Outcome of cardiopulmonary resuscitation in a 2300-bed hospital in a developing country

Do-not-attempt resuscitation policy reduced in-hospital cardiac arrest rate and the cost of care in a developing country

We aim to study the characteristics and outcomes of patients with a Do-Not-Attempt Resuscitation and to determine its impact on the Cost of In-Hospital Cardiac Arrest. A retrospective study of all adult patients admitted to the hospital from June 2021 to May 2022 who had a Do-Not-Resuscitate order. We abstracted patients' socio-demographics, physiologic parameters, primary diagnosis, and comorbidities from the electronic medical records. We calculated the potential economic cost using the median ICU length of stay for the admitted IHCA patients during the study period. There were 28,866 acute admissions over the study period, and 788 patients had DNR orders. The median (IQR) age was 71 (55-82) years, and 50.3% were males. The most prevalent primary diagnosis was sepsis, 426 (54.3%), and cancer was the most common comorbidity. More than one comorbidities were present in 642 (80%) of the cohort. Of the DNR patients, 492 (62.4%) died, while 296 (37.6%) survived to discharge. Cancer was the primary diagnosis in 65 (22.2%) of those who survived, compared with 154 (31.3%) of those who died (P = 0.002). Over the study period, 153 patients had IHCA and underwent CPR, with an IHCA rate of 5.3 per 1,000 hospital admissions. Without a DNR policy, an additional 492 patients with cardiac arrest would have had CPR, resulting in an IHCA rate of 22.3 per 1000 hospital admissions. Most DNR patients in our setting had sepsis complicated by multiple comorbidities. The DNR policy reduced our IHCA incidence by 76% and prevented unnecessary post-resuscitation ICU care.

Cardiopulmonary resuscitation in low-resource settings: a statement by the International Liaison Committee on Resuscitation, supported by the AFEM, EUSEM, IFEM, and IFRC

Most recommendations on cardiopulmonary resuscitation were developed from the perspective of high-resource settings with the aim of applying them in these settings. These so-called international guidelines are often not applicable in low-resource settings. Organisations including the International Liaison Committee on Resuscitation (ILCOR) have not sufficiently addressed this problem. We formed a collaborative group of experts from various settings including low-income, middle-income, and high-income countries, and conducted a prospective, multiphase consensus process to formulate this ILCOR Task Force statement. We highlight the discrepancy between current cardiopulmonary resuscitation guidelines and their applicability in low-resource settings. Successful existing initiatives such as the Helping Babies Breathe programme and the WHO Emergency Care Systems Framework are acknowledged. The concept of the chainmail of survival as an adaptive approach towards a framework of resuscitation, the potential enablers of and barriers to this framework, and gaps in the knowledge are discussed, focusing on low-resource settings. Action points are proposed, which might be expanded into future recommendations and suggestions, addressing a large diversity of addressees from caregivers to stakeholders. This statement serves as a stepping-stone to developing a truly global approach to guide resuscitation care and science, including in health-care systems worldwide.

The epidemiology and outcomes of adult in-hospital cardiac arrest in a high-income developing country

Aim

Methods

Results

Conclusion

Assessment of cardiopulmonary resuscitation equipment in resuscitation trolleys in district hospitals in Botswana: A cross-sectional study

INTRODUCTION

Successful cardiopulmonary resuscitation (CPR) relies, in part, on the availability and the correct functioning of resuscitation equipment. These data are often lacking in resource-constrained African settings.

AIM

To assess the availability and the functional status of CPR equipment in resuscitation trolleys at district hospitals in Botswana.

SETTING

The study was conducted across four district hospitals in Botswana.

METHODS

A cross-sectional study was conducted using a checklist adopted following the Emergency Medical Services of South Africa (EMSSA) guidelines, modified and contextualised to Botswana.

RESULTS

All the four district hospitals had inadequate number of CPR equipment available in the resuscitation trolleys. The overall availability of drugs and equipment ranged from 19% to 31.1%. Availability of equipment needed for maintaining circulation and fluids ranged from 27% to 49%, while availability of items for airway and breathing ranged from 9.2% to 24.1%. The overall availability of essential drugs for resuscitation was only 20.4%, and in some wards expired drugs were kept in the trolley. Out of 40 wards that participated in the study, only 10 kept CPR algorithms in the resuscitation trolley. The resuscitation trolley was checked on a daily basis only in the critical care units.

