Elsevier

Resuscitation

Volume 79, Issue 2, November 2008, Pages 234-240
Resuscitation

Clinical paper
Risk of cardiopulmonary arrest after acute respiratory compromise in hospitalized patients,☆☆

https://doi.org/10.1016/j.resuscitation.2008.06.025Get rights and content

Summary

Background

Hospitalized patients with serious medical conditions such as shock, aspiration, pulmonary edema or stroke may develop acute respiratory compromise (ARC) requiring rescue treatment by medical emergency teams. We determined the characteristics and clinical course of hospitalized patients experiencing ARC as well as their risk of developing subsequent CPA.

Methods

We examined data from the National Registry of Cardiopulmonary Resuscitation (NRCPR). We identified patients experiencing ARC, defined as medical crisis requiring emergency assisted ventilation and triggering hospital-wide or unit-based emergency response. We excluded those found initially in CPA. We identified the proportion of patients subsequently progressing to CPA, the elapsed time from ARC recognition to CPA, the clinical factors associated with developing CPA, and subsequent survival to hospital discharge.

Results

Of 4358 ARC events, CPA occurred in 726 (16.7%; 95% CI: 15.6, 17.8%). One-fourth occurred in general inpatient units. Median time from ARC recognition to CPA was 7 min (IQR: 3, 12 min); CPA occurred within 10 min in 65.3% of these cases. Factors associated with CPA included pulmonary embolism, hypotension or hypoperfusion, or failed invasive airway efforts. Survival to discharge was lower for CPA patients (14.3%) than non-CPA patients (58.4%) (OR 0.12; 95% CI: 0.10, 0.15).

Conclusions

Approximately one in six patients experiencing initial ARC deteriorates to CPA. Most CPA occur within 10 min of ARC recognition. Improved ARC recognition, hospital emergency team response and airway management may potentially enhance care and outcomes for these critically ill patients.

Introduction

During the course of their care, hospitalized patients with serious medical conditions such as shock, aspiration, pulmonary edema or stroke may develop unexpected acute respiratory compromise (ARC). Occurring throughout the hospital, these crises may require emergency rescue therapy such as bag-valve-mask ventilation or endotracheal intubation, among others.1, 2, 3 To provide prompt emergency care and to prevent progression to cardiopulmonary arrest (CPA), many hospitals have developed medical emergency response systems to care for these patients. However, only limited data describe the risk of CPA after ARC, the characteristics of patients progressing to CPA, or the subsequent clinical course of these patients. Enhanced understanding of these factors could help refine system plans for the emergent care provided to ARC victims.

In this study we determined the characteristics and clinical course of hospitalized patients developing ARC. Specifically, we identified the proportion of ARC patients progressing to CPA, the elapsed time from ARC recognition to CPA, the clinical factors associated with developing CPA, and subsequent survival to hospital discharge.

Section snippets

Methods

The University of Pittsburgh Institutional Review Board approved this study.

We identified adult (age ≥18 years) acute respiratory compromise (ARC) cases from patients enrolled in the National Registry of Cardiopulmonary Resuscitation (NRCPR). Initiated in 2000, NRCPR is an international quality improvement database of resuscitation events at hospitals in the United States, Canada, Germany, Brazil and Japan. Using standard data collection forms, participating facilities provide structured data

Results

There were 4358 adult ARC events. The mean patient age was 65.7 years (95% CI: 65.2, 66.2). The majority of patients were male (54.1%) (Table 1). Over one-fourth of ARC events occurred in general inpatient units. The remaining cases occurred in intensive care units, step down units, emergency departments and other hospital or healthcare units.

The ARC event ended with controlled ventilation in 3145 (72.2%; 95% CI: 70.8, 73.5%) and return of spontaneous ventilation in 487 (11.1%; 10.3, 12.1%);

Discussion

Even when receiving appropriate care, a portion of hospitalized patients may deteriorate acutely and unexpectedly, requiring rescue therapy for ensuing ARC. The early identification of these cases offers opportunities to initiate stabilizing airway, ventilatory, pharmacologic and other interventions. Hospitals have invested in medical emergency response teams to expedite emergency care and to prevent these patients from deteriorating to CPA. Despite these systems of rescue care, in this series

Conclusion

Approximately one in six patients experiencing initial ARC deteriorates to CPA. Most CPA occur within 10 min of ARC recognition. Improved ARC recognition, hospital emergency team response and airway management may potentially enhance care and outcomes for these critically ill patients.

Conflicts of interest

None.

Acknowledgements

We acknowledge Matthew D. Weaver, NREMT for his assistance with preparing the manuscript. Dr. Wang had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Details of funding: Dr. Wang is supported by Clinical Scientist Development Award K08-HS013628 from the Agency for Healthcare Research and Quality, Rockville, MD, USA. This research was independent from the funders.

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A Spanish translated version of the summary of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2008.06.025.

☆☆

Resuscitation Science Symposium, American Heart Association Scientific Sessions 2007, November 2007, Orlando, Florida.

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