Objective
To describe the characteristics and outcomes of patients with severe COVID-19 and in-hospital cardiac arrest (IHCA) in Wuhan, China.
Methods
The outcomes of patients with severe COVID-19 pneumonia after IHCA over a 40-day period were retrospectively evaluated. Between January 15 and February 25, 2020, data for all cardiopulmonary resuscitation (CPR) attempts for IHCA that occurred in a tertiary teaching hospital in Wuhan, China were collected according to the Utstein style. The primary outcome was restoration of spontaneous circulation (ROSC), and the secondary outcomes were 30-day survival, and neurological outcome.
Results
Data from 136 patients showed 119 (87.5%) patients had a respiratory cause for their cardiac arrest, and 113 (83.1%) were resuscitated in a general ward. The initial rhythm was asystole in 89.7%, pulseless electrical activity (PEA) in 4.4%, and shockable in 5.9%. Most patients with IHCA were monitored (93.4%) and in most resuscitation (89%) was initiated <1 min. The average length of hospital stay was 7 days and the time from illness onset to hospital admission was 10 days. The most frequent comorbidity was hypertension (30.2%), and the most frequent symptom was shortness of breath (75%). Of the patients receiving CPR, ROSC was achieved in 18 (13.2%) patients, 4 (2.9%) patients survived for at least 30 days, and one patient achieved a favourable neurological outcome at 30 days. Cardiac arrest location and initial rhythm were associated with better outcomes.
Conclusion
Survival of patients with severe COVID-19 pneumonia who had an in-hospital cardiac arrest was poor in Wuhan.
To our knowledge, this is the first study to report the clinical characteristics and outcomes of patients with severe COVID-19 pneumonia and IHCA using the Utstein style for reporting IHCA events. In our study population, most patients with IHCA (96.3%) underwent attempted resuscitation; however, there were five cases where the patients’ relatives had requested no resuscitation attempt be made if cardiac arrest occurred.
The most frequent underlying comorbidity of patients in our study was hypertension followed by diabetes mellitus and coronary heart disease. This was consistent with other reports in Wuhan. The common symptoms such as fever, shortness of breath, myalgia/arthralgia, and cough were also similar to that of previous studies.
It is commonly accepted that the outcome after IHCA is more favourable when the initial monitored rhythm is VF/VT rather than non-VF/VT (i.e., asystole or PEA). Most of the initial monitored rhythms recorded by responders in our survey of patients who experienced an IHCA were asystole (89.7% of cases), which is more common than described in previous reports of IHCA.A shockable rhythm was recorded in only 5.9% of cases (2.7% of ward cases [3 patients], 22% of ICU cases [5 patients]), but the outcome among these patients was better than those with asystole or PEA.
There have been differences reported in previous studies regarding the mortality rate of patients with COVID-19. A retrospective cohort study in Wuhan reported that 54 of 191 patients died in the hospital, and older age, higher SOFA score, and elevated d-dimer at admission were risk factors for death of adults with COVID-19.In another report from Wuhan, the mortality rate was 62% among critically ill patients with COVID-19 and 81% among those requiring mechanical ventilation.Meanwhile, Washington state, USA reported a mortality rate of 67%, and 24% of the patients remained critically ill and 9.5% were discharged from the ICU.We observed an overall mortality rate of 19.3% in patients with severe COVID-19 pneumonia during the study period. The difference may be due to the severity of patients enrolled in the analysis, management of intensive care, and the capacity of hospitalisation for patients.
The overall outcome of IHCA in our study was poor, with a ROSC rate of 13.2% and 30-day survival rate of 2.9%. The shortage of medical resources and uncertain quality of CPR were key factors in the resuscitation of patients with severe COVID-19 pneumonia in Wuhan. As COVID-19 spread, the number of critically ill patients exceeded the capacity of ICUs in most hospitals in Wuhan. It was not rare for critically patients to stay in the general ward with limited advanced life-support facilities. With an improvement in recognition and protection strategies, two newly constructed hospitals and several isolation hospitals were soon brought into service. As the west campus of Union Hospital was designated for patients with severe pneumonia, the defibrillation and advanced airway interventions and mechanical ventilation could be established in the general ward with the help of a 24/7 rapid response team. Although a growing number of mechanical compression devices had been introduced in hospitals, there was still a significant lack of intensive care resources. In addition, few patients had do-not-attempt CPR (DNACPR) decision. The patients were cared for in isolation wards, and visiting by relatives was very limited. Only five patients who had a cardiac arrest had a DNACPR decision. We did not make any DNACPR decisions without discussion with a relative.
According to recent international CPR guidelines, post-resuscitation care has been added to the ‘chain of survival’, and its importance to the outcome of cardiac arrests has been emphasised Although the World Health Organisation and National Health Commission of China have issued preliminary guidance on infection control, screening, and diagnosis in the general population, in addition to the guidelines issued by the Surviving Sepsis Campaign COVID-19 panel who provided recommendations to support hospital clinicians managing critically ill adults with COVID-19, there is still limited guidance based on clinical research on the acute management of critically ill patients with COVID-19.Supportive care is the mainstay of treatment among patients with severe COVID-19 pneumonia. In our study, there were numerous patients with severe pneumonia who were resuscitated in the general ward, resulting in a poor outcome when compared with those who received intensive care in the ICU. The difficulties in managing rapid deterioration, acute respiratory failure and acute respiratory distress syndrome in a general ward setting may have also contributed to the poor outcomes.
Based on our observations, chest compressions with PPE require considerable effort, and the person doing compressions should change every minute. In addition, the PPE clothing should be loose fitting to enable compressions and movement. The use of a mechanical chest compression device should be considered if prolonged compressions are required.
This study had some limitations. First, many data points in the resuscitation process were not documented, such as duration of resuscitation efforts, time to first defibrillation, and time to first epinephrine. Second, we do not know the precise interventions that patients had prior to cardiac arrest. Third, this study involved only one centre and the results may not be generalisable to other settings and healthcare systems. The relatively few cases and survivors means that our confidence in our estimates of outcome is low. To explore the risk factors for outcome, univariable and multivariable logistic regression models were applied, but no significant difference were found. More studies are needed to better understand the incidence and outcomes of acute respiratory distress syndrome and critical illnesses caused by COVID-19, which will be important for critical care management and resource planning. Finally, a lack of data regarding CPR quality is also a limitation. It was also difficult to identify the differences between general wards that were managed by staff from different hospitals. These variations in resuscitation efforts and post-arrest care could also affect the survival outcomes and results. Finally, although we did not study this formally, we are not aware of any clinical staff involved in a resuscitation attempt becoming infected with COVID-19 as a result of their involvement.
Conclusions
The overall ROSC and 30-day survival rates of IHCA patients with severe COVID-19 pneumonia in Wuhan were poor. Factors associated with ROSC and 30-day survival were initial rhythm and location of arrest. Providing care for patients at risk of cardiac arrest in an intensive care setting, should be considered to improve the outcome of IHCA patients with severe COVID-19 pneumonia.
Reference & Source information: https://www.resuscitationjournal.com/
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