In-hospital resuscitation: when to call time?

Cardiopulmonary resuscitation guidelines are fairly standardised and didactic but recommendations on when to terminate in-hospital resuscitation attempts are less precise, which often means that resuscitation teams have to make subjective decisions. Validated clinical decision strategies for stopping in-hospital resuscitation exist, but are derived from guidelines no longer in use and thus are rarely used in clinical practice. 

In The Lancet, Goldberger and colleagues¹have used the American Heart Association’s ‘Get with the Guidelines – Resuscitation’ registry (globally, the largest in-hospital cardiac arrest registry). They use it to assess the duration of resuscitation before termination of efforts in non-survivors as an indicator of the overall tendency of a hospital to attempt resuscitation for longer. They analysed data from 64,339 patients with cardiac arrests at 435 US hospitals between 2000 and 2008. Cardiac arrests that lasted less than two minutes were excluded. In the whole study population:

• Median resuscitation duration was 17 minutes (IQR 10-26)
• There were 31,198 patients (48.5%) who achieved return of spontaneous circulation, ie. restoration of a pulse for at least 20 minutes
• There were 9,912 (15.4%) patients who survived to hospital discharge. 

Of the 48.5% of patients who achieved return of spontaneous circulation, circulation returned within 10 minutes in 44.8% and within 30 minutes in 87.6%. The median resuscitation time was 12 minutes (IQR 6-21) in patients achieving return of spontaneous circulation and 20 minutes (14-30) in non-survivors. 

Hospitals were classified into quartiles on the basis of the median duration of resuscitation in non-survivors: 16, 19, 22 and 25 minutes were the median resuscitation durations for the first to fourth quartiles, respectively. Patients at hospitals in the quartile with a median resuscitation duration of 25 minutes (longest quartile in non-survivors) were significantly more likely to achieve return of spontaneous circulation (adjusted risk 1.12, 95% CI 1.06-1.18; p < 0.0001) and survive to discharge (1.12, 1.02-1.23; 0.021) than were those at hospitals in the quartile with a median duration of 16 minutes (shortest quartile in non-survivors). 

The difference was greatest in cardiac arrests where the initial rhythm was asystole or pulseless electrical activity. The proportion of patients surviving to discharge with a favourable neurological status (a cerebral performance category score of 1 or 2) did not differ significantly across all quartiles (p = 0.858). Some 730 (8.4%) of the 8,724 surviving to hospital discharge who had neurological assessments failed to achieve return of spontaneous circulation until ≥ 30 minutes of resuscitation attempts – broadly true for all initial cardiac arrest rhythms.

Goldberger and colleagues’ study reassures clinicians that prolonged resuscitation attempts do not seem to result in a substantial increase in severe neurological injury in survivors:

• To improve outcomes, all hospitals should audit their cardiac arrests and benchmark outcomes as part of a quality improvement programme 
• Duration of resuscitation attempts should be established on a case-by-case basis and take into account other known determinants of survival 
• Prolonged resuscitation efforts can result in high-quality survival 
• If the cause of cardiac arrest is potentially reversible, it might be worthwhile to try for a little longer.

Reference

1. Goldberger Z, Chan P, American Heart Association Get With The Guidelines – Resuscitation (formerly the National Registry of Cardiopulmonary Resuscitation) Investigators et al. Duration of resuscitation efforts and survival after in-hospital cardiac arrest: an observational study. Lancet 2012; 9852: 1473-1481