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PubMed2005

Cardiac arrest during neuraxial anesthesia: frequency and predisposing factors associated with survival.

The frequency and predisposing factors associated with cardiac arrest during neuraxial anesthesia remain undefined, and the survival outcome data are contradictory. In this retrospective study, we evaluated the frequency of cardiac arrest, as well as the association of preexisting medical conditions and periarrest events with survival after cardiac arrest during neuraxial anesthesia between 1983 and 2002. To assess whether survival after cardiac arrest differs for patients who arrest during neuraxial versus general anesthesia, data were also obtained for patients who experienced cardiac arrest under general anesthesia during similar surgical procedures during the same time interval. Over the 20-yr study period at the Mayo Clinic, there were 26 cardiac arrests during neuraxial blockade and 29 during general anesthesia. The overall frequency of cardiac arrest during neuraxial anesthesia for 1988 to 2002 was 1.8 per 10,000 patients, with more arrests in patients receiving spinal versus epidural anesthesia (2.9 versus 0.9 per 10,000; P = 0.041). In 14 (54%) of the 26 patients who arrested during a neuraxial technique, the anesthetic contributed directly to the arrest (high sympathectomy or respiratory depression after sedative administration), whereas in 12 (46%) patients, the arrest was associated with a specific surgical event (cementing of joint components, spermatic cord manipulation, reaming of the femur, and rupture of amniotic membranes). Patients who arrested during general anesthesia had a higher ASA classification than those who arrested during a neuraxial block (P = 0.031). Hospital survival was significantly improved for patients who arrested during neuraxial anesthesia versus general anesthesia (65% vs 31%; P = 0.013). The association of improved survival with neuraxial anesthesia remained statistically significant after adjusting for all patient/procedural characteristics, with the exception of ASA classification and emergency procedures. We conclude that a cardiac arrest during neuraxial anesthesia is associated with an equal or better likelihood of survival than a cardiac arrest during general anesthesia.

Adolescent↗

PubMed2003

Myocardial protection during resuscitation from cardiac arrest.

PURPOSE OF REVIEW: Successful treatment of cardiac arrest requires that an electrically stable and mechanically competent cardiac activity be promptly reestablished. However, many interventions used to attempt to reestablish cardiac activity may also inflict additional myocardial injury and, in turn, compromise resuscitability. In this review, we examine mechanisms of such myocardial injury and discuss potential new strategies for myocardial protection during resuscitation from cardiac arrest. RECENT FINDINGS: Efforts are currently directed at understanding underlying mechanisms of myocardial injury associated with current resuscitation methods, with the purpose of developing alternative approaches that are safer and more effective. These new approaches include, among others, the development of alternative low-energy defibrillation waveforms, methods for optimizing the timing for attempting defibrillation, and the use of vasopressor agents devoid of beta-agonist effects. There is also interest in understanding the role that activation of pathways of ischemic and reperfusion injury could play during resuscitation from cardiac arrest. To this end, activation of the sarcolemmal sodium-hydrogen exchanger isoform 1 seems to play an important role. Other potentially important pathways involve adenosine metabolism, activation of potassium ATP channels, and generation of oxygen radical species. These pathways may become novel pharmacologic targets for cardiac resuscitation. SUMMARY: The growing body of research in these areas is bringing hope that in a not so distant future new approaches and interventions for cardiac resuscitation could be available for resuscitation of humans in various clinical settings.

Anti-Arrhythmia Agents↗

PubMed2006

Perioperative cardiac arrest: a study of 53,718 anaesthetics over 9 yr from a Brazilian teaching hospital.

