Saudi Critical Care Journal

ORIGINAL ARTICLE
Year
: 2021  |  Volume : 5  |  Issue : 1  |  Page : 1--6

Incidence of unexpected cardiac arrest among intensive care unit patients in national guard hospitals in Jeddah, Riyadh, and Al Ahsa


Abdullah M Alharbi, Ahmed A Alghamdi, Rashid A Albakistani, Mohammed A Alshehri 
 College of Applied Medical Sciences, Department of Emergency Medical Services. King Saud bin Abdulaziz University, Jeddah, Kingdom of Saudi Arabia

Correspondence Address:
Ahmed A Alghamdi
College of Applied Medical Sciences, King Saud bin Abdulaziz University, P. O. Box: 23763, Jeddah
Kingdom of Saudi Arabia

Abstract

Background: Cardiac arrest (CA) is a sudden collapse of cardiac mechanical function as evidenced by the absence of detectable pulse and the absence or gasping of breath, which all combined with a loss of consciousness. Although researches on resuscitation efforts have been increasing significantly recently, little investigations have been done on the incidence of unexpected CA among intensive care unit (ICU) patients, in particular, in Saudi Arabia. Aim: The main goal of this research is to explore the rate and patient characteristics of unexpected CA among in ICU patients in the National Guard Health Affairs hospitals in Jeddah, Riyadh, and Al Ahsa. Materials and Methods: This study was a retrospective analysis of ICU patients who experienced unexpected CA. Settings: The study was conducted at the ICUs of three National Guard hospitals in Saudi Arabia. Results: Findings showed that only 11% of the ICU patients who received cardiopulmonary resuscitation (CPR) had a successful return of spontaneous circulation and the overall mortality rate was 89%. The most common cause of unexpected CA is sepsis, found in 348 out of 1233 patients (28%). The most common medical history accompanied by the ICU patients' medical history is a multi-organ dysfunction, found in 184 out of 1233 (14.9%) patients. We found a weak negative relationship between patients' gender and the causes of unexpected CA (relative risk = −0.069 and P < 0.05). Conclusion: The findings are in line with prior studies confirming that mortality increases when unexpected CA occurs on patients with sepsis. There was no significant relationship seen between patients' age and CPR outcomes.



How to cite this article:
Alharbi AM, Alghamdi AA, Albakistani RA, Alshehri MA. Incidence of unexpected cardiac arrest among intensive care unit patients in national guard hospitals in Jeddah, Riyadh, and Al Ahsa.Saudi Crit Care J 2021;5:1-6


How to cite this URL:
Alharbi AM, Alghamdi AA, Albakistani RA, Alshehri MA. Incidence of unexpected cardiac arrest among intensive care unit patients in national guard hospitals in Jeddah, Riyadh, and Al Ahsa. Saudi Crit Care J [serial online] 2021 [cited 2021 Oct 27 ];5:1-6
Available from: https://www.sccj-sa.org/text.asp?2021/5/1/1/314441


Full Text



 Background



Cardiac arrest (CA) is a sudden collapse of cardiac mechanical function as evidenced by the absence of detectable pulse and the absence or gasping of breath, which all combined with a loss of consciousness.[1],[2] The first report of cardiopulmonary resuscitation (CPR) for in-hospital CA was published >50 years ago.[3] In the meantime, resuscitation research has significantly increased; guidelines for cardiac resuscitation have been implemented on an international level and have experienced several substantial changes. Etiologies of unexpected CA in intensive care unit (ICU) are not commonly described in the literature, perhaps since they can be related to the patient's medical characteristics. According to the British registry, 17.6% of all CA occurs in ICUs or other high acuity care units. This contrast two others' analysis of the American Heart Association (AHA) National Registry of Cardiopulmonary Resuscitation, which included all in-hospital CA; they showed that 37% of in-hospital CA occurs in the ICU.[4] Another registry used a similar dataset that documented a median incidence of 4.02 In hospital cardiac arrest (IHCA) per 1000 hospital admissions.[5] These data illustrate that critically ill patients in the ICU are more susceptible to in-hospital CA.[6] Mostly, ICU patients are extensively monitored, which allows early activation of the resuscitation team who are well trained.[7],[8] A study shows that there is evidence for survival for hemodynamic-directed CPR rather than standard CPR in ICU patients.[9] The initiation of CPR within 30 s has been reported in the ICU-CA series.[10],[11] However, the event can occur in critically ill patients with a very-limited physiological reserve. In addition, the success rate of resuscitation among ICU patients who experienced CA is high. Despite the success rate of ICU resuscitation, the survival rate upon hospital discharge is usually low.[12],[13] The institution of CA teams for in-hospital resuscitation has become a standard for many health centers worldwide. However, the reported survival rates vary significantly with the center, patient, and event characteristics.[14],[15] Examining patients' characteristics and factors that affect the outcome of IHCA could possibly offer a new extent of the existing knowledge about patients' outcomes in the ICU. According to a study, the posttreatment for ICU patients who survived after CPR recommends hypothermia therapy and coronary artery intervention to improve patients' outcomes and stay under observation.[16]

