Unexpected cardiac arrests occurring inside the ICU: outcomes of a French prospective multicenter study

A comparison of Simplified Acute Physiology Score II and Sepsis-related Organ Failure Assessment Score for prediction of mortality after Intensive Care Unit cardiac arrest

BACKGROUND

This study investigates the predictive value and suitable cutoff values of the Sepsis-related Organ Failure Assessment Score (SOFA) and Simplified Acute Physiology Score II (SAPS-II) to predict mortality during or after Intensive Care Unit Cardiac Arrest (ICU-CA).

METHODS

In this secondary analysis the ICU database of a German university hospital with five ICU was screened for all ICU-CA between 2016-2019. SOFA and SAPS-II were used for prediction of mortality during ICU-CA, hospital-stay and one-year-mortality. Receiver operating characteristic curves (ROC), area under the ROC (AUROC) and its confidence intervals were calculated. If the AUROC was significant and considered "acceptable," cutoff values were determined for SOFA and SAPS-II by Youden Index. Odds ratios and sensitivity, specificity, positive and negative predictive values were calculated for the cutoff values.

RESULTS

A total of 114 (78 male; mean age: 72.8±12.5 years) ICU-CA were observed out of 14,264 ICU-admissions (incidence: 0.8%; 95% CI: 0.7-1.0%). 29.8% (N.=34; 95% CI: 21.6-39.1%) died during ICU-CA. SOFA and SAPS-II were not predictive for mortality during ICU-CA (P>0.05). Hospital-mortality was 78.1% (N.=89; 95% CI: 69.3-85.3%). SAPS-II (recorded within 24 hours before and after ICU-CA) indicated a better discrimination between survival and death during hospital stay than SOFA (AUROC: 0.81 [95% CI: 0.70-0.92] vs. 0.70 [95% CI: 0.58-0.83]). A SAPS-II-cutoff-value of 43.5 seems to be suitable for prognosis of hospital mortality after ICU-CA (specificity: 87.5%, sensitivity: 65.6%; SAPS-II>43.5: 87.5% died in hospital; SAPS-II<43.5: 65.6% survived; odds ratio:13.4 [95% CI: 3.25-54.9]). Also for 1-year-mortality (89.5%; 95% CI: 82.3-94.4) SAPS-II showed a better discrimination between survival and death than SOFA: AUROC: 0.78 (95% CI: 0.65-0.91) vs. 0.69 (95% CI: 0.52-0.87) with a cutoff value of the SAPS-II of 40.5 (specificity: 91.7%, sensitivity: 64.3%; SAPS-II>40.5: 96.4% died; SAPS-II<40.5: 42.3% survived; odd ratio: 19.8 [95% CI: 2.3-168.7]).

CONCLUSIONS

Compared to SOFA, SAPS-II seems to be more suitable for prediction of hospital and 1-year-mortality after ICU-CA.

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

OBJECTIVE

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

DESIGN

Retrospective observational study.

SETTING

Swedish ICUs, between 2011 and 2017.

PATIENTS

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

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

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

CONCLUSIONS

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

Trends in Return of Spontaneous Circulation and Survival to Hospital Discharge for In-Intensive Care Unit Cardiac Arrests

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.

Critical illness-related cardiac arrest: Protocol for an investigation of the incidence and outcome of cardiac arrest within intensive care units in the United Kingdom

Critical illness-related cardiac arrest (CIRCA) as a distinct entity is not well described epidemiologically. There is currently a knowledge gap regarding how many occur in the UK or the impact on patient outcome. The CIRCA study is a prospective multi-centre observational cohort study of patients in the United Kingdom experiencing a cardiac arrest while in a Critical Care Unit embedded in the Case Mix Programme and National Cardiac Arrest Audit. The duration of data collection is 12 months, with surviving patients and family members receiving questionnaire follow-up at 90 days, 180 days and 12 months. This paper describes the protocol for the CIRCA study which received favourable ethical opinion from South Central - Berkshire Research Ethics Committee and approval from the Health Research Authority. Study registration is on clinicaltrials.gov (NCT04219384).

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

OBJECTIVES

We aim to describe incidence and outcomes of cardiopulmonary resuscitation (CPR) efforts and their outcomes in ICUs and their changes over time.

DESIGN

Retrospective cohort analysis.

