心肺復(fù)蘇低溫治療課件-2

1、Therapeutic hypothermia in PostCardiac Arrest Care2015 VS 2010Therapeutic hypothermia in Po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 住院患者心臟驟停的流行病學(xué)400,000 驟停 / 每年在 U.S.心肺復(fù)蘇低溫治療課件_2心肺復(fù)蘇低溫治療課件_2 hypoxemiaischemia reperfusion multiple organ systems Influence of cardiac arrest and resuscitation Inf

2、luence of cardiac arrest a低溫治療定義低溫治療：是一種以物理方法將患者的體溫降低到預(yù)期水平而達(dá)到治療疾病目的的方法。 低溫治療定義低溫治療：是一種以物理方法將患者的體溫降低到預(yù)期低溫療法是荷蘭物理學(xué)家卡曼林昂內(nèi)斯（1853-1926）發(fā)明的，被譽(yù)為“低溫學(xué)之父。”低溫學(xué)之父低溫療法是荷蘭物理學(xué)家卡曼林昂內(nèi)斯（1853-1926）發(fā)低溫治療的分類分類英文名稱目標(biāo)溫度輕度低溫mild hypothermia3335亞低溫(mild hypothermia)，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moderate hypothermia28

3、32深度低溫profound hypothermia172728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ultraprofound hypothermia16低溫治療的分類分類英文名稱目標(biāo)溫度輕度低溫mild hypo低溫治療作用機(jī)制的新觀念降低腦的代謝水平，減低氧耗，改善并恢復(fù)能量供給；抑制氧自由基產(chǎn)生，減輕氧化應(yīng)激損傷；下調(diào)炎癥介質(zhì)的產(chǎn)生和炎癥細(xì)胞的集聚，減輕炎癥損傷；減低神經(jīng)細(xì)胞及心肌細(xì)胞凋亡。 IntensiveCareMed.1996,22(11):1191-6.低溫治療作用機(jī)制的新觀念降低腦的代謝水平，減低氧耗，改善并恢適應(yīng)癥心肺復(fù)述后病人顱腦損傷及重型顱腦

4、手術(shù)后病人低溫麻醉病人高熱驚厥或超高熱病人感染中毒性休克早期病人及顱內(nèi)感染病人急性重癥腦血管病心肺復(fù)蘇后病人適應(yīng)癥心肺復(fù)述后病人顱腦損傷及重型顱腦手術(shù)后病人低溫麻醉病人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 hypoth

5、ermia group was 32 to 34 , and the duration of cooling was 24 hours. Only patients with recorded temperatures were included in the analysis. N Engl J Med. 2002, 346(8): 557-563. The 2010 Guidelines advised hypothermia(32C to 34C) Bladder Temperature in the NorAfter 6 months: 75 of the 136 (55%) in h

6、ypothermia group had better favorable neurologic outcome than normothermia group (39%).After 6 months: 75 of the 136 After 6 months: Rate of death (41%) in the hypothermia is 14% lower than in the normothermia group (55%).After 6 months: Rate of death The 2010 Guidelines advised hypothermia duration

7、 temperature 12 to 24 hours N Engl J Med. 2002, 346(8): 549-556. hypothermia (33C maintained 12 hours) VS normothermia. The 2010 Guidelines advised hyThe 2015 Guidelines advised hypothermia(32C to 36C) N Engl J Med. 2013, 369(23): 2197-2206. The 2015 Guidelines advised hy2015 Guidelines advised hypo

8、thermia at least 24 hours N Engl J Med. 2013, 369(23): 2197-2206. 2015 Guidelines advised hypoth（cerebral performance category，CPC）腦功能功能分類敏感性較差1. 好的腦功能： 有意識(shí)，靈敏，和能夠工作并且正常生活。 可能有輕微心理或者神經(jīng)病學(xué)缺陷(輕度的語(yǔ)言障礙，輕癱或者輕微腦神經(jīng)異常) .2. 中度腦殘疾： 有意識(shí)。在一保護(hù)的環(huán)境有足夠腦功能勝任部分工作或者能進(jìn)行獨(dú)立日常生活活動(dòng)(如穿，乘公共交通，食品準(zhǔn)備). 這樣的病人可能有半身不遂，發(fā)作，共濟(jì)失調(diào)，構(gòu)語(yǔ)障礙，

