Survival after cardiopulmonary resuscitation and factors influencing it in the emergency department of a tertiary care hospital in Bangalore, India.
Sudden Cardiac Arrest (SCA) is a major cause of mortality and morbidity in the emergency department. Cardiopulmonary resuscitation by trained providers in a case of cardiac arrest has been proven to have survival benefit across the world. (1),(2) Many studies have been done regarding predictors of survival outcomes in SCA yet little data exists from India and other parts of the developing world and other parts of the developing world. (3),(4),(5),(6)
In this study, we aim to look at the effectiveness of cardiopulmonary resuscitation when performed according to the American Heart Association's Advanced Cardiac Life Support (ACLS) 2010 guidelines. (7) in the emergency department of a tertiary care hospital in Bangalore, India over a period of 6 months from January 2014 to June 2014. Wethen attempt to ascertain the factors that independently determine the occurrence of a favourable outcome.
Based on our findings we then formulate some recommendations to further improve the survival likelihood of patients having a cardiac arrest in an emergency department in a similar setting as ours.
The study site was a 1200 bedded tertiary care hospital in the metropolitan area of Bangalore city and has a fully equipped emergency department that has an average turnover of more than 100 patients per day. The resuscitation team consisted of 5-6 members at least two of whom (but often more) are ACLS certified. In the emergency department a register is maintained for all patients undergoing cardiopulmonary resuscitation. This record along with supplemental data from their medical records documenting further course in the hospital was analysed for the purpose of this study.
Patient characteristics such as age, sex, and previous medical history. Cerebral Performance Categories score (CPC). (8) before cardiac arrest, location of cardiac arrest, bystander witnessed arrest, bystander CPR performed, first documented pulseless rhythm, time interval from collapse/arrival to start of CPR in minutes, CPR duration, time of arrest, initial cause of cardiac arrest and total ampoules of adrenalin used were recorded.
The initial outcomes of CPR were categorized as no Return of Spontaneous Circulation (ROSC), do not attempt resuscitation (Order in the emergency room), ROSC for more than or equal to 20 minutes or sustained ROSC. Patients with sustained ROSC were then followed up and categorised as death in hospital or survival at discharge. Some patients were also discharged against medical advice while others were transferred out of the emergency department due to nonavailability of Intensive Care Unit (ICU) beds at the time.
Retrospective Cohort Study.
1. Received cardiopulmonary resuscitation within the emergency department.
2. Witnessed and unwitnessed cardiac arrests were both included. Patients were either wheeled in with no central pulse and resuscitation efforts begun in the emergency department or were patients under observation in the emergency department who had a witnessed cardiac arrest.
3. Arrest occurred between 1st January 2014 and 30th June 2014-06-25.
1. Patients below 15 years of age.
2. Out-of-hospital arrests that were deemed to be nonsalvageable or brought dead by the treating physician and in whom no cardiopulmonary resuscitation was attempted.
3. Patients in whom prior consent was taken to withhold active resuscitation and life support.
4. Patients where no documented evidence of cardiopulmonary resuscitation in the emergency department could be traced.
Data was reported on an adapted version of the Utstein templates provided by the AHA.CT and then transcribed into a Microsoft Excel worksheet. Using STATA 11 statistical software, student't' test, Chi square test and Fisher's exact test were carried out as appropriate and the results analysed.
[TABLE 1 OMITTED]
CPR, cardiopulmonary resuscitation; ED, emergency department; ROSC, return of spontaneous circulation.
During the study period, there were 41 patients diagnosed to have SCA and who received CPR in the emergency department. This excludes patients in whom no CPR was performed or those in whom inadvertently no record of CPR was maintained. Of the 41 patients, no ROSC was achieved in 18 patients (43.9%) while 23 patients (56.1%) had a sustained ROSC for more than 20 minutes.
Of the 23 patients with sustained ROSC, 11 patients (47.8%) expired in the hospital, 6 patients (26.1%) were discharged alive, 2 patients (8.7%) were discharged against medical advice post admission and 4 patients (17.4%) were transferred out of the emergency department itself due to non-availability of intensive care unit beds in our hospital.
