inpatient CPR duration

[lunaire]

Curious about your standard practice on the duration of inpatient CPR, before calling it.

Specifically, how long would you continue CPR in the setting of:
1. Unclear etiology non-shockable rhythm, typical 45-65 y.o patient
2. Unclear etiology young patient, potential eCPR
3. Poor prognosis full code patient

---

Members don't see this ad.

 

[SpacemanSpifff]

Curious about your standard practice on the duration of inpatient CPR, before calling it.

Specifically, how long would you continue CPR in the setting of:
1. Unclear etiology non-shockable rhythm, typical 45-65 y.o patient
2. Unclear etiology young patient, potential eCPR
3. Poor prognosis full code patient

Assuming codes are outside the ICU, and I don’t personally know the patient and/or family…

1. Depends. Some additional factors to consider would be the initial rhythm, physiologic age, and clinical context. In most cases you have a good differential with a reason for admission and a quick recap of the last 24 hours. Asystole and last seen 4 hours ago? Less than 10 minutes. Witnessed PEA would get more thought and some more time, but probably not much more if persistent PEA - 20 minutes, max.
2. If ECPR is in the mix (rare at my current hospital) and the team is en route then the code goes until they are on circuit or until the cannulator declines, preferably before 60 minutes of low flow time. I would activate between the 2nd and 3rd round, because the discussion usually takes some time and you need to be able to call refractory arrest, which usually is persistent VF/VT after 3 defib.
3. As long as it takes to get family on the phone and agree to terminate resuscitation or 10 minutes, whichever comes first.

 

[chessknt]

I've seen a good outcome after 35 minutes of ooh cpr one time but it was done by a paramedic and I am suspicious pt may have not actually been in cardiac arrest but having etoh withdrawal seizures. Vast majority of the time there is a true cardiac arrest that goes on longer than 15 minutes outcomes are functionally non existent in the routine inpatient. I usually won't ever do more than 20 minutes unless there is something that appears to actually be fixable going on.

 

[CCM-MD]

I call it after 15-20 mins in most situations. There are exceptions.

 

[Siggy]

Depends on the situation. The overall answer is that I run codes until I can look myself in the eye.

I've ran codes for 45 minutes and had good outcomes, but both good outcomes and 45 minutes are rare.

Most are likely in the 10-15 minute range.

I've also walked into rooms and called it immediately after 1 round. This is normally that patient that has already arrested multiple times, on epi, norepi, vasopressin, and with refractory acidosis or has a catastrophic brain injury already (e.g. large bleeds with herniation, but non-op per neurosurgery).

 

[WheezyBaby]

Curious about your standard practice on the duration of inpatient CPR, before calling it.

Specifically, how long would you continue CPR in the setting of:
1. Unclear etiology non-shockable rhythm, typical 45-65 y.o patient
2. Unclear etiology young patient, potential eCPR
3. Poor prognosis full code patient

I'll offer as firm of answers as possible for a scenario that would require a lot more detail to answer

1. 20 minutes
2. Widely variable based on markers of high quality CPR and effective perfusion. Particularly if there's brief periods of ROSC. Potentially an hour with the latter
3. 6 minutes

 

[SurfingDoctor]

I really don’t have issues with physicians coding a patient for “X” number of minutes. If the patient is truly dead, they won’t know anyhow.

My frustration lies more in scenario 3 where a physician refuses to do CPR by enacting a uni-lateral DNR and would rather let the family (ie parents) do CPR while they gawk based on some preconceived relative moral high ground and giving themselves a self high-five for “doing the right thing”.

 

[Radetzky]

Curious about your standard practice on the duration of inpatient CPR, before calling it.