BACKGROUND: Little information exists regarding factors influencing perioperative cardiac arrests and their outcome. This survey evaluated the incidence, causes and outcome of perioperative cardiac arrests in a Brazilian tertiary general teaching hospital between April 1996 and March 2005. METHODS: The incidence of cardiac arrest during anaesthesia was prospectively identified from an anaesthesia database. There were 53,718 anaesthetics during the study period. Data collected included patient characteristics, surgical procedures (elective, urgent or emergency), ASA physical status classification, anaesthesia provider information, type of surgery, surgical areas and outcome. All cardiac arrests were retrospectively reviewed and grouped by cause of arrest and death into one of four groups: totally anaesthesia related, partially anaesthesia related, totally surgery related or totally patient disease or condition related. RESULTS: One hundred and eighty-six cardiac arrests (34.6:10,000) and 118 deaths (21.97:10,000) were found. Major risk factors for cardiac arrest were neonates, children under 1 yr and the elderly (P<0.05), male patients with ASA III or poorer physical status (P<0.05), in emergency surgery (P<0.05) and under general anaesthesia (P<0.05). Patient disease/condition was the major cause of cardiac arrest or death (P<0.05). There were 18 anaesthesia-related cardiac arrests (3.35:10,000) -- 10 totally attributed (1.86:10,000) and 8 partially related to anaesthesia (1.49:10,000). There were 6 anaesthesia-related deaths (1.12:10,000) -- 3 totally attributable and 3 partially related to anaesthesia (0.56:10,000 in both cases). The main causes of anaesthesia-related cardiac arrest were respiratory events (55.5%) and medication-related events (44.5%). CONCLUSIONS: Perioperative cardiac arrests were relatively higher in neonates, infants, the elderly and in males with severe underlying disease and under emergency surgery. All anaesthesia-related cardiac arrests were related to airway management and medication administration which is important for prevention strategies.

Adolescent↗

PubMed1995

Pentoxifylline ameliorates postischemic delayed hypoperfusion of the cerebral cortex following cardiac arrest in cats.

Two major events occurring in the cerebral hemodynamics after successful resuscitation from cardiac arrest are reactive hyperemia and postischemic hypoperfusion. We examined the effect of pentoxifylline on the feline cerebral hemodynamics following cardiac arrest. Fifteen cats were anesthetized and artificially ventilated. Using our photoelectric method, the local cerebral blood volume (CBV), mean transit time of blood (MTT), and cerebral blood flow (CBF) in the parietotemporal region were measured. Thoracotomy was performed, and cardiac arrest (ventricular fibrillation) was induced by direct application of a 2-V DC countershock. The heart was resuscitated with a DC countershock at 30 sec after cardiac arrest. In 9 cats, pentoxifylline (25 mg/kg) was infused into the femoral vein at 5 min before cardiac arrest (PTX group). The other 6 cats served as controls (control group). In both groups, the CBV, CBF and mean arterial blood pressure (MABP) overshot the control levels just after resuscitation, whereas the MTT was decreased. In the control group, postischemic hypoperfusion was detected at 30-180 min after resuscitation from cardiac arrest (CBF (ml/100 g/min): 51 +/- 4 (control), 38 +/- 4 (30 min, p < 0.05), and 23 +/- 3 (180 min, p < 0.05)). However, the postischemic hypoperfusion was not observed in the PTX group. Pentoxifylline ameliorated postischemic delayed hypoperfusion in the cerebral cortex after a short period of cardiac arrest. Pentoxifylline may be useful in the emergency situations following cardiac arrest.

Animals↗

PubMed1999

Long-acting psychotraumatic properties of a cardiac arrest experience.

