ICU Without Walls Concept Sympo Copy 2

8/15/2019 ICU Without Walls Concept Sympo Copy 2

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ICU without walls

concept; Early detection and intervention of patients at risk of cardiac arrest

outside the ICU


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Etiology of cardiac arrest

Nolan J. ERC Guidelines for Resuscitation 200!introduction. Resuscitation. 200; "#$suppl%&'()!("

• Etiologi – Cardiac $pri*ary& +,C-

• ,eart attac $/CI&

• elainan 1antung lain

– Non!Cardiac $secondary& I,C-• Internal

– (eere 3neu*onia4 (eptic (hoc4 etc

• E5ternal – 6rau*a he*orrhage4 Into5ication etc


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Etiology of +,C-(Out-of-hospital Cardiac Arrest)

Nolan J. ERC Guidelines forResuscitation 200!introduction.Resuscitation. 200; "#$suppl %&'()!("


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7e8nition

• 6he Utstein!style de8nition of cardiac arrest$2009&; – :the cessation of cardiac *echanical actiity. . .

con8r*ed y the asence of a detectale pulse4

unresponsieness and apnoea $or agonal respirations&ahr J4 >erg R-4 >illi JE4 >ossaert ?4 Cassan 34 Cooa! dia -4 7


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In!,ospital Cardiac -rrest

• In U(4 etween )#04000 and #04000 in!hospitalresuscitation atte*pts are *ade each year.

• Intensiists are freFuently inoled in the*anage*ent of in!hospital cardiac arrests $I,C-s& – as *e*ers of cardiac arrest tea*s

– or to proide post!resuscitation care.

• 3role*; – *a1ority of patients resuscitated successfully fro* I,C- die

efore hospital discharge4 and their prognosis has changed littleoer the past )0 years

>allew -4 3hilric J6 $%& Causes of ariation in reported in!hospital C3R surial' a critical reiew. Resuscitation

)0'20)D2%

3eerdy /-4 aye B4 +rnato J34 ?arin G?4 Nadarni =4 /ancini /E4 >erg R-4 Nichol G4 ?ane!6rultt 6 $200)&

Cardiopul*onary resuscitation of adults in the hospital' a report of %9#20 cardiac arrests fro* the National Registry of


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In!,ospital Cardiac -rrest

• 7elays in the treat*ent of hospitaliAed patients often result

in e*ergency ad*ission to the ICU4 which in turn i*plies a

prolongation of hospital stay and een increased *ortality.(Goldhill DR !edical e"er#ency tea"s Care Crit Ill $%%%)

• 0H of hospitaliAed patients failed to receie opti*u*

*anage*ent efore ad*ission to the ICU4 and that 90H of

all ad*issions to the ICU are in fact aoidale. (!c&uillan '!**+)

• +n the other hand4 delays in ad*ission to the ICU ! *ainlydue to a li*itation or shortage of aailale eds

– /ortality increase in the ICU and in hospital %.H and %H respectiely4

for eery hour of delayed ad*ission. (Cardoso et al Crit Care $%)


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Incidence

• Incidence of 0.%# eentsedannually oer a total of %94#20arrests in 2# -*erican hospi! tals$3eerdy et 200)&

• Incidence of % to arrests per %000patient ad*issions $(ogoll et al4%&4$,odgetts et al 2002&4 $(androni 2009&


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(urial

• (urial fro* cardiac arrest can e e5pressed in relation to ti*e

as'

– :i**ediate< $R+(C&4

– :short!ter*< $discharged alie fro* the hospital&4 and

– :long!ter*< $"D%2 *onths&.

• R+(C represents *ainly a success of the cardiopul*onary

resuscitation $C3R& *anoeures. Unfortunately4 etween 2H

and "#H of the successfully resuscitated patients die during the

8rst 29 h after R+(C $(androni 2009&4 $6unstall!3edoe %2& $(rifars200)&

• (urial to hospital discharge is the *ost co**only Fuoted

outco*e. docu*ented surial rates for I,C- range fro* 0H to

92H4 although *a1or studies report a surial to discharge of

appro5. 20H


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(urial rate of +,C- andI,C-

6he -*erican ,eart -ssociation pulished the ,eart 7isease and(troe (tatistics ! 20%) Update online on 7ece*er %24 20%2.


