Current Status of 2015 ILCOR CoSTR - 대한심폐소생협회 Ehime University Hospital Mayuki... · Current Status of 2015 ILCOR CoSTR Mayuki Aibiki, MD, PhD, Chairman of Ehime University

Current Status of 2015 ILCOR CoSTR

Mayuki Aibiki, MD, PhD, Chairman of Ehime University Graduate School of Medicine,

Department of Emergency and Critical Care Medicine;Vice-President of Ehime University Hospital

CoSTR: Consensus on Resuscitation Science and Treatment Recommendations

Disclosures of COIs

There are no COIs to disclose in this presentation.

Today’s Talk

ü History and Current Status of ILCOR (International Liaison Committee on Resuscitation)

ü  2015 CoSTR (Consensus on Resuscitation Science and Treatment Recommendations) of ILCOR….using GRADE System

ü GRADE System

ü  PICO questions of ALS (ex. eCPR vs mCPR)

Today’s Talk

ü History and Current Status of ILCOR (International Liaison Committee on Resuscitation)

ü  2015 CoSTR (Consensus on Resuscitation Science and Treatment Recommendations) of ILCOR….using GRADE System

ü GRADE System


International Liaison Committee on Resuscitation (ILCOR)

•  First meeting at end of ERC Congress 1992–  American Heart Association–  European Resuscitation Council–  Heart and Stroke Foundation of

Canada–  Australian Resuscitation Council–  Resuscitation Council of

Southern Africa

International Liaison Committee on Resuscitation (ILCOR)

•  First meeting at end of ERC Congress 1992–  American Heart Association–  European Resuscitation Council–  Heart and Stroke Foundation of

Canada–  Australian Resuscitation Council–  Resuscitation Council of

Southern AfricaILCOR is the international society of dealing with resuscitation science, such as publishing the CoSTR, the source of resuscitation guidelines.

RCA (Resuscitation Council of Asia) has been a member of ILCOR from 2005, consisting of Korea, Singapore, Taiwan and Japan. RCA has the right of getting CoSTR, the scientific source for the guidelines. JRC, a member of RCA, has published 2010 guidelines independently.

ILCOR Members

Signing Ceremony of Resuscitation Council of Asia (RCA)

RCA has been founded at the Nagoya International Exposition in 2005 Japan.

Dr. Swee Han Lim, Singapore

Dr. Hang Chang, Taiwan

Dr. Soon Hwong, Korea

Dr. Kazuo Okada, Japan

Signing Ceremony of Resuscitation Council of Asia (RCA)

RCA has been founded at the Nagoya International Exposition in 2005 Japan.

Dr. Swee Han Lim, Singapore

Dr. Hang Chang, Taiwan

Dr. Soon Hwong, Korea

Dr. Kazuo Okada, Japan

Now, RCA includes Korea (KACPR), Philippines, Singapore (NRCS), Thailand (TRC) , Taiwan (NRCT) and Japan (JRC).

ILCOR Homepage

RCA: Resuscitation Council of Asia founded in 2005

Today’s Talk

ü History and Current Status of International Liaison Committee on Resuscitation (ILCOR)

ü  2015 CoSTR of ILCOR….using GRADE System

ü GRADE System


2010 PICOs •  Shortly after the 2005 CoSTR were published, questions

were then refined to fit the Population Intervention Comparator Outcome (PICO) format based on knowledge gap.

•  For developing CoSTR, generally two authors were invited to complete independent reviews of each PICO question.

•  A total of 356 worksheet authors from 29 countries completed 411 evidence reviews on 277 topics.

v

Now, total 169 PICOs, decreasing from 277 topics of 2010 from all areas. In ALS, 35 PICOs, for them 2 or 3 task force members (TFM) have been assigned.

PICOs have been assessed by the GRADE evaluation. PICO: P, population; I, intervention; C, comparison; O, outcome.

