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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,ow to i*proe the outco*e
%. 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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,ow to i*proe the outco*e
2. Intra!arrest factors'• Resuscitation Guidelines 2010
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,ow to i*proe the outco*e
). 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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,ow to i*proe the outco*e
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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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