Recommended guidelines for reviewing, reporting, and conducting research on in-hospital resuscitation: the in-hospital 'Utstein style'. A statement for healthcare professionals from the American Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, the Australian Resuscitation Council, and the Resuscitation Councils of Southern Africa

In-hospital cardiac arrest: the state of the art

In-hospital cardiac arrest (IHCA) is associated with a high risk of death, but mortality rates are decreasing. The latest epidemiological and outcome data from several cardiac arrest registries are helping to shape our understanding of IHCA. The introduction of rapid response teams has been associated with a downward trend in hospital mortality. Technology and access to defibrillators continues to progress. The optimal method of airway management during IHCA remains uncertain, but there is a trend for decreasing use of tracheal intubation and increased use of supraglottic airway devices. The first randomised clinical trial of airway management during IHCA is ongoing in the UK. Retrospective and observational studies have shown that several pre-arrest factors are strongly associated with outcome after IHCA, but the risk of bias in such studies makes prognostication of individual cases potentially unreliable. Shared decision making and advanced care planning will increase application of appropriate DNACPR decisions and decrease rates of resuscitation attempts following IHCA.

Factors Associated With In-Hospital Post-Cardiac Arrest Survival in a Referral Level Hospital in Uganda

BACKGROUND

Cardiac arrest (CA) is still associated with high mortality and morbidity across all practice settings despite resuscitation attempts and advancements in its management. Patient outcomes vary and are affected by multiple factors. Nonetheless, there is a paucity of information on survival after CA and associated factors in low-resource settings such as East Africa where Uganda is located. This study set out to describe post-CA survival, associated factors, and neurological outcome at a hospital in Southwestern Uganda.

METHODS

This was a descriptive study in which we followed up with resuscitated CA patients from any of the selected hospital locations at Mbarara Regional Referral Hospital in Southwestern Uganda. We included all patients who were resuscitated after an index CA in the operating room (OR), intensive care unit (ICU), the pediatric ward, or accident and emergency (A&E) wards. Details of resuscitation were obtained from resuscitation team leader interviews and patient medical records. We followed up with patients with return of spontaneous circulation (ROSC) for up to 7 days after CA when neurological outcomes were measured using the age-appropriate Cerebral Performance Category (CPC) score. Factors affecting survival were then determined.

RESULTS

A total of 74 participants were enrolled over 8 months. Seven-day survival was 14.86%. Eight of the 11 survivors had a CPC score of 1 seven days after CA. Admission with trauma was associated with increased mortality with an adjusted hazard ratio (HR) of 4.06; 95% confidence interval (CI), 1.19-13.82. Compared to the A&E ward, HR for index CA in OR, ICU, and pediatric ward was 0.15; 95% CI, 0.05-0.45; 0.67; 95% CI, 0.32-1.40, and 0.65; 95% CI, 0.25-1.69, respectively. Compared to cardiopulmonary resuscitation (CPR) <10 minutes, the HR for CPR duration between 10 and 20 minutes was 2.26; 95% CI, 0.78-3.24 and for >20 minutes was 2.26; 95% CI, 1.12-4.56. Prevention of hypotension after ROSC was associated with decreased mortality with an HR of 0.23; 95% CI, 0.08-0.58.

CONCLUSIONS

Whereas 7-day survival of resuscitated CA patients at Mbarara Regional Referral Hospital (MRRH) was low, survivors had a good neurologic outcome. CA in the OR, CPR <20 minutes, and prevention of hypotension postarrest seemed to be associated with survival.

A national effort to improve outcomes for in-hospital cardiac arrest in China: The BASeline Investigation of Cardiac Arrest (BASIC-IHCA)

Background

In-hospital cardiac arrest (IHCA) is a common clinical event with poor outcomes. Former IHCA registries in China were local, inconsistent in data reporting, and lacked attention to the process of care. Therefore, we designed and implemented the BASeline Investigation of In-hospital Cardiac Arrest (BASIC-IHCA), the first national IHCA registry in China.

Methods

BASIC-IHCA is a prospective, multicenter, observational study with a nationwide surveillance network covering urban and rural hospitals from seven geographic regions of China. IHCA patients were enrolled continuously, and data were collected from medical records by investigators at participating hospitals. Key variables referring to the updated Utstein Template included patient information, event variables, process of care, and outcomes. Follow-up was conducted by telephone interview to obtain details on long-term survival and neurological status.

Results

Thirty-two urban hospitals and eight rural hospitals from twenty-nine provinces in seven geographic regions of China participated in BASIC-IHCA. The starting time of enrollment ranged from July 1, 2019, to January 1, 2020. By December 31, 2020, 35,451 IHCAs were enrolled in all participating hospitals, of which 19,493 (55%) received CPR, with a predominance of males (65%) and a median age of 65 years.

Conclusion

BASIC-IHCA is the first national registry for IHCA in China. It will describe the epidemiology and outcomes of IHCA from a nationwide perspective, with a particular focus on details of the process of care for quality improvement. Meanwhile, it will help to facilitate the standardization of IHCA-related data reporting in China.

Quality of life and functional outcomes after in-hospital cardiopulmonary resuscitation. A systematic review

AIM

Our aim was to determine the association of cardiopulmonary resuscitation (CPR) for in hospital cardiac arrest (IHCA) with quality of life after discharge.

METHODS

We performed a systematic review using available databases for studies that measured any quality-of-life or functional outcome both before and after CPR for IHCA. All screening and data abstraction was performed in duplicate.

RESULTS

We screened 10,927 records and included 24 papers representing 20 unique studies. Fifteen studies measured Cerebral Performance Category. Survival ranged from 11.8% to 39.5%. The risk of impaired cerebral function after discharged ranged from -16.1% (lower risk) to 44.7% increased risk of poor cerebral function after surviving to discharge. Four studies measured discharge to an institutional environment finding that the risk was increased by 18.2-72.2% among survivors. One study measured EQ-5D and found no difference pre and post CPR. One study measured performance of activities of daily living finding that survivors needed assistance with more activities after discharge.

CONCLUSION

Our review is limited by the lack of adjustment for confounders, including the baseline level of each outcome, in all included studies. Therefore, although risk for most outcomes was increased after discharge vs pre-admission we cannot be certain if this is a causal relationship.

Critical Care Unit Organizational and Personnel Factors Impact Cardiac Arrest Prevention and Rescue in the Pediatric Cardiac Population

OBJECTIVES

Patient-level factors related to cardiac arrest in the pediatric cardiac population are well understood but may be unmodifiable. The impact of cardiac ICU organizational and personnel factors on cardiac arrest rates and outcomes remains unknown. We sought to better understand the association between these potentially modifiable organizational and personnel factors on cardiac arrest prevention and rescue.

DESIGN

Retrospective analysis of the Pediatric Cardiac Critical Care Consortium registry.

SETTING

Pediatric cardiac ICUs.