Today’s Talk



ü GRADE System


I B

II V

III

Quality: High Quality: Moderate

Quality: Low

Old system (for Each Paper)

Outcome #1 Outcome #2

Outcome #3

GRADE (for a PICO)

Quality of Evidence across Studies

Yngve Falck-‐YFer, M.D. Assistant Professor of Medicine

Case Western Reserve University

GRADE (Grading of RecommendaLons Applicability, Development and EvaluaLon)

Quality: Very Low

Oxford Centre of Evidence Based Medicine; hFp://www.cebm.net

Before GRADE Level of evidence

Ia Ib II

III

IV

V

Source of evidence

Systematic reviews (SR) RCTs Cohort studies

Case-control studies

Case series

Expert opinion

A

Grades of recomend.

B

C

D



Factors determining evidence quality in GRADE

•  RCTs start form high.

•  ObservaLonal studies start from low.

What lowers quality of evidence? 5 factors:

Methodological limitaLons

Inconsistency of results

Indirectness of evidence

Imprecision of results

PublicaLon bias



Assessment of detailed design and execuLon (risk of bias) For RCTs: –  Lack of allocaLon concealment –  No true intenLon to treat principle –  Inadequate blinding –  Loss to follow-‐up –  Early stopping for benefit





PublicaLon bias



•  Judgment –  variaLon in size of effect –  overlap in confidence intervals –  staLsLcal significance of heterogeneity –  I2 (or τ2)

•  Look for explanaLon for inconsistency –  paLents, intervenLon, comparator, outcome, methods





PublicaLon bias



21

Inconsistency ex. Heterogeneity Neurological or vascular complicaLons or death within 30 days of endovascular treatment (stent, balloon angioplasty) vs. surgical caroLd endarterectomy (CEA)







PublicaLon bias

All phase II and III licensing trials for anLdepressant drugs between 1987 and 2004. 74 trials – 23 were not published.



Systematic review

Guideline development

P I C O

Outcome

Outcome

Outcome

Outcome

Critical

Important

Critical

Low Summary of findings & estimate of effect for each outcome

Rate overall quality of evidence across outcomes based on

lowest quality of critical outcomes

RCT start high, Obs. data start low

1.  Risk of bias 2.  Inconsistency 3.  Indirectness 4.  Imprecision 5.  Publication

bias

Grade dow

n Grade up 1.  Large effect

2.  Dose response

3.  Confounders

Very low Low Moderate High

Formulate recommenda.ons: •  For or against (direcLon) •  Strong or weak (strength)

By considering: q  Quality of evidence q  Balance benefits/harms q  Values and preferences

Revise if necessary by considering: q  Resource use (cost)

•  “We recommend using…” •  “We suggest using…” •  “We recommend against using…” •  “We suggest against using…”

Case Western Reserve University, Yngve Falck-‐YFer, M.D.

Today’s Talk



ü GRADE System


Evidence Review Progress

Dec/8th/2014

2015 PICO Status

PICO : eCPR vs manual CPR

l  Among adults who are in cardiac arrest in any setting (Population),

l  does the use of extracorporeal CPR techniques (eCPR)(including ECMO or cardiopulmonary bypass)(Intervention),

l  compared with manual CPR or mechanical CPR (Comparison),

l  change survival to 180 days with good neurological outcome, …..survival to hospital discharge with good neurological outcome, survival to hospital discharge, ROSC (Outcome)?

Evidence Review Progress

eCPR vs manual CPR 80 papers selected from 637 ajer EVREV

80 selected papers

3: one Sys. Review, Meta Analy., RCT

(on-‐going) 71 Non-‐RCTs

26 prospecLve Obs.

6 with two arms: 3 propensity (+) 3 propensity (-‐)

20: one arm

45 Retrospect. Obs

2 with two arms: propensity (+)

43: one arm

6: one Review, 5 case reports

Non-‐RCTs of eCPR vs mCPR

Non-‐RCTs of eCPR vs mCPR

Non-RCTs of eCPR vs mCPR in IHCA

Non-RCTs of eCPR vs mCPR in OHCA

2014/12/06 7:10GRADE

1/1 ページfile:///Users/aibikimayuki/Desktop/2nd%20KCPR-Revman/11eCPR%20vs%20cCPR%20in%20OHCA%20or%20IHCA-Oct-6th-2014.html

Question: Should eCPR vs cCPR be used for Cardiac Arrest?Bibliography: Aibiki M, Wang T. eCPR vs Manual CPR. Cochrane Database of Systematic Reviews [Year], Issue [Issue].

