How long should CPR be performed for shockable in-hospital cardiac arrests?

A series to help inform the final life-and-death decision

Although cardiopulmonary resuscitation (CPR) is performed on more than 250,000 people in U.S. hospitals each year, physicians receive no formal guidance or training on how, when, or why it should be made.

How long should CPR be performed after cardiac arrest in the hospital?

This results in a wide variation in practice—a quarter of unsuccessful resuscitations are stopped before 15 minutes, while a quarter go longer than 30 minutes.

New CPR guidelines: What changed?

This series of posts explores the available data that can support clinicians in making the ultimate life-and-death decision: stopping CPR in the hospital.

Here we examine the category of cardiac arrests with the best outcomes: shockable rhythms. But first, let’s recap our overview of in-hospital cardiac arrest from the first post in the series.

All In-Hospital Cardiac Arrests Are Not Created Equal

As we detailed in a previous post, about two-thirds of patients survive their initial in-hospital cardiac arrest, but only one-third of them (about one-quarter) survive to hospital discharge.

Most (~60-80%) of those who survive to hospital discharge have good functional status (mild-to-moderate disability, or none, able to function independently).

Both survival to hospital discharge and survival with good functional status decline with a longer duration of CPR in a nonlinear fashion:

Data source: Okubo et al, BMJ 2024 https://www.bmj.com/content/384/bmj-2023-076019

Ibid.

(If you’re reading this in an email, click the post title for a better view of the plots on the website or app.)

While informative, these plots hide enormous complexity among the patients experiencing in-hospital cardiac arrests, which contribute directly to a wide variety in outcomes.

Clinicians deciding the duration of CPR should know about and consider these differences to ensure patients receive an appropriate amount of possibly beneficial CPR (and a minimum of futile CPR).

The biggest bifurcation in treatments and outcomes lies in the presenting rhythm of cardiac arrest. Patients with shockable arrests receive different treatments (defibrillation and anti-arrhythmic drugs) and have better outcomes generally.

Should they also receive a different duration of CPR?

Shockable Rhythms: A Distinct Class of Cardiac Arrest