纳洛酮在心肺复苏中疗效的系统评价

目的 评价纳洛酮在心肺复苏中的疗效.方法 计算机检索中国期刊全文数据库、中文科技期刊全文数据库、数字化期刊全文数据库、中国生物医学文献数据库、EMBASE、PubMed、Cochrane Library、SCI等并辅以手工检索,按照纳入标准,两名研究者独立筛选文献并提取资料,采用Jadad评分标准评价纳入文献的质量,采用RevMan5.0软件进行统计学处理.结果 纳入14篇文献(953例患者).Meta分析结果显示,纳洛酮联合常规心肺复苏在复苏成功率(P<0.00001)、自主循环恢复成功率(P=0.0001)、自主呼吸恢复成功率(P<0.00001)、从呼吸心跳恢复到脑复苏的时间(P<0.00001)等方面均有统计学意义.结论 纳洛酮对部分患者可以提高心肺复苏的成功率,并有促进脑复苏作用.由于纳入研究样本的地域性限制,尚需要高质量、大样本、多中心的随机双盲对照试验加以证实.     

Catecholamines during cardiopulmonary resuscitation for cardiac arrest.

Serum catecholamines were measured during continued prolonged cardiopulmonary resuscitation and after 10 mg increments of intravenous epinephrine. This was part of an ongoing trial of 10 mg epinephrine versus placebo. Eight patients were in the placebo arm and seven in the epinephrine arm and the rhythms were two ventricular fibrillation, nine asystole and four electromechanical dissociation. Data were analysed by time from onset of the cardiac arrest and samples were analysed for levels of DHPG (dihydroxyphenylglycol) nor-epinephrine, epinephrine, DOPA (dihydroxyphenylalanine) and DOPAC (dihydroxyphenyl acetic acid). There was a significant (P < 0.001) difference between arterial and venous samples of epinephrine but not the other catecholamines. High levels of catecholamines were maintained in all time phases except for nor-epinephrine where significant (P < 0.0003) reduction occurred progressively after 20 min. Non-steady state kinetics were suggested between epinephrine and nor-epinephrine and DHPG and nor-epinephrine for the first 20 min. Very large increases in epinephrine were achieved with administered 10 mg epinephrine and this resulted in high DHPG levels supporting the experimental belief that exogenously administered epinephrine induces myocardial release of nor-epinephrine. This data supports the known effects of CPR on catecholamine release. It provides data on the other neurotransmitter hormones and supports the relationships shown in other animal and human data. It is suggested that supplementation with epinephrine during CPR may be unnecessary and the levels reached may be deleterious. Nor-adrenaline supplementation may be necessary after prolonged CPR.     

Extracorporeal cardiopulmonary resuscitation for adult cardiac arrest patients

Cardiac arrest is a major cause of unexpected death in developed countries, and patients with cardiac arrest generally have a poor prognosis. Despite the use of conventional cardiopulmonary resuscitation (CPR), few patients could achieve return of spontaneous circulation (ROSC). Even if ROSC was achieved, some patients showed re-arrest and many survivors were unable to fully resume their former lifestyles because of severe neurological deficits. Safar et al reported the effectiveness of emergency cardiopulmonary bypass in an animal model and discussed the possibility of employing cardiopulmonary bypass as a CPR method. Because of progress in medical engineering, the system of veno-arterial extracorporeal membrane oxygenation (ECMO) became small and portable, and it became easy to perform circulatory support in cardiac arrest or shock patients. Extracorporeal cardiopulmonary resuscitation (ECPR) has been reported to be superior to conventional CPR in in-hospital cardiac arrest patients. Veno- arterial ECMO is generally performed in emergency settings and it can be used to perform ECPR in patients with out-of-hospital cardiac arrest. Although there is no sufficient evidence to support the efficacy of ECPR in patients with out-of-hospital cardiac arrest, encouraging results have been obtained in small case series.     

Mechanical cardiopulmonary resuscitation for patients with cardiac arrest

BACKGROUND:

Although modern cardiopulmonary resuscitation (CPR) substantially decreases the mortality induced by cardiac arrest, cardiac arrest still accounts for over 50% of deaths caused by cardiovascular diseases. In this article, we address the current use of mechanical devices during CPR, and also compare the CPR quality between manual and mechanical chest compression.

