Cardiopulmonary Resuscitation in the COVID-19 Era

Cardiopulmonary Resuscitation in the COVID-19 Era

By: Syed Nazeer Mahmood, MD
Palliative and End-of-Life Care Network
Published: September 9, 2021

In-hospital cardiac arrest (IHCA) portends very poor outcomes, with only 18% to 21% surviving to discharge.^1-3 Over the last 2 decades, survival after IHCA has improved substantially, including improvement in neurologic outcomes. However, these trends toward better mortality rates have been affected by the COVID-19 pandemic. Here, we briefly review the literature on the outcomes of IHCA in the COVID-19 era.

What the literature says

IHCA outcomes have worsened overall during the COVID-19 pandemic. While the inherently high mortality in patients with severe COVID-19 has affected the mortality rate, the outcomes of non-COVID-19 patients have also seemed to worsen.

• A single-center, retrospective study of all admitted patients reported an IHCA incidence of 2.8% (125/4,470 patients, of whom 79% had COVID-19) during the pandemic.⁴ This was much higher than the IHCA rate of 0.6% (117/20,181) reported over the year before the pandemic. During the pandemic, there was a shorter duration of cardiopulmonary resuscitation (CPR) as well (11 minutes (8.5-26.5) vs 15 minutes (7.0-20.0), P =.001). Return of spontaneous circulation (ROSC) was achieved in more patients before the pandemic (56% vs 36%, P =.001), and the previous survival rate was also higher (13% vs 3%, P =.007). The survival rate during the pandemic was similar between the COVID-19 and non-COVID-19 cohorts, indicating that the worsening outcome was not solely due to increased mortality in patients with COVID-19.

• A report from the Swedish registry for cardiopulmonary resuscitation compared 532 cases of IHCA prepandemic to 548 cases during the pandemic, of which 16.1% had COVID-19.⁵ There was a 2.3-fold increased risk of 30-day mortality in all IHCA cases during the pandemic compared with the prepandemic period. During the pandemic, the adjusted 30-day survival was 23.1% in COVID-19-positive cases and 39.5% in COVID-19-negative cases. This study's findings indicated that the worsening mortality in IHCA during the pandemic was driven primarily by mortality in patients with COVID-19.

• A small, retrospective, single-center study in New York City reported IHCA in 27/31 patients with COVID-19.⁶ ROSC was achieved in 42% of the patients after IHCA, but this was only for the short term, with no patients surviving to discharge and a median survival time until death of 2.8 hours (IQR 1.5-13.3).

• Another retrospective study from Michigan of 1,309 hospitalized patients with COVID-19 reported an IHCA rate of 4.6%.⁷ Most patients were Black (66.7%), with a median age of 61.5 years. ROSC was achieved in 29 out of 54 patients (53.7%) with a median time to ROSC of 8 minutes (IQR 4-10 minutes). No patients survived to discharge, however.

• A retrospective study from the Phoebe Putney Health System in Georgia of 1,094 hospitalized patients with COVID-19 reported 63 IHCA cases with attempted resuscitation.⁸ The patient population was predominantly Black with high rates of hypertension, obesity, and diabetes. ROSC was achieved in 29% of patients. However, in-hospital mortality was 100%.

• A larger retrospective study from the Cleveland Clinic Health system evaluated 1,372 patients with COVID-19.⁹ Of these, 58 patients had IHCA with 87.9% occurring in the ICU setting and the rest on the wards. Thirty-four patients (58.6%) were supported by mechanical ventilation prior to the cardiac arrest with a median duration of mechanical ventilation of 9 days. A total of 35 patients (60.3%) achieved ROSC, with 13 (22.4%) surviving to hospital discharge.

• Finally, Lim et al¹⁰ published a systematic review of eight studies including 847 patients with COVID-19 who had IHCA. The cardiac arrest incidence varied between 1.5% and 5.8% among all hospitalized patients and was 8% to 11.4% among patients in the ICU. Older patients (age ≥ 60 years) were more likely to have IHCA. ROSC was achieved in 33.3% of patients; however, the in-hospital mortality was 91.7%. The mortality of IHCA was lower if it occurred in the ICU (88.7% vs. 98.1%; P =.001) and higher in those over the age of 60 years (93.1% vs 87.9%; P =.019).

