Continuing resuscitation attempts just a little longer could save lives during in-hospital cardiac arrest, a registry study suggested.
Hospitals that tried the longest on average were 12% more likely to achieve spontaneous circulation for a given patient and 12% more likely to discharge them home alive compared with those with the shortest mean attempts (adjusted risk ratio 1.12, 95% CI 1.06 to 1.18, P<0.0001), reported Brahmajee K. Nallamothu, MD, MPH, of the University of Michigan Health System in Ann Arbor, and colleagues.
Duration of attempts varied widely among centers, the group noted online in The Lancet.
But the difference between centers in the quartile with the shortest median resuscitation attempts in nonsurvivors versus the quartile with the longest median resuscitation attempts was only 9 minutes (16 versus 25 minutes).
“Prolongation of resuscitation attempts by 10 or 15 minutes might have only slight effects on resources once efforts have already begun, but could improve outcomes,” the authors wrote.
The group recommended that standardizing a minimum duration for CPR might help, but hesitated to provide an exact cutoff. “Clinical judgment will always be needed for this aspect of care,” they said.
An accompanying editorial out of the U.K. also stated that cases must be decided on a patient-by-patient basis, taking into account other determinants of survival.
However, the findings were reassuring, explained editorialists Jerry P. Nolan, MBChB, of Royal United Hospital in Bath, and Jasmeet Soar, MBBChir, of Southmead Hospital in Bristol.
“Prolonged resuscitation efforts can result in high-quality survival,” they wrote. “If the cause of cardiac arrest is potentially reversible, it might be worthwhile to try for a little longer.”
Prolonged resuscitation attempts were actually associated with slightly higher cerebral performance scores among survivors rather than severe neurological injury in the analysis of 64,339 patients with cardiac arrests at 435 U.S. hospitals reporting to the Get With The Guidelines-Resuscitation registry.
Favorable neurological status (no major disability) was seen in 81% of people who took less than 15 minutes of CPR for resuscitation compared with 80% who took 15 to 30 minutes and 78% in those who received CPR for more than 30 minutes (P=0.131).
Overall in the registry, 49% of the patients were returned to spontaneous circulation for at least 20 minutes after an in-hospital cardiac arrest.
Notably, 8% of the survivors took at least 30 minutes of resuscitation efforts to return to spontaneous circulation, which was roughly the case across all types of initial cardiac arrest rhythms.
For the nonsurvivors, hospitals terminated efforts within 10 minutes in 16% of the cases and within 30 minutes in 77%.
Hospitals with longer median duration of resuscitation duration for nonsurvivors (as a measure of overall tendency to attempt resuscitation for longer) also had the highest rates of return of spontaneous circulation:
- 51% at hospitals in the top quartile, with a median duration of 25 minutes for nonsurvivors (P<0.0001 versus bottom quartile)
- 49% for hospitals in the quartile with a median duration of 22 minutes for nonsurvivors (P=0.002 versus bottom quartile)
- 47% for centers in the quartile with a median duration of 19 minutes for nonsurvivors
- 45% for the bottom quartile, with a median of 16 minutes
The same pattern was seen for those hospitals’ survival to discharge rates, ranging from 16% at the most persevering centers to 15% at the least (P=0.021 for top versus bottom quartiles).
“This additional time might seem to be a slight increase, but could have substantial implications in critically ill patients if it is thought of as time for reassessment of clinical responses and provision of further treatments,” the researchers noted.
The observational registry results could have faced some confounding, they acknowledged.
Duration of resuscitation could have been a marker of more comprehensive care within a group of typically large, motivated centers.
Factors not recorded in the database, such as quality of chest compressions and standard of the code team’s work, could have played a role in decisions and outcomes as well. Another limitation was lack of data on long-term outcomes in survivors.
Also, hospitals better equipped and prepared to identify and treat causes of cardiac arrest, such as pericardial tamponade, or that offer better care after arrest (therapeutic hypothermia) might take a more aggressive approach to resuscitation, the editorialists pointed out.
Hospitals need to audit their own cardiac arrests and benchmark their outcomes as a part of quality improvement programs, Nolan and Soar urged.
Primary source: The Lancet