Analysis of clinical outcomes following in-hospital adult cardiac arrest

AIMS: The outcome of in-hospital resuscitation following cardiac arrest depends on many factors related to the patient, the environment and the extent of resuscitation efforts. The aim of the present study was to determine predictors of successful resuscitation and survival to -hospital discharge following in-hospital cardiac arrest and to assess functional outcomes of survivors (cerebral performance scores). METHODS: Medical records of adult patients sustaining in-hospital cardiac arrest between June 2001 and January 2003 were reviewed. Successful resuscitation was defined as the return of spontaneous circulation at the completion of resuscitative efforts, irrespective of degree of inotropic/vasopressor support. Thirty demographic and clinical variables were analysed to determine predictors of successful resuscitation and in-hospital survival. RESULTS: In 105 patients with cardiac arrest, 46 patients (44%) were successfully resuscitated and 22 (21%) survived to hospital discharge. Predictors of successful resuscitation included a primary cardiac admission diagnosis, monitoring at the time of the arrest, a longer duration of resuscitation and the absence of the need for endotracheal intubation. Patients with ventricular tachycardia/fibrillation were more likely to survive to hospital discharge than those with asystolic or pulseless electrical activity (45 vs 12 vs 20%, P = 0.01). The sole independent predictor of survival to hospital discharge was the absence of the need for endotracheal intubation (odds ratio 0.14, 95% confidence interval 0.02-0.88, P < 0.01). The majority of survivors (73%) had normal cerebral performance scores. CONCLUSIONS: Identification of predictors of successful resuscitation following cardiac arrest is important for risk stratification. Ongoing appraisal of in-hospital cardiac arrests through a multicentre registry could improve clinical outcomes.     

胺碘酮对于急性心梗后室性早搏的临床疗效及对心功能的影响

目的:观察胺碘酮对急性心肌梗死(AMI)后室性早搏的疗效及对患者心功能的影响。方法:选择本院的94例AMI后室性早搏患者,患者被分为常规治疗组(给予常规利多卡因治疗),胺碘酮组(在常规治疗组的基础上给予胺碘酮治疗);治疗14d后,对比两组患者的疗效,观察两组患者治疗前后心功能等指标的情况及治疗后不良反应率。结果:胺碘酮组治疗总有效率显著高于常规治疗组(97.87%比74.47%,P=0.001)。治疗后,与常规治疗组比较,胺碘酮组左室射血分数(LVEF)[(0.49±0.06)比(0.64±0.07)]、左室短轴缩短率(LVFS)[(0.43±0.05)比(0.57±0.06)]、二尖瓣舒张早期峰值流速与晚期峰值流速的比值E/A[(0.88±0.07)比(0.98±0.11)]均显著提高,心室率[(128.47±15.34)次/min比(86.49±14.96)次/min]、QTc离散度[(49.51±11.96)ms比(41.09±11.73)ms]、室性早搏次数[(21.05±6.91)次/h比(12.07±5.47)次/h]均显著下降,P均=0.001。两组不良反应率无统计学差异(P=0.064)。结论:胺碘酮结合利多卡因治疗急性心梗后室性早搏疗效显著,可显著降低心率,改善心功能,且用药安全。     

Post-resuscitation care for survivors of cardiac arrest

Cardiac arrest can occur following a myriad of clinical conditions. With advancement of medical science and improvements in Emergency Medical Services systems, the rate of return of spontaneous circulation for patients who suffer an out-of-hospital cardiac arrest (OHCA) continues to increase. Managing these patients is challenging and requires a structured approach including stabilization of cardiopulmonary status, early consideration of neuroprotective strategies, identifying and managing the etiology of arrest and initiating treatment to prevent recurrence. This requires a closely coordinated multidisciplinary team effort. In this article, we will review the initial management of survivors of OHCA, highlighting advances and ongoing controversies.     

Retrospective study of perioperative cardiac arrest from a Chinese tertiary hospital

Studies on perioperative cardiac arrest in Chinese hospitals have rarely been retrieved from international journals. This survey evaluated the incidence, causes, and outcomes of perioperative cardiac arrests in a Chinese tertiary general hospital between July 2013 and December 2020. The incidence of cardiac arrest within 24 hours of anesthesia administration was retrospectively identified using an anesthesia database in Liaocheng People''s Hospital. During the study period, there were 118,152 anesthetics. Data collected included patient characteristics, surgical procedures (elective or emergency), American Society of Anesthesiologists (ASA) physical status score, type of surgery, anesthesia technique, and outcome. Cardiac arrests were grouped into one of 3 groups: totally anesthesia-related, partially anesthesia-related, or anesthesia-unrelated. In total, 41 cardiac arrests (3.5:10,000) and 26 deaths (2.2:10,000) were found. Major risk factors for cardiac arrest were children under 1 year, adults between 19 and 65 years, and the elderly (>80 years) (P < .001), male patients (P = .02), emergency surgery (P < .001), and ASA grade V patients without anesthesia (P = .009). There were 19 anesthesia-related cardiac arrests (1.6:10,000) – 2 were totally related, and 17 were partially related to anesthesia. There were 9 anesthesia-related deaths (0.8:10,000), all of which were partially related to anesthesia. Perioperative cardiac arrests were correlated with age, gender, ASA grade and surgical procedures. The 2 most important patient factors leading to cardiac arrest were hemorrhagic shock from trauma and septic shock, respectively.     

