Resuscitation Survival Research Articles

Introduction of intravenous amiodarone has little impact on survival of in‐hospital resuscitation

Clinical Pharmacology & Therapeutics (2003) 73, P3–P3; doi:

One-year survival and neurological outcome after pediatric cardiopulmonary resuscitation.

Reported survival after cardiopulmonary resuscitation (CPR) in children varies considerably. We aimed to identify predictors of 1-year survival and to assess long-term neurological status after in- or outpatient CPR. Retrospective review of the medical records and prospective follow-up of CPR survivors. Tertiary care pediatric university hospital. During a 30-month period, 89 in- and outpatients received advanced CPR. Survivors of CPR were prospectively followed-up for 1 year. Neurological outcome was assessed by the Pediatric Cerebral Performance Category scale (PCPC). Variables predicting 1-year survival were identified by multivariable logistic regression analysis. None. Seventy-one of the 89 patients were successfully resuscitated. During subsequent hospitalization do-not-resuscitate orders were issued in 25 patients. At 1 year, 48 (54%) were alive, including two of the 25 patients with out-of-hospital CPR. All patients died, who required CPR after trauma or near drowning, when CPR began >10 min after arrest or with CPR duration >60 min. Prolonged CPR (21-60 min) was compatible with survival (five of 19). At 1 year, 77% of the survivors had the same PCPC score as prior to CPR. Predictors of survival were location of resuscitation, CPR during peri- or postoperative care, and duration of resuscitation. A clinical score (0-15 points) based on these three items yielded an area under the ROC of 0.93. Independent determinants of long-term survival of pediatric resuscitation are location of arrest, underlying cause, and duration of CPR. Long-term survivors have little or no change in neurological status.

Implantation of an intra-hospital resuscitation program

The authors present their own experience on the installation of an in-hospital resuscitation programme, in a new tertiary hospital with 400 beds, an ICU with 8 beds and an emergency room 24 hours per day. The most important features presented are: the support by the Board of the Hospital, the engagement of all the health professionals, the distribution standardization and maintenance of the resuscitation equipment, the training in basic life-support techniques the doctors and nurses in the hospital, the performance of the cardiac arrest teams, all of which are fundamental to the maintenance of the chain of survival of cardiopulmonary resuscitation.

Short- and long-term survival after cardiopulmonary resuscitation.

The objective was to evaluate the effect of patient characteristics and other factors on cardiopulmonary resuscitation (CPR) survival, hospital discharge survival and function, and long-term survival. All patients 18 years and older experiencing in-hospital CPR from December 1983 through November 1991 at Marshfield Medical Center (Marshfield Clinic and adjoining St Joseph's Hospital), Marshfield, Wis, were selected. We performed a retrospective medical record review and augmented these data with updated vital status information. Cardiopulmonary resuscitation survival, hospital discharge survival and function, and long-term survival. Of 948 admissions during which CPR was performed, 61.2% of patients survived the arrest and 32.2% survived to hospital discharge. Mechanism of arrest was the most important variable associated with hospital discharge. Patients with pulseless electrical activity had the worst chance of hospital discharge, followed by those with asystole and bradycardia. Follow-up information was available for 298 patients who survived to discharge. One year after hospital discharge, 24.5% of patients, regardless of age, had died. Survival was 18.5% at 7 years in those 70 years or older, compared with 45.4% in those aged 18 to 69 years. Heart rhythm at the time of arrest strongly influenced long-term survival. Bradyarrhythmias produced a nearly 2-fold increased mortality risk compared with normal sinus rhythm. Survival until hospital discharge after CPR at our institution during an 8-year period was higher than previously reported for other institutions. Long-term survival after discharge was equal to or higher than reported estimates from other institutions. Hospital admission practices and selection of patients receiving CPR may account for these findings.

Cardiopulmonary resuscitation in pediatric trauma patients: survival and functional outcome.

