Survival and neurological outcome in the elderly after in-hospital cardiac arrest

Risk factors for neurological disability outcomes in patients under extracorporeal membrane oxygenation following cardiac arrest: An observational study

OBJECTIVES

This study aimed to identify factors associated with neurological and disability outcomes in patients who underwent ECMO following cardiac arrest.

METHODS

This retrospective, single-center, observational study included adult patients who received ECMO treatment for in-hospital cardiac arrest (IHCA) or out-of-hospital cardiac arrest (OHCA) between February 2016 and March 2020. Factors associated with neurological and disability outcomes in these patients who underwent ECMO were assessed.

SETTING

Hamad General Hospital, Qatar.

MAIN OUTCOME MEASURES

Neurological disability outcomes were assessed using the Modified Rankin Scale (mRS) and the Cerebral Performance Category (CPC) scale.

RESULTS

Among the 48 patients included, 37 (77 %) experienced OHCA, and 11 (23 %) had IHCA. The 28-day survival rate was 14 (29.2 %). Of the survivors, 9 (64.3 %) achieved a good neurological outcome, while 5 (35.7 %) experienced poor neurological outcomes. Regarding disability, 5 (35.7 %) of survivors had no disability, while 9 (64.3 %) had some form of disability. The results showed significantly shorter median time intervals in minutes, including collapse to cardiopulmonary resuscitation (CPR) (3 vs. 6, P = 0.001), CPR duration (12 vs. 35, P = 0.001), CPR to extracorporeal cardiopulmonary resuscitation (ECPR) (20 vs. 40, P = 0.001), and collapse-to-ECPR (23 vs. 45, P = 0.001), in the good outcome group compared to the poor outcome group.

CONCLUSION

This study emphasizes the importance of minimizing the time between collapse and CPR/ECMO initiation to improve neurological outcomes and reduce disability in cardiac arrest patients. However, no significant associations were found between outcomes and other demographic or clinical variables in this study. Further research with a larger sample size is needed to validate these findings.

IMPLICATIONS FOR CLINICAL PRACTICE

The study underscores the significance of reducing the time between collapse and the initiation of CPR and ECMO. Shorter time intervals were associated with improved neurological outcomes and reduced disability in cardiac arrest patients.

Neurological function before and after an in-hospital cardiac arrest - A nationwide registry-based cohort study

BACKGROUND

According to the Utstein Registry Template for in-hospital cardiac arrest (IHCA), a good neurological outcome is defined as either Cerebral Performance Category (CPC) 1-2 at discharge from hospital or unchanged CPC compared to baseline. However, the latter alternative has rarely been described in IHCA. This study aimed to examine CPC at admission to hospital, the occurrence of post-arrest neurological deterioration, and the factors associated with such deterioration.

METHODS

We studied adult IHCA survivors registered in the Swedish Registry of Cardiopulmonary Resuscitation between 2007 and 2022. The CPC was assessed based on information from admission and discharge from hospital. The data were analyzed using descriptive statistics and significance tests.

RESULTS

One in ten IHCA had a CPC score > 1 at admission to hospital. Out of 7,677 IHCA who survived until hospital discharge and had full CPC data, 6,774 (88%) had preserved CPC, 150 (2%) had improved CPC, and 753 (10%) had deteriorated CPC. Among the factors significantly associated with deteriorated neurological function are IHCA in a general ward or intensive care unit, non-shockable rhythm, no ECG surveillance, and a higher proportion of intra-arrest and post-resuscitation treatments (all p-values < 0,05).

CONCLUSION

Most patients had preserved neurological function compared to admission. Factors associated with deteriorated neurological function are mainly concordant with established risk factors for adverse outcomes and are primarily intra-arrest and post-resuscitation, making deterioration hard to predict. Further, every tenth survivor was admitted with CPC more than 1, stressing the use of unchanged CPC as an outcome in IHCA.

Individual- and Community-Level Predictors of Hospital-at-Home Outcomes

Advanced Care at Home is a Mayo Clinic hospital-at-home (HaH) program that provides hospital-level care for patients. The study examines patient- and community-level factors that influence health outcomes. The authors performed a retrospective study using patient data from July 2020 to December 2022. The study includes 3 Mayo Clinic centers and community-level data from the Agency for Healthcare Research and Quality. The authors conducted binary logistic regression analyses to examine the relationship among the independent variables (patient- and community-level characteristics) and dependent variables (30-day readmission, mortality, and escalation of care back to the brick-and-mortar hospital). The study examined 1433 patients; 53% were men, 90.58% were White, and 68.2% were married. The mortality rate was 2.8%, 30-day readmission was 11.4%, and escalation back to brick-and-mortar hospitals was 8.7%. At the patient level, older age and male gender were significant predictors of 30-day mortality (P-value <0.05), older age was a significant predictor of 30-day readmission (P-value <0.05), and severity of illness was a significant predictor for readmission, mortality, and escalation back to the brick-and-mortar hospital (P-value <0.01). Patients with COVID-19 were less likely to experience readmission, mortality, or escalations (P-value <0.05). At the community level, the Gini Index and internet access were significant predictors of mortality (P-value <0.05). Race and ethnicity did not significantly predict adverse outcomes (P-value >0.05). This study showed promise in equitable treatment of diverse patient populations. The authors discuss and address health equity issues to approximate the vision of inclusive HaH delivery.

What factors are effective on the CPR duration of patients under extracorporeal cardiopulmonary resuscitation: a single-center retrospective study

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (ECPR) is an alternative method for patients with reversible causes of cardiac arrest (CA) after conventional cardiopulmonary resuscitation (CCPR). However, cardiopulmonary resuscitation (CPR) duration during ECPR can vary due to multiple factors. Healthcare providers need to understand these factors to optimize the resuscitation process and improve outcomes. The aim of this study was to examine the different variables impacting the duration of CPR in patients undergoing ECPR.

METHODS

This retrospective, single-center, observational study was conducted on adult patients who underwent ECPR due to in-hospital CA (IHCA) or out-of-hospital CA (OHCA) at Hamad General Hospital (HGH), the tertiary governmental hospital of Qatar, between February 2016 and March 2020. Univariate and multivariate binary logistic regression analyses were performed to identify the prognostic factors associated with CPR duration, including demographic and clinical variables, as well as laboratory tests.

RESULTS

The mean ± standard division age of the 48 participants who underwent ECPR was 41.50 ± 13.15 years, and 75% being male. OHCA and IHCA were reported in 77.1% and 22.9% of the cases, respectively. The multivariate analysis revealed that several factors were significantly associated with an increased CPR duration: higher age (OR: 1.981, 95%CI: 1.021-3.364, P = 0.025), SOFA score (OR: 3.389, 95%CI: 1.289-4.911, P = 0.013), presence of comorbidities (OR: 3.715, 95%CI: 1.907-5.219, P = 0.026), OHCA (OR: 3.715, 95%CI: 1.907-5.219, P = 0.026), and prolonged collapse-to-CPR time (OR: 1.446, 95%CI:1.092-3.014, P = 0.001). Additionally, the study found that the initial shockable rhythm was inversely associated with the duration of CPR (OR: 0.271, 95%CI: 0.161-0.922, P = 0.045). However, no significant associations were found between laboratory tests and CPR duration.

CONCLUSION

These findings suggest that age, SOFA score, comorbidities, OHCA, collapse-to-CPR time, and initial shockable rhythm are important factors influencing the duration of CPR in patients undergoing ECPR. Understanding these factors can help healthcare providers better predict and manage CPR duration, potentially improving patient outcomes. Further research is warranted to validate these findings and explore additional factors that may impact CPR duration in this population.

Perceptions on Specialist Palliative Care Involvement During and After Cardiopulmonary Resuscitation: A Qualitative Study

IMPORTANCE

Cardiopulmonary resuscitation (CPR) is an exceptional physical situation and may lead to significant psychological, spiritual, and social distress in patients and their next of kin. Furthermore, clinicians might experience distress related to a CPR event. Specialist palliative care (sPC) integration could address these aspects but is not part of routine care.

OBJECTIVES

This study aimed to explore perspectives on sPC integration during and after CPR. A needs assessment for sPC, possible triggers indicating need, and implementation strategies were addressed.

DESIGN SETTING AND PARTICIPANTS

A multiprofessional qualitative semistructured focus group study was conducted in a German urban academic teaching hospital. Participants were clinicians (nursing staff, residents, and consultants) working in the emergency department and ICUs (internal medicine and surgical).

ANALYSIS

The focus groups were recorded and subsequently transcribed. Data material was analyzed using the content-structuring content analysis according to Kuckartz.

RESULTS

Seven focus groups with 18 participants in total were conducted online from July to November 2022. Six main categories (two to five subcategories) were identified: understanding (of palliative care and death), general CPR conditions (e.g., team, debriefing, and strains), prognosis (e.g., preexisting situation, use of extracorporeal support), next of kin (e.g., communication, presence during CPR), treatment plan (patient will and decision-making), and implementation of sPC (e.g., timing, trigger factors).

