005 2000年国际心肺复苏指南简介

近年来,有关心肺复苏(CPR)基础研究及临床试验领域研究十分活跃,为此美国心脏协会在汇同了各大洲权威复苏委员会意见后,于2000年8月首次拟定并公布了国际心肺复苏指南.本文拟就该新指南中的若干重要进展简介如下. 1 2000年国际CPR指南更注重以科学、循证为据 新指南的重要标志在于,参照大量随机对照试验(RCT)结果,依科学、循证医学为据,对既往指南进行了全面、公正、客观的论证与评价,摒弃了地区和国界的差异,且不拘泥于某学术权威、机构或国家的各自标准,首次由跨国度、洲际的权威机构共同撰写而成,乃是全体专家智慧与实践的结晶. 2 2000年国际CPR指南建议取消检测脉搏有无来判定心脏聚停 新指南的另一重要标志在于删除了复苏前检核脉搏.认为检测脉搏并不可靠.实践证明,对于现场救助者尤其是非医务人员,检测脉搏不仅手法往往不规范,且耗时较久,结果使之不能及时实施CPR和电除颤.此外,据统计,由现场非专业救助者因触及患者脉搏自身的细微自颤,而作出其心脏并未真正停搏的假阴性漏诊率高达10%,终至此类患者在事发现场由于漏诊而丧失或延误了室贵的抢救时间,而不幸生物死亡.故新指南建议,取消现场检测脉搏,认为在决定实施胸外按压前,无需检测脉搏,只需结合患者意识丧失、呼吸停止、以及对咳嗽、触动等刺激的反应来综合判定即可. 3 2000年国际CPR指南更强调现场急救与早期除颤 新指南再次强调,对于心脏骤停者,事发现场应争分夺秒,全力抢救.认为现场急救的成败与生存链(chain of survival)的建立息息相关.该生存链包括早期通路、早期CPR、早期除颤与早期高级生命支持4链环节,亦即在心脏骤停事发现场,均应立即通知医疗部门,同时实施CPR,尽早除颤和高级生命支持.并建议应尽早使用紧急自动体外除颤(AED). 4 2000年国际CPR指南建议简化胸外按压与人工呼吸频度 新指南建议,将CPR时的胸外按压频度由既往的80～100次/min上调至100次/min,调幅达25%;并建议无论单、双人复苏,胸外按压/人工呼吸比均统一为15∶2(原指南中双人复苏按压/呼吸比为5∶1,单人复苏按压/呼吸比15∶2).实践证明,高频按压能获得更有效的前向血流;而按压/呼吸15∶2配合比,既可减少胸外按压中断间期,又能获得更大的胸腔内压;且每次中断胸外按压而行人工呼吸后,均需多次按压才能恢复先前按压所维持的血流,而许多复苏者按压频率往往过低.故新指南减少了每次按压之间的间隔,而增加了每分钟按压频率.从而保证了在等同时间内,既增加前向血流,又提高胸腔内压,且操作更有节律,更简便易行. 5 2000年国际CPR指南建议CPR时实施二阶段ABCD四步复苏 新指南建议,抢救心脏骤停者时,实施CPR可按以下二阶段ABCD四步进行.第1个ABCD四步包括:A开放气道,B正压通气,C胸外按压,D如为室速/室颤则应立即除颤;第2个ABCD四步包括:A进一步气道控制,B评估气管内插管是否充分、正压通气,C建立液路及给药,D鉴别处理一切可逆转病因. 6 2000年国际CPR指南认为CPR时面罩给氧等效于气管内插管给氧 新指南认为,抢救实施CPR时,口对口人工呼吸给氧效果较差.而选择气囊一面罩给氧,较气管插管给氧更简捷且等效,建议在现场及转运途中亦不应中断.据晚近的1项RCT结果证明,气囊一面罩给氧与气管插管给氧一样能有效提高CPR成功率.是否行气管插管最好依据患者情况和救助者经验而定. 7 2000年国际CPR指南建议CPR时的辅助用药 新指南建议,抢救心脏骤停者,如属室速/室颤,可首先连续3次电除颤.对3次除颤仍无效者,选用肾上腺素1mg静注,每3～5min可复行,或/和单剂加压素40U静注,继之再电除颤数次;如为非室速/室颤,建议仅用肾上腺素1mg静注,每3～5min可重复,暂不主张电除颤.对于顽固性室速/室颤,实践证明只有胺碘酮才显示了它有益的治疗前景,而其它传统药物如利多卡因、Bretyhium、普鲁卡因酰胺等的抗室速/室颤作用,均未能得到RCT的证实,且疗效均差. 8 2000年国际CPR指南建议CPR时的液体选择 新指南建议,CPR宜选用生理盐水,不宜再用糖水,因后者可在缺氧条件下代谢成乳酸,而加重酸中毒;且晶体液尚有助于使浓缩的血液稀释,益于循环重建. 9 2000年国际CPR指南中CPR其它相关建议 新指南建议,进一步普及CPR规范抢救方法,建议在各公共场所增设或更新先进的便携式AED仪,尽快建全全球急救网络网站及CPR专门机构. (袁志敏石延华摘)     

