Long-term survival following in-hospital cardiac arrest: A matched cohort study

Effects of Prolonged Serum Calcium Suppression during Extracorporeal Cardiopulmonary Resuscitation in Pigs

Controlled reperfusion by monitoring the blood pressure, blood flow, and specific blood parameters during extracorporeal reperfusion after cardiac arrest has the potential to limit ischemia-reperfusion injury. The intracellular calcium overload as part of the ischemia-reperfusion injury provides the possibility for the injury to be counteracted by the early suppression of serum calcium with the aim of improving survival and the neurological outcome. We investigated the effects of prolonged serum calcium suppression via sodium citrate during extracorporeal resuscitation using the CARL protocol (CARL-controlled automated reperfusion of the whole body) compared to a single-dose approach in a porcine model after prolonged cardiac arrest. A control group (N = 10) was resuscitated after a 20 min cardiac arrest, initially lowering the intravascular calcium with the help of a single dose of sodium citrate as part of the priming solution. Animals in the intervention group (N = 13) received additional sodium citrate for the first 15 min of reperfusion. In the control group, 9/10 (90.0%) animals survived until day 7 and 7/13 (53.8%) survived in the intervention group (p = 0.09). A favorable neurological outcome on day 7 after the cardiac arrest was observed in all the surviving animals using a species-specific neurological deficit score. The coronary perfusion pressure was significantly lower with a tendency towards more cardiac arrhythmias in the intervention group. In conclusion, a prolonged reduction in serum calcium levels over the first 15 min of reperfusion after prolonged cardiac arrest tended to be unfavorable regarding survival and hemodynamic variables compared to a single-dose approach in this animal model.

Duration of Resuscitation and Long-Term Outcome After In-Hospital Cardiac Arrest: A Nationwide Observational Study

BACKGROUND

Prior studies have investigated the association between duration of resuscitation and short-term outcomes following in-hospital cardiac arrest (IHCA). However, it remains unknown whether there is an association between duration of resuscitation and long-term survival and functional outcomes.

METHOD

We linked data from the Danish in-hospital cardiac arrest registry with nationwide registries and identified 8,727 patients between 2013 and 2019. Patients were stratified into four groups (A-D) according to quartiles of duration of resuscitation. Standardized average probability of outcomes was estimated using logistic regression.

RESULTS

Of 8,727 patients, 53.1% (n=4,604) achieved return of spontaneous circulation. Median age was 74 (1^st-3^rd quartile [Q1-Q3] 65-81 years) and 63.1% were men. Among all IHCA patients the standardized 30-day survival was 62.0% (95% CI 59.8%-64.2%) for group A (< 5 minutes), 32.7% (30.8%-34.6%) for group B (5-11 minutes), 14.4% (12.9%-15.9%) for group C (12-20 minutes) and 8.1% (7.0%-9.1%) for group D (21 minutes or more). Similarly, 1-year survival was also highest for group A (50.4%; 48.2%-52.6%) gradually decreasing to 6.6% (5.6%-7.6%) in group D. Among 30-day survivors, survival without anoxic brain damage or nursing home admission within one-year post-arrest was highest for group A (80.4%; 78.2%-82.6%), decreasing to 73.3% (70.0%-76.6%) in group B, 67.2% (61.7%-72.6%) in group C and 73.3% (66.9%-79.7%) in group D.

CONCLUSION

Shorter duration of resuscitation attempt during an IHCA is associated with higher 30-day and 1-year survival. Furthermore, we found that the majority of 30-day survivors were still alive 1-year post-arrest without anoxic brain damage or nursing home admission despite prolonged resuscitation.

Effect of Vasopressin and Methylprednisolone vs. Placebo on Long-Term Outcomes in Patients with In-Hospital Cardiac Arrest A Randomized Clinical Trial

OBJECTIVE

The primary results from the Vasopressin and Methylprednisolone for In-Hospital Cardiac Arrest (VAM-IHCA) trial have previously been reported. The objective of the current manuscript is to report long-term outcomes.

