Incidence and Survival After In-Hospital Cardiopulmonary Resuscitation in Nonelderly Adults

Disrupted Lives: Caregivers' Experiences of In-Hospital Cardiac Arrest Survivors' Recovery 5 Years Later

Background Survivors of in-hospital cardiac arrest (IHCA) experience ongoing physical and cognitive impairments, often requiring support from a caregiver at home afterwards. Caregivers are important in the survivor's recovery, yet there is little research specifically focused on their experiences once the survivor is discharged home. In this study, we highlight how caregivers for veteran IHCA survivors described and experienced their caregiver role, the strategies they used to fulfill their role, and the additional needs they still have years after the IHCA event. Methods and Results Between March and July 2019, semistructured telephone interviews were conducted with 12 caregivers for veteran IHCA survivors. Interviews were transcribed, and content analysis was performed. Patterns within the data were further analyzed and grouped into themes. A predominant theme of "disruption" was identified across 3 different domains including the following: (1) disruption in caregiver's life, (2) disruption in caregiver-patient relationship, and (3) disruption in caregiver's well-being. Disruption was associated with both positive and negative caregiver experiences. Strategies caregivers used and resources they felt would have helped them adjust to their caregiver role were also identified. Conclusions Caregivers for veteran IHCA survivors experienced a disruption in many facets of their lives. Caregivers felt the veterans' IHCA impacted various aspects of their lives, and they continued to need additional support in order to care for the IHCA survivor and themselves. Although some were able to procure coping strategies, such as counseling and engaging in stress-relieving activities, most indicated additional help and resources were still needed.

Survival after multiple episodes of cardiac arrest

BACKGROUND

Cardiopulmonary resuscitation (CPR) is widely used in response to cardiac arrest. However, little is known regarding outcomes for those who undergo multiple episodes of cardiac arrest while in the hospital.

OBJECTIVES

The purpose of this study was to evaluate the association of multiple cardiac events with in-hospital mortality for patients admitted to our tertiary care hospital who underwent multiple code events.

METHODS

We performed a retrospective cohort study on all patients who underwent cardiac arrest from 2012 to 2016. Primary outcome was survival to discharge. Secondary outcomes included post-cardiac-arrest neurologic events (PCANE), non-home discharge, and one-year mortality.

RESULTS

There were 622 patients with an overall mortality rate of 78.0%. Patients undergoing CPR for cardiac arrest once during their admission had lower in-hospital mortality rates compared to those that had multiple (68.9% versus 91.3%, p<.01). Subset analysis of those who had multiple episodes of CPR revealed that more than one event within a 24-hour period led to significantly higher in-hospital mortality rates (94.7% versus 74.4%, p<.01). Other variables associated with in-hospital mortality included body mass index, female sex, malignancy, and increased down time per code. Patients that had a non-home discharge were more likely to have sustained a PCANE than those that were discharged home (31.4% versus 3.9%, p<.01). A non-home discharge was associated with higher one-year mortality rates compared to a home discharge (78.4% versus 54.3%, p=.01).

CONCLUSION

Multiple codes within a 24-hour period and the average time per code were associated with in-hospital mortality in cardiac arrest patients.

Impact of Hospital Safety-Net Burden on Outcomes of In-Hospital Cardiac Arrest in the United States

High safety-net burden hospitals (HBHs) treating large numbers of uninsured or Medicaid-insured patients have generally been linked to worse clinical outcomes. However, limited data exist on the impact of the hospitals' safety-net burden on in-hospital cardiac arrest (IHCA) outcomes in the United States.

OBJECTIVES

To compare the differences in survival to discharge, routine discharge home, and healthcare resource utilization between patients at HBH with those treated at low safety-net burden hospital (LBH).

DESIGN SETTING AND PARTICIPANTS

Retrospective cohort study across hospitals in the United States: Hospitalized patients greater than or equal to 18 years that underwent cardiopulmonary resuscitation (CPR) between 2008 and 2018 identified from the Nationwide Inpatient Database. Data analysis was conducted in January 2022.

EXPOSURE

IHCA.

MAIN OUTCOMES AND MEASURES

The primary outcome is survival to hospital discharge. Other outcomes are routine discharge home among survivors, length of hospital stay, and total hospitalization cost.

