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Although the upper limits for CPR duration in patients with initial shockable and non-shockable rhythms are 55–62 min and 24–34 min, respectively, favorable neurological outcomes can be achieved with prolonged CPR according to each patient's resuscitation-related factors.
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Read More »This multicenter retrospective observational study based on reliable pre-hospital and in-hospital variables showed that the upper limits of resuscitation times and optimal pre-hospital and total CPR durations differed among the stratified groups by major determinant factors. Similar to other studies [2, 3, 16, 24], an initial shockable rhythm and witnessed arrest were major factors determining favorable neurological outcomes. This study showed that males had a high likelihood of favorable neurological outcomes. However, there were some etiological differences according to sex. The males were younger and likely to have initial shockable rhythms (Additional file 2: Table S2). These differences made male patients seem to have a better prognosis. In this study, the upper limit of total CPR duration in the shockable rhythm group (55–62 min) was longer than that in the non-shockable rhythm group (24–34 min), a finding that was similar to the results of Grunau et al. [24], who showed that the total CPR duration with a probability of favorable neurological outcomes < 1% were 48 and 15 min in the shockable and non-shockable rhythm groups, respectively. The reason for this is the difference in the characteristics of shockable and non-shockable rhythms. A shockable rhythm is caused by electrical changes due to myocardial ischemia, while a non-shockable rhythm is caused by poor perfusion and tissue hypoxia due to non-cardiac causes or spontaneous or electrical termination of shockable rhythm. Patients with an initial non-shockable rhythm may have more comorbidities and delayed initial recognition and response [25, 26]. Therefore, favorable neurological outcomes are more likely in patients with a shockable rhythm, even if prolonged CPR is required. Different CPR durations are recommended for different patient groups stratified by their characteristics. Grunau et al. recommended that patients be transported to hospitals for ECPR within 8–24 min [27]. Similarly, we recommend 12 min as the optimal pre-hospital CPR duration cut-off, within which patients with OHCA should be transported to the hospital for evaluation of the cause of the OHCA and clinical decisions about ECPR implementation. Furthermore, this study showed that total CPR durations of 25 and 21 min are optimal for transitioning to ECPR and achieving favorable neurological outcomes in patients with shockable and non-shockable rhythms. Similarly, Kim et al. showed that the optimal cut-off for total conventional CPR is 21 min, beyond which ECPR should be considered [7]. Moreover, French medical scientific societies recommend ECPR in patients with refractory cardiac arrest with CPR performed for > 30 min [28]. ECPR implemented within 60 min results in favorable neurological outcomes [6, 7, 29]. In patients with an initial shockable rhythm with and without witnessed arrest, we revealed that total CPR for 62 min and 55 min, respectively, are the upper limits of conventional CPR for the dynamic probability of favorable neurological outcomes < 1%. This finding supports the hypothesis that implementing ECPR within 60 min of cardiac arrest in selected patients with an initial shockable rhythm may result in favorable neurological outcomes. In most cases, a shockable rhythm is caused by ischemic events that maintain myocardial viability and have a good response to ECPR. Although the effectiveness of ECPR in patients with a non-shockable rhythm is debatable, several studies have shown favorable neurological outcomes in patients with non-shockable rhythms [7,8,9]. We showed that the upper limit of total CPR duration in patients with an initial non-shockable rhythm with or without witnessed arrest are 34 and 24 min, respectively. The effect of ECPR is considered negligible after this time, which is similar to that observed in patients with an initial shockable rhythm. Although there are differences in the time interval from team activation to ECMO pump “ON” time due to regional variations in EMS systems, it usually takes > 20 min. Therefore, in patients with a non-shockable rhythm, ECPR should be considered quickly because they have a shorter time window for ECPR compared than those with a shockable rhythm. Drennan et al. [30] disclosed that the application of the basic life support TOR rule (arrest not witnessed by EMS personnel, no ROSC, and no AED shock) at 20 min of resuscitation identified > 99% of survivors and favorable neurological outcomes. Similarly, we showed that the upper limit of total CPR duration for patients with an initial non-shockable rhythm with or without witnessed arrest were 34 and 24 min, respectively. Therefore, it might be feasible to apply the TOR rule within this time window to patients with a non-shockable rhythm in the field. However, the total CPR duration with a cumulative proportion of favorable neurological outcomes > 99% in patients with an initial non-shockable rhythm with and without witnessed arrest was 71 and 45 min, respectively. Thus, if prolonged CPR is performed, some patients with an initial non-shockable rhythm may have favorable neurological outcomes. Similarly, in patients with an initial shockable rhythm but without pre-hospital ROSC, the total CPR duration with a > 99% cumulative proportion of favorable neurological outcomes was 83 min, while the dynamic probability of < 1% favorable neurological outcomes was 54 min. Therefore, we recommend that treatment not be abandoned too early, even in patients with an initial non-shockable rhythm and in those without pre-hospital ROSC.
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Read More »There have been many attempts to determine the upper limit of CPR duration beyond which resuscitation may be futile [1,2,3,4, 16, 17, 24]. Some studies focused on the upper limit of the pre-hospital CPR duration [1,2,3]. Even if few of these studies focused on total CPR duration, they excluded patients who underwent TOR in the field [4, 16, 24] and included patients who received bystander CPR only [17]. In conclusion, they determined the upper limit of CPR duration in limited patient groups. Conversely, this study focused on patients who did not experience TOR in the field and included all patients who underwent CPR by EMS at the pre-hospital level. Likewise, the present study could aid healthcare providers more clearly determine the appropriate duration of CPR performed at the pre-hospital level and the time to transfer from conventional CPR to ECPR in the hospital within the upper limit of CPR duration.
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