Predictive factors of spontaneous circulation return following in-hospital cardiac arrest: a cross-sectional study
Abstract
Objective: Existing predictive models for in-hospital cardiac arrest (IHCA) outcomes are mainly based on out-of-hospital cardiac arrest (OHCA) studies. This study aimed to identify factors that can independently predict the sustained return of spontaneous circulation (ROSC) following IHCA. Methods: This retrospective cross-sectional study included all patients aged 18 or older who underwent cardiopulmonary resuscitation (CPR) following IHCA in the emergency departments of two general hospitals in Tehran, Iran, from March 2021 to April 2024. The association of patient baseline characteristics, type of cardiac arrest, CPR characteristics, time-related parameters, and laboratory data with sustained ROSC were evaluated using multivariate logistic regression analysis trying to identify independent associated factors of sustained ROSC following IHCA. Results: 614 patients with a mean age of 68.23±17.65 (range: 18-115) years meeting the eligibility criteria were included (59.28% Male). 184 (29.96%) cases experienced sustained ROSC. Multivariate logistic regression analysis revealed a significant association between sustained ROSC and CPR duration less than 30 minutes (coefficient=4.38, 95% CI: 3.70,5.06, P<0.001), arrest due to cardiac etiologies (coefficient=1.05, 95% CI: 0.35,1.74, P=0.003), and administration of IV bicarbonate (coefficient=1.42, 95% CI: 0.72,2.13, P<0.001). Administration of amiodarone showed a borderline association with sustained ROSC (coefficient=1.07, 95% CI: -0.03,2.18, P=0.05). Conclusion: CPR duration of less than 30 minutes, arrest with cardiac etiologies, administration of bicarbonate and amiodarone were independent predictors of sustained ROSC.
2. Schluep M, Gravesteijn BY, Stolker RJ, Endeman H, Hoeks SE. One-year survival after in-hospital cardiac arrest: a systematic review and meta-analysis. Resuscitation. 2018;132:90-100.
3. Holmberg MJ, Ross CE, Fitzmaurice GM, Chan PS, Duval-Arnould J, Grossestreuer AV, et al. Annual incidence of adult and pediatric in-hospital cardiac arrest in the United States. Circ Cardiovasc Qual Outcomes. 2019;12(7):e005580.
4. Rea T, Kudenchuk PJ, Sayre MR, Doll A, Eisenberg M. Out of hospital cardiac arrest: past, present, and future. Resuscitation. 2021;165:101-9.
5. Sinha SS, Sukul D, Lazarus JJ, Polavarapu V, Chan PS, Neumar RW, et al. Identifying important gaps in randomized controlled trials of adult cardiac arrest treatments: a systematic review of the published literature. Circ Cardiovasc Qual Outcomes. 2016;9(6):749-56.
6. Andersen LW, Lind PC, Vammen L, Høybye M, Holmberg MJ, Granfeldt A. Adult post-cardiac arrest interventions: an overview of randomized clinical trials. Resuscitation. 2020;147:1-11.
7. Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, et al. European resuscitation council and European society of intensive care medicine guidelines 2021: post-resuscitation care. Intensive Care Med. 2021;47(4):369-421.
8. Soar J, Böttiger BW, Carli P, Couper K, Deakin CD, Djärv T, et al. European resuscitation council guidelines 2021: adult advanced life support. Resuscitation. 2021;161:115-51.
9. Moskowitz A, Holmberg MJ, Donnino MW, Berg KM. In-hospital cardiac arrest: are we overlooking a key distinction? Curr Opin Crit Care. 2018;24(3):151-7.
10. Gue YX, Adatia K, Kanji R, Potpara T, Lip GYH, Gorog DA. Out-of-hospital cardiac arrest: A systematic review of current risk scores to predict survival. Am Heart J. 2021;234:31-41.
11. Franco C, Toner E, Waldhorn R, Maldin B, O'Toole T, Inglesby TV. Systemic collapse: medical care in the aftermath of Hurricane Katrina. Biosecur Bioterror. 2006;4(2):135-46.
