Delphi Approach Meaning

[Eunice Beady]

Maternalcardiac arrest is a rare and complex process requiring pregnancy-specific responses and techniques. The goals of this study were to (1) identify, evaluate, and determine the most current best practices to treat this patient population and (2) establish a standardized set of guidelines to serve as a foundation for a future educational simulation-based curriculum.

We used a three-step modified Delphi process to achieve consensus. Twenty-two healthcare experts from across North America agreed to participate in the expert panel. In round 1, 12 pregnancy-specific best practice statements were distributed to the expert panel. Panelists anonymously ranked these using a 7-point Likert scale and provided feedback. Round 2 consisted of a face-to-face consensus meeting where statements that had not already achieved consensus were discussed and then subsequently voted upon by the panelists.

Through two rounds, we achieved consensus on nine evidence-based pregnancy-specific techniques to optimize response to maternal cardiac arrest. Round one resulted in one of the 12 best practice statements achieving consensus. Round two resulted in six of the remaining 12 gaining consensus. Best practice techniques involved use of point-of care ultrasound, resuscitative cesarean delivery, cardiopulmonary resuscitation techniques, and the use of extracorporeal cardiopulmonary resuscitation.

The results of this study provide the foundation to develop an optimal, long-term strategy to treat cardiac arrest in pregnancy. We propose these nine priorities for standard practice, curricula, and guidelines to treat maternal cardiac arrest and hope they serve as a foundation for a future educational curriculum.

Maternal cardiac arrest (MCA) is the final common pathway for many critical illnesses and comorbidities, however, anatomic and physiologic changes specific to pregnancy and the presence of a fetus create a very different situation as compared to non-pregnant patients. Therefore, pregnant patients who suffer cardiac arrest require a modified and multidisciplinary approach to maximize their survival and ensure optimal outcomes for the fetus. Rates of maternal mortality in the United States are increasing [1], and too many women are dying from pregnancy-related complications [2]. Research suggests that 60 % of these deaths are preventable [3], affording a meaningful opportunity to address these devastating outcomes.

Collectively, cardiovascular conditions, cardiomyopathy, and stroke accounted for more than 30% of pregnancy-related deaths from 2011 to 2016 [4]. Although cardiac arrest during delivery is rare [5], the incidence of this clinically challenging scenario may be increasing [4, 6, 7].

Recognizing this practical deficit, the core investigators (A.S, J.B, B.T, P.N.) identified critical gaps in treatment since the publication of the AHA statement, developed a consensus on treatment priorities, and created a foundation for a future simulation-based curriculum to train providers to treat maternal cardiac arrest successfully. The AHA have subsequently updated their guidelines in 2020, and ILCOR updated their guidelines in 2021. While the AHA guidelines do specifically address MCA resuscitation, ILCOR did not. Table 1 highlights several key similarities and differences between the 2020 AHA and 2022 OBLS guidelines.

We contacted specialists in) the prehospital arena (paramedics, flight nursing, and EMS medical director), anesthesia, emergency medicine, obstetrics/gynecology, maternal-fetal-medicine, family medicine, neonatology, pulmonary critical care, nursing, certified nurse midwifery and cardiology. We invited subject matter experts in these fields as we felt these fields were most likely to come into contact with a patient in MCA. We invited them to join the panel based on their leadership positions on national committees/panels, or publications in related subject matter. Of the 25 experts invited; 22 individuals agreed to serve as panelists. Of those, almost half are women (42%), nearly half actively treat pregnant patients (46%), nearly a fifth represent those who provide out-of-hospital care (19%), and more than half (54%) represent in-hospital sectors.

After reviewing the literature, internal investigator assessments, and expert assessment of the AHA statement, we developed and assigned a class of recommendation and level of evidence [13] to 12 pregnancy-specific resuscitation techniques for expert consideration. We categorized these into four themes: (1) resuscitative cesarean delivery, (2) point-of-care ultrasound, (3) extracorporeal cardiopulmonary resuscitation, and (4) targeted temperature management. We then performed two modified Delphi rounds to gain consensus on relevant pregnancy-specific technique statements.

Techniques that met preset criteria advanced to final affirmation. Via REDCap, participants individually and anonymously voted to include the pregnancy-specific resuscitation technique in the final overall curriculum priorities.

