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      Low Rates of Survival Seen in Orthopedic Patients Receiving In-Hospital Cardiopulmonary Resuscitation

      research-article
      , BSc(hons), MBBS, MRCS, MSc 1 , 2 , , BMedSci, BMBS 2 , 3 , , MBChB, FRCP 4 , , MBBCh, FRCSEd (Tr & Orth) 5
      Geriatric Orthopaedic Surgery & Rehabilitation
      SAGE Publications
      geriatric medicine, geriatric trauma, trauma surgery, hospitalist, cardiopulmonary resuscitation, hip fracture, survival

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          Abstract

          Introduction:

          Despite awareness of overall poor survival rates following cardiopulmonary resuscitation (CPR), some orthopedic patients with significant comorbidities continue to have inappropriate resuscitation plans. Furthermore, in certain injury groups such as patients with hip fractures, survival outcome data are very limited; current discussions regarding resuscitation plans may be inaccurate. This study assesses survival in orthopedic patients following CPR, to inform decision-making between physicians, surgeons, and patients.

          Methods:

          A dual center, retrospective cohort study was performed analyzing all orthopedic admissions that received CPR over a 25-month period, with a minimum of 1 year follow-up. National Cardiac Arrest Audit data, “mortality and morbidity” meeting records, National Hip Fracture Databases, and electronic notes were analyzed. Survival duration was measured, alongside reason for admission, location CPR occurred, and initial rhythm encountered.

          Results:

          Thirty-two patients received CPR over the 25-month period (median age: 83; range: 30-96). Three (9%) of 32 patients survived to discharge. Only 1 of the 26 patients older than 65 years survived to discharge. Fifteen (47%) of 32 had hip fractures, where 4 (27%) of 15 of this group survived 24 hours; none survived to discharge. When recorded, 22 (92%) of 24 initially had a nonshockable rhythm.

          Discussion:

          Cardiopulmonary resuscitation was conceptualized as a treatment for reversible cardiopulmonary causes. When used in trauma and orthopedic patients, especially older and/or hip fracture patients, it seldom led to hospital discharge. Different admission practices such as “front door” orthogeriatric reviews may explain the contrast in usage of CPR between the hospitals.

          Conclusion:

          Survival rates following CPR were very low, with it proving specifically ineffective in hip fracture patients. Although every decision about resuscitation should be patient centered and individualized, this study will allow clinicians to be more realistic about outcomes from CPR, particularly in the hip fracture group.

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          Most cited references21

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          The influence of the probability of survival on patients' preferences regarding cardiopulmonary resuscitation.

          Studies suggest that a majority of elderly patients would want to undergo cardiopulmonary resuscitation (CPR) if they had a cardiac arrest. Yet few studies have examined their preferences after clinicians have informed them about the outcomes of CPR. To study older patients' preferences regarding CPR, we interviewed as many ambulatory patients as possible in one geriatrics practice in Denver from August 1, 1991, through July 31, 1992. A total of 371 patients at least 60 years of age were eligible; 287 completed the interview (mean age, 77 years; range, 60 to 99). When asked about their wishes if they had cardiac arrest during an acute illness, 41 percent opted for CPR before learning the probability of survival to discharge. After learning the probability of survival (10 to 17 percent), 22 percent opted for CPR. Only 6 percent of patients 86 years of age or older opted for CPR under these conditions. When asked about a chronic illness in which the life expectancy was less than one year, 11 percent of the 287 patients opted for CPR before learning the probability of survival to discharge. After learning the probability of survival (0 to 5 percent), 5 percent said they would want CPR. Older patients readily understand prognostic information, which influences their preferences with respect to CPR. Most do not want to undergo CPR once a clinician explains the probability of survival after the procedure.
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            Pre-arrest predictors of failure to survive after in-hospital cardiopulmonary resuscitation: a meta-analysis.

            Our objective was to perform a systematic review of pre-arrest predictors of the outcome of in-hospital cardiopulmonary resuscitation (CPR) in adults. We searched PubMed for studies published since 1985 and bibliographies of previous meta-analyses. We included studies with predominantly adult patients, limited to in-hospital arrest, using an explicit definition of cardiopulmonary arrest and CPR and reporting survival to discharge by at least one pre-arrest variable. A total of 35 studies were included in the final analysis. Inclusion criteria, design elements and results were abstracted in parallel by both investigators. Discrepancies were resolved by consensus. The rate of survival to discharge was 17.5%; we found a trend towards increasing survival in more recent studies. Metastatic malignancy [odds ratio (OR) 3.9] or haematologic malignancy (OR 3.9), age over 70, 75 or 80 years (OR 1.5, 2.8 and 2.7, respectively), black race (OR 2.1), altered mental status (OR 2.2), dependency for activities of daily living (range OR 3.2-7.0 depending on specific activity), impaired renal function (OR 1.9), hypotension on admission (OR 1.8) and admission for pneumonia (OR 1.7), trauma (OR 1.7) or medical non-cardiac diagnosis (OR 2.2) were significantly associated with failure to survive to discharge; cardiovascular diagnoses and co-morbidities were associated with improved survival (range OR 0.23-0.53). Elevated CPR risk scores predicted failure to survive but have not been validated consistently in different populations. We identified several pre-arrest variables associated with failure to survive to discharge. This information should be shared with patients as part of a shared decision-making process regarding the use of do not resuscitate orders.
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              Patient preferences for communication with physicians about end-of-life decisions. SUPPORT Investigators. Study to Understand Prognoses and Preference for Outcomes and Risks of Treatment.

