Elsevier

Resuscitation

Volume 92, July 2015, Pages 1-6
Resuscitation

Clinical Paper
Echocardiography for prognostication during the resuscitation of intensive care unit patients with non-shockable rhythm cardiac arrest

https://doi.org/10.1016/j.resuscitation.2015.03.024Get rights and content

Abstract

Aim

Transthoracic echocardiography (TTE) during cardiopulmonary arrest (CPA) has been studied in victims of cardiac arrests. Our objective was to evaluate the feasibility and usefulness of TTE in victims of cardiac arrest with non-shockable rhythms hospitalized in intensive care units (ICUs).

Methods

This prospective and observational cohort study evaluated ICU patients with CPA in asystole or pulseless electrical activity (PEA). Intensivists performed TTE during intervals of up to 10 s as established in the treatment protocol. Myocardial contractility was defined as intrinsic movement of the myocardium coordinated with cardiac valve movement. PEA without contractility was classified as electromechanical dissociation (EMD), and with contractility as pseudo-EMD. The images, the rates of return of spontaneous circulation (ROSC) and the survival upon hospital discharge and after 180 days were evaluated.

Results

A total of 49 patients were included. Image quality was considered adequate in all cases and contributed to the diagnosis of CPA in 51.0% of the patients. Of the 49 patients included, 17 (34.7%) were in asystole and 32 (65.3%) in PEA, among which 5 (10.2%) were in EMD and 27 (55.1%) in pseudo-EMD. The rates of ROSC were 70.4% for those in pseudo-EMD, 20.0% for those in EMD, and 23.5% for those in asystole. Survival upon hospital discharge and after 180 days occurred only in patients in pseudo-EMD (22.2% and 14.8%, respectively).

Conclusions

TTE conducted during cardiopulmonary resuscitation in ICU patients can be performed without interfering with care protocols and can contribute to the differential diagnosis of CPA and to the identification of a subgroup of patients with better prognosis.

Introduction

In the United States, approximately 220,000 cases of in-hospital cardiopulmonary arrest (IH-CPA) are estimated to occur annually, which represents one case per 339 admissions.1 Asystole or pulseless electrical activity (PEA) is observed in approximately 80% of cases, and hospital survival rates in different countries vary between 5% and 37%.2, 3, 4, 5 In addition to the initial rhythm in asystole or PEA, the event location (ward versus emergency unit), time of cardiopulmonary resuscitation (CPR), and the occurrence of non-witnessed CPA have been associated with poor outcomes.

Transthoracic echocardiography (TTE) has been increasingly used as a diagnostic and prognostic tool for critically ill patients, particularly for those in intensive care units (ICUs).6 Decision-making for these patients has been increasingly based on the triad of clinical status, patient, and TTE.7, 8 For assistance in CPA, Breitkreutz developed the Focused Echocardiographic Evaluation Life Support (FEEL) protocol, which allows the assessment of myocardial contractility and is able to identify indirect signs of hypovolemic shock, pulmonary thromboembolism, and restrictive pericardial effusion without interfering with patient care.9

Portable TTE equipment has allowed data acquisition in real time, rapidly, and without the need to move the patient or expose the patient to radiation. However, most of the evidence of TTE during CPA comes from out-of-hospital CPA, and its results have been extrapolated to IH-CPA conditions. Therefore, this study aimed to evaluate the use of TTE during CPA in ICU patients.

Section snippets

Study design

The study was approved by the research ethics committee (REC) of the Dante Pazzanese Institute of Cardiology (Instituto Dante Pazzanese de Cardiologia) under protocol No. 4010 and the Sisterhood of Santa Casa de Misericórdia of São Paulo (Irmandade da Santa Casa de Misericórdia de São Paulo – ISCMSP) under protocol No. 243640. This prospective and observational cohort study used TTE for the evaluation of CPA patients with non-shockable rhythm hospitalized in an academic tertiary ICU (ISCMSP)

Results

Between April 2013 and April 2014, there were 2024 hospitalizations in the ICU of ISCMSP, with 473 episodes of CPA, and resuscitation was attempted in 135 cases (28.5%). DNR had been recommended for 338 patients. Of the 135 attempts, in 88 cases (65.2%), the initial rhythm was asystole or PEA, and the patients were eligible for enrollment in the study. However, 39 cases (44.3%) were not included (Fig. 1) because trained professionals were unavailable to perform TTE (n = 25). In six episodes, the

Discussion

Studies on TTE during CPR in hospitalized patients are rare and involve out-of-hospital CAP victims treated in emergency units.17, 18 To the best of our knowledge, no previous studies have evaluated the use of TTE during CPR in ICU patients. Our study population reflects the heterogeneity of ICU patients, with their multiple comorbidities, invasive procedures, and high-risk scores. The performance of TTE during the resuscitation of these patients was feasible and yielded good-quality images at

Conclusions

Despite the study limitations, primarily associated with the total number of patients and the small number of long-term survivors, we conclude that TTE performed during CPR in ICU patients can be easily performed by trained personnel and allows rapid and reliable image acquisition without interfering with treatment protocols. TTE contributes to the differential diagnosis of CPA by non-shockable rhythms and the characterization of pseudo-EMD, identifying a subgroup that may benefit from the

Conflict of interest statement

There are no conflicts of interest to declare.

Author contributions

Flato U.P. and Timerman A. designed the study; Paiva E. and Buehler A. reviewed results for the study protocol; Flato U.P. and Marco R. performed data collection; Carballo M.T. analyzed the data; Flato U.P., Paiva E., Timerman A., and Marco R. prepared and revised the manuscript; Flato U.P., Paiva E., Timerman A., Marco R., and Buehler A. take responsibility for the results and the paper as a whole.

Acknowledgments

We thank Renata Guimarães and Theodore Nielsen for continuous support.

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    A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2015.03.024.

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