胺碘酮对老年心律失常患者甲状腺功能的影响

目的探讨口服小剂量胺碘酮(AD)对老年心律失常患者甲状腺功能的作用和影响.方法老年冠心病心律失常住院患者56例,均给予负荷量AD(600mg/d),6d后渐减至维持剂量(50～100mg/d);放射免疫法测定甲状腺激素水平.结果服用AD第6天即可见甲状腺激素水平变化,与用药前相比较,总三碘甲状腺原氨酸(TT3)和游离三碘甲状腺原氨酸(FT3)1个月时下降幅度最大,分别由(1.7±0.7)nmol/L、(3.1±1.1)pmol/L下降为(1.4±0.6)nmol/L、(2.3±1.6)pmol/L,下降了17.2%和27.6%(均为P<0.01);促甲状腺激素(TSH)、游离甲状腺激素(FT4)3个月时上升达峰值,由(2.1±1.6)mU/L和(16.2±4.0)pmol/L升为(4.4±4.7)mU/L及(20.7±4.8)pmol/L,分别为118.8%和15.2%(均为P<0.01),总甲状腺素(TT4)于6个月达峰,由(126.3±20.5)nmol/L升为(154.1±32.6)nmol/L(22.0%,P<0.01).监测1年,仅有12例出现TSH异常上升,6例TSH>15.0mU/L者给予左旋甲状腺片后,有4例逐渐恢复正常.结论老年心律失常患者、特别是安装心脏起搏器的老年患者服用AD第6天即可检测到甲状腺激素水平的变化,1～6个月变化最显著,但大多数变化是在正常值范围内.     

Study of pre-hospital care of out of hospital cardiac arrest victims and their outcome in a tertiary care hospital in India

BackgroundIndia does not have a formal cardiac arrest registry or a centralized emergency medical system. In this study, we aimed to assess the prehospital care received by the patients with OHCA and predict the factors that could influence their outcome.MethodsOut-of-hospital cardiac arrest patients presenting to the emergency department in a tertiary care centre were included in the study. Prehospital care was assessed in terms of bystander cardiopulmonary resuscitation (CPR), mode of transport, resuscitation in ambulance. OHCA outcomes like Return of spontaneous circulation (ROSC), survival to hospital discharge and favourable neurological outcome at discharge were assessed.ResultsAmong 205 patients, the majority were male (71.2%) and were above 60 years of age (49.3%); Predominantly non-traumatic (82.4%). 30.7% of the patients had sustained cardiac arrest in transit to the hospital. 41.5% of patients reached hospital by means other than ambulance. Only 9.8% patients had received bystander CPR. Only 12.5% ambulances had BLS trained personnel. AED was used only in 1% of patients. The initial rhythm at presentation to the hospital was non-shockable (96.5%). Return of spontaneous circulation (ROSC) was achieved in 17 (8.3%) patients, of which only 3 (1.4%) patients survived till discharge. The initial shockable rhythm was a significant predictor of ROSC (OR 18.97 95%CI 3.83–93.89; p < 0.001) and survival to discharge (OR 42.67; 95%CI 7.69–234.32; p < 0.001).ConclusionThe outcome of OHCA in India is dismal. The pre-hospital care received by the OHCA victim needs attention. Low by-stander CPR rate, under-utilised and under-equipped EMS system are the challenges.     

