Code Blue for COVID-19 Patients: No Survivors

Survival chances were bleak among COVID-19 patients who sustained in-hospital cardiac arrest (IHCA), U.S. data showed.

After a median 8 minutes of CPR on 54 such patients, 53.7% had return of spontaneous circulation, according to Corey Mayer, DO, MBA, of William Beaumont Hospital in Royal Oak, Michigan, and colleagues reporting online in JAMA Internal Medicine.

Roughly half of those patients had their code status changed to "do not resuscitate"; the other half were re-coded but died nonetheless after additional CPR.

Ultimately, none of the 54 COVID-19 patients survived to discharge after IHCA.

"The high mortality following CPR is likely multifactorial," according to Mayer's group.

The initial rhythm was nonshockable in 96.3%, with 81.5% showing pulseless electrical activity and 14.8% in asystole. Two patients had pulseless ventricular tachycardia.

"Given that most of the patients in this study developed a nonshockable rhythm, the outcome was likely to be poor. Additionally, at the time of cardiac arrest, many patients were either receiving mechanical ventilation, kidney replacement therapy, or vasopressor support, all factors previously shown to be associated with a poor outcome following IHCA," the authors said.

Their findings echoed a previous report from Wuhan, China, that found 30-day survival of IHCA in COVID-19 to be only 2.9% in a cohort that also largely had nonshockable rhythms.

In contrast, an estimated one-quarter of IHCA patients survived to discharge before the pandemic, and the initial rhythm was nonshockable in 81% of cases, Mayer's team noted.

More research is needed to understand the risks and benefits of performing prolonged CPR in COVID-19 patients in hospital given the aerosol-generating nature of the resuscitation process and the limited supply of PPE across the country, the group urged.

"Improving our understanding of the likelihood of successful outcomes after CPR is crucial to informing goals-of-care discussions, determining the appropriateness of resuscitative efforts, and guiding policy," agreed J. Randall Curtis, MD, MPH, and colleagues of Harborview Medical Center and University of Washington in Seattle, in an invited commentary.

In March, the American Heart Association issued interim guidance on protective measures for hospital and EMS workers resuscitating people in cardiac arrest.

The investigators identified 1,309 adults diagnosed with COVID-19 who were admitted to Mayer's institution in the early phase of the pandemic from March 15 to April 3, 2020.

Of those patients, 60 received CPR for IHCA and 54 had adequate documentation for the present analysis (median age 61.5 years, 61.1% men).

Most patients had comorbidities, including hypertension (77.8%), diabetes (55.6%), or hyperlipidemia (50.0%). Median BMI was 33.

Median time from hospital admission to cardiac arrest was 8 days. At the time of cardiac arrest, 79% were on mechanical ventilation, 33% kidney replacement therapy, and 46.3% vasopressor support.

The Chinese and U.S. case series "must be interpreted with caution, as only one or two additional survivors would make important differences in the observed estimates," cautioned Curtis and colleagues.

"Outcomes in the setting of COVID-19 may not actually differ from pre-COVID-19 outcomes of IHCA for patients with nonshockable rhythms, for whom hospital survival is often less than 15%," according to the editorialists.

In any case, it will be "challenging" to improve outcomes for severely ill people with COVID-19 and IHCA, since few of the likely drivers of poor outcomes are modifiable, they wrote.

"While these early results should not warrant universal do-not-attempt-resuscitation orders for patients with COVID-19, they highlight the importance of conducting goals-of-care discussions early during the course of COVID-19 and revisiting those discussions with changes in clinical status," Curtis' group emphasized.

It was notable that two-thirds of cohort were African American, a group that tends to request CPR despite poor prognosis, to have less advance care planning documentation, and to report poorer quality communication during serious illness and greater mistrust in the health system, they commented.

"Although there are important limitations on current data regarding outcomes of IHCA for patients with COVID-19, we have enough data to conclude that it is important to implement programs to promote conversations about values and goals in the community and early goals-of-care discussions for patients hospitalized with COVID-19," according to the editorialists.

Established programs to start these discussions include The Conversation Project and PREPARE For Your Care.

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