Increasing survival after admission to UK critical care units following cardiopulmonary resuscitation

Nolan, J.P. et al. (2016) Critical Care.20(219)

Background: In recent years there have been many developments in post-resuscitation care. We have investigated trends in patient characteristics and outcome following admission to UK critical care units following cardiopulmonary resuscitation (CPR) for the period 2004–2014. Our hypothesis is that there has been a reduction in risk-adjusted mortality during this period.

Methods: We undertook a prospectively defined, retrospective analysis of the Intensive Care National Audit & Research Centre (ICNARC) Case Mix Programme Database (CMPD) for the period 1 January 2004 to 31 December 2014. Admissions, mechanically ventilated in the first 24 hours in the critical care unit and admitted following CPR, defined as the delivery of chest compressions in the 24 hours before admission, were identified. Case mix, withdrawal, outcome and activity were described annually for all admissions identified as post-cardiac arrest admissions, and separately for out-of-hospital cardiac arrest and in-hospital cardiac arrest. To assess whether in-hospital mortality had improved over time, hierarchical multivariate logistic regression models were constructed, with in-hospital mortality as the dependent variable, year of admission as the main exposure variable and intensive care unit (ICU) as a random effect. All analyses were repeated using only the data from those ICUs contributing data throughout the study period.

Results: During the period 2004–2014 survivors of cardiac arrest accounted for an increasing proportion of mechanically ventilated admissions to ICUs in the ICNARC CMPD (9.0 % in 2004 increasing to 12.2 % in 2014). Risk-adjusted hospital mortality following admission to ICU after cardiac arrest has decreased significantly during this period (OR 0.96 per year). Over this time, the ICU length of stay and time to treatment withdrawal has increased significantly. Re-analysis including only those 116 ICUs contributing data throughout the study period confirmed all the results of the primary analysis.

Conclusions: Risk-adjusted hospital mortality following admission to ICU after cardiac arrest has decreased significantly during the period 2004–2014. Over the same period the ICU length of stay and time to treatment withdrawal has increased significantly.

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Near-infrared spectroscopy during cardiopulmonary resuscitation and after restoration of spontaneous circulation: a valid technology?

Wik, L.Current Opinion in Critical Care. June 2016. Volume 22 (3). pp. 191–198

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Image source: Z22 // CC BY-SA 4.0

Purpose of review: This article explores the status of using near-infrared spectroscopy and reporting cerebral oximetry (rSO2) for cardiac arrest patients.

Recent findings: Bystander cardiopulmonary resuscitation (CPR) patients have significantly higher rSO2 compared with no bystander CPR patients. It is unclear how quickly rSO2changes with hemodynamic instability. rSO2 during mechanical CPR varies between 44 and 55% and manual CPR varies between 20 and 40%, representing a significant relative rSO2increase. Studies have found a relationship between rSO2 and restoration of spontaneous circulation (ROSC) and rSO2 increase can be used as a sign of ROSC. rSO2 evaluation is effective for monitoring quality of resuscitation and neurological prognostication. It seems that cardiac arrest patients with good neurologic outcome have significantly higher rSO2 levels (CPC 1–2 median rSO2 68%, CPC 3–5 median rSO2 58%, P < 0.01) and good neurologic outcome (CPC 1–2) increased ‘in proportion to the patients’ rSO2 levels irrespective of their ROSC status at hospital arrival’. However, most of the studies are small and a prospective outcome study focusing on rSO2 values is needed.

Summary: Near-infrared spectroscopy and rSO2 have been used as a monitor during CPR, detection of ROSC, after ROSC, and during post-resuscitation care. Prospective, controlled, randomized clinical studies are needed to document their wide use.

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High-quality cardiopulmonary resuscitation: current and future directions

Abella, B. Current Opinion in Critical Care. June 2016. Volume 22 (3). pp. 218–224

Purpose of review: Cardiopulmonary resuscitation (CPR) represents the cornerstone of cardiac arrest resuscitation care. Prompt delivery of high-quality CPR can dramatically improve survival outcomes; however, the definitions of optimal CPR have evolved over several decades. The present review will discuss the metrics of CPR delivery, and the evidence supporting the importance of CPR quality to improve clinical outcomes.

Recent findings: The introduction of new technologies to quantify metrics of CPR delivery has yielded important insights into CPR quality. Investigations using CPR recording devices have allowed the assessment of specific CPR performance parameters and their relative importance regarding return of spontaneous circulation and survival to hospital discharge. Additional work has suggested new opportunities to measure physiologic markers during CPR and potentially tailor CPR delivery to patient requirements.

Summary: Through recent laboratory and clinical investigations, a more evidence-based definition of high-quality CPR continues to emerge. Exciting opportunities now exist to study quantitative metrics of CPR and potentially guide resuscitation care in a goal-directed fashion. Concepts of high-quality CPR have also informed new approaches to training and quality improvement efforts for cardiac arrest care.

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