Although injury is the leading cause of cardiac arrests in children older than 1 year, few studies have examined the survival and functional outcome of cardiopulmonary resuscitation (CPR) in pediatric trauma patients. A historical cohort of 957 trauma patients younger than 15 years who received CPR at the scene of injury or at the admitting hospital was constructed on the basis of the National Pediatric Trauma Registry. The rate of survival to discharge and factors related to survival were examined. Functional impairments were documented for surviving patients. The overall survival rate was 23.5%. With adjustment for the Injury Severity Score, the risk of fatality after CPR increased for children with systolic blood pressure below 60 mm Hg at admission (odds ratio [OR] 24.5, 95% confidence interval [CI] 8.6-69.3), for those who were comatose at admission (OR, 4.7; 95% CI, 1.9-11.6), for those with penetrating injury (OR, 4.4; 95% CI, 1.5-13.3), and for those with CPR initiated at the hospital (OR, 2.4; 95% CI, 1.5-3.9). Surviving patients stayed in hospitals for an average of 24.3 days; at discharge, 64% had at least one impairment in the functional activities of daily living. Survival outcome of CPR in pediatric trauma patients appears to be comparable to that reported in adults of mixed arrest causes. Future research needs to identify factors underlying the excess mortality associated with penetrating trauma.

Predicting survival, In-hospital cardiac arrests: Resuscitation survival variables and training effectiveness

Aim: the purpose of this study was to determine the key factors influencing survival from cardiopulmonary resuscitation and to analyse the effectiveness of a resuscitation training programme. Method: a prospective analysis of all cardiopulmonary resuscitation attempts was performed over a period of 3 years. Included in the study were 808 in hospital cardiac arrests, on whom a full cardiopulmonary resuscitation attempt was performed. Immediate, 24 h and discharge survival rates were the main outcome measures. Results: the immediate survival rate was 43.2%, then 30.2% at 24 h, and 21.9% by discharge. Multivariate analysis of all variables showed that the key factors influencing immediate survival were the `duration of the arrest', the `primary arrhythmia', `basic life support within 3 min of an arrest', `age less than 70 years', `the primary mode of arrest-respiratory or cardiac' and `difficulties with equipment and staff skills during a resuscitation'. Resuscitation training over the 3 year period was shown to have been effective, with improved survival rates on the wards and a reduced number of serious difficulties at arrests. Conclusion: data collection and analysis of cardiopulmonary resuscitation attempts are essential for the formulation of survival indicators, and the subsequent training of resuscitation teams.

Survival of 1476 patients initially resuscitated from out of hospital cardiac arrest

To determine the short and long term outcome of patients admitted to hospital after initially successful resuscitation from cardiac arrest out of hospital. Review of ambulance and hospital records. Follow up of mortality by "flagging" with the registrar general. Cox proportional hazards analysis of predictors of mortality in patients discharged alive from hospital. Scottish Ambulance Service and acute hospitals throughout Scotland. 1476 patients admitted to a hospital ward, of whom 680 (46%) were discharged alive. Survival to hospital discharge, neurological status at discharge, time to death, and cause of death after discharge. The median duration of hospital stay was 10 days (interquartile range 8-15) in patients discharged alive and 1 (1-4) day in those dying in hospital. Neurological status at discharge in survivors was normal or mildly impaired in 605 (89%), moderately impaired in 58 (8.5%), and severely impaired in 13 (2%); one patient was comatose. Direct discharge to home occurred in 622 (91%) cases. The 680 discharged survivors were followed up for a median of 25 (range 0-68) months. There were 176 deaths, of which 81 were sudden cardiac deaths, 55 were non-sudden cardiac deaths, and 40 were due to other causes. The product limit estimate of 4 year survival after discharge was 68%. The independent predictors of mortality on follow up were increased age, treatment for heart failure, and cardiac arrest not due to definite myocardial infarction. About 40% of initial survivors of resuscitation out of hospital are discharged home without major neurological disability. Patients at high risk of subsequent cardiac death can be identified and may benefit from further cardiological evaluation.

