Cardiopulmonary resuscitation should be extended to more than 35 minutes for children, study shows

BMJ 2013; 346 doi: (Published 22 January 2013) Cite this as: BMJ 2013;346:f458
  1. Susan Mayor
  1. 1London

Extending cardiopulmonary resuscitation (CPR) for longer than previously recommended—to more than 35 minutes—is associated with higher rates of survival than expected without impairing neurological function, says a large study1 in children that follows similar findings in a recent study2 in adults.

The study analysed data from the American Heart Association’s Get With the Guidelines Resuscitation programme (GWTG-R), a prospective multicentre registry that collects information on in-hospital cardiac arrest. Researchers examined hospital records for 3419 children (mean age 4.9 years) undergoing cardiopulmonary resuscitation after cardiac arrest in 328 US and Canadian hospitals between 2000 and 2009.

Results showed that CPR duration was independently associated with survival to hospital discharge. The adjusted probability of survival was 41% for children whose CPR lasted for 1-15 minutes, but 12% of children undergoing resuscitation for longer than 35 minutes survived to be discharged from hospital. Nearly two thirds (60%) of the children who survived prolonged CPR had good neurological outcomes.

“These findings about the duration of CPR are game changing, and we hope they will rapidly affect hospital practice,” said Robert Berg, one of the study’s authors and chief of critical care medicine at the Children’s Hospital of Philadelphia and chairman of the registry’s scientific advisory board.

“Most physicians thought that continuing CPR for longer than 15 to 20 minutes was futile and chances of survival were approximately zero,” he said. “But the figures show that 12% of children who are still getting CPR at 35 minutes survive to hospital discharge. It’s clearly not a futile intervention.”

Berg said he was so surprised when he first saw the survival curve for CPR beyond 30 minutes that he asked the statisticians if they were the real figures.

“The findings suggest that some children who would presumably die without CPR survive with a favorable neurologic outcome even after prolonged resuscitation efforts,” he said.

Among the 954 survivors in the study, just over a third (36%) had CPR for over 15 minutes and 16.5% for longer than 35 minutes. As expected, outcomes in the first 15 minutes of CPR declined rapidly, underlining the importance of rapid return of spontaneous circulation. Survival decreased linearly by 2.1% and rates of favourable neurological outcome by 1.2% per minute between 1 and 15 minutes of CPR.


Probability of survival to discharge after cardiopulmonary resuscitation

“But the finding that survival after more than 35 minutes of CPR is as high as 16.2% in certain patient groups is novel,” the research group said. Surgical cardiac patients had the highest odds ratios for survival and favourable neurological outcomes, whereas trauma patients had the lowest.

The findings in children parallel those seen in a similar study of 64 000 adults who had in-hospital cardiac arrest between 2000 and 2008.2 Patients in the top quartile of CPR duration (25 minutes) had a 12% higher chance of surviving cardiac arrest than those in the lowest quartile (16 minutes), with similar neurological outcomes.


Cite this as: BMJ 2013;346:f458