www.thelancet.com Published online September 5, 2012 http://dx.doi.org/10.1016/S0140-6736(12)61182-9 1
Duration of in-hospital resuscitation: when to call time?
Cardiopulmonary resuscitation guidelines are fairly
standardised and didactic but recommendations on
when to terminate in-hospital resuscitation attempts
are less precise, which often means that resuscitation
teams have to make subjective decisions.1,2 Validated
clinical decision strategies for stopping in-hospital
resuscitation exist, but are derived from guidelines no
longer in use and thus are rarely used in clinical practice.3
In The Lancet, Zachary Goldberger and colleagues4
have used the American Heart Association’s Get with
the Guidelines—Resuscitation registry (globally, the
largest in-hospital cardiac arrest registry) to assess the
duration of resuscitation before termination of eff orts
in non-survivors as an indicator of the overall tendency
of a hospital to attempt resuscitation for longer. They
analysed data from 64 339 patients with cardiac arrests
at 435 US hospitals between 2000 and 2008. Cardiac
arrests that lasted less than 2 min were excluded. In
the whole study population, the median resuscitation
duration was 17 min (IQR 10–26); 31 198 patients
(48·5%) achieved return of spontaneous circulation
(ie, restoration of a pulse for at least 20 min) and
9912 (15·4%) survived to hospital discharge. Of the
48·5% of patients who achieved return of spontaneous
circulation, circulation returned within 10 min in
44·8% and within 30 min in 87·6%. The median
resuscitation time was 12 min (IQR 6–21) in patients
achieving return of spontaneous circulation and
20 min (14–30) in non-survivors.
Hospitals were classifi ed into quartiles on the basis of
the median duration of resuscitation in non-survivors:
16, 19, 22, and 25 min were the median resuscitation
durations for the fi rst to fourth quartiles, respectively.
Patients at hospitals in the quartile with a median
resuscitation duration of 25 min (ie, the longest
quartile in non-survivors) were signifi cantly more likely
to achieve return of spontaneous circulation (adjusted
risk ratio 1·12, 95% CI 1·06–1·18; p<0·0001) and survive
to discharge (1·12, 1·02–1·23; 0·021) than were those
at hospitals in the quartile with a median duration
of 16 min (ie, the shortest quartile in non-survivors).
The diff erence was greatest in cardiac arrests in which
the initial rhythm was asystole or pulseless electrical
activity. The proportion of patients surviving to
discharge with a favourable neurological status (ie, a
cerebral performance category score of 1 or 2) did not
diff er signifi cantly across all quartiles (p=0·858).
730 (8·4%) of the 8724 patients surviving to hospital
discharge who had neurological assessments did not
achieve return of spontaneous circulation until after
30 min or more of resuscitation attempts; this was
broadly the case for all initial cardiac arrest rhythms. A
small study5 of 330 in-hospital resuscitation attempts in
Taiwan had similar fi ndings; fi ve of the 58 people who
survived to discharge achieved return of spontaneous
circulation after 30 min of resuscitation.5
To our knowledge, Goldberger and coworkers’ study
is the fi rst time that analysis of duration of resuscitation
attempts in non-survivors has been used to assess
a hospital’s tendency for longer or shorter duration
of resuscitation eff orts and to relate this tendency
to survival. The study’s strength is its use of a large
database that includes and adjusts for many of the
known variables that aff ect outcome after cardiac arrest,
including pre-existing patients’ factors, treatment inter-
ventions, and time and location of the cardiac arrest.
Retrospective analyses of databases, such as that
done by Goldberger and colleagues, have several limi-
tations. The investigators have reported an association
between median duration of resuscitation attempts
in non-survivors and outcome in all patients, but it is
possible that unmeasured confounders account for
this fi nding. Variation between hospitals in duration of
resuscitation attempts and outcome could be associated
September 5, 2012
www.thelancet.com Published online September 5, 2012 http://dx.doi.org/10.1016/S0140-6736(12)61182-9
with process (eg, the presence of a rapid response system
or the seniority and experience of the resuscitation
team), cultural, and behavioural diff erences that a
registry might not detect. Duration of resuscitation
attempts could be a surrogate for the delivery of higher
quality resuscitation—chest compression fraction (ie, the
proportion of time spent delivering chest compressions
during resuscitation attempts), depth, and rate are
all associated with survival in out-of-hospital cardiac
arrest.6–8 Longer resuscitation attempts might refl ect
the ability of a hospital’s resuscitation team to identify
and treat potentially reversible causes of cardiac arrest
(eg, echocardiography to detect and treat pericardial
tamponade) or to allow time for interventions to work.
Hospitals that off er a comprehensive package of care
after cardiac arrest (including the use of therapeutic
hypothermia and percutaneous coronary intervention),
which improves survival,9 might have a more aggressive
approach to resuscitation than do hospitals that do
not off er such comprehensive strategies. Infrequent
implementation of so-called do-not-attempt resusci-
tation decisions could lead to shorter median resusci-
tation durations because the resuscitation team might
tend to stop earlier in cases that are clearly futile. Only
further observational data from other national audits—
such as the UK National Cardiac Arrest Audit—will
help to confi rm and explain these fi ndings because
randomised trials are not ethically feasible.
Monitoring could provide information about the
chances of successful return of spontaneous circu-
lation. Promising technologies include waveform
capnography to measure exhaled carbon dioxide and
cerebral oximetry with near-infrared spectroscopy.10,11
Alternatively, interventions such as extracorporeal
life support can be used to increase the window for
What are the implications for clinical practice?
Goldberger and colleagues’ study reassures clinicians
that prolonged resuscitation attempts do not seem to
result in a substantial increase in severe neurological
injury in survivors. To improve outcomes, all hospitals
should audit their cardiac arrests and benchmark
outcomes as part of a quality improve ment programme.
Duration of resuscitation attempts should be established
on a case-by-case basis and take into account other
known determinants of survival. Prolonged resuscitation
eff orts can result in high-quality survival. If the cause
of cardiac arrest is potentially reversible, it might be
worthwhile to try for a little longer.
*Jerry P Nolan, Jasmeet Soar
Royal United Hospital NHS Trust, Bath BA1 3NG, UK (JPN); and
Southmead Hospital, North Bristol NHS Trust, Bristol, UK (JS)
JPN is editor-in-chief of Resuscitation (honorarium received). JS is an editor of
Resuscitation (honorarium received).
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Resuscitation Council guidelines for resuscitation 2010 section 10.
The ethics of resuscitation and end-of-life decisions. Resuscitation 2010;
Morrison LJ, Kierzek G, Diekema DS, et al. Part 3: ethics: 2010 American
Heart Association guidelines for cardiopulmonary resuscitation and
emergency cardiovascular care. Circulation 2010; 122: S665–75.
van Walraven C, Forster AJ, Parish DC, et al. Validation of a clinical decision
aid to discontinue in-hospital cardiac arrest resuscitations. JAMA 2001;
Goldberger ZD, Chan PS, Berg RA, et al, for the American Heart Association
Get With The Guidelines—Resuscitation (formerly the National Registry of
Cardiopulmonary Resuscitation) Investigators. Duration of resuscitation
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Shih CL, Lu TC, Jerng JS, et al. A web-based Utstein style registry system of
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Christenson J, Andrusiek D, Everson-Stewart S, et al. Chest compression
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For the UK National Cardiac
Arrest Audit see