Quality assessment Summary of FindingsParticipants(studies)Follow up

Risk ofbias

Inconsistency Indirectness Imprecision Publicationbias

Overallqualityofevidence

Study eventrates (%)

Relativeeffect(95% CI)

Anticipatedabsolute effects

WithCCPR

WithECPR

Risk withCCPR

Riskdifferencewith ECPR(95% CI)

90 day poor neurological outcome48(1 study)3 months

serious1 no seriousinconsistency

no seriousindirectness

no seriousimprecision

undetected ⊕⊝⊝⊝VERYLOW1

due torisk ofbias

22/24 (91.7%)

17/24 (70.8%)

OR 0.22(0.04 to1.2)

Study population

917 per1000

209fewerper 1000(from611fewer to13 more)

Moderate

917 per1000


180 day poor neurological outcome (CRITICAL OUTCOME)

393(1 study)6 months

noseriousrisk ofbias

no seriousinconsistency



undetected ⊕⊕⊝⊝LOW

154/159(96.9%)

205/234(87.6%)

OR 0.23(0.09 to0.61)

Study population

969 180Doutcomeper 1000

92 fewer180 Doutcomeper 1000(from 19fewer to234fewer)

Moderate



Poor neurological outcome at discharge in IHCA (IMPORTANT OUTCOME)

410(3 studies)






209/236(88.6%)

133/174(76.4%)

OR 0.42(0.24 to0.72)

Study population

886 per1000

121fewerper 1000(from 38fewer to236fewer)

Moderate

894 per1000


one year poor neurological outcome in OHCA (CRITICAL OUTCOME)

290(2 studies)






156/176(88.6%)

97/114 (85.1%)

OR 0.77(0.38 to1.54)

Study population

886 per1000

29 fewerper 1000(from139fewer to37 more)

Moderate

876 per1000


1 one institutional study

2014/12/06 7:10GRADE




Risk ofbias






WithCCPR

WithECPR

Risk withCCPR







due torisk ofbias

22/24 (91.7%)

17/24 (70.8%)

OR 0.22(0.04 to1.2)

Study population

917 per1000


Moderate

917 per1000









154/159(96.9%)

205/234(87.6%)

OR 0.23(0.09 to0.61)

Study population



Moderate




410(3 studies)






209/236(88.6%)

133/174(76.4%)

OR 0.42(0.24 to0.72)

Study population

886 per1000


Moderate

894 per1000



290(2 studies)






156/176(88.6%)

97/114 (85.1%)

OR 0.77(0.38 to1.54)

Study population

886 per1000


Moderate

876 per1000



2014/12/06 7:10GRADE




Risk ofbias






WithCCPR

WithECPR

Risk withCCPR







due torisk ofbias

22/24 (91.7%)

17/24 (70.8%)

OR 0.22(0.04 to1.2)

Study population

917 per1000


Moderate

917 per1000









154/159(96.9%)

205/234(87.6%)

OR 0.23(0.09 to0.61)

Study population



Moderate




410(3 studies)






209/236(88.6%)

133/174(76.4%)

OR 0.42(0.24 to0.72)

Study population

886 per1000


Moderate

894 per1000



290(2 studies)






156/176(88.6%)

97/114 (85.1%)

OR 0.77(0.38 to1.54)

Study population

886 per1000


Moderate

876 per1000



2014/12/06 7:10GRADE




Risk ofbias






WithCCPR

WithECPR

Risk withCCPR







due torisk ofbias

22/24 (91.7%)

17/24 (70.8%)

OR 0.22(0.04 to1.2)

Study population

917 per1000


Moderate

917 per1000









154/159(96.9%)

205/234(87.6%)

OR 0.23(0.09 to0.61)

Study population



Moderate




410(3 studies)






