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ORIGINAL ARTICLE
Year : 2019  |  Volume : 4  |  Issue : 2  |  Page : 39-46

Patterns and outcomes of in-hospital cardiac arrest in a tertiary-care centre in the southern region of Saudi Arabia


1 Department of Medicine, Division of Critical Care, College of Medicine, King Khalid University, Abha, Kingdom of Saudi Arabia
2 Department of Medicine, College of Medicine, King Khalid University, Abha, Kingdom of Saudi Arabia
3 Department of Medicine, College of Medicine, King Khalid University, Abha, Kingdom of Saudi Arabia (Intern), Kingdom of Saudi Arabia

Date of Web Publication13-Aug-2020

Correspondence Address:
MD, FRCP Ali Al Bshabshe
Department of Medicine, Division of Critical Care, College of Medicine, King Khalid University, Abha
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None


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  Abstract 


Objective: To study patterns and outcomes of IHCA. Setting: Tertiary care centre in the southern region of Saudi Arabia. Design: Retrospective case-series study. Methods: Patients aged ≥12 years exhibiting IHCA and subjected to the hospital protocol including CPR from January 2014 to July 2017 were enrolled. Results: The study included 700 patients with a mean age of 59 years (range, 12–103 years; 59% males). Cardiac arrest occurred in 93% of patients, while 7% presented with respiratory arrest. The majority (94%) of cardiac arrest cases were asystole, followed by ventricular fibrillation (3%), pulseless electrical activity (2%), and pulseless ventricular tachycardia (1%). Of the arrest rhythms, 4% were classified as shockable. Overall return to spontaneous circulation occurred in 36.9% of cases. A logistic regression model revealed that age, need of mechanical ventilation, and CPR duration were the most significant predictors of survival among the arrested patients. Conclusions: Asystole was the predominating arrest rhythm in patients with IHCA. CPR duration, age, and need of mechanical ventilation are the main predictors of survival.

Keywords: cardiopulmonary resuscitation, cardiac arrest, asystole, ventricular fibrillation


How to cite this article:
Al Bshabshe A, Aziz S, Aslouf A, Hadi R, Al-Alfard H, AlQahtani N, Suhluli M, Aljarad F, Almalky A. Patterns and outcomes of in-hospital cardiac arrest in a tertiary-care centre in the southern region of Saudi Arabia. King Khalid Univ J Health Scii 2019;4:39-46

How to cite this URL:
Al Bshabshe A, Aziz S, Aslouf A, Hadi R, Al-Alfard H, AlQahtani N, Suhluli M, Aljarad F, Almalky A. Patterns and outcomes of in-hospital cardiac arrest in a tertiary-care centre in the southern region of Saudi Arabia. King Khalid Univ J Health Scii [serial online] 2019 [cited 2020 Oct 23];4:39-46. Available from: https://www.kkujhs.org/text.asp?2019/4/2/39/292037




  Introduction Top


Cardiac arrest is defined as an abrupt cessation of cardiac pump function, which may be reversible, but is fatal in the absence of appropriate and prompt intervention. Treatment involves immediate cardiopulmonary resuscitation (CPR).[1] Survival rates associated with in-hospital cardiac arrest (IHCA) have fallen to approximately 20%, varying from 15%–40%.[2],[3],[4],[5],[6],[7],[8] The survival rate to discharge in admitted patients ranges from 6%–21%.[9] Prognosis for cardiac arrest remains poor,[10] with irreversible neurological injury being the main cause of death in 25% of patients presenting with IHCA.[11]

Compared to asystole, the rate of survival to hospital discharge was higher when the first documented rhythm was shockable followed by pulseless electrical activity (PEA). The rate of survival to hospital discharge was lower following PEA/asystole with subsequent ventricular tachycardia (VT)/ventricular fibrillation (VF).[12] Assessment of cognitive injury has indicated that reduced memory attention and executive neurological impairment are common in patients following IHCA.[13],[14],[15] A study by the King Faisal Specialist Hospital group (Riyadh, Saudi Arabia) in 1995 revealed that >12,000 patients had a short-term survival rate of 36.2% (range 13%–59%).[16] Few studies have addressed these issues in Saudi Arabia, especially in the southern region. Thus, the present study estimated patterns and outcomes of IHCA in a tertiary care centre in this region.


