Delays in Cardiopulmonary Resuscitation, Defibrillation, and Epinephrine Administration All Decrease Survival in In-Hospital Cardiac Arrest

Nicholas G. Bircher, M.D.; Paul S. Chan, M.D., M.Sc.; Yan Xu, Ph.D.

Disclosures

Anesthesiology. 2019;130(3):414-422. 

In This Article

Abstract and Introduction

Abstract

Background: Because the extent to which delays in initiating cardiopulmonary resuscitation (CPR) versus the time from CPR to defibrillation or epinephrine treatment affects survival remains unknown, it was hypothesized that all three independently decrease survival in in-hospital cardiac arrest.

Methods: Witnessed, index cases of cardiac arrest from the Get With The Guidelines–Resuscitation Database occurring between 2000 and 2008 in 538 hospitals were included in this analysis. Multivariable risk-adjusted logistic regression examined the association of time to initiation of CPR and time from CPR to either epinephrine treatment or defibrillation with survival to discharge.

Results: In the overall cohort of 57,312 patients, there were 9,802 survivors (17.1%). Times to initiation of CPR greater than 2 min were associated with a survival of 14.7% (91 of 618) as compared with 17.1% (9,711 of 56,694) if CPR was begun in 2 min or less (adjusted odds ratio [95% CI], 0.68 [0.54 to 0.87]; P < 0.002). Times from CPR to either defibrillation or epinephrine treatment of 2 min or less were associated with a survival of 18.0% (7,654 of 42,475), as compared with 15.0% (1,680 of 11,227) for 3 to 5 min (reference, 0 to 2 min; adjusted odds ratios [95% CI], 0.83 [0.78 to 0.88]; P < 0.001), 12.8% (382 of 2,983) for 6 to 8 min (0.67 [0.60 to 0.76], P < 0.001), and 13.7% (86 of 627) for 9 to 11 min (0.54 [0.42 to 0.69], P < 0.001).

Conclusions: Delays in the initiation of CPR and from CPR to defibrillation or epinephrine treatment were each associated with lower survival.

Introduction

Although in-hospital cardiac arrest is a common event in U.S. hospitals, survival remains as low as about 20%.[1,2] Prior studies for out-of-hospital cardiac arrests have emphasized the critical importance of prompt initiation of cardiopulmonary resuscitation (CPR). Others have documented the importance of prompt treatment with defibrillation for patients with shockable in-hospital cardiac arrest[3] and with epinephrine for those with nonshockable in-hospital cardiac arrest.[4]However, the relationship between time to initiation of CPR and survival for in-hospital cardiac arrest is not well understood. Moreover, the total time between pulselessness and defibrillation or epinephrine treatment comprises both time to initiation of CPR and time from CPR to either treatment. The effect on survival of each of these intervals has not been previously characterized.

Accordingly, we examined the association between time to initiation of CPR and time from CPR to either defibrillation or epinephrine treatment on in-hospital cardiac arrest outcomes using data from Get With The Guidelines–Resuscitation, a large prospective, hospital-based, multicenter clinical registry that uses standardized definitions to assess both care processes and outcomes.[5] We hypothesized that delays in the initiation of CPR and from time of CPR to defibrillation or epinephrine treatment are each associated with lower in-hospital cardiac arrest survival.

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