Long-term outcome of paediatric cardiorespiratory arrest in Spain

OBJECTIVE: To analyse the final outcome of cardiorespiratory arrest (CRA) in children and the neurological and functional state of survivors at 1 year. METHODS: An 18-month prospective, multicentre study analysing out-of-hospital and in-hospital CRA in children was carried out; 283 children between 7 days and 17 years of age were included. CRA and resuscitation data were registered according to Utstein style. The outcome variables were: sustained return of spontaneous circulation (initial survival), and survival at 1 year (final survival). The status of survivors was evaluated by means of the paediatric cerebral performance category (PCPC) scale and the paediatric overall performance category (POPC) scale at Paediatric Intensive Care Unit discharge, at hospital discharge, and at 1 year follow-up. RESULTS: In 283 children, 311 CRA episodes, 73 respiratory arrests (23.5%) and 238 cardiac arrests (76.5%) were analysed. Seventeen children suffered more than one CRA episode (range: 2-6). The initial survival was 60.2% and 1-year survival was 33.2%. The final survival was significantly higher in respiratory arrest than in cardiac arrest patients (70.0% versus 21.1%) (P < 0.0001). After 1 year follow-up, 87.3% of patients had scores 1 or 2 on the PCPC scale and 84.0% had scores 1 or 2 in the POPC scale; these results indicate that 1 year after CRA, the majority of survivors had normal neurological and functional status or showed only mild disability. CONCLUSIONS: Prognosis of CRA in children continues to be poor in terms of survival but quite good in terms of neurological and functional status among survivors. Additional strategies and efforts are needed to improve the short-term prognosis of paediatric CRA. However, the long-term outcome of survivors is reassuring.     

Survival after out-of-hospital cardiac arrests in Katowice (Poland): outcome report according to the "Utstein style"

The purpose of this study was to evaluate the outcome of out-of-hospital cardiac arrest (CA) and cardiopulmonary resuscitation (CPR) in the city of Katowice, Poland, during a period of 1 year prior to the planned reorganization of the national emergency system. Data were collected prospectively according to a modified Utstein style. To ensure accurate data collection, a special method of reporting resuscitation events with the use of a tape-recorder was introduced. Patients were followed for a 1-year period. Between 1 July 2001 and 30 June 2002, out-of-hospital cardiac arrest was confirmed in 1153 patients. Cardiopulmonary resuscitation was attempted in 188 patients. Cardiac arrest of presumed cardiac aetiology (147) was bystander witnessed in 105 (71%) cases and lay-bystander basic life support was performed in 35 (24%). In the group of bystander witnessed arrest ventricular fibrillation (VF) or tachycardia was documented in 59, asystole in 40 and other non-perfusing rhythms in six patients. Of 147 patients with cardiac aetiology, return of spontaneous circulation (ROSC) was achieved in 64 (44%) patients, 15 (10%) were discharged alive and 9 (6%) were alive 1 year later. Most of these patients had a good neurological outcome. Time to first defibrillatory shock was significantly shorter for survivors (median 7 min) compared to non-survivors (median 10 min). The most important resuscitation and patient characteristics associated with survival were VF as initial rhythm, arrest witnessed, and lay-bystander CPR.     

Long-term evolution after in-hospital cardiac arrest in children: Prospective multicenter multinational study

ObjectiveThe main objective was to study survival and neurologic evolution of children who suffered in-hospital pediatric cardiac arrest (CA). The secondary objective was to analyze the influence of risk factors on the long term outcome after CA.Methodsprospective, international, observational, multicentric study in 48 hospitals of 12 countries. CA in children between 1 month and 18 years were analyzed using the Utstein template. Survival and neurological state measured by Pediatric Cerebral Performance Category (PCPC) scale one year after hospital discharge was evaluated.Results502 patients with in-hospital CA were evaluated. 197 of them (39.2%) survived to hospital discharge. PCPC at hospital discharge was available in 156 of survivors (79.2%). 76.9% had good neurologic state (PCPC 1–2) and 23.1% poor PCPC values (3–6). One year after cardiac arrest we could obtain data from 144 patients (28.6%). PCPC was available in 116 patients. 88 (75.9%) had a good neurologic evaluation and 28 (24.1%) a poor one. A neurological deterioration evaluated by PCPC scale was observed in 40 patients (7.9%). One year after cardiac arrest PCPC scores compared to hospital discharge had worsen in 7 patients (6%), remained constant in 103 patients (88.8%) and had improved in 6 patients (5.2%).ConclusionSurvival one year after cardiac arrest in children after in-hospital cardiac arrest is high. Neurologic outcome of these children a year after cardiac arrest is mostly the same as after hospital discharge. The factors associated with a worst long-term neurological outcome are the etiology of arrest being a traumatic or neurologic illness, and the persistency of higher lactic acid values 24 h after ROSC. A standardised basic protocol even practicable for lower developed countries would be a first step for the new multicenter studies.     

