Claudio Sandroni - ircouncil.it · Post Resuscitation Care Claudio Sandroni Dept. of...
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Post Resuscitation Care
Claudio SandroniDept. of Anaesthesiology and Intensive Care
Catholic University School of Medicine –Rome –Italy
IRC Scientific Committee
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2010…..
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…..2015
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Post Resuscitation Care
Corso Post-ROSC 1° Livello
Workshop Post-ROSC 2° Livello Adulto
Workshop Post-ROSC 2° Livello Pediatrico/Neonatale
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Post Resuscitation Care
• Obiettivo: fornire un approccio standard ed
aggiornato all’evidenza clinica recente
• Focus sulla fase intraospedaliera
• Pronto soccorso
• Emodinamica
• UTI
• Riabilitazione neurologica per acuti
• Destinatari: medici ed infermieri
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Competenze principali
1. Gestione della temperatura
2. Gestione emodinamica e riperfusione
3. Ossigenazione e ventilazione
4. Prognosi
5. Raccolta dati (Utstein)
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1 - Gestione della temperatura
• 33 vs. 36 °C
• Durata 24 h
• VF/pVT vs. tutti i ritmi
• Extra- vs. intra
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2 - Emodinamica e riperfusione
Circolatoria (shock)
Neurologica
Giorni dopo il ricovero in terapia intensiva
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2 - Emodinamica e riperfusione
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J.P. Nolan et al. Resuscitation 2015; 95:202-22.
2 - Emodinamica e riperfusione
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Dumas F et al Circ Cardiovasc Interv. 2010;3:200-207
n = 310
ECG post-arresto e PCI
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3 - Ossigenazione e ventilazione
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• Multicentrico osservazionale, da registro clinico di ICU in Australia
• n = 11.000 pazienti rianimati da OHCA
• Outcome primario: mortalità intraospedaliera
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4 - Prognosi
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PrognosiGiorni
3-5
Due o più dei seguenfi
- Stato mioclono ≤48h dal ROSC
- Livelli elevati di NSE
- EEG areagente con burst-suppression o stato epilettico
- Danno diffuso su base anossica alla TAC/RMN cerebrale
Prognosi infausta
molto probabile(FPR <5%, 95%CI stretti)
Sì
No
Esito indeterminato
Osserva e rivaluta
No
Escludere interferenze, specie sedazione residua
Riscaldamento
Giorni
1-2
Prognosi infausta
probabile
Sì
Temperatura controllata
Arresto cardiaco
Usare più di una metodica ogni volta che è possible
Uno o entrambi :
- Pupillari + corneali assenti
- N20 dei SSEP bilateralmente assente
SS
EP
Paziente incosciente, M=1-2 a ≥72h dopo ROSC
Attendere almeno 24h
Ma
gn
eti
c R
eso
na
nce
Ima
gin
g (
MR
I)
CT
EE
G -
NS
E
Sta
tus
My
ocl
on
us
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Cause di morte dopo rianimazione
Dragancea 2013, Svezia
Other
13%
Cardiac
16%
WLST
66%
Brain
death
5%
Neuro
71%
Elmer 2016, USA
Dragancea I et al Resuscitation 2013; 84:337-42 Elmer J et al Resuscitation 2016; 102:127-35
Other
10%
Cardiac
20%
WLST
59%
Brain
death
11%
Neuro
70%
n= 86 n= 2760
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La prognosi non è solo in UTI
• Mortalità post-UTI elevata
• Evoluzione dei pazienti con esito intermedio(CPC = 2-3)
• Recupero funzionale dissociato dal CPC
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5 – Report ed Utstein
Perkins GD et al. Circulation 2015
In-hospital Utstein in preparation (2018)
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• Radeschi G. et al, 2017; 119:48-55
• Primo report multicentrico italiano sull’IHCA
• La raccolta dati continua
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Mortalità dopo ACC intraospedaliero
0
200
400
600
800
1000
1200
1400
1600
1800
Cardiac arrest ROSC Discharge 6 months
Patients
Piedmont Cardiac Arrest Registry, 2012-2014.
62.3%
61.9%
n =1590
Radeschi G et al Resuscitation 2017; 119:48-55
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Caratteristiche del corso
Formato didattico: Seminari + discussione a piccoli gruppi
Requisiti di accesso: ALS <5 anni
Durata: 1 giorno (8 ore)
Docenti: Istruttori full ALS/EPALS con esperienza di ITU
• Possibile la partecipazione di esperti non istruttori ≤50% della
Faculty
Valutazione: Quiz pre/post MCQ
Materiale Didattico: Manuale IRC + linee guida: studio obbligatorio
prima del corso.
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Qualità specifiche del corso
• Alto contenuto scientifico
• Necessità di relatori esperti
• Struttura flessibile
• Frequenti aggiornamenti
• Manuale agile e facilmente aggiornabile
• “State of the art” lectures
• Multidisciplinarietà
• Aperto agli esperti non-istruttori
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Manuale Post-resuscitation care
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Programma (bozza)
08.00 – 08.30 Registrazione
08:30 – 10:00 Lezioni 1
10.15 – 11.45 Discussione chiusa a piccoli gruppi
12.00 – 13.00 Lezioni 2
13.00 – 13.30 Lunch break
13:30 – 15:00 Lezioni 3
15-15 – 16.45 Discussione chiusa a piccoli gruppi
17:00 – 17.30 Quiz a scelta multipla
17.30 Chiusura
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Argomenti delle lezioni (bozza)
1. Inquadramento epidemiologico
2. Riperfusione post-ROSC
3. Ottimizzazione emodinamica
4. Insufficienze d’organo extracerebrali
5. Previsione prognostica
6. Esiti a lungo termine
7. Raccolta dati e risultati dei grandi registri
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Domande?