Elsevier

Resuscitation

Volume 62, Issue 1, July 2004, Pages 35-42
Resuscitation

A predictive model for survival after in-hospital cardiopulmonary arrest

https://doi.org/10.1016/j.resuscitation.2004.01.035Get rights and content

Abstract

Background: In-hospital cardiopulmonary resuscitation (CPR) has seen a steady increase in the application of technology and techniques since the introduction of closed cardiac massage in 1960. Despite this progress, there has not been a demonstrated improvement in survival rates after in-hospital cardiac arrest over the last 40 years. Identification of prognostic factors associated with survival after a resuscitation attempt can help physician decisions and patients’ end-of-life choices in a pre-arrest situation. Methods: Using an Utstein-based template we analyzed 219 consecutive adult attempted resuscitations in a large urban teaching hospital over a 3-year period. The main outcome measures were survival to discharge, 1 and 3 months. Backwards stepwise logistic regression was used to select baseline variables that predict survival at discharge, 1 and 3 months. Results: Survival rates at discharge, 1 and 3 months were 15.1, 13.3, and 11.5%. Meaningful neurological status (cerebral performance score of 1) at discharge was achieved in 61% of survivors. Independent predictors of survival were: higher body-mass index (BMI), presence of chronic renal insufficiency (CRI), respiratory arrest, ventricular tachycardia/fibrillation (VT/VF) as initial rhythm and arrest early during the hospital stay. A risk model based on these variables demonstrated a significant fit between predicted and observed survival at discharge with goodness of fit test P-value of 0.87. Conclusions: Survival after in-hospital cardiopulmonary arrest is poor and can be estimated by using clinical variables. If validated in a large prospective trial, this score could help physicians in attempting resuscitation, patients and families in making end-of-life decisions and hospitals in resource allocation.

Sumàrio

Contexto: A reanimação cardio-pulmonar intra-hospitalar (CPR) tem sofrido um incremento progressivo, desde a introdução da massagem cardı́aca fechada em 1960, na aplicação de tecnologia e técnicas. Apesar deste progresso, não há uma melhoria demonstrável nas taxas de sobrevivência após a paragem cardı́aca intra-hospitalar nos últimos 40 anos. A identificação de factores de prognóstico associados à sobrevivência após a tentativa de reanimação pode ajudar os médicos a tomarem decisões de “Fim de vida” numa situação de pré-paragem. Métodos: Utilizando um modelo baseado no template Utstein analizámos 219 tentativas de reanimação consecutivas em adulto, num grande hospital urbano de ensino, durante um perı́odo de 3 anos. As principais medidas de outcome foram sobrevivência à alta, 1 e 3 meses. Foi utilizado um modelo de regressão logı́stica para seleccionar as variáveis de base que previam a sobrevivência à alta, e após 1 e 3 meses. Resultados: A taxa de sobrevivência à alta e ao 1° e 3° mês foi de 15.1, 13.3 e 11.5% respectivamente. Foi obtido um estado neurológico significativo (score de performance cerebral de 1) à alta em 61% dos sobreviventes. Foram considerados factores predictivos independentes de sobrevivência: ı́ndice de massa corporal (BMI) mais elevado, presença de insuficiência renal crónica (CRI), paragem respiratória, Taquicardia/Fibrilhação Ventricular (VT/VF) como ritmo inicial e paragem precoce durante a estadia hospitalar. Um modelo de risco baseado nestas variáveis mostrou uma correlação significativa entre a sobrevivência prevista e a observada à alta com valor de P 0.87. Conclusão: A sobrevivência após paragem cardio-pulmonar intra-hospitalar é pequena e pode ser estimada pela utilização de variáveis clı́nicas. Se este score for validado num estudo prospectivo amplo pode ajudar os médicos nas decisões de iniciar reanimação, os doentes e as famı́lias na tomada de decisões de fim de vida e os hospitais na a locação de recursos.