METHODS:

We compared the quality and survival rate between manual and mechanical CPR, and then reviewed the mechanical CPR in special circumstance, such as percutaneous coronary intervention, transportation, and other fields.

RESULTS:

Compared with manual compression, mechanical compression can often be done correctly, and thus can compromise survival; can provide high quality chest compressions in a moving ambulance; enhance the flow of blood back to the heart via a rhythmic constriction of the veins; allow ventilation and CPR to be performed simultaneously.

CONCLUSION:

Mechanical devices will be widely used in clinical practice so as to improve the quality of CPR in patients with cardiac arrest.KEY WORDS: Cardiopulmonary resuscitation, Manual compression, Mechanical compressionCardiopulmonary resuscitation (CPR), also called basic life support, is an emergency medical procedure performed to restore blood flow (circulation) and breathing. The goal of CPR is to provide oxygen quickly to the brain, heart, lungs, and other organs until normal function of the heart and lung is restored. CPR can help prevent brain damage and death in children.[1] It is reported that approximately 600 000 individuals suffer from cardiac arrest and receive cardiopulmonary resuscitation in the United States and Europe each year.[2,3] Although modern CPR substantially decreases the mortality induced by cardiac arrest, cardiac arrest still accounts for over 50% of deaths caused by cardiovascular diseases.[4]The success rate of CPR ranging widely from 5% to 10% is based on many factors such as (1) causes of cardiac or respiratory arrest; (2) underlying health conditions of victims; (3) time elapse between arrest and CPR; and (4) techniques for CPR.[5,6] The survival rate is affected not only by CPR but more importantly by its quality. Effective CPR can contribute more blood flow to the brain, heart and other organs, and thus increase the survival rate of patients with cardiac arrest.[7] In November 2005 the AHA revised CPR guidelines to emphasize chest compression and its effect on blood pressure.[8] Studies[7,9,10] showed that by taking fewer breaks between compressions, rescuers can keep blood pressure higher, which helps to pump blood to the brain and other vital organs. However, during CPR even with the best manual chest compressions, cardiac output is approximately 20% to 30% of normal value, and performer''s fatigue may also reduce the quality of the compressions. Besides, chest compressions can not be performed during the transportation of patients, which prolong the time between the arrest and CPR, and also increase the difficulty of resuscitation.[11,12] Therefore, to avoid or reduce these negative factors and to improve the CPR quality, mechanical devices are frequently used.In this article we address the current use of mechanical devices during CPR, and also compare the CPR quality between manual and mechanical chest compression.

Comparison of quality between manual and mechanical CPR

In 1961, Harrison-Paul[13] applied the electric pneumatic device clinically, and then Kouwenhoven et al[14] introduced closed chest cardiac massage for CPR in 1969. The Kouwenhoven technique has been shown repeatedly its clinically inefficacy. Although this technique can clearly save lives, its inherent inefficiency and the challenges related to teaching and retaining the skills needed to perform the technique correctly have limited its overall effectiveness. This has prompted us to develop new life-saving CPR techniques and devices.At present, the most commonly used mechanical chest-compression devices include LUCASTM, Autopluse, Lifebelt, Thumper and Brunswick-TM HLR R30. Compared with manual compression, mechanical compression can: (1) often be done correctly, and thus can compromise survival; (2) potentially improve the quality of chest compression with automatic mechanical devices, which can potentially apply compression more consistently than manually; (3) can provide high quality chest compressions in a moving ambulance, which is very difficult to accomplish with manual CPR; (4) allow a reduction in a number of emergency medical systems (EMS) personnel needed to perform resuscitation;[15] (5) allow ventilation and CPR to be performed simultaneously; (6) enhance the flow of blood back to the heart via a rhythmic constriction of the veins.[16]Autopulse can markedly increase the mean systolic blood pressure from 72 mmHg to 106 mmHg, and the average diastolic blood pressure from 17 mmHg to 23 mmHg as compared with manual compression (P<0.05). In addition, Autopulse can obviously improve coronary perfusion, and generate approximately 36% of the normal blood flow, which is much higher than that generated by manual compression (13%).[17] But before and after use of Autopulse, there is no significant difference in the pressure of end tidal carbon dioxide (PETCO₂), which serves as an important parameter for evaluating cardiac output and pulmonary blood flow.[18] Axelsson et al[5] reported that in 126 patients who participated in the study, 64 were enrolled in a mechanical chest compression group and 62 in a control group. The group receiving mechanical ACD-CPR showed highest PETCO₂ values in contrast to the average (P=0.04), initial (P=0.01) and minimum (P=0.01) values. There was no significant difference in the maximum values between the two groups. This indicated that chest compression can increase blood supply to the heart and lung.