RESULTS

From 2008 to 2018, an estimated 555,016 patients were hospitalized with IHCA, of which 19.2% occurred at LBH and 55.2% at HBH. Compared with LBH, patients at HBH were younger (62 ± 20 yr vs 67 ± 17 yr) and predominantly in the lowest median household income (< 25th percentile). In multivariate analysis, HBH was associated with lower chances of survival to hospital discharge (adjusted odds ratio [aOR], 0.88; 95% CI, 0.85-0.96) and lower odds of routine discharge (aOR, 0.6; 95% CI, 0.47-0.75), compared with LBH. In addition, IHCA patients at publicly owned hospitals and those with medium and large hospital bed size were less likely to survive to hospital discharge, while patients with median household income greater than 25th percentile had better odds of hospital survival.

CONCLUSIONS AND RELEVANCE

Our study suggests that patients who experience IHCA at HBH may have lower rates and odds of in-hospital survival and are less likely to be routinely discharged home after CPR. Median household income and hospital-level characteristics appear to contribute to survival.

Trends in In-Hospital Cardiopulmonary Resuscitation from 2010 through 2019: A Nationwide Cohort Study in South Korea

We aimed to examine recent trends in in-hospital cardiopulmonary resuscitation in South Korea from 2010 to 2019. A population-based sample of all adult patients who experienced in-hospital cardiopulmonary resuscitation between 1 January 2010 and 31 December 2019, was included. In all, 298,676 patients who received in-hospital cardiopulmonary resuscitation were included in the survival analysis. In 2010, 60.7 per 100,000 adults experienced in-hospital cardiopulmonary resuscitation. A similar rate was observed until 2015. The rate increased to 83.5 per 100,000 adults in 2016 and gradually increased to 92.1 per 100,000 adults in 2019. Among all patients, 78,783 (26.2%) were discharged alive after in-hospital cardiopulmonary resuscitation. The 6-month and 1-year survival rates were 9.8% and 8.7%, respectively. In 2010, the mean total cost of hospitalization was USD 5822.80 (United States Dollar) (standard deviation; SD: USD 7493.4), which increased to USD 7886.20 (SD: USD 13,071.6) in 2019. The rate of in-hospital cardiopulmonary resuscitation and cost of care have significantly increased since 2010, while the 6-month and 1-year rates of survival post in-hospital resuscitation remain low.

Early Thalamocortical Reperfusion Leads to Neurologic Recovery in a Rodent Cardiac Arrest Model

BACKGROUND

Cerebral blood flow (CBF) plays an important role in neurological recovery after cardiac arrest (CA) resuscitation. However, the variations of CBF recovery in distinct brain regions and its correlation with neurologic recovery after return of spontaneous circulation (ROSC) have not been characterized. This study aimed to investigate the characteristics of regional cerebral reperfusion following resuscitation in predicting neurological recovery.

METHODS

Twelve adult male Wistar rats were studied, ten resuscitated from 7-min asphyxial CA and two uninjured rats, which were designated as healthy controls (HCs). Dynamic changes in CBF in the cerebral cortex, hippocampus, thalamus, brainstem, and cerebellum were assessed by pseudocontinuous arterial spin labeling magnetic resonance imaging, starting at 60 min after ROSC to 156 min (or time to spontaneous arousal). Neurologic outcomes were evaluated by the neurologic deficit scale at 24 h post-ROSC in a blinded manner. Correlations between regional CBF (rCBF) and neurological recovery were undertaken.

RESULTS

All post-CA animals were found to be nonresponsive during the 60-156 min post ROSC, with reductions in rCBF by 24-42% compared with HC. Analyses of rCBF during the post-ROSC time window from 60 to 156 min showed the rCBF recovery of hippocampus and thalamus were positively associated with better neurological outcomes (rs = 0.82, p = 0.004 and rs = 0.73, p < 0.001, respectively). During 96 min before arousal, thalamic and cortical rCBF exhibited positive correlations with neurological recovery (rs = 0.80, p < 0.001 and rs = 0.65, p < 0.001, respectively); for predicting a favorable neurological outcome, the thalamic rCBF threshold was above 50.84 ml/100 g/min (34% of HC) (area under the curve of 0.96), whereas the cortical rCBF threshold was above 60.43 ml/100 g/min (38% of HC) (area under the curve of 0.88).

CONCLUSIONS

Early magnetic resonance imaging analyses showed early rCBF recovery in thalamus, hippocampus, and cortex post ROSC was positively correlated with neurological outcomes at 24 h. Our findings suggest new translational insights into the regional reperfusion and the time window that may be critical in neurological recovery and warrant further validation.

