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Guidelines:ILCOR
Resuscitation
Guidelines
CliftonW.Callaway,MD,PhD
UniversityofPittsburgh
Pittsburgh,PA,USA
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InternationalLiaisonCommitteeon
Resuscitation(ILCOR)
AmericanHeartAssociation(AHA)
EuropeanResuscitation
Council
(ERC)
HeartandStrokeFoundationofCanada(HSFC)
AustralianandNewZealandCommitteeon
Resuscitation(ANZCOR)
ResuscitationCouncilsofSouthernAfrica(RCSA)
Inter
American
Heart
Foundation
(IAHF) ResuscitationCouncilofAsia(RCA)
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Consensuson
Science
Process
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CoSTRProcess
ILCORTaskForces GenerateQuestions
RefineQuestions
RecruitWorksheet
Authors
AssignQuestionstoAuthors
WorksheetAuthors SearchLiterature
RateLevels
of
Evidence
(LOE)
PreliminaryRecommendations
ILCORTaskForces Finalizeworksheets
Synthesizeinto
Consensus
on
Science
and
TreatmentRecommendations(CoSTR)
IndividualResuscitationCouncils RegionalGuidelinesbasedonCoSTR
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CoSTRProcess
ILCORTaskForces GenerateQuestions
RefineQuestions
RecruitWorksheet
Authors
AssignQuestionstoAuthors
WorksheetAuthors SearchLiterature
RateLevels
of
Evidence
(LOE)
PreliminaryRecommendations
ILCORTaskForces Finalizeworksheets
Synthesizeinto
Consensus
on
Science
and
TreatmentRecommendations(CoSTR)
IndividualResuscitationCouncils RegionalGuidelinesbasedonCoSTR
BasicLifeSupport(BLS)
AdvanceLifeSupport
(ALS)
PediatricLifeSupport
(PED)
NeonatalLife
Support
AcuteCoronary
Syndrome(ACS)
Education,
Implementationand
Teams(EIT)
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Whois
on
aTask
Force?
Volunteers
Selectedby
each
council
Expertsinfield
Willing
to
represent
the
council
in
ILCOR Committedtoparticipationinwholeprocess
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CoSTRProcess
ILCORTaskForces GenerateQuestions
RefineQuestions
Recruit
Worksheet
Authors
AssignQuestionstoAuthors
WorksheetAuthors SearchLiterature
RateLevels
of
Evidence
(LOE)
PreliminaryRecommendations
ILCORTaskForces Finalizeworksheets
Synthesizeinto
Consensus
on
Science
and
TreatmentRecommendations(CoSTR)
IndividualResuscitationCouncils RegionalGuidelinesbasedonCoSTR
Reviewedresearch
Gaps identified
duringprevious
Guidelinesprocess
EvidenceMapping
fromfromprevious
guidelines
Discussionofissues
raisedbyeachcouncil
Generatealistoftopics
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GenerateList
of
Questions
DiscussionofNew
Literature
QuestionsaboutPrior
Guidelines
ListofTopicsand
Questions
Gapsidentified
in
prior
cycleofevidencereview
KnowledgeMapping
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Questionsin
PICO Format
Population/Patient Adultpatientswithoutofhospitalcardiacarrest
Intervention Vasopressin
Comparison
Epinephrine Outcome
Survivaltohospitaldischarge
Inadult
patients
with
out
of
hospital
cardiac
arrest,
doestheuseofvasopressincomparedtoepinephrineincreasesurvivaltohospitaldischarge?
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CoSTRProcess
ILCORTaskForces GenerateQuestions
RefineQuestions
Recruit
Worksheet
Authors
AssignQuestionstoAuthors
WorksheetAuthors SearchLiterature
RateLevels
of
Evidence
(LOE)
PreliminaryRecommendations
ILCORTaskForces Finalizeworksheets
Synthesizeinto
Consensus
on
Science
and
TreatmentRecommendations(CoSTR)
IndividualResuscitationCouncils RegionalGuidelinesbasedonCoSTR
Expertsinthefield
Recommendedby
TaskForce
Callforreferrals
fromSpecialty
Organizations
VolunteerstoWebsite
Task
Force
reviewed
CV
andqualifications
ConflictsofInterest!
