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Abstract

Background: In-hospital cardiopulmonary arrest (IHCA) is defined as Cardiac arrest (CA) occurring within inpatients areas of a hospital. The incidence of IHCA is often associated with high mortality. Data on IHCA is very deficient in Saudi Arabia (SA). This study aimed to bridge this information gap by evaluating IHCA data in SA over the last 30 years with a focus on etiologies, outcomes and mortality rates among these patients.

Methods: This systematic review included and analyzed all papers related to IHCA in SA published between 1993 and 2023.

Results: Twelve studies, making a total of 6913 patients were analyzed. Ten studies (83.33%) had a retrospective design. Five studies (41.66% each) were conducted in the central and western regions of SA. Return of Spontaneous Circulation (ROSC) was achieved in 1964 (28.41%) patients, and survival to discharge was seen in 290 (4.19%). The average cardiopulmonary resuscitation (CPR) duration was 19 (± 5.04) min. Common predictors for ROSC included sex, age, CPR duration, initial rhythm, immediate administration of intravenous epinephrine, amiodarone, and pre-arrest intubation. Sepsis was identified as a common predictor for poor CPR outcomes.

Conclusion: The factors associated with ROSC included female sex, younger age groups, monitored initial rhythms, immediate administration of intravenous

epinephrine and early endotracheal intubation. Rapid response teams was an important intervention which significantly reduced mortality in survivors.

Keywords

in- hospital cardiac arrest, cardiac arrest, emergency department

Introduction

CA is defined as the cessation of functional cardiac activity resulting in the loss of palpable pulse, perfusing rhythm, or apnea [1]. It carries high mortality and the survivors of CA usually end up with ischemic brain injury, organ failure, and neuropsychiatric conditions [1-6]. CA are classified based on the location: In-Hospital (IHCA) or Out-of-Hospital (OHCA) [2,3]. The global and Saudi Arabian ROSC rates post CA are 9.9% and 7.4% respectively [4,5]. One of these four types heart rthyms i-e asystole, pulseless electrical activity (PEA), ventricular fibrillation (VFib) or pulseless ventricular tachycardia (pVT) are the presenting rhythms during CA, and can flip during resuscitation. American Heart Association (AHA) guidelines lay the foundation principles with regards to management of CA [7]. IHCA has received less attention in the literature compared to OHCA, which also reflects in SA. Moreover the IHCA data has come out of intensive care units (ICU) settings and less from emergency departments (ED). We wanted to find more IHCA data from ED due to current problem of boarding within EDs. We intended to do this systematic review to mail address the knowledge deficiency surrounding IHCA and add more information with regards to the associated etiologies, ROSC outcomes, and predictors of IHCA. In addition, this study can facilitate future comparisons with international data and inform clinical practice and policy development within SA.

Methods

Literature search was conducted (PubMed, Cochrane, Google Scholar, and Science Direct) using the terms “in-hospital cardiac arrest,” “predictors,” outcomes,” “resuscitation,” and “Saudi Arabia” in the abstract and title. Two reviewers independently screened studies for relevance, gathered data, and evaluated study quality. All data were refined to include a 30-year span (1983–2023) and identify studies that meet the pre-determined inclusion and exclusion criteria. Furthermore, any difference between the two reviewers was settled through consultation with a third reviewer. Key information was extracted from the final records of the included studies. The references of the included studies were manually reviewed to identify related studies.

Inclusion and exclusion criteria

This review included retrospective and prospective studies assessing predictors and outcomes of IHCA, either alone or in comparison with OHCA. Studies published in languages other than English, narrative reviews, clinical trials, letters, and conference abstracts, duplicated studies, studies with insufficient data or findings, and studies for which full text is unavailable were excluded.

Screening and data extraction

The following data were gathered from the included articles: authors, publication date, study design, sample size, study objectives, study duration, predictors, study outcomes, and interventions. Each reviewer independently collected and analyzed the data, which were then consolidated. In cases of discrepancy, a third reviewer was brought in for consultation.

Outcome measures

A scoping search was conducted, and multiple studies were reviewed to assess IHCA outcomes and identify mortality and outcome predictors in the KSA. This was performed during the design step before doing the actual search.

Statistical analysis

The sub analysis was performed using Stata software version 17. Qualitative data were described as frequency tables and percentages, whereas quantitative data were given as means, standard deviations, or median and interquartile ranges.

Results

A total of 3272 articles have been published. Only twelve studies including 6913 patients were eligible for the study (Figure 1), complete details of findings are shown in (Table 1A and 1B). Majority of studies were conducted in the central region (41.66%) and western region (41.66%). Most studies had a retrospective design (83.33%), and some followed a prospective design (16.66%). Most studoes were single centered (91.66%), and only one study had a multicenter setting (8.33%). Regarding the publication year, the studies in years 2018, 2021, and 2023 amounted 16.66% (Table 2).

