Prof Gavin Perkins Chairman ALS Subcommittee Resuscitation Council - - PowerPoint PPT Presentation

Prof Gavin Perkins

Chairman ALS Subcommittee Resuscitation Council (UK)

• Charitable organisation
• Founded 1981
• Focus

– Policy document – Clinical guidelines – Training – Research

Chain of survival

Key messages Resuscitation Council (UK) perspective

• Cardiac arrest prevention
• CPR process

– Airway – Defibrillation

• Post resuscitation care
• Decisions relating to CPR

Key messages Resuscitation Council (UK) perspective

• Cardiac arrest prevention
• CPR process

– Airway – Defibrillation

• Post resuscitation care
• Decisions relating to CPR

Airway management

Complex skill Often inadequate ventilation Stomach inflation Adverse effects on haemodynamics Simple to use Some airway protection Less stomach inflation Asynchronous compression / ventilation Definitive airway Complex skill Dangerous in untrained or inadequately trained hands Asynchronous compression / ventilation

Airway

• Advisors

– Problems with airway management in 17% of cases

• Team leaders

– Airway problems 1 in 20 resuscitation attempts

• 25% of teams had no

anaesthetist / intensivist

Delays

Airway management

• BVM, pocket mask or SGA suitable for initial

airway management

• BVM is suboptimal for prolonged resuscitation
• Resuscitation teams must

– have identified person responsible for airway management who is trained in SGA or intubation – have clearly processes for escalation to someone with advanced airway skills

High‐score group

Emergency call to team with critical care competencies and diagnostic skills. The team should include a medical practitioner skilled in the assessment of the critically ill patient, who possesses advanced airway management and resuscitation skills. There should be an immediate response.

• 1 hour workshop

– Airway assessment – Basic airway interventions – Ventilation – Supraglottic airway devices

Resuscitation 2010

Defined as adequate

% defined adequate

Use of I‐gel by non‐anaesthetists for in‐hospital cardiac arrest

• 100 insertions: nurses (49); doctors (47);

ROs (4)

• 99% successful insertion

– 82 on 1st attempt

• Audible leak/ventilation data in 61

– Chest rise, no leak 36 (59%) – Chest rise with leak 24 (39%) – No chest rise 1/61 (5%)

• Compression + vent OK in 23/31

Larkin CB. Resuscitation 2012 Jun;83(6):e141

Initial rhythm: incidence and survival to hospital discharge

Incidence %; Survival (%) NCAA (n = 7,330) NRCPR (n = 55,701) VF 12 (37) 16 (37) VT 4 (48) 7 (37) Asystole 29 (5) 36 (11) PEA 45 (9) 35 (12) Other 10 7 All rhythms (13.9) (16.4)

Meaney PA. Crit Care Med 2010;38:101‐8 NCAA unpublished

Resuscitated patient characteristics

• Median age 77 (IQR 68‐84)
• 70% fatal condition (21% rapidly fatal)

Percentage of patients with substantial functional impairment

DNACPR Decisions

• CPR status infrequently considered
• Incomplete compliance with DNACPR decisions
• Communication poor
• Senior staff rarely involved in discussions
• Advisors felt DNACPR decisions should have

been made in 85% of cases

• Difficulty in differentiating between DNACPR and

active treatment

DNACPR orders

• Futility
• Benefit / burdens
• Patient refusal
• Apply only to

resuscitation decision

Variability in implementation DNACPR policy

1. Assessment of capacity 2. Discussion of decision for those with capacity 3. For those without capacity is it discussed with relatives 4. The validity of decision/time period 5. Is it a multi‐professional decision?

Hospital 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Richard Field et al In preparation

Variability in implementation DNACPR policy

So what needs to change

• Process

– CPR decision all patients – CPR in context overall treatment

• Education

– Staff – Patients – Families

• Engagement
• Quality improvement
• Research

Conclusion

• Vital reading
• Wake up call
• Policy to practice
• DNACPR

http://www.resus.org.uk/pages/ncepodst.pdf