亚低温技术在心肺复苏中的应用.ppt

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,亚低温技术在心肺复苏中的应用,Therapeutic hypothermia in post-resuscitation patients,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,猝死病人死亡率近,70%,350000,猝死病人,100000,尝试做,CPR,40000,到达医院病人,20000,活着出医院,12000,没有或很少有后遗症,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,Mry Ann Peberdy,Joseph P Ornato,High quality,post resuscitation care,Survival rates among those admitted vary from 0 60%!,低温治疗的分类,分类,英文名称,目标温度,轻度低温,mild hypothermia,33,35,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 hypothermia,28,32,深度低温,profound hypothermia,17,27,28,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,ultraprofound hypothermia,16,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,低温治疗作用机制的新观念,抗凋亡、,Ca,2+,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 percentile 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 End,After 6 months:,75 of the 136,(55%),in,hypothermia,group had better favorable neurologic 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（,HACA trial),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！,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,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,Preliminary evidence in patients with asystole/PEA,Polderman KH,et al.,Induced hypothermia improves neurological outcome,in asystolic patients with out-of hospital cardiac arrest.,Circulation,2003;108:IV-581 abstract 2646,欧洲,HART Study-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,: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)2001-2003,Before-and after comparison in 665 out-of hospital cardiac arrest in the Stavanger area(population 300 000)2001-2003,Cooling Procedure,introduce the cooling device,(Icy and CoolGard 3000;Alsius Corp),foley-catheter,24 h,target,temperature at 33,rewarmed,0.5 /h,3637,Icy-catheter,Start up Kit,All patients in the database from August 1991 to November 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 quartile 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 hr,388 min,36,1.2 /hour,Adverse Event,Endovascular Cooling,(n=62),Control,(n=104),P,Within the first 32 h,Atrial fibrillation,n(%),2(3),2(3),0.987,Ventricular tachycardia,n(%),14(23),9(14),0.231,Ventricular fibrillation,n(%),6(10),6(10),0.977,Narrow complex tachycardia,n(%),0,3(5),0.082,Bradycardia,n(%),9(15),2(3),0.025,Any Bleeding,n(%),16(26),27(26),0.982,Within the first 7 d,Pneumonia,n(%),17(27),20(19),0.233,Elevation of pancreatic enzymes,n(%),1(2),0,0.194,Sepsis,n(%),0,0,.,Acute renal failure,n(%),4(6),4(4),0.448,Complications 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 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,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;adjusted 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.Tempera