Current trends in resuscitation Nelda K. Martin, RN, ANP, CCNS Barnes-Jewish Hospital Heart and Vascular Center
During a Code, medication errors are: 39 times more likely to result in harm 51 times more likely to result in death compared to non-code related medication errors Lipshtz, et al. 2008 Most code drugs are high-alert Potential for patient harm is high Serious Errors are often missed, even if the patient died or is harmed, because there was no suspicion the drugs actually caused or contributed to the morbidity or mortality. Patients are at most vulnerable state. Preventing Medication Errors During Codes
Preventing Medication Errors During Codes • Most Common Errors: • Dosing Errors: 25% of time MD does not specify dose. Caused a 10-fold increase in overdoses • Drug Selection Errors: by MD, but also between crash cart nurse and med nurse. • Confusion of the “A” drugs: • Atropine • Adenosine • Amiordarone • Drug Preparation Errors: wrong concentrations, wrong diluent. • Omissions: 12 % of drug ordered were never given
Contributing Factors • Weight-based Errors • DOPamine drip programmed in infused 10 mcg/kg/hr instead of intended 10 mcg/kg/min • Weight-based DOPamine drip. Weight in pounds entered as KG weight. • Look-a-like packaging • ex. Atropine 0.5 mg are in exact same packaging as Atropine 1.0 mg • Look-a-like or sound-a-like drug names: • DOPamine, DOBUTamine, • Three “A” drugs: Atropine, Amoidarone, Adenosine • Alternative Drugs in code carts during a drug shortage • CaCl to Calcium Gluconate, Epinephrine (no pre-filled syringe to reconstituted), Atropine, Metoprolol • Multiple concentrations of drug in code cart drawers • Ex. Epinephrine 1mg (no pulse), Epinephrine High Dose Multi-dose vial (gtts and rare single boluses), EpiPEN 300 mcg (anaphylaxis)
Other Contributing Factors • Disorganized and non-standardized code carts • Excessive stock in code carts • Distractions from a hectic environment • Poorly communicate verbal orders • Inexperienced staff/Knowledge Deficit
Strategies to Reduce Errors: Code Cart Stock • 5 “S” the crash cart. • Separate adult, pediatric and neonatal code carts. • Standardize common code cart equipment whenever possibly throughout the organization. Ex. Defibs • Standardize concentrations, container sizes, quantities. • Provide drugs in ready-to-use syringes/premixed solutions to avoid error-prone calculations and admixtures. • Assign full responsibility to restocking meds to pharmacy for all code carts in all areas. • Preprinted, ready-to-use labels for infusions. • Label Drawers on the outside of the crash cart for easier retrievel of supplies.
Sealed, Standardized Drug tray IV, Blood Work Drawer
Strategies to Reduce Errors: Accessibility to Drug Information • Standardized emergency drug reference sheets for all drugs in the cart. Consistency with concentrations found in cart. • Pharmacists at codes.
Strategies to Reduce Errors: Communication • Repeat back verbal medication orders for verification and clarify incomplete orders. • MD Nurse • Crash Cart Nurse Medication Nurse • Conduct Code Debriefings with staff who responded to the code to communicate specific • Code leaders to establish clear guidance of interventions and medications. • Interdisplinary Code Simulations
Quality Indicators of CPR • Standards of Quality Indicators: • 100 compressions/minute • 2 inches in depth • Complete chest recoil • Any interruption in chest compression is < 10 seconds • Ultimate indicator of Quality CPR is survival
Quality Indicators of CPR • Immediate delivery of high-quality CPR has been shown to increase the survival rate 2- to 3- fold. • Berg, et al, 2001; Dowie, et al, 2003 • CPR quality is highly variable and often poor. • Study shows that CPR improves with verbal feedback (debriefing) after the event but improves even more with real-time feedback device. • Dine, et al, 2008
Devices to assist Manual CPR • Real-time Feedback device • an electronic sensor which connects to a monitoring device to measure, compression rate and depth, ventilation rate and volume, and hands off period • Feedback can be audio, visual or both
Feedback devices • Q-CPR: Philips • PocketCPR and Zoll AED Plus: Zoll Only recommended for training
Feedback devices: medtronic • CPR Metronome, integrated into the LIFEPAK® 15 monitor/defibrillator • cprMAX™ Technology built into our LIFEPAK AEDs
Would the use the Mechanical Devices help? • Lucas • http://www.fdnntv.com/Lucas-2-Chest-Compression-System • Autopulse • http://www.zoll.com/medical-products/cardiac-support-pump/autopulse/video/
Research • Limited: few large, randomized studies, involved out-of-hospital arrests, one randomized trial had design issue. • Ong, 2006 Hallstrom, 2006 • No difference in the incidence of injuries between manual and mechanical CPR. • Rubertsson, 2011 • Mixed results as to survival. • Cost: $12,00-15,000 • Large in size: about 25 lbs. • Battery life: 30-45 minutes • Skin abrasions with the band • It may find a place in-hospital in areas with frequent CPR or when CPR needed during procedures: OR orcath alb.
