Cardiopulmonary Resuscitation Above 75 Years: Is It Worthwhile?* Claudio Sandroni, MD, FERC Antonio Maria Dell’ Anna, MD Department of Anesthesiology and Intensive Care Catholic University School of Medicine Rome, Italy

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bout 276,000 victims of cardiac arrest are registered each year in United States and 51% of them are older than 64 years (1). This percentage is expected to increase in the next decades, consistently with a progressive ageing of the population. In the world, people older than 60 years are increasing twice as faster than the total population and are expected to reach 107 million in United States by 2050 (2). Older age is associated with increased mortality after cardiac arrest (3), although the independence of this association is debated (4, 5). However, little is known on whether age also affects neurological outcome, which is a major determinant of quality of life after cardiac arrest and an independent predictor of long-term survival (6). Major clinical trials evaluating the effects of neuroprotective interventions excluded patients who are older than 75 years (7). In a study published in this issue of Critical Care Medicine, Grimaldi et al (8) retrospectively analyzed the clinical data of 225 consecutive patients who are older than 75 years (median, 79.5 yr; interquartile range, 76–83.5) admitted to a French ICU from 2000 to 2009 after successful resuscitation from out-ofhospital cardiac arrest. The authors investigated on the factors associated with survival and with neurological status, assessed using cerebral performance categories (CPC), both at ICU discharge and at 5-year follow-up. Long-term survival rates were compared with those of a large community-based cohort of subjects who are older than 75 years (9). Variables potentially associated with neurological outcome were investigated using logistic regression analysis. At ICU discharge, 60 of 225 patients (27%) were alive. Of these, 57 (95%) had a good neurological outcome (CPC 1 or 2). At 5-year follow-up (mean, 28.4 mo), 23 of 60 ICU-discharged patients (38%) were still alive, all with CPC 1–2. Despite a progressive increase of mean age of resuscitated patients across the study period (from 79.5 to 82 yr), the proportion of good outcome patients remained stable over time. After adjustment for covariates, an initial shockable rhythm, a short no flow time, and low lactate

*See also p. 2350. Key Words: aged; cardiopulmonary resuscitation; heart arrest; outcome; out of hospital The authors have disclosed that they do not have any potential conflicts of interest. Copyright © 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/CCM.0000000000000567

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levels at admission were independent predictors of good short- or long-term outcome, whereas age less than 79.5 years was not. Results of this study are encouraging and suggest that resuscitation in those patients was worthwhile. One quarter of the initially resuscitated elderly patients survived to ICU discharge and more than 10% of them survived at 5-year follow-up, all with good neurological outcome. Long-term survival was significantly lower than that of age-matched controls (9), but it was still higher than that reported in a recent larger follow-up study (6) on elderly patients who are older than 65 years resuscitated from in-hospital cardiac arrest. How can those brilliant results be explained? One of the reasons could be the characteristics of the study population. First, the study was restricted to patients admitted to ICU, therefore excluding the most severe patients who died in the preadmission phase. Furthermore, the study was conducted in France, where prehospital advanced cardiac life support is provided by medical teams (10) who can stop resuscitation and certify the patient death in the field when futility is perceived. This may have resulted in a prehospital selection of patients with the most favorable characteristics; in fact, almost 60% of included patients (70% of those with good outcome) had a shockable initial rhythm, which is consistent with the short rescue times reported in the study: in fact, 57% of patients had cardiopulmonary resuscitation (CPR) started within 3 minutes from the arrest. These short rescue times are in turn consistent with the distribution of the cardiac arrest location: despite their old age, 28% of included patients (43% in the good outcome group) were resuscitated in a public place versus only 3% reported in a comparable population in a large Australian study (3), where 94% of victims were at home or in a nursing home. This selective process may have not occurred only in the prehospital phase. Another observational study recently published in Critical Care Medicine (5) demonstrated that when compared with younger victims of cardiac arrest with similar event characteristics, patients who are older than 75 years are not only less likely to be resuscitated but also more likely to undergo withdrawal of life-sustaining treatment (WLST) after resuscitation. When compared with a recent large trial on targeted temperature management (TTM) after cardiac arrest (11), which had similar admission criteria but included younger patients, the study by Grimaldi et al (8) showed a significantly lower number of ICU survivors (60/285 [21%] vs 629/939 [67%]), but the rate of good neurological outcome in these patients was much higher (57/60 [95%] vs 371/629 [59%]; p < 0.0001 for both), with virtually no patient leaving ICU with persisting unconsciousness, as compared with 18.3% in the TTM trial. Almost half of the ICU deaths in the study by Grimaldi et al (8) (79/165 patients; 48%) were due to WLST, based on prediction of poor neurological outcome made according to a rigorous prognostication protocol applied during the early postresuscitation November 2014 • Volume 42 • Number 11

