Peter Brindley - Resuscitation: What’s the Point
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Transcript of Peter Brindley - Resuscitation: What’s the Point
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Resuscitation: what’s the point?Peter Brindley MD FRCPC FRCP Edin
Clinician…& proud to be
Other Stuff: Professor, Critical Care Medicine, Ethics, Anesthesiology
University of Alberta, Canada
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Declare your biases
Circa 1780
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What families think?The Age ofAcquarius
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What ICU Doctors think?The Age of Eos and Tithonus
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Reality check
Most critical conditions fatal 50yrs ago
Now, >80% (all comers) survive to leave ICU
….But NOT if they arrestBrindley CJGIM 2010
Brindley & Beed BJA 2014
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• CPR unless explicit contrary documentation
• >8 billion on ICU (1 billion futile CPR)
• 75% die in hospital; 25% in ICU
• 90% die following w/d or w/h
Finfer NEJM 2013Brindley BJA 2013Meaney (and DeCaen ) Circulation 2013
The other reality check
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Getting the point across
Indian YogaEdmonton Yoga
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“JOB-ONE”ResuscitationDiagnosisDisease ManagementProceduresPerioperative-CareComfort and recoveryEnd of Life CarePaediatricsTransportSafetyProfessionalism
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CPR: A Janus Head?
Brindley. Preventing Medical Crashes: Psychology Matters. J Crit Care 2010 Brindley. Cardiopulmonary Resuscitation BJA 2014
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• Outcome depends most upon:– Who gets resuscitated
• Arrest type• If witnessed (or not)• If reversed within 10 mins
–WHO gets CPR; less HOW
near 100% Sensitivity
–Van Walraven Arch Intern Med 1999
Brindley et al CMAJ ’02Kutsogiannis et al CMAJ ‘11Brindley and Beed BJA ‘14
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In-hospital cardiac arrest
death
5)Not knowing when to stop
2)Inadequate communication
1)Lack of knowledge
3)Inadequate recognition
4)Inadequate early response
Inappropriate CPR?J Reason BMJ
P Brindley Crit Care
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In-hospital cardiac arrest
death
4)Not knowing when to stop
5)Inadequate communication
1)Lack of knowledge
2)Inadequate recognition
3)Inadequate early response
CPR: background knowledgeJ Reason BMJ
P Brindley Crit Care
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Survival after adult CPR(in-hospital wards)
i) <1 in 2ii) <1 in 3iii) <1 in 4iv) <1 in 5
Brindley P.G, Markland, Kutsogiannis CMAJ 2002; Brindley Critical Care Rounds. 2003/ Brindley Can J Anesth 2005/ Crit Care. 2006
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Witnessed ArrestsIn hospital (non ICU)
Survived Initial Discharged Able to Live
Resuscitation from HospitalIndependently
All Arrests48.3% 22.4% 18.9%
Respiratory 96.3% 55.6% 44.4%
All Cardiac 37.1% 14.7% 12.9%
VT/VF 38.3% 25.6% 21.3%
Asy/PEA 36.2% 7.2% 7.2%Brindley et al. CMAJ 2002
“<1 in 2” “<1 in 3”“<1 in 4” “<1 in 5”
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Un-witnessed Arrests (45%) In hospital (non ICU)
Survived Initial Discharged Able to Live
Resuscitation from HospitalIndependently
All Arrests48.3% 1.0% 1.0%
Respiratory 50.0% 50.0% 50.0%
All Cardiac 20.6% 0% 0%
VT/VF 42.1% 0% 0%
Asys/PEA 15.7% 0% 0%Brindley et al. CMAJ 2002
“<1 in 2”
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• Greatest impact on survival: ARREST TYPE & IF WITNESSED
• Consider all stages: “ROSC is the beginning of new suffering”.
• ? Universal resuscitation• “Full code” unless explicitly documented
otherwise
• ? Cardiac resuscitation c/t respiratory• 1-in-2 respiratory arrests survived
Brindley et al. CMAJ 2002;
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No un-wit cardiac arrest dischargedSafest place to arrest…Vegas casino (>70% Valenzuela NEJM)Or TV medical drama (>60% Diem NEJM)
No improvement in >60 years
Survival not associated with “chronologic” age
Frailty matters more
Survival worse at night/early am.More un-witnessed, more PEA/ASY, less staff
Brindley et al. CMAJ 2002; Brindley critical care review 2005
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& the Expensive Care Unit ? Is survival increased ?
