Year : 2017 | Volume
| Issue : 4 | Page : 415-420
An audit of in-hospital cardiopulmonary resuscitation in a teaching hospital in Saudi Arabia: A retrospective study
Abdullah Mohammed Kaki1, Kamal Waheeb Alghalayini2, Mohamed Nabil Alama2, Adnan Abdullah Almazroaa3, Norah Abdullah A Khathlan4, Hassan Sembawa5, Beena M Ouseph6
1 Department of Anesthesia and Critical Care, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
2 Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
3 Department of Anesthesia and Critical Care, Faculty of Medicine, Taibah University, Madinah Al Munawarah, Saudi Arabia
4 Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
5 Department of Emergency Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
6 Department of Nursing, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
Abdullah Mohammed Kaki
Department of Anesthesia and Critical Care, Faculty of Medicine, King Abdulaziz University, P. O. Box 2907, Jeddah 21461
Source of Support: None, Conflict of Interest: None
|Date of Web Publication||22-Sep-2017|
Objectives: Data reflecting cardiopulmonary resuscitation (CPR) efforts in Saudi Arabia are limited. In this study, we analyzed the characteristics, and estimated the outcome, of in-hospital CPR in a teaching hospital in Saudi Arabia over 4 years.
Methods: A retrospective, observational study was conducted between January 2009 and December 2012 and included 4361 patients with sudden cardiopulmonary arrest. Resuscitation forms were reviewed. Demographic data, resuscitation characteristics, and survival outcomes were recorded.
Results: The mean ± standard deviation age of arrested patient was 40 ± 31 years. The immediate survival rate was 64%, 43% at 24 h, and 30% at discharge. The death rate was 70%. Respiratory type of arrest, time and place of arrest, short duration of arrest, witnessed arrest, the use of epinephrine and atropine boluses, and shockable arrhythmias were associated with higher 24-h survival rates. A low survival rate was found among patients with cardiac types of arrest, and those with a longer duration of arrest, pulseless electrical activity, and asystole. Comorbidities were present in 3786 patients with cardiac arrest and contributed to a poor survival rate (P < 0.001).
Conclusions: The study confirms the findings of previously published studies in highly developed countries and provides some reflection on the practice of resuscitation in Saudi Arabia.
Keywords: Cardiopulmonary resuscitation; in-hospital arrest; outcome; survival rate
|How to cite this article:|
Kaki AM, Alghalayini KW, Alama MN, Almazroaa AA, Khathlan NA, Sembawa H, Ouseph BM. An audit of in-hospital cardiopulmonary resuscitation in a teaching hospital in Saudi Arabia: A retrospective study. Saudi J Anaesth 2017;11:415-20
|How to cite this URL:|
Kaki AM, Alghalayini KW, Alama MN, Almazroaa AA, Khathlan NA, Sembawa H, Ouseph BM. An audit of in-hospital cardiopulmonary resuscitation in a teaching hospital in Saudi Arabia: A retrospective study. Saudi J Anaesth [serial online] 2017 [cited 2020 May 25];11:415-20. Available from: http://www.saudija.org/text.asp?2017/11/4/415/215414
| Introduction|| |
For any arrested patient, cardiopulmonary resuscitation (CPR) is indicated to restore his/her cardiac and pulmonary function in the shortest possible time and to achieve a high survival rate with a good outcome. Many studies have been conducted to determine the actual success rate and the average survival rate following in-hospital CPR.,,,,,,, Most of these studies were conducted in developed countries with advanced drugs and equipment and great health facilities. Data regarding the outcome of the in-hospital CPR survival rate and outcome in developing countries are limited. In our study, the objective was to determine the survival rate among in-hospital cardiopulmonary arrested patients and to predict any determinant factors for survival in a tertiary care teaching hospital in Saudi Arabia.
| Methods|| |
Approval of the study was provided by the Research Ethics Committee of our medical center (reference no. 648-11). A retrospective epidemiological study was conducted to review all CPR sheets over the 4-year period from January 2009 to December 2012. The need for informed consent was waived by the Research Ethics Committee. The CPR sheet followed the Utstein format in documenting resuscitation activity. Patients' characteristics and information related to resuscitation in various hospital departments were reported. Our medical center is an 800-bed tertiary care teaching hospital, with 26 adult intensive care beds, twenty neonatal intensive care beds, and ten pediatric intensive care beds. It is located in a major city with a population of 5 million. All types of patients are treated in this hospital.