209/236(88.6%)

133/174(76.4%)

OR 0.42(0.24 to0.72)

Study population

886 per1000


Moderate

894 per1000



290(2 studies)






156/176(88.6%)

97/114 (85.1%)

OR 0.77(0.38 to1.54)

Study population

886 per1000


Moderate

876 per1000



2014/12/06 7:10GRADE




Risk ofbias






WithCCPR

WithECPR

Risk withCCPR







due torisk ofbias

22/24 (91.7%)

17/24 (70.8%)

OR 0.22(0.04 to1.2)

Study population

917 per1000


Moderate

917 per1000









154/159(96.9%)

205/234(87.6%)

OR 0.23(0.09 to0.61)

Study population



Moderate




410(3 studies)






209/236(88.6%)

133/174(76.4%)

OR 0.42(0.24 to0.72)

Study population

886 per1000


Moderate

894 per1000



290(2 studies)






156/176(88.6%)

97/114 (85.1%)

OR 0.77(0.38 to1.54)

Study population

886 per1000


Moderate

876 per1000



Timeline:21-22 Apr 2013…. ILCOR Meeting, Melbourne 30 Apr-2 May 2014… ILCOR Meeting, Banff, CAN.15-16 Nov 2014… ILCOR Meeting, Chicago, USA

Feb 2015 …………International Consensus Conf.Late 2015 …………ILCO GLs published

Draft development for eCPR CoSTR

•  Next step is writing a draft of CoSTR for the eCPR PICO question.

•  Depending upon the present assessments, a very limited expression would be required for recommendation for eCPR.

Induced Hypothermia vs Normothermia

•  We ? targeted temperature management as opposed to no targeted temperature management for adults with OHCA with ??? rhythm who remain unresponsive after ROSC (? recommendation, ?evidence).

•  We ? targeted temperature management for adults with IHCA with ? rhythm who remain unresponsive after ROSC (? recommendation, ? evidence).

•  We ? selecting and maintaining a constant target temperature between ? °C and ? °C for those patients in whom targeted temperature management is used (? recommendation, ? evidence).

Targeted temperature management following cardiac arrest-An ILCOR Update-

Key messages: 1) Targeted temperature management (TTM) remains an important component of PCAS.2) No greater risk of adverse events can occur with a strategy that includes TTM at 33ºC. 3) A potential new regimen targeting 36ºC

Pending formal Consensus on the optimal temperature, we suggest that clinicians provide postresuscitation care based on the current treatment recommendations of 2010 GLs.Ian Jacobs, Vinay Nadkarni, ILCOR Co-Chair, 10th Dec 2013.

RCA TFMs to 2015 ILCOR CoSTR

•  BLS …. SH Lim (Singapore); T Sakamoto (Tokyo)•  ACS….. CK Ching (Singapore); H Nonogi (Shizuoka)•  EIT……. MH Ma (Taipei); T Iwami (Kyoto)•  First Aid.. WT Chang (Taipei); HJ Yang (Seoul)•  Ped…… KC Ng (Singapore); N Shimizu (Tokyo)•  Neo…… M Tamura (Saitama); •  ALS…… TL Wang (Taipei); M Aibiki (Ehime)

*SO Hwang, a delegate from KCPR; K Okada, the President of JRC to to 2014 Banff Meeting.

•  Next step is writing a draft of r question.•  Depending upon the present assessment, ………. Apr 21-22 2013……ILCOR Meeting, Melbourne Apr 30 2014……ILCOR Meeting, Banff, CAN.Nov 15-16 2014……ILCOR Meeting, Chicago, USA

Jan 31- Feb 4 2015…………Internatl Consensus Conf.

Nov? 2015 …………ILCOR CoSTR and GLs will be published.

Timeline:

Hopefully!

Thank you very much for your attention.

Documents

Current Status of 2015 ILCOR CoSTR - 대한심폐소생협회 Ehime University Hospital Mayuki... · Current Status of 2015 ILCOR CoSTR Mayuki Aibiki, MD, PhD, Chairman of Ehime University