KARDIOPULMONÁLNÍ RESUSCITACE rok v přehledu

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1 Zdravotnická záchranná služba Královéhradeckého kraje, Letecká záchranná služba Hradec Králové Klinika anesteziologie, resuscitace a intenzivní medicíny, Univerzita Karlova v Praze, Lékařská fakulta v Hradci Králové, Fakultní nemocnice Hradec Králové KARDIOPULMONÁLNÍ RESUSCITACE rok v přehledu MUDr. ANATOLIJ TRUHLÁŘ

2 Obsah sdělení Významné práce s praktickým významem publikované v RESUSCITATION 2012 IF 3,601 Etiologie a patofyziologie Diagnostika Léčba akutních stavů Klinický / experimentální výzkum Přehledové články Kazuistiky the only journal in the area of CPR that is general in nature and not specific to a single body system

3 Iniciální EKG rytmus Resuscitation Outcomes Consortium (USA) EMS-treated cardiac arrests ( ) Survival to discharge 8,4% (VF 22,0%) VT/VF 23%, asystole 40%, PEA 20% Japonsko Nichol G et al. Regional variation in OHCA incidence and outcome. JAMA EMS-treated cardiac arrests ( ) Asystole or PEA 86% (!) Higihara T et al. Prehopsital epinephrine use and survival among patients with OHCA. JAMA 2012 the good patients responding immediately to CPR will never need vasopressors Wenzel V. Shape and size of CPR trials to optimize impact of ALS interventions. Resuscitation 2012

4 Adrenalin... going, going, gone? Kontroverzní efekt CPP a CorPP, zvyšuje úspěšnost defibrilace Dysfunkce myokardu, arytmie, mikrocirkulace ILCOR evaluation process: PICO question Population/Pt, Intervention, Comprator, Outcome In patients in cardiac arrest (asystole, PEA, pulseles VT and VF), does the use of vasopressors (epinephrine, norepinephrine, others) or combination of vasopressors, compared with not using vasopressors (or a standard drug regimen), improve outcomes (e.g. ROSC, survival)? 3 RCT (LOE 1), 1 concurrent controls (LOE 2), 1 restrospective controls (LOE 3): ADR vs. placebo No positive effect on survival / neurological status McQueen C et al. Adrenaline fro the pharmacological treatment of CA. Resuscitation 2012

5 Adrenalin vs. placebo OHCAs treated with/without ADR Improved initial survival OR 2.51 (95% CI ), but worse 1 month survival adjusted OR 0.54 (95% CI ) and neurologically intact OR 0.23 (95% CI ) Hagihara A et al. Prehospital epinephrine use and survival among patients OHCA. JAMA 2012 Post hoc analysis of pts enrolled in the Norwegian RCT of IV/drugs vs. no IV/drugs Admission OR 2.5 (95% CI ) Hospital discharge OR 0.52 (95% CI ) CPC 1-2 OR 0.4 ( ) 57/481 vs. 19/367 Olasveengen TM et al. Intravenous drug administration during OHCA: a randomized trial. JAMA 2009 Olasveengen TM et al. Outcome when adrenaline was actually given vs. not given. Resuscitation 2012

6 Adrenalin v léčbě PEA Is adrenaline actually harmful when given for the treatment of cardiac arrest? ECG analysis 101 pts ADR vs. 73 no drugs ADR increased transitions from PEA to ROSC and extended the time window for ROSC to develop Nordseth T et al. Dynamic effects of adrenaline in OHCA with initial PEA. Resuscitation 2012

7 Farmakoterapie ADR zlepšuje pouze krátkodobé přežití Vysoké dávky ADR méně účinné (maximální dávka?) Noradrenalin může být lepší k dosažení ROSC

8 Any solution? Further studies appropriately powered to examine long-term outcomes Placebo-controlled RCTs or ADR in combination with agents reducing effects of β 1 /α 1 stimulation

9 Betablokátory? Beta-blockade Review (propranolol, esmolol, landiolol) 12 animal, 2 human studies, 10 case reports Reduces of myocardial oxygen requirements Reduces No of shocks for defibrillation Improves postresuscitation myocardial function Diminishes arrhythmia High quality human trials still lacking to answer this question definitely de Oliveira FC et al. Use of beta-blockers for the treatment of cardiac arrest due to VF/pulseless VT: A systematic review. Resuscitation 2012

10 Návrat od KPR ke KPCR Potenciální vliv na mozkovou cirkulaci SADs reduce carotid blood flow in anaesthetised humans (LMA vs. igel) Epinephrine during CPR can further reduce carotid blood flow Extracorporeal life support and prehospital cooling of pts may be the right direction Burnett AM et al. Potential negative effects of epinephrine on carotid blood flow and ETCO(2) during ACD-CPR utilizing an impedance threshold device. Resuscitation 2012 Thomas M et al. CPR cardiopulmonary resuscitation or cerebral perfusion restoration. Resuscitation 2012

11 Airway management Tracheal intubation vs. SADs Retrospektivní analýza Resuscitation Outcomes Consortium (ROC) PRIMED trial adult OHCA: 81.2% ETI and 18.8% SAD (63.0% King LT, 20.5% Combitube, 16.6% LMA) Wang HE. Endotracheal intubation versus supraglottic airway insertion OHCA, Resuscitation 2012

