Year in Review: Cardiac Arrest 2019 - Perelman School of ... › resuscitation › assets ›...
Transcript of Year in Review: Cardiac Arrest 2019 - Perelman School of ... › resuscitation › assets ›...
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Year in Review: Cardiac Arrest 2019
Robert W. Neumar, MD, PhDProfessor and Chair,
Department of Emergency MedicineUniversity of Michigan
Ann Arbor, Michigan, [email protected] @neumar_robert
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Disclosures
• Co-Chair: International Liaison Committee on Resuscitation (ILCOR)
• Member: ILCOR ALS Task Force• President and Board Chair, SaveMiHeart• NIH and AHA Research Funding• PhysioControl/Stryker: Equipment support for research
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IncludedOriginal research published since
ReSS 2018
Excluded• Systematic reviews
• Meta-analyses
• Practice guidelines
Year in Review: Cardiac Arrest 2019
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Year in Review: Cardiac Arrest 2019
Post-Cardiac Arrest• Ventilation/oxygenation targets• Blood pressure targets• Targeted temperature management (TTM)• Coronary angiography• Antibiotics• Neuroprognostication
CPR• Ventilation
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Sutton Ped Crit Care 2019
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Ventilation Rates and Pediatric IHCA Outcomes Sutton Ped Crit Care 2019
Design: Prospective, multicenter observational studySetting: Pediatric and pediatric cardiac ICUs of the Collaborative Pediatric Critical Care Research Network.Population: 47 Intubated children (> 37 week <19 yrs) who received at least 1 minute of CPRVariables Studied: Ventilation rate and arterial diastolic pressureOutcome: Survival to hospital discharge
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Ventilation Rates and Pediatric IHCA Outcomes
Children < 1 Year Old Children > 1 Year Old
Prob
abili
ty o
f Sur
viva
l
Sutton Ped Crit Care 2019
Odds ratio for survival with good neurologic function 4.7 (1.2-19) if > 30 bpm for infants <1 yr or >25 bpm for children > 1 yr
Median ventilation rate was 30 breaths/min (IQR 24–36)
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Jakkula ICM 2018
Jakkula ICM 2018
COMACARE Study
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COMACARE StudyJakkula ICM 2018
Design: Prospective, randomized 23 factorial design multicenter clinical trialSetting: Adult ICUs of the COMACARE Research NetworkSubjects: 123 unconscious intubated post-arrest patients with witnessed VF/VT as initial rhythmIntervention: Targeted PaCO2, PaO2, and MAP x 36 hours Primary Outcome: Neuron specific enolase at 48 hoursSecondary Outcome: Survival with good neurologic function (CPC 1-2 at 6 months)
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PaCO
2(m
mHg
)
MAP
(mm
Hg)
75
150
PaCO
2(m
mHg
)
225
30
37
45
52
COMACARE StudyJakkula ICM 2018
PaCO2 PaO2 MAP
65-75 mmHg80-100 mmHg150-187 mmHg 75-112 mmHg34-35 mmHg43-45mmHg
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Brain Near-Infrared Spectroscopy (NIRS)
COMACARE StudyJakkula ICM 2018
65-75 mmHg80-100 mmHg150-187 mmHg 75-112 mmHg34-35 mmHg43-45mmHg
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0%
10%
20%
30%
40%
50%
60%
70%
80%
Low-NormalPaCO2
High-NormalPaCO2
Normoxia ModerateHyperoxia
Low-NormalMAP
High-NormalMAP
p = 0.20 p > 0.37 p > 0.44
Survival with Good Neurologic Function (CPC 1-2)
COMACARE StudyJakkula ICM 2018
PaCO2 PaO2 MAP
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Targeting low-normal or high-normal mean arterial pressure after cardiac arrest and resuscitation: a randomised pilot trial
Ameloot Eur Heart J 2019
Design: Prospective, single center, randomized clinical trialSetting: Adult ICUSubjects: 112 unconscious OHCA patients with all presenting rhythmsIntervention: Early goal-directed hemodynamic optimization (EGDHO) MAP 80-100 mmHg + SVO2 65-75% vs. MAP 65 mmHg for first 36 hours in ICUPrimary Outcome: MRI evidence of anoxic brain injurySecondary Outcome: Survival with good neurologic function (CPC 1-2) at 180 days
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0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
MAP65 EGDHO
Targeting low-normal or high-normal mean arterial pressure after cardiac arrest and resuscitation: a randomised pilot trial