Atrial-selective sodium channel block as a novel strategy for the management of atrial fibrillation

Pharmacological management of atrial fibrillation (AF) remains an important unmet medical need. Because available drugs for rhythm control of AF are often associated with a significant risk for development of ventricular arrhythmias or extracardiac toxicity, recent drug development has focused on agents that are atrial selective. Inhibition of the ultrarapid delayed rectifier potassium current (I_Kur), a current exclusive to atria, is an example of an atrial-selective approach. Recent studies, however, have shown that loss-of-function mutations in KCNA5, the gene that encodes K_V1.5, the α subunit of the I_Kur channel, is associated with the development of AF and that inhibition of I_Kur can promote the induction of AF in experimental models. Another potential atrial-selective approach has recently been identified. Experimental studies have demonstrated important atrioventricular differences in the biophysical properties of the sodium channel and have identified sodium channel blockers that can exploit electrophysiological distinctions between atria and ventricles. Atrial-selective/predominant sodium channel blockers such as ranolazine effectively suppress AF in experimental models involving canine-isolated right atrial preparations at concentrations that produce little to no effect on electrophysiological parameters in ventricular myocardium. Chronic administration of amiodarone was also found to exert atrial-selective depression of I_Na-dependent parameters and thus to prevent the induction of AF. Ranolazine and amiodarone have in common the ability to rapidly dissociate from the sodium channel and to prolong the atrial action potential duration via inhibition of I_Kr. Our observations suggest that atrial-selective sodium channel block may be a fruitful strategy for the management of AF.     

A multicentre, randomized trial on the benefit/risk profile of amiodarone, flecainide and propafenone in patients with cardiac disease and complex ventricular arrhythmias

The long-term benefit/risk profiles of amiodarone, flecainideand propafenone were compared in 141 patients with complex ventriculararrhythmias and cardiac disease, in a trial designed to mimicthe clinical decision-making process. The patients were randomizedto various sequences of the three drugs, at two dose levelsandfollowedfor 2 years. Drug or doses were changed to deal withinsufficient reduction of arrhythmias at 24 h ECG or severeadverse drug reaction (ADR). At 2 years 18 patients haddied(9/18 suddenly), 19 had withdrawn because of major clinicalevents or severe ADR, 13 had dropped out, seven hadbeen non-respondersthroughout the entire sequence of drugs, whereas eight werenon-responders only at the last visit. Thus, 76 patients (54%)were responders after 2 years. Of these, 57 were respondersfor 2 years with thefirst drug. Median exposure time to amiodarone,518 days . patienr', was higher than for flecainide and propafenone,218 and 178, respectively, indicating better overall responseto amiodarone (P<001). A total of50 ADRs led to drug with-drawal,with cardiovascular ADR being less frequent (P<003) for amiodarone(2/11) than for flecainide (13/16) and propafenone (16/23).In conclusion, with sequences of amiodarone, flecainide andpropafenone, an overall response rate of 79% couldbe obtainedintheshort-term (7–28 days) and54% at 2years. Amiodaronehas a morefavourable therapeutic profile than flecainide andpropafenone in these patients, having less tendency to worsenheartfailure.     

A comparison between patients suffering in-hospital and out-of-hospital cardiac arrest in terms of treatment and outcome

Abstract. Herlitz J, Bång A, Ekström L, Aune S, Lundström G, Holmberg S, Holmberg M, Lindqvist J (Sahlgrenska University Hospital, Göteborg, Sweden). A comparison between patients suffering in‐hospital and out‐of‐hospital cardiac arrest in terms of treatment and outcome. J Intern Med 2000; 248: 53–60. Aim. To compare treatment and outcome amongst patients suffering in‐hospital and out‐of‐hospital cardiac arrest in the same community. Patients. All patients suffering in‐hospital cardiac arrest in Sahlgrenska University Hospital covering half the catchment area of the community of Göteborg (500 000 inhabitants) and all patients suffering out‐of‐hospital cardiac arrest in the community of Göteborg. Criteria for inclusion were that resuscitation efforts should have been attempted. Time of survey. From 1 November 1994 to 1 November 1997. Methods. Data were recorded both prospectively and retrospectively. Results. In total, 422 patients suffered in‐hospital cardiac arrest and 778 patients suffered out‐of‐hospital cardiac arrest. Patients with in‐hospital cardiac arrest included more women and were more frequently found in ventricular fibrillation. The median interval between collapse and defibrillation was 2 min in in‐hospital cardiac arrest compared with 7 min in out‐of‐hospital cardiac arrest (< 0.001). The proportion of patients being discharged from hospital was 37.5% after in‐hospital cardiac arrest, compared with 8.7% after out‐of‐hospital cardiac arrest (P < 0.001). Corresponding figures for patients found in ventricular fibrillation were 56.9 vs. 19.7% (P < 0.001) and for patients found in asystole 25.2 vs. 1.8% (P < 0.001). Conclusion. In a survey evaluating patients with in‐hospital and out‐of‐hospital cardiac arrest in whom resuscitation efforts were attempted, we found that the former group had a survival rate more than four times higher than the latter. Possible strong contributing factors to this observation are: (i) shorter time interval to start of treatment, and (ii) a prepared selection for resuscitation efforts.     

