体外心肺复苏在成人难治性院内心脏骤停中的应用
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摘要
目的总结体外心肺复苏(ECPR)技术用于成人院内心脏骤停(IHCA)患者抢救性循环辅助治疗的临床经验。方法总结分析2012年7月至2017年12月间于首都医科大学附属北京安贞医院住院的74例成人IHCA患者进行ECPR辅助患者临床资料,按照是否存活出院分为出院存活组(SG组,n=23)和住院死亡组(DG组,n=51),通过多元回归来分析影响患者临床预后的高危风险因素。结果存活出院患者,神经系统功能良好(脑功能分级为CPC 1～2级)。与SG组患者相比较,DG组患者接受ECPR辅助前的平均年龄较高、血气p H值较低和细胞外剩余碱较低,差异均有统计学意义(P值均小于0. 05)。体外膜氧合(ECMO)辅助期间DG组患者肾脏功能衰竭需接受持续肾脏替代治疗和严重神经系统并发症的发生率均较高,差异均有统计学意义(P值均小于0. 05)。多元回归分析结果提示高龄(年龄≥65岁)、肾脏功能衰竭需要持续肾脏替代治疗和严重神经系统并发症是影响IHCA患者住院死亡的独立高危风险因素。结论 ECMO能够为成人IHCA患者提供有效循环辅助,挽救部分患者生命。
Objective To identified the impact of extracorporeal cardiopulmonary resuscitation(ECPR) on survival and neurologic outcome in adults with refractory in-hospital cardiac arrest(IHCA).Methods All 74 adult patients who underwent ECPR for IHCA were enroued from July 2012 to December2017 in Beiing Anzhen Hospital,Capital Medical University.Survival to discharge and cerebral performance category(CPC) scale were evaluated.The independent high-risk factors were determined using multivariate regression analysis models.Results Patients were discharged alive with favorable neurologic outcomes(CPC1-2).Compared with patients in the SG group,the value of blood gas pH and extracellular residual alkaloids in the DG group were statistically lower(with P values below 0.05).The incidence of renal function failure requiring continuous renal replacement treatment(CRRT) and severe neurological complications were statistically higher in DG group patients.Multivariate regression analysis suggested that advanced age(age≥65 years),renal function failure requiring CRRT,and severe neurological complications were independent high-risk factors for hospital death.Conclusions ECMO can provide stable hemodynamic support to inhospital cardiac arrest patients and save the lives of some patients.ECMO should be actively implanted when the cause of cardiac arrest is expected to be recoverable.
Objective To identified the impact of extracorporeal cardiopulmonary resuscitation(ECPR) on survival and neurologic outcome in adults with refractory in-hospital cardiac arrest(IHCA).Methods All 74 adult patients who underwent ECPR for IHCA were enroued from July 2012 to December2017 in Beiing Anzhen Hospital,Capital Medical University.Survival to discharge and cerebral performance category(CPC) scale were evaluated.The independent high-risk factors were determined using multivariate regression analysis models.Results Patients were discharged alive with favorable neurologic outcomes(CPC1-2).Compared with patients in the SG group,the value of blood gas pH and extracellular residual alkaloids in the DG group were statistically lower(with P values below 0.05).The incidence of renal function failure requiring continuous renal replacement treatment(CRRT) and severe neurological complications were statistically higher in DG group patients.Multivariate regression analysis suggested that advanced age(age≥65 years),renal function failure requiring CRRT,and severe neurological complications were independent high-risk factors for hospital death.Conclusions ECMO can provide stable hemodynamic support to inhospital cardiac arrest patients and save the lives of some patients.ECMO should be actively implanted when the cause of cardiac arrest is expected to be recoverable.
引文
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[9]中国医师协会体外生命支持专业委员会.成人体外膜氧合循环辅助专家共识[J].中华医学杂志,2018,98(12):886-894.
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[11]Tirkkonen J,Huhtala H,Hoppu S.In-hospital cardiac arrest after a rapid response team review:A matched case-control study[J].Resuscitation,2018,126:98-103.
[12]Abrams D,Garan AR,Abdelbary A,et al.Position paper for the organization of ECMO programs for cardiac failure in adults[J].Intensive Care Med,2018,44(6):717-729.
[13]Nolan JP,Berg RA,Callaway CW,et al.The present and future of cardiac arrest care:international experts reach out to caregivers and healthcare authorities[J].Intensive Care Med,2018,44(6):823-832.
[14]Kleinman ME,Perkins GD,Bhanji F,et al.ILCOR Scientific Knowledge Gaps and Clinical Research Priorities for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care:A Consensus Statement[J].Circulation,2018,137(22):e802-819.
[15]侯晓彤.规范发展体外膜氧合循环辅助支持[J].中国体外循环杂志,2018,16(4):193-195.
[2]Stub D,Bernard S,Pellegrino V,et al.Refractory cardiac arrest treated with mechanical CPR,hypothermia,ECMO and early reperfusion(the CHEER trial)[J].Resuscitation,2015,86:88-94.
[3]Link MS,Berkow LC,Kudenchuk PJ,et al.Part 7:Adult Advanced Cardiovascular Life Support:2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care[J].Circulation,2015,132(18 Suppl 2):S444-S464.
[4]Perkins GD,Olasveengen TM,Maconochie I,et al.European Resuscitation Council Guidelines for Resuscitation:2017 update[J].Resuscitation,2018,123:43-50.
[5]贾明,王红,周晔,等.体外膜肺氧合在心脏手术后心肺复苏困难患者的应用[J].中国体外循环杂志,2014,12(2):73-76.
[6]江春景,杨峰,郝星,等.体外膜肺氧合辅助院内难治性心脏骤停患者转归的预测指标[J].心肺血管病杂志,2015,34(12):899-903.
[7]陈英,李呈龙,王红,等.机械循环辅助下发生小腿骨筋膜室综合症患者的转归及预后影响因素分析[J].中国医药,2017,12:1032-1035.
[8]Li CL,Wang H,Jia M,et al.The early dynamic behavior of lactate is linked to mortality in postcardiotomy patients with extracorporeal membrane oxygenation support:A retrospective observational study[J].J Thorac Cardiovasc Surg,2015,149(5):1445-1450.
[9]中国医师协会体外生命支持专业委员会.成人体外膜氧合循环辅助专家共识[J].中华医学杂志,2018,98(12):886-894.
[10]Combes A,Brodie D,Chen YS,et al.The ICM research agenda on extracorporeal life support[J].Intensive Care Med,2017,43(9):1306-1318.
[11]Tirkkonen J,Huhtala H,Hoppu S.In-hospital cardiac arrest after a rapid response team review:A matched case-control study[J].Resuscitation,2018,126:98-103.
[12]Abrams D,Garan AR,Abdelbary A,et al.Position paper for the organization of ECMO programs for cardiac failure in adults[J].Intensive Care Med,2018,44(6):717-729.
[13]Nolan JP,Berg RA,Callaway CW,et al.The present and future of cardiac arrest care:international experts reach out to caregivers and healthcare authorities[J].Intensive Care Med,2018,44(6):823-832.
[14]Kleinman ME,Perkins GD,Bhanji F,et al.ILCOR Scientific Knowledge Gaps and Clinical Research Priorities for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care:A Consensus Statement[J].Circulation,2018,137(22):e802-819.
[15]侯晓彤.规范发展体外膜氧合循环辅助支持[J].中国体外循环杂志,2018,16(4):193-195.
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