12. Gräsner JT, Wnent J, Herlitz J, Perkins GD, Lefering R, Tjelmeland I, et al. Survival after out-of-hospital cardiac arrest in Europe - results of the EuReCa TWO study. Resuscitation. 2020;148:218-26.
13. Tanaka H, Ong MEH, Siddiqui FJ, Ma MHM, Kaneko H, Lee KW, et al. Modifiable factors associated with survival after out-of-hospital cardiac arrest in the Pan-Asian resuscitation outcomes study. Ann Emerg Med. 2018;71(5):608-17.e15.
14. Rattananon P, Tienpratarn W, Yuksen C, Aussavanodom S, Thiamdao N, Termkijwanich P, et al. Associated factors of cardiopulmonary resuscitation outcomes; a cohort study on an adult in-hospital cardiac arrest registry. Arch Acad Emerg Med. 2024;12(1):e30.
15. Liu N, Ong MEH, Ho AFW, Pek PP, Lu TC, Khruekarnchana P, et al. Validation of the ROSC after cardiac arrest (RACA) score in Pan-Asian out-of-hospital cardiac arrest patients. Resuscitation. 2020;149:53-9.
16. Hashemi B, Baratloo A, Rahmati F, Forouzanfar MM, Motamedi M, Safari S. Emergency department performance indexes before and after establishment of emergency medicine. Emerg (Tehran). 2013;1(1):20-3.
17. Jacobs I, Nadkarni V, Bahr J, Berg RA, Billi JE, Bossaert L, et al. Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries: a statement for healthcare professionals from a task force of the international Liaison committee on resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Councils of Southern Africa). Circulation. 2004;110(21):3385-97.
18. Liu N, Wnent J, Lee JW, Ning Y, Ho AFW, Siddiqui FJ, et al. Validation of the CaRdiac Arrest Survival Score (CRASS) for predicting good neurological outcome after out-of-hospital cardiac arrest in an Asian emergency medical service system. Resuscitation. 2022;176:42-50.
19. Yonis H, Andersen MP, Mills EHA, Winkel BG, Wissenberg M, Køber L, et al. Duration of resuscitation and long-term outcome after in-hospital cardiac arrest: a nationwide observational study. Resuscitation. 2022;179:267-73.
20. Matsuyama T, Ohta B, Kiyohara K, Kitamura T. Cardiopulmonary resuscitation duration and favorable neurological outcome after out-of-hospital cardiac arrest: a nationwide multicenter observational study in Japan (the JAAM-OHCA registry). Crit Care. 2022;26(1):120.
21. Rohlin O, Taeri T, Netzereab S, Ullemark E, Djärv T. Duration of CPR and impact on 30-day survival after ROSC for in-hospital cardiac arrest-a Swedish cohort study. Resuscitation. 2018;132:1-5.
22. Fernando SM, Tran A, Cheng W, Rochwerg B, Taljaard M, Vaillancourt C, et al. Pre-arrest and intra-arrest prognostic factors associated with survival after in-hospital cardiac arrest: systematic review and meta-analysis. BMJ. 2019;367:l6373.
23. Hannen LEM, Toprak B, Weimann J, Mahmoodi B, Fluschnik N, Schrage B, et al. Clinical characteristics, causes and predictors of outcomes in patients with in-hospital cardiac arrest: results from the SURVIVE-ARREST study. Clinical Research in Cardiology. 2023;112(2):258-69.
24. Goldberger ZD, Chan PS, Berg RA, Kronick SL, Cooke CR, Lu M, et al. Duration of resuscitation efforts and survival after in-hospital cardiac arrest: an observational study. Lancet. 2012;380(9852):1473-81.
25. Cooper S, Evans C. Resuscitation predictor scoring scale for inhospital cardiac arrests. Emerg Med J. 2003;20(1):6-9.