Snoring and dementia

The frequency of snoring was studied in 46 patients with Alzheimer's disease (AD), 37 with multiinfarct dementia (MID), and in a random sample of 124 elderly community residents without known diseases affecting higher cortical functions. The demented patients were reported to snore twice as frequently as the control subjects (P less than 0.05). No difference in the frequency of snoring was present between the patients with AD and MID. In contrast to younger populations, snoring was not significantly associated with cardiovascular morbidity in this elderly population.     

Post-operative degree of mobilization at two weeks predicts one-year mortality after hip fracture

BACKGROUND AND AIMS: Although several investigations have tested physical activity a few months or one year after hip fracture, only a few have assessed physical activity shortly after hip fracture. The aim of this study was to evaluate how physical function two weeks after hip fracture operation predicts 12-month mortality. This was a prospective study of hip fracture patients with one-year follow-up, carried out in Jyv?skyl? Central Hospital in Finland. METHODS: In this study, there were 243 consecutive community-dwelling patients aged 65 or older, who were able to walk before hip fracture. Two weeks after operation, information was gathered on pre-fracture activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Patients' ability to stand up, sit down and walk was assessed. The follow-up lasted 12 months. RESULTS: The best predictor for mortality after one year was inability to stand up, hazard ratio (HR) 4.64 (95% CI 2.11-10.18, p < 0.001). The corresponding HRs concerning inability to sit down were 4.52 (95% CI 2.10-9.72, p < 0.001), inability to walk 2.39 (95% CI 1.20-4.78, p = 0.013), ADL score 1.43 (95% CI 1.16-1.76, p = 0.001) and IADL score 1.19 (95% CI 1.03-1.38, p = 0.017). These variables were age- and sex-adjusted. According to the multiple proportional hazard model there was only one variable with statistical significance, i.e., the pre-fracture ADL-score (p = 0.025). CONCLUSION: Inability to stand up, sit down or walk two weeks after operation were the strongest predictors for mortality among operated hip fracture patients. We suggest that focus should be directed to verify if better survival might be achieved by more intensive rehabilitation immediately after the operation. The pre-fracture ADL-score appeared to be the only variable reaching statistical significance in the multiple proportional hazard model. This fact may reflect frailty and affect decisions concerning the rehabilitation program.     

Effects of supporting community-living demented patients and their caregivers: a randomized trial

OBJECTIVES: To determine whether community care of demented patients can be prolonged by means of a 2-year support program based on nurse case management. DESIGN: Randomized controlled intervention study with 2-year follow-up. SETTING: Demented patients entitled to payments from the Social Insurance Institution for community care, in five municipalities in eastern Finland. PARTICIPANTS: One hundred demented patients, age 65 and older, living at home with the primary support of informal caregivers, allocated at random to the intervention (n = 53) or control group (n = 47). INTERVENTION: Intervention patients and their caregivers were provided with a 2-year intervention program of systematic, comprehensive support by a dementia family care coordinator. MEASUREMENTS: Time to institutionalization (period in community care) from enrollment of patients in the study to their placement in long-term institutional care. RESULTS: During the first months, the rate of institutionalization was significantly lower in the intervention group than in the control group (P = .042), but the benefit of the intervention decreased with time (P = .028). Estimated probability of staying in community care up to 6, 12, and 24 months was 0.98, 0.92, and 0.63 in the intervention group and 0.91, 0.81, and 0.68 in the control group, respectively. Results also suggest that the intervention used in the study might be especially beneficial to patients with severe dementia and those with problems threatening the continuity of community care. CONCLUSIONS: The placement of demented patients in long-term institutional care can be deferred with the support of a dementia family care coordinator. However, by the end of the 2-year intervention, the number of patients institutionalized was similar in the intervention and control group. It seems to be beneficial to direct this type of intensive support at severely demented patients and their caregivers. On the basis of our experiences, we suggest that intervention by a dementia family care coordinator should be targeted especially at patients with problems threatening the continuity of community care.     