CONCLUSIONS

Perceptions about the need for sPC to support during and after CPR depend on roles, areas of practice, and individual understanding of sPC. Although some participants perceive CPR itself as a trigger for sPC, others define, for example, pre-CPR-existing multimorbidity or complex family dynamics as possible triggers. Suggestions for implementation are multifaceted, especially communication by sPC is emphasized. Specific challenges of extracorporeal CPR need to be explored further. Overall, the focus groups show that the topic is considered relevant, and studies on outcomes are warranted.

Mortality and healthcare resource utilisation after cardiac arrest in the United States - A 10-year nationwide analysis prior to the COVID-19 pandemic

AIM

Understanding the public health burden of cardiac arrest (CA) is important to inform healthcare policies, particularly during healthcare crises such as the COVID-19 pandemic. This study aimed to analyse outcomes of in-hospital mortality and healthcare resource utilisation in adult patients with CA in the United States over the last decade prior to the COVID-19 pandemic.

METHODS

The United States (US) National Inpatient Sample was utilised to identify hospitalised adult patients with CA between 2010 and 2019. Logistic and Poisson regression models were used to analyse outcomes by adjusting for 47 confounders.

RESULTS

248,754 adult patients with CA (without "Do Not Resuscitate"-orders) were included in this study, out of which 57.5% were male. In-hospital mortality was high with 51.2% but improved significantly from 58.3% in 2010 to 46.4% in 2019 (P < 0.001). Particularly, elderly patients, non-white patients and patients requiring complex therapy had a higher mortality rate. Although the average hospital LOS decreased by 11%, hospital expenses have increased by 13% between 2010 and 2019 (each P < 0.001), presumably due to more frequent use of mechanical circulatory support (MCS, e.g. ECMO from 2.6% to 8.7% or Impella® micro-axial flow pump from 1.8% to 14.2%). Strong disparities existed among patient age groups and ethnicities across the US. Of note, the number of young adults with CA and opioid-induced CA has almost doubled within the study period.

CONCLUSION

Over the last ten years prior to the COVID-19 pandemic, CA-related survival has incrementally improved with shorter hospitalisations and increased medical expenses, while strong disparities existed among different age groups and ethnicities. National standards for CA surveillance should be considered to identify trends and differences in CA treatment to allow for standardised medical care.

Investigation of mortality rates and the factors affecting survival in out-of-hospital cardiac arrest patients

BACKGROUND

It is known that even if spontaneous circulation returns after cardiopulmonary resuscitation(CPR) in geriatric out-of-hospital cardiac arrests(OHCA), the overall one-year survival rate of these patients is very low. In our study, we aimed to investigate the factors affecting survival in OHCA cases.

METHODS

OHCA patients over 18 years of age were examined in two different groups as 18-64 years old and over 65 years old. Demographic data, comorbidities, cardiac arrest rhythms and minutes, and the number of days they were hospitalized in the intensive care unit were recorded.

RESULTS

The mean age was 65.9 ± 15.8 years and 39.9% (n = 110) of the patients were female. The number of intensive care unit stays was significantly higher in the over-65 age group (p = 0.011). The mortality rate and one-year survival rate were significantly lower in the over-65 age group (p < 0.001). Median CPR time was 21 min (IQR:14-32) in the entire patient population. The duration of CPR was 22 min (IQR:14-35) in patients with in-hospital mortality, and 15 min (IQR:13-25) in patients discharged from the hospital. In this comparison, the difference is statistically significant (p = 0.008).

CONCLUSION

In our study, it was determined that especially over 65 years of age, coronary artery disease, and post-arrest CPR duration were determinant and predictive factors in in-hospital and long-term survival.

To withhold resuscitation - The Swedish system's rules and challenges

The aim of this article is to describe current Swedish legalisation, clinical practice and future perspectives on the medical ethical decision "Do-Not-Attempt-Cardio-Pulmonary-Resuscitation" (DNACPR) in relation to prevent futile resuscitation of in-hospital cardiac arrests. Sweden has about 2200 in-hospital cardiac arrests yearly, with an overall 30-day survival ratio of 35%. This population is highly selected, although the frequency of DNACPR orders for hospitalized patients is unknown, resuscitation is initiated in only 6-13% of patients dying in Swedish hospitals. According to Swedish law and although shared decision making is sought, the physician is the ultimate decision-maker and consultation with the patient, her relatives and another licenced health care practitioner is mandatory. According to studies, these consultations is documented in only about 10% of the decisions. Clinicians lack tools to assess risk of IHCA, tools to predict outcome and we are not good at guessing patients own will. Future directives for clinical practice need to address difficulties for physicians in making decisions as well as the timing of decisions. We conclude that the principles in Swedish law needs to be fulfilled by a more systematic approach to documentation and planning of meetings between patients, relatives and colleagues.

A model for predicting return of spontaneous circulation and neurological outcomes in adults after in-hospital cardiac arrest: development and evaluation

Introduction

In-hospital CA (IHCA) is associated with rates of high incidence, low return of spontaneous circulation (ROSC), low survival to discharge, and poor neurological outcomes. We aimed to construct and evaluate prediction models for non-return of spontaneous circulation (non-ROSC) and poor neurological outcomes 12 months after ROSC (PNO-12).

Methods

We retrospectively analyzed baseline and clinical data from patients experiencing cardiac arrest (CA) in a big academic hospital of Jilin University in China. Patients experiencing CA between September 1, 2019 and December 31, 2020 were categorized into the ROSC and non-ROSC groups. Patients maintaining ROSC >20 min were divided into the good and PNO-12 subgroups.

Results

Univariate and multivariate logistic regression identified independent factors associated with non-ROSC and PNO-12. Two nomogram prediction models were constructed and evaluated. Of 2,129 patients with IHCA, 851 were included in the study. Multivariate logistic regression analysis revealed that male sex, age >80 years, CPR duration >23 min, and total dose of adrenaline >3 mg were significant risk factors for non-ROSC. Before CA, combined arrhythmia, initial defibrillation rhythm, and advanced airway management (mainly as endotracheal intubation) also influenced outcomes. The area under the receiver operating characteristic curve in the prediction model was 0.904 (C-index: 0.901). Respiratory failure, shock, CA in the monitoring area, advanced airway management, and noradrenaline administration were independent risk factors for PNO-12. The AUC was 0.912 (C-index: 0.918).

Conclusions

Prediction models based on IHCA data could be helpful to reduce mortality rates and improve prognosis.

Chest compression quality and patient outcomes with the use of a CPR feedback device: A retrospective study

Feedback devices were developed to guide resuscitations as targets recommended by various guidelines are difficult to achieve. Yet, there is limited evidence to support their use for in-hospital cardiac arrests (IHCA), and they did not correlate with patient outcomes. Therefore, this study has investigated the compression quality and patient outcomes in IHCA with the use of a feedback device via a retrospective study of inpatient code blue activations in a Singapore hospital over one year. The primary outcome was compression quality and secondary outcomes were survival, downtime and neurological status. 64 of 110 (58.2%) cases were included. Most resuscitations (71.9%) met the recommended chest compression fraction (CCF, defined as the proportion of time spent on compressions during resuscitation) despite overall quality being suboptimal. Greater survival to discharge and better neurological status in resuscitated patients respectively correlated with higher median CCF (p = 0.040 and 0.026 respectively) and shorter downtime (p < 0.001 and 0.001 respectively); independently, a higher CCF correlated with a shorter downtime (p = 0.014). Overall, this study demonstrated that reducing interruptions is crucial for good outcomes in IHCA. However, compression quality remained suboptimal despite feedback device implementation, possibly requiring further simulation training and coaching. Future multicentre studies incorporating these measures should be explored.

Introducing "A Question That Might, Perhaps, Scare you": How Geriatric Physicians Approach the Discussion About Cardiopulmonary Resuscitation with Hospitalized Patients

Decisions about the relevance of life-sustaining treatment, such as cardiopulmonary resuscitation (CPR), are commonly made when a patient is admitted to the hospital. This article aims to refine our understanding of how discussions about CPR are introduced, to identify and classify the components frequently occurring in these introductions, and discuss their implications within the overarching activity (discussing CPR). We recorded 43 discussions about CPR between physicians and patients, taking place during the admission interview. We applied an inductive qualitative content analysis and thematic analysis to all the encounter content from the launch of the conversation on CPR to the point at which the physician formulated a question or the patient an answer. We identified this part of the encounter as the "introduction." This systematic method allowed us to code the material, develop and assign themes and subthemes, and quantify it. We identified four major themes in the introductions: (i) agenda setting; (ii) circumstances leading to CPR (subthemes: types of circumstances, personal prognostics of cardiac arrest); (iii) the activity of addressing CPR with the patient (subthemes: routine, constrain, precedence, sensitivity); and (iv) mentioning advance directives. Our findings reveal the elaborate effort that physicians deploy by appealing to combinations of these themes to account for the need to launch conversations about CPR, and highlight how CPR emerges as a sensitive topic.

Survey of hospital practitioners: common understanding of cardiopulmonary resuscitation definition and outcomes

BACKGROUND

Cardiopulmonary resuscitation (CPR) is internationally defined as chest compressions and rescue breaths, and is a subset of resuscitation. First used for out-of-hospital cardiac arrest, CPR is now frequently used for in-hospital cardiac arrest (IHCA) with different causes and outcomes.

