National Registry Of Cardiopulmonary Resuscitation Research Articles

The first documented cardiac arrest rhythm in hospitalized patients with heart failure

Background Patients with heart failure (HF) have abnormal cellular anatomy and myocardial mechanics that may impact the initial rhythm and subsequent outcomes in cardiac arrest (CA). Hypothesis Patients with pre-existing HF are less likely to have ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT) as the first documented rhythm in CA and have poorer survival than patients without pre-existing HF. Purpose Identify the first documented cardiac arrest rhythm (FDR) in hospitalized patients with and without a pre-existing history of HF. Methods We evaluated 60,389 consecutive, adult, index, pulseless CA events with documented initial rhythm in the National Registry of Cardiopulmonary Resuscitation. The primary endpoint was the FDR in patients with and without a history of pre-existing HF. Secondary endpoints were return of spontaneous circulation (ROSC), survival to discharge, and neurological outcome. Results Thirty three percent of patients had a pre-existing diagnosis of HF. HF patients were more likely to have VF/pVT (25.9 vs. 23.2%) and less likely to have asystole (34.4 vs. 35.3%, p = <.0001) than non-HF. There was no difference in survival to discharge (18.3 vs. 18.2%, p = .66), or good neurological outcomes (82.2 vs. 83.2%, p = .23) between the groups. Women were less likely to have VF/pVT as the first documented rhythm in both HF and non-HF groups. Conclusions Hospitalized patients with HF are more likely than those without HF to have VF/pVT as the FDR in CA, however the clinical magnitude of this difference is small. Overall survival and neurological outcomes are no different than hospitalized arrest patients without HF.

Body temperature changes are associated with outcomes following in-hospital cardiac arrest and return of spontaneous circulation

Introduction Spontaneous changes in body temperature after return of circulation (ROSC) from cardiac arrest are common, but the association of these changes with outcomes in hospitalized patients who survive to 24 h post-ROSC is not known. We tested the hypothesis that adults who experience temperature lability in the first 24 h have worse outcomes compared with those who maintain normothermia. Materials and methods A prospective observational study from a multicenter registry of cardiac arrests (National Registry of Cardiopulmonary Resuscitation) from 355 US and Canadian hospitals. 14,729 adults with return of circulation from a pulseless cardiac arrest. We excluded those who died or were discharged before 24 h post-event, those made Do-Not-Resuscitate (DNR) within 24 h of event, those that had a preceding trauma, and those with multiple cardiac arrests. Finally, we included only subjects that had both a lowest ( T min) and highest ( T max) body temperature value recorded during the first 24-h after ROSC, resulting in a study sample of 3426 patients. Results After adjustment for potential covariates, there was a lower odds of survival in those having an episode of hypothermia (adjusted odds ratio [OR], 0.62; 95% confidence interval [CI], 0.48–0.80), those having an episode of hyperthermia (OR, 0.67; 95% CI, 0.48–0.80), and those having an episode of both (OR, 0.59; 95% CI, 0.39–0.91). Among those who survived to discharge, there was also a lower odds of favorable neurologic performance in those who had an episode of hyperthermia (OR, 0.71; 95% CI, 0.51–0.98). Conclusions Episodes of temperature lability following in-hospital resuscitation from cardiac arrest are associated with lower odds of surviving to discharge. Hyperthermia is also associated with fewer patients leaving the hospital with favorable neurologic performance. Further studies should identify whether therapeutic control over changes in body temperature after in-hospital cardiac arrest improves outcomes.

Factors Associated With Neurologically Intact Survival for Patients With Acute Heart Failure and In-Hospital Cardiac Arrest

Hospitalized patients with heart failure are at risk for cardiac arrest. The ability to predict who may survive such an event with or without neurological deficit would enhance the information on which patients and providers establish resuscitative preferences. We identified 13 063 adult patients with acute heart failure who had cardiac arrest at 457 hospitals participating in the National Registry of Cardiopulmonary Resuscitation between January 1, 2000 and December 31, 2007. Neurological status was determined on admission and discharge by cerebral performance category with neurologically intact survival (NIS)=cerebral performance category 1 (no) or 2 (moderate dysfunction) and non-NIS=cerebral performance category 3 (severe dysfunction), 4 (coma), or 5 (brain death). Factors available prearrest (demographics, preexisting conditions, and interventions in-place) were assessed for association with NIS using multivariable logistic regression, initially without then with adjustment for arrest-related variables and hospital characteristics. NIS occurred in 2307 patients (17.7%) and was associated by adjusted odds ratio with 18 prearrest factors; 4 positively and 14 negatively. The association (odds ratio; 95% CI) was strongest for 4 specific variables: acute stroke (0.38; 0.25 to 0.58), history of malignancy (0.49; 0.39 to 0.63), vasopressor use (0.50; 0.43 to 0.59), and assisted or mechanical ventilation (0.53; 0.45 to 0.61). A number of prearrest factors seem to be associated with NIS, the majority inversely. Consideration of these before cardiac arrest could enhance the resuscitative decision-making process for patients with acute heart failure.