Effectiveness and long-term outcome of cardiopulmonary resuscitation in paediatric intensive care units in Spain

OBJECTIVE: To analyse the immediate effectiveness of resuscitation and long-term outcome of children who suffered a cardiorespiratory arrest when admitted to paediatric intensive care units (PICU). DESIGN AND SETTING: Secondary analysis of data from an 18-month prospective, multicentre study analysing cardiorespiratory arrest in children in 16 paediatric intensive care units in Spain. PATIENTS AND METHODS: We studied 116 children between 7 days and 17 years of age. Data were recorded according to the Utstein style. Analysed outcome variables were sustained return of spontaneous circulation (ROSC), survival to hospital discharge and survival at 1 year. Neurological and general performance outcome was assessed by means of the Paediatric Cerebral Performance Category (PCPC) and the Paediatric Overall Performance Category (POPC) scales. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: In 80 patients (69%) ROSC was achieved and it was sustained > 20 min in 69 (59.5%). At one-year follow-up, 40 children (34.5%) were alive. Survival was not associated with sex, age or weight of patients. Mortality from cardiac arrest was higher than respiratory arrest (69.8% versus 40%, p = 0.01). Patients with sepsis had a higher mortality than other diagnostic groups. Mechanically ventilated children and those treated with vasoactive drugs had a higher mortality. Initial mortality was slightly higher in patients with slow ECG rhythms (35.7%) compared to those with ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) (27.2%). Duration of resuscitation effort was correlated with mortality (p < 0.0001). Patients who required one or more doses of adrenaline had also a higher mortality (77.8% versus 20.7%, p < 0.0001) and survivors needed less doses of adrenaline (0.85 +/- 1.14 versus 4.4+/-2.9, p < 0.0001). At hospital discharge 86.8 and 84.6% of patients had scores 1 or 2 (normal or near-normal) in the PCPC and POPC scales. At 1-year follow-up these figures were 90.8 and 86.3%, respectively. CONCLUSION: One-third of children who suffer a cardiac or respiratory arrest when admitted to PICU survive, and most of them had a good long-term neurological and functional outcome. The duration of cardiopulmonary resuscitation attempts is the best indicator of mortality.     

The epidemiology and resuscitation effects of cardiopulmonary arrest among hospitalized children and adolescents in Beijing: An observational study

Aim

To investigate the epidemiology and resuscitation effects of cardiopulmonary arrest among hospitalized children and adolescents in Beijing.

Methods

A prospective multicentre study was conducted in four hospitals in urban/suburban areas of Beijing. Patients aged 1 month–18 years with cardiopulmonary arrest and received cardiopulmonary resuscitation (CPR) who were consecutively hospitalised during the study period (1 September 2008–31 December 2010) were enrolled. Data was collected and analyzed using the “in-hospital Utstein style”. Neurological outcome was assessed with the pediatric cerebral performance category (PCPC) among patients who survived.

Result

201 of 108,673 hospitalized patients (0.18%) had cardiopulmonary arrest during their hospitalization. Of these, 174 patients underwent CPR. The most common causes of cardiopulmonary arrest were the diseases of respiratory system (29.3%) and circulatory system (19.0%). The most common initial rhythm was bradycardia (72.4%). About 108 patients (62.1%) had restoration of spontaneous circulation (ROSC). Forty-nine patients (28.2%) survived to hospital discharge, 25 (14.5%) survived 6 months post discharge, and 21 (12.1%) survived 1 year post discharge. Out of the 21 patients who survived 1 year after hospital discharge, 18 had good neurological outcome. Multivariate logistic regression analysis showed age, duration of CPR and endotracheal intubation performed before cardiopulmonary arrest were independent factors of cardiopulmonary resuscitation effect.

