ORIGINAL ARTICLE Cardiac and Pulmonary Resuscitation: Focusing on what matters.

Peter G Brindley MD FRCPC, Division of Critical Care Medicine, University of Alberta, Edmonton, Canada

ABSTRACT

RÉSUMÉ

Cardiopulmonary resuscitation (CPR) has the remarkable ability to prevent otherwise inevitable death. Sadly, it can also significantly prolong the dying process, increase family duress and patient suffering, and squander scarce resources. Attempts to revive the failing heart and lungs date back hundreds of years. However, it was not until the 196O's that CPR was formalized.'' Fifty years on, it remains a topic of intense study, impassioned debate, divisive opinion, and legal consequence. It is, therefore, an important issue for all Healthcare Practitioners. While admission to a dedicated Palliative Care Unit typically means that CPR will typically no longer be an option, this is not the case for larger numbers of equally sick patients admitted to general hospital wards. In fact, CPR's "special status" is emphasized by the fact that it is the only medical intervention that requires explicit documentation not to be performed. Therefore, optimal communication cannot be overemphasized. Standardized Algorithms - as outlined by the guidelines for Advanced Cardiac Life Support (ACLS) - remain the recommended way to perform CPR. Guidelines are regularly updated, and widely taught.'^"'' As such, it is comparatively simple to proceed with CPR. It is far more important to decide upon its appropriateness. This review will therefore focus on prognostic factors in order to promote communication and advocacy. The intent is not to dictate who must (or must not) receive CPR. Instead, it is to provide baseline knowledge in order to encourage informed dialogue with patients and families. Only in this way can we deliver empathetic patientcentered care, even where the research is imperfect or the emotions extreme. The goal of CPR should be to extend life, not to prolong death.

La réanimation cardiorespiratoire (RCR) présente la capacité remarquable d'empêcher un décès autrement inévitable. Malheureusement, elle peut aussi prolonger l'agonie, augmenter les contraintes imposées à la famille et les souffrances du patient et gaspiller des ressources précieuses. Les efforts de réanimation des fonctions cardiorespiratoires remontent à des centaines d'années. Ce n'est cependant que durant les années 1960 que la RCR a été structurée'\ Cinquante ans plus tard, la RCR demeure un sujet d'intenses études, de débats passionnés, d'opinions divisées et de conséquences juridiques. Il s'agit donc d'un enjeu important pour les professionnels de la santé. Si l'admission dans une unité de soins palliatifs signifie habituellement que la RCR n'est plus une option, ce n'est pas le cas pour un grand nombre d'autres patients tout aussi gravement malades admis dans les unités de soins réguliers. En fait, le « statut particulier » de la RCR est accentué par le fait qu'il s'agit de la seule intervention médicale qui exige une documentation explicite pour ne pas être exécutée. Par conséquent, on ne peut trop insister sur l'importance d'une communication optimale. Les algorithmes normalisés — énoncés dans les directives sur les techniques spécialisées de réanimation cardiorespiratoire restent la façon recommandée de pratiquer la RCR. Les directives sont mises à jour régulièrement et largement enseignées"^'. À ce titre, si l'utilisation de la RCR est relativement simple, il est beaucoup plus important d'en déterminer le caractère approprié. Cet examen mettra par conséquent l'accent sur les facteurs pronostiques, de façon à favoriser la communication et la promotion. L'intention n'est pas de dicter qui doit (ou ne doit pas) bénéficier de la RCR. Il s'agit plutôt de fournir des connaissances de base afin de favoriser un dialogue éclairé avec les patients et les familles. Ce n'est que de cette façon que nous pourrons offrir des soins empathiques centrés sur le patient, même dans les cas où les recherches sont imparfaites ou l'émotivité extrême. Le but de la RCR doit être de prolonger la vie, pas de prolonger l'agonie.

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Canadian Journal of Respiratory Therapy Revue canadienne de la thérapie respiratoire

