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Clinical Context

Survival of cardiac arrest both within the hospital and in the community have declined precipitously since the advent of the pandemic, according to the authors of a recent 2022 interim guidance on CPR/ACLS in known or suspected COVID-19 patients. Several factors could explain these results, such as the severity of SARS-CoV-2 related cardiac arrest, the implementation or termination of resuscitation guidance, local crisis standards of care or patient hesitancy to seek medical care contributing to delays in care.

The provision of prompt chest compressions and defibrillation may also have been delayed due to the additional time required in donning personal protective equipment (PPE) or securing the airway and the PPE may have accelerated rescuer fatigue resulting in decreased CPR quality of which is a lack of PPE or delay in resuscitation resulting from the time required to don PPE.

Experts recommend that the resuscitation team wear PPE for all aerosol-generating procedures (AGPs) involving patients with known or suspected COVID-19. AGPs include chest compressions, defibrillation, bag-mask ventilation, intubation, and positive-pressure ventilation. The current interim guidance highlights specific recommendations for in-hospital resuscitation.

Study Synopsis and Perspective

Based on new and more transmittable COVID-19 strains, declining vaccine effectiveness and feedback from the healthcare community, it became clear that that there was a need to create interim guidance for basic and advanced life support. The American Heart Association, working with the American Academy of Pediatrics, the American Association for Respiratory Care, the Society of Critical Care Anesthesiologists, and the American Society of Anesthesiologists, have issued the 2022 Interim Guidance for Basic and Advanced Life Support in Adults, Children and Neonates with Suspected or Confirmed COVID-19.

The updated guidance was published online January 24^th, 2022, in Circulation: Cardiovascular Quality and Outcomes. The goal was to fully protect healthcare providers who perform resuscitation and highlights specific recommendations for in-hospital resuscitation. The guidance can be considered a best practice statement and have not gone through a formal evidence review and subsequently, cannot be assigned a Class of Recommendation or Level of Evidence. The guidance is based on available scientific evidence at the time of its development and will continue to evolve as the pandemic continues.

Updates in the interim guidance focus on three tenets:

1. Incorporating the most recent Centers for Disease Control and Prevention and World Health Organization guidance

All healthcare providers should wear a respirator (eg, N95) along with other PPE (gown, gloves, and eye protection) for patients with suspected or confirmed COVID-19 infection before performing Aerosol-generating procedures (AGPs) or in a setting where such procedures are regularly performed. This may also apply to patients in cardiac arrest who tested negative for COVID-19 on admission. In the event initial responders are not already wearing appropriate PPE, they should immediately don it and then begin CPR.

(AGPs) include chest compressions, defibrillation, bag-mask ventilation, intubation, and positive-pressure ventilation.

2. Reinforcing resuscitation best practices

Cardiac arrest survival is dependent on early initiation of CPR and performing chest compressions as soon as it is safely possible is recommended. Patients with confirmed or suspected COVID-19 should receive the best resuscitative efforts possible.

3. Ensuring adequate PPE supply

Effective use of PPE is critical for the safety of healthcare providers performing resuscitations, and at this time, all healthcare providers should be following appropriate precautions and should have access to PPE in all clinical settings, regardless of the potential of encountering resuscitation events.

"Healthcare professionals are paramount to the health of communities around the world, especially during a pandemic, and they should be protected while performing healthcare procedures, including resuscitation," Dianne Atkins, MD, pediatric cardiologist, and lead author of the new interim guidance, said in a news release.

"Protecting the health and safety of healthcare professionals remains critical and includes ensuring the recommended [PPE] is available and that healthcare professionals are trained to use it properly," added Dr Atkins, who chairs the AHA emergency cardiovascular care committee.

Circ Cardiovasc Qual Outcomes. Published online January 24, 2022.^[1]

Clinical Implications

• AGPs during CPR include chest compressions, defibrillation, bag-mask ventilation, intubation, and positive-pressure ventilation.
• The current interim guidance recommends the following interventions during CPR for patients with known or suspected COVID-19: universal application of HEPA filters to ventilation devices, using the most accomplished person to attempt intubation on such patients, avoiding the use of endotracheal medications, and initiating compressions among patients in the prone position while considering transition to the supine position.
• Implications for the healthcare team: Health care professionals should work collaboratively as a team to understand the current guidance for CPR among patients with known or suspected COVID-19 infection. All team members should understand their roles.

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