Redefining resuscitation

Cardiopulmonary resuscitation (CPR) has evolved over the last 40 years into a significant part of healthcare training. International organisations govern resuscitation protocols. Yet survival to discharge after in-hospital CPR is poor. Study survival rates range from 2 to 14%. Public perception of CPR is informed by television where there are far better outcomes than in reality.

A great deal of attention is focused on saving life after cardiac arrest, but the vast majority of in-hospital cardiac arrests are predictable. Hardly any attention is focused on detecting commonplace reversible physiological deterioration or preventing cardiac arrest in the first place. Two studies illustrate this well. In 1990, Schein et al. found that 84% of patients had documented observations of clinical deterioration or new complaints within 8 hours of arrest; 70% had either deterioration of respiratory or mental function observed during this time. Whilst there did not appear to be any single reproducible warning signs, the average respiratory rate of the patients prior to arrest was 30 per minute. The investigators observed that the predominantly respiratory and metabolic derangements which preceded cardiac arrest (hypoxaemia, hypotension, and acidosis) were not rapidly fatal and that efforts to predict and prevent arrest would therefore be beneficial. Only 8% patients survived to discharge after CPR in this study. In 1994, Franklin et al. observed that documented

Box 1.1 Recognition of critical illness

1. Physiological

• Signs of massive sympathetic activation, for example, raised heart rate, blood pressure, pale, shut down

• Signs of systemic inflammation (see chapter 7)

• Signs of organ hypoperfusion, for example, cold peripheries, increased respiratory rate, oliguria (see chapter 5)

2. Biochemical

• Base deficit/raised lactate

• Raised or low white cell count

Low platelets

• Raised urea and creatinine

physiological deterioration occurred within 6 hours in 66% of patients with cardiac arrest, but no action was taken.

Researchers have commented that there appears to be a failure of the system to recognise and effectively intervene when patients in hospital deteriorate. There is little postgraduate training in the resuscitation of critically ill adults (that is, A, B, C, D - airway, breathing, circulation and disability), and in the UK there are too few available senior staff who have the skills to manage these patients effectively. This impacts on the quality of admissions to the Intensive Care Unit (ICU). In 1999, McGloin et al. observed that 36% ICU admissions received suboptimal care beforehand and that survival was worse in this group. In 1998 McQuillan et al. looked at 100 emergency ICU admissions. Two external assessors observed that only 20 cases were well managed beforehand. The majority (54) received suboptimal care prior to admission to ICU and there was disagreement over the remaining 26 cases. The patients were of a similar case-mix and APACHE II (acute physiological and chronic health evaluation) scores. In the suboptimal group, ICU admission was considered late in 69% cases and avoidable altogether in 41%. The main causes of suboptimal care were considered to be failure of organisation, lack of knowledge, failure to appreciate the clinical urgency, lack of supervision, and failure to seek advice. Other studies have shown that suboptimal care before admission to ICU increases mortality by around 50%. ICU mortality is doubled if the patient is admitted from a general ward rather than from theatres or the Emergency Department, in theory because they arrive so sick that they are unlikely to recover.

Resuscitation is therefore not about CPR. It is about recognising patients in physiological decline in the first place and then effectively treating them. This is an area of medicine that has been neglected in terms of training, organisation, and resources.

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