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AP025 CHEST COMPRESSION SYNCHRONIZED VENTILATION DURING CPR: INFLUENCE ON HAEMODYNAMICS IN A PIG MODEL
Abstracts, Resuscitation 2011 – Implementation / Resuscitation 82S1 (2011) S1–S34
S15
AP023
AP025
Improved accuracy of prediction of defibrillation success by shortening amplitude spectrum area integration intervals in out-of-hospital cardiac arrest
CHEST COMPRESSION SYNCHRONIZED VENTILATION DURING CPR: INFLUENCE ON HAEMODYNAMICS IN A PIG MODEL
Giuseppe Ristagno 1 , Weilun Quan 2 , Frederick Geheb 2 , Gary Freeman 2 , Joe Bisera 3
Clemens Kill 1 , Pascal Wallot 1 , Oliver Hahn 1 , Christian Neuhaus 2 , Florian Dietz 3 , Stefan Schwarz 1 , Robert Mahling 1 , Hinnerk Wulf 1 , Wolfgang Dersch 1
1
Mario Negri Institute, Milan, Italy 2 Zoll Medical Corp., Chelmsford, MA, USA 3 Weil Institute of Critical Care Medicine, Rancho Mirage, CA, USA
1
Departement of Anesthesiology and Critical Care, Philipps-University, Marburg, Germany Institut für Automatisierungstechnik und Qualitätssicherung e.V., Heidelberg, Germany 3 Weinmann Geräte für Medizin GmbH+Co.KG, Hamburg, Germany 2
Background: Amplitude spectrum area (AMSA), calculated by fast Fourier transformation of ventricular fibrillation (VF) waveform, has been recognized as an accurate predictor of successful defibrillation (DF). However, the optimum ECG window integration interval for AMSA calculation in humans has not been determined yet. In the present study, we retrospectively evaluated the association of AMSA integration interval with its prediction accuracy of DF success. Methods: ECG data were obtained through an internal registry of ZOLL AED defibrillators in the US. The sampling rate of the ECG data files was 250 Hz. AMSA was calculated based on 256, 512, 1024, 2048, and 4096 points, representing respectively 1.05, 2.1, 4.2, 8.4, and 16.8 sec ECG windows ending at 0.5 sec before each DF attempt. AMSA values calculated based on the different ECG windows were then normalized to 1024 point window. DF was defined as successful in the presence of spontaneous rhythm ≥40 beats/min starting within 60 secs from the DF and lasting for >30 secs. The accuracy in predicting DF success by each of these ECG window intervals were evaluated and compared. Logistic regression was used to calculate the odds ratio as predicted by AMSA. Results: A total of 573 patients with out-of-hospital VF cardiac arrest were included in the analyses. Only ECG intervals prior to the first defibrillation attempt, consisting of 156 successful and 417 unsuccessful DFs, were analyzed. Odds ratio was significantly higher based on AMSA measurement using shorter integration intervals: 1.27, 1.17, 1.14, 1.04, and 1.01 for intervals respectively of 1, 2, 4, 8, and 16 secs. Conclusions: In this population, AMSA using 1 sec as integration interval was confirmed to be more accurate in predicting DF success compared with longer intervals. These findings may lead to future AED analyses algorithms requiring minimal pre-DF interruptions of chest compressions.