PATIENTS

All cardiac ICU admissions were evaluated for cardiac arrest and survival outcomes.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Successful prevention was defined as the proportion of admissions with no cardiac arrest (inverse of cardiac arrest incidence). Rescue was the proportion of patients surviving to cardiac ICU discharge after cardiac arrest. Cardiac ICU organizational and personnel factors were captured via site questionnaires. The associations between organizational and personnel factors and prevention/rescue were analyzed using Fine-Gray and multinomial regression, respectively, accounting for clustering within hospitals. We analyzed 54,521 cardiac ICU admissions (29 hospitals) with 1,398 cardiac arrest events (2.5%) between August 1, 2014, and March 5, 2019. For both surgical and medical admissions, lower average daily cardiac ICU occupancy was associated with better cardiac arrest prevention. Better rescue for medical admissions was observed for higher registered nursing hours per patient day and lower proportions of "part time" cardiac ICU physician staff (< 6 service weeks/yr). Increased registered nurse experience was associated with better rescue for surgical admissions. Increased proportion of critical care certified nurses, full-time intensivists with critical care fellowship training, dedicated respiratory therapists, quality/safety resources, and annual cardiac ICU admission volume were not associated with improved prevention or rescue.

CONCLUSIONS

Our multi-institutional analysis identified cardiac ICU bed occupancy, registered nurse experience, and physician staffing as potentially important factors associated with cardiac arrest prevention and rescue. Recognizing the limitations of measuring these variables cross-sectionally, additional studies are needed to further investigate these organizational and personnel factors, their interrelationships, and how hospitals can modify structure to improve cardiac arrest outcomes.

Endotracheal Intubation Versus No Endotracheal Intubation During Cardiopulmonary Arrest in the Emergency Department

Background

There is a lack of studies addressing the short and long-term outcomes of using different airway interventions in patients with cardiopulmonary arrest in the emergency department (ED). This retrospective chart review aimed to investigate the effect of endotracheal intubation (ETI) versus no ETI during cardiopulmonary arrest in the ED on return of spontaneous circulation (ROSC) and survival to discharge.

Methodology

A total of 168 charts were reviewed from August 2017 to April 2019. Resuscitation characteristics were obtained from Utstein-style-based cardiopulmonary arrest flow sheets.

Results

Unadjusted analysis showed no difference in ROSC (45.5% in ETI vs. 54.5% in no-ETI) (p = 0.08) and survival to hospital discharge at 28 days (26.7% in ETI vs. 73.3% in non-ETI) (p = 0.07) when comparing ETI versus non-ETI airway management methods during cardiopulmonary resuscitation (CPR). After adjusting for confounding factors, our regression analysis revealed that the use of ETI is associated with lower odds of ROSC (odds ratio [OR] = 3.40, 95% confidence interval [CI] = [0.14-0.84]) and survival to hospital discharge at 28 days (OR = 0.20, 95% CI = [0.04-0.84]).

Conclusions

ETI during CPR in the ED is associated with worse ROSC and survival to hospital discharge at 28 days.

Documentation during neonatal resuscitation: a systematic review

OBJECTIVE

Accurate documentation in healthcare is necessary for ethical, legal, research and quality improvement purposes. In this review, we aimed to evaluate the accuracy of methods of documentation of delivery room resuscitations.

METHODS

A systematic literature search in MEDLINE was conducted to identify original studies that reported the quality of documentation records during newborn resuscitation in the delivery room. Data extracted from the studies included population characteristics, methodology, documentation protocols, use of gold standard and main results (initial assessment of heart rate and peripheral oxygen saturation, respiratory support and supplementary oxygen).

RESULTS

In total, 197 records were screened after initial database search, of which seven studies met the inclusion criteria and were finally included in this review. Four studies were chart reviews and three studies compared conventional documentation methods with video recording. Only one study tested an intervention to improve documentation. Documentation was often inaccurate and important resuscitation events and interventions were poorly recorded. Lack of uniformity among studies preclude pooled analysis, but it seems that complex or advanced procedures were more accurately reported than basic interventions.

CONCLUSIONS

There is little literature regarding accuracy of documentation during neonatal resuscitation, but current quality of documentation seems to be unsatisfactory. There is a need for consensus guidelines and innovative solutions in newborn resuscitation documentation.

Utstein Style for emergency care - the first 30 years

BACKGROUND

Utstein Abbey near Stavanger in Norway, hosted a meeting in 1990 on guidelines for the uniform reporting of data from out-of-hospital cardiac arrest. In this paper we describe the last 30 years of the Utstein style.

METHODS

A systematic literature search identified publications from Utstein-style meetings or groups using the Utstein format.

RESULTS

30 outputs were found, describing primarily resuscitation structure, process and outcome measures. They originated from all over the world and from multiple medical disciplines. Some were co-published in multiple journals.

CONCLUSIONS

The meeting at Utstein Abbey in 1990 has had a sustained and far-reaching impact, particularly in resuscitation science, implementation and outcomes. The Utstein format will continue to evolve following the key principles from the original meeting and with the ultimate aim of improving patient care and outcomes.

Out-of-hospital cardiac arrest across the World: First report from the International Liaison Committee on Resuscitation (ILCOR)

BACKGROUND

Since development of the Utstein style recommendations for the uniform reporting of cardiac arrest, increasing numbers of national and regional out-of-hospital cardiac arrest (OHCA) registries have been established worldwide. The International Liaison Committee on Resuscitation (ILCOR) created the Research and Registries Working Group and aimed to systematically report data collected from these registries.

METHODS

We conducted two surveys of voluntarily participating national and regional registries. The first survey aimed to identify which core elements of the current Utstein style for OHCA were collected by each registry. The second survey collected descriptive summary data from each registry. We chose the data collected for the second survey based on the availability of core elements identified by the first survey.

RESULTS

Seven national and four regional registries were included in the first survey and nine national and seven regional registries in the second survey. The estimated annual incidence of emergency medical services (EMS)-treated OHCA was 30.0-97.1 individuals per 100,000 population. The combined data showed the median age varied from 64 to 79 years and more than half were male in all 16 registries. The provision of bystander cardiopulmonary resuscitation (CPR) and bystander automated external defibrillator (AED) use was 19.1-79.0% in all registries and 2.0-37.4% among 11 registries, respectively. Survival to hospital discharge or 30-day survival after EMS-treated OHCA was 3.1-20.4% across all registries. Favorable neurological outcome at hospital discharge or 30 days after EMS-treated OHCA was 2.8-18.2%. Survival to hospital discharge or 30-day survival after bystander-witnessed shockable OHCA ranged from 11.7% to 47.4% and favorable neurological outcome from 9.9% to 33.3%.

CONCLUSION

This report from ILCOR describes data on systems of care and outcomes following OHCA from nine national and seven regional registries across the world. We found variation in reported survival outcomes and other core elements of the current Utstein style recommendations for OHCA across nations and regions.

