scholarly journals THE EFFECT OF A CHECKLIST ON VARIABILITY OF CARE AFTER IN HOSPITAL CARDIAC ARREST AT A TERTIARY ACADEMIC MEDICAL CENTER

CHEST Journal ◽  
2021 ◽  
Vol 160 (4) ◽  
pp. A1049
Author(s):  
Vince Raikhel ◽  
Stephen Ferraro ◽  
David Carlbom ◽  
Vera Schulte ◽  
James Town
Keyword(s):  
Cardiac Arrest ◽  
Medical Center ◽  
Academic Medical Center ◽  
Academic Medical ◽  
Hospital Cardiac Arrest

Predicting Outcome After Out-of-Hospital Cardiac Arrest: Lactate, Need for Vasopressors, and Cytochrome c

2019 ◽  
Vol 35 (12) ◽  
pp. 1483-1489 ◽  
Author(s):  
Michael N. Cocchi ◽  
Justin Salciccioli ◽  
Tuyen Yankama ◽  
Maureen Chase ◽  
Parth V. Patel ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Cytochrome C ◽  
Prospective Observational Study ◽  
Medical Center ◽  
Academic Medical Center ◽  
Receiver Operating Curve ◽  
Academic Medical ◽  
Predicting Outcome ◽  
Logistic Regressions ◽  
Hospital Cardiac Arrest

Background: Outcome prediction after out-of-hospital cardiac arrest (OHCA) is difficult. We hypothesized that lactate and need for vasopressors would predict outcome, and that addition of a mitochondrial biomarker would enhance performance of the tool. Methods: Prospective observational study of OHCA patients presenting to an academic medical center September 2008 to April 2016. We conducted univariate and multivariate logistic regressions. Results: Patients were divided based on 2 variables: vasopressor status and initial lactate (<5 mmol/L, 5-10, ≥10). Three hundred fifty-two patients were evaluated; 249 had a lactate within 3 hours and were included. Patients on vasopressors had higher mortality (74% vs 40%; P < .001). A stepwise increase in mortality is associated with increasing lactate (45% lactate <5, 66% 5-10, and 83% ≥10; P < 001). Multivariable models with lactate group and vasopressors as predictors demonstrated excellent discrimination (area under the receiver operating curve [AUC]: 0.73 [95% confidence interval, CI: 0.66-0.79]; adjusted for additional covariates: AUC: 0.81 [95% CI: 0.75-0.86]). Thirty-six patients had cytochrome c levels available; among these 36, when comparing models with and without cytochrome c, there was no difference (AUC: 0.88 [95% CI: 0.76-1.00] vs AUC: 0.85 [95% CI: 0.73-0.98], respectively; P = .30). Conclusion: In this prospective validation, the combination of lactate and vasopressors in the immediate postarrest period is predictive of mortality. Cytochrome c offered minimal additional predictive power.

Palliative Care Utilization in In-Hospital Cardiac Arrest at an Urban Academic Medical Center

2019 ◽  
Author(s):  
D. Khateeb ◽  
T. Bekker ◽  
N. Zahustecher ◽  
L. Tang ◽  
J. Stout ◽  
...  
Keyword(s):  
Palliative Care ◽  
Cardiac Arrest ◽  
Medical Center ◽  
Academic Medical Center ◽  
Care Utilization ◽  
Academic Medical ◽  
Hospital Cardiac Arrest

Abstract 9740: Factors Associated With Performing Urgent Coronary Angiography in Out-of-Hospital Cardiac Arrest

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
David H Lam ◽  
Lauren M Glassmoyer ◽  
Roger B Davis ◽  
Donald E Cutlip ◽  
Michael W Donnino ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Cardiac Arrest ◽  
Coronary Angiography ◽  
Medical Center ◽  
Academic Medical Center ◽  
Do Not Resuscitate ◽  
Factors Associated ◽  
Shockable Rhythm ◽  
History Of ◽  
Hospital Cardiac Arrest