  Methods Top


After institutional review board (IRB) approval (REC# 2017-04-09), a retrospective case series study was conducted including all patients presenting with IHCA aged ≥12 years subjected to hospital protocols from January 2014 to July 2017. The exclusion criteria were as follows: paediatric cardiac arrest (patients age <12 years), cardiac arrest occurring in the emergency department, cardiac arrest in the day care surgery and patients with missing CPR forms. A total of 700 cases with complete data files and fulfilling the inclusion criteria were included in the study. Data were retrieved using the CPR form in relation to cardiac arrest, which contains all the pertinent information related to the inpatients included during the study period.

Data analysis

After data were collected, they were revised and filtered for errors before being entered into the Statistical Package for the Social Sciences (SPSS) version 21. Descriptive statistical analysis was used to compare frequencies and proportions for all categorical variables, while mean with standard deviation or median with range were used to describe To identify the predictors of survival (return of spontaneous circulation) among the arrested patients, a logistic regression model comprising all the studied predictors was constructed, with age, need of a mechanical ventilator, and duration of CPR being the most important (significant) predictors when keeping scale variables. Any associations between CPR outcome data and sample attributes were tested using chi-square or exact tests, based on the assumptions fulfilled. A multiple logistic regression model was used to identify significant predictors of survival among patients who had undergone CPR, using the adjusted odds ratio (OR) as a magnitude of effect. Graphs were constructed using Microsoft Excel software. A p-value ≤0.05 was considered statistically significant for all analyses.


  Results Top


The study included 700 patients who had undergone CPR, with a mean age of 59 years (range 12–103 years). Of the included patients, 59% were males. With regard to the pattern of cardiac arrest, the vast majority (94%) presented with asystole, while the remaining consisted of VF (3%), PEA (2%), and pulseless VT (pVT) (1%) [Table 1]. Of the included cases, 93% presented with cardiac arrest and 7% respiratory arrest. Of the arrest rhythms, 4% were classified as shockable and the majority received non-synchronized defibrillation using biphasic defibrillators [Table 2].
Table 1: Bio-demographic characteristics of patients with in-hospital cardiac arrest from January 2014 to July 2017

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Table 2: Arrest-related data of patients with in-hospital cardiac arrest from January 2014 to July 2017

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CPR was performed in the following hospital units: Intensive Care Unit (ICU) in 38.4% of the patients, Coronary Care Unit (CCU) in 10.5%, intermediate care unit in 18.1%, and in general wards for 32.9% of patients. The duration of CPR ranged from 1–60 minutes, with an average of 30 minutes. The number of personnel in the medical team performing the CPR ranged from two to 13 healthcare providers, with an average number of eight individuals involved [Table 3].
Table 3: Bio-demographic characteristics of patients with in-hospital cardiac arrest from January 2014 to July 2017

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Table 4: Results of a multiple logistic regression model for predictors of survival among patients with in-hospital cardiac arrest from January 2014 to July 2017

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Epinephrine was the most frequently used agent (99.3% of patients), while other drugs used included sodium bicarbonate, vasopressin, calcium gluconate, amiodarone, and magnesium sulphate. Atropine was given to two patients only. Death was recorded as final outcome of CPR in 63% of the cohort [Figure 1]. all other predictors constant. Stratifying using age as a predictor of survival, each 1-year increase in age of the arrested patient translated to an approximately 10% higher probability of survival (OR = 1.1; 95% confidence interval [CI]: 1.0–2.31). In contrast, any patient requiring a mechanical ventilator before the arrest had an approximately 52% decreased probability of survival (OR = 0.48; 95% CI: 0.20–0.96). Finally, if the duration of CPR for the arrested patients was prolonged, this predicted a 22% lower survival rate (OR = 0.78; 95% CI: 0.75–0.80).
Figure 1: CPR code outcome of patients with in-hospital cardiac arrest from January 2014 to July 2017

