亚低温技术在心肺复苏中的应用陆一鸣.ppt

亚低温技术在心肺复苏中的应用Therapeutichypothermiainpost resuscitationpatients 上海交通大学医学院附属瑞金医院陆一鸣 提纲 心跳骤停的流行病学及其预后亚低温疗法和其作用机制亚低温治疗心跳骤停病人的循证学依据哪一种亚低温疗法最有效 教育 实施和科研方面的挑战 猝死病人死亡率近70 心脏骤停的流行病学 400 000骤停 每年在U S A医院 3 4门急诊 1 4住院患者 出院时的存活率 1 5 10 20 只有2 的幸存患者神经性功能良好 MryAnnPeberdy JosephPOrnato Highqualitypostresuscitationcare Survivalratesamongthoseadmittedvaryfrom0 60 低温治疗的分类 低温治疗作用机制 传统认为 低温主要通过降低葡萄糖和氧耗延缓代谢而起到保护作用 低温治疗作用机制的新观念 抗凋亡 Ca2 介导的蛋白水解作用和线粒体损伤稳定离子泵和抑制神经兴奋性级联反应抑制免疫和炎症反应抗自由基损伤降低血管渗透性和减轻脑水肿减轻细胞膜渗透性改变和细胞内酸中毒抑制脑内局部温度升高后的脑损害降低脑代谢 BladderTemperatureintheNormothermiaandHypothermiaGroups TheTbarsindicatethe75thpercentileinthenormothermiagroupandthe25thpercentileinthehypothermiagroup Thetargettemperatureinthehypothermiagroupwas32 to34 andthedurationofcoolingwas24hours Onlypatientswithrecordedtemperatureswereincludedintheanalysis CoolingEnd After6months Rateofdeath 41 inthehypothermiais14 lowerthaninthenormothermiagroup 39 欧洲多中心临床试验 HACAtrial 随机将275名患者分组为低温或常温两组降温时间 使用体表降温降到34度耗时6 5个小时结果 低体温正常体温好的结果55 39 p 0 009死亡率41 55 p 0 02 每六个接受治疗的患者 有一个可救活 Numberneededtotreattoachievegoodneurologicaloutcomeinoneextrapatient 6 HolzerMetal CritCareMed2005 33 414 8 澳大利亚的研究 77名患者的随机临床试验使用冰袋冷却0 9度 小时结果 低体温正常体温好结果49 26 p 0 046死亡率51 68 P NS Preliminaryevidenceinpatientswithasystole PEA PoldermanKHetal Inducedhypothermiaimprovesneurologicaloutcomeinasystolicpatientswithout ofhospitalcardiacarrest Circulation2003 108 IV 581 abstract2646 欧洲HARTStudy ICY在心脏骤停的多中心试验 心搏停跳后 ICY导管亚低温治疗 前瞻性的 多中心研究对心搏停搏患者使用ICY导管进行可行性和安全性评估多中心参加 HenryFord Duke UniversityofHouston欧洲复苏理事会资助30多个中心参加 包括500名患者 结果在2005年9月阿姆斯特丹会议上公布 欧洲HACA调查者将使用CoolGard3000和Icy导管作为金标准降温疗法 Before andaftercomparisonin665out ofhospitalcardiacarrestintheStavangerarea population300000 2001 2003 Before andaftercomparisonin665out ofhospitalcardiacarrestintheStavangerarea population300000 2001 2003 CoolingProcedure introducethecoolingdevice IcyandCoolGard3000 AlsiusCorp foley catheter 24h targettemperatureat33 rewarmed 0 5 h 36 37 Icy catheter StartupKit AllpatientsinthedatabasefromAugust1991toNovember2004werescreened Foroutcomeevaluationallpatientswhowerecooledwithendovascularcoolingduringthisperiodwereevaluated Forevaluationofcoolingratewerestrictedtheanalysistopatientswhoreceivedendovascularcoolingexclusively Bladdertemperaturecourse Median 25thand75thquartileofbladdertemperatureafterreturnofspontaneouscirculationinpatients whowereexclusivelycooledwiththeendovascularcoolingdevice n 56 Targettemperature 33 C coolingduration 24hours 95min35 3 1 0 253min33 24hr 388min36 1 2 hour AdverseEvent EndovascularCooling n 62 Control n 104 P ComplicationsDuringandAfterEndovascularCoolingComparedtoFrequency MatchedControls Methods Consecutivecomatosesurvivorsofcardiacarrest whowereeithercooledfor24hoursto33 Cwithendovascularcoolingortreatedwithstandardpostresuscitationtherapy wereanalyzed Complicationdatawereobtainedbyretrospectivechartreview Results Patientsintheendovascularcoolinggrouphad2 foldincreasedoddsofsurvival 67 97patientsvs466 941patients oddsratio2 28 95 CI 1 45to3 57 P 0 001 Afteradjustmentforbaselineimbalancestheoddsratiowas1 96 95 CI 1 19to3 23 P 0 008 Intheendovascularcoolinggroup 51 97patients 53 survivedwithfavorableneurologyascomparedwith320 941 34 inthecontrolgroup oddsratio2 15 95 CI 1 38to3 35 P 0 0003 adjustedoddsratio2 56 1 57to4 17 