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Hospitals where staff try a little longer and a little harder to re-start a stopped heart might see better survival rates, new research finds.
They’re called “code blue,” “code alert,” “full code” and other dramatic names and without last-ditch resuscitation attempts, television hospital dramas would be nowhere. But common wisdom holds that in real life, drawn-out efforts to save someone whose heart has stopped are often a waste of time. But are they?
Maybe not, researchers report on Tuesday. They found that in hospitals where resuscitation teams try a little longer and a little harder, patients are more likely to survive. And they are not any more likely to be disabled or brain-damaged than patients who revive more quickly.
“Our findings suggest that prolonging resuscitation efforts by 10 or 15 minutes might improve outcomes,” said Dr. Zachary Goldberger of the University of Washington, who led the research published in the Lancet medical journal.
There aren’t any firm guidelines on how long to keep trying to revive someone whose heart has stopped. Skilled doctors, nurses or technicians can keep the blood pumping and supply oxygen to the brain and other organs while working to re-start a stopped heart. The American Heart Association has detailed pointers on which measurements show a patient has a better chance of living, and on which treatments to give, from simple cardiopulmonary resuscitation or CPR to defibrillation and drugs.
But how long do you keep trying?
“There is this thought that it is futile, or that even if you get immediate survival, that in the long-term you are not doing these patients any favors,” said Dr. Brahmajee Nallamothu of the University of Michigan and the Ann Arbor VA Medical Center, who worked on the study.
Each patient is different, so the researchers looked at hospitals, comparing the average time spent trying to resuscitate patients and tracking how many patients survived until they were released. “How long do hospitals try for before they call the code?” Nallamothu said.
They looked at the records of 64,000 patients from 435 U.S. hospitals who suffered cardiac arrest in hospitals between 2000 and 2008. They divided the hospitals into four groups -- those whose staff tried on average for 25 minutes to revive patients, those where the average time was 22 minutes, then 19 minutes and then 16 minutes.
It is clearly bad news for the heart to stop; only 15 percent of all the patients lived. And the hospitals clearly didn’t give up easily. Usually a patient revived quickly if at all. But looking at the hospital averages showed trying a little longer could pay off.
“Patients at hospitals where resuscitation attempts lasted the longest were significantly more likely to be successfully revived (achieve restoration of a pulse for at least 20 minutes) and survive to be discharged from hospital than those at hospitals where attempts were shortest,” Nallamothu’s team wrote.
“The whole resuscitation team, the code team is already there,” Nallamothu said in a telephone interview. “To try a bit longer -- I don’t think it is too much of a burden. It didn’t seem that those patients at the hospitals where attempts were longer were having a worse outcome, neurologically.”
There could be other factors at work, Nallamothu said. It could be the patients are sicker at some hospitals than others. Some hospitals could be treating patients who are older and less likely to survive. Some hospitals may have staff who are more skilled at reviving patients.
“My gut feeling is when I think about this situation, it is an incredibly difficult clinical situation,” Nallamothu said. “We don’t want to give hard and fast rules. This is a first step.”
Another caveat -- the findings apply to hospital resuscitation only, and not CPR or other rescue attempts outside a hospital. But two British doctors, Jerry Nolan of the Royal United Hospital NHS Trust in Bath and Jasmeet Soar of Southmead Hospital in Bristol said it’s clear that trying for longer doesn’t necessarily hurt.
“If the cause of cardiac arrest is potentially reversible, it might be worthwhile to try for a little longer,” they wrote in a commentary in the Lancet.
Related stories:
- Risky cooling therapy saves mom, baby
- Hands-only CPR is enough, studies find
- New CPR guidelines switch up the pace
Gabe Shallouf, 19, raced into action after spotting an unconscious elderly man on a front lawn off the side of the road. KGW's Abbey Gibb reports.
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http://thenurseinpurpleconverse.blogspot.com/2009/04/psa-what-full-code-really-means-for.html
I wrote this blog entry awhile ago, but every time the topic of "full code" comes up, I think of it again. A higher chance of "successful" resuscitation does not necessarily mean things are going to be okay for the patient. People need to know what they're getting into when they want "everything done" for Grandma.
Sudden cardiac arrest can happen to young or middle-aged folks with no known signs of heart disease. These are the patients most likely to benefit from prolonged resuscitation efforts.
Last year, a 52-yo healthy man I know had a sudden cardiac arrest at home and his wife called 911 and started CPR immediately (primarily fast, hard chest compressions). Paramedics then worked on him for 15 minutes while getting him to an ER. Amazingly, the ER team spent another 45 minutes with drugs, defibrillators, and CPR -- likely because the man appeared otherwise healthy. His heart resumed beating and he was given hypothermia treatment (chilling the body to prevent more brain damage from loss of oxygen).
He awoke confused and needed some rehab, but today is 99% recovered and enjoying life with his family and little kids. This man tracked down his paramedics and ER personnel and personally thanked them for fighting for his life -- showing them that yes, working hard and long CAN have great outcomes. We later discovered that the ER team was just a minute away from stopping resuscitation efforts.