Racial differences in survival after in-hospital cardiac arrest.

Racial differences in survival have not been previously studied after in-hospital cardiac arrest, an event for which access to care is not likely to influence treatment. To estimate racial differences in survival for patients with in-hospital cardiac arrests and examine the association of sociodemographic and clinical factors and the admitting hospital with racial differences in survival. Cohort study of 10,011 patients with cardiac arrests due to ventricular fibrillation or pulseless ventricular tachycardia enrolled between January 1, 2000, and February 29, 2008, at 274 hospitals within the National Registry of Cardiopulmonary Resuscitation. Survival to hospital discharge; successful resuscitation from initial arrest and postresuscitation survival (secondary outcome measures). Included were 1883 black patients (18.8%) and 8128 white patients (81.2%). Rates of survival to discharge were lower for black patients (25.2%) than for white patients (37.4%) (unadjusted relative rate [RR], 0.73; 95% confidence interval [CI], 0.67-0.79). Unadjusted racial differences narrowed after adjusting for patient characteristics (adjusted RR, 0.81 [95% CI, 0.75-0.88]; P < .001) and diminished further after additional adjustment for hospital site (adjusted RR, 0.89 [95% CI, 0.82-0.96]; P = .002). Lower rates of survival to discharge for blacks reflected lower rates of both successful resuscitation (55.8% vs 67.4% for whites; unadjusted RR, 0.84 [95% CI, 0.81-0.88]) and postresuscitation survival (45.2% vs 55.5% for whites; unadjusted RR, 0.85 [95% CI, 0.79-0.91]). Adjustment for the hospital site at which patients received care explained a substantial portion of the racial differences in successful resuscitation (adjusted RR, 0.92 [95% CI, 0.88-0.96]; P < .001) and eliminated the racial differences in postresuscitation survival (adjusted RR, 0.99 [95% CI, 0.92-1.06]; P = .68). Black patients with in-hospital cardiac arrest were significantly less likely to survive to discharge than white patients, with lower rates of survival during both the immediate resuscitation and postresuscitation periods. Much of the racial difference was associated with the hospital center in which black patients received care.

Derangements in blood glucose following initial resuscitation from in-hospital cardiac arrest: A report from the national registry of cardiopulmonary resuscitation

Study aims Hyperglycemia is associated with poor outcomes in critically ill patients. We examined blood glucose values following in-hospital cardiac arrest (IHCA) to (1) characterize post-arrest glucose ranges, (2) develop outcomes-based thresholds of hyperglycemia and hypoglycemia, and (3) identify risk factors associated with post-arrest glucose derangements. Methods We retrospectively studied 17,800 adult IHCA events reported to the National Registry of Cardiopulmonary Resuscitation (NRCPR) from January 1, 2005 through February 1, 2007. Results Data were available from 3218 index events. Maximum blood glucose values were elevated in diabetics (median 226 mg/dL [IQR, 165–307 mg/dL], 12.5 mmol/L [IQR 9.2–17.0 mmol/L]) and non-diabetics (median 176 mg/dL [IQR, 135–239 mg/dL], 9.78 mmol/L [IQR 7.5–13.3 mmol/L]). Unadjusted survival to hospital discharge was higher in non-diabetics than diabetics (45.5% [95% CI, 43.3–47.6%] vs. 41.7% [95% CI, 38.9–44.5%], p = 0.037). Non-diabetics displayed decreased adjusted survival odds for minimum glucose values outside the range of 71–170 mg/dL (3.9–9.4 mmol/L) and maximum values outside the range of 111–240 mg/dL (6.2–13.3 mmol/L). Diabetic survival odds decreased for minimum glucose greater than 240 mg/dL (13.3 mmol/L). In non-diabetics, arrest duration was identified as a significant factor associated with the development of hypo- and hyperglycemia. Conclusions Hyperglycemia is common in diabetics and non-diabetics following IHCA. Survival odds in diabetics are relatively insensitive to blood glucose with decreased survival only associated with severe (>240 mg/dL, >13.3 mmol/dL) hyperglycemia. In non-diabetics, survival odds were sensitive to hypoglycemia (<70 mg/dL, <3.9 mmol/L).