Comparison of survival rate

Although mechanical CPR can increase cardiac output, coronary and cerebral blood flow, arterial blood pressure, and PETCO₂, whether mechanical CPR can increase the survival rate of patients with cardiac arrest is still in debate. Skogvoll et al[19] reported that there were no significant differences between mechanical and manual CPR compression (survival rates 13% vs. 12%) in 302 patients with cardiac arrest. Another prospective trial showed that the survival rate of patients after hospitalization for 24, 48, and 72 hours and the number of patients who had reestablished spontaneous circulation was increased in the mechanical compression group, but no differences were observed between the mechanical and manual CPR compression groups.[18] In a prospective randomized trial conducted by Kouwenhoven[14], 1410 patients received mechanical CPR and 1456 received manual CPR. The survival rate of the mechanical CPR group was significantly higher than that of the manual CPR group (23.8% vs. 20.6%, P< 0.05). Ong et al[17] also reported that mechanical CPR increased the survival rate of patients. But Skogvoll et al[19] described in their randomized clinical trial that mechanical CPR increased the mortality of patients. Thus further clinical studies or animal experiments are needed to confirm this finding.

Mechanical CPR in special circumstance

Percutaneous coronary intervention (PCI)

In most cases, cardiopulmonary arrest is derived from the heart. Myocardial ischemia caused by acute coronary occlusion can lead to the development of ventricular fibrillation. PCI was thought to be useful in patients with acute ST elevation myocardial infarction (STEMI),[20,21] and it was also beneficial to patients after recovery of spontaneous circulation.[22] Sunde et al[23,24] found that the mortality of patients treated with PCI (n=12) was significantly lower than that of patients treated conservatively (n=20) (17% vs. 70%). However, PCI is seldom used in patients with cardiac arrest.[25] CPR is still required to perform PCI during cardiac arrest, but it is very difficult to simultaneously perform manual CPR and PCI. Mechanical chest compression allows for continued PCI despite ongoing cardiac or circulatory arrest with artificially sustained circulation. A study[25] reported that in 3058 patients treated with PCI for ST-elevation myocardial infarction (STEMI), 118 were in cardiogenic shock and 81 required defibrillation. LUCAS was used in 38 patients, 1 underwent a successful pericardiocentesis, and 36 were treated with PCI. Eleven of these patients were discharged alive in good neurological conditions. Similarly, other studies have shown that that it is feasible to perform mechanical CPR during PCI.[26–29]

Transportation

During ambulance transport to hospital, it may not be possible to perform manual CPR, while mechanical devices may play an important role in maintaining circulation.

Other fields

Mechanical devices have been used in imaging diagnosis. Agostoni et al[30] evaluated both CT image quality in a phantom study and feasibility in an initial case series using automated chest compression (A-CC) devices for cardiopulmonary resuscitation (CPR), and they found under CPR conditions multidetector CT diagnostics supports either focused treatment or the decision to terminate efforts.

Limitations of mechanical CPR

Delayed time-elapse between arrest and CPR

Device use may delay the time-elapse between arrest and CPR. Ong et al[31] reported that LUCAS device delayed CPR for 2.9±2.1 minutes when compared with manual compression. Another study showed that the median no-flow time, defined as the sum of all pauses between compressions longer than 1.5 seconds, during the first 5 minutes of resuscitation, was manual CPR 85 seconds (interquartile range [IQR] 45 to 112 seconds) versus mechanical CPR 104 seconds (IQR 69 to 151 seconds). The mean no-flow ratio, defined as no-flow time divided by segment length, was manual 0.28 versus mechanical CPR 0.40 (difference=−0.12; 95% confidence interval −0.22 to −0.02). However, from 5 to 10 minutes into the resuscitation, the median no-flow time was manual 85 seconds (IQR 59 to 151 seconds) versus mechanical CPR 52 seconds (IQR 34 to 82 seconds) and the mean no-flow ratio manual 0.34 versus mechanical CPR 0.21 (difference=0.13; 95% confidence interval 0.02 to 0.24). The average time to apply mechanical CPR during this period was 152 seconds. This suggests that in the first 5 minutes, the quality of manual CPR is higher than that of mechanical CPR; while during 5-10 minutes, the quality of mechanical CPR was improved. Hallstrom et al[19] reported that use of an automated LDB-CPR device as used in this study was associated with worse neurological outcomes and a trend toward worse survival than manual CPR. These factors might partly explain the varied outcomes treated with mechanical CPR.

