August 1994, Volume 44, Issue 8

Original Article

In Hospital Cardiopulmonary Resuscitation - Analysis of 188 CPRs

Farrukh Iqbal  ( Department of Medicine, Federal Postgraduate Medical Institute, Shaikh Zayed Hospital, Lahore. )

Abstract

Of 188 patients with cardiac arrest, who received cardiopulmonary resuscitation ver a period of 13 months, 34 (18%) survived to leave the hospital. Most cardiac arrests (36%) occurred at the age of 60-69 years. Majority of CPRs were performed in the accident and emergency (31%) coronary care unit (28%) and acute medical wards (21%). Most common cause (48%) was myocardial infarction. Poor outcome was associated with initial rhythm of asystole. These figures suggest that the incidence of successful outcome for CPRs in hospital has not changed significantly over the past twenty-five years (JPMA 44:190, 1994).

Introduction

The last few decades have witnessed rapid development of modem resuscitative instruments This has lead to wide spread practice of cardiopulmonary resuscitation (CPR) Unfortunately there is a tendency to resuscitate any candidate regardless of his age underlying disease or ultimate progno­sis. This attitude to save human life has decreased the overall success rate and has raised the question, that “how ethical is it to resuscitate terminally ill patients"?

Patients and Methods

A prospective study over a 13 months period was conducted at Stafford District General Hospital, Staffordshire, United Kingdom. A specially designed cardiac arrest from (Table I)

was filled soon after the resuscitation by the team leader. Other necessary information was obtained from the patient\\\'s record. Cardiac arrest was diagnosed clinically by absent major pulses, loss of consciousness, absent respiration and electro­cardiographic evidence when the patient was on a monitor. The cardiac arrest team consisted of a medical registrar (leader), two senior house officers, one each from coronary care unit (CCU) and intensive care unit UCU), one anaesthetist and a medical house officer.

Results

A total of 188 CPRs were performed during a thirteen month period representing an average of 3.6 CPRs per week. There were 115 males (61%) and 73 females (39%). Initially 83 calls (44%) were successful but subsequently 45 died. Thirty-four patients (18%) were able to leave the hospital. Majority of the arrests were in the age group 60-69 years. Most of the calls were from accident and emergency department, coronary care unit and medical wards. Results of CPRs in relation to location are shown in Table II.

Least successful CPRs were those where the patient had cardiac arrest outside the hospital and there was undue delay in transportation to the hospital. No calls were received from maternity or gynaecology departments. The survey also revealed that most of the cardiac arrests were on those patients who had coronary heart disease and its complications. Other causes included respiratory failure, massive gastrointestinal haemorrhage, cerebro-vascular acci­dents and terminally ill patients due to malignant diseases.

Table III shows the causes of cardiac arrest in this survey. Ventricular fibrillation was the most frequent (67 patients) initial rhythm, followed by asystole (61 patients). Ten patients had ventricular tachycardia and seven were resuscitated successfully (70%). If the initial rhythm was very slow, i.e., severe bradycardia or other brady-arrhythniias, the success rate was low (Table IV).

Midnight arrest calls were often found to be a waste of time and effort. Patients were mostly found dead and the team was called by the nurses to seek coverparticularly onthe surgical floor. Defibrillation was the most effective and useful way of resuscitation and the most commonly used drug was lignocaine for tachyarrhythmia.
It was noted that in places where cardiac arrest was uncommon, only cardiac arrest trays were sufficient. In acute cardiac units, emergency, ICU and acute medical wards, all the resuscitation equipment was required. The duration of resus­citation ranged from 20-40 minutes. “When to stop resuscita­tion” was a problem faced by most junior doctors.

Discussion

Introduction of closed cardiac massage1 and external alternating current defibrillator2 have revolutionized the methods of cardiopulmonary resuscitation. Studies done to survey in- hospital cardiac arrests showed a much lower percentage of adult patients to leave the hospital after resuscitation than the paediatric age group3,4. The high success rate in this study was due to well trained and skilled medical personnel being present on the spot in the coronary care and acute medical wards. The patients who arrest in intensive care unit are resuscitated successfully initially but due to the underlying pathology, the ultimate outcome was grim. Some institutions have a “no CPR” policy in intensive care unit. Though it is not generally advocated but the data in different studies do suggest that cardiac arrest is an event which sometimes delays the decision to stop aggressive management of patients who are terminally ill. However, if the medical status of the patient is not known, it is best to proceed. In other studies the outcome of CPR in cancer patients has proved disappointing and has been suggested to be a waste of time and effort5,6. The “do not-resuscitate” policy due to advanced disease should be individual based and cancer patients as a whole should not be excluded from CPR. CPR in the elderly has rarely been effective7, especially in those who are out-of-hospital, un witnessed or associated with asystole and electro-mechanical dissociation. The study also confirms that prognosis was more favourable when the mode of arrest was ventricular fibrillation rather than asystole8-11 (Table V).

This does not apply to patients developing cardiac arrest out of the hospital, as delay in transportation changes the rhythm to asystole. American Heart Association (AMA) recommends pre-cardial thump for patients on ECG monitoring12. This may prove successful in a few cases The guidelines for advanced support have been revised in 1989 by the Resuscitation Council of UK13. Sweden, Denmark, Norway and Finland have similar recommenda­tions. Evaluation of the cost- effectiveness of CPR has brought about a ‘no’ CPR policy in selected eases thus avoiding inappropriate short term prolongation of life. Continued education in CPR techniques of the nursing and medical staff would give an improved outcome. Some studies show that family members of cardiac patients could learn CPR success­fully14. The selection of patients for CPR should be against precise criteria so that the desired outcome is obtained. A vegatative existence should be more agonising. Due to limited resources organized cardiac arrest teams are scarce in hospi­tals in Pakistan. A well trained team along with the necessary equipment will give good results in the resuscitation efforts.

Acknowledgements

I am grateful to Dr. J.L. Francis, Dr. P.R. Daggett, Dr. Eyre Walker and Miss C. Mackenzie from Stafford District General Hospital, Stafford, UK and Mt Amjad Ali, Shaikh Zayed Postgraduate Medical Institute, Lahore for their help and assistance in this study and preparation of this manuscript.

References

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