CONCLUSION

The resuscitation trolleys were not maintained as per standards. Failure to improve the existing situation could negatively impact the outcome of CPR. Evidence-based standard checklists for resuscitation trolleys need to be enforced to improve the quality of CPR provision in district hospitals in Botswana.

Incidences and factors associated with perioperative cardiac arrest in trauma patients receiving anesthesia

Purpose

The aim of this study was to determine the incidences and factors associated with perioperative cardiac arrest in trauma patients who received anesthesia for emergency surgery.

Patients and methods

This retrospective cohort study was approved by the medical ethical committee, Faculty of Medicine, Maharaj Nakorn Chiang Mai Hospital, Thailand. Data of 19,683 trauma patients who received anesthesia between January 2007 and December 2016, such as patient characteristics, surgery procedures, anesthesia information, anesthetic drugs, and cardiac arrest outcomes, were analyzed. Data of patients receiving local anesthesia by surgeons or monitoring anesthesia care (MAC) and those with much information missing were excluded. Factors associated with perioperative cardiac arrest were identified using univariate analysis and the multiple regression model. A stepwise algorithm was chosen at a P-value of <0.20 which was selected for multivariate analysis. A P-value of <0.05 was concluded as statistically significant.

Results

The perioperative cardiac arrest in trauma patients receiving anesthesia for emergency surgery was 170.04 per 10,000 cases. Factors associated with perioperative cardiac arrest in trauma patients were as follows: age >65 years (risk ratio [RR] =1.41, CI =1.02–1.96, P=0.039), American Society of Anesthesiologist (ASA) physical status 3 or higher (ASA physical status 3–4, RR =4.19, CI =2.09–8.38, P<0.001; ASA physical status 5–6, RR =21.58, CI =10.36–44.94, P<0.001), sites of surgery (intracranial, intrathoracic, upper intra-abdominal, and major vascular, each P<0.001), cardiopulmonary comorbidities (RR =1.55, CI =1.10–2.17, P=0.012), hemodynamic instability with shock prior to receiving anesthesia (RR =1.60, CI =1.21–2.11, P<0.001), and having a history of alcoholism (RR =5.27, CI =4.09–6.79, P<0.001).

Conclusion

The incidence of perioperative cardiac arrest in trauma patients receiving anesthesia for emergency surgery was very high and correlated with patient’s factors, especially old age and cardiopulmonary comorbidities, a history of drinking alcohol, increased ASA physical status, hemodynamic instability with shock prior to surgery, and sites of surgery such as brain, thorax, abdomen, and the major vascular region. Anesthesiologists and surgeons should be aware of a warning system and a well-equipped track to manage the surgical trauma patients.

Acute care for the three leading causes of mortality in lower-middle-income countries: A systematic review

According to the World Health Organization, the three leading causes of mortality in lower-middle-income countries (LMIC) are ischemic heart disease (IHD), stroke, and lower respiratory infections (LRIs), causing 111.8, 68.8, and 51.5 annual deaths per 100,000, respectively. Due to barriers to healthcare, patients frequently present in critical stages of these diseases. Measured implementations in critical care in LMIC have been published; however, the literature has not been formally reviewed. We performed a systematic review of the literature indexed in PubMed as of October 2017. Abstracts were limited to human studies in English, French, and Spanish, conducted in LMIC, and containing quantitative data on acute care of IHD, stroke, and LRI. The search resulted in 4994 unique abstracts. Through multiple rounds of screening using criteria determined a priori, 161 manuscripts were identified: 38 for IHD, 20 for stroke, 26 for adult LRI, and 78 for pediatric LRI. These studies, predominantly from Asia, demonstrate successful diagnostic and treatment measures used in providing acute care for patients in LMIC. Given that, only four manuscripts originated in Central or South America, original research from these areas is lacking. IHD, stroke, and LRIs are significant causes of mortality, especially in LMIC. Diagnostic and therapeutic interventions for IHD (monitoring, medications, thrombolytics, percutaneous intervention, coronary artery bypass graft), stroke (therapeutic hypothermia, medications, and thrombolytics), and LRI (oxygen saturation measurement, diagnostic ultrasound, administration of oxygen, appropriate antibiotics, and other medications) have been studied in LMIC and published.

