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Survival after cardiopulmonary resuscitation and factors influencing it in the emergency department of a tertiary care hospital in Bangalore, India.

INTRODUCTION

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.

METHODOLOGY

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.

Study Design

Retrospective Cohort Study.

Inclusion Criteria

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.

Exclusion Criteria:

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.

RESULTS

[TABLE 1 OMITTED]

ABBREVIATIONS

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.

DISCUSSION

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.

CONCLUSION

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.

BIBLIOGRAPHY

(1.) Hollenberg J, Herlitz J, Lindqvist J, Riva G, Bohm K, Rosenqvist M, et al. Improved survival after out-of-hospital cardiac arrest is associated with an increase in proportion of emergency crew-witnessed cases and bystander cardiopulmonary resuscitation. Circulation. 2008;118(4):389-396.

(2.) Sodhi K, Shrivastava A, Singla M. Impact of advanced cardiac life support training program on the outcome of cardiopulmonary resuscitation in a tertiary care hospital. Indian Journal of Critical Care Medicine. 2011;15(4):209.

(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.

(4.) Chakravarthy M, Mitra S, Nonis L. Outcomes of in-hospital, out of intensive care and operation theatre cardiac arrests in a tertiary referral hospital. Indian Heart Journal. 2012;64(1):7-11.

(5.) Rajaram R, Rajagopalan RE, Pai M, et al. Survival after cardiopulmonary resuscitation in an urban Indian hospital. Natl Med J India 1999;12(2):51-55.

(6.) Cooper S, Janghorbani M, Cooper G. A decade of in-hospital resuscitation: Outcomes and prediction of survival? Resuscitation. 2006;68(2):231-237.

(7.) Field J, Hazinski M, Sayre M, Chameides L, Schexnayder S, Hemphill R, et al. Part 1: Executive Summary: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18_suppl_3):S640-S656.

(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 [1], Girish Narayan [2], Shakuntala Murty [3]

[1] Junior Resident, Department of Emergency Medicine, St. John's Medical College and Hospital.

[2] Associate Professor, Department of Emergency Medicine, St. John's Medical College and Hospital.

[3] 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.

Corresponding Author:

Dr. Alan de Lima Pereira, House No. 1/FXimbhat, Maina-Curtorim-403709, Goa, India.

E-mail: dr.a.d.pereira@gmail.com

DOI: 10.14260/jemds/2016/40
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
Article Type:Report
Geographic Code:9INDI
Date:Jan 11, 2016
Words:2205
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