Cardiopulmonary arrest was defined as no palpable pulse, unmeasurable blood pressure, or absence of breathing. Patients with more than one cardiopulmonary arrest during their hospitalization were included as one arrest. Once the patient had had a cardiopulmonary arrest, a hospital-wide code alarm was activated and the resuscitation team was called to initiate resuscitation. The team was led by an intensive care senior resident, with support from an anesthesia senior resident, medical or surgical junior resident, and an intensive care nurse. All the members of resuscitation team were trained in both basic and advanced cardiac life support on a regular basis, except for the junior residents for whom the training was limited to basic life support (BLS). The nursing role was limited to assisting with drugs and equipment preparation and documentation of the resuscitation effort. The American Heart Association Guidelines were followed during resuscitation.
The reported data were reviewed by two of the authors, stored in a computer database, and transferred to the IBM SPSS Statistics Version 20 (Armonk, New York, USA). The following data were included in the study: patients' characteristics such as age, sex, and previous medical history; location and time of arrest, the time from the arrest to the arrival of the resuscitation team, and start of resuscitation; type of arrest and whether witnessed or not; duration of resuscitation, resuscitation effort, initial arrest rhythm, and need for defibrillation; the need and type of airway management devices; administered medications, particularly adrenaline and atropine; and the outcome of the resuscitation and patient survival rate for the first 24 h, and upon discharge from the hospital. All survivors of cardiopulmonary arrest were transferred to critical care areas after the return of spontaneous circulation (ROSC) for continuous care.
The mean with standard deviation (SD) or the range was calculated to show the central tendency of continuous variables, while frequency distribution and corresponding percentage were reported for nominal and categorical variables. Chi-square test and two-tailed P value were calculated to establish the relationship between categorical variables. P < 0.05 was considered statistically significant. The statistical analysis was performed using IBM SPSS Statistics version 20 (Armonk, New York).
| Results|| |
A total of 4981 patient charts were reviewed for patients who had cardiopulmonary arrest during the study period. Of these, 620 charts were excluded from the study. In 234, resuscitation was not needed and another 386 patients were labeled as “Do not attempt resuscitation” cases. Finally, 4361 CPR forms were included in the study. Patients' demographic and resuscitation characteristics are shown in [Table 1]. The mean ± SD age of arrested patients was 40 ± 31 years.
|Table 1: Patients demographic data and cardiopulmonary resuscitation characteristics|
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[Table 2] shows the 24-h survival rate in relation to type of arrest, time and place of arrest, duration of arrest, witnessed arrests, and the airway tools used. The administered medications and their relationship to 24-h survival rate are shown in [Table 3], both during the resuscitation period and as infusions during the postresuscitation period after ROSC. The correlation between the type of arrhythmia and survival rate is presented in [Table 4].
|Table 3: Survival rate in relation to administered medication throughout the cardiopulmonary resuscitation|
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Comorbidities were reported in 3786 cardiac arrest victims. End-organ failure (lungs, liver, kidneys, and hematological) was diagnosed in 30% of patients, cardiovascular diseases (ischemic heart diseases and hypertension) in 24%, and infectious diseases in 19%, while prematurity and congenital anomalies were recorded in 15% (P< 0.001). Adequate air entry was reported in 3573 of 4204 and had a strong correlation with survival (P< 0.001). Return of spontaneous breathing was recorded in 1094 sheets (26%) from 4192 total cases and had a positive relationship with survival rate (P< 0.001).
| Discussion|| |
In this 4-year retrospective study, CPR analysis of 4631 hospitalized patients revealed a higher occurrence of arrest among males (55%) than females (44%), with greater distributions in the two age extremes: those aged younger than 10 years and those aged older than 61 years. Cardiac diseases were the most frequent comorbidity of patients with arrest followed by respiratory ones. Fortunately, the majority of the arrests were witnessed arrests (90%). The 24-h survival rate was 43%, and survival upon discharge from the hospital was 30%. Survival rates were higher in our study when compared to previous ones.,,,,,,,,,,,,,,,,,,, Differences in the study designs, sample sizes, and assessment techniques may contribute significantly to the variability in the survival rates. In addition, the inclusion of respiratory arrest in addition to the cardiac ones might contribute to the increase in survival rates. Respiratory arrest was associated with a better survival rate when compared to cardiac arrest or when both types of arrest occurred. This was reported by Tunstall-Pedoe et al. in the BRESUS study, Brindley et al. in their Canadian study, and Cooper et al. in their study in the UK where they reported that patients whose primary mode of arrest was respiratory were more likely to survive in comparison to those with a primary cardiac arrest.
