peter brindley - resuscitation: what’s the point
TRANSCRIPT
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