AIMS

This paper aims to describe clinical understanding of the role of in-hospital CPR and perceived outcomes for IHCA.

METHODS

An online survey of a secondary care staff involved in resuscitation was conducted, focussing on definitions of CPR, features of do-not-attempt-CPR conversations with patients and clinical case scenarios. Data were analysed using a simple descriptive approach.

RESULTS

Of 652 responses, 500 were complete and used for analysis. Two hundred eleven respondents were senior medical staff covering acute medical disciplines. Ninety-one percent of respondents agreed or strongly agreed that defibrillation is part of CPR, and 96% believed CPR for IHCA included defibrillation. Responses to clinical scenarios were dissonant, with nearly half of respondents demonstrating a pattern of underestimating survival and subsequently showing a desire to offer CPR in similar scenarios with poor outcomes. This was unaffected by seniority and level of resuscitation training.

CONCLUSIONS

The common use of CPR in hospital reflects the broader definition of resuscitation. Recapturing the CPR definition for clinicians and patients as only chest compressions and rescue breaths may allow clinicians to better discuss individualised resuscitation care to aide meaningful shared decision-making around patient deterioration. This may involve reframing current in-hospital algorithms and uncoupling CPR from wider resuscitative measures.

Resuscitation of older adults in Norway; a comparison of survival and outcome after out-of-hospital cardiac arrest in healthcare institutions and at home

BACKGROUND

Perceptions about expected outcome after out-of-hospital cardiac arrest (OHCA) influence treatment decisions, and there is a need for updated evidence about outcomes for the elderly.

METHOD

We conducted a cross-sectional study of cases reported to the Norwegian Cardiac Arrest Registry from 2015 through 2021 of patients 60 years and older, suffering cardiac arrest in healthcare institutions or at home. We examined reasons for emergency medical service (EMS) withholding or withdrawing resuscitation. We compared survival and neurological outcome for EMS-treated patients and explored factors associated with survival using multivariate logistic regression.

RESULT

We included 12,191 cases and the EMS started resuscitation in 10,340 (85%). The incidence per capita of OHCA the EMS were alerted to was 267/100,000 in healthcare institutions and 134/100,000 at home. Resuscitation was most frequently withdrawn due to medical history (n = 1251). In healthcare institutions, 72 of 1503 (4.8%) patients survived to 30 days compared to 752 of 8837 (8.5%) at home (P <.001). We found survivors in all age cohorts both in healthcare institutions and at home, and most of the 824 survivors had a good neurological outcome with a Cerebral Performance Category ≤2 (88%).

CONCLUSION

Medical history was the most frequent reason for EMS not to start or continue resuscitation, indicating a need for a discussion about, and documentation of, advance directives in this age group. When EMS attempted resuscitation, most survivors had a good neurological outcome, both in healthcare institutions and at home.

Prognosis of Cardiac Arrest-Peri-arrest and Post-arrest Considerations

There has been only a small improvement in survival and neurologic outcomes in patients with cardiac arrest in recent decades. Type of arrest, length of total arrest time, and location of arrest alter the trajectory of survival and neurologic outcome. In the post-arrest phase, clinical markers such as blood markers, pupillary light response, corneal reflex, myoclonic jerking, somatosensory evoked potential, and electroencephalography testing can be used to help guide neurological prognostication. Most of the testing should be performed 72 hours post-arrest with special considerations for longer observation periods in patients who underwent TTM or who had prolonged sedation and/or neuromuscular blockade.

Lazarus Phenomenon or the Return from the Afterlife-What We Know about Auto Resuscitation

Autoresuscitation is a phenomenon of the heart during which it can resume its spontaneous activity and generate circulation. It was described for the first time by K. Linko in 1982 as a recovery after discontinued cardiopulmonary resuscitation (CPR). J.G. Bray named the recovery from death the Lazarus phenomenon in 1993. It is based on a biblical story of Jesus' resurrection of Lazarus four days after confirmation of his death. Up to the end of 2022, 76 cases (coming from 27 countries) of spontaneous recovery after death were reported; among them, 10 occurred in children. The youngest patient was 9 months old, and the oldest was 97 years old. The longest resuscitation lasted 90 min, but the shortest was 6 min. Cardiac arrest occurred in and out of the hospital. The majority of the patients suffered from many diseases. In most cases of the Lazarus phenomenon, the observed rhythms at cardiac arrest were non-shockable (Asystole, PEA). Survival time after death ranged from minutes to hours, days, and even months. Six patients with the Lazarus phenomenon reached full recovery without neurological impairment. Some of the causes leading to autoresuscitation presented here are hyperventilation and alkalosis, auto-PEEP, delayed drug action, hypothermia, intoxication, metabolic disorders (hyperkalemia), and unobserved minimal vital signs. To avoid Lazarus Syndrome, it is recommended that the patient be monitored for 10 min after discontinuing CPR. Knowledge about this phenomenon should be disseminated in the medical community in order to improve the reporting of such cases. The probability of autoresuscitation among older people is possible.

Aetiology and outcome in hospitalized cardiac arrest patients

Aims

To study aetiologies of in-hospital cardiac arrests (IHCAs) and their association with 30-day survival.

Methods and results

Observational study with data from national registries. Specific aetiologies (n = 22) of IHCA patients between April 2018 and December 2020 were categorized into cardiac vs. non-cardiac and six main aetiology categories: myocardial ischemia, other cardiac causes, pulmonary causes, infection, haemorrhage, and other non-cardiac causes. Main endpoints were proportions in each aetiology, 30-day survival, and favourable neurological outcome (Cerebral Performance Category scale 1-2) at discharge. Among, 4320 included IHCA patients (median age 74 years, 63.1% were men), approximate 50% had cardiac causes with a 30-day survival of 48.4% compared to 18.7% among non-cardiac causes (P < 0.001). The proportion in each category were: myocardial ischemia 29.9%, pulmonary 21.4%, other cardiac causes 19.6%, other non-cardiac causes 11.6%, infection 9%, and haemorrhage 8.5%. The odds ratio (OR) for 30-day survival compared to myocardial ischemia for each category were: other cardiac causes OR 1.48 (CI 1.24-1.76); pulmonary causes OR 0.36 (CI 0.3-0.44); infection OR 0.25 (CI 0.18-0.33); haemorrhage OR 0.22 (CI 0.16-0.3); and other non-cardiac causes OR 0.56 (CI 0.45-0.69). IHCA caused by myocardial ischemia had the best favourable neurological outcome while those caused by infection had the lowest OR 0.06 (CI 0.03-0.13).

Conclusion

In this nationwide observational study, aetiologies with cardiac and non-cardiac causes of IHCA were evenly distributed. IHCA caused by myocardial ischemia and other cardiac causes had the strongest associations with 30-day survival and neurological outcome.

Evaluation of Serum Biomarkers and Electroencephalogram to Determine Survival Outcomes in Pediatric Post-Cardiac-Arrest Patients

Cardiac arrest causes primary and secondary brain injuries. We evaluated the association between neuron-specific enolase (NSE), serum S-100B (S100B), electroencephalogram (EEG) patterns, and post-cardiac arrest outcomes in pediatric patients. A prospective observational study was conducted in the pediatric intensive care unit and included 41 post-cardiac arrest patients who underwent EEG and serum sampling for NSE and S100B. The participants were aged 1 month to 18 years who experienced cardiac arrest and underwent CPR after a sustained return of spontaneous circulation for ≥48 h. Approximately 19.5% (n = 8) of patients survived until ICU discharge. Convulsions and sepsis were significantly associated with higher mortality (relative risk: 1.33 [95% CI = 1.09-1.6] and 1.99 [95% CI = 0.8-4.7], respectively). Serum NSE and S100B levels were not statistically associated with the outcome (p = 0.278 and 0.693, respectively). NSE levels were positively correlated with the duration of CPR. EEG patterns were significantly associated with the outcome (p = 0.01). Non-epileptogenic EEG activity was associated with the highest survival rate. Post-cardiac arrest syndrome is a serious condition with a high mortality rate. Management of sepsis and convulsions affects prognosis. We believe that NSE and S100B may have no benefit in survival evaluation. EEG can be considered for post-cardiac arrest patients.

Clinical characteristics, causes and predictors of outcomes in patients with in-hospital cardiac arrest: results from the SURVIVE-ARREST study

INTRODUCTION

In-hospital cardiac arrest (IHCA) is acutely life-threatening and remains associated with high mortality and morbidity. Identifying predictors of mortality after IHCA would help to guide acute therapy.

METHODS

We determined patient characteristics and independent predictors of 30-day in-hospital mortality, neurological outcome, and discharge/referral pathways in patients experiencing IHCA in a large tertiary care hospital between January 2014 and April 2017. Multivariable Cox regression model was fitted to assess predictors of outcomes.

