1/23/2015
2015 AHA Guidelines for CPR and ECC: Time for a Change
Michael Sayre, MD
University of Washington
Emergency Medicine
Disclosures
• Medtronic Foundation: Research Grant
• Physio‐Control: EMS Fellowship Program Support
AHA CPR & ECC Guidelines Development Process in Past
1
1/23/2015
Goals
• Reduce inventory of science with much more frequent “focused updates.”
• Adopt an internationally recognized, transparent system for evaluating scientific evidence.
• Encourage broad participation in the process
– Enhance quality of scientific reviews
– Speed development of revised guidelines
Grading of Recommendations
Assessment, Development, and
Evaluation (GRADE)
• Process to take evidence to guidelines
• Developed by key international groups
• Widely accepted internationally
2
1/23/2015
GRADE
• Offers a transparent and structured process for developing and presenting summaries of evidence, including its quality, for systematic reviews and recommendations in health care.
• Provides guideline developers with a comprehensive and transparent framework for carrying out the steps involved in developing recommendations.
• Use is appropriate and helpful irrespective of the quality of the evidence: whether high or very low.
• Does not eliminate the inevitable need for judgments.
www.guidelinedevelopment.org
GRADE Uptake
3
1/23/2015
www.ILCOR.org/SEERS
4
1/23/2015
Let’s Dive in…
DRAFTS
The information provided is currently in DRAFT format and is NOT a FINAL version.
5
1/23/2015
Vasopressors for cardiac arrest (1. Epi v Placebo)
The information provided is currently in DRAFT format and is NOT a FINAL version
Consensus on Science:
For all four long term (critical) and short term (important) outcomes, we found one underpowered trial that provided low quality evidence comparing SDE to placebo (Jacobs, 2001, 1138). Among 534 subjects, there was uncertain benefit or harm of SDE over placebo for the critical outcomes of survival to discharge [RR 2.12, 95% CI 0.75‐6.02, p=0.16] and good neurological outcome defined as CPC of 1‐2 [RR 1.73, 95% CI 0.59‐5.11, p=0.32]. However, patients who received SDE had higher rates of the two important outcomes of survival to admission [RR 1.95, 95% CI, 1.34‐2.84, p=0.0004] and ROSC in the prehospital setting [RR 2.80, 95% CI 1.78‐4.41, p<0.00001] compared to those who received placebo.
Vasopressors for cardiac arrest (1. Epi v Placebo)
The information provided is currently in DRAFT format and is NOT a FINAL version
Treatment Recommendation Given the observed benefit in short term outcomes, we suggest Standard Dose Epinephrine be administered to patients in cardiac arrest (weak recommendation, low quality).
Values and Preferences Statement: In making this statement, we place value on the short‐term outcomes of ROSC and survival to admission, and our uncertainty about the absolute effect on survival and neurological outcome. Public Comments
6
1/23/2015
Dispatcher Instruction in CPR
Consensus on Science
For the critical outcome of survival, we have identified very low to moderate quality evidence from three RCTs (one reporting outcomes at one day, 30 days, and hospital discharge [Svensson 2010, 434]; one to hospital admission and hospital discharge [Hallstrom 2000, 190]; and one to hospital discharge only [Rea 2010, 423]). Hüpfl
[2010, 1552] meta‐analysed the three RCTs (moderate quality) and found an absolute survival benefit of 2.4% (95%CI 0.1%‐4.9%) in favour of continuous chest compressions over traditional CPR [NNT 41; (95%CI 20‐
1,250); RR 1.22 (95%CI 1.01‐1.46)]. Dispatcher Instruction in CPR
Treatment Recommendation
We recommend that dispatchers should provide CPR instructions to callers in order to improve survival from OHCA. (serious indirectness, strong recommendation, moderate quality of evidence). We recommend that dispatchers should provide CPR instructions to callers in order to improve bystander CPR rates (some indirectness, strong recommendation, low to very low quality of evidence).