AP024 Chest compression synchronized ventilation during CPR: Influence of a novel ventilator mode on gas exchange in a pig model Clemens Kill 1 , Wolfgang Dersch 1 , Oliver Hahn 1 , Christian Neuhaus 3 , Florian Dietz 2 , Robert Mahling 1 , Stefan Schwarz 1 , Hinnerk Wulf 1 , Pascal Wallot 1 1 Departement of Anesthesiology and Critical Care, Philipps-University, Marburg, Germany 2 Weinmann Geräte für Medizin GmbH+Co.KG, Hamburg, Germany 3 Institut für Automatisierungstechnik und Qualitätssicherung e.V., Heidelberg, Germany
Objective: Mechanical ventilation with an automated ventilator is recommended during CPR with secured airway.1,2 A novel ventilator mode named Chest Compression Synchronized Ventilation (CCSV) generates a pressure controlled ventilation triggered by each chest compression. We investigated the gas exchange and acid-base state under CCSV in a pig model.3 Methods: After approval by local authorities seven pigs were anaesthetized with endotracheal intubation and ventilated with room air. Ventricular fibrillation (VF) was induced. Following 3 min cardiac arrest 10 min continuous chest compressions (LUCAS device) and CCSV with a pressure controlled inspiration (pmax 60 mbar, tinsp 205 ms, FiO2 1.0) simultaneously with the start of each chest compression were performed. After 10 min CPR arterial and venous blood gas lab was drawn. Data were analyzed with Wilcoxon-test and are presented as median (25/75 percentiles). Results: After 10 min of CPR, arterial PO2 increased from baseline (FiO2 0.21) 91 (85/94) mmHg to 634 (115/693) mmHg (p=0.018), arterial PCO2 decreased from 40 (39/42) mmHg to 26 (18/29) mmHg (p=0.018), venous pH from 7.40 (7.38/7.42) to 7.35 (7.34/7.36) (p=0.034), venous PO2 from 40 (34/46) mmHg to 32 (24/34) mmHg (p=0.018), venous PCO2 was 49 (42/50) mmHg and 50 (44/52) mmHg (p=0.735). Conclusions: Chest Compression Synchronized Ventilation (CCSV) with pure oxygen provided an excellent oxygenation with low carbondioxide whereas venous blood gas values could be kept in normal range during 10 minutes CPR in this pig model.4 References: 1. Yannopoulos D, Matsuura T, McKnite S, Goodman N, Idris A, Tang W, Aufderheide TP, Lurie KG. Crit Care Med. 2010;38:254–60. 2. Dorph E, Wik L, Steen PA. Resuscitation 2004;61:23–7. 3. Kill C, Torossian A, Freisburger C, Dworok S, Massmann M, Nohl T, Henning R, Wallot P, Gockel A, Steinfeldt T, Graf J, Eberhart L, Wulf H: Resuscitation 2009;80: 1060. 4. Oranto JPM, Bryson BLM, Donovan PJM, Farquharson RRM, Jaeger CR. Critical Care Medicine 1983;11:79–82.
Objective: Mechanical ventilation with an automated ventilator is recommended during CPR with secured airway.1,2 We investigated the influence of the novel ventilator mode Chest Compression Synchronized Ventilation (CCSV), a pressure controlled ventilation triggered by each chest compression, on haemodynamics in a pig model.3 Methods: After approval by local authorities seven pigs were anaesthetized, intubated, instrumented and ventricular fibrillation (VF) was induced. After 3 min cardiac arrest 10 min continuous chest compressions (LUCAS device) with CCSV followed, applying a pressure controlled inspiration (pmax 60 mbar, tinsp 205 ms, 100% O2 ) simultaneously with each chest compression. After 10 min ALS (up to six defibrillations, vasopressors) was started. At the timepoints of 13 and 17 min invasive blood pressures were measured with and without CCSV. Data were analyzed with Wilcoxon-test and are presented as median (25/75 percentiles). Results: Baseline before cardiac arrest were: Mean arterial pressure (MAP) = 60.4 (59.6/94.4) mmHg and MAP-central venous pressure (MAP-CVP) = 53.0 (52.3/88.5) mmHg. Results at t=13 min (after 10 min BLS) with and without CCSV were: MAP = 32.7 (30.4/33.4) vs. 27.0 (24.5/27.7) mmHg (p=0.018), MAP-CVP = 11.6 (9.9/14.1) vs. 10.4 (9.1/12.9) mmHg (p=0.499). Two pigs achieved return of spontaneous circulation (ROSC) before administration of epinephrine, results at t=17 min (after 1 mg epinephrine iv, n=5 pigs) with and without CCSV: MAP = 61.8 (58.3/67.9) vs. 47.8 (46.6/48.9) mmHg (p=0.08) and MAP-CVP = 40.0 (37.6/45.4) vs. 32.0 (30.6/32.8) (p=0.255). ROSC could be achieved in 4/7 animals. Conclusions: Chest Compression Synchronized Ventilation (CCSV) leads to higher mean arterial pressure during CPR, associated with a trend to increased coronary perfusion pressure. References: 1. Deakin CD, Nolan JP, Soar J, Sunde K, Koster RW, Smith GB, Perkins GD: European Resuscitation Council Guidelines for Resuscitation 2010 section 4. Adult advanced Life Support. Resuscitation 2010;81:1305–52. 2. Yannopoulos D, Matsuura T, McKnite S, Goodman N, Idris A, Tang W, Aufderheide TP, Lurie KG. Crit Care Med. 2010;38: 254–60. 3. Kill C, Torossian A, Freisburger C, Dworok S, Massmann M, Nohl T, Henning R, Wallot P, Gockel A, Steinfeldt T, Graf J, Eberhart L, Wulf H: Resuscitation 2009;80: 1060.
