Een reanimatie gaat over presteren onder druk, over leven en dood. Hoeveel stress geeft dit de eerste hulpverleners? En heeft dat effect op de daadwerkelijke (reanimatie) prestatie? Is er een verschil tussen mannen en vrouwen? Kun je beter fysiologische, biochemische of (zelf gerapporteerde) psychologische stress metingen doen? Een mooi en leerzaam artikel (1)en overzicht van de literatuur. Ik haal er 9 kleine punten uit. Advies: lees het hele stuk anders mis je de helft en de nuances.
1. Hoeveel stress geeft reanimeren?
“Different investigators documented considerable stress levels in response to CPR situations using different measures to quantify stress.”
En later:
“we have shown that resuscitators often experience stress during CPR on a biological and psychological level “
2. Hoe kun je het beste stress meten tijdens een reanimatie?
Hier wordt het interessant, let maar op:
“Taken together, it appears that subjective compared to biological stress parameters are more strongly associated with CPR performance. However, if perceived stress has a causal effect on performance or vice versa is largely left untested.”
En later in het artikel:
“By contrast, all studies except for two [46,47] found performance impairments associated with higher selfreported stress”
3. Zijn fysiologische stressmarkers valide?
Hoe meet je nu het beste stress tijdens bijvoorbeeld een fysieke activiteit als reanimeren? Hier wordt het leerzaam en verrassend:
- a higher heart rate showed conflicting results and was associated with both decreased [25] and enhanced resuscitation performance [24]. The mixed results concerning physiological markers such as heart rate indicate that physical activity during resuscitation may act as a possible confounder and is, therefore, not suitable as a stress marker.
En later:
- Self-reported stress showed the strongest association with performance, while physiological measures, such as heart rate, showed an inverse association with performance. This may be due to the physical activity, limiting its value as a mental stress marker in this acute setting [24].
- Third, mostly self-reported but not biological stress is associated with poorer performance [6-8,44,45].
- Biological measures may be unrelated to performance or be confounded by physical activity during CPR.
- Furthermore, biological measures may not differentiate between stressful and challenging situations, e.g. tense and energetic arousal. These considerations need further investigation.
4. Verband tussen biologische en psychologische stress markers?
Je zou verwachten dat alle wijzers de zelfde kant op zouden slaan maar dat is niet zo.
“Also, the different stress parameters were mostly uncorrelated [36], further strengthening the finding that stress parameters are not easily comparable [37,38].”
En later:
“However, it was also found that stress experienced in CPR does not always lead to performance impairments [44-47], and that self-reported stress and biological stress measures often do not coincide [36-38]”.
5. Stress en presteren
In het algemeen leidt teveel stress (zie de stress prestatie curve) tot verminderd presteren. vaak wordt er echter niet naar de echte prestatie gekeken maar naar indirecte maten als beleefde stress of cortisol waarden etc. Maar wat verslechterd er nu concreet tijdens een reanimatie t.g.v. teveel stress? Met andere woorden: hoe is stress gerelateerd aan bijvoorbeeld de kwaliteit van de reanimatie, time to start, hands on time enzovoorts? In het artikel vindt je een mooie overzichtstabel m.b.t. deze vraag.
6. Stress en presteren: mogelijke mechanismen
Tabel-2 biedt een mooi overzicht van verschillende prestatie domeinen van een reanimatie en de potentiele effecten van (teveel) stress. Bekijk de tabel eens rustig. Drie interessante bevindingen:
Effect van stress op geheugen
- Memory is enhanced for affect-laden aspects of the situation [65,66].
- Impairment of retrieval of previously learned information, especially information learned under non-stressful conditions retrieved under stress [63,64].
Effect van stress op leren
Hier worden een paar bekende maar nog steeds leerzame zaken besproken:
- Information acquired under stress can also be retrieved more easily under stress [43].
- Training for stressful situations should include exposure to stressful conditions with gradually increasing intensity [75].
Effect van stress op sociale processen
- Directive leadership, i.e. short and clear statements to specific team members help to optimize team performance, especially in ambiguous situations [77].
- The leader should “step back” in order to keep the overview [78] and only interfere if needed [40,41].
- Leadership should give opportunities to raise questions and concerns [79] to prevent and recognize errors [80].
7. Stress en gender
Er is gekeken naar de effecten van stress bij mannen en vrouwen tijdens reanimatie.
“When considering gender differences, female students have shown inferior performance [52] and reported to be more stressed during CPR than male students [36] which was found to be negatively associated with each other [6], explaining female’ worse performance. However, women have equal medical knowledge as men [54] and CPR performance can be improved with a gender-focused intervention [59].
En later:
“However, it has been shown that women have equal, in some cases even better, medical knowledge than men [54]. Furthermore, if female medical students receive a brief gender-focused intervention focusing on leadership instructions and self-perception of female rescuers, leadership skills can be significantly improved [59].”
Echter, deze studies zijn vooral gedaan onder medische studenten/beginners. In een studie bij meer ervaren hulpverleners vond men:
“Within a subgroup of 227 resuscitations with an initial 5 min of CPR parameter data, female physician code leaders were two times more likely to achieve return of spontaneous rhythm (ROSC) and females did not doworse in regard to either chest compression rate, depth or fraction. Unfortunately, stress was not measured in this study.”
8. Stress management
In deze paragraaf worden de positieve effecten van leiderschap en andere strategieën kort besproken.
- Leadership trainings have been found to effectively decrease stress levels and increase confidence while performing simulated resuscitation [59].
- Further, an intervention focusing on leadership instructions versus technical instructions showed better overall CPR performance for the leadership instructions [60]. The group receiving leadership instruction demonstrated longer hands-on time, shorter time to start CPR and more leadership utterances with sustained effects at a 4-month followup [60].
- Also, a systematic review considering stress and decisionmaking during resuscitation showed that cognitive aids, stress management training and mindfulness meditation improve non-technical skills such as decision-making [61].
9. Weinig specifiek bewijs
Zoals eerder besproken: alleen het verminderen van stress is niet hetzelfde als het verbeteren van de concrete reanimatie (of wat voor prestatie dan ook). Dat is een belangrijke aanwijzing voor alle mentale trainers en sportpsychologen en vooral ook om onderzoekers: het gaat uiteindelijk om de daadwerkelijke (en specifieke) prestatie.
“There are many stress reducing interventions [5,57,58], yet to the best of our knowledge, only one intervention targeting stress reduction during CPR exists [7].
Bron
- A. Vincent, N.K. Semmer, C. Becker, et al., Does stress influence the performance of cardiopulmonary resuscitation? A
narrative review of the li…, Journal of Critical Care, https://doi.org/10.1016/j.jcrc.2020.09.020