Introduction: Out-of-hospital cardiac arrest (OHCA) is associated with high mortality and is most commonly caused by cardiovascular disease. Current guidelines recommend urgent coronary angiography (UCA) if ST-elevation myocardial infarction (STEMI) or high suspicion of acute myocardial infarction exist. Some have advocated for UCA in all OHCA without an obvious non-cardiac cause of arrest. The reasons for large clinical variation in performance of UCA in OHCA are not well understood. Objective: We sought to identify factors associated with performing UCA in OHCA. Methods: A retrospective chart review was conducted on 535 consecutive cardiac arrest patients who achieved return of spontaneous circulation (ROSC) and were admitted at a tertiary academic medical center from January 2008 to August 2014. Exclusion criteria included in-hospital cardiac arrests (201), outside hospital UCA (8), and lack of medical records (1). Univariable analysis followed by multivariable forward selection forcing age and gender were used to determine correlates of performing UCA, defined as within 6 hours of presentation. Results: Out of 325 resuscitated OHCA patients (mean age, 64; women, 35%), 69 were taken to UCA. Factors associated with performing UCA were history of coronary artery disease (CAD) (OR 2.76, 95% CI 1.22-6.28), initial shockable rhythm (OR 3.04, 95% CI 1.31-7.06), following commands post-ROSC (OR 2.77, 95% CI 1.06-7.25), and STEMI (OR 15.17, 95% CI 6.57-35.04). Increasing age (OR 0.97, 95% CI 0.95-0.999) and obvious non-cardiac cause of arrest (OR 0.10, 95% CI 0.03-0.37) were negatively associated. Gender, prior stroke, dementia, bystander cardiopulmonary resuscitation, hypotension, contraindication to anticoagulant, presenting from nursing home or rehabilitation, do not resuscitate order prior to admission, non-English primary language, and presenting during off-hours were not associated with the decision for UCA. Conclusions: In resuscitated out-of-hospital cardiac arrest patients, history of CAD, shockable rhythm, ability to follow commands, and STEMI were associated with performing urgent coronary angiography. Older patients and those with an obvious non-cardiac cause of arrest were less likely to receive coronary angiography.

Abstract 11233: A Trigger and Response System for Preventing Cardiac Arrest in the Intensive Care Unit

Circulation ◽  
2021 ◽  
Vol 144 (Suppl_2) ◽  
Author(s):  
Ari Moskowitz ◽  
Katherine Berg ◽  
Michael N Cocchi ◽  
Anne V Grossestreuer ◽  
Lakshman Balaji ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Medical Center ◽  
Academic Medical Center ◽  
Interrupted Time Series ◽  
Arrest Rate ◽  
Academic Medical ◽  
Slope Change ◽  
Time Series Approach ◽  
A Prospective Study ◽  
The Impact

Background: Although patients in the ICU are closely monitored, some ICU cardiac arrest events may be preventable. In this study we sought to reduce the rate of ICU cardiac arrests. Methods: This was a prospective study of a novel clinical trigger and response tool deployed in the ICUs of a single, tertiary academic medical center. An interrupted time series approach was used to assess the impact of the tool on ICU cardiac arrests. Results: Forty-three patients experienced an ICU cardiac arrest in the pre-intervention epoch (6.79 arrests per 1000 discharges) and 59 patients experienced an ICU cardiac arrest in the intervention epoch (7.91 arrests per 1000 discharges). In the intervention epoch, the clinical trigger and response tool was activated 106 times over a 1-year period, most commonly due to unexpected new or worsening hypotension. There was no step change in arrest-rate (2.24 arrests/1000 patients, 95%CI -1.82, 6.28, p=0.28) or slope change (-0.02 slope of arrest rate, 95%CI -0.14, 0.11, p=0.79) comparing the pre-intervention and intervention time epochs (see Figure). Cardiac arrests occurring in the pre-intervention epoch were more likely to be deemed ‘potentially preventable’ than those in the intervention epoch (25.6% prior to the intervention vs. 12.3% during the intervention, OR 0.58, 95%CI 0.20, 0.88, p<0.01). Conclusions: A trigger-and-response tool did not reduce the incidence of ICU cardiac arrest. Arrests occurring after introduction of the tool were less likely to be rated as ‘potentially preventable.’

scholarly journals Variations in survival after cardiac arrest among academic medical center-affiliated hospitals

PLoS ONE ◽  
2017 ◽  
Vol 12 (6) ◽  
pp. e0178793 ◽  
Author(s):  
Michael Christopher Kurz ◽  
John P. Donnelly ◽  
Henry E. Wang
Keyword(s):  
Cardiac Arrest ◽  
Medical Center ◽  
Academic Medical Center ◽  
Academic Medical

Abstract 9160: Epinephrine-Dominant versus Non-Epinephrine Dominant Resuscitation for In-Hospital Cardiac Arrest

Circulation ◽  
2021 ◽  
Vol 144 (Suppl_2) ◽  
Author(s):  
Jennifer W Chou ◽  
Amy Lin ◽  
Juan Toledo ◽  
Gabriel Wardi ◽  
Katrina Derry ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Diastolic Pressure ◽  
Medical Center ◽  
Academic Medical Center ◽  
Cerebral Performance Category ◽  
Myocardial Oxygen Demand ◽  
Coronary Perfusion ◽  
Dose Ratio ◽  
The Impact ◽  
Hospital Cardiac Arrest