Injuries associated with mechanical CPR

Mechanical chest compression can also cause injuries in patients. Hallstrom et al[32,33] reported that fracture was present in 10/47 in the manual group and in 11/38 in the LUCAS group (P=0.46), and there were multiple rib fractures (> or =3 fractures) in 13/47 in the manual group and in 17/38 in the LUCAS group (P=0.12). Bleeding in the ventral mediastinum was noted in 2/47 and 3/38 in the manual and LUCAS groups respectively (P=0.65), retrosternal bleeding in 1/47 and 3/38 (P=0.32), epicardial bleeding in 1/47 and 4/38 (P=0.17), and hemopericardium in 4/47 and 3/38 (P=1.0), respectively. This finding indicates that mechanical chest compression with the LUCAS device appears to be associated with the same variety and incidence of injuries as manual chest compression. For the injuries caused by mechanical CPR, we still need further clinical studies.In conclusion, mechanical devices will be widely used in clinical practice so as to improve the quality of CPR in patients with cardiac arrest.     

Extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest: A review of the Japanese literature

Aim

Although favourable outcomes in patients receiving extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest have been frequently reported in Japanese journals since the late 1980s, there has been no meta-analysis of ECPR in Japan. This study reviewed and analysed all previous studies in Japan to clarify the survival rate of patients receiving ECPR.

Material and methods

Case reports, case series and abstracts of scientific meetings of ECPR for out-of-hospital cardiac arrest written in Japanese between 1983 and 2008 were collected. The characteristics and outcomes of patients were investigated, and the influence of publication bias of the case-series studies was examined by the funnel-plot method.

Results

There were 1282 out-of-hospital cardiac arrest patients, who received ECPR in 105 reports during the period. The survival rate at discharge given for 516 cases was 26.7 ± 1.4%. The funnel plot presented the relationship between the number of cases of each report and the survival rate at discharge as the reverse-funnel type that centred on the average survival rate. In-depth review of 139 cases found that the rates of good recovery, mild disability, severe disability, vegetative state, death at hospital discharge and non-recorded in all cases were 48.2%, 2.9%, 2.2%, 2.9%, 37.4% and 6.4%, respectively.

Conclusions

Based on the results of previous reports with low publication bias in Japan, ECPR appears to provide a higher survival rate with excellent neurological outcome in patients with out-of-hospital cardiac arrest.     

Bystander cardiopulmonary resuscitation for out-of-hospital cardiac arrest in the Hispanic vs the non-Hispanic populations

Study Objective

The aim of this study is to compare rates of bystander cardiopulmonary resuscitation (CPR) for Hispanic and non-Hispanic out-of-hospital cardiac arrest (OOHCA) victims in Arizona.

Methods

This is a secondary analysis of consecutive OOHCA victims prospectively enrolled into our statewide OOHCA quality improvement database between November 2004 and November 2006. Continuous data are presented as means ± SDs and analyzed using t tests; categorical data are presented as frequency of occurrence and analyzed using χ². The primary outcome was whether bystander CPR rates were different for Hispanic vs non-Hispanic OOHCA victims. Secondary comparisons were initial cardiac rhythms and survival to hospital discharge.

Results

There were 2411 OOHCA victims during the period of analysis. A total of 952 arrests were excluded because ethnicity was not documented; 80 arrests were excluded because they were traumatic. A total of 1379 arrests were included for analysis, of which 273 (19.8%) were Hispanic. Hispanics were less likely to receive bystander CPR than non-Hispanics (32.2% vs 41.5%; P < .0001). Hispanics and non-Hispanics were dissimilar with respect to age (53.2 ± 25 vs 64.5 ± 19.3 years; P = .0001), paramedic response time (5.1 vs 5.5 minutes; P = .0006), initial rhythm asystole (53.8% vs 44.5%; P = .005), and initial rhythm ventricular fibrillation (20.5% vs 26.7%; P = .036). Survival to hospital discharge (8.1% vs 7.1%) was not statistically different.

