[The Lancet] Longer duration of resuscitation efforts associated with increased survival in patients with in-hospital cardiac arrests

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Primer: When dealing with cardiac arrests, one of the biggest dilemmas facing clinicians is deciding when to stop resuscitation efforts. Little research evidence is available to guide clinicians regarding the appropriate length of resuscitation efforts, and this decision is largely made based on case-series and expert opinions, as there are no guidelines to address this issue. Given the lack of evidence, the length of resuscitation efforts may vary tremendously between hospitals.

This [prospective] study: Published in The Lancet, a large, multicentre observational study of in-hospital cardiac arrests sought to explore whether the duration of resuscitation efforts varied between hospitals, and whether the length of resuscitation efforts impacted survival rates. Data were obtained from a large registry of in-hospital cardiac arrests, which included data from 537 acute care hospitals in the USA and Canada. The primary endpoints were immediate survival with spontaneous return of circulation (i.e., restoration of a spontaneous pulse for at least 20 minutes) and survival to hospital discharge. The key independent variable was median duration of resuscitation attempts in non-survivors.

The final analysis involved 64,339 patients with in-hospital cardiac arrests and 31,198 of these patients achieved return of spontaneous circulation (48.5%) while 9,912 patients survived until discharge (15.4%). The median duration of resuscitation efforts in non-survivors of hospitals in the shortest quartile was 16 min. (15-17), then 19 min. (18-20), 22 min. (21-23), and 25 min. (25-28) in the subsequent quartiles. Patients who had cardiac arrests in hospitals with longer median duration of resuscitation efforts had higher overall survival. Compared to the lowest quartile, patients with arrests in hospitals of the highest quartile were more likely to achieve return to spontaneous circulation (ARR 1.12; 95% CI 1.06-1.18) and survive to discharge (ARR 1.12; 95% CI 1.02-1.23).

In sum: Patients with cardiac arrests in hospitals with longer median duration of resuscitation efforts had higher likelihood of both spontaneous return of circulation and survival to discharge. Nevertheless, overall survival after in-hospital cardiac arrest remains low. Limitations of this study include the fact that it is an observational study (and cannot directly show a causal relationship) and that there may be errors and inconsistencies in data collection. As a randomized trial would never be done, this may be the best data we will be able to obtain. However, one should be aware that the internal bias of those running the codes may be an integral part of the results: if a patient is perceived as having a better chance of survival, are they resuscitated for longer?

Click to read the study in The Lancet

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