RESULTS

A total of 368 patients with IHCA were analysed (median age 73 years (interquartile range 65-78), 123 (33.4%) women). Most patients (45.9%) had an initial non-shockable rhythm and shockable rhythms were found in 20.9%; 23.6% of patients suffered from a recurrent episode of cardiac arrest. 172/368 patients died within 30 days (46.7%). Of 196/368 patients discharged alive after IHCA, the majority (72.9%, n = 143) had a good functional neurological outcome (modified Rankin Scale ≤ 3 points). In the multivariable analysis, return of spontaneous circulation without mechanical circulatory support (hazard ratio (HR) 0.36, 95% confidence interval (CI) 0.21-0.64), invasive coronary angiography and/or percutaneous intervention (HR 0.56, 95% CI 0.34-0.92), and antibiotic therapy (HR 0.87, 95% CI 0.83-0.92) were associated with a lower risk of 30-day in hospital mortality.

CONCLUSION

In the present study, IHCA was survived in ~ 50% in a tertiary care hospital, although only a minority of patients presented with shockable rhythms. The majority of IHCA survivors (~ 70%) had a good neurological outcome. Recovery of spontaneous circulation and presence of treatable acute causes of the arrest are associated with better survival. Clinical Characteristics, Causes and Predictors of Outcomes in Patients with In-Hospital Cardiac Arrest: Results from the SURVIVE-ARREST Study.

ABBREVIATIONS

CPR, cardiopulmonary resuscitation; IHCA, In-hospital cardiac arrest; MCS, mechanical circulatory support; PCI, percutaneous coronary intervention; ROSC, return of spontaneous circulation; SBP, systolic blood pressure.

Frailty and Survival After In-Hospital Cardiopulmonary Resuscitation

BACKGROUND

Older adults face high mortality following resuscitation efforts for in-hospital cardiac arrest. Less is known about the role of frailty in survival to discharge after in-hospital cardiopulmonary resuscitation.

OBJECTIVE

To investigate whether frailty, measured by the Clinical Frailty Scale, is associated with mortality after cardiopulmonary resuscitation following in-hospital cardiac arrest in older adults in the USA.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Patients ≥ 65 years who had undergone cardiopulmonary resuscitation during an inpatient admission at two urban academic hospitals and three suburban community hospitals within a Boston area healthcare system from January 2018-January 2020. Patients with Clinical Frailty Scale scores 1-3 were considered not frail, 4-6 were considered very mildly, mildly, and moderately frail, respectively, and 7-9 were considered severely frail.

MAIN MEASURES

In-hospital mortality after cardiopulmonary resuscitation.

KEY RESULTS

Among 324 patients who underwent cardiopulmonary resuscitation following in-hospital cardiac arrest, 73.1% experienced in-hospital mortality. Patients with a Clinical Frailty Scale score of 1-3 had 54% in-hospital mortality, which increased to 66%, 78%, 84%, and 84% for those with a Clinical Frailty Scale score of 4, 5, 6, and 7-9, respectively (p = 0.001). After adjusting for age, sex, race, and Charlson Comorbidity Index, higher frailty scores were significantly associated with higher odds of in-hospital mortality. Compared to those with a Clinical Frailty Scale score of 1-3, odds ratios (95% CI) for in-hospital mortality for patients with a Clinical Frailty Scale score of 4, 5, 6, and 7-9 were 1.6 (0.8-3.3), 3.0 (1.3-7.1), 4.4 (1.9-9.9), and 4.6 (1.8-11.8), respectively (p = 0.001).

CONCLUSIONS

Higher levels of frailty are associated with increased mortality after in-hospital cardiopulmonary resuscitation in older adults. Clinicians may consider using the Clinical Frailty Scale to help guide goals of care conversations, including discussion of code status, in this patient population.

Outcomes in adults living with frailty receiving cardiopulmonary resuscitation: A systematic review and meta-analysis

Background

Frailty is a clinical expression of adverse ageing which could be a valuable predictor of outcomes from cardiac arrest. The aim of this systematic review was to evaluate survival outcomes in adults living with frailty versus adults living without frailty receiving cardiopulmonary resuscitation (CPR) following cardiac arrest.

Methods

A comprehensive search of MEDLINE, EMBASE, CINAHL, and Web of Science databases was performed using pre-defined search terms, with no date or language restrictions applied. Prospective and retrospective observational studies measuring outcomes from CPR in adults assessed for frailty using an accepted clinical definition were selected.

Results

Eight eligible studies were included. Seven retrospective observational studies presenting high methodological quality were included in a meta-analysis comprising 1704 participants. Frailty was strongly associated with an increased likelihood of mortality after CPR, with moderate inter-study heterogeneity (OR = 3.56, 95% CI = 2.74–4.63, I² = 71%).

Discussion

This review supports the consideration of frailty status in a holistic approach to CPR. The present findings suggest that frailty status provides valuable prognostic information and could complement other known pre-arrest prognostic factors such as comorbidities in the context of Do Not Attempt CPR consideration. Awareness of the poorer outcomes in those living with frailty could support the identification of individuals less likely to benefit from CPR. Validation of our findings and evaluation of quality-of-life in frail individuals surviving cardiac arrest are prerequisites for the future integration of frailty status into CPR clinical decision-making.

Registration

Prospectively registered on PROSPERO: CRD42020223670.

The association between signs of medical distress preceding in-hospital cardiac arrest and 30-day survival – A register-based cohort study

Background

Identifying signs of medical distress prior to in-hospital cardiac arrest (IHCA) is important to prevent IHCA and improve survival. The primary objective of this study was to investigate the association between signs of medical distress present within 60 minutes prior to cardiac arrest and survival after cardiac arrest.

Methods

The register-based cohort study included adult patients (≥18 years) with IHCA in the Swedish Registry of Cardiopulmonary Resuscitation (SRCR) from 2017-01-01 to 2020–07-15. Signs of distress prior to IHCA were defined as the medical signs arrhythmia, pulmonary oedema, hypotension, hypoxia or seizures present within 60 minutes prior to cardiac arrest (pre-arrest signs). Using multivariable logistic regression, the association between these pre-arrest signs and 30-day survival was analysed in both unadjusted and adjusted models. The covariates used were demographics, comorbidities, characteristics and treatment of cardiac arrest.

Results

In total, 8525 patients were included. After adjusting for covariates, patients with arrhythmia had a 58% higher probability of 30-day survival. The adjusted probability of 30-day survival was 41% and 52% lower for patients with hypotension and hypoxia prior to IHCA, respectively. Pulmonary oedema and seizures were not associated with any change in 30-day survival.

Conclusions

Among signs of medical distress prior to in-hospital cardiac arrest, arrhythmia was associated with a higher 30-day survival. Hypotension and hypoxia were associated with lower survival after IHCA. These findings indicate that future research on survival after cardiac arrest should take pre-arrest signs into account as it impacts the prerequisites for survival.

“Impact of age on management and prognosis of resuscitated sudden cardiac death patients”

Background

Sudden cardiac death (SCD) has a great impact on healthcare due to cardiologic and neurological complications. Admissions of elderly people in Cardiology Intensive Care Units have increased. We assessed the impact of age in presentation, therapeutic management and in vital and neurological prognosis of SCD patients.

Methods

We carried out a retrospective, observational, multicenter registry of patients who were admitted with a SCD in 5 tertiary hospitals from January 2013 to December 2020. We divided our cohort into two groups (patients < 80 years and ≥ 80 years). Clinical, analytical and hemodynamic variables as well as in-hospital management were registered and compared between groups. The degree of neurological dysfunction, vital status at discharge and the influence of age on them were also reviewed.

Results

We reviewed 1160 patients admitted with a SCD. 11.3% were ≥ 80 years. Use of new antiplatelet agents, performance of a coronary angiography, use of pulmonary artery catheter and temperature control were less carried out in the elderly. Age, non-shockable rhythm, Killip class > 1 at admission, time to CPR initiation > 5 min, time to ROSC > 20 min and lactate > 2 mmol/L were independent predictors for in-hospital mortality. Non-shockable rhythm, Killip class > 1 at admission, time to CPR initiation > 5 min and time to ROSC > 20 min but not age were independent predictors for poor neurological outcomes.

Conclusions

Age determined a less aggressive management and it was associated with a worse vital prognosis in patients admitted with a SCD. Nevertheless, age was not associated with worse neurological outcomes.

The association between anion gap and in-hospital mortality of post-cardiac arrest patients: a retrospective study

We aimed to determine the association between anion gap and in-hospital mortality in post-cardiac arrest (CA) patients. Extracted the data of patients diagnosed with CA from MIMIC-IV database. Generalized additive model (GAM), Cox regression and Kaplan–Meier survival analysis were used to demonstrate the association between AG levels and in-hospital mortality. ROC curve analysis for assessing the discrimination of AG for predicting in-hospital mortality. Totally, 1724 eligible subjects were included in our study finally. 936 patients (551 males and 385 females) died in hospital, with the prevalence of in-hospital mortality was 54.3%. The result of the Kaplan–Meier analysis showed that the higher value of AG had significant lower survival possibility during the hospitalization compared with the lower-value of AG patients. In the crude Cox regression model, high-level of AG subjects was associated with significant higher HR compared with low-level of AG subjects. After adjusted the vital signs data, laboratory data, and treatment, high-level of AG (group Q3 and group Q4) were also associated with increased risk of in-hospital mortality compared with low-level of AG group, 1.52 (95% Cl 1.17–1.85; P < 0.001), 1.64 (95% Cl 1.21–2.08; P < 0.001), respectively. The ROC curve indicated that AG has acceptable discrimination for predicting in-hospital mortality. The AUC value was found to be 0.671 (95% CI 0.646–0.698). Higher AG levels was associated with poor prognosis in post-CA patients. AG is a predictor for predicting in-hospital mortality of CA, and could help refine risk stratification.