AP026 Key performance indicators for non-traumatic cardiac arrest. Can stickers improve documentation in pre-hospital cardiac arrest? Adam Chesters 1 , Anne Weaver 2 , Gareth Grier 3 , Christopher King 3 , Sophie Jefferys 3 1
London’s Air Ambulance, London, UK Essex and Herts Air Ambulance Trust, Essex, UK 3 The Royal London Hospital, London, UK 4 University of Cambridge, Cambridge, UK 2
Essex and Herts Air Ambulance Trust (EHAAT) is a charity that provides two helicopter-based doctor-paramedic pre-hospital care teams to provide support to land ambulance crews and additional medical skills and interventions as required in the two counties. Non-traumatic cardiac arrest (NTCA) forms a large part of our medical case load. Between 2008 and 2009, EHAAT pre-hospital care teams were tasked to around 100 NTCAs. The team carries specialist equipment to improve the quality of cardiopulmonary resuscitation (CPR). Clinical notes for all patients seen by the team are recorded on a patient report form (PRF), a generic A4 pro forma document. In May 2010, EHAAT introduced an adhesive sticker listing interventions for NTCA grouped into a series of key performance indicators (KPI) that are evidence-based and should be achieved for all patients in NTCA treated by the team. The EHAAT audit standard is that a sticker is placed on all PRFs relating to NTCA, and that all KPIs are met. The overall aims were to improve, clarify and standardise documentation in addition to providing an aide memoire for the package of interventions provided on scene. Following this change, we performed a retrospective audit and applied the KPIs to the PRFs of all NTCAs since the inception of our doctor-paramedic service. We proposed that the introduction of stickers improved the documentation of pre-hospital management of these patients. Prior to the introduction of the stickers, 56% of interventions that later became service pre-ROSC KPIs were documented as complete and 54.4% of interventions that later became service post-ROSC KPIs were documented as complete. Since
S15
AP023
AP025
Improved accuracy of prediction of defibrillation success by shortening amplitude spectrum area integration intervals in out-of-hospital cardiac arrest
CHEST COMPRESSION SYNCHRONIZED VENTILATION DURING CPR: INFLUENCE ON HAEMODYNAMICS IN A PIG MODEL
Giuseppe Ristagno 1 , Weilun Quan 2 , Frederick Geheb 2 , Gary Freeman 2 , Joe Bisera 3
Clemens Kill 1 , Pascal Wallot 1 , Oliver Hahn 1 , Christian Neuhaus 2 , Florian Dietz 3 , Stefan Schwarz 1 , Robert Mahling 1 , Hinnerk Wulf 1 , Wolfgang Dersch 1
1
Mario Negri Institute, Milan, Italy 2 Zoll Medical Corp., Chelmsford, MA, USA 3 Weil Institute of Critical Care Medicine, Rancho Mirage, CA, USA
1
Departement of Anesthesiology and Critical Care, Philipps-University, Marburg, Germany Institut für Automatisierungstechnik und Qualitätssicherung e.V., Heidelberg, Germany 3 Weinmann Geräte für Medizin GmbH+Co.KG, Hamburg, Germany 2
Background: Amplitude spectrum area (AMSA), calculated by fast Fourier transformation of ventricular fibrillation (VF) waveform, has been recognized as an accurate predictor of successful defibrillation (DF). However, the optimum ECG window integration interval for AMSA calculation in humans has not been determined yet. In the present study, we retrospectively evaluated the association of AMSA integration interval with its prediction accuracy of DF success. Methods: ECG data were obtained through an internal registry of ZOLL AED defibrillators in the US. The sampling rate of the ECG data files was 250 Hz. AMSA was calculated based on 256, 512, 1024, 2048, and 4096 points, representing respectively 1.05, 2.1, 4.2, 8.4, and 16.8 sec ECG windows ending at 0.5 sec before each DF attempt. AMSA values calculated based on the different ECG windows were then normalized to 1024 point window. DF was defined as successful in the presence of spontaneous rhythm ≥40 beats/min starting within 60 secs from the DF and lasting for >30 secs. The accuracy in predicting DF success by each of these ECG window intervals were evaluated and compared. Logistic regression was used to calculate the odds ratio as predicted by AMSA. Results: A total of 573 patients with out-of-hospital VF cardiac arrest were included in the analyses. Only ECG intervals prior to the first defibrillation attempt, consisting of 156 successful and 417 unsuccessful DFs, were analyzed. Odds ratio was significantly higher based on AMSA measurement using shorter integration intervals: 1.27, 1.17, 1.14, 1.04, and 1.01 for intervals respectively of 1, 2, 4, 8, and 16 secs. Conclusions: In this population, AMSA using 1 sec as integration interval was confirmed to be more accurate in predicting DF success compared with longer intervals. These findings may lead to future AED analyses algorithms requiring minimal pre-DF interruptions of chest compressions.
