In-Hospital Cardiac Arrest: A Review Andersen, Lars W; Holmberg, Mathias J; Berg, Katherine M ...
JAMA : the journal of the American Medical Association,
2019-Mar-26, Letnik:
321, Številka:
12
Journal Article
Recenzirano
In-hospital cardiac arrest is common and associated with a high mortality rate. Despite this, in-hospital cardiac arrest has received little attention compared with other high-risk cardiovascular ...conditions, such as stroke, myocardial infarction, and out-of-hospital cardiac arrest.
In-hospital cardiac arrest occurs in over 290 000 adults each year in the United States. Cohort data from the United States indicate that the mean age of patients with in-hospital cardiac arrest is 66 years, 58% are men, and the presenting rhythm is most often (81%) nonshockable (ie, asystole or pulseless electrical activity). The cause of the cardiac arrest is most often cardiac (50%-60%), followed by respiratory insufficiency (15%-40%). Efforts to prevent in-hospital cardiac arrest require both a system for identifying deteriorating patients and an appropriate interventional response (eg, rapid response teams). The key elements of treatment during cardiac arrest include chest compressions, ventilation, early defibrillation, when applicable, and immediate attention to potentially reversible causes, such as hyperkalemia or hypoxia. There is limited evidence to support more advanced treatments. Post-cardiac arrest care is focused on identification and treatment of the underlying cause, hemodynamic and respiratory support, and potentially employing neuroprotective strategies (eg, targeted temperature management). Although multiple individual factors are associated with outcomes (eg, age, initial rhythm, duration of the cardiac arrest), a multifaceted approach considering both potential for neurological recovery and ongoing multiorgan failure is warranted for prognostication and clinical decision-making in the post-cardiac arrest period. Withdrawal of care in the absence of definite prognostic signs both during and after cardiac arrest should be avoided. Hospitals are encouraged to participate in national quality-improvement initiatives.
An estimated 290 000 in-hospital cardiac arrests occur each year in the United States. However, there is limited evidence to support clinical decision making. An increased awareness with regard to optimizing clinical care and new research might improve outcomes.
Background
We investigated hospital‐level variation in outcomes after in‐hospital cardiac arrest (IHCA) in Denmark, and assessed whether variation in outcomes could be explained by differences in ...patient characteristics.
Methods
Adult patients (≥18 years old) with IHCA in 2017 and 2018 were included from the Danish IHCA Registry (DANARREST). Data on patient characteristics and outcomes were obtained from population‐based registries. Predicted probabilities, likelihood ratio tests, intraclass correlation coefficients (ICCs), and median odds ratios (ORs) were calculated for return of spontaneous circulation (ROSC), survival to 30 days, and survival to 1 year.
Results
A total of 3340 patients with IHCA from 24 hospitals were included. We found that hospital‐level variation in outcomes after IHCA existed across all measures of variation. The unadjusted median OR for ROSC, survival to 30 days, and survival to 1 year were 1.28 (95% confidence interval CI: 1.24, 1.45), 1.38 (95% CI: 1.33, 1.60), and 1.44 (95% CI: 1.39, 1.70), respectively. The unadjusted ICC suggest that 2.0% (95%: 1.6%, 4.4%), 3.3% (95%: 2.7%, 6.8%), and 4.3% (95%: 3.5%, 8.6%) of the total individual variation in ROSC, survival to 30 days, and survival to 1 year was attributable to hospital‐level variation. These results decreased but persisted in the analyses adjusted for select patient characteristics.
Conclusions
In this study, we found that outcomes after IHCA varied across hospitals in Denmark. However, only about 2%–4% of the total individual variation in outcomes after IHCA was attributable to differences between hospitals, suggesting that most of the individual variation in outcomes was attributable to patient‐level variation.
To perform a systematic review and meta-analysis on targeted temperature management in adult cardiac arrest patients.
PubMed, Embase, and the Cochrane Central Register of Controlled Trials were ...searched on June 17, 2021 for clinical trials. The population included adult patients with cardiac arrest. The review included all aspects of targeted temperature management including timing, temperature, duration, method of induction and maintenance, and rewarming. Two investigators reviewed trials for relevance, extracted data, and assessed risk of bias. Data were pooled using random-effects models. Certainty of evidence was evaluated using GRADE.
The systematic search identified 32 trials. Risk of bias was assessed as intermediate for most of the outcomes. For targeted temperature management with a target of 32–34 °C vs. normothermia (which often required active cooling), 9 trials were identified, with six trials included in meta-analyses. Targeted temperature management with a target of 32–34 °C did not result in an improvement in survival (risk ratio: 1.08 95%CI: 0.89, 1.30) or favorable neurologic outcome (risk ratio: 1.21 95%CI: 0.91, 1.61) at 90 to 180 days after the cardiac arrest (low certainty of evidence). Three trials assessed different hypothermic temperature targets and found no difference in outcomes (low certainty of evidence). Ten trials were identified comparing prehospital cooling vs. no prehospital cooling with no improvement in survival (risk ratio: 1.01 95%CI: 0.92, 1.11) or favorable neurologic outcome (risk ratio: 1.00 95%CI: 0.90, 1.11) at hospital discharge (moderate certainty of evidence).
