Cardiac Arrest & COVID: A Very Poor Combination

The stories of COVID patients spontaneously meeting their demise in the non-ICU and non-stepdown units have decreased substantially during the course of the pandemic. My non-scientific rationale for this is that we’re getting better at anti-coagulating our patients and therefore decreasing the incidence of the pro-thrombotic sequelae of COVID. That being said, when these patients reach the ICU, they’re signing up to be there for the long haul. Many of you have seen what I have seen where COVID patients linger in the ICU on mechanical ventilation or high-flow nasal cannula for weeks on end. Especially those facilities who do not have a local LTAC nor insured patients to help make the length of stay numbers look pretty. Nonetheless, we witness some these patients decline to the point where their COVID course leads them down the path of cardiac arrest.

I do not know the exact numbers from my practice regarding how many patients who have suffered a cardiac arrest during their hospitalization survive, but my gut feeling is zero. I honestly can’t recall one patient off the top of my head who has survived a cardiac arrest. When a patient is under the care of my team, we put a lot of work into realistically communicating the current condition to the family. We are all aware of the mortality numbers once a patient is on mechanical ventilation and even worse if they have another organ fail during their hospitalization. Short answer: not good. But in that conversation, I mention what we have historically seen. People who are intubated stay on the ventilator for at least a week and the longest we have successfully treated a patient on mechanical ventilation is currently 57 days. Families, as expected, shudder and receive this information with a bit of denial. But time has the ability to beat any hopeful person down. I also mention that we have seen our COVID patients rapidly deteriorate to the point of cardiac arrest.

I have an open book policy with families. They’re part of my team. I offer them lab values so they can follow along with us. I teach them simple numbers on the vent to empower them and help them understand if their loved one is getting better or worsening. For example, a PEEP of 5 is good. A PEEP of 20 is not good. An FiO2 of 30 is good and an FiO2 of 100% is bad. Numbers going in the wrong direction are not good. I work hard every day to speak to the family members to build that trust and rapport that is usually developed in face to face conversations. But here is something I say quite often. “We cannot give up on your loved one. Right now they are critically ill from COVID, perhaps the sickest person in the hospital, but we need to give them time to try to get better. This is going to take a long time” I do not beat them with requests for code status discussions. But I do say that “right now is not the time to make a tough decision, but when I call you and tell you that it’s time to make that decision, it’s time to make that decision. This is because out of nowhere, their heart just stops and when it does, there’s no coming back”. When a COVID patient suffers a cardiac arrest, they do not survive. Now we have some data to support this rather than my personal experience in this pandemic.

The cited article was published two days ago and it reflects real-world practice at institutions such as my own. This retrospective study found a mortality rate of 100% in the 63 COVID patients who suffered cardiac arrests. That is incredibly depressing but at the same time it is not shocking once you really think about it. Due to the the geographic location of the hospital system publishing this paper, 90.5% of patients were African American. 88.9% had hypertension. 69.85% were obese. 60.3% had diabetes. The paper digs into their inflammatory markers which I will not cover here, but the median length of stay was 11 days of these patients and 14 days being their duration of symptoms.

When these 63 COVID patients suffered their cardiac arrest, the team was able to achieve ROSC in 18 (29%) of these patients. Within 2 hours, though, they lost another 17 of these patients. Hopefully this was enough time to allow the families to come in to see their loved ones one last time. The most sobering fact is that in-hospital mortality was 100% for these patients. Sigh.

My takeaway from this paper is that these data reinforces what we have all seen in our respective hospitals. This also provides data for us to be able to have honest conversations with families regarding the prognosis of these patients. We also need to be aware that there are intrinsic limitations that occur in all of our hospitals with regards to cardiac arrest situations in COVID patients. We need to put on our PPE before going into the room. We need to ensure the safety of our team as well as ourselves during these tragic events. How are the cardiac arrest outcomes at your facility? A huge hat tip to the authors. In this day where all these Ivory Towers are publishing these statistics that are not applicable to the real world, it is important to see what the real world shops are seeing.

UPDATED: There is now new data that shows from a systematic review and meta-analysis that the mortality rate after in-hospital cardiac arrest after looking at 10 articles with a total of 1179 patients was approximately 90%. It was 89.9% to be exact. This includes both in-hospital and 30-day mortality. See the link to the article in the citations below.

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Shah P, Smith H, Olarewaju A, Jani Y, Cobb A, Owens J, Moore J, Chenna A, Hess D. Is Cardiopulmonary Resuscitation Futile in Coronavirus Disease 2019 Patients Experiencing In-Hospital Cardiac Arrest? Crit Care Med. 2021 Feb 1;49(2):201-208. doi: 10.1097/CCM.0000000000004736. PMID: 33093278.
Link to Article and FULL FREE PDF

Ippolito M, Catalisano G, Marino C, Fuca R, Giarratano A, Baldi E, Einav S, Cortegiani A, Mortality after In-Hospital Cardiac Arrest in Patients with COVID-19: A Systematic Review and Meta-Analysis, Resuscitation (2021),
Link to Article

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Before people get upset at me for even posing this question, I feel the answer is no. It is not futile. We absolutely have far more losses when this happens but it’s our job to try. 100% mortality rate was noted at this multi-hospital center, though. It is likely very close to what we are all seeing. But there may be a person who we can save, a big win as we say, if we are able to sort out what caused the initial arrest and it be reversible. Personally, I have noted the same mortality rate noted in this paper published a couple days ago that’s free to download along with my more thorough blog post on the matter at 🎩 tip to the authors for having the guts to publish their honest outcomes. Read it for yourself and don’t trust me. Since the bulk of this post is on my website (check my stories for the next 24 hours for a better link), I would rather use this space to ask you all to share whether you have or haven’t had success with CPR/ACLS in your COVID patients. To those who have also noted a 100% mortality rate at their shop, let us know. Although more importantly I would love to read some success stories as they help uplift people who have lost hope. This institution reported a minute from the arrest until the staff got their PPE on and got to work on the patient in the ICU. That seems about accurate. After all, we need to completely protect ourselves in what can be a chaotic environment for the uninitiated. We can’t get ourselves sick. During the codes of COVID patients I have participated in, the phone calls to the family typically don’t come as a surprise. In addressing goals of care every day, I make sure to mention that COVID can pull the rug out from underneath all of our feet and cause a sudden cardiac arrest at any point in time. It sucks but it’s a reality. Thank you all for your support in my insanity. Thanks for sharing with your friends and colleagues. We need to stay strong and keep pushing. Amongst all the tumultuous discourse taking place in society today, the only thing that remains consistent and solid is our unwavering resolve to take the best care of patients we possibly can. 💪🏼💪🏼💪🏼

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