Search Results (34)

Background and objectives: In older and frail patients, in-hospital cardiac arrest (IHCA) is associated with high mortality. Early warning scores such as the National Early Warning Score 2 (NEWS2) are widely used to detect clinical deterioration, but their predictive accuracy in frail populations remains uncertain. This study aimed to assess whether integrating frailty measures with NEWS2 could better describe elderly IHCA patients. Materials and Methods: We conducted a single-center, retrospective observational study in adult and frail patients (≥18 years) admitted to medical and surgical wards of the University Hospital of Siena who experienced IHCA between January 2022 and January 2024. Data on demographics, such as last NEWS2 before IHCA, Clinical Frailty Scale (CFS), Barthel Index (BI), and Charlson Comorbidity Index (CCI) were retrospectively collected and analyzed. Patients were stratified into three categories, according to NEWS2: Stable (A), Potentially Unstable or Unstable (B), and Critical (C). Results: Seventy patients were analyzed (mean age 76.9 ± 11.0 years; 56% male). The mean pre-IHCA NEWS2 score was 6.0 ± 3.5, with 41% of patients classified as NEWS2-C, 48% classified as NEWS2-B, and 11% classified as NEWS2-A. The NEWS2-A category showed higher BI and lower CFS than NEWS2-B and NEWS2-C (p < 0.01), while CCI and age did not significantly differ. Conclusions: The association of NEWS2 with frailty scores could identify some elderly patients with limited pre-arrest physiological derangements but high frailty who suffered from IHCA. These findings provide descriptive insights that may inform monitoring strategies for “at-risk” elderly patients to help prevent IHCA. Full article

Background: In-hospital cardiac arrest (IHCA) constitutes a high-impact clinical event, associated with substantial mortality, frequent neurological and functional impairment. There is a pressing need for primary IHCA studies that evaluate risk predictors, given the inherent challenges of IHCA data collection, previously unharmonized reporting frameworks, and the predominant focus of prior investigations on other domains. Among potential contributors, the “off-hours effect” has consistently been linked to poorer IHCA outcomes. Accordingly, we sought to examine whether in-hospital mortality after IHCA varies according to the time and day of occurrence within a tertiary academic center in Northern Greece. Methods: We conducted a single-center observational cohort study using a prospectively maintained in-hospital resuscitation registry at AHEPA University General Hospital, Thessaloniki. All adults with an index IHCA between 2017 and 2019 were included, and definitions followed Utstein-style recommendations. Results: Multivariable logistic regression adjusted for organizational, patient, and process-of-care factors demonstrated that afternoon/night arrests, weekend arrests, heart failure comorbidity, and need for mechanical ventilation were independent predictors of higher in-hospital mortality. Conversely, arrhythmia as the cause of IHCA and arrests occurring in the intensive care unit or operating room were associated with improved survival. Subgroup analyses confirmed consistent off-hours differences, with weekend events showing reduced 30-day and 6-month survival and worse functional status at discharge. Afternoon/night arrests were more frequent, characterized by longer response intervals and lower survival at both time points. Conclusions: Organizational factors during nights and weekends, rather than patient case mix, drive poorer IHCA outcomes, underscoring the need for targeted system-level improvements. Full article