SETTING

Patient data documented in the Austrian Center for Documentation and Quality Assurance in Intensive Care database.

PATIENTS

Adult patients (age ≥ 18 yr) admitted to Austrian ICUs between 2005 and 2019.

INTERVENTIONS

None.

MEASUREMENTS ANDN MAIN RESULTS

Information on CPR was deduced from the Therapeutic Intervention Scoring System. End points were overall occurrence rate of CPR in the ICU and CPR for unexpected cardiac arrest after the first day of ICU stay as well as survival to discharge from the ICU and the hospital. Incidence and outcomes of ICU-CPR were compared between 2005 and 2009, 2010 and 2014, and 2015 and 2019 using chi-square test. A total of 525,518 first admissions and readmissions to ICU of 494,555 individual patients were included; of these, 72,585 patients (14.7%) died in hospital. ICU-CPR was performed in 20,668 (3.9%) admissions at least once; first events occurred on the first day of ICU admission in 15,266 cases (73.9%). ICU-CPR was first performed later during ICU stay in 5,402 admissions (1.0%). The incidence of ICU-CPR decreased slightly from 4.4% between 2005 and 2009, 3.9% between 2010 and 2014, and 3.7% between 2015 and 2019 (p < 0.001). A total of 7,078 (34.5%) of 20,499 patients who received ICU-CPR survived until hospital discharge. Survival rates varied slightly over the observation period; 59,164 (12.0%) of all patients died during hospital stay without ever receiving CPR in the ICU.

CONCLUSIONS

The incidence of ICU-CPR is approximately 40 in 1,000 admissions overall and approximately 10 in 1,000 admissions after the day of ICU admission. Short-term survival is approximately four out of 10 patients who receive ICU-CPR.

Changes in the incidence of cardiopulmonary resuscitation before and after implementation of the Life-Sustaining Treatment Decisions Act

Background

Methods

Results

Conclusions

Incidence, characteristics and predictors of mortality following cardiac arrest in ICUs of a German university hospital: A retrospective cohort study

BACKGROUND

Cardiac arrest in intensive care is a rarely studied type of in-hospital cardiac arrest.

OBJECTIVE

This study examines the incidence, characteristics, risk factors for mortality as well as long-term prognosis following cardiac arrest in intensive care.

DESIGN

Retrospective cohort study.

SETTING

Five noncardiac surgical ICUs (41 surgical and 37 medical beds) at a German university hospital between 2016 and 2019.

PATIENTS

Adults experiencing cardiac arrest defined as the need for chest compressions and/or defibrillation occurring for the first time on the ICU.

MAIN OUTCOME MEASURES

Primary endpoint: occurrence of cardiac-arrest in the ICU. Secondary endpoints: diagnostic and therapeutic measures; risk factors and marginal probabilities of no-return of spontaneous circulation; rates of return of spontaneous circulation, hospital discharge, 1-year-survival and 1-year-neurological outcome.

RESULTS

A total of 114 cardiac arrests were observed out of 14 264 ICU admissions; incidence 0.8%; 95% confidence interval (CI) 0.7 to 1.0; 45.6% received at least one additional diagnostic test, such as blood gas analysis (36%), echocardiography (19.3%) or chest x-ray (9.9%) with a resulting change in therapy in 52%, (more frequently in those with a return of spontaneous circulation vs none, P = 0.023). Risk factors for no-return of spontaneous circulation were cardiac comorbidities (OR 5.4; 95% CI, 1.4 to 20.7) and continuous renal replacement therapy (OR 5.9; 95% CI, 1.7 to 20.8). Bicarbonate levels greater than 21 mmol l-1 were associated with a higher mortality risk in combination either with cardiac comorbidities (bicarbonate <21 mmol l-1: 13%; 21 to 26 mmol l-1: 45%; >26 mmol l-1: 42%) or with a SOFA at least 2 (bicarbonate <21 mmol l-1: 8%; 21 to 26 mmol l-1: 40%; >26 mmol l-1: 37%). In-hospital mortality was 78.1% (n=89); 1-year-survival-rate was 10.5% (95% CI, 5.5 to 17.7) and survival with a good neurological outcome was 6.1% (95% CI, 2.5 to 12.2).

