In-Hospital Cardiac Arrests: Potential for ECPR

Abstract

In-hospital cardiac arrests (IHCA) have a poor survival. We studied IHCAs occurring over two years in order to identify subset of patients in whom extracorporeal cardiopulmonary resuscitation (ECPR) will have most favorable impact. We retrospectively analyzed patient charts for 2017 and 2018 in a tertiary hospital and examined survival to return of spontaneous circulation (ROSC) to determine characteristics and predictors of survival and find the areas best suitable for ECPR. Due to non-normality of distribution of most variables, we have compared continuous variables by the Mann-Whitney U test. Categorical variables were compared with the Chi square test and expressed as counts and percentages. Of the 710 codes in 572 patients, 543 (76.5%) codes resulted in ROSC, but only 199 (28%) patients were discharged alive. Mean age was 59.7±15.5 years. Mean duration of the code was 22.8±19.0 minutes. Out of 710 total codes, 409 (57.5%) codes occurred in the intensive care unit (ICU) or the cath lab, with 80% of those codes surviving to ROSC, 138 (19.4%) in telemetry (72.5% surviving to ROSC), 87 (12.3%) in the emergency room (survival 69%). Only 76 (10.7%) arrests occurred in unmonitored wards and still, 73.7% of those codes survived to ROSC. Only 189 (26.6%) codes had initial shockable rhythms (survival to ROSC 85.7%), while 410 (57.7%) arrests had pulseless electrical activity (PEA) as an initial rhythm and 109 (15.4%) arrests started asystolic, survival to ROSC 73.4% and 72.7%, respectively, p<0.05 when compared with shockable rhythm. When categorizing etiologies of arrest, cardiac emergencies make up 247 (34.8%) of all codes with 80.6% surviving to ROSC, similar to medical emergencies and better than any other diagnostic category, p<0.05. 164 codes (23.1%) occurred secondary to sepsis, and terminal diseases come in third with a 72% survival in both. Medical emergencies caused only 52 codes (7.3%) but had a code survival of 82.7%. Medical and cardiac emergencies represent reversible conditions have the highest potential for improvement in outcomes. Consideration of ECMO during the code should be primarily focused on cardiac and medical emergencies, especially if they occur in the cath lab or in the intensive care unit, followed by telemetry and emergency room. Survival is poor in patients with sepsis, and caution should be used when considering ECPR in this subset.