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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
• Po...
• American Heart Association (AHA)
• European Resuscitation Council (ERC)
• Heart and Stroke Foundation of Canada (HSFC)
•...
ILCOR
• every 5 years a new set of treatment
recommendation is released
• The first set of guidelines was released in
2000...
• 15 October 2015
2015 CPR Guidelines Developmental
Process
• 250 evidence reviewers from 39 countries
• 169 specific resuscitation question...
2015 CPR Guidelines Developmental
Process
• The output of the GRADE process :
 2015 International Consensus on CPR and EC...
• Emphasize the interactions between the
emergency medical dispatcher, the bystander
who provides CPR and the use of AED a...
• Emphasize the importance of early diagnosis
of cardiac arrest and the provision of
dispatcher assisted CPR( Telephone CP...
Highlights in BLS 2015
• Emphasis on high quality CPR
 The compression rate is 100 – 120 compression /
minute
 Compressi...
• Be aware that seizures could be a sign of
Cardiac Arrest
• Suggest to use of Real Time Audiovisual
feedback and prompt d...
2015 ALS guidelines
What’s
new
2015 ALS Guidelines
• ILCOR review focused on 42 topics
• Organized in the approximate sequence of
ACLS interventions:
 d...
Chain of prevention:
 staff education
 Monitoring of patients
 Recognition of the patient’s deterioration
 Effective e...
Defibrillation
• Minimal changes
• Defibrillators using biphasic waveform are preferred
( greater success in arrhythmia te...
Defibrillation
• Resume CPR immediately after a shock ( not
assessing rhythm/ checking for pulse post
defibrillation attem...
Defibrillation : energy level for
subsequent shock ( VF/pVT )
• Higher termination of arrhythmia in the
escalating higher ...
‘Refibrillation’ ( recurrent VF )
• Defined as :
 ‘recurrence of VF during a documented cardiac
arrest episode, occurring...
Defibrillation : single shock vs stacked
shock ( VF/pVT )
• One RCT, 845 OHCA , no difference in 1- year survival
with the...
Witnessed, monitored VF/pVT…
• When there is a witnessed VF/pVT in a
monitored patient and he/she is already
connected to ...
Witnessed, monitored VF/pVT…
• If this initial three-shock strategy is
unsuccessful for a monitored VF/pVT cardiac
arrest,...
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
e...
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
• Eval...
Bag-mask ventilation vs advanced
airway placement during CPR
• Either a bag-mask device or an advanced
airway may be used ...
Drugs
• although drugs are still included among ALS
interventions, they are of secondary
importance to high-quality uninte...
Adrenaline vs no adrenaline
• Significant higher rates of pre-hospital ROSC &
survival to hospital admission compared to
p...
• Large observational study ( 25095 patients ) of
cardiac arrest with non-shockable rhythm
compared epinephrine given at
...
Timing of administration of adrenaline
( non-shockable rhythm )
• It may be reasonable to administer
epinephrine as soon a...
Adrenaline vs vasopressin
• Comparing outcomes (ROSC, survival to
discharge, or neurological outcome) with
vasopressin ver...
• 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
•...
Vasopressin, steroid, epinephrine
protocol
• Conclusions:
Improved survival to hospital discharge with
favorable neurolog...
Extracorporeal cardiopulmonary
resuscitation (eCPR )
• The 2015 ILCOR systematic review compared
the use of ECPR (or ECMO)...
Extracorporeal cardiopulmonary
resuscitation (eCPR )
• require vascular access and a circuit with a
pump and oxygenator an...
Veno-arterial extracorporeal membrane oxygenation
for cardiogenic shock & cardiac arrest: A meta-analysis
• 22 observation...
Extracorporeal cardiopulmonary
resuscitation (eCPR )
• Improved outcome when
o there is reversible cause for cardiac arres...
Post Cardiac Arrest Care
Keeping the heart beat (ROSC )…..
• ROSC is just a starting point & the first step
towards the goal of complete recovery o...
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
• ischemic
CPR
• reperfusion
ROSC
• Post anoxic-ischemic-reperfusion syndrome
• Triggered by cardiac arrest and return of
spontaneous circulation
• Main com...
Myocardial dysfunction
accounts for the most
death for the first 3
days
Starts to recover after
2-3 days post cardiac
arre...
• Clinical features:
 its intensity varies
 but , roughly proportional to the duration of ‘ no
flow’ and ‘ low flow ‘
• ...
Post Cardiac Arrest Care
Control of ventilation
• Consider tracheal intubation, sedation and
controlled ventilation in any patient with
obtunded ce...
Control of ventilation
• keep normocarbia ( PaCO2 35-45mmHg )
• No hyperoxia
• AVOID hypoxia ( also harmful )
titrate the ...
• Coronary reperfusion
• Hemodynamic management
Circulation control
Coronary reperfusion
• Coronary angiography should be performed
emergently for OHCA patients with suspected cardiac
etiolo...
• optimal targets for mean arterial pressure
and/or systolic arterial pressure remain
unknown
• Study – MAP ≥ 70 mmHg , go...
Optimizing Neurological Recovery
• Adequate cerebral perfusion
• Targeted Temperature Management
• Control of seizures
• G...
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 temperatu...
Targeted temperature Management
( TTM )
• Adopted term in 2015 as compared to
‘therapeutic hypothermia’ in 2010
• Refers t...
• Recommendations:
the comatose adult patients with ROSC after
cardiac arrest , must have TTM
select and maintain a cons...
Seizures Control
• Seizure is common after cardiac arrest ( 30% )
• Myoclonus – most common
• Others : focal or generalize...
Glucose Control
• blood glucose after cardiac arrest poor
neurological outcome
• In critically ill patient , tight sugar c...
Glucose Control
• Increased blood glucose variability
– associated with increased mortality and
unfavourable neurological ...
Post Cardiac Arrest….
• Death is common
 hypoxic-ischemic brain injury
 active withdrawal of life sustaining treatment
(...
When to prognosticate?
• The earliest time for prognostication using in
patients treated with TTM, may be 72 hours
after r...
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ALS2015 UPDATE