Several studies have reported an association between advanced age and poor survival following CPR. "who" is resuscitated) that currently has a greater influence upon survival than resuscitation technique or technology (i. what is concerning is that > 40% of all in-hospital arrests are still unwitnessed.S. and had no ROSC after ten minutes of CPR has a predicted mortality of 100%. CPR for > 20 mins without ROSC is associated with decreased survival. for Canadian Journal of Respiratory Therapy Revue canadienne de la thérapie respiratoire Spring | Printemps 2010 Volume I Numéro 46. This is a large part of why survival following cardiac arrest has not improved for the general hospital population despite 40 years of medical advances. by responding to RA. The Association Between Age. or the false impression that the medical staff are simply "giving-up". the greatest determinants of outcome are: whether the arrest was witnessed. more in-hospital cardiac arrests (IH CA) are witnessed compared to out-of-hospital cardiac arrests (OH CA). death has become an institutionalized experience and is intimately associated with technology. reliable prognositicators are available to help determine whether to start and when to stop.'" This means that. United States (U."'" The likelihood of survival is greatest following ventricular fibrillation (VF) with decreasing survival following ventricular tachycardia (VT). Many studies have found an association between being house-bound/functional dependant and significantly decreased survival following cardiac arrest. but not full CPR (i.e. Co-Morbidities.'" This difference is presumed to be because. many are reluctant to stop CPR once they have started. and Survival The order of "survivability" following cardiac arrest is consistent between studies.e. As will be outlined. in North America.e. that began as asystole. it is appropriate to recommend pulmonary resuscitation alone (i.S." As such. full cardiac collapse is avoided. while at the same time avoiding potentially futile therapy. and introduces the potential influence of co-morbidity upon survival. However.1 53 . However. namely most ASY/PEAs are un-witnessed and most VF/VT are witnessed.000 CPR attempts occur annually in the United States (U. "how" they are resuscitated) PATIENT FACTORS Initial Cardiac Rhythm and 2/3rds of in-hospital arrests are currently ASY/PEA "(see below).e. As a result of the different survival rates. for some patients. This "middle-ground" may be reassuring to families who might otherwise misconstrue a DNR to mean patient neglect. Furthermore.' Of note. physicians can estimate non-survival. and how long until restoration of spontaneous circulation (ROSC). survival following primary RAs is significandy higher. the initial arrest type.)' and the cost of unsuccesful efforts exceeds $1 billion U. 11 This raises the adage familiar to clinicians of the contrast between "the good 80 year-old" and "the bad 80 year-old".e."" Primary respiratory arrest (RA) versus primary cardiac arrest (CA) versus In contrast to cardiac arrests. This also facilitates treatment of reversible illness and adequate attention to symptom control such as discomfort or dyspnea. intubation and mechanical ventilation). Furthermore. This also prevents a do-not-resuscitate order (DNR) being misconstrued as "do-not-respond". followed by pulseless electrical activity (PEA) and is lowest for asystole (ASY). requiring intubation but no need for chest compressions/defibrillation) survive to be discharged home. Equally. Greater than 40% of respiratory arrest patients (i. at least 70% of North Americans die in Hospital. Strong co-linearity also exists between the arrest type and whether an arrest is witnessed. overall." This compares with less than 15% discharged home following unwitnessed cardiac arrest. and ICU/CCU transfer." In fact.) Un-witnessed cardiac Arrest (UW CA) Ventricularfibrillation(VF) Ventricular tachycardia (VT) Witnessed cardiac arrest (W CA) BACKGROUND Up to 750."' " Understandably. and 25% of these occur in Intensive Care Units (ICUs). intubation plus chest compressions and defibrillation). This means patients still receive rapid attention.Abbreviations (alphabetically): Advanced Cardiac Life Support (ACLS) Asystole (ASY) Cardiac Arrest (CA) Cardiopulmonary resuscitation (CPR) Coronary Care Unit (CCU) Do not resuscitate (DNR) In hospital (IH) Intensive Care Unit (ICU) Operating rooms (ORs) Out ofHospital (OH) Pulseless electrical Activity (PEA) Restoration ofspontaneous circulation (ROSC). CPR is an expectation for anyone without explicit contrary documentation " and many physicians feel pressured to offer CPR regardless of patient factors.'^™ Similarly. 14 but just as many have not.S. an arrest that is unwitnessed. it is patient factors (i.