Specifically, how long would you continue CPR in the setting of:
1. Unclear etiology non-shockable rhythm, typical 45-65 y.o patient
2. Unclear etiology young patient, potential eCPR
3. Poor prognosis full code patient

1. 20 mins
2. Really depends on the potential causes, proximity of ecpr etc.
3. Thankfully I live in a country where physicians have ultimate authority on DNRs

 

[PTPoeny]

My frustration lies more in scenario 3 where a physician refuses to do CPR by enacting a uni-lateral DNR and would rather let the family (ie parents) do CPR while they gawk based on some preconceived relative moral high ground and giving themselves a self high-five for “doing the right thing”.

I am very glad I haven't seen that. I have seen a hospital system enact a unilateral DNR against a family's wishes but it was a months long process with ethics and the legal team and outside consults ect

For 2 I do CPR until the surgeon gets there and either cannulates or declares uncannulateable. Longest I have been a part of was over 90 minutes and the kid walked out of the hospital.

Generally in situation 3 I will give two doses of epi while getting an airway and an EPOC to look for reversible electrolyte issues.

 

[SurfingDoctor]

I am very glad I haven't seen that. I have seen a hospital system enact a unilateral DNR against a family's wishes but it was a months long process with ethics and the legal team and outside consults ect

I wasn’t personally there, but I know it has happened because it’s was a big deal. The people involved still believe they did “the right thing” even though they let the family do CPR on the child for 40 minutes in the ICU.

I also know of several terminal extubations against the parents wishes which I also fine unsettling.

 

[aafisahar]

Curious about your standard practice on the duration of inpatient CPR, before calling it.

Specifically, how long would you continue CPR in the setting of:
1. Unclear etiology non-shockable rhythm, typical 45-65 y.o patient
2. Unclear etiology young patient, potential eCPR
3. Poor prognosis full code patient

1. Depends, but prob at least 10 minutes to gather information and determine futility of continuing.

2. Until surgery says no or they are on the circuit.

3. 1-2 rounds.

 

[Siggy]

I really don’t have issues with physicians coding a patient for “X” number of minutes. If the patient is truly dead, they won’t know anyhow.

My frustration lies more in scenario 3 where a physician refuses to do CPR by enacting a uni-lateral DNR and would rather let the family (ie parents) do CPR while they gawk based on some preconceived relative moral high ground and giving themselves a self high-five for “doing the right thing”.

Do you have the same problem when surgeons refuse to take patients who are almost certainly going to die to the OR because of futility?

I find it interesting that when surgeons refuse to provide futile care no one blinks an eye... when it occurs on the medical side everyone loses their proverbial mind.

I will stipulate that family presence does make a difference vs family not being present.

 

[SurfingDoctor]

Do you have the same problem when surgeons refuse to take patients who are almost certainly going to die to the OR because of futility?

I find it interesting that when surgeons refuse to provide futile care no one blinks an eye... when it occurs on the medical side everyone loses their proverbial mind.

Yep, because if it was child, I’d want them to try.

I actually have argued with them a handful of times personally for kids who were hemorrhaging from a bad injury who they refused to take to the OR for some reason or another. The teenager with refractory ITP who fell and had a head bleed comes to mind. I offered everything I could think of before they became brain dead, but the neurosurgeons refused. But, at the end of the day, I tried and that was the best I could do and I can live with that.

 

[Siggy]

Yep, because if it was child, I’d want them to try.

I actually have argued with them a handful of times personally for kids who were hemorrhaging from a bad injury who they refused to take to the OR for some reason or another. The teenager with refractory ITP who fell and had a head bleed comes to mind. I offered everything I could think of before they became brain dead, but the neurosurgeons refused. But, at the end of the day, I tried and that was the best I could do and I can live with that.

I'll also agree that there's a difference between a 60 or 70 year old and a kid when it comes to futility. The cold logical side is the same, but the emotional part that makes us human sees it different.

 

[SurfingDoctor]

I'll also agree that there's a difference between a 60 or 70 year old and a kid when it comes to futility. The cold logical side is the same, but the emotional part that makes us human sees it different.

I only work with kids and my observations don’t go beyond that. My point remains even if it is not broadly applicable.

