亞低溫技術(shù)在心肺復(fù)蘇中的應(yīng)用課件

亞低溫技術(shù)在心肺復(fù)蘇中的應(yīng)用

Therapeutichypothermiain

post-resuscitationpatients2011-09亞低溫技術(shù)在心肺復(fù)蘇中的應(yīng)用

Therapeutichyp提綱心跳驟停的流行病學(xué)及其預(yù)后亞低溫療法和其作用機(jī)制亞低溫治療心跳驟停病人的循證學(xué)依據(jù)哪一種亞低溫療法最有效?教育、實(shí)施和科研方面的挑戰(zhàn)提綱心跳驟停的流行病學(xué)及其預(yù)后猝死病人死亡率近70%

350000猝死病人100000

嘗試做CPR40000到達(dá)醫(yī)院病人20000

活著出醫(yī)院

12000

沒(méi)有或很少有后遺癥猝死病人死亡率近70%350000猝死病人100000心臟驟停的流行病學(xué)400,000驟停/每年在U.S.A醫(yī)院3/4門急診1/4住院患者出院時(shí)的存活率1-5%10-20%只有2%的幸存患者神經(jīng)性功能良好心臟驟停的流行病學(xué)400,000驟停/每年在U.S.MryAnnPeberdy,JosephPOrnatoHighqualitypostresuscitationcare

Survivalratesamongthoseadmittedvaryfrom0–60%!MryAnnPeberdy,JosephPOrna低溫治療的分類分類英文名稱目標(biāo)溫度輕度低溫mildhypothermia33－35℃亞低溫(mildhypothermia)，亞低溫狀態(tài)下，對(duì)心腦肺的保護(hù)作用與深度低溫相似，但無(wú)明顯不良反應(yīng)中度低溫moderatehypothermia28－32℃深度低溫profoundhypothermia17－27℃28℃以下低溫容易引起低血壓和心律失常等并發(fā)癥，目前較少使用超深度低溫ultraprofoundhypothermia≤16℃低溫治療的分類分類英文名稱目標(biāo)溫度輕度低溫mildhypo低溫治療作用機(jī)制傳統(tǒng)認(rèn)為：低溫主要通過(guò)降低葡萄糖和氧耗延緩代謝而起到保護(hù)作用誘導(dǎo)低溫條件下體溫下降1℃腦代謝率下降5－7％低溫治療作用機(jī)制傳統(tǒng)認(rèn)為：低溫主要通過(guò)降低葡萄糖和氧耗延緩代低溫治療作用機(jī)制的新觀念抗凋亡、Ca2+介導(dǎo)的蛋白水解作用和線粒體損傷穩(wěn)定離子泵和抑制神經(jīng)興奮性級(jí)聯(lián)反應(yīng)抑制免疫和炎癥反應(yīng)抗自由基損傷降低血管滲透性和減輕腦水腫減輕細(xì)胞膜滲透性改變和細(xì)胞內(nèi)酸中毒抑制腦內(nèi)局部溫度升高后的腦損害降低腦代謝低溫治療作用機(jī)制的新觀念抗凋亡、Ca2+介導(dǎo)的蛋白水解作用和亞低溫技術(shù)在心肺復(fù)蘇中的應(yīng)用課件BladderTemperatureintheNormothermiaandHypothermiaGroups.TheTbarsindicatethe75thpercentileinthenormothermiagroupandthe25thpercentileinthehypothermiagroup.Thetargettemperatureinthehypothermiagroupwas32℃to34℃,andthedurationofcoolingwas24hours.Onlypatientswithrecordedtemperatureswereincludedintheanalysis.CoolingEndBladderTemperatureintheNorAfter6months:75ofthe136(55%)inhypothermiagrouphadbetterfavorableneurologicoutcomethannormothermiagroup(39%).After6months:75ofthe136After6months:Rateofdeath(41%)inthehypothermiais14%lowerthaninthenormothermiagroup(39%).After6months:Rateofdeath歐洲多中心臨床試驗(yàn)（HACAtrial)隨機(jī)將275名患者分組為低溫或常溫兩組降溫時(shí)間：使用體表降溫降到34度耗時(shí)6.5個(gè)小時(shí)結(jié)果：

低體溫正常體溫好的結(jié)果

55% 39%p=0.009死亡率

41% 55%p=0.02每六個(gè)接受治療的患者，有一個(gè)可救活！歐洲多中心臨床試驗(yàn)（HACAtrial)隨機(jī)將275名患Numberneededtotreattoachievegoodneurologicaloutcomeinoneextrapatient:

6

HolzerMetal.,CritCareMed2005;33:414-8.