METHODS

The VAM-IHCA trial was a multicenter, randomized, double-blind, placebo-controlled trial conducted at ten hospitals in Denmark. Adult patients (age ≥ 18 years) were eligible for the trial if they had an in-hospital cardiac arrest and received at least one dose of epinephrine during resuscitation. The trial drugs consisted of 40 mg methylprednisolone (Solu-Medrol®, Pfizer) and 20 IU of vasopressin (Empressin®, Amomed Pharma GmbH) given as soon as possible after the first dose of epinephrine. This manuscript report outcomes at 6 months and 1 year including survival, survival with favorable neurological outcome, and health-related quality of life.

RESULTS

501 patients were included in the analysis. At 1 year, 15 patients (6.3%) in the intervention group and 22 patients (8.3%) in the placebo group were alive corresponding to a risk ratio of 0.76 (95% CI, 0.41-1.41). A favorable neurologic outcome at 1 year, based on the Cerebral Performance Category score, was observed in 14 patients (5.9%) in the intervention group and 20 patients (7.6%) in the placebo group (risk ratio, 0.78 [95% CI, 0.41-1.49]. No differences existed between groups for favorable neurological outcome and health-related quality of life at either 6 months or 1 year.

CONCLUSIONS

Administration of vasopressin and methylprednisolone, compared with placebo, in patients with in-hospital cardiac arrest did not improve long-term outcomes in this trial.

Serum Lactate for Predicting Cardiac Arrest in the Emergency Department

Objectives: Early recognition and prevention of in-hospital cardiac arrest (IHCA) play an increasingly important role in the Chain of Survival. However, clinical tools for predicting IHCA in the emergency department (ED) are scanty. We sought to evaluate the role of serum lactate in predicting ED-based IHCA. Methods: Data were retrieved from 733,398 ED visits over a 7-year period in a tertiary medical centre. We selected one ED visit per person and excluded out-of-hospital cardiac arrest, children, or those without lactate measurements. Patient demographics, computerised triage information, and serum lactate levels were extracted. The initial serum lactate levels were grouped into normal (≤2 mmol/L), moderately elevated (2 < lactate ≤ 4), and highly elevated (>4 mmol/L) categories. The primary outcome was ED-based IHCA. Results: A total of 17,392 adult patients were included. Of them, 342 (2%) developed IHCA. About 50% of the lactate levels were normal, 30% were moderately elevated, and 20% were highly elevated. In multivariable analysis, the group with highly elevated lactate had an 18-fold increased risk of IHCA (adjusted odds ratio [OR], 18.0; 95% confidence interval [CI], 11.5-28.2), compared with the normal lactate group. In subgroup analysis, the poor lactate-clearance group (<2.5%/h) was associated with a 7.5-fold higher risk of IHCA (adjusted OR, 7.5; 95%CI, 3.7-15.1) compared with the normal clearance group. Conclusions: Elevated lactate levels and poor lactate clearance were strongly associated with a higher risk of ED-based IHCA. Clinicians may consider a more liberal sampling of lactate in patients at higher risk of IHCA with follow-up of abnormal levels.

Sudden cardiac arrest during the immediate revascularization period in patients with non-ST elevation myocardial infarction: A case series

INTRODUCTION

The timing of sudden cardiac arrest (SCA) after myocardial infarction (MI) has been a subject of research because of the impact on preventive strategies. Currently, there is limited data on the risk of SCA in the immediate post revascularization period (≤48 h) in non-ST segment elevation myocardial infarction (NSTEMI).

METHODS

We retrospectively reviewed the electronic medical record system and identified patients who underwent revascularization for NSTEMI at Grady Memorial Hospital, Atlanta, Georgia between January 1st, 2014-December 31st, 2019. We selected patients who had SCA within 48 h of revascularization and evaluated their socio-demographic and inpatient characteristics and outcomes.

