1
|
Haar M, Müller J, Hartwig D, von Bargen J, Daniels R, Theile P, Kluge S, Roedl K. Intensive care unit cardiac arrest among very elderly critically ill patients - is cardiopulmonary resuscitation justified? Scand J Trauma Resusc Emerg Med 2024; 32:84. [PMID: 39261863 PMCID: PMC11389322 DOI: 10.1186/s13049-024-01259-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2024] [Accepted: 09/02/2024] [Indexed: 09/13/2024] Open
Abstract
INTRODUCTION The proportion of very elderly patients in the intensive care unit (ICU) is expected to rise. Furthermore, patients are likely more prone to suffer a cardiac arrest (CA) event within the ICU. The occurrence of intensive care unit cardiac arrest (ICU-CA) is associated with high mortality. To date, the incidence of ICU-CA and its clinical impact on outcome in the very old (≥ 90 years) patients treated is unknown. METHODS Retrospective analysis of all consecutive critically ill patients ≥ 90 years admitted to the ICU of a tertiary care university hospital in Hamburg (Germany). All patients suffering ICU-CA were included and CA characteristics and functional outcome was assessed. Clinical course and outcome were assessed and compared between the subgroups of patients with and without ICU-CA. RESULTS 1,108 critically ill patients aged ≥ 90 years were admitted during the study period. The median age was 92.3 (91.0-94.2) years and 67% (n = 747) were female. 2% (n = 25) of this cohort suffered ICU-CA after a median duration 0.5 (0.2-3.2) days of ICU admission. The presumed cause of ICU-CA was cardiac in 64% (n = 16). The median resuscitation time was 10 (2-15) minutes and the initial rhythm was shockable in 20% (n = 5). Return of spontaneous circulation (ROSC) could be achieved in 68% (n = 17). The cause of ICU admission was primarily medical in the total cohort (ICU-CA: 48% vs. No ICU-CA: 34%, p = 0.13), surgical - planned (ICU-CA: 32% vs. No ICU-CA: 37%, p = 0.61) and surgical - unplanned/emergency (ICU-CA: 43% vs. No ICU-CA: 28%, p = 0.34). The median Charlson Comorbidity Index (CCI) was 2 (1-3) points for patients with ICU-CA and 1 (0-2) for patients without ICU-CA (p = 0.54). Patients with ICU-CA had a higher disease severity according to SAPS II (ICU-CA: 54 vs. No ICU-CA: 36 points, p < 0.001). Patients with ICU-CA had a higher rate of mechanically ventilation (ICU-CA: 64% vs. No ICU-CA: 34%, p < 0.01) and required vasopressor therapy more often (ICU-CA: 88% vs. No ICU-CA: 41%, p < 0.001). The ICU and in-hospital mortality was 88% (n = 22) and 100% (n = 25) in patients with ICU-CA compared to 17% (n = 179) and 28% (n = 306) in patients without ICU-CA. The mortality rate for patients with ICU-CA was observed to be 88% (n = 22) in the ICU and 100% (n = 25) in-hospital. In contrast, patients without ICU-CA had an in-ICU mortality rate of 17% (n = 179) and an in-hospital mortality rate of 28% (n = 306) (both p < 0.001). CONCLUSION The occurrence of ICU-CA in very elderly patients is rare but associated with high mortality. Providing CPR in this cohort did not lead to long-term survival at our centre. Very elderly patients admitted to the ICU likely benefit from supportive care only and should probably not be resuscitated due to poor chance of survival and ethical considerations. Providing personalized assurances that care will remain appropriate and in accordance with the patient's and family's wishes can optimise compassionate care while avoiding futile life-sustaining interventions.
Collapse
Affiliation(s)
- Markus Haar
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Jakob Müller
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- Department of Anaesthesiology, Tabea Hospital, Kösterbergstraße 32, 22587, Hamburg, Germany
| | - Daniela Hartwig
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Julia von Bargen
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Rikus Daniels
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Pauline Theile
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Kevin Roedl
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| |
Collapse
|
2
|
Mir T, Shafi O, Balla S, Munir MB, Qurehi WT, Kakouros N, Bhat Z, Koul P, Rab T. Intensive Care Admissions and Outcome of Cardiac Arrests; A National Cohort Study From the United States. J Intensive Care Med 2024; 39:118-124. [PMID: 37528646 DOI: 10.1177/08850666231192844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023]
Abstract
OBJECTIVE Outcomes of cardiac arrest among patients who had cardiopulmonary resuscitation (CPR) in intensive care units (ICU) has limited data on the national level basis in the United States. We aimed to study the outcomes of ICU CPRs. METHODS Data from the national readmissions database (NRD) sample that constitutes 49.1% of the stratified sample of all hospitals in the United States were analyzed for ICU-related hospitalizations for the years 2016 to 2019. ICU CPR was defined by procedure codes. RESULTS A total of 4,610,154 ICU encounters were reported for the years 2016 to 2019 in the NRD. Of these patients, 426,729 (9.26%) had CPR procedure recorded during the hospital encounter (mean age 65 ± 17.81; female 42.4%). And 167,597 (39.29%) patients had CPR on the day of admission, of which 63.16% died; while 64,752 (15.18%) patients had CPR on the day of ICU admission, of which 72.85% died. And 36,002 (8.44%) had CPR among patients with length of stay 2 days, of which 73.34% died. A total of 1,222,799 (26.5%) admitted to ICU died, and patients who had ICU CPR had higher mortality, 291,391(68.3%). Higher complication rates were observed among ICU CPR patients, especially who died. Over the years from 2016 to 2019, ICU CPR rates increased from 8.18% (2016) to 8.66% (2019); p-trend = 0.001. The mortality rates among patients admitted to ICU increased from 22.1% (2016) to 24.1% (2019); p-trend = 0.005. CONCLUSION The majority of ICU CPRs were done on the first day of ICU admission. The trend for ICU CPR was increasing. The mortality trend for overall ICU admissions has increased, which is concerning and would suggest further research to improve the high mortality rates in the CPR group.