Of the 6 patients discharged alive only one had a CPC score >3 after suffering hypoxic brain injury as a consequence of CPR. The rest had a CPC score of 1 or 2.
Clinical characteristics of patients with and without ROSC were compared (Table 4). Two factors that were found to be significantly associated with sustained ROSC were a younger age and those who needed a shorter duration of CPR for achievement of ROSC. All other factors that were compared in Table 4 such as location of arrest, first documented pulseless rhythm and suspected initial cause of arrest were not found to have a statistically significant association with ROSC.
In out-of-hospital cardiac arrests, bystander initiated CPR was not documented in a single case.
One of the limitations of this study is that all patients who received CPR were not recruited as medical documentation of a small unknown number could not be traced. This is more so in the case of patients who might have achieved ROSC and got admitted as those who expired in the emergency department were traced back from mortality audits. This may account for a decrease in the number of patients where ROSC was successfully achieved and consequently for the number of patients that might have been discharged alive.
Due to the short duration of the study, we also have a limited sample size. It would be well advised to carry this study forward prospectively and reanalyse the data with a larger sample size at a later date. Mechanisms have been put in place for more complete recruitment of subjects so that it reflects in the results accurately.
Of note was the fact that in out of hospital arrests, not a single patient received CPR from bystanders. Several studies in the past have proven the increase in favourable outcomes in patients who receive CPR from bystanders before arrival of the emergency medical services. Further efforts have to be made in our country to increase training in basic life support for civilians.
As many members of the resuscitation team were trained as per ACLS guidelines, that may have helped improve the outcomes of CPR.
While the number of ampoules of adrenaline used in the two groups was significantly different in univariate analysis, it was an insignificant finding on multivariate modelling as it was found to be dependent on the duration of CPR (as per ACLS protocol).
There is a significant association between age and ROSC with younger patients more likely to survive. This may be due to a multitude of factors including lesser co-morbidities.
Younger patients and those requiring a lesser duration of CPR for achieving a sustained ROSC were more likely to survive.
Recruitment of a larger sample size should continue so that more accurate findings are obtained.
Basic life support training so that more bystanders initiate CPR at the site of an SCA is a pressing need in India.
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(3.) Sawanyawisuth K, Sittichanbuncha Y, Prachanukool T. A 6-year experience of CPR outcomes in an emergency department in Thailand. Therapeutics and Clinical Risk Management. 2013;377.
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(8.) Stiell I, Nesbitt L, Nichol G, Maloney J, Dreyer J, Beaudoin T, et al. Comparison of the cerebral performance category score and the health utilities index for survivors of cardiac arrest. Annals of Emergency Medicine. 2009;53(2):241-248.e1.
(9.) Jacobs I. Cardiac arrest and cardiopulmonary resuscitation outcome reports: Update and simplification of the Utstein Templates for resuscitation registries: A Statement for Healthcare Professionals from a Task Force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Councils of Southern Africa). Circulation. 2004;110(21):3385-3397.
Alan de Lima Pereira , Girish Narayan , Shakuntala Murty 
 Junior Resident, Department of Emergency Medicine, St. John's Medical College and Hospital.
 Associate Professor, Department of Emergency Medicine, St. John's Medical College and Hospital.
 Professor, Department of Emergency Medicine, St. John's Medical College and Hospital.
Financial or Other, Competing Interest: None.
Submission 14-11-2015, Peer Review 16-11-2015, Acceptance 11-12-2015, Published 08-01-2016.
Dr. Alan de Lima Pereira, House No. 1/FXimbhat, Maina-Curtorim-403709, Goa, India.
