Is it possible to terminate resuscitation in accordance with the termination of resuscitation rule?

We appreciate the interests of Bernhard et al. and Yoon et al. regarding our article in Critical Care, which showed a high false-positive rate (FPR) for the termination of resuscitation (TOR) rules in patients with out-of-hospital cardiac arrest (OHCA) with a non-cardiac etiology (1). We agree with their views (2,3), and herein we respond to their comments and provide results of our reanalysis.

Bernhard et al. pointed out generalizability as a problem of our study, such as the exclusion of trauma or young patients (<18 years old), regional limitation, and fact that we did not evaluate the basic life support (BLS) TOR rule as a universal TOR rule (2). First, the prognosis of young patients with OHCA is better than that of older patients. Therefore, the exclusion of young patients may underestimate, not overestimate, the result of our study. In addition, the result of young patients will be reported in another study subgroup. Second, we excluded trauma patients when evaluating BLS and advanced life support (ALS) TOR rules, because there are other TOR position statements by the National Association of Emergency Medical Service Physicians and the Subcommittee on Emergency Services-Prehospital of the American College of Surgeons’ Committee on Trauma (4). Third, we investigated the diagnostic accuracy of BLS and ALS TOR rules according to the American Heart Association cardiopulmonary resuscitation (CPR) guideline, not the BLS TOR rule as a universal TOR rule (5). On the basis of the comments by Bernhard et al., we reanalyzed the BLS TOR rule as a universal TOR rule and included trauma patients (Table 1). Even after this reanalysis, the BLS TOR rule had a low specificity and high FPR in patients with a non-cardiac etiology, although it had a high specificity and low FPR in patients with a cardiac etiology. Finally, the Kanto area in Japan where our study was conducted has a denser population than other regions in Japan. The regional limitation is important, as we mentioned previously (1), and a population-based study is needed. However, an emergency medical service system, including transportation of patients with OHCA, is authorized regionally. The result of our study suggested that the TOR rule may be established for each region, because the diagnostic accuracy of the TOR rule can differ in each region or emergency medical service system.

Table 1 Diagnostic accuracy of basic life support termination of resuscitation rules for 1-month neurological outcomes
Full table

The CPR duration is an important problem in TOR for OHCA, as Yoon et al. mentioned. The CPR duration is independently and inversely associated with favorable neurological outcomes and survival. Previous studies have shown that the prehospital CPR durations for OHCA are 35–48 minutes in patients with initial shockable rhythm, and 15–48 minutes in those with initial pulseless electrical activity or asystole, at which time the probability of survival decreased to <1% (6,7). However, the current CPR guidelines did not mention a specific time limit for CPR duration (5). In the future, the CPR duration should be considered to establish a new TOR rule.

Cost-effectiveness is very important with regard to the TOR rule. Moreover, emergency services providers are at risk of injury from motor vehicle crashes during emergency transportation. Using the BLS TOR rule decreased futile transportation by approximately 50% in previous study (8). However, the decision of TOR is more challenging compared to other interventions with an ethical dilemma. Therefore, it has been argued that success rates of <1% still justify the effort of resuscitation (9), and we should validate or re-evaluate the TOR rule according to the result of our study.

In conclusion, the present TOR rule has several limitations if used as the universal TOR rule. Additionally, the TOR rule should be reconsidered for each region and emergency medical service system.

Acknowledgements

None.

Footnote

Provenance: This is an invited article commissioned by the Section Editor Zhongheng Zhang (Department of Critical Care Medicine, Jinhua Municipal Central Hospital, Jinhua Hospital of Zhejiang University, Jinhua, China).

Conflicts of Interest: The authors have no conflicts of interest to declare.

Response to: Bernhard M, Becker TK, Hossfeld B. Should we resuscitate or not-that is the question! J Thorac Dis 2016;8:1053-6.
Yoon JC, Kim WY. What should we consider when applying termination of resuscitation rules? J Thorac Dis 2016;8:1377-80.

References

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