Collapse
Affiliation(s)
- Tanveer Mir
- Department of Internal Medicine, Wayne State University, Detroit, MI, USA
- Department of Internal Medicine, Baptist Health System, Montgomery, AL, USA
| | - Obeid Shafi
- Department of Clinical Informatics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Sudarshan Balla
- Division of Cardiology, West Virginia University, Morgantown, WV, USA
| | | | - Waqas T Qurehi
- Cardiology Division, University of Massachusetts, Amherst, MA, USA
| | | | - Zeenat Bhat
- Nephrology Division, University of Michigan, Ann Arbor, MI, USA
| | - Parvaiz Koul
- Department of Internal Medicine, Sheri-Kashmir Institute of Medical Sciences SKIMS, Srinagar, Kashmir, India
| | - Tanveer Rab
- Division of Cardiology, Emory University, Atlanta, GA, USA
| |
Collapse
|
3
|
Flam B, Andersson Franko M, Skrifvars MB, Djärv T, Cronhjort M, Jonsson Fagerlund M, Mårtensson J. Trends in Incidence and Outcomes of Cardiac Arrest Occurring in Swedish ICUs. Crit Care Med 2024; 52:e11-e20. [PMID: 37747306 DOI: 10.1097/ccm.0000000000006067] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
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.
Collapse
Affiliation(s)
- Benjamin Flam
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Section of Anesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Mikael Andersson Franko
- Department of Clinical Science and Education, South General Hospital, Karolinska Institutet, Stockholm, Sweden
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Markus B Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Therese Djärv
- Medical Unit Acute/Emergency Department, Karolinska University Hospital, Stockholm, Sweden
- Division of Clinical Medicine, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Maria Cronhjort
- Department of Clinical Science and Education, South General Hospital, Karolinska Institutet, Stockholm, Sweden
- Department of Anesthesiology and Intensive Care, South General Hospital, Stockholm, Sweden
| | - Malin Jonsson Fagerlund
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Section of Anesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Johan Mårtensson
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Section of Anesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
4
|
Booke H, Zacharowski K, Adam EH, Raimann FJ, Bauer F, Flinspach AN. Cardiopulmonary resuscitation in veno-venous-ECMO patients-A retrospective study on incidence, causes and outcome. PLoS One 2023; 18:e0290083. [PMID: 37566592 PMCID: PMC10420365 DOI: 10.1371/journal.pone.0290083] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 08/01/2023] [Indexed: 08/13/2023] Open
Abstract
INTRODUCTION Cardiac arrest in a modern intensive care unit (ICU) is associated with poor outcome although optimal resources are present at all times. Data on cardiac arrest (CA) of the increasing cohort of patients with veno-venous-extracorporeal membrane oxygenation (VV-ECMO) are not available. Due to the highly invasive nature of this procedure, other incidences and causes of cardiac arrest are expected when compared to the ICU population without ECMO. This study focuses on cardiac arrest under VV-ECMO treatment. METHODS Retrospective single-center observational study including all VV-ECMO patients from 1st January 2019 until 31st March 2022. Primary focus of this study was number and causes for CA during VV-ECMO treatment. Secondary endpoints were treatment procedure, complications and outcome. RESULTS 140 patients were treated with VV-ECMO in the study period. Of those, 23 patients had 29 CA with need for cardiopulmonary resuscitation (CPR) during VV-ECMO treatment. Nearly half of all CA (48%; n = 14) occurred during medical procedures and 21% (n = 6) were device related. Pulseless electric activity (PEA) was the most common rhythm upon CPR initiation (72%). ROSC was achieved in 86%, two CA (6.9%) resulted in extracorporeal CPR. Survival to hospital discharge was 13% following CPR. CONCLUSION CA occurs in over 15% of all patients treated with a VV-ECMO. Medical procedures during VV-ECMO are associated with a high risk of CA and should be planned with care. Also, the rate of ROSC was very high, only a small number of patients survived the overall VV-ECMO treatment course.
Collapse
Affiliation(s)
- Hendrik Booke
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt/Main, Germany
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, University of Muenster, Muenster, Germany
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt/Main, Germany
| | - Elisabeth Hannah Adam
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt/Main, Germany
| | - Florian Jürgen Raimann
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt/Main, Germany
| | - Frederike Bauer
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt/Main, Germany
| | - Armin Niklas Flinspach
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt/Main, Germany
| |
Collapse
|
5
|
Cagino LM, Moskowitz A, Nallamothu BK, McSparron J, Iwashyna TJ. Trends in Return of Spontaneous Circulation and Survival to Hospital Discharge for In-Intensive Care Unit Cardiac Arrests. Ann Am Thorac Soc 2023; 20:1012-1019. [PMID: 36939838 DOI: 10.1513/annalsats.202205-393oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 03/17/2023] [Indexed: 03/21/2023] Open
Abstract
Rationale: Nearly 3 in 5 in-hospital cardiac arrests (IHCAs) occur in the intensive care unit (ICU), yet large-scale data on the outcomes of in-ICU cardiac arrests have not been published for over a decade. Objectives: We sought to examine outcomes of in-ICU cardiac arrests, evaluating both achievement of return of spontaneous circulation (ROSC) and subsequent survival to hospital discharge and how these have changed over time and by type of cardiac arrest. Methods: This was an observational study using the Get With The Guidelines-Resuscitation registry, an American Heart Association-sponsored, prospective, multisite registry of IHCAs in the United States, including adults 18 years of age and older with a confirmed initial cardiac arrest occurring in the ICU who underwent resuscitation. Outcomes included achievement of ROSC and survival to hospital discharge. Multivariable hierarchical logistic regression adjusting for patient-level factors and hospitals as random effects was used to evaluate ROSC and survival. Results: A total of 114,371 adult, in-ICU IHCAs from January 2006 to December 2018 were studied. The mean age was 63.8 years, 41.3% were women, and 82.1% had a nonshockable initial rhythm. Of the 114,371 ICU cardiac arrests, 70,610 (61.7%) achieved ROSC, and 21,747 (19.0%) survived until hospital discharge. The rate of ROSC improved from 2006 to 2018 (unadjusted rate, 55.0-65.4%; adjusted odds ratio [OR] per year, 1.04; 95% confidence interval [CI], 1.03-1.05). There was an increase in overall survival to discharge during this time (unadjusted rate, 16.7-20.5%; adjusted OR per year, 1.03; 95% CI, 1.03-1.04). The survival to discharge rate of the 70,610 patients who achieved ROSC increased slightly (unadjusted rate, 30.3-31.4%; adjusted OR per year, 1.02; 95% CI, 1.01, 1.02). Conclusions: There is an increase in survival to discharge for patients who experienced a cardiac arrest in the ICU between 2006 and 2018. There is an increase in achievement of ROSC and post-ROSC survival to discharge, although the increase in achievement of ROSC was greater than the increase in post-ROSC survival.
