Longer CPR Efforts
May Be Beneficial, Study Says
Ashley
Gilbertson for The New York Times
Published:
September 4, 2012
At
Maimonides Medical Center, Dr. Kim-Tan Nguyen, above right, tried unsuccessfully
to help revive a patient.
By
RONI CARYN RABIN
When
a hospital patient goes into cardiac arrest, one of the most difficult
questions facing the medical team is how long to continue cardiopulmonary
resuscitation. Now a new study involving hundreds of hospitals suggests that
many doctors may be giving up too soon.
The
study found that patients have a better chance of surviving in hospitals that
persist with CPR for just nine minutes longer, on average, than hospitals where
efforts are halted earlier.
There
are no clear, evidence-based guidelines for how long to continue CPR efforts.
The
findings challenge conventional medical thinking, which holds that prolonged
resuscitation for hospitalized patients is usually futile because when patients
do survive, they ofte n suffer permanent neurological damage. To the contrary,
the researchers found that patients who survived prolonged CPR and left the
hospital fared as well as those who were quickly resuscitated.
The
study, published online Tuesday in The Lancet, is one of the largest of its
kind and one of the first to link the duration of CPR efforts with survival
rates. It should prompt hospitals to review their practices and consider
changes if their resuscitation efforts fall short, several experts said.
Between
one and five of every 1,000 hospitalized patients suffer a cardiac arrest.
Generally they are older and sicker than nonhospitalized patients who suffer
cardiac arrest, and their outcomes ar e generally poor, with fewer than 20
percent surviving to be discharged from the hospital.
“One
of the challenges we face during an in-hospital cardiac arrest is determining
how long to continue resuscitation if a patient remains unresponsive,” said Dr.
Zachary D. Goldberger, the lead author of the new study, which was financed by
the American Hospital Association, the Robert Wood Johnson Foundation and the
National Institutes of Health. “This is one area in which there are no
guidelines.”
Dr.
Goldberger and his colleagues gathered data from the world’s largest registry
of in-hospital cardiac arrest, maintained by the American Heart Association,
identifying 64,339 patients who went into cardiac arrest at 435 hospitals in
the United States from 2000 to 2008.
The
researchers examined adult hospital patients in regular beds or intensive care
units, excluding patients in the emergency room and those who suffered arrest
during procedures. They calculated the median duration of resuscitation efforts
for the nonsurvivors rather than the survivors, in order to measure a
hospital’s tendency to engage in more prolonged resuscitation efforts.
One
of the first surprises was the significant variation in duration of CPR among
the hospitals, ranging from a median of 16 minutes in hospitals spending the
least amount of time trying to revive patient s to a median of 25 minutes among
those spending the most — a difference of more than 50 percent.
The
researchers initially thought they would find that some patients were being
subjected to protracted resuscitation efforts in vain, said the senior author,
Dr. Brahmajee Nallamothu, an associate professor at the University of Michigan
and a cardiologist at the Ann Arbor VA Medical Center.
But
as it turned out, those extra minutes made a positive difference. Patients in
hospitals with the longest CPR efforts were 12 percent more likely to survive
and go home from the hospital than those with the shortest times.
Dr.
Nallamothu and his colleagues found that neurological function was similar,
regardless of the duration of CPR.
The
patients who got the most added benefit from prolonged CPR were those whose
conditions do not respond to defibrillation, or being shocked. The extra time
spent on prolonged CPR may give doctors time to analyze the situation and try
different interventions, they said.
“You
can keep circulating blood and oxygen using CPR for sometimes well over 30
minutes and still end up with patients who survive and, importantly, have good
neurological survival,” said Dr. Jerry P. Nolan, a consultant in anesthesia and
critical care medicine at Royal United Hospital NHS Trust in Bath, England, who
wrote a commentary accompanying the article.
Dr.
Stephen J. Green, associate chairman of cardiology at North Shore-Long Island
Jewish Health System, who was not involved in the study, said hospitals might
have to modify their practices in light of the new research.
“You
don’t want to be on the low end of this curve,” Dr. Green said. “Hospitals that
are outliers should reassess what they’re doing and think about extending the
duration of their CPR.”
Still, he and other experts worried that the new findings could
lead to protracted efforts to resuscitate patients for whom it is inappropriate
because they are at the end of their lives or for other reasons.
“There
isn’t going to be a magic number,” Dr. Green said. “If you’re in there 10 to 15
minutes, you need to push higher, but as you get up higher and higher, you get
to the point of very little return.”
The
study authors acknowledge that their research does not indicate that longer CPR
is better for every patient.
<
p class="MsoNormal">“The last thing we want is for the take-home
message to be that everyone should have a long resuscitation,” Dr. Goldberger
said. “We’re not able to identify an optimal duration for all patients in the
hospital.”
This
article has been revised to reflect the following correction:
Correction:
September 4, 2012
A
photo caption with an earlier version of this article misspelled the name of
the Maimonides Medical Center.