Conclusion

The prevalence of in-hospital cardiopulmonary arrest in children and adolescents is low. The long-term result of children and adolescents survived from cardiopulmonary resuscitation is quite good. Age, CPR duration and endotracheal intubation performed before cardiopulmonary arrest were independent factors of cardiopulmonary resuscitation effect.     

Avoiding the futility of resuscitation.

PURPOSE: To identify patients who should not have resuscitation started or continued. DESIGN: Multi-disciplinary prospective study. SUBJECTS: Two hundred forty-one consecutive patients with cardiopulmonary arrests from January 1995 to February 1997 were evaluated, of which 200 were studied. METHODS: Subjects were studied for age, sex, arrest location, CPR duration, recovery from arrest, hospital discharge, 6 weeks' survival, sepsis and co-morbid conditions. RESULTS: Overall 69 (34.5%) recovered from the arrest, 24 (12.0%) left the hospital, and 17 (8.5%) survived 6 weeks. Of inpatients, 13.7% (16/117) were alive at 6 weeks in contrast to 1.2% (1/83) of field/emergency room (ER) arrests. Sepsis did not lessen the immediate recovery rate; however, none of 25 septic patients survived hospitalization. Outcomes were not different between men and women or regular floor and ICU/CCU arrests. Age of survivors was the same as non-survivors. Survivors were resuscitated for 18.7+/-16.5 min and non-survivors 33.1+/-18.4 min (P=0.15). The initial rhythm of asystole or the presence of three or more co-morbid conditions had a negative prognosis. CONCLUSION: CPR survival is problematic, and it is especially poor in field/BR arrests. Emergency squads should terminate CPR for pulseless patients after communicating with the ER physician. Age is not a determinant of recovery or survival. Arrest outside of the hospital, sepsis, three or more co-morbid conditions, previous CPR, asystole or resuscitation for >25 min all decrease the chance of hospital discharge and survival. Instituting or continuing CPR in a great majority of these patients is futile. Families should be so advised.     

The three-phase model of cardiac arrest as applied to ventricular fibrillation in a large, urban emergency medical services system

BACKGROUND: Cardiac arrest is responsible for significant morbidity and mortality, with consistently poor outcomes despite the rapid availability of prehospital personnel for defibrillation attempts in patients with ventricular fibrillation (VF). Recent evidence suggests a period of cardiopulmonary resuscitation (CPR) prior to defibrillation attempts may improve outcomes in patients with moderate time since collapse (4-10 min). OBJECTIVES: To determine cardiac arrest outcomes in our community and explore the relationship between time since collapse, performance of bystander CPR, and survival. METHODS: Non-traumatic cardiac arrest data were collected prospectively over an 18-month period. Patients were excluded for: age <18 years, a "Do Not Attempt Resuscitation" (DNAR) directive, determination of a non-cardiac etiology for arrest, and an initially recorded rhythm other than VF. Patients were stratified by time since collapse (<4, 4-10, > 10 min, and unknown) and compared with regard to survival and neurological outcome. In addition, patients with and without bystander CPR were compared with regard to survival. RESULTS:: A total of 1141 adult non-traumatic cardiac arrest victims were identified over the 18-month study period. This included 272 patients with VF as the initially recorded rhythm. Of these, 185 had a suspected cardiac etiology for the arrest; survival to hospital discharge was 15% in this group, with 82% of these having a good outcome or only moderate disability. Survival was highest among patients with time since collapse of less than 4 min and decreased with increasing time since collapse. There were no survivors among patients with time since collapse greater than 10 min. Among patients with time since collapse of 4 min or longer, survival was significantly higher with the performance of bystander CPR; there was no survival advantage to bystander CPR among patients with time since collapse less than 4 min. CONCLUSIONS: The performance of bystander CPR prior to defibrillation by EMS personnel is associated with improved survival among patients with time since collapse longer than 4 min but not less than 4 min. These data are consistent with the three-phase model of cardiac arrest.     

Eleven years of experience with extracorporeal cardiopulmonary resuscitation for paediatric patients with in-hospital cardiac arrest

Purpose

The study aims to describe 11 years of experience with extracorporeal cardiopulmonary resuscitation (ECPR) for in-hospital paediatric cardiac arrest in a university affiliated tertiary care hospital.

