Patients on maintenance dialysis who experienced in-hospital cardiac arrest received similar quality of care, leading to comparable outcomes at discharge, to those not on dialysis, according to a recent study.
“It has been suggested that the lower survival for patients on maintenance dialysis with in-hospital cardiac arrest may be because of differences in cardiac arrest mechanisms or less optimal resuscitation care, given the unique features of these patients,” Monique Anderson Starks, MD, of Duke Clinical Research Institute, and colleagues wrote. “Because prior large studies utilized only administrative data to characterize cardiac arrest events and outcomes, no study has examined detailed data on the clinical characteristics of cardiac arrest and specic processes of resuscitation care for patients on dialysis with in-hospital cardiac arrest.”
Initially hypothesizing that patients on dialysis would receive lower-quality resuscitation care, as well as have lower survival rates, researchers used data from the American Heart Association’s Get With the Guidelines-Resuscitation (GWTG-R) program, designed specifically to improve in-hospital cardiac arrest care. Considering age, sex, race, hospital and year of arrest, investigators matched patients on dialysis were to those not on dialysis in a 1:3 ratio. In reviewing cardiac arrest characteristics, researchers noted that patients on dialysis were less likely to have a shockable initial rhythm (20% vs. 21%) or to be in the intensive care unit at the time of the arrest (54% vs 58%). Patients on dialysis had a higher prevalence of diabetes, congestive heart failure and prior myocardial infarction, but were less likely to have malignancy, pneumonia or respiratory insufficiency.
The primary outcome of the study was survival to discharge. Secondary outcomes included return of spontaneous circulation (ie, acute survival) and favorable neurologic status.
Investigators determined that composite resuscitation quality was slightly lower for patients on dialysis (89% vs. 90%), and that they were less likely to receive a first shock within 2 minutes. They were also less likely to have their cardiac arrest witnessed or monitored. Despite these differences, researchers observed no significant differences between groups for most individual processes of care. Further, patients on dialysis had similar odds of survival to discharge (OR = 1.05), higher odds of acute survival (OR = 1.33) and were more likely to have favorable neurologic status compared with those not on dialysis (OR = 1.12).
“Although many factors should be considered in provider-patient discussions about advanced directives, our study suggests that CPR is not a futile intervention in patients on dialysis with in-hospital cardiac arrest,” the researchers concluded, “Our ndings also present the opportunity to further improve resuscitation outcomes in patients on maintenance dialysis by improving patient monitoring and resuscitation response times during periods of increased risk.”
In a related editorial, Simon I. Hsu, MD, MS, and Susan P.Y. Wong, MD, MS, both of the University of Washington, posed the question: “How do we reconcile these new findings with those of prior studies indicating poorer long-term outcomes among patients with ESKD?” In response, they suggest several possible explanations including the idea that the considered short-term outcomes may not reflect the acquired morbidity or other complications that follow in-hospital cardiac arrest, as well as the fact that little is known about differences in post-discharge care between the two patient populations. Additionally, they wrote, “even the highest quality resuscitation” may not be enough to prevent the poor health outcomes and limited life expectancy associated with the disease.
They argued that, despite the potential for long-term complications, “these findings underscore the uniformity with which clinicians strive to provide high-quality CPR irrespective of whether patients have ESKD.” – by Melissa J. Webb
Disclosures: Starks reports being co-chair of the American Heart Association GWTG-R Adult Research Task Force. Please see full study for all other authors’ relevant financial disclosures.