Clinical antecedents to in-hospital cardiopulmonary arrest.

University of Miami, كورال غيبلز، فلوريدا, Florida, United States
Chest (Impact Factor: 7.13). 01/1991; 98(6):1388-92. DOI: 10.1378/chest.98.6.1388
Source: PubMed

ABSTRACT While the outcome of in-hospital cardiopulmonary arrest has been studied extensively, the clinical antecedents of arrest are less well defined. We studied a group of consecutive general hospital ward patients developing cardiopulmonary arrest. Prospectively determined definitions of underlying pathophysiology, severity of underlying disease, patient complaints, and clinical observations were used to determine common clinical features. Sixty-four patients arrested 161 +/- 26 hours following hospital admission. Pathophysiologic alterations preceding arrest were classified as respiratory in 24 patients (38 percent), metabolic in 7 (11 percent), cardiac in 6 (9 percent), neurologic in 4 (6 percent), multiple in 17 (27 percent), and unclassified in 6 (9 percent). Patients with multiple disturbances had mainly respiratory (39 percent) and metabolic (44 percent) disorders. Fifty-four patients (84 percent) had documented observations of clinical deterioration or new complaints within eight hours of arrest. Seventy percent of all patients had either deterioration of respiratory or mental function observed during this time. Routine laboratory tests obtained before arrest showed no consistent abnormalities, but vital signs showed a mean respiratory rate of 29 +/- 1 breaths per minute. The prognoses of patients' underlying diseases were classified as ultimately fatal in 26 (41 percent), nonfatal in 23 (36 percent), and rapidly fatal in 15 (23 percent). Five patients (8 percent) survived to hospital discharge. Patients developing arrest on the general hospital ward services have predominantly respiratory and metabolic derangements immediately preceding their arrests. Their underlying diseases are generally not rapidly fatal. Arrest is frequently preceded by a clinical deterioration involving either respiratory or mental function. These features and the high mortality associated with arrest suggest that efforts to predict and prevent arrest might prove beneficial.