How long should we run the code? Survival analysis based on location and duration of cardiopulmonary resuscitation (CPR) after in-hospital cardiac arrest

Background: The duration of cardiopulmonary resuscitation (CPR) significantly affects long-term survival in patients with in-hospital cardiac arrests (IHCA). In this study, we questioned the long-term clinical benefits of extending CPR beyond twenty minutes for patients with in-hospital cardiac arrest. Additionally, we aimed to compare the outcomes of CPR at different locations of a large tertiary care community hospital.

Methods: This study was a retrospective chart review of 169 patients with IHCA recorded between 1 January 2016, and 31 December 2018, at a large volume tertiary care community hospital.

Results: Of the 169 patients suffering from cardiac arrest during hospitalization, 44.4% arrested in the intensive care unit (ICU) and 55.6% in a non-critical care setting. Return of spontaneous circulation (ROSC) was achieved in 60% of ICU and 70.2% of non-ICU patients. While only 20% of ICU patients survived the cardiac arrest, the overall survival for non-ICU patients was 31.9%. Despite the significant difference in percentage survival, survival difference did not reach statistical significance (p = 0.082) due to the small sample size. Overall survival was 26.6%. An initial shockable rhythm was associated with improved survival compared to a non-shockable rhythm (41% vs. 22.5%, p = 0.022).

In patients who had cardiac arrest for less than 20 minutes, 60.9% of patients achieved ROSC, compared to 37.9% who arrested for more than 20 minutes. Survival to hospital discharge was significantly lower for patients who had cardiac arrest for more than 20 minutes, compared to patients who were arrested for less than 20 minutes (3.1% vs. 41.3%, p = <0.0001). For patients who had a cardiac arrest for more than 30 minutes, ROSC was achieved in only 14.8% of patients. None of these patients survived to be discharged from the hospital (p = <0.0001).

The mean age for the patients in this study was 70 years. 52.6% of subjects were male, and 47.4% were females. Older age was not related to shorter duration of CPR (Pearson correlation: 0.030, P = 0.69).

Conclusion: Survival was significantly lower when CPR was unsuccessful for twenty minutes, and there is no survival benefit of extending CRP for more than 30 minutes. Lowest survival after a cardiac arrest on the general medical floor, compared to telemetry and ICU, may be related to delay in recognizing cardiac arrest and barriers in implementing standardized advanced cardiac life support (ACLS) protocol.

Dementia and Early Do-Not-Resuscitate Orders Associated With Less Intensive of End-of-Life Care: A Retrospective Cohort Study

BACKGROUND

Dementia is a leading cause of death among US older adults. Little is known about end-of-life care intensity and do-not-resuscitate orders (DNRs) among patients with dementia who die in hospital.

AIM

Examine the relationship between dementia, DNR timing, and end-of-life care intensity.

DESIGN

Observational cohort study.

SETTING/PARTICIPANTS

Inpatient electronic health record extraction for 2,566 persons age 65 and older who died in 2 New York City hospitals in the United States from 2015 to 2017.

RESULTS

Multivariable logistic regression analyses modeled associations between dementia diagnosis, DNR timing, and 6 end-of-life care outcomes. 31% of subjects had a dementia diagnosis; 23% had a DNR on day of hospital admission. Patients with dementia were 18%-40% less likely to have received 4 of 6 types of intensive care (mechanical ventilation AOR: 0.82, 95%CI: 0.67 -1.00; intensive care unit admission AOR: 0.60, 95%CI: 0.49-0.83). Having a DNR on file was inversely associated with staying in the intensive care unit (AOR: 0.57, 95%CI: 0.47-0.70) and avoiding other intensive care measures. DNR placement later during the hospitalization and not having a DNR were associated with more intensive care compared to having a DNR upon admission.

CONCLUSIONS

Having dementia and a do-not resuscitate order upon hospital admission are associated with less intensive end-of-life care. Additional research is needed to understand why persons with dementia receive less intensive care. In clinical practice, encouraging advance care planning prior to and at hospital admission may be particularly important for patients wishing to avoid intensive end-of-life care, including patients with dementia.

