R J Price, M A Garrioch
Department of Anaesthesia, Management Buildings, Southern General Hospital, 1345 Govan Road, Glasgow
Correspondence to: Dr R J Price, Department of Anaesthesia, Management Buildings, Southern General Hospital, 1345 Govan Road, Glasgow, G41 5TF.
Email: rjp@doctors.org.uk
SMJ 2005 50(1): 13-14
Abstract:
Background and Aims: We wanted to determine whether the practice of routinely sending an anaesthetist to cardiac arrests is common within Scotland. We also wished to evaluate the interventions performed by our intensive care anaesthetist when responding to cardiac arrest calls. Methods: We performed a telephone survey of the 26 Scottish hospitals with an intensive care unit. We conducted a prospective observational survey over a period of six months in one Scottish teaching hospital. Structured interviews with the anaesthetist who responded to the cardiac arrest call were undertaken. Results: Routine attendance of an anaesthetist at cardiac arrests occurs in 25 of the 26 hospitals surveyed. We analysed 68 of 73 arrest calls. In 28 calls (41%) there was no requirement for anaesthetic intervention. In 40 (59%) the anaesthetist intervened. The interventions were for cardiac arrest procedures in 33 cases and ventilatory failure in the remaining 7 cases. One patient survived to hospital discharge: a mortality of 98%. Conclusions: Patients who remain in cardiac arrest upon the arrival of the anaesthetist have a very high mortality. The practice of routinely sending an anaesthetist to cardiac arrest calls is not justified. Key words: Cardiac arrest, anaesthetist, cardiopulmonary resuscitation
Introduction
It has been recommended that anaesthetists are included on cardiac arrest teams.1 Expertise in airway management, vascular access and care of the critically ill may be of value in the management of patients in cardiac arrest. The presence of an anaesthetist may not improve outcome2 and first responder resuscitation may select survivors.3 The Southern General Hospital is a Glasgow teaching hospital with 960 beds. The site is geographically disparate and it takes several minutes to reach some wards. The purpose of this survey was to evaluate the contribution that anaesthetists made to the arrest procedures. Routine attendance of the intensive care anaesthetist at ward cardiac arrests can leave the intensive care unit (ICU) medically unattended. We wished to verify whether this practice can be justified and also whether these circumstances were widespread throughout Scotland.
Methods
A telephone survey of all 26 Scottish National Health Service hospitals with an ICU was undertaken. The duty ICU doctor was interviewed about routine practice in each hospital. We wished to establish whether an anaesthetist (or other ICU doctor) routinely responds to cardiac arrest calls. We conducted a prospective observational survey of cardiac arrest calls over six months within the Southern General Hospital. Records of cardiac arrest calls are kept at the hospital switchboard. The anaesthetist who attended the arrest was subsequently interviewed; data were collected on a standardised form. This interview determined the condition of the patient upon the arrival of the anaesthetist, the interventions performed and final outcome. This was an observational survey without identifiable patient data or use of patients records, therefore we did not seek ethics committee approval.
Results
In 22 of the 26 Scottish hospitals (85%) the ICU doctor routinely responds to a cardiac arrest call. The ICU doctor is always an anaesthetist in 19 hospitals and in 10 of these, out of hours duties are divided between operating theatres and the ICU. In three hospitals the theatre anaesthetist responds. One hospital operates an anaesthetist on request only system. A routine response by a designated critical care doctor to cardiac arrests therefore occurs in 25 of 26 hospitals. Within the Southern General, during the study period there were 73 arrest calls. Sixty eight calls (93%) were included in the survey. Five calls were not analysed due to an unavoidable delay in interviewing the anaesthetist. None of the omitted calls resulted in an ICU admission; the admission rate to the ICU is therefore accurate. Cardiac arrests in the emergency department were managed without the cardiac arrest team.