Factors Affecting Outcomes of Cardiopulmonary Resuscitation in a Nephro-Urology Unit: A Retrospective Analysis

Background

Availability of cardiopulmonary resuscitation (CPR) data from India is limited in published literature and data on patients with renal disease even more so. Documented survival-to-discharge rates worldwide range from 8 to 15% in renal disease as compared to 25% in the general population.

Methods

An institution-wide format for collection of cardiac arrest data was introduced in late 2015. We have analyzed all adult onsite cardiac arrests from January 2016 to December 2019. Patient characteristics and CPR parameters were both studied in detail. Primary endpoint was defined as survival to discharge. Association between patient and treatment characteristics and survival to discharge was studied.

Results

Successful CPR resulting in patient discharge occurred in 28 (31.4%) out of 89 patients. A very strong association was found between mortality and prolonged CPR (p <0.00001). Events occurring out of hours (p = 0.0029), patients admitted in the intensive care unit (ICU) (p = 0.03), initiated on inotropes (p = 0.003), and patients already on a ventilator (p = 0.0018) had poorer outcomes. Sepsis as the etiology emerged as the most significant association with mortality (p = 0.0007). Patient characteristics such as age, sex, presence or absence of chronic kidney disease, type of dialysis treatment, and vintage were found to be insignificant.

Conclusion

Analysis revealed survival to discharge of 31.4%. Sepsis in association with renal disease has been found to be consistent with higher risk for mortality. Other factors such as an out of hours event, admission to ICU, early intubation and inotrope initiation were associated with worse outcomes.

How to cite this article

Sharma S, Raman P, Sinha M, Deo AS. Factors Affecting Outcomes of Cardiopulmonary Resuscitation in a Nephro-Urology Unit: A Retrospective Analysis. Indian J Crit Care Med 2022;26(3):322–326.

Outcomes Following In-Hospital Cardiopulmonary Resuscitation in People Receiving Maintenance Dialysis

Rationale & Objective

Previous studies showing poor cardiopulmonary resuscitation (CPR) outcomes in the dialysis population have largely been derived from claims data and are somewhat limited by a lack of detailed characterization of CPR events. We aimed to analyze CPR-related outcomes in individuals receiving maintenance dialysis.

Study Design

Retrospective chart review.

Setting & Participants

Using electronic medical records from a single academic health care system, we identified all hospitalized adult patients receiving maintenance dialysis who had undergone in-hospital CPR between 2006 and 2014.

Exposure

Initial in-hospital CPR.

Outcomes

Overall survival, predictors of unsuccessful CPR, predictors of death during the same hospitalization among initial survivors, predictors of discharge-to-home status.

Analytical Approach

We provide descriptive statistics for the study variables and used t tests, χ² tests, or Fisher exact tests to compare differences between the groups. We built multivariable logistic regression models to examine the CPR-related outcomes.

Results

A total of 184 patients received in-hospital CPR: 51 (28%) did not survive the initial CPR event, and 77 CPR survivors died (additional 42%) later during the same hospitalization (overall mortality 70%). Only 18 (10%) were discharged home, with the remaining 32 (17%) discharged to a rehabilitation facility or a nursing home. In the multivariable model, the only predictor of unsuccessful CPR was CPR duration (OR, 1.41; 95% CI, 1.24-1.61; P < 0.001). Predictors of death during the same hospitalization after surviving the initial CPR event were CPR duration (OR, 1.15; 95% CI 1.04-1.27; P = 0.007) and older age (OR, 1.64; 95% CI, 1.23-2.2; P < 0.001). Older people also had lower odds of discharge-to-home status (OR, 0.25; 95% CI, 0.11-0.54; P < 0.001).

Limitations

Retrospective study design, single-center study, no information on functional status.

Conclusions

Patients receiving maintenance dialysis experience high mortality following in-hospital CPR and only 10% are discharged home. These data may help clinicians provide useful prognostic information while engaging in goals of care conversations.

Clinical outcomes of in-hospital cardiac arrest in a tertiary hospital and factors related to 28-day survival: A retrospective cohort study

OBJECTIVES:

METHODS:

RESULTS:

CONCLUSIONS:

Intensive care-treated cardiac arrest: a retrospective study on the impact of extended age on mortality, neurological outcome, received treatments and healthcare-associated costs

Background

Cardiac arrest (CA) is a leading cause of death worldwide. As population ages, the need for research focusing on CA in elderly increases. This study investigated treatment intensity, 12-month neurological outcome, mortality and healthcare-associated costs for patients aged over 75 years treated for CA in an intensive care unit (ICU) of a tertiary hospital.

Methods

This single-centre retrospective study included adult CA patients treated in a Finnish tertiary hospital’s ICU between 2005 and 2013. We stratified the study population into two age groups: <75 and \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\ge$$\end{document}≥75 years. We compared interventions defined by the median daily therapeutic scoring system (TISS-76) between the age groups to find differences in treatment intensity. We calculated cost-effectiveness by dividing the total one-year healthcare-associated costs of all patients by the number of survivors with a favourable neurological outcome. Favourable outcome was defined as a cerebral performance category (CPC) of 1–2 at 12 months after cardiac arrest. Logistic regression analysis was used to identify independent associations between age group, mortality and neurological outcome.

Results

This study included a total of 1,285 patients, of which 212 (16 %) were \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\ge$$\end{document}≥75 years of age. Treatment intensity was lower for the elderly compared to the younger group, with median TISS scores of 116 and 147, respectively (p < 0.001). The effective cost in euros for patients with a good one-year neurological outcome was €168,000 for the elderly and €120,000 for the younger group. At 12 months after CA 24 % of the patients in the elderly group and 47 % of the patients in the younger group had a CPC of 1–2 (p < 0.001). Age was an independent predictor of mortality (multivariate OR = 2.90, 95 % CI: 1.94–4.31, p < 0.001) and neurological outcome (multivariate OR = 3.15, 95 % CI: 2.04–4.86, p < 0.001).

Conclusions

The elderly ICU-treated CA patients in this study had worse neurological outcomes, higher mortality and lower cost-effectiveness than younger patients. Elderly received less intense treatment. Further efforts are needed to recognize the tools for assessing which elderly patients benefit from a more aggressive treatment approach in order to improve the cost-effectiveness of post-CA management.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00923-0.

General health condition of patients hospitalized after an incident of in-hospital or out-of hospital sudden cardiac arrest with return of spontaneous circulation

Background

Sudden cardiac arrest (SCA) is one of the main reasons for admission to the intensive care unit (ICU), which influences discharge in a good neurological state.

Hypothesis

To analyze patients who had recovery of spontaneous circulation (ROSC) during hospitalization in the ICU using the Glasgow Outcome Scale (GOS).

Methods

The study group comprised 78 patients after SCA (35 after out‐of‐hospital cardiac arrest [OHCA] and 43 after in‐hospital cardiac arrest [IHCA]) with ROSC who were admitted to the ICU of Regional Hospital No. 5 in Sosnowiec from January 1, 2016 to December 31, 2016. GOS was used to assess neurological status. Basic anthropological data, with, arterial blood pH, lactate concentration (LAC), and catecholamine treatment were also collected.

Results

In the study group, 32.1% (n = 25/78) of patients survived until ICU discharge and 30.8% (n = 24/78) until discharge from the hospital. SCA in cardiac mechanism was more common in OHCA than in the IHCA group (OHCA vs. IHCA: 85.7% vs. 62.8%, p = .02). There was no statistically significant difference between the two groups for neurological status assessed using GOS. There was no statistically significant difference between LAC or arterial blood pH and survival to ICU discharge, survival to hospital discharge, or mortality. The need for using catecholamines increased the mortality rate (GOS 1) (p < .001).

Conclusions

Most patients after RSOC were assigned to a group other than GOS 1, and 25% of all subjects belonged to GOS 4–5. Treatment with catecholamines was more common in patients who do not survive hospital or ICU discharge.

Predicting in-hospital mortality after an in-hospital cardiac arrest: A multivariate analysis

Aim of the study

Most survivors of an in-hospital cardiac arrest do not leave the hospital alive, and there is a need for a more patient-centered, holistic approach to the assessment of prognosis after an arrest. We sought to identify pre-, peri-, and post-arrest variables associated with in-hospital mortality amongst survivors of an in-hospital cardiac arrest.