Conclusion

In the state of Arizona, significantly fewer Hispanic OOHCA victims receive bystander CPR than non-Hispanics.     

Hemodynamic-directed cardiopulmonary resuscitation during in-hospital cardiac arrest

Cardiopulmonary resuscitation (CPR) guidelines assume that cardiac arrest victims can be treated with a uniform chest compression (CC) depth and a standardized interval administration of vasopressor drugs. This non-personalized approach does not incorporate a patient's individualized response into ongoing resuscitative efforts. In previously reported porcine models of hypoxic and normoxic ventricular fibrillation (VF), a hemodynamic-directed resuscitation improved short-term survival compared to current practice guidelines. Skilled in-hospital rescuers should be trained to tailor resuscitation efforts to the individual patient's physiology. Such a strategy would be a major paradigm shift in the treatment of in-hospital cardiac arrest victims.     

Bacteremia following cardiac arrest and cardiopulmonary resuscitation

After but of hospital CPR thirty three resuscitated patients were studied for bacteremic complications. Thirteen patients (39%) had two or more positive blood cultures during the twelve hours following CPR. Source of superinfection was a central venous catheter in one case (staphylococcus). The twelve other bacteremic patients had fetid diarrhea a few hours after admission. The same organism were found in blood and faeces (streptococcus D, Escherichia coli, Pseudomonas aeruginosa, acinetobacter, enterobacter). Mesenteric ischemia caused by a low cardiac output may explain the diarrhea and the intestinal origin of the septicemia. All patients (12 cases) with diarrhoea and bacteremia died. Patients who recovered without neurologic sequelae (4 cases) had never been septic and never had diarrhea.     

Year in review 2010: Critical Care - cardiac arrest and cardiopulmonary resuscitation

This review will summarize some of the data published in 2010 and focus on papers published in Critical Care in regard to cardiac arrest and cardiopulmonary resuscitation. In particular, we discuss the latest research in therapeutic hypothermia after cardiac arrest, including methods of inducing hypothermia, potential protective mechanisms, spontaneous hypothermia versus therapeutic hypothermia, and several predictors of outcome. Furthermore, we will discuss the effects of bystander-initiated cardiopulmonary resuscitation (CPR) in patients with physician-assisted advanced cardiac life support, the role of hypercapnea in near-death experiences during cardiac arrest, markers of endothelial injury and endothelial repair after CPR, and the prognostic value of cell-free plasma DNA as a marker of poor outcome after cardiac arrest.     

Emergency cardiopulmonary bypass for resuscitation from prolonged cardiac arrest

After cardiac arrest (no flow) of more than approximately 5 minutes' duration, standard external cardiopulmonary resuscitation (CPR) basic, advanced, and prolonged life support (BLS, ALS, PLS) do not reliably produce cerebral and coronary perfusion pressures to maintain viability and achieve stable spontaneous normotension; nor do they provide prolonged control over pressure, flow, composition, and temperature of blood. Since these capabilities are often needed to achieve conscious survival, emergency closed-chest cardiopulmonary bypass (CPB) by veno-arterial pumping via oxygenator is presented in this review as a potential addition to ALS-PLS for selected cases. In six dog studies by the Pittsburgh group (n = 221; 1982 through 1988), all 179 dogs that received CPB after prolonged cardiac arrest (no flow) or after CPR (low flow) states had restoration of stable spontaneous circulation. The use of CPB enhanced survival and neurological recovery over those achieved with CPR-ALS attempts only. With CPB and standard intensive care, it was possible to reverse normothermic ventricular fibrillation (VF) cardiac arrest (no flow) of up to 15 minutes and to achieve survival without neurologic deficit; VF of 20 minutes to achieve survival but with neurologic deficit; and VF of 30 minutes to achieve transient restoration of spontaneous circulation followed by secondary cardiac death. CPB could restore stable spontaneous circulation after ice water submersion of up to 90 minutes. Other groups' laboratory and clinical results agree with these findings in general. Clinical feasibility trials are needed to work out logistic problems and to meet clinical challenges. Future possibilities for emergency CPB require further research and development.     