Publicada em: Saúde e medicina
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Updates in resuscitation.pptx ( hpp )

  1. 1. Updates in resuscitation 2015 CPR guidelines Dr Luah Lean Wah Consultant anaesthesiologist Penang Hospital
  2. 2. Content of lecture • ILCOR and 2015 CPR guidelines development process • Highlights in BLS guideline • Updates in ALS • Post cardiac arrest care
  3. 3. • 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
  4. 4. 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
  5. 5. • 15 October 2015
  6. 6. 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
  7. 7. 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
  8. 8. • 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
  9. 9. • 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
  10. 10. 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
  11. 11. • 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
  12. 12. 2015 ALS guidelines What’s new
  13. 13. 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
  14. 14. Chain of prevention:  staff education  Monitoring of patients  Recognition of the patient’s deterioration  Effective emergency response system Post cardiac arrest care
  15. 15. 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
  16. 16. 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
  17. 17. Defibrillation : energy level for subsequent shock ( VF/pVT ) • Higher termination of arrhythmia in the escalating higher energy group But, 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
  18. 18. ‘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
  19. 19. 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 )
  20. 20. 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.
  21. 21. 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.
  22. 22. Airway, oxygenation and ventilation
  23. 23. 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
  24. 24. Bag-mask ventilation vs advanced airway placement during CPR
  25. 25. 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
  26. 26. 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 hospital and 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
  27. 27. Drugs • although drugs are still included among ALS interventions, they are of secondary importance to high-quality uninterrupted chest compressions and early defibrillation.
  28. 28. 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
  29. 29. • 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.
  30. 30. 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.
  31. 31. 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
  32. 32. • Therefore, to simplify the algorithm, Adult Cardiac Arrest Algorithm– 2015 Update. Vasopressin removed
  33. 33. 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
  34. 34. 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
  35. 35. 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.
  36. 36. 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
  37. 37. 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
  38. 38. 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)
  39. 39. Post Cardiac Arrest Care
  40. 40. 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?
  41. 41. Post cardiac arrest syndrome • Complex pathophysiological process • When does it start? • How does it happen?
  42. 42. Post cardiac arrest syndrome • No flow • anoxic Cardiac arrest • Minimal flow • ischemic CPR • reperfusion ROSC
  43. 43. • 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
  44. 44. 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
  45. 45. • 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
  46. 46. Post Cardiac Arrest Care
  47. 47. Control of ventilation • Consider tracheal intubation, sedation and controlled ventilation in any patient with obtunded cerebral function • Adequate sedation reduce O2 consumption • Boluses dose of neuromuscular blocking agent may be required ( esp using targeted temperature management /TTM ) prevent shivering
  48. 48. 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%
  49. 49. • Coronary reperfusion • Hemodynamic management Circulation control
  50. 50. 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 hemodynamically unstable) adult patients who are comatose after OHCA of suspected cardiac origin but without ST elevation on ECG
  51. 51. • 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
  52. 52. Optimizing Neurological Recovery • Adequate cerebral perfusion • Targeted Temperature Management • Control of seizures • Glucose control
  53. 53. How does hypothermia help in optimizing the neurological recovery
  54. 54. 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 excitotoxin exposure • Reduces inflammatory response associated with post cardiac arrest syndrome
  55. 55. 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
  56. 56. • 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 )
  57. 57. Seizures Control • Seizure is common after cardiac arrest ( 30% ) • Myoclonus – most common • Others : focal or generalized tonic-clonic seizures or mixed type • MUST treat ( seizures may increase CMRO2 and exacerbate brain injury caused by cardiac arrest ) • BUT, routine seizure prophylaxis is not recommended
  58. 58. 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
  59. 59. 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
  60. 60. 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
  61. 61. 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 ….

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