Introduction: Vasopressors are used during CPR to increase arterial resistance and aortic diastolic pressure, improving coronary perfusion and likelihood of ROSC. In comparison to epinephrine, vasopressin remains effective in an acidemic environment, has favorable cerebral perfusion, and does not directly increase myocardial oxygen demand. Studies comparing epinephrine and vasopressin report variable ROSC, survival, and neurological outcome. Most studies used few vasopressin doses and it is unclear whether greater vasopressin use leads to clinical benefit. Hypothesis: We hypothesized that a non-epinephrine dominant CPR approach with vasopressin would lead to greater ROSC than an epinephrine-dominant approach. Methods: This was a retrospective, single-center study conducted at an 800-bed academic medical center. All first cardiac arrests among adult inpatients between Jan 2018 and Mar 2021 were screened, and those with at least 2 vasopressor doses used were included. Patients who received epinephrine-dominant resuscitation (epinephrine-to-vasopressin dose ratio >2 or CPR using only epinephrine) were compared to patients who received a non-epinephrine dominant approach (epinephrine-to-vasopressin dose ratio ≤2). The incidence of ROSC was analyzed using a Chi-squared test where p <0.05 was considered significant. Secondary outcomes included survival to discharge with favorable neurologic outcome, survival to discharge, and Cerebral Performance Category scores. Results: Of 663 in-hospital cardiac arrests screened, 264 were included. Two hundred twenty-eight (86%) presented with PEA/asystole as the initial rhythm, and the most common etiologies were circulatory (41%) and respiratory (26%). The epinephrine-dominant arm achieved ROSC in 89 (66%) patients compared to 87 (67%) patients in the non-epinephrine dominant arm (RR 0.99, 95% CI 0.84-1.18, p=0.93). Survival to discharge was higher in the epinephrine-dominant arm (25% vs 15%, p=0.04). Conclusion: There was no difference in ROSC between epinephrine-dominant and non-epinephrine dominant resuscitation for adult in-hospital cardiac arrest. Future studies should examine the impact of non-epinephrine dominant CPR on long term neurologic outcomes.

Abstract 406: Are Providers Overconfident in Predicting Outcome After Cardiac Arrest?

Circulation ◽  
2019 ◽  
Vol 140 (Suppl_2) ◽  
Author(s):  
Alexis Steinberg ◽  
Clifton W Callaway ◽  
Cameron Dezfulian ◽  
Jonathan Elmer
Keyword(s):  
Cardiac Arrest ◽  
Medical Center ◽  
Academic Medical Center ◽  
Favourable Outcome ◽  
Academic Medical ◽  
Predicting Outcome ◽  
Using Data ◽  
And Function ◽  
Future Work ◽  
Attending Physicians

Objective: Prognostication after cardiac arrest is challenging. We tested if providers’ confidence in their neuroprognostic assessments correlates with accuracy. Methods: We presented physicians with clinical synopses using data from real-time, post-arrest patients being treated at a single academic medical center. We allowed providers to ask for any additional data available at the time the assessment was performed. We asked providers: (1) will the patient survive to hospital discharge?; (2) will the patient have favourable function at discharge?; and, (3) their confidence in each prediction (0-100%). We repeated assessments daily until death or post-arrest day 5. Results: We completed 414 assessments of 51 patients with 59 providers. Of patients, 79% died, 8% were discharged with unfavourable function and 12% had functionally favourable survival. Providers accurately predicted survival in 257/414 (62%) assessments. In most errors (136/141, 96%), providers predicted survival in a patient who died. Providers accurately predicted function in 282/414 (68%) assessments. In most errors (125/132, 95%), providers incorrectly predicted a favourable outcome. Providers were confident in their assessments (median confidence predicting survival 80 [IQR 60 - 90]; median confidence predicting function 80 [IQR 60 - 95]). Accuracy predicting survival and function were both positively correlated with confidence (both P<0.001), but confidence explained only 7% and 15% of observed variance in accuracy, respectively. When providers reported 100% confidence predicting survival, they were correct in 31/42 (74%) cases. Accuracy did not vary over time. Attending physicians were not more accurate than trainees predicting survival (65% vs 60% accurate) and were less accurate prediciting functional outcome (62% vs 84% accurate, P< 0.001). Confidence did not differ between attendings and trainees. Conclusions: Providers were overly optimistic predicting outcomes at discharge. Self-reported confidence explained only a small percentage of variance in accuracy. Even when extremely confident, providers were often wrong. Our future work will explore patient and provider factors that contribute to error.