RESULTS

Sixteen (16) cases of SCA in the immediate post revascularization period (within 48 h) were identified and analyzed which corresponds to an incidence rate of 1.8% (n = 16/869). The mean age (SD) was 69 years (14.6) and 75% were males. On angiography, more than 80% of the patients had hemodynamically significant lesions in the left anterior descending arteries and its territories and 50% had multivessel disease. All 16 patients had at least one coronary artery with hemodynamically significant lesion and successfully underwent revascularization. Three-quarter of the patients had a shockable rhythm. The etiology of SCA was in-stent thrombosis in 25% of the patients, cardiogenic shock in 19%, acute respiratory failure in 13% and unknown in 44% of the cases. The 30-day mortality rate was 38%.

CONCLUSION

The rate of SCA is high in the first 48 h after MI even with revascularization. Risk stratification for SCA during this critical period may improve outcomes.

The Effect of Group Random Quality Control on the First Aid Ability of Ward Doctors and Nurses with Respect to the Resuscitation of Patients with In-Hospital Cardiac Arrest

Objective

This study was designed to verify the effect of group random quality control on the first aid ability of ward doctors and nurses with regard to the resuscitation of patients with in-hospital cardiac arrest (IHCA).

Methods

The first aid quality control team of our hospital was established in December 2018, when the number, qualifications, organizational structure, quality control methods, and responsibilities of the team and team members were determined. The baseline data and assessment results of examinees, the rates of return of spontaneous circulation (ROSC), and the discharge survival rate of IHCA patients in 2019 and 2020 were compared.

Results

There were no significant differences in the baseline data of examinees at each stage (p > 0.05). As time went on, the results of the four practical examinations were significantly improved (pairwise comparison, p < 0.05). The number of problems in examinations was significantly higher for physicians than for nurses. After guidance in department relearning, the incidence of related problems was significantly reduced, but the mastery of the frequency and depth of extracorporeal cardiac compression were not always up to standard. The proportion of critically ill patients and the incidence of IHCA in the hospital in 2020 was higher than in 2019 (p < 0.05), and the ROSC rate was also significantly higher than it was in 2019 (p < 0.05), but the difference in the survival rate at discharge was not statistically significant (p > 0.05).

Conclusion

Group random quality control meets the needs of IHCA emergencies, and it can improve the first aid skills and organizational coordination of doctors and nurses on the ward through continuous discovery and problem solving so that the ultimate goal of improving the success rate of resuscitation can be achieved.

Albumin Level at Admission to the Intensive Care Unit Is Associated With Prognosis in Cardiac Arrest Patients

Aim Cardiac arrest is a global health concern with consistently high mortality. It is also a common condition seen in the intensive care unit (ICU). We aimed to investigate the importance of albumin level on admission, which is a widely available and simple test, to predict in-hospital mortality in cardiac arrest patients. Methods The retrospective study collected data from the eICU Collaborative Research Database. It contains data from 171 hospitals, 276 ICU wards, and 4,529 patients who were treated for cardiac arrest from 2014 to 2015. We analyzed the patients' laboratory results and vital signs during the first 24 hours after admission to the ICU. The primary outcome was in-hospital mortality, and the secondary outcome was the length of ICU stay among survivors. Results In total, 2,414 patients were eligible. After adjusting for severity scores, including the Acute Physiology and Chronic Health Evaluation (APACHE) IV and Sequential Organ Failure Assessment (SOFA) scores, serum albumin was found to be a protective factor for survival (odds ratio of mortality: 0635, 95% confidence interval: 0.458-0.734, P<0.001). Among patients who survived until discharge, those with hypoalbuminemia had a long duration of stay in the ICU (P=0.005). Conclusion The higher albumin level at admission to the ICU was associated with lower mortality in patients with cardiac arrest.

Long-term outcomes after in-hospital cardiac arrest: 30-day survival and 1-year follow-up of mortality, anoxic brain damage, nursing home admission and in-home care

AIMS

Long-term functional outcomes after in-hospital cardiac arrest (IHCA) are scarcely studied. However, survivors are at risk of neurological impairment from anoxic brain damage which could affect quality of life and lead to need of care at home or in a nursing home.