CPR Prior to Defibrillation
Consensus on Science
For the critical outcome of survival to hospital discharge with favorable neurological outcome (define as CPC score of ≤ 2, MRS score ≤ 3), we identified low grade evidence (downgraded for inconsistency and imprecision) from 4 RCTs (OR 0.95, 95% CI [0.786 to 1.15]). For the critical outcome of survival to one year with good neurological function (CPC ≤ 2), we identified low grade evidence (downgraded for bias and imprecision) from a single trial (OR 1.18, 95% CI [0.522 to 2.667]). For the critical outcome of survival to hospital discharge, we identified low grade evidence (downgraded for bias and imprecision) from 4 RCTs (OR 1.095, 95% CI [0.695 to 1.725]). For the critical outcome of survival to one year we identified low grade evidence (downgraded for bias and imprecision) from 2 RCTs (OR 1.15, 95% CI [0.625 to 2.115]). With respect to ROSC, we identified low grade evidence (downgraded for bias and imprecision) from 4 RCTs (OR 1.193, 95% CI [0.871 to 1.634]). 7
1/23/2015
CPR Prior to Defibrillation
Treatment Recommendation
We suggest an initial period of CPR for 30‐60 seconds while the defibrillator is being applied (weak recommendation based on low quality evidence).
Impedance Threshold Device + Standard CPR (I) vs Standard CPR (C): Consensus on Science
For the critical outcome of neurologically intact survival at hospital discharge (assessed with Modified Rankin ≤ 3), there was one RCT (Aufderheide 2011, 798) of high quality in 8718 out‐of‐hospital cardiac arrests that was unable to demonstrate a clinically significant benefit from the addition of the ITD to standard CPR: RR 0.97 (95% CI 0.82 to 1.15). For the critical outcome of survival to hospital discharge, there was one RCT (Aufderheide 2011, 798) of high quality in 8718 out‐of‐hospital cardiac arrests that was unable to demonstrate a clinically significant benefit from the addition of the ITD to standard CPR: RR 1 (95% CI 0.87 to 1.15). Impedance Threshold Device + Active Compression Decompression CPR (I) vs Standard CPR (C): Consensus on Science
For the critical outcome of neurologically intact survival at 12 months (assessed with CPC ≤ 2), there was one RCT (Frascone 2013, 1214) of very low quality (downgraded for risk of bias and suspected publication bias) in 2738 out‐of‐hospital cardiac arrests that was unable to demonstrate a clinically significant benefit from the addition of the ITD to ACD CPR (when compared with standard CPR): RR 1.34 (95% CI 0.97 to 1.85). For the critical outcome of neurologically intact survival at hospital discharge (assessed with CPC ≤ 2), there was one RCT (Frascone 2013, 1214, which incorporated data published in Aufderheide 2011, 301) of very low quality (downgraded for risk of bias, inconsistency, and suspected publication bias) in 2738 out‐of‐hospital cardiac arrests that was unable to demonstrate a clinically significant benefit from the addition of the ITD to ACD CPR (when compared with standard CPR): RR 1.28 (95% CI 0.98 to 1.69). 8
1/23/2015
Treatment Recommendation (DRAFT)
Impedance Threshold Device + Standard CPR (I) vs Standard CPR (C): We recommend against routine use of ITD in addition to standard CPR (strong recommendation, high quality of evidence). Values and preferences statement: In making this recommendation we place a higher value on not allocating resources to an ineffective intervention over any yet to be proven benefit for critical or important outcomes. Impedance Threshold Device + Active Compression Decompression CPR (I) vs Active Compression Decompression CPR (C): We suggest against the routine use of ITD in addition to Active Compression‐Decompression CPR (weak recommendation, very low quality of evidence). Values and preferences statement: In making this recommendation we place a higher value on not allocating resources to an ineffective intervention over any yet to be proven benefit for critical or important outcomes. Impedance Threshold Device + Active Compression Decompression CPR (I) vs Standard CPR (C): We suggest against the routine use of ITD with Active Compression‐Decompression CPR as an alternative to standard CPR (weak recommendation, very low quality of evidence). Values and preferences statement: In making this recommendation we place a higher value on not allocating resources to an intervention with equivocal benefit for critical or important outcomes.
Analysis of Rhythm during Chest Compression
Consensus on Science
There are currently no human studies that address the identified critical outcomes criteria of neurologically intact survival, survival or ROSC or the important outcomes criteria of CPR quality, time to commencing CPR or time to first shock.
Treatment Recommendation
We suggest against the use of artifact‐filtering algorithms for analysis of ECG rhythm during CPR unless as part of a research programme.
