Introduction. Introduction EVIDENCE-BASED CPR: HOW THE RECOVER GUIDELINE CHANGED US. VETgirl on the run! VETgirl elite! 6/11/17

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1 EVIDENCE-BASED CPR: HOW THE RECOVER GUIDELINE CHANGED US Introduction Garret Pachtinger, VMD, DACVECC COO, VETgirl Kenichiro Yagi MS, RVT, VTS (ECC, SAIM) Introduction Justine A. Lee, DVM, DACVECC, DABT CEO, VETgirl VETgirl on the run! The tech-savvy way to get online veterinary CE! A subscription-based podcast and webinar service offering veterinary RACE-approved CE VETgirl elite! Up to 5 members: $599/year podcasts/year plus 30+ hours of webinars! $199/year 40+ hours of RACE-CE Up to 10 members: $999/year > 10 members: Ping us 1

2 Video archives On-demand video Download our podcasts Social media Ce certificates Speaker introduction n Type in questions n ed to you 48 hours after the webinar n Active participation = no quiz n Watching video later, must complete quiz n ELITE members only n / contact with ANY questions n garret@vetgirlontherun.com n justine@vetgirlontherun.com Kenichiro Yagi, MS, RVT, VTS (ECC, SAIM) 2

3 DO IT ALL NOW!! Get the epi! Hook up the ECG! Get a tube in! How much epi? What should we do first? What does the ECG show us? Do we have an IV yet!? CPA Assessment Compression Cycle Reassessment Campaign on Veterinary Resuscitation CPR Flow Compression Technique Start immediately Rate: bpm Depth: 33-50% of chest Allow full recoil 2 min uninterrupted Compression Point Round Chested As wide as deep Highest point of chest Thoracic pump theory Keel Chested Deeper than wide Over the heart Cardiac pump theory Flat Chested Wider than deep Over the sternum Cardiac pump theory This is a rare case!! 3

4 Chest Compressions Recumbency No significant difference Physical Tips Lock Elbows, use back Use height advantage Chest Compressions Cycle Interruption = Bad n Less perfusion during pauses n Blood flow build-up takes time n Cheske et al (14%) Recommendations n Limit rhythm checks to q2min n <10 sec pauses n Switch every 2 minutes Ventilation Technique Ventilation Timing Out of hospital Mouth-to-snout Close mouth, blow in Keep neck straight Brisk breaths Single rescuer 30:2 ratio In veterinary practice Intubate Ambu-bag / Anesthetic machine Continuous application The ABCs of CPR? Airway Circulation Breathing Airway Circulation Breathing The Evidence In Veterinary Medicine Reduced Oxygen Requirement Oxygen Supply without Ventilation Detrimental Effects Reason for CPA Circumstances Conclusions Low pulmonary oxygen uptake PF ratio maintained with lowered alveolar ventilation Lungs serve as a large oxygen reserve Compression Induced Ventilation Interrupted chest compressions CPA occurs largely from noncardiogenic (respiratory) causes Usually occurs in a hospital setting where airway is more easily secured ABC should be happening virtually simultaneously If caught alone, go with Circulation first Ventilate as soon as possible, but do not withhold compressions 4

5 Monitoring Which of the following is the best measure for effective perfusion in CPR? Monitoring Vascular Access Reversals A. Palpable pulses B. EtCO 2 C. Doppler D. ECG E. Lactate Defib Epi/Atropine Anti-arrhythmics Capnography Useful Monitors Ventilation ECG ETCO2 >10-15mmHg ETCO2 Perfusion Capnography Electrocardiography Confirms Intubation Predictor of ROSC Dogs: 15mmHg Cats: 20mmHg Indicator of ROSC Sudden increase Asystole (most common) Continue compressions Pulseless Electrical Activity Check pulses Continue compressions Non-shockable Rhythm 5

6 Electrocardiography Ventricular Fibrillation Coarse vs Fine Pulseless Ventricular Tachycardia Shockable Rhythms Defibrillator Charge in between 2 min cycles Mechanical Defib? Other Doppler/Oscillometric On the eye? Pulse palpation Venous pulsation Pulse Oximetry Vasoconstriction Motion Monitoring Which of the following is the best measure for effective perfusion in CPR? A. Palpable pulses B. EtCO 2 C. Doppler D. ECG E. Lactate CPR Drugs Epinephrine ( mg/kg) Arterial Vasoconstrictor Increased aortic pressure -> Increased CPP Low Dose: 0.01ml/kg or 0.1ml/10 lb High Dose: 0.1ml/kg or 1ml/10 lb Vasopressin ( U/kg) Smooth muscle vasoconstrictor Alternative to Epinephrine Half life longer (10-20 min) Timing: Atropine (0.05mg/kg) Blocks vagus nerve (Parasympathetic) Typically after the 1st compression cycle Increases HR 0.05mg/kg or 1ml/10 lb Then every other cycle CPA Cycle 1 Cycle 2 Cycle 3 Cycle 4 Cycle 5 Epi/Atropine Epi/Atropine CPA Cycle 1 Cycle 2 Cycle 3 Cycle 4 Cycle 5 Epinephrine Atropine Epinephrine Atropine Epinephrine Other Drugs Anti-arrhythmic Amiodarone, Lidocaine - Raise fibrillatory threshold Reversals Naloxone Opioid reversal Flumazenil Benzodiazepine reversal Atipamezole Alpha 2 agonist reversal 6

