Meta-analysis of outcomes of the 2005 and 2010 cardiopulmonary resuscitation guidelines for adults with in-hospital cardiac arrest

[Quality of life after in-hospital cardiac arrest : An 11-year experience from an university center]

BACKGROUND

Cardiac arrest is a life-threatening condition requiring urgent medical care and is one of the leading causes of death worldwide. Given that in-hospital cardiac arrest (IHCA) is still poorly investigated, data on health-associated quality of life thereafter remains scarce. The available evidence is mostly transferred from out-of-hospital cardiac arrest studies, but the epidemiology and determinants of success might be different. The aim of the study was to investigate the change in the quality of life after in-hospital cardiac arrest and to identify potential risk factors for a poor outcome.

MATERIAL AND METHODS

This retrospective analysis of data and prospective evaluation of quality of life included all patients surviving an IHCA and being treated by the emergency medical team between 2010 and 2020. The primary endpoint of the study was the quality of life after IHCA at the reference date. Secondary endpoints covered determination of risk factors and predictors of poor outcome after in-hospital cardiopulmonary resuscitation.

RESULTS

In total 604 patients were resuscitated within the period of 11 years and 61 (10%) patients survived until the interview took place. Finally, 48 (79%) patients fulfilled the inclusion criteria and 31 (65%) were included in the study. There was no significant difference in the quality of life before and after cardiac arrest (EQ-5D-5L utility 0.79 vs. 0.78, p = 0.567) and in the EQ-5D-5L visual analogue scale (VAS) score.

CONCLUSION

The quality of life before and after IHCA in survivors was good and comparable. The quality of life was mostly affected by reduced mobility and anxiety/depression. Future studies with larger patient samples should focus on potentially modifiable factors that could prevent, warn, and limit the consequences of in-hospital cardiac arrest. Moreover, research on outcomes of IHCA should include available tools for the quality of life assessment.

Extracorporeal Versus Conventional Cardiopulmonary Resuscitation for In-Hospital Cardiac Arrest: A Propensity Score Matching Cohort Study

OBJECTIVE

Comparing the effects of extracorporeal cardiopulmonary resuscitation (ECPR) and conventional cardiopulmonary resuscitation (CCPR) on outcomes in patients with in-hospital cardiac arrest (IHCA) in China. The benefits of ECPR over CCPR in patients with IHCA remain controversial.

DESIGN

This article analyzed data from the BASeline Investigation of In-hospital Cardiac Arrest (BASIC-IHCA) study, which consecutively enrolled patients with IHCA from July 1, 2019, to December 31, 2020. Patients who received ECPR were selected as the case group and matched with patients who received CCPR as the control group by propensity score at a ratio of 1:4. A parallel questionnaire survey of participating hospitals was conducted, to collect data on ECPR cases from January 1, 2021 to November 30, 2021. The primary outcome was survival to discharge or 30-day survival.

SETTING

We included 39 hospitals across 31 provinces in China.

PATIENTS

Patients receiving cardiopulmonary resuscitation and without contraindications to ECPR were selected from the BASIC-IHCA database. Patients older than 75 years, not witnessed, or with cardiopulmonary resuscitation duration less than 10 min were excluded.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 4853 patients met the inclusion criteria before matching, with 34 undergoing ECPR (median age, 56.5 yr; 67.65% male) and 4819 underwent CCPR (median age, 59 yr; 64.52% male). There were 132 patients receiving CCPR and 33 patients receiving ECPR who were eventually matched. The ECPR group had significantly higher survival rates at discharge or 30-day survival (21.21% vs. 7.58%, p = 0.048). The ECPR group had significantly lower mortality rates (hazard ratio 0.57; 95% CI, 0.38-0.91) than the CCPR group at discharge or 30 days. Besides the BASIC-IHCA study, the volume of ECPR implementations and the survival rate of patients with ECPR (29.4% vs. 10.4%. p = 0.004) in participating hospitals significantly improved.

CONCLUSIONS

ECPR may be beneficial compared with CCPR for patient survival after IHCA and should be considered for eligible patients with IHCA.

Nurses' motivation for performing cardiopulmonary resuscitation: a cross-sectional study

BACKGROUND

Nurse motivation can have a significant impact on the quality of cardiopulmonary resuscitation and the patients' survival. Therefore, the present study aimed to examine nurses' motivation for performing cardiopulmonary resuscitation.

METHODS

This cross-sectional study focused on 217 nurses in a teaching hospital in Iran, in 2023. A random sample of nurses was selected from four hospital departments (emergency, critical care, medical, and surgery). These nurses completed the demographic information and motivation for cardiopulmonary resuscitation questionnaires. The data were analyzed using Mann-Whitney, Spearman coefficients, and Kruskal-Wallis and multiple linear regression tests.

