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Clinical Articles, Lead Article

CPR should continue for at least 35 minutes

Cardiopulmonary resuscitation (CPR) for out-of-hospital cardiac arrest should be conducted for at least 35 minutes, according to research presented recently at the European Society of Cardiology (ESC) Congress 2015.1 The study in more than 17,000 patients found that nearly all survivals were achieved within 35 minutes and longer CPR achieved little benefit.

This prospective, population-based study included 17,238 adults who received CPR by EMS personnel in the field in 2011 and 2012. Patient records were obtained from a national database. The researchers analysed the relationship between the duration of pre-hospital CPR by EMS personnel (time from EMS-initiated CPR to return of spontaneous circulation) and two endpoints: one month survival and one month favourable neurological outcome after cardiac arrest.

The study found that the probability of survival declined with each minute of CPR (see figure 1). It also showed that 99.1% of all survivors and 99.2% of survivors with favourable neurological outcomes achieved return of spontaneous circulation within 35 minutes of EMS-initiated CPR (see figure 2). No patient with a CPR duration of ≥53 minutes survived one month after cardiac arrest (see figure 2).

 1. Dynamic probability of 1-month survival and 1-month favourable neurological outcomes

Figure 1. Dynamic probability of 1-month survival and 1-month favourable neurological outcomes

 1. Dynamic probability of 1-month survival and 1-month favourable neurological outcomes

Figure 2. Cumulative proportion of survivors and survivors with favourable neurological outcomes 1 month after cardiac arrest

Dr Yoshikazu Goto (Kanazawa University Hospital, Kanazawa, Japan), who presented the research, said: “The decision regarding when to stop resuscitation efforts is one of the biggest challenges for emergency medical services (EMS) personnel or clinicians. However, the appropriate duration of CPR is not clear. Clinicians have raised concerns that lengthy resuscitation efforts might be futile. We investigated how long CPR should be conducted to achieve maximum survival and favourable neurological outcome.”

Dr Goto added: “Our study shows that EMS personnel or clinicians should continue CPR for at least 35 minutes in patients who suffer cardiac arrest outside the hospital. More than 99% of survivals and favourable neurological outcomes were achieved by 35 minutes with minimal gains afterwards. CPR leads to absolutely no benefit from 53 minutes onwards.”

“Our finding that the likelihood of surviving with a favourable neurological outcome declines with each minute of CPR indicates that the time from cardiac arrest to CPR is a crucial factor in determining whether a patient will return to a normal life,” added Dr Goto. “This implies that we need to start CPR as soon as possible.”

He concluded: “We hope our findings give EMS personnel and clinicians the confidence that if they stop CPR after 35 minutes they have done everything they can do for a patient. This should help them know when it is appropriate to move on to the next medical emergency.”

…and refractory cardiac arrest patients brought to hospital with ongoing CPR can recover

Screen shot 2015-09-30 at 10.58.06Refractory cardiac arrest patients brought to hospital with ongoing CPR can survive with good brain function, according to research in nearly 4,000 patients presented recently at the ESC Congress by Dr Helle Søholm, a cardiologist at Copenhagen University Hospital Righospitalet in Denmark.2

Nearly 60 out of 100,000 people suffer cardiac arrest outside the hospital each year and only one in 10 survive. Survival and outcome greatly depend on immediate response with early call for help, bystander resuscitation attempt and fast use of defibrillators. In patients with refractory cardiac arrest, pre-hospital physicians in the emergency medical services may terminate CPR outside the hospital or continue CPR while bringing patients to the hospital.

The current study investigated the survival and, just as importantly, the functional status in patients with refractory cardiac arrest brought to the hospital with ongoing CPR and treated conservatively without the support of extracorporeal life systems. The study included 3,992 patients who had a cardiac arrest outside hospital in a large urban area and were treated by physician-based emergency medical services between 2002 and 2011. Of these, 1,285 (32%) were successfully resuscitated outside hospital and 108 (3%) were brought to the hospital with refractory cardiac arrest.

Approximately half of the patients brought to the hospital with ongoing CPR were successfully resuscitated and were admitted to a hospital ward. In the other half the resuscitation attempt was terminated in the emergency department after more than one hour of CPR on average. Of the successfully resuscitated patients with refractory cardiac arrest about a third were suffering from cardiac arrest due to acute myocardial infarction.

The rate of survival in patients with refractory cardiac arrest who received ongoing CPR was 20% compared to 42% in those who were resuscitated before arrival at the hospital (p<0.001). Sufficient function for carrying out independent daily activities was found in approximately nine out of 10 in both patient groups discharged from hospital with a high functional status (86% in the ongoing CPR group and 84% in those with successful pre-hospital resuscitation, p=0.7).

“The faster a patient with cardiac arrest is resuscitated and brought back to life the better,” said Dr Søholm. “The prognosis for patients with refractory cardiac arrest with long resuscitation attempts has previously been shown to be poor. The use of extracorporeal life systems, which have an artificial pump to help the blood circulate the body, are currently being investigated to improve survival in these patients.”

She added: “However, we found in our study that patients with refractory cardiac arrest treated without the support of extracorporeal life systems do not have such a dismal prognosis as one might think, which encourages longer resuscitation attempts.”

“Even though the survival rate in patients with refractory cardiac arrest is lower the prognosis is not dismal and importantly the functional status at hospital discharge is similar to patients resuscitated before arrival at the hospital,” said Dr Søholm. “Our results indicate that maybe resuscitation attempts should be extended as the prognosis for patients with refractory cardiac arrest is not as poor as we previously thought. In general we recommend that cardiac arrest patients are given post-resuscitation care in dedicated cardiac arrest centres with highly specialised treatment options and experienced physicians.”

She concluded: “Our study shows that it is worth bringing patients with refractory cardiac arrest to the hospital with ongoing CPR. Patients with refractory cardiac arrest have a higher survival than expected – even without the use of extracorporeal life systems.”

British Heart Foundation presents ‘Call Push Rescue’ – three simple steps that could mean the difference between life and death. Know it and one day you could help save a life. For more information, visit https://www.bhf.org.uk/heart-health/nation-of-lifesavers/call-push-rescue

References

1. Goto Y, Maeda T, Funada A, Nakatsu-Goto Y. Duration of resuscitation efforts and survival after out-of-hospital cardiac arrest: an observational study. Euro Heart J 2015;36 (Abstract Supplement), 192.

2. Søholm H, Kjaergaard J, Lippert FK, Thomsen JH, Kober L, Wanscher M, Hassager C. Refractory out-of-hospital cardiac arrest with ongoing cardiopulmonary resuscitation at hospital arrival – survival and neurological outcome after conservative post-resuscitation care. Euro Heart J 2015;36 (Abstract Supplement), 5–6.

Published on: September 30, 2015

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