12 Kapnometrie Ověření správné polohy tracheální rourky po intubaci Kontinuální sledování její správné polohy Monitorace kvality prováděné resuscitace Včasná detekce ROSC (obnovení spontánního oběhu)

13 Kapnometrie

14 Kapnometrie Interpretace EtCO 2 během KPR EMS Bergen, Norsko (575 pts) Capnography distinguished between pts with or without ROSC for any initial rhythm and cause of the arrest (p<0.001) Respiratory vs. primary cardiac cause (p<0.001) Bård E. Heradstveit. Factors complicating interpretation of capnography during advanced life support in cardiac arrest A clinical retrospective study in 575 patients. Resuscitation 2012 EtCO 2 > 2,4 kpa ROSC EtCO 2 < 1,3 kpa death

15 Hyperoxia after cardiac arrest Debate continues? Conflicting findings from observational studies in pts admitted to ICU Controlled animal studies FiO 2 1,0 vs. lower 6 studies incl. 95 animals FiO 2 1,0 resulted in a worse neurological deficit score Neuronal damage (4 of 5) Pilcher J et al. The effect of hyperoxia following cardiac arrest A systematic review and meta-analysis of animal trials. Resuscitation 2012 Cílová hodnota SpO %

16 IO vstup Někdy tu žílu prostě nemůžu najít, ačkoliv na tom závisí celej můj život.

17 IO vstup Which device? Systematic review In patients undergoing resuscitation, does the use of semi-automatic IO infusion devices compared to manual needles influence IO placement success rate, time for IO placement, and ease-of-use and user preference? 179 papers, 10 studies included 2 RCT (LOE 1) Low level of evidence Superiority of the battery-powered IO driver over manual needles, and other semi-automatic IO infuson devices Weiser G et al. Current advances in intraosseous infusion A systematic review. Resuscitation 2012

18 Terapeutcká hypotermie Different rewarming strategies and outcome GL hrs C, rewarm at C/h How early, how fast, how long and how deep? Sunde K. Rewarming after therapeutic hypothermia. Resuscitation 2012

19 Ohřívání nemocných po TH Passive vs. active rewarming? active rewarming indicated if pts did not reach normal BT after 12h of passive rewarming active rewarming (38%) = no risk for poor outcome OR 1.51 ( ) fever post TH was not associated with outcome OR 0.64 ( ), p=0.22 Bouwes A et al. The influence of rewarming after TH on outcome after cardiac arrest. Resuscitation 2012

20 Ohřívání nemocných po TH Pts who needed active rewarming were significantly older than those who rewarmed spontaneously (p<0.01) older age is correlated with worse outcome Bouwes A et al. The influence of rewarming after TH on outcome after cardiac arrest. Resuscitation 2012 Questions? Is a high, spontaneous, rewarming rate in itself detrimental or a sign of severe brain damage? Will it further worsen the reperfusion injury? Or is it just a sign of an intact brain recovery?

21 Tonutí Drowning: more hope for patients, less hope for guidelines 3rd leading cause of accidental death ( /y) If water warmer than 6 C, survival unlikely if submerged longer than 30 min If water is 6 C or below, survival unlikely if submerged longer than 90 min Deakine CD. Drowning: more hope for patients, less hope for guidelines. Resuscitation 2012 Švédsko: 1-month survival 5.6% (14/250) Claesson A. Characteristics of lifesaving from drowning by the Swedish Rescue Services. Resuscitation 2012

22 Tonutí Dánsko: 15 young pts immersed min in 2 C water following a boating accident BT 23 C 7 CPR (up to 2.5 hrs), ECMO, TH 7 survived (6 CPC 1-2) Wanscher. Outcome of accidental hypothermia with or without circulatory arrest. Experience from the Danish Præstø Fjord boating accident. Resuscitation 2012

23 KPR u dětí resuscitací ročně Simulation study 1191 KPR u 25/50 kg 24 odlišných podmínek Backboards should be used when performed on soft surfaces (ICU beds) Lighter torso weights were associated with larger mattress displacements Nishisaki A et al. Backboards are important CC are provided on a soft mattress. Resuscitation 2012

24 KPR novorozenců po porodu Optimální poloha hlavy? Reviewed books, manuals and articles from 1860 Jaw thrust appears to be more effective Additional application of chin lift might reduce leak during mask ventilation Chua C. Airway manoeuvres to achieve upper airway patency during mask ventilation in newborn infants An historical perspective. Resuscitation 2012

25 Výuka resuscitace Retention of adult ALS knowledge and skills in healthcare providers? Recommendations for retraining every two years or longer 11 of 336 papers included Medline, CINAHL, Cochrane Library, PubMed ALS knowledge and skills decay by 6 months to 1 year Skills decay faster than knowledge Chih-Wei Yang et al. A systematic review of retention of adult ALS knowledge and skills in healthcare providers. Resuscitation 2012

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27 Human factors Critical incident reporting Lack of organisation at an arrest Lack of equipment / non-functioning equipment Obstructions preventing good care Four strategies for improving human factors Team dynamics (team membership, leadership) Influence of stress Debriefing Conflict management within teams Norris E. Human factors and resuscitation teaching. Resuscitation 2012

28 Závěr Síla důkazů v resuscitační medicíně nízká Zpochybnění řady dogmat Přežití nemocných závisí na jednoduchých postupech Flow

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