In-Hospital Cardiopulmonary Resuscitation Survival in 1 Hospital and Literature Review

Cardiopulmonary resuscitation (CPR) has been used extensively in the hospital setting since its introduction over 3 decades ago. We reviewed the CPR records at 1 hospital during a 2-year period and the results from 113 published reports of inpatient CPR with a total patient population of 26,095. We compared the survival rates of patients following CPR and the pre-arrest and intra-arrest factors related to survival. At the hospital where CPR records were reviewed, 44% of patients initially survived following CPR, and the 1-year survival rate was 5%. Patients with shorter durations of CPR and those administered fewer procedures and medications during CPR survived longer than patients with prolonged CPR. Patients with witnessed cardiac arrests were more likely to survive than those with unwitnessed arrests. Also, patients with respiratory arrests had much better survival than patients with cardiopulmonary arrests. Worldwide, 113 studies showed a survival to discharge rate of 15.2% (United States = 15%, Canada = 16%, United Kingdom = 17%, other European countries = 14%). Patients were more likely to survive to discharge if they were treated in a community hospital (versus a teaching or Veterans Affairs hospital) or were younger. Patients with ventricular tachycardia or fibrillation were more likely to survive than those with asystole or electromechanical dissociation. Patient's location was related to outcome, with emergency room and coronary care unit patients more likely to survive than intensive care unit and general ward patients. Other factors related to better survival rates were respiratory arrest, witnessed arrest, absence of comorbidity, and short duration of CPR. Knowledge of the likelihood of survival following CPR for subgroups of the hospital population based on pre-arrest and intra-arrest factors can help patients, their families, and their physicians decide, with compassion and conviction, in what situations CPR should be administered.

Cardiopulmonary Resuscitation Survival-Reply

Lewis makes an important point that the apparent failure of cardiopulmonary resuscitation (CPR) outcome predictors to predict CPR outcome in the study by Rosenberg et al 1 may have been due to a bias that resulted from the proper application of DNA orders that, in turn, resulted in the exclusion of those least likely to survive among the attempted CPR population. If this were the case, we would hope that Rosenberg et al would enlighten us as to the manner in which this selection was accomplished. There is no mention, however, by Rosenberg et al that any unusual application of the do-not-resuscitate process was in place at either one or both of the hospitals examined. Indeed, there was a rather wide variation from hospital A to hospital B in survival of resuscitation (Table 2 1 ) and in survival to discharge (Table 3 1 ) in a number of the subgroups analyzed.

Cardiopulmonary Resuscitation Survival

In the article on cardiopulmonary resuscitation survival by Rosenberg et al, 1 and commented on by McIntyre, a retrospective review of survival was done on hospitalized patients to determine characteristics that might be predictive of successful outcome of cardiopulmonary resuscitation. Survival in this study was almost 70% higher than in other recent studies. This suggests that there may have been a selection bias. This would occur if those less likely to be successfully resuscitated were eliminated from the pool of potential survivors by do not resuscitate orders. If do not resuscitate orders were appropriately applied, those with the least chance of survival would not undergo CPR, survival rates of those resuscitated would improve, and age and disease would not be determining factors for short-term survival. If this is the case here, Rosenberg may have shown the ability of the physicians in these community hospitals to predict survival and use do

Cardiopulmonary Resuscitation Survival-Reply

We appreciate Lewis re-emphasizing the important issue of patient selection and its potential role in explaining the wide variance in survival statistics found in the medical literature. It is important to note that other studies have documented rates of successful cardiopulmonary resuscitation similar to those found in our study.1George et al,2in 1989, found cardiopulmonary resuscitation survival rates of 55% and survival to hospital discharge rates of 23.3% in a community hospital setting.2Other studies conducted in different settings with different patient populations have found survival rates to be significantly lower. We agree with Lewis that one explanation for this variance may be that physicians in some institutions are better able to select patients with poor prognoses for do not resuscitate status. Institution-specific variations in comorbidities may also be responsible for a portion of the observed differences in survival. Our study found that conventional clinical definitions

Decisions for and Against Resuscitation in an Acute Geriatric Medicine Unit Serving the Frail Elderly

