Research Article| Volume 58, P98-103, March 2023

Survival after multiple episodes of cardiac arrest

Published:November 26, 2022DOI:


      • Multiple code patients had higher in-hospital mortality
      • Multiple codes within 24 hours led to significantly higher in-hospital mortality
      • Patients sustaining a neurologic event were more likely to have a non-home discharge



      Cardiopulmonary resuscitation (CPR) is widely used in response to cardiac arrest. However, little is known regarding outcomes for those who undergo multiple episodes of cardiac arrest while in the hospital.


      The purpose of this study was to evaluate the association of multiple cardiac events with in-hospital mortality for patients admitted to our tertiary care hospital who underwent multiple code events.


      We performed a retrospective cohort study on all patients who underwent cardiac arrest from 2012 to 2016. Primary outcome was survival to discharge. Secondary outcomes included post-cardiac-arrest neurologic events (PCANE), non-home discharge, and one-year mortality.


      There were 622 patients with an overall mortality rate of 78.0%. Patients undergoing CPR for cardiac arrest once during their admission had lower in-hospital mortality rates compared to those that had multiple (68.9% versus 91.3%, p<.01). Subset analysis of those who had multiple episodes of CPR revealed that more than one event within a 24-hour period led to significantly higher in-hospital mortality rates (94.7% versus 74.4%, p<.01). Other variables associated with in-hospital mortality included body mass index, female sex, malignancy, and increased down time per code. Patients that had a non-home discharge were more likely to have sustained a PCANE than those that were discharged home (31.4% versus 3.9%, p<.01). A non-home discharge was associated with higher one-year mortality rates compared to a home discharge (78.4% versus 54.3%, p=.01).


      Multiple codes within a 24-hour period and the average time per code were associated with in-hospital mortality in cardiac arrest patients.



      CPR (Cardiopulmonary resuscitation), ACLS (Advanced circulatory life support)
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        • Merchant R.M.
        • Yang L.
        • Becker L.B.
        • et al.
        Incidence of treated cardiac arrest in hospitalized patients in the United States.
        Crit Care Med. 2011; 39: 2401-2406
        • Mallikethi-Reddy S.
        • Briasoulis A.
        • Akintoye E.
        • et al.
        Incidence and survival after in-hospital cardiopulmonary resuscitation in nonelderly adults.
        Circ Cardiovasc Qual Outcomes. 2017; 10e003194
        • Marco C.A.
        • Larkin G.L.
        Cardiopulmonary resuscitation: knowledge and opinions among the U.S. general public. State of the science-fiction.
        Resuscitation. 2008; 79: 490-498
        • Jones G.K.
        • Brewer K.L.
        • Garrison H.G.
        Public expectations of survival following cardiopulmonary resuscitation.
        Acad Emerg Med. 2000; 7: 48-53
        • Rhodes A.
        • Evans L.E.
        • Alhazzani W.
        • et al.
        Surviving Sepsis Campaign: international Guidelines for Management of Sepsis and Septic Shock: 2016.
        Crit Care Med. 2017; 43: 304-377
        • Bloom H.L.
        • Shukrullah I.
        • Cuellar J.R.
        • et al.
        Long-term survival after successful inhospital cardiac arrest resuscitation.
        Am Heart J. 2007; 153: 831-836
        • Schluep M.
        • Gravesteijn B.Y.
        • Stolker R.J.
        • et al.
        One-year survival after in-hospital cardiac arrest: a systematic review and meta-analysis.
        Resuscitation. 2018; 132: 90-100
        • Lurie K.G.
        • Nemergut E.C.
        • Yannopoulos D.
        • et al.
        The Physiology of Cardiopulmonary Resuscitation.
        Anesth Analg. 2016; 122: 767-783
        • Rea T.D.
        • Cook A.J.
        • Hallstrom A.
        CPR during ischemia and reperfusion: a model for survival benefits.
        Resuscitation. 2008; 77: 6-9
        • Rohlin O.
        • Taeri T.
        • Netzereab S.
        • et al.
        Duration of CPR and impact on 30-day survival after ROSC for in-hospital cardiac arrest—A Swedish cohort study.
        Resuscitation. 2018; 132: 1-5
        • Goldberger Z.D.
        • Chan P.S.
        • Berg R.A.
        • et al.
        Duration of resuscitation efforts and survival after in-hospital cardiac arrest: an observational study.
        The Lancet. 2012; 380: 1473-1481
        • Gil E.
        • Na S.J.
        • Ryu J.A.
        • et al.
        Association of body mass index with clinical outcomes for in-hospital cardiac arrest adult patients following extracorporeal cardiopulmonary resuscitation.
        PLoS One. 2017; 12e0176143
        • Secombe P.
        • Sutherland R.
        • Johnson R.
        Body mass index and thoracic subcutaneous adipose tissue depth: possible implications for adequacy of chest compressions.
        BMC Res Notes. 2017; 10: 575
        • Guha A.
        • Buck B.
        • Biersmith M.
        • et al.
        Contemporary impacts of a cancer diagnosis on survival following in-hospital cardiac arrest.
        Resuscitation. 2019; 142: 30-37
        • Eranti A.
        • Kerola T.
        • Aro A.L.
        • et al.
        Diabetes, glucose tolerance, and the risk of sudden cardiac death.
        BMC Cardiovasc Disord. 2016; 16: 51
        • Jouven X.
        • Lemaître R.N.
        • Rea T.D.
        • et al.
        Diabetes, glucose level, and risk of sudden cardiac death.
        Eur Heart J. 2005; 26: 2142-2147
        • Petursson P.
        • et al.
        Patients with a history of diabetes have a lower survival rate after in-hospital cardiac arrest.
        Resuscitation. 2008; 76: 37-42
        • Fowler M.J.
        Microvascular and macrovascular complications of diabetes.
        Clin Diabetes. 2011; 29: 116-122
        • Levy B.I.
        • Schiffrin E.L.
        • Mourad J.J.
        • et al.
        Impaired tissue perfusion a pathology common to hypertension, obesity, and diabetes mellitus.
        Circulation. 2008; 118: 968-976
        • Hoybye M.
        • Stankovic N.
        • Holmberg M.
        • et al.
        In-hospital versus out-of-hospital cardiac arrest: patient characteristics and survival.
        Resuscitation. 2021; 158: 157-165
        • Washida K.
        • Kato T.
        • Ozasa N.
        • et al.
        Risk factors and clinical outcomes of nonhome discharge in patients with acute decompensated heart failure: an observational study.
        J Am Heart Assoc. 2021; 10: 20292
        • Lala A.
        • Chang H.
        • Liu x
        • et al.
        Risk for non-home discharge following surgery for ischemic mitral valve disease.
        J Thorac Cardiovasc Surg. 2021; 162: 1769-1778
        • Mori M.
        • Usman S.
        • Mahmood B.
        • et al.
        Persistence of risk of death after hospital discharge to locations other than home after cardiac surgery.
        J Thorac Cardiovasc Surg. 2020; 159: 528-535
        • Malik A.T.
        • et al.
        Incidence, risk factors, and clinical impact of non-home discharge following surgical management of proximal humerus fractures.
        Shoulder Elbow. 2019; 11: 430-439