post cardiac arrest by bernard (smacc gold)
DESCRIPTION
From ECPR to ECMO. Steve Bernard examines evolving trends and technology for post-arrest care in Australia. Hear the talk on Intensive Care Network.TRANSCRIPT
Resuscitation Science
Stephen Bernard MD FACEM FCICM FCCM
___________________________________________________________________
Disclosures- grants
�NHMRC
�Paramedics Australia
�TAC
�Faulk Foundation
CHARACTERISTIC Odd ratio 95% CI P value
Age 0.957 0.950 - 0.964 <0.001
EMS arrival to ROSC time
0.998 0.896 - 0.920 <0.001
EMS Response time 0.968 0.940 - 0.997 0.03
No EMS Intubation Patient GCS > 8
4.96* 2.60 – 9.59 <0.001
No EMS intubationPatient GCS < 8
1.64* 1.10 – 2.43 0.015
Initial rhythm VF/VT 4.31 3.41 – 5.45 <0.001
Witnessed arrest 1.50 1.16 – 1.93 0.002
Bystander CPR 1.31 1.06 – 1.61 0.011
Transport to Cardiac Centre
1.40 1.12 – 1.74 0.003
Admission in hours (0800-1700)
1.34 1.10 – 1.64 0.004
Male Gender 1.30 1.03 – 1.64 0.025
Stub D, Bernard SA, Duffy S, et al. Hospital characteristics are associated with
patient outcomes following out-of-hospital cardiac arrest. Heart 2011; 97:1489-1494
Post Arrest Team
�Therapeutic temperature management
�Decrease inspired oxygen
�Aim systolic BP 120mmHg
�Transfer to cardiac catheter lab
�ECMO
�IAOC
Resuscitation. 2012 Apr;83(4):417-22
Animal studies
Post Arrest Management in 2014
What systolic BP ?
�Victorian Ambulance Cardiac Arrest Register (VACAR)
�3620 OHCA cases
�Median age was 69 years, 70% were male, and
60% were in a shockable rhythm on ambulance arrival
�For VF/VT patients, survival was maximal at 120-129mmHg (54%)
Bray J, Bernard S, Cantwell K, et al. Resuscitation 2014; Apr;85(4):509-15
Post Arrest Management in 2014
Transfer to cardiac catheter lab (angio+/-IABP)
�714 patients with OHCA at a tertiary centre in Paris
�435 patients with cardiac cause of arrest underwent
coronary angiogram
�304 (70%) patients had a significant lesion
�128 (96%) of 134 patients with STEMI and in 176 (58%)
of 301 patients without STEMI had a relevant lesion
Dumas F,et al. Immediate percutaneous coronary intervention is associated with better
survival after out-of-hospital cardiac arrest: insights from the PROCAT (Parisian Region
Out of hospital Cardiac ArresT) registry. Circ Cardiovasc Interv. 2010 Jun 1;3(3):200-7
Number 65 31
Year 2011-12 2013 (Nov)
Arrest duration 20 min 15min
Decrease FIO2 34% 77%
TTM 82% 100%
Cath Lab 40% 52%
ICU 1st SBP 90mmHg 100mmHg
ICU 1st pO2 151mmHg 104mmHg
Hospital survival 62% 81%
Bring on the PAT team
Temperature Management (after 17/11/13)
TTM
TTM
TTM
TTM
�This study should change practice !
�Maintaining 36°C for 24 hours is easier than 33°C
�Control with sedation/ paralysis and a cooling
device
�Prognostication - day 5 (24+12+72=108 hours)
Refractory Arrest: What more can be done?
�Just keep going
�VA ECMO during CPR (ECPR)
�Mechanical CPR to cardiac
catheter laboratory
Cold IV saline
3L bolus IV
Cools rapidly
Bernard SA, et al. Therapeutic hypothermia induced during cardiopulmonary resuscitation using
large-volume, ice-cold intravenous fluid. Resuscitation 2008; 76:311-3
To the ICU:
�Cooling for 24 hours
�33°C
�Slow rewarming over 24 hours @ 0.25°C/hr
�ECMO out when ROSC or CNS hopeless
THE CHEER TRIAL
�February 2012 to January 2014
�21 patients had attempted E-CPR
�9/21 with out-of-hospital cardiac arrest
�The site of cannulationo 13/21 (62%) in the ED
o 7/21 (33%) in the ICU
o 1/21 (5%) in the cath lab
�The average age 47 years (21-62)
�16/21 (76%) male
THE CHEER TRIAL
�Percutaneous cannulation was successful in 19/21 (90.5%)
�The average duration of ECMO support
in the 19 cannulated patients was 4.2 days
�13/21 (62%) patients awoke and 12/21 (57%) patients were discharged home
I have a dream….
� Post arrest patient go to a 24/7 cath lab hospital with interested staff
� Post arrest team?
� ECPR available in selected centres (at least one in each capital city)
� ED or ICU driven
� IAOC for arrest due to bleeding subdiaphragm