Recent studies indicate continuing controversy over the appropriateness of intensive care in various clinical settings, particularly for very young and very old patients. We studied decisions regarding cardiopulmonary resuscitation (CPR) and the associated clinical course in an acute geriatric unit serving the frail elderly. Despite multiple acute and chronic conditions, advanced age, and functional impairment, patients overwhelmingly preferred CPR. The patients with do-not-resuscitate (DNR) orders were more functionally dependent, more acutely and chronically ill, and less likely to participate in the decision regarding CPR. The majority of DNR orders were made by surrogates, while the majority of CPR directives were made by the patients themselves. Other forms of acute and supportive care, such as parenteral antibiotics, artificial feeding, and transfusions were not withheld from the DNR patients unless a separate decision to limit a specific treatment was undertaken following consultation between the attending physician and the patient or family. Acuity of illness greater than two SDs above the unit mean and the presence of a surrogate decision maker predicted the majority of DNR orders. Length of stay averaged 28 days for all unit patients, 24 days for patients choosing CPR, and 46 days for patients with DNR orders. The four patients who were resuscitated but died stayed an average of 25 days, while the two survivors of resuscitation stayed 20 and 53 days, respectively. The findings indicate that patients and their families considered appropriate clinical criteria including severity of illness when making their decisions about CPR. Nevertheless, the majority chose to be resuscitated in the event of an arrest. Further studies are needed to explore medical decision making by elderly inpatients and their surrogates and to describe the associated clinical course.

Acute traumatic aortic aneurysm: The Duke experience from 1970 to 1990

Improvements in the operative management of acute traumatic thoracic aortic aneurysm have resulted in safe and expeditious repair. Nonetheless, multisystem injuries continue to inflict significant numbers of deaths. From 1970 to 1990, 108 patients with acute traumatic thoracic aortic aneurysm were evaluated. Mean injury severity score, excluding aortic injury, was 17.5. Ninety-three patients (86%) survived beyond initial resuscitation and came to operation. Median interval from injury to aortic repair was 8 hours (range, 2 hours to 19 days); there were five operative deaths. Lethal nonaortic injuries included 18 closed head injuries, four myocardial contusions, two intraabdominal vascular injuries, and one pulmonary contusion. The overall mortality rate was 39% of total admissions (42 of 108), and 29% of survivors of resuscitation (27 of 93). It is significant that only 11 of the 42 deaths (26%) were directly attributable to thoracic aortic aneurysm. Adjuncts to prevent spinal cord ischemia (shunt/bypass) were used in 76 patients, whereas 12 underwent clamp/repair. Postoperative paraplegia developed in 5 of 79 patients (6.8%, including 4 of 68 (5.9%) repaired with shunt/bypass and 1 of 11 (9.1%) repaired with clamp/repair (p = NS). Among those who developed paraplegia, the injury severity score was 27.0, and the median interval from injury to repair was 4.9 hours (range, 2 to 6.5). Intraoperative hypotension occurred in three of five patients with paraplegia. Death in patients with thoracic aortic aneurysm is due primarily to associated injuries and has remained relatively constant over the 20-year period of review. Overall injury severity, intraoperative hypotension, and extensive aortic tissue destruction may correlate with the development of postoperative paraplegia; however, a larger population sample is required to confirm this conclusion. A plea is made for standardized reporting of all patients with thoracic aortic aneurysm.