9
1/23/2015
Peds Compression Depth
Consensus on Science
For the critical outcomes of “survival with good neurological outcome” and “survival to hospital discharge” we have identified very low quality evidence (downgraded for indirectness and imprecision) from one observational study, (Sutton 2014 1179) enrolling 89 cardiac arrest events, showing those who received chest compression of > 51 mm trended to better survival but did not reach significance. Peds Compression Depth
Treatment Recommendation
We suggest that in infants, rescuers should be taught to compress the chest by at least one third the anterior‐posterior dimension or approximately 1½ inches (4 cm). In children, rescuers should be taught to compress the chest by at least one third the anterior‐posterior dimension or approximately 2 inches (5 cm). Mechanical Chest Compression
Consensus on Science
For the critical outcome of survival to hospital discharge with good neurologic outcome (defined as CPC 1‐2 or mRS 0‐3), we have identified moderate quality evidence from 3 RCTs enrolling 7582 OHCA patients showing variable results (Hallstrom 2006 2620, Wik 2014 741, Rubertsson 2013 53). One study (Hallstrom 2006 2620) (n=767) demonstrated harm with the use of a load‐distributing band mechanical chest compression device compared to manual chest compressions (7.5% of patients in the control group versus 3.1% in the intervention group, p=0.006). Two other RCTs (Wik 2014 741, Rubertsson 2013 53) (n=6820), one using a load‐distributing band and the other a LUCAS (Lund University Cardiac Arrest System), did not demonstrate benefit or harm when compared with manual chest compressions.
10
1/23/2015
Mechanical Chest Compression
Treatment Recommendation
We suggest mechanical chest compression devices should not be considered the standard of care for cardiac arrest patients, but can be considered a reasonable alternative to high quality manual chest compressions in some settings (weak recommendation, moderate quality of evidence). Values and preferences statement: In making this recommendation we place value on data from a large, high‐quality RCT demonstrating equivalence between high quality manual chest compressions and manual chest compressions (Wik). Local considerations such as relative costs and resource availability for maintenance of high quality manual chest compressions and mechanical chest compression device implementation should guide decisions around which mode of chest compression delivery is most appropriate. Also, there may be scenarios not directly addressed in the literature reviewed to support this treatment recommendation such as CPR in a moving ambulance, in the angiography suite or during preparation for ECLS, where mechanical chest compressions are more practical. Advanced airway placement (ETT vs SGA)
Consensus on Science
Supraglottic airways (SGAs: Combitube, LMA, laryngeal tube) versus tracheal intubation For the critical outcome of favourable neurological survival, we have identified low quality evidence from one observational study of 5377 OHCAs showing no difference between tracheal intubation and insertion of a SGA (adjusted OR 0.71; 95% CI 0.39 – 1.30) [Kajino 2011 R236], from one observational study of 281,522 OHCAs showing higher rates of favourable neurological outcome between insertion of a SGA and tracheal intubation (OR 1.11; 95% CI 1.0 – 1.2) [Hasegawa 2013 257] and from two studies showing higher rates of favourable
neurological outcome between tracheal intubation and insertion of a SGA (8701 OHCAs adjusted OR 1.44; 95% CI 1.10 – 1.88 [McMullan 2014 617]) and (10,455 OHCAs adjusted OR 1.40; 95% CI 1.04 – 1.89 [Wang 2012 1061]). Advanced airway placement (ETT vs SGA)
Treatment Recommendation
We suggest using either
a supraglottic airway or tracheal tube as the initial advanced airway management during CPR (weak recommendation, very low quality evidence) for out of hospital cardiac arrest.
11
1/23/2015
Ventilation rate during continuous chest compression
Consensus on Science
We did not identify any evidence to address the critical outcomes of Survival with favorable neurological/functional outcome at discharge, 30 days, 60 days, 180 days and, or 1 year Survival at discharge, 30 days, 60 days, 180 days AND/OR 1 year. We identified very low quality evidence (downgraded for very serious risk of bias and indirectness, and serious inconsistency and imprecision) from 10 animal studies [Sanders 2002 553, Aufderheide
2004 s345, Aufderheide 2004 1960, Yannopoulos 2004 75, Yannopoulos 2006 1444, Hayes 2007 357, Cavus 2008 118, Hwang 2008 183, Gazmuri 2012 259, Kill 2014 e89] and 1 human non‐RCT [Abella 2005 305] that does not enable us to estimate the effect of a ventilation rate of 10 per minute compared to any other rate for the important outcome of ROSC with confidence. Ventilation rate during continuous chest compression
Treatment Recommendation
We suggest a ventilation rate of 10 breaths per minute in adults with cardiac arrest with a secure airway receiving continuous chest compressions (weak recommendation, very low quality evidence).
