Updates in resuscitation.pptx ( hpp )

Updates in resuscitation 2015 CPR guidelines

Dr Luah Lean Wah

Consultant anaesthesiologist

Penang Hospital

Content of lecture

• ILCOR and 2015 CPR guidelines development process

• Highlights in BLS guideline

• Updates in ALS

• Post cardiac arrest care

• American Heart Association (AHA)• European Resuscitation Council (ERC)• Heart and Stroke Foundation of Canada (HSFC)• Australian and New Zealand Committee on Resuscitation

(ANZCOR)• Resuscitation Council of Southern Africa (RCSA)• Inter American Heart Foundation (IAHF)• Resuscitation Council of Asia (RCA)

Was formed in 1992 Forum for liaison between principal

resuscitation organizations worldwide allow evaluation process by which the

international science and knowledge relevant to CPR and ECC is identified and reviewed

ILCOR

• every 5 years a new set of treatment recommendation is released

• The first set of guidelines was released in 2000, then 2005, 2010 and the latest is released in October of 2015

• 15 October 2015

2015 CPR Guidelines Developmental Process

• 250 evidence reviewers from 39 countries

• 169 specific resuscitation questions in standard PICO ( population, intervention, comparison, Outcome ) format

• Specific GRADE ( Grading of Recommendations Assessment, Development and Evaluation ) methodology

2015 CPR Guidelines Developmental Process

• The output of the GRADE process :

2015 International Consensus on CPR and ECC Science With Treatment Recommendations (CoSTR)

• Recent International Consensus Conference in Dallas ( Feb 2015 )

Experts discussed & debated

• Emphasize the interactions between the emergency medical dispatcher, the bystander who provides CPR and the use of AED and EMS

• Public CPR – hands- only CPR

Highlights in BLS 2015

• Emphasize the importance of early diagnosis of cardiac arrest and the provision of dispatcher assisted CPR( Telephone CPR) through MECC Call Dispatcher via MERS 999 call

Highlights in BLS 2015

Highlights in BLS 2015

• Emphasis on high quality CPR

The compression rate is 100 – 120 compression / minute

Compression depth : at least 5 cm but not more than 6 cm

Minimal Interruption (less than 10 sec)

Full chest wall recoil

• Be aware that seizures could be a sign of Cardiac Arrest

• Suggest to use of Real Time Audiovisual feedback and prompt devices during CPR in clinical practice and against in isolation practice

Highlights in BLS 2015

2015 ALS guidelines

What’s new

2015 ALS Guidelines

• ILCOR review focused on 42 topics

• Organized in the approximate sequence of ACLS interventions:

defibrillation

airway, oxygenation and ventilation

circulatory support

monitoring during CPR

drugs during CPR

Chain of prevention: staff education Monitoring of patients Recognition of the patient’s deterioration Effective emergency response system

Post cardiac arrest care

Defibrillation

• Minimal changes

• Defibrillators using biphasic waveform are preferred

( greater success in arrhythmia termination )

• No difference in energy joule used

• Pre-shock pause should be less than 5 seconds

• Self adhesive pad should be used if available

Defibrillation

• Resume CPR immediately after a shock ( not assessing rhythm/ checking for pulse post defibrillation attempt )

• Even if the defibrillation is successful to restore a perfusing rhythm, it takes time to establish a post shock circulation

Defibrillation : energy level for subsequent shock ( VF/pVT )

• Higher termination of arrhythmia in the escalating higher energy groupBut, no significant differences in ROSC, survival to

discharge, or survival with favourable neurologic outcome

• Both strategies are acceptable

• It is reasonable that selection of fixed versus escalating energy for subsequent shocks be based on the specific manufacturer’s instructions

‘Refibrillation’ ( recurrent VF )

• Defined as :

‘recurrence of VF during a documented cardiac arrest episode, occurring after initial termination of VF while the patient remains under the care of the same providers

higher subsequent energy level is more beneficial for the termination of the refibrillation

Defibrillation : single shock vs stacked shock ( VF/pVT )

• One RCT, 845 OHCA , no difference in 1- year survival with these two protocols

• A single shock strategy is reasonable for defibrillation ( benefit of CPR in providing myocardial blood flow

post shock period / outcome is improved by minimizing interruption to chest compression )

Witnessed, monitored VF/pVT…

• When there is a witnessed VF/pVT in a monitored patient and he/she is already connected to a manual defibrillator, give up to 3 quick , successive (stacked ) shocks

• Reason :

it is unlikely that chest compressions will improve the already very high chance of ROSC when defibrillation occurs early in the electrical phase, immediately after onset of VF.

Witnessed, monitored VF/pVT…

• If this initial three-shock strategy is unsuccessful for a monitored VF/pVT cardiac arrest, the ALS algorithm should be followed and these three-shocks treated as if only the first single shock has been given.