RESULTS

The mean score of the dimension of the feeling of achievement (4.10 ± 0.50) was high in the nurses' motivation for performing cardiopulmonary resuscitation. There were more motivational factors in the emergency department compared to the other departments in terms of the feeling of achievement, high chance of success, low chances of success, recognition and appreciation, perceived importance, and beliefs (p < 0.05). The nurses who had participated in cardiopulmonary resuscitation workshops and had a bachelor's degree had a higher mean score in the dimension of perceived importance (p < 0.05). The correlation coefficient showed that there was a significant negative correlation between the nurses' frequency of participation in cardiopulmonary resuscitation and their motivation scores in the dimensions of the feeling of achievement(r=-0.170), low chances of success(r=-0.183), perceived importance (r = -0.302), and beliefs (r = -0.250; p < 0.05). The department variable predicted the motivation score in the dimensions of feeling of achievement, high chance of success, low chance of success, perceived importance, and beliefs. The sex variable predicted the motivation score in the dimensions of facilitator of resuscitation and high chance of success. Besides, the variable of years of membership in the CPR team predicted the motivation score in the feeling of achievement and high chance of success (p < 0.05).

CONCLUSION

Nurses would be more motivated to perform a quality cardiopulmonary resuscitation if they had a feeling of success. The nurses' motivation was affected by certain factors such as their department, sex, education level, years of membership in CPR team, number of participation in CPR, and participation in educational workshops.

Outcomes of cardiac arrest hospitalizations in patients with obesity with versus without prior bariatric surgery status:A nationwide propensity-matched analysis

Introduction

Prior bariatric surgery (PBS) status in obese patients is thought to curtail the risk of cardiovascular events, but its role in change of outcomes of patients with obesity developing new acute cardiac events such as cardiac arrests (CA) remains largely unknown.

Methods

Hospitalizations among adult patients with obesity and CA were identified retrospectively using the National Inpatient Sample (2015 October-2017 December). Propensity-matched analysis (1:1) was performed for sociodemographic/hospital characteristics to identify two cohorts, with (PBS+) or without (PBS-) status. The primary endpoint was in-hospital mortality, and the secondary endpoint was healthcare resource utilization.

Results

Both cohorts (n = 1275 each), had patients with comparable age (mean 58 years), with a higher frequency of white (>70 %), females (>60 %), and Medicare enrollees (>40 %). PBS + cohort had lower rates of diabetes (27.8 % vs 36.1 %), hyperlipidemia (33.7 % vs 48.6 %), renal failure (17.3 % vs 22.0 %), chronic pulmonary disease (11.8 % vs 21.2 %) and higher rates of anemias (18.4 % vs 12.2 %), liver disease (5.1 % vs 2.4 %) and alcohol abuse (6.7 % vs 2.4 %) than PBS- cohort (p < 0.05). All-cause mortality (46.3 % vs 45.1 %, p = 0.551) was comparable between the two cohorts. The PBS + cohort was less often transferred routinely (p<0.001) but had a shorter hospital stay (p<0.001) with equivalent hospital charges compared to the PBS- cohort.

Conclusions

The PBS status (regardless of chronology) did not increase survival in CA admissions among patients with obesity. Preventive measures are necessary to manage enduring cardiovascular disease risk factors that may limit the advantages of surgery for patients with obesity and aggravate the worse outcomes of future cardiac events.

Does a Transition to Single-Occupancy Patient Rooms Affect the Incidence and Outcome of In-Hospital Cardiac Arrests?

BACKGROUND

It is proposed that patients in single-occupancy patient rooms (SPRs) carry a risk of less surveillance by nursing and medical staff and that resuscitation teams need longer to arrive in case of in-hospital cardiac arrest (IHCA). Higher incidences of IHCA and worse outcomes after cardiopulmonary resuscitation (CPR) may be the result.

OBJECTIVES

Our study examines whether there is a difference in incidence and outcomes of IHCA before and after the transition from a hospital with multibedded rooms to solely SPRs.

METHODS

In this prospective observational study in a Dutch university hospital, as a part of the Resuscitation Outcomes in the Netherlands study, we reviewed all cases of IHCA on general adult wards in a period of 16.5 months before to 16.5 months after the transition to SPRs.

RESULTS

During the study period, 102 CPR attempts were performed: 51 in the former hospital and 51 in the new hospital. Median time between last-seen-well and start basic life support did not differ significantly, nor did median time to arrival of the CPR team. Survival rates to hospital discharge were 30.0% versus 29.4% of resuscitated patients (p = 1.00), with comparable neurological outcomes: 86.7% of discharged patients in the new hospital had Cerebral Performance Category 1 (good cerebral performance) versus 46.7% in the former hospital (p = .067). When corrected for telemetry monitoring, these differences were still nonsignificant.

CONCLUSIONS

The transition to a 100% SPR hospital had no negative impact on incidence, survival rates, and neurological outcomes of IHCAs on general adult wards.

