redefining resuscitation

Ken Hillman

REDEFINING RESUSCITATION

Don Harrison Perpetual Lecture,

Spark of Life Conference, Perth.

7th-10th April 2011

HISTORY OF

RESUSCITATION

LIFE-SAVING AFTER NEAR-DROWNING

HOLLAND 1767 – Society for resuscitation of the drowned

BRITAIN 1774 – Society for the recovery of persons apparently drowned

Royal Humane Society for the Apparently Dead

2/0179

RESUSCITATION Trespassing the boundary between life

and death

Scientifically possible (sometimes)

Religious - only the Creator could give or

Ethical take life

2/0190

RESUSCITATION – rekindling the

flame of a taper by blowing gently –

MEDICINE’s work

RE-ANIMATION – bringing a corpse

back to life after the spark is fatally

extinct – GOD’s work

2/0161

RESUSCITATION

DOESN’T WORK AFTER

PUTREFACTION HAS SET

IN!!

Royal HUMANE Society 1809

2/0163

REVIVING TEMPORARILY

DEAD PEOPLE

1803 – religiously sound

activity

2/0162

EARLY RESUSCITATION

TECHNIQUES

• Warming

• Rolling body over barrel

• Rubbing the body

• Tickling throat with a feather

2/0191

2/0127

2/0128

UP UNTIL WORLD

WAR II

• Fogging on mirror over mouth –

warm

• No fogging on mirror – SILVESTER

or SCHAFER resuscitation

techniques

2/0165

2/0110

HOLGER NIELSON

TECHNIQUE

Back pressure + arm lift

Started dominating post-World War II

2/0166

2/0111

THE AIRWAY!

Not considered until

Safar 1958

2/0167

CPR

Combination of

• Open airway

• Mouth to mouth respiration

• External cardiac compressions

2/0168

1968 – INCONSISTENT ARTIFICIAL

VENTILATION – GERMAN STUDY 1968

Aim to compare ventilatory effect of:

Howard-Thomsen

Holger Nielsen Chest compression

Silvester-Brosch Arm lift

Mouth-to-nose Exhaled air

Mouth-to-mouth

Acta Anaesth Scand 1968; suppl XXIX

GA – pentobarbitone

Paralysed with methyl-curare

Ventilation with Ambu bag + Ruben valve

Femoral artery catheter

ECG

End exp CO2 %

Pulse rate


“LATIN SQUARE” SEQUENCE Volunteers Methods

1+6 A C B E D

2+7 D A E C B

3+8 B D C A E

4+9 C E D B A

5+10 E B A D C

A – Mouth to nose

B – Mouth to mouth

C – Howard-Thomsen

D – Holger Nielsen

E – Silvester-Brosch


ABG - normal ventilation

Apnoea - 60 secs

Then one of the 5 ‘methods’

• ABGs/30 sec for 3 min

• The ‘method’ for 9 min


ABG - Clark electrode

pH & PaCO2 - Astrup

O2 sat - slide rule designed by

Severinghaus


SOME CASES

PaO2 <30 mmHg

O2 sat < 50%


CONCLUSION

Manual methods should no

longer be used


CPR

• Initially for anaesthesia – induced

cardiac arrest

• “Miraculous, effective, simple”

Kovwenlioven NEJM 1960;173:1064

2/0062

CPR “Anywhere….. Anytime”

Universally applicable to

death and dying – no matter

what the cause

2/0170

CPR LEADS TO:

• Medical personnel in ambulances

• Paramedics

• Coronary Care Units

2/0171

1970’s Widespread community

awareness and education

programmes

2/0193

CPR

• Intimately linked to the practice of

medicine

• Associated with acute medicine through

the media

2/0033

CARDIAC ARREST

TEAM

2/0012

2/0022

HOSPITAL CPR

• Most die in hospital

• Half of all survivors have

significant decrease in

functional status Arch Int Med 2000;160:1969

2/0068

IN-HOSPITAL CARDIAC

ARRESTS

• Extracorporeal CPR

• Better than CPR

Crit Care Med 2011;39:1

PORTRAYAL CPR ON

TELEVISION

UK USA

Survival 16% 77%

2/0045

2/0108

REDEFINING

RESUSCITATION IN ACUTE

HOSPITALS

• Where and why do patients have

cardiac arrests?

