Iranian Journal of Critical Care Nursing Summer 2010, Volume 3, Issue 2; 45-49

Survival rate and outcomes of cardiopulmonary resuscitation

Salari A.* MSc, Mohammadnejad E.1 MSc, Vanaki Z.2 PhD, Ahmadi F.2 PhD
*
Imam Khomeini Clinical & Emergency Complex, Tehran University of Medical Sciences, Tehran, Iran;
1
Imam Khomeini Clinical & Emergency Complex, Tehran University of Medical Sciences, Tehran, Iran;
2
Faculty of Medical Sciences, Tarbiat-Modarres University, Tehran, Iran
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Abstract
Aims: Restoring the vital functions of heart and lung and the efforts to establish circulation and respiration are among the
most important measures of professional resuscitators in health centers. The aim of this study was to investigate the rate of
survival and the outcomes of cardiopulmonary resuscitation in educational hospitals of Tehran.
Methods: This cross-sectional longitudinal study was conducted during 5 months in 3 educational and university selected
hospitals on 250 patients who underwent cardiopulmonary resuscitation procedure. Data were collected with standard form
of recording resuscitation cases in hospital (Utstein) including various variables such as age, sex, working shift, location of
arrest, cause of arrest, initial cardiac rhythm, short and long term resuscitation outcomes. Data were analyzed with SPSS 14
software and descriptive and inferential statistical tests (Chi-square and logistic regression).
Results: 59.6% of participants were male and the average age of total sample was 57.1721.10 years old. 64.4% of CPR
attempt were unsuccessful and led to patients death. 28.4% of cases were successful in Short-term. Only 7.2% of studied
cases had long-term survival after resuscitation procedure and were discharged from hospital.
Conclusion: More attention to the chain of survival and causes of success and failure of cardiopulmonary resuscitation and
addressing the predictors of the success of cardiopulmonary resuscitation seem necessary.

Keywords: Cardio Pulmonary Resuscitation (CPR), Chain of Survival, Short-Term Outcomes, Long-Term Outcomes

Introduction possess a team of cardiopulmonary resuscitation that

operates, using and utilizing the advanced technology
Cardiopulmonary resuscitation includes some and standard protocols, when a cardio-respiratory
measures to restore the vital functions of heart and arrest occurs. However, the patients survival rate and
lung, the two important organs, and it is tried to their discharge from hospital after a cardiopulmonary
establish the blood circulation and the respiration arrest has remained 14.7% in the U.S. and 16.7% in
artificially up, till the return of the spontaneous blood Britain over 30 years [6].
flow. But because without these measures, due to the Cardiopulmonary arrest is one of the cases that happen
lack of oxygen, permanent brain death is caused unexpectedly at any time and gives rise to half of
within less than 4-6 minutes (golden time), the deaths. Even though, many of these cases can be saved
cardiopulmonary resuscitation (CPR) term was by the rapid onset of resuscitation and conducting the
renamed by Peter Safars suggestion (father of advanced cardiac interventions. Survival rate and the
resuscitation science) to cardiopulmonary and cerebral improvement of patients long term outcomes after
resuscitation (CPCR), due to importance of brain resuscitation depends on the early onset of
resuscitation and maintaining its function [1, 2]. resuscitation and conducting advanced cardiac
In the United States, annually 335 thousand people interventions. Indeed, it depends on the very sequence
suffer from cardiac arrest out of hospital and of survival chain steps, including patients
according to estimates, the same number of cardiac identification and immediate access; quick beginning
arrests occur during hospitalization [3, 4]. According of resuscitation and basic life support, patients timely
to the American Heart Association in 2006, the rapid defibrillation and conducting the basic life support [7,
onset of cardiopulmonary resuscitation (CPR) within 8]. In a prospective study in Croatia on 32,861
5-3 minutes after patients cardiac arrest, along with admitted patients in 120 cases, 96 of cases (80%)
the rapid onset of advanced life support, causes an underwent cardiopulmonary resuscitation. 76.7% of
increase in survival rate and long-term consequences cardiac arrest were witnessed and the rest were non-
to more than 50% in patients with cardiac arrest and witnessed cases. Totally, 22.5% of patients were
with initial rhythm of ventricular fibrillation. For discharged alive from the hospital [6]. Survival rate of
every one minute delay in defibrillation, 7-10% of patients after cardiac arrest in hospitals is lower in the
patients survival rate is reduced [5]. Many hospitals night shift because of lower preparedness and the low
* Correspondence; Email: [email protected] Received 2010/03/12; Accepted 2010/05/22
 Survival rate and outcomes of cardiopulmonary resuscitation _____________________________________________________________