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Conflictsof
Interest
(COI)
TwoCOICoChairsassignedtooverseeCOIprocess
Everyparticipant
completed
an
AHA
COI
form
AHAStaffmadecertainallparticipantshadcompletedformspriortoanymeetingsorassignments
802COIFormscollectedandreviewed
TaskForce
co
chairs
were
required
to
be
free
of
major
COI
in
thetopicareaoftheTaskForce
TaskForcecochairsreviewedallCOIforms
Reassignedtopics
to
new
authors
when
there
was
any
perceivedCOI
WorksheetshadanadditionalspacetodiscloseCOI
No
Worksheet
could
be
accepted
without
COI
disclosure
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Managementof
COI
yCOIinformationpostedwithworksheetson
website
y Industryemployeesexcluded
yNo
industry
support
accepted
for
C2005
or
C2010
yCOIprintedinC2010programandfinalGuidelines
publication
yCOIquestionnairescompletedbyallparticipants
(802collectedandreviewed)
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ManagementofCOI
COIforeachspeakerprojectedduringmeetings
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CoSTRProcess
ILCORTaskForces GenerateQuestions
RefineQuestions
Recruit
Worksheet
Authors
AssignQuestionstoAuthors
WorksheetAuthors SearchLiterature
Rate
Levels
of
Evidence
(LOE)
PreliminaryRecommendations
ILCORTaskForces Finalizeworksheets
Synthesizeinto
Consensus
on
Science
and
TreatmentRecommendations(CoSTR)
IndividualResuscitationCouncils RegionalGuidelinesbasedonCoSTR
Worksheets!
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Worksheet
StatementofQuestion
Assignedto
Worksheet
Author
LiteratureSearchStrategyandResults
Author
generates
Worksheetexpertreviewsandapproves
SummaryofEvidenceTable
UseILCOR
Levels
of
Evidence 1
5
CommentsandSummaryofEvidence
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Reproducibleand
Comprehensive
Search
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Levelsof
Evidence
(LOE)
Directlyaddressesquestion?
Hasitsowncontrolgroup?
Usesconcurrentcontrols?
Usestrue
randomization?
LOE5
LOE4
LOE3
LOE2
LOE1
No
Yes
Yes
Yes
Yes
No
No
No
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CoSTRProcess
ILCORTaskForces GenerateQuestions
RefineQuestions
Recruit
Worksheet
Authors AssignQuestionstoAuthors
WorksheetAuthors SearchLiterature
Rate
Levels
of
Evidence
(LOE)
PreliminaryRecommendations
ILCORTaskForces Finalizeworksheets
Synthesizeinto
Consensus
on
Science
and
TreatmentRecommendations(CoSTR)
IndividualResuscitationCouncils RegionalGuidelinesbasedonCoSTR
Meetings
Webinarsand
ConferenceCalls
2010
Consensus
Conference
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ILCORTask
Force
Meetings
2TFChairsMembersandWorksheet
AuthorsfromeachCouncil
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EvidenceEvaluationProcess
411scientificevidencereviews
on277topics
PostedonInternetforPublic
Comment
Presentedeachoneinaseriesofin
personmeetings,
webinars
or
teleconferences
Writinggroupmembersvotedon
eachrecommendation
ParticipantswithanyCOIabstained
WordsmithTreatment
Recommendationsatthistime
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2010ConsensusConference
(February2010)
313participantsat2010ConsensusConference
Invitedexperts,stakeholdersandsociety
representatives
FinalizedConsensusonScienceandTreatment
Recommendations
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CoSTRProcess
ILCORTaskForces GenerateQuestions
RefineQuestions
Recruit
Worksheet
Authors AssignQuestionstoAuthors
WorksheetAuthors SearchLiterature
RateLevels
of
Evidence
(LOE)
PreliminaryRecommendations
ILCORTaskForces Finalizeworksheets
Synthesize
into
Consensus
on
Science
and
TreatmentRecommendations(CoSTR)
IndividualResuscitationCouncils RegionalGuidelinesbasedonCoSTR
PublishinResuscitation
andCirculation
AfterPeer
Review
November2010
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CoSTRProcess
ILCORTaskForces GenerateQuestions
RefineQuestions
Recruit
Worksheet
Authors AssignQuestionstoAuthors
WorksheetAuthors SearchLiterature
RateLevels
of
Evidence
(LOE)
PreliminaryRecommendations
ILCORTaskForces Finalizeworksheets
Synthesize
into
Consensus
on
Science
and
TreatmentRecommendations(CoSTR)
IndividualResuscitationCouncils RegionalGuidelinesbasedonCoSTR
Guidelinesin
October
2010
Educationalproducts
andcourses(ACLS,
PALSappear
Mid
2011)
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IndividualCouncils
Write
Guidelines
Specificrecommendationsvarybetween
regionsbecause
of
Localdrugordeviceavailability
Differentinterpretationofdata
DecisionsabouttopicswithInsufficient
evidencetorecommendfororagainst
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Whatwill
we
change
for
2015?