CONCLUSION

Cardiac arrest in ICU is a rare complication with a high mortality and low rate of good neurological outcome. The development of a structured approach to resuscitation should include all available resources of an ICU and adequately consider the complete diagnostic and therapeutic spectra as our results indicate that these are still underused. The development of prediction models of death should take into account cardiac and hepatic comorbidities, continuous renal replacement therapy, SOFA at least 2 before cardiac arrest and bicarbonate level. Further research should concentrate on identifying early predictors and on the prevention of cardiac arrest in ICU.

Clinical Characteristics, Complications and Outcomes of Patients with Severe Acute Respiratory Distress Syndrome Related to COVID-19 or Influenza Requiring Extracorporeal Membrane Oxygenation-A Retrospective Cohort Study

Extracorporeal membrane oxygenation (ECMO) represents a viable therapy option for patients with refractory acute respiratory distress syndrome (ARDS). Currently, veno-venous (vv) ECMO is frequently used in patients suffering from coronavirus disease 2019 (COVID-19). VV-ECMO was also frequently utilised during the influenza pandemic and experience with this complex and invasive treatment has increased worldwide since. However, data on comparison of clinical characteristics and outcome of patients with COVID-19 and influenza-related severe ARDS treated with vv-ECMO are scarce. This is a retrospective analysis of all consecutive patients treated with vv/(veno-arterial)va-ECMO between January 2009 and January 2021 at the University Medical Centre Hamburg-Eppendorf in Germany. All patients with confirmed COVID-19 or influenza were included. Patient characteristics, parameters related to ICU and vv/va-ECMO as well as clinical outcomes were compared. Mortality was assessed up to 90 days after vv/va-ECMO initiation. Overall, 113 patients were included, 52 (46%) with COVID-19 and 61 (54%) with influenza-related ARDS. Median age of patients with COVID-19 and influenza was 58 (IQR 53-64) and 52 (39-58) years (p < 0.001), 35% and 31% (p = 0.695) were female, respectively. Charlson Comorbidity Index was 3 (1-5) and 2 (0-5) points in the two groups (p = 0.309). Median SAPS II score pre-ECMO was 27 (24-36) vs. 32 (28-41) points (p = 0.009), and SOFA score was 13 (11-14) vs. 12 (8-15) points (p = 0.853), respectively. Median P/F ratio pre-ECMO was 64 (46-78) and 73 (56-104) (p = 0.089); pH was 7.20 (7.16-7.29) and 7.26 (7.18-7.33) (p = 0.166). Median days on vv/va-ECMO were 17 (7-27) and 11 (7-20) (p = 0.295), respectively. Seventy-one percent and sixty-nine percent had renal replacement therapy (p = 0.790). Ninety-four percent of patients with COVID-19 and seventy-seven percent with influenza experienced vv/va-ECMO-associated bleeding events (p = 0.004). Thirty-four percent and fifty-five percent were successfully weaned from ECMO (p = 0.025). Ninety-day mortality was 65% and 57% in patients with COVID-19 and influenza, respectively (p = 0.156). Median length of ICU stay was 24 (13-44) and 28 (16-14) days (p = 0.470), respectively. Despite similar disease severity, the use of vv/va-ECMO in ARDS related to COVID-19 and influenza resulted in similar outcomes at 90 days. A significant higher rate of bleeding complications and thrombosis was observed in patients with COVID-19.

Clinical Characteristics, Complications and Outcomes of Patients with Severe Acute Respiratory Distress Syndrome Related to COVID-19 or Influenza Requiring Extracorporeal Membrane Oxygenation-A Retrospective Cohort Study