The witnessing of arrest is another factor that might lead to higher survival rate, and this was documented in previously published studies.,,, A third factor that might result in higher survival rates is the level of training of the resuscitation team members and their adherence to resuscitation guidelines. Many previously published studies reported better survival rates after formal resuscitation training,,,,, while Curry and Gass  found that the death rate was not lower when resuscitation was performed by BLS-trained staff in comparison to untrained staff.
When we correlated the survival rate to both the time and place of arrest, we found that most of the arrests occurred in the period between 07:00 and 24:00 h and the lowest survival rate was found in the early morning time (00:01–07:00 h). Previous studies verified that there is a greater risk of cardiac arrest up to 3 h after patients wake up than during other hours of the day. This might be the result of an increase in blood pressure and cardiac frequency, which raises the muscle tone, blood viscosity, and promotes platelet aggregation., Similar to previously published studies, a higher risk of death was reported if the arrest occurred at night., Further studies are needed to better understand the lower survival rate among arrests occurring at night, to exclude contributions related to a slower response time of the resuscitation team or poor performance in resuscitation secondary to lack of sleep and less concentration.
Regarding the location of arrest and survival rate, the critical care area is associated with poor resuscitation outcomes when compared to various other hospital wards. The critical condition of such patients might be the main contributor to the higher mortality rate. However, in a sample of 200 patients, Khalafi et al. reported that there was no difference in the outcomes of arrest between patients on the regular floor and Intensive Care Unit patients and further studies are needed to reach a conclusion on this subject.
Consistent with findings from other studies,,,,,,,, witnessed arrests and shorter time of CPR were associated with higher survival rates when compared to unwitnessed arrests or a longer duration of resuscitation. The administration of adrenaline boluses during the resuscitation was associated with a higher survival rate than continuous infusion. In a randomized study, Jacobs et al. compared the provision of adrenaline to placebo on the ROSC in out-of-hospital cardiac arrests. They found that adrenaline markedly increased rates of ROSC. In a retrospective study conducted in Japan, the authors suggested that there was an increase in the ROSC, but worse long-term outcomes. Future investigations should consider the timing of adrenaline administration in the design and interpretation of the results. Although atropine is no longer recommended for the treatment of pulseless electrical activity (PEA) and asystole (AS), and the use of adrenaline is more favorable than atropine for the treatment of bradycardia,, atropine was the treatment of choice for PEA and AS at the time of resuscitation. Similar to adrenaline, atropine use was associated with a higher survival rate.
The use of intravenous infusion of inotropic or vasopressor agents following the ROSC, as well as the use of various airway tools during the resuscitation, had no positive effect on the survival rate.
Consistent with the findings of other studies, the survival rate was low when nonshockable rhythm (PEA and AS) was the cause of cardiac arrest, and high among victims of defibrillation amenable rhythm (pulseless ventricular tachycardia/ventricular fibrillation).,,,,,,,
Although the findings of this study provide a better understanding of resuscitation, it has some limitations. One limitation is the retrospective nature of the study where the data were collected after the occurrence of the events, and access to the documented data in the CPR forms was limited, which might contribute to the absence of accurate information about important variables. Second, data regarding the neurological outcome of the surviving patients was unavailable, and third, the results represent the experience of only one hospital and the results might not be generalizable to all other health institutions.
| Conclusions|| |
This study provides reflections on the practice of CPR in Saudi Arabia and confirms the findings of previously published studies.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Cooper S, Evans C. Resuscitation Predictor Scoring Scale for inhospital cardiac arrests. Emerg Med J 2003;20:6-9.
Schneider AP 2nd
, Nelson DJ, Brown DD. In-hospital cardiopulmonary resuscitation: A 30-year review. J Am Board Fam Pract 1993;6:91-101.
McGrath RB. In-house cardiopulmonary resuscitation – After a quarter of a century. Ann Emerg Med 1987;16:1365-8.
Cohn EB, Lefevre F, Yarnold PR, Arron MJ, Martin GJ. Predicting survival from in-hospital CPR: Meta-analysis and validation of a prediction model. J Gen Intern Med 1993;8:347-53.