26. Cheema MA, Ullah W, Abdullah HMA, Haq S, Ahmad A, Balaratna A. Duration of in-hospital cardiopulmonary resuscitation and its effect on survival. Indian Heart J. 2019;71(4):314-9.
27. Andersen LW, Holmberg MJ, Berg KM, Donnino MW, Granfeldt A. In-Hospital cardiac arrest: a review. JAMA. 2019;321(12):1200-10.
28. Cooper S, Cade J. Predicting survival, in-hospital cardiac arrests: resuscitation survival variables and training effectiveness. Resuscitation. 1997;35(1):17-22.
29. Ravindran R, Kwok CS, Wong CW, Siller-Matula JM, Parwani P, Velagapudi P, et al. Cardiac arrest and related mortality in emergency departments in the United States: analysis of the nationwide emergency department sample. Resuscitation. 2020;157:166-73.
30. Wallmuller C, Meron G, Kurkciyan I, Schober A, Stratil P, Sterz F. Causes of in-hospital cardiac arrest and influence on outcome. Resuscitation. 2012;83(10):1206-11.
31. Kayser RG, Ornato JP, Peberdy MA. Cardiac arrest in the emergency department: a report from the national registry of cardiopulmonary resuscitation. Resuscitation. 2008;78(2):151-60.
32. Panchal AR, Berg KM, Kudenchuk PJ, Del Rios M, Hirsch KG, Link MS, et al. 2018 American heart association focused update on advanced cardiovascular life support use of antiarrhythmic drugs during and immediately after cardiac arrest: an update to the American heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2018;138(23):e740-e9.
33. Perman SM, Elmer J, Maciel CB, Uzendu A, May T, Mumma BE, et al. 2023 American heart association focused update on adult advanced cardiovascular life support: an update to the American heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2024;149(5):e254-e73.
34. Panchal AR, Bartos JA, Cabañas JG, Donnino MW, Drennan IR, Hirsch KG, et al. Part 3: adult basic and advanced life support: 2020 American heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2020;142(16_suppl_2):S366-S468.
35. Perkins GD, Gräsner J-T, Semeraro F, Olasveengen T, Soar J, Lott C, et al. European resuscitation council guidelines 2021: executive summary. Resuscitation. 2021;161:1-60.
36. Ali MU, Fitzpatrick-Lewis D, Kenny M, Raina P, Atkins DL, Soar J, et al. Effectiveness of antiarrhythmic drugs for shockable cardiac arrest: a systematic review. Resuscitation. 2018;132:63-72.
37. Valdes SO, Donoghue AJ, Hoyme DB, Hammond R, Berg MD, Berg RA, et al. Outcomes associated with amiodarone and lidocaine in the treatment of in-hospital pediatric cardiac arrest with pulseless ventricular tachycardia or ventricular fibrillation. Resuscitation. 2014;85(3):381-6.
38. Wang Q, Lin Z, Chen H, Pan B. Comparison the efficacy of amiodarone and lidocaine for cardiac arrest: a network meta-analysis. Medicine (Baltimore). 2023;102(15):e33195.
39. Kudenchuk PJ, Cobb LA, Copass MK, Cummins RO, Doherty AM, Fahrenbruch CE, et al. Amiodarone for resuscitation after out-of-hospital cardiac arrest due to ventricular fibrillation. N Engl J Med. 1999;341(12):871-8.
40. Dorian P, Cass D, Schwartz B, Cooper R, Gelaznikas R, Barr A. Amiodarone as compared with lidocaine for shock-resistant ventricular fibrillation. N Engl J Med. 2002;346(12):884-90.
41. Kudenchuk PJ, Brown SP, Daya M, Rea T, Nichol G, Morrison LJ, et al. Amiodarone, lidocaine, or placebo in out-of-hospital cardiac arrest. N Engl J Med. 2016;374(18):1711-22.
