Bleak outcomes for COVID-19 patients with cardiac arrest

Survival is poor among COVID-19 patients who develop in-hospital cardiac arrest (IHCA) — with none surviving the ordeal even with cardiopulmonary resuscitation (CPR), reveals a recent study.

Among 54 COVID-19 patients with IHCA who underwent CPR, about half (53.7 percent) returned to spontaneous circulation after a median of 8 minutes but none survived to discharge. [JAMA Intern Med 2020;doi:10.1001/jamainternmed.2020.4796]

Out of the patients who achieved return of spontaneous circulation (ROSC) after CPR, code status was changed to do not resuscitate for 51.7 percent of them, while the rest were recoded and received additional CPR, but still died nonetheless.

“The high mortality following CPR is likely multifactorial,” said the researchers. “Given that most of the patients in this study developed a nonshockable rhythm, the outcome was likely to be poor.”

Majority of the patients with IHCA (96.3 percent) had nonshockable rhythm initially — of which, 81.5 percent were due to pulseless electrical activity and 14.8 percent were in asystole.

“Additionally, at the time of cardiac arrest, many patients were either receiving mechanical ventilation, kidney replacement therapy, or vasopressor support, all factors previously shown to be associated with a poor outcome following IHCA,” noted the researchers.

CPR for IHCA in patients with COVID-19 presents unique challenges, according to experts led by Dr J Randall Curtis, University of Washington, Seattle, Washington, US, in a linked commentary. [JAMA Intern Med 2020;doi:10.1001/jamainternmed.2020.4779]

“CPR may be delayed because of isolation procedures, and advanced life support resources may be limited. Additionally, CPR for patients with COVID-19 exposes healthcare workers to increased risk of viral transmission,” they wrote.

Furthermore, risk of exposure to virus could be further aggravated by limited personal protective equipment, the researchers pointed out. Hence, further studies are necessary to understand the risks vs benefits of prolonged CPR in patients with COVID-19 in view of the aerosol-generating nature of the process.

“Improving our understanding of the likelihood of successful outcomes after CPR is crucial to informing goals-of-care discussions, determining the appropriateness of resuscitative efforts, and guiding policy,” stated Curtis and co-authors.

To resuscitate or not?

Prior to the pandemic period, the overall survival rate to discharge was 25 percent. [JAMA 2019;321:1200-1210]

At any rate, the small number of patients included in the current study present limited data. “These small case series reporting hospital survival after IHCA among patients with COVID-19 must be interpreted with caution, as only one or two additional survivors would make important differences in the observed estimates,” Curtis and co-authors pointed out. 

In a separate study involving 5,019 critically ill patients with COVID-19 who developed IHCA, 12.0 percent of the 400 patients who received CPR survived to hospital discharge. Of note, the rate of survival to hospital discharge was particularly poor among older patients (2.9 percent in patients aged ≥80 years). [BMJ 2020;371:m3513]

“Outcomes in the setting of COVID-19 may not actually differ from pre-COVID-19 outcomes of IHCA for patients with nonshockable rhythms, for whom hospital survival is often less than 15 percent,” wrote Curtis and co-authors.

Given that drivers of poor outcomes are not modifiable — such as nonshockable rhythms, underlying critical illness, and respiratory aetiologies of arrest — improving outcomes for patients with IHCA remains challenging in any case, regardless of COVID-19, according to the editorialists.

“Nonetheless, [the JAMA study] represents important early evidence suggesting outcomes for IHCA in patients with COVID-19 pneumonia are likely poor, particularly among patients with respiratory failure,” they continued.

 “While these early results should not warrant universal do-not-attempt-resuscitation orders for patients with COVID-19, they highlight the importance of conducting goals-of-care discussions early during the course of COVID-19 and revisiting those discussions with changes in clinical status,” commented Curtis and co-authors.