Vasopressors in cardiac arrest: a systematic review

ObjectivesTo review the literature addressing whether the use of vasopressors improves outcomes in patients who suffer cardiac arrest.MethodsDatabases were searched using the terms: “(adrenaline or noradrenaline or vasopressor) and (heart arrest or cardiac arrest) and therapy”. Inclusion criteria were human studies, controlled trials, meta-analysis or case series. Exclusion criteria were articles with no abstract, abstract-only citations without accompanying article, non-English abstracts, vasopressor studies without human clinical trials, case reports, reviews, and articles addressing traumatic arrest.Results1603 papers were identified of which 53 articles were included for review. The literature addressed 5 main therapeutic questions. (1) Outcomes comparing any vasopressor to placebo. (2) Outcomes comparing vasopressin (alone or in combination with epinephrine) to epinephrine. (3) Outcomes comparing high dose epinephrine to standard dose epinephrine. (4) Outcomes comparing any alternative vasopressor to epinephrine. (5) Outcomes examining vasopressor use in pediatric cardiac arrest.ConclusionThere are few studies that compare vasopressors to placebo in resuscitation from cardiac arrest. Epinephrine is associated with improvement in short term survival outcomes as compared to placebo, but no long-term survival benefit has been demonstrated. Vasopressin is equivalent for use as an initial vasopressor when compared to epinephrine during resuscitation from cardiac arrest. There is a short-term, but no long-term, survival benefit when using high dose vs. standard dose epinephrine during resuscitation from cardiac arrest. There are no alternative vasopressors that provide a long-term survival benefit when compared to epinephrine. There is limited data on the use of vasopressors in the pediatric population.     

心源性心脏骤停心肺复苏成功的分析

目的分析影响心源性心脏骤停患者心肺复苏成功的临床因素。方法选择该院收治的心源性心脏骤停患者共58例,根据复苏成功与否分成心肺复苏成功组(成功组)22例和心肺复苏失败组(失败组)36例。分析两组患者的临床资料,探讨与心肺复苏成功的相关因素。结果两组患者性别比和发病种类比较,差异无统计学意义(P0.05);成功组患者的年龄和入院时间明显低于失败组,院前给予抢救的比例明显高于失败组,差异均有统计学意义(P0.05)。成功组患者的心脏停搏时间、抢救时间、心肺复苏循环平均次数、肾上腺素剂量和电除颤次数明显低于失败组,应用辅助机械通气的比例明显高于失败组,差异均有统计学意义(P0.05)。结论心肺复苏成功的因素可能与发病年龄、入院时间、院前给予抢救的比例、心脏停搏时间、抢救时间、心肺复苏循环次数、肾上腺素剂量、平均电除颤次数和应用辅助机械通气有关。     

Methods of assessing cardiopulmonary resuscitation skills: a systematic review.

Valid and reliable instruments are needed for assessment and comparison of training outcomes after various methods of cardiopulmonary resuscitation training. Trials were retrieved by searching MEDLINE (1990-February 2005) and using the reference lists of original communications and reviews. Studies were considered relevant if they included an intervention, a study population of life support providers randomized and divided into groups and an evaluation or assessment of the performance. The studies were analyzed and scored to assess their validity. Twenty-five studies fulfilled the criteria. Nineteen of them assessed cardiopulmonary resuscitation skills, four cardiopulmonary resuscitation and defibrillation and two assessed defibrillation only. The mean number of participants was 107 (range 36-495). A wide variety of assessment methods were used in the studies with methodological shortcomings. Most studies in this review compared participants with each other, not against a standard or a defined passing level. Qualified studies with well defined study populations, standardized study settings and explicit, comparable outcomes would be needed to assess the quality of cardiopulmonary resuscitation and defibrillation performance.     