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  Discussion Top


Cardiac arrest is a condition characterised by sudden cessation of cerebral blood flow leading to the loss of consciousness and ultimately death in the absence of a prompt appropriate intervention, namely active CPR. When a triggering event such as electrophysiological derangement, or an ischemic, metabolic, or haemodynamic event acts on susceptible myocardium, this may lead to arrhythmias and cardiac arrest and to its potentially lethal sequelae.[17] The underlying aberration is a disorganised pattern of myocardial activation leading to multiple uncoordinated re-entrant pathways, or more specifically, pVT and VF.

Asystolic cardiac arrest, which occurred in the majority of patients in our cohort, implies a very poor outcome and is caused by failure of the pacemaking function of the heart due to a disruption in the normal function of the sinus node or atrio-ventricular (AV) junction, or both. Hearts with multiple cardiac pathologies and in patients with end-stage disorders, whether of cardiac or non-cardiac origin, are more likely to display bradyarrhythmic and asystolic arrests. The involvement of subendocardial Purkinje fibres in advanced heart disease has been postulated as the major mechanism underlying this presentation. An increase in extracellular potassium concentration, which occurs due to systemic influences such as anoxia, acidosis, or shock, can make normal or diseased pacemaker cells in the His-Purkinje system susceptible to depolarisation. These processes can induce a global dysfunction of automatic cell activity, leading to persistent asystole.

Electromechanical dissociation, currently defined as PEA, is classified into primary and secondary forms. In both the primary and secondary forms, electrical rhythmicity is maintained although mechanical function is disrupted. In secondary PEA a sudden disruption of cardiac venous return may occur in the event of a massive pulmonary embolism, acute onset prosthetic valve malfunction, severe hypovolemia, tension pneumothorax, or acidosis. In primary PEA, these factors are absent but ventricular contraction is inadequate even though the electrical activity is present. Primary PEA is more common than secondary PEA. It usually occurs in advanced heart disease as an end-stage event but may also occur in the event of coronary thrombosis, or in conditions of metabolic derangements, or global ischemia, which may provide the pathophysiological precondition.

Clinico-epidemiological studies have found that prodromal symptoms could be reliable warning signs of an impending serious cardiac event such as myocardial infarction (MI) and sudden cardiac death and provide a chance for the patient to consult the physician weeks to months before the critical event.[18],[19] A study of ambulatory recordings of patients suggestive of the onset of unanticipated cardiac arrest revealed an alteration in cardiac electrical activity during the hour or less preceding the event.[20] This duration, which may vary from one hour to minutes, in which acute changes in the cardiovascular status can be deciphered, is defined as the “onset of the terminal event”. During this onset phase, an increase in heart rate and an advance in ventricular ectopy may suggest an impending VF. Autonomic nervous system dysfunction is also a contributing factor in the onset of the event. Studies of short-term variations of heart rate variability, or related measures, have identified changes that correlate with the occurrence of ventricular arrhythmias.[21]

Successful resuscitation depends on a number of factors, such as the setting in which cardiac arrest occurs, the underlying mechanism of the arrest, as well as the clinical profile of the patient.[22] In a USA-based study published in 1983, only 14% of the patients who underwent in-hospital CPR survived and were discharged from hospital.[23] Of these discharged patients, 20% died within 6 months of hospital discharge. In this study, 73% of the patients had a history of congestive heart failure, while 20% had a history of prior cardiac arrest, and 41% presented with acute MI. Noncardiac clinical diagnoses were mainly renal failure, pneumonia, sepsis, diabetes, and a history of cancer.

In accordance with our findings, de Vos and his group observed a 22% survival to discharge rate and they found that age >70 years, prior history of stroke, or renal failure were adverse risk factors as was heart failure on admission. However, prior angina pectoris or hospital admission for management of ventricular arrhythmias predicted better outcomes.[24] Predictors of mortality after in-hospital CPR can be grouped as: (i) before cardiac arrest: hypotension (systolic BP <100 mmHg), pneumonia, renal failure (blood urea nitrogen [BUN] >50 mg/dL), cancer, and restricted homebound life style; (ii) during cardiac arrest: arrest duration >15 min, intubation, hypotension (systolic BP <100 mmHg), pneumonia, and restricted homebound life style; and (iii) after resuscitation: coma, need for vasopressor therapy, and arrest duration of >15 min.