Numberneededtotreattoachi澳大利亞的研究77名患者的隨機(jī)臨床試驗(yàn)使用冰袋冷卻0.9度/小時(shí)結(jié)果: 低體溫正常體溫好結(jié)果

49% 26%p=0.046死亡率

51% 68%P=NS澳大利亞的研究77名患者的隨機(jī)臨床試驗(yàn)Preliminaryevidenceinpatientswithasystole/PEA…PoldermanKHetal.Inducedhypothermiaimprovesneurologicaloutcomeinasystolicpatientswithout-ofhospitalcardiacarrest.Circulation2003;108:IV-581[abstract2646]Preliminaryevidenceinpatien亞低溫技術(shù)在心肺復(fù)蘇中的應(yīng)用課件歐洲HARTStudy-ICY在心臟驟停的多中心試驗(yàn)

心搏停跳后，ICY

導(dǎo)管亞低溫治療。前瞻性的，多中心研究對(duì)心搏停搏患者使用ICY導(dǎo)管進(jìn)行可行性和安全性評(píng)估多中心參加:HenryFord,Duke,UniversityofHouston歐洲復(fù)蘇理事會(huì)資助30多個(gè)中心參加，包括500名患者，結(jié)果在2005年9月阿姆斯特丹會(huì)議上公布。歐洲HACA調(diào)查者將使用CoolGard3000和Icy導(dǎo)管作為金標(biāo)準(zhǔn)降溫療法。歐洲HARTStudy-ICY在心臟驟停的多中心試驗(yàn)亞低溫技術(shù)在心肺復(fù)蘇中的應(yīng)用課件Before-andaftercomparisonin665out-ofhospitalcardiacarrestintheStavangerarea(population300000)2001-2003Before-andaftercomparisoniBefore-andaftercomparisonin665out-ofhospitalcardiacarrestintheStavangerarea(population300000)2001-2003Before-andaftercomparisoni亞低溫技術(shù)在心肺復(fù)蘇中的應(yīng)用課件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亞低溫技術(shù)在心肺復(fù)蘇中的應(yīng)用課件AnadvisorystatementbytheAdvancedLifeSupportTaskForceoftheInternationalLiaisonCommitteeonResuscitation

(ILCOR–includesAHA)

(PublishedinResuscitation,June2003andCirculation,July2003)對(duì)于無(wú)知覺(jué)的具有自發(fā)循環(huán)的門急診心臟驟?；颊撸绻霈F(xiàn)最初室顫節(jié)律，則應(yīng)該將該患者體溫降到32-34度達(dá)12-24小時(shí)。像這樣的降溫也對(duì)其它的節(jié)律性疾病或住院的心臟驟?；颊哂幸?。

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體表降溫－冰袋冰袋，通常把它放在患者腹股溝，位于身體體表的位置，腋窩下和頭周圍。護(hù)士要不斷地清理由于冰袋融化而出來(lái)的冷凝水和不斷地挪動(dòng)冰袋的位置以防溫度太低造成的局部組織損傷體表降溫－冰袋冰袋，通常把它放在患者腹股溝，位于身體體表的位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體表降溫－kcl床kcl床，這種床用于歐洲的HACA(心臟停搏后的低溫治療）實(shí)驗(yàn)，將病人放置到帶有拉鏈的袋子中，然后吹入冷氣包圍患者身體，可以想象患者被包圍住的護(hù)理有多困難。體表降溫－kcl床kcl床，這種床用于歐洲的HACA(心臟Invasiveornon-invasivecoolingtechnique?Newknowledge,newmethodsandnewequipment!Invasiveornon-invasivecooli

亞低溫治療程序：治療的3個(gè)不同階段快速冷卻階段CrashCoolPhase最大化冷卻率MaximumCoolingRate37°C33°C復(fù)溫階段RewarmPhase維持階段嚴(yán)格控制在32-34度緩慢，可控的復(fù)溫以免顱內(nèi)壓反彈

必須能夠完全控制3個(gè)階段亞低溫治療程序：治療的3個(gè)不同階段快速冷卻階段Cra亞低溫技術(shù)在心肺復(fù)蘇中的應(yīng)用課件TemperatureProfileUsingIcy?Catheter

(Coolingtime:98minutes）與目標(biāo)溫度一致快速降溫緩慢，可控復(fù)溫階段TemperatureProfileUsingIcy?HACA試驗(yàn)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(低體溫）ControlHACATrialn(%).28.02

結(jié)果趨向于使用血管內(nèi)冷卻方法更有效。6個(gè)月的結(jié)果HACA試驗(yàn)vsALSIUSIcy?21(51)體表降溫和血管腔內(nèi)降溫體表降溫護(hù)理工作強(qiáng)度大(icepacks/lavagebladder,ngt/coolingblanket)很難維持目標(biāo)溫度-降溫過(guò)度不可控制復(fù)溫–

ICP(顱壓）反彈和體溫過(guò)高增加寒戰(zhàn)過(guò)度的護(hù)理操作（冰墊/降溫毯）對(duì)病情不穩(wěn)定的患者有不良影響血管腔內(nèi)降溫開(kāi)始治療容易（中心靜脈入路）不影響患者的護(hù)理工作與體表降溫相比減少寒戰(zhàn)次數(shù)容易快速與患者分離有效地控制降溫后的患者體溫反彈，ICU患者最多可以使用4天體表降溫和血管腔內(nèi)降溫體表降溫血管內(nèi)降溫冰毯結(jié)果：與表面降溫組相比，血管內(nèi)降溫組：降溫迅速在溫度維持階段，溫度波動(dòng)小(±0.1℃)復(fù)溫更加迅速血管內(nèi)降溫冰毯結(jié)果：與表面降溫組相比，血管內(nèi)降溫組：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