Collapse
Affiliation(s)
- Leigh M Cagino
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Ari Moskowitz
- Division of Critical Care Medicine, Montefiore Medical Center, Bronx, New York
| | - Brahmajee K Nallamothu
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
- VA Center for Clinical Management Research, Ann Arbor, Michigan; and
| | - Jakob McSparron
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Theodore J Iwashyna
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
- VA Center for Clinical Management Research, Ann Arbor, Michigan; and
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| |
Collapse
|
6
|
Hu B, Zhong L, Yuan M, Min J, Ye L, Lu J, Ji X. Elevated albumin corrected anion gap is associated with poor in-hospital prognosis in patients with cardiac arrest: A retrospective study based on MIMIC-IV database. Front Cardiovasc Med 2023; 10:1099003. [PMID: 37034339 PMCID: PMC10076801 DOI: 10.3389/fcvm.2023.1099003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 03/06/2023] [Indexed: 04/11/2023] Open
Abstract
Background Cardiac arrest(CA) is one of the most leading causes of death. Most of the indicators which used to predict the prognosis of patients with CA are not recognized. Previous studies have suggested that albumin corrected anion gap (ACAG) is associated with recovery of spontaneous circulation in patients with CA, but the predictive value of ACAG for prognosis has not been investigated. This study aims to explore the relationship between ACAG and prognosis during hospitalization in patients with CA. Methods The baseline data of adult patients with CA hospitalized in the intensive care unit (ICU) from 2008 to 2019 in the American Intensive Care Database (MIMIC-IV, version v2.0) were collected. According to the in-hospital prognosis, patients were divided into survival and non-survival group. Based on the criteria of ACAG level in the previous literature, patients enrolled were divided into normal ACAG (12-20 mmol/L) and high ACAG (>20 mmol/L) group. The basic information of patients during hospitalization were compared and analyzed between the two groups with propensity score matching (PSM). The Kaplan-Meier method was used to compare the cumulative survival rates of normal ACAG and high ACAG groups before and after matching. Restricted cubic spline (RCS) method and multivariate COX proportional hazards regressions were used to analyze whether elevated ACAG was associated with all-cause mortality during hospitalization. Results A total of 764 patients were included. A matched cohort (n = 310) was obtained after PSM analysis. The mortality rate before and after matching in the high ACAG group was higher than that in the normal ACAG group (χ 2 = 25.798; P < 0.001; χ 2 = 6.258; P = 0.012) The Kaplan-Meier survival analysis before and after matching showed that the cumulative survival rate of the high ACAG group was lower (P < 0.05). RCS analysis showed that ACAG had a non-linear relationship with the risk of in-hospital all-cause mortality (χ 2 = 6.060, P < 0.001). Multivariate COX regression analysis before and after PSM suggested that elevated ACAG was an independent risk factor for all-cause mortality in patients with CA during hospitalization (P < 0.01). Conclusions Elevated ACAG is associated with increased all-cause mortality in patients with CA during hospitalization, it can be an independent risk factor for poor prognosis in patients with CA and remind clinicians to pay more attention to these patients.
Collapse
|
7
|
Roessler LL, Holmberg MJ, Pawar RD, Lassen AT, Moskowitz A, Grossestreuer A, Moskowitz A, Edelson D, Ornato J, Peberdy MA, Churpek M, Kurz M, Starks MA, Chan P, Girotra S, Perman S, Goldberger Z. Resuscitation Quality in the ICU. Chest 2022; 162:569-577. [DOI: 10.1016/j.chest.2022.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 02/24/2022] [Accepted: 03/06/2022] [Indexed: 11/25/2022] Open
|
8
|
Incidence and Outcomes of Cardiopulmonary Resuscitation in ICUs: Retrospective Cohort Analysis. Crit Care Med 2022; 50:1503-1512. [PMID: 35834661 DOI: 10.1097/ccm.0000000000005624] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
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.
Collapse
|
9
|
Chelly J, Plantefève G, Kamel T, Bruel C, Nseir S, Lai C, Cirillo G, Skripkina E, Ehrminger S, Berdaguer-Ferrari FD, Le Marec J, Paul M, Autret A, Deye N. Incidence, clinical characteristics, and outcome after unexpected cardiac arrest among critically ill adults with COVID-19: insight from the multicenter prospective ACICOVID-19 registry. Ann Intensive Care 2021; 11:155. [PMID: 34773516 PMCID: PMC8590126 DOI: 10.1186/s13613-021-00945-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 10/27/2021] [Indexed: 01/28/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Jonathan Chelly
- Intensive Care Unit, Centre Hospitalier Intercommunal Toulon-La Seyne sur Mer, Hôpital Sainte Musse, 54 rue Henri Sainte Claire Deville, 83056, Toulon, France.