Methods

Paediatric patients who received extracorporeal membrane oxygenation (ECMO) during active extracorporeal cardiopulmonary resuscitation (ECPR) at our centre from 1999 to 2009 were included in this retrospective study. The results from three different cohorts (1999–2001, 2002–2005 and 2006–2009) were compared. Survival rates and neurological outcomes were analysed. Favourable neurological outcome was defined as paediatric cerebral performance categories (PCPC) 1, 2 and 3.

Results

We identified 54 ECPR events. The survival rate to hospital discharge was 46% (25/54), and 21 (84%) of the survivors had favourable neurological outcomes.The duration of CPR was 39 ± 17 min in the survivors and 52 ± 45 min in the non-survivors (p = NS). The patients with pure cardiac causes of cardiac arrest had a survival rate similar to patients with non-cardiac causes (47% (18/38) vs. 44% (7/16), p = NS).The non-survivors had higher serum lactate levels prior to ECPR (13.4 ± 6.4 vs. 8.8 ± 5.1 mmol/L, p < 0.01) and more renal failure after ECPR (66% (19/29) vs. 20% (5/25), p < 0.01).The patients resuscitated between 2006 and 2009 had shorter durations of CPR (34 ± 13 vs. 78 ± 76 min, p = 0.032) and higher rates of survival (55% (16/29) vs. 0% (0/8), p = 0.017) than those resuscitated between 1999 and 2002.

Conclusions

In our single-centre experience with ECPR for paediatric in-hospital cardiac arrest, the duration of CPR has become shorter and outcomes have improved in recent years. Higher pre-ECPR lactate levels and the presence of post-ECPR renal failure were associated with increased mortality. The presence of non-cardiac causes of cardiac arrest did not preclude successful ECPR outcomes. The duration of CPR was not significantly associated with poor outcomes in this study.     

Improved neurologically intact survival with the use of an automated, load-distributing band chest compression device for cardiac arrest presenting to the emergency department

ABSTRACT: INTRODUCTION: It has been unclear if mechanical cardiopulmonary resuscitation (CPR) is a viable alternative to manual CPR. We aimed to compare resuscitation outcomes before and after switching from manual CPR to load-distributing band (LDB) CPR in a multi-center emergency department (ED) trial. METHODS: We conducted a phased, prospective cohort evaluation with intention-to-treat analysis of adults with non-traumatic cardiac arrest. At these two urban EDs, systems were changed from manual CPR to LDB-CPR. Primary outcome was survival to hospital discharge, with secondary outcome measures of return of spontaneous circulation, survival to hospital admission and neurological outcome at discharge. RESULTS: A total of 1,011 patients were included in the study, with 459 in the manual CPR phase (January 01, 2004, to August 24, 2007) and 552 patients in the LDB-CPR phase (August 16, 2007, to December 31, 2009). In the LDB phase, the LDB device was applied in 454 patients (82.3%). Patients in the manual CPR and LDB-CPR phases were comparable for mean age, gender and ethnicity. The mean duration from collapse to arrival at ED (min) for manual CPR and LDB-CPR phases was 34:03 (SD16:59) and 33:18 (SD14:57) respectively. The rate of survival to hospital discharge tended to be higher in the LDB-CPR phase (LDB 3.3% vs Manual 1.3%; adjusted OR, 1.42; 95% CI, 0.47, 4.29). There were more survivors in LDB group with cerebral performance category 1 (good) (Manual 1 vs LDB 12, P=0.01). Overall performance category 1 (good) was Manual 1 vs LDB 10, P=0.06. CONCLUSIONS: A resuscitation strategy using LDB-CPR in an ED environment was associated with improved neurologically intact survival on discharge in adults with prolonged, non-traumatic cardiac arrest.     

Cardiopulmonary resuscitation in a pediatric ICU

A 30-month, retrospective study of CPR was undertaken in a 10-bed, medical/surgical pediatric ICU (PICU). The 121 episodes of CPR reviewed represented 81 of 1357 admissions and 7537 cumulative days of PICU care. Of the 121 CPR attempts, 64% were initially successful, 48% were associated with at least 24-h survival, and 31% were followed by discharge from PICU. Unlike pediatric arrests outside the hospital or on general pediatric wards, PICU arrests were seldom unanticipated, were commonly nonrespiratory in origin, and generally occurred in spite of aggressive support. Of 118 PICU deaths during the study period, 45 (38%) were associated with CPR. In the 73 remaining PICU deaths, CPR had been withheld because of an order not to resuscitate. CNS status before arrest was the most important factor influencing outcome. In this pediatric population, 29% were noncomatose survivors 24 h after more than 30 min of resuscitation.     

