客制化CPR可以增加心脏停止后存活


  【24drs.com】根据一篇新研究,使用舒张压和潮气末二氧化碳测量指引院内心肺复苏术,与显著改善心脏停止后的存活机会有关。
  
  费城宾州大学医学院儿童医院Robert Sutton医师表示,健康照护提供者必须监测病患对于复苏急救的反应;他在重症照护医学会第44届重症照护研讨会中表示,事实上,或许需要改变他们的方法,如果他们在提供CPR时没有足够的病患生理数据的话。
  
  院内心脏停止大部分发生于加护病房,都有血压与二氧化碳监测设备,尽管如此,往往是以制式的方法进行CPR,而未根据这些读数调整。
  
  Sutton医师解释,当使用测量读数时,CPR可以更密切反应病患的立即需求;这个监测过程是一种个人化医疗;这些监测数据代表CPR时的血流初步估计。我们认为,CPR时血流改善相当于病患有比较好的结果。
  
  Sutton医师曾参与的动物研究显示,根据个别的生理资料调整复苏力道,可以挽救生命。
  
  在这次的研究中,他的团队评估了「2000-2012年间遵循复苏术临床指引(Get With the Guidelines- Resuscitation)」登录计画的245,300个CPR事件。
  
  分析舒张压时,16,301次CPR事件中的11,259例(69%)获得自主循环恢复,有4,212例(26%)使用舒张压监测CPR的质量。
  
  潮气末二氧化碳的分析中,47,135次CPR事件中的30,980例(66%)获得自主循环恢复,有1,648例(3.5%)使用潮气末二氧化碳监测质量。
  
  没有使用动脉导管的事件、或在心脏停止时有侵入性呼吸道急救的病患未被纳入研究。
  
  校正年龄、性别、种族、骤停发生的年份、初次无脉搏节律、骤停的时间等共变项之后,使用舒张压监测CPR的质量时,自主循环恢复比未监测者好(胜算比[OR],1.23,95%信心区间[CI],1.12- 1.36;P< .001);潮气末二氧化碳也是为真(OR,1.25;95% CI,1.10- 1.43;P< .001)。
  
  当潮气末二氧化碳值大于10 mm Hg时,自主循环恢复与潮气末二氧化碳的关联更强(P< .001)。
  
  Sutton医师表示,这些研究结果强调了从舒张压与潮气末二氧化碳测量指引与帮助CPR决策的价值。
  
  他解释,医师可能需要压快一点、慢一点、大力一点或小力一点;但是,那些确认因素是相当个人化的,无法适用多数病患。
  
  Sutton医师表示,目前在基本救命术和高阶救命术皆未强调监测或把监测列入优先,可能是因为少有人类研究资料显示这种复苏方法可以改善目前标准方法的结果;这次的研究可望开始改变我们的焦点。
  
  克里夫兰大学医院彩虹婴幼童医院的Alexandre Rotta医师表示,这是一篇重要的研究,因为它增加了有关CPR质量的文献资料;近几年来,我们知道并非每次CPR都有效,施作CPR时有显著的操作变化。
  
  他指出,这篇研究的强度在于大样本数。
  
  Rotta医师表示,虽然这篇研究有一些限制,例如回溯性研究的本质,但它应可推动迫切需要的进一步研究。
  
  他解释,这不是不可能,但是难以辨别病患是否因为在复苏时调整了CPR过程,而达到较高的舒张压或较高的潮气末二氧化碳,或者是这些病患只是有比较高的舒张压与潮气末二氧化碳;已知这些与较佳的结果有关。
  
  他指出,这个问题只能用前瞻研究来回答。目前的研究提供了足够的有趣证据等待这类研究来证明,在CPR时使用这两个变项来探讨。
  
  资料来源:http://www.24drs.com/professional/list/content.asp?x_idno=7155&x_classno=0&x_chkdelpoint=Y

'Personalized' CPR Increases Survival From Cardiac Arrest

By Nancy A. Melville
Medscape Medical News

PHOENIX — The use of diastolic blood pressure and end tidal carbon dioxide measures to guide in-hospital cardiopulmonary resuscitation (CPR) is associated with a significant improvement in the chance of survival from cardiac arrest, according to new research.