Prognostic factors affecting respiratory-related death in patients with rheumatoid arthritis complicated by interstitial lung disease: An ANSWER cohort study

The aim of this multi-centre retrospective study was to clarify the prognostic factors for respiratory-related death in patients with interstitial lung disease (ILD) complicated rheumatoid arthritis (RA). Patient background data, treatment regimen, and disease activity indicators of RA and ILD at baseline, 6 months after the diagnosis of ILD, and at the last follow-up visit were extracted. A total of 312 patients with RA-ILD (17 patients who died from respiratory-related causes and 295 survivors) were included. Patients who died from respiratory-related causes had an older median age, a higher proportion of being male, and a higher anti-cyclic citrullinated peptide antibody positivity rate than survivors (p = .0001, .038, and .016, respectively); they also had significantly higher baseline serum levels of Krebs von den Lungen-6 (KL-6) than survivors (p = .013). Patients who died from respiratory-related causes showed significantly greater changes in serum KL-6 levels between the 6-month time point and the last visit [ΔKL-6 (6 months - last)] than survivors (p = .011). Multivariate analysis showed that the ΔKL-6 (6 months - last) corrected by disease duration was a predictor of respiratory-disease-related death in patients with RA-ILD (p < .0001). Long-term increase in serum KL-6 levels is associated with respiratory-disease related death in patients with RA-ILD.

Resuscitation outcomes in patients with cancer: experience in a large urban cancer centre

PURPOSE

Hospitalized patients with cancer who experience cardiopulmonary arrest have historically low survival rates. This retrospective cohort study describes outcomes of patients at a large Canadian cancer centre who had a "code medical emergency" activated, and the use of pragmatic criteria to identify patients with poor survival following resuscitation.

METHODS

We included hospitalized patients with cancer who had a "code blue" activated between January 2007 and December 2018. Our primary outcome was intensive care unit (ICU) mortality. We developed pragmatic criteria to identify patients with "poor prognosis" for survival from cardiopulmonary resuscitation (CPR) based on disease status and candidacy for further cancer treatment. We used descriptive statistics to analyze the outcomes of poor prognosis patients.

RESULTS

Two hundred and twenty-five patients had a code blue activated. The median age was 61 yr, 52% were male, and 48% had a solid tumour. Overall, 173/225 (77%) patients survived the code blue; 164 were admitted to the ICU, where 49% (81/164) died; 31% survived to hospital discharge; and 16% (n = 27) were alive at one year. One hundred and twenty out of 225 (53%) required chest compressions; spontaneous circulation returned in 61% (73/120), and 12% (14/120) survived to hospital discharge. Patients meeting "poor prognosis" criteria (114, 51%) were more likely to die in the ICU (64% vs 35%; P < 0.001) or in hospital (86% vs 59%; P < 0.001), and more often had goals-of-care discussions prior to the code blue (46% vs 7%; P < 0.001). At one year, only 2% of poor prognosis patients were alive, compared with 24% of patients who did not meet any poor prognosis criteria.

CONCLUSION

Hospitalized patients with cancer requiring CPR have poor hospital and long-term outcomes. The proposed set of pragmatic criteria may be useful to identify patients unlikely to benefit from CPR and life support, to trigger early goals of care discussions, and to avoid potentially goal-discordant interventions.

Factors Influencing Pre-Cardiopulmonary Arrest Signs among Post-General Surgery Patients in Critical Care Service System

Health service system factors can lead to pre-cardiopulmonary arrest signs (pre-CA), which refer to a critical condition in the body leading to a circulatory and respiratory system disruption. The purpose of this study was to assess the incidence rate of an event leading to pre-cardiopulmonary arrest signs within the first 24 h, and also to analyze the factors influencing the health service system in critical post-general surgery patients in the intensive care unit. These results of the study found the incidence rate of pre-CA was 49.05 per 1000 person-hours, especially 1 h after admission to the ICU. Hemodynamic instability, respiratory instability, and neurological alteration were the most common pre-CA symptoms. The patient factors associated with high pre-CA arrest sign scores were the age from 18-40 years, with an operation status as emergency surgery, elective surgery compared with urgent surgery, and the interaction of operation status and age in critical post-general surgery patients. The organization factors found advanced hospital level and nurse allocation were associated with pre-CA. To improve quality of care for critical post-general surgery patients, critical care service delivery should be delegated to nurses with nurse allocation and critical care nursing training. Guidelines must be established for critically ill post-general surgery patient care.

Anemia before in-hospital cardiac arrest and survival from cardio-pulmonary resuscitation-a retrospective cohort study

BACKGROUND

Multiple patient-related variables have been associated with reduced rates of survival to hospital discharge (SHD) after in-hospital cardiac arrest (IHCA). As opposed to most of these, anemia may be reversible. This retrospective single-center study aims to examine the relationship between prearrest hemoglobin levels, comorbidities, and survival after cardiopulmonary resuscitation (CPR) among patients with non-traumatic IHCA. Patients were classified as anemic (hemoglobin < 10 g/dL) or non-anemic (hemoglobin ≥ 10 g/dL) based on their lowest hemoglobin measurement in the 48 h preceding the arrest. The primary outcome was SHD. The secondary outcome was return of spontaneous circulation (ROSC).