Periodic acceleration (pGz) CPR in a swine model of asphyxia induced cardiac arrest. Short-term hemodynamic comparisons

BACKGROUND: Asphyxia is one of the most common causes of pediatric cardiac arrest, and becoming a more frequently recognized cause in adults. Periodic acceleration (pGz) is a novel method of cardiopulmonary resuscitation (CPR). pGz is achieved by rapid motion of the supine body headward-footward that generates adequate perfusion and ventilation during cardiac arrest. In a swine ventricular fibrillation cardiac arrest model, pGz produced a higher return of spontaneous circulation (ROSC), superior neurological outcome, less echocardiography evidence of post resuscitation myocardial stunning, and decreased indices of tissue injury. In contrast to standard chest compression CPR, pGz does not produce rib fractures. We investigated the feasibility of pGz in severe asphyxia cardiac arrest and assessed whether beneficial effects seen in the VF model of cardiac arrest could be realized. METHODS AND RESULTS: Sixteen swine weight 4+/-1 kg were anesthetized, tracheally intubated, and instrumented to measure, hemodynamics and echocardiography. Asphyxia was induced by occlusion of the tracheal tube. After loss of aortic pulsations (median time 10 min) animals were observed for three additional minutes following which all were in cardiac arrest. The animals were then randomized to receive 10 min of pGz or standard chest compression ventilation performed with a commercial device (Thumper). A single dose of epinephrine (adrenaline) and sodium bicarbonate were given and defibrillation attempted if appropriate for a maximum of 10 min. Both groups received fractional inspired O2 concentration of 100% during CPR and after resuscitation. Four animals in each group (50%) had an initial ROSC, however only two of the four initial survivors remained alive 3h after ROSC. There were no significant differences in blood pressure, coronary perfusion pressure during CPR and after early ROSC between groups. pGz treated animals had significantly lower pulmonary artery pressure; 20+/-4 mmHg compared to Thumper 46+/-5 mmHg, 30 min after ROSC (p<0.01). Surviving animals in both groups had severe myocardial dysfunction at 30 min after ROSC. At necropsy, 25% of the Thumper treated animals had rib fractures, while none occurred in the pGz group. CONCLUSIONS: In a lethal model of asphyxia cardiac arrest, pGz is equivalent to standard CPR, with respect to acute outcomes and resuscitation survival rates but is associated with significantly lower pulmonary artery pressures and does not produce traumatic rib fractures.     

A predictive model for survival after in-hospital cardiopulmonary arrest

BACKGROUND: In-hospital cardiopulmonary resuscitation (CPR) has seen a steady increase in the application of technology and techniques since the introduction of closed cardiac massage in 1960. Despite this progress, there has not been a demonstrated improvement in survival rates after in-hospital cardiac arrest over the last 40 years. Identification of prognostic factors associated with survival after a resuscitation attempt can help physician decisions and patients' end-of-life choices in a pre-arrest situation. METHODS: Using an Utstein-based template we analyzed 219 consecutive adult attempted resuscitations in a large urban teaching hospital over a 3-year period. The main outcome measures were survival to discharge, 1 and 3 months. Backwards stepwise logistic regression was used to select baseline variables that predict survival at discharge, 1 and 3 months. RESULTS: Survival rates at discharge, 1 and 3 months were 15.1, 13.3, and 11.5%. Meaningful neurological status (cerebral performance score of 1) at discharge was achieved in 61% of survivors. Independent predictors of survival were: higher body-mass index (BMI), presence of chronic renal insufficiency (CRI), respiratory arrest, ventricular tachycardia/fibrillation (VT/VF) as initial rhythm and arrest early during the hospital stay. A risk model based on these variables demonstrated a significant fit between predicted and observed survival at discharge with goodness of fit test P-value of 0.87. CONCLUSIONS: Survival after in-hospital cardiopulmonary arrest is poor and can be estimated by using clinical variables. If validated in a large prospective trial, this score could help physicians in attempting resuscitation, patients and families in making end-of-life decisions and hospitals in resource allocation.     