Methods

This was a retrospective cohort study of patients ≥18 years of age who were resuscitated from an in-hospital arrest at our University Medical Center from January 1, 2013 to September 31, 2016. In-hospital mortality was chosen as a primary outcome and unfavorable discharge disposition (discharge disposition other than home or skilled nursing facility) as a secondary outcome.

Results

925 patients comprised the in-hospital arrest cohort with 305 patients failing to survive the arrest and a further 349 patients surviving the initial arrest but dying prior to hospital discharge, resulting in an overall survival of 29%. 620 patients with a ROSC of greater than 20 min following the in-hospital arrest were included in the final analysis. In a stepwise multivariable regression analysis, recurrent cardiac arrest, increasing age, time to ROSC, higher serum creatinine levels, and a history of cancer were predictors of in-hospital mortality. A history of hypertension was found to exert a protective effect on outcomes. In the regression model including serum lactate, increasing lactate levels were associated with lower odds of survival.

Conclusion

Amongst survivors of in-hospital cardiac arrest, recurrent cardiac arrest was the strongest predictor of poor outcomes with age, time to ROSC, pre-existing malignancy, and serum creatinine levels linked with increased odds of in-hospital mortality.

Coronary angiography in patients after cardiac arrest without ST-elevation myocardial infarction : A retrospective cohort analysis

Background

Coronary artery disease (CAD) is the most common cause of sudden cardiac arrest (SCA). Although coronary angiography (CAG) should be performed also in the absence of ST-elevation (STE) after sustained return of spontaneous circulation (ROSC), this recommendation is not well implemented in daily routine.

Methods

A retrospective database analysis was conducted in a tertiary care center between January 2005 and December 2014. We included all SCA patients aged ≥ 18 years with presumed cardiac cause and sustained ROSC in the absence of STE at hospital admission. The rate and timing of CAG were defined as the primary endpoints. As secondary endpoints, the reasons pro and contra CAG were analyzed. Furthermore, we observed if the signs and symptoms used for decision making occurred more often in patients with treatable CAD.

Results

We included 645 (53.6%) of the 1203 screened patients, CAG was performed in 343 (53.2%) patients with a diagnosis of occlusive CAD in 214 (62.4%) patients. Of these, 151 (71.0%) patients had occlusive CAD treated with coronary intervention, thrombus aspiration, or coronary artery bypass grafting. In an adjusted binomial logistic regression analysis, age ≥ 70 years, female sex, non-shockable rhythms, and cardiomyopathy were associated with withholding of CAG. In patients diagnosed and treated with occlusive CAD, initially shockable rhythms, previously diagnosed CAD, hypertension, and smoking were found more often.

Conclusion

Although selection bias is unavoidable due to the retrospective design of this study, a high proportion of the examined patients had occlusive CAD. The criteria used for patient selection may be suboptimal.

Age and sex differences in outcomes after in-hospital cardiac arrest

INTRODUCTION

While specific factors have been associated with outcomes after in-hospital cardiac arrest, the association between sex and outcomes remains debated. Moreover, age-specific sex differences in outcomes have not been fully characterized in this population.

METHODS

Adult patients (≥18 years) with an index in-hospital cardiac arrest were included from the Danish In-Hospital Cardiac Arrest Registry (DANARREST) from January 1st, 2017 to December 31st, 2018. Population-based registries were used to obtain data on patient characteristics, cardiac arrest characteristics, and outcomes. Unadjusted and adjusted estimates for return of spontaneous circulation (ROSC), survival to 30 days, survival to one year, duration of resuscitation, and post-cardiac arrest time-to-death were computed.

RESULTS

A total of 3266 patients were included, of which 2041 (62%) patients were male with a median age of 73 years (quartiles: 64, 80). Among 1225 (38%) female patients, the median age was 76 years (quartiles: 67, 83). Younger age was associated with higher odds of ROSC and survival. Sex was not associated with ROSC and survival in the unadjusted analyses. In the adjusted analyses, women had 1.32 (95%CI: 1.12, 1.54) times the odds of survival to 30 days and 1.26 (95%CI: 1.02, 1.57) times the odds of survival to one year compared to men. The overall association between sex and survival did not vary substantially across age categories, although female sex was associated with a higher survival within certain age categories. Among patients who did not achieve ROSC, female sex was associated with a shorter duration of resuscitation, which was more pronounced in younger age categories.

CONCLUSIONS

In this study of patients with in-hospital cardiac arrest, female sex was associated with a shorter duration of resuscitation among patients without ROSC but a higher survival to 30 days and one year. While the overall association between sex and outcomes did not vary substantially across age categories, female sex was associated with a higher survival within certain age categories.

Family Presence and Support During Resuscitation

Family presence during cardiopulmonary resuscitation (FPDR) is an evidence-based practice in the hospital setting. Members of the interdisciplinary team should adhere to ethical principles and patient and family-centered care concepts when offering interventions to support the family member during this potential end-of-life crisis. FPDR is an option for family members who are interested, screened as appropriate, and supported by a family facilitator. Essential components to guide this practice include developing an FPDR policy, educating the health care team, and creating evaluation methods.

Effect of intra-arrest trans-nasal evaporative cooling in out-of-hospital cardiac arrest: a pooled individual participant data analysis

Background

Randomized trials have shown that trans-nasal evaporative cooling initiated during CPR (i.e. intra-arrest) effectively lower core body temperature in out-of-hospital cardiac arrest patients. However, these trials may have been underpowered to detect significant differences in neurologic outcome, especially in patients with initial shockable rhythm.

Methods

We conducted a post hoc pooled analysis of individual data from two randomized trials including 851 patients who eventually received the allocated intervention and with available outcome (“as-treated” analysis). Primary outcome was survival with favourable neurological outcome at hospital discharge (Cerebral Performance Category [CPC] of 1–2) according to the initial rhythm (shockable vs. non-shockable). Secondary outcomes included complete neurological recovery (CPC 1) at hospital discharge.

Results

Among the 325 patients with initial shockable rhythms, favourable neurological outcome was observed in 54/158 (34.2%) patients in the intervention and 40/167 (24.0%) in the control group (RR 1.43 [confidence intervals, CIs 1.01–2.02]). Complete neurological recovery was observed in 40/158 (25.3%) in the intervention and 27/167 (16.2%) in the control group (RR 1.57 [CIs 1.01–2.42]). Among the 526 patients with initial non-shockable rhythms, favourable neurological outcome was in 10/259 (3.8%) in the intervention and 13/267 (4.9%) in the control group (RR 0.88 [CIs 0.52–1.29]; p = 0.67); survival and complete neurological recovery were also similar between groups. No significant benefit was observed for the intervention in the entire population.

Conclusions

In this pooled analysis of individual data, intra-arrest cooling was associated with a significant increase in favourable neurological outcome in out-of-hospital cardiac arrest patients with initial shockable rhythms. Future studies are needed to confirm the potential benefits of this intervention in this subgroup of patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03583-9.

'It's not magic': A qualitative analysis of geriatric physicians' explanations of cardio-pulmonary resuscitation in hospital admissions

BACKGROUND

Discussing patient preferences for cardio-pulmonary resuscitation (CPR) is routine in hospital admission for older people. The way the conversation is conducted plays an important role for patient comprehension and the ethics of decision making.

OBJECTIVE

The objective was to examine how CPR is explained in geriatric rehabilitation hospital admission interviews, focussing on circumstances in which physicians explain CPR and the content of these explanations.

METHOD

We recorded forty-three physician-patient admission interviews taking place in a hospital in French-speaking Switzerland, during which CPR was discussed. Data were analysed in French with thematic and conversation analysis, and the extracts used for publication were translated into English.

RESULTS

Mean patient age was 83.7 years; 53.5% were admitted for rehabilitation after surgery or traumatism. CPR was explained in 53.8% of the conversations. Most explanations were brief and concerned the technical procedures, mentioning only rarely potential outcome. With one exception, medical indication and prognosis of CPR did not feature in these explanations. Explanations occurred either before the patient's answer (as part of the question about CPR preferences) or after the patient's answer, generated by patients' indecision, misunderstanding and by the need to clarify answers.

DISCUSSION AND CONCLUSIONS

The scarcity and simplicity of CPR explanations highlight a reluctance to have in-depth discussions and reflect the assumption that CPR does not need explaining. Providing patients with accurate information about the outcomes and risks of CPR is incremental for reaching informed decisions and patient-centred care.

PATIENT CONTRIBUTION

Patients were involved in the data collection stage of the study.

Low adherence to legislation regarding Do-Not-Attempt-Cardiopulmonary-Resuscitation orders in a Swedish University Hospital

Background

The ethical principles of resuscitation have been incorporated into Swedish legislation so that a decision to not attempt cardiopulmonary resuscitation (DNACPR) entails (1) consultation with patient or relatives if consultation with patient was not possible and documentation of their attitudes; (2) consultation with other licensed caregivers; (3) documentation of the grounds for the DNACPR. Our aim was to evaluate adherence to this legislation, explore the grounds for the decision and the attitudes of patients and relatives towards DNACPR orders.

Methods

We included DNACPR forms issued after admission through the emergency department at Karolinska University Hospital between 1st January and 31st October, 2015. Quantitative analysis evaluated adherence to legislation and qualitative analysis of a random sample of 20% evaluated the grounds for the decision and the attitudes.

