2009 terni, workshop interattivo, arresto cardiaco intraospedaliero

In-Hospital Cardiac ArrestIn-Hospital Cardiac ArrestEEvidencevidence B Basedased M Medicineedicine

realtà dell’incidenza ed efficacia dei soccorsi realtà dell’incidenza ed efficacia dei soccorsi

Stefano Nardi

AZIENDA OSPEDALIERA SANTA MARIA TERNIAZIENDA OSPEDALIERA SANTA MARIA TERNI DIVISION OF CARDIOLOGY DIVISION OF CARDIOLOGY

ARRHYTHMIA, ELECTROPHYSIOLOGIC CENTER ARRHYTHMIA, ELECTROPHYSIOLOGIC CENTER AND CARDIAC PACING UNIT AND CARDIAC PACING UNIT

SSudden udden CCardiac ardiac DDeatheath

Definition• Natural Death

(due to CARDIAC CAUSES)

• Preceeding by a sudden loose of coscience until 1 h of start of the ACUTE ACUTE SYMPTOMSSYMPTOMS, in a pts W or w/o note pre-existent CARDIAC DISEASECARDIAC DISEASE, in which the die was not considered imminent.

• AGE and modality of DEATH are not prevedible

Myerburg RJ, Castellanos A ’80 Myerburg RJ, Castellanos A ’80

Task- Task-force on SD of ESC. EHJ ’01 force on SD of ESC. EHJ ’01


Suddenly Suddenly FILIPPIDE FILIPPIDE die immediately after his die immediately after his announcement at Atheniesis the victory ofannouncement at Atheniesis the victory of MARATONAMARATONA

ANCIENT PROBLEM ......


Vittorio Gassman

Massimo Troisi

Beniamino Andreatta

Umberto Bossi

Sergio Leone

Clark Gable

Dwight Eisenhower

..... CURRENT PROBLEM !!!!


Total DeathTotal Death 557.584 (100%) 557.584 (100%)

Death for CV diseaseDeath for CV disease 242.248 (43%) 242.248 (43%)

Sudden DeathSudden Death 65.000 (10.2%)65.000 (10.2%)

ISTAT source ‘00ISTAT source ‘00

0

50000

100000

150000

200000

250000 Cancro dellaMammellaCancro ColonRettoCancroBronchi/PolmoniIctus

Morte Improvvisa

MalattieCardiovascolari

Mort

i p

er

an

no

Mortality Distribution


• Incidence variable 0.36-1.28/1000 Incidence variable 0.36-1.28/1000 pts in general population pts in general population

• In industrialized pts, the total In industrialized pts, the total annual incidence is 1/ 1000 annual incidence is 1/ 1000 inhabitants inhabitants

• In ITALYIn ITALY: studio FACS (Friuli) : studio FACS (Friuli) incidence of 0.95 cases each incidence of 0.95 cases each 1000/people for yr; LIFE PROJECT 1000/people for yr; LIFE PROJECT of Piacenza (Emilia) 1.10 CA each of Piacenza (Emilia) 1.10 CA each 1000 inhabitants for yr 1000 inhabitants for yr

Epidemiology

• Until 8/1000 inhabitants between 60 and 69 yrs

EBM


• Incidence Incidence 1 1 eacheach 1000/inhabitants/yr1000/inhabitants/yr

• Nr. of cases each yrNr. of cases each yr 65.00065.000

• Nr. of cases each day Nr. of cases each day 172172

• 1 case each 1 case each 9 9 hours hours (UMBRIA)(UMBRIA)

• 10 %10 % of all total mortality of all total mortality

• 40 %40 % of all deaths for CARDIAC DISEASE of all deaths for CARDIAC DISEASE

Epidemiology (Italy)


