2009 terni, workshop interattivo, arresto cardiaco intraospedaliero

In-Hospital Cardiac ArrestIn-Hospital Cardiac Arrest
EEvidencevidence BBasedased MMedicineedicine
realtà dell’incidenza ed efficacia dei soccorsirealtà dell’incidenza ed efficacia dei soccorsi
Stefano Nardi
AZIENDA OSPEDALIERA SANTA MARIA TERNIAZIENDA OSPEDALIERA SANTA MARIA TERNI
DIVISION OF CARDIOLOGYDIVISION OF CARDIOLOGY
ARRHYTHMIA, ELECTROPHYSIOLOGIC CENTERARRHYTHMIA, ELECTROPHYSIOLOGIC CENTER
AND CARDIAC PACING UNITAND CARDIAC PACING UNIT

20:56:23 II
20:56:35 II
20:56:47 II Medtronic Physio-Control

SSuddenudden CCardiacardiac DDeatheath
20:56:23 II
20:56:35 II
20:56:47 II Medtronic Physio-Control

Definition
• Natural Death
(due to CARDIAC
CAUSES)
• Preceeding by a sudden loose
of coscience until 1 h of start
of the ACUTE SYMPTOMSACUTE SYMPTOMS, in
a pts W or w/o note pre-
existent CARDIAC DISEASECARDIAC DISEASE,
in which the die was not
considered imminent.
• AGE and modality of DEATH are
not prevedible
Myerburg RJ, Castellanos A ’80Myerburg RJ, Castellanos A ’80

SuddenlySuddenly FILIPPIDEFILIPPIDE die immediately after hisdie immediately after his
announcement at Atheniesis the victory ofannouncement at Atheniesis the victory of MARATONAMARATONA
ANCIENT PROBLEM ......

Vittorio Gassman
Massimo Troisi
Beniamino Andreatta
Umberto Bossi
Sergio Leone
Clark Gable
Dwight Eisenhower
..... CURRENT PROBLEM !!!!

Total DeathTotal Death →→ 557.584 (100%)557.584 (100%)
Death for CV diseaseDeath for CV disease →→ 242.248 (43%)242.248 (43%)
Sudden DeathSudden Death →→ 65.000 (10.2%)65.000 (10.2%)
ISTAT source ‘00ISTAT source ‘00
0
50000
100000
150000
200000
250000 Cancro della
Mammella
Cancro Colon
Retto
Cancro
Bronchi/Polmoni
Ictus
Morte Improvvisa
Malattie
Cardiovascolari
Mortiperanno
Mortality Distribution

• Incidence variable 0.36-1.28/1000Incidence variable 0.36-1.28/1000
pts in general populationpts in general population
• In industrialized pts, the total annualIn industrialized pts, the total annual
incidence is 1/ 1000 inhabitantsincidence is 1/ 1000 inhabitants
• In ITALYIn ITALY: studio FACS (Friuli): studio FACS (Friuli)
incidence of 0.95 cases eachincidence of 0.95 cases each
1000/people for yr; LIFE PROJECT1000/people for yr; LIFE PROJECT
of Piacenza (Emilia) 1.10 CA eachof Piacenza (Emilia) 1.10 CA each
1000 inhabitants for yr1000 inhabitants for yr
Epidemiology
• Until 8/1000 inhabitants
between 60 and 69 yrs
EBM

• IncidenceIncidence →→ 11 eacheach 1000/inhabitants/yr1000/inhabitants/yr
• Nr. of cases each yrNr. of cases each yr →→ 65.00065.000
• Nr. of cases each dayNr. of cases each day →→ 172172
• 1 case each1 case each 99 hourshours (UMBRIA)(UMBRIA)
• 10 %10 % of all total mortalityof all total mortality
• 40 %40 % of all deaths for CARDIAC DISEASEof all deaths for CARDIAC DISEASE
Epidemiology (Italy)

