Cardiac Arrest in the Hospitalized Patient and Termination of Resuscitation: A Case Report and Discussion

Case Presentation:

A 56‐year‐old man was admitted to the referring hospital with progressive anemia—hemoglobin of 7.8 g/dL. He received 2 units of red blood cells. Four days later he was tachypneic and tachycardic, with a hemoglobin of 4.8 g/dL. The Blood Bank reported that the patient had multiple antibodies; only 1 unit of blood in the state of Michigan matched the patient, which he received. His hemoglobin increased to 7 g/dL, and he was transferred to the University of Michigan. On admission his hemoglobin was 5.2 g/dL, anti‐C and anti‐e positive. Arterial blood gas (ABG) showed a pH of 7.05, pCO₂ of 55 mm Hg, pO₂ of 67 mmHg, and a lactate of 10 mM. The patient was intubated and transferred to the intensive care unit. Progressive hypotension was followed by pulseless electrical activity (PEA) arrest. The ABG was pH 6.85, pCO₂ 54.5 mm Hg, pO₂ 16.6 mmHg, lactate 16 mM, with a hemoglobin of 3.7 g/dL. He converted to pulseless ventricular tachycardia (VT) was shocked back into PEA. There was resumption of spontaneous circulation 25 minutes into the code. Family was present during the code. The patient had a second PEA arrest 2 hours later. The code was terminated at the family's request, and the patient died.

Discussion:

In the study of cardiopulmonary resuscitations in British hospitals (BRESUS), in 3765 resuscitations, for every 8 patients, 3 survived immediately, 2 survived 24 hours, 1.5 survived to discharge, and 1 survived 1 year. De Voss audiotaped in‐hospital resuscitations. In 36 attempts, termination of resuscitation (TOR) occurred around 30 minutes. Meany examined initial rhythms and survival to discharge: ventricular fibrillation/VT 37%, PEA 12%, and asystole with 11% survival. Ferguson examined 4 factors: initial rhythm, duration of cardiopulmonary resuscitation (CPR), time of arrest, and number of arrests. At 5 minutes’ duration of CPR, initial survival was 37%, and survival at 6 months was 22.2%. After 10 minutes, initial survival was 24.5%, and survival at 6 months was 14.9%. After 15 minutes of CPR, survival was 9.8% and 5.9%, respectively. After 20 and 25 minutes, initial survival was 4.8% and 3.3%, respectively, and survival at 6 months was 0%.

Conclusions:

As the physicians supervising and frequently in charge of in‐hospital resuscitation, hospitalists need to be cognizant of the often poor outcomes in cardiac arrest, even with the best of care. In this case, the patient would have a predicted survival to discharge of 3.3%–12% and a 6‐month survival of 0%. It is also important to recognize that CPR or advanced cardiac life support longer than 10 minutes correlates with decreased survival to discharge and decreased survival at 6 months after discharge.

Disclosures:

D. Stephenson ‐ none