Resumen

Antecedentes: Desde la introducción del masaje cardiaco en 1960, la reanimación cardiopulmonar(CPR) intrahospitalaria ha visto un constante aumento en la aplicación de tecnologı́a y técnicas. Pese a estos progreso, en los últimos 40 años no se ha demostrado mejorı́a en las tasas de sobrevida después de un paro cardı́aco intrahospitalario. La identificación de factores pronósticos asociados con sobrevida después de un intento de reanimación podrı́a ayudar en las decisiones médicas y en las elecciones del paciente acerca de el final de su vida en situaciones previas al paro cardiorrespiratorio. Métodos: Analizamos, usando un templado tipo Utstein, 219 resucitaciones consecutivas, intentadas en adultos, en un gran hospital docente urbano, en un perı́odo de tres años. Las principales medidas de resultado fueron la sobrevida al alta, de uno a tres meses. Se usó regresión logı́stica retrógrada por pasos para seleccionar variables basales que puedan predecir sobrevida al alta al mes y tres meses. Resultados: Las tasas de sobrevida al alta, al mes y a los tres meses fueron 15.1, y 13.3 y 11.5%. Se alcanzó un buen estado neurológico (puntaje de desempeño cerebral) al alta en un 61% de los sobrevivientes. Factores independientes de predicción de sobrevida fueron: mayor ı́ndice de masa corporal (BMI), presencia de insuficiencia renal crónica (CRI), paro respiratorio, fibrilación o taquicardia ventricular(VF/VT) como ritmo inicial y paro en momento temprano dentro de la estadı́a hospitalaria. Un modelo de riesgo basado en estas variables demostró coincidencia significativa entre la sobrevida predicha y la observada con un valor de P de 0.87 en la prueba de coincidencia. Conclusiones: La sobrevida después de un paro cardı́aco extrahospitalario es pobre y puede ser calculada usando variables clı́nicas. Si este puntaje fuera validado en un estudio prospectivo grande, podrı́a ayudar a los médicos en el intento de resucitación, a las familias en el momento de tomar decisiones respecto al final de la vida, y a los hospitales respecto a la localización de los recursos.

Introduction

Since the discovery of the effectiveness of closed chest compression in 1960, healthcare personnel have made cardiopulmonary resuscitation (CPR) one of the most frequently performed medical interventions. Despite a steady increase in the application of technology and techniques, there has not been a demonstrated improvement in survival rates after in-hospital cardiac arrest over the last 40 years. Combined data from large studies in over 40,000 patients show a survival rate to discharge of 15.9% [1], [2].

In most of these studies, the data collection was not standardized, and therefore inter-study comparisons are somewhat difficult. Recently, several organizations have published standards for data collection (the “Utstein style”) and the conduct of research on in-hospital CPR [3]. The most comprehensive study of in-hospital CPR published by the National Registry of Cardiopulmonary Resuscitation Investigators is the first Utstein-based, standardized characterization of in-hospital resuscitations in the United States [2].

Although many studies have been published on survival after in-hospital cardiopulmonary arrest, little is known about predictors of survival. In general, factors associated with better survival are younger age [4], absence of multiple comorbidities [1], respiratory arrest [1], ventricular arrhythmias [5], witnessed arrest [6], and rapid return of spontaneous circulation (short duration of CPR) [7]. Survival is poor in patients with asystole or pulseless electrical activity (PEA) [5], unwitnessed arrest [6], or multiple comorbidities [1]. The most commonly cited score for predicting survival after in-hospital cardiopulmonary arrest is the pre-arrest morbidity index developed by George et al. [5] in 1989. The variables collection in this study was not standardized and the index is cumbersome to calculate because of the complexity of information that needs to be obtained and entered. Other more recent predictive rule was published by van Walraven [8]. However, this set of criteria can be applied only during (after 10 min) or after the emergency, when most of the initial resuscitative measures have been initiated.

Our study attempted to assess outcomes of in-hospital CPR in a large urban teaching hospital and identify the most important prognostic factors for survival. Based on our data we developed a model to estimate the chance of short- and intermediate-term survival after in-hospital CPR. Such a tool might prove helpful to physicians when attempting resuscitation, to patients and families in making end-of-life decisions and might assist hospitals in resource allocation.

Section snippets

Materials and methods

We conducted a retrospective chart review by examining medical records of all adult patients who underwent CPR from 1 january 2000 to 31 december 2002 at the Advocate Illinois Masonic Medical Center, a 551-bed urban teaching hospital with 40 intensive care unit (ICU) beds located in Chicago, IL. The study included all patients aged 18 years or older for whom a resuscitation attempt was appropriately initiated.

The CPR team at the Advocate Illinois Masonic Medical Center consists of a senior

Results

During the study period there were 219 patients with cardiopulmonary arrest for which a resuscitation attempt was initiated adequately. Of these, 172 patients (78.5%) had only one cardiac arrest during hospitalization, 35 (16%) experienced two arrests, and 12 (5.5%) had three or more arrests.

Immediately after the arrest 132 (60.3%) of the patients had return of spontaneous circulation, which was maintained in only 73 (33.3%) of the patients after 24 h. The survival after the index

Discussion

In the present study we analyzed the results of 219 consecutive resuscitations, one of the largest recent series from a single institution using a standardized Utstein protocol for data collection. In addition, this is to our knowledge one of the largest series examining the survival not only to discharge, but also to 1 and 3 months, a time-frame where survival is likely to be related to the initial arrest.

In our study, the clinical characteristics of the patient population were similar to

Conclusions

Advising DNAR status upon admission is one of the most difficult tasks that the admitting physician faces. In the busy admission period, it is very hard to achieve the level of comfort in a physician–patient/family relationship for a very detailed and in depth DNAR discussion. We believe these discussions should ideally take place in the outpatient setting, with the primary care provider who has a long term trusty relationship with the patient, being a resource and offering guidance for making

Acknowledgements

The authors wish to thank Nancy Davis for her help with the statistical analysis.

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