Available from: Roland M Schein, May 27, 2015
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    ABSTRACT: Severe adverse events such as cardiac arrest and death are often heralded by abnormal vital signs hours before the event. This necessitates an organized track and trigger approach of early recognition and response to subtle changes in a patient's condition. The Modified Early Warning System (MEWS) is one of such systems that use temperature, blood pressure, pulse, respiratory rate, and level of consciousness with each progressive higher score triggering an action. Root cause analysis for mortalities in our institute has led to the implementation of MEWS in an effort to improve patient outcomes. Here we discuss our experience and the impact of MEWS implementation on patient care at our community academic hospital. MEWS was implemented in a protocolized manner in June 2013. The following data were collected from non-ICU wards on a monthly basis from January 2010 to June 2014: 1) number of rapid response teams (RRTs) per 100 patient-days (100PD); 2) number of cardiopulmonary arrests 'Code Blue' per 100PD; and 3) result of each RRT and Code Blue (RRT progressed to Code Blue, higher level of care, ICU transfer, etc.). Overall inpatient mortality data were also analyzed. Since the implementation of MEWS, the number of RRT has increased from 0.24 per 100PD in 2011 to 0.38 per 100PD in 2013, and 0.48 per 100PD in 2014. The percentage of RRTs that progressed to Code Blue, an indicator of poor outcome of RRT, has been decreasing. In contrast, the numbers of Code Blue in non-ICU floors has been progressively decreasing from 0.05 per 100PD in 2011 to 0.02 per 100PD in 2013 and 2014. These improved clinical outcomes are associated with a decline of overall inpatient mortality rate from 2.3% in 2011 to 1.5% in 2013 and 1.2% in 2014. Implementation of MEWS in our institute has led to higher rapid response system utilization but lower cardiopulmonary arrest events; this is associated with a lower mortality rate, and improved patient safety and clinical outcomes. We recommend the widespread use of MEWS to improve patient outcomes.
    01/2015; 5(2):26716.
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    ABSTRACT: Abstract Background Fulminant hepatic failure (FHF) in children is a devastating disease, with guarded prognosis and ultimate outcome. Viral hepatitis is very common reasons for this acute fulminant hepatitis.Patients in developing countries like Pakistan are referred late where treatments are inadequate and improper. Subtle signs and laboratory parameters pointing to bad prognosis are missed and treatment is started late. We aimed to study behavior of fulminant hepatic failure due to viral etiology, determine the prognostic factors and outcome in children. Methods It is cross sectional study conducted at department of Gastroenterology, Hepatology and Nutrition, The Children’s Hospital and Institute Of Child Health Lahore during Jan 2010 till Dec 2013. Children younger than 15 years of age with admitting diagnosis of fulminant hepatic failure due to viral etiology were enrolled. Their grade of encephalopathy, liver function tests, viral markers, coagulation profile, and serum potassium levels were recorded on a proforma. Discharge disposition (alive or dead) were study outcome. Chi square and p-value were calculated. Results During three year period 108 children were admitted with fulminant hepatic failure due to suspected viral etiology. Among them 65 (60%) were males. The etiologies were: 40(37%)were due to hepatitis A, 18(23.6%)were due to non A –Eviral hepatitis,13(12%) were due to hepatitis B, 1(0.92%) was due to hepatitis while 4 (3.1%)were due to co-infection(Hepatitis A & typhoid fever).Out of 108 patients admitted with fulminant hepatitis 53(49%) survived, 39(36%) expired while 16(17%) left against medical advice. Children who had a higher grade of encephalopathy grade IV had bad prognostic outcome with 13 (77%)dying (p=<0.001), while those with lower grade of encephalopathy had a good outcome with 100 % survival in grade 1 encephalopathy. In grade II encephalopathy 22 (92%)survived and in grade III encephalopathy 22 (48%) survived. Delay between the first symptom of liver disease and the onset of hepatic encephalopathy (within 10 days versus more than 10 days), lower plasma albumin (less than 2.5 g/dL), higher prothrombin time (more than 60 seconds) on admission were more likely to die of fulminant hepatic failure (p=<0.05). Conclusions Fulminant hepatitis is a potentially fatal disease. In our study hepatitis A and B were the most common viruses causing fulminant hepatic failure.Children with fulminant hepatic failure with severe coagulopathy, hypoalbuminemia and hypokalemia on admission and prolonged duration of illness before the onset of hepatic ncephalopathy are more likely have a significant mortality and morbidity. Key words: Acute Viral hepatitis, fulminant hepatic failure (FHF), coagulopathy
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    ABSTRACT: Background Modified Early Warning (MEW) scoring system is a simple bed-side tool which can be administered by a nurse. We conducted this study to look at the utility of a MEW scoreis a marker of in-hospital outcomes of acutely ill adult medical patients and can be effectively utilize for early detection of warning signs. Methods One hundred and twelve age-matched patients who were admitted the medical service from the emergency room of our hospital over a 6 month (August 2010 - February 2011) period were included. MEW scores of these patients were calculated once at the time of admission; the patients were followed till their discharge or death. Fischer’s exact test was used to calculate statistical differences in outcome between the groups. Results Patients were categorized into 4 groups based on their MEW Scores: group 1:0-1, group 2: 2-3, group 3:4-5 and group 4: score of >5;26 patients died. There was no mortality in group 1. Mortality was significantly higher in group 4 (MEWS>5) when compared with group 2 (MEWS 2-3, p= <0.001; Fisher exact test) and with group 3 (MEWS 4-5, p=<0.001; Fisher exact test). Conclusions A single calculation of MEWS at the time of admission is a reliable predictor of in-hospital mortality in our patients. Acutely ill patients and those at imminent risk of deterioration are identified quickly on the basis of clinical criteria alone, making MEWS a cost-effective tool in triaging patients, prioritizing admission to high dependency areas and predicting outcomes. MEWS can be used at secondary and tertiary care centers in a resource-poor country to identify patients in need of urgent intensive care. Key words MEWS, prediction of in-hospital outcome, resource-poor settings