Long-term outcomes and predictors of survival after cardiopulmonary resuscitation for in-hospital cardiac arrest in a tertiary care hospital in Thailand

Background

There are limited data available regarding long-term survival and its predictors in cases of in-hospital cardiac arrest (IHCA) in which patients receive cardiopulmonary resuscitation.

Purpose

The objectives of this study were to determine the 1-year survival rates and predictors of survival after IHCA.

Patients and methods

Data were retrospectively collected on all adult patients who were administered cardiopulmonary resuscitation from January 1, 2013 to December 31, 2014 in Srinagarind Hospital (Thailand). Clinical outcomes of interest and survival at discharge and 1 year after hospitalization were reviewed. Descriptive statistics and survival analysis were used to analyze the outcomes.

Results

Of the 202 patients that were included, 48 (23.76%) were still alive at hospital discharge and 17 (about 8%) were still alive at 1 year post cardiac arrests. The 1-year survival rate for the cardiac arrest survivors post hospital discharge was 72.9%. Prearrest serum HCO₃<20 meq/L, asystole, urine <800 cc/d, postarrest coma, and absence of pupillary reflex were predictors of death.

Conclusion

Only 7.9% of patients with IHCA were alive 1 year following cardiac arrest. Prearrest serum HCO₃<20 meq/L, asystole, urine <800 cc/d, postarrest coma, and absence of pupillary reflex were the independent factors that predicted long-term mortality.

A Prospective Investigation into the Epidemiology of In-Hospital Cardiopulmonary Resuscitation Using the International Utstein Reporting Style

Introduction

The Utstein template has been used to guide the assessment and study of cardiopulmonary resuscitation (CPR) in many countries. This article used the Utstein templates for cardiac arrest and resuscitation registries to evaluate outcomes of CPR at Hainan Provincial People's Hospital (HPPH), China.

Methods

A prospective observational study using Utstein CPR registry form to evaluate the epidemiological characteristics and outcomes of 511 resuscitation cases in the emergency department, HPPH.

Results

A total of 511 CPR patients registered were studied. Higher cardiac arrest rates were observed for the group of patients who were 40-70 years old. In preexisting chronic diseases, cardiovascular diseases (190, 37.2%) cerebrovascular diseases (48, 9.4%) and respiratory diseases (39, 7.6%) were common in the recruited patients. (173, 33.9%) of the cardiac arrest patients had underlying cardiac causes, of which 109 (21.3%) had acute myocardial infarct (AMI). Eighty (15.7%) patients had ventricular fibrillation as the first witnessed arrest rhythm. The return of spontaneous circulation (ROSC) and survival to discharge rates were 47.0% and 13.5% in the in-hospital cardiac arrest (IHCA) group but 16.7% and 4.7% in out-of-hospital cardiac arrest (OHCA) group (p<0.01) respectively.

Conclusions

This study indicated that the cardiovascular diseases, cerebrovascular diseases, and respiratory diseases were the most common preexisting chronic diseases. Myocardial infarct, stroke and trauma were the most common precipitation cause of cardiac arrest in the recruited patients. The rate of ROSC and survival to discharge for the patients with IHCA were higher than the ones with OHCA, but figures were still low. (Hong Kong j.emerg.med. 2011;18:391-396)

Outcome and predictors of cardiopulmonary resuscitation among patients admitted in Medical Intensive Care Unit in North India

Background:

Outcome and predictors of survival after cardiopulmonary resuscitation (CPR) in Intensive Care Units (ICUs) have been extensively studied in western world, but data from developing countries is sparse.

Objectives:

To study the outcome and predictors of survival after CPR in a Medical ICU (MICU) of a tertiary level teaching hospital in North India.

Materials and Methods:

A 1-year prospective cohort study.

Results:

Of 105 in-MICU CPRs, forty patients (38.1%) achieved return of spontaneous circulation (ROSC). Only one patient (0.9%) survived up to hospital discharge. The predictors of ROSC were ventricular tachycardia/ventricular fibrillation as first monitored rhythm, intubation during CPR and CPR duration ≤ 10 min. CPR duration > 10 min was a significant factor for resuscitation failure.

Conclusions:

The rate of survival to hospital discharge after in-MICU CPRs is extremely poor. Our data may aid treating physicians, resuscitation teams, and families in understanding the likely outcome of patients after in-MICU CPRs.