RESULTS

Of 1515 CPR reports screened, 773 patients were included. Half of the patients (50.5%, 390) were classified as anemic. Anemic patients had higher Charlson Comorbidity Indices (CCIs), less cardiac causes, and more metabolic causes for the arrest. An inverse association was found between CCI and lowest hemoglobin. Overall, 9.1% (70 patients) achieved SHD and 49.5% (383) achieved ROSC. Similar rates of SHD (7.3 vs. 10.7%, p = 0.118) and ROSC (49.5 vs. 51.0%, p = 0.688) were observed in anemic and non-anemic patients. These findings remained consistent after adjustment for comorbidities, in sensitivity analyses on the independent variable (i.e., hemoglobin) and on potential confounders and in subgroups based on sex or blood transfusion in the 72 h preceding the arrest.

CONCLUSIONS

Prearrest hemoglobin levels lower than 10 g/dL were not associated with lower rates of SHD or ROSC in IHCA patients after controlling for comorbidities. Further studies are required to confirm our findings and to establish whether post-arrest hemoglobin levels reflect the severity of the inflammatory post-resuscitation processes.

Between-centre differences in care for in-hospital cardiac arrest: a prospective cohort study

BACKGROUND

Survival after in-hospital cardiac arrest is poor, but current literature shows substantial heterogeneity in reported survival rates. This study aims to evaluate care for patients suffering in-hospital cardiac arrest (IHCA) in the Netherlands by assessing between-hospital heterogeneity in outcomes and to explain this heterogeneity stemming from differences in case-mix or differences in quality of care.

METHODS

A prospective multicentre study was conducted comprising 14 centres. All IHCA patients were included. The adjusted variation in structure and process indicators of quality of care and outcomes (in-hospital mortality and cerebral performance category [CPC] scale) was assessed with mixed effects regression with centre as random intercept. Variation was quantified using the median odds ratio (MOR), representing the expected odds ratio for poor outcome between two randomly picked centres.

RESULTS

After excluding centres with less than 10 inclusions (2 centres), 701 patients were included of whom, 218 (32%) survived to hospital discharge. The unadjusted and case-mix adjusted MOR for mortality was 1.19 and 1.05, respectively. The unadjusted and adjusted MOR for CPC score was 1.24 and 1.19, respectively. In hospitals where personnel received cardiopulmonary resuscitation (CPR) training twice per year, 183 (64.7%) versus 290 (71.4%) patients died or were in a vegetative state, and 59 (20.8%) versus 68 (16.7%) patients showed full recovery (p < 0.001).

CONCLUSION

In the Netherlands, survival after IHCA is relatively high and between-centre differences in outcomes are small. The existing differences in survival are mainly attributable to differences in case-mix. Variation in neurological outcome is less attributable to case-mix.

Cardiac arrest in older adult patients

PURPOSE OF REVIEW

To describe the epidemiology, prognostication, and treatment of out- and in-hospital cardiac arrest (OHCA and IHCA) in elderly patients.

RECENT FINDINGS

Elderly patients undergoing cardiac arrest (CA) challenge the appropriateness of attempting cardiopulmonary resuscitation (CPR). Current literature suggests that factors traditionally associated with survival to hospital discharge and neurologically intact survival after CA cardiac arrest in general (e.g. presenting ryhthm, bystander CPR, targeted temperature management) may not be similarly favorable in elderly patients. Alternative factors meaningful for outcome in this special population include prearrest functional status, comorbidity load, the specific age subset within the elderly population, and CA location (i.e., nursing versus private home). Age should therefore not be a standalone criterion for withholding CPR. Attempts to perform CPR in an elderly patient should instead stem from a shared decision-making process.

SUMMARY

An appropriate CPR attempt is an attempt resulting in neurologically intact survival. Appropriate CPR in elderly patients requires better risk classification. Future research should therefore focus on the associations of specific within-elderly age subgroups, comorbidities, and functional status with neurologically intact survival. Reporting must be standardized to enable such evaluation.

Real-time audio-visual feedback with handheld nonautomated external defibrillator devices during cardiopulmonary resuscitation for in-hospital cardiac arrest: A meta-analysis

Objective:

Restoring cardiopulmonary circulation with effective chest compression remains the cornerstone of resuscitation, yet real-time compressions may be suboptimal. This project aims to determine whether in patients with in-hospital cardiac arrest (IHCA; population), chest compressions performed with free-standing audiovisual feedback (AVF) device as compared to standard manual chest compression (comparison) results in improved outcomes, including the sustained return of spontaneous circulation (ROSC), and survival to the intensive care unit (ICU) and hospital discharge (outcomes).

