derived and validated an updated model to risk-standardize hospital rates of survival for IHCA. The updated model yielded RSSRs that were similar to the initial model for IHCAs in the pre-pandemic period and can be used for supporting ongoing efforts to benchmark hospitals and facilitate research that uses data from either before or after the emergence of COVID-19.
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Affiliation(s)
- Paul S Chan
- Saint Luke's Mid America Heart Institute, USA; University of Missouri, Kansas City, MO, USA.
| | | | - Saket Girotra
- University of Texas-Southwestern Medical Center, USA
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Carnicelli AP, Keane R, Brown KM, Loriaux DB, Kendsersky P, Alviar CL, Arps K, Berg DD, Bohula EA, Burke JA, Dixson JA, Gerber DA, Goldfarb M, Granger CB, Guo J, Harrison RW, Kontos M, Lawler PR, Miller PE, Nativi-Nicolau J, Newby LK, Racharla L, Roswell RO, Shah KS, Sinha SS, Solomon MA, Teuteberg J, Wong G, van Diepen S, Katz JN, Morrow DA. 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). Resuscitation 2023; 183:109664. [PMID: 36521683 PMCID: PMC9899313 DOI: 10.1016/j.resuscitation.2022.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/19/2022] [Accepted: 12/05/2022] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Anthony P Carnicelli
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA.
| | - Ryan Keane
- Division of Cardiology, Department of Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Kelly M Brown
- Duke University Hospital, Division of Cardiology, Durham, NC, USA
| | - Daniel B Loriaux
- Duke University Hospital, Division of Cardiology, Durham, NC, USA
| | - Payton Kendsersky
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Carlos L Alviar
- Leon H Charney Division of Cardiology, Bellevue Hospital Center, New York University School of Medicine, New York, NY, USA
| | - Kelly Arps
- Duke University Hospital, Division of Cardiology, Durham, NC, USA
| | - David D Berg
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Erin A Bohula
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Jeffrey A Dixson
- Duke University Hospital, Division of Cardiology, Durham, NC, USA
| | - Daniel A Gerber
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Michael Goldfarb
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | | | - Jianping Guo
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Michael Kontos
- Division of Cardiology, Department of Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Patrick R Lawler
- Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - P Elliott Miller
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Jose Nativi-Nicolau
- Division of Cardiology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - L Kristin Newby
- Duke University Hospital, Division of Cardiology, Durham, NC, USA
| | | | - Robert O Roswell
- Lennox Hill Hospital, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Kevin S Shah
- Division of Cardiology, Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA, USA
| | - Michael A Solomon
- Critical Care Medicine Department, National Institutes of Health Clinical Center and Cardiovascular Branch, National Heart, Lung, and Blood Institute of the National Institutes of Health, Bethesda, MD, USA
| | - Jeffrey Teuteberg
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Graham Wong
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Alberta, Canada
| | - Jason N Katz
- Duke University Hospital, Division of Cardiology, Durham, NC, USA
| | - David A Morrow
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Monard C, Bianchi N, Poli E, Altarelli M, Debonneville A, Oddo M, Liaudet L, Schneider A. Cytokine hemoadsorption with CytoSorb ® in post-cardiac arrest syndrome, a pilot randomized controlled trial. Crit Care 2023; 27:36. [PMID: 36691082 PMCID: PMC9869834 DOI: 10.1186/s13054-023-04323-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 01/14/2023] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Hemoadsorption (HA) might mitigate the systemic inflammatory response associated with post-cardiac arrest syndrome (PCAS) and improve outcomes. Here, we investigated the feasibility, safety and efficacy of HA with CytoSorb® in cardiac arrest (CA) survivors at risk of PCAS. METHODS In this pilot randomized controlled trial, we included patients admitted to our intensive care unit following CA and likely to develop PCAS: required norepinephrine (> 0.2 µg/kg/min), and/or had serum lactate > 6 mmol/l and/or a time-to-return of spontaneous circulation (ROSC) > 25 min. Those requiring ECMO or renal replacement therapy were excluded. Eligible patients were randomly allocated to either receive standard of care (SOC) or SOC plus HA. Hemoadsorption was performed as stand-alone therapy for 24 h, using CytoSorb® and regional heparin-protamine anticoagulation. We collected feasibility, safety and clinical data as well as serial plasma cytokines levels within 72 h of randomization. RESULTS We enrolled 21 patients, of whom 16 (76%) had out-of-hospital CA. Median (IQR) time-to-ROSC was 30 (20, 45) minutes. Ten were assigned to the HA group and 11 to the SOC group. Hemoadsorption was initiated in all patients allocated to the HA group within 18 (11, 23) h of ICU admission and conducted for a median duration of 21 (14, 24) h. The intervention was well tolerated except for a trend for a higher rate of aPTT elevation (5 (50%) vs 2 (18%) p = 0.18) and mild (100-150 G/L) thrombocytopenia at day 1 (5 (50%) vs 2 (18%) p = 0.18). Interleukin (IL)-6 plasma levels at randomization were low (< 100 pg/mL) in 10 (48%) patients and elevated (> 1000 pg/mL) in 6 (29%). The median relative reduction in IL-6 at 48 h was 75% (60, 94) in the HA group versus 5% (- 47, 70) in the SOC group (p = 0.06). CONCLUSIONS In CA survivors at risk of PCAS, HA was feasible, safe and was associated with a nonsignificant reduction in cytokine plasma levels. Future trials are needed to further define the role of HA after CA. Those studies should include cytokine assessment to enrich the study population. TRIAL REGISTRATION NCT03523039, registered 14 May 2018.