Training laypersons and hospital personnel in basic resuscitation techniques: an approach to impact the global trauma burden in Mozambique

INTRODUCTION

Over half of prehospital deaths in low-income countries are the result of airway compromise, respiratory failure, or uncontrolled hemorrhage; all three conditions can be addressed using simple first-aid measures. For both hospital personnel and laypersons, a basic trauma resuscitation training in modified ABCD (airway, breathing, circulation, disability) techniques can be easily learned and applied to increase the number of first responders in Mozambique, a resource-challenged country.

METHODS

A trauma training session was administered to 100 people in Mozambique: half were hospital personnel from 7 district medical centers and the other half were selected laypersons. This session included a pre-test, intervention, and post-test to evaluate and demonstrate first response skills.

RESULTS

Eighty-eight people completed both the pre- and post-tests. Following the education intervention, both groups demonstrated an improvement in test scores. Hospital personnel had a mean post-test score of 60% (SD = 17, N = 43) and community laypeople had a mean score of 51% (SD = 16, N = 45). A t test for equal variances demonstrated significant difference between the post-intervention scores for the two groups (p = 0.01). All 100 participants were able to open an airway, externally control hemorrhage, and transport a patient with appropriate precautions.

CONCLUSION

The trauma training session served as new information that improved knowledge as well as skills for both groups, and increased the number of capable responders in Mozambique. This study supports WHO recommendations to utilize the strengths of a developing nation-population-as the first step in establishing an organized trauma triage system.

Non-critical care telemetry and in-hospital cardiac arrest outcomes

BACKGROUND

Telemetry is increasingly used to monitor hospitalized patients with lower intensities of care, but its effect on in-hospital cardiac arrest (IHCA) outcomes in non-critical care patients is unknown.

HYPOTHESIS

Telemetry utilization in non-critical care patients does not affect IHCA outcomes.

METHODS

A retrospective cohort analysis of all patients in non-critical care beds that experienced a cardiac arrest in a university-affiliated teaching hospital during calendar years 2011 and 2012 was performed. Data were collected as part of AHA Get With the Guidelines protocol. The independent variable and exposure studied were whether patients were on telemetry or not. Telemetry was monitored from a central location. The primary endpoint was return of spontaneous circulation (ROSC) and the secondary end point was survival to discharge.

RESULTS

Of 123 IHCA patients, the mean age was 75±15 and 74 (61%) were male. 80 (65%) patients were on telemetry. Baseline demographics were similar except for age; patients on telemetry were younger with mean age of 70.3 vs. 76.8 in the non-telemetry group (p=0.024). 72 patients (60%) achieved ROSC and 46 (37%) achieved survival to discharge. By univariate analysis, there was no difference between patients that had been on telemetry vs. no telemetry in ROSC (OR=1.13, p=0.76) or survival to discharge (OR=1.18, p=0.67). Similar findings were obtained with multivariate analysis for ROSC (0.91, p=0.85) and survival to discharge (OR=0.92, p=0.87).

CONCLUSIONS

The use of cardiac telemetry in non-critical care beds, when monitored remotely in a central location, is not associated with improved IHCA outcomes.

In-hospital pediatric cardiac arrest in Honduras

OBJECTIVES

The objective of this study was to analyze the characteristic and the prognostic factors of in-hospital pediatric cardiac arrest (CA) in a public hospital Honduras.

METHODS

A prospective observational study was performed on pediatric in-hospital CA as a part of a multicenter international study. One hundred forty-six children were studied. The primary end point was survival at hospital discharge. Univariate and multivariate logistic regression analyses were performed to assess the influence of each factor on mortality.

RESULTS

Cardiac arrest occurred in the emergency department in 66.9%. Respiratory diseases and sepsis were predominant causes of CA. Return of spontaneous circulation was achieved in 60% of patients, and 22.6% survived to hospital discharge. The factors related with mortality were nonrespiratory cause of CA (odds ratio [OR], 2.55; P = 0.045), adrenaline administration (OR, 4.96; P = 0.008), and a duration of cardiopulmonary resuscitation more than 10 minutes (OR, 3.40; P = 0.012).

CONCLUSIONS

In-hospital CA in children in a developing country has low survival. Patients with nonrespiratory causes and those who need adrenaline administration and prolonged resuscitation had worse prognosis.

Prognostic factors for death and survival with or without complications in cardiac arrest patients receiving CPR within 24 hours of anesthesia for emergency surgery

Purpose

To determine prognostic factors for death and survival with or without complications in cardiac arrest patients who received cardiopulmonary resuscitation (CPR) within 24 hours of receiving anesthesia for emergency surgery.

