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1 대한응급의학회지제 21 권제 6 호 Volume 21, Number 6, December, 2010 원 저 중증기저질환이병원내심정지환자의예후에미치는영향 성균관대학교의과대학삼성서울병원응급의학과 김신념 신태건 심민섭 조익준 송형곤 Prognosis of In-Hospital Cardiac Arrest and Severe Comorbidities Shin Nyum Kim, M.D, Tae Gun Shin, M.D, Min Seob Sim, M.D, Ik Joon Jo, M.D, Hyoung Gon Song, M.D Purpose: The purpose of our study was to evaluate the relevance of a patient s critical comorbidities to his survival rate, along with factors that influence the prognosis of patients who went through in-hospital cardiac arrest. We also investigated the association between the physical burden of the patients comorbidities and the prognosis of inhospital arrest patients using the Deyo-Charlson score. Methods: We retrospectively reviewed data for 1,094 patients with in-hospital cardiopulmonary arrest between January 2003 and June 2009 according to the Utstein-style guidelines. Severe comorbidities included congestive heart disease, chronic renal failure, severe liver disease, pulmonary disease, and hematologic or metastatic solid malignancy. Multivariate Cox regression analysis and logistic regression models were used to assess the hazard ratio and survival factors. Results: The hazard ratio of patients with severe liver disease or hematologic or metastatic solid cancer were 1.42 (95% CI, , p=0.002) and 1.60 (95% CI, , p<0.001), respectively. Shorter CPR duration and subsequent intervention were significant prognostic factors in patients with severe comorbidities. The Deyo-Charlson score was one of the independent prognostic factors in the overall study population. Conclusion: The six month survival rate of patients with a 책임저자 : 송형곤서울특별시강남구일원동 50 성균관대학교의과대학삼성서울병원응급의학과 Tel: 02) , Fax: 02) cprking@skku.edu 접수일 : 2010년 4월 30일, 1차교정일 : 2010년 5월 30일게재승인일 : 2010년 6월 29일 749 history of severe liver disease or hematologic or solid metastatic cancer that underwent in-hospital cardiac arrest is low. Key Words: Heart arrest, Cardiopulmonary resuscitation, Comorbidity, Mortality Department of Emergency Medicine, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Korea 서 병원내심정지환자의자발순환회복은 40~80% 로높게보고되고있으나생존퇴원율은 13~15% 로매우낮게보고되고있다 1-3). 특히환자의기저질환은이러한병원내심정지환자의생존율에영향을미치는것으로알려져있으며, 일부중증기저질환은자체회복가능성이매우낮기때문에불필요한병원내심폐소생술의시행을유발하여, 의료자원의낭비, 환자및보호자의경제적, 정신적부담의증가등을유발할수있다 4-7). 기저질환과병원내심정지환자의생존율에관한과거연구를살펴보면, 각기저질환들을개별적으로연구한논문은있으나통합적으로시행한연구는없었으며, 특히국내사망환자의많은부분을차지하는만성간질환환자의심정지후의예후에대한연구는부족한실정이다 1,8-13). 이에저자들은병원내심정지환자에서만성간질환을포함한중증기저질환과생존율과의연관성및생존에영향을미치는예후인자를알아보고자하였다. 론 대상과방법 2003년 1월 1일부터 2009년 6월 30일까지삼성서울병원에서발생한성인심정지환자중심폐소생술을시행받은환자를대상으로 삼성서울병원원내심정지환자레지스트리 ( 심정지레지스트리 ) 와의무기록을이용한후향적연구를시행하였다. 심정지레지스트리는환자의나이, 성별, 심정지의발생장소와원인, 기저질환, 목격자및감

