How to Improve Cardiac Arrest Survival in your Center
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1 How to Improve Cardiac Arrest Survival in your Center Ankur A. Doshi, MD FACEP Post Cardiac Arrest Service UPMC Presbyterian Department of Emergency Medicine University of Pittsburgh School of Presenter Disclosure Information Ankur A. Doshi, MD FACEP How to Improve Cardiac Arrest Survival in your Center FINANCIAL DISCLOSURE: Employer: University of Pittsburgh/UPMC Grants/Research Support: Pittsburgh Emergency Medicine Foundation 2 1
2 Learning objectives Review survival rates/outcomes after cardiac arrest Discuss patient variables after cardiac arrest that affect outcomes Describe ICU treatments helpful in managing cardiac and neurologic injury after cardiac arrest Discuss post-icu treatments that affect outcomes for post arrest patients What we won t cover Treatment during cardiac arrest Targeted temperature management Ventilator management Detailed neuroprognostication 2
3 First the good news Buick CCQO 2018 Daya Resusc
4 Girotra NEJM 2012 Regional variation in survival Daya Resusc
5 Tertiary centers affect early survival Survival different for first 5 days More intensive cardiac AND ICU interventions Søholm CCQO 2015 Differences persist long term N=987 persons discharged from 7 hospitals. Link to National Death Index to determine survival time. Center 1 has a dedicated post-arrest service line with >250 patients per year Elmer UNPUBLISHED 5
6 Step 1 identify patient variations Etiologies of CA patients vary Nolan Semin Neurol
7 Initial severity of patients vary Rittenberger Resusc
8 Initial illness severity and outcome Pretest Admitted after Cardiac Arrest Survival 46% (207 / 459) Good Outcome 31% (141 / 459) Type 1 Check Cardiopulmonary Status and FOUR Score Posttest Awake 30% (141/459) 81% (114/141) survive 60% (85/141 ) good outcome Coma without Shock 22% (99/459) 58% (57/99) survive 34% (34/99 ) good outcome Coma with Shock 14% (63/459) 44% (28/63) survive 25% (16/63 ) good outcome Rittenberger Resusc 2011 Type 2 Type 3 Type 4 Missing Brainstem Reflexes 34% (156/459) 9% (14/156) survive 5% (8/156) good outcome Why does this matter? 8
9 Step 2 treat what can be treated Cardiac catheterization for STEMI AHA CPR/ECC Guideline (2015): Coronary angiography should be performed emergently (rather than later in the hospital stay or not at all) for OHCA patients with suspected cardiac etiology of arrest and ST elevation on ECG (Class I, LOE B-NR) Kern JACC 2012 Callaway Circulation
10 Cardiac catheterization for nonstemi Dumas CircCVInterventions 2010 Type 1 Type 2 Type 3 Type 4 Reynolds Resusc
11 Caveat: Non-randomized data AHA CPR/ECC Guideline (2015): Emergency coronary angiography is reasonable for select (eg, electrically or hemodynamically unstable) adult patients who are comatose after OHCA of suspected cardiac origin but without ST elevation on ECG (Class IIa, LOE B-NR) Coming soon to a center near you. 11
12 FYI: another new approach Yannopoulos JACC
13 Step 3 neuroresuscitation Elmer Semin Neurol
14 Perfuse/oxygenate the brain Cerebral blood flow (ml/100g/min) 100 Absent Normal Pressure passive Mean arterial pressure (mmhg) Individual physiology varies Intact autoregulation Tissue hypoxia Pressure passive Hypoxia corrected Autoregulation essentially intact throughout No tissue hypoxia at any MAP 109mmHg 75mmHg Elmer Semin Neurol
15 Hemodynamic goal Kilgannon CritCareMed 2014 MAP > 80 mmhg Beylin IntCareMed 2013 Local brain tissue hypoxia is bad and common O 2 delivery/diffusion impaired Perivascular edema Menon CritCareMed