OBJECTIVE: Progress in resuscitation medicine allows an increasing proportion of patients to survive an out-of-hospital cardiac arrest. However, little is known about long-term adaptation to the vital breakdown. The present study assessed the long-term prevalence and severity of emotional disability of cardiac arrest survivors and ascertained whether survivors suffer from recurrent and intrusive recollections of the cardiac arrest. METHOD: Follow-up analysis was performed on all cardiac arrest survivors discharged from the hospital over a 5-year interval (1990-1994) in a defined inner city and suburban area. From 118 initially hospitalized cardiac arrest survivors, 45 patients were discharged alive from the hospital. After a mean follow-up period of 39 months (range = 22-64), 25 patients exhibited sufficient cerebral performance for psychodiagnostic assessment; 21 patients were assessed. RESULTS: Despite an impaired ability to concentrate, cardiac arrest survivors had levels of psychological adjustment at follow-up that were similar to those of 35 cardiac patients whose clinical course was not complicated by cardiac arrest. However, the diagnosis of psychotraumatic symptoms in cardiac arrest survivors led to a sharp separation between favorable and nonfavorable outcome in affective regulation and level of functioning. Of the cardiac arrest patients, those with high scores of intrusion and avoidance (N = 8) reported an enduring sense of demoralization with significantly more somatic complaints, depression, anxiety, lack of confidence in the future, and narrowing of social activities than those with low scores (N = 11). Long-acting sedation at illness onset significantly predicted a favorable outcome. CONCLUSIONS: This study provides the first empirical evidence that the application of the posttraumatic stress disorder paradigm in the long-term evaluation of cardiac arrest survivors significantly contributes to defining a patient population at high risk for serious emotional disability.

Adaptation, Psychological↗

PubMed1995

Blunt impact to the chest leading to sudden death from cardiac arrest during sports activities.

BACKGROUND: Sudden death from cardiac arrest in a young person may occur during sports play after a blunt blow to the chest in the absence of structural cardiovascular disease or traumatic injury (cardiac concussion or commotio cordis). We studied the clinical features of this apparently uncommon but important phenomenon. METHODS: We identified cases from the registries of relevant agencies and organizations, as well as newsmedia accounts, and developed a clinical profile of 25 children and young adults, 3 to 19 years of age. RESULTS: Each victim collapsed with cardiac arrest immediately after an unexpected blow to the chest, which was usually inflicted by a projectile (such as a baseball or hockey puck). Incidents took place during organized competitive sports in 16 cases and in recreational settings at home, at school, or on the playground in 9. In each instance, the impact to the chest was not judged to be extraordinary for the sport involved and did not appear to have sufficient force to cause death. Twelve victims collapsed virtually instantaneously on impact, whereas 13 remained conscious and physically active for a brief time before cardiac arrest. Cardiopulmonary resuscitation was administered within about three minutes to 19 victims, but normal cardiac rhythm could be restored in only 2 (both incurred irreversible brain damage and died shortly thereafter). Seven victims (28 percent) were wearing some form of protective chest padding. CONCLUSIONS: We speculate that most sudden deaths related to impact to the chest (not associated with traumatic injury) are due to ventricular dysrhythmia induced by an abrupt, blunt precordial blow, presumably delivered at an electrically vulnerable phase of ventricular excitability. This profile of blunt chest impact leading to cardiac arrest adds to our understanding of the range of causes of sudden death on the athletic field and may help in the development of preventive measures.

Adolescent↗

PubMed2006

Cardiac arrest in public locations--an independent predictor for better outcome?

OBJECTIVE: Outcome after cardiac arrest is known to be influenced by immediate access to resuscitation. We aimed to analyse the location of arrest in relation to the prognostic value for outcome. DESIGN: Retrospective review from prospective databases (ambulance routine documentation database and emergency department database on patients treated for cardiac arrest). SETTING: Vienna (1.7 million inhabitants) ambulance service and tertiary care facility (university clinics). PATIENTS: Two independent cohorts: (1) a population-based cohort of patients who were treated for cardiac arrest by the municipal ambulance service outside the hospital. The endpoint in this group was survival to hospital admission with spontaneous circulation. (2) A cohort of patients who were admitted to the emergency department after successful out of hospital resuscitation. The endpoint in this group was survival to 6 months with good neurological status (best Cerebral Performance Category 1 or 2 within 6 months). MEASUREMENTS: We analysed whether the location of non-traumatic adult out-of-hospital cardiac arrest (public versus private place) was a predictor for good outcome. RESULTS: PATIENTS who had cardiac arrest in a public location were more likely to arrive in hospital alive (39% versus 31%, crude OR 1.4, 95% CI 1.001-1.975, p=0.049) and were more likely to have a good neurological outcome after 6 months (35% versus 25%, crude OR 1.65, adjusted OR 1.59, 95% CI 1.07-2.36, p=0.023), compared to patients who had cardiac arrest in a non-public location. CONCLUSION: Cardiac arrest in a public location is independently associated with a better outcome.

