Resuscitation For In-hospital Cardiac Arrest Research Articles

Prolonged chest compressions during cardiopulmonary resuscitation for in-hospital cardiac arrest due to acute pulmonary embolism.

Patients with hemodynamic collapse due to acute pulmonary embolism have a dismal prognosis if not treated rapidly. Therapeutic options include systemic thrombolytic therapy, rheolytic thrombectomy, and surgical embolectomy. However, the efficacy of thrombolytic therapy is diminished because the low-output state hinders effective delivery of the lytic agent to the thrombus. In the absence of any form of mechanical circulatory support, such as extracorporeal membrane oxygenation or cardiac surgery on site, we think that prolonged vigorous manual compressions might be the only way to support the circulation during the initial critical state, when thrombolytic therapy has been administered. We report the results of prolonged manual chest compressions (exceeding 30 minutes) on 6 patients who received tenecteplase in treatment of acute pulmonary embolism that induced in-hospital cardiopulmonary arrest. Four of 6 patients survived and were discharged from the hospital. In an era of increasing technologic complexity for patients with hemodynamic instability, we emphasize the importance of prolonged chest compressions, which can improve systemic perfusion, counteract the prothrombotic state associated with cardiopulmonary arrest, and give the lytic agent time to act.

Improved neurologic outcomes after cardiac arrest with combined administration of vasopressin, steroids, and epinephrine compared to epinephrine alone.

Is a vasopressin, steroid, and epinephrine (VSE) protocol for in-hospital cardiac arrest resuscitation associated with better survival to hospital discharge with favourable neurologic outcome compared to epinephrine alone? Article chosen Mentzelopoulos S, Malachias S, Konstantopoulos D, et al. Vasopressin, steroids, and epinephrine and neurologically favorable survival after in-hospital cardiac arrest: a randomized clinical trial. JAMA 2013;310:270-9. To determine if a VSE protocol during cardiopulmonary resuscitation with hydrocortisone administration in patients with postresuscitative shock at 4 hours after return of spontaneous circulation would improve survival to hospital discharge with favourable neurologic outcome.

Relation of Smoking Status to Outcomes After Cardiopulmonary Resuscitation for In-Hospital Cardiac Arrest

In-hospital cardiac arrest (IHCA) is common and is associated with poor prognosis. Data on the effect of smoking on outcomes after IHCA are limited. We analyzed the Nationwide Inpatient Sample databases from 2003 to 2011 for all patients aged≥18 years who underwent cardiopulmonary resuscitation (CPR) for IHCA to examine the differences in survival to hospital discharge and neurologic status between smokers and nonsmokers. Of the 838,464 patients with CPR for IHCA, 116,569 patients (13.9%) were smokers. Smokers were more likely to be younger, Caucasian, and male. They had a greater prevalence of dyslipidemia, coronary artery disease, hypertension, chronic pulmonary disease, obesity, and peripheral vascular disease. Atrial fibrillation, heart failure, and diabetes mellitus with complications were less prevalent in smokers. Smokers were more likely to have a primary diagnosis of acute myocardial infarction (14.8% vs 9.1%, p<0.001) and ventricular tachycardia or ventricular fibrillation as the initial cardiac arrest rhythm (24.3% vs 20.5%, p<0.001). Smokers had a higher rate of survival to hospital discharge compared with nonsmokers (28.2% vs 24.1%, adjusted odds ratio 1.06, 95% confidence interval 1.05 to 1.08, p<0.001). Smokers were less likely to have a poor neurologic status after IHCA compared with nonsmokers (3.5% vs 3.9%, adjusted odds ratio 0.92, 95% confidence interval 0.89 to 0.95, p<0.001). In conclusion, among patients aged ≥18 years who underwent CPR for IHCA, we observed a higher rate of survival in smokers than nonsmokers-consistent with the "smoker's paradox." Smokers were also less likely to have a poor neurologic status after IHCA.