| | - Gaetan Plantefève
- Intensive Care Unit, Centre Hospitalier Victor Dupouy, Argenteuil, France
| | - Toufik Kamel
- Intensive Care Unit, Centre Hospitalier Régional d'Orléans, Orléans. Inserm UMR1153, ECSTRRA, Université de Paris, Paris, France
| | - Cédric Bruel
- Intensive Care Unit, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Saad Nseir
- Médecine Intensive Réanimation, CHU Lille, Inserm U1285, Université de Lille, CNRS, UMR 8576-UGSF, Unité de Glycobiologie Structurale et Fonctionnelle, Lille, France
| | - Christopher Lai
- Medical Intensive Care Unit, Hôpital de Bicêtre, Université Paris-Saclay, Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
| | - Giulia Cirillo
- Intensive Care Department, Groupe Hospitalier Sud Ile de France, Melun, France
| | - Elena Skripkina
- Service d'anesthésie-réanimation chirurgicale, DMU CARE, DHU A-TVB, Assistance Publique Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Sébastien Ehrminger
- Intensive Care Unit, Grand Hôpital de l'Est Francilien-site de Marne la Vallée, Jossigny, France
| | | | - Julien Le Marec
- Intensive Care Unit, Département R3S, Pitié-Salpétrière hospital, Assistance Publique Hôpitaux de Paris (AP-HP), Sorbonne Université, Paris, France
| | - Marine Paul
- Intensive Care Unit, Centre Hospitalier de Versailles-site André Mignot, Le Chesnay, France
| | - Aurélie Autret
- Clinical Research Department, Centre Hospitalier Intercommunal Toulon-La Seyne sur Mer, Toulon, France
| | - Nicolas Deye
- Medical and Toxicological Intensive Care Unit, Inserm U942, Assistance Publique Hôpitaux de Paris (AP-HP), Centre Hospitalier Universitaire Lariboisière, Paris, France
| | | |
Collapse
|
10
|
Roedl K, Kluge S. [Novel aspects on causes of in-hospital cardiac arrest]. Dtsch Med Wochenschr 2021; 146:733-737. [PMID: 34062588 DOI: 10.1055/a-1258-5243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
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.
Collapse
Affiliation(s)
- Kevin Roedl
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg
| |
Collapse
|
11
|
Characteristics and Risk Factors for Intensive Care Unit Cardiac Arrest in Critically Ill Patients with COVID-19-A Retrospective Study. J Clin Med 2021; 10:jcm10102195. [PMID: 34069530 PMCID: PMC8160993 DOI: 10.3390/jcm10102195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 05/09/2021] [Accepted: 05/17/2021] [Indexed: 01/26/2023] Open
Abstract
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.
Collapse
|
12
|
Robbins AJ, Ingraham NE, Sheka AC, Pendleton KM, Morris R, Rix A, Vakayil V, Chipman JG, Charles A, Tignanelli CJ. Discordant Cardiopulmonary Resuscitation and Code Status at Death. J Pain Symptom Manage 2021; 61:770-780.e1. [PMID: 32949762 PMCID: PMC8052631 DOI: 10.1016/j.jpainsymman.2020.09.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/04/2020] [Accepted: 09/09/2020] [Indexed: 01/09/2023]
Abstract
CONTEXT One fundamental way to honor patient autonomy is to establish and enact their wishes for end-of-life care. Limited research exists regarding adherence with code status. OBJECTIVES This study aimed to characterize cardiopulmonary resuscitation (CPR) attempts discordant with documented code status at the time of death in the U.S. and to elucidate potential contributing factors. METHODS The Cerner Acute Physiology and Chronic Health Evaluation (APACHE) outcomes database, which includes 237 U.S. hospitals that collect manually abstracted data from all critical care patients, was queried for adults admitted to intensive care units with a documented code status at the time of death from January 2008 to December 2016. The primary outcome was discordant CPR at death. Multivariable logistic regression models were used to identify patient-level and hospital-level associated factors after adjustment for age, hospital, and illness severity (APACHE III score). RESULTS A total of 21,537 patients from 56 hospitals were included. Of patients with a do-not-resuscitate code status, 149 (0.8%) received CPR at death, and associated factors included black race, higher APACHE III score, or treatment in small or nonteaching hospitals. Of patients with a full code status, 203 (9.0%) did not receive CPR at death, and associated factors included higher APACHE III score, primary neurologic or trauma diagnosis, or admission in a more recent year. CONCLUSION At the time of death, 1.6% of patients received or did not undergo CPR in a manner discordant with their documented code statuses. Race and institutional factors were associated with discordant resuscitation, and addressing these disparities may promote concordant end-of-life care in all patients.
Collapse
Affiliation(s)
- Alexandria J Robbins
- Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA.
| | - Nicholas E Ingraham
- Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Adam C Sheka
- Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Kathryn M Pendleton
- Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Rachel Morris
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Alexander Rix
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Victor Vakayil
- Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Jeffrey G Chipman
- Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA; Department of Surgery, North Memorial Health Hospital, Robbinsdale, Minnesota, USA
| | - Anthony Charles
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA; School of Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Christopher J Tignanelli
- Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA; Department of Surgery, North Memorial Health Hospital, Robbinsdale, Minnesota, USA; Institute for Health Informatics, University of Minnesota Academic Health Center, Minneapolis, Minnesota, USA
| |
Collapse
|
13
|
Roedl K, Söffker G, Fischer D, Müller J, Westermann D, Issleib M, Kluge S, Jarczak D. Effects of COVID-19 on in-hospital cardiac arrest: incidence, causes, and outcome - a retrospective cohort study. Scand J Trauma Resusc Emerg Med 2021; 29:30. [PMID: 33557923 PMCID: PMC7868866 DOI: 10.1186/s13049-021-00846-w] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 02/01/2021] [Indexed: 01/08/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Kevin Roedl
- Department of Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Gerold Söffker
- Department of Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Dominik Fischer
- Department of Anaesthesiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob Müller
- Department of Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.,Department of Anaesthesia, Tabea Hospital, Hamburg, Germany
| | - Dirk Westermann
- Department of Interventional and General Cardiology, University Heart Centre Hamburg, Hamburg, Germany
| | - Malte Issleib
- Department of Anaesthesiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Dominik Jarczak
- Department of Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| |
Collapse
|
14
|
Roedl K, Jarczak D, Blohm R, Winterland S, Müller J, Fuhrmann V, Westermann D, Söffker G, Kluge S. Epidemiology of intensive care unit cardiac arrest: Characteristics, comorbidities, and post-cardiac arrest organ failure - A prospective observational study. Resuscitation 2020; 156:92-98. [PMID: 32920114 DOI: 10.1016/j.resuscitation.2020.09.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 08/18/2020] [Accepted: 09/02/2020] [Indexed: 12/14/2022]
Abstract
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.