 Introduction



CA defines as the failure of cardiac mechanical function as it proves by the absence of a detectable pulse in the central artery and failure of the body to maintain full respiratory oxygenation and loss of any sign of breathing, all combined with a loss of consciousness.[17] People usually have mistaken between CA and the heart attack to differentiate between them; there is a set of clinical features including symptoms to investigate. The heart attack is characterized by a blockage that prevents the blood flow in and to the heart, resulting in the death of cardiac muscle tissues. When the heart attack is left untreated, it can develop to be CA. Meanwhile, the CA itself happens due to a malfunction in the electrical system of the heart, and it usually occurs suddenly.[18] Early work established the term of unexpected as a subclass of in-hospital CA from which it differs on several points.[19] Each year, 180,000–400,000 people in the United States of America (USA) experienced CA, a large portion due to unknown reasons.[20] A recent report shows a high success rate of recovering spontaneous circulation after a CPR (50%), but only 15% survive their hospital stay.[19] Another report from the AHA shows that one in every 7.4 people will die of sudden cardiac death in the USA.[21] Notwithstanding a surge in interest and research regarding ICU-CA, not much has been reported in Saudi Arabia regarding etiologies and the consequences of such event. Therefore, the primary goal of this research is to explore the incidence of unexpected CA among ICU patients in the National Guard Hospitals in Jeddah, Riyadh, and Al Ahsa. Moreover, secondary goals are to identify the most common causes of unexpected CA and their correlation to patients' characteristics and also to explore the outcomes of CPR and their correlation to patients' characteristics. Besides, to explore the most common ICU patients' medical history who experienced unexpected CA.

To our knowledge, no study has investigated the nature and duration of ICU support for patients with IHCA in the Saudi Arabia context.

 Materials and Methods



Study type

This study was a retrospective data analysis. This study sas a cross-sectional study design, since we were trying to find the incidence of ICU patients who experienced unexpected CA over the past 5 years ranging 2014–2019 in ICUs in National Guard Hospitals in Jeddah, Riyadh, and Al Ahsa.

Study area, setting

The study was conducted on ICUs in National Guard Health Affairs Hospitals in Jeddah, Riyadh, and Al Ahsa.

Study subjects

Inclusion criteria

All the eligible patients who experienced unexpected CA over the past 5 years ranging 2014–2019 in ICUs in National Guard Hospitals in Jeddah, Riyadh, and Al Ahsa.

Exclusion criteria

Any patient who experienced unexpected cardiac but not inside the ICU and patients who experienced unexpected cardiac but agreed before to do not resuscitate protocol were excluded.

Sample size

The sample size was 1233, a convenience sampling technique, with a 95% confidence interval (CI) since there were no previous studies regarding our object in Saudi Arabia. 1233 patients, who met the research's inclusion criteria, were found in BEST CARE, which is a program where all patients' data in the National Guard Hospitals in Saudi Arabia are collected. All patients' data, 1233 patients, were collected in the data collection stage as avoiding bias.

Sampling technique

All patients' data were collected from each National Guard Health Affairs Hospital individually in Jeddah, Riyadh, and Al Ahsa in a convenience sampling technique. The BEST CARE program was used to fill the research's organized spreadsheet after checking for accuracy and reliable data.

Data management and analysis plan

After data accuracy and reliability had been checked, the IBM® SPSS® Statistics Subscription, version 1.0.0.1406, was used for data analysis.

