Longer-duration CPR does not improve survival after in-hospital cardiac arrest
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Key takeaways:
- A person’s chance of survival after in-hospital cardiac arrest decreases with CPR duration.
- The data could help guide shared decision-making for clinicians and families.
Odds for survival after an in-hospital cardiac arrest decline from 22% after 1 minute of CPR to less than 1% after 39 minutes, with similar odds observed for brain function, according to registry data.
Data suggest that longer resuscitation time for patients experiencing in-hospital cardiac arrest is associated with lower odds for survival; however, there are no specific recommendations on when to stop CPR efforts, according to Masashi Okubo, MD, MS, clinical assistant professor of emergency medicine at the University of Pittsburgh School of Medicine, and colleagues.
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“When patients do not achieve return of spontaneous circulation despite cardiopulmonary resuscitation, clinical providers face challenges in deciding how long to continue cardiopulmonary resuscitation,” the researchers wrote in The BMJ. “For patients with out-of-hospital cardiac arrest, previous studies showed that longer duration of prehospital cardiopulmonary resuscitation before return of spontaneous circulation was associated with poor outcomes for patients. However, the association of duration of cardiopulmonary resuscitation with patients’ outcomes has not been fully investigated for in-hospital cardiac arrest.”
In an observational study, Okubo and colleagues analyzed data from 348,996 adults who experienced an in-hospital cardiac arrest and received CPR from 2000 to 2021 using the Get With the Guidelines–Resuscitation registry, a quality improvement registry of in-hospital cardiac arrest in the U.S. The main exposure was duration of CPR in minutes, defined as an interval in whole minutes between the start of chest compression and the first return of spontaneous circulation or termination of resuscitation.
“We defined return of spontaneous circulation as return of adequate pulse by palpation, Doppler or arterial BP waveform,” the researchers wrote.
The primary outcomes were survival to hospital discharge and favorable functional outcome at hospital discharge, defined as a Cerebral Performance Category score of 1 (good cerebral performance) or 2 (moderate cerebral disability). Researchers estimated the time-dependent probabilities of subsequently surviving to hospital discharge or having favorable functional outcome of patients pending the first return of spontaneous circulation at each minute they received CPR.
Of the included patients, 66.9% achieved a return of spontaneous circulation and 22.6% survived to hospital discharge. The median interval between start of chest compressions and the first return of spontaneous circulation was 7 minutes. The median interval between start of chest compressions and termination of resuscitation was 20 minutes among patients who did not have return of spontaneous circulation.
Ninety-nine percent of patients who survived to hospital discharge had the first return of spontaneous circulation within 44 minutes duration of CPR. Similarly, 99% of patients with favorable functional outcome at hospital discharge had the first return of spontaneous circulation within 43 minutes.
The time-dependent probabilities of survival and favorable functional outcome among patients pending return of spontaneous circulation at 1-minute duration of CPR were 22% and 15.1%, respectively. The probabilities decreased over time and were less than 1% for survival at 39 minutes and less than 1% for favorable functional outcome at 32 minutes duration of CPR.
“As duration of CPR increased, the probabilities of survival and favorable functional outcome decreased and plateaued at 0.3% to 0.9% and 0.1% to 0.5% between 40 minutes and 60 minutes, respectively,” the researchers wrote.
The researchers noted that the time-dependent probabilities of survival and favorable functional outcome among patients pending the first return of spontaneous circulation at each minute’s duration of CPR provide resuscitation teams, patients and their family members with insights into the likelihood of favorable outcomes if the patient continues to receive CPR beyond a certain time point, which aids in shared decision-making.
“The findings provide resuscitation teams, patients and their surrogates with the objective probabilities of subsequent favorable outcomes if patients pending the first return of spontaneous circulation received further cardiopulmonary resuscitation,” the researchers wrote.
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