Hospital cardiac arrest resuscitation practice in the United States: A nationally representative survey

In-hospital cardiac arrest (IHCA) outcomes vary widely between hospitals, even after adjusting for patient characteristics, suggesting variations in practice as a potential etiology. However, little is known about the standards of IHCA resuscitation practice among US hospitals. To describe current US hospital practices with regard to resuscitation care. A nationally representative mail survey. A random sample of 1000 hospitals from the American Hospital Association database, stratified into 9 categories by hospital volume tertile and teaching status (major teaching, minor teaching, and nonteaching). Surveys were addressed to each hospital's cardiopulmonary resuscitation (CPR) committee chair or chief medical/quality officer. A 27-item questionnaire. Responses were received from 439 hospitals with a similar distribution of admission volume and teaching status as the sample population (P = 0.50). Of the 270 (66%) hospitals with a CPR committee, 23 (10%) were chaired by a hospitalist. High frequency practices included having a rapid response team (91%) and standardizing defibrillators (88%). Low frequency practices included therapeutic hypothermia and use of CPR assist technology. Other practices such as debriefing (34%) and simulation training (62%) were more variable and correlated with the presence of a CPR committee and/or dedicated personnel for resuscitation quality improvement. The majority of hospitals (79%) reported at least 1 barrier to quality improvement, of which the lack of a resuscitation champion and inadequate training were the most common. There is wide variability among hospitals and within practices for resuscitation care in the United States with opportunities for improvement.

Development and Validation of the Good Outcome Following Attempted Resuscitation (GO-FAR) Score to Predict Neurologically Intact Survival After In-Hospital Cardiopulmonary Resuscitation

Informing patients and providers of the likelihood of survival after in-hospital cardiac arrest (IHCA), neurologically intact or with minimal deficits, may be useful when discussing do-not-attempt-resuscitation orders. To develop a simple prearrest point score that can identify patients unlikely to survive IHCA, neurologically intact or with minimal deficits. The study included 51,240 inpatients experiencing an index episode of IHCA between January 1, 2007, and December 31, 2009, in 366 hospitals participating in the Get With the Guidelines-Resuscitation registry. Dividing data into training (44.4%), test (22.2%), and validation (33.4%) data sets, we used multivariate methods to select the best independent predictors of good neurologic outcome, created a series of candidate decision models, and used the test data set to select the model that best classified patients as having a very low (<1%), low (1%-3%), average (>3%-15%), or higher than average (>15%) likelihood of survival after in-hospital cardiopulmonary resuscitation for IHCA with good neurologic status. The final model was evaluated using the validation data set. Survival to discharge after in-hospital cardiopulmonary resuscitation for IHCA with good neurologic status (neurologically intact or with minimal deficits) based on a Cerebral Performance Category score of 1. The best performing model was a simple point score based on 13 prearrest variables. The C statistic was 0.78 when applied to the validation set. It identified the likelihood of a good outcome as very low in 9.4% of patients (good outcome in 0.9%), low in 18.9% (good outcome in 1.7%), average in 54.0% (good outcome in 9.4%), and above average in 17.7% (good outcome in 27.5%). Overall, the score can identify more than one-quarter of patients as having a low or very low likelihood of survival to discharge, neurologically intact or with minimal deficits after IHCA (good outcome in 1.4%). The Good Outcome Following Attempted Resuscitation (GO-FAR) scoring system identifies patients who are unlikely to benefit from a resuscitation attempt should they experience IHCA. This information can be used as part of a shared decision regarding do-not-attempt-resuscitation orders.