Background/Objectives: In-hospital cardiac arrest (IHCA) carries high mortality and substantial risk of neurological and functional impairment. Given that contemporary, clinically relevant risk models remain limited, especially within Southern European systems, the aim of this study was to develop a process-aware model for bedside risk stratification. Methods: We retrospectively analyzed a single-center cohort from a prospectively maintained resuscitation registry (AHEPA University General Hospital, Thessaloniki). Adults (≥18 years) with index IHCA in 2017–2019 were included. Utstein-defined variables underwent univariable screening, LASSO selection, and collinearity checks before multivariable logistic regression for in-hospital mortality. We assessed discrimination (AUC) and calibration (Hosmer–Lemeshow). Results: Among 826 IHCAs, 137 survived to discharge and 689 died. Higher mortality was independently associated with longer CPR (aOR = 1.115, 95% CI: 1.080–1.158), older age (aOR = 1.034, 95% CI: 1.014–1.055), and CCU location (aOR = 7.303, 95% CI: 2.557–25.798), while operating room (aOR = 0.029, 95% CI: 0.003–0.252), ICU/HDU (aOR = 0.203, 95% CI: 0.065–0.630), and an initial shockable rhythm (aOR = 0.297, 95% CI: 0.144–0.611) were protective. Longer time to CPR initiation also predicted mortality (aOR = 1.746, 95% CI: 1.001–3.162). Model performance was strong (AUC = 0.897, 95% CI: 0.865–0.928) with good calibration (Hosmer–Lemeshow p = 0.879). Conclusions: A process-aware model integrating patient factors, intra-arrest metrics, and location showed excellent internal performance for predicting IHCA mortality. Findings reaffirm the prognostic importance of age, rhythm, and resuscitation timeliness/intensity and support future work extending prediction to neurological/functional outcomes and testing targeted care bundles in high-risk strata. Full article

Introduction: In-hospital cardiac arrest (IHCA) is still associated with high mortality. Introduction of multi-parameter early warning systems (EWS) could reduce the incidence of IHCA. However, data regarding prevention of IHCA remains conflicting. Moreover, an aging population and a shortage of healthcare workers strain Austrian acute care hospitals. Sicker patients and fewer staff could hinder the implementation of multi-parameter EWS in Austria. Therefore, we sought to identify such barriers by assessing local and national data. Furthermore, we investigated the incidence of in-hospital cardiac arrests at Medical University Innsbruck. Methods: In this perspective study, we retrospectively analyzed all patients experiencing an in-hospital cardiac arrest between 2017 and 2024. In the qualitative part, ten experts in in-hospital emergency medicine were interviewed using guided interviews. The main results from the interviews were identified using a structured content analysis according to Mayring. Quantitative and qualitative data were integrated through narrative. Using the Consolidated Framework for Implementation Research, we stratified our data into five domains. Finally, we applied the “eight steps for leading change” to develop a practice guideline. Results: In six years, 1356 patients were treated by an emergency medical team; 1317 emergencies were included, with 365 of them being resuscitated. Overall, 114 survived for 24 h. The incidence rate of in-hospital cardiac arrests was 0.86 cases/1000 admissions per year. The guided interviews demonstrated a nearly complete absence of EWS using multiple parameters in Austria. Strained human resources after the pandemic, the fear of an increased workload and the lack of robust data regarding the benefit of survival were mentioned as main reasons. The best practice tutorial considers the challenges identified and provides guidance for structured implementation in hospitals. Conclusions: Implementing NEWS2 can facilitate detection of critically ill patients despite decreased staffing. Identifying common barriers and facilitators in five domains described and applying this to the “eight steps for leading change” enabled us to provide a tutorial for implementation of an EWS. This could help master future challenges in in-hospital emergency medicine. Full article

Background/Objectives: In-hospital cardiac arrest (IHCA) remains a critical event with high mortality, requiring coordinated multidisciplinary response. Return of spontaneous circulation (ROSC) and hospital discharge rates are key quality indicators in resuscitation efforts. In Costa Rica, there is limited published data on team performance, protocol adherence, and the pharmacist’s role in code blue events, despite similar evidence gaps across Latin America. This study aimed to evaluate clinical outcomes and operational performance of in-hospital cardiac arrest events at a Costa Rica hospital. Methods: This retrospective cohort study included 77 adult patients who experienced IHCA at Clínica Bíblica between 2020 and 2024. Data collection was conducted between February and May 2025 from electronic medical records and code blue activation logs. Clinical variables, comorbidities, pharmacologic interventions, and outcomes were analyzed. Predictive models (Charlson Comorbidity Index [CCI], IHCA-ROSC, RISQ-PATH) and Kaplan–Meier survival analysis were applied. Results: ROSC was achieved in 55.8% of patients, and 21% were discharged alive. Asystole was the predominant initial rhythm (76.6%), and comorbidities such as renal disease and myocardial infarction were most frequent. A higher comorbidity burden was significantly associated with lower discharge rates (p = 0.032). Despite 98.7% of patients being classified as low probability for ROSC by the IHCA-ROSC model, observed outcomes exceeded expectations (predicted: 5.53% vs. actual: 55.84%; p < 0.000001). The code team adhered to institutional protocols in 100% of cases, with clinical pharmacists playing a key role in documentation and medication tracking. Conclusions: Structured multidisciplinary response was associated with ROSC rates notably higher than predicted by validated models. Opportunities for improvement include post-event laboratory testing, pharmacist-led documentation, and therapeutic hypothermia in shockable rhythms. Full article

