How does the length of cardiopulmonary resuscitation affect brain damage in patients surviving cardiac arrest? A systematic review

Abstract

BackgroundBrain injury can occur after cardiac arrest due to the effects of ischaemia and reperfusion. In serious cases this can lead to permanent disability. This risk must be considered when making decisions about terminating resuscitation. There are very specific rules for termination of resuscitation in the prehospital setting however a similar rule for resuscitation in hospital does not exist. The aim of this review was to explore the effects of duration of cardiopulmonary resuscitation on neurological outcome in survivors of both in-hospital and out-of-hospital cardiac arrest achieving return of spontaneous circulation in hospital.MethodsA systematic review was conducted. Five databases were searched in addition to hand searching the journals Resuscitation and Circulation and reference lists, quality of the selected studies was assessed and a narrative summary of the data presented. Studies reporting relevant outcomes were included if the participants were adults achieving return of spontaneous circulation in the hospital setting. Studies looking at additional interventions such as extracorporeal resuscitation and therapeutic hypothermia were not included. Case studies were excluded. The study period was from January 2010 to March 2016.ResultsSeven cohort studies were included for review. Quality scores ranged from eight to 11 out of 12. Five of the studies found a significant association between shorter duration of resuscitation and favourable neurological outcome.ConclusionsThere is generally a better neurological outcome with a shorter duration of CPR in survivors of cardiac arrest however a cut-off beyond which resuscitation is likely to lead to unfavourable outcome could not be determined and is unlikely to exist. The findings of this review could be considered by clinicians making decisions about terminating resuscitation. This review has highlighted many gaps in the knowledge where future research is needed; a validated and reliable measure of neurological outcome following cardiac arrest, more focused research on the effects of duration on neurological outcome and further research into the factors leading to brain damage in cardiac arrest.Electronic supplementary materialThe online version of this article (10.1186/s13049-018-0476-3) contains supplementary material, which is available to authorized users.

Mode of Death after Extracorporeal Cardiopulmonary Resuscitation

“…Despite this recommendation, which was incorporated in our local standard operating procedures, a considerable amount of patients in our registry died due to cerebral damage before day 3. Considering the long conventional CPR-durations in ECPR patients [ 15 ], a high incidence of devastating brain damage in ECPR has to be presumed [ 27 ] and has been demonstrated earlier [ 28 ]. In these patients, a neuroprognostication before day 3 is reasonable.…”

Study of the Effects of 3 h of Continuous Cardiopulmonary Resuscitation at 27°C on Global Oxygen Transport and Organ Blood Flow

“…Normothermic CPR can provide ∼30% of pre-arrest cardiac output (CO) (Wik et al, 1996;Sunde et al, 1998;Pytte et al, 2006) but is usually considered discontinued after 20-30 min if the return of spontaneous circulation is not achieved, as these patients show poor clinical outcome (Torke et al, 2015;Perkins et al, 2015a,b). Preclinical studies (Wik et al, 1996;Gervais et al, 1997;Schwarz et al, 2002;Tomte et al, 2010;Welbourn and Efstathiou, 2018) also support this clinical notion, but the maximum duration of CPR in normothermic patients has so far not been determined (Welbourn and Efstathiou, 2018).…”

Serum fibroblast growth factor 21 levels after out of hospital cardiac arrest are associated with neurological outcome

“…The cessation of circulation during cardiac arrest causes ischaemia in tissues, disturbing normal cellular function and resulting in cell death. Reperfusion during cardiopulmonary resuscitation and after return of spontaneous circulation (ROSC) leads to generation of reactive oxygen species (ROS) and an inflammatory stress response 4 . The brain is particularly vulnerable to the hypoxia-reperfusion injury in cardiac arrest due to its high metabolic activity and limited energy reserves 5 , but also extracerebral organ failure complicates recovery 6 .…”