A Qualitative Exploration of Seriously Ill Patients' Experiences of Goals of Care Discussions in Australian Hospital Settings

BACKGROUND

Goals of care (GOC) is a communication and decision-making process that occurs between a clinician and a patient (or surrogate decision-maker) during an episode of care to facilitate a plan of care that is consistent with the patient's preferences and values. Little is known about patients' experiences of these discussions.

OBJECTIVE

This study explored patients' perspectives of the GOC discussion in the hospital setting.

DESIGN

An explorative qualitative design was used within a social constructionist framework.

PARTICIPANTS

Adult patients were recruited from six Australian hospitals across two states. Eligible patients had had a GOC discussion and they were identified by the senior nurse or their doctor for informed consent and interview.

APPROACH

Semi-structured individual or dyadic interviews (with the carer/family member present) were conducted at the bedside or at the patient's home (for recently discharged patients). Interviews were audio-recorded and transcribed verbatim. Data were analysed for themes.

KEY RESULTS

Thirty-eight patient interviews were completed. The key themes identified were (1) values and expectations, and (2) communication (sub-themes: (i) facilitators of the conversation, (ii) barriers to the conversation, and (iii) influence of the environment). Most patients viewed the conversation as necessary and valued having their preferences heard. Effective communication strategies and a safe, private setting were facilitators of the GOC discussion. Deficits in any of these key elements functioned as a barrier to the process.

CONCLUSIONS

Effective communication, and patients' values and expectations set the stage for goals of care discussions; however, the environment plays a significant role. Communication skills training and education designed to equip clinicians to negotiate GOC interactions effectively are essential. These interventions must also be accompanied by systemic changes including building a culture supportive of GOC, clear policies and guidelines, and champions who facilitate uptake of GOC discussions.

Ethical guidelines on cardiopulmonary resuscitation in the context of the COVID-19 pandemic in Colombia

The pandemic caused by COVID19 is associated with an increase in the number of cases of cardiorespiratory arrest, which has resulted in ethical concerns regarding the enforceability of cardiopulmonary resuscitation, as well as the conditions to carry it out. The risk of aerosol transmission and the clinical uncertainties about the efficacy, the potential sequelae, and the circumstances that could justify limiting this procedure during the pandemic have multiplied the ethical doubts on how to proceed in these cases. Based on ethical and legal grounds, this paper offers a practical guide on how to proceed in the clinical setting in cases of cardiopulmonary arrest during the pandemic. The criteria of justice, benefit, no harm, respect for autonomy, precaution, integrity, and transparency are asserted in an organized and practical framework for decision-making regarding cardiopulmonary resuscitation.

Real-time audio-visual feedback with handheld nonautomated external defibrillator devices during cardiopulmonary resuscitation for in-hospital cardiac arrest: A meta-analysis

Objective:

Restoring cardiopulmonary circulation with effective chest compression remains the cornerstone of resuscitation, yet real-time compressions may be suboptimal. This project aims to determine whether in patients with in-hospital cardiac arrest (IHCA; population), chest compressions performed with free-standing audiovisual feedback (AVF) device as compared to standard manual chest compression (comparison) results in improved outcomes, including the sustained return of spontaneous circulation (ROSC), and survival to the intensive care unit (ICU) and hospital discharge (outcomes).

Methods:

Scholarly databases and relevant bibliographies were searched, as were clinical trial registries and relevant conference proceedings to limit publication bias. Studies were not limited by date, language, or publication status. Clinical randomized controlled trials (RCT) were included that enrolled adults (age ≥ 18 years) with IHCA and assessed real-time chest compressions delivered with either the standard manual technique or with AVF from a freestanding device not linked to an automated external defibrillator (AED) or automated compressor.

Results:

Four clinical trials met inclusion criteria and were included. No ongoing trials were identified. One RCT assessed the Ambu CardioPump (Ambu Inc., Columbia, MD, USA), whereas three assessed Cardio First Angel™ (Inotech, Nubberg, Germany). No clinical RCTs compared AVF devices head-to-head. Three RCTs were multi-center. Sustained ROSC (4 studies, n = 1064) was improved with AVF use (Relative risk [RR] 1.68, 95% confidence interval [CI] 1.39–2.04), as was survival to hospital discharge (2 studies, n = 922; RR 1.78, 95% CI 1.54–2.06) and survival to hospital discharge (3 studies, n = 984; RR 1.91, 95% CI 1.62–2.25).

Conclusion:

The moderate-quality evidence suggests that chest compressions performed using a non-AED free-standing AVF device during resuscitation for IHCA improves sustained ROSC and survival to ICU and hospital discharge.