Acute traumatic aortic aneurysm: The Duke experience from 1970 to 1990

Improvements in the operative management of acute traumatic thoracic aortic aneurysm have resulted in safe and expeditious repair. Nonetheless, multisystem injuries continue to inflict significant numbers of deaths. From 1970 to 1990, 108 patients with acute traumatic thoracic aortic aneurysm were evaluated. Mean injury severity score, excluding aortic injury, was 17.5. Ninety-three patients (86%) survived beyond initial resuscitation and came to operation. Median interval from injury to aortic repair was 8 hours (range, 2 hours to 19 days); there were five operative deaths. Lethal nonaortic injuries included 18 closed head injuries, four myocardial contusions, two intraabdominal vascular injuries, and one pulmonary contusion. The overall mortality rate was 39% of total admissions (42 of 108), and 29% of survivors of resuscitation (27 of 93). It is significant that only 11 of the 42 deaths (26%) were directly attributable to thoracic aortic aneurysm. Adjuncts to prevent spinal cord ischemia (shunt/bypass) were used in 76 patients, whereas 12 underwent clamp/repair. Postoperative paraplegia developed in 5 of 79 patients (6.8%, including 4 of 68 (5.9%) repaired with shunt/bypass and 1 of 11 (9.1%) repaired with clamp/repair (p = NS). Among those who developed paraplegia, the injury severity score was 27.0, and the median interval from injury to repair was 4.9 hours (range, 2 to 6.5). Intraoperative hypotension occurred in three of five patients with paraplegia. Death in patients with thoracic aortic aneurysm is due primarily to associated injuries and has remained relatively constant over the 20-year period of review. Overall injury severity, intraoperative hypotension, and extensive aortic tissue destruction may correlate with the development of postoperative paraplegia; however, a larger population sample is required to confirm this conclusion. A plea is made for standardized reporting of all patients with thoracic aortic aneurysm.

Rupture of thoracic aorta caused by blunt trauma: A fifteen-year experience

During the 15 years from 1971 through 1985, 114 patients with rupture of the thoracic aorta caused by blunt trauma were admitted to the Shock Trauma Center of the Maryland Institute for Emergency Medical Services Systems. Mean age was 31.3 years (range, 15 to 80). Ninety were male and 24 were female, a 3.75:1 ratio. Of the 114, 89 (78.1%) survived initial resuscitation in the admitting area. Twenty five of the 89 initial survivors (28.1%) died during or after surgical repair. Paraplegia occurred in 11 of the 78 operating room survivors (14.1%). Further analysis was done of the 83 patients admitted in the 10-year period from 1976 through 1985. Mean Injury Severity Score, excluding aortic injury, was 18.2. Twenty-five of the 83 (30.1%) died during resuscitation in the admitting area or operating room. Seven others died during surgical repair and 12 died postoperatively, leaving 39 survivors (39/83 [47%] of total admissions and 39/58 [67.2%] of survivors of resuscitation). Paraplegia/paresis developed postoperatively in six of 34 (17.6%) cases involving shunt and four of 17 (23.5%) without shunt. Other major complications occurred in 21 of the operating room survivors. Statistically significant risk of death or major complication was associated with female sex, higher Injury Severity Score, lower admission blood pressure, larger hemothorax on admission, less qualified surgeon, major operation before aortic repair, use of shunt, and transfer directly from scene of injury. There was no advantage in this series to using or not using a shunt in preventing paraplegia. Mortality rates are realistic for a highly developed trauma system. Better techniques are needed to manage exsanguination and prevent paraplegia.

Results of cardiopulmonary resuscitation in a cardiology hospital

The authors analysed a series of 557 consecutive patients who suffered cardiorespiratory arrest at the Dante Pazzanese Institute of Cardiology (DPIC) during a period of 5 years in order to examine factors predicting successful resuscitation and long-term survival. Cardiopulmonary resuscitation (CPR) maneuvers were tried in 536 patients, with the following results: 284 patients (53%) died immediately, another 102 (19%) died within the first 24 h after the cardiac arrest and 150 patients (28%) survived more than 24 h. Among these, 65 (12.1%) died in the first month after cardiac arrest and other 29 (5.4%) died after that period. There were 43 late survivors (8%). Thirteen patients (2.4%) were lost to follow-up. After 9 years, the accumulative life expectancy was 8.7%. Coronary heart disease, cardiomyopathy and valvular heart disease were the most frequent underlying diseases. None of the 49 patients with cyanotic congenital heart disease survived. The heart arrest was mostly caused by heart failure (55.8%) and primary arrhythmia (17.2%) in the whole group, whereas the survivor group showed primary arrhythmia in 81.7% and heart failure in 7.3%. In those patients where the initial mechanism of cardiac arrest was ventricular fibrillation, 33.2% survived more than 1 month, while among those on ventricular asystole, only 3.4% survived more than 1 month.