急诊体外循环在心肺复苏中的应用

近年来由于体外循环 (ｃａｒｄｉｏ ｐｕｌｍｏｎａｒｙｂｙｐａｓｓ ,ＣＰＢ)技术的发展和有关设备的更新 ,不仅使ＣＰＢ技术成为心脏大血管手术的安全辅助方法 ,同时也在抢救和治疗危重病人中取得良好临床效果 ;特别是对于心搏骤停者的心肺脑复苏 ,显示了其独特的价值。本院1989年 1月至 2 0 0 1年 5月应用急诊体外循环 (ｅｍｅｒｇｅｎｃｙｃａｒｄｉｏｐｕｌｍｏｎａｒｙｂｙｐａｓｓ,ＥＣＰＢ)抢救心搏骤停病人 8例 ,现总结报道如下。一、临床资料8例心搏骤停者原发病为先天性心脏病 5例 ,二尖瓣狭窄伴关闭不全 2例 ,主动脉瓣关闭不全 …     

经皮穿刺急诊体外循环心肺复苏的实验与临床研究

目的探讨经皮穿刺插管快速建立急诊体外循环(ECPB)心肺复苏(CPR)的方法与疗效,方法自行研制经皮穿刺体外循环插管及鼓泡式氧合器、动脉滤器、泵管、管道连接的一体化无菌密闭系统。先将15只犬随机分为有搏动经皮穿刺插管组(A组)5只,无搏动绛皮穿刺插管组(B组)5只,无搏动切开插管组(C组)5只,通过动物实验探讨经皮穿刺插管方法建立急诊体外循环的可行性及对心肺复苏的影响。后将6例心脏停搏常规复苏8min无效患者进行床边经皮穿刺急诊体外循环方法的研究及对心肺复苏疗效的观察,结果无论在动物或人体上均快速建立了ECPB．使CPR的自主循环恢复率(ROSC)显著提高。结论经皮穿刺周围大血管插管能快速建立急诊体外循环,使CPR的ROSC显著提高。     

心肺辅助循环用于心肺复苏的实验研究

目的　用心肺辅助循环的方法进一步提高心肺复苏的成功率。方法　试验对象为杂种犬１０ 只。通过右股动脉插入 Ｆ１２ 导管至腹主动脉做动脉输血管,双侧股静脉插入 Ｆ１３ 导管至下腔静脉做静脉引流管,用２０伏交流电通过心肌穿刺致室颤。致室颤后用心肺转流机做辅助循环,转流量占实验犬心输出量的６０ ％ 。转流９０分钟后电除颤。结果　８ 只犬恢复窦性心律,２ 只犬死于意外事故。转流后 Ｐａ Ｏ２ 较转流前有明显提高,颈动脉较股动脉的 Ｐａ Ｏ２ 为高, Ｐａ Ｃ Ｏ２ 变化不大,血红细胞数无明显减少,血小板数减少较为明显。结论　心肺转流形式的辅助循环能够保证实验动物在室颤状态下心肺脑等重要器官的存活,心肺转流用于临床心肺复苏是可能的。     

心肺转流行心肺复苏的实验研究

观察狗心脏停搏３０分钟后的心肺复苏效果，以１０％氯化钾溶液静脉注射使实验狗心脏停搏、呼吸停止３０分钟后，分两组进行心肺苏实验研究。实验狗每组５只，第一组采用常规法，第二组采用心肺转流法。实验期间，定时对心电图、动脉压、静脉压、动脉血气和瞳孔进行监测。心脏骤停后６０分钟检查最终复苏效果。结果第一组仅１只狗于１５分钟后恢复自主循环，瞳孔开始缩小，其余４只狗均未获复苏，第二组于２－３分钟后全部恢复自主循     

