All 54 COVID-19 patients who underwent cardiopulmonary resuscitation (CPR) in a Michigan hospital died, leading to questions about the risks and benefits of performing a procedure that exposes healthcare personnel to the coronavirus amid limited supplies of personal protective equipment (PPE).
The findings, published yesterday in a research letter in JAMA Internal Medicine, found that 52 of 54 patients who experienced cardiac arrest from Mar 15 to Apr 3 (96.3%) had nonshockable rhythms, 44 (81.5%) with pulseless cardiac electrical activity, and 8 (14.8%) with asystole (flatlining). Nonshockable rhythms are those in which the use of defibrillation is highly unlikely to restore a normal heartbeat.
Two patients (3.7%) had pulseless ventricular tachycardia (an abnormally fast heart rhythm). CPR achieved a return of spontaneous circulation (ROSC) in 29 patients (53.7%) after a median of 8 minutes. Of the 29 patients, 15 (51.7%) had their code status changed to do not resuscitate, and 14 patients (48.3%) were recoded and underwent additional CPR; all died.
Median time from hospital admission to cardiac arrest was 8 days, and median duration of CPR was 10 minutes. At cardiac arrest, 43 patients (79.6%) were receiving mechanical ventilation, 18 (33.3%) were on dialysis, and 25 (46.3%) required vasopressor drugs to treat low blood pressure.
Median patient age was 61.5 years, 33 of 54 patients (61.1%) were men, 36 (66.7%) were black, and many had obesity (median body mass index was 33 kg/m2), high blood pressure (42 patients, 77.8%), diabetes (50 [55.6%]), and high cholesterol (27 [50.0%]).
Nonshockable rhythms, critical illness
The authors noted that, before the pandemic, 25% of patients who experienced in-hospital cardiac arrest (81% of them with initially nonshockable heart rhythms) survived to hospital release. They attributed the dismal death rate in their study to the high proportion of patients with nonshockable rhythms and those with critical illness requiring mechanical ventilation, dialysis, and vasopressor support—all of which are linked to poor outcomes after in-hospital cardiac arrest.
The findings, the researchers said, are similar to those of a Chinese study from early in the pandemic showing a 30-day survival rate of only 2.9% in COVID-19 patients who had in-hospital cardiac arrest. While 94.1% of patients in that study had nonshockable rhythms, only 13% experienced ROSC.
The authors called for more studies and the development of guidelines on the risks and benefits of prolonged CPR, an aerosol-generating procedure that can expose healthcare personnel to airborne pathogens such as SARS-CoV-2, the virus that causes COVID-19, in this group of patients.
"The transmission of severe acute respiratory syndrome coronavirus 1 [the virus that causes SARS] to health care personnel during CPR has been previously documented," they wrote, referencing a 2004 Canadian study. "Exposure may be further compounded by the limited supply of personal protective equipment nationwide."
Critical role of early goals-of-care discussions
In an invited commentary in the same journal, Matthew Modes, MD, MPP, MS; Robert Lee, MD, MS; and J. Randall Curtis, MD, MPH; of the University of Washington in Seattle, pointed out that the lack of effective COVID-19 treatments and delayed initiation of CPR because of the need to first don PPE likely contributed to the 100% death rate.
They said that the study findings do not warrant universal do-not-resuscitate orders for coronavirus patients but that they do underscore the importance of discussing goals of care with patients and families early in the course of their illness and again if the patient's clinical status worsens.
"Promotion of early goals-of-care discussions should be a priority for patients, families, clinicians, health systems, and policy makers," Modes, Lee, and Curtis said. "Such a shared focus offers substantial opportunity for health system and public health interventions."
Because two thirds of the study patients were black, and black patients are less likely than others to have advance care planning documentation and report poor communication with and a lack of trust in healthcare professionals, it is critical for providers to respect individual preferences and foster good communication, the authors of the commentary said.
"In the context of COVID-19, Black persons and persons of color are more likely to contract COVID-19 or develop serious illness requiring hospitalization; this association is most likely because of disparities," they wrote. "As such, the urgency of eliminating racial disparities in health care has never been clearer."