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Affiliation(s)
- Céline Monard
- Adult Intensive Care Unit, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Nathan Bianchi
- Adult Intensive Care Unit, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Elettra Poli
- Adult Intensive Care Unit, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Marco Altarelli
- Adult Intensive Care Unit, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Anne Debonneville
- Adult Intensive Care Unit, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
- Thoracic Surgery Unit, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Mauro Oddo
- Adult Intensive Care Unit, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
- Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland
- Medical Directorate, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Lucas Liaudet
- Adult Intensive Care Unit, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
- Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Antoine Schneider
- Adult Intensive Care Unit, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland.
- Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland.
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Tekin FC, Köylü R, Köylü Ö, Kunt M. Factors Related to Resuscitation Success and Prognosis of Cardiopulmonary Arrest Cases. Indian J Crit Care Med 2023; 27:26-31. [PMID: 36756484 PMCID: PMC9886048 DOI: 10.5005/jp-journals-10071-24382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 12/18/2022] [Indexed: 01/02/2023] Open
Abstract
Background In cases where return of spontaneous circulation (ROSC) is provided in the Emergency Department (ED) after cardiopulmonary arrest (CA), it is important to investigate the parameters affecting ROSC rates, to determine the factors affecting the survival status and prognosis in the short and medium term, and to determine to what extent these factors affect the prognosis. Materials and methods This is a cross-sectional study that retrospectively investigates the factors affecting the success of resuscitation over a 5-year period in out-of-hospital cardiac arrest (OHCA) cases. Results We determined that ROSC was achieved in 26.1% of 1616 adult cardiopulmonary arrest cases, 14.8% survived the first 24 hours, and 3.8% were discharged from the hospital. Conclusion We determined that ROSC decreased by 21% with a 1-mg increase in the amount of adrenaline used, by 98% with a 1 mmol/L increase in HCO3 (std) value, by 27% with a 1 mmol/L increase in BE (B) value, and by 15% with a 1 mmol/L increase in lactate value. In terms of short-term survival, we found that a 1 mmol/L increase in lactate value reduced the probability of survival by 12%, and a 1 mEq/L increase in K value decreased the probability by 29%. With regard to the probability of survival in the medium term, we determined that the growth in age by 1 year decreased the probability by 4%, and the increase in K value by 1 mEq/L decreased the probability by 35%. How to cite this article Tekin FC, Köylü R, Köylü O, Kunt M. Factors Related to Resuscitation Success and Prognosis of Cardiopulmonary Arrest Cases. Indian J Crit Care Med 2023;27(1):26-31.
