PowerPoint Presentation 2015... · 30-3-2015 1 Waarom beademen belangrijk is Waarom beademen belangrijk is Ruud Koster Academisch Medisch Centrum Amsterdam Waarom beademen belangrijk

30-3-2015

1

Waarom beademen belangrijk is


Ruud Koster Academisch Medisch Centrum

Amsterdam


0%

10%

20%

30%

40%

50%

60%

1995 2006 2007 2008 2009 2010 2011 2012 2013

Totale overleving Overleving bij schokbaar 1e ritme Overleving bij geen schokbaar 1e ritme

Overleving Arrest Noord-Holland


Overleving in Europa

77

55

??

1010

33

??

2525

1111

1010

2222??

??


Hoe komt de overleving in Nederland zo hoog?

• Grote bereidheid BLS uit te voeren• Snelle en goede acceptatie van de AED• Kwaliteit van BLS onderwijs, al 40 jaar lang!


Basale reanimatie in Europa

3030

2525

5050

1010

1919

1515

5050

4444

4848

60603737

55

Statistische analyse:

Overleving met BLS

2-3x beter!


Overleving na reanimatiewereldwijd

6-106-107-107-10

2-72-7

10-1310-13

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Probleem groot in de USA: weinig BLS

1. Weinig hulpverleners kunnen ventileren2. Veel hulpverleners doen geen BLS omdat ze geen mond-op-mond

beademing willen doen3. Geen BLS uit angst voor juridische aansprakelijkheid?4. Beademingen onderbreken de borstcompressies

Wat zouden de redenen kunnen zijn?


Compression-only CPR

• Gebaseerd op jaren dieronderzoek in Tucson (Arizona)

• Beademing geen voordeel

• Onderbreking compressies nadelig


Retrospectieve analyse van oude gegevens


AHA takes position


Retrospectieve analyse van oude gegevens


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Omstander BLS

Land Omstander BLS

Japan (Iwami) 1998-2003: 27%

Japan (SOS-Kanto) 2002-2003: 29%

USA (Bobrow) 2005-2009: 34%

USA (Weisfeldt) 2005-2007: 32%

USA, Seattle (Rea) 1980: 22%; 2000: 50%

Zweden (Bohm) 1992: 31%; 2005: 50%

Noorwegen (Olasveengen) 2007: 59%%

Denemarken (Wissenberg) 2010: 45%

Nederland (Waalewijn/Berdowski) 1995: 53%; 2010: >70%


(Te emotioneel - <10%)

(Patient te onsmakelijk – <2%)

Geen BLS willen doen?

1. Herkenning hartstilstand– 65%

2. Omstander kan het fysiek niet –

20%

Swor Acad Emerg Med 2006


1. Herkenning hartstilstand– 65%

2. Omstander kan het fysiek niet –

20%

(Te emotioneel - <10%)

Geen BLS willen doen?

(Patient te onsmakelijk – <2%) Swor Acad Emerg Med 2006


Waarom zouden burgers moeten

leren beademen?

• Als je het leert, ben je nog niet verplicht om het te doen

• Als je het niet leert – zal je het nooit kunnen doen


• Als je het leert, ben je nog niet verplicht om het te doen

• Als je het niet leert – zal je het nooit kunnen doen

• Zuurstof en beademing is nodig

– Altijd voor niet-cardiale oorzaken van een arrest

– Altijd voor kinderen

– Meestal voor arrest met een cardiale oorzaak

Waarom zouden burgers moeten

leren beademen?


Hoe lang kunnen we zonder zuurstof?

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Meursing JACC 1983: 6 honden (alleen abstract)


Turner Resuscitation 2002

Zuurstof is verbruikt <2-3 minuten

Dorph Resuscitation 2004

Ambulance aankomsttijd 6-10 minuten


Human evidence

Is de overleving werkelijk “similar”?


Compression-only CPR vs. Standard CPR (Bohm 2007)



Early: ≤8 minutes Late: >8 minutes


Compression-only CPR vs. Full CPR (Bohm 2007)

Electrical

phase

Circulatory

phase

Metabolic

phase

Three-phase model

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Waarom beademen belangrijk is Waarom beademen belangrijk is


0

5

10

15

20

25

30

35

40

45

2005 2006 2007 2008 2009

Su

rviv

al

What CPR is delivered?

