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Outcomes of In-Hospital Cardiopulmonary Resuscitation among Cancer Patients: Experience from Pakistan | OMICS International
ISSN: 2577-0535
Journal of Cancer Clinical Trials

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Outcomes of In-Hospital Cardiopulmonary Resuscitation among Cancer Patients: Experience from Pakistan

Waleed Zafar*

Department of Cancer Registry and Clinical Data Management, Shaukat Khanum Memorial, Cancer Hospital & Research Centre, Lahore, Pakistan

*Corresponding Author:
Waleed Zafar
Department of Cancer Registry and Clinical Data Management
Shaukat Khanum Memorial
Cancer Hospital & Research Centre, Lahore, Pakistan
Tel: 92-42-3590-5000
Fax: 92-42-3594-5206
E-mail: [email protected]

Received date: January 21, 2016; Accepted date: March 24, 2016; Published date: March 28, 2016

Citation: Zafar W (2016) Outcomes of In-Hospital Cardiopulmonary Resuscitation among Cancer Patients: Experience from Pakistan. J Cancer Clin Trials 1:107. doi: 10.4172/jcct.1000107

Copyright: © 2016 Zafar W. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Cardiopulmonary resuscitation (CPR) is a component of the standard of care for hospitalized cancer patients who undergo cardiac arrest. Typically, an emergency code, sometimes called “code blue”, is called to alert health care personnel within the hospital whenever a patient collapses suddenly or is perceived to need urgent life-saving care. Not all episodes of code blue, though, result in a CPR [1]. Many cancer patients with cardiopulmonary arrest may not benefit from a CPR [2-4]. The aim of this study was to review outcomes of all episodes where “code blue” was called in a tertiary care cancerspecialized hospital in Pakistan over a forty months period. Reports from a variety of socio-economic and cultural contexts are likely to paint a more nuanced global picture and will help in development of interventions that are specific to medical needs of subgroups of patients, improve upon current outcomes, and are more responsive to patients’ and their families’ stated preferences. Shaukat Khanum Memorial cancer hospital & research centre located in Lahore, Pakistan is a 180-bed non-profit tertiary-care cancer-specialized hospital. From the hospital’s electronic medical records we obtained a list of all episodes of “code blue” calls from September 2010 to December 2013. Multivariate logistic regression analyses were used to test the association of clinical characteristics with the primary outcome of survival to discharge. A total of 646 code blue calls were included in the analysis (Table 1).

  All episodes of code blue All patients who received CPR
Characteristics N % N %
Episodes of code blue on unique patients        
1 547 92.1 - -
2 45 7.6 - -
3 or more 2 0.3 - -
Age of patients in years        
Less than 18 years 213 33.0 126 32.5
18 years or older 433 67.0 262 67.5
Mean age & Standard deviation 33.6 23.2 33.8 23.3
Sex of unique patients        
Female 248 41.5 155 39.9
Male 349 58.5 233 60.1
Type of tumour        
Solid organ        
Head and neck 78 13.1 49 12.6
Gastrointestinal 76 12.7 44 11.3
Lungs 16 2.7 11 2.8
Musculoskeletal 37 6.2 24 6.2
Others 169 28.3 100 25.8
Lymphoma 135 22.6 96 24.7
Myeloma 1 0.2 1 0.3
Leukaemia 79 13.2 59 15.2
Other haematological malignancies 5 0.9 4 1.1
Metastasis for solid organ tumours        
No 224 59.1 137 59.8
Yes 155 40.9 92 40.2
Location of code blue (all episodes)        
Emergency department 153 23.7 70 18.0
Intensive care unit 231 35.8 208 53.6
Inpatient floor 219 33.9 100 25.8
Other 43 6.6 10 2.6
CPR done        
Yes 388 60.0 - -
No 258 40.0 - -
Reason CPR not done        
Respiratory distress 147 56.3 - -
Seizures 43 16.5 - -
DNR agreed after code 19 7.3 - -
Accidental code 14 5.4 - -
Other reasons e.g., hypoglycaemia 35 13.8 - -

Table 1: Demographic and clinical characteristics of cancer patients that triggered code blue calls.