Aged↗

PubMed2005

A quantitative analysis of the acidosis of cardiac arrest: a prospective observational study.

INTRODUCTION: Metabolic acidosis is common in patients with cardiac arrest and is conventionally considered to be essentially due to hyperlactatemia. However, hyperlactatemia alone fails to explain the cause of metabolic acidosis. Recently, the Stewart-Figge methodology has been found to be useful in explaining and quantifying acid-base changes in various clinical situations. This novel quantitative methodology might also provide useful insight into the factors responsible for the acidosis of cardiac arrest. We proposed that hyperlactatemia is not the sole cause of cardiac arrest acidosis and that other factors participate significantly in its development. METHODS: One hundred and five patients with out-of-hospital cardiac arrest and 28 patients with minor injuries (comparison group) who were admitted to the Emergency Department of a tertiary hospital in Tokyo were prospectively included in this study. Serum sodium, potassium, ionized calcium, magnesium, chloride, lactate, albumin, phosphate and blood gases were measured as soon as feasible upon arrival to the emergency department and were later analyzed using the Stewart-Figge methodology. RESULTS: Patients with cardiac arrest had a severe metabolic acidosis (standard base excess -19.1 versus -1.5; P < 0.0001) compared with the control patients. They were also hyperkalemic, hypochloremic, hyperlactatemic and hyperphosphatemic. Anion gap and strong ion gap were also higher in cardiac arrest patients. With the comparison group as a reference, lactate was found to be the strongest determinant of acidosis (-11.8 meq/l), followed by strong ion gap (-7.3 meq/l) and phosphate (-2.9 meq/l). This metabolic acidosis was attenuated by the alkalinizing effect of hypochloremia (+4.6 meq/l), hyperkalemia (+3.6 meq/l) and hypoalbuminemia (+3.5 meq/l). CONCLUSION: The cause of metabolic acidosis in patients with out-of-hospital cardiac arrest is complex and is not due to hyperlactatemia alone. Furthermore, compensating changes occur spontaneously, attenuating its severity.

Acidosis↗

PubMed2006

Out-of-hospital resuscitation in Estonia: a bystander-witnessed sudden cardiac arrest.

OBJECTIVE: To evaluate the results of the first epidemiological study on out-of-hospital resuscitation in Estonia. METHODS: A prospective cohort study of 2108 consecutive standardized reports on out-of-hospital resuscitation attempts from 1 January 1999 to 31 December 2002 was conducted according to the Utstein style. RESULTS: In all, 67.3% (1419/2108) of the cardiac arrests were of presumed cardiac aetiology and 60.2% (854/1419) of them were bystander-witnessed. Of these, the 28% bystander cardiopulmonary resuscitation was initiated, and the first rhythm was recorded as ventricular fibrillation or pulseless ventricular tachycardia in 40% of the cases. In the subgroup of patients with bystander-witnessed cardiac arrest of cardiac origin, 10.7% (91/854) were discharged alive in good cerebral performance categories and 7.7% were alive at the 1-year follow-up. The chances of survival increased if the median response time interval was <6 min, cardiac arrest occurred in a public place, patients received bystander cardiopulmonary resuscitation and had an initial rhythm of ventricular fibrillation or pulseless ventricular tachycardia. The discharge rate was 24% (82/343) in the subgroup of patients who had bystander-witnessed cardiac arrest of cardiac origin and an initial rhythm of ventricular fibrillation or pulseless ventricular tachycardia. In this subgroup, the survival rate was 42.6% (40/94) in Tartu urban area, 16.9% (22/130) in Tallinn urban area and 16.8% (20/119) in other regions of Estonia (mostly urban and suburban areas). CONCLUSION: The results demonstrate that despite the progress in the management of out-of-hospital cardiac arrest in Estonia, only one centre (Tartu) achieves a better survival rate. Further improvements are needed to raise the quality of the Estonian emergency medical services system, especially in rural areas.