Trentino → 1/ 9 ore
Lombardia → 1/ 57 minuti
Friuli → 1/ 7 ore
Veneto → 1/ 2 ore
Piemonte → 1/ 2 ore
Liguria → 1/ 5 ore
Emilia → 1/ 2 ore
Marche → 1/ 6 ore
Toscana → 1/ 2 ore
Umbria → 1 caso ogni 9 ore
Lazio → 1 caso ogni ora e 1/2
Abruzzo → 1 caso ogni 9 ore
Campania → 1 caso ogni ora e 20
Puglia → 1 caso ogni 2 ore
Molise → 1 caso ogni 26 ore
Basilicata → 1 caso ogni 14 ore
Calabria → 1 caso ogni 4 ore
Sicilia → 1 caso ogni ora e 1/2
Sardegna → 1 caso ogni 5 ore
Regional Distribution

• 2 peak age-related in which SCD is more prevalent
• Between born and 6 mo (sudden infant death syndrome)
• Between 45 and 75 years old
• In Adult population, the ratio between SCD and
Global mortality decrease with the age.
• 76% of total mortality are SUDDEN between 20 and 39 years
• 58% of total mortality between 55 and 64 years
• 42% are between 65 and 74 years
Relationship with Age

• Until 20% survival
• Between 30 - 80% of
survivals suffer of
Anoxic Encephalopaty
Magnitude (annual mortality)
• U. S.U. S. →→ 450.000450.000
• EuropeEurope →→ 600.000600.000
• GermanyGermany →→ 80.00080.000
• ItalyItaly →→ 65.00065.000
Incidence in ItalyIncidence in Italy
11

PATHOGENESIS BradiarrhythmiasBradiarrhythmias
15-20%15-20%
VT/VFVT/VF
75-80%75-80%
EMDEMD
5%5%
Cardiac Rhythm recordedCardiac Rhythm recorded
in pts resuscitate to CAin pts resuscitate to CA
Cummins RO, Annals Emerg Med. ‘89
Albert CM. Circulation ‘03
Bayés de Luna A. Am Heart J. ‘89
Which rhythm during CA ?Which rhythm during CA ?

IInn-H-Hospitalospital CCardiacardiac AArrestrrest
66% potentially avoidable

STUDIO BRESUSSTUDIO BRESUS
(3765 pts rianimati) in 12 Ospedali Inglesi

IInn-H-Hospitalospital CCardiacardiac AArrestrrestSopravvivenza nell’Arresto Cardiaco Intraospedaliero (ACC)
REGISTRO NAZIONALE AMERICANOREGISTRO NAZIONALE AMERICANO
(Virginia University,
USA)

BRESUSBRESUS GwinnuttGwinnutt PeberdyPeberdy
YearYear 1992 2000 2003
Number ofNumber of
arrestsarrests
3765 1368 14720
% Survival% Survival
to dischargeto discharge
17 17.6 17
SURVIVAL

EFFICACIA del TEAM di SOCCORSOEFFICACIA del TEAM di SOCCORSO
(Anestesiologia e
Terapia Intensiva Pol. “Gemelli” di Roma)

• Few seconds after CAFew seconds after CA,,
the subject loose consciousnessthe subject loose consciousness
and stop to breath.and stop to breath.
• 4-6 minutes after CA4-6 minutes after CA, it’s, it’s
clearly evident a significativeclearly evident a significative
Brain DamageBrain Damage
• More fastly is recoveryMore fastly is recovery
cerebral circulationcerebral circulation moremore
probability a complete recoveryprobability a complete recovery
of Cerebral Functionof Cerebral Function
• 90 % of CA90 % of CA are completelyare completely
worked out if defibrillation isworked out if defibrillation is
applied until 2 minutesapplied until 2 minutes
SURVIVAL is Time-dependentSURVIVAL is Time-dependent

AECD in pts MONITORIZZATIAECD in pts MONITORIZZATI
(Istituto di Coracao – Università
di Sao Paulo, Brazil)

