Hong Kong Med J 2023;29:Epub 23 Aug 2023
© Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
Survival of out-of-hospital cardiac arrest following a return of spontaneous circulation beyond 30 minutes
KL Hon, MB, BS, MD1; Karen KY Leung, MB, BS, MRCPCH1; KL Chan, MB, ChB, MRCPCH1; WF Hui, MB, ChB, MRCPCH1; KT Chau, MB, BS, FRCPCH1; SY Qian, MD2
1 Department of Paediatrics and Adolescent Medicine, Hong Kong Children’s Hospital, Hong Kong SAR, China
2 Pediatric Intensive Care Unit, Beijing Children’s Hospital, Capital Medical University, Beijing, China
Corresponding author: Dr KL Hon (ehon@hotmail.com)
 Full paper in PDF
To the Editor—There was a local blog report in Hong Kong of a 5-year-old girl who experienced out-of-hospital cardiac arrest (OHCA) with return of spontaneous circulation (ROSC) after 31 minutes and was discharged with an implantable cardioverter defibrillator.1 However, ROSC within 30 minutes is usually required for a favourable outcome.2 3
We performed a literature search to determine the longest time to ROSC and survival rates of OHCA in children (Table). Out-of-hospital cardiac arrest in children has a poor prognosis and prolonged in-hospital resuscitation beyond 30 minutes does not improve survival.3 Predictors of survival to discharge include witnessed arrest (P=0.012), delivery of bystander cardiopulmonary resuscitation (P=0.003), and duration of resuscitation (P=0.028). However, none who received more than 30 minutes of in-hospital resuscitation survived.4 A prospective study found that no patients who required >2 doses of adrenaline or in-hospital resuscitation for longer than 20 minutes survived to discharge.5 However, it is possible that ROSC beyond 30 minutes has not been reported, or that this case is an exception.

Table. Selective paediatric references on out-of-hospital cardiac arrest following return of spontaneous circulation
Evidence suggests that either death or a poor outcome is inevitable if OHCA occurs more than 30 minutes from the nearest healthcare facility or the resuscitation exceeds 30 minutes.6 7 A 2017 study reported that the survival rate to discharge in Hong Kong was only 2.3%, which was considerably lower than the global survival rate in adults (8.8%).8 9 As OHCA in children has not been evaluated in Hong Kong, we concur with a 2019 editorial published in the Hong Kong Medical Journal that suggested the establishment of an OHCA registry.10
Many parents and family members who are present during a resuscitation attempt would want to be in attendance if their child were likely to die, and this experience can help with later grieving without impacting on the resuscitation process. If appropriate, family-centred care should be practised and parents should be involved in the decision-making process.6 As paediatricians, although our patient is the child, his/her family members are also important—after all, if the child passes away, it is the family who must shoulder the lifelong emotional burden.
In summary, OHCA in children has a poor prognosis and prolonged resuscitation does not improve survival or outcome.
Author contributions
All authors contributed to the drafting of the letter and critical revision for important intellectual content. All authors approved the final version for publication and take responsibility for its accuracy and integrity.
Conflicts of interest
As an editor of the journal, KL Hon was not involved in the peer review process. Other authors have disclosed no conflicts of interest.
This letter received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
1. Philip. 死去31分鐘的女兒 [in Chinese]. Available from: https://todecidenow.wordpress.com/2021/01/31/死去31分鐘的女兒!/. Accessed 24 Jul 2023.
2. Hon KL, Tse TT, Au CC, et al. Brain death in children: a retrospective review of patients at a paediatric intensive care unit. Hong Kong Med J 2020;26:120-6. Crossref
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4. Tham LP, Chan I. Paediatric out-of-hospital cardiac arrests: epidemiology and outcome. Singapore Med J 2005;46:289-96.
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6. American College of Surgeons Committee on Trauma; American College of Emergency Physicians Pediatric Emergency Medicine Committee; National Association of EMS Physicians; American Academy of Pediatrics Committee on Pediatric Emergency Medicine; Fallat ME. Withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary arrest. Pediatrics 2014;133:e1104-16. Crossref
7. American Heart Association. Highlights of the 2020 American Heart Association Guidelines for CPR and ECC. 2020. Available from: https://cpr.heart.org/-/media/cpr-files/cpr-guidelines-files/highlights/hghlghts_2020_ecc_guidelines_english.pdf. Accessed 3 Apr 2021.
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9. Yan S, Gan Y, Jiang N, et al. The global survival rate among adult out-of-hospital cardiac arrest patients who received cardiopulmonary resuscitation: a systematic review and meta-analysis. Crit Care 2020;24:61. Crossref
10. Wu WY. Out-of-hospital cardiac arrest: the importance of a registry. Hong Kong Med J 2019;25:176-7. Crossref