Fifty seven (78%) calls were to medical wards or the coronary care unit (CCU). The ICU was left medically unattended in 40 (59%) instances during which time one incident of potential patient harm occurred. Twenty eight (41%) calls did not require any contribution from the anaesthetist. The problem had either resolved or was not as serious as first thought. Four of these patients needed simple airway adjuncts. Twenty of these patients were fully selfterminating ventricular tachycardia (VT); two had VT with a cardiac output; one had been successfully resuscitated from ventricular fibrillation (VF). Four patients were subsequently transferred to the coronary care unit and one to the operating theatre.
The anaesthetist assisted with the management of 40 (59%) patients. Thirty three patients were in cardiac arrest that had persisted until the arrival of the anaesthetist; seven had suffered ventilatory failure. Of the 33 patients in cardiac arrest, the presenting rhythm was non-VF/VT in 28 and VF in five. Anaesthetists inserted 22 tracheal tubes and three laryngeal mask airways (LMA). Ward doctors attempted five tracheal intubations of which two were unrecognised oesophageal intubations corrected by the anaesthetist. A ward nurse inserted one LMA. The remaining patients were managed with face-mask techniques. Eight patients required induction of anaesthesia to facilitate intubation, ventilation or transfer. The anaesthetist placed two central venous lines and two arterial lines.
Thirty of 40 patients died on the ward. In three of these patients the resuscitation was initially successful but treatment was then withdrawn when further information became available. Two patients were transferred to CCU; both died the next day. Eight patients were transferred to ITU; seven had been intubated with anaesthetic agents. One patient survived to be discharged from hospital. Therefore, 39 out of 40 patients died (98%). This is summarised in Fig 1.
Discussion
The practice of routinely sending a critical care doctor to attend cardiac arrests occurs in 96% of Scottish hospitals. This is also the situation elsewhere.4 We believe that this is not justified. Although this is a small survey and from a single institution, we think that it gives insight into the current situation in many hospitals. We have shown that in 41% of cases, the ICU anaesthetist did not contribute to patient management. In the remaining 59% of cases and even with intervention, the mortality was 98%. Hospital mortality from cardiac arrest on general wards has previously been shown to be 95%3,5. The larger BRESUS study (3765 patients) showed a hospital mortality of 84% for general ward patients6. The mortality that we observed is higher and includes patients in high dependency environments.
The patient group that we are reporting are hospital inpatients who remain in cardiac arrest or ventilatory failure upon the arrival of the anaesthetist. This represents a specifically selected group that has not previously been reported. It has been claimed that patients who survive to hospital discharge are resuscitated by first responders3. Others have demonstrated that a prolonged resuscitation is related to a high mortality.2,7,8 We are concerned that patients who remain in cardiac arrest upon the arrival of the anaesthetist have such a high mortality. Antecedent factors may be identifiable in ward patients9, making 78% of cardiac arrests avoidable.5 Education of ward doctors in the early recognition and treatment of critical illness could be improved.10 The IMPACT course (Ill Medical Patients Acute Care and Treatment) is now established through the Royal College of Physicians and Surgeons of Glasgow to help address this. Follow-up from a similar course (ALERTTM) has demonstrated knowledge retention of critical care issues by doctors11. Medical emergency teams have been formed in some hospitals in an attempt to prevent cardiac arrest. Specific criteria12,13 or scoring systems14 are used to activate these teams. While this concept is appealing, the published effect on mortality is variable.12,13,15 A scoring system that stratifies the medical response14 may allow the most appropriate use of medical personnel. In fact, the interventions of a medical emergency team may be quite simple and suitable for implementation by a house officer or nurse.15 In at least 76% of cases specific anaesthetic skills are not required (our interpretation).15
In conclusion, routine attendance at cardiac arrests by anaesthetists is common within Scotland. From observations in our hospital, this does not utilise anaesthetic personnel efficiently. The mortality of patients who require anaesthetic intervention is unacceptably high. Alternative ways of managing cardiac arrest and its prevention should be explored.
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