Table 1A. Characteristics of the included studies

Table 1B. Characteristics of the included studies

Table 2. Characteristics of the 12 studies included in the primary analysis

Description	No of studies (%)
Region of study
Central region	5 (41.66%)
Western region	5 (41.66%)
Eastern region	1 (8.33%)
Multiple regions	1 (8.33%)
Study design
Retrospective	10 (83.33%)
Prospective	2 (16.66%)
Sites
Single center	11 (91.66%)
Multicenter	1 (8.33%)
Year of publication
1993	1 (8.33%)
2007	1 (8.33%)
2009	1 (8.33%)
2016	1 (8.33%)
2018	2 (16.66%)
2019	1 (8.33%)
2021	2 (16.66%)
2022	1 (8.33%)
2023	2 (16.66%)

Table 3 shows 1964 (28.41%) of the 6913 had ROSC. The distribution of initial rhythm is presented in Table 4. The most common initial rhythm observed was asystole (26.28%), followed by PEA (17.67%) and bradycardia (11.05%). VF, VT, and a combination of VF/VT were less common initial rhythms, each accounting for <3% of cases. A large proportion of cases (40.73%) had undocumented initial rhythm, highlighting the importance of thorough documentation in emergency medical situations (Table 4). Table 5 presents the percentage of patients who survived discharge post ROSC. Out of 6913 patients with CA, 14.7% survived to discharge. Among the 1964 patients who achieved ROSC, only 4.19% survived to discharge (Table 5). Table 6 demonstrates the average duration of cardiopulmonary resuscitation (CPR) in the seven included studies. The mean CPR duration was 19.07 min (SD +/- 5.04) (Table 6).

Table 3. Distribution of return of spontaneous circulation among 6913 cases

(% of 6913)	Count	Variable
(28.41%)	1964	ROSC

Table 4. Distribution of initial rhythm in 6913 cases

(% of 6913)	Count	Variable
Initial rhythm
(2.357%)	163	VF
(1.157%)	80	VT
(0.708%)	49	VF/VT
(17.67%)	1222	PEA
(26.28%)	1817	Asystole
(11.05%)	764	Bradycardia
(0.028%)	2	Sinus rhythm
(40.73%)	2816	Not documented

Table 5. Survival to discharge rates among ROSC and total number of patients with cardiac arrest

(% of 6913)	(% of 1964 ROSC)	Count	Variable
(4.19%)	(14.76%)	290	Survival to discharge

Table 6. Average duration of cardiopulmonary resuscitation in the included studies (N = 7)

Mean ± SD	Variable
19.07 ± 5.04	CPR duration

Figure 1. Flow diagram of the included studies

Discussion

It is pertinent to delineate the most prevalent associated factors discussed in published data, which we divided in Patient related factors and Hospital factors. We noticed most of the IHCA data was derived from the ICU and some from ED, in-patient wards, day surgical units, hemodialysis units, and infusion units.

Patient-related factors

A retrospective analysis of a tertiary hospital in the central region was reviewed to compare the prevalence of IHCA within ICU patient population and the correlation of patient characteristics with CPR outcomes in the ICU setting. The most commonly identified comorbidities in this population were sepsis (28%), brain injury (5%), and myocardial infarction (4.9%). Factors associated with the highest mortality were sepsis and older age (age > 55 years) (RR = 0.99). No significant association with sex was found [8].The influence of patient factors was associated with poor outcomes in a retrospective study conducted at a tertiary-care hospital in the central region with a primarily high-risk patient demographic. The high-risk demographics in this context included patients with immunocompromised status, oncological diseases, metabolic disorders and transplantation status. Out of 143 patients that experienced IHCA during the study period, 41 (42%) achieved ROSC; however, only 15 (15%) survived to discharge, of which 6 (6.1%) were discharged in good neurological and physical condition. Further retrospective evaluation of the patients who had CA history showed that some may have been candidates for a DNAR (Do Not Attempt Resuscitation Order) status before the CA and that resuscitation failure was more related to their overwhelming comorbid condition [9]. Population comorbidities were identified in an ED study suggesting that hypertension (HTN, 43.8%) and coronary artery disorder (CAD, 41.8%) were the two most common concurrent comorbidities, with significant effect on mortality. Other comorbidities with the effect on ROSC outcome were sepsis, overall health status, and need for ICU admission [10].