Vasopressin for in-hospital pediatric cardiac arrest: Results from the American Heart Association National Registry of Cardiopulmonary Resuscitation*

To describe the landscape of vasopressin uses reported to the American Heart Association National Registry of cardiopulmonary resuscitation (CPR) and test the hypothesis that vasopressin use will be associated with improved return of a sustained circulation (ROSC) following in-hospital pediatric cardiac arrest. Multicentered, national registry of in-hospital CPR. One hundred seventy-six North American Hospitals reporting to registry from October 1999 to November 2004. Totally, 1293 consecutive pediatric patients with pulseless cardiac arrest meeting criteria for analysis identified from a registry of all patients resuscitated for cardiac arrest. Inclusion criteria were age <18 years, chest compressions and/or defibrillation, in-hospital location, and documented resuscitation record. None. Prearrest, event, cardiopulmonary resuscitation, and postresuscitation variables were collected. Primary outcome variable was ROSC >20 minutes. Secondary survival outcomes included 24 hour, discharge and favorable neurologic survival on hospital discharge. Descriptive, univariate, and multivariable analysis to evaluate the association of vasopressin with survival outcomes were performed. Only 5% of patients received vasopressin in this review. Vasopressin was most often given in a pediatric hospital (57%) and in and intensive care setting (76.6%). Patients who were given vasopressin had longer arrest duration (median 37 minutes) vs. those who did not (24 minutes) (p = 0.004). In multivariate analysis, vasopressin was associated with worse ROSC but no difference in 24 hours or discharge survival. Vasopressin was given infrequently in in-hospital cardiac arrest. It was most likely to be given in an intensive care setting, and in a pediatric hospital. Multivariate analysis shows an association with vasopressin use and worse ROSC.

Using the American Heart Association’s National Registry of Cardiopulmonary Resuscitation for Performance Improvement

Data suggest that the overall quality of inhospital resuscitation is suboptimal and contributes to poor patient outcomes. In 2000 the American Heart Association created the National Registry of Cardiopulmonary Resuscitation (NRCPR) as an evidence-based hospital safety program. Participating hospitals voluntarily join the registry and pay an annual fee that includes data support and report generation. The primary purpose of NRCPR is to support local facility efforts in practice management and performance improvement (PI). The Chain of Survival illustrates the series of critical, interdependent actions necessary to maximize patient outcome from sudden cardiac arrest--early access to the emergency response system, early cardiopulmonary resuscitation (CPR), early defibrillation, and early advanced cardiovascular care. NRCPR specifically addresses each link and helps hospitals develop, implement, and monitor their resuscitation processes in a manner that builds on available evidence. On enrollment into NRCPR, each hospital identifies an onsite coordinator who is instructed on a standardized method for abstracting data from patient charts and how to enter data into the NRCPR database. The NRCPR database is managed centrally and provides participating organizations with ongoing, quarterly, and annual reports related to their resuscitation events. NRCPR is used as both a local PI tool as well as a source of data that scientists are analyzing to further the understanding of inhospital resuscitation processes and outcomes. Over time, researchers have recognized the need to refine the Chain of Survival to reflect the unique aspects of inhospital resuscitation. A rapid response system provides a new link at the beginning, and postresuscitation care provides a new link at the end of the Chain of Survival.

Cardiac arrests of hospital staff and visitors: Experience from the national registry of cardiopulmonary resuscitation

Aim of the studyApproximately 750,000 in-hospital cardiac arrests occur annually in the United States. Many will occur to visitors or staff members within the hospital's public areas. We sought to provide a descriptive analysis of visitor cardiac arrests in hospitals and to compare survival outcomes to matching inpatient arrests. MethodsWe queried the National Registry of Cardiopulmonary Resuscitation (NRCPR®) for all adult cardiac arrests from January 2000 to May 2006 that occurred to visitors or employees anywhere within the hospital. Visitors were matched to inpatient cardiac arrests from within the same NRCPR database for age, gender, race, prior residence and functional status, and presenting rhythms. The compared outcomes were return of spontaneous circulation (ROSC), survival to 24h (S24), and survival to discharge (SHD). Results147 visitors suffered a cardiac arrest during the study period. S24 (48% vs. 37%, p=0.011) and SHD (42% vs. 24%, p<0.0001) were both higher in the visitor cohort. However, ROSC did not significantly differ between visitors and controls (57% vs. 51%). Visitor cardiac arrests occurred in a wide variety of locations. ConclusionCardiac arrest among hospital visitors is a relatively common event. The survival outcomes of hospital visitors compared unfavorably to that of recently published experience with out-of-hospital cardiac arrest victims.

