Novità nel campo della defibrillazione

Transcript

1 Novità nel campo della defibrillazione SITI, 2013 Giuseppe Ristagno, MD, PhD Laboratorio di Farmacologica Clinica Cardiovascolare Departimento di Ricerca Cardiovascolare Istituto di Ricerche Farmacologiche Mario Negri, Milano, Italia

2 26 Congresso Nazionale della Società Italiana di Terapia Intensiva Il sottoscritto dott. Giuseppe Ristagno dichiara che negli ultimi due anni ha avuto i seguenti rapporti anche di finanziamento con soggetti portatori di interessi commerciali in campo sanitario: ZOLL Med. Corp. Il sottoscritto dichiara altresì che detti rapporti non sono tali da poter influenzare l attività di docenza espletata nell ambito di questo evento pregiudicando la finalità esclusiva di educazione/formazione di professionisti. Il dott. G. Ristagno non si trova pertanto in una situazione di conflitto di interessi rispetto all evento ai sensi e per gli effetti dell Accordo Stato-Regioni del 5 /01/2009

3

4 STORIA DELLA DEFIBRILLAZIONE 1791 Galvani descrive la capacità dell elettricità di stimolare la contrazione muscolare 1899 Prevost and Battelli osservano per la prima volta che la corrente AC può terminare FV nel cane 1933 Hooker and Kouwenhoven studiano I livelli di energia più appropriati per la defibrillazione nel cane 1940 Carl Wiggers conferma l efficacia della defibrillazione elettrica nel cane 1947 Claude Beck rianima un ragazzo di 14 anni che sviluppa FV intraoperatoriamente 1955 Dr. Paul Zoll esegue la prima defibrillazione con successo a torace chiuso nell uomo 1962 Dr. Bernard Lown introduce la defibrillazione a corrente DC monofasica 1979 Viene introdotto il primo defibrillatore portatile, precursore dei DAE. Ristagno et al Crit Care Clins 2009

5 Defibrillazione Onde bifasiche (90 s) Shock singolo ( ) Alto successo della defibrillazione con minori richieste di energia/corrente (present) Defibrillazione rapida (2000-present) Riduzione delle interruzioni nelle compressioni toraciche ( )

6 Currently available biphasic waveforms Morphology of (A) biphasic truncated exponential (BTE) waveform, (B) rectilinear biphasic waveform (RBW) and (C) pulsed biphasic waveform (PBW)

7 ORCA Study Defibrillation Efficacy Patients Defibrillated 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 57% 67% 62% 94% 98% 1-3 Shocks: P< Shocks: P< Shock Only: P< J Monophasic 150 J Biphasic AED Schneider et al, Circulation 100(18) #1647, 1999

8 Defibrillation parameters: Energy, Current, Voltage, Duration The best balance among those parameters assures the best defibrillation efficacy.

9 La defibrillazione, grazie al passaggio di corrente elettrica attraverso il cuore, rappresenta l unico intervento in grado di garantire il ripristino di un'attività elettrica coordinata del miocardio

10 Li Y, Ristagno G, et al. Resuscitation 2009 Waveforms of the current-based (A), energy-based (B), and voltage-based (C) impedance compensation defibrillators at different pathway impedance levels.

11 The amount of current that passes the heart is main determinant for a successful defibrillation. It depends by the patient s transthoracic impedance. The optimal current for a successful defibrillation is in the range of ma.

12 Resuscitation 2012

13 BLS taskforce Melbourne Many thanks to the BLS Taskforce and observers

14 Incidence/Prevalence PAD Programs? Pre-Arrest C2015 BLS Evidence Map Work in Progress: Red Intervention, Blue Diagnosis Rapid Evidence Review Next 10 Questions Arrest Pt positioning? Precordial thump? Choking? Barrier device? CC vs No CPR? CC vs Standard CPR? Hand placement ID? Hand placement position? Optimal surface? Diagnosis Etiology? Diagnosis CA? Harm patient? Harm provider? Bystander airway? Community Response EMS Response CPR prior to DF? EMS CC vs Standard CPR? Rate? Depth? Recoil? Handsoff Interval? CPR feedback? Rhythm analysis during compressions? Pulse check for ROSC? minute cycle? Rhythm check timing? Rescuer fatigue? Passive ventilation? OPA/Adjuncts? 30:2 vs 2:30? CV Ratio? Ventilation rate/volume? Interposed abd compressions? ALS 911 Rescuer Communication? Recognition of Cardiac Arrest Dispatch CPR Dispatch Instructions?