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Affiliation(s)
- Fatih Cemal Tekin
- Department of Emergency, University of Health Sciences, Konya Training and Research Hospital, Konya, Turkey,Fatih Cemal Tekin, Department of Emergency, University of Health Sciences, Konya Training and Research Hospital, Konya, Turkey, Phone: +90 5324077717, e-mail:
| | - Ramazan Köylü
- Department of Emergency, University of Health Sciences, Konya Training and Research Hospital, Konya, Turkey
| | - Öznur Köylü
- Department of Biochemistry, University of Health Sciences, Konya Training and Research Hospital, Konya, Turkey
| | - Muammer Kunt
- Department of Quality Coordinatorship, Konya Provincial Health Directorate, Konya, Turkey
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O'Halloran AJ, Grossestreuer AV, Balaji L, Ross CE, Holmberg MJ, Donnino MW, Kleinman ME. Characteristics and Outcomes of Cardiac Arrest in Adult Patients Admitted to Pediatric Services: A Descriptive Analysis of the American Heart Association's Get With The Guidelines-Resuscitation Data. Pediatr Crit Care Med 2023; 24:17-24. [PMID: 36516345 PMCID: PMC9812904 DOI: 10.1097/pcc.0000000000003104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Differences between adult and pediatric in-hospital cardiac arrest (IHCA) are well-described. Although most adults are cared for on adult services, pediatric services often admit adults, particularly those with chronic conditions. The objective of this study is to describe IHCA in adults admitted to pediatric services. DESIGN Retrospective cohort analysis from the American Heart Association's Get With The Guidelines-Resuscitation registry of a subpopulation of adults with IHCA while admitted to pediatric services. Multivariable logistic regression was used to evaluate adjusted survival outcomes and compare outcomes between age groups (18-21, 22-25, and ≥26 yr old). SETTING Hospitals contributing to the Get With The Guidelines-Resuscitation registry. PATIENTS Adult-aged patients (≥ 18 yr) with an index pulseless IHCA while admitted to a pediatric service from 2000 to 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 491 adult IHCAs were recorded on pediatric services at 17 sites, during the 19 years of review, and these events represented 0.1% of all adult IHCAs. In total, 221 cases met inclusion criteria with 139 events excluded due to an initial rhythm of bradycardia with poor perfusion. Median patient age was 22 years (interquartile range, 19-28 yr). Ninety-eight percent of patients had at least one pre-existing condition. Return of spontaneous circulation occurred in 63% of events and 30% of the patients survived to discharge. All age groups had similar rates of survival to discharge (range 26-37%; p = 0.37), and survival did not change over the study period (range 26-37%; p = 0.23 for adjusted survival to discharge). CONCLUSIONS In this cohort of adults with IHCA while admitted to a pediatric service, we failed to find an association between survival outcomes and age. Additional research is needed to better understand resuscitation in this population.
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Affiliation(s)
- Amanda J O'Halloran
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA
| | - Anne V Grossestreuer
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Lakshman Balaji
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Catherine E Ross
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
- Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Mathias J Holmberg
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | - Michael W Donnino
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Monica E Kleinman
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
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Variation in Survival After Cardiopulmonary Arrest in Cardiac Catheterization Laboratories in the United States. JACC Cardiovasc Interv 2022; 15:2463-2471. [PMID: 36543439 DOI: 10.1016/j.jcin.2022.10.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 10/24/2022] [Accepted: 10/24/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND In-hospital cardiac arrest during cardiac catheterization is not uncommon. The extent of variation in survival after cardiac arrest occurring in the cardiac catheterization laboratory (CCL) and underlying factors are not well known. OBJECTIVES The aim of this study was to identify the factors associated with higher survival rates after an index cardiac arrest in the CCL. METHODS Within the GWTG (Get With The Guidelines)-Resuscitation registry, patients ≥18 years of age who had index in-hospital cardiac arrest in the CCL between January 1, 2003, and December 31, 2017, were identified. Hierarchical models were used to adjust for demographics, comorbidities, and cardiac arrest characteristics to generate risk-adjusted survival rates (RASRs) to discharge for each hospital with ≥5 cases during the study period. Median OR was used to quantify the extent of hospital-level variation in RASR. RESULTS The study included 4,787 patients from 231 hospitals. The median RASR was 36% (IQR: 21%) and varied from a median of 20% to 52% among hospitals in the lowest and highest tertiles of RASR, respectively. The median OR was 1.71 (95% CI: 1.52-1.87), suggesting that the odds of survival for patients with identical characteristics with in-hospital cardiac arrest in the CCL from 2 randomly chosen different hospitals varied by 71%. Hospitals with greater annual numbers of cardiac arrest cases in the CCL had higher RASRs. CONCLUSIONS Even in controlled settings such as the CCL, there is significant hospital-level variation in survival after in-hospital cardiac arrest, which suggests an important opportunity to improve resuscitation outcomes in procedural areas.