2 750 / 대한응급의학회지 : 제 21 권제 6 호 2010 시장치의유무, 초기심정지리듬, 심폐소생술시간, 자발순환의회복여부, 생존퇴원여부및퇴원시대뇌수행분류점수 (cerebral performance categories score, CPC score) 등을포함하고있다. 15세이하의소아환자및심정지레지스트리와의무기록을통해정확한자료를얻을수없는환자는연구에서제외하였다. 6개월생존율을 1차예후평가인자 (primary outcome measures) 로, 생존퇴원율및 CPC score( 퇴원당시및심정지발생 6개월후 ) 를 2차예후평가인자 (secondary outcome measures) 로조사하였다. 중증기저질환은울혈성심부전 (New York Heart Association class III, IV에해당하는증상이있거나, 좌심실구혈률이 30% 이하인경우 ), 중증폐질환 ( 만성폐쇄성폐질환, 천식, 간질성폐질환등으로다음중하나에해당하는경우 : 동맥혈이산화탄소분압이 45 mmhg 이상, 폐성심 (cor pulmonale), 최근 1년이내호흡부전병력, 1초강제호기율이 0.75 L 이하 ), 만성신부전 ( 투석을받아야하거나, 크레아티닌청소율이 10 ml/min 이하인경우 ), 만성간질환 (Child s class B, C에해당하는경우 ), 및혈액암또는전이성고형암으로정의하였다 5). 중증기저질환의유무는일차적으로심정지레지스트리를통해수집하였으며, 심정지레지스트리의내용이부족하거나불명확한경우의무기록을통해조사하였다. 또한, 같은방법으로 Deyo-Charlson score를구하였다 (Table 1). Deyo- Charlson score 는만성질환의양적인면을나타내는것으로입원환자의예후판정에이용할수있는지표이다. 총 Table 1. Weighted index of comorbidity in Deyo-Charlson score Charlson weights Conditions 1 Myocardial infarction 1 Congestive cardiac failure 1 Peripheral vascular disease 1 Cerebrovascular disease 1 Dementia 1 Chronic pulmonary disease 1 Rheumatologic disease 1 Peptic ulcer disease 1 Mild liver disease 1 Diabetes, mild to moderate 2 Diabetes with chronic complications 2 Hemiplegia or paraplegia 2 Renal disease 2 Any malignancy, including lymphoma and leukemia 3 Moderate or severe liver disease 6 Metastatic solid tumor 6 AIDS 17개항목을기준으로점수화하여 0~33점으로표현되며점수가높을수록만성질환을많이가지고있는것을나타낸다 14). 심폐소생술후추가적인시술이나수술 (subsequent intervention) 로는심장동맥우회로수술 (coronary artery bypass grafting) 등의심장수술, 장기이식수술, 비심장성수술, 경피경혈관심장동맥확장술 (percutaneous coronary intervention) 등을조사하였다. 통계적분석은 SPSS 13.0 for Windows (SPSS Inc, USA) 를이용하였으며연속변수는평균 ± 표준편차로표시하였다. 연속형변수들의비교는 Students t-test를사용하였고, 명목변수의분석에는카이제곱검정 (Chisquare test) 과 Fisher s exact test를사용하였다. 중증질환의여부가 6개월생존에미치는영향을알아보기위해 multivariate Cox regression analysis를사용하여위험비 (hazard ratio) 와생존곡선을구하였다. 보정변수로는나이, 성별, 심정지원인 ( 심인성또는비심인성 ), 목격여부, 초기심정지리듬, 심폐소생술지속시간, 심정지발생장소, 심정지발생일시 ( 야간, 주말, 2005년이전여부 ), 심폐소생술중체외심폐보조기사용, 기저질환 ( 당뇨, 고혈압, 뇌혈관질환및중증기저질환유무 ) 등을 multivariate Cox regression model에포함시켰다 1,12,13,15-17). 기저만성질환의양적인면이 6개월생존에미치는영향을알아보기위해먼저 Deyo-Charlson score와생존과의연관성을 ROC (receiver operating characteristic) curve를사용하여분석하였다. 세부분석으로각중증질환군에서소생술후생존에미치는인자를 multivariate Cox regression analysis로분석하였다. 생존에영향을미치는인자는기존에알려져있는나이, 심폐소생술시간, 심정지원인, 초기심정지리듬, 심정지발생장소, 심폐소생술후에원인교정을위한추가적인치료적시술이나수술시행여부 (subsequent intervention), Deyo-Charlson score 등을포함하였다 12,13,15,17-22). 모든분석의통계학적유의수준은 p-value< 0.05로하였다. 본연구는삼성서울병원임상시험심사위원회 (Institutional review board) 의심사를통과하였다. 결과연구기간동안총 1,322명의원내심정지환자가발생하였고, 이중소아 215명과자료가부족한 13건을제외한총 1,094명의심정지레지스트리와의무기록을분석하였다. 1. 대상환자군의특성및생존율 (Table 2) 중증기저질환별로울혈성심부전환자가 104명

