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Automated External Defibrillators
Bill Meltzer
Publish Date: October 10, 2007

As the nurse checked in on the elderly female patient awaiting a consultation in the Houma, La., office of oral and maxillofacial surgeon Christopher Saal, MD, DDS, she saw the patient slumped over in the chair.

"Sleeping on me in there?" asked the nurse.

When the patient didn't respond, the nurse investigated and found a woman in cardiac arrest, specifically ventricular fibrillation. Even by emergency-response standards, the situation was dire. "Not that there's ever a good day for a patient emergency, but ours happened minutes after a power outage," recalls Dr. Saal. While assistants called for emergency crews on cell phones, Dr. Saal laid the patient on the floor and began mouth-to-mouth resuscitation. A nurse retrieved an automated external defibrillator (AED) and attached the leads to the patient. Dr. Saal administered two shocks. The second restored the patient's heartbeat. Paramedics arrived and transferred the patient to the hospital.

Access Cardio Solutions
Access AED
(866) 238-3631
www.accesscardiosystems.com
List price: $1,795 (includes extra battery, extra electrodes, resuscitation supplies and a carrying case)
Key features: Escalating energy (200J, 360J) with impedance compensation; integrated electrodes; only two buttons (on-off and shock buttons) lightweight and portable

Cardiac Science, Inc.
Powerheart G3 AED
(949) 797-3800
www.cardiacscience.com
List price: Not provided
Key features: Variable, escalating energy waveform (105J to 360J) customized to compensate for impedance; one-button operation and pre-connected, non-polarized electrodes; programmable to meet facility protocols; monitors during CPR

Defibtech
Reviver AED (sold in conjunction with Cintas)
(866) DEFIB-4-U (333-4248)
www.defibtech.com
List price: $1,495
Key features: Automatically adjusts the shock delivery to the person's individual needs; so simple and unintimidating to use that even non-medical personnel can effectively save lives, says the company; low cost

Equipment you never want to use
Defibrillators, of course, are a necessary capital equipment expense in every surgical setting. Even facilities that primarily do conscious sedation procedures or minimally invasive surgery with healthy patients are required to have emergency equipment available for their patients.

The ASA's Guidelines for Sedation and Analgesia by Non-Anesthesiologists say that a defibrillator should be available immediately for all patients during deep sedation procedures. During moderate sedation, a defibrillator should be available immediately even for patients with mild cardiovascular disease (hypertension, for example) as well as those with more severe conditions, such as ischemia or congestive failure.

You should "approach buying and maintaining the defibrillator the same as any other piece of equipment, taking into account clinical efficacy, user-friendliness, features and cost-efficiency for your practice's needs," says Dr. Saal. The one big difference, adds Harold Finkel, MD, a pediatric neurologist at the Michigan Institute for Neurological Disorders, is that "you hope you'll never actually have to use your defibrillator."

AED, manual or both?
Increasingly, outpatient surgical facilities find themselves deciding between AEDs, manual biphasic defibrillators or combinations thereof. Many manufacturers, such as Philips, offer both types as well as hybrid devices that are either AEDs with certain manual features or manual defibrillators with AED modes. Zoll, for instance, offers both an AED (the AED ) and M-Series, a combination manual and automated defibrillator, monitor and pacing device.

From a pure pricing standpoint, AEDs are the clear favorite over manual defibrillators, listing anywhere from about $1,500 for a no-frills automated shock box to about $4,000 for models designed to provide more substantial clinical information and allow greater user control of the waveform and energy delivered.

Manual defibrillators - most of which include an AED mode - typically have ECG monitoring capabilities and are designed for personnel comfortable with ACLS-level patient rescue. They list anywhere from about $7,500 to $30,000. The less expensive models incorporate ECG monitoring and display. The higher-end models incorporate many monitoring functions, including pulse oximetry, end-tidal CO2, invasive and non-invasive blood pressure, ECG and manual and automated defibrillation capabilities.