Extracorporeal membrane oxygenation (ECMO) represents a viable therapy option for patients with refractory acute respiratory distress syndrome (ARDS). Currently, veno-venous (vv) ECMO is frequently used in patients suffering from coronavirus disease 2019 (COVID-19). VV-ECMO was also frequently utilised during the influenza pandemic and experience with this complex and invasive treatment has increased worldwide since. However, data on comparison of clinical characteristics and outcome of patients with COVID-19 and influenza-related severe ARDS treated with vv-ECMO are scarce. This is a retrospective analysis of all consecutive patients treated with vv/(veno-arterial)va-ECMO between January 2009 and January 2021 at the University Medical Centre Hamburg-Eppendorf in Germany. All patients with confirmed COVID-19 or influenza were included. Patient characteristics, parameters related to ICU and vv/va-ECMO as well as clinical outcomes were compared. Mortality was assessed up to 90 days after vv/va-ECMO initiation. Overall, 113 patients were included, 52 (46%) with COVID-19 and 61 (54%) with influenza-related ARDS. Median age of patients with COVID-19 and influenza was 58 (IQR 53–64) and 52 (39–58) years (p < 0.001), 35% and 31% (p = 0.695) were female, respectively. Charlson Comorbidity Index was 3 (1–5) and 2 (0–5) points in the two groups (p = 0.309). Median SAPS II score pre-ECMO was 27 (24–36) vs. 32 (28–41) points (p = 0.009), and SOFA score was 13 (11–14) vs. 12 (8–15) points (p = 0.853), respectively. Median P/F ratio pre-ECMO was 64 (46–78) and 73 (56–104) (p = 0.089); pH was 7.20 (7.16–7.29) and 7.26 (7.18–7.33) (p = 0.166). Median days on vv/va-ECMO were 17 (7–27) and 11 (7–20) (p = 0.295), respectively. Seventy-one percent and sixty-nine percent had renal replacement therapy (p = 0.790). Ninety-four percent of patients with COVID-19 and seventy-seven percent with influenza experienced vv/va-ECMO-associated bleeding events (p = 0.004). Thirty-four percent and fifty-five percent were successfully weaned from ECMO (p = 0.025). Ninety-day mortality was 65% and 57% in patients with COVID-19 and influenza, respectively (p = 0.156). Median length of ICU stay was 24 (13–44) and 28 (16–14) days (p = 0.470), respectively. Despite similar disease severity, the use of vv/va-ECMO in ARDS related to COVID-19 and influenza resulted in similar outcomes at 90 days. A significant higher rate of bleeding complications and thrombosis was observed in patients with COVID-19.

Incidence, clinical characteristics, and outcome after unexpected cardiac arrest among critically ill adults with COVID-19: insight from the multicenter prospective ACICOVID-19 registry

Background

Initial reports have described the poor outcome of unexpected cardiac arrest (CA) in intensive care unit (ICU) among COVID-19 patients in China and the USA. However, there are scarce data on characteristics and outcomes of such CA patients in Europe.

Methods

Prospective registry in 35 French ICUs, including all in-ICU CA in COVID-19 adult patients with cardiopulmonary resuscitation (CPR) attempt. Favorable outcome was defined as modified Rankin scale ranging from 0 to 3 at day 90 after CA.

Results

Among the 2425 COVID-19 patients admitted to ICU from March to June 2020, 186 (8%) experienced in-ICU CA, of whom 146/186 (78%) received CPR. Among these 146 patients, 117 (80%) had sustained return of spontaneous circulation, 102 (70%) died in the ICU, including 48 dying within the first day after CA occurrence and 21 after withdrawal of life-sustaining therapy. Most of CA were non-shockable rhythm (90%). At CA occurrence, 132 patients (90%) were mechanically ventilated, 83 (57%) received vasopressors and 75 (51%) had almost three organ failures. Thirty patients (21%) had a favorable outcome. Sepsis-related organ failure assessment score > 9 before CA occurrence was the single parameter constantly associated with unfavorable outcome in multivariate analysis.

Conclusions

In-ICU CA incidence remains high among a large multicenter cohort of French critically ill adults with COVID-19. However, 21% of patients with CPR attempt remained alive at 3 months with good functional status. This contrasts with other recent reports showing poor outcome in such patients.

Trial registration: This study was retrospectively registered in ClinicalTrials.gov (NTC04373759) in April 2020 (https://www.clinicaltrials.gov/ct2/show/NCT04373759?term=acicovid&draw=2&rank=1).

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-021-00945-y.

Cardiac Arrest Survival Postresuscitation In-Hospital (CASPRI) Score Predicts Neurological Favorable Survival in Emergency Department Cardiac Arrest

Background: This study was conducted to identify the predictive factors for survival and favorable neurological outcome in patients with emergency department cardiac arrest (EDCA). Methods: ED patients who suffered from in-hospital cardiac arrest (IHCA) from July 2014 to June 2019 were enrolled. The electronic medical records were retrieved and data were extracted according to the IHCA Utstein-style guidelines. Results: The cardiac arrest survival post-resuscitation in-hospital (CASPRI) score was associated with survival, and the CASPRI scores were lower in the survival group. Three components of the CASPRI score were associated with favorable neurological survival, and the CASPRI scores were lower in the favorable neurological survival group of patients who were successfully resuscitated. The independent predictors of survival were presence of hypotension/shock, metabolic illnesses, short resuscitation time, receiving coronary angiography, and TTM. Receiving coronary angiography and low CASPRI score independently predicted favorable neurological survival in resuscitated patients. The performance of a low CASPRI score for predicting favorable neurological survival was fair, with an AUROCC of 0.77. Conclusions: The CASPRI score can be used to predict survival and neurological status of patients with EDCA. Post-cardiac arrest care may be beneficial for IHCA, especially in patients with EDCA.