CPR was performed in 388 (60%) of these calls. For every 20 episodes of CPR among cancer patients of all ages, only one resulted in a patient’s survival to discharge even though in 46.6% episodes there was a return of spontaneous circulation (Tables 2 and 3).

  N %
Rhythm at initiation of CPR    
Asystole 239 65.7
Pulseless Electrical activity 110 30.2
Ventricular tachycardia 15 4.1
Return of spontaneous circulation after CPR    
No 197 53.4
Yes 172 46.6
Survived 6-24 hours 44  
Survived more than 24 hours 86  
Survival to discharge    
No 369 95.1
Yes 19 4.9

Table 2: Outcomes among cancer patients who received a cardiopulmonary resuscitation (CPR).

  Adjusted odds ratio 95% Confidence interval
Male (Compared to females) 1.434 0.50-3.58
Paediatric (Compared to adults) 2.10 0.79-5.57
Primary diagnosis (Compared to non-metastatic solid organ tumours)    
Metastatic solid organ tumours 0.86 0.28-2.65
Haematological malignancies   0.30* 0.09-0.95
Rhythm at initiation of CPR (Compared to Asystole)    
Ventricular tachycardia 1.67 0.20-14.1
Pulseless electrical activity 1.21 0.45-3.25
*Significant at p=0.05    

Table 3: Adjusted odds of survival to discharge among all cancer patients who received cardiopulmonary resuscitation (CPR).

Among patients who received CPR, 201 (52.2%) had a return of spontaneous circulation. Out of these, 75 patients survived for less than 6 hours, 44 survived longer than 6 hours but less than a day and 85 survived more than 24 hours. Only 19 out of these 85 patients survived to discharge. No association was found between the type of rhythm at initiation of CPR and likelihood of survival to discharge. Several recent studies have looked at outcomes of CPR among cancer patients. A meta-analysis identified 42 studies of survival to discharge among adult cancer patients who underwent in hospital CPR. It found an overall survival to discharge across all studies to be 6.2% [3]. Our finding of 4.9% patients surviving to discharge is thus broadly in line with the international data. A notable finding of this study is that about half of the cancer patients who received CPR had a return of spontaneous circulation. However, even among those who survived for more than 24 hours, only 2 out of every 9 patients survived to discharge. This certainly does not mean that there are no cancer patients with advanced disease who will benefit from resuscitation. More work is, however, needed to identify those subgroups of cancer patients who are likely to benefit from CPR. In this context, institution of rapid response systems for early identification of patients who are at high-risk of deterioration is likely to improve outcomes of resuscitation [5-7]. Another important implication of this study is the need for attending physicians to engage with patients and their families early to encourage them to document their advance directives regarding resuscitation. Data, such as presented in this study, that most advanced cancer patients do not benefit from aggressive end-of-life interventions, are likely to justify and help in the early conduct of such discussions. Training of physicians in communication skills, availability of decision support tools, and use of multiple media to engage with patients and families are also likely to increase the proportion of cancer patients with documented advance directives that are based in realistic expectations about interventions and their outcomes.

In conclusion, most cancer patients who receive in-hospital CPR do not survive to discharge and do not appear to benefit from aggressive and expensive resuscitation. Advance directives by patients limiting such interventions and their proper documentation will help in provision of care that is humane, compassionate, consonant with patients’ wishes for a dignified death, and not wasteful of resources. Patients’ early appreciation of the limited benefits of CPR in advanced cancer is likely to help them formulate such advance directives.


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  1. Aurora
    Posted on Jul 19 2016 at 5:48 pm
    The author shares experience on outcome of in-hospital cardiopulmonary resuscitation among cancer patients in a hospital in Pakistan. The study was conducted on the response of Cardiopulmonary Resuscitation in cancer patients in order to study and review the outcome "code Blue" that is also called a tertiary care over forty months periods. The authors revealed that most cancer patients receiving in-hospital CPR do not survive to discharge and did not get any benefits from the resuscitation. The authors suggested directions that may help in provisioning the patient’s care in a humane, compassionate, and consonant manner.

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