Medtronic Physio-Control Corp.
Lifepak20
(800) 442-1142
www.medtronicphysiocontrol.com
List price: Not provided
Key features: Designed for healthcare market; choice between pure AED and manual modes; offers both monitoring and therapeutic functions; intuitive controls; conducive to rapid response in manual or AED modes; small and portable; automatic self-test every 24 hours

Philips Medical
HeartStart MRx
(978) 687-1501
www.medical-philips.com
List price: $3,000
Key features: Waveform proven in peer-reviewed independent studies, according to the company; compact and portable; doesn't require field maintenance; intuitive controls

Welch Allyn
AED 20
(800) 535-6663
www.welchallyn.com
List price: $3,400 to $4,000
Key features: Offers user-control options, including variation of energy delivery; diagnostic-quality ECG waveform; monitoring feature - background and continuous analysis; rechargeable battery

Zoll Medical Corp.
AED
800-348-9011
www.zoll.com
List price: $1,895 (with package variations from $1,600 to $2,600)
Key features: 2nd generation "full rescue" AED designed to incorporate entire AHA chain of survival -prompts user through first two steps and includes "intelligent electrodes" and reports on depth of chest compressions during CPR; portable or wall-mountable

Chain Of Survival

The Joint Commission expects JCAHO-accredited facilities, including office-based facilities, to have defibrillation equipment available to patients to be able to meet the third step of The American Heart Association's "Chain of Survival." The steps:

' Early-care access. Your staff serves as the first response team. Call immediately for EMS support.

' Early CPR. Before defibrillation, begin mouth-to-mouth resuscitation and chest compressions.

' Early defibrillation. If you don't begin defibrillation within three minutes (one minute is ideal), the odds of patient survival drop rapidly, decreasing about 10 percent with each passing minute.

' Early advanced care. Your personnel, if ACLS trained, may be able to successfully administer cardiac drugs from the crash cart and insert an endotracheal tube. Regardless, the goal is to quickly transfer the successfully defibrillated patient to the paramedics for hospital admission.

- Bill Meltzer

Mayo clinic anesthesiologist John Abenstein, MD, says AEDs are a strong option in settings manned primarily by staff with BLS training but "do not necessarily produce a better diagnosis" than an advanced practitioner controlling a manual model. The trained clinician, he says, can recognize and treat types of arrhythmia other than ventricular fibrillation or asystole.

Ultimately, it comes down to the types of procedures a facility does and clinician preference, emergency-response experience and comfort. Dr. Finkel would prefer to hold to the "first do no harm" dictum and use an AED designed to help deliver the patient to more experienced rescuers. Dr. Saal prefers a higher-end AED that "takes away some of the decision-making pressure" but still lets him at least control the energy of the shock. He replaced a device at his facility that only let him administer a shock when and how the machine decided to deliver energy. Jay Klarsfeld, MD, an ENT surgeon and the president of Advanced Specialty Care in Danbury, Conn., still maintains a manual device in his center because "our anesthesiologist prefers it, and it feels more comfortable" taking full control in case of rescuing a patient in cardiac arrest.

Evaluating energy delivery
The waveform or clinical delivery of energy is one way defibrillator manufacturers differentiate themselves. Some point to studies showing the superiority of their waveform over competitors. "We now have a rather confused marketplace because energy protocols differ widely now, unlike in the past," says Jim Casella of Philips Medical. Not long ago, all devices delivered 200 Joules at the first shock, 300J on the second and 360J on the third.

A Take Home Defibrillator?

The Lifevest from Lifecor, Inc., is an external defibrillator that can be used to continuously monitor - and potentially defibrillate - at-risk patients after their surgery. More typically used after cardiac surgery, company spokesman John Katrouba says the device may also have outpatient surgery applications, such as for some bariatric surgery patients or those at heightened temporary risk of cardiac events. The device sells for between $35,000 and $40,000 and is typically covered by the patient's insurance, says the company.

- Bill Meltzer

When evaluating a device's energy delivery, keep several factors in mind, says David Barash, MD, the vice president and medical director of Access Cardio Solutions. These include elapsed time to first shock, impedance compensation performance (does the shock compensate for chest resistance?) and progressive energy on repeat shocks that limit the peak current. Buyers and manufacturers we talked to pointed to several other major decision-making factors.

  • Early response. This entails not only the time elapsed to analyze the patient and deliver the first shock, but also the ease of attaching the electrodes (which replace paddles in AEDs), convenience of storage (such as wall-mounting or portable, so you can place it on a crash cart), weight and portability and ease of use. For example, how many buttons does the device have? How easy is it to read the displays?
  • Ease of routine maintenance. Most devices perform an automatic self-test, eliminating the need for daily tests before the first case. Companies can help troubleshoot the devices, but the user's still responsible for battery upkeep and replacing the electrodes. Some devices offer a rechargeable battery. Another includes a tag that informs staff of the due date for changing the pad.
  • Customizability. Some facilities want more extensive memory cards to be able to review the event. Some want to upgrade the device software piece by piece, adding monitoring functions as they go along. Still others merely want the physician to be able to re-program the AED waveform or alarm functions.

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