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Penketh J, Nolan JP. In-hospital cardiac arrest: the state of the art. Crit Care 2022; 26:376. [PMID: 36474215 PMCID: PMC9724368 DOI: 10.1186/s13054-022-04247-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 11/18/2022] [Indexed: 12/12/2022] Open
Abstract
In-hospital cardiac arrest (IHCA) is associated with a high risk of death, but mortality rates are decreasing. The latest epidemiological and outcome data from several cardiac arrest registries are helping to shape our understanding of IHCA. The introduction of rapid response teams has been associated with a downward trend in hospital mortality. Technology and access to defibrillators continues to progress. The optimal method of airway management during IHCA remains uncertain, but there is a trend for decreasing use of tracheal intubation and increased use of supraglottic airway devices. The first randomised clinical trial of airway management during IHCA is ongoing in the UK. Retrospective and observational studies have shown that several pre-arrest factors are strongly associated with outcome after IHCA, but the risk of bias in such studies makes prognostication of individual cases potentially unreliable. Shared decision making and advanced care planning will increase application of appropriate DNACPR decisions and decrease rates of resuscitation attempts following IHCA.
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Affiliation(s)
- James Penketh
- grid.416091.b0000 0004 0417 0728Intensive Care Unit, Royal United Hospital, Bath, UK
| | - Jerry P. Nolan
- grid.416091.b0000 0004 0417 0728Intensive Care Unit, Royal United Hospital, Bath, UK ,grid.7372.10000 0000 8809 1613Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
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Olson T, Anders M, Burgman C, Stephens A, Bastero P. Extracorporeal cardiopulmonary resuscitation in adults and children: A review of literature, published guidelines and pediatric single-center program building experience. Front Med (Lausanne) 2022; 9:935424. [PMID: 36479094 PMCID: PMC9720280 DOI: 10.3389/fmed.2022.935424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 11/04/2022] [Indexed: 09/19/2023] Open
Abstract
Extracorporeal cardiopulmonary resuscitation (ECPR) is an adjunct supportive therapy to conventional cardiopulmonary resuscitation (CCPR) employing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in the setting of refractory cardiac arrest. Its use has seen a significant increase in the past decade, providing hope for good functional recovery to patients with cardiac arrest refractory to conventional resuscitation maneuvers. This review paper aims to summarize key findings from the ECPR literature available to date as well as the recommendations for ECPR set forth by leading national and international resuscitation societies. Additionally, we describe the successful pediatric ECPR program at Texas Children's Hospital, highlighting the logistical, technical and educational features of the program.
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Affiliation(s)
- Taylor Olson
- Pediatric Critical Care Medicine, Children's National Hospital, Washington, DC, United States
| | - Marc Anders
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
- Pediatric Critical Care Medicine, Texas Children's Hospital, Houston, TX, United States
| | - Cole Burgman
- ECMO, Texas Children's Hospital, Houston, TX, United States
| | - Adam Stephens
- Department of Surgery, Baylor College of Medicine, Houston, TX, United States
- Congenital Heart Surgery, Texas Children's Hospital, Houston, TX, United States
| | - Patricia Bastero
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
- Pediatric Critical Care Medicine, Texas Children's Hospital, Houston, TX, United States
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Ciullo AL, Wall N, Taleb I, Koliopoulou A, Stoddard K, Drakos SG, Welt FG, Goodwin M, Van Dyk N, Kagawa H, McKellar SH, Selzman CH, Tonna JE. Effect of Portable, In-Hospital Extracorporeal Membrane Oxygenation on Clinical Outcomes. J Clin Med 2022; 11:6802. [PMID: 36431279 PMCID: PMC9693180 DOI: 10.3390/jcm11226802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/08/2022] [Accepted: 11/14/2022] [Indexed: 11/19/2022] Open
Abstract
The time between onset of cardiogenic shock and initiation of mechanical circulatory support is inversely related to patient survival as delays in transporting patients to the operating room (OR) for venoarterial extracorporeal membrane oxygenation (VA ECMO) could prove fatal. A primed and portable VA ECMO system may allow faster initiation of ECMO in various hospital locations and subsequently improve outcomes for patients in cardiogenic shock. We reviewed our institutional experience with VA ECMO based on two time periods: beginning of our VA ECMO program and from initiation of our primed and portable in-hospital ECMO system. The primary endpoint was patient survival to discharge. A total of 137 patients were placed on VA ECMO during the study period; n = 66 (48%) before and n = 71 (52%) after program initiation. In the second era, the proportion of OR ECMO initiation decreased significantly (from 92% to 49%, p < 0.01) as more patients received ECMO in other hospital units, including the emergency department (p < 0.01) and during cardiac arrest (12% vs. 38%, p < 0.01). Survival to hospital discharge was equivalent between the two groups (30% vs. 42%, p = 0.1) despite more patients being placed on ECMO during ongoing cardiac arrest. Finally, we observed increased clinical volume since initiation of the in-hospital, portable ECMO system. Developing an in-hospital, primed and portable VA ECMO program resulted in increased clinical volume with equivalent patient survival despite a sicker cohort of patients. We conclude that more rapid deployment of VA ECMO may extend the treatment eligibility to more patients and improve patient outcomes.