number of employees on night shifts [9]. In a report patients, work shift, cardiac arrest occurrence location
published by the national cardiopulmonary and reason, patients initial cardiac rhythm, type of
resuscitation center which is currently the largest initial cardiac rhythm, duration of resuscitation team's
center of recording statistics, diagrams and research in arrival, time interval between cardiac arrest and the
the field of resuscitation, during 2000 to 2002, from first cardiac shock, time interval between cardiac
among the total number of 14,720 adult patients with arrest and intra-tracheal intubation, the time period
cardiac arrest in 207 United States hospitals, the three from cardiac arrest till the end of resuscitation (CPR
major causes for cardiac arrest in adults were length), and short-term and long-term consequences of
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considered as "cardiac arrhythmia", "acute respiratory resuscitation and patients brain function at the time of
failure" and "hypotension". Finally, from this number, discharge from hospital.
44% had the return of circulation and pulse and 17% Final results of resuscitation were considered as
were discharged alive from the hospital [10]. In Iran, unsuccessful resuscitation (patient's death), initial
the death rate after resuscitation has reported to be survival (short-term outcome), i.e., the return of
more than 90% and the rate of patients discharge spontaneous current (ROSC) less than or equal to 20
from hospital has been reported less than 7% [7, 11]. minutes, more than 20 minutes but less than 24 hours
None of them has used the Utstein pattern and the or more than 24 hours, and patients' discharge from
proposed model of American heart association and hospital (long-term outcome). This form was filled by
other reputable world Associations including physicians and nurses who participated in
resuscitation association of Europe, Australia, New resuscitation. Meanwhile, the accuracy and
Zealand, South Africa etc. for recording the correctness of the completed forms was revised by
resuscitation cases [12]. researchers regularly. For patients who had undergone
Thus, with regard to the lack of using this tool in the resuscitation many times during the hospital stay only
researches done in Iran, this study was conducted the first filled form was evaluated in order to avoid
using this standard recording tool in order to false results.
investigate the outcomes and indicators of SPSS 14 software was used for data analysis. Chi-
cardiopulmonary resuscitation success in Tehran square test was used for measuring qualitative
educational hospitals. variables and their relation to final results of
resuscitation and logistic regression was used to
determine the predictors of patients' survival.
Methods
Results
This cross-sectional longitudinal study was conducted
on patients who underwent cardiopulmonary 149 participants were male and the whole sample
resuscitation during the period of July to November average age was 57.1721.1 years (ranging from 15-
2006 in three selected educational hospitals of Tehran 94 years). The survival rate was similar for both
and the subjects were evaluated in terms of survival genders, while the patients survival and discharge rate
rate and short-term and long-term outcomes after significantly correlated with patients age (p=0.0001);
resuscitation. so that any of the patients over 60 years did not
After obtaining permission from the research deputy discharge from the hospital after resuscitation. From
of studied hospitals, 250 adult patients with the 28.4% of the resuscitation cases that were
cardiopulmonary arrest who underwent the successful in short-term period, in 23 cases (9.2%) the
cardiopulmonary resuscitation operation were selected return of spontaneous blood flow lasted less than or
by available sampling method and entered the study. equal to 20 minutes, in 31 cases (12.4%) higher than
Patients with mere respiratory arrest, or patients with 20 minutes but less than 24 hours, and in 35 cases
cardiac rhythm disturbances and pulse, were excluded (14%) was more than 24 hours (Table 1). Cardiac
from the study even if they were treated by arrest in most cases (45.2%) had a cardiac cause.
resuscitation team. There was a significant correlation between the
Data collection tool was the standard form of location of cardiac arrest and the final outcomes of
recording the resuscitation cases in hospital based on resuscitation (p=0.0001; Table 1).
the Utstein pattern that was the agreed pattern of 29.2% of cardiopulmonary resuscitation cases were
American heart association and other reputable world done in the morning shift, 34.4% in the afternoon shift
associations in field of resuscitation and has been and 36.4% in the night shift. Patients survival and
lately reviewed in Melbourne, Australia, in 2002. This discharge rate in the morning shift was significantly
form includes information including age and gender of higher than other shifts (p=0.0001) (Diagram 1).
 ___________________________________________________________________________________________________ Salari A. et al.

