Emergency Medicine Resident and MedED Enthusiast. Learning and teaching medicine one doodle at a time! Twitter @physiciandoodle
The Pre-brief
You are moonlighting in the ED at a small community hospital when you are asked to help with a floor code. You arrive and are stopped at the door by the floor charge nurse, who tells you the patient is COVID positive. As you don the appropriate PPE, the medical resident responding to the code pager arrives.
She asks, “Is this even going to be worth the effort? I mean, he’s got COVID and has arrested…”
The pandemic has undoubtedly created a myriad of (sometimes false) perceptions of outcomes. Early on in the pandemic, there was much talk about the futility of care for certain scenarios – one of those was the outcome of those who had COVID-19 infection and then suffered a cardiac arrest. This was exacerbated by a few papers that showed a parallel increase in the number of out-of-hospital cardiac arrest numbers. Some areas debated the benefit or otherwise of even attempting resuscitation in this group.
However, as with many things in the pandemic, the evidence is building to support our management decisions, and cardiac arrest in COVID-19-infected patients is no different. Jeff Pepin reviewed a large multicenter cohort study on this topic here. Since then, three papers have looked at outcomes for in-hospital cardiac arrest in adult patients infected with COVID-19.
The Papers
Bhardwaj et al retrospectively studied outcomes in in-hospital cardiac arrest amongst a cohort in multi-hospital health system in the USA. Here are the key facts:
- Study period was March 1, 2020 to October 15, 2020
- Of 3555 patients admitted in this period with COVID-19, 58 suffered in-hospital arrest
- Median age was 66.5 years and they were mainly male patients
- 87.9% occurred in the ICU
- Initial arrest rhythm was:
- PEA in 63.8%
- Asystole in 29.3%
- Pulseless VT or VF in 6.9%
- ROSC was achieved in 60.3%
- Survival to discharge occurred in 22.4% of patients
Lim et al recently published in Critical Care Medicine their systematic review of outcomes of COVID-19 patients suffering in-hospital arrest. They compared outcomes when the arrest occurred in the ICU versus in non-ICU settings. Here are the highlights:
- 8 papers identified from January 2020 to December 2020 recording 847 arrests across two countries (USA and China)
- Incidence of in-hospital arrest: 1.5%-5.8% in non-ICU settings and 8.0%-11.4% in ICU settings
- Older (>50 years) male patients most commonly affected
- Initial rhythm non-shockable in 83.9% of cases: asystole 36.4% and PEA 47.6%)
- ROSC occurred in 33.3%
- ROSC incidence higher in ICU patients (36.6%) versus non-ICU patients (18.7%)
- Overall mortality 91.7%
- ICU mortality was lower (88.7% versus 98.1%)
- Mortality was significantly higher in those over 60 years old (93.1% versus 87.9%)
Ippolito et al also performed a systematic review and meta-analysis on this topic. Here is what they found:
- Ten articles reviewed for a total of 1179 COVID-19 patients suffering cardiac arrest (in any in-hospital setting)
- ICU setting 64.9%
- Non-ICU setting 35.1%
- Mean patient age was 61-69 years
- The majority of patients had a non-shockable rhythm (89%)
- ROSC occurred in 32.9%
- The overall mortality rate was 89.9%
- ICU setting 85.8%
- Non-ICU setting 95.5%
- Survival rate with favorable neurologic outcomes defined as Cerebral Performance Category (CPC) scores of 1 or 2 at 30 days was 6.3%
- Data obtained from 4 studies
- Remember CPC grades performance outcomes on a 1-5 scale, where 1=full recovery or mild disability; 2=moderate disability but able to independently perform ADLs; 3=severe disability; 4=persistent vegetative state; and 5=death
Key Limitations
Both studies make a valiant attempt to review outcomes in a challenging clinical condition. It is important to understand the key limitations
- Much of the data is retrospective.
- Clinical decision making and goals of care discussions may have evolved during the study period as our knowledge of COVID-19 changed, which could have influenced results.
- Specific factors contributing to the arrest as well as specific treatments during the arrest management were not fully delineated in all cases.
- The studies primarily reviewed patients in the US (as well as China).
- Long-term outcomes (beyond 30 days) of survivors were not reviewed.
The Debrief
In-hospital cardiac arrest in COVID-19 infected patients carries similar outcomes to similar pre-pandemic events. Therefore, management in this instance should not be seen as futile just because of the COVID-19 diagnosis and does not support the use of a universal DNR.
The most common in-hospital arrest rhythm is non-shockable
Outcomes are better when the arrest has occurred in the ICU as compared to non-ICU hospital locations, likely due to the more favorable monitoring and staffing ratios
Continued study is necessary to elucidate medium- and long-term outcomes in survivors as well as outcomes in health systems outside the US and China
Reference
Bhardwaj A, Alwakeel M, Saleem T, et al. A multicenter evaluation of survival after in-hospital cardiac arrest in coronavirus disease 2019 patients. Critical Care Explorations 2021 May;3(5):e0425
Ippolito M, Catalisano G, Marino C, et al. Mortality after in-hospital cardiac arrest in patients with COVID-19: a systematic review and meta-analysis. Resuscitation 2021 May 5;S0300-9572(21)00168-4. PMID: 33964332
Lim ZJ, Reddy MP, 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 Jun 1;49(6):901-911 PMID: 33710030
McVaney KE, Pepe PE, Maloney LM, et al. The relationship of large city out-of-hospital cardiac arrests and the prevalence of COVID-19. EClinicalMedicine 2021 Apr 7;34:100815. PMID: 33997730