15 Early Defibrillation 100 Survival (%) Decreases 10-12% per each minute Minutes prior to first defibrillation

16 P.A.D.

17 Chicago Airports AED Program June 1, 1999 May 31, 2001 O Hare 42 AEDs Midway 7 AEDs Defibrillation < 5 min: 67% Good Samaritan: 89% Arrests % VF 18 Non-VF 3 53 ROSC Discharge 1 Year Caffrey SL et al: N Engl J Med 2002;347:1242 Survival 61% Survival 0%

18 Las Vegas Gaming Casinos <3 min to DF AED placement Security officers DF first, then CPR 86% witnessed arrest Collapse to DF min Collapse to EMS min 105 VF arrests Survival to discharge 56 (53%) Su rvival 80% 60% 40% 20% 74% 49% 0% Valenzuela TD, Roe DJ, et al. N Engl J Med 2000;343: DF <3 min DF >3 min

19 Survival was 9% (382 of 4,403) with bystander CPR but no AED, 24% (69 of 289) with AED application, and 38% (64 of 170) with AED shock delivered. JAMA 2010

20 14-20 Ottobre 2013

21 The travel distance was significantly shorter in the Mobile AED Map group compared to the control group (606m vs. 891m, p=0.019) Resuscitation 2011

22 Distance to AED: ~ 300 m Time to AED: < 6 min Location: limit of public places?

23 High quality CPR AHA Guidelines 2010

24 2.103 adult patients from 10 U.S. and Canadian centers Resuscitation 2011

25 Minimal compression interruptions Berg RA, Circulation 2001;104:2465 Berg et al Circulation 2001

26

27 Cardiopulmonary Resuscitation Quality: Improving Cardiac Resuscitation Outcomes Both Inside and Outside the Hospital by Peter A. Meaney, Bentley J. Bobrow, Mary E. Mancini, Jim Christenson, Allan R. de Caen, Farhan Bhanji, Benjamin S. Abella, Monica E. Kleinman, Dana P. Edelson, Robert A. Berg, Tom P. Aufderheide, Venu Menon, and Marion Leary Circulation Volume 128(4): July 23, 2013

28 Target CPR performance

29 Target monitoring

30 Data review

31 1947 Primo defibrillatore (usato dal Dr. ZOLL) Zoll PM, Linenthal AJ, Gibson W, et al. Termination of ventricular fibrillation in man by externally applied electric countershock. N Engl J Med 1956; 254(16):727-32

32

33

34 CPR feedback: Profondità Frequenza Interruzioni Messaggi audio/video Trasmissione dati

35 Monitoraggio della ventilazione durante CPR Monitoraggio della qualità della CPR

36

37 A randomized manikin study Fischer et al Resuscitation 2011 A cluster-randomised clinical trial Hostler et al BJM 2011 Perkins GD, et al. Heart 2012

38 See-Thru CPR

39 Evaluation of the effect of use of a new defibrillator technology, which filters compression-induced artifact and provides reliable rhythm analysis with automatic defibrillator charging during chest compressions, on preshock chest compression interruption Barash et al. Prehosp Emerg Care 2011 CPR 8 cycles 1 cycle = 2 min di chest compression, rhythm analysis, and defibrillation. Pre-shock pauses was reduced of 80% (2.13 ± 0.99 sec vs ± 1.33, p < )

40

41 Debriefing dopo RCP: cosa, come, quali dati

42 Debriefing dopo RCP: cosa, come, quali dati :02: :04:

43 Debriefing dopo RCP: cosa, come, quali dati

44 A nonguidelines-compliant approach EWY GA, 2012 Chamberlain D, 2012

45 Don t Touch Patient During Analysis

46 Effects of interrupting chest compression on calculated probability of successful defibrillation during out-of-hospital cardiac arrest P ROSC, % Eftestol T et al: Circulation 2002;105: n= Duration of hands-off, seconds

47 815 patients Circulation. 2011;124:58-66

48 Baseline Untreated VF Precordial compression Hands-off mmhg Coronary perfusion pressure P < S Time of CPR (minute) Blanket group No-blanket group 6 male pigs, kg

49 50% Defibrillation Threshold 100 P < 0.01 Joule Blanket No blanket 8 male pigs, kg

50

51 MECHANICAL COMPRESSORS

52 Defibrillation Delivered during the Latter Phase of Mechanical Chest Decompression Improves Shock Success pigs 40 ± 5 kg Li, Ristagno, et al. Crit Care Med 2010

53

54 CPR first prior to defibrillation in OHVF (Survival to hospital discharge) Response time < 5 min: CPR first (3 min): 23 % ( 9/64) Defibrillation first: 29 % (12/55) OR 0,70 (IC 95% 0,26-1,91) p=0,61 Response time > 5 min: CPR first (3 min): 22 % (14 /40) Defibrillation first: 4 % ( 2/41) OR 7,42 (IC 95% 1,61-34,3) p=0,006 Wik L, et al. JAMA 2003; 289:

55 Two randomized controlled trials (LOE 1) demonstrated no improvement in ROSC or survival to hospital discharge in patients suffering out-of-hospital VF or pulseless VT who received CPR by EMS personnel for a period of 1.5 to 3 minutes before defibrillation, regardless of EMS response interval being greater or less than 5 minutes. Baker PW, Resuscitation 2009; Jacobs IG, Emerg Med Australas 2005 One study LOE 3 and two other clinical studies (LOE 4) failed to demonstrate significant improvements in ROSC or survival to hospital discharge with bystander versus no bystander CPR before defibrillation. Hayakawa M, Am J Emerg Med 2009; Campbell RL, Resuscitation 2007 Bradley SM, Resuscitation 2010