3 김신념외 : 중증기저질환이병원내심정지환자의예후에미치는영향 / 751 (9.50%), 중증폐질환환자가 28명 (2.56%), 만성간질환환자가 114명 (10.42%), 만성신부전환자가 103명 (9.41%), 혈액암또는전이성고형암환자가 280명 (25.59%) 이었다. 전체환자군의 6개월생존율이 17.9% 인반면, 중증기저질환군에서는울혈성심부전환자가 23%, 중증폐질환환자가 10.7%, 만성간질환환자가 7.9%, 만성신부전환자가 15.5%, 혈액암또는전이성고형암환자가 4.3% 였다. 2. Deyo-Charlson score와생존율과의연관성 (Fig. 1) Deyo-Charlson score는심정지 6개월후사망률과유의한관계가있었다 ( 위험비 : 1.03, 95% CI, ; AUC of ROC curve=0.638, 95% CI, ). Deyo-Charlson score 2점을기준값 (cut-off value) 으로했을경우 6개월사망에대한민감도는 66.9%, 특이도는 55.1% 였다. 4. 생존인자분석 (Table 4) 각환자군에서생존에영향을미치는인자를알아보기위해 multivariate Cox regression analysis를시행하였다. 전체환자군에서환자의나이, 심폐소생술지속시간, 심정지원인, 초기심정지리듬, 심폐소생술후에원인교정을위한추가적인치료적시술이나수술시행여부 (subsequent intervention), Deyo-Charlson score는심정지후생존율과유의한연관성을보였다. 반면표본수가작은중증폐질환군을제외한모든중증기저질환군에서심폐소생술지속시간이생존율과유의한관계가있었으며, 중증간질환, 중증심부전, 혈액암또는전이성고형암환자군에서는심폐소생술후추가적인시술이나수술의시행여부가생존율과유의한관계가있었다. 고찰 3. 중증기저질환과생존율과의연관성 (Table 3, Fig. 2) 심정지환자의예후에영향을미칠수있는변수들을보정한 multivariate Cox regression analysis 에서중증간질환및혈액암또는전이성고형암환자는 6개월사망에대한위험비가각각 1.42(95% CI, , p=0.002), 1.60(95% CI, , p<0.001) 으로유의하게높았다. 중증신부전은사망률을높이는경향을보였으나통계적으로유의하지는않았다. Fig. 1. Receiver Operating Characteristic (ROC) curve of Deyo-Charlson score for six-month survival of inhospital cardiac arrest patients with severe comobidities. 병원내심정지환자중에는소생가능성이낮은중증기저질환을가진환자들이적지않다. 패혈증, 신부전, 전이성종양, 활동이제한된환자 (house-bound life style), 뇌졸중등은병원내심정지환자의낮은생존율과연관이있는것으로보고되고있다 1,9,10,13). 이러한기저질환들은심정지환자의소생가능성을예측하기위해만들어진지표인 Pre-Arrest Morbidity (PAM) score 및 Prognosis After Resuscitation (PAR) score의변수로사용되었으나. 이러한점수체계가현재까지심정지환자의예후를판단하는데추천되지는않는다 1,11,12,23-25). 본연구에서는중증간질환과혈액암또는전이성고형암이병원내심정지환자의 6개월사망률과유의한관계가있는것으로나타났다. 중증간질환을가진심정지환자의예후에대해서구체적으로알려져있지는않으나, Larkin 등 26) 은병원내심정지환자에관한대규모연구를통해간질환이심정지환자의병원내사망과유의한관련이있음을보고한바있다. 혈액암과전이성고형암을가진심정지환자의경우에는 Reisfield 등 27) 이보고한 meta-analysis에서생존퇴원율이각각 2.0%, 5.6% 로매우낮게보고되었다. 이와같이이두가지중증질환군은심정지후생존퇴원율이낮을뿐만아니라기저질환자체의치료도어려워기대생존기간이길지않으므로, 본연구의결과와같이 6개월사망률이유의하게높았던것으로생각된다. 심폐소생술지속시간은생존율및예후에중요한영향을미치는인자이다 17,19). 본연구에서도표본수가적은중증폐질환군을제외한모든기저질환군에서심폐소생술지속시간이생존율과유의한관계가있었다. 따라서증증기저질환환자에서심폐소생술지속시간은가장먼저고려해야할예후인자로생각되며, 특히본연구에서예후가좋지않