Therewasnodifferenceintherateofcomplicationsexceptforbradycardia Conclusion Endovascularcoolingimprovedsurvivalandshort termneurologicalrecoverycomparedwithstandardtreatmentincomatoseadultsurvivorsofcardiacarrest Temperaturecontrolwaseffectiveandsafewiththisdevice AnadvisorystatementbytheAdvancedLifeSupportTaskForceoftheInternationalLiaisonCommitteeonResuscitation ILCOR includesAHA PublishedinResuscitation June2003andCirculation July2003 对于无知觉的具有自发循环的门急诊心脏骤停患者 如果出现最初室颤节律 则应该将该患者体温降到32 34度达12 24小时 像这样的降温也对其它的节律性疾病或住院的心脏骤停患者有益 ILCORRecommendations InternationalEmergencyCardiacCareGuidelines 2005 mildhypothermiamaybebeneficialtoneurologicoutcomeandislikelytobewelltoleratedwithoutsignificantriskofcomplications InaselectsubsetofpatientswhowereinitiallycomatosebuthemodynamicallystableafterawitnessedVFarrestofpresumedcardiacetiology activeinductionofhypothermiawasbeneficial Thus unconsciousadultpatientswithROSCafterout of hospitalcardiacarrestshouldbecooledto32 to34 for12to24hourswhentheinitialrhythmwasVF ClassIIa Similartherapymaybebeneficialforpatientswithnon VFarrestoutofhospitalorforin hospitalarrest ClassIIb Probablyasquicklyaspossible CardiacArrest ROSC 012345678 Time Intra arrestAbella 2004Katz 2000 SoonafterROSCSterz 1991Kuboyama 1993 HACA 2002 Whentostartcooling Bernard 2002 PrehospitalandEDcooling YES 体表降温 冰袋 冰袋 通常把它放在患者腹股沟 位于身体体表的位置 腋窝下和头周围 护士要不断地清理由于冰袋融化而出来的冷凝水和不断地挪动冰袋的位置以防温度太低造成的局部组织损伤 Bernardetal Rescuscitation2003 56 9 13 Virkkunenetal Resuscitation2004 62 299 302 RijnsburgerIntensiveCareMed200430 Suppl1abstr475 Poldermanetal CriticalCareMed2005 33 2744 51 Coldfluidinfusion ThreestudiesPost ROSCpatientsRefrigeratedRingerslactate 40C salineorcolloidstoinducehypothermiaAveragevolume1500 3000mlwithin30 60minHemodynamicimprovementandnolungproblemsSafeandeffective 30 60mintoreachtargettemp 体表降温 kcl床 kcl床 这种床用于欧洲的HACA 心脏停搏后的低温治疗 实验 将病人放置到带有拉链的袋子中 然后吹入冷气包围患者身体 可以想象患者被包围住的护理有多困难 Invasiveornon invasivecoolingtechnique Newknowledge newmethodsandnewequipment 亚低温治疗程序 治疗的3个不同阶段 严格控制在32 34度 缓慢 可控的复温以免颅内压反弹 必须能够完全控制3个阶段 TemperatureProfileUsingIcy Catheter Coolingtime 98minutes 与目标温度一致 快速降温 缓慢 可控复温阶段 HACA试验vsALSIUSIcy 21 51 18 65 75 55 54 39 Good 18 44 23 56 Allrhythmsn 41 Icy 8 29 20 71 VFonlyn 28 Icy 56 41 76 55 Dead 81 59 62 45 Alive Hypothermia 低体温 Control HACATrialn 28 02 结果趋向于使用血管内冷却方法更有效 6个月的结果 体表降温和血管腔内降温 体表降温护理工作强度大 icepacks lavagebladder ngt coolingblanket 很难维持目标温度 降温过度不可控制复温 ICP 颅压 反弹和体温过高增加寒战过度的护理操作 冰垫 降温毯 对病情不稳定的患者有不良影响血管腔内降温开始治疗容易 中心静脉入路 不影响患者的护理工作与体表降温相比减少寒战次数容易快速与患者分离有效地控制降温后的患者体温反弹 ICU患者最多可以使用4天 血管内降温 冰毯 结果 与表面降温组相比 血管内降温组 降温迅速在温度维持阶段 温度波动小 0 1 复温更加迅速 EuropeanICUsurvey therapeutichypothermiause Boerrigeretal 2006 Around60 reporteduseoftherapeutichypothermia65 cooledallcomatosesurvivors10 onlywitnessedarrest10 onlyVF VTReasonsgivenfornotusingTH lackofscience 5 andfearofside effects 2 lackofconsensus 10 lackofequipment 25 A COOL SUCCESSSTORY rapidimplementationoftherapeutichypothermiainNorway AllpatientswithROSCaftercardiacarrestwhoarenotfollowingverbalcommands OnlywitnessedarrestOnlyVF VTandage18 75 HACA Bernardstudyinclusioncriteria out of hospitalventricularfibrillation Asystole pulselesselectricalactivity PEA Patientselection Whenshouldmildhypothermiabestarted Howrapidlyshouldthecoolingtakeplace Howlongtocool 12hoursor24hours NEJM2002 346 549 556vs 346 557 563 Targett