peter brindley - resuscitation: what’s the point

Resuscitation: what’s the point?Peter Brindley MD FRCPC FRCP Edin

Clinician…& proud to be

Other Stuff: Professor, Critical Care Medicine, Ethics, Anesthesiology

University of Alberta, Canada

Declare your biases

Circa 1780

What families think?The Age ofAcquarius

What ICU Doctors think?The Age of Eos and Tithonus

Reality check

Most critical conditions fatal 50yrs ago

Now, >80% (all comers) survive to leave ICU

….But NOT if they arrestBrindley CJGIM 2010

Brindley & Beed BJA 2014

• CPR unless explicit contrary documentation

• >8 billion on ICU (1 billion futile CPR)

• 75% die in hospital; 25% in ICU

• 90% die following w/d or w/h

Finfer NEJM 2013Brindley BJA 2013Meaney (and DeCaen ) Circulation 2013

The other reality check

Getting the point across

Indian YogaEdmonton Yoga

“JOB-ONE”ResuscitationDiagnosisDisease ManagementProceduresPerioperative-CareComfort and recoveryEnd of Life CarePaediatricsTransportSafetyProfessionalism

CPR: A Janus Head?

Brindley. Preventing Medical Crashes: Psychology Matters. J Crit Care 2010 Brindley. Cardiopulmonary Resuscitation BJA 2014

• Outcome depends most upon:– Who gets resuscitated

• Arrest type• If witnessed (or not)• If reversed within 10 mins

–WHO gets CPR; less HOW

near 100% Sensitivity

–Van Walraven Arch Intern Med 1999

Brindley et al CMAJ ’02Kutsogiannis et al CMAJ ‘11Brindley and Beed BJA ‘14

In-hospital cardiac arrest

death

5)Not knowing when to stop

2)Inadequate communication

1)Lack of knowledge

3)Inadequate recognition

4)Inadequate early response

Inappropriate CPR?J Reason BMJ

P Brindley Crit Care

In-hospital cardiac arrest

death

4)Not knowing when to stop

5)Inadequate communication

1)Lack of knowledge

2)Inadequate recognition

3)Inadequate early response

CPR: background knowledgeJ Reason BMJ

P Brindley Crit Care

Survival after adult CPR(in-hospital wards)

i) <1 in 2ii) <1 in 3iii) <1 in 4iv) <1 in 5

Brindley P.G, Markland, Kutsogiannis CMAJ 2002; Brindley Critical Care Rounds. 2003/ Brindley Can J Anesth 2005/ Crit Care. 2006

Witnessed ArrestsIn hospital (non ICU)

Survived Initial Discharged Able to Live

Resuscitation from HospitalIndependently

All Arrests48.3% 22.4% 18.9%

Respiratory 96.3% 55.6% 44.4%

All Cardiac 37.1% 14.7% 12.9%

VT/VF 38.3% 25.6% 21.3%

Asy/PEA 36.2% 7.2% 7.2%Brindley et al. CMAJ 2002

“<1 in 2” “<1 in 3”“<1 in 4” “<1 in 5”

Un-witnessed Arrests (45%) In hospital (non ICU)

Survived Initial Discharged Able to Live

Resuscitation from HospitalIndependently

All Arrests48.3% 1.0% 1.0%

Respiratory 50.0% 50.0% 50.0%

All Cardiac 20.6% 0% 0%

VT/VF 42.1% 0% 0%

Asys/PEA 15.7% 0% 0%Brindley et al. CMAJ 2002

“<1 in 2”

• Greatest impact on survival: ARREST TYPE & IF WITNESSED

• Consider all stages: “ROSC is the beginning of new suffering”.

• ? Universal resuscitation• “Full code” unless explicitly documented

otherwise

• ? Cardiac resuscitation c/t respiratory• 1-in-2 respiratory arrests survived

Brindley et al. CMAJ 2002;

No un-wit cardiac arrest dischargedSafest place to arrest…Vegas casino (>70% Valenzuela NEJM)Or TV medical drama (>60% Diem NEJM)

No improvement in >60 years

Survival not associated with “chronologic” age

Frailty matters more

Survival worse at night/early am.More un-witnessed, more PEA/ASY, less staff

Brindley et al. CMAJ 2002; Brindley critical care review 2005

& the Expensive Care Unit ? Is survival increased ?