Methods:

Scholarly databases and relevant bibliographies were searched, as were clinical trial registries and relevant conference proceedings to limit publication bias. Studies were not limited by date, language, or publication status. Clinical randomized controlled trials (RCT) were included that enrolled adults (age ≥ 18 years) with IHCA and assessed real-time chest compressions delivered with either the standard manual technique or with AVF from a freestanding device not linked to an automated external defibrillator (AED) or automated compressor.

Results:

Four clinical trials met inclusion criteria and were included. No ongoing trials were identified. One RCT assessed the Ambu CardioPump (Ambu Inc., Columbia, MD, USA), whereas three assessed Cardio First Angel™ (Inotech, Nubberg, Germany). No clinical RCTs compared AVF devices head-to-head. Three RCTs were multi-center. Sustained ROSC (4 studies, n = 1064) was improved with AVF use (Relative risk [RR] 1.68, 95% confidence interval [CI] 1.39–2.04), as was survival to hospital discharge (2 studies, n = 922; RR 1.78, 95% CI 1.54–2.06) and survival to hospital discharge (3 studies, n = 984; RR 1.91, 95% CI 1.62–2.25).

Conclusion:

The moderate-quality evidence suggests that chest compressions performed using a non-AED free-standing AVF device during resuscitation for IHCA improves sustained ROSC and survival to ICU and hospital discharge.

Trial Registration:

PROSPERO (CRD42020157536).

Neurological outcome after extracorporeal cardiopulmonary resuscitation for in-hospital cardiac arrest: a systematic review and meta-analysis

BACKGROUND

In-hospital cardiac arrest (IHCA) is a major adverse event with a high mortality rate if not treated appropriately. Extracorporeal cardiopulmonary resuscitation (ECPR), as adjunct to conventional cardiopulmonary resuscitation (CCPR), is a promising technique for IHCA treatment. Evidence pertaining to neurological outcomes after ECPR is still scarce.

METHODS

We performed a comprehensive systematic search of all studies up to December 20, 2019. Our primary outcome was neurological outcome after ECPR at any moment after hospital discharge, defined by the Cerebral Performance Category (CPC) score. A score of 1 or 2 was defined as favourable outcome. Our secondary outcome was post-discharge mortality. A fixed-effects meta-analysis was performed.

RESULTS

Our search yielded 1215 results, of which 19 studies were included in this systematic review. The average survival rate was 30% (95% CI 28-33%, I2 = 0%, p = 0.24). In the surviving patients, the pooled percentage of favourable neurological outcome was 84% (95% CI 80-88%, I2 = 24%, p = 0.90).

CONCLUSION

ECPR as treatment for in-hospital cardiac arrest is associated with a large proportion of patients with good neurological outcome. The large proportion of favourable outcome could potentially be explained by the selection of patients for treatment using ECPR. Moreover, survival is higher than described in the conventional CPR literature. As indications for ECPR might extend to older or more fragile patient populations in the future, research should focus on increasing survival, while maintaining optimal neurological outcome.

Survival after in-hospital cardiopulmonary resuscitation from 2003 to 2013: An observational study before legislation on the life-sustaining treatment decision-making act of Korean patients

We analyzed cardiopulmonary resuscitation (CPR) rates, deaths preceded by CPR, and survival trends after in-hospital CPR, using a sample of nationwide Korean claims data for the period 2003 to 2013.The Korean National Health Insurance Service-National Sample Cohort is a stratified random sample of 1,025,340 subjects selected from among approximately 46 million Koreans. We evaluated the annual incidence of CPR per 1000 admissions in various age groups, hospital deaths preceded by CPR, and survival rate following in-hospital CPR. Analyses of the relationships between survival and patient and hospital characteristics were performed using logistic regression analysis.A total of 5918 in-hospital CPR cases from 2003 to 2013 were identified among eligible patients. The cumulative incidence of in-hospital CPR was 3.71 events per 1000 admissions (95% confidence interval 3.62-3.80). The CPR rate per 1000 admissions was highest among the oldest age group, and the rate decreased throughout the study period in all groups except the youngest age group. Hospital deaths were preceded by in-hospital CPR in 18.1% of cases, and the rate decreased in the oldest age group. The survival-to-discharge rate in all study subjects was 11.7% during study period, while the 6-month and 1-year survival rates were 8.0% and 7.2%, respectively. Survival tended to increase throughout the study period; however, this was not the case in the oldest age group. Age and malignancy were associated with lower survival rates, whereas myocardial infarction and diabetes mellitus were associated with higher survival rates.Our result shows that hospital deaths were preceded by in-hospital CPR in 18.1% of case, and the survival-to-discharge rate in all study subjects was 11.7% during the study period. Survival tended to increase throughout the study period except for the oldest age group. Our results provide reliable data that can be used to inform judicious decisions on the implementation of CPR, with the ultimate goal of optimizing survival rates and resource utilization.

A Population-Based Retrospective Analysis of Post-In-Hospital Cardiac Arrest Survival after Modification of the Chain of Survival

BACKGROUND

In 2010, the American Heart Association recommended that postcardiac arrest care should be included in the chain of survival to reduce permanent neurological damage, improve quality of life, and reduce health care expenses of postcardiac arrest care.

