Hemodynamic-directed cardiopulmonary resuscitation during in-hospital cardiac arrest

Cardiopulmonary resuscitation (CPR) guidelines assume that cardiac arrest victims can be treated with a uniform chest compression (CC) depth and a standardized interval administration of vasopressor drugs. This non-personalized approach does not incorporate a patient's individualized response into ongoing resuscitative efforts. In previously reported porcine models of hypoxic and normoxic ventricular fibrillation (VF), a hemodynamic-directed resuscitation improved short-term survival compared to current practice guidelines. Skilled in-hospital rescuers should be trained to tailor resuscitation efforts to the individual patient's physiology. Such a strategy would be a major paradigm shift in the treatment of in-hospital cardiac arrest victims.     

The relationship between ICU hypotension and in-hospital mortality and morbidity in septic patients

Purpose

Current guidelines recommend maintaining a mean arterial pressure (MAP)?≥?65 mmHg in septic patients. However, the relationship between hypotension and major complications in septic patients remains unclear. We, therefore, evaluated associations of MAPs below various thresholds and in-hospital mortality, acute kidney injury (AKI), and myocardial injury.

Methods

We conducted a retrospective analysis using electronic health records from 110 US hospitals. We evaluated septic adults with intensive care unit (ICU) stays?≥?24 h from 2010 to 2016. Patients were excluded with inadequate blood pressure recordings, poorly documented potential confounding factors, or renal or myocardial histories documented within 6 months of ICU admission. Hypotension exposure was defined by time-weighted average mean arterial pressure (TWA-MAP) and cumulative time below 55, 65, 75, and 85 mmHg thresholds. Multivariable logistic regressions determined the associations between hypotension exposure and in-hospital mortality, AKI, and myocardial injury.

Results

In total, 8,782 patients met study criteria. For every one unit increase in TWA-MAP?<?65 mmHg, the odds of in-hospital mortality increased 11.4% (95% CI 7.8%, 15.1%, p?<?0.001); the odds of AKI increased 7.0% (4.7, 9.5%, p?<?0.001); and the odds of myocardial injury increased 4.5% (0.4, 8.7%, p?=?0.03). For mortality and AKI, odds progressively increased as thresholds decreased from 85 to 55 mmHg.

Conclusions

Risks for mortality, AKI, and myocardial injury were apparent at 85 mmHg, and for mortality and AKI risk progressively worsened at lower thresholds. Maintaining MAP well above 65 mmHg may be prudent in septic ICU patients.

     

移动ICU院内急救模式在呼吸心搏骤停患者抢救中的应用

目的探讨移动ICU院内急救模式在呼吸心搏骤停患者抢救中的应用效果。方法设立移动ICU,基本设施包括必要的抢救设备及足量的抢救药物,并在此基础上提供有急救技术准入的医护人力支援。对临床科室抢救的22例呼吸心搏骤停患者,启动移动ICU协助救治。分析其应用效果。结果移动ICU在（2.5±0.5）min到达急救现场并建立抢救团队。22例患者中,死亡4例（18.18%）,抢救成功12例（54.55%）,转入ICU继续救治6例（27.27%）。未发生一例医疗纠纷。结论移动ICU院内急救模式的建立,提高了住院患者呼吸心搏骤停的救治水平,提高了救治成功率,最大限度地挽救了患者的生命。     

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.     

ICU心脏骤停患者心肺复苏的相关临床因素分析

目的 分析影响ICU心脏骤停患者心肺复苏的相关因素.方法 收集ICU心脏骤停并行心肺复苏抢救病例131例,分为自主循环恢复(ROSC)组与未恢复(Non-ROSC)组,分析患者临床资料及影响ROSC的相关因素.结果 单因素分析显示,ROSC 组和Non-ROSC 组有统计学意义的项目:原发病(χ2=11.015,P=0.026)、心脏骤停形式(χ2=7.048,P=0.029)、目击察觉(χ2=15.886,P＜0.001),无统计学意义的项目:性别、年龄及心脏骤停时间点等.Logistic回归分析显示,原发病为心血管疾病(OR=0.129,P=0.003)、脑血管疾病(OR=7.818,P=0.002)、严重多发伤(OR=0.141,P=0.014),心脏骤停形式为心脏停搏或无脉电活动(OR=4.573,P=0.006),目击察觉(OR=0.078,P=0.000)是影响ICU心脏骤停患者心肺复苏的重要因素.结论 原发病、心脏骤停形式及目击察觉是影响ICU心脏骤停患者心肺复苏的重要因素.     