Ameloot Eur Heart J 2019 Survival with Good Neurologic
Function (CPC 1-2)
p > 0.96
MAP 80-100 mmHgSVO2 65-75%
MAP 65 mmHg
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Lemkes NEJM 2019
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Coronary Angiography after Cardiac Arrest Without ST-Segment Elevation (COACT Trial)
Lemkes NEJM 2019
Design: Prospective randomize open-label multicenter clinical trialSetting: Adult ICUSubjects: 522 unconscious adult patients s/p OHCA who had initial shockable rhythm and without signs of STEMI, shock or obvious non-cardiac cause of the arrestIntervention: Immediate coronary angiography vs. coronary angiography that was delayed until after neurologic recoveryPrimary Outcome: Survival at 90 days
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Coronary Angiography after Cardiac Arrest Without ST-Segment Elevation (COACT Trial)
Lemkes NEJM 2019
Incidence of acute thrombotic occlusion:• 3.4% immediate angiography • 7.6% delayed angiography
Time to target temperature (hrs):• 6.5 (5.9 to 7.1) immediate angiography• 5.5 (5.0 to 6.0) delayed angiography
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Francois NEJM 2019
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Prevention of Early Ventilator Associated Pneumonia After Cardiac Arrest
Francois NEJM 2019
Design: Prospective multicenter, double-blind, randomized, placebo-controlled trialSetting: Adult ICUSubjects: 198 adult mechanically ventilated adult patients s/p witnessed OHCA who had initial shockable rhythmIntervention: Intravenous amoxicillin–clavulanate or placebo x 2 days starting less than 6 hours after the cardiac arrest.Primary Outcome: Early ventilator-associated pneumonia (first 7 days of hospitalization).
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Prevention of Early Ventilator Associated Pneumonia After Cardiac Arrest
Francois NEJM 2019
0%
10%
20%
30%
40%
50%
Control Anibiotics
4 % (95% CI: −10% to 18%)
Survival 90 days
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PRINCESS TrialNordberg JAMA 2019
Design: Prospective multicenter open-label randomized controlled clinical trialSetting: Out-of-hospitalSubjects: 677 adult patients with bystander witnessed OHCAIntervention: Intra-arrest transnasal evaporative cooling vs. standard carePrimary Outcome: Survival with good neurologic function (CPC 1-2 at 90 days)
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PRINCESS TrialNordberg JAMA 2019
0%
10%
20%
30%
40%
All Patients Shockable Nonshockable
ControlIntervention
RR 1.2 (0.9-1.7)
RR 1.3 (0.9-1.7)
RR 0.8 (0.3-2.0)
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PRINCESS TrialNordberg JAMA 2019
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Lascarrou NEJM 2019
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HYPERION TrialLascarrou NEJM 2019
Design: Prospective open-label multicenter randomized controlled clinical trialSetting: Adult ICUSubjects: 584 adult comatose patients following IHCA (27%) or OHCA (73%) with nonshockable initial rhythmIntervention: 33°C vs. 37°C during the first 24 hoursPrimary Outcome: Survival with good neurologic function (CPC 1-2 at 90 days)
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Lascarrou NEJM 2019HYPERION Trial
Hours Since Randomization
Tem
pera
ture
(o C)
Mea
n +
2 SD
Enrollment up to 5 hours post-ROSC
Median time from randomization to 33oC was 317 min [214 ; 477]
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Lascarrou NEJM 2019
0%
2%
4%
6%
8%
10%
12%
37C 33C
Survival with Good Neurologic Function (CPC 1-2)
Difference 4.5% (0.1% to 8.9%)
HYPERION Trial
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Lascarrou NEJM 2019
Subgroup AnalysisSurvival with Good Neurologic Function (CPC 1-2)
HYPERION Trial
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ProNeCA StudyScarpino Resuscitation 2019
Design: Prospective multicenter prognostication studySetting: 13 mixed medical-surgical intensive care units(ICUs)Population: Adult comatose cardiac arrest survivors admitted to ICUVariables Studied: Somatosensory evoked potentials (SSEP), Brain CT, and EEGOutcome: Poor neurologic outcome (CPC 4-5) at 6 months
“Withdrawal of life sustaining therapy (WLST) was not performed in any of the participating centres and treatment was continued in all patients, except when brain death occurred.”
