Association Between Duration of Resuscitation and Favorable Outcome After Out-of-Hospital Cardiac Arrest

Abstract

Background Little evidence guides the appropriate duration of resuscitation in out-of-hospital cardiac arrest (OHCA), and case features justifying longer or shorter durations are ill-defined. We estimated the impact of resuscitation duration on the probability of favorable functional outcome in OHCA using a large, multi-center cohort. Methods Secondary analysis of a North American, single blind, multi-center, cluster-randomized clinical trial (ROC-PRIMED) of consecutive adults with non-traumatic, EMS-treated, OHCA. Primary exposure was duration of resuscitation in minutes (onset of professional resuscitation to return of spontaneous circulation [ROSC] or termination of resuscitation). Primary outcome was survival to hospital discharge with favorable outcome (modified Rankin scale [mRS] 0-3). Subjects were additionally classified as survival with unfavorable outcome (mRS 4-5), ROSC without survival (mRS 6), or without ROSC. Subject accrual was plotted as a function of resuscitation duration, and the dynamic probability of favorable outcome at discharge was estimated for the whole cohort and subgroups. Adjusted logistic regression models tested the association between resuscitation duration and survival with favorable outcome. Results The primary cohort included 11,368 subjects (median age 69 years [IQR: 56-81 years]; 7,121 men [62.6%]). Of these, 4,023 (35.4%) achieved ROSC, 1,232 (10.8%) survived to hospital discharge, and 905 (8.0%) had mRS 0-3 at discharge. Distribution of CPR duration differed by outcome (p<0.00001). For CPR duration up to 37.0 minutes (95%CI 34.9-40.9 minutes), 99% with eventual mRS 0-3 at discharge achieved ROSC. Dynamic probability of mRS 0-3 at discharge declined over elapsed resuscitation duration, but subjects with initial shockable cardiac rhythm, witnessed cardiac arrest, and bystander CPR were more likely to survive with favorable outcome after prolonged efforts (30-40 minutes). Adjusting for prehospital (OR 0.93; 95%CI 0.92-0.95) and inpatient (OR 0.97; 95%CI 0.95-0.99) covariates, resuscitation duration was associated with survival to discharge with mRS 0-3. Conclusions Shorter resuscitation duration was associated with likelihood of favorable outcome at hospital discharge. Subjects with favorable case features were more likely to survive prolonged resuscitation up to 47 minutes.

Sodium bicarbonate on severe metabolic acidosis during prolonged cardiopulmonary resuscitation: a double-blind, randomized, placebo-controlled pilot study

“…These data do not address the possibility of combining sodium bicarbonate along with extracorporeal membrane support or administration earlier in the resuscitation. We have previously reported most favorable outcomes are achieved with shorter resuscitation intervals (22,23).…”

Age-Specific Differences in the Duration of Prehospital Cardiopulmonary Resuscitation Administered by Emergency Medical Service Providers Necessary to Achieve Favorable Neurological Outcome After Out-of-Hospital Cardiac Arrest

“…6-8, 11 In these studies, patients with non-shockable rhythms were older than those with shockable rhythms. In the present study, the proportion of nonshockable rhythm increased with age.…”

“…1- 4 Recently, several studies have investigated the relationship between CPR duration and outcome, and in particular according to initial documented rhythm. [5][6][7][8][9][10][11] crew consists of 3 EMS staff members, including at least 1 emergency lifesaving technician (ELST). ELSTs are allowed to use various resuscitation methods, including for whom resuscitation was attempted after OHCA in Japan between January 2011 and December 2014.…”

Out-of-hospital cardiac arrest: prehospital management

“…In a recent analysis, the elapsed duration at which the probability of survival fell below 1% was 48 and 15 min in the shockable and non-shockable groups, respectively (52). A secondary analysis of 11,368 cases of OHCA from the US ROC-PRIMED (Resuscitation Outcomes Consortium Prehospital Resuscitation Using an Impedance Valve and Early Versus Delayed) identified that that with conventional resuscitation, 90% of patients with good outcome achieved initial ROSC within 20 minutes and 99% within 37 minutes (53). There were no survivors with favourable neurological outcome where ROSC occurred after 47 minutes.…”