7 Communication Post Resuscitative Care Clear, direct, communication Closed-loop communication Situational awareness/cross-monitoring Respiratory Optimization Hemodynamic Support Neuroprotective therapy Has your practice implemented the RECOVER guideline? Reassessment Campaign on Veterinary Resuscitation Why implement? Standardizing of CPR No Official protocol beforehand n Doctor/Tech/Shift dependent differences n Helplessness and frustration Adobe Animal Hospital 24hr General/Emergency Practice 27 Veterinarians 90 Technical (50 RVT, 3 VTS) Emergency, ICU, Surgery Evidence-based guideline n Best current practice n Smooth, simplified CPR n Patient outcome 7

8 Challenges Large Scale Training Coordinated training effort n Guideline adaptation n Training resources (documents, tests, lab) 24/7 period, 4 departments n Technicians and Assistants n 27 Veterinarians Will the training make a difference? Is it even worth it? Success rate is low Do we really need this? Patients die for a reason Is it worth it? Initial Training Cost Expense Number Hourly Cost Hours Needed Tech (CPR) $22 3 Tech (Lead) $25 2 Vet (CPR) 27 $50 2 Vet (Lost Revenue) 27 $88 2 Training q6 months recommended $20-22,000/yr commitment Total $ $ $2700 $4752 $10-11k Will training make a difference? Effect of guideline unknown Many knowledge gaps Frequency of exposure low Turn-over Patients die for a reason Do we really need this? Justification Experienced, competent staff Up-to-date knowledge through CE Parts of staff feel success rate is high Training Cost Initial plan to train annually Standardizing of cost Evaluate Effectiveness Good will on EBVM Record/Debriefing n Staff feedback n Details of CPR Record of ailment and outcome 8

9 Efficiency Lacked official structure and training Defined Roles Organized double up and switch offs Allow other staff to be freed up Role Tasks Compression Compressions (alternate) Airway Management Drug Administration Establish Airway Ventilate Venous Access Administer Drugs Recorder Document events Timer CPR Leader Organizes CPR Team Leader The preponderance of evidence finds no difference with physicians present in either survival of the event or survival to discharge There are, in fact, a few studies that report worse outcome when physicians are present. Veterinarian CPR Lead Veterinarian Medical decisions Fills no other roles Attention to Patient dx Client Primary Vet CPR Leader Organizes CPR Assigns other roles Attention to CPR flow Independent function Tech or another Vet Veterinarian/Technician Team Function Other Intangible Gains Realistic resuscitation order discussion CPR cost Chances of success Yes Codes n Less frequent n More appropriate Improve chances of success Other Intangible Gains Bring order to the chaos Less frustration Sense of control Happier staff Training CPR Leaders 1 Session 11 Trained Tech/Assistants 4 Sessions 37 Trained Veterinarians 5 Sessions 20 Trained 2 nd Year Retraining 18 additional VT/VTAs 9

10 The Result Survival to Discharge Number Average Age Average Length ROSC Discharged yr 11min 13 (24.1%) 2 (3.7%) yr 12.7min 12 (42.9%) 2 (7.1%) yr 6.47min 6 (28.6%) 3 (14.3%) Total yr 10.5min 31 (30.1%) 7 (6.8%) Species Age Length Dx 1 Canine 12yr 6min DKA (Hyper-K+) 2 Feline 7yr 15min UO Hyper-K+ 3 Canine 7.5yr 26min Anesthetic 4 Canine 6.5yr 5min Addison s Hypoglycemia Hypothermia 8.25yr 13min Fixable? All fixable problems Arrest directly witnessed Some worth trying longer? Was it worth it? Efficiency Survival to discharge still low ROSC higher Gained perspective on performance Performance prior unknown Defined Roles Optimized staff use Allowed other staff to be freed up? Role Tasks Compression Compressions (alternate) Airway Management Drug Administration Establish Airway Ventilate Venous Access Administer Drugs Recorder Document events Timer CPR Leader Organizes CPR Veterinarian CPR Lead Veterinarian Medical decisions Fills no other roles Attention to Patient dx Client Primary Vet CPR Leader Organizes CPR Assigns other roles Attention to CPR flow Independent function Tech or another Vet Veterinarian/Technician Team Function Teamwork Veterinarian Focus on Dx Communication with client Less delay Technician team Empowered Key communication points 10

11 Other Intangible Gains Other Intangible Gains Honest, open conversations Realistic expectations Effect? Less CPR attempts Higher ROSC rate Bring order to the chaos Less frustration Sense of control Happier staff I feel like things are so organized. We have very smooth CPR attempts. It was totally worth it. I can t remember how we used to do this before the new protocol. It feels so calm going through the compression cycles. We still have our chaotic sessions, but I like how everyone knows what should be happening. The debriefing helps a lot. With the new protocol, we are doing the best job possible. Our patients get the best chance. Better efficiency Better communication Better teamwork Higher morale Better outcome(?) Adobe Animal Hospital Large scale training EBVM awareness Future Directions Questions? Kenichiro Yagi, MS, RVT, VTS (ECC, SAIM) kenyagirvt@gmail.com ACVECC approved certification BLS ALS Certification Training Collaborative data collection EBVM Progress Laymen training? 11

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