4 752 / 대한응급의학회지 : 제 21 권제 6 호 2010 room, ICU: intensive care unit, ROSC: return of spontaneous circulation, CPC: cerebral performance categories SD: standard deviation, VF: ventricular fibrillation, VT: ventricular tachycardia, PEA: pulse less electrical activity, CPR: cardiopulmonary resuscitation, ER: emergency CPC 1 or 2 (six months) 0161 (14.7) 023 (22.1) 02 (07.1) 008 (07.0) 014 (13.6) 011 (03.9) Survival (six months) 0196 (17.9) 025 (23.0) 03 (10.7) 009 (07.9) 016 (15.5) 012 (04.3) CPC 1 or (15.7) 026 (25.0) 02 (07.1) 008 (07.0) 015 (14.6) 015 (05.4) Survival discharge 0223 (20.4) 028 (26.9) 04 (14.3) 014 (12.3) 017 (16.5) 021 (07.5) ROSC 0612 (55.9) 063 (60.6) 16 (57.1) 056 (49.1) 068 (66) (46.4) Result, N (%) Deyo - Charlson score (±SD) 3.31± ± ± ± ± ±3.15 Defibrillation, N (%) 0313 (28.6) 050 (48.1) 06 (21.4) 021 (18.4) 033 (32) (19.6) CPR duration, minute (±SD) 28.61± ± ± ± ± ±26.35 Unknown 0037 (03.4) 001 (01.0) 00 (00.0) 004 (03.5) 002 (01.9) 017 (06.1) PEA 0591 (54.0) 049 (47.1) 19 (67.9) 065 (57.0) 059 (57.3) 136 (48.6) Asystole 0245 (22.4) 009 (08.7) 05 (17.9) 029 (25.4) 023 (22.3) 093 (33.2) VF/pulse less VT 0221 (20.2) 045 (43.3) 04 (14.3) 016 (14.0) 019 (18.4) 034 (12.1) Initial rhythm, N (%) ER 0282 (25.8) 013 (12.5) 07 (25.0) 017 (14.9) 022 (21.4) 071 (25.4) General ward 0422 (38.6) 047 (45.2) 12 (42.9) 050 (43.9) 050 (48.5) 135 (48.2) ICU or operating room 0390 (35.6) 044 (42.3) 09 (32.1)% 047 (41.2) 031 (30.1) 074 (26.4) CPR location, N (%) Other non-cardiac 0075 (06.8) 002 (01.9) 00 (00.0) 017 (14.9) 002 (01.9) 020 (07.1) Septic 0176 (16.1) 007 (06.7) 01 (03.6) 032 (28.1) 020 (19.4) 073 (26.1) Hypovolemic 0096 (08.8) 000 (00.0) 00 (00.0) 035 (30.7) 005 (04.9) 032 (11.4) Respiratory 0198 (18.1) 004 (03.8) 12 (42.9) 010 (08.8) 009 (08.7) 085 (30.4) Cardiac 0549 (50.2) 091 (87.5) 15 (53.6) 020 (17.5) 067 (65.0) 070 (25.0) Cause of arrest, N (%) Witnessed or monitored, N (%) 1069 (97.7) 102 (98.1) 28 (100). 110 (96.5) 102 (99) (97.5) Female 0420 (38.4) 033 (31.7) 09 (32.1) 041 (36) (29.1) 098 (35)0. Male 0674 (61.6) 071 (68.3) 19 (67.9) 073 (64) (70.9) 182 (65)0. Sex, N (%) Mean Age, year (±SD) 59.34± ± ± ± ± ±15.06 (n=1094) disease (n=104) disease (n=28) disease (n=114) failure (n=103) solid malignancy (n=280) Characteristics Overall patients Congestive heart Severe pulmonary Severe liver Chronic renal Hematologic or metastatic Table 2. Baseline characteristics of the study population

5 김신념외 : 중증기저질환이병원내심정지환자의예후에미치는영향 / 753 Table 3. Multivariable-adjusted hazard ratio of mortality at 6 months from in-hospital cardiac arrests according to severe comorbidities Hazard ratio 95% CI p value Congestive heart disease (n=104) <0.770 Severe pulmonary disease (n=28) <0.150 Severe liver disease (n=114) <0.002 Chronic renal failure (n=103) <0.130 Hematologic or metastatic solid malignancy (n=280) <0.001 CI : confidence interval A B C D E Fig. 2. Comparison of survival curves by multivariate Cox regression analysis.