9、言語(yǔ)障礙或者永久記憶或者精神變化（cerebral performance category3.嚴(yán)重腦殘疾：有意識(shí)；因?yàn)槭軗p的大腦功能病人依靠其他人得到日常幫助(在一個(gè)機(jī)構(gòu)里或者在家需要特別的家庭幫助)。至少已經(jīng)有認(rèn)知限制。這個(gè)種類包括大范圍腦的不正常，病人能行走但是有嚴(yán)重的記憶混亂或者癡呆不能獨(dú)立生存，那些全身癱瘓并且只能用眼睛交流的人，如同閉鎖綜合癥。4.昏迷/植物的狀態(tài)：沒(méi)有意識(shí)，沒(méi)意識(shí)到環(huán)境，沒(méi)有認(rèn)知。沒(méi)有文字和或心理與環(huán)境的相互作用。5.腦死亡。 JAMA.2006,295(1):50-573.嚴(yán)重腦殘疾：有意識(shí)；因?yàn)槭軗p的大腦功能病人依靠其他人Follow-up and Outco

10、mesFollow-up and Outcomes序貫器官衰竭估計(jì)評(píng)分(SOFA)每一變量的分值均為03分，總分09分。分值越大，表明細(xì)胞受損/臟器功能受損越重，預(yù)后也越差 序貫器官衰竭估計(jì)評(píng)分(SOFA)每一變量的分值均為03分Cardiovascular component of Sequential Organ Failure Assessment score Day 1 to 3Cardiovascular component of SeSerious adverse events excluding deathSerious adverse events excludiPatient

11、s were excluded due to exclusion criteria 13 known bleeding diathesis 15 suspected or confirmed acute intracranial bleeding 5 suspected or confirmed acute strokePatients were excluded due to Seizures might be preferred lower temperaturesNeurol Res. 2013, 35(2): 163-168. Seizures might be preferred l

12、ocerebral edema might be preferred lower temperaturesAm Heart J. 2012, 163(4): 541-548.cooling defined as a temperature less than 34.5 C within 8 h cerebral edema might be preferHigher temperatures might be preferred in bleeding J Trauma. 1998 May;44(5):846-54.Higher temperatures might be p心肺復(fù)蘇低溫治療課

13、件_2Rewarming maintain the body temperature After 28 hours, gradual rewarming to 37C in hourly increments of 0.5C was commenced in both groups. At 36 hours, mandatory sedation was discontinued or tapered. After the intervention period, the intention was to maintain the body temperature for unconsciou

14、s patients below 37.5C until 72 hours after the cardiac arrest, with the use of fever-control measures at the discretion of the sites.Rewarming maintain the body terebound hyperthermiaA newly described phenomenon is known as “rebound hyperthermia”, which is defined as a core body temperature of 38.5

15、 C or greater within 24 h of cessation of THrebound hyperthermiaA newly deAvoidance of Hyperthermia fever Am Heart J 2012;163:541-8.Avoidance of Hyperthermia feveAssociation of rebound hyperthermia with mortalityCirculation 2011;124:206-14.Association of rebound hyperthRisk factors for rebound hyper

16、thermiaCrit Care Med 2009;37:1101-20.Risk factors for rebound hyperThe presence of rebound hyperthermia is associated with anincreased risk of in-hospital mortality. 40 of the 99 (40.4%) patients without rebound hyperthermia experienced any cause in-hospital death. This is compared to 27 of the 42 (

17、64.3%) patients who experienced rebound hyperthermia (OR: 2.66; 95% CI: 1.265.61; p = 0.011). The risk of rebound hyperthermia. Resuscitation 2013;84:927-34.The presence of rebound hypertTreat fever until at least 72 hrs after cardiac arrest. Treat fever until at least 72 Reasons for early rewarming Arrhythmia (severe bradycardia, recurrent ventricular fibrillation) Severe circulatory instability Bleedin