42. Wagner D, Kronick SL, Nawer H, Cranford JA, Bradley SM, Neumar RW. Comparative effectiveness of amiodarone and lidocaine for the treatment of in-hospital cardiac arrest. Chest. 2023;163(5):1109-19.
43. Vandersmissen H, Gworek H, Dewolf P, Sabbe M. Drug use during adult advanced cardiac life support: an overview of reviews. Resuscitation Plus. 2021;7:100156.
44. Kramser N, Duse DA, Gröne M, Stücker B, Voß F, Tokhi U, et al. Amiodarone administration during cardiopulmonary resuscitation is not associated with changes in short-term mortality or neurological outcomes in cardiac arrest patients with shockable rhythms. J of Clin Med. 2024;13(13):3931.
45. Standards for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). 3. Advanced life support. JAMA. 1974;227(7):Suppl:852-60.
46. Bar-Joseph G, Abramson NS, Kelsey SF, Mashiach T, Craig MT, Safar P. Improved resuscitation outcome in emergency medical systems with increased usage of sodium bicarbonate during cardiopulmonary resuscitation. Acta Anaesthesiol Scand. 2005;49(1):6-15.
47. Weaver WD, Fahrenbruch CE, Johnson DD, Hallstrom AP, Cobb LA, Copass MK. Effect of epinephrine and lidocaine therapy on outcome after cardiac arrest due to ventricular fibrillation. Circulation. 1990;82(6):2027-34.
48. Wu KH, Chang CY, Chen YC, Chang CP, Hsiao CT, Weng HH. Effectiveness of sodium bicarbonate administration on mortality in cardiac arrest patients: a systematic review and meta-analysis. J Emerg Med. 2020;59(6):856-64.
49. Alshahrani MS, Aldandan HW. Use of sodium bicarbonate in out-of-hospital cardiac arrest: a systematic review and meta-analysis. Int J Emerg Med. 2021;14(1):21.
50. Suljaga-Pechtel K, Goldberg E, Strickon P, Berger M, Skovron ML. Cardiopulmonary resuscitation in a hospitalized population: prospective study of factors associated with outcome. Resuscitation. 1984;12(2):77-95.
51. Delooz HH, Lewi PJ. Are inter-center differences in EMS-management and sodium-bicarbonate administration important for the outcome of CPR? The cerebral resuscitation study group. Resuscitation. 1989;17 Suppl:S161-72; discussion S99-206.
52. Stiell IG, Wells GA, Hebert PC, Laupacis A, Weitzman BN. Association of drug therapy with survival in cardiac arrest: limited role of advanced cardiac life support drugs. Acad Emerg Med. 1995;2(4):264-73.
53. van Walraven C, Stiell IG, Wells GA, Hébert PC, Vandemheen K. Do advanced cardiac life support drugs increase resuscitation rates from in-hospital cardiac arrest? The OTAC Study Group. Ann Emerg Med. 1998;32(5):544-53.
54. Bar-Joseph G, Abramson NS, Jansen-McWilliams L, Kelsey SF, Mashiach T, Craig MT, et al. Clinical use of sodium bicarbonate during cardiopulmonary resuscitation--is it used sensibly? Resuscitation. 2002;54(1):47-55.
55. Neumar RW, Otto CW, Link MS, Kronick SL, Shuster M, Callaway CW, et al. Part 8: adult advanced cardiovascular life support: 2010 American heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122(18 Suppl 3):S729-67.
56. Vanden Hoek TL, Morrison LJ, Shuster M, Donnino M, Sinz E, Lavonas EJ, et al. Part 12: cardiac arrest in special situations: 2010 American heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122(18 Suppl 3):S829-61.
57. Neumar RW, Shuster M, Callaway CW, Gent LM, Atkins DL, Bhanji F, et al. Part 1: executive summary: 2015 American heart association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132(18 Suppl 2):S315-67.
58. Merchant RM, Topjian AA, Panchal AR, Cheng A, Aziz K, Berg KM, et al. Part 1: executive summary: 2020 American heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2020;142(16_suppl_2):S337-s57.
