Concise Critical Appraisal: Is CPR Futile for COVID-19 Patients?

Providing cardiopulmonary resuscitation (CPR) is routine for many healthcare professionals. However, since the start of the COVID-19 pandemic, initiating CPR has become uncharacteristically complicated. CPR can be essential to patients with COVID-19, but disturbingly little data are available regarding outcomes of patients hospitalized with COVID-19 who have cardiac arrest. Shah et al published one of the first studies in the United States that offers insight into the mortality of these patients and dares to question the futility of CPR in patients with COVID-19.¹
 
The authors conducted a retrospective, cohort, single-center, multihospital study that consisted of all patients admitted to their health system with COVID-19 who had cardiac arrest. Shah et al recorded location of arrest; time before initiation of CPR; patient demographics such as age, race, and comorbidities; pertinent laboratory data; and relevant ongoing therapies such as mechanical ventilation. During the study period, 1094 patients were hospitalized for COVID-19, and 63 of those patients had in-hospital cardiac arrest (IHCA). The most common initial heart rhythms were pulseless electrical activity (58%) and asystole (33%) secondary to primary respiratory failure. Nonshockable lethal arrythmias are generally more fatal than shockable arrhythmias due to their associated comorbidities. Shah et al found that patients admitted with COVID-19 who had IHCA had 100% mortality. Although return of spontaneous circulation was achieved in 29% of these patients, it was brief.
 
This study has some limitations. The first is the study size. Shah et al note this limitation as well as the need for further studies. The authors also note that their analysis is a single-center study that may not be applicable to the general population.
 
Thapa et al performed a similar study regarding clinical outcomes of COVID-19 patients with IHCA.² This study used many of the same data points including patient demographics, comorbidities, and treatments such as mechanical ventilation, vasopressors, and continuous renal replacement. The study included 54 of 1309 patients admitted to the hospital between March 2, 2020, and August 26, 2020. They found that 29 patients (53.7%) achieved return of spontaneous circulation. Of these 29 patients, 15 had a status change to “do not resuscitate.” The remaining 14 patients had another IHCA, received additional CPR, and died.
 
During CPR, the chest is compressed to provide circulation and the air that is trapped in the lungs is forcefully exhaled, aerosolizing the contents. Patients on the brink of death likely have large viral loads, increasing the risk of transmission and infection of healthcare responders, particularly if their personal protective equipment fails.² Performing high-quality CPR is demanding at best, but being covered in nonbreathable plastic and latex and donning flow-limiting respirators and N95 masks can make performing CPR extremely difficult. Masks can slip due to sweat and vigorous movement or become loose and fail to provide adequate filtration of the virus.
 
It is of paramount importance that other large institutions publish several more studies so experts can make rational and informed decisions regarding whether CPR is effective in this population subset and whether the inherent risk/benefit ratio is meaningful to healthcare professionals. Shah et al highlights the importance of incorporating goals-of-care discussions early in the care pathway, particularly in critically ill patients. The study also raises some important questions regarding futility of advanced cardiovascular life support measures in this population and emphasizes that some institutions have considered universal do-not-resuscitate orders for these patients.
 
Theresa A. Ganoe, ACNP, is a critical care nurse practitioner at Inova Fairfax Hospital.
 
Jim H. Lantry III, MD, is an assistant professor of emergency and critical care medicine and the associate program director of the critical care fellowship at the University of Maryland Medical Center in Baltimore, Maryland, USA. Dr. Lantry is an editor of Concise Critical Appraisal.
 
References

1. Shah P, Smith HO, Olarewaju A, et al. Is cardiopulmonary resuscitation futile in coronavirus disease 2019 patients experiencing in-hospital cardiac Arrest? Crit Care Med. 2020 Oct 21. Online ahead of print. Accessed November 10, 2020. https://journals.lww.com/ccmjournal/Abstract/9000/Is_Cardiopulmonary_Resuscitation_Futile_in.95450.aspx
2. Thapa SB, Kakar TS, Mayer C, Khanal D. Clinical outcomes of in-hospital cardiac arrest in COVID-19. JAMA Intern Med. 2020 Sept 28;e204796. Accessed November 10, 2020. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2771090