Table 1- Frequency and relative distribution of patients rhythm, with the final results of resuscitation
cardiopulmonary resuscitation results (figures outside parentheses (p=0.0001; Table 1).
are the number and those inside the parentheses are percentage)
Unsuccessful
Discharge
Results resuscitation Initial Unsuccessful(death)
from
Variable and patients survival
hospital
death
30 Initial survival
Less than 20 9(52.9) 7(41.2) 1(5.9) 26.4
21-20 28(41.9) 20(35.1) 9(15.8) Discharge from hospital
Age 25
41-60 28(57.6) 20(30.3) 8(12.1) 22
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(Years)
61-80 62(72.9) 23(27.1) 0

Percent of patients
More than 80 24(96) 1(4) 0 20
Male 103(69.1) 36(24.2) 10(6.7) 16
Gender
Female 58(57.4) 35(34.7) 8(7.9)
15
Morning 40(53.3) 23(30.7) 12(16)
Work Shift Evening 55(64.7) 26(30.6) 4(4.7)
10.4
9.2 8.8
Night 66(73.3) 22(24.4) 2(2.2) 10
Witness of Yes 122(59.2) 66(32) 18(8.7) 4.8
arrest No 39(88.6) 5(11.4) 0 5
CCU 24(54.5) 14(31.8) 6(13.6) 1.6 0.8
ICU 26(56.2) 17(35.4) 5(10.4)
Emergency
0
50(57.5) 31(35.6) 6(6.9)
room Morning Evening Night
Occurrence
Internal ward 48(87.3) 7(12.7) 0
place
Operating Work Shift
3(60) 1(20) 1(20) Diagram 1- Distribution of resuscitations based on the final
Room
General 10(90.9) 1(9.1) 0 outcomes of resuscitation and work shift
Total 161(64.4) 71(28.4) 18(7.2)
Cardiac 74(65.5) 33(29.2) 6(5.3) The average time of the resuscitation team arrival to
Cerebrovascular the patient's bedside since the occurrence of cardiac
16(57.1) 8(28.6) 4(14.3)
accident
Respiratory 21(51.2) 15(36.6) 5(12.2)
arrest was 3.562.01 minutes, the mean time of giving
Cause of Renal 5(100) 0 0 the first shock to patients with shockable rhythms was
occurrence Cancer 17(73.9) 6(26.1) 0 3.691.89 minutes, the mean time period between
Bleeding 6(100) 2(25) 0 endotracheal intubation and occurrence of cardiac
Infection 7(100) 0 0 arrest was 4.10 2.48 minutes and the mean duration
Trauma 5(62.5) 2(25) 1(12.5) of resuscitation was 38.6810.49 minutes.
Others 10(58.8) 5(29.4) 2(11.8)
Ventricular
20(35.7) 27(48.2) 9(16.1) Table 2- Factors affecting CPR patients' discharge
fibrillation
Variable B SE Exp(B) P value
Ventricular
6(27.2) 10(45.5) 6(27.3) Work Shift 1.061 1.063 2.889 0.02
tachycardia
Asystole 112(80.6) 26(18.7) 1(7) Initial cardiac rhythm 3.839 0.475 46.495 0.0001
Initial
rhythm Bradycardia 7(63.6) 2(18.2) 2(18.2) Resuscitation team
1.095 0.374 2.99 0.003
response time
Pulseless
electrical 19(72.7) 6(27.3) 0 Duration of CPR 2.695 0.72 14.8 0.0001
activity (PEA)
Total 161(64.4) 71(28.4) 18(7.2) There was a significant correlation between mentioned
Shock Yes 26(33.3) 37(47.4) 15(19.2) time periods and the final results of patients
capability No 135(78.5) 34(19.8) 3(1.7) resuscitation (p=0.0001), so that increasing of
Total 161(64.4) 71(28.4) 18(7.2)
mentioned time periods resulted in reduction of
patients' survival and discharge rate.
There was a significant relationship between the The most important patient discharge indicators were
cardiac arrest being witnessed and the patients final cardiac rhythm, resuscitation team response time and
resuscitation outcome (p=0.0001), in a way that none the duration of CPR (Table 2).
of patients who had non-witnessed cardiac arrest were
discharged alive. Patients survival and discharge rate
was significantly higher in patients who had shockable
rhythms and there was a significant correlation Discussion
between the type of initial cardiac rhythm and the Overall, the study results are upsetting. Only 7.2% of
ability of performing the shock considering the type of patients have been discharged alive after resuscitation,
 Survival rate and outcomes of cardiopulmonary resuscitation _____________________________________________________________