Post–Cardiac Arrest Syndrome

The contributors to this statement were selected to ensure expertise in all the disciplines relevant to post–cardiac arrest care. In an attempt to make this document universally applicable and generalizable, the authorship comprised clinicians and scientists who represent many specialties in many regions of the world. Several major professional groups whose practice is relevant to post–cardiac arrest care were asked and agreed to provide representative contributors. Planning and invitations took place initially by e-mail, followed a series of telephone conferences and face-to-face meetings of the cochairs and writing group members. International writing teams were formed to generate the content of each section, which corresponded to the major subheadings of the final document. Two team leaders from different countries led each writing team. Individual contributors were assigned by the writing group cochairs to work on 1 or more writing teams, which generally reflected their areas of expertise. Relevant articles were identified with PubMed, EMBASE, and an American Heart Association EndNote master resuscitation reference library, supplemented by hand searches of key papers. Drafts of each section were written and agreed on by the writing team authors and then sent to the cochairs for editing and amalgamation into a single document. The first draft of the complete document was circulated among writing team leaders for initial comment and editing. A revised version of the document was circulated among all contributors, and consensus was achieved before submission of the final version for independent peer review and approval for publication. This scientific statement outlines current understanding and identifies knowledge gaps in the pathophysiology, treatment, and prognosis of patients who regain spontaneous circulation after cardiac arrest. The purpose is to provide a resource for optimization of post–cardiac arrest care and to pinpoint the need for research focused on gaps in knowledge that would potentially improve outcomes …

Abstract P62: Derangements in Blood Glucose Following Initial Resuscitation from In-Hospital Cardiac Arrest: A Report from the American Heart Association National Registry of Cardiopulmonary Resuscitation

BACKGROUND: Hyperglycemia is associated with poor outcomes in a variety of critically-ill patient populations; however, little is known about the role of hyperglycemia in determining outcomes following in-hospital cardiac arrest (IHCA). METHODS: We performed a retrospective analysis of 17,800 adult in-hospital cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Minimum and maximum blood glucose values during the first 24 hours following return of spontaneous circulation (ROSC) were examined. RESULTS: Glucose data from 3,226 patients were available for analysis. Post-ROSC maximum blood glucose values were markedly elevated in diabetic (median, 226 mg/dL, [IQR, 165 – 307 mg/dL)] as well as non-diabetic patients (176 mg/dL, 135 – 239 mg/dL). Survival to hospital discharge was higher in non-diabetics than diabetics (45.5% [95% CI, 43.3 – 47.6%] vs. 41.7% [95% CI, 38.9 –44.5%], p = 0.037). In non-diabetics, survival to hospital discharge varied significantly when stratified by glucose value with optimal survival odds occurring across a broad range of minimum (71 – 170 mg/dL) and maximum (111 – 240 mg/dL) glucose values. Cardiac arrest duration quartile was identified as a significant factor associated with the development of post-ROSC hypo- and hyperglycemia in non-diabetics. CONCLUSIONS: Derangements in blood glucose are common following IHCA in both diabetic and non-diabetic patients. Optimal survival odds occur across a relatively broad range of glucose values in non-diabetics; however, both hypo- and hyperglycemia are associated with worse outcomes and associated with longer arrest durations.