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Affiliation(s)
- Anna L. Ciullo
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
- Department of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
| | - Natalie Wall
- Department of Surgery, Virginia Commonwealth University, Richmond, VA 23284, USA
| | - Iosif Taleb
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
| | - Antigone Koliopoulou
- Division of Cardiothoracic Surgery, Evangelismos Hospital, Athens, AL 35611, USA
| | - Kathleen Stoddard
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
| | - Stavros G. Drakos
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
| | - Fred G. Welt
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
| | - Matthew Goodwin
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
| | - Nate Van Dyk
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
- Department of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
| | - Hiroshi Kagawa
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
| | - Stephen H. McKellar
- Division of Cardiothoracic Surgery, Department of Surgery, Intermountain Healthcare, Salt Lake City, UT 84132, USA
| | - Craig H. Selzman
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
| | - Joseph E. Tonna
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
- Department of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
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The Neuroprotective Effects of Administration of Methylprednisolone in Cardiopulmonary Resuscitation in Experimental Cardiac Arrest Model. Cell Mol Neurobiol 2022:10.1007/s10571-022-01300-w. [DOI: 10.1007/s10571-022-01300-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 10/07/2022] [Indexed: 11/12/2022]
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Calcium Administration During Cardiopulmonary Resuscitation for In-Hospital Cardiac Arrest in Children With Heart Disease Is Associated With Worse Survival-A Report From the American Heart Association's Get With The Guidelines-Resuscitation (GWTG-R) Registry. Pediatr Crit Care Med 2022; 23:860-871. [PMID: 35894607 DOI: 10.1097/pcc.0000000000003040] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES IV calcium administration during cardiopulmonary resuscitation (CPR) for pediatric in-hospital cardiac arrest (IHCA) is associated with worse survival. We evaluated survival to hospital discharge in children with heart disease (HD), where calcium is more frequently administered during CPR. DESIGN Retrospective study of a multicenter registry database. SETTING Data reported to the American Heart Association's (AHA) Get With The Guidelines-Resuscitation registry. PATIENTS Children younger than 18 years with HD experiencing an index IHCA event requiring CPR between January 2000 and January 2019. Using propensity score matching (PSM), we selected matched cohorts of children receiving and not receiving IV calcium during CPR and compared the primary outcome of survival to hospital discharge. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We included 4,556 children with HD experiencing IHCA. Calcium was administered in 1,986 (44%), more frequently in children younger than 1 year old (65% vs 35%; p < 0.001) and surgical cardiac (SC) compared with medical cardiac patients (51% vs 36%; p < 0.001). Calcium administration during CPR was associated with longer duration CPR (median 27 min [interquartile range (IQR): 10-50 min] vs 5 min [IQR, 2-16 min]; p < 0.001) and more frequent extracorporeal-CPR deployment (25% vs 8%; p < 0.001). In the PSM cohort, those receiving calcium had decreased survival to hospital discharge (39% vs 46%; p = 0.02) compared with those not receiving calcium. In a subgroup analysis, decreased discharge survival was only seen in SC cohorts. CONCLUSIONS Calcium administration during CPR for children with HD experiencing IHCA is common and is associated with worse survival. Administration of calcium during CPR in children with HD should be restricted to specific indications as recommended by the AHA CPR guidelines.
