Introduction - VETgirlIntroduction Justine A. Lee, DVM, DACVECC, DABT CEO, VETgirl Introduction...
Transcript of Introduction - VETgirlIntroduction Justine A. Lee, DVM, DACVECC, DABT CEO, VETgirl Introduction...
6/11/17
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Kenichiro Yagi MS, RVT, VTS (ECC, SAIM)
EVIDENCE-BASED CPR:
HOW THE RECOVER GUIDELINE CHANGED US
GarretPachtinger,VMD,DACVECC
COO,VETgirl
Introduction
JustineA.Lee,DVM,
DACVECC,DABTCEO,VETgirl
Introduction
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Kenichiro Yagi,MS,RVT,VTS(ECC,SAIM)
Speaker introduction
6/11/17
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Get the epi!
Get a tube in!
Hook up the ECG!
DO IT ALLNOW!!
Do we have an IV yet!?
What does the ECG show us?
How much epi?
What should we do first?
Reassessment Campaign on Veterinary Resuscitation
CPA Assessment
Compression Cycle
CPR Flow
Compression Technique
¨ Start immediately¨ Rate: 100-120bpm¨ Depth: 33-50% of chest¨ Allow full recoil¨ 2 min uninterrupted¨ Compression Point
Round Chested
As wide as deepHighest point of chestThoracic pump theory
Keel Chested
Deeper than wideOver the heart
Cardiac pump theory
Flat Chested
Wider than deepOver the sternum
Cardiac pump theory
This is a rare case!!
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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. 2011 (14%)
¤ Recommendationsn Limit rhythm checks to
q2minn <10 sec pausesn Switch every 2 minutes
Ventilation Technique
¨ 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
AirwayBreathingCirculation
The “ABCs” of CPR?
CirculationAirwayBreathing
Ventilation Timing
The Evidence
Reduced Oxygen
Requirement
Low pulmonary oxygen uptake
PF ratio maintained with lowered
alveolar ventilation
Lungs serve as a large oxygen
reserve
Oxygen Supply without
Ventilation
Compression Induced Ventilation
Detrimental Effects
Interrupted chest compressions
In Veterinary Medicine…
Reason for CPA
CPA occurs largely from non-
cardiogenic (respiratory)
causes
Circumstances
Usually occurs in a hospital setting where airway is
more easily secured
ABC should be happening virtually
simultaneously
Conclusions
If caught alone, go with Circulation first
Ventilate as soon as possible, but do not
withhold compressions
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MonitoringVascularAccess Reversals
Epi/AtropineDefib
Anti-arrhythmics
Monitoring
¨ Which of the following is the best measure for effective perfusion in CPR?
A. Palpable pulsesB. EtCO2
C. DopplerD. ECGE. Lactate
Capnography
Ventilation
Perfusion
ETCO2
Useful Monitors
¨ ECG¨ ETCO2
¤ >10-15mmHg
Capnography
¨ Confirms Intubation
¨ Predictor of ROSC¤ Dogs: ≥15mmHg¤ Cats: ≥20mmHg
¨ Indicator of ROSC¤ Sudden increase
Electrocardiography
¨ Asystole (most common)¤ Continue compressions
¨ Pulseless Electrical Activity¤ Check pulses¤ Continue compressions
¨ Non-shockable Rhythm
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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 pulsesB. EtCO2
C. DopplerD. ECGE. Lactate
CPR Drugs
¨ Epinephrine (0.01-0.1mg/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 (0.4-0.8 U/kg)¤ Smooth muscle vasoconstrictor¤ Alternative to Epinephrine¤ Half life longer (10-20 min)
¨ Atropine (0.05mg/kg)¤ Blocks vagus nerve (Parasympathetic)¤ Increases HR¤ 0.05mg/kg or 1ml/10 lb
Timing:Typically after the 1st compression cycleThen 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
Epinephrine
Epinephrine
Atropine
Atropine
Other Drugs
¨ Anti-arrhythmic¤ Amiodarone, Lidocaine - Raise fibrillatory threshold
¨ Reversals¤ Naloxone – Opioid reversal¤ Flumazenil – Benzodiazepine reversal¤ Atipamezole – Alpha 2 agonist reversal
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Communication
¨ Clear, direct, communication
¨ Closed-loop communication
¨ Situational awareness/cross-monitoring
Post Resuscitative Care
¨ Respiratory Optimization
¨ Hemodynamic Support¨ Neuroprotective
therapy
Reassessment Campaign on Veterinary Resuscitation
Has your practice implemented the
RECOVER guideline?
• 24hr General/Emergency Practice• 27 Veterinarians• 90 Technical (50 RVT, 3 VTS)• Emergency, ICU, Surgery
Adobe Animal Hospital
Why implement?
¨ Standardizing of CPR¤ No “Official” protocol beforehand
n Doctor/Tech/Shift dependent differencesn Helplessness and frustration
¤ Evidence-based guidelinen Best current practicen “Smooth”, simplified CPRn Patient outcome
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Challenges
¨ Large Scale Training¤ Coordinated training
effortn Guideline adaptationn Training resources
(documents, tests, lab)¤ 24/7 period,
4 departmentsn 40-50 Technicians and
Assistantsn 27 Veterinarians
Is it even worth it? Success rate
is low
Will the training make a difference?
Do we really need this?
Patients die for a reason
Is it worth it?