Commentary

Predicting the disease course and complications has been difficult in most patients with COVID-19. It is clear now that the mortality in severe COVID-19 disease is very high, and it stands to reason that patients with IHCA and COVID-19 would have dismal outcomes. These studies report very low survival rates in patients with COVID-19 and IHCA, with a majority reporting more than 90% in-hospital mortality.

IHCA outcomes in patients without COVID-19 have also worsened during this pandemic. This is likely due to time delays in donning personal protective equipment, the large volume of critically ill patients, and limited ICU bed availability.

The integration of palliative care in caring for these critically ill patients is crucial. Performing CPR in the majority of critically ill patients with COVID-19 and IHCA has limited benefit and may lead to increased suffering. Addressing goals of care early could prevent futile interventions and allow patients to die with dignity and comfort.

Bottom line

IHCA in patients with COVID-19 has an extremely high mortality rate and a bleak outcome. Early goals of care discussions should be held with patients with COVID-19, especially those requiring ICU admission.

References

1. Girotra S, et al. Trends in survival after in-hospital cardiac arrest. N Engl J Med. 2012; 367(20): 1912-1920.
2. Sandroni C, Nolan J, Cavallaro F, Antonelli M. In-hospital cardiac arrest: incidence, prognosis and possible measures to improve survival. Intensive Care Med. 2007;33:237–245.
3. Merchant RM, Yang L, Becker LB, et al. Incidence of treated cardiac arrest in hospitalized patients in the United States. Crit Care Med. 2011;39:2401–2406.
4. Miles JA, Mejia M, Rios S, et al. Characteristics and Outcomes of In-Hospital Cardiac Arrest Events During the COVID-19 Pandemic.
5. Sultanian P, Lundgren P, Strömsöe A, Cardiac arrest in COVID-19: characteristics and outcomes of in- and out-of-hospital cardiac arrest: A report from the Swedish Registry for Cardiopulmonary Resuscitation, EurHeart J. 2021;42(11): 1094–1106.
6. Sheth V, Chishti I, Rothman A, et al. Outcomes of in-hospital cardiac arrest in patients with COVID-19 in New York City. Resuscitation. 2020;155:3-5. doi: 10.1016/j.resuscitation.2020.07.011. Epub 2020 Jul 21. PMID: 32707146; PMCID: PMC7372263.
7. Thapa SB, Kakar TS, Mayer C, Khanal D. Clinical outcomes of in-hospital cardiac arrest in COVID-19. JAMA Intern Med. 2021;181(2):279–281. doi:10.1001/jamainternmed.2020.4796.
8. Shah P, Smith H, Olarewaju A, et al. Is cardiopulmonary resuscitation futile in coronavirus disease 2019 patients experiencing in-hospital cardiac arrest? Crit Care Med. 2021; 49(2):201-208 doi: 10.1097/CCM.0000000000004736.
9. Bhardwaj A, Alwakeel M, Saleem T, et al. A multicenter evaluation of survival after in-hospital cardiac arrest in coronavirus disease 2019 patients. Crit Care Explor. 2021;3(5):e0425. doi: 10.1097/CCE.0000000000000425. PMID: 34036276; PMCID: PMC8133239.
10. Lim ZJ, Ponnapa Reddy M, Curtis JR, et al. A systematic review of the incidence and outcomes of in-hospital cardiac arrests in patients with coronavirus disease 2019. Crit Care Med. 2021;49(6):901-911. doi: 10.1097/CCM.0000000000004950. PMID: 33710030.

Syed Nazeer Mahmood, MD

Dr. Mahmood is a Pulmonary and Critical Care Fellow at MedStar Washington Hospital Center in Washington, DC, and is interested in pulmonary vascular diseases, lung transplant, end of life and palliative care in the ICU, and graduate medical education. He is a Fellow-in-Training member of CHEST’s Palliative and End-of-Life Care Network Steering Committee.

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