Trends Over Time in Drug Administration During Adult In-Hospital Cardiac Arrest

OBJECTIVES

Clinical providers have access to a number of pharmacologic agents during in-hospital cardiac arrest. Few studies have explored medication administration patterns during in-hospital cardiac arrest. Herein, we examine trends in use of pharmacologic interventions during in-hospital cardiac arrest both over time and with respect to the American Heart Association Advanced Cardiac Life Support guideline updates.

DESIGN

Observational cohort study.

SETTING

Hospitals contributing data to the American Heart Association Get With The Guidelines-Resuscitation database between 2001 and 2016.

PATIENTS

Adult in-hospital cardiac arrest patients.

INTERVENTIONS

The percentage of patients receiving epinephrine, vasopressin, amiodarone, lidocaine, atropine, bicarbonate, calcium, magnesium, and dextrose each year were calculated in patients with shockable and nonshockable initial rhythms. Hierarchical multivariable logistic regression was used to determine the annual adjusted odds of medication administration. An interrupted time series analysis was performed to assess change in atropine use after the 2010 American Heart Association guideline update.

MEASUREMENTS AND MAIN RESULTS

A total of 268,031 index in-hospital cardiac arrests were included. As compared to 2001, the adjusted odds ratio of receiving each medication in 2016 were epinephrine (adjusted odds ratio, 1.5; 95% CI, 1.3-1.8), vasopressin (adjusted odds ratio, 1.5; 95% CI, 1.1-2.1), amiodarone (adjusted odds ratio, 3.4; 95% CI, 2.9-4.0), lidocaine (adjusted odds ratio, 0.2; 95% CI, 0.2-0.2), atropine (adjusted odds ratio, 0.07; 95% CI, 0.06-0.08), bicarbonate (adjusted odds ratio, 2.0; 95% CI, 1.8-2.3), calcium (adjusted odds ratio, 2.0; 95% CI, 1.7-2.3), magnesium (adjusted odds ratio, 2.2; 95% CI, 1.9-2.7; p < 0.0001), and dextrose (adjusted odds ratio, 2.8; 95% CI, 2.3-3.4). Following the 2010 American Heart Association guideline update, there was a downward step change in the intercept and slope change in atropine use (p < 0.0001).

CONCLUSIONS

Prescribing patterns during in-hospital cardiac arrest have changed significantly over time. Changes to American Heart Association Advanced Cardiac Life Support guidelines have had a rapid and substantial effect on the use of a number of commonly used in-hospital cardiac arrest medications.

Cardiac Arrest and Cardiopulmonary Resuscitation Outcome Reports: Update of the Utstein Resuscitation Registry Template for In-Hospital Cardiac Arrest: A Consensus Report From a Task Force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian and New Zealand Council on Resuscitation, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, Resuscitation Council of Asia)

Utstein-style reporting templates provide a structured framework with which to compare systems of care for cardiac arrest. The 2004 Utstein reporting template encompassed both out-of-hospital and in-hospital cardiac arrest. A 2015 update of the Utstein template focused on out-of-hospital cardiac arrest, which makes this update of the in-hospital template timely. Representatives of the International Liaison Committee on Resuscitation developed an updated in-hospital Utstein reporting template iteratively by meeting face-to-face, by teleconference, and by online surveys between 2013 and 2018. Data elements were grouped by hospital factors, patient variables, pre-event factors, cardiac arrest and postresuscitation processes, and outcomes. Elements were classified as core or supplemental by use of a modified Delphi process. Variables were described as core if they were considered essential. Core variables should enable reasonable comparisons between systems and are considered essential for quality improvement programs. Together with core variables, supplementary variables are considered useful for research.

The Danish in-hospital cardiac arrest registry (DANARREST)

Aim of database: The aim of DANARREST is to collect data on processes of care and outcomes for patients with in-hospital cardiac arrest in Denmark, and thereby facilitate and monitor quality and quality improvement initiatives. Study population: In-hospital cardiac arrest patients with a clinical indication for cardiopulmonary resuscitation in Denmark. Main variables: DANARREST includes a number of descriptive variables as well as seven quality of care indicators; four related to processes of care and three related to clinical outcomes. The four process measures are related to whether the cardiac arrest was witnessed, whether the cardiac arrest was ECG-monitored, the timing of cardiopulmonary resuscitation, and the timing of the first rhythm analysis. The three outcomes measures include return of spontaneous circulation, 30-day survival, and 1-year survival. Database status: DANARREST started in 2013, and the coverage has increased steadily since. As of 2017, 95% of relevant hospitals are reporting data with an estimated coverage rate of approximately 80%. Conclusion: DANARREST is a relatively new national registry of in-hospital cardiac arrests in Denmark, with a high coverage rate. The registry provides an opportunity to monitor and improve quality of care for patients with in-hospital cardiac arrest.

The incidence of cardiac arrest in the intensive care unit: A systematic review and meta-analysis

The incidence of cardiac arrest in the intensive care unit (ICU-CA) has not been widely reported. We undertook a systematic review and meta-analysis of studies reporting the incidence of cardiac arrest in adult, general intensive care units. The review was prospectively registered with PROSPERO (CRD42017079717). The search identified 7550 records, which included 20 relevant studies for qualitative analysis and 16 of these were included for quantitative analyses. The reported incidence of ICU-CA was 22.7 per 1000 admissions (95% CI: 17.4-29.6) with survival to hospital discharge of 17% (95% CI: 9.5-28.5%). We estimate that at least 5446 patients in the UK have a cardiac arrest after ICU admission. There are limited data and significant variation in the incidence of ICU-CA and efforts to synthesise these are limited by inconsistent reporting. Further prospective studies with standardised process and incidence measures are required to define this important patient group.

Assessment of serum biomarkers and coagulation/fibrinolysis markers for prediction of neurological outcomes of out of cardiac arrest patients treated with therapeutic hypothermia

Objective

Despite increased survival in patients with cardiac arrest, it remains difficult to determine patient prognosis at the early stage. This study evaluated the prognosis of cardiac arrest patients using brain injury, inflammation, cardiovascular ischemic events, and coagulation/fibrinolysis markers collected 24, 48, and 72 hours after return of spontaneous circulation (ROSC).

Methods

From January 2011 to December 2016, we retrospectively observed patients who underwent therapeutic hypothermia. Blood samples were collected immediately and 24, 48, and 72 hours after ROSC. Neuron-specific enolase (NSE), S100-B protein, procalcitonin, troponin I, creatine kinase-MB, pro-brain natriuretic protein, D-dimer, fibrin degradation product, antithrombin-III, fibrinogen, and lactate levels were measured. Prognosis was evaluated using Glasgow-Pittsburgh cerebral performance categories and the predictive accuracy of each marker was evaluated. The secondary outcome was whether the presence of multiple markers improved prediction accuracy.