心肺转流行心肺复苏的实验研究

观察狗心脏停搏30分钟后的心肺复苏效果,以10%氯化钾溶液静脉注射使实验狗心脏停搏、呼吸停止30分钟后,分两组进行心肺复苏实验研究.实验狗每组5只.第一组采用常规法;第二组采用心肺转流(cardiopul-monary bypass,CPB)法.实验期间,定时对心电图、动脉压、静脉压、动脉血气和瞳孔进行监测.心肺骤停后60分钟检查最终复苏效果.结果第一组仅1只狗(20%)于第15分钟后恢复自主循环,瞳孔开始缩小,其余4只狗均未获复苏;第二组于2—3分钟后全部恢复自主循环(100%),瞳孔缩小.复苏30分钟后,其平均动脉压为8—14.0kPa,明显高于第一组(0—12.0kPa)(P<0.05),其静脉压为0.09—0.12kPa,明显低于第一组(0.14—0.24kPa)(P<0.01),PaCO_2为2.06—5.73kPa,明显低于第一组7.22—11.90kPa;PaO_2为21.70一59.81kPa,明显高于第一组(5.88—14.56kPa)(P<0.01).上述实验结果表明,心搏呼吸骤停30分钟后,以心肺转流法进行复苏可有效地恢复自主循环,并可能有益于脑复苏.从少量实验动物复苏效果提示,CPB法明显优于常规法.     

急诊体外循环动脉灌注管位置对心肺复苏效果的影响

目的 探讨急诊体外循环（ECPB）动脉灌注管位置对肺门部火器伤后心脏骤停犬心肺复苏（CPR）的影响。方法 杂种犬14只随机均分为两组,麻醉后用小口径步枪射击犬右肺门区,心脏骤停后10min开始复苏。A、B两组分别采用股动脉、颈动脉插管建立ECPB,同时给予人工呼吸、胸内心脏按压、静注肾上腺素治疗。观察动物CPR情况。结果 A、B两组动物均全部复苏成功,B组恢复自主循环时间明显短于A组（P＜0．05）;复苏1min时B组平均动脉压（MAP）显著高于A组（P＜0．05）,PaO2显著高于A组（P＜0．01）,PaO2显著低于A组（P＜0．05）;复苏3min时B组PaO2显著高于A组（P＜0．05）,PaCO2显著低于A组（P＜0．05）。自主循环恢复后10min两组间MAP、PaO2、PaCO2均无统计学差异。辅助循环停止后,两组动物自主循环基本保持稳定。结论 ECPB能有效地应用于心脏骤停的CPR,动脉灌注管靠近升主动脉根部有助于提高急诊体外循环心肺复苏的治疗效果。     

经股静——动脉心肺转流术心肺脑复苏机制的探讨

目的观察犬电击致室颤/心跳骤停(VF/CA)8min后经开胸心肺复苏(CPR)和/或经股静-动脉心肺转流(CPB)心肺复苏对心脏复苏和脑脊液(CSF)内乳酸(LA)含量的影响.方法采用犬经胸壁电击VF/CA8min,经CPR恢复自主循环(RSC)后观察4h内CSF内LA含量的变化.9只犬分为两组,Ⅰ组(n＝5)采用开胸心脏按压等方法复苏,Ⅱ组(n＝4)于开胸心脏按压同时经一侧股静、动脉心肺转流,并维持2h.结果Ⅱ组RSC时间较Ⅰ组显著缩短(6.3±2.1minvs13.6±5.9min,P＜0.05);Ⅱ组CPB后室颤波幅较Ⅰ组明显提高;Ⅰ组RSC后30、60、120和240minCSF内LA含量均较CA前明显升高(10.7±3.3、8.8±3.8、7.8±3.5、5.6±1.0vs3.2±1.0,P均＜0.05),而Ⅱ组RSC后除30min外各时点CSF内LA含量均较CA前无明显升高(4.1±2.6、3.9±2.4、2.6±1.7vs3.0±0.4,P均＞0.05),且明显低于Ⅰ组各值(P均＜0.05).结论CA后经开胸CPR辅以CPB能提高心脏复苏的有效性,抑制单一开胸CPR后发生的CSF内LA含量升高,提示其能减轻脑内糖无氧代谢,改善脑氧供需关系,对脑复苏有利.     