The sounds of cardiac arrest: Innovating to obtain an accurate record during in-hospital cardiac arrest

BackgroundTo obtain an accurate audit during in-hospital cardiac arrest, following recommendations of the Utstein style and measuring time intervals between the different interventions, is difficult. ObjectiveTo assess whether the use of an audio recording system during in-hospital cardiac arrest resuscitation allows the register of more items during cardiopulmonary resuscitation. Material and methodsProspective observational study between January 2008 and December 2009. The population that were included, were hospitalized patients and non-hospitalized patients assisted by a cardiac arrest team, except for critical areas. An audio recording system with a timer was turned on when cardiac arrest team was alerted. Recordings were reviewed to fill in the items recommended by the Utstein style. Time intervals were calculated. Mean number of completed items per patient were compared between recorded and non-recorded cardiac arrest. Results119 CA team alerts took place. 64 (53.7%) cases were real CA and 37 (57.8%) of them were properly recorded. A mean number of items per patient in recorded cardiac arrest cases were 18.18 (±3.2) vs. 15.96 (±4.1) in non-recorded cardiac arrest cases (p<0.05). In the recorded cases, mean times were: alert – arrival: 1.23 (±0.95)min; arrival – cardiopulmonary resuscitation initiation: 0.63 (±0.38)min; arrival – first defibrillation: 2.06 (±1.33)min; arrival – intubation: 8.42 (±4.64)min; arrival – first adrenaline: 3.30 (±1.98)min. ConclusionsThe audio recording system permits the register of a larger number of items per patient during in-hospital cardiac arrest and allows measurement of time intervals between the different interventions during cardiopulmonary resuscitation.

Vasopressin rescue for in-pediatric intensive care unit cardiopulmonary arrest refractory to initial epinephrine dosing

To assess the feasibility of a large, randomized controlled trial of combination epinephrine-arginine vasopressin for in-pediatric intensive care unit cardiopulmonary arrest refractory to initial epinephrine dosing. Prospective, pilot, matched controlled clinical trial using exception from informed consent. Pediatric intensive care unit in a university-affiliated tertiary care children's hospital. All patients <18 yrs of age admitted to the pediatric intensive care unit with cardiopulmonary arrest requiring chest compressions and epinephrine (0.01 mg/kg) were eligible. Patients who remained in cardiopulmonary arrest despite an initial dose of epinephrine received arginine vasopressin (0.8 U/kg) rescue as the second vasopressor, followed by additional epinephrine if needed. Outcome variables included return of spontaneous circulation (≥20 min), survival at 24 hrs, survival to hospital discharge, and neurologic status at discharge. Favorable neurologic status was defined as Pediatric Cerebral Performance Categories 1, 2, and 3, or no change from admission. Data were compared to a retrospective, matched cohort of patients who experienced cardiopulmonary arrest requiring ≥ two doses of vasopressor, and did not receive arginine vasopressin (n = 20). Of 2,654 patients admitted to the pediatric intensive care unit, 29 (1.1%) had refractory cardiopulmonary arrest: five patients were excluded, 14 missed for inclusion, and ten were enrolled. There was increased 24-hr survival (80% vs. 30%, odds ratio 9.33, 95% confidence interval 1.51-57.65) in arginine vasopressin patients. There was no significant difference in return of spontaneous circulation, survival to hospital discharge, or favorable neurologic status at discharge. These pilot data provide support for a larger randomized controlled trial of arginine vasopressin therapy during cardiopulmonary resuscitation for in-hospital pediatric cardiac arrest.

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

PurposeThe 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. MethodsPaediatric 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. ResultsWe 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±17min in the survivors and 52±45min 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±5.1mmol/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±76min, 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. ConclusionsIn 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.

Extracorporeal Life Support After Prolonged Resuscitation for In-Hospital Cardiac Arrest due to Refractory Ventricular Fibrillation: Two Cases Resulting in a Full Recovery

Extracorporeal life support (ECLS) has well demonstrated its efficacy in treating in-hospital cardiac arrest and is being used for broader indications. However, ECLS after prolonged cardiopulmonary resuscitation (CPR) has been traditionally contraindicated and is now challenging. Here, we introduce two cases of successful ECLS after prolonged CPR, resulting in a immediate and full recovery. Both these acute ST elevation myocardial infarction patients waiting for primary percutaneous coronary intervention (PCI) suddenly collapsed due to ventricular fibrillation (VF), which was refractory to conventional treatment. After 2 hours of conventional CPR, the ECLS had been implemented and primary PCI could be performed. Subsequent to successful revascularization, the VF was stopped with a single electric shock. In our second case, normal sinus rhythm was spontaneously restored after ECLS implementation, which was completed after 45 minutes of conventional resuscitation. Both patients made a full neurological recovery on the day of the event and were discharged with only minor complications.