Results

A total of 102 patients were included in the study: 39 with good neurologic outcomes and 63 with poor neurologic outcomes. The mean NSE level of good outcomes measured 72 hours after ROSC was 18.50 ng/mL. The area under the curve calculated on receiver operating characteristic analysis was 0.92, which showed the best predictive power among all markers included in the study analysis. The relative integrated discrimination improvement and category-free net reclassification improvement models showed no improvement in prognostic value when combined with all other markers and NSE (72 hours).

Conclusion

Although biomarker combinations did not improve prognostic accuracy, NSE (72 hours) showed the best predictive power for neurological prognosis in patients who received therapeutic hypothermia.

Emergency Airway Response Team (EART) Documentation: Criteria, Feasibility, and Usability

Patients in an acute care hospital who experience a difficult airway event outside the operating room need a specialized emergency airway response team (EART) immediately. This designated team manages catastrophic airway events using advanced airway techniques as well as surgical intervention. Nurses respond as part of this team. There are no identified difficult airway team documentation instruments in the literature, and the lack of metrics limits the quality review of the team response. This study identified EART documentation criteria and incorporated them into a nursing documentation instrument to be completed by a nurse scribe during the event. The EART instrument was tested by nurses for usability, feasibility, and completeness. Twenty-one critical care nurses participated in this study. The results confirmed good usability, positive feasibility, and 79% documentation completeness using this tool. These criteria and this instrument can be important in documenting the EART and in evaluating the quality of the team performance.

Prognostic value of computed tomography score in patients after extracorporeal cardiopulmonary resuscitation

BACKGROUND

We evaluated whether Alberta Stroke Program Early Computed Tomography Score (ASPECTS) with some modifications could be used to predict neurological outcomes in patients after extracorporeal cardiopulmonary resuscitation (ECPR).

METHODS

This was a retrospective, multicenter, observational study of adult unconscious patients who were evaluated by brain computed tomography (CT) within 48 hours after ECPR between May 2010 and December 2016. ASPECTS, bilateral ASPECTS (ASPECTS-b), and modified ASPECTS (mASPECTS) were assessed by ROC curves to predict neurological outcomes. The primary outcome was neurological status upon hospital discharge assessed with the Cerebral Performance Categories (CPC) scale.

RESULTS

Among 58 unconscious patients, survival to discharge was identified in 25 (43.1%) patients. Of these 25 survivors, 19 (32.8%) had good neurological outcomes (CPC score of 1 or 2). Interrater reliability of CT scores was excellent. Intraclass correlation coefficients of ASPECTS, ASPECTS-b, and mASPECTS were 0.918 (95% CI, 0.865-0.950), 0.918 (95% CI, 0.866-0.951), and 0.915 (95% CI, 0.860-0.949), respectively. The predictive performance of mASPECTS for poor neurological outcome was better than that of ASPECTS or ASPECTS-b (C-statistic for mASPECTS vs. ASPECTS, 0.922 vs. 0.812, p = 0.004; mASPECTS vs. ASPECTS-b, 0.922 vs. 0.818, p = 0.003). A cutoff of 25 for poor neurological outcome had a sensitivity of 84.6% (95% CI, 69.5-94.1%) and a specificity of 89.5% (95% CI, 66.9-98.7%) in mASPECTS.

CONCLUSIONS

mASPECTS might be useful for predicting neurological outcomes in patients after ECPR.

Design and Deployment of a Pediatric Cardiac Arrest Surveillance System

Objective

We aimed to increase detection of pediatric cardiopulmonary resuscitation (CPR) events and collection of physiologic and performance data for use in quality improvement (QI) efforts.

Materials and Methods

We developed a workflow-driven surveillance system that leveraged organizational information technology systems to trigger CPR detection and analysis processes. We characterized detection by notification source, type, location, and year, and compared it to previous methods of detection.

Results

From 1/1/2013 through 12/31/2015, there were 2,986 unique notifications associated with 2,145 events, 317 requiring CPR. PICU and PEDS-ED accounted for 65% of CPR events, whereas floor care areas were responsible for only 3% of events. 100% of PEDS-OR and >70% of PICU CPR events would not have been included in QI efforts. Performance data from both defibrillator and bedside monitor increased annually. (2013: 1%; 2014: 18%; 2015: 27%).

Discussion

After deployment of this system, detection has increased ∼9-fold and performance data collection increased annually. Had the system not been deployed, 100% of PEDS-OR and 50–70% of PICU, NICU, and PEDS-ED events would have been missed.

Conclusion

By leveraging hospital information technology and medical device data, identification of pediatric cardiac arrest with an associated increased capture in the proportion of objective performance data is possible.

Derivation and Internal Validation of a Mortality Prediction Tool for Initial Survivors of Pediatric In-Hospital Cardiac Arrest

OBJECTIVES

To develop a clinical prediction score for predicting mortality in children following return of spontaneous circulation after in-hospital cardiac arrest.

DESIGN

Observational study using prospectively collected data.

SETTING

This was an analysis using data from the Get With The Guidelines-Resuscitation registry between January 2000 and December 2015.

PATIENTS

Pediatric patients (< 18 yr old) who achieved return of spontaneous circulation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was in-hospital mortality. Patients were divided into a derivation (3/4) and validation (1/4) cohort. A prediction score was developed using a multivariable logistic regression model with backward selection. Patient and event characteristics for the derivation cohort (n = 3,893) and validation cohort (n = 1,297) were similar. Seventeen variables associated with the outcome remained in the final reduced model after backward elimination. Predictors of in-hospital mortality included age, illness category, pre-event characteristics, arrest location, day of the week, nonshockable pulseless rhythm, duration of chest compressions, and interventions in place at time of arrest. The C-statistic for the final score was 0.77 (95% CI, 0.75-0.78) in the derivation cohort and 0.77 (95% CI, 0.74-0.79) in the validation cohort. The expected versus observed mortality plot indicated good calibration in both the derivation and validation cohorts. The score showed a stepwise increase in mortality with an observed mortality of less than 15% for scores 0-9 and greater than 80% for scores greater than or equal to 25. The model also performed well for neurologic outcome and in sensitivity analyses for events within the past 5 years and for patients with or without a pulse at the onset of chest compressions.

CONCLUSIONS

We developed and internally validated a prediction score for initial survivors of pediatric in-hospital cardiac arrest. This prediction score may be useful for prognostication following cardiac arrest, stratifying patients for research, and guiding quality improvement initiatives.

The STAR Data Reporting Guidelines for Clinical High Altitude Research

Brodmann Maeder, Monika, Hermann Brugger, Matiram Pun, Giacomo Strapazzon, Tomas Dal Cappello, Marco Maggiorini, Peter Hackett, Peter Baärtsch, Erik R. Swenson, Ken Zafren (STAR Core Group), and the STAR Delphi Expert Group. The STARdata reporting guidelines for clinical high altitude research. High AltMedBiol. 19:7-14, 2018.

AIMS

The goal of the STAR (STrengthening Altitude Research) initiative was to produce a uniform set of key elements for research and reporting in clinical high-altitude (HA) medicine. The STAR initiative was inspired by research on treatment of cardiac arrest, in which the establishment of the Utstein Style, a uniform data reporting protocol, substantially contributed to improving data reporting and subsequently the quality of scientific evidence.