Rating the acceptability, usability, and feasibility of the AHA statement, experts scored stakeholder involvement level low (58%) and clarity of presentation high (90%). They ranked the other four domains (scope and purpose, rigor of development, applicability, and editorial independence) greater than 72%. Reviewer comments for suggested modifications were collected and summarized into several common themes listed in Table 5.

Following the second round, nine of the 11 techniques met the predetermined rank for affirmation (> 4). Following participant discussion, experts scored three of these lower than they had in the first round. Investigators removed these methods from further consideration.

We obtained consensus among a diverse stakeholder group of experts regarding the most current evidence-based techniques to treat maternal cardiac arrest successfully. Experts agreed on themes related to resuscitative cesarean delivery, point-of-care ultrasound, extracorporeal cardiopulmonary resuscitation, and targeted temperature management. We hope that clinicians will incorporate these critical techniques to treat maternal cardiac arrest into future simulation-based education. (Table 7).

Our decision to use anonymous voting was to limit bias. However, because we chose not to link answers to specific individuals, we were unable to calculate analytic statistics of individual member responses during the consensus rounds. Although we chose experts to represent diverse expertise and backgrounds, they may not adequately represent the full spectrum of views.

One other possible limitation is the rare nature of the topic of MCA. While best practice statements were based on a robust literature search it was primarily low-level evidence papers, which included multiple case reports and studies.. Future metrics to determine the validity of the best practices will also most likely rely heavily on simulation data due to the overall low volume of MCA. Low volume aside, there is still great benefit to assembling these best practices, as research has also shown significantly improved maternal response to resuscitation in MCA, particularly when they are applied promptly and aggressively.

The results of this study provide the foundation to develop an optimal, long-term strategy to treat cardiac arrest in pregnancy through simulation-based training. We propose these nine priorities for standard practice, curricula, and guidelines to treat maternal cardiac arrest and hope they serve as a foundation for a future educational curriculum.

Delivery of the fetus early in a maternal cardiac arrest following the absence of ROSC results in a high probability of ROSC in the pregnant patient, more than 50% in some studies, by improving maternal cardiac output through the reduction of aortocaval compression, and the resultant autotransfusion from the decompressed uterus [14, 15]. A recent study of 462 women with maternal cardiac arrest found that only 11.2% presented with a shockable rhythm [16, 17]. This highlights the need for simultaneous RCD preparations with ongoing cardiopulmonary resuscitation (CPR) efforts, and immediate performance of an RCD if the maternal cardiac rhythm is non-shockable and the uterus is at or above the umbilicus, regardless of gestational age or the presence of fetal cardiac activity.

Inherent in our recommendations is the recognition that medical professionals staffing emergency departments and hospitals who do not provide obstetric care need to have the capability to perform a resuscitative cesarean delivery to improve maternal survival within the 5 min window from arrest (if in-hospital) or at the time of admission to the Emergency Department if the maternal cardiac arrest occurred out-of-hospital. It is imperative that physicians in all fields that staff emergency departments learn the proper techniques of resuscitative cesarean delivery through proctored clinical experience and maintain clinical competency via simulation [18,19,20].

Consider ECPR to manage maternal cardiac arrest when there is no ROSC after RCD or for refractory CPR where the uterus has not yet reached the umbilicus and the patient is in an extracorporeal membrane oxygenation center with the capacity to care for critically ill pregnant patients (Class IIa; Level of Evidence C).

Extracorporeal cardiopulmonary resuscitation (ECPR) has emerged as a beneficial intervention when sustained ROSC is not achieved. ECPR maintains organ perfusion while the underlying etiology of the cardiac arrest is determined and treated. As of 2018, we identified 36 cases of ECPR use in maternal cardiac arrest, with many cases resulting in maternal survival [18, 19, 18,19,21,22,23]. ECPR has been used for a variety of etiologies in maternal cardiac arrest including massive pulmonary embolism, severe cardiomyopathy/cardiac disease, amniotic fluid embolism, sepsis, and postpartum hemorrhage in which CPR failed to result in sustained ROSC [19, 24,25,26,27,28]. Although ECPR has been applied at a variety of gestational ages, it is generally applied after RCD in the second half of pregnancy [24]. When ECPR has been applied in the setting of maternal cardiac arrest without ROSC, survival rates to discharge have been reported as high as 77% of women and 67% of fetuses [21]. These rates compare very favorably to a recently published overall maternal survival rate to discharge of 40.7% after cardiac arrest [17].

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