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Elkaryoni A, Tran AT, Saad M, Darki A, Lopez JJ, Abbott JD, Chan PS. Patient characteristics and survival outcomes of cardiac arrest in the cardiac catheterization laboratory: Insights from get with the Guidelines®-Resuscitation registry. Resuscitation 2022; 180:121-127. [PMID: 35944818 DOI: 10.1016/j.resuscitation.2022.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/02/2022] [Accepted: 08/03/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Characteristics and outcomes of patients with in-hospital cardiac arrest (IHCA) in the cardiac catheterization laboratory (CCL) have not been well-described. Thus, we compared the outcomes of patients with an IHCA in the CCL versus those in the intensive care unit (ICU) and operating rooms (OR). METHODS Within the American Heart Association's Get With the Guidelines®-Resuscitation registry, we identified patients ≥ 18 years old with IHCA in the CCL, ICU, or OR between 2000-2019. Using hierarchical multivariable logistic regression, we compared rates of survival to discharge for patients with IHCA in the CCL versus ICU and OR. RESULTS Across 428 hospitals, 193,950 patients had IHCA, of whom 6865, 181,905 and 5180 were in the CCL, ICU and OR, respectively. Overall, 2614 (38.1%) patients with IHCA in the CCL survived to discharge, whereas 30,830 (16.9%) and 2096 (40.5%) survived to discharge from the ICU and OR, respectively. After adjustment, patients with IHCA in CCL were more likely to survive to discharge as compared to those with IHCA in the ICU (odds ratio, 1.37 [95%CI: 1.29-1.46], p < 0.001). In contrast, those who had IHCA in the CCL were less likely to survive to discharge as compared to patients with IHCA in the OR (odds ratio, 0.81 [95%CI: 0.69-0.94], p = 0.006). CONCLUSION IHCA in the CCL is not uncommon and has a lower survival rate when compared with IHCA in the OR. The reasons for this difference deserve further study given that cardiac arrest in both settings is witnessed and response time should be similar.
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Affiliation(s)
- Ahmed Elkaryoni
- Division of Cardiovascular Disease, Loyola University Medical Center, Loyola Stritch School of Medicine, Maywood, IL, United States.
| | - Andy T Tran
- Cardiovascular Research, Saint Luke's Mid America Heart Institute, Kansas City, MO, United States; University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States; Department of Medicine, University of California, Irvine School of Medicine, Orange, CA, United States
| | - Marwan Saad
- Lifespan Cardiovascular Institute Providence, RI, United States; Division of Cardiology, Warren Alpert Medical School of Brown University, Lifespan Cardiovascular Institute, Providence, RI, United States
| | - Amir Darki
- Division of Cardiovascular Disease, Loyola University Medical Center, Loyola Stritch School of Medicine, Maywood, IL, United States
| | - John J Lopez
- Division of Cardiovascular Disease, Loyola University Medical Center, Loyola Stritch School of Medicine, Maywood, IL, United States
| | - J Dawn Abbott
- Lifespan Cardiovascular Institute Providence, RI, United States; Division of Cardiology, Warren Alpert Medical School of Brown University, Lifespan Cardiovascular Institute, Providence, RI, United States
| | - Paul S Chan
- Cardiovascular Research, Saint Luke's Mid America Heart Institute, Kansas City, MO, United States; University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States
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Roessler LL, Holmberg MJ, Pawar RD, Lassen AT, Moskowitz A, Grossestreuer A, Moskowitz A, Edelson D, Ornato J, Peberdy MA, Churpek M, Kurz M, Starks MA, Chan P, Girotra S, Perman S, Goldberger Z. Resuscitation Quality in the ICU. Chest 2022; 162:569-577. [DOI: 10.1016/j.chest.2022.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 02/24/2022] [Accepted: 03/06/2022] [Indexed: 11/25/2022] Open
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Penketh JA. China joins the family of in-hospital cardiac arrest registries. Resusc Plus 2022; 11:100281. [PMID: 35924181 PMCID: PMC9340428 DOI: 10.1016/j.resplu.2022.100281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 07/11/2022] [Indexed: 11/18/2022] Open
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Dadon Z, Fridel T, Einav S. The association between CPR quality of In-hospital resuscitation and sex: A hypothesis generating, prospective observational study. Resusc Plus 2022; 11:100280. [PMID: 35935175 PMCID: PMC9352447 DOI: 10.1016/j.resplu.2022.100280] [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] [Received: 03/27/2022] [Revised: 07/12/2022] [Accepted: 07/12/2022] [Indexed: 11/21/2022] Open
Abstract
