Recent substantial advances in medical science, numerous studies and constantly improved standards of management have not resulted in significantly better survival amongst resuscitated patients. Cardiac arrest is still associated with high mortality rates.

According to the studies performed, in many cases, in-hospital cardiac arrest is preceded by undiagnosed life-threatening conditions, such as a slow decrease in arterial blood pressure or patient`s agitation resulting from brain hypoxia, which is misinterpreted as mental disorders and treated with sedatives. The early diagnosis and treatment of life-threatening conditions may effectively prevent cardiac arrest [1]. Many scales of early detection of conditions related to circulatory or respiratory failure and CNS dysfunction were designed. Hospital emergency teams are organized, which consist of physicians and nurses of intensive therapy units and general wards.

The aim of the study was to analyse hospital reports of cardiopulmonary resuscitation.

METHODS

Reports on cardiopulmonary resuscitation prepared between 01.01. – 31.10.2009 were analysed. The report form was based on “the Utstein template” (Fig. 1).

Cardiopulmonary resuscitation (CPR) was carried out in the multi-profile hospital with 436 beds, including 10 ITU and 15 intensive care beds at the Department of Neurology, General Surgery and Vascular Surgery. The hospital resuscitation team consists of an anaesthesiologist and an anaesthesiological nurse.

The emergency procedure in the ward where the cardiac arrest event occurred was started by phone (used only for this purpose). The team called took the portable resuscitation set with the equipment for airway maintenance and artificial lung ventilation as well as indispensible drugs and medical agents. Defibrillators and basic monitoring devices belonged to the individual wards.

In each case, the intervention involved basic and advanced life support procedures carried out according to the algorithms based on the current guidelines [1].

The analysis involved: age and gender of patients, baseline heart rhythm, primary cause of cardiac arrest, location and time between notification and arrival of the CPR team,  immediate resuscitation outcome, witnessed cardiac arrest or otherwise. The reports on cardiopulmonary resuscitation in ITU patients were excluded. The results were assessed using descriptive statistics.    

RESULTS

In the period analysed, 10 356 patients were hospitalized; 277 died. Cardiopulmonary resuscitation administered by the CPR team documented by the report was carried out in 38 cases. Male patients constituted 60% of resuscitated cases. Their mean age was 66 years, in female patients – 71 years.

Surgical wards were the most common places of cardiac arrest (Table 1). The time from cardiac arrest notification to arrival of the CPR team ranged from 0 to 5.5 min, 2.7 min, on average. Pre-cardiac arrest monitoring of basic vital parameters in 66% of patients had beneficial effects on the onset of undertaking resuscitation by the personnel of a given ward. Longer times to initiate rescue actions were found in un-witnessed cardiac arrest cases (8/21%) compared to witnessed cases (30/79%).

Amongst the recorded cardiac rhythms of resuscitated patients, 63% were defibrillation-susceptible rhythms: ventricular fibrillation and ventricular tachycardia; in 37% of cases, non-defibrillation-susceptible rhythms were observed: asystole and pulseless cardiac activity (Fig. 2).

In 37% of patients, the primary cause of cardiac arrest was undetected based on the available results of additional tests, clinical symptoms and history. In the remaining cases, causes of cardiac arrest were varied (Table 2).

The return of spontaneous circulation (ROSC) was observed in 45% of all the resuscitation procedures undertaken. Cardiopulmonary resuscitation was more effective when ventricular fibrillation or tachycardia were found during cardiac arrest compared to non-defibrillation-susceptible rhythms (Fig. 3).

In the period analysed, there were also cases in which resuscitation was not initiated before the arrival of the CPR team.