AP024 Chest compression synchronized ventilation during CPR: Influence of a novel ventilator mode on gas exchange in a pig model Clemens Kill 1 , Wolfgang Dersch 1 , Oliver Hahn 1 , Christian Neuhaus 3 , Florian Dietz 2 , Robert Mahling 1 , Stefan Schwarz 1 , Hinnerk Wulf 1 , Pascal Wallot 1 1 Departement of Anesthesiology and Critical Care, Philipps-University, Marburg, Germany 2 Weinmann Geräte für Medizin GmbH+Co.KG, Hamburg, Germany 3 Institut für Automatisierungstechnik und Qualitätssicherung e.V., Heidelberg, Germany
Objective: Mechanical ventilation with an automated ventilator is recommended during CPR with secured airway.1,2 A novel ventilator mode named Chest Compression Synchronized Ventilation (CCSV) generates a pressure controlled ventilation triggered by each chest compression. We investigated the gas exchange and acid-base state under CCSV in a pig model.3 Methods: After approval by local authorities seven pigs were anaesthetized with endotracheal intubation and ventilated with room air. Ventricular fibrillation (VF) was induced. Following 3 min cardiac arrest 10 min continuous chest compressions (LUCAS device) and CCSV with a pressure controlled inspiration (pmax 60 mbar, tinsp 205 ms, FiO2 1.0) simultaneously with the start of each chest compression were performed. After 10 min CPR arterial and venous blood gas lab was drawn. Data were analyzed with Wilcoxon-test and are presented as median (25/75 percentiles). Results: After 10 min of CPR, arterial PO2 increased from baseline (FiO2 0.21) 91 (85/94) mmHg to 634 (115/693) mmHg (p=0.018), arterial PCO2 decreased from 40 (39/42) mmHg to 26 (18/29) mmHg (p=0.018), venous pH from 7.40 (7.38/7.42) to 7.35 (7.34/7.36) (p=0.034), venous PO2 from 40 (34/46) mmHg to 32 (24/34) mmHg (p=0.018), venous PCO2 was 49 (42/50) mmHg and 50 (44/52) mmHg (p=0.735). Conclusions: Chest Compression Synchronized Ventilation (CCSV) with pure oxygen provided an excellent oxygenation with low carbondioxide whereas venous blood gas values could be kept in normal range during 10 minutes CPR in this pig model.4 References: 1. Yannopoulos D, Matsuura T, McKnite S, Goodman N, Idris A, Tang W, Aufderheide TP, Lurie KG. Crit Care Med. 2010;38:254–60. 2. Dorph E, Wik L, Steen PA. Resuscitation 2004;61:23–7. 3. Kill C, Torossian A, Freisburger C, Dworok S, Massmann M, Nohl T, Henning R, Wallot P, Gockel A, Steinfeldt T, Graf J, Eberhart L, Wulf H: Resuscitation 2009;80: 1060. 4. Oranto JPM, Bryson BLM, Donovan PJM, Farquharson RRM, Jaeger CR. Critical Care Medicine 1983;11:79–82.
