温州地区开展亚低温治疗对心肺复苏后昏迷患者预后影响的研究
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摘要
目的探讨温州地区推广亚低温治疗(HT)对心肺复苏(CPR)后昏迷患者预后的影响。方法温州地区成立1家推广示范基地及10家推广基地,自2014年1月至2016年12月,对CPR后昏迷患者实施HT。记录所有患者亚低温治疗相关信息,比较推广期间3年患者ICU出院存活率、神经功能恢复良好率及严重致残率。结果推广期间共对133例CPR后昏迷患者实施HT,推广第1年、第2年、第3年分别为28、46、59例。推广第1年、第2年、第3年达到目标体温时间[8.0(3.0,18.8)、10.0(4.8,20.0)、6.0(2.0,12.0)h]、药物使用率[17(60.7%)、43(93.5%)、42(71.2%)]及肌松剂使用率[0(0%)、1(2.2%)、13(22.0%)]比较,差异均有统计学意义(H=10.475,P=0.005;χ~2=12.250,P=0.002;χ~2=17.647,P <0.001)。推广期间ICU出院存活率呈现逐年上升趋势,严重致残率呈现逐年下降趋势;但3年间比较差异均无统计学意义(χ~2=2.537,P=0.281;χ~2=0.308,P=0.857)。推广3年间神经功能恢复良好率比较,差异有统计学意义(χ~2=12.232,P=0.002),且推广第3年较第1年及第2年神经功能恢复良好率更高[16 (27.1%)、1 (3.6%)、3(6.5%),P均<0.017]。结论规范化的HT能有效地促进神经功能恢复。
Objective To analyze the prognosis of hypothermia treatment(HT) for coma patients after cardiopulmonary resuscitation(CPR) in Wenzhou. Methods A implementation demonstration base and 10 implementation bases were established in Wenzhou. HT was implemented in patients with coma after CPR from January 2014 to December 2016. The data of HT were recorded. The survival rate of ICU discharge, recovery rate of neurological functions and severe disability rate in the 3-year implementation period were compared. Results In the implementation period, 133 coma patients after CPR were implemented TH. Respectively, 28, 46 and 59 cases were implemented in the first, second and third years. Time to target temperature [8.0(3.0,18.8), 10.0(4.8, 20.0), 6.0(2.0, 12.0) h], and rates of drug use [17(60.7%), 43(93.5%), 42(71.2%)] and muscle relaxant use [0(0%), 1(2.2%), 13(22.0%)] were significantly different in the first, second and third years(H = 10.475, P = 0.005; χ~2= 12.250, P = 0.002; χ~2= 17.647, P <0.001). The survival rate of ICU discharge presented an upward trend, and the severe disability rate showed an downward trend year by year. However, there were no significant differences in above indicators( χ~2= 2.537, P = 0.281; χ~2= 0.308, P = 0.857) during the implementation period.The recovery rate of neurological functions during the implementation period was significantly different( χ~2= 12.232, P = 0.002); it was higher in the third year than in the first and second years [16(27.1%), 1(3.6%), 3(6.5%), both P < 0.017). Conclusion The standardized HT can significantly improve favorable neurological recovery.
Objective To analyze the prognosis of hypothermia treatment(HT) for coma patients after cardiopulmonary resuscitation(CPR) in Wenzhou. Methods A implementation demonstration base and 10 implementation bases were established in Wenzhou. HT was implemented in patients with coma after CPR from January 2014 to December 2016. The data of HT were recorded. The survival rate of ICU discharge, recovery rate of neurological functions and severe disability rate in the 3-year implementation period were compared. Results In the implementation period, 133 coma patients after CPR were implemented TH. Respectively, 28, 46 and 59 cases were implemented in the first, second and third years. Time to target temperature [8.0(3.0,18.8), 10.0(4.8, 20.0), 6.0(2.0, 12.0) h], and rates of drug use [17(60.7%), 43(93.5%), 42(71.2%)] and muscle relaxant use [0(0%), 1(2.2%), 13(22.0%)] were significantly different in the first, second and third years(H = 10.475, P = 0.005; χ~2= 12.250, P = 0.002; χ~2= 17.647, P <0.001). The survival rate of ICU discharge presented an upward trend, and the severe disability rate showed an downward trend year by year. However, there were no significant differences in above indicators( χ~2= 2.537, P = 0.281; χ~2= 0.308, P = 0.857) during the implementation period.The recovery rate of neurological functions during the implementation period was significantly different( χ~2= 12.232, P = 0.002); it was higher in the third year than in the first and second years [16(27.1%), 1(3.6%), 3(6.5%), both P < 0.017). Conclusion The standardized HT can significantly improve favorable neurological recovery.
引文
1 Bernard SA, Gray TW, Buist MD, et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia[J]. N Engl J Med, 2002, 346(8):557-563.
2 Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest[J]. N Engl J Med, 2002,346(8):549-556.
3 Saigal S, Sharma JP, Dhurwe R, et al. Targeted temperature management:current evidence and practices in critical care[J]. Indian J Crit Care Med, 2015, 19(9):537-546.
