SCCM Resource Library-40-Novel Strategy for Identifying an Optimal Bundle of Management for Sudden Cardiac Arrest

Video Transcription

Hello, I'm Paul Pepe, and I'm here to present abstract number 40, a novel strategy for identifying an optimal bundle of management for sudden cardiac arrest.  I mean, to be frank, I think this presentation is a little bit anticlimactic and many of you out there already understand this concept and also have been well ahead of me in terms  of this experience. But nevertheless, I want to basically present and at least announce that there was the effort  over the last three years of several dozen resuscitation scientists and EMS leaders from around the globe to produce the work that I'm about to present to you.  Actually, after we had submitted this abstract, we did have an article published already about this in Critical Care Explorations. Great.  Really appreciate the editors actually in helping us get this thing through and out. A lot of information there, lots of appendices, so I'll be truly trivializing things with  this presentation. But I do want to do it more of a narrative than a scientific presentation and give you a little bit of the background for this at least.  One of the things is that randomized controlled clinical trials have always been considered the gold standard evidence-based medicine.  I've been accused of being one of the greatest zealots for this over the years, and you can see here why that is.  But unfortunately, the problem has been that over the last four decades, numerous, if anything, most cardiac arrest clinical trials have been very, very disappointing.  These are various interventions that we were studying that work extremely well in the laboratory and yet we couldn't take it to the field.  So is it human versus a pig or whatever it may be, but it's much more than that. So why are the clinical trials so compromised in cardiac arrest?  Well, it's really straightforward to me. There are many, many interwoven, interdependent variables that go on. The techniques affect blood flow, CPR is affected by numerous factors.  For example, rate affects depth, depth affects rate. And of course, the ventilatory techniques are interwoven in that and affect the delays or interruptions.  So drugs or devices that don't work too late, yeah, straightforward, but interventions need at one point in time may not be needed at another point in time.  I think this is the most important point is that an individual device or intervention effectiveness requires other coordinator interventions at the same time.  And they are not only just additive, they may be synergistic and we've begun to understand how important that effect is and therefore the bundle that we're talking about today.  I just wanted to give like one example and that's the trial of the penis threshold device. I don't think you need to know what it does, except that if something is attached to the  airway, it helps with a better flow out of the brain and into the chest. And in 2011, the NIH launched its New England journals publication that was an elegant study  with impressive design. I mean, everybody got an ITD, for example, but half of them were inactivated and just didn't know which ones were the sham valves.  But the study didn't show any distinct advantages in survival. And it was really disappointing because it worked so well, I've used it in laboratory  settings myself or even in some clinical settings and just totally surprised by the outcome. So why the discrepancy?  Well, this is where we really started learning that there are things like quality of CPR  that can be an important effect modifier or some other things like death by hyperventilation, as we've called it in some publications.  And it just, let's go back to the quality of CPR. One of the things we found was that 10 years ago, when they were changing some of the standards,  we wanted to see if that had an effect on things. Well, we applied this to the perspective data set that were being collected for this ITD.  And what you see on over on the left is the sham ITD. And you can see in that circular area in green, which is about a 6% chance of patients, basically  the proportion of patients that are going to be going home neurologically intact are in that so-called sweet spot.  The interesting thing though, is that sweet spot still exists for the active ITD. But if you had that thing on, it actually doubles the survival.  You get this hot zone in the center, but it's gotta be really dead center. Turned out in this study, 80% of people didn't even get what I would call quality CPR, let  alone this optimal target that we were looking at. So it means that quality of CPR and other factors are just really important.  And by the way, if you add in other devices, for example, to the ITD, it not only is additive in effect, but it's really synergistic.  And particularly if you're loading in some other things like head up CPR and done at a very sequential manner.  Well, anyways, so the point is, is that the truth is really pure and never simple. It's not a binary equation that something works or doesn't work. It's not simply good or bad.  It's basically how you use it and how it's used with other interventions going on at the same time. And there are probably dozens going on at the same time in cardiac arrest.  So is there any alternative to the single intervention RCT in sudden cardiac arrest after a quarter century of frustration?  Well, many of you in critical care have been way ahead of us on this in terms of looking at bundles of care in your own settings.  The classic experimental concept, though, I thought about, I just remember that my teachers in the laboratory, when I was excited that I'd gotten a successful experiment done, and  they would very wisely look at me and said, it's not a success yet. And he said, why is that? And they said, because you have to be able to reproduce the results.  And so you have to be able to communicate this to others. You need to be able to have definitions and you have to be able to reproduce it in another  laboratory and get the same results. And if you don't, then you've got to figure out why. So it became an interesting thing.  Maybe we can reproduce the results in other laboratories. So the purpose of this analysis was to alternatively construct a highly detailed yet practical  attainable roadmap for enhancing the likelihood of improved outcomes, neurologically intact. Well, how do we do it?  We got together. We tried to look through the literature to include, and we did include 10 EMS systems  we had found geographically different, demographically different, but we had found them that had  independently reported truly significant improvements in neuro intact survival after introducing various new elements using this comprehensive bundled system of care approach.  And elements commonly reported in the respective cardiac arrest bundles included evolving strategies  for innovative technologies, but not just in the hospitals or at the EMS level, but even with the public.  And more importantly, it was highly choreographed streetwise tactics and pragmatic training methods that really made a difference.  Making sure that you get a device on in literally four or five seconds and not 30 seconds or a minute.  There were high levels of coordination with the public, the dispatchers, the public safety personnel, the hospitals, the whole thing.  So we took detailed inventories of incommon elements that were collated from the EMS tenant and assimilated by this team, what we call the international resuscitation collaborative.  And we created a modified Delphi approach and came up with what we thought were the elements that were maybe things we should try to reproduce.  And just to give some reference and validate the effectiveness of this is that we looked at one year outcomes and compared it to the concurrent nationwide outcomes reported by  the well-established and very highly respected CARES registry, which is a real robust international  database that is used in the most high performing EMS systems in the US and abroad. So what are the results?  Well, the results were that compared with the CARES data, the EMS 10 demonstrated significantly  increased likelihoods of not only return to spontaneous circulation, getting the pulses back, et cetera, but also neurologically favorable hospital discharge.  And particularly after witness collapses involving bystander CPR and a shockable cardiac rhythms. I mean, significant, very significant differences.  And that just was to put this in kind of into context to some extent. But more importantly, I think what was happening was that we found that based on clear commonalities  the similarity from the 10 independent high functioning EMS systems improvements in neurologically  and favorable survival following out of hospital cardiac arrest can likely be very reproducible.  And these results can be improved substantially in other communities that conscientiously  introduced this well-sequenced, highly choreographed system-wide portfolios of traditional and  non-conventional approaches to training technologies and choreography, and most importantly, physiological management augmented by technology.  And we've already seen it starting to work. Once again, I'm Paul Pepe and I approve this message, but thank you very, very much, everyone  for what you do on a day-to-day basis and what you've been through this past year. Just our heart goes out to everyone. Thank you very much.

