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Snipelisky D, Fudim M, Perez A, Nayor M, Lever NM, Raymer DS, Rosenbaum AN, AbouEzzeddine O, Hernandez AF, Stevenson LW, Gilstrap LG. Expected vs Actual Outcomes of Elective Initiation of Inotropic Therapy During Heart Failure Hospitalization. MAYO CLINIC PROCEEDINGS: INNOVATIONS, QUALITY & OUTCOMES 2020; 4:529-536. [PMID: 33083701 PMCID: PMC7557209 DOI: 10.1016/j.mayocpiqo.2020.05.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Objective To describe the intent and early outcomes of elective inotrope use during heart failure hospitalization. Patients and Methods A prospective multisite design was used to collect data for hemodynamically stable patients started electively on inotrope therapy between January 1 and August 31, 2018. We prospectively recorded data when intravenous inotropic therapy was initiated, including survey of the attending cardiologists regarding expectations for the clinical course. Patients were followed up for events through hospital discharge and an additional survey was administered at the end of hospitalization. Results For the 92 patients enrolled, average age was 60 years and ejection fraction was 24%±12%. At the time of inotrope initiation, attending heart failure cardiologists predicted that 50% (n=46) of the patients had a “high or very high” likelihood of becoming dependent on intravenous inotropic therapy and 58% (n=53) had a “high” likelihood of death, transplant, or durable ventricular assist device placement within the next 6 months. Provider predictions regarding death/hospice or need for continued home infusions were accurate only 51% (47 of 92) of the time. Only half the patients (n=47) had goals-of-care conversations before inotrope treatment initiation. Conclusion More than half the patients (51 of 92) electively started on inotrope treatment without present or imminent cardiogenic shock ultimately required home inotrope therapy, died during admission, or were discharged with hospice. Heart failure clinicians could not reliably identify those patients at the time of inotrope therapy initiation and goals-of-care discussions were not frequently performed.
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Snipelisky D, Dumitrascu A, Ray J, Roy A, Matcha G, Harris D, Vadeboncoeur T, Kusumoto F, Burton MC. Mayo registry for telemetry efficacy in arrest study: An evaluation of the feasibility of the do not intubate code status. ACTA ACUST UNITED AC 2017; 18:79-84. [PMID: 29210596 DOI: 10.1080/17482941.2017.1408917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Introduction: Guidelines recommend discussing code status with patients on hospital admission. No study has evaluated the feasibility of a full code with do not intubate (DNI) status. Methods: A retrospective analysis of patients who experienced a cardiopulmonary arrest was performed between May 1, 2008 and June 20, 2014. A descriptive analysis was created based on whether patients required mechanical ventilatory support during the hospitalization and comparisons were made between both patient subsets. Results: A total of 239 patients were included. Almost all (n = 218, 91.2%) required intubation during the hospitalization. Over half (n = 117, 53.7%) were intubated on the same day as the cardiopulmonary arrest and 91 patients (41.7%) were intubated at the time of arrest. Comparisons between intubated and non-intubated patients showed little differences in clinical characteristics, except for a higher proportion of medical cardiac etiology for admission in patients who did not require intubation (n = 10, 47.6% versus n = 55, 25.2%; p = 0.18) and initial arrest rhythm of ventricular tachycardia/fibrillation (n = 8, 38.1% versus n = 50, 22.9%; p = 0.37). No differences in 24-hour and posthospital survivals were present. Conclusion: Mechanical ventilatory support is commonly utilized in patients who experience a cardiopulmonary arrest. The DNI status may not be a feasible code status option for most patients.
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Affiliation(s)
- David Snipelisky
- a Department of Medicine, Division of Cardiovascular Diseases , Mayo Clinic , Rochester , MN, USA
| | - Adrian Dumitrascu
- b Department of Medicine, Division of Hospital Medicine , Mayo Clinic , Jacksonville , FL , USA
| | - Jordan Ray
- c Department of Medicine, Division of Internal Medicine , Mayo Clinic , Jacksonville , FL , USA
| | - Archana Roy
- d Department of Emergency Medicine , Mayo Clinic , Jacksonville , FL , USA
| | - Gautam Matcha
- b Department of Medicine, Division of Hospital Medicine , Mayo Clinic , Jacksonville , FL , USA
| | - Dana Harris
- b Department of Medicine, Division of Hospital Medicine , Mayo Clinic , Jacksonville , FL , USA
| | - Tyler Vadeboncoeur
- d Department of Emergency Medicine , Mayo Clinic , Jacksonville , FL , USA
| | - Fred Kusumoto
- e Department of Medicine, Division of Cardiovascular Diseases , Mayo Clinic , Jacksonville , FL, USA
| | - M Caroline Burton
- b Department of Medicine, Division of Hospital Medicine , Mayo Clinic , Jacksonville , FL , USA