Aged↗

PubMed1998

Factors influencing hospital transport of patients in continuing cardiac arrest.

STUDY OBJECTIVE: Prior research has established the futility of continued resuscitation efforts for patients in cardiac arrest who fail to respond to out-of-hospital advanced cardiac life support. Determination of both medical and nonmedical factors resulting in the transport of patients in continuing cardiac arrest to the hospital may encourage the development of new systems or strategies to increase the appropriateness of these transports. METHODS: The attending paramedic completed a prospective survey after unsuccessful resuscitation efforts in our urban, hospital-based, two-tier emergency medical services (EMS) system. All nontraumatic adult arrests were included unless they were clearly noncardiac in nature. RESULTS: Paramedics responded to 259 cardiac arrests between September 12, 1996, and April 31, 1997. Seventy-nine patients were pronounced dead without resuscitation efforts. Of the remaining 180 patients, 44 had return of spontaneous circulation and were transported to the hospital, 68 were pronounced dead in the field, and 68 were transported to the hospital in continuing cardiac arrest. The 68 patients transported while in cardiac arrest are the focus of this study. Rare problems with field termination were identified. Reasons for transport of the 68 patients in continuing cardiac arrest included arrest in ambulance or going to ambulance (n = 6), arrest in a public place (n = 17), environmental factors (n = 6), road hazard to paramedics (n = 1), possible reversible cause (n = 4), persistent ventricular dysrhythmia (n = 5), no intravenous access (n = 5), airway difficulties (n = 5), family unable to accept field termination (n = 3), cultural or language barrier (n = 1), EMS physician ordered transport (n = 1), and obesity (n = 1). A protocol allowing pronouncement of death in the ambulance and transport of the body to a designated area could have prevented lights-and-siren transport to the emergency department in 24 of the 68 cases. CONCLUSION: Factors other than medical ones often influence the decision to transport patients in continuing cardiac arrest. In our urban system, physician, medical examiner, and paramedic education and protocols were needed to aid decision-making in this situation.

Cardiopulmonary Resuscitation↗

PubMed2001

Factors associated with the occurrence of cardiac arrest during hospitalization for acute myocardial infarction in the second national registry of myocardial infarction in the US.

Cardiac arrest can occur as a complication of acute myocardial infarction (AMI). To date, few studies have described factors associated with cardiac arrest occurrence and survival during hospitalization for treatment of AMI. We used data from a large national registry of hospitalized AMI patients to identify these factors. Data were collected from 1073 participating institutions, representing 14.4% of US hospitals. Hospital site coordinators conducted periodic chart reviews for AMI patients and data were submitted to an independent center for periodic review. Univariate analysis and multivariate logistic regression were used to identify factors associated with cardiac arrest. We found that cardiac arrest occurred in 4.8% (14,725/305,812) of hospitalized AMI patients. The survival rate to hospital discharge for these individuals was 29.4%. Sustained ventricular tachycardia or fibrillation (VT/VF) was present in 34.7% and was associated with a higher rate of survival to hospital discharge compared to cardiac arrest patients without a ventricular tachyarrhythmia (47.5 vs. 19.8%, P < 0.00001). Hypotension (initial systolic BP < 90 mmHg), q-wave AMI, old age, heart failure and initial heart rate abnormalities (bradycardia or tachycardia) were associated with a higher prevalence of cardiac arrest. A higher percentage of women compared to men experienced cardiac arrest (6.0 vs. 4.41%, P < 0.0001). Cardiac arrest prevalence was lower in patients with inferior wall infarction than in other types of ST-elevation infarction. Use of reperfusion therapy (PTCA or tPA) was associated with improved survival compared to hospitalized AMI patients who did not receive such therapy.