CO CPR

% CPR delivered


0

5

10

15

20

25

30

35

40

45

2005 2006 2007 2008 2009

Su

rviv

al


CO CPR

Full CPR

All CPR

% CPR delivered


0

5

10

15

20

25

30

35

40

45

2005 2006 2007 2008 2009

Su

rviv

al


CO CPR

Full CPR

All CPR

0,0

2,0

4,0

6,0

8,0

10,0

12,0

2005 2006 2007 2008 2009

Su

rviv

al

Survival

Survival

% CPR delivered


0

5

10

15

20

25

30

35

40

45

2005 2006 2007 2008 2009


CO CPR

Full CPR

All CPR

0,0

2,0

4,0

6,0

8,0

10,0

12,0

2005 2006 2007 2008 2009

Su

rviv

al

Survival

Survival

CPC 1+2

In >30% was informatie over functionele uitkomst onbekend

% CPR delivered

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Uitkomst Geen BLS CC + ventilatie

Comp only BLS

Goed: CPC 1+2 (%) 3.0 5.2 7.9 (+2.7%)

Slecht: CPC 3+4 (%) 0.6 0.5 3.0 (+2.5%)

0%

20%

40%

60%

80%

100%

No CPR CC + vent Comp only CPR

CPC 1+2

CPC 3+4

Bobrow JAMA 2010


Is dit de toekomst?


Dit heeft zijn waarde bewezen


Nederland zit in de top 3 van de wereld!

77

55

??

1010

33

??

2525

1111

1010

2222??

??

Dank zij goede omstander BLS


Leer en stimuleer borstcompressies

met beademing

Er is geen snellere weg naar goede reanimatie!


Discussie

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For children who have out-of-hospital cardiac arrests from non-cardiac causes,

conventional CPR (with rescue breathing) by bystander is the preferable approach

to resuscitation. For arrests of cardiac causes, either conventional or compression-

only CPR is similarly effective.

This nationwide observational study indicates that rescue breathing has an

incremental benefit for OHCAs of noncardiac origin, but the impact on the overall

survival after OHCA was small.


2005


We have to deal mainly with

cardiac cases in need for CPR.

So…

the important question

then is….


The formula of Survival

SurvivalX

Effective

Education

0.4

Medical Science

(Knowledge)

0.9

Local

Implementation

0.2 X = 0.07

Conventi-onalCPR

The formula of Survival

SurvivalX

Effective

Education

0.8

Medical Science

(Knowledge)

0.5

Local

Implementation

0.5 X = 0.20CC only

CPR


The formula of Survival: which is the best choice?

SurvivalX

Effective

Education

0.8

Medical Science

(Knowledge)

0.9

Local

Implementation

0.6X = 0.43Full CPR

SurvivalX

Effective

Education

0.8

Medical Science

(Knowledge)

0.5

Local

Implementation

0.5 X = 0.20CC only

CPR

SurvivalX

Effective

Education

0.4

Medical Science

(Knowledge)

0.9

Local

Implementation

0.2 X = 0.07

Conventi-onal CPR


Teach good bystander CPR – it helps!

• Bystander CPR doubles survival

• Bystander CPR is needed for 5-10 minutes

• Arterial oxygen supply lasts 2-3 minutes

• Education remains critical

• In class teach full CPR – C:V 30:2

triples!

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Waarom beademen belangrijk isOptimal C:V ratio (ventilation 15

s)

Babbs, Resuscitation 2002


Avg. survival 42/604 = 6.9%

Avg. survival 15/447 = 3.3%

Lancet CC only 1

Table 3

Table 2


Lancet CC only 2


Who did CPR?Survival by provider

CPR by CO CPR Full CPR OR (C.I.) Average

Lay person 23/342 (7%) 19/362 (5%) 1.3 (0.7-2.4) 42/704 (6.0%)

Off-duty medical worker 4/97 (4%) 11/350 (3%) 1.3 (0.4-4.3) 15/447 (3.4%)


Who did CPR?Survival by provider

CPR by CO CPR Full CPR OR (C.I.) Average

Lay person 23/342 (7%) 19/362 (5%) 1.3 (0.7-2.4) 42/704 (6.0%)

Off-duty medical worker 4/97 (4%) 11/350 (3%) 1.3 (0.4-4.3) 15/447 (3.4%)

Evenly distributed?