 Results



In our sample size of 1233, we found out that 60% of them were male patients (n = 744) and 40% were female patients (n = 489). The mean age of the included patients was 62.28 years, with a standard deviation 18.98. After patients' data were collected, the analysis showed some significant outcomes, and some are predictable. According to the most common cause of unexpected CA, the results pointed out that sepsis is the most common cause, found in 348 patients out of 1233 patients (28%), as shown in [Figure 1].{Figure 1}

Sepsis was seen as the most common cause of unexpected CA in our ICU patients' sample, 348/1233 (28%). We found that patients with sepsis are more likely to not survive when compared to no septic patients (RR = 1.13). Brain damage comes as the second most common cause with 68 patients out of 1234 (5%). MI was seen in 61 patients out of 1234 (4.9%). Cerebrovascular accents including stroke, deep vein thrombosis, pulmonary embolism, and coronary artery thrombosis were found in 51/1233 (4.13%). In the infant population, prematurity was the most cause of CA in the ICU, 48/1233 (3.8%). We found that pneumonia was the eighth common cause of unexpected CA found in 37/1233 (2.99%). Kidney diseases that include bowel ischemia, urinary tract infection and glomerulonephritis 36/1233 (2.91%). Traumatic brain injury, TBI, 27/1233 (2.1%). Those are the most common ten causes of unexpected CA among ICU patients in National Guard Hospitals in Jeddah, Riyadh, and Al Ahsa.

Gender and its association with causes of arrest

[Table 1] shows the causes of unexpected CA among ICUs' distribution and patients' age.{Table 1}

We found a weak negative relationship between patients' gender and the causes of unexpected CA (RR = −0.069.)

After conducting the Chi-square test (1.2172), we calculated the P value and determined that there is no significance between males and females in CPR outcomes.

Patients' medical history and comorbidity

In our sample of ICU patients, we found that the most common medical history was multi-organ failure found in 229/1233 (18.6%) patients with survival RR of 1.14. Pneumonia comes the second common medical history found in 79/1233 (6.4%) patients with survival RR of 1.03. Patients with no prior significant medical history were seen in the ICU sample as the third in 70/1233 (5.7%) with survival RR 1.09 [Table 2].{Table 2}

In our sample of ICU patients, the most common medical history was multi-organ dysfunction found in 185/1233 (14.9%) patients. Diabetes comes the second with 75/1233 (6%) patients. Third, patients with a history of previous CA, 72/1233 (5.83%). Kidney disease 60/1233 (4.86%). No history can also be seen in ICU patients who experienced unexpected cardiac, i.e., 57/1233 (4.6%) patients. Myocardial diseases 50/1233 (4.05%). Sepsis 40/1233 (3.24%). Pneumonia and cancer come at the same stage as 38/1233 (3.07%) both. Hypertension 29/1233 (2.35%). we calculated the P value from the Chi-square which is 3.1193. Therefore, the P value is 0.959 which means there is a significance between the RRs.

Cardiopulmonary resuscitation outcome analysis

[Figure 2] shows the CPR outcomes among ICUs' patients who experienced unexpected CA in National Guard Hospitals in Jeddah, Riyadh, and Al Ahsa.{Figure 2}

In terms of CPR outcomes, the main outcome was survival. We found that 136 patients (11%) of the ICU patients who received CPR survived to return of spontaneous circulation (ROSC), whereas 1097 patients out of 1233 (89%) deceased.

Relation between age and cardiopulmonary resuscitation outcome

[Figure 3] and [Table 3] are the same just only different analytic demography.{Figure 3}{Table 3}

We found out that there is no significant relationship between the age and CPR outcomes since we calculated Chi-square as 13.3779 and determined the P value as 0.02. Therefore, we are failing to reject a null hypothesis. However, we found out that patients whose age >51 years have higher chances of survival (RR = 0.99) compared to patients aged 20–30 years. Surprisingly, pediatric patients in our sample size had a survival rate of 3.9% and RR of 1.09. This may be due to the prematurity causes which is seen as the fifth common cause of arrest overall ICU patients, adults, and pediatrics and the first common cause in infants.

Type of intensive care unit analysis

The most common type of ICU that faces unexpected CA which is internal medicine (IM) ICU with the highest numbers of causes or arrest, i.e., 474 patients. The second type is cardiology ICU with 213 patients. The third type is general surgery ICU with 178 patients. After calculating the P value which is 8.4027, we found out that there is a great significance between types of ICU and their CPR outcomes. The P value is odd because of 0 in most of the ROSC outcomes [Table 4].{Table 4}

