Lancet March 2015 Patient Schematic Perkins GD et al The Lancet, - PowerPoint PPT Presentation

Lancet March 2015

Patient Schematic Perkins GD et al The Lancet, 385, 2015, 947 - 955

Background • Adequate CPR is critical for survival for CA patients • Maintenance of high-quality compressions during OHCA is difficult because: – small number of crew present – fatigue – patient access – competing tasks (eg, defibrillation, vascular access) – difficulty of performing resuscitation in a moving vehicle Perkins GD et al The Lancet, 385, 2015, 947 - 955

Background • Mechanical compression devices have been developed to automate and potentially improve CPR • Prior trials have been equivocal: – Load distributing band mechanical device: • One trial terminated early because of the worsened long-term outcomes in treated patients • The CIRC trial reported it was equivalent to manual CPR – The LINC trial assessed the LUCAS device and concluded it did not result in improved outcomes • The purpose of this study was to assess whether LUCAS-2 was better than manual CPR for the improvement of 30 day survival in OHCA adults Perkins GD et al The Lancet, 385, 2015, 947 - 955

LUCAS-2 CPR Device

Methods • On-line training included: – access to online training resources – the study protocol and procedures – how to operate the LUCAS-2 device – importance of high-quality CPR – Face-to-face training included – hands-on device deployment practice, with a resuscitation manikin – emphasized the importance of rapid deployment with minimum CPR interruptions – A competency checklist was completed before the LUCAS-2 could be deployed

Results • From 4/10-6/13, 4471 patients were enrolled • Very few adverse events • 40% of the pts in the LUCAS-2 group did not receive mechanical chest compression • Reasons for non-use : – crew not trained 78 – Crew error 168 – no device in vehicle 26; – unsuitable patients 102 – Pts too large (n-58) or too small (n=22), other pt reasons (n=22) – not possible to use device 140 – reason unknown 110

Results • Patient characteristics – Age 71 – 63% male – presumed cardiac in 86% – witnessed in 61% – bystander CPR in 43% • Initial rhythm: – VF 34% – VT 1% – PEA 25 – Asystole 50% Perkins GD et al The Lancet, 385, 2015, 947 - 955

Results • No serious adverse events were reported. • Seven clinical adverse events in the LUCAS-2 group – chest bruising 3 – chest laceration 2 – blood in mouth 2 • 15 device incidents occurred during operational use – alarms sounded 4 – Device stopped working 7 – other 4 • No adverse or serious adverse events were reported in the control group. Perkins GD et al The Lancet, 385, 2015, 947 - 955

Outcomes

Outcomes No change if included only cases where LUCAS-2 used appropriately

Subgroup Analysis

Conclusions • The LUCAS-2 did not improve the primary outcome of survival to 30 days • Neurological outcomes were marginally worse • There was lower survival in patients presenting with an initially shockable rhythm

Potential Reasons for Results • Increased training may have improved CPR quality in the control group • Low numbers of patients treated: avg of 1 control and 1 LUCAS-2 a year • Interruptions in CPR during device deployment could cause reduced cardiac and cerebral perfusion. • Slightly more patients received epinephrine after randomization in the LUCAS group, which might increase cardiac instability and impair cerebral microcirculation • Deployment of LUCAS before the first shock is likely to have led to a shock delays, which might reduce survival

Journal American College of Cardiology Dec 2014

Background • International resuscitation guidelines recommend giving epinephrine every 3-5 min during CA resuscitation • Prior observational and randomized trials have shown that epinephrine was associated with: – greater likelihood of ROSC – No difference in long-term survival • Epinephrine effects (potential double edged sword): – Increases coronary and cerebral perfusion pressure which can help achieve ROSC – May exert adverse effects post ROSC which: • contribute to myocardial dysfunction • increase oxygen requirements – cause microcirculatory abnormalities Dumas F, et al JACC 2014;64:2360 - 2367

Methods • Included pts with OHCA who had ROSC, and were admitted to a large Parisian CA–receiving hospital from 1/00-8/12 • OHCA resuscitation performed by an emergency team, which includes at least 1 EM MD • Patients in whom the resuscitation process fails are not transported to the hospital • Most patients who achieve ROSC are brought to the CA– receiving hospital, admitted to the ICU, and treated according to standard resuscitative guidelines including coronary angiography and mild therapeutic hypothermia Dumas F, et al JACC 2014;64:2360 - 2367

Results • A total of 1,646 patients achieved ROSC and were admitted to the hospital • Pt characteristics: – age 60 ± 16 years – male 71% – Initial shockable rhythm 54% – Coronary angiography was performed in 63% and PCI in 44% – Therapeutic hypothermia 70% • Nearly three-fourths of patients received epinephrine as part of OHCA resuscitation Dumas F, et al JACC 2014;64:2360 - 2367

Patient Flow Patient outcomes are presented according to treatment with or without EPI during resuscitation. Dumas F, et al JACC 2014;64:2360 - 2367

Patient Arrest Characteristics Dumas F, et al JACC 2014;64:2360 - 2367

Association Between Outcome and Early Dose of EPI and According to the Initial Rhythm Dumas F, et al JACC 2014;64:2360 - 2367

Outcome according to duration of CA and administration of epinephrine Dumas F, et al JACC 2014;64:2360 - 2367

Conclusions • The use of epinephrine during resuscitation of OHCA was associated with a worse neurological outcome • The adverse association was not modified by post-ROSC interventions such as PCI or therapeutic hypothermia • Later first administration and increasing epinephrine dose response was associated with worse outcomes

Caveats/Limitations • Single center and may not be generalizable to all communities • Not known why about 25% of pts not given epinephrine • Observational design which precludes any causal relationship between use of epinephrine and outcome • Epinephrine may be considered a surrogate marker of severity of the CA • Those receiving epinephrine had less favorable prognostic characteristics (older, less likely to have a witnessed event, and less likely to have a shockable rhythm, longer duration of resuscitation)