Jastremski MS. In-hospital cardiac arrest. Ann Emerg Med 1993;22:113-7.
Fifield DH. Outcomes of resuscitative efforts at Wild Rose Hospital. Wis Med J 1994;93:55-7.
Robinson GR 2nd
, Hess D. Postdischarge survival and functional status following in-hospital cardiopulmonary resuscitation. Chest 1994;105:991-6.
Rosenberg M, Wang C, Hoffman-Wilde S, Hickam D, Hickham D corrected to Hickam D. Results of cardiopulmonary resuscitation. Failure to predict survival in two community hospitals. Arch Intern Med 1993;153:1370-5.
Jacobs I, Nadkarni V, Bahr J, Berg RA, Billi JE, Bossaert L, et al.
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;110:3385-97.
Camp BN, Parish DC, Andrews RH. Effect of advanced cardiac life support training on resuscitation efforts and survival in a rural hospital. Ann Emerg Med 1997;29:529-33.
McDonald KM, Hlatky MA, Saynina O, Geppert J, Garber AM, McClellan MB. Trends in hospital treatment of ventricular arrhythmias among Medicare beneficiaries, 1985 to 1995. Am Heart J 2002;144:413-21.
Parish DC, Dane FC, Montgomery M, Wynn LJ, Durham MD. Resuscitation in the hospital: Differential relationships between age and survival across rhythms. Crit Care Med 1999;27:2137-41.
FitzGerald JD, Wenger NS, Califf RM, Phillips RS, Desbiens NA, Liu H, et al.
Functional status among survivors of in-hospital cardiopulmonary resuscitation. SUPPORT Investigators Study to Understand Progress and Preferences for Outcomes and Risks of Treatment. Arch Intern Med 1997;157:72-6.
Miranda DR. Quality of life after cardiopulmonary resuscitation. Chest 1994;106:524-30.
Tresch D, Heudebert G, Kutty K, Ohlert J, VanBeek K, Masi A. Cardiopulmonary resuscitation in elderly patients hospitalized in the 1990s: A favorable outcome. J Am Geriatr Soc 1994;42:137-41.
Peberdy MA, Kaye W, Ornato JP, Larkin GL, Nadkarni V, Mancini ME, et al.
Cardiopulmonary resuscitation of adults in the hospital: A report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation 2003;58:297-308.
Brindley PG, Markland DM, Mayers I, Kutsogiannis DJ. Predictors of survival following in-hospital adult cardiopulmonary resuscitation. CMAJ 2002;167:343-8.
Cooper S, Cade J. Predicting survival, in-hospital cardiac arrests: Resuscitation survival variables and training effectiveness. Resuscitation 1997;35:17-22.
Roberts D, Landolfo K, Light RB, Dobson K. Early predictors of mortality for hospitalized patients suffering cardiopulmonary arrest. Chest 1990;97:413-9.
George AL Jr., Folk BP 3rd
, Crecelius PL, Campbell WB. Pre-arrest morbidity and other correlates of survival after in-hospital cardiopulmonary arrest. Am J Med 1989;87:28-34.
Albert CM, McGovern BA, Newell JB, Ruskin JN. Sex difference in cardiac arrest survivors. Circulation 1996;93:1170-6.
Tunstall-Pedoe H, Bailey L, Chamberlain DA, Marsden AK, Ward ME, Zideman DA. Survey of 3765 cardiopulmonary resuscitations in British hospitals (the BRESUS Study): Methods and overall results. BMJ 1992;304:1347-51.
Cooper S, Janghorbani M, Cooper G. A decade of in-hospital resuscitation: Outcomes and prediction of survival? Resuscitation 2006;68:231-7.
Krittayaphong R, Saengsung P, Chawaruechai T, Yindeengam A, Udompunturak S. Factors predicting outcome of cardiopulmonary resuscitation in a developing country: The Siriraj cardiopulmonary resuscitation registry. J Med Assoc Thai 2009;92:618-23.
Kantamineni P, Emani V, Saini A, Rai H, Duggal A. Cardiopulmonary resuscitation in the hospitalized patient: Impact of system-based variables on outcomes in cardiac arrest. Am J Med Sci 2014;348:377-81.
Chon GR, Lee J, Shin Y, Huh JW, Lim CM, Koh Y, et al.