Active compression/decompression CPR (ACD-CPR) • ResQPump: Hand-held active device placed on the sternum instead of allowing the chest wall to recoil passively, the rescuers pulls up on the ResQ Pump’s handle with its suction cup actively decompressing the chest. This negative pressure or vacuum increase blood flow to the patient’s heart. • ResQPOD: impedance threshold device: Fits on ambu bag and prevents hyperventilation by limiting the tidal volume deliver to patient. Allows for slight negative pressure and vacuum to further support the blood flow to the patient’s heart. • Advanced Circulatory Systems, Inc.
ACD-CPR • One Cochrane meta-analysis of 10 studies involving both in-hospital arrest (826 patients) and out-of-hospital arrest (4162 patients) and other controlled trials comparing ACD-CPR to conventional CPR showed no difference in ROSC or survival. The meta-analysisdid not find any increase in ACD-CPR–related complications. • Lafuente-Lafuente, 2004 Goralski, 1998 • There is insufficient evidence to recommend for or against the routine use of ACD-CPR. ACD-CPR may be considered for use when providers are adequately trained and monitored (Class IIb, LOE B). • AHA, 2010
Impedance Threshold Device • The ITD is a pressure-sensitive valve that is attached to an endotracheal tube, supraglottic airway, or face mask. The ITD limits air entry into the lungs during the decompression phase of CPR, creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR. • The ITD and ACD-CPR devices are thought to act synergistically to enhance venous return. During ACD-CPR with or without the ITD, 1 randomized studyfound no difference in survival, whereas another randomized study found that the addition of an ITD improved short-term survival (24-hour survival and survival to ICU admission). • Plaisance, 2000 and 2004 • One meta-analysis of pooled data from both conventional CPR and ACD-CPR randomized trials demonstrated improved ROSC and short-term survival associated with the use of an ITD in the management of adult out-of-hospital cardiac arrest patients but no significant improvement in either survival to hospital discharge or neurologically intact survival to discharge. • Cabrini, 2008 • The use of the ITD may be considered by trained personnel as a CPR adjunct in adult cardiac arrest (Class IIb, LOE B).
Therapeutic Hypothermia USES • TBI: Traumatic Brain Injury • Acute Stroke • Hemorrhagic Cerebral Infarction • Acute MI • Organ Transplantation • Post Cardiac Arrest
ACLS guidelines increased recommendation level of post-arrest hypothermia for any arrest patient from IIb to IIa. • IIa: Reasonable to perform • IIb: May be considered
Post-arrest brain • Caption: This axial (cross section) CT of the brain was obtained after a patient was resuscitated from a cardiac arrest. There are symmetrical areas of low density (dark areas) in the deep regions of the brain (the basal ganglia) which represents areas of infarction (stroke) due to lack of blood flow as a result of the cardiac arrest. Theses regions are especially vulnerable to lack of oxygen and subsequent damage (reperfusion injury).
Methods of Cooling • Although there are multiple methods for inducing hypothermia, no single method has proved to be optimal.
Cooled IV Fluids w/ Ice Bags • Cooled with 4 ◦C intravenous saline infusion combined with ice packs applied in the groins, axillae, and along the neck. • Treatment was maintained for 26 h after cardiac arrest. It was estimated that passive rewarming would occur over a period of 8 h. • All patients reached the target temperature interval of 32–34 ◦C within 279±185 min from cardiac arrest and 216±177 min from induction of cooling. In nine patients the temperature dropped to below 32 ◦C during a period of 15 min up to 2.5 h. The target temperature was maintained by periodically applying ice packs on the patients. • Passive rewarming started 26 h after cardiac arrest and continued for 8±3 h. Rebound hyperthermia (>38 ◦C) occurred in eight patients 44 h after cardiac arrest. • Conclusions: Intravenous cold saline infusion combined with ice packs is effective in inducing and maintaining therapeutic hypothermia, with good temperature control even during rewarming. • Larsson, 2010.