Collapse
Affiliation(s)
- Kevin Roedl
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Dominik Jarczak
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Rasmus Blohm
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Sarah Winterland
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Jakob Müller
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Tabea Hospital Hamburg, Hamburg, Germany.
| | - Valentin Fuhrmann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Dirk Westermann
- Department of Interventional and General Cardiology, University Heart Center Hamburg, Hamburg, Germany.
| | - Gerold Söffker
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| |
Collapse
|
15
|
Cardiac arrest in adult intensive care units in the Medellin metropolitan area, Colombia: observational study. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2020. [DOI: 10.1097/cj9.0000000000000156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Introduction: In-hospital cardiac arrest (CA) is a rare but lifethreatening event. However, the epidemiology of this event in intensive care units (ICU) is not clear.
Objective: To determine the clinical characteristics of CA in adult patients hospitalized in several ICU of the Metropolitan Area of the Aburrá Valley, Colombia, over a period of 1 year.
Methods: Observational study for a limited period of 1 year for adult patients with CA in the ICU of the hospitals of the Metropolitan Area of the Aburrá Valley, Colombia: San Vicente Foundation University Hospital, IPS University, and Manuel Uribe Ángel Hospital.
Results: Of 3710 eligible patientswhowere treated in 91 beds, 646 CA events occurred during this period, of which 151 were candidates for resuscitation maneuvers. The overall incidence of CA in the ICU was 17.1%, without differences between the 3 hospitals included and the incidence of resuscitable CA was 39.9 cases per 1000 admissions to the ICU. The most common CA rhythm was asystole (54.3%) and the overall survival at hospital discharge was 3.3%.
Conclusion: In the analyzed ICU, CA was an infrequent event, but it presents a high mortality at discharge from the ICU and hospital. However, the few patients who survive have a good neurological prognosis.
Collapse
|
16
|
Unexpected cardiac arrests occurring inside the ICU: outcomes of a French prospective multicenter study. Intensive Care Med 2020; 46:1005-1015. [DOI: 10.1007/s00134-020-05992-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 02/26/2020] [Indexed: 11/30/2022]
|
17
|
Wilcox SR, Richards JB, Stevenson EK. Association Between Do Not Resuscitate/Do Not Intubate Orders and Emergency Medicine Residents’ Decision Making. J Emerg Med 2020; 58:11-17. [PMID: 31708311 DOI: 10.1016/j.jemermed.2019.09.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 09/10/2019] [Accepted: 09/20/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Research has shown that do not resuscitate (DNR) and do not intubate (DNI) orders may be construed by physicians to be more restrictive than intended by patients. Previous studies of physicians found that DNR/DNI orders are associated with being less willing to provide invasive care. OBJECTIVES The purpose of this study was to assess the influence of code status on emergency residents' decision-making regarding offering invasive procedures for those patients with DNR/DNI compared with their full code counterparts. METHODS We conducted a nationwide survey of emergency medicine residents using an instrument of 4 clinical vignettes involving patients with serious illnesses. Two versions of the survey, survey A and survey B, alternated the DNR/DNI and full code status for the vignettes. Residency leaders were contacted in August 2018 to distribute the survey to their residents. RESULTS Three hundred and three residents responded from across the country. The code status was strongly associated with decisions to intubate or perform CPR and influenced the willingness to offer other invasive procedures. DNR/DNI status was associated with less frequent willingness to place central venous catheters (88.2% for DNR/DNI vs. 97.2% for full code, p < 0.001), admit patients to the intensive care unit (89.9% vs. 99.0%, p < 0.001), offer dialysis (79.3% vs. 98.0%, p < 0.001), and surgical consultation (78.7% vs. 94.2%, p < 0.001). CONCLUSIONS In a nationwide survey, emergency medicine residents were less willing to provide invasive procedures for patients with DNR/DNI status, including the placement of central venous catheters, admission to the intensive care unit, and consultation for dialysis and surgery.
Collapse
|
18
|
Moskowitz A, Berg KM, Cocchi MN, Chase M, Yang JX, Sarge J, Grossestreuer AV, Sarge T, O' Donoghue S, Donnino MW. Cardiac arrest in the intensive care unit: An assessment of preventability. Resuscitation 2019; 145:15-20. [PMID: 31521775 PMCID: PMC7076735 DOI: 10.1016/j.resuscitation.2019.09.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 08/07/2019] [Accepted: 09/02/2019] [Indexed: 10/26/2022]
Abstract
AIM Cardiac arrest in the intensive care unit (ICU-CA) is a common and highly morbid event. We investigated the preventability of ICU-CAs and identified targets for future intervention. METHODS This was a prospective, observational study of ICU-CAs at a tertiary care center in the United States. For each arrest, the clinical team was surveyed regarding arrest preventability. An expert, multi-disciplinary team of physicians and nurses also reviewed each arrest. Arrests were scored 0 (not at all preventable) to 5 (completely preventable). Arrests were considered 'unlikely but potentially preventable' or 'potentially preventable' if at least 50% of reviewers assigned a score of ≥1 or ≥3 respectively. Themes of preventability were assessed for each arrest. RESULTS 43 patients experienced an ICU-CA and were included. A total of 14 (32.6%) and 13 (30.2%) arrests were identified as unlikely but potentially preventable by the expert panel and survey respondents respectively, and an additional 11 (25.6%) and 10 (23.3%) arrests were identified as potentially preventable. Timing of response to clinical deterioration, missed/incorrect diagnosis, timing of acidemia correction, timing of escalation to a more senior clinician, and timing of intubation were the most commonly cited contributors to potential preventability. Additional themes identified included the administration of anxiolytics/narcotics for agitation later identified to be due to clinical deterioration and misalignment between team and patient/family perceptions of prognosis and goals-of-care. CONCLUSIONS ICU-CAs may have preventable elements. Themes of preventability were identified and addressing these themes through data-driven quality improvement initiatives could potentially reduce CA incidence in critically-ill patients.