Arterial hyperoxia and in-hospital mortality after resuscitation from cardiac arrest

Introduction  

Hyperoxia has recently been reported as an independent risk factor for mortality in patients resuscitated from cardiac arrest. We examined the independent relationship between hyperoxia and outcomes in such patients.     

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.     

Prediction of long-term mortality in ICU patients: model validation and assessing the effect of using in-hospital versus long-term mortality on benchmarking

Purpose

To analyze the influence of using mortality 1, 3, and 6 months after intensive care unit (ICU) admission instead of in-hospital mortality on the quality indicator standardized mortality ratio (SMR).

Methods

A cohort study of 77,616 patients admitted to 44 Dutch mixed ICUs between 1 January 2008 and 1 July 2011. Four Acute Physiology and Chronic Health Evaluation (APACHE) IV models were customized to predict in-hospital mortality and mortality 1, 3, and 6 months after ICU admission. Models’ performance, the SMR and associated SMR rank position of the ICUs were assessed by bootstrapping.

Results

The customized APACHE IV models can be used for prediction of in-hospital mortality as well as for mortality 1, 3, and 6 months after ICU admission. When SMR based on mortality 1, 3 or 6 months after ICU admission was used instead of in-hospital SMR, 23, 36, and 30 % of the ICUs, respectively, received a significantly different SMR. The percentages of patients discharged from ICU to another medical facility outside the hospital or to home had a significant influence on the difference in SMR rank position if mortality 1 month after ICU admission was used instead of in-hospital mortality.

Conclusions

The SMR and SMR rank position of ICUs were significantly influenced by the chosen endpoint of follow-up. Case-mix-adjusted in-hospital mortality is still influenced by discharge policies, therefore SMR based on mortality at a fixed time point after ICU admission should preferably be used as a quality indicator for benchmarking purposes.     

Monitoring of serum lactate level during cardiopulmonary resuscitation in adult in-hospital cardiac arrest

IntroductionSerum lactate level may correlate with no-flow and low-flow status during cardiac arrest. Current guidelines have no recommended durations for cardiopulmonary resuscitation (CPR) before transition to the next strategy. We hypothesized that the lactate level measured during CPR could be associated with the survival probability and accordingly be useful in estimating the optimal duration for CPR.MethodsWe conducted a retrospective observational study in a single medical centre and included adult patients who had suffered an in-hospital cardiac arrest between 2006 and 2012. We used multivariable logistic regression analysis to study the association of lactate level measured during CPR and outcomes. We used generalized additive models to examine the nonlinear effects of continuous variables and conditional effect plots to visualize the estimated survival probability against CPR duration.ResultsOf the 340 patients included in our analysis, 50 patients (14.7 %) survived to hospital discharge. The mean lactate level was 9.6 mmol/L and mean CPR duration was 28.8 min. There was an inverse near-linear relationship between lactate level and probability of survival to hospital discharge. A serum lactate level <9 mmol/L was positively associated with patient survival to hospital discharge (odds ratio 2.00, 95 % confidence interval 1.01-4.06). The optimal CPR duration may not be a fixed value but depend on other conditions.ConclusionsSerum lactate level measured during CPR could correlate with survival outcomes. A lactate level threshold of 9 mmol/L may be used as a reference value to identify patients with different survival probabilities and determine the optimal CPR durations.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-1058-7) contains supplementary material, which is available to authorized users.     

Survival and outcome prediction using the Apache III and the out-of-hospital cardiac arrest (OHCA) score in patients treated in the intensive care unit (ICU) following out-of-hospital, in-hospital or ICU cardiac arrest

Background

There are few data comparing outcome and the utility of severity of illness scoring systems following intensive care after out-of-hospital (OHCA), in-hospital (IHCA) and intensive care unit (ICUCA) cardiac arrest. We investigated survival, factors associated with survival and the correlation and accuracy of general and specific scoring systems, including the Apache III score and the OHCA score in OHCA, IHCA and ICUCA patients.

Material and methods

Prospective analysis of data on all cardiac arrest patients treated in a tertiary hospital between August 1st 2008 and July 30th 2010. Collected data included resuscitation and post-resuscitation care data as defined by the Utstein Guidelines, Apache III on admission and the OHCA score on admission in OHCA and IHCA patients and after the arrest in ICUCA patients. Statistical methods were used to identify factors associated with outcome and the predictive ability and correlation of the aforementioned scores.