OBJECTIVES

To investigate post-in-hospital cardiac arrest (IHCA) survival prior to and after modification of the chain of survival in 2010, with subgroup analyses per age and concomitant coronary heart disease (CHD).

METHODS

We retrospectively searched the National Health Insurance Research Database for the 2007-2015 period to collect case data coded as "427.41" or "427.5" per International Classification of Disease Clinical Modification, Ninth revision codes and analyzed the data with SPSS v22.0.

RESULTS

The 1-day survival rate in the 2011-2015 period was 2% higher than that in the 2007-2010 period (odds ratio [OR] 1.02, 95% confidence interval [CI] 1.01-1.04). Moreover, in the 2011-2015 period, the survival-to-discharge rate was increased by 1% in patients under 65 years (OR 1.01, 95% CI 1.00-1.02) and 1% in CHD patients (OR 1.01, 95% CI 1.01-1.02) compared with that in the 2007-2010 period.

CONCLUSION

For patients with IHCA, the overall short-term survival improved significantly after modification of the chain of survival. Younger patients and patients with CHD had better long-term survival.

Meta-Analysis Comparing Cardiac Arrest Outcomes Before and After Resuscitation Guideline Updates

Updates of resuscitation guidelines have limited high-level supporting evidence. Moreover, the overall effect of such bundled practice changes depends not only on the impact of the individual interventions but also on their interplay and swift functioning of the entire chain of survival. Therefore, real-world data monitoring is essential. We performed a meta-analysis of comparative studies on outcomes before and after successive guideline updates. On January 16, 2019, we searched for comparative studies (PubMed, Web-of-Science, Embase, and the Cochrane Libraries) reporting outcomes before and after resuscitation guidelines 2005, 2010, and 2015. We followed PRISMA, Cochrane, and Moose-recommendations. Studies on outcomes during the 2005 versus 2000 guideline period (n = 23; 40,859 patients) reported significantly higher ROSC (odds ratio [OR] 1.21 [1.04 to 1.42], p = 0.014), survival to admission (OR 1.34 [1.09 to 1.65], p = 0.005), survival to discharge (OR 1.46 [1.25 to 1.70], p <0.001), and favorable neurologic outcome (OR 1.35 [1.01 to 1.81], p = 0.040). Studies on outcomes during the 2010 versus 2005 guideline period (n = 11; 1,048,112 patients) indicated no difference in ROSC (OR 1.25 [95% confidence interval 0.95 to 1.63], p = 0.11), whereas survival to discharge improved significantly (OR 1.30 [1.17 to 1.45], p <0.001). Only 2 studies reported on neurologic outcomes, both showing improved outcome after the 2010 guideline update. No data on the 2015 guidelines were available. This meta-analysis on real-world data of >1 million patients demonstrates improved outcomes after the 2005 and 2010 resuscitation guideline updates, and a lack of data on the 2015 guideline. In conclusion, although limited in terms of causality, this study suggests that the sum of all efforts to improve outcomes, including updated CPR guidelines, contributed to increased survival after cardiac arrest.

Pre-arrest and intra-arrest prognostic factors associated with survival after in-hospital cardiac arrest: systematic review and meta-analysis

OBJECTIVE

To determine associations between important pre-arrest and intra-arrest prognostic factors and survival after in-hospital cardiac arrest.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Medline, PubMed, Embase, Scopus, Web of Science, and the Cochrane Database of Systematic Reviews from inception to 4 February 2019. Primary, unpublished data from the United Kingdom National Cardiac Arrest Audit database.

STUDY SELECTION CRITERIA

English language studies that investigated pre-arrest and intra-arrest prognostic factors and survival after in-hospital cardiac arrest.

DATA EXTRACTION

PROGRESS (prognosis research strategy group) recommendations and the CHARMS (critical appraisal and data extraction for systematic reviews of prediction modelling studies) checklist were followed. Risk of bias was assessed by using the QUIPS tool (quality in prognosis studies). The primary analysis pooled associations only if they were adjusted for relevant confounders. The GRADE approach (grading of recommendations assessment, development, and evaluation) was used to rate certainty in the evidence.

RESULTS

The primary analysis included 23 cohort studies. Of the pre-arrest factors, male sex (odds ratio 0.84, 95% confidence interval 0.73 to 0.95, moderate certainty), age 60 or older (0.50, 0.40 to 0.62, low certainty), active malignancy (0.57, 0.45 to 0.71, high certainty), and history of chronic kidney disease (0.56, 0.40 to 0.78, high certainty) were associated with reduced odds of survival after in-hospital cardiac arrest. Of the intra-arrest factors, witnessed arrest (2.71, 2.17 to 3.38, high certainty), monitored arrest (2.23, 1.41 to 3.52, high certainty), arrest during daytime hours (1.41, 1.20 to 1.66, high certainty), and initial shockable rhythm (5.28, 3.78 to 7.39, high certainty) were associated with increased odds of survival. Intubation during arrest (0.54, 0.42 to 0.70, moderate certainty) and duration of resuscitation of at least 15 minutes (0.12, 0.07 to 0.19, high certainty) were associated with reduced odds of survival.