Among adult patients with cardiac arrest, the use of targeted temperature management at 32–34 °C, when compared to normothermia, did not result in improved outcomes in this meta-analysis. There was no effect of initiating targeted temperature management prior to hospital arrival. These findings warrant an update of international cardiac arrest guidelines.
To assess the use of extracorporeal cardiopulmonary resuscitation (ECPR), compared with manual or mechanical cardiopulmonary resuscitation (CPR), for out-of-hospital cardiac arrest (OHCA) and ...in-hospital cardiac arrest (IHCA) in adults and children.
The PRISMA guidelines were followed. We searched Medline, Embase, and Evidence-Based Medicine Reviews for randomized clinical trials and observational studies published before May 22, 2018. The population included adult and pediatric patients with OHCA and IHCA of any origin. Two investigators reviewed studies for relevance, extracted data, and assessed risk of bias using the ROBINS-I tool. Outcomes included short-term and long-term survival and favorable neurological outcome.
We included 25 observational studies, of which 15 studies were in adult OHCA, 7 studies were in adult IHCA, and 3 studies were in pediatric IHCA. There were no studies in pediatric OHCA. No randomized trials were included. Results from individual studies were largely inconsistent, although several studies in adult and pediatric IHCA were in favor of ECPR. The risk of bias for individual studies was overall assessed to be critical, with confounding being the primary source of bias. The overall quality of evidence was assessed to be very low. Heterogeneity across studies precluded any meaningful meta-analyses.
There is inconclusive evidence to either support or refute the use of ECPR for OHCA and IHCA in adults and children. The quality of evidence across studies is very low.
To systematically review studies comparing bystander automated external defibrillator (AED) use to no AED use in regard to clinical outcomes in out-of-hospital cardiac arrest (OHCA), and to provide a ...descriptive summary of studies on the cost-effectiveness of bystander AED use.
We searched Medline, Embase, the Web of Science, and the Cochrane Library for randomized trials and observational studies published before June 1, 2017. Meta-analyses were performed for patients with all rhythms, shockable rhythms, and non-shockable rhythms.
Forty-four observational studies, 3 randomized trials, and 13 cost-effectiveness studies were included. Meta-analysis of 6 observational studies without critical risk of bias showed that bystander AED use was associated with survival to hospital discharge (all rhythms OR: 1.73 95%CI: 1.36, 2.18, shockable rhythms OR: 1.66 95%CI: 1.54, 1.79) and favorable neurological outcome (all rhythms OR: 2.12 95%CI: 1.36, 3.29, shockable rhythms OR: 2.37 95%CI: 1.58, 3.57). There was no association between bystander AED use and neurological outcome for non-shockable rhythms (OR: 0.76 95%CI: 0.10, 5.87). The Public-Access Defibrillation trial found higher survival rates when volunteers were equipped with AEDs. The other trials found no survival difference, although their study settings differed. The quality of evidence was low for randomized trials and very low for observational studies. AEDs were cost-effective in settings with high cardiac arrest incidence, with most studies reporting ratios < $100,000 per quality-adjusted life years.
The evidence supports the association between bystander AED use and improved clinical outcomes, although the quality of evidence was low to very low.
Adult in-hospital cardiac arrest in Denmark Andersen, Lars W.; Holmberg, Mathias J.; Løfgren, Bo ...
Resuscitation,
July 2019, 2019-07-00, 20190701, Letnik:
140
Journal Article
Recenzirano
The aim of this study was to describe patient characteristics, event characteristics, and outcomes for patients with in-hospital cardiac arrest in Denmark.
Data was obtained from DANARREST. DANARREST ...is a nationwide registry that covers all in-hospital cardiac arrests in Denmark with a clinical indication for cardiopulmonary resuscitation (i.e. without a prior “do-not-resuscitate” order).
A total of 4069 adult in-hospital cardiac arrests were registered between January 1st, 2017 and December 31st, 2018. The median age was 74 years (quartiles: 65, 81) and 37% were female. 71% had a non-shockable rhythm and the presumed etiology was primarily non-cardiac (57%). A total of 2180 patients (53.8%) achieved ROSC, with an additional 36 patients (0.9%) receiving extracorporeal cardiopulmonary resuscitation. At 30-days 1124 patients (27.8%) were alive. Of cardiac arrests from 2017, 404 patients (20.0%) survived to 1 year after the cardiac arrest. The incidence of adult in-hospital cardiac arrest in Denmark was estimated at 1.8 per 1000 admissions or 0.6 per 1000 in-patient days.
In-hospital cardiac arrest occurs in at least 2000 patients each year in Denmark with a 30-day survival of approximately 28%. The establishment of a national registry for in-hospital cardiac arrest in Denmark will allow for quality improvement and research projects.
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