StreamlineLiteratureSearch
2010:Worksheet
Author
performs
search
2015:Professionallibrarians
ReplaceLevelsofEvidencesystem
2010:ILCORGrades15
2015:
GRADE
System
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Search Select
Articles
Rate
Features
of
Articles
WriteProse
Summary
Build
Tables
WriteCoSTR
Worksheet
Authors TaskForce
TaskForce
/Experts2010
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Search Select
Articles
Rate
Features
of
Articles
WriteProse
Summary
Build
Tables
WriteCoSTR
Librarian(s) WorksheetAuthors TaskForce
Worksheet
Authors TaskForce
TaskForce
/Experts2010
2015
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GradingofRecommendations
Assessment,Development
and
Evaluation(GRADE)
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TheGRADE
system
classifies
evidence
into
one
offourqualitygrades
GRADE DEFINITIONHigh Further research is very unlikely to change ourconfidence in the estimate of effect.Moderate{
Further research is likely to have an important impact onour confidence in the estimate of effect and may changethe estimate.Low{{
Further research is very likely to have an importantimpact on our confidence in the estimate of effect and islikely to change the estimate.Very Low{{{
Any estimate of effect is very uncertain.
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GRADEapproachtostudiesandtrials
Randomizedcontrolled
trials
without
importantlimitationsprovideHIGH qualityevidence
Observationalstudieswithoutspecial
strengths
provide
LOW quality
evidence
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GRADE
Evidence
Evaluation
Limitationsorspecialstrengthscanmodifythequalityoftheevidenceofboth
randomized
trials
and
observational
studies. Upgradealevel
Downgradealevel
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Levels
of
Evidence
in
GRADE
Randomized
Controlled
Trial
Observational
Study
HighSpecialStrengths
WeaknessesLow
High
Moderate
Low
VeryLow
{{
{{{
{
EvaluationofStudy
{{
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AlgorithmstoEvaluateEvidence
Table 5.GRADE profile for assessing quality of evidence for the randomized controlled trials
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Table 5.GRADE profile for assessing quality of evidence for the randomized controlled trials
Quality assessment
No. of
studiesDesign Limitations Inconsistency Indirectness Imprecision
Other
considerations
Mortality (follow-up 6 months)
2Randomised
trialsSerious1
No serious
inconsistencySerious2 Serious3 None
Neurological outcome (follow-up 6 months)
1Randomised
trialsSerious4
No serious
inconsistencySerious5 Serious6 None
Summary of findings
ImportanceNo. of patients Effect
QualityTherapeutic
hypothermiaControl
Relative
(95%CI)Absolute
17/22
(77.3%)
20/22
(90.9%)
RR 0.85
(0.65 to1.12)
136 fewer
per 1000
(from 318fewer to
109 more)
VERY
LOW
CRITICAL
14/16
(87.5%)
17/17
(100%)
RR 0.88
(0.71 to
1.08)
120 fewer
per 1000
(from 290
fewer to
80 more)
VERY
LOW
CRITICAL
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Conclusion SystematicProcess
Involveslarge
number
of
stakeholders
ProactivelymanagesConflictsofInterest
Emphasizestransparency
PersonnelIntensive
Worksheetauthorsspecificallydisadvantaged
becausetheymustlearnprocessononeortwo
worksheets Staffandtaskforcesmustmonitormanymoving
parts
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Conclusion Thisprocessiscoupledwithastrong
knowledgedissemination
machine
AHATrained~55MillionpeopleinCPRandFirst
Aid
ACLSis
taught
to
12million
providers
in
the
UnitedStates
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Questions?