Survey of outcome of CPR in pediatric in-hospital cardiac arrest in a medical center in Taiwan

Purpose of the studyWhile the outcomes of cardiopulmonary resuscitation (CPR) for pediatric in-hospital cardiac arrest (IHCA) are reported for many regions, none is reported for Asian countries. We report the outcomes of CPR for pediatric IHCA in a tertiary medical center in Taiwan and also identify prognostic factors associated with poor outcome.MethodsData were retrieved retrospectively from 2000 to 2003 and prospectively from 2004 to 2006 from our web-based registry system. We evaluated patients younger than 18 years of age who had IHCA and received CPR. The primary outcome was survival to hospital discharge, and the secondary outcomes were sustained return of spontaneous circulation (ROSC), and favorable neurological outcomes as assessed by pediatric cerebral performance categories (PCPC).ResultsWe identified 316 patients and the overall hospital survival was 20.9% and 16.1% had favorable neurological outcomes. Sixty-four patients ever supported with ECMO. We further analyzed 252 patients who underwent conventional CPR only and most had cardiac disease (133/252, 52.8%). The second most common preexisting condition was hematologic or oncologic disease (43/252, 17.1%). Of the 252 patients, 153 (60.7%) achieved sustained ROSC, 50 (19.8%) survived to discharge, and 39 patients (15.5%) had favorable neurological outcomes. CPR during off-work hours resulted in inferior chances of reaching sustained ROSC. Multivariate analysis showed that long CPR duration, hematology/oncology patients, and pre-arrest vasoactive drug infusion were significantly associated with decreased hospital survival (p < 0.05).ConclusionsOutcomes of CPR for pediatric patients with IHCA in Taiwan were comparable to corresponding reports in Western countries, but more hematology/oncology patients were included. Long CPR duration, hematologic or oncologic underlying diseases, and vasoactive agent infusion prior IHCA were associated with poor outcomes. The concept of palliative care should be proposed to families of terminally ill cancer patients in order to avoid unnecessary patient suffering. Also, establishing a balanced duty system in the future might increase chances of sustained ROSC.     

体外膜肺氧合治疗用于心肺复苏的临床研究

目的 总结体外膜肺氧合（ECMO）治疗对于常规心肺复苏（CPR）困难患者的临床治疗经验。方法 自2005-09-2006-05我院进行ECMO治疗37例患者，其中11例心脏骤停后实施电除颤和心脏按压等CPR措施无效或自主循环恢复后持续低心排而行ECMO循环辅助。结果 8例顺利停机，6例存活恢复出院，其中2例行心脏移植后康复出院。3例不能顺利撤机者在ECMO辅助期间由于循环功能恶化，最终因多器官功能衰竭死亡。顺利撤机和存活出院的患者治疗前乳酸水平较低。ECMO治疗后乳酸清除率较快（P〈0．05）。ECMO期间出现的并发症包括出血、神经精神系统异常、肢体缺血坏死和多脏器功能不全。4例患者因膜肺出现血浆渗漏而更换膜肺。结论 ECMO可为危重心脏病患者心脏骤停后复苏困难时提供心肺功能支持，提高危重心脏病患者CPR的存活率。CPR后动脉血乳酸值和ECMO治疗后乳酸清除率可以预测患者预后。     

Outcome of cardiopulmonary resuscitation in hospitalized patients

Background: Information on who is likely to benefit from cardiopulmonary resuscitation (CPR) is essential for decision-making regarding resuscitative efforts. The purpose of the present study was to evaluate the results of CPR in hospitalized patients and to investigate the influence of clinical variables and their value as prognostic tools. Methods: We analysed prospectively collected data of 253 consecutive hospitalized patients in whom CPR was performed. Main outcome measures were: success of CPR, 24-h survival, discharge from hospital, mental status at the time of hospital discharge, diagnosis, age, adequacy of basic life support, duration of CPR, time of CPR. Results: The mean age was 69.5 years, with a range of 27 to 97 years. Distribution of sex was 145 men and 108 women. Of 253 CPR efforts, 141 (56%) were successful, and in 110 (43%), patients were alive after 24 h. Fifty patients (20%) were discharged alive. The mechanism of arrest with the best outcome was ventricular tachycardia or fibrillation. Advanced age and adequacy of basic life support by first-responders did not affect survival to discharge. Prolonged duration of the resuscitative effort was associated with a poor outcome. Among patients whose arrest lasted longer than 30 min, 89% died. Conclusion: 20% of patients who underwent in-hospital resuscitation were discharged alive. Need for prolonged resuscitation as well as certain mechanisms of arrest, such as progression of a shock state, were associated with a poor outcome. Patients who are likely to benefit from CPR performed for >30 min are rare. Therefore, a decision for prolonged CPR should be made only in reasonable cases.     