Age Distribution↗

PubMed2002

Anesthetic-related cardiac arrest and its mortality: a report covering 72,959 anesthetics over 10 years from a US teaching hospital.

BACKGROUND: A prospective and retrospective case analysis study of all perioperative cardiac arrests occurring during a 10-yr period from 1989 to 1999 was done to determine the incidence, cause, and outcome of cardiac arrests attributable to anesthesia. METHODS: One hundred forty-four cases of cardiac arrest within 24 h of surgery were identified over a 10-yr period from an anesthesia database of 72,959 anesthetics. Case abstracts were reviewed by a Study Commission composed of external and internal members in order to judge which cardiac arrests were anesthesia-attributable and which were anesthesia-contributory. The rates of anesthesia-attributable and anesthesia-contributory cardiac arrest were estimated. RESULTS: Fifteen cardiac arrests out of a total number of 144 were judged to be related to anesthesia. Five cardiac arrests were anesthesia-attributable, resulting in an anesthesia-attributable cardiac arrest rate of 0.69 per 10,000 anesthetics (95% confidence interval, 0.085-1.29). Ten cardiac arrests were found to be anesthesia-contributory, resulting in an anesthesia-contributory rate of 1.37 per 10,000 anesthetics (95% confidence interval, 0.52-2.22). Causes of the cardiac arrests included medication-related events (40%), complications associated with central venous access (20%), problems in airway management (20%), unknown or possible vagal reaction in (13%), and one perioperative myocardial infarction. The risk of death related to anesthesia-attributable perioperative cardiac arrest was 0.55 per 10,000 anesthetics (95% confidence interval, 0.011-1.09). CONCLUSIONS: Most perioperative cardiac arrests were related to medication administration, airway management, and technical problems of central venous access. Improvements focused on these three areas may result in better outcomes.

Adolescent↗

PubMed2002

Diurnal, weekly and seasonal rhythm of out of hospital cardiac arrest in Sweden.

AIM: To describe the diurnal, weekly and seasonal rhythm among patients suffering from out of hospital cardiac arrest in Sweden. METHODS: All patients in Sweden between 1990 and 1999 participating in a National Registry covering 65% of all patients suffering from out of hospital cardiac arrest where cardiopulmonary resuscitation (CPR) was attempted. Only patients with a cardiac arrest of a cardiac aetiology and aged > 18 years were included in the survey. RESULTS: 10,868 patients fulfilled inclusion criteria. In terms of the diurnal rhythm, there was a progressive increase in the development of cardiac arrest from 06:00 h, reaching a peak at about 10:00 h. Thereafter, there was a progressive decline until 05:00 h. The diurnal rhythm was more marked among patients aged > 65 years and among patients in whom the arrest occurred outside home. There was a weekly rhythm with an increased incidence of cardiac arrest on Mondays. This was particularly evident among patients aged < 66 years and among men. A cardiac arrest occurred most frequently in January and December. This was particularly observed in the large cities. CONCLUSION: We found that out of hospital cardiac arrest of a cardiac etiology has a diurnal, weekly and seasonal rhythm occurring most frequently in the morning hours, on Mondays and in December and January. Age, sex and place of arrest influence these rhythms.

Adolescent↗

PubMed1996

Plasma thyroid hormone profiles immediately following out-of-hospital cardiac arrest.

Previous studies have shown abnormal thyroid hormone profiles during cardiac arrest. We explored this association further by characterizing plasma thyroid hormone profiles in 473 patients with out-of-hospital cardiac arrest and correlating them with clinical outcomes. Paramedics collected blood at the end of attempted resuscitation regardless of success. Bloods were collected and processed in a similar manner from 18 control subjects randomly selected from the community. Total thyroxine and total triiodothyronine were lower and reverse triiodothyronine and thyrotropin were higher in cardiac arrest patients than control subjects (all p < 0.001). Except for reverse triiodothyronine, findings were similar for a subgroup of cardiac arrest patients considered to be previously healthy (n = 30). Being discharged alive was associated with total thyroxine, total triiodothyronine and reverse triiodothyronine concentrations closer to the control range and thyrotropin concentrations farther from it, namely higher. In a multivariate stepwise model, only total triiodothyronine and thyrotropin were significantly associated with outcome. Whether these profoundly abnormal profiles represent a pre-existing state or a sudden change of thyroid hormone concentrations cannot be answered with this retrospective study. These observations suggest that thyroid hormones may play a role in the etiology of cardiac arrest, its prognosis, or both.

