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Cardiopulmonary Resuscitation in Surgical Patients: Comment on “Cardiac Arrest Among Surgical Patients: An Analysis of Incidence, Patient Characteristics, and Outcomes in ACS-NSQIP”

Cardiopulmonary Resuscitation in Surgical Patients: Comment on “Cardiac Arrest Among Surgical... During the past 20 years, much has been written about do not resuscitate (DNR) orders and cardiopulmonary resuscitation (CPR) in surgical patients, but because no prospective data are available, most of these articles are opinion pieces. Kazaure et al1 are one of the first to address this matter using information from the National Surgical Quality Improvement Project. Their article gives us a glimpse into the incidence, risk factors, outcomes, and ability to improve our care based on accurate data. 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. I would stress the following observations from this study (none of which are surprising). The need for CPR in surgical patients is fortunately rare but devastating. Older age, American Society of Anesthesiologists score, and the presence of comorbidities are significant risk factors. Survival is better in a cardiothoracic or vascular surgical patient compared with a general surgical patient and if the event occurs while the patient is in the operating room. Finally, CPR mortality is greatly affected by the development of postoperative complications. The most important finding in the study by Kazaure et al1 is that early postoperative complications (postoperative day 1 or 2) occurred in 75.2% of patients before arrest. These complications, including sepsis, respiratory failure, renal failure, and bleeding, were typical for those who need aggressive treatment in the intensive care unit. This finding suggests that aggressive prevention, recognition, and treatment of postoperative complications can reduce the incidence of CPR. This concept is not new. Failure to rescue is a known determinant of outcome after complicated surgery.2,3 The determinants for success are hospital demographic characteristics, such as size, occupancy, and presence of teaching and technology. The National Surgical Quality Improvement Project has the ability to stratify such hospitals, so the authors can now address these variables. Rescue of patients who are identified to be at risk for adverse events should be our next goal. Identification of which patients are at risk and early aggressiveintervention with intensive medical and surgical care will decrease the need for CPR and its ultimate negative outcome. The presence of intensivists and hospitalists to watch these at-risk patients around-the-clock would likely greatly help. Although these interventions are expensive, decreased downstream costs in intensive care and ultimately regionalization of patients at risk to appropriately staffed hospitals could contain these costs. So, how does this study affect how we discuss DNR status with our patients? The authors confirm that CPR in the postoperative period can succeed because most factors that lead to an arrest in the perioperative period are reversible. If those at risk are rapidly identified and appropriately treated, CPR in the early postoperative period is not futile. Surgical patients who need CPR can be saved. Therefore, DNR orders should not be active during this time. In fact, the American College of Surgeons published a position statement on DNR in the operating room, which really should be incorporated in all hospitals.4 They suggest modification of DNR orders in the perioperative period via a “required reconsideration of advance directives.” Bluntly, temporarily rescind the order. Back to top Article Information Correspondence: Dr Zenilman, Department of Surgery, Suburban Hospital/Johns Hopkins Medicine, 8600 Old Georgetown Rd, Bethesda, MD 20814 (mzenilm1@jhmi.edu). Conflict of Interest Disclosures: None reported. References 1. Kazaure HS, Roman SA, Rosenthal RA, Sosa JA. Cardiac arrest among surgical patients: an analysis of incidence, patient characteristics, and outcomes in ACS-NSQIP. JAMA Surg. 2013;148(1):14-21Google Scholar 2. Ghaferi AA, Birkmeyer JD, Dimick JB. Complications, failure to rescue, and mortality with major inpatient surgery in Medicare patients. Ann Surg. 2009;250(6):1029-103419953723PubMedGoogle ScholarCrossref 3. Ghaferi AA, Osborne NH, Birkmeyer JD, Dimick JB. Hospital characteristics associated with failure to rescue from complications after pancreatectomy. J Am Coll Surg. 2010;211(3):325-33020800188PubMedGoogle ScholarCrossref 4. American College of Surgeons. Position statement. Bull Am Coll Surg. 1994;79:29Google Scholar http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Surgery American Medical Association

Cardiopulmonary Resuscitation in Surgical Patients: Comment on “Cardiac Arrest Among Surgical Patients: An Analysis of Incidence, Patient Characteristics, and Outcomes in ACS-NSQIP”