体外心肺复苏技术在成人心搏骤停抢救中的应用

目的 回顾性总结应用体外心肺复苏(E-CPR)技术救治成人心搏骤停患者的临床经验.方法 2005年7月至2009年7月,有11例心源性心搏骤停成人患者(男7例,女4例,年龄24～71岁)经常规心肺复苏(CPR)抢救10～15 min无法有效恢复自主循环,而采用E-CPR技术抢救.7例心脏手术后患者在CPR抢救同时自原胸骨切口先建立升主动脉-右心房常规体外循环辅助,再转为体外膜肺氧合(ECMO)辅助;4例患者在CPR抢救同时直接经股动、静脉置管建立ECMO辅助.结果 11例患者CPR时间30～90 min,平均(51±14)min,10例患者可恢复自主心律.11例患者ECMO辅助时间2～223 h,中位时间126 h.6例患者成功撤离ECMO辅助,但存活出院率为36.4%(4/11).2例患者在ECMO辅助的同时加用主动脉内球囊反搏术(IABP),1例存活.3例患者因合并肾功能衰竭而需血液滤过治疗.结论 E-CPR为抢救危重的心搏骤停患者提供了一个新的手段.如何有效评估和选择病例,及时开始救治以提高成功率,值得进一步研究.     

Adrenaline for out-of-hospital cardiac arrest resuscitation: A systematic review and meta-analysis of randomized controlled trials

Introduction

The evidence for adrenaline in out-of-hospital cardiac arrest (OHCA) resuscitation is inconclusive. We systematically reviewed the efficacy of adrenaline for adult OHCA.

Methods

We searched in MEDLINE, EMBASE, and Cochrane Library from inception to July 2013 for randomized controlled trials (RCTs) evaluating standard dose adrenaline (SDA) to placebo, high dose adrenaline (HDA), or vasopressin (alone or combination) in adult OHCA patients. Meta-analyses were performed using random effects modeling. Subgroup analyses were performed stratified by cardiac rhythm and by number of drug doses. The primary outcome was survival to discharge and the secondary outcomes were return of spontaneous circulation (ROSC), survival to admission, and neurological outcome.

Results

Fourteen RCTs (n = 12,246) met inclusion criteria: one compared SDA to placebo (n = 534), six compared SDA to HDA (n = 6174), six compared SDA to an adrenaline/vasopressin combination (n = 5202), and one compared SDA to vasopressin alone (n = 336). There was no survival to discharge or neurological outcome differences in any comparison group, including subgroup analyses. SDA showed improved ROSC (RR 2.80, 95%CI 1.78–4.41, p < 0.001) and survival to admission (RR 1.95, 95%CI 1.34–2.84, p < 0.001) compared to placebo. SDA showed decreased ROSC (RR 0.85, 95%CI 0.75–0.97, p = 0.02; I² = 48%) and survival to admission (RR 0.87, 95%CI 0.76–1.00, p = 0.049; I² = 34%) compared to HDA. There were no differences in outcomes between SDA and vasopressin alone or in combination with adrenaline.

Conclusions

There was no benefit of adrenaline in survival to discharge or neurological outcomes. There were improved rates of survival to admission and ROSC with SDA over placebo and HDA over SDA.     

Intra-arrest hypothermia during cardiac arrest: a systematic review

ABSTRACT: INTRODUCTION: Therapeutic hypothermia is largely used to protect the brain following return of spontaneous circulation (ROSC) after cardiac arrest (CA), but it is unclear whether we should start therapeutic hypothermia earlier, that is, before ROSC. METHODS: We performed a systematic search of PubMed, EMBASE, CINAHL, the Cochrane Library and Ovid/Medline databases using "arrest" OR "cardiac arrest" OR "heart arrest" AND "hypothermia" OR "therapeutic hypothermia" OR "cooling" as keywords. Only studies using intra-arrest therapeutic hypothermia (IATH) were selected for this review. Three authors independently assessed the validity of included studies and extracted data regarding characteristics of the studied cohort (animal or human) and the main outcomes related to the use of IATH: Mortality, neurological status and cardiac function (particularly, rate of ROSC). RESULTS: A total of 23 animal studies (level of evidence (LOE) 5) and five human studies, including one randomized controlled trial (LOE 1), one retrospective and one prospective controlled study (LOE 3), and two prospective studies without a control group (LOE 4), were identified. IATH improved survival and neurological outcomes when compared to normothermia and/or hypothermia after ROSC. IATH was also associated with improved ROSC rates and with improved cardiac function, including better left ventricular function, and reduced myocardial infarct size, when compared to normothermia. CONCLUSIONS: IATH improves survival and neurological outcome when compared to normothermia and/or conventional hypothermia in experimental models of CA. Clinical data on the efficacy of IATH remain limited.