Abstract 204: Extracorporeal Membrane Oxygenation Supported Cardiopulmonary Resuscitation Is Not Associated with Increased Survival Compared to Conventional Cardiopulmonary Resuscitation for Pediatric In-Hospital Cardiac Arrest in the United States

INTRODUCTION: Survival after cardiopulmonary resuscitation (CPR) in children remains poor. The use of extracorporeal membrane oxygenation (ECMO) during or shortly after CPR (E-CPR) has been advocated as a strategy to improve outcomes. However, previous studies have been limited by lack of a conventional CPR (C-CPR) control group. HYPOTHESIS: E-CPR is associated with improved survival to hospital discharge compared with C-CPR. METHODS: Retrospective review of the 2000, 2003, and 2006 Kids' Inpatient Database, a large nationally representative database of pediatric hospital admissions, was performed. All episodes of CPR were identified; E-CPR was defined as the use of ECMO on the same day as CPR. Propensity scores were constructed reflecting the likelihood of E-CPR with arrest. Univariate, multivariable, and propensity matched analyses were performed to assess the influence of E-CPR on survival. RESULTS: Out of 8.6 million pediatric hospitalizations, 9,000 CPR events were identified, of which 82 were E-CPR (0.9%). Factors associated with E-CPR use included age &gt; 1 year, congenital heart disease, myocarditis, and hospitalization in a children's hospital (p&lt;0.001 for all). E-CPR was associated with higher hospital charges (median $187,661, interquartile range (IQR) $107,865 - $311,196) compared to C-CPR (median $23,157, IQR $5,875 - $92,004) (p&lt;0.001). Overall, hospital mortality was significantly higher with E-CPR (65.9%) compared to C-CPR (50.9%) (OR 1.9, 95% CI 1.2 - 2.9). Other factors associated with increased mortality after CPR included age &gt; 1 year, sepsis, congenital heart disease, and acute renal failure (p&lt;0.001 for all). Multivariable analysis controlling for age, hospital type, and comorbid conditions revealed no survival difference between E-CPR and C-CPR (OR 0.94, 95% CI 0.6-1.5). Propensity matched analysis also demonstrated similar survival between E-CPR and C-CPR (OR 0.68, 95% CI 0.4-1.2). CONCLUSIONS: E-CPR is rarely utilized for pediatric in-hospital cardiac arrest in the US. E-CPR was not associated with improved survival compared to C-CPR. However, E-CPR was associated with an 8 fold increase in hospital charges. Further study is needed to identify patients most likely to benefit from this resource-intensive therapy.

Impact of resuscitation system errors on survival from in-hospital cardiac arrest

