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Effectiveness of mechanical cardiopulmonary resuscitation for patients with COVID-19 and in hospital cardiac arrest

  • Author Footnotes
    1 Abhishek Bhardwaj and Mahmoud Alwakeel equally contributed to this article.
    Abhishek Bhardwaj
    Correspondence
    Corresponding author at: Pulmonary & Critical Care Medicine Department of Pulmonary & Critical Care Medicine Cleveland Clinic Foundation, A-90, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
    Footnotes
    1 Abhishek Bhardwaj and Mahmoud Alwakeel equally contributed to this article.
    Affiliations
    Department of Pulmonary & Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
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  • Author Footnotes
    1 Abhishek Bhardwaj and Mahmoud Alwakeel equally contributed to this article.
    Mahmoud Alwakeel
    Correspondence
    Corresponding author.
    Footnotes
    1 Abhishek Bhardwaj and Mahmoud Alwakeel equally contributed to this article.
    Affiliations
    Department of Internal Medicine, Cleveland Clinic Fairview Hospital, Cleveland, OH, USA
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  • Xiaofeng Wang
    Affiliations
    Department of Biostatistics, Quantitative health Sciences, Cleveland Clinic, Cleveland, OH, USA
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  • Abhijit Duggal
    Affiliations
    Department of Pulmonary & Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA

    Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
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  • David F. Gaieski
    Affiliations
    Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA, USA
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  • Francois Abi Fadel
    Affiliations
    Department of Pulmonary & Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA

    Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
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  • Author Footnotes
    1 Abhishek Bhardwaj and Mahmoud Alwakeel equally contributed to this article.
      To the Editor,
      Cardiopulmonary resuscitation (CPR) is an aerosol generating event where healthcare workers (HCW) are at an increased risk of exposure during resuscitation of coronavirus disease 2019 (COVID-19) patients. To decrease HCW exposure, professional societies recommended the use of mechanical CPR devices where available.
      • Edelson D.P.
      • Sasson C.
      • Chan P.S.
      • et al.
      Interim Guidance for basic and advanced life support in adults, children, and neonates with suspected or confirmed COVID-19.
      Previously, two randomized control trials showed that mechanical CPR devices were equally efficacious when compared to manual CPR for management of out-of-hospital cardiac arrest.
      • Perkins G.D.
      • Lall R.
      • Quinn T.
      • et al.
      Mechanical versus manual chest compression for out-of-hospital cardiac arrest (PARAMEDIC): a pragmatic, cluster randomised controlled trial.
      • Rubertsson S.
      • Lindgren E.
      • Smekal D.
      • et al.
      Mechanical chest compressions and simultaneous defibrillation vs conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: the LINC randomized trial.
      However, there is limited data on the use of mechanical CPR device in IHCA with conflicting results.
      • Couper K.
      • Yeung J.
      • Nicholson T.
      • Quinn T.
      • Lall R.
      • Perkins G.D.
      Mechanical chest compression devices at in-hospital cardiac arrest: a systematic review and meta-analysis.
      • Wang P.L.
      • Brooks S.C.
      Mechanical versus manual chest compressions for cardiac arrest.
      We assessed the feasibility of mechanical CPR in IHCA of COVID-19 patients and present the first report on role of mechanical CPR in COVID-19 patients.
      This single healthcare system, multi-center, retrospective cohort study, included patients aged ≥18 years admitted to the Cleveland Clinic Health System’s ten hospitals in North-East Ohio with COVID-19 who subsequently had IHCA between 03/01/2020 and 10/15/2020. Data were extracted from the electronic medical records and supplemented with the quality data registry. The LUCAS® Mechanical CPR device was introduced across the healthcare system in March 2020 after an online training session followed subsequently by hands-on training of healthcare workers. After initial training, the use of LUCAS® Mechanical CPR at our institutions was left up to the discretion of the physician leading the resuscitation effort.
      During the study period, 58 patients with confirmed COVID-19 and IHCA received CPR. Baseline characteristics were similar and are reported in Table 1. Initial arrest rhythm was respectively pulseless electrical activity, 63.8%, asystole, 29.3%, and pulseless ventricular tachycardia or ventricular fibrillation, 6.9%. The majority of IHCA events occurred in the ICU (51/58; 87.9%) and the remainder occurred on the regular wards (7/58; 12.1%). Return of spontaneous circulation (ROSC) occurred in 35 patients (60.3%) and 13 patients (22.4%) were discharged alive from the hospital. Of the patients who had IHCA, 41/58 (70.6%) received manual CPR and 17/58 (29.3%) received mechanical CPR. Although, the median duration of resuscitation was shorter with manual CPR compared to mechanical CPR (6 min vs. 14 min P = 0.01), there was no significant difference in achieving ROSC (65.9 vs 58.8; p = 0.61). While manual compression led to more survivors at 24 h post arrest (56.1 vs 23.5; p = 0.02), there were no difference in survival to ICU discharge (31.7 vs 11.7; p = 0.12) or survival to hospital discharge between the two groups (26.8 vs 11.8; p = 0.31). There was no difference between arrest location in implementation of mechanical vs manual CPR. No immediate complications or harm were reported from its usage. Our small sample size makes the study underpowered to detect all differences. However, as hospitals reach capacity and a large number of HCW are contracting COVID-19 disease, the use of mechanical CPR device could decrease the risk to HCW while allowing similar outcomes. To our knowledge, this is the first study to report outcomes of mechanical CPR use in COVID-19 patients. Larger studies are needed to confirm the impact on outcomes with the use of mechanical CPR devices.
      Table 1Demographics, comorbidities, characteristics and resuscitation outcomes for COVID-19 patients who had in-hospital cardiac arrest.
      CharacteristicsTotal (N = 58)Manual (N = 41)Mechanical (N = 17)p Value
      Age (yr), median (IQR)66.5 (55.0–76.0)65.0 (58.0–73.0)71.0 (54.0–77.0)0.41
      Age, no (%)0.52
       age<=6017 (29.3%)11 (26.8%)6 (35.3%)
       age>6041 (70.7%)30 (73.2%)11 (64.7%)
      Sex, no (%)0.26
       Male36 (62.1%)27 (65.9%)9 (52.9%)
       Female21 (36.2%)14 (34.1%)7 (41.2%)
       Others1 (1.7%)0 (0.0%)1 (5.9%)
      Race, no (%)0.01
       White31 (53.4%)24 (58.5%)7 (41.2%)
       Black17 (29.3%)14 (34.1%)3 (17.6%)
       Other10 (17.2%)3 (7.3%)7 (41.2%)
      Ethnicity, no (%)0.31
       Hispanic5 (8.6%)5 (12.2%)0 (0.0%)
       Non-Hispanic53 (91.4%)36 (87.8%)17 (100.0%)
      BMI, median (IQR)29.7 (25.8–34.6)30.0 (27.1–35.5)27.5 (24.2–31.8)0.19
      Comorbidities, no (%)
       Coronary artery disease16 (27.6%)8 (19.5%)8 (47.1%)0.03
       Congestive heart failure13 (22.4%)9 (22.0%)4 (23.5%)1.00
       Hypertension38 (65.5%)27 (65.9%)11 (64.7%)0.93
       Diabetes mellitus24 (41.4%)16 (39.0%)8 (47.1%)0.57
       Chronic obstructive pulmonary disease14 (24.1%)11 (26.8%)3 (17.6%)0.52
      On renal replacement therapy, no (%)11 (19.0%)7 (17.1%)4 (23.5%)0.57
      APACHE II on admission, Median (IQR)14.0 (9.0–20.0)13.0 (9.0–17.0)16.0 (12.0–22.0)0.10
      P/F ratio before cardiac arrest, median (IQR)166.0 (100.0–235.0)127.0 (92.0–218.0)206.0 (140.0–278.0)0.07
      Intubation days before cardiac arrest0.23
       N (%)34 (59%)22 (54%)12 (71%)
       Median (IQR)9.0 (2.0–18.0)10.0 (2.0–25.0)2.5 (1.5–10.5)
      On vasopressor before the cardiac arrest, no (%)24 (41.4%)16 (39.0%)8 (47.1%)0.57
      Diagnosed by VTE during the admission, no (%)8 (13.8%)6 (14.6%)2 (11.8%)1.00
      Location of cardiac arrest, no (%)1.00
       Regular nursing floor7 (12.1%)5 (12.2%)2 (11.8%)
       Intensive care unit51 (87.9%)36 (87.8%)15 (88.2%)
      Initial rhythm, no (%)0.48
       Asystole17 (29.3%)14 (34.1%)3 (17.6%)
       PEA37 (63.8%)24 (58.5%)13 (76.5%)
       p.VT/VF4 (6.9%)3 (7.3%)1 (5.9%)
      Received defibrillation, no (%)13 (22.4%)8 (19.5%)5 (29.4%)0.49
      Duration of resuscitation (min), median (IQR)9.5 (5.0–20.0)6.0 (4.0–19.0)14.0 (10.0–22.0)0.01
      ROSC achieved, no (%)37 (63.8%)27 (65.9%)10 (58.8%)0.61
      24 h alive, no (%)27 (46.6%)23 (56.1%)4 (23.5%)0.02
      Discharged from ICU alive, no (%)15 (25.9%)13 (31.7%)2 (11.7%)0.12
      Discharged from hospital alive, no (%)13 (22.4%)11 (26.8%)2 (11.8%)0.31
      CPC at discharge from hospital, no (%)0.12
       N13112
       CPC 1- 25 (38%)3 (27%)2 (100%)
      Change in code to DNR after cardiac arrest, no (%)30 (51.7%)21 (51.2%)9 (52.9%)0.9
      Post ROSC hypothermia, no (%)7 (12.1%)4 (9.8%)3 (17.6%)0.41
      ICU LOS (days), median (IQR)10.5 (3.9–23.0)15.6 (4.0–27.7)8.1 (2.7–9.8)0.07
      Hospital LOS (days), median (IQR)17.0 (9.0–29.0)19.0 (10.0–30.0)9.0 (4.0–17.0)0.02
      BMI, body mass index; APACHE II score, acute physiology and chronic health evaluation II score; VTE, venous thromboembolism, PEA, pulseless electrical activity; p.VT, pulseless ventricular tachycardia; VF, ventricular fibrillation; DNR, do not resuscitate; CPC, cerebral performance category; ROSC, return of spontaneous circulation; ICU, intensive care unit; LOS, length of stay.

      Conflict of interest statement

      There are no conflicts of interest by any of the authors of this manuscript.
      All authors have made substantial contributions to the manuscript in study design, data collection, analysis or interpretation designing of the study, drafting and revising the manuscript. The final submission has been approved by all the authors.

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