Risk of cardiopulmonary arrest after acute respiratory compromise in hospitalized patients

Hospitalized patients with serious medical conditions such as shock, aspiration, pulmonary edema or stroke may develop acute respiratory compromise (ARC) requiring rescue treatment by medical emergency teams. We determined the characteristics and clinical course of hospitalized patients experiencing ARC as well as their risk of developing subsequent CPA. We examined data from the National Registry of Cardiopulmonary Resuscitation (NRCPR). We identified patients experiencing ARC, defined as medical crisis requiring emergency assisted ventilation and triggering hospital-wide or unit-based emergency response. We excluded those found initially in CPA. We identified the proportion of patients subsequently progressing to CPA, the elapsed time from ARC recognition to CPA, the clinical factors associated with developing CPA, and subsequent survival to hospital discharge. Of 4358 ARC events, CPA occurred in 726 (16.7%; 95% CI: 15.6, 17.8%). One-fourth occurred in general inpatient units. Median time from ARC recognition to CPA was 7 min (IQR: 3, 12 min); CPA occurred within 10 min in 65.3% of these cases. Factors associated with CPA included pulmonary embolism, hypotension or hypoperfusion, or failed invasive airway efforts. Survival to discharge was lower for CPA patients (14.3%) than non-CPA patients (58.4%) (OR 0.12; 95% CI: 0.10, 0.15). Approximately one in six patients experiencing initial ARC deteriorates to CPA. Most CPA occur within 10 min of ARC recognition. Improved ARC recognition, hospital emergency team response and airway management may potentially enhance care and outcomes for these critically ill patients.

An Indecent Proposal: Withholding Cardiopulmonary Resuscitation

I n the February 20, 2008, issue of the Journal of the American Medical Association, Peberdy and associates reported an analysis of probabilities of survival from in-hospital cardiac arrest. Although their purpose was to examine whether outcomes differed according to the time and day of the week when the arrest occurred, their data raise other important questions about use of cardiopulmonary resuscitation (CPR). The current norm in acute care facilities is to assume that CPR should be performed in every case of cardiac arrest, unless a specific physician order to the contrary is in place. In this column, I propose a reversal of this; that is, I propose that in every case of cardiac arrest, unless a specific physician order to the contrary is in place, CPR should be withheld.

If a patient arrests after cardiac surgery is it acceptable to delay cardiopulmonary resuscitation until you have attempted either defibrillation or pacing?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether it is acceptable to delay cardiopulmonary resuscitation if a patient arrests after cardiac surgery in order to attempt defibrillation or pacing, prior to performing external cardiac massage. Altogether 550 papers were found in Medline and 990 in Embase using the reported search, of which 22 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that current resuscitation guidelines state that there is no evidence to support or refute external cardiac massage prior to defibrillation in-hospital, although a benefit has been shown for patients out-of-hospital if the response time is over 4-5 min. In addition, four large studies including the AHA National Registry of Cardiopulmonary Resuscitation, who reported the findings of 6789 in-hospital arrests, emphasise the importance of early defibrillation within 1-2 min. More concerning in patients post-cardiac surgery are four case reports after cardiothoracic surgery and five in the non-surgical literature where significant harm has been caused from external cardiac massage, although equally we found cohort studies of cardiac surgical patients who had external cardiac massage followed by re-sternotomy and found no trauma due to external cardiac massage. We recommend that guidelines for immediate external massage should be adhered to currently as the evidence that these guidelines may do harm is not yet strong enough to recommend a change in practice. However, we acknowledge that there are no in-hospital data to support very short periods of external massage prior to defibrillation and there have been examples of damage to the myocardium due to external massage. This should be borne in mind when external massage is being performed on a patient after cardiac surgery.

Cardiac arrest in the Emergency Department: A report from the National Registry of Cardiopulmonary Resuscitation

Little is known about cardiac arrests (CA) in the Emergency Department (ED). The objective of this study was to determine the characteristics of ED CAs. 60,852 adult, in-patient CA events in the National Registry of Cardiopulmonary Resuscitation were included. Multiple regression analysis compared ED CA with those occurring in the ICU, telemetry, or general floors. Subgroup analysis examined traumatic vs. non-traumatic ED CA and ED CA occurring after a successful pre-hospital resuscitation (recurrent) vs. primary ED event. In multivariate analysis, ED location predicted improved survival to discharge (OR 0.74, 95%CI [0.67-0.82]). ED CAs had higher survival to discharge rates (ED 22.2, ICU 15.5, Tele 19.8, Floor 10.8, p<0.0001), better cerebral performance category scores (ED 1.59, ICU 1.73, Tele 1.96, Floor 1.69, p<0.0001), and shorter post-event length of stays (ED 8.6, ICU 17.5, Tele 16.5, Floor 14.2 days, p<0.0001) than other locations. Recurrent ED CAs were less likely to survive to discharge (10.1% vs. 24.6%, p<0.0001) than primary events. Trauma-related ED CAs had a lower survival to discharge rate (7.5% vs. 23.8%, p<0.0001), were less likely to be caused by an arrhythmia (23.6% vs. 32.5%, p<0.0008), and more likely to be preceded by hypotension or shock (41.6% vs. 29.0%, p<0.0001) than non-trauma ED events. ED CAs have unique characteristics, and better survival and neurologic outcomes compared to other hospital locations. Primary ED CAs have a better chance of survival to discharge than recurrent events. Traumatic ED CAs have worse outcomes than non-traumatic CA.