Background: Cardiac arrests can occur both in and out of hospital settings. Over the years, several protocols have been developed to standardize the behavior of healthcare professionals called upon to deal with these emergencies. Advanced Cardiac Life Support (ACLS) algorithms enable healthcare professionals to effectively manage cardiac arrest and achieve better patient outcomes, particularly at the time of discharge. Methods: We conducted a narrative review. Three databases (PubMed, Embase, Cochrane) were searched for relevant articles. The articles were screened and analyzed in accordance with the PRISMA guidelines. Results: A total of 1252 articles were initially identified. After screening, 11 papers were included in the review. From the selected studies, it has emerged that ACLS training had several positive effects, including an overall decrease in mortality rates. Adherence to ACLS protocols throughout an event is associated with increased Return of Spontaneous Circulation (ROSC) in the setting of In-Hospital Cardiac Arrest (IHCA). Advanced Life Support (ALS) response interval in out-of-hospital cardiac arrest was associated with decreased survival and a favorable neurological outcome. ALS response ≤ 10 min was associated with improved survival and favorable neurological outcomes. Conclusions: This review underscores the importance of adherence to ALS/ACLS guidelines in the resuscitation of patients who suffer in-hospital and out-of-hospital cardiac arrest. Full article

Unexpected in-hospital cardiac arrest (IHCA) in the emergency department is defined as an unexpected cardiac arrest during the stay in the emergency department with measured vital signs when entering the emergency department, requiring immediate emergency treatment to save a life. Since IHCA is an urgent medical event, especially in the emergency department, this study explored the risk prediction of IHCA events in the emergency department. IHCA not only has a high mortality rate, but is also likely to cause permanent neurological damage. In the emergency environment, due to the complexity and rapid changes in the patient’s condition, traditional assessment tools often fail to identify high-risk cases in a timely manner. In view of this, this study uses both the Power BI visual analysis platform and the binary decision tree model to construct a data-driven risk prediction tool. Power BI analysis successfully presented the dynamic ranking of influencing factors, and the decision tree prediction model showed excellent performance, with an accuracy of 91%, a recall rate of 89%, an F1-score of 89%, and an overall accuracy of 100%; this prediction system is expected to improve the efficiency of emergency medical care, identify high-risk patients in a timely manner, and assist medical staff in intervening in advance and implementing preventive measures. This study provided two different approaches: Power BI and decision tree. Power BI requires no coding and can be used by medical professionals without a programming background, while decision tree is designed for professionals with a programming background. While the structures of Power BI and decision tree differ slightly, they are generally similar and can both serve as intelligent clinical tools. Full article

Extracorporeal cardiopulmonary resuscitation (ECPR) is an established intervention for select patients experiencing refractory cardiac arrest. Among modifiable predictors of survival and neurologic recovery during ECPR implementation, timely restoration of circulation remains critical in the setting of refractory cardiac arrest (CA). The in-hospital cardiac arrest (IHCA) setting is particularly amenable to reducing the low-flow interval through structured system-based design and implementation. Despite increasing utilization of ECPR, the literature remains limited regarding operational standards, quality improvement metrics, and performance evaluation. Establishing operational standards and performance metrics is a critical first step toward systematically reducing low-flow interval duration. In support of this aim, we conducted a comprehensive literature review structured around the Extracorporeal Life Support Organization (ELSO) framework for ECPR implementation. At each step, we synthesized evidence-based best practices and identified operational factors that directly influence time-to-circulation. Our goal is to provide a stepwise evaluation of ECPR initiation to consolidate existing best practices and highlight process components with potential for further study and standardization. We further evaluated the literature surrounding key technical components of ECPR, including cannula selection, placement technique, and positioning. Ongoing research is needed to refine and standardize each stage of the ECPR workflow. Developing optimized, protocol-driven approaches to ensure rapid, high-quality deployment will be essential for improving outcomes with this lifesaving but resource-intensive therapy. Full article