Introduction The relationship between sex and cardiopulmonary resuscitation (CPR) outcomes remains unclear. Particularly, questions remain regarding the potential contribution of unmeasured confounders. We aimed to examine the differences in the quality of chest compression delivered to men and women. Methods Prospective study of observational data recorded during consecutive resuscitations occurring in a single tertiary center (Feb-1-2015 to Dec-31-2018) with real-time follow-up to hospital discharge. The studied variables included time in CPR, no-flow-time and fraction, compression rate and depth and release velocity. The primary study endpoint was the unadjusted association between patient sex and the chest compression quality (depth and rate). The secondary endpoint was the association between the various components of chest compression quality, sex, and survival to hospital discharge/neurologically intact survival. Results Overall 260 in-hospital resuscitations (57.7% male patients) were included. Among these 100 (38.5%) achieved return of spontaneous circulation (ROSC) and 35 (13.5%) survived to hospital discharge. Female patients were significantly older. Ischemic heart disease and ventricular arrhythmias were more prevalent among males. Compression depth was greater in female vs male patients (54.9 ± 11.3 vs 51.7 ± 10.9 mm; p = 0.024). Other CPR quality-metrics were similar. The rates of ROSC, survival to hospital discharge and neurologically intact survival did not differ between males and females. Univariate analysis revealed no association between sex, quality metrics and outcomes. Discussion Women received deeper chest compressions during in-hospital CPR. Our findings require corroboration in larger cohorts but nonetheless underscore the need to maintain high-quality CPR in all patients using real-time feedback devices. Future studies should also include data on ventilation rates and volumes which may contribute to survival outcomes.
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Girotra S, Jones P, Peberdy MA, Vaughan-Sarrazin M, Chan PS. Association of Rapid Response Teams With Hospital Mortality in Medicare Patients. Circ Cardiovasc Qual Outcomes 2022; 15:e008901. [PMID: 36065818 PMCID: PMC9489642 DOI: 10.1161/circoutcomes.122.008901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although rapid response teams have been widely promoted as a strategy to reduce unexpected hospital deaths, most studies of rapid response teams have not adjusted for secular trends in mortality before their implementation. We examined whether implementation of a rapid response team was associated with a reduction in hospital mortality after accounting for preimplementation mortality trends. METHODS Among 56 hospitals in Get With The Guidelines-Resuscitation linked to Medicare, we calculated the annual rates of case mix-adjusted mortality for each hospital during 2000 to 2014. We constructed a hierarchical log-binomial regression model of mortality over time (calendar-year), incorporating terms to capture the effect of rapid response teams, to determine whether implementation of rapid response teams was associated with reduction in hospital mortality that was larger than expected based on preimplementation trends, while adjusting for hospital case mix index. RESULTS The median annual number of Medicare admissions was 5214 (range, 408-18 398). The median duration of preimplementation and postimplementation period was 7.6 years (≈2.5 million admissions) and 7.2 years (≈2.6 million admissions), respectively. Hospital mortality was decreasing by 2.7% annually during the preimplementation period. Implementation of rapid response teams was not associated with a change in mortality during the initial year (relative risk for model intercept, 0.98 [95% CI, 0.94-1.02]; P=0.30) or in the mortality trend (relative risk for model slope, 1.01 per year [95% CI, 0.99-1.02]; P=0.30). Among individual hospitals, implementation of a rapid response team was associated with a lower-than-expected mortality at only 4 (7.1%) and higher-than-expected mortality at 2 (3.7%) hospitals. CONCLUSIONS Among a large and diverse sample of US hospitals, we did not find implementation of rapid response teams to be associated with reduction in hospital mortality. Studies are needed to understand best practices for rapid response team implementation, to ensure that hospital investment in these teams improves patient outcomes.
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Affiliation(s)
- Saket Girotra
- Division of Cardiovascular Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Philip Jones
- Saint Luke’s Mid-America Heart Institute, Kansas City, MO
| | - Mary Ann Peberdy
- Division of Cardiology, Virginia Commonwealth University, Richmond, VA
| | - Mary Vaughan-Sarrazin
- Division of General Internal Medicine, University of Iowa Carver College of Medicine
- Comprehensive Access and Delivery Research and Evaluation, Veterans Affairs Medical Center, Iowa City
| | - Paul S. Chan
- Saint Luke’s Mid-America Heart Institute, Kansas City, MO
- University of Missouri, Kansas City, MO
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