METHODS

We linked data on ICHAs in Denmark with nationwide registries to report 30-day survival as well as factors associated with survival. Furthermore, among 30-day survivors we reported the one-year cumulative risk of anoxic brain damage or nursing home admission with mortality as the competing risk.

RESULTS

In total, 517 patients (27.3%) survived to day 30 out of 1892 eligible patients; 338 (65.9%) were men and median age was 68 (interquartile range 58-76). Lower age, witnessed arrest by health care personnel, monitored arrest and presumed cardiac cause of arrest were associated with 30-day survival. Among 454 30-day survivors without prior anoxic brain damage or nursing home admission, the risk of anoxic brain damage or nursing home admission within the first-year post-arrest was 4.6% (n = 21; 95% CI 2.7-6.6%) with a competing risk of death of 15.6% (n = 71; 95% CI 12.3-19.0%), leaving 79.7% (n = 362) alive without anoxic brain damage or nursing home admission. When adding the risk of need of in-home care among 343 30-day survivors without prior home care needs, 68.8% (n = 236) were alive without any of the composite events one-year post-arrest.

CONCLUSION

The majority of 30-day survivors of IHCA are alive at one-year follow-up without anoxic brain damage, nursing home admission or need of in-home care.

Early termination of resuscitation in in-hospital cardiac arrest and impact to the outcome calculations

BACKGROUND

Some in-hospital resuscitation attempts are assessed futile and terminated early on. We hypothesized that if these cases are reported separately, the true outcome of in-hospital cardiac arrest is better reflected.

METHODS

We conducted a 3-year prospective observational Utstein-style study in Tampere, Finland. All adult in-hospital cardiac arrests outside critical care areas attended by hospital's rapid response team were included. Resuscitation attempts that were terminated within 10 minutes were considered early terminations.

RESULTS

The cohort consisted of 199 in-hospital cardiac arrest patients. Twenty-seven (14%) resuscitation attempts were terminated early due to the presumed futility of the attempt with median resuscitation duration of 5 (4, 7) minutes. These cases and the 172 patients with full resuscitation attempt were of comparable age, sex and comorbidity. Early terminated resuscitation attempts were more often unwitnessed (63% vs. 10%, P < .001) with initial non-shockable rhythm (100% vs. 80%, P = .006) when compared with full attempts. The most frequently reported reasons for termination decisions were non-witnessed arrest presenting asystole as initial rhythm and severe acute illness. The hospital survival with good neurological outcome and 1-year survival were 30% and 25% for the whole cohort, and 34% and 29% when early terminated resuscitation attempts were excluded.

CONCLUSION

One-seventh of resuscitation attempts were terminated early on due to presumed futility of the attempt. Short- and long-term outcomes were 5% and 4% better when early terminated attempts were excluded from the outcome analyses. We believe that in-hospital cardiac arrest outcome is not as poor as repeatedly presented in the literature.

Association of hemoglobin with incidence of in-hospital cardiac arrest in patients with acute coronary syndrome complicated by cardiogenic shock

Objective

This study was performed to investigate the association of the admission hemoglobin level with the incidence of in-hospital cardiac arrest (IHCA) in patients with acute coronary syndrome (ACS) complicated by cardiogenic shock (CS).

Methods

In this retrospective study, we reviewed the medical records of consecutive patients with ACS complicated by CS admitted to the coronary care unit from January 2014 to October 2017. Logistic regression models were carried out to evaluate the association between hemoglobin and the incidence of IHCA. Interaction and subgroup analyses were also performed.

Results

In total, 211 patients were included in the study, and 61 (28.9%) patients developed IHCA. In the multivariable analysis, hemoglobin was a strong independent predictor of IHCA (odds ratio, 0.971; 95% confidence interval, 0.954–0.989). In the fully adjusted model, patients in the higher hemoglobin tertile were less likely to develop IHCA than patients in the lowest hemoglobin tertile (odds ratio, 0.194; 95% confidence interval, 0.071–0.530). The relationship remained stable in most subgroups except patients aged ≥70 years.