Trial Registration:

PROSPERO (CRD42020157536).

In-Hospital Cardiopulmonary Resuscitation of Patients With Human Immunodeficiency Virus Infection: A Population-Based Cohort Study of Epidemiology and Outcomes

Background

Marked improvements were realized in both short-term and long-term outcomes of human immunodeficiency virus (HIV)-infected patients following the introduction of combination antiretroviral therapy. However, the contemporary population-level patterns of in-hospital cardiopulmonary resuscitation (CPR) and the outcomes of HIV-infected patients were not systematically examined.

Methods

We used the Texas Inpatient Public Use Data File to identify hospitalizations aged ≥ 18 years with and without HIV during 2009 - 2014, and those in each group who have undergone in-hospital CPR. Short-term survival (defined as absence of hospital mortality or discharge to hospice) following in-hospital CPR was examined. Multivariate logistic regression modeling was used to assess the prognostic impact of HIV infection following in-hospital CPR and predictors of short-term survival among HIV hospitalizations.

Results

In-hospital CPR was reported in 437 and 54,135 hospitalizations with and without HIV, respectively. The rates of in-hospital CPR (per 1,000 hospitalizations) were 4.4 and 4.1 among hospitalizations with and without HIV, respectively (P = 0.1659). The corresponding rates of in-hospital CPR among decedents were 11% and 11.8%, respectively (P = 0.1531). Crude short-term survival following in-hospital CPR among hospitalizations with and without HIV was 19% and 26.8%, respectively (P = 0.0003). The corresponding adjusted short-term survival between 2009 and 2014 rose from 14.2% to 27% (P = 0.0009 for trend) and from 25.5% to 28% (P < 0.0001 for trend). HIV infection was associated with lower odds of short-term survival following in-hospital CPR (adjusted odds ratio (aOR): 0.50, 95% confidence interval (95% CI): 0.39 - 0.65). Select comorbid conditions (congestive heart failure, aOR: 2.03, 95% CI: 1.20 - 2.46; cerebrovascular disease, aOR: 2.08, 95% CI: 1.15 - 3.75; and diabetes, aOR: 1.53, 95% CI 1.31 - 4.71) were the only independent predictors of short-term survival following in-hospital CPR among HIV hospitalizations.

Conclusions

The rates of in-hospital CPR were similar among hospitalizations with and without HIV infection, with similar level of selectivity among decedents. Although HIV infection was associated with lower short-term survival following in-hospital CPR for the whole cohort, a dramatic improvement was observed during the study period among affected patients, with short-term survival rates becoming near-similar to those without HIV. Further studies are needed to identify modifiable factors to further improve the outcomes following in-hospital CPR among patients with HIV infection.

Influence of cardiac arrest and SCAI shock stage on cardiac intensive care unit mortality

BACKGROUND

Patients with concomitant cardiac arrest (CA) and shock are at increased risk of mortality, even when stratified according to shock severity. We sought to determine whether the presence of ventricular fibrillation (VF) modified the relationship between CA and mortality in cardiac intensive care unit (CICU) patients.

METHODS

We retrospectively analyzed unique Mayo Clinic CICU patients admitted between 2007 and 2015. Society for Cardiovascular Angiography and Intervention (SCAI) shock stages A through E were classified at admission. Hospital mortality in each SCAI shock stage was stratified by the presence of CA, VF CA, or non-VF CA.

RESULTS

We included 9,898 patients with a mean age of 68 years (38% females). CA was present in 12%, including 53% with VF CA and 47% with non-VF CA. Hospital mortality was higher in patients with CA compared to patients without CA (34% vs. 6%; adjusted odds ratio [OR] = 3.1, 95% CI [2.4, 4.0], p < .001), and patients with non-VF CA had higher hospital mortality than patients with VF CA (44% vs. 25%; adjusted OR = 2.1, 95% CI [1.4, 3.0], p < .001). After adjustment, patients with any CA or non-VF CA had higher hospital mortality at each SCAI stage, except stage E (all other p < .05), whereas patients with VF CA did not (all p > .1).

CONCLUSIONS

CA rhythm modifies the relationship between CA and mortality in CICU patients, when accounting for coma, shock, and organ failure. Outcome studies examining CA in patients with cardiogenic shock need to account for important differences such as CA rhythm.