Collapse
Affiliation(s)
- Ari Moskowitz
- Beth Israel Deaconess Medical Center, Division of Pulmonary, Critical Care and Sleep Medicine, Boston, MA, United States
| | - Katherine M Berg
- Beth Israel Deaconess Medical Center, Division of Pulmonary, Critical Care and Sleep Medicine, Boston, MA, United States
| | - Michael N Cocchi
- Beth Israel Deaconess Medical Center, Division of Anesthesia Critical Care, Boston, MA, United States; Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, MA, United States
| | - Maureen Chase
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, MA, United States
| | - Jesse X Yang
- Beth Israel Deaconess Medical Center, Division of Cardiology, Boston, MA, United States
| | - Jennifer Sarge
- Beth Israel Deaconess Medical Center, Critical Care Nursing, Boston, MA, United States
| | - Anne V Grossestreuer
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, MA, United States
| | - Todd Sarge
- Beth Israel Deaconess Medical Center, Division of Anesthesia Critical Care, Boston, MA, United States
| | - Sharon O' Donoghue
- Beth Israel Deaconess Medical Center, Division of Cardiology, Boston, MA, United States
| | - Michael W Donnino
- Beth Israel Deaconess Medical Center, Division of Pulmonary, Critical Care and Sleep Medicine, Boston, MA, United States; Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, MA, United States.
| |
Collapse
|
19
|
Abstract
Creating nurse-driven protocols empower nurses to practice at the top of their scope and provide early interventions. This article describes the development and implementation of an evidence-based, nurse-driven resuscitation protocol for cardiac surgical patients who suffer cardiac arrest using a theoretical framework and leadership-driven process. Readers will gain knowledge of the collaborative process required to develop and implement a complex practice change. Process measures, outcomes, and lessons learned are presented.
Collapse
Affiliation(s)
- Melanie Roberts
- Author Affiliations: Critical Care Clinical Nurse Specialist (Dr Roberts) and Cardiothoracic Surgery Nurse Practitioner Supervisor (Ms Miller), UCHealth Medical Center of the Rockies, Loveland, Colorado
| | | |
Collapse
|
20
|
Armstrong RA, Kane C, Oglesby F, Barnard K, Soar J, Thomas M. The incidence of cardiac arrest in the intensive care unit: A systematic review and meta-analysis. J Intensive Care Soc 2019; 20:144-154. [PMID: 31037107 PMCID: PMC6475987 DOI: 10.1177/1751143718774713] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The incidence of cardiac arrest in the intensive care unit (ICU-CA) has not been widely reported. We undertook a systematic review and meta-analysis of studies reporting the incidence of cardiac arrest in adult, general intensive care units. The review was prospectively registered with PROSPERO (CRD42017079717). The search identified 7550 records, which included 20 relevant studies for qualitative analysis and 16 of these were included for quantitative analyses. The reported incidence of ICU-CA was 22.7 per 1000 admissions (95% CI: 17.4-29.6) with survival to hospital discharge of 17% (95% CI: 9.5-28.5%). We estimate that at least 5446 patients in the UK have a cardiac arrest after ICU admission. There are limited data and significant variation in the incidence of ICU-CA and efforts to synthesise these are limited by inconsistent reporting. Further prospective studies with standardised process and incidence measures are required to define this important patient group.
Collapse
Affiliation(s)
| | - Caroline Kane
- Intensive Care Unit, Southmead Hospital, Bristol, UK
| | - Fiona Oglesby
- Department of Anaesthesia, Royal United Hospital, Bath, UK
| | - Katie Barnard
- Library and Knowledge Service, Southmead Hospital, Bristol, UK
| | - Jasmeet Soar
- Intensive Care Unit, Southmead Hospital, Bristol, UK
| | - Matt Thomas
- Intensive Care Unit, Southmead Hospital, Bristol, UK
| |
Collapse
|
21
|
Littlewood S, Snow TAC. Reporting the incidence of cardiac arrest on the ICU: Are we still waiting for ROSC? A letter in response to: 'Armstrong RA, Kane C, Oglesby F, et al. The incidence of cardiac arrest in the intensive care unit: A systematic review and meta-analysis. JICS 2018. In press'. J Intensive Care Soc 2019; 20:NP4-NP5. [PMID: 30792773 PMCID: PMC6376582 DOI: 10.1177/1751143718788764] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
| | - Timothy AC Snow
- GICU, St George's Hospital, London, UK
- Institute of Medical and Biomedical Education, St George's, University of London, UK
| |
Collapse
|
22
|
Ollila A, Vikatmaa L, Sund R, Pettilä V, Wilkman E. Efficacy and safety of intravenous esmolol for cardiac protection in non-cardiac surgery. A systematic review and meta-analysis. Ann Med 2019; 51:17-27. [PMID: 30346213 PMCID: PMC7856921 DOI: 10.1080/07853890.2018.1538565] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Haemodynamic instability predisposes patients to cardiac complications in non-cardiac surgery. Esmolol, a short-acting cardioselective beta-adrenergic blocker might be efficient in perioperative cardiac protection, but could affect other vital organs, such as the kidneys, and post-discharge survival. We performed a systematic review on the use of esmolol for perioperative cardiac protection. We searched PubMed, Ovid Medline and Cochrane Central Register for Controlled trials. Eligible randomized controlled studies (RCTs) reported a perioperative esmolol intervention with at least one of the primary (major cardiac or renal complications during the first 30 postoperative days) or secondary (postoperative adverse effects and all-cause mortality) outcomes. We included 196 adult patients from three RCTs. Esmolol significantly reduced postoperative myocardial ischaemia, RR =0.43 [95% confidence interval, CI: 0.21-0.88], p = .02. No association with clinically significant bradycardia and hypotension compared to patients receiving control treatment could be confirmed (RR =7.4 [95% CI: 0.29-139.81], p = .18 and RR =2.21 [95% CI: 0.34-14.36], p = .41, respectively). No differences regarding other outcomes were observed. No study reported postoperative renal outcomes. Esmolol seems promising for the prevention of perioperative myocardial ischaemia. However, the association with bradycardia and hypotension remains unclear. Randomized trials investigating the effect of β1-selective blockade on clinically relevant outcomes and non-cardiac vital organs are warranted. Key messages Short-acting cardioselective esmolol seems efficient in the prevention of perioperative myocardial ischaemia. The possibly increased risk of bradycardia and hypotension with short-acting intravenous beta blockade could not be confirmed or refuted by available data. Future adequately powered trials investigating the effect of β1-selective blockade on clinically relevant outcomes and non-cardiac vital organs are warranted.