              Physicians are frequently unaware of patient preferences for end-of-life care. Identifying and exploring barriers to patient-physician communication about end-of-life issues may help guide physicians and their patients toward more effective discussions. To examine correlates and associated outcomes of patient communication and patient preferences for communication with physicians about cardiopulmonary resuscitation and prolonged mechanical ventilation. Prospective cohort study. Five tertiary care hospitals. 1832 (85%) of 2162 eligible patients completed interviews. Surveys of patient characteristics and preferences for end-of-life care; perceptions of prognosis, decision making, and quality of life; and patient preferences for communication with physicians about end-of-life decisions. Fewer than one fourth (23%) of seriously ill patients had discussed preferences for cardiopulmonary resuscitation with their physicians. Of patients who had not discussed their preferences for resuscitation, 58% were not interested in doing so. Of patients who had not discussed and did not want to discuss their preferences, 25% did not want resuscitation. In multivariable analyses, patient factors independently associated with not wanting to discuss preferences for cardiopulmonary resuscitation included being of an ethnicity other than black (adjusted odds ratio [OR], 1.48 [95% CI, 1.10 to 1.99), not having an advance directive (OR, 1.35 [CI, 1.04 to 1.76]), estimating an excellent prognosis (OR, 1.72 [CI, 1.32 to 2.59]), reporting fair to excellent quality of life (OR, 1.36 [CI, 1.05 to 1.76]), and not desiring active involvement in medical decisions (OR, 1.33 [CI, 1.07 to 1.65]). Factors independently associated with wanting to discuss preferences for resuscitation but not doing so included being black (OR, 1.53 [CI, 1.11 to 2.11]) and being younger (OR, 1.14 per 10-year interval younger [CI, 1.04 to 1.25]). Among seriously ill hospitalized adults, communication about preferences for cardiopulmonary resuscitation is uncommon. A majority of patients who have not discussed preferences for end-of-life care do not want to do so. For patients who do not want to discuss their preferences, as well as patients with an unmet need for such discussions, failure to discuss preferences for cardiopulmonary resuscitation and mechanical ventilation may result in unwanted interventions.
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                Author and article information

                Journal
                Geriatr Orthop Surg Rehabil
                Geriatr Orthop Surg Rehabil
                GOS
                spgos
                Geriatric Orthopaedic Surgery & Rehabilitation
                SAGE Publications (Sage CA: Los Angeles, CA )
                2151-4585
                2151-4593
                16 January 2019
                2019
                : 10
                : 2151459318818972
                Affiliations
                [1 ]Department for Health, University of Bath, Bath, United Kingdom
                [2 ]Severn Postgraduate Medical Education School of Surgery, Bristol, United Kingdom
                [3 ]Royal United Hospitals Bath NHS Foundation Trust, Bath, United Kingdom
                [4 ]Department of Geriatric Medicine, North Bristol NHS Trust, Bristol, United Kingdom
                [5 ]Department of Trauma & Orthopaedics, North Bristol NHS Trust, Bristol, United Kingdom
                Author notes
                [*]James W. A. Fletcher, Applied Biomechanics Suite 1.308, University of Bath, Claverton Down, Bath, United Kingdom. Email: jwa.fletcher@ 123456doctors.net.uk
                Author information
                https://orcid.org/0000-0003-4147-5013
                Article
                10.1177_2151459318818972
                10.1177/2151459318818972
                6350114
                faad4f79-dd02-4d24-ac6a-ffd82bb2a155
                © The Author(s) 2019

                This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License ( http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages ( https://us.sagepub.com/en-us/nam/open-access-at-sage).

                History
                : 15 May 2018
                : 10 October 2018
                : 13 November 2018
                Categories
                Article
                Custom metadata
                January-December 2019

                geriatric medicine,geriatric trauma,trauma surgery,hospitalist,cardiopulmonary resuscitation,hip fracture,survival

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