Conclusion

In patients with ACS complicated by CS, the incidence of IHCA is related to the hemoglobin concentration, and a high hemoglobin concentration is a protective factor against the development of IHCA.

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

BACKGROUND

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

METHODS

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

MEASUREMENTS AND MAIN RESULTS

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

CONCLUSIONS

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

Growth differentiation factor-15 predicts poor survival after cardiac arrest

BACKGROUND

Early prognostication in post-cardiac arrest (CA) patients remains challenging and biomarkers have evolved as helpful tools in risk assessment. The stress-response cytokine growth differentiation factor-15 (GDF-15) is dramatically up-regulated during various kinds of tissue injury and predicts outcome in many pathological conditions. We aimed to assess the predictive value of circulating GDF-15 in post-CA patients.

METHODS

This prospective observational study included 128 consecutive patients (median age 60.3 years, 75.8% male) with return of spontaneous circulation after in- or out-of-hospital CA who were treated at a tertiary university hospital. GDF-15 serum levels were determined at admission.

RESULTS

A total of 52 patients (40.6%) died during the 6-month follow-up. Median GDF-15 levels were significantly lower in survivors (1601 ng/L (interquartile range: 1114-2983 ng/L) than in non-survivors (3172 ng/L (1927-8340 ng/L); p < 0.001). GDF-15 levels were also significantly lower in patients with favourable neurological 6-month outcome (cerebral performance category (CPC) 1-2) than in those with poor neurological outcome (CPC 3-5; p < 0.001). GDF-15 significantly predicted 6-month mortality in univariate Cox regression analysis (hazard ratio (HR) per 1-standard deviation increase 1.76 [95% confidence interval (CI) 1.35-2.31; p < 0.001] and remained significant after multivariable adjustment (HR 1.57 [95% CI 1.19-2.07; p = 0.001]). Subgroup analysis revealed that the association between GDF-15 and 6-month outcome was present both in patients with in- and out-of-hospital CA.

CONCLUSIONS

GDF-15 predicts poor survival and neurological outcome in post-CA patients. GDF-15 may reflect the extent of hypoxic injury to the brain and other organs and might help to improve early risk stratification after CA.

Incidence, predictors, causes, and costs of 30-day readmission after in-hospital cardiopulmonary resuscitation in the United States

BACKGROUND

Readmissions after in-hospital cardiopulmonary resuscitation (ICPR) are common and contribute to increased health care utilization and costs. This study aimed to estimate the burden and patterns of 30-day readmission after ICPR from the US Nationwide Readmission Database (NRD).

METHODS

Using International Classification of Diseases-Ninth Revision-Clinical Modification codes, patients who underwent ICPR in the 2014 NRD were included. The incidence, predictors, causes, and costs of 30-day readmission were analyzed with discharge weights to obtain national estimates.

RESULTS

Among the 27,278 index admissions that survived to hospital discharge after ICPR, 5439 (20.0%) were readmitted within 30 days. Length of stay (LOS) ≥11 days during index hospitalization, chronic pulmonary disease, congestive heart failure, renal failure, discharge from the teaching metropolitan hospital, Medicare insurance, depression, and diabetes were independent predictors of 30-day readmission. The most common causes of readmission among the 5439 cases were sepsis (13.7%), heart failure (10.9%), and respiratory failure (6.4%). The estimated median costs of readmission were $10,498 (interquartile range, $5797-21,364), which accounted for 25.7% of the total episodes of care (index + readmission). The median LOS of readmission was 5 (3-9) days.

CONCLUSIONS

Thirty-day readmissions after ICPR were associated with patient comorbidities and significant cost burden. Recognition of these predictors and individualization of care would allow for the provision of appropriate interventions, and reduce readmissions and healthcare costs.

