Abstract
A critical retrospective cohort study conducted across Get With The Guidelines-Resuscitation participating hospitals between January 2000 and December 2016 has demonstrated a significant variation in survival rates of in-hospital cardiac arrest (IHCA) patients, correlating with different approaches to airway management, mainly endotracheal intubation during cardiopulmonary resuscitation (CPR). The study, involving 155,252 patients and 656 hospitals, revealed an inverse association between the rate of endotracheal intubation during CPR and patient survival, especially notable in patients who did not suffer respiratory failure prior to the cardiac arrest. The findings underscore the critical need for evaluating and potentially revising airway management guidelines to enhance patient outcomes post-IHCA. This article delves into the study details, its implications, and future directions for critical care.
Introduction
In-hospital cardiac arrest (IHCA) is a life-threatening event necessitating immediate and effective resuscitation efforts to ensure patient survival and favorable neurological outcomes. One of the key components of resuscitation is airway management, but the optimal strategy during CPR remains a subject of ongoing debate. The study, led by Bradley S.M. and colleagues (2019), provides valuable insights into the relationship between airway management techniques and IHCA outcomes, revealing a strong inverse association between hospital use of endotracheal intubation during CPR and survival to discharge. The critical implications of this study call for a reassessment of clinical guidelines to improve resuscitation practices and patient survival in IHCA cases.
Study Overview
Researchers conducted a retrospective cohort study using data from the Get With The Guidelines-Resuscitation program, which included adult patients who experienced IHCA across various hospitals. The key objective was to describe hospital-level variations in the use of endotracheal intubation during CPR and to assess its association with patient survival to hospital discharge. Hospitals were categorized into quartiles based on their rates of endotracheal intubation during resuscitation, and risk-adjusted mixed models were implemented to determine the impact on survival outcomes.
Results and Discussion
The data revealed a median hospital intubation rate of 71.2%, with a range from 26.6% to 100%. Wide variation across hospitals suggests a lack of consensus or standardization in airway management during IHCA. Crucially, the study identified an inverse association between the frequency of intubation and survival rates, with the highest quartile of intubating hospitals showing a lower chance of survival compared to the lowest quartile (odds ratio 0.81; 95% CI, 0.74 to 0.90; p-value < .001). Intriguingly, this relationship was significantly affected by whether patients had pre-arrest respiratory failure, indicating that the benefit of intubation may pertain more to this subgroup.
The study sheds light on the complex nature of airway management during in-hospital cardiac arrests and its profound impact on patient survival. It highlights an essential consideration for clinicians: the indiscriminate use of endotracheal intubation may not be universally beneficial, particularly for patients without respiratory failure prior to the arrest. This distinction underscores the need for tailored airway management strategies based on individual patient circumstances.
Clinical Implications
The implications of these findings for critical care are significant. A standardized approach to airway management during IHCA that does not account for the nuances of individual patient conditions may be detrimental. Hospitals and healthcare providers must reconsider current protocols and ensure that decisions regarding airway management are backed by a careful assessment of each patient’s scenario before and during cardiac arrest.
Recommendations and Future Directions
The study conducted by Bradley S.M. et al. acts as a clarion call for further research to define optimal airway management strategies during IHCA. It suggests the potential benefits of incorporating advanced airway management techniques selectively rather than universally. There is a need for randomized controlled trials that could provide a clearer direction for clinical best practices in airway management during IHCA resuscitation efforts. Additionally, education and training programs for hospital staff on the implications of this study can also play a significant role in improving survival outcomes.
Limitations
As with any retrospective study, there were limitations, including the potential for confounding variables not accounted for in the study design. Furthermore, the study could not determine causality, only association, in the findings. It is also critical to acknowledge the “resuscitation time bias” that poses a unique challenge for observational cardiac arrest research, as noted by Andersen LW and colleagues.
Conclusion
The retrospective cohort study by Bradley S.M. and co-authors provides groundbreaking evidence that hospital practices regarding endotracheal intubation during IHCA vary considerably and are associated with survival outcomes. It emphasizes the importance of re-evaluating current airway management guidelines to ensure they reflect the most effective and evidence-based practices for patient survival. As the optimal approach continues to be explored, this study serves as an essential reference point for future clinical trials and resuscitation protocol development.
References
1. Bradley S.M., Zhou Y., Ramachandran S.K., Engoren M., Donnino M., Girotra S. (2019). Retrospective cohort study of hospital variation in airway management during in-hospital cardiac arrest and the association with patient survival: insights from Get With The Guidelines-Resuscitation. Critical Care, 23(1), 158. doi: 10.1186/s13054-019-2426-5
2. Merchant R.M., Yang L., Becker L.B., et al. (2011). Incidence of treated cardiac arrest in hospitalized patients in the United States. Critical Care Medicine, 39(11), 2401-2406. doi: 10.1097/CCM.0b013e3182257459
3. Wang H.E., Simeone S.J., Weaver M.D., Callaway C.W. (2009). Interruptions in cardiopulmonary resuscitation from paramedic endotracheal intubation. Annals of Emergency Medicine, 54(5), 645-652.e1. doi: 10.1016/j.annemergmed.2009.05.024
4. Chan P.S., Krumholz H.M., Nichol G., Nallamothu B.K. (2008). Delayed time to defibrillation after in-hospital cardiac arrest. New England Journal of Medicine, 358(1), 9–17. doi: 10.1056/NEJMoa0706467
5. Andersen L.W., Granfeldt A., Callaway C.W., et al. (2017). Association between tracheal intubation during adult in-hospital cardiac arrest and survival. JAMA, 317(5), 494–506. doi: 10.1001/jama.2016.20165
Keywords
1. In-hospital cardiac arrest survival
2. Airway management during CPR
3. Endotracheal intubation IHCA
4. Critical care resuscitation protocols
5. Optimal airway management strategies