IMPORTANCE
In-hospital cardiac arrest is common and associated with a high
mortality rate. Despite this, in-hospital cardiac arrest has received little
attention compared with other high-risk cardiovascular conditions, such as
stroke, myocardial infarction, and out-of-hospital cardiac arrest.
OBSERVATIONS
In-hospital cardiac arrest occurs in over 290 000 adults each year in
the United States. Cohort data from the United States indicate that the mean
age of patients with in-hospital cardiac arrest is 66 years, 58% are men,
and the presenting rhythm is most often (81%) nonshockable (ie, asystole or
pulseless electrical activity). The cause of the cardiac arrest is most
often cardiac (50%-60%), followed by respiratory insufficiency (15%-40%).
Efforts to prevent in-hospital cardiac arrest require both a system for
identifying deteriorating patients and an appropriate interventional
response (eg, rapid response teams). The key elements of treatment during
cardiac arrest include chest compressions, ventilation, early
defibrillation, when applicable, and immediate attention to potentially
reversible causes, such as hyperkalemia or hypoxia. There is limited
evidence to support more advanced treatments. Post–cardiac arrest
care is focused on identification and treatment of the underlying cause,
hemodynamic and respiratory support, and potentially employing
neuroprotective strategies (eg, targeted temperature management). Although
multiple individual factors are associated with outcomes (eg, age, initial
rhythm, duration of the cardiac arrest), a multifaceted approach considering
both potential for neurological recovery and ongoing multiorgan failure is
warranted for prognostication and clinical decision-making in the
Post–cardiac arrest period. Withdrawal of care in the absence of
definite prognostic signs both during and after cardiac arrest should be
avoided. Hospitals are encouraged to participate in national
quality-improvement initiatives.
CONCLUSIONS AND RELEVANCE
An estimated 290 000 in-hospital cardiac arrests occur each year in
the United States. However, there is limited evidence to support clinical
decision making. An increased awareness with regard to optimizing clinical
care and new research might improve outcomes.
Lactate levels are commonly evaluated in acutely ill patients. Although most commonly used in the context of evaluating shock, lactate can be elevated for many reasons. While tissue hypoperfusion is probably the most common cause of elevation, many other etiologies or contributing factors exist. Clinicians need to be aware of the many potential causes of lactate elevation as the clinical and prognostic importance of an elevated lactate varies widely by disease state. Moreover, specific therapy may need to be tailored to the underlying cause of elevation. The current review is based on a comprehensive PubMed search and contains an overview of the pathophysiology of lactate elevation followed by an in-depth look at the varied etiologies, including medication-related causes. The strengths and weaknesses of lactate as a diagnostic/prognostic tool and its potential use as a clinical endpoint of resuscitation will be discussed. The review ends with some general recommendations on management of patients with elevated lactate.
Utstein-style reporting templates provide a structured framework with which to compare systems of care for cardiac arrest. The 2004 Utstein reporting template encompassed both out-of-hospital and in-hospital cardiac arrest. A 2015 update of the Utstein template focused on out-of-hospital cardiac arrest, which makes this update of the in-hospital template timely. Representatives of the International Liaison Committee on Resuscitation developed an updated in-hospital Utstein reporting template iteratively by meeting face-to-face, by teleconference, and by online surveys between 2013 and 2018. Data elements were grouped by hospital factors, patient variables, pre-event factors, cardiac arrest and postresuscitation processes, and outcomes. Elements were classified as core or supplemental by use of a modified Delphi process. Variables were described as core if they were considered essential. Core variables should enable reasonable comparisons between systems and are considered essential for quality improvement programs. Together with core variables, supplementary variables are considered useful for research.
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