Short "Infraslow" Activity (SISA) With Burst Suppression in Acute Anoxic Encephalopathy: A Rare, Specific Ominous Sign With Acute Posthypoxic Myoclonus or Acute Symptomatic Seizures

OBJECTIVE

Slow wave with frequency <0.5 Hz are recorded in various situations such as normal sleep, epileptic seizures. However, its clinical significance has not been fully clarified. Although infra-slow activity was recently defined as activity between 0.01 and 0.1 Hz, we focus on the activity recorded with time constant of 2 seconds for practical usage. We defined short "infraslow" activity (SISA) less than 0.5 Hz recorded with time constant of 2 seconds and investigated the occurrence and clinical significance of SISA in acute anoxic encephalopathy.

METHODS

This study evaluated the findings of electroencephalography in consecutive 98 comatose patients with acute anoxic encephalopathy after cardiac arrest. We first classified electroencephalography findings conventionally, then investigated SISA by time constant of 2 second and a high-cut filter of 120 Hz, to clarify the relationship between SISA and clinical profiles, especially of clinical outcomes and occurrence of acute posthypoxic myoclonus or acute symptomatic seizures.

RESULTS

Short infra-slow activity was found in six patients (6.2%), superimposed on the burst phase of the burst-suppression pattern. All six patients showed acute posthypoxic myoclonus or acute symptomatic seizures (generalized tonic-clonic seizures) and its prognosis was poor. This 100% occurrence of acute posthypoxic myoclonus or acute symptomatic seizures was significantly higher than that in patients without SISA (39.1%; P < 0.05).

CONCLUSIONS

Short infra-slow activity in acute anoxic encephalopathy could be associated with acute posthypoxic myoclonus and acute symptomatic seizures. Short infra-slow activity could be a practically feasible biomarker for myoclonus or seizures and poor prognosis in acute anoxic encephalopathy, if it occurs with burst suppression.

Intravenous Transplants of Human Adipose-Derived Stem Cell Protect the Rat Brain From Ischemia-Induced Damage

BACKGROUND

Survival following cardiac arrest (CA) and subsequent cardiopulmonary resuscitation (CPR), to a great extent, depends on brain damage. Adipose-derived stem cells (ADSCs), as a source of paracrine growth factors and the capacity of neural differentiation may reduce this brain damage.

OBJECTIVE

The purpose of this study is to evaluate the protection of ADSCs to brain damage following CPR.

METHODS

Rats were divided into 3 groups, sham, CA, and ADSCs group. Rats in sham group went through sham surgery. Rats in CA group went through CA, CPR, and injection PBS (phosphate buffer saline). Rats in ADSCs group went through CA, CPR, and intravenous injection of ADSCs. Rats in sham group were sacrificed immediately after operation. At 24, 72, and 168 hours after return of spontaneous circulation operation, rats in CA and ADSCs group were randomly selected and sacrificed. Brain damage was evaluated by using Neurological Deficit Scale (NDS) score, hippocampal pathology, serum level of S100β, and apoptosis ratio of hippocampal neurons. Protein of brain derived neurotrophic factor (BDNF) and IL-6 (interleukin-6) in the hippocampus were detected.

RESULTS

Compared with sham group, CA and ADSCs group showed a decrease in NDS score, an increased apoptosis ratio of hippocampal nerve cells, increased serum level of S100-β, and a significant increase in neuroprotective IL-6 and BDNF. In comparison to CA group, ADSCs group had a mild degree of brain damage and higher expression of IL-6 and BDNF.

CONCLUSIONS

In the acute stage of cerebral injury following CA, ADSCs might improve the prognosis of brain damage by stimulating the expression of neuroprotective IL-6 and BDNF.