" To put this into stark contrast."'^^ Survival to discharge following CA in ICU/CCU is as high as 30%.000 cases) and found that survival to hospital discharge was roughly 5. there was no significant survival improvement?''" Authors have therefore recommended not offering ACLS in this setting. This is likely because delay in CPR is a significant predictor of death. neurological recovery is often acceptable with > 50% of both adult and pédiatrie survivors maintain satisfactory cerebral performance. and Intensive Care (ICU) and Coronary Care Unit (CCU) back-up." As such.^'' Even with on-site ACLS-trained physicians. again the literature raises doubts. For example. consistent evidence exists linking the location of a cardiac arrest with survival. In contrast for the 55% of arrests that were witnessed approximately l-in-2 still achieved ROSC. myocardial infarction. Doig et al. survival is very poor with most studies reporting < 5% survival following CPR and <1% survival for unwitnessed Nursing Home cardiac arrestSi'''^''^^ However. In contrast. > 50% patients were not offered CPR. as the hospital studied were large tertiary-care urban hospitals that possessed 24hr "code teams". and l-in-5 were able to return home. a Danish study reported an impressive 8."'' Canadian data showed that. however. found that survival was not significantly lower for those with four or more active medical problems versus three or less. sepsis.7% survival-to-discharge for OH arrests (and A&Vo survival to ten years)." OTHER ISSUES Surgery for patients with pre-existing DNRs Many physicians are unsure what to do when the patient with a DNR order requires surgery. LOCATION OF CARDIAC ARREST Out of Hospital Cardiac Arrest (OH CA) OH CA has significantly lower survival compared to inhospital (IH) CA. Of note. However. even this may represent a "best-case scenario".e. Many hospitals are also focusing on ensuring rapid response with the hope of early identification and stabilization of patients in order to prevent full cardiovascular collapse.'^ Definitive conclusions are likely complicated by differing study design and disease definition.^' Bedell et al. Witnessed Arrests (WA) versus Unwitnessed Cardiac Arrests (UWA) As stated above.""* This nearly two-fold survival improvement when compared to general hospital inpatients is believed to be because arrests are witnessed and resuscitation begins almost immediately. Therefore. 18.'^ There is also a common assumption that those with cardiac illness who suffer a primary cardiac event are more likely to survive than those with non-cardiac illness (i. in the above mentioned Canadian study when WA and UWA were combined approximately l-in-3 had R o s e . as compared to a UWA. with 13. renal failure or hypotension. congestive heart failure. and defibrillators. despite 40 years of medical advances. In a prospective study. many authors advocate ceasing CPR immediately.'° Interestingly. l-in-4 survival to discharge. if patients arrive in ASY despite OH CPR.1 Canadian Journal of Respiratory Therapy Revue canadienne de la thérapie respiratoire . it has been recommended to withhold CPR. Regardless.0 %. survival following IH CPR has not significantly improved. survival is significantly higher following a WA. Furthermore. with l-in-3 survival to 24 hrs.4% survival to hospital discharge. but disappointingly there is insufficient evidence to definitively predict the outcome solely based upon pre-existing illness or advanced age. This is in stark contrast to the lesser resources of rural hospitals.'^ Despite the apparent common sense that patients with single organ disease are likely to do better than those with multi-organ dysfunction. hypotension. many hospitals wish to increase the number of monitored beds. there is also disagreement in the literature regarding the influence of co-morbidities. ptieumonia." fot unwitnessed OH ASY.'-"^" Similarly.elderly Nursing Home patients. l-in-7 survived to hospital discharge. un-witnessed OH PEA with CPR greater than five minutes appears uniformly fatal. In-Hospital (IH) Survival to discharge following IH CPR for the general hospital population (and excluding those admitted to ICU/CCU) is typically <15%. almost 30% of NH patients receive CPR following un-witnessed arrests. sepsis.^' However. This selection bias reduces the study's generalizability at the same time as emphasizing the impottance of who is resuscitated upon survival. a Canadian multivariate analysis failed to find a significant association between survival and the presence of malignancy. This is in contrast to the 45% of arrests that were unwitnessed where only one-fifth had R o s e and where nobody survived to discharge. This is relevant as up to 15% of patients with pre-existing DNR orders currently 54 Spring | Printemps 2010 Volume I Numéro 46.^' or not to exceed ten minutes. pneumonia) who then suffer a cardiac arrest. pneumonia and cancer." Of note. did fmd an association between decreased survival and renal failure. and 1-in-lO returned to independent living. this data emphasizes the importance of early response and also whether an arrest is witnessed. for the survivors." However. this pre-hospital system includes dispatched physicians who decided whether or not to perform CPR.^' The Ontario Prehospital Advanced Life Support (OPALS) Study is the largest OH CA multi-centre study (17 cities.