Editorials

phase (see Supplementary Fig. 1 in [8]). Most of the remaining patients (47%) died of cardiovascular collapse or organ failure, which suggests that the intrinsic frailty of elderly patients may also have contributed to this high early mortality. In summary, exclusion of patients who are older than 75 years from CPR is not warranted on the basis of age alone. Elderly victims of cardiac arrest can have an excellent long-term outcome, but this concerns mainly a minority of patients with favorable characteristics. The retrospective study by Grimaldi et al (8) provided important clues to identify the ideal elderly patient to be resuscitated, although achieving this goal will need further investigation in larger prospective studies. REFERENCES

1. McNally B, Robb R, Mehta M, et al; Centers for Disease Control and Prevention: Out-of-hospital cardiac arrest surveillance—Cardiac Arrest Registry to Enhance Survival (CARES), United States, October 1, 2005–December 31, 2010. MMWR Surveill Summ 2011; 60:1–19 2. United Nations-Department of Economic and Social AffairsPopulation Division: Magnitude and speed of population ageing. 2002. Available at: http://www.un.org/esa/population/publications/ worldageing19502050/. Accessed June 10, 2014

3. Deasy C, Bray JE, Smith K, et al; VACAR Steering Committee: Outof-hospital cardiac arrests in the older age groups in Melbourne, Australia. Resuscitation 2011; 82:398–403 4. Sandroni C, Caricato A: Outcomes in elderly patients resuscitated from cardiac arrest: Is age an independent predictor? Crit Care Med 2014; 42:453–454 5. Seder DB, Patel N, McPherson J, et al: Geriatric experience following cardiac arrest at six interventional cardiology centers in the United States 2006–2011: Interplay of age, do-not-resuscitate order, and outcomes. Crit Care Med 2014; 42:289–295 6. Chan PS, Spertus JA, Nallamothu BK: Long-term outcomes in elderly survivors of cardiac arrest. N Engl J Med 2013; 368:2438–2439 7. HACA Study Group: Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med 2002; 346:549–556 8. Grimaldi D, Dumas F, Perier M-C, et al: Short- and Long-Term Outcome in Elderly Patients After Out-of-Hospital Cardiac Arrest: A Cohort Study. Crit Care Med 2014; 42:2350–2357 9. 3C Study Group: Vascular factors and risk of dementia: Design of the Three-City Study and baseline characteristics of the study population. Neuroepidemiology 2003; 22:316–325 10. Bougouin W, Lamhaut L, Marijon E, et al: Characteristics and prognosis of sudden cardiac death in Greater Paris: Population-based approach from the Paris Sudden Death Expertise Center (ParisSDEC). Intensive Care Med 2014; 40:846–854 11. Nielsen N, Wetterslev J, Cronberg T, et al: Targeted temperature management at 33 degrees C versus 36 degrees C after cardiac arrest. N Engl J Med 2013; 369:2197–2206

When Is “Dead” Actually Dead?* Divya Gupta, MD Advanced Heart Failure and Transplant Division of Cardiology Emory University School of Medicine Atlanta, GA

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ho would ever think that the simple concept of “death” could actually be so complicated? Through debate and trial, we have legally and medically defined the permanent end to life. Organ donation and procurement is a major topic that spurs controversy behind the definition and timing of death. Although brain death was first defined in 1968, the Uniform Brain Death Act of 1978 nationally acknowledged that although a person may have a pulse, their irreversible lack of brain function was grounds to declare them legally dead (1–3). The legal definition of death was expanded to include the “irreversible cessation of circulatory and respiratory function” by the Uniform

*See also p. 2358. Key Words: autoresuscitation; brain death; circulatory death; death; organ donation The author has disclosed that she does not have any potential conflicts of interest. Copyright © 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/CCM.0000000000000442

Critical Care Medicine

Determination of Death Act of 1981 (2); irreversible being the operative word. In the 1800s, when checking for a pulse and looking for chest rise to assess respiration were some of the only rudimentary methods of determining death, concern for autoresuscitation or the “Lazarus phenomenon” plagued society. Coffins were built with escape mechanisms in place as a provisional measure (2). Interestingly, our methods of determining death have become more sophisticated; however, organ procurement remains haunted by this concern when dealing with donation after circulatory death (DCD). The “dead donor rule” causes us to take pause: it is unethical to cause death by organ procurement and unethical for organ procurement to precede death (4). To assure such travesties did not take place, the Institute of Medicine in 1997 mandated monitoring the deceased for 5 minutes after the stated time of death to confirm irreversibility prior to procurement (4–6). How exactly can we declare circulatory death and what is the appropriate amount of time to wait after time of death to confirm a person’s demise is irreversible? We have clearly defined brain death and can test for brain activity, reflexes, and spontaneous respiration. Concerning organ donation, the continued flow of blood and oxygen to organs despite death allows for greater leeway when timing confirmation of brain death and organ procurement. However, circulatory death is just that, the end of circulation to organs, starting the clock on ischemic injury. In an effort to decrease www.ccmjournal.org

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Cardiopulmonary resuscitation above 75 years: is it worthwhile?.

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