Arrests witnessedStaff and resources present

? Is survival decreased ?Patients f-sick Already receiving ““CPR””

Kutsogiannis DJ et al. CMAJ 2011 (n=510)Chang SH et al. J Crit Care 2009 (n=202)

Tiam J et al. Am J Resp CCM 2006 (n=49,000)

ROSC incr’d in ICU59% v 48%

Survival to discharge highest in CVICU CCU GSICU 75% v 70% v 45%

No effect from arrest time-of-day

Kutsogiannis, Bagshaw, Brindley CMAJ 2011

Similar to witnessed in-hospital

Advantage d/t less PEA/ASY

3-month survival not significantly better

No improvement in 2 decades

WHO NOT HOWKutsogiannis et al. 2011 (n=510)

ICU post-CPR survival:

Inappropriate CPR

4)Not knowing when to stop

5)Inadequate communication

1)Lack of background knowledge

2)Inadequate recognition

3)Inadequate early response

CPR survival: recognition and response

In-hospital (non-ICU) Cardiac Arrest

63% Pulseless electrical activity/ Asystole

12% Primary respiratory 27% Ventricular fibrillation/Pulseless ventricular

tachycardia

Brindley et al. CMAJ 2002

Least recorded BUT most specific predictor

…of deterioration, “unexpected” ICU

Pulse-ox not a replacementEducation priority

MJA 2009

In-hospital cardiac arrest

death

4)Not knowing when to stop

5)Inadequate communication

1)Lack of background knowledge

2)Inadequate recognition

3)Inadequate early response

In-hospital arrest…a system failure

ECMO & adult cardiac arrest

Adult E-CPR?

• 40% survival to discharge (c/t 25%)

• Higher mortality if: started >30mins; >65 yrs; >2 days ecmo

• Large resource/cost commitment

Shin TG CCM 2011 (n=120); Chen Resusc 2010 (n=122); Chen Lancet 2008 (n= 59) ; Cardarelli ASAIO 2009 (n=135)

Adult ECMO arrest better if:– Sooner– Briefer– Arrest type/ Path (AMI; PE)

WHO not

HOW

1940's Russian experiment. part 1

Cardarelli et al. ASAIO 2009

Inappropriate CPR

4)Not knowing when to stop

5)Inadequate communication

1)Lack of background knowledge

2)Inadequate recognition

3)Inadequate early response

CPR survival: recognition and response

“everything” v “nothing”

“Assault”

“Natural Death”

“Neglect”

“Giving up”

ICU/ED RRURelationship Repair Unit

• >30% DNAR w/o consent• 9% “ageism”; 8% “anti-disabled”; 5%

“euthanasia”

• 2%: d/t “over resuscitation”• 6%: pre-emptive decision-making

Beed, De Beer, Brindley. Resuscitation 2014 .

Draft 1

Oh, and the OR…

• >10% of OR patients have a DNR

• ‘Widespread confusion…’– anesthetist’s job involves

‘resuscitation’– OR death NOT like other death

Ewanchuk M, Brindley P.G. Crit Care 2009Brindley P.G. BMC Anesthesiology 2012

Dr Cheryl Misak, UofT

Am J Respir Crit Care Med 2004; J Med Philos 2005; Chest 2010

Oh…and autonomy

WTF : ”””Patient focused care””””?

• What it is :– Communication– Partnership– Includes values

• What it is not :– Technology-centered– Doctor-centered– Hospital-centered

Irwin and Richardson CHEST 2006

More ICU v Better Death?

• PFC not collected by QUALY • EOL care rarely “cost effective”

• Lots of limitations…………BUT

Bryce et al Quality of Death. Med Care 2004Ward and Teno (commentary) 406-407

So what do patients want?• EOL Survey

• ¾ trade shorter-life for better EOL– ¼ wouldn’t

• Average 10 months– Low 7; high 24

In summary:

•Resuscitating sick people works•Resuscitating dead people

doesn’t

peter.brindley@albertahealthservices.ca