Video Summary

In this presentation, Paul Pepe discusses a novel strategy for identifying the optimal management bundle for sudden cardiac arrest. He highlights the challenges of conducting clinical trials in this field due to the complex nature of the interventions and the interdependent variables involved. Pepe explains the importance of coordinated interventions and the synergistic effects they can have. He shares findings from a study that analyzed 10 EMS systems and their use of bundled care approaches, which resulted in significantly improved outcomes for patients. Pepe suggests that reproducing these results in other communities could lead to substantial improvements in cardiac arrest survival rates.

Asset Subtitle

Resuscitation, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Paul E. Pepe

Introduction/Hypothesis: With the challenges posed by traditional clinical trial methods, the purpose of this analysis was to alternatively construct a highly-detailed yet practical, attainable roadmap for enhancing the likelihood of neurologically-intact survival following sudden cardiac arrest.

Methods: Population-based outcomes following out-of-hospital cardiac arrest (OHCA) were collated for ten demographically/geographically-diverse U.S. 9-1-1 EMS systems (EMS-10) that had recently reported significant improvements in neuro-intact survival after introducing a comprehensive bundled system of care including evolving strategies for incorporating innovative technologies, highly-choreographed, street-wise tactics and pragmatic training methods for EMS, hospitals and the public at large. Detailed inventories of in-common elements were collated from the EMS-10 and assimilated. For reference, combined 1-year outcomes for OHCA from the EMS-10 were compared to concurrent U.S. outcomes reported by the well-established Cardiac Arrest Registry to Enhance Survival (CARES).

Results: Compared with CARES (n=78,704), EMS-10 cohorts (n=2,911) demonstrated significantly-increased likelihoods of return of spontaneous circulation (mean 37.4% vs. 31.5%; p<0.001) and neurologically-favorable hospital discharge, particularly after witnessed collapses involving bystander CPR and shockable cardiac rhythms (mean 10.7% vs. 8.4%; p<0.001; and 41.6% vs. 29.2%; p<0.001, respectively). In-common elements were: population-wide CPR training, 9-1-1 system-connected smart phone applications, expedited dispatcher procedures, CPR quality monitoring, mechanical CPR, devices for enhancing negative intrathoracic pressure regulation, extracorporeal membrane oxygenation protocols, body temperature management, rapid cardiac angiography and intensive involvement of medical directors, operational and quality assurance officers and training staff.

Conclusions: Based on clear commonalities assimilated from 10 highly-functioning EMS systems, the likelihood of neurologically-favorable survival following OHCA will likely be improved substantially in other communities that conscientiously introduce well-sequenced, highly-choreographed, system-wide portfolios of both traditional and non-conventional approaches to training, technologies and physiological management.

Meta Tag

Content Type Presentation

Knowledge Area Resuscitation

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Cardiac Arrest

Year 2021

Keywords

Paul Pepe

optimal management bundle

sudden cardiac arrest

clinical trials

coordinated interventions

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