萨博心肺复苏与徒手心肺复苏临床效果的对比观察

目的比较萨博心肺复苏与徒手心肺复苏的临床效果。方法按照随机分组方法收集符合观察条件的病例222例,分别施行萨博辅助胸外心脏按压复苏(萨博复苏组,n=113)和徒手胸外心脏按压复苏(徒手复苏组,n=109),对比观察两组首次复苏时间、复苏首阶段(≤30 min)平均自主心律存续时间、由复苏首阶段复苏成功进入高级生命支持病例率、超长复苏(复苏30 min)率和复苏出院率。结果 1萨博复苏组平均首次复苏时间10.8±4.1 min,少于徒手复苏组15.6±5.6 min(P0.05);2在复苏初始≤30 min,萨博复苏组复苏后自主心律存续时间7.1±1.8 min明显长于徒手复苏组3.1±1.6 min(P0.01);3在复苏初始≤30 min成功复苏进入高级生命支持的比率,萨博复苏组28.31%明显高于徒手复苏组17.43%(P0.05);4在实施超长复苏方面,萨博复苏组超长复苏率(43.36%)明显高于徒手复苏组(17.31%)(P0.01)。5在出院率方面,萨博复苏组和徒手复苏组分别为7.96%和6.42%,两组间无显著差异(P0.05)。结论除出院率外,萨博器械辅助心肺复苏在首次复苏时间、复苏首阶段≤30 min平均自主心律存续时间、≤30 min内成功复苏进入高级生命支持病例率、超长复苏率方均明显优于徒手心肺复苏,值得临床推广应用。     

心肺复苏中动静脉血气分析的临床探讨

本文对8例心搏骤停后心肺复苏 CPR 中动静脉血气进行检查。结果:动静脉血 PH、PaO_2、BE、HCO_3~- 均明显降低,而 PaCO_2 均明显升高。表明动静脉血均呈现混合性酸中毒及严重低氧血症。认为在复苏期间增大人工通气量的同时应进行补碱治疗。并提出胸内心脏按压的必要性。     

体外心肺复苏启动前因素对患者预后的影响

目的:分析体外心肺复苏（extracorporeal cardiopulmonary resuscitation,ECPR）启动前因素对患者预后的影响,以探讨ECPR的干预时机和改进策略。方法:回顾性分析2018年7月至2021年4月在湖南师范大学附属第一医院（湖南省人民医院）行ECPR的29例患者。按患者是否存活出院分为生存组( n=13)及死亡组( n=16),分析两组常规心肺复苏（conventional cardiopulmonary resuscitation,CCPR）时间（开始心肺复苏到体外膜肺氧合运转的时间）、ECPR前初始心律、院外及院内心搏骤停的构成比、外院转运病例构成比。按CCPR时间分为≤45 min组、45~60 min组及>60 min组分别比较其出院存活率及持续自主循环恢复（sustained return of spontaneous circulation,ROSC）率。本院院内心搏骤停患者按心搏骤停（cardiac arrest,CA）发生地点分为本科室亚组和其他科室亚组,比较其存活率。 结果:29例患者总体生存率44.83%,体外膜肺氧合（extracorporeal membrane oxygenation,ECMO）平均辅助时长114（33.5,142.5） h,CCPR平均时长60（44.5,80） min。生存组ECMO辅助时间（140.15±44.80）h较死亡组长（ P=0.001）,生存组CCPR时间明显低于死亡组（ P=0.010）。初始心律为可除颤心律组生存率更高（ P=0.010）。OHCA较IHCA患者病死率高（ P=0.020）。外院转运病例病死率高于本院病例（ P=0.025）。CCPR时间≤45min、45~60 min、>60 min三组患者出院生存率依次递减（ P=0.001）,ROSC率依次递减（ P=0.001)。本院院内心搏骤停患者,CA发生地点在本科室（急诊医学科）组与其他科室组生存率差异无统计学意义（ P=0.54）。 结论:ECPR出院存活率高于国内外报道的CCPR存活率,ECPR对难治性心搏骤停是有效的。ECPR的预后跟CCPR时间、CA初始心律、CA发生地点明显相关,提高ECPR存活率需加强宣教及团队建设。     