Results

Of a total of 3931 patients treated in the ICU, 51 were admitted following OHCA, 50 following IHCA and 22 suffered an ICUCA and had sustained return of spontaneous circulation (ROSC). Survival at 30 days was highest among ICUCAs (67%) followed by IHCAs (38%) and OHCAs (29%). Using multivariate analysis delay ROSC was the only independent predictor of survival. The OHCA score performed with moderate accuracy for predicting 30-day mortality (area under the curve 0.77 [0.69–0.86] and was slightly better than the Apache III score 0.71 (0.61–0.80). Using multiple logistic regression the Apache III and the OHCA score were both independent predictors of hospital survival and correlation between these two scores was weak (correlation coefficient of 0.244).

Conclusions

Latency to ROSC seems to be the most important determinant of survival in patients following ICU care after a cardiac arrest in this single center trial. The OHCA score and the Apache III score offer moderate predictive accuracy in ICU cardiac arrest patients but correlated weakly with each other. Illness severity adjustment for cardiac arrest patients in ICU should include features of both these scoring systems.     

3796例院内心肺复苏患者的回顾性分析

目的 了解10年来院内心肺复苏（cardiopulmonary resuscitation,CPR）现状,探索如何提高CPR特别是脑复苏水平。方法 对本院1995至2004年记录完整的3796例患者资料进行院内CPR回顾性研究。对病例数量,疾病种类,CPR有关时程、实施地点、肾上腺素用量,心肺复苏成功率及脑复苏成功率等数据进行统计与分析。结果 CPR病例数量逐年上升,21～50岁年龄段构成比增长显著,而10岁以下病例逐年减少;1999年起,创伤后CPR病例数量超过心血管病而跃居首位;心脏停搏时间大于10min者CPR成功率明显低于10min内开始CPR者（P〈0．001）;全部病例CPR成功率为30．4％,24小时生存率3．6％,脑复苏成功率仅1．4％;CPR成功率与心脏停搏时间、肾上腺素用量、初期复苏地点等有关,ICU及手术室内CPR和脑复苏成功率相对较好,普通病房最低。结论 院内CPR成功率较低,脑复苏成功率则极低。主要原因是早期生命支持“生存链”未得到切实应用。普及、加强院前和院内复苏标准化训练,完善急诊医学体系建设和管理,是提高CPR成功率的根本途径。     

Analysis of limited resuscitations in patients suffering in-hospital cardiac arrest

Background

Although clinicians are expected to help patients make decisions about end-of-life care, there is insufficient data to help guide patient preferences. The objective of this study was to determine the frequency of patients who undergo ‘limited code’ and compare survival to discharge with those who undergo maximum resuscitative efforts (‘full code’).

Methods

We performed a retrospective analysis of all adult in-hospital cardiac arrests (IHCA) at a tertiary care teaching hospital from January 1999 to December 2003 to compare survival in patients with limited code to survival in patients with a full code. We collected data on demographic and clinical variables known to influence survival in IHCA. Logistic regression was used to assess the association of code status with subsequent survival through the code and to hospital discharge after adjusting for potential confounding factors.

Results

Of the 309 patients having IHCA, there were 17 (5.5%) patients with limited code status and 292 (94.5%) with full code status. Among full code patients, 171 (58.6%) survived the code compared to five patients (29.4%) who had a limited code (p = 0.023). After adjusting for demographic variables and pre-arrest co-morbidities, patients with full code status compared to limited code status had an odds ratio for return of spontaneous circulation of 3.69 (95% CI: 1.13–14.34).

Conclusions

Patients who opt for limited code have a significantly lower probability of survival compared to patients who choose full code. Patients who choose limited code should be informed of the likely negative outcome as compared to full resuscitation.     

The gradient between arterial and end-tidal carbon dioxide predicts in-hospital mortality in post-cardiac arrest patient

Purpose

We investigated the predictive value of the gradient between arterial carbon dioxide (PaCO₂) and end-tidal carbon dioxide (ETCO₂) (Pa-ETCO₂) in post-cardiac arrest patients for in-hospital mortality.

Risk prediction of in-hospital mortality in patients with venoarterial extracorporeal membrane oxygenation for cardiopulmonary support: The ECMO-ACCEPTS score

PurposeVenoarterial extracorporeal membrane oxygenation (VA-ECMO) is an increasingly used treatment option for patients in need of mechanical cardiopulmonary support, while available outcome data is limited. The aim of this study was to identify predictors for 30-day in-hospital mortality.Material and methodsWe analyzed baseline characteristics and outcomes of 8351 VA-ECMO procedures performed in Germany from 2007 to 2015. Using a multivariable model, we identified the ten most important variables to allow for prediction of 30-day in-hospital mortality. Based on these variables, we created a mortality prediction score (ECMO-ACCEPTS score) to enhance decision making in patients considered for or treated with VA-ECMO support.ResultsOf 8351 patients (71.7% male) 3567 had prior CPR. Mean age was 62 years in the present cohort. The overall 30-day in-hospital mortality was 61%. The ECMO-ACCEPTS score, derived among randomly selected 4175 patients, included ten independent predictors for in-hospital mortality. Internal validation in the remaining 4176 patients confirmed strong differentiation between low and high risk of 30-day in-hospital mortality (r = 0.97 for correlation of predicted with observed mortality, p < .001).ConclusionsThe ECMO-ACCEPTS score might help clinicians to improve risk prediction among VA-ECMO patients for refractory cardiogenic shock.     