Effects of individual dietary counseling as part of a comprehensive geriatric assessment (CGA) on frailty status: A population-based intervention study

Background/PurposeIn this study, our aim was to evaluate the effects of individual dietary counseling as part of a comprehensive geriatric assessment (CGA) on frailty status among community-dwelling people aged 75 years or older.MethodsData were obtained from a subpopulation of participants in the population-based Geriatric Multidisciplinary Strategy for the Good Care of the Elderly (GeMS) intervention study in 2004 to 2007. In the present study, the population consisted of 159 persons at risk of malnutrition in the year 2005 in an intervention and a control group. Nutritional status was assessed with the Mini Nutritional Assessment (MNA). Frailty was defined according to the five frailty criteria used in the Cardiovascular Health Study (CHS). Assessment of nutritional status and frailty status was performed at the beginning of the study and at 1-year follow-up.ResultsAt baseline the mean age of the 159 community-dwelling participants with risk of malnutrition was 83 years and 126 (79%) of them were female. The proportions of frail and pre-frail persons were 25% (n = 19) and 61% (n = 47) in the intervention group, and 26% (n = 21) and 61% (n = 50) in the control group. After the 1-year nutritional intervention, compared to the control group, the intervention group tended to have a better outcome of frailty and MNA (OR = 1.89, 95% CI: 1.08–3.54, OR = 2.61, 95% CI: 1.67–5.56, respectively) and was less likely to deteriorate as assessed with MNA (OR = 0.23, 95% CI: 0.14–0.87). In multivariate analysis, change in MNA (OR = 1.12, 95% CI: 1.03–1.31) was associated independently with improved frailty status.ConclusionIt appears that multidisciplinary geriatric assessment including individual dietary counseling has a positive effect on frailty status. More emphasis on good nutrition in the older population might have a preventive effect on the incidence of frailty.     

The non-use of hearing aids in people aged 75 years and over in the city of Kuopio in Finland

Hearing loss is one of the most prevalent chronic conditions affecting the health of the aged. It is typically medically non-treatable, and hearing aid (HA) use remains the treatment of choice. However, only 15–30% of older adults with hearing impairment possess an HA. Many of them never use it. The purpose of our study was to investigate the use of provided HAs and reasons for the non-use of HAs. This population-based survey was set in the city of Kuopio in eastern Finland. A total of 601 people aged 75 years or older participated in this study. A geriatrician and a trained nurse examined the subjects. Their functional and cognitive capacity was evaluated. A questionnaire about participants socioeconomic characteristics and the use of HAs were included in the study protocol. The subjects who had an HA were assigned to three groups on the basis of HA use: full-time users, part-time users and non-users. Inquiries were made about the subjective reasons for the non-use of HAs. An HA had been prescribed earlier to 16.6% of the study group. Fourteen percent of the females and 23% of the males had been provided with an HA. The HA owners were older than persons who had not been provided with an HA. Twenty-five percent of the HA owners were non-users, and 55% were full-time users. A decline in cognitive or functional capacity and low income explained the non-use of HAs. The most common subjective reasons for the non-use of HAs were that the use did not help at all (10/24), the HA was broken (4/24) or it was too complicated to use (5/24). The non-use of HAs is still common among the aged. Elderly people who have been provided with an HA and who have a cognitive or functional decline are at risk to be a non-user of an HA. Therefore, they need special attention in counseling.     

Intensive geriatric rehabilitation of hip fracture patients: a randomized,controlled trial

We determined the effect of geriatric rehabilitation of hip fracture patients on mortality, length of hospital stay, and functional recovery. In a randomized, controlled intervention study, 243 community dwelling hip fracture patients over 64 years of age were randomly assigned to 2 rehabilitation groups. The intervention group (n = 120) was referred to a geriatric ward for team rehabilitation, and the controls (n = 123) to local hospital wards for standard care. The median length of total hospital stay after a hip fracture operation was 34 (95% CI 28-38) days in the intervention group and 42 (95% CI 35-48) days in the control group (p = 0.05). The intervention group recovered instrumental activities of daily living faster (p = 0.05). Direct costs of medical care during the first year did not differ remarkably.     

Musculoskeletal pain and use of analgesics in relation to mobility limitation among community‐dwelling persons aged 75 years and older

Pain and factors related to it constitute serious health problems in the older population. This populationbased cross‐sectional study aimed to investigate whether musculoskeletal pain is associated with mobility limitation and whether the relationship between pain and mobility limitation varies according to the use of analgesics among community‐dwelling older people. A total of 622 community‐dwelling participants aged 75 years and older (mean age 80.4, 74% women) were interviewed about presence and severity of musculoskeletal pain. Self‐reported analgesic drug utilization was verified against medical records. Mobility limitation was assessed by the Timed Up & Go test (TUG) time of >13.5 s or inability to perform the test. Logistic regression was used to evaluate the pain‐affect associations, with associations expressed as odds ratios with 95% confidence intervals (CI). After adjustment for several covariates, musculoskeletal pain remained independently associated with mobility limitation (odds ratio = 1.83; 95% CI 1.16, 2.89). The risk of mobility limitation was highest among those who reported severe or moderate pain (1.84; 1.13, 3.13) and among those who used analgesics (2.37; 1.37, 4.11). In conclusion, musculoskeletal pain increases the risk for mobility limitation. The present findings underline the importance of the careful assessment and pharmacological and nonpharmacological management of pain in promoting mobility in older age.