Impact of Change in 2010 American Heart Association Cardiopulmonary Resuscitation Guidelines on Survival After Out-of-Hospital Cardiac Arrest in the United States: An Analysis From 2006 to 2015

BACKGROUND

In October 2010, the American Heart Association/Emergency Cardiovascular Care updated cardiopulmonary resuscitation guidelines. Its impact on the survival rate among out-of-hospital cardiac arrest patients (OHCA) is not well studied. We sought to assess the survival trends in OHCA patients before and after the introduction of the 2010 American Heart Association cardiopulmonary resuscitation guidelines in the United States.

METHODS

A retrospective observational study from the National Emergency Department (ED) Sample was designed to identify patients presenting to the ED primarily after an OHCA in the United States between January 1, 2006, and December 31, 2015. The main outcome studied was the change in trends of ED survival and survival-to-discharge rates before and after guideline modification.

RESULTS

Among 1 282 520 patients presenting to the ED after OHCA (mean [SD] age, 65.8 [17.2] years; 62% men), ED survival rate (23%) and survival-to-discharge rate (16%) trends showed significant improvement after implementation of the 2010 American Heart Association cardiopulmonary resuscitation guidelines, 1.25% ([95% CI, 0.72%-1.78%] P=0.001) and 0.89% ([95% CI, 0.35%-1.43%] P=0.006), respectively. Notably, among patients with nonshockable rhythm (change in ED survival rate trend, 1.3% [95% CI, 0.89%-1.74%]; P<0.001 and survival-to-discharge trend, 0.94% [95% CI, 0.42%-1.47%]; P=0.004). Among patients admitted to the presenting hospital (n=145 592), 46% were discharged alive, of which 49% were discharged home. Significant decrease in discharge to home was noted (-1.7% [95% CI, -3.18% to -0.22%]; P=0.03), while a significant increase in neurological complication (0.17% [95% CI, 0.06%-0.28%]; P=0.007) was noted with the guideline modification.

CONCLUSIONS

The change in 2010 American Heart Association cardiopulmonary resuscitation guidelines was associated with only slight improvement in ED survival and survival-to-discharge trends among US OHCA patients and only 1 in 6 OHCA patients survival to discharge.

In-hospital cardiopulmonary resuscitation of patients with cirrhosis: A population-based analysis

Objective

To examine the epidemiology and outcomes of in-hospital cardiopulmonary resuscitation (CPR) among patients with cirrhosis.

Methods

We used the Texas Inpatient Public Use Data File to identify hospitalizations aged ≥ 18 years with and without cirrhosis during 2009–2014 and those in each group who have undergone in-hospital CPR. Short-term survival (defined as absence of hospital mortality or discharge to hospice) following in-hospital CPR was examined. Multivariate logistic regression modeling was used to assess the prognostic impact of cirrhosis following in-hospital CPR and predictors of short-term survival among cirrhosis hospitalizations.

Results

In-hospital CPR was reported in 2,511 and 51,969 hospitalizations with and without cirrhosis, respectively. The rate of in-hospital CPR (per 1,000 hospitalizations) was 7.6 and 4.0 among hospitalizations with and without cirrhosis, respectively. The corresponding rate of in-hospital CPR among decedents was 10.7% and 13.4%, respectively. Short-term survival following in-hospital CPR among hospitalizations with and without cirrhosis was 14.9% and 27.3%, respectively, and remained unchanged over time on adjusted analyses among the former (p = 0.1753), while increasing among the latter (p = 0.0404). Cirrhosis was associated with lower odds of short-term survival following in-hospital CPR (adjusted odds ratio [aOR] 0.55 [95% CI: 0.49–0.62]). Lack of health insurance (vs. Medicare) (aOR] 0.47 [95% CI: 0.34–0.67]) and sepsis ([aOR] 0.67 [95% CI: 0.53–85]) were associated with lower odds of short-term survival following in-hospital CPR among cirrhosis hospitalizations.

Conclusions

The rate of in-hospital CPR was nearly 2-fold higher among hospitalizations with cirrhosis than among those without it, though it was used more selectively among the former. Short-term survival following in-hospital CPR remained markedly lower among cirrhosis hospitalizations, while progressively improving among those without cirrhosis. Strategies to increase access to health insurance and improve early identification and control of infection should be explored in future preventive and interventional efforts.