CPR by CO CPR (n=439) Full CPR (n=712)

Lay person 342 (78%) 362 (51%)

Off-duty medical worker

97 (22%) 350 (49%)

confounder: –Covariate, not related to variable of interest (compression only resuscitation)–Determinant of outcome (survival)–Unevenly distributed among groups


“difference not proven” ≠ “treatments are equal”

Not superior, therefore equal or “similar”?

Non-inferiority analysis would not have rejected inferiority

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New discussion 2008


Survival after cardiac arrest

Study (outcome)“standard”

= CC en MMVCC only RR (95% CI)

Nagao 2002-2003 (Japan)

(30 days, good neurologic)4% 6% 1.5 (0.9-2.5)

Bohm 1990-2005(Sweden)

(1 month, good neurologic)7.2 6.7 0.93 (0.74-1.17)

Iwami 1998-2003 (Japan)

(1 year, good neurologic)3.6 3.5 0.97 (0.55-1.73)

Bobrow 2005-2007 (USA)

(survival to discharge)1.8 5.4 2.94 (1.06-8.16)


Follow the ERC Guidelines 2010

Teach full CPR with ventilations

Do full CPR with ventilations

Recommend CO CPR for:

not willing or able to do ventilations

telephone instructed CPR

Recommendations


• Alle hulpverleners, met en zonder training, moeten borstcompressies geven aan slachtoffers van een hartstilstand.

• Getrainde hulpverleners moeten ook beademen met een compressie–ventilatie (CV) verhouding 30:2.

• Telefoon-instructies doen BLS met alleen borstcompressies voor omstanders zonder training.

ERC Richtlijnen 2010

AHA Richtlijnen 2010

• ….• Als borstcompressies zijn gestart, moet een getrainde

hulpverlener ook mond-op-mond beademen of met een ballon

• Gebruik een C:V verhouding van 30 borstcompressies op 2 ventilaties


Type of CPR 2005 2006 2007 2008 2009 change

none 72% 67% 68% 64% 60%

full 23% 17% 17% 12% 10%

CC only 5% 15% 15% 23% 30%

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none 72% 67% 68% 64% 60% -12%

full 23% 17% 17% 12% 10% -13%

CC only 5% 15% 15% 23% 30% +25%



none 72% 67% 68% 64% 60% -12%

full 23% 17% 17% 12% 10% -13%

CC only 5% 15% 15% 23% 30% +25%

Overall survival 3.7% 7.2% 6.7% 6.6% 9.8% +6.1%


Gordon Ewy Circulation 2008:


Is CO CPR the better way?

1. Scientific evidence remains on low level

2. Severe methodological problems in the design and analysis

3. The only effectiveness study shows modest increase

in bystander CPR but no overall benefit of a relevant

outcome

4. Compression only CPR is not suitable for children

and for patients with a respiratory cause


Wat is de vraag van het onderzoek?

• Therapie onderzoek:

– Meestal “nieuw middel is beter dan oud middel”

• Bewijs: significant beter

b.v. nieuw tenminste 10% beter

– Soms “nieuw middel is gelijk aan oud middel”

• Bewijs: nieuw niet significant slechter dan oud -

b.v. nieuw maximaal 10 % slechter


Recommendations

• Do CPR – it helps

• Teach good chest compressions

• After 2-3 minutes of CPR oxygen is needed

• Teach ventilations

• Use AED’s for early defibrillation!