Abstract 336: Data-driven Classification of Arrest Location for Emergency Department Cardiac Arrests

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_4) ◽  
Author(s):  
Nancy Mikati ◽  
Clifton W Callaway ◽  
Patrick J Coppler ◽  
Jonathan Elmer
Keyword(s):  
Emergency Department ◽  
Cardiac Arrest ◽  
Unsupervised Learning ◽  
Hospital Discharge ◽  
Medical Center ◽  
Academic Medical Center ◽  
Clinical Information ◽  
Large Majority ◽  
Cluster Center ◽  
Hospital Cardiac Arrest

Introduction: Out-of-hospital cardiac arrest (OHCA), in-hospital cardiac arrest (IHCA), and emergency department (ED) cardiac arrests differ in epidemiology, etiology, and outcomes. Resuscitation research is inconsistent in how ED arrests are classified. We used unsupervised learning to compare ED arrests to non-ED OHCA and to non-ED IHCA. Hypothesis: Clinical features of ED cardiac arrest patients who achieve return of spontaneous circulation (ROSC) are more similar to IHCA than to OHCA. Methods: We performed a retrospective study including all patients resuscitated from cardiac arrest who were treated at a single academic medical center from January 2010 to December 2019. We abstracted clinical information from our prospective registry, including the details of arrest location (ED arrests, OHCA, or IHCA); age; sex; initial arrest rhythm; number of doses of epinephrine, bicarbonate and shocks given during the arrest; duration of arrest; most advanced airway placed intra-arrest; number of rearrests; early post-arrest illness severity (Pittsburgh Cardiac Arrest Category: PCAC); and survival to hospital discharge. We used unsupervised learning (K-prototypes) to identify clusters within the OHCA and IHCA cohorts. We determined the number of subgroups using Scree plots. Finally, we assigned individual ED arrest patients the nearest OHCA or IHCA cluster based on the shortest Gower distance from that patient to the nearest cluster center. Results: We included 2,723 patients: 1,709 (63%) OHCA, 642 (23%) IHCA, and 372 (14%) ED arrests. We identified 3 clusters in the OHCA cohort, and 4 clusters in the IHCA cohort. Of the total ED arrest cases, 292 (78%) most closely resembled an IHCA cluster and 80 (22%) most closely resembled an OHCA cluster. The large majority (64%) of ED arrests that were closest to an IHCA cluster survived to hospital discharge; 50% of this subset were awake post-arrest (PCAC I), and 16% were deeply comatose (PCAC IV). In contrast, only 13% of ED arrests that were closest to an OHCA cluster survived to hospital discharge; 65% of this subset were deeply comatose (PCAC IV) and only 5% were awake post arrest (PCAC I). Conclusion: Among cardiac arrest patients with ROSC, the large majority of ED arrests resemble IHCA more than OHCA.

Abstract 334: Evaluating Sedation Regimens and Time to Awakening in Post Cardiac Arrest Patients

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_4) ◽  
Author(s):  
Marissa Levito ◽  
Cory McGinnis ◽  
Lara Groetzinger ◽  
Joseph Durkin ◽  
Jonathan Elmer
Keyword(s):  
Cardiac Arrest ◽  
Cox Regression ◽  
Medical Center ◽  
Academic Medical Center ◽  
Practice Variation ◽  
Academic Medical ◽  
Outcome Information ◽  
Benzodiazepine Use ◽  
Neurological Event ◽  
Independent Association

Introduction: Guidelines for post-arrest care recommend use of short acting sedation, but there is currently significant practice variation. We tested whether benzodiazepine use was associated with delayed awakening in this population. Methods: We performed a retrospective cohort study at a large academic medical center including comatose patients hospitalized after resuscitation from in- or out-of-hospital cardiac arrest from January 2010 to September 2019. We excluded patients with cardiac arrest secondary to primary neurological event or trauma, those with severe cerebral edema on initial head imaging, those who were awake post-arrest and those with severe shock for whom benzodiazepines might have been chosen for hemodynamic reasons. We extracted all medication information from the electronic medical record and standard clinical and outcome information from a prospective registry maintained at our center. We considered patients to be exposed to benzodiazepines if they received > 10mg midazolam equivalents in the first 72 hours after cardiac arrest and censored cumulative mediation data at awakening for those who awakened before 72 hours. Our primary outcome of interest was days from arrest to awakening, which we defined as following verbal commands. We compared median time to awakening across sedation groups, then performed Cox regression to test the independent association of benzodiazepine exposure with time to awakening after adjusting for age, sex, weight, presenting rhythm, arrest location, initial serum creatinine, initial shock severity, initial neurological examination and presence of epileptiform. Results: Overall, 2,778 patients presented during the study period of which 621 met inclusion criteria for analysis and 209/621 (34%) awakened after a median of 4 [IQR 3 - 7] days. Patients who received benzodiazepines for sedation awakened significantly later than those who did not (5 days vs. 3 days, P=0.004). In adjusted regression, benzodiazepine exposure was independently associated with delayed awakening (adjusted hazard ratio 0.64 (95% CI 0.44 - 0.94)). Conclusion: Benzodiazepine exposure is associated with delayed awakening in comatose survivors of cardiac arrest.

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