Brain resuscitation by extracorporeal circulation after prolonged cardiac arrest in cats

Objective Brain reanimation after prolonged ischemia is limited by post-ischemic reperfusion deficits (no-reflow phenomenon). The present study was undertaken to establish whether after 30 min cardiac arrest extracorporeal circulation is able to restore brain reperfusion and to promote functional and metabolic recovery.Design Adult normothermic cats were submitted to 30 min cardiac arrest by KCl-induced cardioplegia. Resuscitation was carried out by extracorporeal circulation (ECC) until spontaneous heart function returned. The quality of brain recovery was assessed 3 h later by electrophysiological recording and by imaging of the regional distribution of brain energy metabolites.Results In 6 of 10 cats cardiac sinus rhythm returned after 32±15 min. In the other 4 cats cardiac function did not return or only intermittently returned during the 3 h observation period. Cerebral blood flow measured by laser Doppler flowmetry returned to 102%±40% of control immediately after the beginning of resuscitation but then gradually declined to 43%±32% after 3 h despite normotensive perfusion. In all cats pupils started to constrict within less than 5 min of recirculation but in 2 animals they secondarily dilated 1.5 and 2 h later, respectively. Spontaneous EEG activity reappeared in 4 of the 6 successfully resuscitated cats after 111±40 min but failed to recover in the others. Bioluminescent imaging of ATP after 3 h recirculation revealed near-complete depletion throughout the brain in all 4 cats without cardiac recovery. Of the 6 successfully resuscitated cats 5 exhibited patchy areas of low ATP, glucose and pH in 22%–92% of the cross sectional area of brain; in one cat recovery of energy metabolism and acid-base homoiostasis was homogenous without any focal deficits. The cross sectional area of ATP recovery correlated directly with CBF and hematocrit and inversely with the plasma lactate level.Conclusions This study demonstrates for the first time that ECC is able to restore electrophysiological and metabolic brain function after cardiac arrest of as long as 30 min, but recovery is heavily restricted by delayed postischemic disturbances of recirculation. Progress in cardiac resuscitation by ECC requires substantial improvement in the efficiency of cerebrovascular reperfusion.     

体外膜肺氧合在心肺脑复苏中的应用

目的 探讨体外膜肺氧合(extlacorporeal membrane oxygenation,ECMO)在心脏骤停患者中的治疗作用及应用价值.方法 回顾分析2002年6月至2007年6月期间,本院急诊和重症监护室应用体外膜肺氧合(ECMO)治疗的心脏骤停15例患者,按照美国心脏学会<2005年心肺复苏和心血管急救国际指南>的标准诊治方案进行救治,同时行体外膜肺氧合(ECMO)治疗.采用治疗前后自身对照的方法,监测ECMO治疗前、ECMO治疗后10 min、1 h、6 h、12 h、24 h,患者的心率、平均动脉压、中心静脉压(eve);并抽取桡动脉血检测动脉血氧分压、二氧化碳分压、血氧饱和度、酸碱度、动脉血乳酸含量等指标;统计数据以((x)±s)表示,采用SPSS 10.0统计软件包进行t检验,以P<0.05为差异具有统计学意义;同时就患者的神经性后遗症进行了观察和描述.结果 平均动脉压在ECMO治疗后10min比ECMO治疗前明显升高(P<0.01),ECMO治疗后1 h比ECMO治疗后10 min有所升高(P<0.05);CVP在ECMO治疗后10 min比ECMO治疗前,ECMO治疗后1 h比ECMO治疗后10 min有所降低(P<0.05);经ECMO治疗后10 min动脉血氧分压、血氧饱和度较ECMO治疗前明显上升(P<0.01),pH明显升高(P<0.01),动脉血乳酸含量明显降低(P<0.01).15例患者中,11例康复出院,其中5例完全康复,没有后遗症,2例有部分记忆障碍,无躯体后遗症;2例有精神障碍,2例有肢体偏瘫.结论 ECMO治疗可辅助心脏维持有效的血液循环,明显改善低氧血症,为大脑提供稳定的氧合血灌流,对心肺脑复苏有利.     