小剂量胺碘酮治疗扩张性心肌病伴发心律失常

目的 探讨小剂量胺碘酮治疗扩张性心肌病伴发阵发性室性心动过速和预防心脏性猝死的疗效。方法 扩张性心肌病患者65例,分为小剂量胺碘酮治疗组（n=33）及对照组（n=32）,基础治疗用利尿药、强心苷、血管紧张素转化酶抑制药及硝酸酯,随访12个月,用超声心动图测定心功能指数,动态心电图监测阵发性室性心动过速和猝死率,进行两组病例比较。结果 治疗12个月后,两组心功能指数均较治疗前改善,小剂量胺碘酮治疗组患者阵发性室性心动过速较对照组明显减少。两组猝死率没有明显区别。结论 小剂量胺碘酮对于改善心功能和治疗扩张性心肌病患者恶性室性心律失常有效．可减少新发室性心律失常。     

芍药苷对心脏钾通道电生理功能的影响

目的研究芍药苷对内向整流钾电流(IK1)、瞬时外向钾电流(Ito)以及延迟整流钾电流(IKs和IKr)的作用。方法用全细胞膜片钳技术记录大鼠心室肌细胞的Ito和IK1电流。而IKs和IKr电流在转染相应质粒的HEK293细胞上记录。对比芍药苷使用前后的电流图,观察芍药苷对各种离子通道电流的影响。结果在-100mV测试电压下,100μmol/L的芍药苷能使IK1峰值密度从(-25.26±8.21)pA/pF降至(-17.65±6.52)pA/pF,平均抑制率为30.13%(n=6,P<0.05),但对其反转电位以及内向整流特性无影响。此外,100μmol/L芍药苷对Ito、IKs和IKr电流无明显作用。结论芍药苷对IK1电流具有明显的抑制作用,而对Ito、IKs及IKr无明显作用。     

Successful use of emergency transthoracic pacing in bradyasystolic cardiac arrest

We present the document successful resuscitation of six patients using emergency transthoracic pacing. Two patients were resuscitated from asystole, one had a slow supraventricular bradycardia following head trauma and spinal shock, and three patients had cardiovascular collapse secondary to complete A-V dissociation. One patient developed a non-fatal pericardial tamponade, but there were no cases of pneumothorax. All patients failed to respond to standard medical therapy. We believe that the initially successful resuscitation of these patients was related directly to the pacing procedure. Three patients had underlying pathology that did not allow longterm survival. Three patients were discharged from the hospital without neurologic sequelae. Although emergency transthoracic pacing has a relatively low success rate in bradyasystolic cardiac arrest and may be associated with serious complications, the procedure may be life-saving in selected cases.     

Definition of performance metrics and methods for screening for sudden cardiac arrest risk at a tertiary care medical center

Purpose  

The purpose of this study is to describe the results of manual and automatic electronic medical record-based screening of patients at risk of sudden cardiac arrest (SCA) based on measurements of left ventricular ejection fraction (LVEF).     

The association between age of hospitalized patients and the delivery of advanced cardiac life support

OBJECTIVE: To determine the extent of variability in the administration of advanced cardiac life support (ACLS) and to determine if age is associated with variability. DESIGN: Retrospective cohort. SETTING: Urban teaching hospital. PATIENTS: One hundred twenty-two adult inpatients without a “do-not-resuscitate” order who suffered cardiopulmonary arrest during 1993. MEASUREMENTS AND MAIN RESULTS: Of the total, 35 (29%) survived the arrest and 87 (71%) died. Among the nonsurvivors, two patients received no ACLS and six were not intubated, despite the inclusion of intubation in all ACLS protocols. Of the 87 nonsurvivors, 31 had a single electrocardiographic rhythm during their arrest and should have had similar ACLS trials. However, the 9 nonsurvivors with ventricular fibrillation received a range of 0 to 17 interventions, the 11 with electromechanical dissociation received 1 to 22, and the 11 with asystole received 0 to 14. Based on a protocol-derived definition of a minimal trial of ACLS (a “short ACLS trial”) for all 87 nonsurvivors, age greater than 75 was associated with receiving a short trial. Dependent functional status and being on a medical service were also associated with a short ACLS trial. In a logistic regression model including these variables as covariates, age remained significantly associated with a short ACLS trial; odds ratio, 9.71 (95% confidence interval 1.68, 56.1). CONCLUSIONS: Wide variability exists in the administration of ACLS at the studied site. The finding that some patients receive no ACLS suggests that physicians at this site may be making bedside determinations of the likelihood of its benefit based on individual patient characteristics. The association between older age and short ACLS trials among all nonsurvivors suggests that age is most important of these characteristics. From Rhode Island Hospital, Brown University, Providence, RI.