Collapse
Affiliation(s)
- Aino Ollila
- a Department of Perioperative, Intensive Care and Pain Medicine , University of Helsinki and Helsinki University Hospital , Helsinki , Finland
| | - Leena Vikatmaa
- a Department of Perioperative, Intensive Care and Pain Medicine , University of Helsinki and Helsinki University Hospital , Helsinki , Finland
| | - Reijo Sund
- b Institute of Clinical Medicine, University of Eastern Finland , Kuopio , Finland.,c Faculty of Social Sciences , Centre for Research Methods, University of Helsinki , Helsinki , Finland
| | - Ville Pettilä
- a Department of Perioperative, Intensive Care and Pain Medicine , University of Helsinki and Helsinki University Hospital , Helsinki , Finland
| | - Erika Wilkman
- a Department of Perioperative, Intensive Care and Pain Medicine , University of Helsinki and Helsinki University Hospital , Helsinki , Finland
| |
Collapse
|
23
|
Outcomes Following Sepsis and Cardiopulmonary Resuscitation: Fare Thee Well or Worse for Wear? Crit Care Med 2017; 44:1232-3. [PMID: 27182853 DOI: 10.1097/ccm.0000000000001695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
|
24
|
Silva RMFLD, Silva BAGDLE, Silva FJME, Amaral CFS. Cardiopulmonary resuscitation of adults with in-hospital cardiac arrest using the Utstein style. Rev Bras Ter Intensiva 2017; 28:427-435. [PMID: 28099640 PMCID: PMC5225918 DOI: 10.5935/0103-507x.20160076] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 10/17/2016] [Indexed: 12/02/2022] Open
Abstract
Objective The objective of this study was to analyze the clinical profile of patients
with in-hospital cardiac arrest using the Utstein style. Methods This study is an observational, prospective, longitudinal study of patients
with cardiac arrest treated in intensive care units over a period of 1
year. Results The study included 89 patients who underwent cardiopulmonary resuscitation
maneuvers. The cohort was 51.6% male with a mean age 59.0 years. The
episodes occurred during the daytime in 64.6% of cases.
Asystole/bradyarrhythmia was the most frequent initial rhythm (42.7%). Most
patients who exhibited a spontaneous return of circulation experienced
recurrent cardiac arrest, especially within the first 24 hours (61.4%). The
mean time elapsed between hospital admission and the occurrence of cardiac
arrest was 10.3 days, the mean time between cardiac arrest and
cardiopulmonary resuscitation was 0.68 min, the mean time between cardiac
arrest and defibrillation was 7.1 min, and the mean duration of
cardiopulmonary resuscitation was 16.3 min. Associations between gender and
the duration of cardiopulmonary resuscitation (19.2 min in women versus 13.5
min in men, p = 0.02), the duration of cardiopulmonary resuscitation and the
return of spontaneous circulation (10.8 min versus 30.7 min, p < 0.001)
and heart disease and age (60.6 years versus 53.6, p < 0.001) were
identified. The immediate survival rates after cardiac arrest, until
hospital discharge and 6 months after discharge were 71%, 9% and 6%,
respectively. Conclusions The main initial rhythm detected was asystole/bradyarrhythmia; the interval
between cardiac arrest and cardiopulmonary resuscitation was short, but
defibrillation was delayed. Women received cardiopulmonary resuscitation for
longer periods than men. The in-hospital survival rate was low.
Collapse
|
25
|
Affiliation(s)
- James Cook
- Department of Anaesthetics, Glangwili General Hospital, Carmarthen, UK
| | | |
Collapse
|
26
|
Simulation Incorporating Cardiac Surgery Life Support Algorithm Into Cardiac Intensive Care Unit Practice. Simul Healthc 2016; 11:419-424. [PMID: 27922571 DOI: 10.1097/sih.0000000000000193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
27
|
|
28
|
Lin S, Scales DC. Cardiopulmonary resuscitation quality and beyond: the need to improve real-time feedback and physiologic monitoring. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:182. [PMID: 27349642 PMCID: PMC4924329 DOI: 10.1186/s13054-016-1371-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
High-quality cardiopulmonary resuscitation (CPR) has been shown to improve survival outcomes after cardiac arrest. The current standard in studies evaluating CPR quality is to measure CPR process measures—for example, chest compression rate, depth, and fraction. Published studies evaluating CPR feedback devices have yielded mixed results. Newer approaches that seek to optimize CPR by measuring physiological endpoints during the resuscitation may lead to individualized patient care and improved patient outcomes.