Zenilman, Michael E.
JAMA Surgery , Volume 148 (1) – Jan 1, 2013
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References (6)

Publisher
American Medical Association
Copyright
Copyright © 2013 American Medical Association. All Rights Reserved.
ISSN
2168-6254
eISSN
2168-6262
DOI
10.1001/jamasurg.2013.1003
Publisher site
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Abstract

During the past 20 years, much has been written about do not resuscitate (DNR) orders and cardiopulmonary resuscitation (CPR) in surgical patients, but because no prospective data are available, most of these articles are opinion pieces. Kazaure et al1 are one of the first to address this matter using information from the National Surgical Quality Improvement Project. Their article gives us a glimpse into the incidence, risk factors, outcomes, and ability to improve our care based on accurate data. 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. I would stress the following observations from this study (none of which are surprising). The need for CPR in surgical patients is fortunately rare but devastating. Older age, American Society of Anesthesiologists score, and the presence of comorbidities are significant risk factors. Survival is better in a cardiothoracic or vascular surgical patient compared with a general surgical patient and if the event occurs while the patient is in the operating room. Finally, CPR mortality is greatly affected by the development of postoperative complications. The most important finding in the study by Kazaure et al1 is that early postoperative complications (postoperative day 1 or 2) occurred in 75.2% of patients before arrest. These complications, including sepsis, respiratory failure, renal failure, and bleeding, were typical for those who need aggressive treatment in the intensive care unit. This finding suggests that aggressive prevention, recognition, and treatment of postoperative complications can reduce the incidence of CPR. This concept is not new. Failure to rescue is a known determinant of outcome after complicated surgery.2,3 The determinants for success are hospital demographic characteristics, such as size, occupancy, and presence of teaching and technology. The National Surgical Quality Improvement Project has the ability to stratify such hospitals, so the authors can now address these variables. Rescue of patients who are identified to be at risk for adverse events should be our next goal. Identification of which patients are at risk and early aggressiveintervention with intensive medical and surgical care will decrease the need for CPR and its ultimate negative outcome. The presence of intensivists and hospitalists to watch these at-risk patients around-the-clock would likely greatly help. Although these interventions are expensive, decreased downstream costs in intensive care and ultimately regionalization of patients at risk to appropriately staffed hospitals could contain these costs. So, how does this study affect how we discuss DNR status with our patients? The authors confirm that CPR in the postoperative period can succeed because most factors that lead to an arrest in the perioperative period are reversible. If those at risk are rapidly identified and appropriately treated, CPR in the early postoperative period is not futile. Surgical patients who need CPR can be saved. Therefore, DNR orders should not be active during this time. In fact, the American College of Surgeons published a position statement on DNR in the operating room, which really should be incorporated in all hospitals.4 They suggest modification of DNR orders in the perioperative period via a “required reconsideration of advance directives.” Bluntly, temporarily rescind the order. Back to top Article Information Correspondence: Dr Zenilman, Department of Surgery, Suburban Hospital/Johns Hopkins Medicine, 8600 Old Georgetown Rd, Bethesda, MD 20814 (mzenilm1@jhmi.edu). Conflict of Interest Disclosures: None reported. References 1. Kazaure HS, Roman SA, Rosenthal RA, Sosa JA. Cardiac arrest among surgical patients: an analysis of incidence, patient characteristics, and outcomes in ACS-NSQIP. JAMA Surg. 2013;148(1):14-21Google Scholar 2. Ghaferi AA, Birkmeyer JD, Dimick JB. Complications, failure to rescue, and mortality with major inpatient surgery in Medicare patients. Ann Surg. 2009;250(6):1029-103419953723PubMedGoogle ScholarCrossref 3. Ghaferi AA, Osborne NH, Birkmeyer JD, Dimick JB. Hospital characteristics associated with failure to rescue from complications after pancreatectomy. J Am Coll Surg. 2010;211(3):325-33020800188PubMedGoogle ScholarCrossref 4. American College of Surgeons. Position statement. Bull Am Coll Surg. 1994;79:29Google Scholar

Journal

JAMA Surgery – American Medical Association

Published: Jan 1, 2013

Keywords: cardiopulmonary resuscitation,cardiac arrest,surgical procedures, operative

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