Patients and methods

A retrospective cohort study approved by the Maharaj Nakorn Chiang Mai University Hospital Ethical Committee. Data used were taken from records of 751 cardiac arrest patients who received their first CPR within 24 hours of anesthesia for emergency surgery between January 1, 2003 and October 31, 2011. The reviewed data included patient characteristics, surgical procedures, American Society of Anesthesiologist (ASA) physical status classification, anesthesia information, the timing of cardiac arrest, CPR details, and outcomes at 24 hours after CPR. Univariate and polytomous logistic regression analyses were used to determine prognostic factors associated with the outcome variable. P-values of less than 0.05 were considered statistically significant.

Results

The outcomes at 24 hours were death (638/751, 85.0%), survival with complications (73/751, 9.7%), and survival without complications (40/751, 5.3%). The prognostic factors associated with death were: age between 13–34 years (OR =3.08, 95% CI =1.03–9.19); ASA physical status three and higher (OR =6.60, 95% CI =2.17–20.13); precardiopulmonary comorbidity (OR =3.28, 95% CI =1.09–9.90); the condition of patients who were on mechanical ventilation prior to receiving anesthesia (OR =4.11, 95% CI =1.17–14.38); surgery in the upper abdominal site (OR =14.64, 95% CI =2.83–75.82); shock prior to cardiac arrest (OR =6.24, 95% CI =2.53–15.36); nonshockable electrocardiography (EKG) rhythm (OR =5.67, 95% CI =1.93–16.62); cardiac arrest occurring in postoperative period (OR =7.35, 95% CI =2.89–18.74); and duration of CPR more than 30 minutes (OR =4.32, 95% CI =1.39–13.45). The prognostic factors associated with survival with complications were being greater than or equal to 65 years of age (OR =4.30, 95% CI =1.13–16.42), upper abdominal site of surgery (OR =10.86, 95% CI =1.99–59.13), shock prior to cardiac arrest (OR =3.62, 95% CI =1.30–10.12), arrhythmia prior to cardiac arrest (OR =4.61, 95% CI =1.01–21.13), and cardiac arrest occurring in the postoperative period (OR =3.63, 95% CI =1.31–10.02).

Conclusion

The mortality and morbidity in patients who received anesthesia for emergency surgery within 24 hours of their first CPR were high, and were associated with identifiable patient comorbidity, age, shock, anatomic site of operation, the timing of cardiac arrest, EKG rhythm, and the duration of CPR. EKG monitoring helps to identify cardiac arrest quickly and diagnose the EKG rhythm as a shockable or nonshockable rhythm, with CPR being performed as per the American Heart Association (AHA) CPR Guidelines 2010. The use of the fast track system in combination with an interdisciplinary team for surgery, CPR, and postoperative care helps to rescue patients in a short time.

The initial success rate of cardiopulmonary resuscitation and its associated factors in patients with cardiac arrest within 24 hours after anesthesia for an emergency surgery

PURPOSE

To determine the initial success rate and its associated factors on cardiopulmonary resuscitation (CPR) in patients with cardiac arrest within 24 hours after receiving anesthesia for an emergency surgery.

PATIENTS AND METHODS

After the hospital ethical committee gave approval for this study, the anesthesia providers recorded all relevant data regarding CPR in patients with cardiac arrest within 24 hours after anesthesia for emergency surgery at Maharaj Nakorn Chiang Mai Hospital, a university hospital in Northern Thailand. Only data from the cardiac arrest patients who received the first CPR attempt were included in the analysis. The end point of the initial success of CPR was return of spontaneous circulation (ROSC). Factors related to ROSC were determined by univariate analyses and multiple logistic regression analysis. The odds ratios (OR) and 95% confidence intervals (CI) were used to calculate the strength of the factors associated with the ROSC.

RESULTS

Of the 96 cardiac arrest patients, 44 patients (45.8%) achieved ROSC. Factors associated with ROSC were electrocardiogram monitoring for detected cardiac arrest (OR =4.03; 95% CI =1.16-14.01; P=0.029), non-shock patients before arrest (OR =8.54; 95% CI =2.13-34.32; P=0.003), timing to response of activated CPR team within 1 minute (OR =9.37; 95% CI =2.55-34.39; P<0.001), having trained CPR teams (OR =8.76; 95% CI =2.50-30.72; P<0.001), and administration of more than one dose of epinephrine (OR =5.62; 95% CI =1.32-23.88; P<0.019).