Elam JO. Most hospitals. Horan MA. Anesthesiology 1957 18(6). Most AS. 7. J. Reappraisal of DNR orders in long-term-care institutions.254(l6):727-32. 16. 22. Regardless. Gardiopulmonary resuscitation in elderly patients hospitalized in the 1990s: a favorable outcome. preemptive on ongoing communication is required in order for the patients wishes to be respected and for the OR staff to feel comfortable to proceed. and restoring spontaneous circulation within 20 mins (i.42:137-41. However. Gulati RS. 11. Canadian Journal of Respiratory Therapy Revue canadienne de la thérapie respiratoire Spring | Printemps 2010 Volume I Numéro 46.261:1582." It appears that much work remains to be done. Markland DM. J Palliât Gare2000. Nolan. for all of these reasons. Bhan GL. Mouth-to-mouth airway. GMAJ 2000. many physicians are reluctant to address resuscitation wishes. found survival to be over 60%. this mandates ongoing debate about when this offers a chance for "better life" and when it threatens a "worse death". 13. Mayers I. Attempting resuscitation in nursing homes: policy considerations. Epstein FH. Diem et al. Harper GM. Girculation 2005. and because operating rooms are inadequate for family visitation and bereavment if death occurs. JAMA 1989. Knickerbocker.lV-5. European resuscitation council guidelines for resuscitation 2005 section 1. Jude JR. "technology" must not replace "humanity". Tranmer J et al. Forster AJ. Arch Intern Med 1999. First documented rhythm and clinical outcome from in-hospital cardiac arrest among children and adults. Stiell IG. technologically supported experience. Survival after cardiopulmonary resuscitation in the hospital. communication is central to Medical Care. the inevitability of eventual death means communication will always be paramount. N Engl J Med 1956. WR. 112(24 Suppl): IV-1 .^^" However. N Engl J Med 1958. Technological advances must not supplant open communication. 9. Berger R. Zoll PM. Heyland DK. Eisenberg MS. Dying in Ganada: is it an institutionalized. Ghesnut. A 2-year prospective cohort study of cardiac resuscitation in a major Ganadian hospital. Even more concerning is that educational initiatives have not significantly improved this. Bedell.1 55 . COMMUNICATION times the actual survival rate. 3. 6. Milnor WR. at the same time that television may minimize the true consequences of attempted resuscitation. Gapone RJ. VanBeek K. Linenthal AJ. Resuscitation 2005. Overall. Termination of ventricular Fibrillation in man by externally applied electrical countershock. Glosed chest defibrillation of the heart. FinucaneTE. SE. many physicians may be overly pessimistic regarding outcome following CPR. families. Unsuccessful emergency medical resuscitations: are continued efforts in the emergency department justified? N EnglJ Med 1991. Masi A. Gray WA. 17.2:267-9. EGG Gommittee.309:569-75. Predictors of survival following in-hospital adult cardiopulmonary resuscitation. Boiteau PJE.258(14):671-7. it is our hope that this manuscript provides sufficient objective information to stimulate meaningful discussion. J Am Geriatr Soc 1999. REFERENCES 1. Kerr D. feeding tubes. Glin Invest Med 2000. Glosed-chest cardiac massage. 4. Kouwenhoven WB.47(10):1261-4.295(l):50-7. 5. Unfortunately. Kutty K. tracheostomies etc. JAMA 2006. Reasons include because routine perioperative management usually requires cardiopulmonary support (i.159(2):129-34. Ghest 1994. 173:1064-7.67(Suppl 1):S3-S6. Delbanco TL.e.325:1393-8. Gibson W. CONCLUSION Therapeutic efforts should continue to improve outcome following CA." Reasons include relief of obstruction/pain. 12. Derivation of a clinical decision rule for the discontinuation of in-hospital cardiac arrest resuscitations.^' In a novel review of cardiac arrests on television. Larkin GL. N EnglJ Med2001. and to patient and family satisfaction. J Am Geriatr Soc 1994. However. Equally. Primary care: cardiac resuscitation. Garey SM.167(4):343-8. Therefore. Doig GJ.23(2):132-143. Peberdy MA.904-6. its voice is needed now and in the future. JAMA 1988. However it may represent the expectation of the lay public. As such. 21. Taffet GE. Few specialties understand this better than Internal Medicine. 20. Introduction. and inadequate communication is a frequent cause of conflict. Gardiopulmonary resuscitation of old people.receive operations. Paul MH. Survival after in-hospital cardiopulmonary arrest of non-critically ill patients.42(3):55O-61. GG. VF/VT as initial cardiac rhythm (as c/t ASY/PEA). it means that a useful starting point is to ask about patient's and families' assumptions. Tresch D. Escarrraga L. Lancet 1983. Obviously issues remain as to what constitutes an appropriate peri-operative period such that the DNR may be re-instated. and patients.'' This is two to four Only three factors have been consistently associated with increased survival witnessed arrest (as c/t to un-witnessed cardiac arrest). JAMA 1960.e intubation for surgery). 106:872-9. et al. Heudebert G. 14. nor can they replace individualized decision-making. 18. In-hospital cardiopulmonary resuscitation. Teasdale. 2. Subcommittees and Task Forces of the American Heart Association. suspend DNR orders for the perioperative period.260:2069-72. Surgery 1957. because routine recovery from the perioperative insult may require an ICU stay. Safer P. 8. 10. Lavery JV. 19. Knickerbocker GG. Kouwenhoven WB. Nadkarni VM. Kelly M. 2005 American Heart Association Guidelines for Gardiopulmonary Resuscitation and Emergency Gardiovascular Gare Part 1: Introduction.^"^ There is also poor agreement between the beliefs of doctors. Ohlert J. Gook EF. N Engl J Med 1983.344(17):1304-12. Brindley PG.l6:S10-l6. Sandham JD. Safer P. Laudable efforts to increase survival will continue. Kutsogiannis DJ. TA. Mengert TJ. Norman LR. appropriately. Luchi R. In short. A comparison of the mouth-tomouth and mouth-to-airway methods of artificial respiration with the chest pressure arm-lift mediod. van Walraven G. not offering prolonged CPR).