Background/Objectives: Near-infrared spectroscopy (NIRS) enables the non-invasive assessment of cerebral oximetry, offering insights into the efficacy of oxygen supply to the brain. NIRS, when combined with other monitoring techniques such as capnography, may play a crucial role in advanced patient monitoring during sudden cardiac arrest and post-resuscitation treatment. This research assessed the relationship between end-tidal carbon dioxide (ETCO₂) and regional cerebral oxygen saturation (rSO₂) during cardiopulmonary resuscitation. Methods: The research was performed from 11 January 2023 until 31 January 2024, at the University Hospital in Poland. The cohort of responders included patients who had in-hospital cardiac arrest (IHCA). The Rapid Response Team attached the rSO₂ and ETCO₂ monitoring devices to each patient during cardiopulmonary resuscitation (CPR). The cohort included 104 patients. Results: The correlation coefficient between ETCO₂ and rSO₂ values was 0.641 (95% CI: 0.636–0.646), and during the last 4 min of CPR before ROSC, it was 0.873 (95% CI: 0.824–0.910). Conclusions: The positive correlation between ETCO₂ and rSO₂ may suggest that concurrent monitoring of both parameters during resuscitation might serve as a valuable predictor of CPR efficacy and the likelihood of achieving recovery of spontaneous circulation in a multimodal framework. In the lack of rapid ETCO₂ monitoring capabilities, rSO₂ may function as a simple and effective alternative for assessment. Full article

Background: Pediatric in-hospital cardiac arrest (IHCA) remains a critical health challenge with high mortality rates. Limited data from Western China prompted this study to investigate the characteristics of IHCA using the Utstein style. Methods: A retrospective analysis of 456 pediatric patients with IHCA (2018–2022) at the Children’s Hospital of Chongqing Medical University assessed demographics, arrest characteristics, outcomes and mortality risk factors. The primary outcome was survival to discharge; the secondary outcomes included return of spontaneous circulation (ROSC) > 20 min, 24 h survival, and favorable neurological outcomes. Logistic regression was used to identify the mortality risk factors. Results: ROSC > 20 min was achieved in 78.07% of cases, with 37.94% surviving to discharge (86.13% of survivors had favorable neurological outcomes). Etiological stratification identified general medical conditions (52.63%) as the predominant diagnoses, with surgical cardiac patients demonstrating superior resuscitation outcomes (ROSC > 20 min: 86.84%, discharge survival: 64.04%). Initial arrest rhythms predominantly featured non-shockable patterns, specifically bradycardia with poor perfusion (79.39%), whereas shockable rhythms (ventricular fibrillation/pulseless ventricular tachycardia) constituted only 4.17% of cases. Multivariable regression analysis identified five independent risk factors: vasoactive infusion before arrest (OR = 7.69), CPR > 35 min (OR = 13.92), emergency intubation (OR = 5.17), administration of >2 epinephrine doses (OR = 3.12), and rearrest (OR = 8.48). Notably, prolonged CPR (>35 min) correlated with higher mortality (8.96% survival vs. 48.54% for 1–15 min), yet all six survivors with CPR > 35 min had favorable neurological outcomes. Conclusions: These findings underscore the persistent challenges in pediatric IHCA management while challenging the conventional CPR duration thresholds for futility. The identified mortality risk factors inform resuscitation decision making and future studies. Full article

