Prevention opportunity for postoperative cardiac arrest

Jan 17 2013

By Eleanor McDermid, Senior medwireNews Reporter

Postoperative complications occur in more than three-quarters of patients who have a cardiac arrest, shows research that suggests an opportunity for intervention.

The most common complications were intubation (in 46.5% of patients), prolonged ventilator use (37.0%), septicemia (33.5%), renal impairment (17.7%), pneumonia (17.3%), and bleeding (16.0%). About three-quarters of the complications occurred before or on the day of cardiopulmonary resuscitation (CPR).

In an invited critique on the study in JAMA Surgery (formerly Archives of Surgery), Michael Zenilman (Johns Hopkins Medicine, Bethesda, Maryland, USA) notes that most factors that led to cardiac arrest are reversible.

"If those at risk are rapidly identified and appropriately treated, CPR in the early postoperative period is not futile," he says, adding that the findings should affect discussions of existing do-not-resuscitate orders. "Bluntly, temporarily rescind the order."

Outcomes were generally poor, however, with an overall 30-day mortality rate of 71.6% among the 6382 patients in the study (nontrauma patients; average age 68 years). By comparison, the mortality rate was 1.7% among the 1.3 surgical cases in the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database from which the study patients were identified.

Just 19.2% of patients survived and were also discharged within 30 days of surgery. A further 9.2% survived but remained in hospital.

Zenilman comments: "The authors do not address the functional status of the patients who survive - their neurologic status, ability to care for themselves, or to where they are ultimately discharged. These are the next questions that need to be asked."

Notably, among patients with complications (77.6% of cardiac arrest patients), mortality rates were significantly worse if the complication occurred before or on the day of CPR, rather than after, say study author Julie Sosa (Yale University School of Medicine, New Haven, Connecticut, USA) and colleagues.

"Perioperative cardiac arrest is often fatal," note the researchers. "Because only a few patients survive, prevention is crucial."

They say: "These findings indicate that a large proportion of cardiac arrests and periarrest deaths among surgical patients might be preventable if prearrest complications would be avoided or expediently treated."

The overall incidence of CPR was one in 203 patients. This varied widely by specialty, however, from one in 33 for cardiac surgery to one in 1666 for gynecology.

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