Don't Give Up Yet! Longer In-Hospital Resuscitation Effort May Improve Survival

Reed Miller

September 05, 2012

September 5, 2012 (London, United Kingdom) — Many professionals treating in-hospital cardiac arrest often find it difficult to give up their resuscitation even after the effort is probably futile, so researchers analyzed hospitals' tendency toward longer or shorter resuscitation efforts. Their findings, published online September 4, 2012 in the Lancet, suggest that systematically extending the duration of these resuscitation attempts could save lives [1].

Dr Zachary D Goldberger (University of Michigan, Ann Arbor) and colleagues identified 64 339 patients with in-hospital cardiac arrests at 435 US hospitals from 2000 to 2008 in the American Heart Association's Get With The Guidelines--Resuscitation registry. Nearly half (31 198) of the patients achieved return of spontaneous circulation, but only 9912 (15.4%) survived to discharge. For the patients who returned to spontaneous circulation, the median duration of resuscitation attempts was 12 minutes, but for nonsurvivors, the average effort lasted 20 minutes.

"Despite several advances in resuscitation care, overall survival after in-hospital cardiac arrest remains poor. Clinicians have raised concerns that prolongation of resuscitation efforts could be futile, but few empirical data are available to guide clinical practice," Goldberger et al explain.

The study found substantial variation between hospitals in the average duration of their resuscitation attempts, and the hospitals were sorted into quartiles based on the length of their average resuscitation effort. The patients treated in the hospitals in the quartile with the longest median resuscitation duration--an average of 25 minutes in nonsurvivors--were more likely to survive to spontaneous circulation (adjusted risk ratio 1.12, p < 0.0001) and survive to discharge (RR: 1.12, p=0.021) compared with patients at hospitals in the quartile with the shortest median resuscitation attempts in nonsurvivors--an average of about 16 minutes.

Because the study analyzed resuscitation duration in survivors and nonsurvivors separately, it confirmed that most survivors' return of spontaneous circulation occurs early during resuscitation attempts. It also confirmed that that some patients return to spontaneous circulation after over a half-hour of resuscitation, but fewer than 25% of the people who died during cardiac arrest were resuscitated for 30 minutes or longer, suggesting that these very long resuscitation attempts are not common, the authors explain.

A few baseline differences appeared to make a difference in the length of resuscitation. Among those who achieved return of spontaneous circulation, patients with preexisting disorders, including septicemia or major trauma, patients undergoing critical-care interventions at the time of cardiac arrest, or patients with arrests in the intensive-care unit were more likely to undergo 10 minutes or less of resuscitation than 30 minutes or more.

However, in nonsurvivors, except those with MI during admission, the proportion of patients with preexisting disorders resuscitated for 30 minutes or more was smaller than those resuscitated for 10 minutes or less.

Is longer resuscitation better, or is it just an indicator of better care?

The most important implication of the study's results, according to its investigators, is that a systematic effort to prolong resuscitation attempts could lead to increased rates of return of spontaneous circulation and survival to discharge, because patients at hospitals where resuscitation efforts lasted longer had the highest survival rates, independent of measured patient characteristics.

"The reason for this improved survival to discharge could be that hospitals that reliably implement guidelines for resuscitation care systematically attempt resuscitation for longer than do hospitals that do not reliably follow guidelines," Goldberger et al explain. "Such a finding would suggest that duration of resuscitation is a marker of more comprehensive care. However, it also suggests an opportunity to improve care in this high-risk population through standardization of duration of resuscitation attempts before termination of efforts."

In accompanying Comment [2], Dr Jerry Nolan (Royal United Hospital, Bath, UK) and Dr Jasmeet Soar (North Bristol NHS Trust, Bristol, UK) argue that further observational data from other national registries like the UK National Cardiac Arrest Audit will be necessary to confirm Goldberger et al's findings, because randomized trials are not ethically feasible. Other types of monitoring, such as waveform capnography to measure exhaled carbon dioxide and cerebral oximetry with near-infrared spectroscopy, may also clarify the value of prolonged resuscitation. All hospitals should track their cardiac arrests and benchmark outcomes as part of a quality-improvement program, they argue, and duration of resuscitation "should be established on a case-by-case basis and take into account other known determinants of survival."

While many questions about in-hospital resuscitation remain unanswered, Noland and Soar are confident that Goldberger and colleagues' study "reassures clinicians" that prolonged resuscitation attempts do not increase the risk of severe neurological injury and that, at least in some cases, 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," they conclude.

One of the study's coauthors, Dr Harlan Krumholz (Yale University, New Haven, CT), is the recipient of a research grant from Medtronic through Yale and is chair of a cardiac scientific advisory board for UnitedHealth. All other authors declare that they have no conflicts of interest. The American Heart Association provides operational funding for Get With The Guidelines--Resuscitation. Nolan is editor in chief of Resuscitation, for which he receives an honorarium, and Soar is an editor of Resuscitation, for which he receives an honorarium.