56 9933 patients included: 5290 early analysis of cardiac rhythm (30-60 secs CPR) 4643 to later analysis (180 secs CPR). Survival to hospital discharge with satisfactory functional status: 310 patients (5.9%) in the early-analysis 273 patients (5.9%) in the later-analysis

57

58 Ventricular Fibrillation (VF) waveform changes over time 0.6 VF 1 min VF 3 min VF 5 min

59 Study VF feature Patients (no.) Sensitivity Specificity Outcome Dalzell 1991 PPA 70 NA NA ROSC Martin 1991 MDF 7 NA NA ROSC Brown 1996 Combination of PF and CF ROSC Strohmenger 1997 PPA, MDF ROSC Eftestol 2000 Combination of CF and PF ROSC Strohmenger 2001 DF ROSC Eftestøl 2001 Combination of CF and Energy ROSC Hamprecht 2001 DmF ROSC Podbregar 2003 Combination of PPA, energy of PSD and ROSC Hurst exponent Jekova 2004 Energy (2-7 Hz) NA (more than 700 trace data set) ROSC Young 2004 AMSA ROSC Watson 2004 Entropy NA (868 trace data set) ROSC Watson COP ROSC Neurauter 2007 MdS ROSC Box 2008 COP ROSC Ristagno 2008 AMSA ROSC Neurauter 2008 MdS (10-22Hz) ROSC Lin 2010 DFA (DFAα2) ROSC Endoh 2011 CF ROSC Shanmugasundarama 2012 Slope ROSC Nakagawa 2012 AMSA ROSC Weaver 1985 PPA Survival Monsieurs 1998 Survival index Survival Goto 2003 DF Survival Callaham 1993 PPA Survival Callaway 2001 ScE 75 NA NA Survival

60

61 LOMBARDIA REGION Surface: km 2 People: EMS response: BLS+AED first responder teams and ALS professional teams

62 For the analyses: A database of episodes of VF with defibrillation (DF) attempts from human out-ofhospital cardiac arrests enrolled between , was used as derivation group. An additional database, including VF with DFs from 567 patients enrolled in 2010, was used as validation group.

63 AMSA calculation

64 Population and outcome

65 ALL Defibrillation Attempts, n = patients Defibrillation success rate: 26.2% AMSA, mv-hz n=641 p< n=1.806 Mean ± SEM OR: 1.44 ( )

66 AMSA & duration of untreated VF (EMS arrival) 9.5 p<0.05 mv-hz < 4 min 4-10 min > 10 min

67 Relationship between AMSA & Chest Compression Depth mv Hz CC depth > 1.75 in All defibrillations Number of Defibrillation Attempts CC depth < 1.75 in

68 Defibrillation Attempts, n = patients

69 Validation of thresholds on 2010 dataset

70 A database of 1260 episodes of VF with defibrillation attempts, from 609 out-of-hospital cardiac arrests in USA An AMSA < 7 mv-hz the likelihood to deliver a successful DF is low (NPV > 95%) An AMSA > 17 mv-hz higher DF success (PPV of 67%)

71 FUTURE PERSPECTIVES CONCLUSIONS Algorithm for predicting DF success incorporated into future AEDs & Manual Defibrillators: Smarter: Do not interrupt chest compression Monitor the effectiveness of chest compression Safer: Deliver shock only when effective Minimize risk of electrical injury to the heart

72

73

74

75 Prima Defibrillazione Defibrillatore monofasico: 360 J Defibrillatore bifasico: non inferiore ai J (energia non inferiore ai 150 joule se si usa una defibrillazione bifasica troncata esponenziale o non inferiore ai 120 joule per una defibrillazione bifasica rettilinea) Defibrillazioni Successive Defibrillatore monofasico: 360 J Defibrillatore bifasico: non inferiore ai J (no evidenza supporta o rifiuta l uso di energia fissa o incrementale. Si possono usare entrambi le metodiche).

76 What is the best intervention for patients requiring multiple shocks? Recurrent VF Refractory VF DF

77 AMSA prior defibrillation for refractory VF and recurrent VF Recurrent VF (n=139) Refractory VF (n=543) Mean AMSA, (mv-hz) 16.2 ± 0.9* 7.6 ± 0.2 AMSA prior to successful DFs, (mv-hz) 16.8 ± ± 1 AMSA prior to failing DFs, (mv-hz) 13.8 ± ± 0.2# Successful DFs, % (n) 79.1 (110/139) 9.2 (50/543) DFs, defibrillation attempts; Mean ± SEM; * p < vs. DF-Resistant VF; # p < vs. successful DFs

78 From the courtesy of Dr. Pellis

79 Resuscitability vs Coronary Perfusion Pressure During Human CPR Resuscitated, % /14 11/14 pts 5/14 0/58 < >24 Adopted from Paradis NA et al. JAMA 1990;263:1105 CPP, mmhg

80 VF Waveform Changes During CPR 0.6 VF 5 min CPR 3 min CPR 5 min