Airway, oxygenation and ventilation

Oxygen during CPR

• CPR goal: restore the energy state of the heart so it can resume mechanical work and to maintain the energy state & minimize ischemic injury

• Adequate oxygen delivery is necessary

• Detrimental effects of hyperoxia that may exist in the immediate post–cardiac arrest period should not be extrapolated to the low-flow state of CPR

maximal feasible inspired oxygen during CPR

is recommended

Bag-mask ventilation vs advanced airway placement during CPR

Bag-mask ventilation vs advanced airway placement during CPR

• No high quality data to favor either airway strategy

• Evaluating the retrospective studies is challenging

• More severe physiologic compromise will require more invasive care

Bag-mask ventilation vs advanced airway placement during CPR

• Either a bag-mask device or an advanced airway may be used for oxygenation and ventilation during CPR in both the in hospitaland out-of-hospital setting

• The choice of bag-mask device versus advanced airway insertion will be determined by the skill and experience of the provider

Drugs

• although drugs are still included among ALS interventions, they are of secondary importance to high-quality uninterrupted chest compressions and early defibrillation.

Adrenaline vs no adrenaline

• Significant higher rates of pre-hospital ROSC & survival to hospital admission compared to placebo

• Long term outcome such as survival to hospital discharge or good neurological survival – no better or worse

• Large observational study ( 25095 patients ) of cardiac arrest with non-shockable rhythm compared epinephrine given at

1 to 3 minutes

4 to 6 minutes

7 to 9 minutes

greater than 9 minutes

• Results : there is association between early administration of epinephrine and increased ROSC, survival to hospital discharge, and neurologically intact survival.

Timing of administration of adrenaline( non-shockable rhythm )

• It may be reasonable to administer epinephrine as soon as feasible after the onset of cardiac arrest due to an initial non-shockable rhythm.

Adrenaline vs vasopressin

• Comparing outcomes (ROSC, survival to discharge, or neurological outcome) with vasopressin versus adrenaline as a first line vasopressor in cardiac arrest ( series of RCTs )

NO difference

• Vasopressin in combination with epinephrine offers no advantage as a substitute for standard-dose epinephrine in cardiac arrest

• Therefore, to simplify the algorithm, Adult Cardiac Arrest Algorithm– 2015 Update.

Vasopressin removed

Steroid

• Use of steroid is of uncertain benefit

• no data to recommend for or against the routine use of steroids alone

• Combination of vasopressin, steroid and epinephrine may be considered

OHCA IHCA

Vasopressin, steroid, epinephrine protocol

• Conclusions:

Improved survival to hospital discharge with favorable neurological status among patients with cardiac arrest requiring vasopressors, combined vasopressin-epinephrine and methylprednisolone during CPR and stress-dose of hydrocortisone in post resuscitation shock, compared with epinephrine/saline placebo

Extracorporeal cardiopulmonary resuscitation (eCPR )

• The 2015 ILCOR systematic review compared the use of ECPR (or ECMO) techniques for adult patients with IHCA and OHCA to conventional (manual or mechanical) CPR, in regard to ROSC, survival, and good neurologic outcome.

Extracorporeal cardiopulmonary resuscitation (eCPR )

• require vascular access and a circuit with a pump and oxygenator and can provide a circulation of oxygenated blood to restore tissue perfusion

• has the potential to buy time for restoration of an adequate spontaneous circulation, and treatment of reversible underlying conditions

Veno-arterial extracorporeal membrane oxygenation for cardiogenic shock & cardiac arrest: A meta-analysis

• 22 observational studies, 1199 patients

• Survival to hospital discharge : 40.2 % ( average )

• 30 –days survival, weighted estimate : 52.8%

• Significant morbidity ( complications )

• Technical expertise

• High cost of ECMO treatment

• Necessitates appropriate case selection in order to maximize its potential benefits

Extracorporeal cardiopulmonary resuscitation (eCPR )

• Improved outcome when

o there is reversible cause for cardiac arrest ( e.g. MI, PE, severe hypothermia, poisoning )

o When there is little comorbidity

o When cardiac arrest is witnessed

o When individual receives immediate high quality CPR

o eCPR is implemented early (within 1 h of collapse)

Post Cardiac Arrest Care

Keeping the heart beat (ROSC )…..

• ROSC is just a starting point & the first step towards the goal of complete recovery of cardiac arrest

Is the job done?

Post cardiac arrest syndrome

• Complex pathophysiological process

• When does it start?

• How does it happen?