Realistic Evaluation of a Rapid Response System: Context, Mechanisms, and Outcomes

The purpose of this study was to describe and explore differences between rapid response system events in a Midwestern community hospital through context, mechanism, and outcome factors. The design was a retrospective review of 1,939 adult inpatient events that occurred on medical (62.8%) and surgical units (37.2%) over 92 months. The immediate outcomes of the events were stabilization (59.0%), transfer to a higher level of care (39%), and cardiopulmonary arrest (2%). Nurses activated 94% of all rapid response events; respiratory (38.8%) and cardiac (29.2%) symptoms were the most common triggers, and worry alone triggered 23% of all events. Medical and surgical events were significantly different with regard to antecedents to unit arrival, most common triggers, immediate clinical outcomes, and occurrence during resource-limited times. Understanding rapid response events and differences between medical and surgical units is important to improve early identification of deterioration and thus intervention for vulnerable patients.

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.

Comparison of Hospital-Wide Code Rates and Mortality Before and After the Implementation of a Rapid Response Team

Objective

To compare hospital-wide code rates and mortality before and after the implementation of a rapid response team (RRT).

Study design

A prospective cohort design with historical controls.

Place of study

This study was conducted at Shifa International Hospital, Islamabad, from January 21, 2016, to January 20, 2017.

Materials and methods

The triggers for the rapid response team (RRT) were displayed on each floor. The in-house staff was trained on when and how to activate the rapid response team (RRT). Data were collected on a specified data collection form. Mortality and hospital-wide code blue rates were calculated and compared with those from one year before the implementation of the rapid response team (RRT) (i.e., from January 21, 2015, to January 20, 2016).

Results

The total number of admissions during the study period was 40,177. In total, 796 RRTs were activated with a rate of activation of 19.81 per 1000 admissions. The most common activator for RRTs was an altered level of consciousness (24.12%), followed by tachycardia (19.22%), and tachypnea (14.45%). The total number of admissions one year before the implementation of the RRT was 39,460. The total number of mortality events before the implementation of the RRT was 1470 (3.725%) and after the implementation of the RRT was 1529 (3.805%), which was not significantly different (P = .576). The total number of code blues before the implementation of the RRT was 146 (0.369%) and after the implementation of RRT was 148 (0.368%), which was not significantly different (P = .929).

Conclusion

In this large single-institution study, rapid response team implementation was not associated with significant reductions in either hospital-wide code blue or mortality.

NSE serum levels in extracorporeal life support patients-Relevance for neurological outcome?

BACKGROUND

Good neurological outcome is a major determinant after cardiac resuscitation. Extracorporeal life support may rapidly stabilize the patient, but cerebral ischemia remains a frequent complication relevant for further therapy. The aim of this study was to prove the value of NSE to indicate cerebral injury in patients with extracorporeal support after CPR.

METHODS

159 patients with CPR were included. NSE 48h peak levels and trends were tested for usability as predictive marker of brain injury, in-hospital mortality and long-term outcome.

RESULTS

Overall mortality in this cohort was 53.5%. Incidence of relevant brain injury was 34.6% with severe diffuse hypoxia in 23.2%. NSE peaks were comparable in patients with and without focal ischemia, but were increased in patients with severe diffuse hypoxic injury (p<0.0001). ROC analysis (area under the curve) of peak values indicating brain injury and in-hospital mortality was 0.73 (95% confidence interval [CI] 0.65-0.82) and 0.74 (95% CI 0.66-0.81), respectively. NSE increased in 56.6% of patients with a sensitivity of 0.82 (95% CI 0.69-0.92) and a specificity of 0.43 (CI 0.0.31-0.55) indicating cerebral injury. Sensitivity and specificity of NSE peak levels >100μg/L was 0.6 (CI 0.49-0.72) and 0.74 (CI 0.63-0.84). In-hospital mortality of patients with NSE >100μg/L was 71.7%. 46.2% of discharged patients are in good neurological status (cerebral performance category scale [CPC] 1-2). Patients with NSE <100μg/L showed an in-hospital mortality of 36.4%, and good neurological status in 67.9%.

CONCLUSION

NSE monitoring reliably indicates relevant cerebral injury in patients on extracorporeal support after cardiopulmonary resuscitation.