亚低温技术在心肺复苏中的应用课件

亚低温技术在心肺复苏中的应用

Therapeutichypothermiain

post-resuscitationpatients2011-09亚低温技术在心肺复苏中的应用

Therapeutichyp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提纲心跳骤停的流行病学及其预后猝死病人死亡率近70%

350000猝死病人100000

尝试做CPR40000到达医院病人20000

活着出医院

12000

没有或很少有后遗症猝死病人死亡率近70%350000猝死病人100000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心脏骤停的流行病学400,000骤停/每年在U.S.MryAnnPeberdy,JosephPOrnatoHighqualitypostresuscitationcare

Survivalratesamongthoseadmittedvaryfrom0–60%!MryAnnPeberdy,JosephPOrna低温治疗的分类分类英文名称目标温度轻度低温mildhypothermia33－35℃亚低温(mildhypothermia)，亚低温状态下，对心脑肺的保护作用与深度低温相似，但无明显不良反应中度低温moderatehypothermia28－32℃深度低温profoundhypothermia17－27℃28℃以下低温容易引起低血压和心律失常等并发症，目前较少使用超深度低温ultraprofoundhypothermia≤16℃低温治疗的分类分类英文名称目标温度轻度低温mildhypo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诱导低温条件下体温下降1℃脑代谢率下降5－7％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亚低温技术在心肺复苏中的应用课件BladderTemperatureintheNormothermiaandHypothermiaGroups.TheTbarsindicatethe75thpercentileinthenormothermiagroupandthe25thpercentileinthehypothermiagroup.Thetargettemperatureinthehypothermiagroupwas32℃to34℃,andthedurationofcoolingwas24hours.Onlypatientswithrecordedtemperatureswereincludedintheanalysis.CoolingEndBladderTemperatureintheNorAfter6months:75ofthe136(55%)inhypothermiagrouphadbetterfavorableneurologicoutcomethannormothermiagroup(39%).After6months:75ofthe136After6months:Rateofdeath(41%)inthehypothermiais14%lowerthaninthenormothermiagroup(39%).After6months:Rateofdeath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！欧洲多中心临床试验（HACAtrial)随机将275名患Numberneededtotreattoachievegoodneurologicaloutcomeinoneextrapatient:

6

HolzerMetal.,CritCareMed2005;33:414-8.

Numberneededtotreattoachi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澳大利亚的研究77名患者的随机临床试验Preliminaryevidenceinpatientswithasystole/PEA…PoldermanKHetal.Inducedhypothermiaimprovesneurologicaloutcomeinasystolicpatientswithout-ofhospitalcardiacarrest.Circulation2003;108:IV-581[abstract2646]Preliminaryevidenceinpatien亚低温技术在心肺复苏中的应用课件欧洲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。欧洲HARTStudy-ICY在心脏骤停的多中心试验亚低温技术在心肺复苏中的应用课件Before-andaftercomparisonin665out-ofhospitalcardiacarrestintheStavangerarea(population300000)2001-2003Before-andaftercomparisoniBefore-andaftercomparisonin665out-ofhospitalcardiacarrestintheStavangerarea(population300000)2001-2003Before-andaftercomparisoni亚低温技术在心肺复苏中的应用课件CoolingProcedure

introducethecoolingdevice(IcyandCoolGard3000;AlsiusCorp)foley-catheter24htarget

temperatureat33℃rewarmed0.5℃/h36~37℃Icy-catheterStartupKitCoolingProcedureintroducethAllpatientsinthedatabasefromAugust1991toNovember2004werescreened.Foroutcomeevaluationallpatientswhowerecooledwithendovascularcoolingduringthisperiodwereevaluated.Forevaluationofcoolingratewerestrictedtheanalysistopatientswhoreceivedendovascularcoolingexclusively.AllpatientsinthedatabasefBladdertemperaturecourse.Median,25thand75thquartileofbladdertemperatureafterreturnofspontaneouscirculationinpatients,whowereexclusivelycooledwiththeendovascularcoolingdevice(n=56).Targettemperature,33°C;coolingduration,24hours.95min35.3±1.0℃

253min33℃

24hr388min36℃1.2℃/hour

Bladdertemperaturecourse.MeAdverseEvent

EndovascularCooling(n=62)

Control(n=104)

P

Withinthefirst32h

Atrialfibrillation,n(%)2(3)2(3)0.987

Ventriculartachycardia,n(%)14(23)9(14)0.231

Ventricularfibrillation,n(%)6(10)6(10)0.977

Narrowcomplextachycardia,n(%)03(5)0.082

Bradycardia,n(%)9(15)2(3)0.025

AnyBleeding,n(%)16(26)27(26)0.982

Withinthefirst7d

Pneumonia,n(%)17(27)20(19)0.233

Elevationofpancreaticenzymes,n(%)1(2)00.194

Sepsis,n(%)00...