CONCLUSION

Moderate to high certainty evidence was found for associations of pre-arrest and intra-arrest prognostic factors with survival after in-hospital cardiac arrest.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018104795.

Frailty and associated outcomes and resource utilization following in-hospital cardiac arrest

BACKGROUND

In-hospital cardiac arrest (IHCA) is common and associated with high mortality. Frailty is increasingly recognized as a predictor of worse prognosis among critically ill patients, but its association with outcomes and resource utilization following IHCA is unknown.

METHODS

We performed a retrospective analysis (2013-2016) of a prospectively collected registry from two hospitals of consecutive hospitalized adult patients with IHCA occurring on the hospital wards. We defined frailty using the Clinical Frailty Scale (CFS) score ≥5. CFS scores were based on validated medical review criteria. The primary outcome is hospital mortality. Secondary outcomes include return of spontaneous circulation (ROSC), discharge to long-term care, and hospital costs. We used multivariable logistic regression to adjust for known confounders.

RESULTS

We included 477 patients, and 124 (26.0%) had frailty. Frailty was associated with increased odds of hospital death (adjusted odds ratio [aOR]: 2.91 [95% confidence interval [CI]: 2.37-3.48) and discharge to long-term care (aOR 1.94 [95% CI: 1.57-2.32]). Compared with patients without frailty, patients with frailty had decreased odds of ROSC following IHCA (aOR 0.63 [95% CI: 0.41-0.93]). No difference in mean total costs was demonstrated between patients with and without frailty ($50,799 vs. $45,849). Frail patients did have higher cost-per-survivor ($947,546 vs. $161,550).

CONCLUSIONS

Frail individuals who experience an IHCA are more likely to die in hospital or be discharged to long-term care, and less likely to achieve ROSC in comparison with individuals who are not frail. The hospital costs per-survivor of IHCA are increased when frailty is present.

Effect of ulinastatin combined with mild therapeutic hypothermia on intestinal barrier dysfunction following cardiopulmonary resuscitation in rats

The aim of the present study was to investigate the effect of ulinastatin (UTI) alone or combined with mild therapeutic hypothermia (MTH) on intestinal barrier dysfunction following cardiopulmonary resuscitation (CPR) in rats. A total of 25 adult male Sprague-Dawley rats were randomly organized into five groups: Sham; control; UTI; MTH; and the combined group. The latter four groups were induced with the asphyxiated cardiac arrest rat model and treated with different interventions. After 6 h of treatment, the intestinal tissues of the rats were examined by electron microscopy, and the levels of intestinal malondialdehyde (MDA) and superoxide dismutase (SOD) were determined. The results of the present study indicated that the target temperature had successfully been attained in MTH and the combined group, and the other three groups of rats all survived at a normal temperature. In the rats treated with UTI or MTH, the epithelial cells exhibited pathological changes in their tight junctions and epithelial cell surface microvilli compared with the sham group. In the rats treated with a combination of UTI and MTH, whilst the epithelial cells exhibited a few slight changes, including mitochondrial edema, they were largely similar to the normal epithelial cells. However, there were significant differences in the levels of MDA and SOD between the different treatment groups. UTI combined with MTH may serve a protective role by suppressing oxidative stress in the small intestinal mucosa following CPR in rats compared with either UTI or MTH treatment alone.

Cost-effectiveness of extracorporeal cardiopulmonary resuscitation after in-hospital cardiac arrest: A Markov decision model

BACKGROUND

This study aimed to estimate the cost-effectiveness of extracorporeal cardiopulmonary resuscitation (ECPR) for in-hospital cardiac arrest treatment.

METHODS

A decision tree and Markov model were constructed based on current literature. The model was conditional on age, Charlson Comorbidity Index (CCI) and sex. Three treatment strategies were considered: ECPR for patients with an Age-Combined Charlson Comorbidity Index (ACCI) below different thresholds (2-4), ECPR for everyone (EALL), and ECPR for no one (NE). Cost-effectiveness was assessed with costs per quality-of-life adjusted life years (QALY).

MEASUREMENTS AND MAIN RESULTS

Treating eligible patients with an ACCI below 2 points costs 8394 (95% CI: 4922-14,911) euro per extra QALY per IHCA patient; treating eligible patients with an ACCI below 3 costs 8825 (95% CI: 5192-15,777) euro per extra QALY per IHCA patient; treating eligible patients with an ACCI below 4 costs 9311 (95% CI: 5478-16,690) euro per extra QALY per IHCA patient; treating every eligible patient with ECPR costs 10,818 (95% CI: 6357-19,400) euro per extra QALY per IHCA patient. For WTP thresholds of 0-9500 euro, NE has the highest probability of being the most cost-effective strategy. For WTP thresholds between 9500 and 12,500, treating eligible patients with an ACCI below 4 has the highest probability of being the most cost-effective strategy. For WTP thresholds of 12,500 or higher, EALL was found to have the highest probability of being the most cost-effective strategy.