Calcium Use During In-hospital Pediatric Cardiopulmonary Resuscitation: A Report From the National Registry of Cardiopulmonary Resuscitation

Specific patterns of calcium use during in-hospital pediatric cardiopulmonary resuscitation have not been reported since publication of pediatric advanced life support guidelines by the American Heart Association in 2000 recommended that calcium use during cardiopulmonary resuscitation be limited to select circumstances. We hypothesized that calcium is used frequently during in-hospital pediatric cardiopulmonary resuscitation and that its use is associated with worse survival to hospital discharge. We reviewed 1477 consecutive pediatric cardiopulmonary resuscitation index events (for patients younger than 18 years) submitted to the National Registry of Cardiopulmonary Resuscitation from January 2000 through July 2004. The primary outcome was survival to hospital discharge. Secondary outcomes included survival of event and neurologic outcome. Multivariable logistic regression was performed to analyze the association between calcium use and outcomes. Calcium was used in 659 (45%) of 1477 events. Calcium was more likely to be used during cardiopulmonary resuscitation in the settings of pediatric facilities, ICUs, cardiac surgery, cardiopulmonary resuscitation duration of > or = 15 minutes, asystole, and concurrently with other advanced life support medications: epinephrine, vasopressin, sodium bicarbonate, and magnesium sulfate. The use of calcium during cardiopulmonary resuscitation adjusted for confounding factors was associated with decreased survival to discharge and was not associated with favorable neurologic outcome. Calcium is used frequently during in-hospital pediatric cardiopulmonary resuscitation. Although epidemiologic associations do not necessarily indicate causality, calcium use during cardiopulmonary resuscitation is associated with decreased survival to hospital discharge and unfavorable neurologic outcome.

Survival From In-Hospital Cardiac Arrest During Nights and Weekends

Occurrence of in-hospital cardiac arrest and survival patterns have not been characterized by time of day or day of week. Patient physiology and process of care for in-hospital cardiac arrest may be different at night and on weekends because of hospital factors unrelated to patient, event, or location variables. To determine whether outcomes after in-hospital cardiac arrest differ during nights and weekends compared with days/evenings and weekdays. We examined survival from cardiac arrest in hourly time segments, defining day/evening as 7:00 am to 10:59 pm, night as 11:00 pm to 6:59 am, and weekend as 11:00 pm on Friday to 6:59 am on Monday, in 86,748 adult, consecutive in-hospital cardiac arrest events in the National Registry of Cardiopulmonary Resuscitation obtained from 507 medical/surgical participating hospitals from January 1, 2000, through February 1, 2007. The primary outcome of survival to discharge and secondary outcomes of survival of the event, 24-hour survival, and favorable neurological outcome were compared using odds ratios and multivariable logistic regression analysis. Point estimates of survival outcomes are reported as percentages with 95% confidence intervals (95% CIs). A total of 58,593 cases of in-hospital cardiac arrest occurred during day/evening hours (including 43,483 on weekdays and 15,110 on weekends), and 28,155 cases occurred during night hours (including 20,365 on weekdays and 7790 on weekends). Rates of survival to discharge (14.7% [95% CI, 14.3%-15.1%] vs 19.8% [95% CI, 19.5%-20.1%], return of spontaneous circulation for longer than 20 minutes (44.7% [95% CI, 44.1%-45.3%] vs 51.1% [95% CI, 50.7%-51.5%]), survival at 24 hours (28.9% [95% CI, 28.4%-29.4%] vs 35.4% [95% CI, 35.0%-35.8%]), and favorable neurological outcomes (11.0% [95% CI, 10.6%-11.4%] vs 15.2% [95% CI, 14.9%-15.5%]) were substantially lower during the night compared with day/evening (all P values < .001). The first documented rhythm at night was more frequently asystole (39.6% [95% CI, 39.0%-40.2%] vs 33.5% [95% CI, 33.2%-33.9%], P < .001) and less frequently ventricular fibrillation (19.8% [95% CI, 19.3%-20.2%] vs 22.9% [95% CI, 22.6%-23.2%], P < .001). Among in-hospital cardiac arrests occurring during day/evening hours, survival was higher on weekdays (20.6% [95% CI, 20.3%-21%]) than on weekends (17.4% [95% CI, 16.8%-18%]; odds ratio, 1.15 [95% CI, 1.09-1.22]), whereas among in-hospital cardiac arrests occurring during night hours, survival to discharge was similar on weekdays (14.6% [95% CI, 14.1%-15.2%]) and on weekends (14.8% [95% CI, 14.1%-15.2%]; odds ratio, 1.02 [95% CI, 0.94-1.11]). Survival rates from in-hospital cardiac arrest are lower during nights and weekends, even when adjusted for potentially confounding patient, event, and hospital characteristics.