Acuterenalfailure,n(%)4(6)4(4)0.448ComplicationsDuringandAfterEndovascularCoolingComparedtoFrequency-MatchedControls

AdverseEventEndovascularCooMethods--

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.Methods--Consecutivecomatos亚低温技术在心肺复苏中的应用课件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。

ILCORRecommendationsAnadvisorystatementbytheAInternationalEmergencyCardiacCareGuidelines（2005）‘mildhypothermiamaybebeneficialtoneurologicoutcomeandislikelytobewelltoleratedwithoutsignificantriskofcomplications.InaselectsubsetofpatientswhowereinitiallycomatosebuthemodynamicallystableafterawitnessedVFarrestofpresumedcardiacetiology,activeinductionofhypothermiawasbeneficial.Thus,unconsciousadultpatientswithROSCafterout-of-hospitalcardiacarrestshouldbecooledto32℃to34℃for12to24hourswhentheinitialrhythmwasVF(ClassIIa).Similartherapymaybebeneficialforpatientswithnon-VFarrestoutofhospitalorforin-hospitalarrest(ClassIIb)’.

InternationalEmergencyCardiaProbablyasquicklyaspossibleCardiacArrestROSC012345678TimeIntra-arrestAbella,2004Katz,2000SoonafterROSCSterz,1991Kuboyama,1993HACA,2002Whentostartcooling?Bernard,2002PrehospitalandEDcooling?

YES!Probablyasquicklyaspossibl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)

Bernardetal,Rescuscitation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。体表降温－kcl床kcl床，这种床用于欧洲的HACA(心脏Invasiveornon-invasivecoolingtechnique?Newknowledge,newmethodsandnewequipment!Invasiveornon-invasivecooli

亚低温治疗程序：治疗的3个不同阶段快速冷却阶段CrashCoolPhase最大化冷却率MaximumCoolingRate37°C33°C复温阶段RewarmPhase维持阶段严格控制在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个阶段亚低温治疗程序：治疗的3个不同阶段快速冷却阶段Cra亚低温技术在心肺复苏中的应用课件TemperatureProfileUsingIcy™Catheter

(Coolingtime:98minutes）与目标温度一致快速降温缓慢，可控复温阶段TemperatureProfileUsingIcy™HACA试验vsALSIUSIcy™

21(51)18(65)75(55)54(39)Good18(44)23(56)Allrhythmsn=41Icy™8(29)20(71)VFonlyn=28Icy™56(41)76(55)Dead81(59)62(45)AliveHypothermia(低体温）ControlHACATrialn(%).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HACA试验vsALSIUSIcy™21(51)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天体表降温和血管腔内降温体表降温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℃)复温更加迅速血管内降温冰毯结果：与表面降温组相比，血管内降温组：European

ICU

survey:therapeutichypothermiause(Boerrigeretal,2006)Around60%reporteduseoftherapeutichypothermia65%cooledallcomatosesurvivors10%onlywitnessedarrest10%onlyVF/VTReasonsgivenfornotusingTH:lackofscience(5%)andfearofside-effects(2%)lackofconsensus(10%)lackofequipment(25%)

EuropeanICUsurvey:therapeutA”COOL”SUCCESSSTORY:

rapidimplementationoftherapeutichypothermiainNorwayA”COOL”SUCCESSSTORY:

rapiAllpatientswithROSCaftercardiacarrestwhoarenotfollowingverbalcommands!OnlywitnessedarrestOnlyVF/VTandage18-75(HACA/Bernardstudyinclusioncriteria)out-of-hospitalventricularfibrillation★★★

Asystole★★

pulselesselectricalactivity（PEA）★★

PatientselectionAllpatientswithROSCaft