Results

The cohort consisted of 3583 DNACPR forms. In 40% of these it was impossible to consult the patient, and relatives were consulted in 46% of these cases. For competent patients, consultation occurred in 28% and the most common attitude was to wish to refrain from resuscitation. Relatives were consulted in 26% and they mainly agreed with the decision. Grounds for the DNAR decision was most commonly severe chronic comorbidity, malignancy or multimorbidity with or without an acute condition. All requirements of the legislation were fulfilled in 10% of the cases.

Conclusion

In 90% of the cases physicians failed to fulfil all requirements in the Swedish legislation regarding DNAR orders. The decision was mostly based on chronic, severe comorbidity or multimorbidity.

Factors affecting outcomes in patients with cardiac arrest who receive target temperature management: The multi-center TIMECARD registry

BACKGROUND

Target temperature management (TTM) is a recommended therapy for patients after cardiac arrest (PCA). The TaIwan Network of Targeted Temperature ManagEment for CARDiac Arrest (TIMECARD) registry was established for PCA who receive TTM therapy in Taiwan. We aim to determine the variables that may affect neurologic outcomes in PCA who undergo TTM.

METHODS

We retrieved demographic variables, resuscitation variables, and cerebral performance category (CPC) scale score at hospital discharge from the TIMECARD registry. The primary outcome was a favorable neurologic outcome, defined as a CPC scale of 1 or 2 at discharge. A total of 540 PCA treated between January 2014 and September 2019 were identified from the registry. Univariate and multivariate analyses were performed to identify significant variables.

RESULTS

The mortality rate was 58.1% (314/540). Favorable neurologic outcomes were noted in 117 patients (21.7%). The factors significantly influencing the neurologic outcome (p < 0.05) were the presence of an initial shockable rhythm or pulseless electric activity, a witnessed cardiac-arrest event, bystander cardiopulmonary resuscitation, a smaller total dose of epinephrine, the diastolic blood pressure value at return of spontaneous circulation, a pre-arrest CPC score of 1, coronary angiography, new-onset seizure, and new-onset serious infection. Older patients and those with premorbid diabetes mellitus, chronic kidney disease, malignancy, obstructive lung disease, or cerebrovascular accident were more likely to have an unfavorable neurologic outcome.

CONCLUSIONS

In the TIMECARD registry, some PCA baseline characteristics, cardiac arrest events, cardiopulmonary resuscitation characteristics, and post-arrest management characteristics were significantly associated with neurologic outcomes.

Age, Frailty, Resuscitation and Intensive Care: With Reference to COVID-19

Discussion regarding cardiopulmonary resuscitation and admission to an intensive care unit is frequently fraught in the context of older age. It is complicated by the fact that the presence of multiple comorbidities and frailty adversely impact on prognosis. Cardiopulmonary resuscitation and mechanical ventilation are not appropriate for all. Who decides and how? This paper discusses the issues, biases, and potential harms involved in decision-making. The basis of decision making requires fairness in the distribution of resources/healthcare (distributive justice), yet much of the printed guidance has taken a utilitarian approach (getting the most from the resource provided). The challenge is to provide a balance between justice for the individual and population justice.

European Resuscitation Council Guidelines 2021: Epidemiology of cardiac arrest in Europe

In this section of the European Resuscitation Council Guidelines 2021, key information on the epidemiology and outcome of in and out of hospital cardiac arrest are presented. Key contributions from the European Registry of Cardiac Arrest (EuReCa) collaboration are highlighted. Recommendations are presented to enable health systems to develop registries as a platform for quality improvement and to inform health system planning and responses to cardiac arrest.

The outcome of in- and out-hospital cardiopulmonary arrest in the older population: a scoping review

Aim

We aimed to collect the available evidence on outcome regarding survival and quality of life after CPR following both IHCA and OHCA in the older population.

Findings

Hospital survival rates following IHCA and OHCA in the older population improved in the recent decade, though do not exceed 28.5% and 11.1%, respectively. The effect of age on outcome remains controversial and age should not be used as the sole decision criterium whether to initiate CPR.

Message

Future research should study frailty and resilience as an independent predictor regardless of age, and add broader, extensive QoL measures as outcome variables.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-021-00454-y.

Purpose

We aimed to collect the available evidence on outcome regarding survival and quality of life after cardiopulmonary resuscitation (CPR) following both in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA) in the older population.

Methods

A scoping review was performed studying published reviews after 2008, focusing on outcome of CPR in patients aged ≥ 70 years following IHCA and OHCA. In addition, 11 (IHCA) and 19 (OHCA) eligible studies published after the 2 included reviews were analyzed regarding: return of spontaneous circulation, survival until hospital discharge, long-term survival, neurological outcome, discharge location or other measurements for quality of life (QoL).

Results

The survival until hospital discharge ranged between 11.6 and 28.5% for IHCA and 0–11.1% for OHCA, and declined with increasing age. The same trend was seen regarding 1-year survival rates with 5.7–25.0% and 0–10% following IHCA and OHCA, respectively. A good neurological outcome defined as a Cerebral Performance Category (CPC) 1–2 was found in 11.5–23.6% (IHCA) and up to 10.5% (OHCA) of all patients. However, the proportion of CPC 1–2 among patients surviving until hospital discharge was 82–93% (IHCA) and 77–91.6% (OHCA). Few studies included other QoL measures as an outcome variable. Other risk factors aside from age were identified, including nursing home residency, comorbidity, non-shockable rhythm, non-witnessed arrest. The level of frailty was not studied as a predictor of arrest outcome in the included studies.

Conclusions

Hospital survival rates following IHCA and OHCA in the older population improved in the recent decade, though do not exceed 28.5% and 11.1%, respectively. The effect of age on outcome remains controversial and age should not be used as the sole decision criterium whether to initiate CPR. Future research should study frailty and resilience as an independent predictor regardless of age, and add broader, extensive QoL measures as outcome variables.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-021-00454-y.

Cardiac arrest in older adult patients

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Association between chronic liver disease and clinical outcomes in out-of-hospital cardiac arrest

OBJECTIVES

Out-of-hospital cardiac arrest (OHCA) and chronic liver disease (CLD) are global health issues. The purpose of this study is to evaluate the association between chronic liver disease and clinical outcomes in OHCA.

METHODS

A retrospective observation study, using a nationwide population-based OHCA registry, was conducted. Adult patients with cardiac OHCAs who were treated by emergency medical service (EMS) providers between January 2013 and December 2015 were screened. The main exposure was the status of chronic liver disease that had been diagnosed before OHCA, categorized into three groups: no CLD, CLD without cirrhosis, and CLD with cirrhosis. Multivariable logistic regression analysis for survival and neurologic recovery were conducted to calculate the adjusted odds ratio (AOR) and confidence intervals (CIs). Interaction analysis for age, gender were performed and sensitivity analysis by imputation for main exposure missing was also.

RESULT

A total of 8844 eligible OHCA patients were enrolled. There were 361 (4.1%) patients in the CLD without cirrhosis group and 1323 (15%) patients in the CLD with cirrhosis group. Compared to no CLD group, CLD with cirrhosis group was less likely to have favorable outcomes for good neurological recovery and survival to discharge. Patients with CLD but without cirrhosis showed similar associations in neurologic recovery and survival with those without CLD. In multivariable logistic regression analysis, the AOR and 95% CIs for good neurological outcome and survival to discharge were as below; good neurological outcome - 1.07 (0.70-1.64) for CLD without cirrhosis, 0.08 (0.04-0.16) for CLD with cirrhosis, survival to discharge - 1.01 (0.70-1.45) for CLD without cirrhosis, 0.13 (0.08-0.20) for CLD with cirrhosis. Same trends of association were demonstrated in interaction and imputation analysis.

CONCLUSION

OHCA patients with liver cirrhosis showed poor clinical outcomes and CLD had no negative association unless they progressed to cirrhotic status.

Characteristics and Outcomes of In-Hospital Cardiac Arrest Events During the COVID-19 Pandemic: A Single-Center Experience From a New York City Public Hospital

Supplemental Digital Content is available in the text.

Background:

Patients hospitalized for severe coronavirus disease 2019 (COVID-19) infection are at risk for in-hospital cardiac arrest (IHCA). It is unknown whether certain characteristics of cardiac arrest care and outcomes of IHCAs during the COVID-19 pandemic differed compared with a pre-COVID-19 period.

Methods:

All patients who experienced an IHCA at our hospital from March 1, 2020 through May 15, 2020, during the peak of the COVID-19 pandemic, and those who had an IHCA from January 1, 2019 to December 31, 2019 were identified. All patient data were extracted from our hospital’s Get With The Guidelines–Resuscitation registry, a prospective hospital-based archive of IHCA data. Baseline characteristics of patients, interventions, and overall outcomes of IHCAs during the COVID-19 pandemic were compared with IHCAs in 2019, before the COVID-19 pandemic.