4 Peberdy MA, Callaway CW, Neumar RW, et al. Part 9 :post-cardiac arrest care:2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care[J]. Circulation,2010, 122(18 Suppl 3):S768-S786.
5 Callaway CW, Donnino MW, Fink EL, et al. Part 8:post-cardiac arrest care:2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care[J].Circulation, 2015, 132(18 Suppl 2):S465-S482.
6 Howes D, Gray SH, Brooks SC, et al. Canadian Guidelines for the use of targeted temperature management(therapeutic hypothermia)after cardiac arrest:a joint statement from The Canadian Critical Care Society(CCCS), Canadian Neurocritical Care Society(CNCCS),and the Canadian Critical Care Trials Group(CCCTG)[J]. Resuscitation, 2016(98):48-63.
7 Cariou A, Payen JF, Asehnoune K, et al. Targeted temperature management in the ICU:guidelines from a French expert panel[J]. Ann Intensive Care, 2017, 7(1):70.
8 中华医学会神经病学分会神经重症协作组.神经重症低温治疗中国专家共识[J].中华神经科杂志,2015,48(6):453-458.
9 心脏骤停后目标温度管理共识专家组.心脏骤停后目标温度管理专家共识[J].中华急诊医学杂志,2016,25(8):1000-1006.
10 Gasparetto N, Scarpa D, Rossi S, et al. Therapeutic hypothermia in Italian Intensive Care Units after 2010resuscitation guidelines:still a lot to do[J].Resuscitation, 2014, 85(3):376-380.
11 Edelson DP, Yuen TC, Mancini ME, et al. Hospital cardiac arrest resuscitation practice in the United States:a nationally representative survey[J]. J Hosp Med, 2014, 9(6):353-357.
12 Mikkelsen ME, Christie JD, Abella BS, et al. Use of therapeutic hypothermia after in-hospital cardiac arrest[J]. Crit Care Med, 2013, 41(6):1385-1395.
13 Nielsen N, Wetterslev J, Cronberg T, et al. Targeted temperature management at 33 degrees C versus 36degrees C after cardiac arrest[J]. N Engl J Med,2013, 369(23):2197-2206.
14 雷远丽,宋文兴,陆金梅,等.急性心肌梗死后心搏骤停患者预后因素随访研究[J].中华急诊医学杂志, 2018,27(7):740-746.
15 何爱文,陈寿权.心肺复苏研究的最新进展[J/CD].中华危重症医学杂志(电子版),2012,5(4):218-223.
16 杨祖军,徐文卫,汪群智,等.参附注射液对心肺复苏后心功能不全患者血流动力学的影响[J/CD].中华危重症医学杂志(电子版),2014,7(4):266-268.
17 袁伟,李春盛.亚低温治疗在心肺脑复苏中的应用与研究进展[J].中华危重病急救医学,2016,28(12):1165-1169.
18 Mooney MR, Unger BT, Boland LL, et al. Therapeutic hypothermia after out-of-hospital cardiac arrest:evaluation of a regional system to increase access to cooling[J]. Circulation, 2011, 124(2):206-214.
19 Che D, Li L, Kopil CM, et al. Impact of therapeutic hypothermia onset and duration on survival, neurologic function, and neurodegeneration after cardiac arrest[J].Crit Care Med, 2011, 39(6):1423-1430.
20 Kim F, Nichol G, Maynard C, et al. Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest:a randomized clinical trial[J]. JAMA, 2014, 311(1):45-52.
21 Wolff B, Machill K, Schumacher D, et al. Early achievement of mild therapeutic hypothermia and the neurologic outcome after cardiac arrest[J]. Int J Cardiol, 2009, 133(2):223-228.
22 Bray JE, Stub D, Bloom JE, et al. Changing target temperature from 33℃to 36℃in the ICU management of out-of-hospital cardiac arrest:a before and after study[J]. Resuscitation, 2017(113):39-43.
23 Kirkegaard H, Soreide E, de Haas I, et al. Targeted temperature management for 48 vs 24 hours and neurologic outcome after out-of-hospital cardiac arrest:a randomized clinical trial[J]. JAMA, 2017, 318(4):341-350.
24 Kandala J, Oommen C, Kern KB. Sudden cardiac death[J]. Br Med Bull, 2017, 122(1):5-15.
25 Irisawa T, Vadeboncoeur TF, Karamooz M, et al. Duration of coma in out-of-hospital cardiac arrest survivors treated with targeted temperature management[J]. Ann Emerg Med, 2017, 69(1):36-43.
26 Lee BK, Park KN, Kang GH, et al. Outcome and current status of therapeutic hypothermia after out-ofhospital cardiac arrest in Korea using data from the Korea Hypothermia Network registry[J]. Clin Exp Emerg Med, 2014, 1(1):19-27.
27 Guterman EL, Kim AS, Josephson SA. Neurologic consultation and use of therapeutic hypothermia for cardiac arrest[J]. Resuscitation, 2017(118):43-48.
2 Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest[J]. N Engl J Med, 2002,346(8):549-556.