¨ Initial Training Cost
¨ Training q6 months recommended¨ $20-22,000/yr commitment
Expense Number Hourly Cost Hours Needed
Tech (CPR) 40-50 $22 3
Tech (Lead) 10-15 $25 2
Vet (CPR) 27 $50 2
Vet (Lost Revenue) 27 $88 2
Total
$2640-3300
$500-750
$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?
¨ Experienced, competent staff
¨ Up-to-date knowledge through CE
¨ Parts of staff feel success rate is high
Justification
¨ Training Cost¤ Initial plan to train
annually¤ Standardizing of cost
¨ Evaluate Effectiveness¤ Good will on EBVM¤ Record/Debriefing
n Staff feedbackn Details of CPR
¤ Record of ailment and outcome
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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
• Establish Airway• Ventilate
DrugAdministration
• 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
¨ Medical decisions¨ Fills no other roles¨ Attention to
¤ Patient dx¤ Client
¨ Primary Vet
¨ Organizes CPR¨ Assigns other roles¨ Attention to
¤ CPR flow¤ Independent function
¨ Tech or another Vet
Veterinarian CPR Leader
Veterinarian/Technician Team Function
Other Intangible Gains
¨ Realistic resuscitation order discussion¤ CPR cost¤ Chances of success¤ “Yes” Codes
n Less frequentn 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
¨ 2nd Year¤ Retraining¤ 18 additional VT/VTAs
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The Result
NumberAverage
AgeAverage Length ROSC Discharged
2013-2014 54 8.90yr 11min 13 (24.1%) 2 (3.7%)
2014-2015
2015-2016
Total
NumberAverage
AgeAverage Length ROSC Discharged
2013-2014 54 8.90yr 11min 13 (24.1%) 2 (3.7%)
2014-2015 28 7.46yr 12.7min 12 (42.9%) 2 (7.1%)
2015-2016
Total
NumberAverage
AgeAverage Length ROSC Discharged
2013-2014 54 8.90yr 11min 13 (24.1%) 2 (3.7%)
2014-2015 28 7.46yr 12.7min 12 (42.9%) 2 (7.1%)
2015-2016 21 8.13yr 6.47min 6 (28.6%) 3 (14.3%)
Total
NumberAverage
AgeAverage Length ROSC Discharged
2013-2014 54 8.90yr 11min 13 (24.1%) 2 (3.7%)
2014-2015 28 7.46yr 12.7min 12 (42.9%) 2 (7.1%)
2015-2016 21 8.13yr 6.47min 6 (28.6%) 3 (14.3%)
Total 103 8.35yr 10.5min 31 (30.1%) 7 (6.8%)
Survival to Discharge
¨ All “fixable” problems¨ Arrest directly
witnessed¨ Some worth trying
longer?
Species Age Length Dx
1 Canine 12yr 6minDKA
(Hyper-K+)
2 Feline 7yr 15minUO
Hyper-K+
3 Canine 7.5yr 26min Anesthetic
4 Canine 6.5yr 5minAddison’s
HypoglycemiaHypothermia
Species Age Length Dx
1 Canine 12yr 6minDKA
(Hyper-K+)
2 Feline 7yr 15minUO
Hyper-K+
3 Canine 7.5yr 26min Anesthetic
4 Canine 6.5yr 5minAddison’s
HypoglycemiaHypothermia
8.25yr 13min Fixable?
Was it worth it?
¨ Survival to discharge still low
¨ ROSC higher¨ Gained perspective on
performance¤ Performance prior
unknown
Efficiency
¨ Defined Roles¨ Optimized staff use¨ Allowed other staff to
be “freed up”?
Role Tasks
Compression • Compressions(alternate)
Airway Management
• Establish Airway• Ventilate
DrugAdministration
• Venous Access• Administer Drugs
Recorder • Document events• Timer
CPR Leader • Organizes CPR
Veterinarian ≠ CPR Lead
¨ Medical decisions¨ Fills no other roles¨ Attention to
¤ Patient dx¤ Client
¨ Primary Vet
¨ Organizes CPR¨ Assigns other roles¨ Attention to
¤ CPR flow¤ Independent function
¨ Tech or another Vet
Veterinarian CPR Leader
Veterinarian/Technician Team Function
Teamwork
¨ Veterinarian¤ Focus on Dx¤ Communication with
client¤ Less delay
¨ Technician team¤ Empowered¤ Key communication
points
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Other Intangible Gains
¨ Honest, open conversations
¨ Realistic expectations
¨ Effect?¤ Less CPR attempts¤ Higher ROSC rate
Other Intangible Gains
¨ 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.”
“With the new protocol, we are doing the best job possible. Our patients get the best chance.”
“We still have our chaotic sessions, but I like how everyone knows what should be happening. The debriefing helps a lot.”
“I can’t remember how we used to do this before the new protocol. It feels so calm going through the compression cycles. ”
• Better efficiency• Better communication• Better teamwork• Higher morale• Better outcome(?)
Adobe Animal Hospital
It was totally worth it.
• Large scale training• EBVM awareness
Future Directions
¨ ACVECC approved certification¤ BLS¤ ALS
¨ Certification Training¨ Collaborative data
collection¨ EBVM Progress¨ Laymen training?
Questions? Email: [email protected]
Kenichiro Yagi, MS, RVT, VTS (ECC, SAIM)
6/11/17
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