Is Cardiopulmonary Resuscitation Futile in Coronavirus Disease 2019 Patients Experiencing In-hospital Cardiac Arrest?

Priyank Shah, MD, MPH, FACC; Hallie Smith, ABJ, MS; Ayodeji Olarewaju, MD; Yash Jani, MS; Abigail Cobb, MSN, FNP; Jack Owens, MD, MPH; Justin Moore, MPH, PhD; Avantika Chenna, MD; David Hess, MD

Disclosures

Crit Care Med. 2021;49(2):201-208. 

In This Article

Abstract and Introduction

Abstract

Objectives: There is limited data regarding outcomes after in-hospital cardiac arrest among coronavirus disease 2019 patients. None of the studies have reported the outcomes of in-hospital cardiac arrest in coronavirus disease 2019 patients in the United States. We describe the characteristics and outcomes of in-hospital cardiac arrest in coronavirus disease 2019 patients in rural Southwest Georgia.

Design: Retrospective cohort study.

Setting: Single-center, multihospital.

Patients: Consecutive coronavirus disease 2019 patients who experienced in-hospital cardiac arrest with attempted resuscitation.

Interventions: Attempted resuscitation with advanced cardiac life support.

Measurement and Main Results: Out of 1,094 patients hospitalized for coronavirus disease 2019 during the study period, 63 patients suffered from in-hospital cardiac arrest with attempted resuscitation and were included in this study. The median age was 66 years, and 49.2% were males. The majority of patients were African Americans (90.5%). The most common comorbidities were hypertension (88.9%), obesity (69.8%), diabetes (60.3%), and chronic kidney disease (33.3%). Eighteen patients (28.9%) had a Charlson Comorbidity Index of 0–2. The most common presenting symptoms were shortness of breath (63.5%), fever (52.4%), and cough (46%). The median duration of symptoms prior to admission was 14 days. During hospital course, 66.7% patients developed septic shock, and 84.1% had acute respiratory distress syndrome. Prior to in-hospital cardiac arrest, 81% were on ventilator, 60.3% were on vasopressors, and 39.7% were on dialysis. The majority of in-hospital cardiac arrest (84.1%) occurred in the ICU. Time to initiation of advanced cardiac life support protocol was less than 1 minute for all in-hospital cardiac arrest in the ICU and less than 2 minutes for the remaining patients. The most common initial rhythms were pulseless electrical activity (58.7%) and asystole (33.3%). Although return of spontaneous circulation was achieved in 29% patients, it was brief in all of them. The in-hospital mortality was 100%.

Conclusions: In our study, coronavirus disease 2019 patients suffering from in-hospital cardiac arrest had 100% in-hospital mortality regardless of the baseline comorbidities, presenting illness severity, and location of arrest.

Introduction

As of September 1, 2020, the novel coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2, has accounted for more than 183,000 deaths in the United States, and more than 5,600 deaths in the state of Georgia alone.[1] This virus primarily affects the respiratory system through angiotensin-converting enzyme (ACE) 2 receptor on host cells, but it also affects other systems as ACE2 is present in the heart, gastrointestinal tract, and kidneys.[2]

Infection with this virus leads to imbalance between ACE and ACE2 eventually causing increased activity of angiotensin II, leading to vasoconstriction, pro-inflammatory, and pro-fibrotic pathways, which play a major role in the progression of acute respiratory distress syndrome (ARDS) in COVID-19 patients.[3] In a study of 50 patients at Aachen University Hospital in Heinsberg, Germany, many of the patients who developed ARDS were older and had coexisting conditions such as preexisting respiratory disease and obesity.[4]

Several studies have identified the risk factors for COVID-19 and a number of related outcomes. The most common comorbidities in COVID-19 patients are hypertension, diabetes, and coronary artery disease (CAD).[5–8]

There is paucity of data on the outcomes of COVID-19 related in-hospital cardiac arrest (IHCA). We are aware of only one study detailing such outcomes in the Chinese population.[9] Our study aims to contribute to this important body of knowledge by describing the characteristics and outcomes of IHCA in COVID-19 patients at our institution, a hospital in the rural Southwest Georgia, "Black belt" where the counties have high percentages of African American residents.

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