from which only 2.8% maintained a satisfactory brain sufficient staff and equipments for regular care and
function. Although, the overall survival rate of monitoring the stage of resuscitation.
patients after cardiac arrest is low in several studies, Logistic regression test showed that the work shift
findings of present study are not consistent with (p=0.02), initial cardiac rhythm (p=0.001), response
results of some researches that have reported a long- time of resuscitation team (p=0.003) and duration of
term survival rate between 17 to 32% [6, 10, 13, 14]. CPR (p=0.001) can be considered as predictor
But patients discharge rate in present study was indicators of patients' discharge after CPR.
higher than the study conducted in 2006 in Thailand, The results of this study [7, 11] are weak and worrying
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which patients discharge rate came out to be 6.9% like other studies conducted in Iran, even though the
[15]. results of this study cannot be generalized to all
In this study, cardiac cause was the most common treatment centers of Iran.
cause of cardiac arrest, similar to a number of other
studies [6, 16]. Hospital discharge rate was also higher
among cardiac patients. In addition, similar to the Conclusion
results of some researches, none of resuscitated cases
of cancer, renal failure, hemorrhage and sepsis were Health care managers and authorities should pay more
discharged alive. attention to cardiopulmonary resuscitation and its
Results of this study show that patients' discharge rate outcomes, and should formulate and implement
is higher among those who have shockable rhythms as regular training programs and provide the necessary
the initial cardiac rhythm at the time of cardiac arrest, facilities for patients' resuscitation and the intensive
like some other studies [17, 18]. This issue is due to care after it, in Iran hospitals.
the sensitivity of shockable rhythms to administering
Acknowledgement: Researchers would like to thank
the cardiac shock and returning to normal rhythm in
all nurses and physicians of the studied hospitals and
cases which the cardiac shock is performed timely.
all the people who helped us in conducting this study,
In this research, like many studies, the discharge rate
including the esteemed research deputies of the
of patients underwent CPR was higher in the morning
studied hospitals for their sincere cooperation.
shift compared to evening and night shifts [9, 19]; this
difference can be attributed to the earlier response
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