Induced Hypothermia
Consensus on Science
For the critical outcome of “survival with good neurological outcome,” we have identified moderate quality evidence from one randomized control trial (RCT) [1] and one pseudorandomized trial [2] enrolling 275 and 77 patients, demonstrating a benefit in patients with out of hospital cardiac arrest (OHCA) with ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) as an initial rhythm. In these studies, cooling to 32‐34°C compared to no temperature management was associated with a risk ratio (RR) and odds ratio (OR) for good neurologic outcome at 6 months and hospital discharge of 1.4 (95% CI 1.08‐1.81) and 2.65 (95% CI 1.02‐6.88), respectively. For the critical outcome of “survival,” moderate quality evidence in the larger study demonstrates benefit in patients treated with induced hypothermia (RR for 180‐day mortality 0.74, 95% CI 0.58‐0.95),[1] while the other study found no significant difference (51% vs 68% hospital mortality, p=0.145).[2]
[1] The Hypothermia After Cardiac Arrest Study Group, Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med; 346:549‐56; 2002. [2] Bernard SA et al, Treatment of comatose survivors of out‐of‐hospital cardiac arrest with induced hypothermia. N Engl J Med; 346:557‐63; 2002.
12
1/23/2015
Induced Hypothermia
Consensus on Science
Is there evidence for an ideal temperature (I) when using targeted temperature management? For the critical outcomes of “survival” and “survival with good neurologic outcome,” we found high quality evidence from one RCT including 939 patients. This study compared cooling to 33°C compared to tight temperature control at 36°C in adult patients with OHCA of any initial rhythm except unwitnessed asystole, and found no benefit (HR for mortality at end of trial 1.06, 95% CI 0.89‐1.28; RR for death or poor neurologic outcome at 6 months 1.02, 95% CI 0.88‐1.16).[6]
[6] Nielsen N et al, Targeted temperature management at 33 C vs. 36 C after cardiac arrest. N Engl J Med; 369: 2197‐206; 2013.
Induced Hypothermia
Treatment Recommendation
We recommend that adults who achieve ROSC after OHCA, with VT or VF as an initial cardiac arrest rhythm, be treated with targeted temperature management (strong recommendation, moderate evidence). Based on the current evidence, neither 32‐34°C nor 36°C appears to be superior in OHCA patients with ROSC. We therefore recommend targeted temperature management maintain a core temperature at either 32‐34 or 36°C, although this may not apply to certain subpopulations including patients with longer no‐flow times or more severe neurologic injury. We suggest targeted temperature management for adults with OHCA and nonshockable initial rhythms, and IHCA with any initial rhythm. Values and Preferences Statement: Based on weaker, indirect evidence extrapolated from studies in VT or VF OHCA, and in the absence of other effective therapies, we believe that targeted temperature management may benefit these patients as well. Induced Hypothermia (timing)
Consensus on Science
Pre‐hospital induction of therapeutic hypothermia (I) vs induction of therapeutic hypothermia after arrival to the hospital (C): For the critical outcome of “survival with good neurological outcome,” we have identified moderate quality evidence from five randomized controlled trials (RCTs) enrolling a total of 1,867 patients with out of hospital cardiac arrest (OHCA), demonstrating no benefit. In these studies, initiation of induced hypothermia in the pre‐hospital environment compared to after hospital arrival was associated with a risk ratio (RR) of 0.96 (95% CI 0.85, 1.09). In order to assess the risk of potential harm related to initiation of induced hypothermia in the pre‐hospital setting, we identified moderate quality evidence from five RCTs which reported the incidence of the important outcome “pulmonary edema.” In these studies, the initiation of pre‐hospital hypothermia was associated with a RR 1.29 (95% 1.12, 1.49) for the complication of pulmonary edema. For the critical outcome of “re‐arrest,” we identified moderate quality evidence from four RCTs which demonstrated an increased risk for re‐arrest among patients who received pre‐
hospital induced hypothermia (RR 1.23 [1.02 to 1.48]. 1. Kim F, Olsulfka M, Longstreth WT, et al. Pilot randomized clinical trial of prehospital induction of mild hypothermia in out‐of‐hospital cardiac arrest patients with a rapid infusion of 4oC Normal Saline. Circulation 2007;115:3064‐3070. 2. Kämäräinen A, Virkkunen I, Tenhunen J, Yli‐Hankala A, Silfvast, T. Prehospital therapeutic hypothermia for comatose survivors of cardiac arrest: a randomized controlled trial. Acta Anaesthesiol Scand 2009;5:900‐907. 3. Bernard SA; Smith K, Cameron P et al. Induction of therapeutic hypothermia by paramedics after resuscitation from out‐