16 This effect also varies across patients Is hyperoxia bad? Exposure Arterial oxygen (per hour) Adjusted OR (95% CI) Severe hyperoxia(>300mmhg) 0.83 ( ) Drives oxidative injury, ROS generation, etc Hyperoxiais common Some OBSERVATIONAL data associate extreme hyperoxia with worse outcomes Moderate hyperoxia ( mmHg) 1.01 ( ) Normoxia(60-100mmHg) 1.01 ( ) Hypoxia (<60mmHg) 0.74 ( ) Kilgannon JAMA
17 Oxygenation goals Measure PaO 2 In vivo PaO 2 5 mmhg lower per 1 o C Normoxia Significant hyperoxia is (probably) bad and frequent Brain tissue hypoxia is (probably) bad and often quite severe PaO mmhg Carbon dioxide goals Observational data Schneider Resus 2013 PaCO2 ~ 40 mmhg (temp corrected) Roberts Circulation
18 Seizures after cardiac arrest bad or fatal? Incidence of malignant patterns: 8-40% Mix of different types AAN Guideline (2006): Patients with myoclonus status epilepticus within the first day after a primary circulatory arrest have a poor prognosis (Level B) Reynolds SeminNeurol 2017 Amorim Resusc
19 Elmer AnnNeuro 2016 Patients awaken late Grossestreuer Resusc
20 Most patients die b/c of withdrawal of care 2,137 non-survivors after OHCA Largest cause of in-hospital death was WLST for neurological reasons (61.2%) Percent of Cases Callaway Resusc 2014 Most neurologic withdrawal is early Elmer Resusc
21 Delay neuroprognostication for 72 hours Step 4 post ICU care 21
22 GDS SF-36 Survival outcome GCS RNLI mrs SF-12 Outcomes after discharge 22
23 Domains that matter to patients Functional / physical Cognitive Spiritual / emotional Psychiatric Social Assess serially at least up to one year Social 23
24 Social ICF* as an Organizer Health condition (disorder or disease) * International Classification of Functioning, Disability and Health (WHO, 2001) Body Functions and Structures Activities Participation Jette Phys Ther 2006 Environmental Factors Personal Factors 24
25 Social Lilja Resusc
26 Social Mateen Neurology
27 Lilja Circulation 2015 Assessment and treatment of cognitive domain Koller Resusc
28 Social KetisdottirA EurJ of Cardiovascular Nursing 2014 I have filtered out those whom I think are a waste to spend time with. Instead, I try to focus on those close to me. You sort of prioritize your relationships differently. Forslund AS J Cardiovasc Nursing 2014 ForslundAS ScandJ Caring Sci2017 There was no room for me in heaven that day I ve got a second chance at life Palacios-Cena D Nurs Health Sci 2011 No one really knows the true meaning of my experience. I literally died and came back [from death]. Who can begin to grasp such a thing? Only someone who has shared the same experience One has to learn to live again, one has to learn to die... it sounds very dramatic but that is how I feel. 28
29 Social 29
30 Lilja CCQO 2108 Services after ICU care Functional / cognitive domains: Structured PT, OT eval PMR, Rehab if needed Cardiac rehab v exercise program Follow > 6 m Psychiatric domain: HADS, GAD-7 In-hospital 6 m 12 m Refer for treatment if needed Spiritual / social domains: Referral to survivor s networks SCAA SCAF Local survivors / peer to peer 30
31 Step 5 track care and outcomes Summary Step 1 identify patient variations Step 2 treat what can be treated Step 3 neuroresuscitation In-hospital interventions Assess individual patients Tailor treatment Cardiac catheterization early TTM MAP > 80 Normoxia(PaO ) PaCO2 ~ 40 Eval and treat seizure Delay neuroprognostion > 72 31
32 Step 4 post ICU care Summary In-hospital interventions PT OT PMR Psychiatry Social work Survivor communities Recovery takes > 12 months Step 5 track outcomes Join a registry Recap We can increase survival after cardiac arrest Some centers are better than others Etiologies of arrest differ and so do treatments somewhat Treat the heart and the brain the bundle still matters Treatment doesn t end at discharge 32
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