Incidences and factors associated with perioperative cardiac arrest in trauma patients receiving anesthesia.

PURPOSE: The aim of this study was to determine the incidences and factors associated with perioperative cardiac arrest in trauma patients who received anesthesia for emergency surgery. PATIENTS AND METHODS: This retrospective cohort study was approved by the medical ethical committee, Faculty of Medicine, Maharaj Nakorn Chiang Mai Hospital, Thailand. Data of 19,683 trauma patients who received anesthesia between January 2007 and December 2016, such as patient characteristics, surgery procedures, anesthesia information, anesthetic drugs, and cardiac arrest outcomes, were analyzed. Data of patients receiving local anesthesia by surgeons or monitoring anesthesia care (MAC) and those with much information missing were excluded. Factors associated with perioperative cardiac arrest were identified using univariate analysis and the multiple regression model. A stepwise algorithm was chosen at a P-value of <0.20 which was selected for multivariate analysis. A P-value of <0.05 was concluded as statistically significant. RESULTS: The perioperative cardiac arrest in trauma patients receiving anesthesia for emergency surgery was 170.04 per 10,000 cases. Factors associated with perioperative cardiac arrest in trauma patients were as follows: age >65 years (risk ratio [RR] =1.41, CI =1.02-1.96, P=0.039), American Society of Anesthesiologist (ASA) physical status 3 or higher (ASA physical status 3-4, RR =4.19, CI =2.09-8.38, P<0.001; ASA physical status 5-6, RR =21.58, CI =10.36-44.94, P<0.001), sites of surgery (intracranial, intrathoracic, upper intra-abdominal, and major vascular, each P<0.001), cardiopulmonary comorbidities (RR =1.55, CI =1.10-2.17, P=0.012), hemodynamic instability with shock prior to receiving anesthesia (RR =1.60, CI =1.21-2.11, P<0.001), and having a history of alcoholism (RR =5.27, CI =4.09-6.79, P<0.001). CONCLUSION: The incidence of perioperative cardiac arrest in trauma patients receiving anesthesia for emergency surgery was very high and correlated with patient's factors, especially old age and cardiopulmonary comorbidities, a history of drinking alcohol, increased ASA physical status, hemodynamic instability with shock prior to surgery, and sites of surgery such as brain, thorax, abdomen, and the major vascular region. Anesthesiologists and surgeons should be aware of a warning system and a well-equipped track to manage the surgical trauma patients.

Prognostic factors for death and survival with or without complications in cardiac arrest patients receiving CPR within 24 hours of anesthesia for emergency surgery.

PURPOSE: To determine prognostic factors for death and survival with or without complications in cardiac arrest patients who received cardiopulmonary resuscitation (CPR) within 24 hours of receiving anesthesia for emergency surgery. PATIENTS AND METHODS: A retrospective cohort study approved by the Maharaj Nakorn Chiang Mai University Hospital Ethical Committee. Data used were taken from records of 751 cardiac arrest patients who received their first CPR within 24 hours of anesthesia for emergency surgery between January 1, 2003 and October 31, 2011. The reviewed data included patient characteristics, surgical procedures, American Society of Anesthesiologist (ASA) physical status classification, anesthesia information, the timing of cardiac arrest, CPR details, and outcomes at 24 hours after CPR. Univariate and polytomous logistic regression analyses were used to determine prognostic factors associated with the outcome variable. P-values of less than 0.05 were considered statistically significant. RESULTS: The outcomes at 24 hours were death (638/751, 85.0%), survival with complications (73/751, 9.7%), and survival without complications (40/751, 5.3%). The prognostic factors associated with death were: age between 13-34 years (OR =3.08, 95% CI =1.03-9.19); ASA physical status three and higher (OR =6.60, 95% CI =2.17-20.13); precardiopulmonary comorbidity (OR =3.28, 95% CI =1.09-9.90); the condition of patients who were on mechanical ventilation prior to receiving anesthesia (OR =4.11, 95% CI =1.17-14.38); surgery in the upper abdominal site (OR =14.64, 95% CI =2.83-75.82); shock prior to cardiac arrest (OR =6.24, 95% CI =2.53-15.36); nonshockable electrocardiography (EKG) rhythm (OR =5.67, 95% CI =1.93-16.62); cardiac arrest occurring in postoperative period (OR =7.35, 95% CI =2.89-18.74); and duration of CPR more than 30 minutes (OR =4.32, 95% CI =1.39-13.45). The prognostic factors associated with survival with complications were being greater than or equal to 65 years of age (OR =4.30, 95% CI =1.13-16.42), upper abdominal site of surgery (OR =10.86, 95% CI =1.99-59.13), shock prior to cardiac arrest (OR =3.62, 95% CI =1.30-10.12), arrhythmia prior to cardiac arrest (OR =4.61, 95% CI =1.01-21.13), and cardiac arrest occurring in the postoperative period (OR =3.63, 95% CI =1.31-10.02). CONCLUSION: The mortality and morbidity in patients who received anesthesia for emergency surgery within 24 hours of their first CPR were high, and were associated with identifiable patient comorbidity, age, shock, anatomic site of operation, the timing of cardiac arrest, EKG rhythm, and the duration of CPR. EKG monitoring helps to identify cardiac arrest quickly and diagnose the EKG rhythm as a shockable or nonshockable rhythm, with CPR being performed as per the American Heart Association (AHA) CPR Guidelines 2010. The use of the fast track system in combination with an interdisciplinary team for surgery, CPR, and postoperative care helps to rescue patients in a short time.