59. Wu K-H, Chang C-Y, Chen Y-C, Chang C-P, Hsiao C-T, Weng H-H. Effectiveness of sodium bicarbonate administration on mortality in cardiac arrest patients: a systematic review and meta-analysis. J Emerg Med. 2020;59(6):856-64.
60. Perkins GD, Graesner JT, Semeraro F, Olasveengen T, Soar J, Lott C, et al. European Resuscitation Council Guidelines 2021: executive summary. Resuscitation. 2021;161:1-60.
61. Velissaris D, Karamouzos V, Pierrakos C, Koniari I, Apostolopoulou C, Karanikolas M. Use of sodium bicarbonate in cardiac arrest: current guidelines and literature review. J Clin Med Res. 2016;8(4):277-83.
62. Wang CH, Wu CY, Wu MC, Chang WT, Huang CH, Tsai MS, et al. A retrospective study on the therapeutic effects of sodium bicarbonate for adult in-hospital cardiac arrest. Sci Rep. 2021;11(1):12380.
63. Roberts D, Landolfo K, Light RB, Dobson K. Early predictors of mortality for hospitalized patients suffering cardiopulmonary arrest. Chest. 1990;97(2):413-9.
64. Spöhr F, Wenzel V, Böttiger BW. Thrombolysis and other drugs during cardiopulmonary resuscitation. Curr Opin Crit Care. 2008;14(3):292-8.
65. Adgey AA, Johnston PW. Approaches to modern management of cardiac arrest. Heart. 1998;80(4):397-401.
66. Bar-Joseph G, Abramson NS, Jansen-McWilliams L, Kelsey SF, Mashiach T, Craig MT, et al. Clinical use of sodium bicarbonate during cardiopulmonary resuscitation—is it used sensibly? Resuscitation. 2002;54(1):47-55.
67. Vukmir RB, Katz L. Sodium bicarbonate improves outcome in prolonged prehospital cardiac arrest. Am J Emerg Med. 2006;24(2):156-61.
68. Weng YM, Wu SH, Li WC, Kuo CW, Chen SY, Chen JC. The effects of sodium bicarbonate during prolonged cardiopulmonary resuscitation. Am J Emerg Med. 2013;31(3):562-5.
69. Batarda Sena PM, Rodrigues J, Das Neves Coelho F, Soares Nunes B, Fernandes O, Fernandes N, et al. Sodium bicarbonate in in-hospital and out-of-hospital cardiac arrest: a systematic literature review. Cureus. 2024;16(8):e68192.
70. Touron M, Javaudin F, Lebastard Q, Baert V, Heidet M, Hubert H, et al. Effect of sodium bicarbonate on functional outcome in patients with out-of-hospital cardiac arrest: a post-hoc analysis of a French and North-American dataset. Eur J Emerg Med. 2022;29(3):210-20.
71. Xu T, Wu C, Shen Q, Xu H, Huang H. The effect of sodium bicarbonate on OHCA patients: a systematic review and meta-analysis of RCT and propensity score studies. Am J Emerg Med. 2023;73:40-6.
72. Niederberger SM, Crowe RP, Salcido DD, Menegazzi JJ. Sodium bicarbonate administration is associated with improved survival in asystolic and PEA out-of-hospital cardiac arrest. Resuscitation. 2023;182:109641.
73. Wang C-H, Wu C-Y, Wu M-C, Chang W-T, Huang C-H, Tsai M-S, et al. A retrospective study on the therapeutic effects of sodium bicarbonate for adult in-hospital cardiac arrest. Sci Rep. 2021;11(1):12380.
Files | ||
Issue | Vol 9 No 1 (2025): Winter (February) | |
Section | Original article | |
Keywords | ||
Advanced Cardiac Life Support Cardio-Pulmonary Resuscitation Spontaneous Circulation Return |
Rights and permissions | |
![]() |
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. |