MATERIALS AND METHODS

The STAR core group used the Delphi method, in which a group of experts reaches a consensus over multiple rounds using a formal method. We selected experts in the field of clinical HA medicine based on their scientific credentials and identified an initial set of parameters for evaluation by the experts.

RESULTS

Of 51 experts in HA research who were identified initially, 21 experts completed both rounds. The experts identified 42 key parameters in 5 categories (setting, individual factors, acute mountain sickness and HA cerebral edema, HA pulmonary edema, and treatment) that were considered essential for research and reporting in clinical HA research. An additional 47 supplemental parameters were identified that should be reported depending on the nature of the research.

CONCLUSIONS

The STAR initiative, using the Delphi method, identified a set of key parameters essential for research and reporting in clinical HA medicine.

Survival factors of hospitalized out-of-hospital cardiac arrest patients in Taiwan: A retrospective study

The chain of survival has been shown to improve the chances of survival for victims of cardiac arrest. Post-cardiac arrest care has been demonstrated to significantly impact the survival of out-of-hospital cardiac arrest (OHCA). How post-cardiac arrest care influences the survival of OHCA patients has been a main concern in recent years. The objective of this study was to assess the survival outcome of hospitalized OHCA patients and determine the factors associated with improved survival in terms of survival to discharge. We conducted a retrospective observational study by analyzing records from the National Health Insurance Research Database of Taiwan from 2007 to 2013. We collected cases with an International Classification of Disease Clinical Modification, 9^threvision primary diagnosis codes of 427.41 (ventricular fibrillation, VF) or 427.5 (cardiac arrest) and excluded patients less than 18 years old, as well as cases with an unknown outcome or a combination of traumatic comorbidities. We then calculated the proportion of survival to discharge among hospitalized OHCA patients. Factors associated with the dependent variable were examined by logistic regression. Statistical analysis was conducted using SPSS 22 (IBM, Armonk, NY). Of the 11,000 cases, 2,499 patients (22.7%) survived to hospital discharge. The mean age of subjects who survived to hospital discharge and those who did not was 66.7±16.7 and 71.7±15.2 years, respectively. After adjusting for covariates, neurological failure, cardiac comorbidities, hospital level, intensive care unit beds, transfer to another hospital, and length of hospital stay were independent predictors of improved survival. Cardiac rhythm on admission was a strong factor associated with survival to discharge (VF vs. non-VF: adjusted odds ratio: 3.51; 95% confidence interval: 3.06–4.01). In conclusion, cardiac comorbidities, hospital volume, cardiac rhythm on admission, transfer to another hospital and length of hospital stay had a significant positive association with survival to discharge in hospitalized OHCA patients in Taiwan.

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

Introduction

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

Methods

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

Results

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

Conclusions

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

The International Liaison Committee on Resuscitation-Review of the last 25 years and vision for the future

2017 marks the 25th anniversary of the International Liaison Committee on Resuscitation (ILCOR). ILCOR was formed in 1992 to create a forum for collaboration among principal resuscitation councils worldwide. Since then, ILCOR has established and distinguished itself for its pioneering vision and leadership in resuscitation science. By systematically assessing the evidence for resuscitation standards and guidelines and by identifying national and regional differences, ILCOR reached consensus on international resuscitation guidelines in 2000, and on international science and treatment recommendations in 2005, 2010 and 2015. However, local variation and contextualization of guidelines are evident by subtle differences in regional and national resuscitation guidelines. ILCOR's efforts to date have enhanced international cooperation, and progressively more transparent and systematic collection and analysis of pertinent scientific evidence. Going forward, this sets the stage for ILCOR to pursue its vision to save more lives globally through resuscitation.

Outcome of in- and out-of-hospital cardiac arrest survivors with liver cirrhosis

Background

Organ failure increases mortality in patients with liver cirrhosis. Data about resuscitated cardiac arrest patients with liver cirrhosis are missing. This study aims to assess aetiology, survival and functional outcome in patients after successful cardiopulmonary resuscitation (CPR) with and without liver cirrhosis.

Methods

Analysis of prospectively collected cardiac arrest registry data of consecutively hospital-admitted patients following successful CPR was performed. Patient’s characteristics, admission diagnosis, severity of disease, course of disease, short- and long-term mortality as well as functional outcome were assessed and compared between patients with and without cirrhosis.

Results

Out of 1068 patients with successful CPR, 47 (4%) had liver cirrhosis. Acute-on-chronic liver failure (ACLF) was present in 33 (70%) of these patients on admission, and four patients developed ACLF during follow-up. Mortality at 1 year was more than threefold increased in patients with liver cirrhosis (OR 3.25; 95% CI 1.33–7.96). Liver cirrhosis was associated with impaired neurological outcome (OR for a favourable cerebral performance category: 0.13; 95% CI 0.04–0.36). None of the patients with Child–Turcotte–Pugh (CTP) C cirrhosis survived 28 days with good neurological outcome. Overall nine (19%) patients with cirrhosis survived 28 days with good neurological outcome. All patients with ACLF grade 3 died within 28 days.

Conclusion

Cardiac arrest survivors with cirrhosis have worse outcome than those without. Although one quarter of patients with liver cirrhosis survived longer than 28 days after successful CPR, patients with CTP C as well as advanced ACLF did not survive 28 days with good neurological outcome.

Electronic supplementary material

The online version of this article (doi:10.1186/s13613-017-0322-1) contains supplementary material, which is available to authorized users.

Physiologic monitoring of CPR quality during adult cardiac arrest: A propensity-matched cohort study

AIM

The American Heart Association (AHA) recommends monitoring cardiopulmonary resuscitation (CPR) quality using end tidal carbon dioxide (ETCO2) or invasive hemodynamic data. The objective of this study was to evaluate the association between clinician-reported physiologic monitoring of CPR quality and patient outcomes.

METHODS

Prospective observational study of index adult in-hospital CPR events using the AHA's Get With The Guidelines - Resuscitation Registry. Physiologic monitoring was defined using specific database questions regarding use of either ETCO2 or arterial diastolic blood pressure (DBP) to monitor CPR quality. Logistic regression was used to evaluate the association between physiologic monitoring and outcomes in a propensity score matched cohort.

RESULTS

In the matched cohort, (monitored n=3032; not monitored n=6064), physiologic monitoring of CPR quality was associated with a higher rate of return of spontaneous circulation (ROSC; OR 1.22, CI95 1.04-1.43, p=0.017) compared to no monitoring. Survival to hospital discharge (OR 1.04, CI95 0.91-1.18, p=0.57) and survival with favorable neurological outcome (OR 0.97, CI95 0.75-1.26, p=0.83) were not different between groups. Of index events with only ETCO2 monitoring indicated (n=803), an ETCO2 >10mmHg during CPR was reported in 520 (65%), and associated with improved survival to hospital discharge (OR 2.41, CI95 1.35-4.30, p=0.003), and survival with favorable neurological outcome (OR 2.31, CI95 1.31-4.09, p=0.004) compared to ETCO2 ≤10mmHg.