Trentino 1/ 9 ore

Lombardia 1/ 57 minuti

Friuli 1/ 7 ore

Veneto 1/ 2 ore

Piemonte 1/ 2 ore

Liguria 1/ 5 ore

Emilia 1/ 2 ore

Marche 1/ 6 ore

Toscana 1/ 2 ore

Umbria 1 caso ogni 9 oreLazio 1 caso ogni ora e 1/2

Abruzzo 1 caso ogni 9 ore

Campania 1 caso ogni ora e 20

Puglia 1 caso ogni 2 ore

Molise 1 caso ogni 26 ore

Basilicata 1 caso ogni 14 ore

Calabria 1 caso ogni 4 ore

Sicilia 1 caso ogni ora e 1/2

Sardegna 1 caso ogni 5 ore

Regional Distribution


• 2 peak age-related in which SCD is more prevalent • Between born and 6 mo (sudden infant death syndrome)

• Between 45 and 75 years old

• In Adult population, the ratio between SCD and Global mortality decrease with the age.

• 76% of total mortality are SUDDEN between 20 and 39 years

• 58% of total mortality between 55 and 64 years

• 42% are between 65 and 74 years

Relationship with Age


• Until 20% survival

• Between 30 - 80% of survivals suffer of Anoxic Encephalopaty

Magnitude (annual mortality)

•U. S. U. S. 450.000 450.000

•Europe Europe 600.000 600.000

•Germany Germany 80.000 80.000

•ItalyItaly 65.00065.000

Incidence in Italy Incidence in Italy

1 case each 9 minutes 1 case each 9 minutes


PATHOGENESIS Bradiarrhythmias Bradiarrhythmias 15-20%15-20%

VT/VF VT/VF 75-80% 75-80%

EMD EMD 5%5%

Cardiac Rhythm Cardiac Rhythm recorded in pts recorded in pts resuscitate to CA resuscitate to CA

Cummins RO, Annals Emerg Med. ‘89

Albert CM. Circulation ‘03

Bayés de Luna A. Am Heart J. ‘89

Which rhythm during CA ?Which rhythm during CA ?

IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest

66% potentially avoidable

IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest STUDIO BRESUS STUDIO BRESUS

(3765 pts rianimati) in 12 Ospedali Inglesi

IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest Sopravvivenza nell’Arresto Cardiaco Intraospedaliero (ACC)

REGISTRO NAZIONALE AMERICANO REGISTRO NAZIONALE AMERICANO (Virginia University, USA)

BRESUSBRESUS GwinnutGwinnuttt

PeberdyPeberdy

YearYear 1992 2000 2003

Number of Number of arrestsarrests

3765 1368 14720

% Survival % Survival to to

dischargedischarge

17 17.6 17

SURVIVAL


IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest Sopravvivenza nell’Arresto Cardiaco Intraospedaliero

(ACC)

EFFICACIA del TEAM di SOCCORSO EFFICACIA del TEAM di SOCCORSO (Anestesiologia e Terapia

Intensiva Pol. “Gemelli” di Roma)

• Few seconds after CAFew seconds after CA, , the subject loose the subject loose consciousness and stop to consciousness and stop to breath.breath.

• 4-6 minutes after CA4-6 minutes after CA, , it’s clearly evident a it’s clearly evident a significative Brain Damage significative Brain Damage

• More fastly is recovery More fastly is recovery cerebral circulation cerebral circulation more probability a complete more probability a complete recovery of Cerebral Function recovery of Cerebral Function

• 90 % of CA90 % of CA are completely are completely worked out if defibrillation is worked out if defibrillation is applied until 2 minutes applied until 2 minutes

SURVIVAL is Time-dependent SURVIVAL is Time-dependent


(ACC)

AECD in pts MONITORIZZATI AECD in pts MONITORIZZATI (Istituto di Coracao – Università di

Sao Paulo, Brazil)


(ACC)

Programma Defibrillazione Intra-Programma Defibrillazione Intra-Ospedaliera Ospedaliera PERSONALE NON PERSONALE NON

RICOVERATO RICOVERATO (Tufts – New England Medical Center Boston, USA)

IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest SINTESI DI CONCETTISINTESI DI CONCETTI


(ACC)

Utilizzo DAEs Intra-Osp. 1Utilizzo DAEs Intra-Osp. 1stst responders responders (Cardiologia –

Università di Bochum, Germania)


(ACC)

Staff infermieristico con AEDs in UWA Staff infermieristico con AEDs in UWA (Ospedale di Lienz,

Austria; 3 yrs sperimentazione)

Schein RMH. Chest ’90; Franklin C. Crit Care Med ‘94Smith AF. Resuscitation 1998; Hodgetts TJ. Resuscitation ’02

• 50-80% have “warning” signs

• 66% potentially avoidable

• 85% pts recovery in Medical or Surgical Division (Unmonitored Ward

Areas – UWA), die for Sudden Death

• Less then 10% pts recovery in Intensive Care Unit (ICU) die for Sudden Death


• Cardiac Arrest usually is a predictable event NOT caused by primary Cardiac Disease.

• CA follows a period of slow and progressive deterioration (unrecognized or inadequately treated Hypoxemia and Hypotension).

• Rhythm is usually Asystole or PEA

• Chance of survival is extremely poor.

Unmonitored Ward Areas Unmonitored Ward Areas (UWA) (UWA)


OBJECTIVES

• Identified CA. • Calling Help. • Start CPR (e.g. Mayo)• If appropriate start

with Defibrillation whithin 3’ from loose of consciousness


END POINT mortality is correct ?END POINT mortality is correct ?

Cardiac Arrest

Complete recovery

Intervention

Brain Damage, kidney Brain Damage, kidney failurefailure

DEATH

Basic

Life

Support

T

I

M

E


Defibrillazione Elettrica Precoce (DP)Defibrillazione Elettrica Precoce (DP)IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest

The Clinical Staff IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest

The ‘Swiss cheese’ model of organizational accidents

Some holes dueTo active failures

Other holes due tolatent conditions

Successive layers of defences

Hazards

Losses

It takes an average of 4.5 errors in the system for a medical accident to result Modified from James

Reason, 1991.

N= 78Hodgetts TJ. Resuscitation ‘02

Delay in the Diagnosis 77%Error in the Diagnosis 58%Nurse delay informing MD 35%Delayed response of MD Staff 29%Bad evaluation of altered analisys 58%Deficiencies in Acute Care 100%Failure to interpret X-rays 24%

Reasons for avoidable Reasons for avoidable CACA


• Pts deterioration is displayed with Common signs (LUNGS, HEART or BRAIN systems)

Recognition of ‘at-risk’ or critically ill pts

• Physiological parameters are monitoring and measured less frequently than desirable.

• Monitoring HR, BP, RR may predict CP arrest.

IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest Unmonitored Ward Areas Unmonitored Ward Areas

(UWA) (UWA) Delay in DiagnosisDelay in Diagnosis

• Significant effects on pt outcome.

• Pts discharged from ICU to GENERAL WARDS during the night have an increased risk of in-hospital death compared to those discharged during the day and those discharged to HIGH-DEPENDENCY UNITS. • Higher NURSE-Pt Staffing RATIOS are also associated with a reduction in CA rates, as well as rates

of PNEUMONIA, SHOCK and DEATH.

Hospital Process

Deficiencies in Acute Deficiencies in Acute CareCare


• Abnormalities of the A.B.C.

Deficiencies in Acute Deficiencies in Acute CareCare

• MD and Nursing staff with poor acute-care knowledge and skills, with lack of confidence when dealing with problems.

• Incorrect use of O2 therapy and failure to monitor pts

Schein RMH. Chest ’90; Franklin C. Crit Care Med ‘94Smith AF. Resuscitation ’98; Hodgetts TJ. Resuscitation ‘02


CPR Quality during CA

• Chest compressions were not delivered adequately and compressions were too shallow

• Quality of multiple CPR parameters was inconsistent and often did not meet published guidelines.