Increasing amiodarone use in cardiopulmonary resuscitation: An analysis of the National Registry of Cardiopulmonary Resuscitation

To examine practice patterns of amiodarone use during in-hospital cardiac arrest. This study addresses the changing pattern of amiodarone use over time, following the publication of landmark studies and the inclusion of amiodarone in the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Furthermore, this study examines the impact of hospital and patient specific factors on the use of amiodarone. Retrospective cohort study, using the National Registry for Cardiopulmonary Resuscitation, an international registry of in-hospital resuscitation events. All patients with an in-hospital ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT) event reported to the national registry from January 1, 2000, to July 31, 2005. During the study period, 14,854 of 29,552 (50%) adults (> 18 yrs old) with VF/pVT received an antiarrhythmic drug; 8,883 (60%) of these patients received amiodarone. In adults, amiodarone use for VF/pVT increased from 25% in 2000 to 72% in 2005 (p < .0001). Among children, 270 of 553 (49%) VF/pVT episodes were treated with an antiarrhythmic drug; 108 (40%) of these patients received amiodarone. Adults in institutions with larger intensive care units (> 50 beds) were more likely than those in institutions with smaller intensive care units (< or = 50 beds) to receive amiodarone; the association persisted in multivariable analysis (odds ratio [OR] = 1.825; 95% confidence interval [CI], 1.694-1.966). Thirty five percent of adults with VF/pVT who received amiodarone also received lidocaine, while 67% of children who received amiodarone also received lidocaine (p < .001). It is not possible to determine from the database the order in which medications were administered. There has been a significant increase in amiodarone use for VF/pVT events over the past 5 yrs. The frequency of amiodarone use in adults correlated positively with the number of intensive care beds. These results suggest that emerging data and national guidelines affect resuscitation practice patterns.

Abstract 2018: Cardiac Arrest in the Emergency Department: A Report from the National Registry of Cardiopulmonary Resuscitation

Background: Little is known about cardiac arrests (CA) in the Emergency Department (ED). The objective of this study was to determine the characteristics of ED CA’s. Methods: Included were 60,852 adult, in-patient CA index events in the National Registry of Cardiopulmonary Resuscitation. Multiple regression analysis compared ED CA with those occurring in the ICU, telemetry, or general floors. Subgroup analysis examined traumatic vs. non-traumatic ED CA and ED CA occurring after a successful pre-hospital resuscitation (recurrent) vs. primary ED CA. Results: In multivariate analysis, ED location significantly predicted improved survival to discharge (OR 0.74, 95% CI[0.67–0.82], p&lt;0.0001). Patients with CA occurring in the ED had better Cerebral Performance Category scores (ED 1.59, ICU 1.73, Tele 1.96, Floor 1.69, p&lt;0.0001), shorter mean post-event length of stays (ED 8.6, ICU 17.5, Tele 16.5, Floor 14.2 days, p&lt;0.0001) and were less likely to be declared DNR (ED 23.0%, ICU 31.7%, Tele 28.8%, Floor 31.8%, p&lt;0.0001) than CA in other locations. Secondary analysis showed that ED patients with recurrent CA were less likely to survive to discharge (10.1% vs. 24.6%, p&lt;0.0001) and were more likely to be declared DNR (27.9% vs. 22.2%, p&lt;0.0006.) than primary ED CA. Mean length of stay for survivors in both groups was similar (8.85 vs. 8.54 days, p=ns). Major traumatic injury preceded 6.3% of all ED CA. Patients whose ED CA was related to traumatic injury were younger (46.2 vs. 65.0 years, p&lt;0.001), more likely to be male (78.2% vs. 58.1, p&lt;0.0001), less likely to have the CA caused by an arrythmia (23.6% vs. 32.5%, p&lt;0.0008), and more likely to have the CA preceded by hypotension or shock (41.6% vs. 29.0%, p&lt;0.0001) than ED patients whose CA was not due to traumatic injury. ED trauma CA patients had a significantly lower survival to discharge rate than ED patients whose CA was not due to trauma (7.5% vs. 23.8%, p&lt;0.0001). Conclusions: ED CA patients are a unique population and have better survival and neurologic outcomes compared to patients in other hospital locations. Primary ED CA patients have a better chance of survival to discharge than those who re-arrest following a successful pre-hospital resuscitation. Traumatic ED CA patients have worse outcomes than non-traumatic CA.