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ProNeCA StudyScarpino Resuscitation 2019
57%
10%
7%
Multimodal
• Grade 2 SSEP or CT G/W ratio <1.21 or highly malignant EEG
• <24 hours• FPR 0% (0-3%)• Sensitivity 74.4% (68-80%)
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Moseby-Knappe JAMA Neurology 2018
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Design: Prospective clinical biobank study of data from TTM trialSetting: International multicenter study with 29 participating sitesPopulation: 782 unconscious patients with out-of-hospital cardiac arrest of presumed cardiac originVariables Studied: Serum NFL concentrations analyzed at 24, 48, and 72 hours after cardiac arrestOutcome: Poor neurologic outcome at 6-months (CPC 3-5)
Serum Neurofilament Light Chain (NFL) for Prognosis of Outcome after Cardiac Arrest
Moseby-Knappe JAMA Neurology 2018
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Serum NFL
• > 641 pg/mL
• 24 hours post-ROSC
• FPR <1% (0-5%)
• Sensitivity 31%
• 50% TTM33 and 50% TTM36
Serum Neurofilament Light Chain (NFL) for Prognosis of Outcome after Cardiac Arrest
Moseby-Knappe JAMA Neurology 2018
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Design: Prospective international multicenter observational studySetting: 10 adult ICUsPopulation: Comatose cardiac arrest survivorsVariables Studied: Quantitative neurological pupil index (Npi) and standard manual pupillary light reflex (sPLR) day 1 to 3 after cardiac arrestOutcome: Poor outcome defined as CPC 3-5 (severe disability, vegetative state, or death) at 3-months
Quantitative Pupillometry: Neural Pupillary Index (Npi®)Oddo ICM 2019
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Quantitative Pupillometry: Neurological Pupil Index (Npi®)
Neurological Pupil Index• NPi* <2.0• First 24 hours post-ROSC• FPR 0% (0-2%)• Sensitivity 22%• 42% TTM33 40% TTM36
* NPi®-200 pupillometer, Neuroptics®, Irvine, CA, USAN
Piva
lue
5
4
3
2
1
0
Oddo ICM 2019
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Brain-Ex
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N A T U RE 2 0 1 9
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N A T U RE 2 0 1 9
• Preservation of cytoarchitecture• Attenuation of cell death• Vascular dilatory responses• Glial inflammatory responses• Spontaneous synaptic activity• Active cerebral metabolism
OBSERVED
NOT OBSERVED• Global electrocortical activity
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What Did We Learn In 2019?
• Ventilation rates in pediatric CPR need to be re-evaluated
• Post-cardiac arrest normoxia, normocarbia, and normotension are reasonable. Studies needed to evaluate individualized goal-directed strategies
• Empiric antibiotics prevented pneumonia in post-cardiac arrest patients treated with hypothermic TTM but did not improves survival
• Immediate post-cardiac arrest PCI for patients without STEMI criteria does not improve survival in a population with low incidence of acute coronary occlusion
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What Did We Learn In 2019?• Intra-arrest intranasal evaporative cooling does not improve
overall survival with good neurologic function in bystander witnessed OHCA, but may benefit subpopulations such as those with an initial shockable rhythm
• TTM at 33oC improves survival with good neurologic function compared to TTM at 37oC in post-cardiac arrest patients with non-shockable initial rhythm
• Reliable neuroprognostication of futility within 24 hours of ROSC may be feasible using a multimodal approach
• BrainEx has challenged the limits of total brain ischemia after which restoration of brain function can be achieved.
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AHA 2019 Focused Updates for First Aid, CPR, and Emergency Cardiovascular Care
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Year in Review: Cardiac Arrest 2019
Robert W. Neumar, MD, PhDProfessor and Chair,
Department of Emergency MedicineUniversity of Michigan
Ann Arbor, Michigan, [email protected] @neumar_robert