Programma Defibrillazione Intra-OspedalieraProgramma Defibrillazione Intra-Ospedaliera
PERSONALE NON RICOVERATOPERSONALE NON RICOVERATO
(Tufts – New England Medical
Center Boston, USA)

SINTESI DI CONCETTISINTESI DI CONCETTI

Utilizzo DAEs Intra-Osp. 1Utilizzo DAEs Intra-Osp. 1stst
respondersresponders
(Cardiologia –
Università di Bochum, Germania)

Staff infermieristico con AEDs in UWAStaff infermieristico con AEDs in UWA
(Ospedale di Lienz,
Austria; 3 yrs sperimentazione)

Schein RMH. Chest ’90; Franklin C. Crit Care Med ‘94
Smith AF. Resuscitation 1998; Hodgetts TJ. Resuscitation ’02
• 50-80% have “warning” signs
• 66% potentially avoidable
• 85% pts recovery in Medical or Surgical
Division (Unmonitored Ward Areas – UWA),
die for Sudden Death
• Less then 10% pts recovery in Intensive Care
Unit (ICU) die for Sudden Death

• Cardiac Arrest usually is a predictable event
NOT caused by primary Cardiac Disease.
• CA follows a period of slow and progressive
deterioration (unrecognized or inadequately
treated Hypoxemia and Hypotension).
• Rhythm is usually Asystole or PEA
• Chance of survival is extremely poor.
Unmonitored Ward Areas (UWA)Unmonitored Ward Areas (UWA)

OBJECTIVES
• Identified CA.
• Calling Help.
• Start CPR (e.g. Mayo)
• If appropriate start
with Defibrillation
whithin 3’ from loose
of consciousness

END POINT mortality is correct ?END POINT mortality is correct ?
Cardiac Arrest
Complete recovery
Intervention
Brain Damage, kidney failureBrain Damage, kidney failure
DEATH
Basic
Life
Support
T
I
M
E

Defibrillazione Elettrica Precoce (DP)Defibrillazione Elettrica Precoce (DP)

The Clinical Staff

The ‘Swiss cheese’ model of
organizational accidents
Some holes due
To active failures
Other holes due to
latent conditions
Successive layers of defences
Hazards
Losses
It takes an average of 4.5 errors in the
system for a medical accident to result Modified from James
Reason, 1991.

N= 78Hodgetts TJ. Resuscitation ‘02
Delay in the Diagnosis 77%
Error in the Diagnosis 58%
Nurse delay informing MD 35%
Delayed response of MD Staff 29%
Bad evaluation of altered analisys 58%
Deficiencies in Acute Care 100%
Failure to interpret X-rays 24%
Reasons for avoidable CAReasons for avoidable CA

• Pts deterioration is displayed with Common signs
(LUNGS, HEART or BRAIN systems)
Recognition of ‘at-risk’ or critically ill pts
• Physiological parameters are monitoring and
measured less frequently than desirable.
• Monitoring HR, BP, RR may predict CP arrest.
Unmonitored Ward Areas (UWA)Unmonitored Ward Areas (UWA)
Delay in DiagnosisDelay in Diagnosis

• Significant effects on pt outcome.
• Pts discharged from ICU to GENERAL WARDS during
the night have an increased risk of in-hospital death
compared to those discharged during the day and
those discharged to HIGH-DEPENDENCY UNITS.
• Higher NURSE-Pt Staffing RATIOS are also
associated with a reduction in CA rates, as well as rates
of PNEUMONIA, SHOCK and DEATH.
Hospital Process
Deficiencies in Acute CareDeficiencies in Acute Care

• Abnormalities of the A.B.C.
• MD and Nursing staff with poor acute-care
knowledge and skills, with lack of confidence
when dealing with problems.
• Incorrect use of O2 therapy and failure to
monitor pts
Schein RMH. Chest ’90; Franklin C. Crit Care Med ‘94
Smith AF. Resuscitation ’98; Hodgetts TJ. Resuscitation ‘02

