Critical Care and Shock

Cardiac arrest and cardiopulmonary resuscitation in hospitalized COVID-19 patients

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Background: The coronavirus disease 2019 (COVID-19) pandemic has resulted in a marked increase in the incidence of in-hospital cardiac arrest (IHCA), with mortality rates surpassing 90% despite cardiopulmonary resuscitation (CPR) efforts. Patients with COVID-19 who experience IHCA are less likely to present with shockable rhythms, have lower rates of return of spontaneous circulation (ROSC), and exhibit significantly lower survival rates. The aim of this paper was to investigate the epidemiology and clinical features of COVID-19 patients who required CPR following an episode of IHCA.

Study design and methods: Retrospective analysis of adult patients aged 18 years or older, who were admitted to our critical care unit and diagnosed with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection using reverse transcription polymerase chain reaction (rtPCR) between March 2020 and February 2022. Patients who experienced IHCA at any point during their hospital stay were included in the study. Data were collected for demographics, pre-admission conditions, comorbidities, resuscitation records, severity scores (such as Sequential Organ Failure Assessment [SOFA], Acute Physiology and Chronic Health Evaluation [APACHE] II, and Ichikado CT), laboratory results, length of stay, and survival to hospital discharge.

Results: Nine hundred and ninety-four patients with a COVID-19 diagnosis were admitted to our high-acuity COVID-19 unit during the study period. Out of those, 129 patients underwent CPR. The median age was 63 years old (52-72). Ninety-one (70.5%) patients were male. Sixty-five (50.8%) patients were Hispanic, 34 (26.6%) Caucasian, 22 (17.2%) African American, and 7 (5.5%) other races. The most common comorbidities were systemic arterial hypertension (48.4%) and diabetes mellitus (32%). Thirty-nine patients (30.5%) had no reported comorbidities. The mean APACHE score was 16 (11-23), and the highest APACHE score during hospitalization was 29 (21.5-35). The mean SOFA score was 4 (2-6.5), with the highest SOFA score during hospitalization being 10 (7-13). The mean Ichikado CT score was 200 (150-245) and an Ichikado CT score >174 was present in 68 (63.6%) patients. Twenty-one (16.3%) patients developed pulmonary embolism, 7 (5.4%) patients developed myocarditis, 22 (17.1%) developed acute kidney injury, and 40 (31%) patients developed disseminated intravascular coagulation (DIC). The most frequent cardiac arrest rhythm was asystole (9.8%), followed by pulseless electrical activity (PEA) (2.6%), pulseless ventricular tachycardia (0.5%), and ventricular fibrillation (0.6%). The mean CPR duration was 22.8 minutes. The mortality of patients that underwent CPR was 98.4%.

Conclusions: Most COVID-19 patients who received CPR in this cohort had a severe disease course, with a low survival rate and a short mean survival time. Our findings revealed that male gender, age above 65 years, hospital admission more than 7.5 days after symptom onset, high scores on admission for severity assessment such as APACHE II and SOFA, as well as high levels of creatine phosphokinase (CPK), blood urea nitrogen:creatinine (BUN:Cr) ratio, interleukin 6 (IL-6), and glucose upon admission, and the presence of a cytokine storm at the time of admission were all factors associated with an increased risk of mortality following CPR.