Non-pharmacological interventions for preventing clotting of extracorporeal circuits during continuous renal replacement therapy

BACKGROUND

Acute kidney injury (AKI) is a common complication amongst people who are critically ill, and it is associated with an increased risk of death. For people with severe AKI, continuous kidney replacement therapy (CKRT), which is delivered over 24 hours, is needed when they become haemodynamically unstable. When CKRT is interrupted due to clotting of the extracorporeal circuit, the delivered dose is decreased and thus leading to undertreatment.

OBJECTIVES

This review assessed the efficacy of non-pharmacological measures to maintain circuit patency in CKRT.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 25 January 2021 which includes records identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) (parallel-group and cross-over studies), cluster RCTs and quasi-RCTs that examined non-pharmacological interventions to prevent clotting of extracorporeal circuits during CKRT.  DATA COLLECTION AND ANALYSIS: Three pairs of review authors independently extracted information including participants, interventions/comparators, outcomes, study methods, and risk of bias. The primary outcomes were circuit lifespan and death due to any cause at day 28. We used a random-effects model to perform quantitative synthesis (meta-analysis). We assessed risk of bias in included studies using the Cochrane Collaboration's tool for assessing risk of bias. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

A total of 20 studies involving 1143 randomised participants were included in the review. The methodological quality of the included studies was low, mainly due to the unclear randomisation process and blinding of the intervention. We found evidence on the following 11 comparisons: (i) continuous venovenous haemodialysis (CVVHD) versus continuous venovenous haemofiltration (CVVH) or continuous venovenous haemodiafiltration (CVVHDF); (ii) CVVHDF versus CVVH; (iii) higher blood flow (≥ 250 mL/minute) versus standard blood flow (< 250 mL/minute); (iv) AN69 membrane (AN69ST) versus other membranes; (v) pre-dilution versus post-dilution; (vi) a longer catheter (> 20 cm) placing the tip targeting the right atrium versus a shorter catheter (≤ 20 cm) placing the tip in the superior vena cava; (vii) surface-modified double-lumen catheter versus standard double-lumen catheter with identical geometry and flow design; (viii) single-site infusion anticoagulation versus double-site infusion anticoagulation; (ix) flat plate filter versus hollow fibre filter of the same membrane type; (x) a filter with a larger membrane surface area versus a smaller one; and (xi) a filter with more and shorter hollow fibre versus a standard filter of the same membrane type. Circuit lifespan was reported in 9 comparisons. Low certainty evidence indicated that CVVHDF (versus CVVH: MD 10.15 hours, 95% CI 5.15 to 15.15; 1 study, 62 circuits), pre-dilution haemofiltration (versus post-dilution haemofiltration: MD 9.34 hours, 95% CI -2.60 to 21.29; 2 studies, 47 circuits; I² = 13%), placing the tip of a longer catheter targeting the right atrium (versus placing a shorter catheter targeting the tip in the superior vena cava: MD 6.50 hours, 95% CI 1.48 to 11.52; 1 study, 420 circuits), and surface-modified double-lumen catheter (versus standard double-lumen catheter: MD 16.00 hours, 95% CI 13.49 to 18.51; 1 study, 262 circuits) may prolong circuit lifespan. However, higher blood flow may not increase circuit lifespan (versus standard blood flow: MD 0.64, 95% CI -3.37 to 4.64; 2 studies, 499 circuits; I² = 70%). More and shorter hollow fibre filters (versus standard filters: MD -5.87 hours, 95% CI -10.18 to -1.56; 1 study, 6 circuits) may reduce circuit lifespan. Death from any cause was reported in four comparisons We are uncertain whether CVVHDF versus CVVH, CVVHD versus CVVH or CVVHDF, longer versus a shorter catheter, or surface-modified double-lumen catheters versus standard double-lumen catheters reduced death due to any cause, in very low certainty evidence. Recovery of kidney function was reported in three comparisons. We are uncertain whether CVVHDF versus CVVH, CVVHDF versus CVVH, or surface-modified double-lumen catheters versus standard double-lumen catheters increased recovery of kidney function. Vascular access complications were reported in two comparisons. Low certainty evidence indicated using a longer catheter (versus a shorter catheter: RR 0.40, 95% CI 0.22 to 0.74) may reduce vascular access complications, however the use of surface-modified double lumen catheters versus standard double-lumen catheters may make little or no difference to vascular access complications.