Characteristics and outcome among patients suffering from in hospital cardiac arrest in relation to the interval between collapse and start of CPR

AIM: To describe survival after in-hospital cardiac arrest in relation to the interval between collapse and start of cardiopulmonary resuscitation (CPR). PATIENTS: All patients suffering in-hospital cardiac arrest in Sahlgrenska University Hospital in G?teborg, Sweden between 1994 and 1999 in whom resuscitative efforts were attempted and for whom the interval between collapse and start of CPR was known. METHODS: Prospective recording of various factors at resuscitation including the interval between collapse and start of CPR. Retrospective evaluation via medical records of patients' previous history, clinical situation prior to cardiac arrest and final outcome. RESULTS: Survival to discharge was 33% among the 344 patients in whom CPR was started within the first minute as compared with 14% among the 88 patients in whom CPR started more than 1 min after collapse (P=0.008). The corresponding figures for patients found in ventricular fibrillation was 50 versus 32% (NS); for patients found in pulseless electrical activity 9 versus 3% (NS) and for patients found in asystole 19 versus 0% (NS). Correcting for dissimililarties in the previous history and factors at resuscitation, the adjusted odds ratio and 95% confidence limits for being discharged from hospital when CPR was started within 1 min compared with a later start was 3.06 with 95% confidence limits of 1.59-6.31. CONCLUSION: Among patients with in-hospital cardiac arrest in whom the interval between collapse and start of CPR was known, we found that in 80% of the cases CPR was started within the first minute after collapse. Among these patients, survival to discharge was twice that of patients in whom CPR was started later. These results highlight the importance of immediate CPR after in-hospital cardiac arrest.     

Quality of life 6-months after cardiac arrest

BACKGROUND: Evaluation of outcome after cardiac arrest focuses mainly on survival. Survivors of cardiac arrest end up in different states of health and survival alone may not be a sensitive measure for successful cardiopulmonary resuscitation (CPR). OBJECTIVES: To evaluate health-related quality of life (HR-QOL) of cardiac arrest survivors with EQ-5D, a generic instrument developed by the EuroQol group. PATIENTS AND METHODS: From April 1997 to December 2000, all cardiac arrest adult patients admitted to an eight-bed medical/surgical (ICU) of a tertiary care hospital were enrolled. At 6-months after ICU discharge survivors attended a follow-up interview and answered EQ-5D questionnaire. A match-control group was created choosing for each survivor of cardiac arrest two controls, with similar age range (+/-5 years) and similar Apache II (+/-3 Apache II units), that were randomly selected among other ICU patients. RESULTS: From a total of 1106 patients, 97 (9%) patients were admitted after cardiac arrest. Forty-seven patients (48%) were discharged from ICU. Of these, 11 patients died in the ward. Thirty-six (37%) patients were discharged from hospital. Twelve patients died after hospital discharge but before 6-month evaluation. Five patients were not evaluated, three because they were living in distant locations and two for unknown reasons. Nineteen patients attended the follow-up consultation. Eight of these patients were actively working and six of them had managed to return to their previous activity. Eleven patients were retired and seven of these managed to return to their previous level of activity while four patients presented with anoxic encephalopathy: one with mild and one with moderate neurological dysfunction, two with severe anoxic neurological dysfunction. Although a higher percentage of cardiac arrest survivors reported more extreme problems in some dimensions than other ICU patients, no significant differences were found on HR-QOL, when evaluated by EQ-5D. CONCLUSIONS: When evaluated with EQ-5D at 6-months after ICU discharge, survivors of cardiac arrest exhibit a HR-QOL similar to other ICU survivors. These results agree with previous reports stating that CPR is frequently unsuccessful but if survival is achieved a fairly good quality of life can be expected.     

