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1、亚低温技术在心肺复苏中的应用亚低温技术在心肺复苏中的应用Therapeutic hypothermia in post-resuscitation patients提纲提纲1.心跳骤停的流行病学及其预后2.亚低温疗法和其作用机制3.亚低温治疗心跳骤停病人的循证学依据4.哪一种亚低温疗法最有效?5.教育、实施和科研方面的挑战猝死病人死亡率近猝死病人死亡率近70%心脏骤停的流行病心脏骤停的流行病学学400,000 骤停骤停/每年在每年在 U.S.A医院医院3/4 门急诊门急诊1/4 住院患者住院患者出院时的存活率出院时的存活率 1-5%10-20%只有只有 2%的幸存患者神经性功能良好的幸存患者神
2、经性功能良好Mry Ann Peberdy,Joseph P Ornato低温治疗的分类低温治疗的分类分类英文名称目标温度轻度低温mild hypothermia3335亚低温亚低温(mild hypothermia)，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moderate hypothermia2832深度低温profound hypothermia172728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ultraprofound hypothermia16低温治疗作用机制低温治疗作用机制 传统认为：低温主要通过降低葡萄糖和氧耗延缓代谢而
3、起到保护作用诱导低温条件下体温下降1 脑代谢率下降57 低温治疗作用机制的新观念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Bladder Temperature in the Normothermia and Hypothermia Groups.The T bars indicate the 75th percentile in the normothermia group and the 25th p
4、ercentile in the hypothermia group.The target temperature in the hypothermia group was 32 to 34,and the duration of cooling was 24 hours.Only patients with recorded temperatures were included in the analysis.Cooling EndAfter 6 months:75 of the 136(55%)in hypothermia group had better favorable neurol
5、ogic outcome than normothermia group(39%).After 6 months:Rate of death(41%)in the hypothermia is 14%lower than in the normothermia group(39%).欧洲多中心临床试验（欧洲多中心临床试验（HACA trial)随机将随机将275名患者分组为低温或常温两组名患者分组为低温或常温两组 降温时间：使用体表降温降到降温时间：使用体表降温降到34度耗时度耗时6.5个小时个小时 结果：结果：低体温低体温 正常体温正常体温 好的结果好的结果 55%39%p=0.009 死亡
6、率死亡率 41%55%p=0.02每六个接受治疗的患者，每六个接受治疗的患者，有一个可救活！有一个可救活！Number needed to treat to achieve good neurological outcome in one extra patient:6 Holzer M et al.,Crit Care Med 2005;33:414-8.澳大利亚的研究澳大利亚的研究 77名患者的随机临床试验名患者的随机临床试验 使用冰袋冷却使用冰袋冷却0.9度度/小时小时 结果结果:低体温低体温 正常体温正常体温 好结果好结果 49%26%p=0.046 死亡率死亡率51%68%P=NSP
7、reliminary evidence in patients with asystole/PEAPolderman KH et al.Induced hypothermia improves neurological outcomein asystolic patients with out-of hospital cardiac arrest.Circulation 2003;108:IV-581 abstract 2646欧洲欧洲HART Study-ICY 在心脏骤停的在心脏骤停的多中心试验多中心试验 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
8、进行可行性和安全性评估多中心参加:Henry Ford,Duke,University of Houston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CoolGard 3000和Icy 导管作为金标准降温疗法。Before-and after comparison in 665 out-of hospital cardiac arrest in the Stavanger area(population 300 000)2001-2003Before-and after comparison in 665 ou
9、t-of hospital cardiac arrest in the Stavanger area(population 300 000)2001-2003Cooling Procedure introduce the cooling device(Icy and CoolGard 3000;Alsius Corp)foley-catheter24 htarget temperature at 33 rewarmed0.5 /h3637 Icy-catheterStart up KitAll patients in the database from August 1991 to Novem
10、ber 2004 were screened.For outcome evaluation all patients who were cooled with endovascular cooling during this period were evaluated.For evaluation of cooling rate we restricted the analysis to patients who received endovascular cooling exclusively.Bladder temperature course.Median,25th and 75th q
11、uartile of bladder temperature after return of spontaneous circulation in patients,who were exclusively cooled with the endovascular cooling device(n=56).Target temperature,33C;cooling duration,24 hours.95 min 35.31.0 253 min 33 24 hr388 min36 1.2 /hour Adverse Event Endovascular Cooling(n=62)Contro
12、l(n=104)P Within the first 32 hAtrial fibrillation,n(%)2(3)2(3)0.987Ventricular tachycardia,n(%)14(23)9(14)0.231Ventricular fibrillation,n(%)6(10)6(10)0.977Narrow complex tachycardia,n(%)03(5)0.082Bradycardia,n(%)9(15)2(3)0.025Any Bleeding,n(%)16(26)27(26)0.982 Within the first 7 dPneumonia,n(%)17(2
13、7)20(19)0.233Elevation of pancreatic enzymes,n(%)1(2)00.194Sepsis,n(%)00.Acute renal failure,n(%)4(6)4(4)0.448Complications During and After Endovascular Cooling Compared to Frequency-Matched Controls Methods-Consecutive comatose survivors of cardiac arrest,who were either cooled for 24 hours to 33C
14、 with endovascular cooling or treated with standard postresuscitation therapy,were analyzed.Complication data were obtained by retrospective chart review.Results-Patients in the endovascular cooling group had 2-fold increased odds of survival(67/97 patients vs 466/941 patients;odds ratio 2.28,95%CI,
15、1.45 to 3.57;P0.001).After adjustment for baseline imbalances the odds ratio was 1.96(95%CI,1.19 to 3.23;P=0.008).In the endovascular cooling group,51/97 patients(53%)survived with favorable neurology as compared with 320/941(34%)in the control group(odds ratio 2.15,95%CI,1.38 to 3.35;P=0.0003;adjus
16、ted odds ratio 2.56,1.57 to 4.17).There was no difference in the rate of complications except for bradycardia.Conclusion-Endovascular cooling improved survival and short-term neurological recovery compared with standard treatment in comatose adult survivors of cardiac arrest.Temperature control was effective and safe with this device.An advisory statement by the Advanced Life Support Task Force of the International Liaison Committee on Resuscitation(ILCOR includes AHA)(Published in Resuscitation
