D)

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1 TFQO: Rudolph Koster Author(s): Alfredo Sierra & Kevin Nation EVREV Date 12 July 2014 QUESTION: Among adults and children who are in cardiac arrest in any setting (P), does analysis of cardiac rhythm during chest compressions (I), compared with standard care (analysis of cardiac rhythm during pauses in chest compressions) (C), change Survival with Favorable neurological/functional outcome at discharge, 30 days, 60 days, 180 days AND/OR 1 year, Survival only at discharge, 30 days, 60 days, 180 days AND/OR 1 year, ROSC, time to first shock, time to commence CPR, CPR quality (O)? SETTINGS: Any settings Bibliography: Non Systematic reviews. Non Randomized Control Trials. 1. Navarro, César O; Cromie, Nick A; Turner, Colin; Escalona, Omar J; Anderson, John McC; Detection of cardiac arrest using a simplified frequency analysis of the impedance cardiogram recorded from defibrillator pads. IEEE 2011, Ruiz, Jesus; Irusta, Unai; Ruiz de Gauna, Sofia; Eftestøl, Trygve; Cardiopulmonary resuscitation artefact suppression using a Kalman filter and the frequency of chest compressions as the reference signal.. Resuscitation 2010; 81: Irusta, Unai; Ruiz, Jesús; Aramendi, Elisabete; Ruiz de Gauna, Sofía; Ayala, Unai; Alonso, Erik; A high- temporal resolution algorithm to discriminate shockable from nonshockable rhythms in adults and children. Resuscitation 2012;83: Krasteva, Vessela; Jekova, Irena; Dotsinsky, Ivan; Didon, Jean- Philippe; Shock advisory system for heart rhythm analysis during cardiopulmonary resuscitation using a single ECG input of automated external defibrillators. Annals of biomedical Engeenering 2010;38 (4) Aramendi, E; Ayala, U; Irusta, U; Alonso, E; Eftestøl, T; Kramer- Johansen, J; Suppression of the cardiopulmonary resuscitation artefacts using the instantaneous chest compression rate extracted from the thoracic impedance. Resuscitation 2012;83: Ruiz, Jesús; Ayala, Unai; Ruiz de Gauna, Sofía; Irusta, Unai; González- Otero, Digna; Aramendi, Elisabete; Alonso, Erik; Eftestøl, Trygve; Direct evaluation of the effect of filtering the chest compression artifacts on the uninterrupted cardiopulmonary resuscitation time. American Journal of Emergency medicine 2013;31: Barash, David M; Raymond, Richard P; Tan, Qing; Silver, Annemarie E; A new defibrillator mode to reduce chest compression interruptions for health care professionals and lay rescuers: a pilot study in manikins. Prehospital Emergency Care 2011; 15 (1) Didon, Jean- Philippe; Krasteva, Vessela; Ménétré, Sarah; Stoyanov, Todor; Jekova, Irena; Shock advisory system with minimal delay triggering after end of chest compressions: accuracy and gained hands- off time.resuscitation 2011;82S:S8- S15 A) Papers included bibliography from 2009 to 2013 B) Papers before 2009 were exclude because were analyzed in 2010 review C) From the 29 total papers we exclude 15 that were in the bibliogrphy before 2009 D) From the 14 included papers 6 were exclude because did not have sufficient statistical data.. E) In the 8 analyzed papers, the central topic was in 3 shock advisory systems Algorithms; 2 artefact filters and 4 hands-off time with compression pause. F) The quality of evidence in GRADE of the 8 papers were in 6 low and 2 very low. G) In the 8 papers priority evaluation was 5 important

2 Summary of findings: Analysis of cardiac rhythm during chest compressions compared to standard care (analysis of cardiac rhythm during pauses in chest compressions) for adults and children who are in cardiac arrest in any setting Patient or population: adults and children who are in cardiac arrest in any setting Settings: Intervention: analysis of cardiac rhythm during chest compressions Comparison: standard care (analysis of cardiac rhythm during pauses in chest compressions) Outcomes Illustrative comparative risks * (95% CI) Assumed risk Corresponding risk Relative effect (95% CI) of participants (Studies) Quality of the evidence (GRADE) Comments standard care (analysis of cardiac rhythm during pauses in chest compressions) analysis of cardiac rhythm during chest compressions Time to start CPR (Time to Low strat CPR) assessed with: new algorithm see comment not pooled Time of first shock (Time of Study population first shock) assessed with: new algorithm see comment not pooled Time to start CPR (Time to star CPR) Study population assessed with: new filter 0 per per 1000 (0 to 0) Time of first shock (Time of first shock) Study population assessed with: new filter 0 per per 1000 (0 to 0) not estimable 4838 (5 observational studies) not estimable 6658 (5 observational studies) not estimable 3240 (3 observational studies) not estimable 3240 (3 observational studies) VERY LOW VERY LOW VERY LOW VERY LOW *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio; OR: Odds ratio;

3 Summary of findings: Analysis of cardiac rhythm during chest compressions compared to standard care (analysis of cardiac rhythm during pauses in chest compressions) for adults and children who are in cardiac arrest in any setting Patient or population: adults and children who are in cardiac arrest in any setting Settings: Intervention: analysis of cardiac rhythm during chest compressions Comparison: standard care (analysis of cardiac rhythm during pauses in chest compressions) Outcomes Illustrative comparative risks * (95% CI) Assumed risk Corresponding risk Relative effect (95% CI) of participants (Studies) Quality of the evidence (GRADE) Comments standard care (analysis of cardiac rhythm during pauses in chest compressions) analysis of cardiac rhythm during chest compressions GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate. 1. Differences in measurement 2. Failure of accurate measurement of all known prognostic factors 3. Heterogeneity 4. Experimental methods 5. Use of database 6. Authors received researcg support Criteria Judgements Research evidence