Comparing the survival between extracorporeal rescue and conventional resuscitation in adult in-hospital cardiac arrests: Propensity analysis of three-year data

Aim

Extracorporeal cardiopulmonary resuscitation (ECPR) has been shown to have survival benefit over conventional CPR (CCPR) in patients with in-hospital cardiac arrest of cardiac origin. We compared the survival of patients who had return of spontaneous beating (ROSB) after ECPR with the survival of those who had return of spontaneous circulation (ROSC) after conventional CPR.

Methods

Propensity score-matched cohort of adults with in-hospital prolonged CPR (>10 min) of cardiac origin in a university-affiliated tertiary extracorporeal resuscitation center were included in this study. Fifty-nine patients with ROSB after ECPR and 63 patients with sustained ROSC by CCPR were analyzed. Main outcome measures were survival at hospital discharge, 30 days, 6 months, and one year, and neurological outcome.

Results

There was no statistical difference in survival to discharge (29.1% of ECPR responders vs. 22.2% of CCPR responders, p = 0.394) and neurological outcome at discharge and one year later. In the propensity score-matched groups, 9 out of 27 ECPR patients survived to one month (33.3%) and 7 out of 27 CCPR patients survived (25.9%). Survival analysis showed no survival difference (HR: 0.856, p = 0.634, 95% CI: 0.453-1.620) between the groups, either at 30 days or at the end of one year (HR: 0.602, p = 0.093, 95% CI: 0.333-1.088).

Conclusions

This study failed to demonstrate a survival difference between patients who had ROSB after institution of ECMO and those who had ROSC after conventional CPR. Further studies evaluating the role of ECMO in conventional CPR rescued patients are warranted.     

Cardiopulmonary resuscitation update

Cardiopulmonary resuscitation (CPR) is vital therapy in cardiac arrest care by lay and trained rescuers. Chest compressions are the key component of CPR. Ventilation and airway management should be secondary to high-quality and continuous chest compressions in patients receiving CPR. Only after the patient has had return of spontaneous circulation or completed a cycle of CPR with defibrillation (if appropriate) should attempts at securing an advanced airway be made. Even then, interruptions of chest compressions should be minimized to maintain cardiocerebral perfusion and increase survival. Finally, the ventilation rate should be no more than 8 to 10 breaths per minute.     

Managing cardiac arrest with refractory ventricular fibrillation in the emergency department: Conventional cardiopulmonary resuscitation versus extracorporeal cardiopulmonary resuscitation

AimRefractory ventricular fibrillation, resistant to conventional cardiopulmonary resuscitation (CPR), is a life threatening rhythm encountered in the emergency department. Although previous reports suggest the use of extracorporeal CPR can improve the clinical outcomes in patients with prolonged cardiac arrest, the effectiveness of this novel strategy for refractory ventricular fibrillation is not known. We aimed to compare the clinical outcomes of patients with refractory ventricular fibrillation managed with conventional CPR or extracorporeal CPR in our institution.MethodThis is a retrospective chart review study from an emergency department in a tertiary referral medical center. We identified 209 patients presenting with cardiac arrest due to ventricular fibrillation between September 2011 and September 2013. Of these, 60 patients were enrolled with ventricular fibrillation refractory to resuscitation for more than 10 min. The clinical outcome of patients with ventricular fibrillation received either conventional CPR, including defibrillation, chest compression, and resuscitative medication (C-CPR, n = 40) or CPR plus extracorporeal CPR (E-CPR, n = 20) were compared.ResultsThe overall survival rate was 35%, and 18.3% of patients were discharged with good neurological function. The mean duration of CPR was longer in the E-CPR group than in the C-CPR group (69.90 ± 49.6 min vs 34.3 ± 17.7 min, p = 0.0001). Patients receiving E-CPR had significantly higher rates of sustained return of spontaneous circulation (95.0% vs 47.5%, p = 0.0009), and good neurological function at discharge (40.0% vs 7.5%, p = 0.0067). The survival rate in the E-CPR group was higher (50% vs 27.5%, p = 0.1512) at discharge and (50% vs 20%, p = 0. 0998) at 1 year after discharge.ConclusionsThe management of refractory ventricular fibrillation in the emergency department remains challenging, as evidenced by an overall survival rate of 35% in this study. Patients with refractory ventricular fibrillation receiving E-CPR had a trend toward higher survival rates and significantly improved neurological outcomes than those receiving C-CPR.     