• Moving from CPR to patient centered

resuscitation

• The role of DNR?

• The future?

2/0078

REDEFINING

RESUSCITATION

WHERE AND WHY DOES

CPR OCCUR IN HOSPITALS?

2/0013

PATIENTS SUDDENLY

DIE IN GENERAL

HOSPITAL WARDS NOT

IN ICU/OT/ED

ENVIRONMENTS

2/0032

WHY DO PATIENTS HAVE

CARDIAC ARRESTS IN

HOSPITAL?

Up to 80% of all so-called ‘arrests’ are

preceded by at least 8 hours of slow

deterioration in vital signs

2/0013

Schein et al Chest 1990;98:1388

WHY DO PATIENTS HAVE

CARDIAC ARRESTS IN

HOSPITAL?

Silo based hospital function

Medical specialisation

Vital sign measurement

Nurses are trained to measure not act

Doctors act on them in hierarchical way

Poor resuscitation training

2/0013

SICK PATIENT

NURSE OBSERVES BUT CAN’T ACT

TRAINEE DOCTORS ACT BUT NOT

TRAINED

SPECIALIST – TRAINED BUT NOT IN

ACUTE MEDICINE

EVENTUALLY MULTIORGAN

FAILURE/CARDIAC ARREST AND

ADMITTED TO ICU

Systems to

connect first

signs with

acute care

specialists

1.2/0073

2/0026

DOES A MET/RRS

WORK?

2/0017

SINGLE CENTRE STUDIES

ALL SHOW A REDUCTION

IN CARDIAC ARRESTS

AND DEATHS

• System implementation is different from

drug and procedural implementation

• A large Hawthorn effect is essential

2/0017

BEFORE/AFTER

MET

50% reduction in CARDIAC ARRESTS

after casemix adjustment odds ratio

0.5: 95% CI 0.35-0.73

BMJ 2002;324:387

2/0039

BEFORE/AFTER MET STUDY

Before After Difference RR

95% CI 95% CI

Cardiac arrests 63 22 41(23-59) 0.35(0.22-0.57)

Deaths from cardiac

arrests 37 16 21(7-35) 0.43(0.26-0.70)

No. days in ICU>C.arrest 163 33 130(110-150) 0.20(0.13-0.33)

No.days in hospital

>C.arrest 1353 159 1194(1119-1269) 0.11(0.70--.79)

Inpatient deaths 302 222 80(37-123) 0.74(0.70-0.79)

MJA 2003;179(6):283-287

2/0040

THE MEDICAL

EMERGENCY

RESUSCITATION

INTERVENTIONAL TRIAL

(MERIT) STUDY

1.4/0002

EVIDENCE

MERIT

Inconclusive – underpowered

1.4/0340

Lancet 2005;365:2091-2097

REDEFINING

RESUSCITATION

FINDINGS AND INSIGHTS

Lancet 2005;365:2091-2097

1.4/0122

CONFOUNDERS

• Over 30% of calls in control

hospitals were ‘MET’ calls –

contamination

• Large variability in MET

hospitals

2/0017

CONFOUNDERS Less than half of all events

had vital signs criteria

documented in the eight

hours beforehand

Lancet 2005;365:2091-2097

CONFOUNDERS In patients with documented

MET criteria followed by an

event, only a minority of

patients overall had an actual

MET call made

1.4/0122 Lancet 2005;365:2091-2097

PROPORTION OF MISSING VITAL

SIGNS WITHIN 24 h OF SERIOUS

ADVERSE EVENT

Respiratory rate - approx 25%

Heart rate - approx 8%

BP - approx 6%

Resuscitation 2009;80:35

INTERVENTIONS

Emergency Team Calls (ie non-cardiorespiratory arrest)

