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ED and Hospital Care  Can Improve Survival ED and Hospital Care  Can Improve Survival

ED and Hospital Care Can Improve Survival - PowerPoint Presentation

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ED and Hospital Care Can Improve Survival - PPT Presentation

after Cardiac Arrest Ankur A Doshi MD FACEP Post Cardiac Arrest Service UPMC Presbyterian Presenter Disclosure Information Ankur A Doshi MD FACEP ED and Hospital Care Can Improve Survival ID: 816441

cardiac arrest care survival arrest cardiac survival care patients post 2013 hyperoxia resuscitation hospital management temperature outcomes center data

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Slide1

ED and Hospital Care Can Improve Survival after Cardiac Arrest

Ankur A. Doshi, MD FACEP

Post Cardiac Arrest Service

UPMC Presbyterian

Slide2

Presenter Disclosure Information

Ankur A. Doshi, MD FACEP

ED and Hospital Care

Can Improve Survival after Cardiac Arrest

2

FINANCIAL DISCLOSURE:

Employer: University of Pittsburgh/UPMC

Grants/Research Support: Pittsburgh Emergency Medicine Foundation

Slide3

Learning objectivesDiscuss immediate steps shown to improve outcomes for patients with ROSC after cardiac arrest in the ED

List proven in-hospital medical therapies for post-cardiac arrest patients

Compare Targeted Temperature Management (TTM) with Induced Therapeutic Hypothermia (ITH)

Slide4

What we won’t coverTreatment during cardiac arrest

Detailed

neuroprognostication

Seizure evaluation and treatmentOther therapies not yet proven to have benefit post-arrest

Slide5

The good news

Girotra

2012 – GWTG Data

Daya

2013 – ROC Data

Slide6

Opportunities

Langhelle

, 2003

% Survival (1 month) for OOHCA bystander witnessed and cardiac etiology

Herlitz, 2006

Slide7

What therapies can improve survival from cardiac arrest?

Blood pressure control / perfusion

Ventilator management (O2 and CO2)

Temperature managementTertiary careCardiac catheterizationDelayed neuroprognostication

Post-discharge planning

Slide8

2015 Post-Arrest Guidelines

Early Coronary Angiography

Hemodynamic Goals

Targeted Temperature ManagementSeizure Detection and ManagementVentilation and OxygenationPrognosticationOrgan Donation

8

Slide9

Blood pressure management

Slide10

Anoxic injury impairs cerebral autoregulation

“Pressure passive”

Mean arterial pressure (mmHg)

50

100150Cerebral blood flow (ml/100g/min)Normal

0

50

100

Absent

Slide11

Hemodynamic goals

Kilgannon

.

Crit

Care Med, 2014Beylin. Int Care Med, 2013MAP > 80 mmHg

Slide12

Ventilation and oxygenation

Slide13

Brain tissue hypoxia is bad and common

O

2

delivery/diffusion impairedPerivascular edemaMenon.

Crit Care Med, 2004

Slide14

Is hyperoxia bad?

Drives oxidative injury, ROS generation,

etc

Hyperoxia is common Some OBSERVATIONAL data associate extreme hyperoxia with worse outcomes

Kilgannon. JAMA, 2010ExposureAdjusted OR

(95% CI)

Arterial oxygen (per hour)

 

Severe

hyperoxia

(

>

300mmHg)

0.83 (0.72 – 0.98)

Moderate hyperoxia (101-299mmHg)

1.01 (0.96 – 1.05)

Normoxia

(60-100mmHg)

1.01 (0.97 – 1.06)

Hypoxia (<60mmHg)

0.74 (0.47 – 1.16)

Slide15

Oxygenation goalsMeasure PaO

2

In vivo

PaO2 5 mmHg lower per 1oCNormoxia (PaO

2 100-200)Significant hyperoxia is (probably) bad and frequentBrain tissue hypoxia is (probably) bad and often quite severe

Slide16

Carbon dioxide goals

PaCO

2

40mmHg (temp corrected)