CONCLUSION

Clinician-reported use of either ETCO2 or DBP to monitor CPR quality was associated with improved ROSC. An ETCO2 >10mmHg during CPR was associated with a higher rate of survival compared to events with ETCO2 ≤10mmHg.

Use of S-100B, NSE, CRP and ESR to predict neurological outcomes in patients with return of spontaneous circulation and treated with hypothermia

BACKGROUND

With the introduction of therapeutic hypothermia (TH), the prediction of neurological outcomes in cardiac arrest (CA) survivors is challenging. Early, accurate determination of prognosis by emergency physicians is important to avoid unnecessarily prolonged critical care with a likely poor neurological outcome.

METHODS

This prospective observational study included patients with non-traumatic CA and return of spontaneous circulation (ROSC) between March 2009 and May 2012 at a tertiary academic hospital. Unconscious patients with ROSC were treated with mild TH (32°C-34°C) for 24 hours. Blood samples were collected for S-100B, neuron-specific enolase (NSE), C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) at 0, 24 and 48 hours post-ROSC. Neurological outcomes were evaluated at hospital discharge and dichotomised as good (cerebral performance category (CPC) 1 or 2) or poor (CPC 3, 4 or 5).

RESULTS

Of the 119 patients (68.1% male, 53±15.6 years old) who underwent TH, 46 patients had a good outcome (38.9%). Poor neurological outcomes were predicted using receiver operating characteristic analyses at cut-off values of 0.12 g/L for S-100B at 24 hours post-ROSC (sensitivity, 95.0%; specificity, 75.6%; area under the curve (AUC) 0.916; 95% CI of AUC: 0.846 to 0.961), 31.03 ng/mL for NSE at 48 hours post-ROSC (sensitivity, 83.9%; specificity, 96.9%; AUC 0.929; 95% CI of AUC: 0.836 to 0.979) and 11.2 mg/dL for CRP at 48 hours post-ROSC (sensitivity, 69.4%; specificity, 75.0%; AUC 0.731; 95% CI of AUC: 0.617 to 0.827). ESR was not significant.

CONCLUSIONS

Among the biomarkers, S-100B at 24 hours and NSE at 48 hours post-ROSC were highly predictive of neurological outcomes in patients treated with TH after CA.

Outcomes Following Single and Recurrent In-Hospital Cardiac Arrests in Children With Heart Disease: A Report From American Heart Association's Get With the Guidelines Registry-Resuscitation

OBJECTIVES

Little is known regarding patient characteristics and outcomes associated with cardiac arrest in hospitalized children with underlying heart disease. We described clinical characteristics and in-hospital outcomes in cardiac patients with both single and recurrent cardiac arrests.

DESIGN

Retrospective analysis evaluating characteristics and outcomes in single versus recurrent arrest groups in unadjusted and adjusted analyses.

SETTING

American Heart Association's Get with the Guidelines-Resuscitation registry (2000-2010).

PATIENTS

Children younger than 18 years, identified with medical or surgical cardiac disease and one or more in-hospital cardiac arrest.

INTERVENTIONS

None.

MEASUREMENT AND MAIN RESULTS

One thousand eight hundred and eighty-nine patients with 2,387 cardiac arrests from 157 centers met inclusion criteria: 1,546 (82%) with a single arrest and 343 (18%) with a recurrent arrest. More than two thirds of recurrent cardiac arrests occurred in ICUs, and those with recurrent arrest had a higher prevalence of baseline comorbidities (e.g., more likely to be mechanically ventilated and receiving vasoactive infusions). Overall survival to hospital discharge was 51%, and was lower in the recurrent versus single arrest group (41% vs 53%; p < 0.001). In analysis adjusted for baseline comorbidities, there was no longer a statistically significant association between recurrent arrest and survival (odds ratio, 0.74; 95% CI, 0.33-1.63; p = 0.45). In stratified analysis, the relationship between recurrent arrest and lower survival was more prominent in the surgical-cardiac (odds ratio, 0.39; 95% CI, 0.14-1.11; p = 0.09) versus medical-cardiac (odds ratio, 0.96; 95% CI, 0.28-3.30; p = 0.95) group.

CONCLUSIONS

In this large multicenter study, half of pediatric cardiac patients who suffered a cardiac arrest survived to hospital discharge. Lower survival in the group with recurrent arrest may be explained in part by the higher prevalence of baseline comorbidities in these patients, and surgical cardiac patients appeared to be at greatest risk. Further study is necessary to develop strategies to reduce subsequent mortality in these high-risk patients.

Early administration of epinephrine (adrenaline) in patients with cardiac arrest with initial shockable rhythm in hospital: propensity score matched analysis

OBJECTIVES

To evaluate whether patients who experience cardiac arrest in hospital receive epinephrine (adrenaline) within the two minutes after the first defibrillation (contrary to American Heart Association guidelines) and to evaluate the association between early administration of epinephrine and outcomes in this population.

DESIGN

Prospective observational cohort study.

SETTING

Analysis of data from the Get With The Guidelines-Resuscitation registry, which includes data from more than 300 hospitals in the United States.

PARTICIPANTS

Adults in hospital who experienced cardiac arrest with an initial shockable rhythm, including patients who had a first defibrillation within two minutes of the cardiac arrest and who remained in a shockable rhythm after defibrillation.

INTERVENTION

Epinephrine given within two minutes after the first defibrillation.

MAIN OUTCOME MEASURES

Survival to hospital discharge. Secondary outcomes included return of spontaneous circulation and survival to hospital discharge with a good functional outcome. A propensity score was calculated for the receipt of epinephrine within two minutes after the first defibrillation, based on multiple characteristics of patients, events, and hospitals. Patients who received epinephrine at either zero, one, or two minutes after the first defibrillation were then matched on the propensity score with patients who were "at risk" of receiving epinephrine within the same minute but who did not receive it.

RESULTS

2978 patients were matched on the propensity score, and the groups were well balanced. 1510 (51%) patients received epinephrine within two minutes after the first defibrillation, which is contrary to current American Heart Association guidelines. Epinephrine given within the first two minutes after the first defibrillation was associated with decreased odds of survival in the propensity score matched analysis (odds ratio 0.70, 95% confidence interval 0.59 to 0.82; P<0.001). Early epinephrine administration was also associated with a decreased odds of return of spontaneous circulation (0.71, 0.60 to 0.83; P<0.001) and good functional outcome (0.69, 0.58 to 0.83; P<0.001).

CONCLUSION

Half of patients with a persistent shockable rhythm received epinephrine within two minutes after the first defibrillation, contrary to current American Heart Association guidelines. The receipt of epinephrine within two minutes after the first defibrillation was associated with decreased odds of survival to hospital discharge as well as decreased odds of return of spontaneous circulation and survival to hospital discharge with a good functional outcome.