Clinical course and long-term outcome following venoarterial extracorporeal life support-facilitated interhospital transfer of patients with circulatory failure

BackgroundInterhospital transfer of patients experiencing circulatory failure and shock has a significant risk of cardiovascular deterioration and death. Extracorporeal life support (ECLS) is a rescue tool for hemodynamic stabilization that makes patient transportation much safer.MethodsDemographic data, clinical course, and outcome data were reviewed for patients who underwent placement of a venoarterial ECLS in a remote hospital and were transported to our tertiary care facility.Results68 patients were transported to our center with ECLS. The majority of these patients (79%) underwent cardiopulmonary resuscitation during or immediately prior to ECLS initiation. The mean patient age was 52 years, and 53 patients were male. The most common underlying diagnosis was acute coronary syndrome (60%). Overall, 23 patients underwent consecutive cardiosurgical procedures, including coronary artery bypass grafting in 12, and left ventricular assist device and biventricular assist device implantation in 11. The median duration of ECLS was 5 days. None of the patients died during transportation. Twelve of the surgically treated patients survived, as well as 21 patients with non-surgical treatment, which resulted in an overall survival of 33 patients (48.5%).ConclusionECLS-facilitated patient transfer enables safe interhospital transfer of critically ill patients. In this study, a relevant percentage of patients were in need of a cardiosurgical intervention. The long-term survival rate of these patients supports the further use of this time-, cost- and personnel-demanding strategy.     

体外膜肺氧合心肺复苏患者死亡的危险因素

目的:分析体外膜肺氧合心肺复苏（extracorporeal cardiopulmonary resuscitation, ECPR）死亡患者的临床特征,探索该类患者死亡相关的危险因素。方法:回顾性分析2014年9月至2019年9月收住本院及杭州市第一人民医院接受体外心肺复苏的60例心搏骤停患者的临床资料。将患者分为存...     

体外膜肺氧合在抢救危重心脏病患者心搏骤停中的作用

目的观察体外膜肺氧合对危重心脏患者心搏骤停后常规心肺复苏困难者的治疗效果。方法本院自2005年9月至2006年5月行体外膜肺氧合(ECMO)治疗危重心脏病患者37例,回顾性分析其中11例发生心搏骤停实施常规心肺复苏无效或复苏后持续低心排而行ECMO循环辅助患者的病历资料。结果5例为心脏术后患者,其中3例心肺复苏(CPR)的同时紧急建立体外循环再次手术,之后因低心排而行ECMO。7例患者床旁建立ECMO,ECMO支持治疗(134．0±113．0)h。8例顺利停机,6例存活出院,其中2例经心脏移植后出院。3例不能顺利脱机者由于ECMO辅助期间循环功能恶化,并最终死于多器官功能衰竭。ECMO期间出现的并发症包括出血、神经精神系统异常、肢体缺血坏死和多脏器功能不全。结论ECMO可以为心搏骤停的患者提供最快的心肺功能支持,为赢得抢救时机和提高抢救质量提供了又一途径,在危重患者心肺复苏中具有良好的疗效。