That being said, there are certainly physicians who take care of kids who don’t feel the same. In my group, I am the minority.

 

[turkeyjerky]

I wasn’t personally there, but I know it has happened because it’s was a big deal. The people involved still believe they did “the right thing” even though they let the family do CPR on the child for 40 minutes in the ICU.

I also know of several terminal extubations against the parents wishes which I also fine unsettling.

I'm trying to picture how this went down. I'm assuming patient is in ICU and expected to expire soon, team trying to make comfort care but family refusing. Patient codes, as expected, and physician immediately calls TOD. Then family starts doing CPR and keeps it up for 45 min while everyone walks out and ignores them?

 

[SurfingDoctor]

I'm trying to picture how this went down. I'm assuming patient is in ICU and expected to expire soon, team trying to make comfort care but family refusing. Patient codes, as expected, and physician immediately calls TOD. Then family starts doing CPR and keeps it up for 45 min while everyone walks out and ignores them?

I don’t know what TOD is? Time of death?

Fortunately, I wasn’t there for the debacle. My understanding is that the family members rotated doing CPR for the duration of the “code” in the ICU. I suspect there were periods of them not doing CPR too in than time period, because that sh-t is tiring. What the staff was doing, I don’t know, but I don’t think anyone intervened and the patient wasn’t pronounced till after the family got tired of doing CPR on their child and stopped. At least that was my recollection of second hand information. This was also years ago so even those details are fuzzy. People still talk about it though.

 

[The Knife & Gun Club]

I don’t know what TOD is? Time of death?

Fortunately, I wasn’t there for the debacle. My understanding is that the family members rotated doing CPR for the duration of the “code” in the ICU. I suspect there were periods of them not doing CPR too in than time period, because that sh-t is tiring. What the staff was doing, I don’t know, but I don’t think anyone intervened and the patient wasn’t pronounced till after the family got tired of doing CPR on their child and stopped. At least that was my recollection of second hand information. This was also years ago so even those details are fuzzy. People still talk about it though.

This is really bizzare. I could see what you’re describing though. We rotate with the PICU during second year of residency I saw some pretty impressive variability in the physicians.

They’d have vastly different definitions of futility of care and what is vs is not survivable.

 

[SurfingDoctor]

This is really bizzare. I could see what you’re describing though. We rotate with the PICU during second year of residency I saw some pretty impressive variability in the physicians.

They’d have vastly different definitions of futility of care and what is vs is not survivable.

The definition of futility is pretty subjective in my opinion. That being said, I think it becomes vastly more nebulous if you are talking about a 90 year old versus a 9 year old. Everyone expects they’ll out live their grandparents, no one expects they’ll out live their children.

 

[The Knife & Gun Club]

Curious about your standard practice on the duration of inpatient CPR, before calling it.

Specifically, how long would you continue CPR in the setting of:
1. Unclear etiology non-shockable rhythm, typical 45-65 y.o patient
2. Unclear etiology young patient, potential eCPR
3. Poor prognosis full code patient

Curious how long it would take at your hospital to activate and get someone on circuit for ECPR?

Does the surgeon have to come from home? Someone in house who can cannulate? Getting the perfusionist, equipment, etc to bedside to be able to actually turn the circuit on?

 

[lymphocyte]

I don’t think anyone intervened and the patient wasn’t pronounced till after the family got tired of doing CPR on their child and stopped.

Gosh that sounds so awful.

 

[PTPoeny]

Curious how long it would take at your hospital to activate and get someone on circuit for ECPR?

Does the surgeon have to come from home? Someone in house who can cannulate? Getting the perfusionist, equipment, etc to bedside to be able to actually turn the circuit on?

Page to flows of 45-60 minutes are standard at my hospital after hours when surgeon, perfusionist and some parts of the OR team are coming from home.

Page going out is fast, charge nurse calls the hospital operator and says "send the ECPR page" when the intensivist asks. Equipment is at beside well before anything else as we have a circuit built on the unit at all times.