512 control hospitals

1864 MET hospitals

Only 5 of these were not critical care interventions

Only 1 had an assessment/examination

Resuscitation 2010;81:25

META ANALYSIS

30% reduction in paediatric mortality

and cardiac arrest rates

30% reduction in adult cardiac arrest

rates

Not achieved by any other intervention

Chen et al 2010;170(1):18-26

MERIT STUDY

The MET system reduces

mortality

Crit Care Med 2009;37:148-153

RAPID RESPONSE

SYSTEMS

• Majority of US hospitals – IHI

• Majority of Canadian hospitals

• UK – mandatory outreach and now RRSs

• Scandinavia – spreading

• Holland – national implementation underway

• Sporadic – Mexico, Subcontinent, remainder of Europe

RAPID RESPONSE

SYSTEMS - AUSTRALIA

• NSW – being rolled out in every acute hospital

• Australia – implementation guidelines being developed by the Australian Commission on Safety and Quality in Health Care

REDEFINING

RESUSCITATION

Is about system implementation

as well as

Individual clinical skills

2/0017

EFFECTIVE IMPLEMENTATION

OF RAPID RESPONSE SYSTEMS

1. Triggering criteria

2. Response – 24/7 of at least one person with advanced resuscitation skills

3. Ownership and administration within a hospital

4. Education • Awareness – EVERYONE

• Basic resuscitation – NURSES AND ON-SITE MEDICAL STAFF

• Advanced resuscitation – MINIMUM 1 PERSON 24/7

5. Key performance Indicators (KPIs) • Measure problem

• Track implementation and maintenance

• Measure effectiveness

ALL IMPLEMENTED SIMULTANEOUSLY

REDEFINING RESUSCITATON

MOVE FROM:

CARDIAC ARREST TEAMS

SYSTEM BUILT AROUND AT-RISK PATIENTS – 24/7 system to identify all at-risk patients

– Patient centred triage according to level of illness

– Small 24/7 teams skilled in ALL aspects of managing the seriously ill, including CPR

2/0113

HOSPITAL CARDIAC ARRESTS

ARE SENTINAL EVENTS

- SHOULD BE SUBJECT TO

DETAILED ANALYSIS

• Most are potentially preventable

• Many should have been DNR

• Few are sudden and unexpected

REDEFINING

RESUSCITATION

THE PLACE OF DNR

2/0017

REDEFINING

RESUSCITATION

• CPR has a low survival rate

• CPR works best in witnessed arrests

with sudden arrhythmia

• CPR almost never works at the natural

end of life in a dying person- witnessed

or non witnessed.

2/0017

• IF CPR UNLIKELY TO BE

– appropriate

– successful

• WHY WRITE DNR ORDERS?

• DISCUSS DYING AND HOW IT IS

TO BE MANAGED

2/0090

HOSPITAL - CPR

CRUEL AND DISHONEST

PERIMORTEM RITUAL

2/0059

THINKING DNR?

Catalyst to begin honest discussions:

• Medical condition

• Therapeutic options

• Prognosis

2/0097

DNR = Diagnosis of dying

= Medicine has no more to offer

= Change thrust of care

HONESTY AND PALLIATION

2/0050

REDEFINING

RESUSCITATION

THE FUTURE

SERIOUSLY ILL AT-RISK

PATIENT vs CARDIAC ARREST

PATIENT

“The seriously ill at-risk patient”

is a syndrome similar to the

“coronary artery syndrome”

2/0178

PATIENT-CENTRED

RESUSCITATION

This is not waiting until the

patient’s heart has stopped

and instituting CPR

2/0017

COMMUNITY

EXPECTATIONS

Sophisticated

and well organised systems to

guarantee patient safety at all

times

2/0140

FUTURE OF MONITORING

• Universal

• Non-invasive

• Wireless

Signals not boxes

Algorithms for signals

CONTINUING WARD CARE DEFINITIONS

FOR TRIAGE

NOT FOR RESUSCITATION

STEP DOWN UNIT

ICU & SPECIALISED UNITS

TRIAGE

Resuscitation

Early

identification

of seriously

ill at-risk

patients

2/0135

REDEFINING

RESUSCITATION

• Resuscitation is not only CPR

• Resuscitation is a complex set of skills

and experience used to stabilise acutely

ill patients

• Require at least one person at all times

in a hospital with appropriate advanced

skills, knowledge and experience 2/0017

NEED TO CARE FOR

CRITICALLY ILL

PATIENTS

NOT

CRITICAL CARE UNITS

redefining resuscitation

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