Incidence of and factors associated with perioperative cardiac arrest within 24 hours of anesthesia for emergency surgery.

PURPOSE: To determine the incidence of and factors associated with perioperative cardiac arrest within 24 hours of receiving anesthesia for emergency surgery. PATIENTS AND METHODS: This retrospective cohort study was approved by the ethical committee of Maharaj Nakorn Chiang Mai Hospital, Thailand. We reviewed the data of 44,339 patients receiving anesthesia for emergency surgery during the period from January 1, 2003 to March 31, 2011. The data included patient characteristics, surgical procedures, American Society of Anesthesiologists (ASA) physical status classification, anesthesia information, location of anesthesia performed, and outcomes. Data of patients who had received topical anesthesia or monitoring anesthesia care were excluded. Factors associated with cardiac arrest were identified by univariate analyses. Multiple regressions for the risk ratio (RR) and 95% confidence intervals (CI) were used to determine the strength of factors associated with cardiac arrest. A forward stepwise algorithm was chosen at a P-value <0.05. RESULTS: The incidence (within 24 hours) of perioperative cardiac arrest in patients receiving anesthesia for emergency surgery was 163 per 10,000. Factors associated with 24-hour perioperative cardiac arrest in emergency surgery were age of 2 years or younger (RR =1.46, CI =1.03-2.08, P=0.036), ASA physical status classification of 3-4 (RR =5.84, CI =4.20-8.12, P<0.001) and 5-6 (RR =33.98, CI =23.09-49.98, P<0.001), the anatomic site of surgery (upper intra-abdominal, RR =2.67, CI =2.14-3.33, P<0.001; intracranial, RR =1.74, CI =1.35-2.25, P<0.001; intrathoracic, RR =2.35, CI =1.70-3.24, P<0.001; cardiac, RR =3.61, CI =2.60-4.99, P<0.001; and major vascular; RR =3.05, CI =2.22-4.18, P<0.001), respiratory or cardiovascular comorbidities (RR =1.95, CI =1.60-2.38, P<0.001 and RR =1.38, CI =1.11-1.72, P=0.004, respectively), and patients in shock prior to receiving anesthesia (RR =2.62, CI =2.07-3.33, P<0.001). CONCLUSION: The perioperative incidence of cardiac arrest within 24 hours of anesthesia for emergency surgery was high and associated with multiple factors such as young age (≤2 years old), cardiovascular and respiratory comorbidities, increasing ASA physical status classification, preoperative shock, and surgery site. Perioperative care providers, including surgeons, anesthesiologists, and nurses, should be prepared to manage promptly this high risk group of surgical patients.

The initial success rate of cardiopulmonary resuscitation and its associated factors in patients with cardiac arrest within 24 hours after anesthesia for an emergency surgery.

PURPOSE: To determine the initial success rate and its associated factors on cardiopulmonary resuscitation (CPR) in patients with cardiac arrest within 24 hours after receiving anesthesia for an emergency surgery. PATIENTS AND METHODS: After the hospital ethical committee gave approval for this study, the anesthesia providers recorded all relevant data regarding CPR in patients with cardiac arrest within 24 hours after anesthesia for emergency surgery at Maharaj Nakorn Chiang Mai Hospital, a university hospital in Northern Thailand. Only data from the cardiac arrest patients who received the first CPR attempt were included in the analysis. The end point of the initial success of CPR was return of spontaneous circulation (ROSC). Factors related to ROSC were determined by univariate analyses and multiple logistic regression analysis. The odds ratios (OR) and 95% confidence intervals (CI) were used to calculate the strength of the factors associated with the ROSC. RESULTS: Of the 96 cardiac arrest patients, 44 patients (45.8%) achieved ROSC. Factors associated with ROSC were electrocardiogram monitoring for detected cardiac arrest (OR =4.03; 95% CI =1.16-14.01; P=0.029), non-shock patients before arrest (OR =8.54; 95% CI =2.13-34.32; P=0.003), timing to response of activated CPR team within 1 minute (OR =9.37; 95% CI =2.55-34.39; P<0.001), having trained CPR teams (OR =8.76; 95% CI =2.50-30.72; P<0.001), and administration of more than one dose of epinephrine (OR =5.62; 95% CI =1.32-23.88; P<0.019). CONCLUSION: Patients undergoing anesthesia for an emergency surgery are at risk for perioperative cardiac arrest with high mortality which requires immediate CPR. Our results have confirmed that early detection of cardiac arrest by vigilant electrocardiogram monitoring and prompt management with a qualified team are important factors in improving the success of CPR. Emergency surgical patients at risk for cardiac arrest should be promptly managed, with facilities available not only during the operation but also during the pre- to postoperative period.