Objective: The purpose of this study was to evaluate the utility of end-tidal carbon dioxide (ETCO₂) values as a predictive marker of in-hospital cardiac arrest (IHCA). This was achieved by comparing the trends of ETCO₂ values in mechanically ventilated ICU patients that experienced an IHCA versus patients that did not. Methods: A single-center, retrospective, observational, and comparative cohort study at an academic medical center. Mechanically ventilated adults in the ICU who received continuous ETCO₂ monitoring were included. Patients who were transferred to our facility already intubated, experienced an out-of-hospital cardiac arrest, or had a do-not-resuscitate order were excluded. Extracted data points included demographics, comorbidities, vitals, labs, and outcomes. Patients were grouped into IHCA and non-IHCA cohorts, and the trends of ETCO₂ values were compared at multiple time points for 48 h before the IHCA or after intubation (time zero) for the groups, respectively. An ROC curve was constructed to determine the predictive value of ETCO₂ for IHCA. Results: A total of 207 patients were included, of which 104 (50.2%) had an IHCA and 103 (49.8%) did not. There were no differences in the mean SOFA scores at the initiation of mechanical ventilation (8.5 vs. 7.6). The ETCO₂ values were decreased in the IHCA cohort, and significantly different at each time point analyzed from 300 min until immediately prior to the arrest (p < 0.001). The ETCO₂ values were a mean of 20.0 mmHg in the IHCA cohort at the index time vs. 34.7 mmHg in the non-IHCA cohort (p < 0.001). The ROC analysis demonstrated moderate reliability, with an AUC = 0.687 (p < 0.0001, 95% CI 0.613–0.761) and with an ETCO₂ of less than 23 mmHg, demonstrating a 67% sensitivity and a 71% specificity, as well as a 70% PPV for predicting the IHCA from our sample. Conclusions: Patients typically have rapid clinical deteriorations prior to cardiac arrest, and monitoring ETCO₂ is easily achieved at the bedside while aiding in clinical decision making. The ETCO₂ values in our study were significantly decreased in the IHCA cohort prior to cardiac arrest compared to the stable values in those that did not experience an IHCA, indicating that ETCO₂ monitoring may have utility in predicting cardiac arrest. Further study is warranted to evaluate if predictive models utilizing ETCO₂ can be constructed to predict IHCAs in mechanically ventilated ICU patients. Full article

Background and Objectives: We aimed to assess the outcomes of pediatric in-hospital cardiac arrests (IHCAs) and to identify key factors influencing survival. Materials and Methods: This retrospective, single-center study examined the demographic characteristics, symptoms, comorbidities, initial rhythm, duration of cardiopulmonary resuscitation (CPR), lactate levels, and outcomes of pediatric patients with IHCAs and compared these parameters between survivors and non-survivors. Results: A total of 43 patients were included in this study, including 21 boys (48.8%) and 22 girls (51.2%) with a median age of 36 months (range 1–203). CPR was initiated due to pulselessness in 23 patients (53.5%), respiratory arrest in 13 (30.2%), and bradycardia in 7 (16.3%). The first monitored rhythm in the emergency department was asystole in 29 patients (67.4%) and bradycardia in 14 (32.6%). Despite effective CPR, the mortality rate was 65.1% (n = 28). As a prognostic factor, asystole was found to be more common in non-survivors than in survivors (83.1% vs. 40%, p = 0.005). Additionally, lactate levels (16.6 vs. 10.6, p = 0.04) and CPR duration (45 vs. 15 min, p < 0.001) were significantly higher in non-survivors. Conclusions: IHCAs remain a critical concern, with varying outcomes influenced by factors such as initial rhythm, lactate levels, and CPR duration. Full article