CPR Quality during CA
• Chest compressions were not delivered
adequately and compressions were too shallow
• Quality of multiple CPR parameters was
inconsistent and often did not meet published
guidelines.
Abella BS, Quality of CPR, During In-Hospital Cardiac Arrest. JAMA, ’05

Hodgetts TJ. Resuscitation ‘02
• Inadequate means (ie defibrillator)
• Presence of architectural barriers
• Presence of institutional barriers
• AED often available in specific divisions
• AED often useless for technical reason
(lack of experiences)
• Missing of dedicated ‘Emergency Team’
• Lengthy delay in CPR
Defibrillation in Italian HospitalDefibrillation in Italian Hospital
occurs ‘OFTEN’ very lateoccurs ‘OFTEN’ very late
Reasons for avoidable CA

Which is the RIGHT way ???Which is the RIGHT way ???
UTIC
Cardiochirurgia
Medicina Generale
Rianimazione Generale
Chirurgia Generale
PS
Sale Operatorie
Medicina d’ Urgenza

SERVICE
Educational
Organizational
aspects
RESCUE Services • ~ 575 beds
• ~ 350 MD
• ~ 800 staff Nurses
• Complex ‘case mix’
of patients

Piano Sanitario Emergenza/UrgenzaPiano Sanitario Emergenza/Urgenza
OBIETTIVIOBIETTIVI

Hospital staff should provide a
resuscitation service that
exceeds what is available in their
local airport, railway station etc
System of Training
Evidence Based Medicine (EBM)

System of TrainingSystem of Training
• Who should we teach?
• What do we teach?
• How do we teach it?
• What resources do we use?
• How meaningful is the session?
• How could this teaching be improved?

Formazione del PersonaleFormazione del Personale

What do we teach?
• Introduction to Critical Care course
• Mandatory Skills Update course
• Immediate or Basic Life Support (BLS)
• Advanced (Cardiac) Life Support (ACLS)
• Newborn Life Support Course (NLS)
• Ad hoc sessions
C
O
U
R
S
E
S

Time from CA
to first
defibrillation
(n=2748)
ss
uu
rr
vv
ii
vv
aa
ll
From: Swedish Cardiac Arrest Registry
• Survival decrease
each m of 10%

Audit compliance 2000 - 2004
0
20
40
60
80
100
2000 2001 2002 2003 2004
Year
%
• Systematic analysis of ‘Assistential Quality System’
• Comparison between ‘Guided lines’ and ‘Real Word’ proposed
new Standard Organizative Models
• Implementation of ‘Guided Lines’
• Verification of ‘outcomes’ over the time

AED’s and survival (AUDIT)
0
10
20
30
40
50
60
70
80
1999 2000 2001 2003
N
u
m
b
e
r
o
f
A
E
D
'
s
i
n
s
i
t
u
0
10
20
30
40
50
60
70
80
%Survival
AED's in situ ROSC Discharge Home

Do outcomes correlate
with training?
Survival from ward-based VF/VT CA

Modelli di Critical CareModelli di Critical Care

IIntrahospitalntrahospital AAccessccess DDefibrillationefibrillation CChainhain

Fornire un trattamento immediato all’individuo in ACC
o in pericolo di ACC mediante precoce BLS-D
SCOPOSCOPO
IIntrahospitalntrahospital AAccessccess DDefibrillationefibrillation CChainhain

Applicazione delle Linee Guida delApplicazione delle Linee Guida del
soccorso intra-ospedaliero alla realtàsoccorso intra-ospedaliero alla realtà
della Struttura Ospedalieradella Struttura Ospedaliera
Conoscere preliminarmenteConoscere preliminarmente

GRAZIE
per la cortese Attenzione

2009 terni, workshop interattivo, arresto cardiaco intraospedaliero

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