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. 2019 May 3;2(5):e194941.
doi: 10.1001/jamanetworkopen.2019.4941.

Reexamination of the UN10 Rule to Discontinue Resuscitation During In-Hospital Cardiac Arrest

Bradley J Petek  1 , Daniel N Bennett  2 , Christian Ngo  3 , Paul S Chan  4 , Brahmajee K Nallamothu  5   6 , Steven M Bradley  7 , Yuanyuan Tang  4 , Rodney A Hayward  5   6 , Carl van Walraven  8 , Zachary D Goldberger  9 ; American Heart Association Get With the Guidelines–Resuscitation Investigators
Affiliations

Reexamination of the UN10 Rule to Discontinue Resuscitation During In-Hospital Cardiac Arrest

Bradley J Petek et al. JAMA Netw Open. .

Abstract

Importance: Several clinical decision rules (CDRs) have been developed to help practitioners know when to safely terminate resuscitative efforts after in-hospital cardiac arrest (IHCA). The UN10 rule, a CDR that uses 3 intra-arrest variables, has been shown to predict a poor chance of survival to discharge. However, its large-scale applicability in clinical settings remains unknown.

Objective: To assess the performance of a parsimonious CDR in a national cohort of individuals with IHCA.

Design, setting, and participants: This retrospective cohort study used a nationwide cohort from the American Heart Association Get With the Guidelines-Resuscitation IHCA registry to derive a sample of 96 509 patients from 716 US hospitals who experienced IHCA from January 1, 2000, to January 26, 2016. Data analysis began in January 2018 and concluded in June 2018.

Exposures: The UN10 rule uses 3 variables: (1) unwitnessed arrest, (2) nonshockable rhythm, and (3) no return of spontaneous circulation within 10 minutes of resuscitative efforts. The CDR indicates futility if all 3 criteria are met. This CDR was analyzed according to the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) reporting guideline.

Main outcomes and measures: The primary outcome was survival to hospital discharge following resuscitation. Favorable neurologic status at discharge was also assessed. Overall rates of survival and survival with favorable neurologic status (cerebral performance category score, 1 or 2) were compared with predicted values by the UN10 rule using 2 × 2 contingency tables.

Results: Of 96 509 patients, 55 761 (57.8%) were men, and the mean (SD) age was 67.1 (15.3) years. In total, 18 713 patients (19.4%) survived to discharge, and 16 134 patients (16.7%) were discharged with a favorable neurologic status. Overall, 15 838 patients (16.4%) met all 3 criteria for futility in the UN10 rule. A total of 1005 patients (6.3%) who met the UN10 rule survived to discharge, and 754 (4.8%) survived with favorable neurologic status. The percentage of patients meeting the UN10 rule (ie, predicting futile resuscitation) who actually survived in our study cohort was substantially higher than the initial derivation cohort (0%) and single-center validation cohort (1.1%). The positive predictive value of the UN10 rule was 93.7% (95% CI, 93.3%-94.0%), which was lower than the initial derivation cohort (100%; 95% CI, 97.5%-100%) and validation cohort (98.9%; 95% CI, 96.5%-99.7%).

Conclusions and relevance: Patients who met the UN10 rule were associated with unfavorable neurologic status and low rates of survival after IHCA. Yet their survival rates are higher than reported in the initial validation study, raising the question of whether the UN10 rule may have limited utility as a definitive measure of futility during resuscitations in real-world clinical settings.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Chan reported performing consulting work for the American Heart Association and Optum Rx during the conduct of the study. Dr Nallamothu reported being a principal investigator or coinvestigator on research grants from the National Institutes of Health, Veterans Affairs Health Services Research and Development Service, the American Heart Association, and Apple, Inc; serving as editor in chief of Circulation: Cardiovascular Quality & Outcomes, a journal of the American Heart Association; and being coinventor on US utility patent US15/356,012 (US20170148158A1, held by the University of Michigan and licensed to AngioInsight Inc, in which Dr Nallamothu holds ownership shares), entitled “Automated Analysis of Vasculature in Coronary Angiograms” that uses software technology with signal processing and machine learning to automate the reading of coronary angiograms. No other disclosures were reported.

Figures

Figure.
Figure.. Population of Patients Used to Revalidate the UN10 Rule
ED indicates emergency department; IHCA, in-hospital cardiac arrest; ROSC, return of spontaneous circulation; VF, ventricular fibrillation; and VT, ventricular tachycardia.
See this image and copyright information in PMC

References

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