Aged↗

PubMed2006

Pediatric in-intensive-care-unit cardiac arrest: incidence, survival, and predictive factors.

OBJECTIVE: To describe the incidence, survival, and neurologic outcome of in-intensive-care-unit (ICU) cardiac arrest and to identify factors predictive of survival to hospital discharge. METHODS: We performed a retrospective cohort study. Eligible patients were <18 yrs of age and experienced a cardiac arrest during their admission to a multidisciplinary pediatric intensive care unit in the 5.5-yr period ending June 2002. Cardiac arrest was defined as the administration of chest compressions or defibrillation for a nonperfusing cardiac rhythm. Mortality and the Paediatric Cerebral Performance Score were measured and presented according to the Utstein style. Factors predictive of survival to hospital discharge were identified by univariate analysis and independent predictors were identified by multivariate analysis. MAIN MEASUREMENTS AND RESULTS: Ninety-one children had cardiac arrest, yielding an incidence of 0.94 cardiac arrests per 100 admissions. Resuscitation was successful in 75 (82%) children, 61 (67%) survived 24 hrs, 25 (27%) children survived to ICU discharge and 23 (25%) to hospital discharge. At hospital discharge, the median Pediatric Cerebral Performance Category score was 2 (range, 1-3) and the median Pediatric Overall Performance Category score was 3 (range, 1-4). No child was assessed as normal on both scores. The independent positive predictors of hospital mortality were the presence of renal failure before cardiac arrest (odds ratio [OR], 6.1; 95% confidence interval [CI], 1.8-31), being on epinephrine infusion at time of cardiac arrest (OR, 9.5; 95% CI, 1.5-62), and the administration of one or more calcium boluses during resuscitation (OR, 5.4; 95% CI, 1.1-25). The use of extracorporeal membrane oxygenation (ECMO) within 24 hrs after cardiac arrest was associated with reduced hospital mortality (OR, 0.18; 95% CI, 0.04-0.76). CONCLUSIONS: In-ICU cardiac arrest is associated with high in-hospital mortality and subsequent morbidity in survivors. Prearrest renal dysfunction and epinephrine infusion were associated with increased in-hospital mortality. The use of post-arrest ECMO within 24 hrs was associated with reduced mortality. Rigorous prospective evaluation of the role of ECMO following cardiac arrest is needed.

Adolescent↗

PubMed1995

Survival among patients with out-of-hospital cardiac arrest found in electromechanical dissociation.

BACKGROUND: Many patients who suffer an out-of-hospital cardiac arrest are found in electromechanical dissociation at the time the Emergency Medical Service (EMS) arrives. Since they have a poor prognosis, less attention has been paid to them. AIM: To describe a consecutive population of patients with out-of-hospital cardiac arrest found in electromechanical dissociation and to try to define indicators for an increased chance of survival in this patient population. SETTING: The municipality of Göteborg. PATIENTS: All the patients who suffered an out-of-hospital cardiac arrest between 1981-1992 and were reached by our EMS system and in whom cardiopulmonary resuscitation (CPR) was attempted. RESULTS: In all, there were 3434 patients with cardiac arrest of whom 748 (22%) were found in electromechanical dissociation. They differed from patients found in ventricular fibrillation as there were more women, a higher frequency of cardiac arrest during the night, a lower frequency of witnessed cardiac arrest and consequently a lower frequency of bystander-initiated CPR. In all, 96 patients (13%) were hospitalized alive and only 16(2%) could be discharged from hospital. In a multivariate analysis relating to age, sex, time of cardiac arrest, interval between collapse and the arrival of the first ambulance, bystander-initiated CPR and treatment with adrenaline, atropine and tribonate, no independent predictor of survival was found. CONCLUSION: Of all the patients with out-of hospital cardiac arrest in whom CPR was attempted by our EMS, 22% were found in electromechanical dissociation. Of these, 13% were hospitalized alive and 2% could be discharged from the hospital. No independent predictor of an increased chance of survival was found.

