Delays in cardiopulmonary resuscitation, defibrillation, and epinephrine administration all decrease survival in in-hospital cardiac arrest
Bircher, N. G., Chan, P. S., Xu, Y., Faillace, R. T., Mancini, M. E., Berg, R. A., Allen, E., Hunt, E. A., Nadkarni, V. M., Peberdy, M. A., Ornato, J. P., Braithwaite, S., Nichol, G., Warren, S., Duncan, K., LaBresh, K., Sasson, C., Knight, L., Donnino, M. W., ... Amer Heart Assoc Get Guidelines Re (2019). Delays in cardiopulmonary resuscitation, defibrillation, and epinephrine administration all decrease survival in in-hospital cardiac arrest. Anesthesiology, 130(3), 414-422. https://doi.org/10.1097/ALN.0000000000002563
WHAT WE ALREADY KNOW ABOUT THIS TOPIC: Rapid response to witnessed, pulseless cardiac arrest is associated with increased survival.
WHAT THIS ARTICLE TELLS US THAT IS NEW: Assessment of witnessed, pulseless cardiac arrests occurring at 538 hospitals during a 9-yr period indicates that CPR did not occur immediately at 0 min in 5.7% of patients despite guidelines for instantaneous initiation. Delay in initiation of CPR was associated with significantly decreased survival.Time to initiation of CPR and subsequent time to initiation of administration of defibrillation shock (for shockable arrhythmias) and epinephrine were both associated with reduced patient survival.
BACKGROUND: Because the extent to which delays in initiating cardiopulmonary resuscitation (CPR) versus the time from CPR to defibrillation or epinephrine treatment affects survival remains unknown, it was hypothesized that all three independently decrease survival in in-hospital cardiac arrest.
METHODS: Witnessed, index cases of cardiac arrest from the Get With The Guidelines-Resuscitation Database occurring between 2000 and 2008 in 538 hospitals were included in this analysis. Multivariable risk-adjusted logistic regression examined the association of time to initiation of CPR and time from CPR to either epinephrine treatment or defibrillation with survival to discharge.
RESULTS: In the overall cohort of 57,312 patients, there were 9,802 survivors (17.1%). Times to initiation of CPR greater than 2 min were associated with a survival of 14.7% (91 of 618) as compared with 17.1% (9,711 of 56,694) if CPR was begun in 2 min or less (adjusted odds ratio [95% CI], 0.68 [0.54 to 0.87]; P < 0.002). Times from CPR to either defibrillation or epinephrine treatment of 2 min or less were associated with a survival of 18.0% (7,654 of 42,475), as compared with 15.0% (1,680 of 11,227) for 3 to 5 min (reference, 0 to 2 min; adjusted odds ratios [95% CI], 0.83 [0.78 to 0.88]; P < 0.001), 12.8% (382 of 2,983) for 6 to 8 min (0.67 [0.60 to 0.76], P < 0.001), and 13.7% (86 of 627) for 9 to 11 min (0.54 [0.42 to 0.69], P < 0.001).
CONCLUSIONS: Delays in the initiation of CPR and from CPR to defibrillation or epinephrine treatment were each associated with lower survival.