Results:

There were 125 IHCAs during a 2.5-month period at our hospital during the peak of the COVID-19 pandemic compared with 117 IHCAs in all of 2019. IHCAs during the COVID-19 pandemic occurred more often on general medicine wards than in intensive care units (46% versus 33%; 19% versus 60% in 2019; P<0.001), were overall shorter in duration (median time of 11 minutes [8.5–26.5] versus 15 minutes [7.0–20.0], P=0.001), led to fewer endotracheal intubations (52% versus 85%, P<0.001), and had overall worse survival rates (3% versus 13%; P=0.007) compared with IHCAs before the COVID-19 pandemic.

Conclusions:

Patients who experienced an IHCA during the COVID-19 pandemic had overall worse survival compared with those who had an IHCA before the COVID-19 pandemic. Our findings highlight important differences between these 2 time periods. Further study is needed on cardiac arrest care in patients with COVID-19.

Assessing the effect of arrival time of physician and cardiopulmonary resuscitation (CPR) team on the outcome of CPR

Introduction

Negligence of proper time and poor performance of resuscitation team can lead to more mortality and negative consequences of cardiac arrest, as well as less survival. This study was conducted with objective of determining the arrival time of physician and resuscitation team to survive the victims of cardiopulmonary arrest.

Materials and methods

In this prospective and descriptive-analytic study, the resuscitation performance and the arrival time of resuscitation team in 143 inpatients who had been diagnosed with witnessed cardiopulmonary arrest were examined using a researcher-made checklist. Data analysis was performed using parametric and non-parametric statistical tests and SPSS.

Results

Initial survival rate was 26.6%. In general, the mean time of physician’s presence after the code announcement in minutes and seconds was 02:31 ± 01:22. It was also 02:24 ± 01:15 in successful cases and 02:34 ± 01:25 in unsuccessful cases. Independent t-test did not show a significant difference between the physician’s presence time and the rate of initial successful resuscitation (p = 0.504). The time of first shock after observing ventricular fibrillation/tachycardia (in minutes and seconds) was 01:30 ± 00:47. According to independent t-test, the aforementioned time was less than the mean time (02:31 ± 01:22) of physician’s presence (p < 0.001).

Conclusions

In this study, the initial survival rate in comparison to other regions in the country was almost more favorable and it was similar to global norms. In this study, the starting time of resuscitation was within the acceptable range. There was no relationship between the presence of physician and the initial survival rate of patients, as well as the use of defibrillator (by physician compared to other team members) and intubation with the initial survival rate. This could indicate the adequate performance of resuscitation team in the absence of physician on the condition of having sufficient knowledge and skill.

The role of age in post-cardiac arrest therapy in an elderly patient population

Aim

We investigated the effect of age on post-cardiac arrest treatment outcomes in an elderly population, based on a local database and a systemic review of the literature.

Methods

Data were collected retrospectively from medical charts and reports. Sixty-one comatose patients, cooled to 32-34 °C for 24 h, were categorized into three groups: younger group (≤65 years), older group (66-75 years), and very old group (>75 years). Circumstances of cardiopulmonary resuscitation (CPR), patients' characteristics, post-resuscitation treatment, hemodynamic monitoring, neurologic outcome and survival were compared across age groups. Kruskal-Wallis test, Chi-square test and binary logistic regression (BLR) were applied. In addition, a literature search of PubMed/Medline database was performed to provide a background.

Results

Age was significantly associated with having a cardiac arrest on a monitor and a history of hypertension. No association was found between age and survival or neurologic outcome. Age did not affect hemodynamic parameter changes during target temperature management (TTM), except mean arterial pressure (MAP). Need of catecholamine administration was the highest among very old patients. During the literature review, seven papers were identified. Most studies had a retrospective design and investigated interventions and outcome, but lacked unified age categorization. All studies reported worse survival in the elderly, although old survivors showed a favorable neurologic outcome in most of the cases.

Conclusion

There is no evidence to support the limitation of post-cardiac arrest therapy in the aging population. Furthermore, additional prospective studies are needed to investigate the characteristics and outcome of post-cardiac arrest therapy in this patient group.

Survival and functional outcome at hospital discharge following in-hospital cardiac arrest (IHCA): A prospective multicentre observational study

AIM

To evaluate the functional outcome of patients after in-hospital cardiac arrest (IHCA) and to identify associations with good functional outcome at hospital discharge.

METHOD

Emergency calls were prospectively screened and data collected for IHCAs in seven Australian hospitals. Patients were included if aged > 18 years, admitted as an acute care hospital in-patient and experienced IHCA; defined by a period of unresponsiveness with no observed respiratory effort and commencement of external cardiac compressions. Data collected included patient demographics, clinical and cardiac arrest characteristics, survival and functional outcome at hospital discharge using the modified Rankin Scale (mRS) and Katz Index of Independence in ADLs (Katz-ADL).

RESULTS

152 patients suffered 159 IHCAs (male 66.4%; mean age 70.2 (± 13.9) years). Sixty patients (39.5%) survived, of whom 43 (71.7%) had a good functional outcome (mRS ≤ 3) and 38 (63.3%) were independent with activities of daily living (ADLs) at hospital discharge (Katz-ADL = 6). Younger age (OR 0.95; 95% CI 0.91-0.98; p = 0.003), shorter duration of CPR (OR 0.84; 95% CI 0.77-0.91; p < 0.0001) and shorter duration of hospital admission prior to IHCA (OR 0.96; 95% CI 0.93-0.998; p = 0.04) were independently associated with a good functional outcome at hospital discharge.

CONCLUSION

The majority of survivors had a good functional outcome and were independent with their ADLs at hospital discharge. Factors associated with good functional outcome at hospital discharge were identified.

Program on high value cost-conscious education in intensive care: Educational program on prediction of outcome and cost awareness on Intensive Care admission

BACKGROUND

Intensive Care (ICU) involves extended and long lasting support of vital functions and organs. However, current training programs of ICU residents mainly focus on extended support of vital functions and barely involve training on cost-awareness and outcome. We incorporated an educational program on high-value cost-conscious care for residents and fellows on our ICU and measured the effect of education.

METHODS

A cohort study with factorial survey design, in which ICU residents and fellows were asked to evaluate clinical vignettes, was performed on the mixed surgical-medical ICU of the Amsterdam University Medical Centre. Residents were offered an educational program focusing on outcome and costs of ICU care. Before and after the program they filled out a questionnaire, which consisted of 23 vignettes, in which known predictors of outcome of community acquired pneumonia (CAP), pancreatitis, acute respiratory distress syndrome (ARDS) and cardiac arrest were presented, together with varying patient factors (age, body mass index (BMI), acute kidney failure (AKI) and haemato-oncological malignancy). Participants were asked to either admit the patient or estimate mortality.

RESULTS

BMI, haemato-oncological malignancy and severity of pancreatitis were discriminative for admission to ICU in clinical vignettes on pancreatitis and CAP. After education, only severity of pancreatitis was judged as discriminative. Before the intervention only location of cardiac arrest (in- vs out of hospital) was distinctive for mortality, afterwards this changed to presence of haemato-oncological malignancy.

CONCLUSION

We incorporated an educational program on high-value cost-conscious care in the training of ICU physicians. Based on our vignette study, we conclude that the improvement of knowledge of costs and prognosis after this program was limited.

Nation-Wide Observational Study of Cardiac Arrests Occurring in Nursing Homes and Nursing Facilities in Singapore

Introduction: Nursing home (NH) residents with out-of-hospital cardiac arrests (OHCA) have unique resuscitation priorities. This study aimed to describe OHCA characteristics in NH residents and identify independent predictors of survival. Materials and Methods: OHCA cases between 2010–16 in the Pan-Asian Resuscitation Outcomes Study were retrospectively analysed. Patients aged <18 years old and non-emergency cases were excluded. Primary outcome was survival at discharge or 30 days. Good neurological outcome was defined as a cerebral performance score between 1–2. Results: A total of 12,112 cases were included. Of these, 449 (3.7%) were NH residents who were older (median age 79 years, range 69–87 years) and more likely to have a history of stroke, heart and respiratory diseases. Fewer NH OHCA had presumed cardiac aetiology (62% vs 70%, P <0.01) and initial shockable rhythm (8.9% vs 18%, P <0.01), but had higher incidence of bystander cardiopulmonary resuscitation (74% vs 43%, P <0.01) and defibrillator use (8.5% vs 2.8%, P <0.01). Non-NH (2.8%) residents had better neurological outcomes than NH (0.9%) residents (P <0.05). Factors associated with survival for cardiac aetiology included age <65 years old, witnessed arrest, bystander defibrillator use and initial shockable rhythm; for non-cardiac aetiology, these included witnessed arrest (adjusted odds ratio [AOR] 3.8, P <0.001) and initial shockable rhythm (AOR 5.7, P <0.001). Conclusion: Neurological outcomes were poorer in NH survivors of OHCA. These findings should inform health policies on termination of resuscitation, advance care directives and do-not-resuscitate orders in this population. Ann Acad Med Singapore 2020;49:285–93 Key words: Advance care directives, Do-not-resuscitate orders, Geriatrics, Out-of- hospital, Palliative care