Emergency care within hospitals: can it be done more efficiently?

INTRODUCTION

Cardiac Arrest Teams (CATs) are frequently activated by nurses when patients experience 'false arrests' (FAs). In those cases activation of the Rapid Response Team (RRT) might be more efficient. The authors determined the level of urgency of FAs to find a scope for improvement in efficiency within emergency care.

METHODS

CAT-activations for FAs in a university hospital from September 2009 to 2012 were retrospectively analysed and classified as urgent or less-urgent.

RESULTS

In 26% (107/405) the CAT was activated for FAs. Calls were classified as urgent in 43% (46/107). Less urgent calls comprised 57% (61/107) of the FAs, difference 14% (95%CI: 1% to 26%).

CONCLUSIONS

A significant part of the CAT-activations for FAs were less urgent and an RRT-activation might be more efficient. To minimise the CAT-activations for FAs, nurses need to recognise early patients who clinically deteriorate. Therefore, nurses should use the Modified Early Warning Score correctly.

Review and Outcome of Prolonged Cardiopulmonary Resuscitation

The maximal duration of cardiopulmonary resuscitation (CPR) is unknown. We report a case of prolonged CPR. We have then reviewed all published cases with CPR duration equal to or more than 20 minutes. The objective was to determine the survival rate, the neurological outcome, and the characteristics of the survivors. Measurements and Main Results. The CPR data for 82 patients was reviewed. The median duration of CPR was 75 minutes. Patients mean age was 43 ± 21 years with no significant comorbidities. The main causes of the cardiac arrests were myocardial infarction (29%), hypothermia (21%), and pulmonary emboli (12%). 74% of the arrests were witnessed, with a mean latency to CPR of 2 ± 6 minutes and good quality chest compression provided in 96% of the cases. Adjunct therapy included extracorporeal membrane oxygenation (18%), thrombolysis (15.8%), and rewarming for hypothermia (19.5%). 83% were alive at 1 year, with full neurological recovery reported in 63 patients. Conclusion. Patients undergoing prolonged CPR can survive with good outcome. Young age, myocardial infarction, and potentially reversible causes of cardiac arrest such as hypothermia and pulmonary emboli predict a favorable result, especially when the arrest is witnessed and followed by prompt and good resuscitative efforts.

Clinical Prediction Rule for Patient Outcome after In-Hospital CPR: A New Model, Using Characteristics Present at Hospital Admission, to Identify Patients Unlikely to Benefit from CPR after In-Hospital Cardiac Arrest

BACKGROUND

Physicians and patients frequently overestimate likelihood of survival after in-hospital cardiopulmonary resuscitation. Discussions and decisions around resuscitation after in-hospital cardiopulmonary arrest often take place without adequate or accurate information.

METHODS

We conducted a retrospective chart review of 470 instances of resuscitation after in-hospital cardiopulmonary arrest. Individuals were randomly assigned to a derivation cohort and a validation cohort. Logistic Regression and Linear Discriminant Analysis were used to perform multivariate analysis of the data. The resultant best performing rule was converted to a weighted integer tool, and thresholds of survival and nonsurvival were determined with an attempt to optimize sensitivity and specificity for survival.

RESULTS

A 10-feature rule, using thresholds for survival and nonsurvival, was created; the sensitivity of the rule on the validation cohort was 42.7% and specificity was 82.4%. In the Dartmouth Score (DS), the features of age (greater than 70 years of age), history of cancer, previous cardiovascular accident, and presence of coma, hypotension, abnormal PaO2, and abnormal bicarbonate were identified as the best predictors of nonsurvival. Angina, dementia, and chronic respiratory insufficiency were selected as protective features.

CONCLUSIONS

Utilizing information easily obtainable on admission, our clinical prediction tool, the DS, provides physicians individualized information about their patients' probability of survival after in-hospital cardiopulmonary arrest. The DS may become a useful addition to medical expertise and clinical judgment in evaluating and communicating an individual's probability of survival after in-hospital cardiopulmonary arrest after it is validated by other cohorts.

The time dependent association of adrenaline administration and survival from out-of-hospital cardiac arrest

BACKGROUND

Recommended for decades, the therapeutic value of adrenaline (epinephrine) in the resuscitation of patients with out-of-hospital cardiac arrest (OHCA) is controversial.

PURPOSE

To investigate the possible time-dependent outcomes associated with adrenaline administration by Emergency Medical Services personnel (EMS).

METHODS

A retrospective analysis of prospectively collected data from a near statewide cardiac resuscitation database between 1 January 2005 and 30 November 2013. Multivariable logistic regression was used to analyze the effect of the time interval between EMS dispatch and the initial dose of adrenaline on survival. The primary endpoints were survival to hospital discharge and favourable neurologic outcome.

RESULTS

Data from 3469 patients with witnessed OHCA were analyzed. Their mean age was 66.3 years and 69% were male. An initially shockable rhythm was present in 41.8% of patients. Based on a multivariable logistic regression model with initial adrenaline administration time interval (AATI) from EMS dispatch as the covariate, survival was greatest when adrenaline was administered very early but decreased rapidly with increasing (AATI); odds ratio 0.94 (95% Confidence Interval (CI) 0.92-0.97). The AATI had no significant effect on good neurological outcome (OR=0.96, 95% CI=0.90-1.02).

CONCLUSIONS

In patients with OHCA, survival to hospital discharge was greater in those treated early with adrenaline by EMS especially in the subset of patients with a shockable rhythm. However survival rapidly decreased with increasing adrenaline administration time intervals (AATI).

In-hospital pediatric cardiac arrest in Honduras

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Temporal trends in cardiac arrest incidence and outcome in Finnish intensive care units from 2003 to 2013

PURPOSE

To estimate temporal trends in incidence and hospital mortality after cardiac arrest in Finnish intensive care units.

METHODS

Using a large nationwide intensive care unit (ICU) database we identified patients suffering from cardiac arrest following ICU admission (ICU-CA) during the study period (2003-2013). ICU-CA was defined as need for cardiopulmonary resuscitation and/or defibrillation (non-arrest cardioversions were excluded) according to the Therapeutic Intervention Scoring System-76. Patients admitted with an admission diagnosis of cardiac arrest were excluded. We determined crude incidence and risk-adjusted hospital mortality (based on a customized severity of illness model) for all ICU-CA patients, and for predefined admission diagnosis subgroups. Temporal trends for the observed period were calculated for crude incidence and risk-adjusted hospital mortality.