Intravascular CoolingBetter Control of coolingBut no change in outcomes compared to External ZOLL
Cooling Hazards Shivering: prehospital/ED give bolus doses of sedation. Decreased Phos, K+, Mg+ Diuresis: monitor CVP Bradycardia Prolonged QTI: Torsades Decreased CO2 production, approx. 30% less: less ventilation required Increase glucose Paralytics may mask seizures due to brain damage: EEG & neuro consult Increased WBC’s: predisposed to infection Rewarming Hazards Hypotension: mgmt w/ radial arterial line and IVF/Inotropes/Vasopressors to maintain MAP above 80 Rebound hyperthermia: AVOID RAPID REWARMING Tx w/ Tylenol Increased K+ Shivering: Do NOT DC sedation and paralysis until temp is 36oC or above. DC paralytics first. When TOF 4/4, wean sedation. Hypothermia Hazards
Encouraging physicians to talk to their patients about end-of-life • Section 1233 of bill HR 3200 which would have paid physicians for providing voluntary counseling to Medicare patients about living wills, advance directives, and end-of-life care options.
References • Lipshutz, AKM, et al. Medication errors associated with code situations in US hospitals: direct and collateral damage. J Comm J Qual Patient Saf. 2008;34(1):46-55. • Kozer, E, et al. prospective observational study on the incidence of medication errors during simulated resuscitation in a pediatric emergency department. BMJ. 2004; 329: 1321. • Kozer, E, et al.Variables associated with medication errors in pediatric emergency medicine. Pediatrics, 2002;110:737-42. • Hunziker, S., et al. Human factors in resuscitation: lessons learned from simulator studie. J Emerg Trauma Shock. 1010;3(4):389-394. • ISMP Medication Safety Alert! Nurse Advise-ERR. Preventing medication errors during codes. Sept 2011;9(9). • Berg, RA, et al: Adverse hemodynamic effects of interrupting chest compressions ofr rescue breathing during CPR for VF cardiac arrest. Circulation, 2001; 104:2465-2470. • Dowie, R, et al: Event tree analysis of out-of hospital cardiac arrest data: confirming the importance of bystander CPR. Resuscitation 2003; 56:173-181.
References, Con’T • Perkins, G., Brace. S, & Gates, S. 1010. Mechanical chest-compression devices; current and future roles. Current Opinion in Critical Care, 16(3), 203-10. • Ong, M, et al. 2006. Use of an automated, load-distributing band chest compression device for out-of-hospital cardiac arrest resuscitation. JAMA, 295(22), 2629-37. • Hallstrom, A, et al. 2006 Manual chest compression vs. use of an automated chest comrpession device during resuscitation following out-of-hospital cardiac arrest: a randomized trial JAMA, 295(22), 2620-8. • Rubertsson, S, Smekal, D. Huzevka, T., Johnansson, J. 2007. Abstract 32: Mechanical chest compressions with the LUCAS device does not increase the incidence of injuries in cardiac arrest victims. Best Original Resuscitation Science. Circulation. 2007;116:II_930. • Larsson, I-M, Wallin, E, Rubertsson, S. Cold saline infusion and ice packs alone are effective in inducing and maintaining therapeutic hypothermia after cardiac arrest. Anaesthesiology& Intensive Care,Uppsala University Hospital, S-751 85 Uppsala, Sweden
References, Con’t • Plaisance P, Lurie KG, Payen D. Inspiratory impedance during active compression-decompression cardiopulmonary resuscitation: a randomized evaluation in patients in cardiac arrest. Circulation. 2000;101:989–994. • PlaisanceP, Lurie KG, VicautE, Martin D, GueugniaudPY, Petit JL, Payen D. Evaluation of an impedance threshold device in patients receiving active compression-decompression cardiopulmonary resuscitation for out of hospital cardiac arrest. Resuscitation. 2004;61:265–271. • Cabrini L, BeccariaP, LandoniG, Biondi-ZoccaiGG, SheibanI, CristofoliniM, FochiO, MajG, Zangrillo A. Impact of impedance threshold devices on cardiopulmonary resuscitation: a systematic review and meta-analysis of randomized controlled studies. Crit Care Med. 2008;36:1625–1632. • Lafuente-LafuenteC, Melero-Bascones M. Active chest compression-decompression for cardiopulmonary resuscitation. Cochrane Database Syst Rev. 2004;:CD002751. • Goralski M, VillegerJL, CamiG, LinassierP, Guilles-Des-Buttes P, FabbriP, VenotP, TazarourteK, Cami M. Evaluation of active compression-decompression cardiopulmonary resuscitation in out-of-hospital cardiac arrest. Reanimation Urgences. 1998;7:543–550. • Sasson, C, Rogers, MAM, Dahl, J, Kellermann, Arthur. Predictors of Survival From Out-of-Hospital Cardiac Arrest and Meta-analysis: A Systematic Review. CircCardiovascQual Outcomes 2010;3;63-8