Abella BS, Quality of CPR, During In-Hospital Cardiac Arrest. JAMA, ’05

IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest Deficiencies in Acute Deficiencies in Acute CareCare

Hodgetts TJ. Resuscitation ‘02

• Inadequate means (ie defibrillator)• Presence of architectural barriers• Presence of institutional barriers• AED often available in specific divisions• AED often useless for technical reason

(lack of experiences)• Missing of dedicated ‘Emergency Team’• Lengthy delay in CPR

Defibrillation in Italian Hospital Defibrillation in Italian Hospital occurs ‘OFTEN’ very late occurs ‘OFTEN’ very late

Reasons for avoidable CA

Which is the RIGHT way ???Which is the RIGHT way ???

UTIC

Cardiochirurgi

a

Medicina Generale

Rianimazione Generale

Chirurgia Generale

PS

Sale

Operatorie Medicina d’ Urgenza

SERVICE

Educational Organizational

aspects

RESCUE Services • ~ 575 beds• ~ 350 MD• ~ 800 staff Nurses• Complex ‘case mix’

of patients


Piano Sanitario Emergenza/UrgenzaPiano Sanitario Emergenza/Urgenza OBIETTIVIOBIETTIVI

Hospital staff should provide a resuscitation service that

exceeds what is available in their local airport, railway

station etc

System of Training

Evidence Based Medicine (EBM)


System of TrainingSystem of Training• Who should we teach?

• What do we teach?

• How do we teach it?

• What resources do we use?

• How meaningful is the session?

• How could this teaching be improved?


Formazione del PersonaleFormazione del PersonaleIInn-H-Hospitalospital C Cardiacardiac A Arrestrrest

What do we teach?

• Introduction to Critical Care course

•Mandatory Skills Update course

• Immediate or Basic Life Support (BLS)

•Advanced (Cardiac) Life Support (ACLS)

•Newborn Life Support Course (NLS)

•Ad hoc sessions

C

O

U

R

S

E

S


Time from CA to first

defibrillation (n=2748)

ssuurrvviivvaall

From: Swedish Cardiac Arrest Registry

• Survival decrease each m of 10%


Audit compliance 2000 - 2004

0

20

40

60

80

100

2000 2001 2002 2003 2004

Year

%

• Systematic analysis of ‘Assistential Quality System’• Comparison between ‘Guided lines’ and ‘Real Word’ proposed new Standard Organizative Models • Implementation of ‘Guided Lines’• Verification of ‘outcomes’ over the time

AED’s and survival (AUDIT)

0

10

20

30

40

50

60

70

80

1999 2000 2001 2003

Number of AED's in situ

0

10

20

30

40

50

60

70

80

% S

urv

iva

l

AED's in situ ROSC Discharge Home

Do outcomes correlate with training?

Survival from ward-based VF/VT CA

IInn-H-Hospitalospital C Cardiacardiac A Arrestrrest Modelli di Critical CareModelli di Critical Care

IIntrahospital ntrahospital AAccessccess D Defibrillation efibrillation CChainhain

Fornire un trattamento immediato all’individuo in

ACC o in pericolo di ACC mediante precoce BLS-D

SCOPOSCOPO

IIntrahospital ntrahospital AAccessccess D Defibrillation efibrillation CChainhain

Applicazione delle Linee Guida del Applicazione delle Linee Guida del soccorso intra-ospedaliero alla realtà soccorso intra-ospedaliero alla realtà

della Struttura Ospedalieradella Struttura Ospedaliera

Conoscere preliminarmenteConoscere preliminarmente

GRAZIE per la cortese Attenzione

2009 terni, workshop interattivo, arresto cardiaco intraospedaliero

Health & Medicine

age sudden cardiac death

sudden death

preexistent cardiac

cardiac causes preceeding

caso ogni ora e

sudden loose of coscience

total mortality

modality of death