of‐hospital ventricular fibrillation cardiac arrest: a randomized controlled trial. Circulation 2010; 122:737‐742. 4. Castrén M, Nordberg P, Svensson L, et al. Intra‐arrest transnasal evaporative cooling: a randomized, prehospital, multicenter study (PRINCE: Pre‐ROSC IntraNasal Cooling Effectiveness). Circulation 2010; 122: 729‐736. 5. Bernard SA; Smith K, Cameron P et al. Induction of prehospital therapeutic hypothermia after resuscitation from nonventricular fibrillation cardiac arrest. Crit. Care Med 2012;40:747‐53. 6. Kim F, Nichol G, Maynard C, et al. Effect of Prehospital Induction of Mild Hypothermia on Survival and Neurological Status among Adults with Cardiac Arrest: A Randomized Clinical Trial. JAMA 2014;311:45‐52. 13
1/23/2015
Induced Hypothermia (timing)
Treatment Recommendation
We recommend against pre‐hospital induction of hypothermia for OHCA (strong recommendation, moderate quality of evidence) with cold saline given the current evidence does not demonstrate survival benefit or favorable neurologic outcome and one large study utilizing cold intravenous fluid suggests possible increased risk of harm related to pre‐hospital initiation of induced hypothermia. We suggest against pre‐hospital cooling in general
given the lack of evidence of efficacy in the face of the need for additional resource allocation. First Aid Use of Tourniquet
Consensus on Science
For the critical outcome of “mortality”, low quality evidence from two human studies with a comparison group (evidence downgraded for risk of bias) enrolling 355 patients showing no difference where 4% (3/71) of patients who had a tourniquet applied died compared to 4% (10/284) of patients who did not have a tourniquet applied (RR 1.2 (0.34 – 4.25)) (Beekley
2008, s28; Passos 2014, 573) and very low quality evidence six human case series studies (evidence downgraded for risk of bias) enrolling 808 patients, where 10% (82/808) of those patients who had tourniquet applied died (Brodie 2007, 74; King 2012, 33; Kragh 2011, 590; Kragh 2012, 1362; Lakstein
2002, s221; Tien 2008, 174). Use of Tourniquet
Treatment Recommendation
We suggest a tourniquet be used when standard first aid hemorrhage control cannot control bleeding by first aid providers (weak recommendation, low quality of evidence). Values and preferences statement: In making this recommendation, we place increased value on the benefits of hemostasis, which outweigh the risks. The cost of the intervention is moderate.
14
1/23/2015
PCI after ROSC without ST‐elevation
Consensus on Science:
For the important outcome of “survival to hospital discharge” we have identified very low quality evidence (downgraded for risk of bias) from 2 observational studies enrolling 513 patients showing benefit (OR 0.51 95% CI 0.35 – 0.73). For the important outcome of “neurologically intact survival” we have identified very low quality evidence (downgraded for risk of bias) from 2 observational studies enrolling 513 patients showing benefit (OR 0.51 95% CI 0.35 – 0.74). PCI after ROSC without ST‐elevation
Treatment Recommendation
We suggest emergent cath
lab evaluation in comparison to cardiac catheterization later in the hospital stay or no catheterization for adult patients who are experiencing ROSC after cardiac arrest without evidence of ST‐elevation on ECG (weak recommendation, very low quality of evidence). Real‐Time Feedback for CPR Quality
Consensus on Science
For the critical outcome of “survival to hospital discharge” we identified moderate quality evidence from one cluster randomised [Hostler 2011 p342] representing 1586 patients and very low evidence from four observational studies in adults [Abella 2007 p54; Bobrow 2013 p47; Kramer‐Johansen 2006 p283; Sainio 2013 p50] and one observational study in children [Sutton 2014 p70] representing 1192 patients. All studies were downgraded due to risk of bias. The randomised
trial found no difference in the number of patients who achieved survival to hospital discharge (control 44.7% vs
44.3%, p=0.962). No studies showed a statistically significant difference in survival to hospital discharge with the use of CPR feedback. Effect of CPR feedback on survival to hospital discharge ranged from ‐0.9 to +5.2.
15
1/23/2015
Real‐Time Feedback for CPR Quality
Treatment Recommendation
Within the focused scope of this question, we suggest against routine implementation of CPR feedback devices in systems in which they are currently not used (weak recommendation, very low quality of evidence). In systems currently using CPR feedback devices we suggest the devices may continue to be used that there is no evidence suggesting significant harm (weak recommendation, very low quality of evidence). Values and preferences statement: In making this recommendation, we place a higher value on resource allocation and cost effectiveness than widespread implementation of a technology with uncertain effectiveness. Be Heard!
Visit www.ILCOR.org/SEERS to contribute!
Questions: sayrem@uw.edu
16