Arrests witnessedStaff and resources present
? Is survival decreased ?Patients f-sick Already receiving ““CPR””
Kutsogiannis DJ et al. CMAJ 2011 (n=510)Chang SH et al. J Crit Care 2009 (n=202)
Tiam J et al. Am J Resp CCM 2006 (n=49,000)
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ROSC incr’d in ICU59% v 48%
Survival to discharge highest in CVICU CCU GSICU 75% v 70% v 45%
No effect from arrest time-of-day
Kutsogiannis, Bagshaw, Brindley CMAJ 2011
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Similar to witnessed in-hospital
Advantage d/t less PEA/ASY
3-month survival not significantly better
No improvement in 2 decades
WHO NOT HOWKutsogiannis et al. 2011 (n=510)
ICU post-CPR survival:
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Inappropriate CPR
4)Not knowing when to stop
5)Inadequate communication
1)Lack of background knowledge
2)Inadequate recognition
3)Inadequate early response
CPR survival: recognition and response
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In-hospital (non-ICU) Cardiac Arrest
63% Pulseless electrical activity/ Asystole
12% Primary respiratory 27% Ventricular fibrillation/Pulseless ventricular
tachycardia
Brindley et al. CMAJ 2002
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Least recorded BUT most specific predictor
…of deterioration, “unexpected” ICU
Pulse-ox not a replacementEducation priority
MJA 2009
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In-hospital cardiac arrest
death
4)Not knowing when to stop
5)Inadequate communication
1)Lack of background knowledge
2)Inadequate recognition
3)Inadequate early response
In-hospital arrest…a system failure
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ECMO & adult cardiac arrest
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Adult E-CPR?
• 40% survival to discharge (c/t 25%)
• Higher mortality if: started >30mins; >65 yrs; >2 days ecmo
• Large resource/cost commitment
Shin TG CCM 2011 (n=120); Chen Resusc 2010 (n=122); Chen Lancet 2008 (n= 59) ; Cardarelli ASAIO 2009 (n=135)
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Adult ECMO arrest better if:– Sooner– Briefer– Arrest type/ Path (AMI; PE)
WHO not
HOW
1940's Russian experiment. part 1
Cardarelli et al. ASAIO 2009
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Inappropriate CPR
4)Not knowing when to stop
5)Inadequate communication
1)Lack of background knowledge
2)Inadequate recognition
3)Inadequate early response
CPR survival: recognition and response
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“everything” v “nothing”
“Assault”
“Natural Death”
“Neglect”
“Giving up”
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ICU/ED RRURelationship Repair Unit
• >30% DNAR w/o consent• 9% “ageism”; 8% “anti-disabled”; 5%
“euthanasia”
• 2%: d/t “over resuscitation”• 6%: pre-emptive decision-making
Beed, De Beer, Brindley. Resuscitation 2014 .
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Draft 1
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Oh, and the OR…
• >10% of OR patients have a DNR
• ‘Widespread confusion…’– anesthetist’s job involves
‘resuscitation’– OR death NOT like other death
Ewanchuk M, Brindley P.G. Crit Care 2009Brindley P.G. BMC Anesthesiology 2012
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Dr Cheryl Misak, UofT
Am J Respir Crit Care Med 2004; J Med Philos 2005; Chest 2010
Oh…and autonomy
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WTF : ”””Patient focused care””””?
• What it is :– Communication– Partnership– Includes values
• What it is not :– Technology-centered– Doctor-centered– Hospital-centered
Irwin and Richardson CHEST 2006
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More ICU v Better Death?
• PFC not collected by QUALY • EOL care rarely “cost effective”
• Lots of limitations…………BUT
Bryce et al Quality of Death. Med Care 2004Ward and Teno (commentary) 406-407
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So what do patients want?• EOL Survey
• ¾ trade shorter-life for better EOL– ¼ wouldn’t
• Average 10 months– Low 7; high 24