BackgroundAn estimated 350,000–750,000 adult, in-hospital cardiac arrest (IHCA) events occur annually in the United States. The impact of resuscitation system errors on survival during IHCA resuscitation has not been evaluated. The purpose of this paper was to evaluate the impact of resuscitation system errors on survival to hospital discharge after IHCA. Methods and resultsWe evaluated subjective and objective errors in 118,387 consecutive, adult, index IHCA cases entered into the Get with the Guidelines National Registry of Cardiopulmonary Resuscitation database from January 1, 2000 through August 26, 2008. Cox regression analysis was used to determine the relationship between reported resuscitation system errors and other important clinical variables and the hazard ratio for death prior to hospital discharge. Of the 108,636 patients whose initial IHCA rhythm was recorded, resuscitation system errors were committed in 9,894/24,467 (40.4%) of those with an initial rhythm of ventricular fibrillation or pulseless ventricular tachycardia (VF/pVT) and in 22,599/84,169 (26.8%) of those with non-VF/pVT. The most frequent system errors related to delay in medication administration (>5min time from event recognition to first dose of a vasoconstrictor), defibrillation, airway management, and chest compression performance errors. The presence of documented resuscitation system errors on an IHCA event was associated with decreased rates of return of spontaneous circulation, survival to 24h, and survival to hospital discharge. The relative risk of death prior to hospital discharge based on hazard ratio analysis was 9.9% (95% CI 7.8, 12.0) more likely for patients whose initial documented rhythm was non-VF/pVT when resuscitation system errors were reported compared to when no errors were reported. It was 34.2% (95% CI 29.5, 39.1) more likely for those with VF/pVT. ConclusionsThe presence of resuscitation system errors that are evident from review of the resuscitation record is associated with decreased survival from IHCA in adults. Hospitals should target the training of first responders and code team personnel to emphasize the importance of early defibrillation, early use of vasoconstrictor medication, and compliance with ACLS protocols.

The first quantitative report of ventilation rate during in-hospital resuscitation of older children and adolescents

Aim During adult cardiac arrest, rescuers frequently provide ventilations at rates exceeding those recommended by the American Heart Association (AHA). Excessive ventilation is associated with worse clinical outcome after adult cardiac arrest. This study is the first to characterize ventilation rate adherence to AHA guidelines during in-hospital pediatric cardiac arrest resuscitation. Patients and methods We prospectively enrolled children and adolescents (≥8 years of age) who suffered a cardiac arrest in a pediatric intensive care unit (PICU) or emergency department (ED) of a tertiary-care pediatric hospital. Ventilation rate (breaths per minute [bpm]) was monitored via changes in chest wall impedance (CWI) recorded by defibrillator electrode pads during cardiopulmonary resuscitation (CPR). Results Twenty-four CPR events were enrolled yielding 588 thirty-second CPR epochs. The proportion of CPR epochs with ventilation rates exceeding AHA guidelines (>10 bpm) was 63% (CI 95 59–67%), significantly higher than our a priori hypothesis of 30% ( p < 0.01). The proportion of CPR epochs with ventilation rates exceeding 20 bpm was 20% (CI 95 17–23). After controlling for location of arrest and initial event rhythm, resuscitations that occurred on nights/weekends were 3.6 times (CI 95: 1.6–7.9, p < 0.01) more likely to have a ventilation rate exceeding AHA guidelines. Conclusions During in-hospital pediatric cardiac arrest, rescuers frequently provide artificial ventilations at rates in excess of AHA guidelines, with twenty percent of CPR time having ventilation rates double that recommended. Excessive ventilation was particularly common during CPR events that occurred on nights/weekends.

Outcomes among neonates, infants, and children after extracorporeal cardiopulmonary resuscitation for refractory in-hospital pediatric cardiac arrest: A report from the National Registry of CardioPulmonary Resuscitation*