In-Hospital Cardiac Arrest in the Cardiac Catheterization Laboratory: Effective Transition from an ICU- to CCU-Led Resuscitation Team

Objectives

(1) To examine the incidence and outcomes of in-hospital cardiac arrests (IHCAs) in a large unselected patient population who underwent coronary angiography at a single tertiary academic center and (2) to evaluate a transitional change in which the cardiologist is positioned as the cardiopulmonary resuscitation (CPR) leader in the cardiac catheterization laboratory (CCL) at our local tertiary care institution.

Background

IHCA is a major public health concern with increased patient morbidity and mortality. A proportion of all IHCAs occurs in the CCL. Although in-hospital resuscitation teams are often led by an Intensive Care Unit- (ICU-) trained physician and house staff, little is known on the role of a cardiologist in this setting.

Methods

Between 2012 and 2016, a single-center retrospective cohort study was performed examining 63 adult patients (70 ± 10 years, 60% males) who suffered from a cardiac arrest in the CCL. The ICU-led IHCAs included 19 patients, and the Coronary Care Unit- (CCU-) led IHCAs included 44 patients.

Results

Acute coronary syndrome accounted for more than 50% of cardiac arrests in the CCL. Pulseless electrical activity was the most common rhythm requiring chest compression, and cardiogenic shock most frequently initiated a code blue response. No significant differences were observed between the ICU-led and CCU-led cardiac arrests in terms of hospital length of stay and 1-year survival rate.

Conclusion

In the evolving field of Critical Care Cardiology, the transition from an ICU-led to a CCU-lead code blue team in the CCL setting may lead to similar short-term and long-term outcomes.

Outcomes of in-hospital cardiopulmonary resuscitation for patients with end-stage liver disease

BACKGROUND AND AIMS

There have been improving survival trends after in-hospital cardiac arrest for the general population, but there is limited information on the outcomes of hospitalized patients with end-stage liver disease (ESLD) who undergo cardiopulmonary resuscitation (CPR). We aimed to examine survival to hospital discharge after receipt of in-hospital CPR in patients with ESLD using a nationally representative sample.

METHODS

We used the Nationwide Inpatient Sample database from 2006 to 2014 to identify adult patients who underwent in-hospital CPR. Using multivariate modelling, we compared survival to hospital discharge for patients with ESLD to those without ESLD. We also compared outcomes of patients with ESLD to patients with metastatic cancer.

RESULTS

A total of 177 533 patients underwent in-hospital CPR, of which 1474 (0.8%) had ESLD. Patients with ESLD had lower rates of survival to hospital discharge compared to patients without ESLD (10.7% vs 28.6%, P < 0.01). In multivariate modelling, ESLD was significantly associated with lower odds of survival to hospital discharge after in-hospital CPR (OR 0.35, 95% CI 0.28-0.44, P < 0.01). Among survivors of in-hospital CPR, ESLD patients had a significantly lower chance of discharge to home compared to patients without ESLD (3.2% vs 8.0%, P < 0.05). Patients with ESLD also had lower rates of survival to hospital discharge compared to those with metastatic cancer (10.7% vs 15.5%, P < 0.01).

CONCLUSIONS

Outcomes are poor after in-hospital CPR in patients with ESLD and are worse than for patients with metastatic cancer. The current analysis can be used to inform goals of care discussions for patients with ESLD.

Real-time compression feedback for patients with in-hospital cardiac arrest: a multi-center randomized controlled clinical trial

Objective

To determine if real-time compression feedback using a non-automated hand-held device improves patient outcomes from in-hospital cardiac arrest (IHCA).

Methods

We conducted a prospective, randomized, controlled, parallel study (no crossover) of patients with IHCA in the mixed medical–surgical intensive care units (ICUs) of eight academic hospitals. Patients received either standard manual chest compressions or compressions performed with real-time feedback using the Cardio First Angel™ (CFA) device. The primary outcome was sustained return of spontaneous circulation (ROSC), and secondary outcomes were survival to ICU and hospital discharge.

Results

One thousand four hundred fifty-four subjects were randomized; 900 were included. Sustained ROSC was significantly improved in the CFA group (66.7% vs. 42.4%, P < 0.001), as was survival to ICU discharge (59.8% vs. 33.6%) and survival to hospital discharge (54% vs. 28.4%, P < 0.001). Outcomes were not affected by intra-group comparisons based on intubation status. ROSC, survival to ICU, and hospital discharge were noted to be improved in inter-group comparisons of non-intubated patients, but not intubated ones.