Clinical outcomes of witnessed and monitored cases of in-hospital cardiac arrest in the general ward of a university hospital in Korea. Respir Care 2013;58:1937-44.
Moretti MA, Cesar LA, Nusbacher A, Kern KB, Timerman S, Ramires JA. Advanced cardiac life support training improves long-term survival from in-hospital cardiac arrest. Resuscitation 2007;72:458-65.
Sanders AB, Berg RA, Burress M, Genova RT, Kern KB, Ewy GA. The efficacy of an ACLS training program for resuscitation from cardiac arrest in a rural community. Ann Emerg Med 1994;23:56-9.
Borimnejad L, Nasrabadi AN, Mohammadi H, Kheirati L. Improving the outcomes of CPR: A report of a reform in the organization of emergency response. Internet J Emerg Med 2008;4:2.
Sodhi K, Singla MK, Shrivastava A. Impact of advanced cardiac life support training program on the outcome of cardiopulmonary resuscitation in a tertiary care hospital. Indian J Crit Care Med 2011;15:209-12.
] [Full text]
Morais DA, Carvalho DV, Correa Ados R. Out-of-hospital cardiac arrest: Determinant factors for immediate survival after cardiopulmonary resuscitation. Rev Lat Am Enfermagem 2014;22:562-8.
Curry L, Gass D. Effects of training in cardiopulmonary resuscitation on competence and patient outcome. CMAJ 1987;137:491-6.
Brooks SC, Schmicker RH, Rea TD, Aufderheide TP, Davis DP, Morrison LJ, et al.
Out-of-hospital cardiac arrest frequency and survival: Evidence for temporal variability. Resuscitation 2010;81:175-81.
Nakanishi N, Nishizawa S, Kitamura Y, Nakamura T, Matsumuro A, Sawada T, et al.
Circadian, weekly, and seasonal mortality variations in out-of-hospital cardiac arrest in Japan: Analysis from AMI-Kyoto Multicenter Risk Study database. Am J Emerg Med 2011;29:1037-43.
Herlitz J, Bång A, Alsén B, Aune S. Characteristics and outcome among patients suffering from in hospital cardiac arrest in relation to the interval between collapse and start of CPR. Resuscitation 2002;53:21-7.
Khalafi K, Ravakhah K, West BC. Avoiding the futility of resuscitation. Resuscitation 2001;50:161-6.
Berg RA, Nadkarni VM, Clark AE, Moler F, Meert K, Harrison RE, et al.
Incidence and outcomes of cardiopulmonary resuscitation in PICUs. Crit Care Med 2016;44:798-808.
Matos RI, Watson RS, Nadkarni VM, Huang HH, Berg RA, Meaney PA, et al.
Duration of cardiopulmonary resuscitation and illness category impact survival and neurologic outcomes for in-hospital pediatric cardiac arrests. Circulation 2013;127:442-51.
Chen CT, Chiu PC, Tang CY, Lin YY, Lee YT, How CK, et al
. Prognostic factors for survival outcome after in-hospital cardiac arrest: An observational study of the oriental population in Taiwan. J Chin Med Assoc 2015;S1:1726-4901.
Xue JK, Leng QY, Gao YZ, Chen SQ, Li ZP, Li HP, et al.
Factors influencing outcomes after cardiopulmonary resuscitation in emergency department. World J Emerg Med 2013;4:183-9.
Jacobs IG, Finn JC, Jelinek GA, Oxer HF, Thompson PL. Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial. Resuscitation 2011;82:1138-43.
Hagihara A, Hasegawa M, Abe T, Nagata T, Wakata Y, Miyazaki S. Prehospital epinephrine use and survival among patients with out-of-hospital cardiac arrest. JAMA 2012;307:1161-8.
Morrison LJ, Deakin CD, Morley PT, Callaway CW, Kerber RE, Kronick SL, et al.
Part 8: Advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2010;122 16 Suppl 2:S345-421.
Tibballs J, Aickin R, Nuthall G; Australian and New Zealand Resuscitation Councils. Basic and advanced paediatric cardiopulmonary resuscitation-Guidelines of the Australian and New Zealand Resuscitation Councils 2010. J Paediatr Child Health 2012;48:551-5.
Murphy DJ, Murray AM, Robinson BE, Campion EW. Outcomes of cardiopulmonary resuscitation in the elderly. Ann Intern Med 1989;111:199-205.
[Table 1], [Table 2], [Table 3], [Table 4]