Abstract 33: Impact of Delayed Time to Defibrillation on Neurological and Functional Status Among Survivors of In-Hospital Cardiac Arrest

Background: Expert guidelines advocate defibrillation within 2 minutes of an in-hospital cardiac arrest due to ventricular arrhythmias. However, the impact of delayed defibrillation on neurological and functional status at discharge among survivors is unknown. Methods: We identified 6,744 patients with cardiac arrests due to ventricular fibrillation or pulseless ventricular tachycardia at 369 hospitals within the National Registry of Cardiopulmonary Resuscitation. Using multivariable logistic regression that adjusted for demographics, clinical variables, hospital site, hospital-level variables (hospital size, monitored bed or intensive care status), and admitting diagnoses, we examined the association between delayed defibrillation (&gt;2 minutes) and neurological and functional status at discharge using the previously developed Cerebral and Overall Performance Categories. Performance categories were dichotomized as no major disability vs. major disability and/or vegetative state. Results: The median time to defibrillation was 1 minute (interquartile range:&lt; 1 to 3 minutes), with delayed defibrillation found in 2,000 (29.7%) patients. Overall, 2,311 (34.3%) patients survived to hospital discharge [n=1,863 (39.3%) for prompt defibrillation; n=448 (n=22.4%) for delayed defibrillation]. Among those surviving to discharge, delayed defibrillation was associated with a lower likelihood of no major disability in neurological status (adjusted OR of 0.73; 95% CI: 0.57 to 0.94; p=0.01) and functional status (adjusted OR of 0.73; 95% CI: 0.55 to 0.96; p=0.02). Conclusion : Delayed defibrillation is associated with worse neurological and functional status among survivors of in-hospital cardiac arrests. Minimizing time to defibrillation represents a major opportunity to improve neurological and functional status in these high-risk patients.

Cardiopulmonary resuscitation: special considerations for infants and children with cardiac disease

Pulseless cardiac arrest, defined as the cessation of cardiac mechanical activity, determined by unresponsiveness, apneoa, and the absence of a palpable central pulse, accounts for around one-twentieth of admissions to paediatric intensive care units, be they medical or exclusively cardiac. Such cardiac arrest is higher in children admitted to a cardiac as opposed to a paediatric intensive care unit, but the outcome of these patients is better, with just over two-fifths surviving when treated in the cardiac intensive care unit, versus between one-sixth and one-quarter of those admitted to paediatric intensive care units. Children who receive chest compressions for bradycardia with pulses have a significantly higher rate of survival to discharge, at 60%, than do those presenting with pulseless cardiac arrest, with only 27% surviving to discharge. This suggests that early resuscitation before the patient becomes pulseless, along with early recognition and intervention, are likely to improve outcomes. Recently published reports of in-hospital cardiac arrests in children can be derived from the multi-centric National Registry of Cardiopulmonary Resuscitation provided by the American Heart Association. The population is heterogeneous, but most arrests occurred in children with progressive respiratory insufficiency, and/or progressive circulatory shock. During the past 4 years at the Children's Hospital of Philadelphia, 3.1% of the average 1000 annual admissions to the cardiac intensive care unit have received cardiopulmonary resuscitation. Overall survival of those receiving cardiopulmonary resuscitation was 46%. Survival was better for those receiving cardiopulmonary resuscitation after cardiac surgery, at 53%, compared with survival of 33% for pre-operative or non-surgical patients undergoing resuscitation. Clearly there is room for improvement in outcomes from cardiac resuscitation in children with cardiac disease. In this review, therefore, we summarize the newest developments in paediatric resuscitation, with an expanded focus upon the unique challenges and importance of anticipatory care in infants and children with cardiac disease.