Describe the use of extracorporeal cardiopulmonary resuscitation as rescue therapy in pediatric patients who experience cardiopulmonary arrest refractory to conventional resuscitation. We report on outcomes and factors associated with survival in children treated with extracorporeal cardiopulmonary resuscitation during cardiopulmonary arrest from the American Heart Association National Registry of CardioPulmonary Resuscitation. Multicentered, national registry of in-hospital cardiopulmonary resuscitation. Two hundred eighty-five hospitals reporting to the registry from January 2000 to December 2007. Pediatric patients <18 yrs of age who received extracorporeal membrane oxygenation during cardiopulmonary resuscitation for in-hospital cardiopulmonary arrest. None. Prearrest and arrest variables were collected. The primary outcome variable was survival to hospital discharge. The secondary outcome was neurologic status after extracorporeal cardiopulmonary resuscitation at hospital discharge. Favorable neurologic outcome was defined as Pediatric Cerebral Performance Categories 1, 2, 3, or no change from admission Pediatric Cerebral Performance Category. Of 6288 pediatric cardiopulmonary arrest events reported, 199 (3.2%) index extracorporeal cardiopulmonary resuscitation events were identified; 87 (43.7%) survived to hospital discharge. Fifty-nine survivors had Pediatric Cerebral Performance Category outcomes recorded, and of those, 56 (94.9%) had favorable outcomes. In a multivariable model, the prearrest factor of renal insufficiency and arrest factors of metabolic or electrolyte abnormality and the pharmacologic intervention of sodium bicarbonate/tromethamine were associated with decreased survival. After adjusting for confounding factors, cardiac illness category was associated with an increased survival to hospital discharge. Forty-four percent of pediatric patients who failed conventional cardiopulmonary resuscitation from in-hospital cardiopulmonary arrest and who were reported to the National Registry of CardioPulmonary Resuscitation database as treated with extracorporeal cardiopulmonary resuscitation survived to hospital discharge. The majority of survivors with recorded neurologic outcomes were favorable. Patients with cardiac illness category were more likely to survive to hospital discharge after treatment with extracorporeal cardiopulmonary resuscitation. Extracorporeal cardiopulmonary resuscitation should be considered for select pediatric patients refractory to conventional in-hospital resuscitation measures.

Extracorporeal cardiopulmonary resuscitation for in-hospital cardiac arrest: Lessons from acute neurotoxicity*

Extracorporeal cardiopulmonary resuscitation for in-hospital cardiac arrest: Lessons from acute neurotoxicity*

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

Purpose of the study While 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. Methods Data 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). Results We 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). Conclusions Outcomes 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.

Abstract 10: Outcome Of Pediatric In-hospital Cardiac Arrest By Extracorporeal Membrane Oxygenation Implementation During Active Cardiopulmonary Resuscitation

Background: To achieve intact neurological survival is a challange for pediatric cardiac arrest. Here we describe the outcome and identify the factors associated with survival among pediatric patients following extracorporeal cardiopulmonary resuscitation (ECPR) for in-hospital pediatric cardiac arrest. Method: Retrospective study of 27 pediatric in-hospital cardiac arrest who received extracorporeal membrane oxygenation during active cardiopulmonary resuscitation-.The primary outcome was survival to hospital discharge. The secondary outcome was neurological status after ECPR at hospital discharge and late follow-up. Continuous variables were expressed as medians (inter-quartile range) Results: . We identified 27 ECPR events. The survival rate to hospital discharge was 41% (11/27). The non-survivors had higher serum lactate levels (14 [10.2–19.6] mmol/L vs 8.5 [4.4 –12.6] mmol/L, p &lt; 0.01), longer durations of cardiopulmonary resuscitation (CPR) (60 [37– 81] minutes vs 45 [25–50] minutes, p &lt; 0.05) with longer activating time for ECMO (12.5 [7.5–33.8] minutes vs 5 [0 –10] minutes, p&lt;0.01),and more renal failure after ECPR (68% 11 / 16 vs 9% 1 / 11 , p &lt; 0.01). By multivariate analysis, the earlier cohort and renal failure after ECPR were independent risk factors for mortality. Among the11 survivors, 10 of them had good neurological outcomes. Conclusions: ECPR successfully rescued some pediatric patients who failed rescue with conventional in-hospital CPR. Good neurological outcomes were achieved in the majority of the survivors. Early cohort and post-ECPR renal failure were associated with poor outcomes. Early activation of the ECMO team could possibly shorten the CPR duration and improve the ECPR results.

