How Long Can We Go? Duration of In-hospital Resuscitation

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While there are no guidelines to recommend how long healthcare professionals should perform resuscitation following in-hospital cardiac arrest, a recent large study indicates that longer efforts may produce better outcomes—in some cases. But, a personalized strategy is always preferred.

Between one and five of every 1,000 hospital inpatients have a cardiac arrest, and less than 20 percent of them survive to discharge (Crit Care Med 2011;39: 2401-2406). Clinical decision- makers face challenges about when to stop resuscitation efforts in hospitalized patients who arrest, particularly because there are no clear-cut guidelines. Yet, due to the assumption of poor prognosis following prolonged resuscitation efforts, practitioners have been hesitant to enact longer strategies.

“It remains unclear when to stop resuscitation, once efforts are underway,” says Zachary D. Goldberger, MD, a cardiologist at Harborview Medical Center in Seattle.

As a result, there is a great deal of variation in the length of resuscitation efforts in hospitals across the U.S. and globally. “Variability in the delivery of resuscitation largely derives from the lack of guidelines, but also may be influenced by the experience of the resuscitation team and the mix of patient subsets in the hospital,” says Jerry P. Nolan, FRCA, of the Royal United Hospital NHS Trust in Bath, England.  

To evaluate how resuscitation duration impacts survival, Goldberger et al identified 64,339 patients with cardiac arrests at 435 U.S. hospitals between 2000 and 2008 within the American Heart Association’s Get with the Guidelines-Resuscitation registry. In the study, 48.5 percent of patients achieved return of spontaneous circulation and 15.4 percent survived to discharge. For patients achieving return of spontaneous circulation, the median duration of resuscitation was 12 minutes compared with 20 minutes for non-survivors.  

Compared with patients at hospitals in the quartile with the shortest median resuscitation attempts in non-survivors (16 minutes), those at hospitals in the quartile with the longest attempts (25 minutes) had a 12 percent higher likelihood of return of spontaneous circulation and survival to discharge.  

“There are obvious concerns that if you resuscitate patients longer, they could be neurologically disabled even if they survive,” says Goldberger. Information about neurological status was available for 88 percent of patients who survived to discharge. The rate of favorable neurological status in these patients did not significantly differ on the basis of resuscitation duration. However, mean and median scores on assessments of cerebral performance categories were slightly higher in patients in whom duration of resuscitation was longer than in those in whom duration was short.

“The lives saved did not come at a cost of neurologic functioning, which was reassuring,” says Goldberger.

However, the researchers are cautious about generalizing the results. “This study challenges the conventional wisdom that longer is not better, by demonstrating that for some patients, longer may be better,” Goldberger adds. “However, this observational analysis does not warrant a guideline stating longer is better for all hospitalized patients, nor can it identify optimal duration. This relies on clinical judgment at the bedside.”

However, this paper could be a starting point for system-level improvement, he adds, perhaps by standardizing a minimum duration of resuscitation rather than a maximum.  

To standardize personalized care, Nolan encourages providers to ask these questions for each patient: What caused the cardiac arrest? Is it something we can reverse through resuscitation? Are these patients naturally coming to the end of life because of their underlying disease?  

Nolan, co-author of an accompanying editorial, says that a comprehensive strategy can result in higher survival rates, and should be considered when a hospital attempts to establish protocols. “While there is a big push to standardize care, protocols can never replace the decision making that must occur for the individual patient at the point of care,” he says.