What is the frequency of rearrest after Return of Spontaneous Circulation (ROSC)?

Frequency of Rearrest After Return of Spontaneous Circulation (ROSC)

Rearrest after ROSC occurs in approximately 36-55% of patients with out-of-hospital cardiac arrest (OHCA), representing a significant challenge in post-cardiac arrest care. 1, 2

Incidence of Rearrest

• Rearrest occurs in 36% (95% CI: 26-46%) of patients who achieve ROSC after OHCA, with a total of 69 rearrest events observed in 41 patients in one observational study 1
• More recent data indicates the frequency may be even higher, with 54.8% of patients experiencing rearrest after achieving prehospital ROSC in a multi-regional observational study 2
• For in-hospital cardiac arrests (IHCA), approximately 61.7% achieve ROSC, but subsequent rearrest can compromise outcomes 3

Timing of Rearrest

• The median time from ROSC to rearrest is 3.1 minutes (interquartile range: 1.6-6.3 minutes), indicating that most rearrest events occur early after resuscitation 1
• This short window emphasizes the importance of immediate post-ROSC stabilization and monitoring 4

Types of Rearrest Rhythms

The distribution of rearrest rhythms has been documented as:

• Pulseless electrical activity (PEA): 37% (95% CI: 26.3-50.2%) 1
• Pulseless ventricular tachycardia (VT): 29% (95% CI: 18.7-41.2%) 1
• Ventricular fibrillation (VF): 24.6% (95% CI: 15.2-36.5%) 1
• Asystole: 8.8% (95% CI: 3.3-18.0%) 1

Risk Factors for Rearrest

• Longer interval from collapse to first prehospital ROSC (OR 1.081; 95% CI 1.050-1.114) is independently associated with rearrest 2
• A cut-off time of 24 minutes from collapse to first ROSC has been identified as a predictor of rearrest (sensitivity 77%, specificity 54%) 2
• Initial non-shockable rhythms are associated with higher rates of rearrest 1, 2

Impact on Survival

• Survival to hospital discharge in patients who experience rearrest is 23.1% (95% CI: 11.1-39.3%), compared to 27.8% (95% CI: 17.9-39.6%) in patients without rearrest 1
• The presence of an initial shockable rhythm is independently associated with survival after rearrest (OR 6.920; 95% CI 2.749-17.422) 2

Prevention and Management Strategies

• Post-ROSC care bundles that include hemodynamic stabilization are recommended to potentially reduce rearrest, though evidence for their effectiveness is mixed 5
• Maintaining mean arterial pressure (MAP) greater than 65 mm Hg is suggested as part of post-ROSC care to improve outcomes 4
• Push-dose epinephrine has been associated with decreased odds of rearrest (OR 0.68,95% CI 0.50,0.94) in exploratory analyses 5
• For patients with ventricular arrhythmias after ROSC, prophylactic antiarrhythmic drugs may be considered, though evidence is limited 4
• Beta-blockers administered for 72 hours after ROSC have shown higher rates of survival in some observational studies 4
• Lidocaine bolus and/or continuous infusion immediately after ROSC has been associated with lower adjusted rates of recurrence of VF (OR, 0.34; 95% CI, 0.26–0.44) 4

Clinical Implications

• Healthcare providers should anticipate and be prepared for rearrest, particularly in the first few minutes after achieving ROSC 1, 2
• Continuous monitoring and immediate access to defibrillation equipment are essential during the post-ROSC period 4
• Comprehensive post-arrest care requires a multidisciplinary team approach, especially for in-hospital cardiac arrests 4
• Attention to hemodynamic parameters, ventilation strategies, and addressing the underlying cause of arrest are critical components of preventing rearrest 4