Out-of-hospital cardiac arrest: early in-hospital hypotension versus out-of-hospital factors in predicting in-hospital mortality among those surviving to hospital admission

Objective

The purpose of this study was to determine the prevalence of in-hospital hypotension in patients surviving to admission after resuscitation from out-of-hospital cardiac arrest and compare it to that of traditional Utstein factors in predicting in-hospital mortality.

Methods

Single-center retrospective cohort of adult patients surviving to hospital admission after resuscitation from out-of-hospital sudden death between January 1, 2006 and October 31, 2009. Study variables included Utstein template data: age, sex, initial rhythm, witnessed or nonwitnessed arrest, presence or absence of bystander CPR, location of arrest, response time (time of 9-1-1 dispatch to first vehicle arrival), and hypotension (systolic pressure < 90 or mean arterial pressure < 60) within 24 h of ROSC. Univariate comparisons of categorical variables were performed and the Wilcoxon rank-sum test was used to compare continuous variables. Multivariable logistic regression was then performed after inclusion of Utstein variables.

Results

73 patients met the inclusion criteria, and in-hospital mortality occurred in 54 (74%). On univariate analysis, in-hospital hypotension (OR = 3.5, 95%CI 1.1–10.0, p = 0.02), pre-hospital rhythm other than VF/VT (OR 4.3, 95%CI 1.4–13.3, p = 0.008), and an unwitnessed arrest (OR = 6.9, 95%CI 0.8–56.5, p = 0.04), were significant predictors of in-hospital mortality. On multivariable analysis, in-hospital hypotension (OR = 9.8, 95%CI 1.5, 63.0, p = 0.02), pre-hospital rhythm other than VT/VF (OR = 8.5, 95%CI 1.3–58.8, p = 0.03), and lack of bystander CPR (OR = 13.2, 95%CI 1.6–111, p = 0.02) remained statistically significant predictors of in-hospital mortality.

Conclusions

In-hospital hypotension was predictive of mortality, as was a pre-hospital nonshockable rhythm and lack of bystander CPR. In contrast, traditional pre-hospital risk factors: age, gender, public location of arrest, response time, and witnessed arrest, were not predictive.     

Do-not-attempt resuscitation independently predict in-hospital mortality in septic patients

IntroductionSepsis patients require timely and appropriate treatment in an intensive care setting. However, “do-not-attempt resuscitation” (DNAR) status may affect physicians' priorities and treatment preferences. The aim of this study was to evaluate whether DNAR status affects the outcomes of septic patients.MethodsThis was a retrospective cohort study included septic patients admitted to the emergency department intensive care unit (ED-ICU) in a university-based teaching hospital during April–November 2015. Septic patients admitted to the ED-ICU were included.ResultsOf the 132 eligible patients, 49.2% (65/132) had DNAR status (median age 80 years old, IQR, 73–86). The overall in-hospital mortality rate was 28.8% (38/132). Non-survivors had a higher percentage of receiving inotropes/vasopressors (52.6% vs 34.0%, p = 0.048), higher median Charlson comorbidity index scores [8.5 (IQR, 7–11.75) vs 8 (IQR, 6–9), p = 0.012], higher APACHE II score [25 (IQR, 20–30.25) vs 20 (IQR, 17–25), p = 0.002], and higher SOFA score [7 (IQR, 6–11) vs 6 (IQR,4–8), p = 0.012]. There was no significant difference in intubation among the two groups. In a multivariate logistic regression analysis, DNAR status was an independent predictor of in-hospital mortality (odds ratio = 6.22, 95% confidence interval (CI) = (2.71–17.88), p < 0.001). The area under the ROC curve for the logistic regression model was 0.84 [95% CI = (0.77–0.92), p < 0.001]. In subgroup analysis, DNAR status remained an independent predictor of mortality among age ≥65 years and ≥80 years.ConclusionAfter adjusting for comorbidities, treatments, and illness severity, DNAR status was associated with in-hospital mortality of septic patients. Further studies should evaluate physicians' attitudes toward septic patients with DNAR status.