Field BF. J Am Geriatr Soc 1993. Ko I-J. et al. 31.95:I23-30. 10:219-23. et al. Advanced cardiac life support in out-of-hospital cardiac arrest. 34. Kuisma M. et al. Termination of resuscitation in the pre-hospital setting for adult patients suffering nontraumatic cardiac arrest. Ethics review: perioperative do not resuscitate orders .157(l):72-6. Acta Anaesthesiol Scand 2008. Lippert F.23. Lantos JD. Outcomes of cardiopulmonary resuscitation in nursing homes: can we predict who will benefit? Am J Med 1993. Bailey ED. Who survives from out-of-hospital pulseless electrical activity? Resuscitation 2008. A controlled trial to improve care for seriously ill hospitalized patients. 35. 25. 274:1591-98. Considering CPR policy. Yu H-Y. Prehosp Emerg Care 2000. Walter C. Califf RM. Wydro GC. Wenger NS. Neilsen SL. Spaite DW. Boyd J. Groll D. 28. Associate Professor and Residency Program Director. 26. Circulation 2000. Unit 3C4. Rasmusen LS. Duthie EH. Wells GH. J Am Coll Cardiol 2003. JAMA 1995. 30. Can Med Assoc J 2006.doing nothing when something can be done. Rocker G. FitzGerald JD. Edmonton.76(2):207-13. 38. Boyd J. New Engl J Med 2002. Division of Critical Care Medicine.346(8):549-56. et al. Wu I-H et al.ca 56 Spring | Printemps 2010 Volume I Numéro 46. Diem SJ. 24. 29. Resuscitation 2007:75:23-8 32. Stiell IG. 27.102 Suppl 8:1142-57. Cheung M. Tresch DD.1 Canadian Journal of Respiratory Therapy Revue canadienne de la thérapie respiratoire . Arch Int Med. New Engl J Med 1996. Alberta T6G 2B7. The SUPPORT Principal Investigators. Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: International Consensus on Science. Gafni A. 36. Ewanchuk M. The Hypothermia After Cardiac Arrest Study Group. 1997. Vayrynen T. Phillips RS.52(l):81-7. Kuisma M. Mild therapeutic hypothermia to improve neurologic outcome after cardiac arrest. Canada Tel: (780) 407-8822 Fax: (780) 407-6018 Email: peterbrindley@cha. Kane RS.48(5). Heyland D. Mackenzie Centre University of Alberta Hospital. 334:1578-82 Correspondence to: Dr. Poor outcome of on-site CPR in a multi-level geriatric facility. Chao A. Tulsky JA. Vayrynen T. New Engl J Med 2004. 37. 174: 627-33. Chen Y-S. Gordon M. Medical futility in asystolic out-of-hospital cardiac arrest. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). Nearing JM. Crit Care 2006. Brindley PG.ab. Analysis and results of prolonged resuscitation in cardiac arrest patients rescued by extracorporeal membrane oxygénation.351:647-56.4l(2):197-203. SUPPORT investigators study to understand progress and preferences for outcomes and risks of treatment. 8440-112 Street. J Am Geriatr Soc 2000. Määttä T. Cardiopulmonary resuscitation on television: Miracles and misinformation. Holler NG.41:163-6. Peter Brindley. Cone DC. Määttä T. National Association of EMS Physicians (NAEMSP) Standards and Clinical Practice Committee. 33. What matters most in end-of-life care: perceptions of seriously ill patients and their family members. Functional status among survivors of in-hospital cardiopulmonary resuscitation. Dodek P. Mantoni T. Long term survival after out-of-hospital cardiac arrest.4:190-5.

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