No evidence blanket 'do-not-resuscitate' orders for COVID-19 patients are necessary

May 22, 2020

DALLAS, May 22, 2020 -- It's inappropriate to consider blanket do-not-resuscitate orders for COVID-19 patients because adequate data is not yet available on U.S. survival rates for in-hospital resuscitation of COVID-19 patients and data from China may not relate to U.S. patients, according to a new article published today in Circulation: Cardiovascular Quality and Outcomes, an American Heart Association journal.

There is a presumption that COVID-19 patients have a low survival rate after resuscitation, based on a recent study from Wuhan, China, that found an overall survival of 2.9% in 136 COVID-19 patients who underwent cardiopulmonary resuscitation for in-hospital cardiac arrest. However, that prognosis should not be applied to the U.S., said Saket Girotra, M.D., S.M., assistant professor of medicine in the division of cardiovascular diseases at the University of Iowa Carver College of Medicine, on behalf of the American Heart Association's Get With The Guidelines®-Resuscitation (GWTG-R) investigators.

In the study, "Survival After In-Hospital Cardiac Arrest In Critically Ill Patients: Implications For Covid-19 Outbreak?," investigators report data from the GWTG-R registry of in-hospital cardiac arrest patients. They examined data from 2014-2018 on patients similar to the COVID-19 population: 5,690 adult patients who underwent CPR for in-hospital cardiac arrest while being treated in an intensive care unit (ICU) for pneumonia or sepsis and were receiving mechanical ventilation at the time of cardiac arrest.

While researchers noted an overall survival rate of only 12.5% in the U.S. simulation, there were many variables that could affect survival and neurologic outcomes. The probability of survival without severe neurological disability ranged from less than 3% to more than 22%, across key patient subgroups. The probability of mild to no disability ranged from about 1% to 17% across key patient subgroups.

While survival rates were low in older and sicker patients in whom the initial heart rhythm was non-shockable, survival rates were much higher (more than 20%) in younger patients with an initial shockable rhythm who were not being treated with vasopressor medications prior to the cardiac arrest. Vasopressor medications are generally used to improve blood pressure and cardiac output in emergency situations such as septic shock or cardiac arrest.

"Such large variation in survival rates suggests that a blanket prescription of do-not-resuscitate orders in patients with COVID-19 may be unwarranted. Such a blanket policy also ignores the fact that early experience of the pandemic in the U.S. reveals that a about a quarter of COVID-19 patients are younger than 50 years of age and otherwise healthy. Cardiac arrest in such patients will likely have a different prognosis," the researchers said.

The article concludes that "... in a cohort of critically ill patients on mechanical ventilation, survival outcomes following in-hospital resuscitation were not uniformly poor. These data may help guide discussions between patients, providers and hospital leaders in discussing appropriate use of resuscitation for COVID-19 patients."

Co-authors are Yuanyuan Tang, Ph.D.; Paul S. Chan M.D., M.Sc.; and Brahmajee K. Nallamothu, M.D., M.P.H. Nallamothu is the Editor-in-Chief of Circulation: Cardiovascular Quality and Outcomes. This manuscript was reviewed by an external guest editor: Dennis T. Ko, M.D., M.Sc. Disclosures and funding sources are listed in the manuscript.

The American Heart Association is a relentless force for a world of longer, healthier lives. We are dedicated to ensuring equitable health in all communities. Through collaboration with numerous organizations, and powered by millions of volunteers, we fund innovative research, advocate for the public's health and share lifesaving resources. The Dallas-based organization has been a leading source of health information for nearly a century. Connect with us on, Facebook, Twitter or by calling 1-800-AHA-USA1.

American Heart Association

Related Cardiac Arrest Articles from Brightsurf:

Outcomes for out-of-hospital cardiac arrest during COVID-19 pandemic
This study used a large US registry of out-of-hospital cardiac arrests to asses the association between the COVID-19 pandemic and the outcomes of out-of-hospital cardiac arrests, including in areas with low and moderate COVID-19 disease.

Cardiac arrest is common in critically ill patients with COVID-19
Cardiac arrest is common in critically ill patients with covid-19 and is associated with poor survival, particularly among patients aged 80 or older, finds a study published by The BMJ today.

In-hospital cardiac arrest in COVID-19
Outcomes of in-hospital cardiac arrest among patients with COVID-19 are examined in this case series.

New risk tool developed for cardiac arrest patients
Experts have developed a risk score to predict cardiac arrest patient outcomes.

Intravenous sodium nitrite ineffective for out-of-hospital cardiac arrest
Among patients who had an out-of-hospital cardiac arrest, intravenous sodium nitrite given by paramedics during resuscitation did not significantly improve their chances of being admitted to or discharged from the hospital alive, according to research presented at the American College of Cardiology's Annual Scientific Session Together with World Congress of Cardiology (ACC.20/WCC).

Getting to the heart of epinephrine use in pediatric cardiac arrest patients
The effectiveness of epinephrine treatment during resuscitation of adult patients with cardiac arrest is generally promising, but little is known about its effects in pediatric patients.

Bystanders can help more cardiac arrest victims survive
Only 8% of Americans survive cardiac arrest outside a hospital, but that percentage could increase significantly if bystanders recognize cardiac arrest and perform simple lifesaving tasks, a UVA Health physician says in a New England Journal of Medicine article.

Opioid-related cardiac arrest patients differ from other cardiac arrests
People who suffer cardiac arrest due to an opioid overdose are younger, have fewer chronic medical conditions and may be more likely to be to receive bystander CPR, according to a review of emergency response records in Maine.

Selective coronary angiography following cardiac arrest
In the current issue of Cardiovascular Innovations and Applications volume 4, issue 2, pp.

Sudden cardiac arrest in athletes: Prevention and management
It's marathon season, and every so often a news report will focus on an athlete who has collapsed from sudden cardiac arrest.

Read More: Cardiac Arrest News and Cardiac Arrest Current Events is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to