Abstract & Commentary
Don't Stop CPR Too Soon: Study Shows Better Outcomes with Longer Attempts
By David J. Pierson, MD, Editor, Professor Emeritus, Pulmonary and Critical Care Medicine, University of Washington, Seattle, is Editor for Critical Care Alert.
SYNOPSIS: Using a nationwide database on resuscitation following in-hospital cardiac arrest, the investigators showed that the duration of CPR prior to abandoning the effort varied considerably among different hospitals. Both return of spontaneous circulation and survival to hospital discharge occurred more often in the quartile of hospitals with the longest CPR duration prior to discontinuation in unsuccessful attempts.
SOURCE: Goldberger ZD, et al. Duration of resuscitation efforts and survival after in-hospital cardiac arrest: An observational study. Lancet 2012; Sept 4. [Epub ahead of print.]
Goldberger and colleagues at the University of Michigan sought to determine the variation in duration of cardiopulmonary resuscitation (CPR) attempts following in-hospital cardiac arrest among different institutions across the United States. Their hypothesis was that there would be substantial variation, and that by examining differences in how long CPR was continued prior to giving up in unsuccessful cases, it might be possible to correlate these with the rates of positive outcomes.
They used data from U.S. hospitals participating in a large, prospective, observational registry of in-hospital cardiac arrests, including all qualifying CPR attempts between 2000 and 2008. At each participating institution, trained research personnel abstracted data on clinical setting, type of initial rhythm, details of resuscitation attempt, duration of CPR (time to return of spontaneous circulation or discontinuation of attempt), and other clinical and organizational information for all arrests. For this study, only data from a given patient's initial arrest were included, with an initial rhythm of pulseless ventricular tachycardia or fibrillation, pulseless electrical activity, or asystole. Arrests occurring in the emergency department, operating room, postoperative areas, or procedure suites (such as the cardiac catheterization laboratory), and those in patients under age 18, were omitted.
During the study interval, out of 93,535 patients who suffered cardiac arrest at 537 acute-care hospitals, data from 64,339 patients at 435 hospitals met all inclusion criteria and were used in the analysis. Median duration of CPR for all patients was 17 minutes (interquartile range, 10-26 minutes). Return of spontaneous circulation was achieved in 31,198 patients (48.5%), whereas CPR was discontinued and the patient died in 33,141 cases (51.5%). Median duration of CPR in the former group was 12 minutes, as compared to 20 minutes in the non-survivors. Of patients with initial return of spontaneous circulation, 9912 (15.4%) survived to hospital discharge.
When the authors arranged the reporting hospitals into quartiles on the basis of overall duration of CPR, resuscitation attempts in those in the longest quartile were more than 50% longer than efforts in those in the shortest quartile. Among non-survivors of CPR, the median duration prior to discontinuation was 16 minutes in the shortest quartile as compared to 25 minutes in the quartile with the longest duration. With respect to survival following cardiac arrest, patients at hospitals with longer median resuscitation attempts had higher overall survival than those who arrested at hospitals with shorter median attempts. For example, patients at hospitals in the quartile with the longest median resuscitation attempts had a significantly higher rate of survival to hospital discharge than did those at hospitals in the quartile with the shortest attempts. These differences were most pronounced among patients with initial rhythms of pulseless electrical activity or asystole. The likelihood of survival with favorable neurological status did not vary significantly among the quartiles of CPR duration. Acknowledging that their observational data cannot define an optimal duration for CPR following in-hospital cardiac arrest, the authors suggest that efforts to systematically increase the duration of resuscitation attempts could improve survival of this high-mortality event.
COMMENTARY
Cardiac arrest is a common event both in the ICU and elsewhere in the acute-care hospital. Numerous studies have documented an overall survival rate of much less than 20%, as also found in this study. Given the frequency with which CPR is initiated for in-hospital cardiac arrest, and the poor overall survival rate, knowing when further efforts are unlikely to be successful in patients who have not had return of spontaneous circulation is a matter of considerable importance. However, this is a particularly difficult issue to address experimentally, and previous attempts to do so have been few in number and limited in generalizability. This study approaches the question indirectly by examining the relationship between CPR duration in unsuccessful episodes and the overall likelihood of survival following cardiac arrest in the same institutions. Although not an interventional study, it nonetheless provides important information to guide our thinking about when to consider abandoning efforts at resuscitation in such cases.
In the authors' database, the proportion of patients achieving return of spontaneous circulation was greatest in the first 20 minutes after CPR was initiated, but 12.4% of the survivors did not achieve this endpoint until after 30 minutes or more of resuscitation. Continued success as the duration of CPR increased occurred in patients with all four types of initial rhythm. However, Goldberger et al found that resuscitation efforts were terminated within 10 minutes in 15.8% of the patients, and within 30 minutes in 76.6% of the non-survivors. These findings support the authors' suggestion that generally continuing CPR for a longer period may increase the likelihood of survival.
Goldberger and colleagues at the University of Michigan sought to determine the variation in duration of cardiopulmonary resuscitation (CPR) attempts following in-hospital cardiac arrest among different institutions across the United States.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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