There are still uncertainties about how long resuscitation procedures will be applied to which cases and how their prognosis is. Various studies have been conducted to predict the prognosis after cardiopulmonary resuscitation. In studies on prognosis after CPR in the world, survival rates in in-hospital CPR are between 13–37%, and values between 15–20% are frequently observed (9). Peberdy et al. (10) evaluated the rate of patients with spontaneous circulation as 44% and the rate of discharge from the hospital as 17% in their study including 14720 patients. Saghafinia et al. (11), in their study including in-hospital cardiac arrest cases, 12% of 290 cases were discharged with survival. There were 11 (10.6%) patients with survival in our study. The survival group was consistent with similar studies, and the mean age was found below. We think this is due to the good response of young people to CPR and better return in spontaneous circulation.
After cardiopulmonary arrest, collapse rhythms are of great importance in patients undergoing CPR. Witness arrest rhythms and the success of CPR can be predictive for prognosis and mortality. In the study in which Oguzturk et al. (12) evaluated the success of CPR after the cardiopulmonary arrest, VF was recorded in 45.7% of 70 patients and asystolic rhythm in 40%. The success of providing spontaneous circulation is 50.8% in VF and 35.6% in asystole, respectively. Spontaneous circulation was achieved in 30 of 32 patients with ventricular fibrillation and 10 patients were discharged in the following period. Also, there was no spontaneous circulation and survival in patients with PEA. Geçmen et al. (13) reported in their study that the most common rhythm was asystole with 70% and spontaneous circulation was achieved in 44%. In ventricular fibrillation, 33% spontaneous circulation was achieved and the relationship between rhythm and mortality was found to be significant. In our study, survival was achieved in 7 (29.2%) of 24 (23.1%) patients with VF rhythm, and 2 (3.3%) of 60 (57.7%) patients with asystolic rhythm. All patients with PEA rhythm died either in the emergency department or intensive care unit. We think that VF is a reversible rhythm due to the etiology in the in-hospital cardiopulmonary arrests.
Several studies are continuing on the effects of cardiopulmonary resuscitation success on mortality, and the effects of some proteins on survival are being investigated recently. Aarsetoy et al. (14) found a significant relationship between N-terminal pro-B-type natriuretic peptide level and mortality after CPR. Sonmez (15), evaluated the relationship between base deficit and lactate and CPR success significantly in his study. In our study, the effect of serum fetuin-A level and serum lactate level on prognosis and mortality after CPR was evaluated. Both parameters were evaluated as a determinant value in terms of collapse rhythm and survival. Fetuin-A is a glycoprotein and cysteine proteinase inhibitor synthesized from the liver (16). Despite the increased C-reactive protein during the acute inflammation process of fetuin-A, its levels decrease with albumin (17). Despite the increase in proinflammatory cytokines, their levels decrease contrarily (18). It also has protective effects against ischemia in cardiomyocyte and nervous system cells (19). It increases insulin resistance by inhibiting insulin tyrosine kinase activity and insulin receptor autophosphilicity (20).
Ketteler et al. (21) showed in their study that serum fetuin-A levels had a negative relationship with mitral annular calcification and aortic stenosis. Also, higher cardiovascular and general mortality rates were found in hemodialysis patients with low fetuin-A levels. Mehrota et al. (22) found a significant relationship between serum fetuin-A level and coronary artery calcification score in patients with diabetic nephropathy before dialysis. Moe et al. (23) showed in their study that there was a negative correlation between low fetuin-A and coronary calcification, and they stated that coronary calcification has an important place in its pathogenesis. It has been reported that low fetuin-A levels are associated with the severity of coronary artery disease, poor reperfusion rates, and mortality in patients with the acute coronary syndrome, and ST-elevation myocardial infarction (24).
We have yet to come across any study on the role of fetuin-A, whose effectiveness has been evaluated in many studies, in cardiopulmonary arrest and CPR, its effect on prognosis and mortality. In our study, serum fetuin-A level was found to be low in patients who resulted in mortality after CPR, whereas serum lactate level was high. Also, serum lactate level was low and serum fetuin-A level was high in living patients. Serum fetuin-A level was found to be the highest in PEA and the lowest in VF among the collapse rhythms. The reason why serum fetuin-A level is lower in ventricular fibrillation compared to other collapse rhythms may be due to the greater destruction as a result of both CPR and defibrillation. In the analysis of fetuin-A with mortality, when the relationship between collapse rhythms was evaluated, the values of the patients who died in the emergency department were significantly different with both the survivors and those who died in the intensive care unit.
There was a strong negative correlation of serum fetuin-A and lactate levels with arrest rhythms. In cases of cardiopulmonary arrest, which is an inflammatory and ischemic process, the decrease in serum fetuin-A level in mortality may explain this situation. We attribute the higher level of fetuin-A in patients with spontaneous circulation compared to mortality groups, to the protective effect of high levels of this negative acute phase reactant protein. Low serum fetuin-A levels are associated with higher prevalence and/or severity of vascular calcification (VC) and risk of cardiovascular mortality (25). According to this information, we can say that the serum fetuin-A level of the patients can be used as a determinant value in predicting prognosis, morbidity, and mortality.
Limitation of the study
The small number of cases was the most important limitation as it was a prospective study. In addition, the fact that it was single-center, the number of fetuin-A kits was limited, and the requirement to obtain informed consent from the relatives of the patients were other important limitations.
We determined that the decrease in serum fetuin-A level after CPR, together with collapse rhythms, may be important in determining the survival rate. Also, fetuin-A values can be used in predicting morbidity and mortality in these patients. More prospective studies are needed to demonstrate its diagnostic and therapeutic potential for the clinical management of cardiopulmonary resuscitation and all inflammatory processes.