• Evaluate all evidence at ILCOR 2010

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none 72% 67% 68% 64% 60% -12%

full 23% 17% 17% 12% 10% -13%

CC only 5% 15% 15% 23% 30% +25%


Neuro intact survival 2,4% 5,5% 4,7% 4,2% 3,6% +1.2%

•Only reporting on patients with a cardiac cause

•Excluded age <18 yr;non-cardiac cause

•Requirements for effectiveness study:

•Interventions in the real world

•All patients in the community accounted for

•Meaningful outcome


Survival after resuscitation

Survival

Lay rescuers42/604

(6.9%) RR

0.48Off-duty medical

personnel

15/447

(3.3%)


Survival after resuscitation

Overall

outcome

CC and

ventilationOR

Lay rescuers 6% 4% ns

Off-duty medical

personnel6.2 3.1

P =

0.02

19.2 11.2P =

0.04

10.1 5.1P =

0.02


Study cohort


Survival Rcc+mmv = 7.8%Survival Rcc only = 6.7%

Odds ratio 1.10 (0.86-1.40)

Overleving kan liggen tussen 5.2% en 8.3%absoluut verschil -2.6% en +0.5%

Wat is het maximum nadeel dat we willen accepteren?0%?0.5%? 1%?

CC only

7.8%CC Only beterCC Only slechter

overlevingskans

Waarom beademen belangrijk isNon-inferiority design II

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Main result: survival

CC only

CC and

ventilatio

n

Overall 6% 4% ns

apnea 6.2 3.1P =

0.02

VF 19.2 11.2P =

0.04

Resuscitation <

4 min10.1 5.1

P =

0.02


Survival without and with Basic Life Support

No BLS

BLS

0

20

40

60

80

0 5 10 15 20 25

First defibrillation (min)

Su

rviv

al (%

)


Conclusion on chest

compression only CPR

•Current guidelines 2005 (including C:V ratio 30:2)

are adequate

•Evidence from Lancet paper is insufficient to

change guidelines

•Re-evaluate science in ILCOR Guidelines process

2010


Change at ILCOR 2000: practice

Compression rate

100/minute

2 respirations in 5 sec

Compressions/minute Respirations/minute

5:1 55 11

15:2 65 8

Compression rate

100/minute

2 respirations in 16 sec*

Compressions

/minuteRespirations/minute

5:1 28 5

15:2 45 4

*Assar Resuscitation 2000


Non-inferiority design I

• Therapie onderzoek:

– Meestal “nieuw middel is beter dan oud middel”

• Bewijs: significant beter

b.v. nieuw tenminste 10% beter

– Soms “nieuw middel is gelijk aan oud middel”

• Bewijs: nieuw niet significant slechter dan oud -

b.v. nieuw maximaal 10 % slechter


Observational cohort

•Confounding

•confounder:

–Covariate, not related to variable of

interest (cardiac only resuscitation)

–Determinant of outcome (survival)

–Unevenly distributed among groups

Off-duty medical personnel vs. lay rescuers

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Waarom beademen belangrijk isSurvival after cardiac arrest

Study

(outcome)

“standard”

= CC en MMVCC only RR (95% CI)

Nagao 2002-2003 (Japan)

(30 days, good neurologic)4% 6% 1.5 (0.9-2.5)

Bohm 1990-

2005(Sweden)

(1 month, good

neurologic)

7.2 6.7 0.93 (0.74-1.17)

Iwami 1998-2003 (Japan)

(1 year, good neurologic)3.6 3.5 0.97 (0.55-1.73)

Bobrow 2005-2007 (USA)

(survival to discharge)1.8 5.4 2.94 (1.06-8.16)

Waalewijn1995 (Holland)

Berdowski 2006 (Holland)

(hospital discharge)

9.7

16.9

Waarom beademen belangrijk isIs Basic Life Support important?

2006

1998-20032003 2005

2003-2006


Four supportive studies


Waarom beademen belangrijk isRespons from ERC Waarom beademen belangrijk is


none 72% 67% 68% 64% 60% -12%

conventional 23% 17% 17% 12% 10% -13%

CC only 5% 15% 15% 23% 30% +25%




•Increase of CC only CPR half from less full CPR

•Neuro intact survival minimal – role of TH?

•Effectiveness study



•Outcome neuro intact survival

30-3-2015

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Relation of collapse to CPR and defibrillation to survival: simplified model.