Outcomes of cardiopulmonary arrest in an acute rehabilitation setting

OBJECTIVE: Fifty consecutive cases of cardiopulmonary arrest with administration of cardiopulmonary resuscitation (CPR) during a 6-yr period at a freestanding academic acute rehabilitation hospital were identified. DESIGN: Medical records of 49 patients were available for review. Outcomes of survival of arrest, survival to 24 hr postarrest, survival to discharge from the hospital were determined, and chi2 or Fisher's exact tests were performed to investigate relationships between survival and admission functional status, age, gender, and medical comorbidities. RESULTS: Forty-three percent of patients survived the initial arrest, 37% survived to 24 hr post-CPR, and 18% survived to hospital discharge. We were unable to identify any statistically significant predictors of survival post-CPR. Six of the nine survivors returned to the acute rehabilitation setting after cardiopulmonary arrest, and five of these patients made significant functional gains. CONCLUSIONS: Outcomes after CPR in patients undergoing acute rehabilitation in one setting were not significantly different from those reported for patients in other healthcare settings. These data may be used by healthcare professionals to enhance discussions concerning advance healthcare planning (including resuscitation plans) with patients and families. Larger studies are needed to clarify the prognostic role of prior functional status in predicting CPR outcomes, particularly in the context of various diagnostic categories and age groups.     

Long-term survival and neurological outcome of patients who received recombinant tissue plasminogen activator during out-of-hospital cardiac arrest

OBJECTIVE: The long-term outcome in patients who received recombinant tissue plasminogen activator during cardiopulmonary resuscitation (CPR) in out-of-hospital cardiac arrest (OHCA) of non-traumatic aetiology was assessed. METHODS: The neurological outcome in survivors and their level of performance, subjective well-being and quality of life were evaluated. RESULTS: A follow-up study of 27 cardiac arrest survivors was conducted; four patients (15%) died during the first year, a total of seven patients (26%) within 5 years. Twenty-two patients (81%) were discharged from hospital without neurological deficit (cerebral performance category (CPC) score: 1), three patients scored CPC 2 and two patients CPC 3. Heart failure classification on discharge was, according to the New York Heart Association (NYHA) criteria 2.1 +/- 0.9. Fifteen patients (56%) managed to return to their previous level of activity. At the time of follow-up 18 patients (67%) were still alive, of whom 15 responded to a survey regarding life satisfaction. Thirteen patients (87%) judged their situation to be worth living and twelve (80%) considered their survival a second chance, while five (33%) feared they could suffer another cardiac arrest. Reactions from close relatives included fear/anxiety (n = 14; 78%), a sustained burden on family life (n = 12; 67%), and occasional depression (n = 7; 39%). CONCLUSIONS: Thrombolytic therapy during cardiopulmonary resuscitation may produce a favourable neurological outcome. The majority of long-term survivors reported a good subjective quality of life. In one-third of close family members some negative factors had a lasting impact on the quality of daily living.     

Association between interval between call for ambulance and return of spontaneous circulation and survival in out-of-hospital cardiac arrest

AIM: To describe the association between the interval between the call for ambulance and return of spontaneous circulation (ROSC) and survival in out-of-hospital cardiac arrest. PATIENTS: All patients suffering an out-of-hospital cardiac arrest in whom cardiopulmonary resuscitation (CPR) was started, included in the Swedish Cardiac Arrest Registry (SCAR) for whom information about the time of calling for an ambulance and the time of ROSC was available. RESULTS: Among 26,192 patients who were included in SCAR and were not witnessed by the ambulance crew, information about the time of call for an ambulance and the time of ROSC was available in 4847 patients (19%). There was a very strong relationship between the interval between call for an ambulance and ROSC and survival to one month. If the interval was less than or equal to 5 min, 47% survived to one month. If the interval exceeded 30 min, only 5% (n = 35) survived to one month. The vast majority of the latter survivors had a shockable rhythm either on admission of the rescue team or at some time during resuscitation. CONCLUSION: Among patients who have ROSC after an out-of-hospital cardiac arrest, there is a very strong association between the interval between the call for ambulance and ROSC and survival to one month. However, even if this delay is very long (> 30 min after calling for an ambulance), a small percentage will ultimately survive; they are mainly patients who at some time during resuscitation have a shockable rhythm. The overall percentage of patients for whom CPR continued for more than 30 min who are alive one month later can be assumed to be extremely low.