CONCLUSION

Patients undergoing anesthesia for an emergency surgery are at risk for perioperative cardiac arrest with high mortality which requires immediate CPR. Our results have confirmed that early detection of cardiac arrest by vigilant electrocardiogram monitoring and prompt management with a qualified team are important factors in improving the success of CPR. Emergency surgical patients at risk for cardiac arrest should be promptly managed, with facilities available not only during the operation but also during the pre- to postoperative period.

Global health and emergency care: a resuscitation research agenda--part 1

At the 2013 Academic Emergency Medicine global health consensus conference, a breakout session on a resuscitation research agenda was held. Two articles focusing on cardiac arrest and trauma resuscitation are the result of that discussion. This article describes the burden of disease and outcomes, issues in resuscitation research, and global trends in resuscitation research funding priorities. Globally, cardiovascular disease and trauma cause a high burden of disease that receives a disproportionately smaller research investment. International resuscitation research faces unique ethical challenges. It needs reliable baseline statistics regarding quality of care and outcomes; data linkages between providers; reliable and comparable national databases; and an effective, efficient, and sustainable resuscitation research infrastructure to advance the field. Research in resuscitation in low- and middle-income countries is needed to understand the epidemiology, infrastructure and systems context, level of training needed, and potential for cost-effective care to improve outcomes. Research is needed on low-cost models of population-based research, ways to disseminate information to the developing world, and finding the most cost-effective strategies to improve outcomes.

Factors influencing outcome in patients with cardiac arrest in the ICU

BACKGROUND

Post-arrest variables associated with long-term survival after cardiopulmonary resuscitation (CPR) in intensive care unit (ICU) patients remain unclear. This study was designed to identify pre- and intra-arrest factors associated with survival 3 months after CPR in ICU patients and to identify post-arrest factors associated with long-term survival in those who survived 24 h after CPR.

METHODS

A total of 131 ICU patients undergoing CPR from January 2009 to June 2010 were included. Data were retrospectively analysed and categorized based on the Utstein template.

RESULTS

The overall survival rate 3 months after CPR was 20.6%. Logistic regression analysis revealed that acute physiology and chronic health evaluation (APACHE) II score (odds ratio, 95% confidence interval, 0.87 [0.83-0.93]; P < 0.001), ventricular tachycardia/ventricular fibrillation (VT/VF, 5.55 [1.55-19.83]; P = 0.032), and normoxia during CPR (4.45 [1.34-14.71]; P = 0.045) were significant independent pre- and intra-arrest predictors of 3-month survival after CPR in ICU patients. Fifty-seven patients survived 24 h after CPR, and their 3-month survival rate was 47.4%. Early enteral nutrition (9.94 [1.96-50.43]; P = 0.030) and normoxia after return of spontaneous circulation (10.75 [2.03-55.56]; P = 0.030) were predictive of 3-month survival in patients who survived 24 h after CPR.

CONCLUSIONS

Normoxia during CPR and VT/VF were predictors of long-term survival after CPR in ICU patients. In patients surviving 24 h after CPR, initiation of enteral nutrition within 48 h and maintenance of normoxia were associated with a positive outcome.

Survival from in-hospital cardiac arrest in Auckland City Hospital

OBJECTIVE

To describe in-hospital resuscitation outcomes and factors associated with survival at Auckland City Hospital, New Zealand.

METHODS

The Utstein template for in-hospital cardiac arrests was used. A retrospective audit of all cardiac arrests 2004-06 determined patient demographics, resuscitation time intervals, interventions, survival and neurological outcome at 12 months. Factors associated with survival to discharge were explored with logistic regression.

RESULTS

There were 3470 in-hospital deaths. Resuscitation was attempted in 415 patients (12%), with survival to discharge 27.2%. Survival was higher in first rhythm VT/VF (52.7% vs 13.1%, χ(2) = 75.3, P < 0.001), when the arrest was 'In-Hours' (41.4% vs 17%, χ(2) = 30.1, P < 0.001) and with younger age (mean [SD] for survivors 59.4 [7.1]vs 69.1 [14] for non-survivors). These associations were independent predictors of survival after multivariate logistic regression, with OR 6.2 (95% CI 3.6-10.5), 3.1 (95% CI 1.8-5.4) and 1.04 (95% CI 1.02-1.06), respectively (all P < 0.001). Other univariate predictors of survival; cardiac arrest team on site, monitored arrest and time to CPR were not significant after multivariate logistic regression. Time intervals to arrest interventions were short. Twelve month neurological outcome was good (CPC1 or 2) in 97.1% (95% CI 91.6-99.4) of survivors.