AUTHORS' CONCLUSIONS

The use of CVVHDF as compared with CVVH, pre-dilution haemofiltration, a longer catheter, and surface-modified double-lumen catheter may be useful in prolonging the circuit lifespan, while higher blood flow and more and shorter hollow fibre filter may reduce circuit life. The Overall, the certainty of evidence was assessed to be low to very low due to the small sample size of the included studies. Data from future rigorous and transparent research are much needed in order to fully understand the effects of non-pharmacological interventions in preventing circuit coagulation amongst people with AKI receiving CKRT.

[Novel aspects on causes of in-hospital cardiac arrest]

Cardiac arrest is one of the most dramatic medical emergencies. The occurence of cardiac arrest in hospitalized patients, the so called in-hospital cardiac arrest, is common and associated with high mortality. However, in-hospital cardiac arrest has received quite little attention compared to cardiac arrest occuring outside the hospital. The present article reviews the recent literature of in-hospital cardiac arrest and outlines differences in characteristics and outcome compared to out of hospital cardiac arrest. Moreover, current literature regarding occurence and outcome of in-hospital cardiac arrest in hospitalized patients with COVID-19 is concisely summarized.

Characteristics and Risk Factors for Intensive Care Unit Cardiac Arrest in Critically Ill Patients with COVID-19-A Retrospective Study

The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) causing the coronavirus disease 2019 (COVID-19) led to an ongoing pandemic with a surge of critically ill patients. Very little is known about the occurrence and characteristic of cardiac arrest in critically ill patients with COVID-19 treated at the intensive care unit (ICU). The aim was to investigate the incidence and outcome of intensive care unit cardiac arrest (ICU-CA) in critically ill patients with COVID-19. This was a retrospective analysis of prospectively recorded data of all consecutive adult patients with COVID-19 admitted (27 February 2020–14 January 2021) at the University Medical Centre Hamburg-Eppendorf (Germany). Of 183 critically ill patients with COVID-19, 18% (n = 33) had ICU-CA. The median age of the study population was 63 (55–73) years and 66% (n = 120) were male. Demographic characteristics and comorbidities did not differ significantly between patients with and without ICU-CA. Simplified Acute Physiological Score II (SAPS II) (ICU-CA: median 44 points vs. no ICU-CA: 39 points) and Sequential Organ Failure Assessment (SOFA) score (median 12 points vs. 7 points) on admission were significantly higher in patients with ICU-CA. Acute respiratory distress syndrome (ARDS) was present in 91% (n = 30) with and in 63% (n = 94) without ICU-CA (p = 0.002). Mechanical ventilation was more common in patients with ICU-CA (97% vs. 67%). The median stay in ICU before CA was 6 (1–17) days. A total of 33% (n = 11) of ICU-CAs occurred during the first 24 h of ICU stay. The initial rhythm was non-shockable (pulseless electrical activity (PEA)/asystole) in 91% (n = 30); 94% (n = 31) had sustained return of spontaneous circulation (ROSC). The median time to ROSC was 3 (1–5) minutes. Patients with ICU-CA had significantly higher ICU mortality (61% vs. 37%). Multivariable logistic regression showed that the presence of ARDS (odds ratio (OR) 4.268, 95% confidence interval (CI) 1.211–15.036; p = 0.024) and high SAPS II (OR 1.031, 95% CI 0.997–1.065; p = 0.077) were independently associated with the occurrence of ICU-CA. A total of 18% of critically ill patients with COVID-19 suffered from a cardiac arrest within the intensive care unit. The occurrence of ICU-CA was associated with presence of ARDS and severity of illness.