"Healthcare providers need to monitor how the patient is responding to the resuscitation effort," said lead investigator Robert Sutton, MD, from the University of Pennsylvania School of Medicine and the Children's Hospital of Philadelphia.

In fact, they might "need to change their approach if they are not getting good patient physiology during the CPR that they are providing," he told Medscape Medical News here at the Society of Critical Care Medicine 44th Critical Care Congress.

Most in-hospital cardiac arrests occur in the intensive care unit, where blood pressure and carbon dioxide are already closely monitored. Despite that, CPR efforts are typically made in a uniform manner and are not adjusted to those readings.

When the measures are used, CPR is more closely responsive to the patient's immediate needs, Dr Sutton explained.

"This monitoring is a form a personalized medicine; these monitors are a rough approximation of blood flow during CPR," he said. "And we think better blood flow during CPR equates to better patient outcome."

We think better blood flow during CPR equates to better patient outcome.

Dr Sutton has been involved in previous animal studies that showed that the titration of resuscitation efforts according to the individual's physiology can save lives.

In this study, his team evaluated 245,300 CPR events reported in the Get With the Guidelines – Resuscitation registry of all in-hospital CPR events from 2000 to 2012.

In an analysis of diastolic blood pressure, 11,259 of 16,301 (69%) CPR events resulted in a return of spontaneous circulation, and in 4212 (26%) events, diastolic blood pressure was used to monitor the quality of CPR.

In an analysis of end tidal carbon dioxide, 30,980 of 47,135 (66%) CPR events resulted in a return of spontaneous circulation, and in 1648 (3.5%) events, end tidal carbon dioxide was used to monitor quality.

Events in which an arterial catheter was not used or an invasive airway was in place at the time of the cardiac arrest were excluded from the study.

The return of spontaneous circulation was better when diastolic blood pressure was used to monitor CPR than when it was not after adjustment for potential confounders such as age, sex, race, year of arrest, first pulseless rhythm, and duration of arrest (odds ratio [OR], 1.23, 95% confidence interval [CI], 1.12 - 1.36; P < .001).

The same was true for end tidal carbon dioxide (OR, 1.25; 95% CI, 1.10 - 1.43; P < .001).

The association between a return to spontaneous circulation and end tidal carbon dioxide was stronger when the end tidal carbon dioxide achieved was above 10 mm Hg than when it was not (P < .001).

These findings underscore the value of guidance from diastolic blood pressure and end tidal carbon dioxide measures and in CPR decision-making, Dr Sutton said.

"Clinicians may need to push faster, slower, harder, or less hard," he explained. "But the determining factor should be the individual patient, not what works with most patients."

New Targets

"Monitoring has not been emphasized or made a priority in our existing basic and advanced life support classes, likely because there was little human data showing that such a resuscitation approach would improve outcomes over our standard methods," Dr Sutton said. "This study will hopefully begin to change our focus."

This is "an important study because it adds to the body of literature on CPR quality," said Alexandre Rotta, MD, from University Hospitals Rainbow Babies & Children's Hospital in Cleveland.

"For a few years now we have known that not every CPR is effective and that there is significant operator variability in delivering CPR," he told Medscape Medical News.

"The strength of this study is in the large sample," he added.

Although the study has some important limitations, such as its retrospective nature, it nevertheless should spur much-needed additional research, said Dr Rotta.

"It is difficult, if not impossible, to discern whether patients who achieved a higher diastolic blood pressure and higher end tidal carbon dioxide did so because adjustments were made to the CPR process during resuscitation, or whether these patients simply had higher diastolic blood pressure and end tidal carbon dioxide, which have been known for years to be associated with better outcomes," he explained.

"This question can only be answered by a prospective study," he added. "The current study provides enough intriguing evidence to justify such a trial using these two candidate variables as targets during CPR."

Dr Sutton's work is supported by a National Institutes of Health award, he is a member of the Get With the Guidelines – Resuscitation Pediatrics Task Force, and he has received speakers honoraria from Zoll Medical. Dr Rotta has disclosed no relevant financial relationships.

Society of Critical Care Medicine (SCCM) 44th Critical Care Congress: Abstract 225. Presented January 18, 2015.

    
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