Conclusion

Use of the CFA compression feedback device improved event survival and survival to ICU and hospital discharge.

Trial registration

The study was registered with Clinicaltrials.gov (NCT02845011), registered retrospectively on July 21, 2016.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Demographic, social, economic and geographic factors associated with long-term outcomes in a cohort of cardiac arrest survivors

BACKGROUND

Demographic, social, economic and geographic factors are associated with increased short-term mortality after cardiac arrest. We sought to determine if these factors are additionally associated with long-term outcome differences using a detailed clinical database linked to state-wide administrative data.

METHODS

We included cardiac arrest patients surviving to hospital discharge from five hospitals in the United States from 2005 to 2013, with follow-up through 2015. We obtained information on sex, race, arrest location, initial rhythm, median ZIP code income, post-arrest illness severity, cardiac catheterization, internal cardioverter-defibrillator insertion, rural residence and drive time from residence to the nearest acute care hospital. We used Cox proportional hazard models identify predictors of mortality.

RESULTS

We included 891 patients followed for 2081 patient-years. There were 340 deaths with median survival 6 years. In adjusted models we identified an interaction effect between median ZIP code income and cardiac catheterization. Among patients who had cardiac catheterization there was an attenuated benefit from cardiac catheterization at progressively lower neighborhood incomes (adjusted HR: 0.21 to 0.46 to 0.56). Residence more than 20 min from the nearest acute care hospital was associated with increased hazard of death (adjusted HR: 1.48; 95%CI: 1.35-1.62), after controlling for rural residence and residence in a Medically Underserved Area/Population. Female patients showed less benefit following ICD placement (male adjusted HR: 0.49; female adjusted HR: 0.66).

CONCLUSIONS

There are persistent long-term outcome differences in cardiac arrest survival based on sex, income, and geographic access acute care.

Hemodynamically Directed Two-Person Chest Compressions: A Case Report

Cardiopulmonary resuscitation has a low success rate both in and out of the hospital setting. Return of spontaneous circulation, however, is considerably higher for intraoperative cardiac arrests. Chest compressions remain of utmost importance. Optimal chest compression depth is believed to be greater than 5 cm. However, this depth is often not achieved. We describe a case in which the adequacy of chest compressions, based on hemodynamic monitoring, was achieved with 2 persons simultaneously providing a compressive force. This hemodynamic-directed care resulted in return of spontaneous circulation on 2 separate occasions.

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.

Neurologic Recovery After Cardiac Arrest: a Multifaceted Puzzle Requiring Comprehensive Coordinated Care

OPINION STATEMENT

Surviving cardiac arrest (CA) requires a longitudinal approach with multiple levels of responsibility, including fostering a culture of action by increasing public awareness and training, optimization of resuscitation measures including frequent updates of guidelines and their timely implementation into practice, and optimization of post-CA care. This clearly goes beyond resuscitation and targeted temperature management. Brain-directed physiologic goals should dictate the post-CA management, as accumulating evidence suggests that the degree of hypoxic brain injury is the main determinant of survival, regardless of the etiology of arrest. Early assessment of the need for further hemodynamic and electrophysiologic cardiac interventions, adjusting ventilator settings to avoid hyperoxia/hypoxia while targeting high-normal to mildly elevated PaCO₂, maintaining mean arterial blood pressures >65 mmHg, evaluating for and treating seizures, maintaining euglycemia, and aggressively pursuing normothermia are key steps in reducing the bioenergetic failure that underlies secondary brain injury. Accurate neuroprognostication requires a multimodal approach with standardized assessments accounting for confounders while recognizing the importance of a delayed prognostication when there is any uncertainty regarding outcome. The concept of a highly specialized post-CA team with expertise in the management of post-CA syndrome (mindful of the brain-directed physiologic goals during the early post-resuscitation phase), TTM, and neuroprognostication, guiding the comprehensive care to the CA survivor, is likely cost-effective and should be explored by institutions that frequently care for these patients. Finally, providing tailored rehabilitation care with systematic reassessment of the needs and overall goals is key for increasing independence and improving quality-of-life in survivors, thereby also alleviating the burden on families. Emerging evidence from multicenter collaborations advances the field of resuscitation at an incredible pace, challenging previously well-established paradigms. There is no more room for "conventional wisdom" in saving the survivors of cardiac arrest.