心肺复苏后心功能不全zs

1、心肺复苏后心功能障碍心肺复苏后心功能障碍 一切恶果的始作俑者？一切恶果的始作俑者？心肺复苏后治疗仍面临巨大挑战心肺复苏后治疗仍面临巨大挑战1.Safar P: Resuscitation from clinical death: pathophysiologic limits and therapeutic potentials. Crit Care Med 1988, 16:923941.2.Keenan SP, Dodek P, Martin C, Priestap F, Norena M, Wong H. Variation in length of intensive care uni

2、t stay after cardiac arrest: where you are is as important as who you are. Crit Care Med 2007;35:83641.3.Nolan JP, Laver SR, Welch CA, Harrison DA, Gupta V, Rowan K. Outcome following admission to UK intensive care units after cardiac arrest: a secondary analysis of the ICNARC Case Mix Programme Dat

3、abase. Anaesthesia 2007;62:120716.4.Herlitz J, Engdahl J, Svensson L, Angquist KA, Silfverstolpe J, Holmberg S. Major differences in 1-month survival between hospitals in Sweden among initial survivors of out-of-hospital cardiac arrest. Resuscitation 2006;70:4049.5.Langhelle A, Tyvold SS, Lexow K, H

4、apnes SA, Sunde K, Steen PA. In-hospital factors associated with improved outcome after out-of-hospital cardiac arrest. A comparison between four regions in Norway. Resuscitation 2003;56:24763.6.Mashiko K, Otsuka T, Shimazaki S, et al. An outcome study of out-of-hospital cardiac arrest using the Uts

5、tein templatea Japanese experience. Resuscitation 2002;55:2416.NationsMortality rateyearCanada265%2007UK371.4%2007Sweden458-86%2006Norway554-70%2003Japan690%2002ROSC患者存在血流动力学不稳定患者存在血流动力学不稳定复苏后心功能障碍心脏骤停后休克状态死亡率复苏复苏后心功能不全的变变化与预与预后密切相关关Manuel Ruiz-Bailn, Eduardo Aguayo de Hoyos, Silvia Ruiz-Navarro, et

6、 al. Reversible myocardial dysfunction after cardiopulmonary resuscitation. Resuscitation 2005;66:175-181.GroupNDieCauseMyocardial dysfunction209Shock and MOF(8) Cerebral death(1) Myocardial function93Cerebral death(2)Hemorrhagic shock(1)心因性心脏骤脏骤停ROSC后的心功能研研究GroupNInvasive monitoringNo hemodynamic i

7、nstability75NoHemodynamic instability73YesI. Laurent, M. Monchi, J.D. Chiche, et al. Reversible myocardial dysfunction in survivors of out-of-hospital cardiac arrest. J Am Coll Cardiol 2002;40:21102116I. Laurent, M. Monchi, J.D. Chiche, et al. Reversible myocardial dysfunction in survivors of out-of

8、-hospital cardiac arrest. J Am Coll Cardiol 2002;40:21102116心因性心脏骤脏骤停ROSC后的心功能研研究I. Laurent, M. Monchi, J.D. Chiche, et al. Reversible myocardial dysfunction in survivors of out-of-hospital cardiac arrest. J Am Coll Cardiol 2002;40:21102116死亡率与与心功能持续续障碍相关关心因性心脏骤脏骤停ROSC后的心功能研研究复苏复苏后心功能不全 是一切麻烦烦的制造者！心

9、功能不全如何发发生？心 1、心肌收缩缩力 2、心脏脏舒张顺应张顺应性 3、心率心肌顿顿抑 是指心肌短时间缺血后不发生坏死，但引起心肌细细胞的结结构构、代谢谢和功能改变变在再灌注后延迟迟恢复复的现现象 临床特征表现为收缩缩功能障碍 持续数数天到数数周 复苏复苏后心功能不全主要是心肌顿顿抑 最早ROSC后30分钟内可监测到左室舒张末压上升（8-10mmHg到20-22mmHg），射血分数显著下降（55%到20%），呈现低心排和低血压。 在整个个心功能障碍期间间冠脉的血流没没有明显显下降，提示是一种真种真正的心肌顿顿抑，而非持续续的心肌损伤损伤或梗死。 这种功能障碍多是暂时性的，大多可在72h完全恢

10、复，但也有低心排持续数周到数月的报道。复苏复苏后存在可逆心功能障碍Manuel Ruiz-Bailn, Eduardo Aguayo de Hoyos, Silvia Ruiz-Navarro, et al. Reversible myocardial dysfunction after cardiopulmonary resuscitation. Resuscitation 2005;66:175-181.黑线：全部患者的左室射血分数（29人）；灰线：心肌异常组的左室射血分数（20人）治疗疗策略 需要强化监护监护 早期血流动动力学优学优化或EGDT，恢复复和维维持全身氧输氧输送和氧氧需平衡成

11、功的关键：成功的关键：尽早监护和治疗，并在起病数小时内达到治疗目标尽早监护和治疗，并在起病数小时内达到治疗目标治疗疗策略 低血压的一线干预措施是通过输液使右室充盈压最佳化（CVP 8-12mmHg） 如果输液使得前负荷达标，但仍未获获得满满意的血流动动力学学目标标，可考虑应虑应用正性肌力和升压药压药K.B. Kern, R.W. Hilwig, R.A. Berg, et al. Postresuscitation left ventricular systolic and diastolic dysfunction: treatment with dobutamine. Circulatio

12、n 1997, 95: 26102613正性肌力药药物可改善心功能心肌顿顿抑是唯一的麻烦烦制造者？I. Laurent, M. Monchi, J.D. Chiche, et al. Reversible myocardial dysfunction in survivors of out-of-hospital cardiac arrest. J Am Coll Cardiol 2002;40:21102116CI改善情况下仍然需要血管活性药物维持血流动力学稳定改善情况下仍然需要血管活性药物维持血流动力学稳定I. Laurent, M. Monchi, J.D. Chiche, et al.

13、 Reversible myocardial dysfunction in survivors of out-of-hospital cardiac arrest. J Am Coll Cardiol 2002;40:21102116心功能改善不是血流动动力学稳学稳定的唯一原因心脏骤脏骤停后综综合征Jerry P. Nolan, Robert W. Neumar, Christophe Adrie, et al. Post-cardiac arrest syndrome: Epidemiology, pathophysiology, treatment, and prognostication

14、: A Scientific Statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; the Council on Stroke. Resuscitation 2008; 79:350-379心脏骤停后独特的病理生理状态及临床表现心脏骤停后综合征Christophe Adrie, Minou Adib-Conquy, Ivan Laurent, et al. Successful Cardiopulmonary Resuscitation After Cardiac Arrest as a “Sepsis-Like” Syndrome. Ci