RESULTS

Crude incidence for all ICU-CA patients was 29/1,000 ICU admissions, with the highest incidence 118/1,000 in the non-operative cardiovascular subgroup. Overall hospital mortality for ICU-CA patients was 55.5% [95% confidence interval (CI) 54-57%]. Hospital mortality was 53.1% (95% CI 50.4-55.8%) for non-operative cardiovascular ICU-CA patients, 32.9% (95% CI 26.9-38.9%) for post cardiac surgery ICU-CA patients, and 56.3% (95% CI 51.2-61.3%) for neurological/neurosurgical ICU-CA patients. There was a significant reduction in the overall ICU-CA incidence and in the risk-adjusted hospital mortality of ICU-CA and non-cardiac arrest cases (non-CA) over the observed study period (p < 0.001).

CONCLUSION

Our data suggest that the incidence of ICU-CA has decreased in Finnish ICUs between 2003 and 2013. Similar reduction in hospital mortality over time was observed for both ICU-CA and non-CA populations.

Post return of spontaneous circulation factors associated with mortality in pediatric in-hospital cardiac arrest: a prospective multicenter multinational observational study

INTRODUCTION

Most studies have analyzed pre-arrest and resuscitation factors associated with mortality after cardiac arrest (CA) in children, but many patients that reach return of spontaneous circulation die within the next days or weeks. The objective of our study was to analyze post-return of spontaneous circulation factors associated with in-hospital mortality after cardiac arrest in children.

METHODS

A prospective multicenter, multinational, observational study in 48 hospitals from 12 countries was performed. A total of 502 children aged between 1 month and 18 years with in-hospital cardiac arrest were analyzed. The primary endpoint was survival to hospital discharge. Univariate and multivariate logistic regression analyses were performed to assess the influence of each post-return of spontaneous circulation factor on mortality.

RESULTS

Return of spontaneous circulation was achieved in 69.5% of patients; 39.2% survived to hospital discharge and 88.9% of survivors had good neurological outcome. In the univariate analysis, post- return of spontaneous circulation factors related with mortality were pH, base deficit, lactic acid, bicarbonate, FiO2, need for inotropic support, inotropic index, dose of dopamine and dobutamine at 1 hour and at 24 hours after return of spontaneous circulation as well as Pediatric Intensive Care Unit and total hospital length of stay. In the multivariate analysis factors associated with mortality at 1 hour after return of spontaneous circulation were PaCO2 < 30 mmHg and >50 mmHg, inotropic index >14 and lactic acid >5 mmol/L. Factors associated with mortality at 24 hours after return of spontaneous circulation were PaCO2 > 50 mmHg, inotropic index >14 and FiO2 ≥ 0.80.

CONCLUSIONS

Secondary in-hospital mortality among the initial survivors of CA is high. Hypoventilation, hyperventilation, FiO2 ≥ 0.80, the need for high doses of inotropic support, and high levels of lactic acid were the most important post-return of spontaneous circulation factors associated with in-hospital mortality in children in our population.

Factors influencing outcomes after cardiopulmonary resuscitation in emergency department

BACKGROUND

The outcome of cardiopulmonary resuscitation (CPR) may depend on a variety of factors related to patient status or resuscitation management. To evaluate the factors influencing the outcome of CPR after cardiac arrest (CA) will be conducive to improve the effectiveness of resuscitation. Therefore, a study was designed to assess these factors in the emergency department (ED) of a city hospital.

METHODS

A CPR registry conforming to the Utstein-style template was conducted in the ED of the First Affiliated Hospital of Wenzhou Medical College from January 2005 to December 2011. The outcomes of CPR were compared in various factors groups. The primary outcomes were rated to return of spontaneous circulation (ROSC), 24-hour survival, survival to discharge and discharge with favorable neurological outcomes. Univariate analysis and multivariable logistic regression analysis were performed to evaluate factors associated with survival.

RESULTS

A total of 725 patients were analyzed in the study. Of these patients, 187 (25.8%) had ROSC, 100 (13.8%) survived for 24 hours, 48 (6.6%) survived to discharge, and 23 (3.2%) survived to discharge with favorable neurologic outcomes. A logistic regression analysis demonstrated that the independent predictors of ROSC included traumatic etiology, first monitored rhythms, CPR duration, and total adrenaline dose. The independent predictors of 24-hour survival included traumatic etiology, cardiac etiology, first monitored rhythm and CPR duration. Previous status, cardiac etiology, first monitored rhythms and CPR duration were included in independent predictors of survival to discharge and neurologically favorable survival to discharge.

CONCLUSIONS

Shockable rhythms, CPR duration ≤15 minutes and total adrenaline dose ≤5 mg were favorable predictors of ROSC, whereas traumatic etiology was unfavorable. Cardiac etiology, shockable rhythms and CPR duration ≤15 minutes were favorable predictors of 24-hour survival, whereas traumatic etiology was unfavorable. Cardiac etiology, shockable rhythms, CPR duration ≤15 minutes were favorable predictors of survival to discharge and neurologically favorable survival to discharge, but previous terminal illness or multiple organ failure (MOF) was unfavorable.

Cardiocerebral Resuscitation: An Approach to Improving Survival of Patients With Primary Cardiac Arrest

Out-of-hospital cardiac arrest (OHCA) is a major public health problem. In the United States, OHCA accounts for more premature deaths than any other cause. For over a half-century, the national "Guidelines" for resuscitation have recommended the same initial treatment of primary and secondary cardiac arrests. Using this approach, the overall survival of patients with OHCA, while quite variable, was generally very poor. One reason is that the etiologies of cardiac arrests are not all the same. The vast majority of nontraumatic OHCA in adults are due to a "primary" cardiac arrest, rather than secondary to respiratory arrest. Decades of research and ongoing reviews of the literature led the University of Arizona Sarver Heart Center Resuscitation Research Group to conclude in 2003 that the national guidelines for patients with primary cardiac arrest were not optimal. Therefore, we instituted a new, nonguidelines approach to the therapy of primary cardiac arrest that dramatically improved survival. We called this approach cardiocerebral resuscitation (CCR), as it is the heart and the brain that are the most vulnerable and therefore need to be the focus of resuscitation efforts for these patients. In contrast, cardiopulmonary resuscitation should be reserved for respiratory arrests. Cardiocerebral resuscitation evolved into 3 components: the community, with emphasis for lay individuals to "Check, Call, Compress" and use an automated external defibrillator if available; the Emergency Medical Services, that emphasizes delayed intubation in favor of passive ventilation, urgent and near continuous chest compressions before and immediately after a single indicated shock, and the early administration of epinephrine; and the third component, added in 2007, the designations of hospitals in Arizona that request this designation and agree to receive patients with return of spontaneous circulation following OHCA and to institute state-of-the-art postresuscitation care that includes urgent therapeutic mild hypothermia and cardiac catheterization as a Cardiac Receiving Center. Each component of CCR is critical for optimal survival of patients with primary OHCA. In each city, county, and state where CCR was instituted, the result was a marked increase in survival of the subgroup of patients with OHCA most likely to survive, for example, those with a shockable rhythm. The purpose of this invited article on CCR is to review this alternative approach to resuscitation of patients with primary cardiac arrest and to encourage its adoption worldwide so that more lives can be saved.