4 Problem Is there a problem priority? Probably no Benefits & harms of the options What is the overall certainty of this evidence? included studies Very low Low Moderate High The relative importance or values of the main outcomes of interest: Outcome Relative importance Certainty of the evidence (GRADE) Time to start CPR IMPORTANT VERY LOW Time of first shock IMPORTANT VERY LOW Is there important uncertainty about how much people value the main outcomes? Important uncertainty or variability Possibly important uncertainty or variability Probably no important Time to start CPR IMPORTANT VERY LOW

5 Is there important uncertainty about how much people value the main outcomes? Are the desirable anticipated effects large? Are the undesirable anticipated effects small? uncertainty of variability important uncertainty of variability known undesirable Uncertain Uncertain Time of first shock IMPORTANT VERY LOW Summary of findings: standard care (analysis of cardiac rhythm during pauses in chest compressions) 1. The algorithm correctly identified 98% of nonshockable segments, 97.5% in adults and 98.4% in children, and identified 99.5% of shockable segments as likely shockable, 100% in adults and 96% in children. When likely shockable segments were further analysed in terms of regularity, spectral content and heart rate to form a complete rhythm analysis algorithm the overall specificity increased to 99.6% and the sensitivity was 99.1%. 4. During each resuscitation simulation, rescuers switched roles as chest compressor and defibrillator operator every two segments of CPR (one segment = 2 minutes of chest compressions, rhythm analysis, and shock delivery, if appropriate), for eight total segments. The participants rested 30 minutes between trials and received brief AC-CPR training (BLS = 30 seconds; ALS = 5 minutes). Heart rate and perceived exertion were measured with pulse oximetry and the Borg scale, respectively. 9. For the test database, the sensitivity improved from 57.8% (95% confidence interval, %) to 93.3% ( %) and the specificity decreased from 92.5% ( %) to 89.1% ( %). 12. ICG was recorded in 132 cardiac arrest patients (53 training, 79 validation) and 97 controls (47 training, 50 validation): the diagnostic algorithm indicated cardiac arrest with a sensitivity of 81.1% ( ) and specificity of 97.1% ( ) for the validation set (95% confidence intervals). 15. For the nonshockable rhythms, the probabilities of delivering at least 2 and 3 minutes of uninterrupted CPR were 58% (95% confidence interval, 54%-62%) and 48% (44%-52%), respectively. These are the probabilities of reducing and substantially reducing the frequency of CPR interruptions for rhythm analysis. For the shockable rhythms, the probability of avoiding unnecessary CPR prolongation beyond 2 minutes was 100% (99%-100%). 25. The achieved sensitivity of 90.1% meets the AHA performance goal for noise-free VF (>90%). The specificity of 88.5% for NR and 83.3% for ASYS are comparable or even better than accuracy reported in literature. It is important to note that, the aim of this SAS is not to recommend shock delivery but to advice the rescuers to "Continue CPR" or to "Stop CPR and Prepare for Shock" thus

6 Are the desirable effects large relative to undesirable effects? Probably no minimizing "hands-off" intervals. 26. Performance of the presented SAS versus AEDs is compared. The median hands-off time gained from earlier starting of ECG analysis is 5.8 s and for earlier shock advice is 12.5 s to 8.5 s when SAS rhythm analysis lasts 3 s to 7 s. The SAS accuracy at 3 7 s is: specificity % (ASYS), % (NSR), % (ONS); sensitivity % (VF), % (VThi). 28. The correlation between the mean chest compression rates estimated using TTI or CD was r = 0.98 (95% confidence interval, ). The sensitivity and specificity after filtering using CD were 95.4% ( %) and 87.0% ( %), respectively. The sensitivity and specificity after filtering using TTI were 95.4% ( %) and 86.3% ( %), respectively. Resource use Are the resources required small? Probably yes Is the incremental cost small relative to the net benefits? Probably yes

7 Equity What would be the impact on health inequities? Increased Probably increased Uncertain Probably reduced Reduced Acceptability Is the option acceptable to key stakeholders? Uncertain Feasibility Is the option feasible to implement?

8 Probably yes Recommendation Should analysis of cardiac rhythm during chest compressions vs. standard care (analysis of cardiac rhythm during pauses in chest compressions) be used for adults and children who are in cardiac arrest in any setting? Balance of consequences Undesirable consequences clearly outweighdesirable consequences in most settings Undesirable consequences probably outweigh desirable consequences in most settings The balance between desirable and undesirable consequences is closely balanced or uncertain Desirable consequences probably outweigh undesirable consequences in most settings Desirable consequences clearly outweigh undesirable consequences in most settings Type of recommendation We recommend against offering this option We suggest not offering this option We suggest offering this option We recommend offering this option We suggest not using new algorithms or artifact filters for the analysis of cardiac rhythm during chest compressions. Recommendation We suggest not using new algorithms or artifact filters for the analysis of cardiac rhythm during chest compressions.

9 The evidence we present has a certainty of evidence very low. Justification The evidence we present has a certainty of evidence very low. Subgroup Implementation Monitoring and evaluation We suggest more human studies in real cardiac arrest settings Research possibilities We suggest more human studies in real cardiac arrest settings