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Fendler TJ, Spertus JA, Kennedy KF, Chan PS. Association between hospital rates of early Do-Not-Resuscitate orders and favorable neurological survival among survivors of inhospital cardiac arrest. Am Heart J 2017; 193:108-116. [PMID: 29129249 DOI: 10.1016/j.ahj.2017.05.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 05/15/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Current guidelines recommend deferring prognostication for 48 to 72 hours after resuscitation from inhospital cardiac arrest. It is unknown whether hospitals vary in making patients who survive an arrest Do-Not-Resuscitate (DNR) early after resuscitation and whether a hospital's rate of early DNR is associated with its rate of favorable neurological survival. METHODS Within Get With the Guidelines-Resuscitation, we identified 24,899 patients from 236 hospitals who achieved return of spontaneous circulation (ROSC) after inhospital cardiac arrest between 2006 and 2012. Hierarchical models were constructed to derive risk-adjusted hospital rates of DNR status adoption ≤12 hours after ROSC and risk-standardized rates of favorable neurological survival (without severe disability; Cerebral Performance Category ≤2). The association between hospitals' rates of early DNR and favorable neurological survival was evaluated using correlation statistics. RESULTS Of 236 hospitals, 61.7% were academic, 83% had ≥200 beds, and 94% were urban. Overall, 5577 (22.4%) patients were made DNR ≤12 hours after ROSC. Risk-adjusted hospital rates of early DNR varied widely (7.1%-40.5%, median: 22.7% [IQR: 19.3%-26.1%]; median OR of 1.48). Significant hospital variation existed in risk-standardized rates of favorable neurological survival (3.5%-44.8%, median: 25.3% [IQR: 20.2%-29.4%]; median OR 1.72). Hospitals' risk-adjusted rates of early DNR were inversely correlated with their risk-standardized rates of favorable neurological survival (r=-0.179, P=.006). CONCLUSIONS Despite current guideline recommendations, many patients with inhospital cardiac arrest are made DNR within 12 hours after ROSC, and hospitals vary widely in rates of early DNR. Higher hospital rates of early DNR were associated with worse meaningful survival outcomes.
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Affiliation(s)
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- Department of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, MO
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Snipelisky D, Ray J, Matcha G, Roy A, Clark B, Dumitrascu A, Bosworth V, Whitman A, Lewis P, Vadeboncoeur T, Kusumoto F, Burton MC. Mayo registry for telemetry efficacy in arrest (MR TEA) study: An assessment of the effect of admission diagnosis on outcomes from in-hospital cardiopulmonary arrest. ACUTE CARDIAC CARE 2015; 17:67-71. [PMID: 27712143 DOI: 10.1080/17482941.2016.1203439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 05/24/2016] [Indexed: 06/06/2023]
Abstract
INTRODUCTION Little data exists evaluating how different risk factors influence outcomes following in-hospital arrests. METHODS A retrospective review of patients that suffered a cardiopulmonary arrest between 1 May 2008 and 30 June 2014 was performed. Patients were stratified into subsets based on cardiac versus non-cardiac reasons for admission. RESULTS 199 patients met inclusion criteria, of which 138 (69.3%) had a non-cardiac reason for admission and 61 (30.7%) a cardiac etiology. No difference in demographics and non-cardiac comorbidities were present. Cardiac-related comorbidities were more prevalent in the cardiac etiology subset. Arrests with a shockable rhythm were more common in the cardiac group (P < 0.0001), yet return of spontaneous circulation from the index event was similar (P = 0.254). More patients in the cardiac group were alive at 24-h post resuscitation (n = 34, 55.7% versus n = 49, 35.5%; P = 0.0085), discharge (n = 21, 34.4% versus n = 19, 13.8%; P = 0.0018), and at last follow-up (n = 13, 21.3% versus n = 14, 10.1%; P = 0.0434). CONCLUSION Although patients with cardiac and non-cardiac etiologies for admission have similar rates of return of spontaneous circulation, those with cardiac etiologies are more likely to survive to hospital discharge and outpatient follow-up.
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Affiliation(s)
- David Snipelisky
- a Department of Medicine , Division of Cardiovascular Diseases, Mayo Clinic , Rochester , MN , USA
| | - Jordan Ray
- b Department of Medicine , Division of Internal Medicine, Mayo Clinic , Jacksonville , FL , USA
| | - Gautam Matcha
- b Department of Medicine , Division of Internal Medicine, Mayo Clinic , Jacksonville , FL , USA
| | - Archana Roy
- c Department of Medicine , Division of Hospital Medicine, Mayo Clinic , Jacksonville , FL , USA
| | - Brooke Clark
- c Department of Medicine , Division of Hospital Medicine, Mayo Clinic , Jacksonville , FL , USA
| | - Adrian Dumitrascu
- c Department of Medicine , Division of Hospital Medicine, Mayo Clinic , Jacksonville , FL , USA
| | - Veronica Bosworth
- c Department of Medicine , Division of Hospital Medicine, Mayo Clinic , Jacksonville , FL , USA
| | - Anastasia Whitman
- c Department of Medicine , Division of Hospital Medicine, Mayo Clinic , Jacksonville , FL , USA
| | - Patricia Lewis
- c Department of Medicine , Division of Hospital Medicine, Mayo Clinic , Jacksonville , FL , USA
| | - Tyler Vadeboncoeur
- d Department of Emergency Medicine , Mayo Clinic , Jacksonville , FL , USA
| | - Fred Kusumoto
- e Department of Medicine , Division of Cardiovascular Diseases, Mayo Clinic , Jacksonville , FL , USA
| | - M Caroline Burton
- c Department of Medicine , Division of Hospital Medicine, Mayo Clinic , Jacksonville , FL , USA
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