Background: Cardiac arrest is a critical condition affecting approximately 1 in every 1000 people in Europe. Feedback devices have been developed to enhance the quality of chest compressions during CPR, but their clinical impact remains uncertain. This study aims to evaluate the effect of feedback devices on key clinical outcomes in adult patients experiencing both out-of-hospital (OHCA) and in-hospital cardiac arrest (IHCA). The primary objective is to assess their impact on the return of spontaneous circulation (ROSC); secondary objectives include the evaluation of neurological status and survival to discharge. Methods: A systematic review was conducted following PRISMA guidelines, utilizing databases including PubMed, Scopus, Web of Science, and Embase. Studies published between 2000 and 2023 comparing CPR with and without the use of feedback devices were included. A fixed-effects network meta-analysis was performed for ROSC and survival, while a frequentist meta-analysis was conducted for neurological outcomes. Results: Twelve relevant studies met the inclusion criteria. The meta-analysis results showed that the use of audiovisual feedback devices significantly increases the likelihood of ROSC (OR 1.26, 95% CI 1.13–1.41, p < 0.0001) and survival (OR 1.52, 95% CI 1.27–1.81, p < 0.0001) compared to CPR without feedback. However, the effect of metronomes did not reach statistical significance. Conclusions: Feedback devices, particularly audiovisual ones, are associated with improved clinical outcomes in cardiac arrest patients. Their use should be encouraged in both training settings and real-life emergency scenarios to enhance survival rates and ROSC. However, further studies are needed to confirm long-term impacts and to explore the potential benefits of metronomes. Full article

Extracorporeal cardiopulmonary resuscitation (ECPR) is an advanced technique using extracorporeal membrane oxygenation (ECMO) to support patients with refractory cardiac arrest. Age significantly influences ECPR outcomes, with younger patients generally experiencing better survival and neurological outcomes due to many aspects. This review explores the impact of age on ECPR effectiveness, emphasizing the need to consider age alongside other clinical factors in patient selection. Survival rates differ notably between in-hospital (IHCA) and out-of-hospital cardiac arrest (OHCA), highlighting the importance of rapid intervention. The potential of artificial intelligence to develop predictive models for ECPR outcomes is discussed, aiming to improve decision-making. Ethical considerations around age-based treatment decisions are also addressed. This review advocates for a balanced approach to ECPR, integrating clinical and ethical perspectives to optimize patient outcomes across all age groups. Full article

Introduction: Cardiac arrests are traditionally classified according to the setting in which they occur, including out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA). However, cardiac arrests that occur in the emergency department (EDCA) could constitute a third category, due to the peculiar characteristics of the emergency department (ED). In recent years, the need to study EDCAs separately from other intra-hospital events has emerged. The aim of this study was to describe the characteristics and outcomes of a cohort of patients experiencing EDCA in an Italian hospital over a 14-year period. Methods: This was a single-centre retrospective observational study conducted in the ED of the Santa Croce e Carle Hospital in Cuneo, Italy. All adult patients who experienced EDCA between 1 January 2010 and 30 June 2023 were included. OHCA patients, those arriving in the ED with on-going resuscitation measures, patients with EDCA not undergoing resuscitation, and patients with post-traumatic cardiac arrest were excluded from the study. The main outcome of the study was survival at hospital discharge with a favourable neurological outcome. Results: 350 cases of EDCA were included. The median age was 78 (63–85) years, and the median Charlson Comorbidity Index score was 5 (3–6). A total of 35 patients (10%) survived to hospital discharge with a cerebral performance category (CPC) Score of 1–2; survival in the ED was 28.3%. The causes of cardiac arrests were identified in 212 cases (60.6%) and included coronary thrombosis (35%), hypoxia (22%), hypovolemia (17%), pulmonary embolism (11%), metabolic (8%), cardiac tamponade (4%), toxins (2%) and hypothermia (1%). Variables associated with survival with a favourable neurological outcome were young age, a lower Charlson Comorbidity Index, coronary thrombosis as the primary EDCA cause, and shockable presenting rhythm; however, only the latter was associated with the outcome in a multivariate age-weighted model. Conclusions: In a cohort of patients with EDCA over a period of more than a decade, the most frequent cause identified was coronary thrombosis; 10% of patients survived with a good neurological status, and the only factor associated with the best prognosis was presenting a shockable rhythm. EDCA should be considered an independent category in order to fully understand its characteristics and outcomes. Full article