 Discussion



This study is a retrospective analysis investigating the relevance and incidence of unexpected CA in intensive care patients. We use the definition of unexpected CA as the failure of cardiac mechanical function as it proves by the absence of a detectable pulse in the central artery and failure of the body to maintain full respiratory oxygenation and loss of any sign of breathing, all combined with a loss of consciousness.[17] We aimed to explore the effects of patients' characteristics and factors such as patients' comorbidities and the type of ICU in overall patients' outcomes. The main patient outcome in our analysis was survival after a successful CPR. We included 1233 ICU patients in our analysis, of which 39.65% were female and 60.35% were male with a mean age of 62.28 years. From our results, we found that there was no statically significant difference seen between genders and CPR outcome (survival vs. deceased) (RR = 1.02). In terms of CPR outcomes, the main outcome was survival. We found that 136 patients (11%) of the ICU patients who received CPR survived to ROSC, whereas 1097 patients out of 1233 (89%) deceased. The incidence of unexpected CA in ICU differs considerably in the literature.[1],[2] This may be attributed to different factors such as ongoing monitoring, more nurses/doctors, and supportive therapies, and the medical response is also necessarily different. Each patient's characteristics and medical history vary from the other, which will eventually impact the IHCA's posttreatment and mortality rate. Recent investigations indicated that IHCA and ICU-CA are distinct groups with diverse outcomes and form their entities.[1] In our investigation, we focused on intensive care CA. Regarding ICU patients' medical history and comorbidities in post-CA, we found that the multi-organ dysfunction had the highest mortality rate, 227/1097 were deceased, and only 2/136 achieved ROSC, with RR of 1.14. Not surprisingly, the data reported that ROSC appeared in <50% of the patients and about half of the initial survivors died later from different causes, commonly hypoxic brain injury or shock with multiple organ failure.[3] According to the WHO, another comorbidity was seen in our sample, which is diabetes mellitus (DM) which ranked Saudi Arabia as the second-highest country in the Middle East.[4] However, DM alone as medical history in ICU patients will not affect their mortality in post-CA, with RR of 0.93. There are various types of ICUs that differ in their services and the level of care provided to name a few; coronary care and cardiothoracic units. Those units provide care for patients with cardiac-related conditions such as heart surgery patients. Moreover, we explored the potential effect of different ICU types on a patient's outcome regarding IHCA in ICU patients. In our cohort of patients, we found that patients admitted to the IM ICUs have higher mortality than patients in cardiac center ICUs (RR: 1.13, 95% CI, P = 0.0003). In addition, we found out that oncology intensive care unit (ONC ICU) patients have the lowest rate of survival outcomes. Patients in ONC ICUs tend to be late-stage cancer patients who require end-of-life care or palliative care.[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22] Early analyses documented a success rate of 39% and survival to discharge of 17% of in-hospital CPR.[7] Subsequent studies concentrated on patients with high risk such as cancer and reported a 0%–10% survival rate.[8],[9] However, CPR's long-term benefit is diminutive among cancer patients, even when the initial CPR is successful. Moreover, this is evident not only in patients where a patient's malignancy precludes long-term survival but even in patients where the underlying malignancy results in decreased reserves of critical organ activity.[10],[11] Future studies should include aspects often concealed within hospital and unit features to disclose potential relationships integrated into interventions to prevent unfavorable consequences.

This analysis has strengths and limitations. First, we extracted data from an ICU registry and included all patients treated at three tertiary care hospital ICUs. Furthermore, in the data collection stage, several causes of arrest were gathered in patients' data into their main category in our organized spreadsheet, for instance*, stroke and any other issues in the cerebral artery into a cerebrovascular accident. Second, we demonstrate the results of high-volume ICUs with much experience in the intensive care management. Therefore, outcomes are generally not transferable to other settings with less experience. Third, data on patient characteristics were limited, as detailed as life support that was provided during the IHCA. This study only included patients with ICU-CA, which should be viewed when interpreting our results. Future work should be directed toward assessing risk factors and prearrest factors.

 Conclusion



CA defined as the failure of cardiac mechanical function as it proves by the absence of a detectable pulse in the central artery and failure of the body to maintain full respiratory oxygenation and loss of any sign of breathing, all combined with a loss of consciousness.[17] Our findings showed that sepsis was the most common cause of unexpected CA, and correlation statistics indicated a weak relationship between patients' gender and arrest causes (r = −0.069 and P < 0.05). Furthermore, most patients' medical history was a multi-organ failure and overall CPR outcomes were 89% deceased, and 11% survived to ROSC. There was no significant relationship seen between patients' age and CPR outcome. The most common type of ICU that faces unexpected CA is IM ICU with 474 patients. The findings were not surprising; previous studies reported similar findings.[16],[17],[18],[19],[20],[21],[22],[23]

Financial support and sponsorship

This research is supported by King Saud bin Abdulaziz university for Health Sciences, College of Applied Medical Sciences, Jeddah. This research is approved by the Institutional Review Board in King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs.

Conflicts of interest

There are no conflicts of interest.

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