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,ow to i*proe the outco*e

%. 3re!arrest factors' – Recognising the critically ill patient and

prevention of cardiac arrest.• Up to 9H cases hae eidence of deterioration during

the hours efore the arrest – the *ost co**on 8ndings eing respiratory prole*s4

deterioration of *ental status and hae*odyna*ic instaility.ause J et al $2009&4 @ranlin C et al $%9& (chein R/ et al $%0&

• "%.H of arrests were potentially aoidale. Clinical signsof deterioration were not acted on in 9H of cases.

• 6he odds of potentially aoidale cardiac arrests were .%ti*es higher in patients in general wards than in criticalcare areas. ,odgetts et al $2009&


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Results

• Results, – -*ong patients with pree5isting pneu*onia4 only )".H

were receiing *echanical entilation and only )).)Hwere receiing infusions of asoactie drugs prior tocardiac arrest.

–

+nly 2.)H of patients on the ward were receiing ECG*onitoring prior to cardiac arrest. – (hocale rhyth*s were unco**on in all patients with

pneu*onia $entricular tachycardia or 8rillation4%9.H&.

– 3atients on the ward were signi8cantly older than

patients in the ICU.• Conclusions,

– In patients with pree5isting pneu*onia4 cardiac arrest*ay occur in the asence of preceding shoc orrespiratory failure. 3hysicians should e alert to thepossiility of arupt cardiopul*onary collapse

– 6he *echanis* *ay inole *yocardial ische*ia4 a*aladaptie response to hypo5ia4 sepsis!related


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%. 3re!arrest factors'• Medical Emergency Teams

Early detection of patients at ris


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Cardiac -rrest outside the ICU afterRR6

I*ple*entation of an RR6 in adults was associated with a

)).H reduction in rates of cardiopul*onary arrest outside

the intensie care unit $ICU&


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,ospital *ortality after RR6

I*ple*entation of an RR6 in adults was notassociated with lower hospital *ortality rates


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Conclusion of this *eta!analysis

• 3ossiilities for these counterintuitie results are – early identi8cation and transfer of the patient to the

ICU4 where the patient suseFuently e5periences anI,C-4 and

– increased use of 7N-R orders.

– +ther possiilities include failure to trigger the tea*when signs of deterioration are noted and poor

sureillance *ethods for identifying clinicaldeterioration


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2. Intra!arrest factors'• Resuscitation Guidelines 2010


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). 3ost!resuscitation care' 6he prognosis of patients ad*itted to the ICU after

resuscitation fro* cardiac arrest is poor in co*parisonwith other ICU patients

-*ong %942 patients ad*itted to ICU in the Unitedingdo* after I,C- the ICU *ortality was H whilehospital *ortality was "H

Interentions in the post!resuscitation period are lielyto inKuence the 8nal outco*e signi8cantly

Guidelines of resuscitation 20%0


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>est 3ractices

• 6he est practices are diided into ) te*poralsections – 3re!arrest4 intra!arrest4 and post!arrest.

– 6he discussion for each period includes;

• $%& a rief introduction4• $2& the structural aspects of the institutional response

$personnel4 training4 eFuip*ent&4

• $)& care pathways followed during the ti*e interal – early identi8cation4

– focus on C3R and early de8rillation4

– co*prehensie post!arrest care4 and

• $9& process issues related to how care is proided and Fualityi*proe*ent *easures

– $real!ti*e feed! ac4 auto*ated eFuip*ent that can replace staL anddelier si*ilar care4 withdrawal of life!sustaining therapy&.


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Conclusion

• +utco*e fro* I,C- is deter*ined y pre4 intra! and post!arrestfactors.

• (o*e pre!arrest conditions are Mti*e!dependent disease such ascancer4 sepsis and renal failure are correlated with lower surial

• /any in!hospital arrests are preceded y warning signs4 which

should e identi8ed early to enale treat*ent to preent patientdeterioration.

• E5perience with speci8cally dedicated tea*s increasedawareness of warning signs y ward personnel

• -fter cardiac arrest has occurred4 etter resuscitation4 early

de8rillation and induced!hypother*ia can i*proe surial.• Recent eidence that etter C3R is associated with increased

resuscitation success should e translated into syste*atictraining and *aintenance of sills a*ong all healthcare proiders.


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ICU Without Walls Concept Sympo Copy 2