If my heart has stopped just leave me alone. Does a person have to get a DNR tattoo or what?
The last time I visited the hospital, for a very common surgery with extremely low chance of death, the nurse specifically asked me to sign something prior to going under the knife proclaiming my wishes regarding DNR.
When was the last time you were in a hospital?
I had bypass surgery in 1998 & 2000 and I had to sign the same sort of waiver.
Mic, look up "Living Will." Outside of a hospital, you may need that tattoo to prevent a Good Samaritan from trying to revive you, but the Living Will takes care of the DNR while in the hospital.
I was defibulated 9 times. The paddle burns didn't go away for 6 months. I woke up after 8 days feeling like every rib in my chest was broken from the CPR. I was on the table for hours. After 12 years I'm truly grateful that they didn't give up too soon.
There are so many variables with cardiac arrest and revival times....et. drowning, electrical shock, drug overdose, etc....all these pose a different set of standards and revival is a wish and a gamble. And the variables are with the healthcare professionals in regard to the quality of CPR and code management. It's really hard to say whether CPR that is prolonged past a certain number of minutes has better outcomes. Wayyyy too many varibles. We all try our best and it's difficult to stop CPR, particularly when cardiac arrest came on unexpectantly. The downside of this is brain damage that does occur if hypoxic long enough.
Read up on the soccer player Fabrice Muamba. His heart was stopped for more than an hour.
If we did not try to revive people with terminal illnesses, statistics would look even better,e.g.. with untreatable widespread cancer. I ran many code events throughout my career as an MD, with many patients with terminal illnesses but were futile. We must learn to accept death when it is time, but this does not mean giving up. I have had two brain surgeries with a ruptured aneurysm in medical school and two malignant cancers. Despite initial shock, after each, I pursued healthy lifestyle changes. Before a code is needed, eat healthfully, exercise, reduce stress, and follow healthy sleep practices. I retired early to focus on healthful living including time for family and friends. When a code occurs in the elderly the resuscitative events are not pretty and if revived cognitive recovery is not always great It is your choice though, and pursue a living will while you can,involving all decision makers in case you are incapacitated. Ensure the wording is clear, your doctors, loved ones and legal representation are fully involved to avoid changes in plans if you are unable to participate. I have seen families destroyed due to disagreements about living wills due to misunderstanding that cannot be resolved in the heat of the moment
"We must learn to accept death when it is time..." We must also recognize when it is not time. All in all your comment was very interesting and like few here, to the point.
On June 17th 2003 I had a I had chest pains. I was taken to emergency where I was revived 3 times. I was in a coma for 9 days but God brought me out of it. I have 62% damage to my heart and I thank God for the Dr. not giving up on me. That was in Bay City Michigan. Nine years later I am still here. My advise is to never give up.
I believe it was Duke University which did a study of 're-starting the heart of elderly patients'. Of the over hour hundred patients studied, not one of the elderly patients went home with a return to a healthy lifestyle.
Hospitals are getting better discussing options before beginning treatment (if possible). I believe that they must be brutally honest with everyone vis-a-vis the statistical likelihood of outcome.
And imagine the changes if the hospital could not charge for resuscitation after "X" number of code blues. It would be fairly easy to 'know' when code blues are matched to age, weight, condition and so on, when it merely becomes a futile excercise--and the hospital personal would be forcoming and honest with all needing to understand the options available.
There is no doubt that preventive medicine should be the preferred method to heroic medicine.
Dick Falkenbury
The problem there is that very often it isn't possible to know if a patient is a DNR or not. In the emergency room setting, cardiac arrest patients are brought in by paramedics, and many times there is no family present. Regardless of what the studies say about the survivability of CPR based on age, weight, or whatever, those patients are still going to be worked on. If the family is present, or if the patient's code status is determined in some other way, then CPR can be stopped.
You won't know how long you were here when you're gone. But if I can hang around a little longer, revive me!
Common question is do you have a living will or DNR when admitted. Been down the road of stopped heart in 99 and thankfully they worked on me for 2 hours and was restarted several times during a heart cath but an aortic ballon pump saved my bacon. So after 22 heart caths, 2 bypass surgeries and a EF rate of 25 I still walk a mile a day at 66....
And you cost somewhere in the neighborhood of 2 million dollars
probably more like 2.5 million
And you are in a very small minority of patients who can claim the same!
Just FEED my dog...AND be good to him !
He's better than MOST people!
Besides...I'm just as TIRED as my heart.
Good night !
( I've done what I could...YOU do the REST....IF you're GOOD ENOUGH ! )
TRY "thinking" on your own......
Many corpses have been revived by doggedly pursuing resuscitation,Believe me,you do NOT want 90 yo granny revived
My Dad was paddled (defibrillator) about 12 times two months ago. They almost quit but tried "one more time". He was discharged 4 days later and is home recouping nicely now with no noticeable neurological damage. Well worth the efforts!