DISCUSSION

The study results confirmed that cardiac arrest was more common amongst male patients whose mean age was lower than that of female patients. The return of spontaneous circulation was more common in females. Similar to other studies, our findings demonstrated that the kind of rhythm causing cardiac arrest markedly influenced immediate survival [2, 3, 4, 5]. Moreover, it was shown that in ventricular fibrillation cases, early defibrillation led to the return of spontaneous circulation. The observations confirm the key role of defibrillation for proper cardiopulmonary resuscitation [6]. Asystole or pulseless electrical activity developed more frequently in patients with inefficient respiration, neurological diseases, multi-organ trauma and in hypovolemic shock. In such cases, cardiopulmonary resuscitation was less effective compared to cases of defibrillation-susceptible rhythms [7, 8].

A substantial percentage of cardiac arrests occurred in patients with basic vital functions monitored, which suggests that their condition during hospitalization deteriorated gradually and imposed such management. Thanks to that, resuscitation was undertaken immediately after the diagnosis of cardiac arrest made by the personnel of a given ward; however, the percentage of immediate survival did not increase. In many cases, the causes of death, besides the underlying diseases, include various co-morbidities masking the symptoms threatening with cardiac arrest   [2, 9, 10].

In the entire diagnostic-therapeutic process, early diagnosis and therapy of vital dysfunctions are essential. Therefore, it seems appropriate to organize an interventional team which will be called whenever the general state of a patients deteriorates, which may reduce the number of in-hospital cardiac arrests.

Numerous studies have demonstrated that the medical personnel lack knowledge and skills of management in life-threatening conditions [11, 12]. Regular trainings of physicians of all specialities and nurses are necessary.

Attempts to improve the outcomes of cardiopulmonary resuscitation are also hindered by the lack of uniform definitions and consistency in keeping the documentation regarding the course of cardiopulmonary resuscitation as well as of outcomes of resuscitation procedures.

In 1991 and 1997, the representatives of the American Heart Association, European Resuscitation Council, Heart and Stroke Foundation of Canada and Australian Resuscitation Council published the guidelines for uniform reporting of data on sudden cardiac arrest, both in- and out-of-hospital (Utstein template) The key issues of these guidelines were precise definitions of interventions, end points, time intervals of management as well as preparation of a resuscitation report template. In Poland, the up-dated form of those guidelines was published in 2007 [13].

Our experience confirms the usefulness of resuscitation reports, which enable verification of actions undertaken and elimination of possible errors. Moreover, gathering data of each resuscitation action according to the Utstein template enables to compare the resuscitation activities within one hospital and among different hospitals [14, 15, 16, 17].

CONCLUSION

1. The mechanism of cardiac arrest markedly affects immediate outcomes of cardiopulmonary resuscitation.

2. Reporting on cardiopulmonary resuscitation activities allows to verify the actions undertaken and to compare the treatment outcomes.

3. The cases in which resuscitation is not undertaken before arrival of the CPR team indicate the necessity of regular trainings of the medical personnel, which will influence the outcomes of treatment of in-hospital cardiac arrest.

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REFERENCES

1.    Nollan J, Deakin Ch, Soar J, Böttiger B, Smith G: Zaawansowane zabiegi resuscytacyjne u osób dorosłych; w: Wytyczne 2005 resuscytacji krążeniowo-oddechowej (Red. J. Andres); PANDIT; Kraków, 2005; 43-98.

2.    Piankowski A, Skowroński R, Sidorowicz M, Owczuk R: Analiza wybranych czynników wpływających na odległe wyniki resuscytacji po wewnątrzszpitalnych zatrzymaniach krążenia. Anest Inten Terap 2008;
40: 22-27.

3.    Lossius M, Langhelle A, Sreide E, Pillgram-Larsen J, Askvik Lossius T, Laake P, Steen P: Reporting data following major trauma and analyzing factors associated with outcome using the new Utstein style recommendations. Resuscitation 2001; 50: 263-272.

4.    Kuisma M, Maatta T, Repo J: Cardiac arrests witnessed by EMS personnel in a multitiered system: epidemiology and outcome. Am J Emerg Med 1998; 16: 12-16.

5.    Śliwkiewicz K, Rasmus A, Gaszyński W: Wykorzystanie wzorca z Utstein do zbierania danych dotyczących pozaszpitalnych zatrzymań krążenia. Med Intens Rat 2002; 5: 209-215.

