To the Editor:
We read with interest the article, published in a recent issue of Critical Care Medicine, by Shah et al (1). The authors report 100% mortality after in-hospital cardiac arrest (IHCA) in patients admitted for acute illness related to coronavirus disease 2019 (COVID-19). The magnitude of reported mortality was surprising to us and differs considerably from that found at our institution, the University of Virginia Medical Center. In our institution, in-hospital mortality for patients admitted with COVID-19 is 9.8%, seen in 83 deaths of 843 total admissions between March 12, 2020, to January 8, 2021; we have attempted resuscitation in seven patients with a prevalence among COVID-19 admissions of 0.8% in our institution.
The characteristics of our patients, including prearrest major therapies and features of the cardiac arrest event, are similar to that reported by Shah et al (1). Prearrest therapies included the following: 71% mechanically ventilated (5/7), 71% vasopressor infusion (5/7), and 42% hemodialysis (3/7). At the time of their arrest, 85% had an initial nonshockable rhythm (6/7). All of our arrests were witnessed in the ICU and had immediate chest compressions. Of patients who suffered cardiac arrest, 42% have survived to discharge (3/7), and 66% survivors live independently with no neurologic deficits (2/3); all survivors are alive greater than 60 days from their cardiac arrest event.
We note several important differences between our experiences and those of the authors. Our rate of attempted resuscitation is much lower (0.8% vs 5.8%; p < 0.001). Selective and appropriate use of do-not-attempt-resuscitation status is an active strategy in our facility; perhaps, timely resuscitation status recognition impacted our lower rate of attempted cardiac arrest resuscitation events. Of the patients who did not survive their index admission, 70 of patients 84 (83%) were ordered do-not-attempt-resuscitation status at least 12 hours before their death. Second, our observed survival to hospital discharge with intact neurologic status is quite different from those reported by the authors (42% vs 0%; p < 0.001), potentially impacted by our identification of resuscitation candidates.
In carefully selected patients hospitalized with COVID-19 who experience cardiac arrest, attempts at resuscitation is appropriate medically and potentially efficacious; furthermore, with adequate provider education and appropriate personal protective equipment for the healthcare team, resuscitation is a safe procedure. We agree with the authors that pooled outcomes data from multiple institutions are needed to address the utility of attempting cardiac arrest resuscitation in patients with COVID-19. Although the authors make no statement about the utility of cardiac arrest resuscitation attempts in IHCA from COVID-19, we are concerned that readers may withhold cardiopulmonary resuscitation and other resuscitative interventions given these reported less-than-optimal outcomes, and we caution labeling a practice as futile without more robust data.
1. Shah P, Smith H, Olarewaju A, et al. Is Cardiopulmonary Resuscitation Futile in Coronavirus Disease 2019 Patients Experiencing In-Hospital Cardiac Arrest? Crit Care Med. 2021; 49:201–208