Among elderly persons, the outcomes after community-based responses to out of hospital cardiac arrests (OHCAs) are poorer than for younger victims.[25] In one study comparing individuals <80 years (mean age = 64 years) with those aged 80–90 years, the survival to hospital discharge rate among the younger group was 19.4%, compared to 9.4% for octogenarians and 4.4% for nonagenarians.[25] However, when the groups were analysed according to markers favouring survival (e.g., VF and pVT), the incremental benefit was better for elderly than younger patients (36%, 24%, and 17%, respectively). These findings suggest that age is only a weak predictor of an adverse outcome and should not be used in isolation as a reason not to resuscitate. Unfortunately, the frequency of ventricular tachyarrhythmias compared to nonshockable rhythms is lower among elderly patients.[25],[26] Long-term neurological status and length of hospitalisation were similar among older and younger surviving patients.

In OHCA patients who survive to reach the hospital, the first 24–48 hours are marked with a tendency towards ventricular arrhythmias, which usually respond well to pharmacological management. Though only 10%–20% of patients have a chance of recurrence of the cardiac arrest, mortality in case of recurrence is as high as 50%.

Recurrent cardiac arrhythmias comprise of just 5%–10% of in-hospital deaths after out-of-hospital resuscitation.[18],[27] Patients with recurrent cardiac arrest have been found to have a high incidence of new or preexisting abnormality of the AV or intraventricular conducting systems.[28]

The clinical presentation of survivors of OHCA is linked to the type and extent of the underlying disease. Coronary heart disease accounts for approximately 80% of OHCA.[29] Cardiomyopathies account for 10%–15% of cardiac arrests, while other structural, functional, toxic, and environmental causes account for the remainder.[30],[31]

For patients who continue to have persistent or recurrent VT or VF despite direct-current cardioversion after epinephrine treatment, intravenous administration of antiarrhythmic agents has been recommended to achieve electrical stability of the heart during continued resuscitative efforts. Based on a single controlled trial with a survival to hospital admission endpoint, intravenous amiodarone emerged as the initial treatment of choice.[32] Bolus therapy (300 mg and 150 mg) followed by a maintenance dose during the subsequent 18 hours and for several days, if necessary, was recommended depending on the response. A bolus of lidocaine (60–100 mg) may be given intravenously and the dose repeated after 2 minutes for patients in whom amiodarone does not have the desired effect and possibly for those who have an acute transmural MI as the underlying cause of the cardiac arrest. IV procainamide is rarely used in this setting now, but it may be tried for persisting, haemodynamically stable arrhythmias.

When bradyarrhythmic/asystolic arrest or PEA is encountered, efforts should focus first on stabilizing the cardiorespiratory status and to establish and reconfirm the rhythm (at least in two leads if possible). Subsequently, interventions to establish stable spontaneous rhythm or an attempt to pace the heart should be undertaken. An assessment of the possible underlying causes, particularly for bradyarrhythmia and asystole, should be undertaken and excluded or treated promptly. Reversible causes underlying such an event may include hypovolemia, hypoxia, tension pneumothorax, cardiac tamponade, pre-existing acidosis, hypothermia hyperkalaemia, and drug overdose. Epinephrine 1 mg (10 mL of a 1:10,000 solution) is commonly used in an attempt to elicit spontaneous electrical activity or to increase the heart rate. The added value of high-dose epinephrine is unclear,[33] as in the case of resistant VF. Atropine is no longer considered of value for PEA or asystole.[32]


  Conclusions Top


Asystole is the predominating arrest rhythm in patients with in-hospital cardiac arrest. CPR duration, age, and need of mechanical ventilation are the main predictors of survival.

Conflicts of Interest: None



 
  References Top

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