6.    Skrifvars M, Saarinen K, Ikola K, Kuisma M: Improved survival after in-hospital cardiac arrest outside critical care areas. Acta Anaesthesiol Scand 2005; 49: 1534-1539.

7.    De Maio V, Stiell I, Wells G, Spaite D: Cardiac arrest witnessed by emergency medical services personnel: descriptive epidemiology, prodromal symptoms, and predictors of survival. Ann Emerg Med 2000; 35: 138-146.

8.    Rudner R, Jałowiecki P, Wartak M, Marciniak R, Byrczek T: Ocena wybranych czynników wpływających na wyniki postępowania resuscytacyjnego w pozaszpitalnych zatrzymaniach krążenia. Anest Inten Terap 2005; 37: 174-187.

9.    Streb W, Duszyńska A, Świątkowski A, Śliwińska A, Jarski P, Honisz G, Stabryła-Deska J, Krupa H, Kalarus Z: Rokowanie u osób z zatrzymaniem krążenia w przebiegu ostrego zawału serca leczonych inwazyjnie. Ann Acad Med Siles 2007; 61: 183-189.

10.    Graves J, Herlitz J, Bang A, Axelsson A, Ekstrom L, Holmberg M, Lindqvist J, Sunnerhagen K, Holmberg S: Survivors of out of hospital cardiac arrest: their prognosis, longevity and functional status. Resuscitation 1997; 35: 117-121.

11.    Grześkowiak M, Bartkowska-Śniatkowska A, Rosada-Kurasińska J, Puklińska K.: Personel medyczny szpitala pediatrycznego  nie ma wystarczającej wiedzy  dotyczącej prowadzenia  bezprzyrządowej resuscytacji krążeniowo-oddechowej. Anest Inten Terap 2009; 41: 155-158.

12.    Grześkowiak M, Bartkowska-Śniatkowska A, Rosada-Kurasińska J, Puklińska K.: Personel medyczny szpitala pediatrycznego nie ma wystarczających umiejętności prowadzenia  resuscytacji krążeniowo-oddechowej. Anest Inten Terap 2009; 41: 234-237.

13.    Europejska Rada Resuscytacji we współpracy z Polską Radą Resuscytacji: Specjalistyczne zabiegi resuscytacyjne u osób dorosłych. Wyd Naukowe DWN, Kraków 2007: 187-192.

14.     Czajkowski G, Jankowski D, Janowski A: Zgodność rozpoznań wstępnych z ostatecznymi u pacjentów po pozaszpitalnym nagłym zatrzymaniu krążenia w materiale Oddziału Intensywnej Terapii Szpitala Wojewódzkiego im. M. Skłodowskiej-Curie w Szczecinie. Med Intens Rat 2008; 11: 11-16.

15.     Skrifvars M, Nurmi J, Ikola K, Saarinen K, Castren M: Reduced survival following resuscitation in patients with documented clinically abnormal observations prior to in-hospital cardiac arrest. Resuscitation 2006; 70: 215-222.

16.    Fredriksson M, Aune S, Thoren A-B, Herlitz J: In-hospital cardiac arrest- an Utstein style report of seven years experience from the Sahlgrenska University Hospital Resuscitation 2006; 68: 351-358H.

17.    European Resuscitation Council, American Heart Association, Heart and Stroke Foundation of Canada and Australian Resuscitation Council: Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest (new abridged version). The “Utstein Style”. Br Heart J 1992; 67: 325-333.

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Address:

*Małgorzata Marmaj
Oddział Anestezjologii i Intensywnej Terapii
Samodzielny Publiczny Szpital Kliniczny nr 7
Śląski Uniwersytet Medyczny
Górnośląskie Centrum Medyczne
ul. Ziołowa 45/47, 40-635 Katowice-Ochojec
tel.: 32-359 81 00
e-mail: oait@gcm.pl

Received: 29.01.2010
Accepted: 25.03.2010