CONCLUSIONS

Survival from cardiac arrest in our hospital compared well to similar centres and good neurological outcome was higher than reported previously. Reduced survival during the 'After-Hours' period is cause for concern, and further research into the factors underlying this is required.

[In-hospital resuscitation concept with first-responder defibrillation. 2-year experience]

BACKGROUND AND PURPOSE

Sudden cardiac arrest appears in 1-5 patients/ 1,000 clinical admissions. In spite of different research approaches, the prognosis after in-hospital resuscitation has not significantly improved in the last 40 years. This account presents the experiences with a hospital-wide emergency plan using the concept of defibrillation by first responders.

METHODS

In 2003, a hospital-wide emergency plan was implemented. The concept comprised the setup of 15 "defibrillator points", training of the entire hospital personnel as first responder, and the introduction of an emergency team. Over the following 3 years, the concept was optimized. In a period from May 2006 to April 2008, the data of all patients who received an in-hospital resuscitation were collected.

RESULTS

Within 24 months, a total of 41 resuscitations were conducted. Out of these, 24 patients (58%) were under intensive monitoring when the event occurred. Initially, 15 patients (36%) showed ventricular fibrillation, 15 (36%) a pulseless electrical activity, and eleven (27%) an asystoly. A total of twelve patients (29%) left hospital alive. About half of them (42%) experienced ventricular fibrillation and were under observation at the time of event.

CONCLUSION

The data collected since the implementation of the hospital- wide emergency plan in 2003 reflect the daily clinical routine. The results show that there is a better outcome especially in patients with ventricular fibrillation when receiving first-responder defibrillation.

Does anesthetic provide similar neuroprotection to therapeutic hypothermia after cardiac arrest?

In the previous issue of Critical Care, Meybohm and colleagues provide evidence to support hypothermia as a kind of therapeutic option for patients suffering cardiac arrest. Although anesthetics had been used to induce hypothermia, sevoflurane post-conditioning fails to confer additional anti-inflammatory effects after cardiac arrest. Further research in this area is warranted.

Evaluation of fundamental critical care course in Kenya: knowledge, attitude, and practice

BACKGROUND

Critical care training for medical personnel is crucial for the survival of the highest acuity patients. The Fundamental Critical Care Course (FCCS), a critical care course developed by the Society of Critical Care Medicine, permits course adaption and, thus, has potential for global dissemination. The FCCS course was provided in two Kenyan hospitals after minimal adaption. Participant knowledge and confidence gain as well as FCCS applicability to an African context were evaluated.

METHODS

Questionnaires and a multiple-choice test were administered to assess knowledge, attitude, and self-reported confidence or self-efficacy. For applicability, the pre-course questionnaire assessed participant expectations and existing levels of confidence/knowledge in the care of the critically ill patient. Post-course, the participant evaluated the overall quality of the course, lectures, and skill stations along with context applicability questions.

RESULTS

There were 100 participants, 45 doctors, 45 nurses, and 10 clinical officers. There was a 22.7% gain in the mean test score (P < 0.0001) after the course, with 98% of participants showing improvement. Confidence to perform new skills post-course, or self-efficacy, was demonstrated by a median of 4 or greater on a Likert scale of 5 (most confident) in 10 of 12 clinical scenarios and in 11 of 14 new procedures. There was a consistency between areas reported as needed expertise, and participant evaluation of similar lecture and skill station's quality and appropriateness. The most common areas reported were mechanical ventilation, patient monitoring, and their related procedures.

CONCLUSIONS

The FCCS course met participant's expectations and was reported as applicable for the Kenyan context with minimal adaption. Post-course, knowledge improved and confidence increased for implementation of new skills in clinical care situations. We confirmed the effectiveness and relevancy of the FCCS course for other resource-constrained health care settings.

Outcomes of cardiopulmonary resuscitation for patients on vasopressors or inotropes: a pilot study

HYPOTHESIS

Outcomes of critically ill patients who receive cardiopulmonary resuscitation (CPR) are poor, and the subgroup on vasopressors or inotropes before cardiopulmonary arrest (CPA) rarely survives.