6 754 / 대한응급의학회지 : 제 21 권제 6 호 2010 * p < 0.05 CPR: cardiopulmonary resuscitation, VF: ventricular fibrillation, VT: ventricular tachycardia, ICU: intensive care unit Charlson score (+1) Odd (95% CI) 1.03 ( )* 1.00 ( )* 1.01 ( ) 1.02 ( )* 0.96 ( )* 1.00 ( )* Subsequent Intervention Odd (95% CI) 0.37 ( )* 0.23 ( )* ( )* 0.63 ( )* 0.34 ( )* Location (ICU, OR) Odd (95% CI) 0.99 ( )* 1.09 ( )* 1.00 ( ) 1.07 ( )* 0.80 ( )* 0.97 ( )* (VF or pulseless VT) Initial rhythm Odd (95% CI) 0.74 ( )* 0.83 ( )* 1.44 ( ) 0.77 ( )* 1.12 ( )* 0.99 ( )* (Cardiac arrest) Cause of arrest Odd (95% CI) 0.76 ( )* 0.64 ( )* 0.98 ( ) 0.76 ( )* 0.72 ( )* 0.79 ( )* CPR (>10 min) Odd (95% CI) 2.78 ( )* 4.71 ( )* 1.11 ( ) 2.28 ( )* 3.00 ( )* 1.80 ( )* Age (+10) Odd (95% CI) 1.05 ( )* 1.17 ( )* 1.22 ( ) 0.96 ( )* 1.13 ( )* 1.01 ( )* disease (n=104) disease (n=28) disease (n=114) failure (n=103) solid malignancy (n=280) Total Congestive heart Severe pulmonary Severe liver Chronic renal Hematologic or metastatic Table 4. Multivariate Cox regression analyses for factors associated with mortality at 6 months from in-hospital cardiac arrests 았던중증간질환이나혈액암또는전이성고형암환자의경우에는더욱중요할것이라생각된다. 본연구에서는심정지후원인교정을위한추가적인시술이나수술여부를조사하였는데, 중증간질환, 중증심부전, 혈액암또는전이성고형암환자군에서이러한시술및수술이생존율과유의한연관성을보였다. 생존환자들을검토해보면, 중증심부전환자의경우에는심정지발생후심장이식등의심장수술을받았거나경피경혈관심장동맥확장술 (percutaneous transluminal coronary angioplasty) 을받은경우등이있었고, 중증간질환군에는간이식수술이나, 출혈성쇽으로인한응급개복수술을받은경우등이있었다. 혈액암또는전이성고형암환자군에서도심장성심정지후경피경혈관심장동맥확장술을시행받은후생존한경우등이있었다. 이러한추가시술또는수술이가능했던것은심정지원인에대한가역적인교정인자가있는것을시사하는것으로, 중증기저질환을가진심정지환자라할지라도교정가능한가역적원인을찾고이를적극적으로교정해야함을의미한다. 본연구의중증기저질환중울혈성심부전환자군에서는심정지후사망률이차이가나지않았다. 이점은타질환군에비해서심정지원인이심인성인경우가많고, 위에서언급한심장수술이나중재술등을통해심정지원인교정이가능한경우가많았기때문인것으로판단된다. Deyo-Charlson score는 17가지의만성질환에대해서사망률 (mortality) 에대한영향력에따른차등점수를합산하여계산한다 28). Ehlenbach 등 29) 에따르면 65세이상고령환자에서 Deyo-Charlson score 3점이상은병원내심정지후낮은생존율과연관성이있었다. 본연구에서도 Deyo-Charlson score는심정지 6개월후사망과유의한관계가있어기저질환의양적인 (burden) 면이병원내심정지발생시고려되어야함을알수있었으나, 심정지후사망률의예측력은높지않았다. 병원내심정지는소생술분야에서다양한관심과연구가시도되는분야이다. 그러나중증기저질환과병원내심정지에관한본연구주제는응급의학과의사나응급의료관련종사자의관심분야와거리가있을수있다. 그러나본원에서는 2007년 10월부터병원내심폐소생술과그교육을응급의학과에서주도하게되었으며, 이로인해저자들은보다많은병원내심정지증례를경험할수있었다. 또한병원전이나응급실내에서발생하는심정지에서도중증기저질환의동반여부나기저질환의정도가환자의예후판단에고려되어야한다고생각되어본연구를진행하게되었다. 앞으로본원의임상경험을바탕으로응급의학과의사에의한병원내심폐소생술팀운영에관한연구또한진행할예정이다. 본연구는일개의료기관의후향적연구로서각각의기저질환환자수가많지않으며, 중등도를세분화하여분석하

7 김신념외 : 중증기저질환이병원내심정지환자의예후에미치는영향 / 755 지못하였고, 입원전환자상태 (functional state), 기저질환의이환기간, 기저질환에따른기대생존기간등을본연구에반영하지못한제한점이있다. 또한각질환군에따라층화분석을시행하면서실제분석단계에서는대규모연구의의미가감소되었다. 마지막으로, 분석대상에실제로심폐소생술을시행받은환자만을포함하였음에도, 심정지발생전 do not attempt resuscitation (DNAR) 에동의한환자가일부포함되어있다. 이는문서화되지않은 DNAR 동의또는설명부족, 보호자에의한심폐소생술진행, 의료진의의사소통문제등때문으로생각된다. 일반적으로 DNAR 동의환자에서심정지발생시그렇지않은환자에비해서예후가나쁘므로, 이점이연구결과에영향을미쳤을가능성이있을수있다 30). 본연구에서반영하지못한다른기저질환들을포함하여중증질환별로향후좀더많은환자군을대상으로한연구가필요할것으로생각된다. 결 중증간질환및혈액암또는전이성고형암은병원내심정지환자의 6개월사망률과유의한관계가있었다. 중증기저질환을가진심정지환자의예후인자로는심폐소생술지속시간, 심폐소생술후원인교정을위한추가적인시술이나수술의시행여부가있었다. 또한환자의기저질환을반영하는 Deyo-Charlson score는 6개월사망률과유의한연관성이있었다. 