Collapse
Affiliation(s)
- Steve Lin
- Rescu, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada. .,Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada. .,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
| | - Damon C Scales
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
29
|
Assar S, Husseinzadeh M, Nikravesh AH, Davoodzadeh H. The Success Rate of Pediatric In-Hospital Cardiopulmonary Resuscitation in Ahvaz Training Hospitals. SCIENTIFICA 2016; 2016:9648140. [PMID: 27293983 PMCID: PMC4884828 DOI: 10.1155/2016/9648140] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/26/2015] [Revised: 04/07/2016] [Accepted: 04/19/2016] [Indexed: 06/06/2023]
Abstract
Research Objective. This study determined the outcome of cardiopulmonary resuscitation (CPR) after in-hospital cardiac arrest and factors influencing it in two training hospitals in Ahvaz. Method. Patients hospitalized in the pediatric wards and exposed to CPR during hospital stay were included in the study (September 2013 to May 2014). The primary outcome of CPR was assumed to be the return of spontaneous circulation (ROSC) and the secondary outcome was assumed to be survival to discharge. The neurological outcome of survivors was assessed using the Pediatric Cerebral Performance Category (PCPC) method. Results. Of the 279 study participants, 138 patients (49.4%) showed ROSC, 81 patients (29%) survived for 24 hours after the CPR, and 33 patients (11.8%) survived to discharge. Of the surviving patients, 16 (48.5%) had favorable neurological outcome. The resuscitation during holidays resulted in fewer ROSC. Multivariate analysis showed that longer CPR duration, CPR by junior residents, growth deficiency, and prearrest vasoactive drug infusion were associated with decreased survival to discharge (p < 0.05). Infants and patients with respiratory disease had higher survival rates. Conclusion. The rate of successful CPR in our study was lower than rates reported by developed countries. However, factors influencing the outcome of CPR were similar. These results reflect the necessity of paying more attention to pediatric CPR training, postresuscitation conditions, and expansion of intensive care facilities.
Collapse
Affiliation(s)
- Shideh Assar
- Pediatric Department, Golestan Hospital, Ahvaz Jundishapur University of Medical Sciences, Iran
| | - Mohsen Husseinzadeh
- Pediatric Department, Abuzar Hospital, Ahvaz Jundishapur University of Medical Sciences, Iran
| | | | - Hannaneh Davoodzadeh
- Department of Anesthesiology, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
- Medical Research Center, Jundishapur Health Development Co., Tehran, Iran
| |
Collapse
|
30
|
Echocardiography for prognostication during the resuscitation of intensive care unit patients with non-shockable rhythm cardiac arrest. Resuscitation 2015; 92:1-6. [DOI: 10.1016/j.resuscitation.2015.03.024] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Revised: 03/26/2015] [Accepted: 03/29/2015] [Indexed: 12/22/2022]
|
31
|
The incidence and outcome of in-ICU cardiac arrest. Intensive Care Med 2015; 41:383. [DOI: 10.1007/s00134-014-3643-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2014] [Indexed: 10/24/2022]
|
32
|
Sudden death in ICU: the Finnish experience. Intensive Care Med 2014; 40:1960-2. [DOI: 10.1007/s00134-014-3528-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 10/23/2014] [Indexed: 10/24/2022]
|
33
|
Temporal trends in cardiac arrest incidence and outcome in Finnish intensive care units from 2003 to 2013. Intensive Care Med 2014; 40:1853-61. [PMID: 25387815 DOI: 10.1007/s00134-014-3509-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2014] [Accepted: 09/26/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE To estimate temporal trends in incidence and hospital mortality after cardiac arrest in Finnish intensive care units. METHODS Using a large nationwide intensive care unit (ICU) database we identified patients suffering from cardiac arrest following ICU admission (ICU-CA) during the study period (2003-2013). ICU-CA was defined as need for cardiopulmonary resuscitation and/or defibrillation (non-arrest cardioversions were excluded) according to the Therapeutic Intervention Scoring System-76. Patients admitted with an admission diagnosis of cardiac arrest were excluded. We determined crude incidence and risk-adjusted hospital mortality (based on a customized severity of illness model) for all ICU-CA patients, and for predefined admission diagnosis subgroups. Temporal trends for the observed period were calculated for crude incidence and risk-adjusted hospital mortality. RESULTS Crude incidence for all ICU-CA patients was 29/1,000 ICU admissions, with the highest incidence 118/1,000 in the non-operative cardiovascular subgroup. Overall hospital mortality for ICU-CA patients was 55.5% [95% confidence interval (CI) 54-57%]. Hospital mortality was 53.1% (95% CI 50.4-55.8%) for non-operative cardiovascular ICU-CA patients, 32.9% (95% CI 26.9-38.9%) for post cardiac surgery ICU-CA patients, and 56.3% (95% CI 51.2-61.3%) for neurological/neurosurgical ICU-CA patients. There was a significant reduction in the overall ICU-CA incidence and in the risk-adjusted hospital mortality of ICU-CA and non-cardiac arrest cases (non-CA) over the observed study period (p < 0.001). CONCLUSION Our data suggest that the incidence of ICU-CA has decreased in Finnish ICUs between 2003 and 2013. Similar reduction in hospital mortality over time was observed for both ICU-CA and non-CA populations.
Collapse
|
34
|
Gosev I, Nikolic I, Aranki S. Resuscitation practices in cardiac surgery. J Thorac Cardiovasc Surg 2014; 148:1152-6. [PMID: 25060550 DOI: 10.1016/j.jtcvs.2014.06.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2014] [Revised: 06/10/2014] [Accepted: 06/11/2014] [Indexed: 11/17/2022]
Affiliation(s)
- Igor Gosev
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
| | - Ivana Nikolic
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Sari Aranki
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| |
Collapse
|