Another factor discussed was advanced age. A study from the Boston group of hospitals reported that of the 258 hospital patients aged ≥70 years who suffered CA, only 17 survived to discharge (6.5%), and of these, about half were impaired in one way or another and proposed the revision of indication for starting CPR in IHCA in older patients or moribund individuals because resuscitation is futile [11,12]. Alanazi et al. found that CA is more common in men; however, no significant difference in ROSC rates was found between sexes. The survival rates were mainly affected by female sex [10]. In a study conducted in the central region, the ROSC rate (74.4%) was significantly higher than those of other studies. The most common initial rhythms were non-shockable (PEA and asystole). However, the ROSC was lower in non-shockable rhythms than in shockable ones (pVT and VF); this raises the question of how predictive is the initial rhythm on survival [13]. In another study in the western region, non-shockable rhythms were more common (93.2%), and the ROSC rate was 56.2% despite the prevalence of an older patient population within the study. Despite the prevalence of the non-shockable rhythms, they were not highlighted as a mortality predictor; instead, respiratory causes were noted as a predictor of survival within this study [10]. Another study found CPR duration of <30 min was the most significant factor in predicting successful ROSC [10]. The possibility of confounding in ICU IHCA data must be considered because many studies have documented poor outcomes of patients in the ICU, and it was postulated to be due to the existing critical state of the patients admitted in the ICU. As stated previously, patient comorbidities and demographics are important survival factors. However, further dedicated studies regarding ICU IHCA outcomes are needed before determining the negative effect of ICU admission on overall IHCA [8,10,11,13,14].

Hospital factors

Some institution-related factors highlighted in the studies include poor organization of in-hospital response teams (also known as rapid response teams (RRTs), delay summoning the resuscitation team, lack of equipment availability and staff training. These factors in conjunction with the patient related factors affect the overall outcome [13]. RRTs have been widely adopted within hospital settings and significantly lower mortality has been reported [15,16].⁠ A study conducted in the eastern region aimed to identify “vital signs” changes that may predict aCA within the hospital environment. Preceding CA, 94% of the patients had abnormal vital signs within the previous 24 h. The prevalence of at least one abnormal vital sign was consistently (100%) observed on monitor beds compared with 82% on unmonitored beds. Within this study, 80% of the patients who had CA had signs of significant physiological deterioration preceding the CA event. Moreover, 70% of these patients showed evidence of respiratory deterioration in the 8 hours prior to CA. The results indicated that the most common predictors of CA were increased respiratory rate, hypotension, and tachycardia [17]. Another study examined the effect of immediate (<2 min) versus early (≥2 min) epinephrine administration. After adjusting for confounding covariates, earlier administration of epinephrine had higher rates of ROSC which sustained for up to 24 h (odds ratio [OR] 1.33, 95% CI [1.13–1.55]) but a worse neurological outcome compared with the placebo group according to a Rankin score of 4–5 (31% in the epinephrine group vs. 17.8% in the placebo group [18]. Many studies have discussed the importance of deploying a 24 hrs. RRT until advanced resuscitation provisions are available. The ROSC in these cases was directly proportional to shorter duration of CA and quicker initiation of treatment.

National data registry

A similar database to “The National Registry of Cardiopulmonary Resuscitation” in USA is needed in SA to collect data on patients with CA for quality improvement programs. Using variables within this registry as a benchmark, the national recommendations can be tailored for local populations [9,19,20]. The authors also recommend creating a concised documentation template for recording CA data. More research is needed to decide which variables are the most valuable to be used in future guidelines [21,22].

Limitations

The study includes a majority of retrospective single-center studies and inconsistent documentation records.

Conclusion

Short duration of CPR (<10 minutes) is commonly associated with ROSC, emphasing need for early intervention. Hypertension and coronary artery disease are the most common co-morbities found in patients with CA, while sepsis is associated with highest mortality. RRTs intervention in critically ill patients reduces risk of progression to CA.

List of abbreviations

AHA: American Heart Association

BLS: Basic Life Support

CAD: Coronary Artery Disorder

CPR: Cardiopulmonary Resuscitation

ED: Emergency Department

EMS: Emergency Medical Services

HCWs: Healthcare Workers

HTN: Hypertension

ICU: Intensive Care Unit

IHCA: In-Hospital Cardiopulmonary Arrest

KAUH: King Abdulaziz University Hospital

KFH: King Fahad Hospital

KSA: Kingdom of Saudi Arabia

OHCA: Out-Of-Hospital CA

PEA: Pulseless Electrical Activity

pVT: Pulseless Ventricular Tachycardia

ROSC: Return of Spontaneous Circulation

RRT: Rapid Response Teams

STD: Survival to Discharge

VFib or VF: Ventricular Fibrillation

Declarations

 Ethics approval and consent to participate were not required for this study as it involved publicly available data.

Consent for publication

 The authors confirm that there are no individual participant details within the published content that require consent for publication.

Availability of data and materials

 The data and materials used in this research are available upon request from the corresponding author.

Competing interests

 The authors declare that they have no competing interests

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Author’s contributions

 MQ, SE and NS initiated and designed the study. RZ, MQ participated in study design. RZ participated in data analysis. MQ, SE, NS, and RZ drafted

the manuscript. All authors read and approved the final manuscript.

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