론 참고문헌 01. Ebell MH. Prearrest predictors of survival following inhospital cardiopulmonary resuscitation: a meta-analysis. J Fam Pract 1992;34: Peberdy MA, Kaye W, Ornato JP, Larkin GL, Nadkarni V, Mancini ME, et al. Cardiopulmonary resuscitation of adults in the hospital: a report of cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation 2003;58: Tunstall-Pedoe H, Bailey L, Chamberlain DA, Marsden AK, Ward ME, Zideman DA. Survey of 3765 cardiopulmonary resuscitations in British hospitals (the BRESUS Study): methods and overall results. BMJ 1992;304: Chen JS, Wang HM, Wu SC, Liu TW, Hung YN, Tang ST. A population-based study on the prevalence and determinants of cardiopulmonary resuscitation in the last month of life for Taiwanese cancer decedents, Resuscitation 2009;80: Heyland DK, Frank C, Groll D, Pichora D, Dodek P, Rocker G, et al. Understanding cardiopulmonary resuscitation decision making: perspectives of seriously ill hospitalized patients and family members. Chest 2006;130: Varon J, Walsh GL, Marik PE, Fromm RE. Should a cancer patient be resuscitated following an in-hospital cardiac arrest? Resuscitation 1998;36: Wallace SK, Ewer MS, Price KJ, Feeley TW. Outcome and cost implications of cardiopulmonary resuscitation in the medical intensive care unit of a comprehensive cancer center. Support Care Cancer 2002;10: Arabi Y, Ahmed QA, Haddad S, Aljumah A, Al- Shimemeri A. Outcome predictors of cirrhosis patients admitted to the intensive care unit. Eur J Gastroenterol Hepatol 2004;16: Ballew KA, Philbrick JT, Caven DE, Schorling JB. Predictors of survival following in-hospital cardiopulmonary resuscitation. A moving target. Arch Intern Med 1994;154: de Vos R, Koster RW, De Haan RJ, Oosting H, van der Wouw PA, Lampe-Schoenmaeckers AJ. In-hospital cardiopulmonary resuscitation: prearrest morbidity and outcome. Arch Intern Med 1999;159: O Keeffe S, Ebell MH. Prediction of failure to survive following in-hospital cardiopulmonary resuscitation: comparison of two predictive instruments. Resuscitation 1994; 28: Sandroni C, Nolan J, Cavallaro F, Antonelli M. In-hospital cardiac arrest: incidence, prognosis and possible measures to improve survival. Intensive Care Med 2007;33: Sowden GR, Robins DW, Baskett PJ. Factors associated with survival and eventual cerebral status following cardiac arrest. Anaesthesia 1984;39: Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol 1992;45: ECC Committee, Subcommittees and Task Forces of the American Heart Association American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2005;112(Suppl IV):IV Ebell MH, Becker LA, Barry HC, Hagen M. Survival after in-hospital cardiopulmonary resuscitation. A meta-analysis. J Gen Intern Med 1998;13: Nadkarni VM, Larkin GL, Peberdy MA, Carey SM, Kaye W, Mancini ME, et al. First documented rhythm and clinical outcome from in-hospital cardiac arrest among children and adults. JAMA 2006;295: Becker LB, Ostrander MP, Barrett J, Kondos GT. Outcome of CPR in a large metropolitan area--where are

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