Cardiopulmonary Resuscitation in an Average Brazilian Intensive Care Unit: Should We Perform Less or Better?

Abstract

IntroductionFew data can be found about cardiac arrest in the intensive care unit outside reference centers in third world countries.ObjectiveTo study epidemiology and prognostic factors associated with cardiac arrest in the intensive care unit (ICU) in an average Brazilian center.MethodsBetween June 2011 and July 2014, 302 cases of cardiac arrest in the intensive care unit were prospectively evaluated in 273 patients (age: 68.9 ± 15 years) admitted in three mixed units. Data regarding cardiac arrest and cardiopulmonary resuscitation were collected in an "Utstein style" form and epidemiologic data was prospectively obtained. Factors associated with do not resuscitate orders, return of spontaneous circulation and survival were studied using binary logistic regression. Statistical package software used was SPSS 19.0 (IBM Inc., USA).ResultsAmong 302 cardiac arrests, 230 (76.3%) had their initial rhythm recorded and 141 (61.3%) was in asystole, 62 (27%) in pulseless electric activity (PEA) and 27 had a shockable rhythm (11.7%). In 109 (36.1%) cases, cardiac arrest had a suspected reversible cause. Most frequent suspected cardiac arrest causes were hypotension (n=98; 32.5%), multiple (19.2%) and hypoxemia (17.5%). Sixty (19.9%) cardiac arrests had do not resuscitate orders. Prior left ventricle dysfunction was the only predictor of do not resuscitate order (OR: 3.1 [CI=1.03-9.4]; P=0.04). Among patients that received cardiopulmonary resuscitation, 59 (24.4%) achieved return of spontaneous circulation and 12 survived to discharge (5.6%). Initial shockable rhythm was the only return of spontaneous circulation predictor (OR: 24.9 (2.4-257); P=0.007) and survival (OR: 4.6 (1.4-15); P=0.01).ConclusionCardiopulmonary resuscitation rate was high considering ICU patients, so was mortality. Prior left ventricular dysfunction was a predictor of do not resuscitate order. Initial shockable rhythm was a predictor of return of spontaneous circulation and survival.

The incidence of cardiac arrest in the intensive care unit: A systematic review and meta-analysis

“…Non-shockable rhythms were more common in eight of nine studies reporting initial rhythm with the proportion of non-shockable rhythms ranging from 61.5 to 89.7%. The presumed aetiology of cardiac arrest was reported in four studies 21,24,25,27 with cardiac and respiratory causes accounting for 24.4–78.5% and 13.3–39.7% of arrests, respectively.…”

“…Studies that reported only a rate of incidence for ICU-CA and did not report an overall number of observations 5,21,23,27 were excluded from quantitative analyses. Similarly for analysis of outcomes, those with only a rate rather than numeric values were excluded.…”

“…Eleven [11][12][13][14][15][16][17][18][19][20][21] of the 20 studies were prospective and 13 5,[10][11][12]14,[16][17][18][19][22][23][24] were single centre. The settings include Europe (8), 5,[12][13][14][15]17,19,25 North America (6), 11,22,23,[26][27][28] Asia (3), 10,20,24 South America (2) 18,21 and Australia 16 and study dates range from 1987 to 2017. The number of ICU admissions ranges from 112 to 362,074.…”

“…The number of cardiac arrests reported varied from 1 to 50,514. Seventeen studies reported both the number of events and the overall number of eligible admissions, three reported rates per 1000 admissions 5,21,23 and the remaining study reported mean event rate per 1000 patient-bed days and was not included in pooled analyses. 27 The prevalence of ICU-CA varied from 0.5 to 7.8% with incidence rates of 5-78 per 1000 admissions.…”

“…Further information is available in the supplementary appendix (supplementary appendix, Table C). 22 2 2 3 Enohumah et al 25 3 2 3 Yi et al 10 2 2 3 Galhotra et al 23 2 3 Maia et al 12 2 1 Roessler et al 13 3 2 Gershengorn et al 26 3 1 3 Schmittinger et al 14 2 2 Lee et al 24 3 1 2 Efendijev et al 15 3 2 3 Rozen et al 16 3 2 3 Haerkens et al 17 3 2 Flato et al 18 2 1 Garcia Huertas et al 19 3 1 Chanthawong et al 20 2 2 3 Perman et al 27 2 2 2 Miana et al 21 2 1 3 Cook and Thomas 5 2 1 2 Quinn et al 28 2 1 13 21/48 43.8 Gershengorn et al 26 1025/6518 15.7% Schmittinger et al 14 4/4 100.0 Lee et al 24 96/131 73.3 57/131 43.5 Efendijev et al 15 1891/4246 44.5 Rozen et al 16 29 Three studies compared survival outcomes in patients who did and did not suffer ICU-CA. 5,15,20 ICU mortality was higher in ICU-CA patients with reported rates of 69.6% versus 10.5% in a study from a mixed ICU 5 and 91.2% versus 6.4% in one SICU study.…”