Effects of COVID-19 on in-hospital cardiac arrest: incidence, causes, and outcome - a retrospective cohort study

Background

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), an emerging virus, has caused a global pandemic. Coronavirus disease 2019 (COVID-19), caused by SARS-CoV-2, has led to high hospitalization rates worldwide. Little is known about the occurrence of in-hospital cardiac arrest (IHCA) and high mortality rates have been proposed. The aim of this study was to investigate the incidence, characteristics and outcome of IHCA during the pandemic in comparison to an earlier period.

Methods

This was a retrospective analysis of data prospectively recorded during 3-month-periods 2019 and 2020 at the University Medical Centre Hamburg-Eppendorf (Germany). All consecutive adult patients with IHCA were included. Clinical parameters, neurological outcomes and organ failure/support were assessed.

Results

During the study period hospital admissions declined from 18,262 (2019) to 13,994 (2020) (− 23%). The IHCA incidence increased from 4.6 (2019: 84 IHCA cases) to 6.6 (2020: 93 IHCA cases)/1000 hospital admissions. Median stay before IHCA was 4 (1–9) days. Demographic characteristics were comparable in both periods. IHCA location shifted towards the ICU (56% vs 37%, p < 0.01); shockable rhythm (VT/VF) (18% vs 29%, p = 0.05) and defibrillation were more frequent in the pandemic period (20% vs 35%, p < 0.05). Resuscitation times, rates of ROSC and post-CA characteristics were comparable in both periods. The severity of illness (SAPS II/SOFA), frequency of mechanical ventilation and frequency of vasopressor therapy after IHCA were higher during the 2020 period. Overall, 43 patients (12 with & 31 without COVID-19), presented with respiratory failure at the time of IHCA. The Horowitz index and resuscitation time were significantly lower in patients with COVID-19 (each p < 0.01). Favourable outcomes were observed in 42 and 10% of patients with and without COVID-19-related respiratory failure, respectively.

Conclusion

Hospital admissions declined during the pandemic, but a higher incidence of IHCA was observed. IHCA in patients with COVID-19 was a common finding. Compared to patients with non-COVID-19-related respiratory failure, the outcome was improved.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00846-w.

Epidemiology of intensive care unit cardiac arrest: Characteristics, comorbidities, and post-cardiac arrest organ failure - A prospective observational study

BACKGROUND

Critically ill patients in intensive care units can frequently suffer from cardiac arrest (ICU-CA), the incidence of ICU-CA is associated with high mortality. Most studies on ICU-CA focused on risk factors and intra-arrest determinants. However, there is a lack of data on organ failure after ICU-CA and its clinical implications for outcome. This study aimed to investigate ICU-CA incidence, outcome and the occurrence of organ failure after ICU-CA.

METHODS

We conducted a prospective observational study over a 1-year at 12 intensive care units of a tertiary care university hospital. We included all consecutive adult patients suffering cardiac arrest (CA) during the ICU stay. Incidence, clinical and neurological outcome, as well as organ failure and support were assessed.

RESULTS

Out of 7690 patients, 176 (2%) with ICU-CA were identified during the study period. Male patients comprised 63% and the median age was 70 (58-78) years. The median ICU stay before ICU-CA was 3 (1-8) days. The initial cardiac rhythm was shockable (VT/VF) in 23% of patients; defibrillation during CPR was performed in 19%. The presumed cause of CA was cardiac in 24%, and sustained ROSC was observed in 80% of patients. Before CA 57% (n = 100) of patients were sedated, 63% (n = 110) mechanically ventilated, 70% needed vasopressor therapy and renal replacement therapy was necessary in 27% (n = 48) of patients. Organ failure after ICU-CA was common, 70% suffered from post-CA cardiac failure, renal replacement therapy was newly initiated in 26% of patients and liver failure occurred in 24% of patients. Mortality at ICU-discharge and at hospital discharge was 66 % and 68 %, respectively. Multivariate regression analysis identified the SOFA score [HR 1.09, 95% CI (0.92-3.18); p < 0.05] and liver failure [HR 2.44, 95% CI (1.39-4.26); p < 0.001] after ICU-CA as independent predictors of mortality.

CONCLUSION

The incidence of ICU-CA is rare in critically ill patients. Organ failure before and after ICU-CA is common; liver failure incidence and severity of illness after ICU-CA are independent predictors of mortality and should be considered in further decisions on ICU therapy.