Objective: Mechanical ventilation with an automated ventilator is recommended during CPR with secured airway.1,2 We investigated the influence of the novel ventilator mode Chest Compression Synchronized Ventilation (CCSV), a pressure controlled ventilation triggered by each chest compression, on haemodynamics in a pig model.3 Methods: After approval by local authorities seven pigs were anaesthetized, intubated, instrumented and ventricular fibrillation (VF) was induced. After 3 min cardiac arrest 10 min continuous chest compressions (LUCAS device) with CCSV followed, applying a pressure controlled inspiration (pmax 60 mbar, tinsp 205 ms, 100% O2 ) simultaneously with each chest compression. After 10 min ALS (up to six defibrillations, vasopressors) was started. At the timepoints of 13 and 17 min invasive blood pressures were measured with and without CCSV. Data were analyzed with Wilcoxon-test and are presented as median (25/75 percentiles). Results: Baseline before cardiac arrest were: Mean arterial pressure (MAP) = 60.4 (59.6/94.4) mmHg and MAP-central venous pressure (MAP-CVP) = 53.0 (52.3/88.5) mmHg. Results at t=13 min (after 10 min BLS) with and without CCSV were: MAP = 32.7 (30.4/33.4) vs. 27.0 (24.5/27.7) mmHg (p=0.018), MAP-CVP = 11.6 (9.9/14.1) vs. 10.4 (9.1/12.9) mmHg (p=0.499). Two pigs achieved return of spontaneous circulation (ROSC) before administration of epinephrine, results at t=17 min (after 1 mg epinephrine iv, n=5 pigs) with and without CCSV: MAP = 61.8 (58.3/67.9) vs. 47.8 (46.6/48.9) mmHg (p=0.08) and MAP-CVP = 40.0 (37.6/45.4) vs. 32.0 (30.6/32.8) (p=0.255). ROSC could be achieved in 4/7 animals. Conclusions: Chest Compression Synchronized Ventilation (CCSV) leads to higher mean arterial pressure during CPR, associated with a trend to increased coronary perfusion pressure. References: 1. Deakin CD, Nolan JP, Soar J, Sunde K, Koster RW, Smith GB, Perkins GD: European Resuscitation Council Guidelines for Resuscitation 2010 section 4. Adult advanced Life Support. Resuscitation 2010;81:1305–52. 2. Yannopoulos D, Matsuura T, McKnite S, Goodman N, Idris A, Tang W, Aufderheide TP, Lurie KG. Crit Care Med. 2010;38: 254–60. 3. Kill C, Torossian A, Freisburger C, Dworok S, Massmann M, Nohl T, Henning R, Wallot P, Gockel A, Steinfeldt T, Graf J, Eberhart L, Wulf H: Resuscitation 2009;80: 1060.
AP026 Key performance indicators for non-traumatic cardiac arrest. Can stickers improve documentation in pre-hospital cardiac arrest? Adam Chesters 1 , Anne Weaver 2 , Gareth Grier 3 , Christopher King 3 , Sophie Jefferys 3 1
London’s Air Ambulance, London, UK Essex and Herts Air Ambulance Trust, Essex, UK 3 The Royal London Hospital, London, UK 4 University of Cambridge, Cambridge, UK 2
Essex and Herts Air Ambulance Trust (EHAAT) is a charity that provides two helicopter-based doctor-paramedic pre-hospital care teams to provide support to land ambulance crews and additional medical skills and interventions as required in the two counties. Non-traumatic cardiac arrest (NTCA) forms a large part of our medical case load. Between 2008 and 2009, EHAAT pre-hospital care teams were tasked to around 100 NTCAs. The team carries specialist equipment to improve the quality of cardiopulmonary resuscitation (CPR). Clinical notes for all patients seen by the team are recorded on a patient report form (PRF), a generic A4 pro forma document. In May 2010, EHAAT introduced an adhesive sticker listing interventions for NTCA grouped into a series of key performance indicators (KPI) that are evidence-based and should be achieved for all patients in NTCA treated by the team. The EHAAT audit standard is that a sticker is placed on all PRFs relating to NTCA, and that all KPIs are met. The overall aims were to improve, clarify and standardise documentation in addition to providing an aide memoire for the package of interventions provided on scene. Following this change, we performed a retrospective audit and applied the KPIs to the PRFs of all NTCAs since the inception of our doctor-paramedic service. We proposed that the introduction of stickers improved the documentation of pre-hospital management of these patients. Prior to the introduction of the stickers, 56% of interventions that later became service pre-ROSC KPIs were documented as complete and 54.4% of interventions that later became service post-ROSC KPIs were documented as complete. Since