Slide17

Carbon dioxide goals

PaCO

2

40mmHg (temp corrected)Observational data

Roberts. Circ, 2013 Schneider. Resus, 2013

Slide18

Temperature management

Slide19

Slide20

Hypotherm

(%)

Normotherm

(%)

RR

[95% CI]

P value

NNT

Favorable neurologic recovery

at discharge

HACA

75/136

(55%)

54/137

(39%)

1.40

[1.08-1.81]

0.006

6.4

Bernard

21/43

(49%)

9/34

(26%)

2.65

[1.02-6.88]

0.046

4.5

Favorable neurologic recovery at

6 months

HACA

71/136

(52%)

50/137

(36%)

1.44

[1.11-1.76]

0.009

7.0

HACA. NEJM, 2002

Bernard. NEJM, 2002

Slide21

950 patients, 36 ICUs in Europe and AustraliaGCS <8 after OHCA due to “presumed cardiac” etiology, regardless of rhythm (except exclude

unwitnessed

asystolic arrests)

Slide22

Nielsen. NEJM, 2013.

Slide23

Temps in RCTs

Slide24

33ºC

37ºC

32-

34ºC

37ºC33ºC36ºCOutcomes in RCTsTTM results in good outcomes (50-60% survival)

Slide25

What does the data tell us?TTM is another way of performing temperature management

Anywhere 33

deg

– 36 deg

C is reasonableDOING NOTHING IS NOT AN OPTION!

Slide26

Tertiary care

Slide27

Systems of Care

A comprehensive, structured, multidisciplinary system of care should be implemented in a consistent manner for the treatment of post–cardiac arrest patients

(Class I, LOE B).

AHA Guidelines 2010

Slide28

Volume matters

Callaway.

Resuscitation

, 2013

Slide29

Volume ~ Survival

Hospitals treat an average of 17 / year

Callaway.

Resuscitation

, 2013

Slide30

Tertiary center effect

Survival different for first 5 days

More intensive cardiac AND ICU interventions

Søholm

. Circ Cardiovasc Qual Outcomes, 2015

Slide31

Tertiary centers in CA

N=7,725 OOHCA cases adjusted for all covariates

OR (good neurological recovery) compared to non-STEMI center at

STEMI center (>40 cases/yr) 1.32 (1.06-1.64)STEMI center (<40 cases/yr)

1.63 (1.35-1.97)Mumma. Am Heart J, 2015

Slide32

Pittsburgh outcomes

N=987 persons discharged from 7 hospitals.

Link to National Death Index to determine survival time.

Center 1 has a dedicated post-arrest service line with >250 patients per year

Slide33

Cardiac catheterization

Slide34

Non ST Elevation

60% survival;

86% with favorable neurological function

Kern.

JACC, 2012

Slide35

Reynolds. Resuscitation, 2014

Slide36

Delayed neuroprognostication

Slide37

Time to awakening

Grossestreuer

.

Resuscitation

, 2013

Slide38

Why do patients die after CA?

2,137 non-survivors after OHCA

Largest cause of in-hospital death was WLST for “neurological” reasons (61.2%)

Callaway. Resuscitation, 2014

Slide39

When do patients die?

151 ROC research hospitals across North America

Elmer. Resuscitation, 2016

Slide40

Prognostication

Delay neuro-prognostication for 72 hours

Slide41

Post-discharge planning

Slide42

Anxiety and depression

Anxiety in 24% of survivors

Depression in 13%

Slide43

Cognitive Function

Cognitive dysfunction in 50%

Slide44

Long term function

Cerebral Performance Category

Modified Rankin

Scale

Reintegration to Normal Living Index

Raina. Biomed Research International, 2015

Slide45

Summary of in-hospital careBP

MAP > 80

Vent

PaCO2 ~ 40Normoxia (PaO2 100-200)TTM33-36 deg C for 24 hr

Tertiary centerCardiac catheterization “early”Delay neuroprognostication > 72 hrsFunctional recovery takes 12 monthsWatch for depression / anxiety / cognitive deficits