3 Saigal S, Sharma JP, Dhurwe R, et al. Targeted temperature management:current evidence and practices in critical care[J]. Indian J Crit Care Med, 2015, 19(9):537-546.
4 Peberdy MA, Callaway CW, Neumar RW, et al. Part 9 :post-cardiac arrest care:2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care[J]. Circulation,2010, 122(18 Suppl 3):S768-S786.
5 Callaway CW, Donnino MW, Fink EL, et al. Part 8:post-cardiac arrest care:2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care[J].Circulation, 2015, 132(18 Suppl 2):S465-S482.
6 Howes D, Gray SH, Brooks SC, et al. Canadian Guidelines for the use of targeted temperature management(therapeutic hypothermia)after cardiac arrest:a joint statement from The Canadian Critical Care Society(CCCS), Canadian Neurocritical Care Society(CNCCS),and the Canadian Critical Care Trials Group(CCCTG)[J]. Resuscitation, 2016(98):48-63.
7 Cariou A, Payen JF, Asehnoune K, et al. Targeted temperature management in the ICU:guidelines from a French expert panel[J]. Ann Intensive Care, 2017, 7(1):70.
8 中华医学会神经病学分会神经重症协作组.神经重症低温治疗中国专家共识[J].中华神经科杂志,2015,48(6):453-458.
9 心脏骤停后目标温度管理共识专家组.心脏骤停后目标温度管理专家共识[J].中华急诊医学杂志,2016,25(8):1000-1006.
10 Gasparetto N, Scarpa D, Rossi S, et al. Therapeutic hypothermia in Italian Intensive Care Units after 2010resuscitation guidelines:still a lot to do[J].Resuscitation, 2014, 85(3):376-380.
11 Edelson DP, Yuen TC, Mancini ME, et al. Hospital cardiac arrest resuscitation practice in the United States:a nationally representative survey[J]. J Hosp Med, 2014, 9(6):353-357.
12 Mikkelsen ME, Christie JD, Abella BS, et al. Use of therapeutic hypothermia after in-hospital cardiac arrest[J]. Crit Care Med, 2013, 41(6):1385-1395.
13 Nielsen N, Wetterslev J, Cronberg T, et al. Targeted temperature management at 33 degrees C versus 36degrees C after cardiac arrest[J]. N Engl J Med,2013, 369(23):2197-2206.
14 雷远丽,宋文兴,陆金梅,等.急性心肌梗死后心搏骤停患者预后因素随访研究[J].中华急诊医学杂志, 2018,27(7):740-746.
15 何爱文,陈寿权.心肺复苏研究的最新进展[J/CD].中华危重症医学杂志(电子版),2012,5(4):218-223.
16 杨祖军,徐文卫,汪群智,等.参附注射液对心肺复苏后心功能不全患者血流动力学的影响[J/CD].中华危重症医学杂志(电子版),2014,7(4):266-268.
17 袁伟,李春盛.亚低温治疗在心肺脑复苏中的应用与研究进展[J].中华危重病急救医学,2016,28(12):1165-1169.
18 Mooney MR, Unger BT, Boland LL, et al. Therapeutic hypothermia after out-of-hospital cardiac arrest:evaluation of a regional system to increase access to cooling[J]. Circulation, 2011, 124(2):206-214.
19 Che D, Li L, Kopil CM, et al. Impact of therapeutic hypothermia onset and duration on survival, neurologic function, and neurodegeneration after cardiac arrest[J].Crit Care Med, 2011, 39(6):1423-1430.
20 Kim F, Nichol G, Maynard C, et al. Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest:a randomized clinical trial[J]. JAMA, 2014, 311(1):45-52.
21 Wolff B, Machill K, Schumacher D, et al. Early achievement of mild therapeutic hypothermia and the neurologic outcome after cardiac arrest[J]. Int J Cardiol, 2009, 133(2):223-228.
22 Bray JE, Stub D, Bloom JE, et al. Changing target temperature from 33℃to 36℃in the ICU management of out-of-hospital cardiac arrest:a before and after study[J]. Resuscitation, 2017(113):39-43.
23 Kirkegaard H, Soreide E, de Haas I, et al. Targeted temperature management for 48 vs 24 hours and neurologic outcome after out-of-hospital cardiac arrest:a randomized clinical trial[J]. JAMA, 2017, 318(4):341-350.
24 Kandala J, Oommen C, Kern KB. Sudden cardiac death[J]. Br Med Bull, 2017, 122(1):5-15.
25 Irisawa T, Vadeboncoeur TF, Karamooz M, et al. Duration of coma in out-of-hospital cardiac arrest survivors treated with targeted temperature management[J]. Ann Emerg Med, 2017, 69(1):36-43.
26 Lee BK, Park KN, Kang GH, et al. Outcome and current status of therapeutic hypothermia after out-ofhospital cardiac arrest in Korea using data from the Korea Hypothermia Network registry[J]. Clin Exp Emerg Med, 2014, 1(1):19-27.
27 Guterman EL, Kim AS, Josephson SA. Neurologic consultation and use of therapeutic hypothermia for cardiac arrest[J]. Resuscitation, 2017(118):43-48.
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