6/11/17

1

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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6/11/17

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Kenichiro Yagi,MS,RVT,VTS(ECC,SAIM)

Speaker introduction

6/11/17

3

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!!

6/11/17

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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

6/11/17

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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

6/11/17

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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

6/11/17

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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: kenyagirvt@gmail.com

Kenichiro Yagi, MS, RVT, VTS (ECC, SAIM)

6/11/17

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