CPR Longer Than 20 Minutes in Kids 'Is Not Futile'

January 24, 2013

PITTSBURGH, Pennsylvania — More children than expected survive cardiac arrests in the hospital following prolonged resuscitation, new research shows [1]. The study--the largest to date in this field--"should help dispel common perceptions that cardiopulmonary resuscitation [CPR] is futile beyond 20 minutes," say Dr Renée Matos (University of Pittsburgh School of Medicine, PA) and colleagues in their report, published online January 22, 2013 in Circulation.

They did show, however, that children with certain illnesses seem to respond better to prolonged CPR than others. "We found that surgical-cardiac patients had the best outcomes and trauma patients had the worst at each incremental increase in CPR duration." And CPR duration was inversely associated with survival and neurologic outcome, so "this really drives home the point that rapid, high-quality CPR is important," Matos stressed to heartwire .

A similar study in adults, published last year, suggested that extending the duration of resuscitation attempts for in-hospital cardiac arrest could save lives. But it also confirmed that most survivors' return of spontaneous circulation occurs early during resuscitation attempts.

Matos says that while the new findings have implications for in-hospital pediatric care, they do not provide a simple solution for when to discontinue CPR. Further studies are needed to determine whether prolonged resuscitative efforts are warranted in particular groups of patients, such as posttraumatic arrests, she says.

Survival Up to 16% in Some Groups, Even After >35 Minutes CPR

Matos and colleagues examined the effect of CPR duration for pediatric in-hospital cardiac arrest (IHCA) from the AHA Get With the Guidelines--Resuscitation prospective multicenter registry of IHCA. They included 3419 children from 328 US and Canadian sites who suffered an in-hospital cardiac arrest between January 2000 and December 2009. Patients were stratified into five illness categories: surgical cardiac, medical cardiac, general medical, general surgical, and trauma.

 
Each minute is critical to achieving both survival and a favorable neurologic outcome.
 

They analyzed outcomes after CPR durations of one to 15 minutes, 16 to 35 minutes, and >35 minutes. Outcomes in the first 15 minutes were linear and declined rapidly, so "each minute is critical to achieving both survival and a favorable neurologic outcome," they stress.

Adjusted probability of survival was 42% for CPR duration of one to 15 minutes and 12% for >35 minutes, although this varied by illness category.

"The finding that survival after >35 minutes CPR is as high as 16.2% in certain patient groups is novel, considering some studies have found overall survival to be 16%," the researchers point out. "Importantly, this study suggests that some children who would presumably die without CPR survive with a favorable neurologic outcome even after prolonged resuscitation efforts."

Surgical-Cardiac Patients Fared the Best, Trauma the Worst

Surgical-cardiac patients had the best outcomes and trauma patients the worst at each incremental increase in CPR duration: in fact, surgical-cardiac patients had a better probability of survival after 90 minutes of chest compressions than trauma patients after one minute.

Adjusted OR* for Survival to Hospital Discharge by Patient Illness Category

CPR duration (min) Surgical cardiac Medical cardiac General surgical General medical Trauma p
1–15 3.34 1.63 1.31 1 0.29 <0.0001
16–35 2.00 0.82 1.93 1 0.16 0.0005
36–180 2.13 2.18 1.10 1 0.40 0.0377

*Adjusted model includes: initial pulseless rhythm, age category, weekend, night, extracorporeal membrane oxygenation, calcium administration, sepsis, renal insufficiency, vasoactive infusion during arrest, event location, sodium-bicarbonate administration, prior history of cardiopulmonary arrest, prearrest apnea monitor, prearrest pulse oximeter, and patient hypotension prior to arrest

Among survivors, favorable neurologic outcomes (pediatric cerebral performance category of 1, 2, or 3) occurred in 70% undergoing <15 minutes of CPR and 60% undergoing CPR >35 minutes.

Adjusted ORa for Favorable Neurologic Outcomes at Hospital Discharge by Patient Illness Category

CPR duration (min) Surgical cardiac Medical cardiac General surgical General medical Trauma p
1–15 2.92 1.29 1.03 1 0.21 <0.0001
16–35 2.20 1.05 1.96 1 0.12 0.004
36–180 3.74 3.21 1.30 1 --b 0.0175

a. Adjusted model includes: initial pulseless rhythm, age category, weekend, night, extracorporeal membrane oxygenation, calcium administration, sepsis, renal insufficiency, vasoactive infusion during arrest, event location, sodium-bicarbonate administration, prior history of cardiopulmonary arrest, prearrest apnea monitor, prearrest pulse oximeter, and patient hypotension prior to arrest

b. Too few cases to report (three of 65 had a favorable neurologic outcome in trauma category)

The authors report no conflicts of interest.

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