CONCLUSIONS

Given that conventional WTP thresholds in Europe and North-America lie between 50,000-100,000 euro or U.S. dollars, ECPR can be considered a cost-effective treatment after in-hospital cardiac arrest from a healthcare perspective. More research is necessary to validate the effectiveness of ECPR, with a focus on the long-term effects of complications of ECPR.

Value of Continuous Video EEG and EEG Responses to Thermesthesia Stimulation in Prognosis Evaluation of Comatose Patients after Cardiopulmonary Resuscitation

Objective

To investigate the clinical value of video-electroencephalography (VEEG) and thermal stimulus on evaluating the prognosis of comatose patients after cardiopulmonary resuscitation.

Methods

Twenty eight comatose patients with cardiopulmonary resuscitation were included in the department of ICU of the First Teaching Hospital of Fujian Medical University from February 2013 to March 2016. Of the included 28 patients, 20 cases died (death group) and 8 cases survived (survival group) after cardiopulmonary resuscitation. The VEEG, Glasgow Coma Scale (GCS) and APACHE II score were recorded and compared between the death and survival group. The prediction value of death for VEEG, GCS and APACHE II were evaluated through sensitivity, specificity and area under the receiver operating characteristic (ROC) curve (AUC).

Results

GCS and APACHEH II score were statistical different between the death and survival group (P<0.05). With the increase of VEEG grading, the mortality rate of patients increased significantly (P<0.05). Predicting value of mortality for GCS, VEEG and APACHEH II were 57.69%, 61.54% and 71.43% respectively without statistical difference (P>0.05). The death prediction sensitivity and specificity for GCS were 67.0% and 85.0%, for APACHEH II were 95.1% and 85.0%, for VEEG were 100.0% and 85.2%. VEEG has the highest sensitivity, Specificity, coincidence rate and Kappa vale compared to GCS, and APACHEH II.

Conclusion

Video-electroencephalography is a useful tool for predicting the death risk for patients who received cardiopulmonary resuscitation.

Outcomes of adults with in-hospital cardiac arrest after implementation of the 2010 resuscitation guidelines

BACKGROUND

The 2015 guidelines for cardiopulmonary resuscitation (CPR) are based on an update of the 2010 guidelines with minor revisions. It is important to assess the 2010 guidelines to ensure their efficacy, which may help promote widespread adoption of the 2015 guidelines.

METHODS

We conducted a retrospective observational study in a single center that evaluated patients with in-hospital cardiac arrest (IHCA) between 2006 and 2014. Multivariable logistic regression analysis was used to evaluate associations between independent variables and outcomes.

RESULTS

A total of 1525 patients were included. For patients with initial non-shockable rhythms, the elapsed time to first adrenaline injection was significantly shorter for patients who received CPR according to the 2010 guidelines (2010-CPR) than for those who were treated according to the 2005 guidelines (2005-CPR). During post-cardiac arrest care, the percentage of patients with fever was significantly lower and the implementation of critical interventions was significantly higher in patients who received 2010-CPR than in those who received 2005-CPR. After adjusting for the effects of confounding factors, patients who received 2010-CPR had improved neurological outcomes (odds ratio [OR], 1.75; 95% confidence interval [CI], 1.05-2.93; p=0.03) and survival (OR, 1.50; 95% CI, 1.06-2.12; p=0.02) at hospital discharge than patients who received 2005-CPR.

CONCLUSIONS

Hospital adoption of the 2010 guidelines may improve the neurological and survival outcomes for IHCA patients. This improvement might result from an emphasis on the importance of high-quality CPR, post-cardiac arrest care, and teamwork in the 2010 guidelines.

Improving CPR Performance

Cardiac arrest continues to represent a public health burden with most patients having dismal outcomes. CPR is a complex set of interventions requiring leadership, coordination, and best practices. Despite the widespread adoption of new evidence in various guidelines, the provision of CPR remains variable with poor adherence to published recommendations. Key steps health-care systems can take to enhance the quality of CPR and, potentially, to improve outcomes, include optimizing chest compressions, avoiding hyperventilation, encouraging intraosseous access, and monitoring capnography. Feedback devices provide instantaneous guidance to the rescuer, improve rescuer technique, and could impact patient outcomes. New technologies promise to improve the resuscitation process: mechanical devices standardize chest compressions, capnography guides resuscitation efforts and signals the return of spontaneous circulation, and intraosseous devices minimize interruptions to gain vascular access. This review aims at identifying a discreet group of interventions that health-care systems can use to raise their standard of cardiac resuscitation.