Post cardiac arrest syndrome

• No flow

• anoxic

Cardiac arrest

• Minimal flow

• ischemicCPR

• reperfusionROSC

• Post anoxic-ischemic-reperfusion syndrome

• Triggered by cardiac arrest and return of spontaneous circulation

• Main component:

early but severe circulatory dysfunction

may lead to multi-organ failure and death

Post Cardiac arrest Syndrome

Myocardial dysfunction

accounts for the most death for the first 3 days

Starts to recover after 2-3 days post cardiac arrest

Anoxic brain injury

may be exacerbated by microcirculatory failure, hypo/hypercarbia, pyrexia, hypo/hyperoxaemia, hypo/hyperglycaemia, hypotension

Multi-organ failure

Systemic ischemic /reperfusion activated immune & coagulation problem

Non specific systemic inflammatory response syndrome

infection

Post Cardiac arrest Syndrome

• Clinical features:

its intensity varies

but , roughly proportional to the duration of ‘ no flow’ and ‘ low flow ‘

• Overall outcome depends on:

underlying cause of collapse

availability of early high quality CPR

Post resuscitation care

Post cardiac arrest syndrome

Post Cardiac Arrest Care

Control of ventilation

• Consider tracheal intubation, sedation and controlled ventilation in any patient with obtunded cerebral function

• Adequate sedation reduce O2consumption

• Boluses dose of neuromuscular blocking agent may be required ( esp using targeted temperature management /TTM )

prevent shivering

Control of ventilation

• keep normocarbia ( PaCO2 35-45mmHg )

• No hyperoxia

• AVOID hypoxia ( also harmful )

titrate the inspired oxygen concentration to maintain the arterial blood oxygen saturation

in the range of 94–98%

• Coronary reperfusion

• Hemodynamic management

Circulation control

Coronary reperfusion

• Coronary angiography should be performed emergently for OHCA patients with suspected cardiac etiology of arrest and ST elevation on ECG

• Emergency coronary angiography is reasonable for selected (eg, electrically or hemodynamicallyunstable) adult patients who are comatose after OHCA of suspected cardiac origin but without ST elevation on ECG

• optimal targets for mean arterial pressure and/or systolic arterial pressure remain unknown

• Study – MAP ≥ 70 mmHg , good neurological outcome

• Tachycardia – bad outcome

• Relative adrenal insufficiency- VSE protocol with good outcome

Hemodynamic management

Optimizing Neurological Recovery

• Adequate cerebral perfusion

• Targeted Temperature Management

• Control of seizures

• Glucose control

How does hypothermia help in optimizing the neurological recovery

Hypothermia

• Suppresses many pathways delayed cell death

• Decreases CMRO2 ( 6% per each 1 ◦C reduction in core temperature)

• Reduces the release of excitatory amino acids and free radicals

• Blocks intracellular consequences of excitotoxinexposure

• Reduces inflammatory response associated with post cardiac arrest syndrome

Targeted temperature Management( TTM )

• Adopted term in 2015 as compared to ‘therapeutic hypothermia’ in 2010

• Refers to ‘ active control of temperature at any target ‘

• Specific features of the collapsed victim may favor certain selected target temperature over another for TTM

• Recommendations:the comatose adult patients with ROSC after

cardiac arrest , must have TTM

select and maintain a constant temperature between 32-36◦C during TTM for at least 24 hours

Pre-hospital cooling with large volume of cooled IVD immediately after ROSC is not recommended

Targeted temperature Management( TTM )

Seizures Control

• Seizure is common after cardiac arrest ( 30% )

• Myoclonus – most common

• Others : focal or generalized tonic-clonicseizures or mixed type

• MUST treat ( seizures may increase CMRO2and exacerbate brain injury caused by cardiac arrest )

• BUT, routine seizure prophylaxis is not recommended

Glucose Control

• blood glucose after cardiac arrest poor neurological outcome

• In critically ill patient , tight sugar control ( 4-6mmol-1 ) – increased 90 days mortality compared to those with conventional sugar control ( 10 mmol-1or less ) & associated with frequent hypoglycemic episodes

Glucose Control

• Increased blood glucose variability

– associated with increased mortality and unfavourable neurological outcome after cardiac arrest

• Recommendation :

maintain the blood glucose at ≤10 mmol-1 and avoid hypoglycaemia following ROSC

Post Cardiac Arrest….

• Death is common

hypoxic-ischemic brain injury

active withdrawal of life sustaining treatment (WLST) based on prognostication of a poor neurological outcome

• Optimal timing for prognostication in post cardiac arrest patient is important

When to prognosticate?

• The earliest time for prognostication using in patients treated with TTM, may be 72 hours after return to normothermia

• The earliest time to prognosticate a poor neurologic outcome in patients not treated with TTM is 72 hours after cardiac arrest

sedation/muscle relaxant---- need to wait ….