Table 2: Clinical characteristics of all sudden cardiac arrest patients by sustained ROSC of more than 20 minutes and by survival at discharge Sustained ROSC [greater than or equal to] 20 minutes Characteristics 18 Failure, n (%) 23 Success, n (%) Sex Male 15 (83.33) 20 (87) Female 3 (16.67) 3(13) Age (years), 56.9 [+ or -) 29.1 44.34 [+ or -) 31.6 mean [+ or -] 2SD Medical History * Hypertension 1 (5.5) 7 (30.4) Diabetes Mellitus 4(22.2) 7 (30.4) Encephalopathy 0(0) 2 (8.7) Intrinsic Heart Disease 3 (16.67) 1 (4.3) Pulmonary Disease 2 (11.1) 3 (13.0) Liver Disease 0(0) 5(21.7) Renal Disease 1 (5.5) 1 (4.3) Malignancy 0(0) 1 (4.3) Haemophilia 1 (5.5) 0(0) Unknown/Not Collected 4(22.2) 2 (8.7) CPC score before cardiac arrest 1 and 2 16 (88.89) 17(73.91) 3 and 4 2 (11.11) 6 (26.09) Location of cardiac arrest Out-of-Hospital 9(50) 8 (34.8) In-Hospital 9(50) 15 (65.2) Witnessed Arrest 14(77.78) 20 (86.95) Bystander performed CPR 9(50) 18 (78.26) First documented pulseless rhythm Non-shockable 13 (72.22) 18 (78.26) Shockable 5 (27.78) 5 (21.74) Collapse to start CPR 1(1,80) 1(1,20) (minutes] median (minimum, maximum) Collapse to start CPR < 10 minutes 14(77.78) 21(91.3) [greater than or 4(22.22) 2 (8.7) equal to] 10 minutes 6 Discharged Alive, n (%) (Subset of Characteristics P-value Success n = 23) Sex Male 1.0000 6 (100) Female 0(0) Age (years), 0.0126 43.2 [+ or -) 37.9 mean [+ or -] 2SD Medical History * Hypertension 0.0594 2 (33.33) Diabetes Mellitus 0.7262 2 (33.33) Encephalopathy 0.4951 1 (16.67) Intrinsic Heart Disease 0.3030 1 (16.67) Pulmonary Disease 1.0000 1 (16.67) Liver Disease 0.0563 1 (16.67) Renal Disease 1.0000 1 (16.67) Malignancy 1.0000 0(0) Haemophilia 0.4390 0(0) Unknown/Not Collected 0.3773 0(0) CPC score before cardiac arrest 1 and 2 0.4290 5 (83.33) 3 and 4 1 (16.67) Location of cardiac arrest Out-of-Hospital 0.3583 3 (50) In-Hospital 3 (50) Witnessed Arrest 0.6786 6 (100) Bystander performed CPR 0.0969 4 (66.67) First documented pulseless rhythm Non-shockable 0.7245 4 (66.67) Shockable 2 (33.33) Collapse to start CPR 0.0756 1 (1,10) (minutes] median (minimum, maximum) Collapse to start CPR < 10 minutes 0.3773 5 (83.33) [greater than or 1 (16.67) equal to] 10 minutes Abbreviations: CPC, Cerebral Performance Categories; CPR, Cardiopulmonary Resuscitation; ROSC, Return of Spontaneous Circulation; SD, Standard Deviation Characteristics Sustained ROSC [greater than or equal to] 20 minutes 18 Failure, n (%) 23 Success, n (%) CPR duration (minutes) 27(12,60) 5 (2,45) median (minimum, maximum) Initial Cause of Arrest Cardio-pulmonary 12 (66.67) 13 (56.52) Non-cardiopulmonary 6(33.33) 10 (43.48) Adrenaline (ampoules) 5.5 (1,14) 2 (1, 7) median (minimum, maximum) Characteristics P-value 6 Discharged Alive, n (%) (Subset of Success n = 23) CPR duration (minutes) <0.0001 4.5 (2, 33) median (minimum, maximum) Initial Cause of Arrest Cardio-pulmonary 0.5396 5 (83.33) Non-cardiopulmonary 1 (16.67) Adrenaline (ampoules) <0.0001 1.5 (1, 3) median (minimum, maximum)
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|Title Annotation:||Original Article|
|Author:||Pereira, Alan de Lima; Narayan, Girish; Murty, Shakuntala|
|Publication:||Journal of Evolution of Medical and Dental Sciences|
|Date:||Jan 11, 2016|
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