Outcomes of cardiopulmonary resuscitation for patients on vasopressors or inotropes: a pilot study.

HYPOTHESIS: Outcomes of critically ill patients who receive cardiopulmonary resuscitation (CPR) are poor, and the subgroup on vasopressors or inotropes before cardiopulmonary arrest (CPA) rarely survives. SETTING: The setting of the study was a critical care unit of a 350-bed community teaching hospital. STUDY DESIGN: This was a retrospective, cohort study. METHODS: A retrospective review was performed of medical records of all patients, identified through medical billing and hospital committee records, who received CPR for CPA in a critical care unit. RESULTS: Of 83 patients, with an average age of 66 years, 14 (17%) survived to hospital discharge. Patients with pulseless electrical activity and asystole were significantly less likely to survive (9% and none, respectively; P = .0001). Only 2 (4%) of 55 critically ill patients receiving vasopressors before CPR survived, whereas 12 of 28 patients not on vasopressors survived (P < .0001). Although mechanical ventilation just before CPR was highly associated with administration of vasopressors, ventilation was not significantly associated with mortality (P = .13). Mortality of patients on vasopressors was higher for both mechanically ventilated (95% vs 33%, P < .001) and spontaneously breathing (100% vs 64%, P = .02) patients. In multiple logistic regression analyses, administration of vasopressors was the only variable independently associated with in-hospital mortality (odds ratio, 35.1; 95% confidence interval = 4.1-304.3). CONCLUSIONS: Survival of patients requiring CPR during critical care admission was 17%. Very few patients survived who required vasopressors or inotropes immediately before CPA. This study is limited significantly by its retrospective design and small cohort, and so this question should be reexamined in a larger study.

Patients' predilections regarding informed consent for hospital treatments.

BACKGROUND: Respect for patient autonomy is a core principle of American medicine. Informed consent is required for surgical procedures and blood transfusions but not for most medical treatments of hospitalized patients. HYPOTHESIS: If given the option, patients want to give permission for common medical therapies during hospitalization. SUBJECTS: Participants in the study were patients admitted to the medical service of a 350-bed community teaching hospital. METHODS: A questionnaire comprising 4 scenarios of varying risk/benefit ratios was administered to all patients who agreed to participate. RESULTS: A total of 634 patients were admitted to the medicine service between June and August 2006. Two hundred and ten patients (103 men, 107 women), with a mean age (+/- SE) of 63.3 +/- 1.1 years, agreed to answer the questionnaire. Of these patients, 85% wished to participate in even trivial medical decision making (ie, potassium supplementation), 92% wished to participate in treatments with moderate risk (ie, diuretic for congestive heart failure). When a risk was initially posed as less than a 5% risk of brain hemorrhage and benefits of therapy were substantially higher (eg, thrombolysis for pulmonary embolus), 93% wanted to make the decision. If the risk of brain hemorrhage was 20% or greater, 95% wanted to make the decision. Younger patients (<65 years) were more likely to prefer requiring doctors to obtain their "permission no matter what" than were older patients (>or=65 years), and older patients were more likely to waive consent across levels of risk. CONCLUSIONS: Most acutely ill hospitalized medicine patients wished to participate in even the most mundane aspects of their medical decision making. Although it is not logistically feasible to obtain informed consent for every treatment of every hospitalized patient, clinicians should be aware of patients' predilections and might consider offering opportunities for patients to participate in clinical decision making, especially for therapies that carry substantial risk.