SETTING

The setting of the study was a critical care unit of a 350-bed community teaching hospital.

STUDY DESIGN

This was a retrospective, cohort study.

METHODS

A retrospective review was performed of medical records of all patients, identified through medical billing and hospital committee records, who received CPR for CPA in a critical care unit.

RESULTS

Of 83 patients, with an average age of 66 years, 14 (17%) survived to hospital discharge. Patients with pulseless electrical activity and asystole were significantly less likely to survive (9% and none, respectively; P = .0001). Only 2 (4%) of 55 critically ill patients receiving vasopressors before CPR survived, whereas 12 of 28 patients not on vasopressors survived (P < .0001). Although mechanical ventilation just before CPR was highly associated with administration of vasopressors, ventilation was not significantly associated with mortality (P = .13). Mortality of patients on vasopressors was higher for both mechanically ventilated (95% vs 33%, P < .001) and spontaneously breathing (100% vs 64%, P = .02) patients. In multiple logistic regression analyses, administration of vasopressors was the only variable independently associated with in-hospital mortality (odds ratio, 35.1; 95% confidence interval = 4.1-304.3).

CONCLUSIONS

Survival of patients requiring CPR during critical care admission was 17%. Very few patients survived who required vasopressors or inotropes immediately before CPA. This study is limited significantly by its retrospective design and small cohort, and so this question should be reexamined in a larger study.

Cardiopulmonary resuscitation: outcome and its predictors among hospitalized adult patients in Pakistan

Introduction

Our aim was to study the outcomes and predictors of in-hospital cardiopulmonary resuscitation (CPR) among adult patients at a tertiary care centre in Pakistan.

Methods

We conducted a retrospective chart review of all adult patients (age ≥14 years), who underwent CPR following cardiac arrest, in a tertiary care hospital during a 5-year study period (June 1998 to June 2003). We excluded patients aged 14 years or less, those who were declared dead on arrival and patients with a “do not resuscitate” order. The 1- and 6-month follow-ups of discharged patients were also recorded.

Results

We found 383 cases of adult in-hospital cardiac arrest that underwent CPR. Pulseless electrical activity was the most common initial rhythm (50%), followed by asystole (30%) and ventricular tachycardia/fibrillation (19%). Return of spontaneous circulation was achieved in 72% of patients with 42% surviving more than 24 h, and 19% survived to discharge from hospital. On follow-up, 14% and 12% were found to be alive at 1 and 6 months, respectively. Multivariable logistic regression identified three independent predictors of better outcome (survival >24 h): non-intubated status [adjusted odds ratio (aOR):3.1, 95% confidence interval (CI):1.6–6.0], location of cardiac arrest in emergency department (aOR: 18.9, 95% CI:7.0–51.0) and shorter duration of CPR (aOR:3.3, 95% CI:1.9–5.5).

Conclusion

Outcome of CPR following in-hospital cardiac arrest in our setting is better than described in other series. Non-intubated status before arrest, cardiac arrest in the emergency department and shorter duration of CPR were independent predictors of good outcome.

Overcoming barriers to in-hospital cardiac arrest documentation

AIMS

(1) To describe the introduction of standardised cardiac arrest documentation to Auckland City Hospital, highlighting how barriers to using the Utstein template were overcome. (2) To determine the adequacy of documentation of cardiac arrest time intervals.

METHOD

A retrospective audit of cardiac arrest documentation for a 3-year period following the introduction of a standard documentation form.

RESULTS

There was an initial improvement in use of the template (29% (95%CI 22-37%) to 88% (95%CI 82-92%), p<0.001) after identification of barriers and implementation of tailored strategies. Use of the template declined (77%, 95%CI 69-84%, p=0.023) after the key facilitator left the hospital. Time interval documentation ranged from 66% (95%CI 54-77%) for tracheal intubation to 91% (95%CI 80-93%) for first dose of adrenaline (epinephrine).

CONCLUSIONS

Designated 'hands-off' senior clinicians were required for accurate documentation of time intervals. Time interval documentation was sub-optimal and further efforts are required to improve this. Transfer of ownership beyond the key facilitator was integral to sustainability of the process. Future reports of in-hospital cardiac arrest outcomes should include baseline information on the adequacy of documentation of time intervals.