Long-term survival after successful inhospital cardiac arrest resuscitation

Little is known about long-term outcomes of patients who survive inhospital cardiac arrest. We examined long-term survival after inhospital cardiac arrest and whether procedural changes that improved survival to discharge impacted long-term survival. Consecutive inhospital arrests in the Atlanta Veterans Affairs Medical Center (Atlanta, GA) from 1995 to 2004 (n = 732) were retrospectively analyzed. Data regarding the arrest was obtained, including age, left ventricular ejection fraction, medications, and comorbidities, presenting rhythm, location of arrest, code duration, and outcomes. Long-term mortality data was obtained based on chart and Social Security Death Index reviews. Further data was gathered on internal cardioverter-defibrillator presence and use in survivors. Overall, 49 subjects (6.6%) survived to discharge. Univariate analysis found that ventricular tachycardia/ventricular fibrillation and the use of beta-blockers, angiotensin-converting enzyme inhibitors, and antiarrhythmics at the time of arrest were associated with increased survival, whereas advancing age and comorbidities were associated with a higher risk of mortality. Multivariate analysis determined that age, rhythm, and comorbidities independently affected survival. Implementation of a resuscitation program previously documented to improve survival to discharge did not translate to durable long-term survival. Three-year survival rate after discharge was only 41%. Alternatively, subjects with internal cardioverter-defibrillator showed a 36% improvement in 3-year survival rate to 77% (P = .001). Subjects with inhospital cardiac arrest have poor long-term prognoses. A strategy that improved inhospital survival did not alter long-term mortality rate. Thus, survival to discharge may not be a sufficient end point for future resuscitation trials.

Outcome of cardiopulmonary resuscitation in the ICU in a university hospital

Cardiac arrest is the third leading cause of coma, second only to trauma and drug overdose. Over the past two decades several publications have reported the outcome of cardiopulmonary resuscitation (CPR) for inhospital cardiac arrest. Only a sparse amount of data is available concerning the initial CPR success rates and long-term survival in adult ICUs from Germany. Initial CPR success rates range from 16.8% to 44% and long-term survival to discharge from hospital ranges from 3.1% to 16.5%. Although the initial successful resuscitation rate in ICU patients may be high, long-term and hospital discharge rates have been reported to be unsatisfactory.

Survival of Cardiac Arrest after Aneurysmal Subarachnoid Hemorrhage

Survival of cardiac arrest (CA) after aneurysmal subarachnoid hemorrhage (SAH) is poorly characterized. We analyzed the clinical course and outcome of patients who survived resuscitation for CA after aneurysmal SAH. Medical records of all patients with acute SAH treated at Mayo Clinic between 1990 and 1997 were reviewed. Three hundred five consecutive patients with angiographically proven aneurysmal SAH presenting within 7 days of ictus were analyzed. CA was defined as a pulseless state, documented by medical personnel, for which resuscitation was performed. Outcome was measured with the Glasgow Outcome Scale score at longest follow-up (mean, 16 mo). Data from 11 patients (3.6%) who had 14 episodes of CA were analyzed. Six patients had CA before reaching the hospital and were successfully resuscitated. Nine of 14 CA episodes occurred at hemorrhage or rehemorrhage. No patient with in-hospital CA failed to be resuscitated. Overall mortality in patients who had CA (46%) was higher than that of patients without CA (15%; P = 0.019). Outcome for all patients who had CA (mean Glasgow Outcome Scale score, 2.5) was worse than for patients without CA (mean Glasgow Outcome Scale score, 3.9; P = 0.005). However, half of the survivors of CA after SAH were living independently with limited deficit at longest follow-up. Most cases of CA occur at the time of initial or recurrent SAH. Resuscitation for in-hospital CA is likely to be successful. Although CA after aneurysmal SAH is associated with significantly higher mortality, the outcome of survivors of CA is not worse than that for other patients after aneurysmal SAH.

Thrombolytic therapy during prolonged in-hospital cardiac arrest

We report a case of cardiac arrest secondary to acute myocardial infarction that was successfully resolved after thrombolytic therapy. This case suggests that thrombolysis can be used safely also during prolonged cardiopulmonary resuscitation for in-hospital cardiac arrest.