Adolescent↗

PubMed2004

Mode of death after admission to an intensive care unit following cardiac arrest.

OBJECTIVE: To determine the mode of death in patients admitted to an intensive care unit (ICU) after cardiac arrest who died before hospital discharge. DESIGN: Prospectively defined retrospective review of a database and individual patient medical records and ICU charts. SETTING: Eleven-bed multidisciplinary intensive care unit in a general hospital in the United Kingdom. PATIENTS AND PARTICIPANTS: All patients admitted to ICU between February 1998 and July 2003 after a cardiac arrest in the previous 24 h. MEASUREMENTS AND RESULTS: The outcome at hospital discharge and mode of death in non-survivors were recorded. Based on the mode of death, non-survivors were placed in one of three groups: multiple organ failure death, neurological death or cardiovascular death. Two hundred and five patients were admitted to ICU after a cardiac arrest; 113 (55.1%) after out-of-hospital cardiac arrest and 92 (44.9%) after in-hospital cardiac arrest. One hundred and twenty-six (61.5%) patients died before hospital discharge and of these 58 (46.0%) died due to neurological injury. After cardiac arrest, 22.9% of the in-hospital patients and 67.7% of the out-of-hospital patients died due to neurological injury, irrespective of the primary cardiac arrest arrhythmia. CONCLUSIONS: Two-thirds of the patients dying after out-of-hospital cardiac arrest died due to neurological injury and this proportion was approximately the same for ventricular fibrillation/ventricular tachycardia and pulseless electrical activity/asystole. Approximately a quarter of the patients dying after in-hospital cardiac arrest died due to neurological injury.

Brain Injuries↗

PubMed1988

Brain enzyme levels in CSF after cardiac arrest and resuscitation in dogs: markers of damage and predictors of outcome.

Levels of brain creatine kinase (CK), aspartate aminotransferase (ASAT), and lactate dehydrogenase (LD) in CSF after cardiac arrest were studied in dog models. Ventricular fibrillation cardiac arrest lasting 10 min or asphyxiation cardiac arrest lasting 0-10 min was followed by cardiopulmonary resuscitation and 96-h intensive care. Outcome was scored as neurologic deficit (0% = normal, 100% = brain death) and overall performance category (1 = normal, 5 = death). Both measures correlated with EEG return time after asphyxiation cardiac arrest, but not after ventricular fibrillation cardiac arrest. Peak activity of enzymes in CSF at 48-72 h post arrest correlated with outcome, and CK was the best predictor. Brain histopathologic damage score at autopsy 96 h post arrest correlated with CK level in CSF (r = 0.79, n = 39) and neurologic deficit (r = 0.70, n = 50). Ischemic neuronal changes occurred after ventricular fibrillation cardiac arrest of 10 min, and neuronal changes plus microinfarcts occurred after asphyxiation cardiac arrest of 1.5-10 min. Brain enzymes were decreased at 6 h post arrest in regions with worst histologic damage (gray matter of neocortex, hippocampus, caudate nucleus, cerebellum). Brain CK decreased further, ASAT remained low, and LD increased at 72 h after arrest. The temporal changes in CK level paralleled the temporal ischemic neuronal changes in the brain, and time to peak activity was unaffected by the severity of the ischemic insult. Peak activity of individual enzymes in CSF was determined predominantly by the brain concentration, but was also influenced by rate of decomposition. This "chemical brain biopsy method" represents a useful adjunctive tool to predict permanent, severe brain damage during comatose states after cardiac arrest and resuscitation.

Animals↗