Elsevier

Resuscitation

Volume 82, Issue 9, September 2011, Pages 1186-1193
Resuscitation

Clinical paper
Strong and weak aspects of an established post-resuscitation treatment protocol—A five-year observational study

https://doi.org/10.1016/j.resuscitation.2011.05.003Get rights and content

Abstract

Aim of study

Favourable hospital survival increased from 26% to 56% in the implementation phase of a new standard operating procedure (SOP) for treatment after out-of hospital cardiac arrest (OHCA) in 2003. We now evaluate protocol adherence and survival rates after five years with this established SOP.

Methods

This observational study is based on prospectively collected registry data from all OHCA patients with cardiac aetiology admitted with spontaneous circulation to Ulleval Hospital between September 2003 and January 2009. Three patient categories are described based on early assessment in the emergency department: conscious, comatose, and comatose patients receiving only palliative care, with main focus on comatose patients receiving active treatment.

Results

Of 248 patients, 22% were consciousness on admission, 70% were comatose and received active treatment, while 8% received only palliative care. Favourable survival from admittance to discharge remained at 56% throughout the study period. Among actively treated patients 83% received emergency coronary angiography and 48% underwent subsequent percutaneous coronary intervention. In this cohort 63% had an acute myocardial infarction, ten of whom did not receive emergency coronary angiography. Among actively treated comatose patients, 6% survived with unfavourable neurology, while 51% of the deaths followed treatment withdrawal after prognostication of severe brain injury.

Conclusion

The previously reported doubling in survival rate remained throughout a five-year study period. Establishing reliable indication for emergency coronary angiography and interventions and validating prognostication rules in the hypothermia era are important challenges for future studies.

Introduction

Survival after out-of-hospital cardiac arrest (OHCA) depends on a well functioning chain of survival, both during out-of hospital resuscitation and the in-hospital post resuscitation phase.1 Regional variations in survival of OHCA2, 3 point toward a substantial potential to improving treatment regimes.4, 5

Large inter-hospital differences in discharge rates among patients admitted with OHCA,6, 7, 8 indicate possibilities for improved post-resuscitation care, and provide opportunities to identify valuable interventions through judicious study of in-hospital data. Poor survival rate among hospitalized OHCA patients in Oslo,8 provided such an incentive to research and develop a new standard operating procedure (SOP) for post resuscitation treatment. The SOP was implemented in conjunction with a clinical trial rigorously tracking both pre- and in-hospital factors, complications, and outcome in a prospective post resuscitation registry.9 Evaluating the implementation phase in a “before-and-after” study design revealed a doubling of survival rate.9 The SOP remained unchanged until 2009 and the post resuscitation registry was kept operational in order to monitor quality control of the treatment and secure an opportunity for further studies.

Based on these registry data we have evaluated protocol adherence and survival rates after five years with an established SOP. Three distinct patient categories are described based on early assessment in the emergency department (ED): conscious, comatose, and comatose patients receiving only palliative care. As patients regaining consciousness early are less likely to require treatment for post cardiac arrest syndrome,10 we focused on comatose patients receiving active treatment, evaluating pre- and in-hospital factors that affected prognostication, end-of-care decisions and clinical outcome.

Section snippets

Materials and methods

The Regional Committee for Medical Research Ethics approved this study and the scientific use of the hospital post-resuscitation registry data.

Results

In the 5½ year study period, 324 resuscitated OHCA patients were brought to Ulleval as the primary hospital. There were 70 patients with non-cardiac cause of arrest, of whom 64% (45/70) received MTH and 18% (14% favourable) survived to hospital discharge (Fig. 1). Among the remaining 254 patients with presumed cardiac aetiology four died prior to ICU admission and two were excluded due to being transferred abroad prior to final hospital discharge, leaving 248 patients eligible for inclusion in

Discussion

Survival with favourable outcome at hospital discharge after OHCA with cardiac aetiology remained unchanged throughout the five-year period. The 56% favourable outcome was the same as that reported for the initial implementation phase of our SOP, doubling the survival rate compared to historical controls.9 Among comatose patient receiving active treatment, 49% survived with favourable outcome and 6% survived with unfavourable neurology.

Identifying and amending the cause of arrest by coronary

Conclusion

The previously reported doubling in survival rate remained throughout the five-year period, demonstrating the usefulness of a standard operating treatment procedure for post resuscitation care. Establishing reliable indications for emergency coronary angiography and interventions after OHCA and validating prognostication rules in the MTH era are important challenges for future studies.

Conflict of interest statement

None of the authors had any conflict of interest.

Acknowledgements

We would like to thank professor Petter Andreas Steen for useful discussion and critique during drafting this manuscript. The study was supported by grants from Eastern Norway Regional Health Authority, Oslo University Hospital, and Anders Jahres Fund.

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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2011.05.003.

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