Valenzuela T D et al. Circulation. 1997;96:3308-3313

Copyright © American Heart Association, Inc. All rights reserved.



No BLS

BLS

0

20

40

60

80

0 5 10 15 20 25


Surv

ival (%

)

Waalewijn Resuscitation 2002



No BLS

BLS

0

20

40

60

80

0 5 10 15 20 25First defibrillation (min)

Surv

ival (%

)

Waalewijn Resuscitation 2001 Valenzuela Circulation 1997


Is ventilation needed during

CPR?•Pro:

–Circulatory arrest is not always primary cardiac

arrest (drowning, ashyxia, children)

–Oxygen content decreases rapidly during CPR

–Carbon dioxide needs to be removed

–Evidence from time of 5:1 C:V ratio

•Con

–Interruption of chest compression decreases CPP

–Animal evidence suggests improved survival

–Rescuers hate to do mouth-to-mouth breathing

–Telephone CPR is better when only CC tought

Guidelines 2005: do C:V ratio 30:2 when acceptable

Waarom beademen belangrijk isVerschillende issues

• Pause/onderbrekingen

– Pre-shock;post-shock;ventilaties

• Niet willen blazen

Waarom beademen belangrijk isChest compressions not/minimally interrupted

Kern Resuscitation 1998

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none 72% 67% 68% 64% 60%

full 23% 17% 17% 12% 10%

CC only 5% 15% 15% 23% 30%



none 72% 67% 68% 64% 60% -12%

full 23% 17% 17% 12% 10% -13%

CC only 5% 15% 15% 23% 30% +25%



none 72% 67% 68% 64% 60% -12%

full 23% 17% 17% 12% 10% -13%

CC only 5% 15% 15% 23% 30% +25%




none 72% 67% 68% 64% 60% -12%

full 23% 17% 17% 12% 10% -13%

CC only 5% 15% 15% 23% 30% +25%




•Excluded age <18 yr;non-cardiac cause

•Requirements for effectiveness study:



•Meaningful outcome


Arrest 2: survival without and with Basic Life Support

Waalewijn 1995-1997

No BLS

BLS

0

20

40

60

80

0 5 10 15 20 25First defibrillation (min)

Surv

ival (%

)


Resuscitation 2007;73:229-235

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Waarom beademen belangrijk isSurvival without and with Basic Life Support

No BLS

BLS

0

20

40

60

80

0 5 10 15 20 25


Su

rviv

al (%

)


Conclusion

Oxygen is needed many minutes

before ambulance arrival

Compression only CPR has not proven to be equal,

and certainly not superior!


Studies 1995-2011

Author-year Journal OR (CI) N=

Marwick 1995 Resuscitation 3.5 (2.0-6.1) 487

Hulik 1997 Resuscitation 2.9 (1.1-7.3) 251

Waalewijn 2001 Resuscitation 2,5 (1.6-4.0) 476

Herlitz 2005 Resuscitation 2.0 (1.7-2.4) 2076

Fridman 2007 Resuscitation 2.0 (1.3-3.3) 3009

Iwami 2007 Circulation 1.6 (0.95-2.6) 783

Hinchey 2010 Ann. Emerg. Med 9.9 (3.2-16.6)

Daisy 2011 Resuscitation 1.3 (1.0-1.7) 6360

Abrams 2011 Resuscitation 1.7 (1.0-3.0) 1156

2-3x better survival


Ambulances are fast……

But are they that fast?


Meursing JACC 1983: 6 dogs (abstract only)


And what about gasping?

Compressions also move air

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Is survival really similar?

Human evidence





Early: ≤8 minutes Late: >8 minutes

The model should follow the data


Compression-only CPR vs. Full CPR (Bohm 2007)

Electrical

phase

Circulatory

phase

Metabolic

phase

Three-phase model


De wereld heeft eindelijk C-A-B geaccepteerd!

2010

1983

30-3-2015

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Documents

PowerPoint Presentation 2015... · 30-3-2015 1 Waarom beademen belangrijk is Waarom beademen belangrijk is Ruud Koster Academisch Medisch Centrum Amsterdam Waarom beademen belangrijk