客製化CPR可以增加心臟停止後存活


  【24drs.com】根據一篇新研究,使用舒張壓和潮氣末二氧化碳測量指引院內心肺復甦術,與顯著改善心臟停止後的存活機會有關。
  
  費城賓州大學醫學院兒童醫院Robert Sutton醫師表示,健康照護提供者必須監測病患對於復甦急救的反應;他在重症照護醫學會第44屆重症照護研討會中表示,事實上,或許需要改變他們的方法,如果他們在提供CPR時沒有足夠的病患生理數據的話。
  
  院內心臟停止大部分發生於加護病房,都有血壓與二氧化碳監測設備,儘管如此,往往是以制式的方法進行CPR,而未根據這些讀數調整。
  
  Sutton醫師解釋,當使用測量讀數時,CPR可以更密切反應病患的立即需求;這個監測過程是一種個人化醫療;這些監測數據代表CPR時的血流初步估計。我們認為,CPR時血流改善相當於病患有比較好的結果。
  
  Sutton醫師曾參與的動物研究顯示,根據個別的生理資料調整復甦力道,可以挽救生命。
  
  在這次的研究中,他的團隊評估了「2000-2012年間遵循復甦術臨床指引(Get With the Guidelines- Resuscitation)」登錄計畫的245,300個CPR事件。
  
  分析舒張壓時,16,301次CPR事件中的11,259例(69%)獲得自主循環恢復,有4,212例(26%)使用舒張壓監測CPR的品質。
  
  潮氣末二氧化碳的分析中,47,135次CPR事件中的30,980例(66%)獲得自主循環恢復,有1,648例(3.5%)使用潮氣末二氧化碳監測品質。
  
  沒有使用動脈導管的事件、或在心臟停止時有侵入性呼吸道急救的病患未被納入研究。
  
  校正年齡、性別、種族、驟停發生的年份、初次無脈搏節律、驟停的時間等共變項之後,使用舒張壓監測CPR的品質時,自主循環恢復比未監測者好(勝算比[OR],1.23,95%信心區間[CI],1.12- 1.36;P< .001);潮氣末二氧化碳也是為真(OR,1.25;95% CI,1.10- 1.43;P< .001)。
  
  當潮氣末二氧化碳值大於10 mm Hg時,自主循環恢復與潮氣末二氧化碳的關聯更強(P< .001)。
  
  Sutton醫師表示,這些研究結果強調了從舒張壓與潮氣末二氧化碳測量指引與幫助CPR決策的價值。
  
  他解釋,醫師可能需要壓快一點、慢一點、大力一點或小力一點;但是,那些確認因素是相當個人化的,無法適用多數病患。
  
  Sutton醫師表示,目前在基本救命術和高階救命術皆未強調監測或把監測列入優先,可能是因為少有人類研究資料顯示這種復甦方法可以改善目前標準方法的結果;這次的研究可望開始改變我們的焦點。
  
  克里夫蘭大學醫院彩虹嬰幼童醫院的Alexandre Rotta醫師表示,這是一篇重要的研究,因為它增加了有關CPR品質的文獻資料;近幾年來,我們知道並非每次CPR都有效,施作CPR時有顯著的操作變化。
  
  他指出,這篇研究的強度在於大樣本數。
  
  Rotta醫師表示,雖然這篇研究有一些限制,例如回溯性研究的本質,但它應可推動迫切需要的進一步研究。
  
  他解釋,這不是不可能,但是難以辨別病患是否因為在復甦時調整了CPR過程,而達到較高的舒張壓或較高的潮氣末二氧化碳,或者是這些病患只是有比較高的舒張壓與潮氣末二氧化碳;已知這些與較佳的結果有關。
  
  他指出,這個問題只能用前瞻研究來回答。目前的研究提供了足夠的有趣證據等待這類研究來證明,在CPR時使用這兩個變項來探討。
  
  資料來源:http://www.24drs.com/professional/list/content.asp?x_idno=7155&x_classno=0&x_chkdelpoint=Y

'Personalized' CPR Increases Survival From Cardiac Arrest

By Nancy A. Melville
Medscape Medical News

PHOENIX — The use of diastolic blood pressure and end tidal carbon dioxide measures to guide in-hospital cardiopulmonary resuscitation (CPR) is associated with a significant improvement in the chance of survival from cardiac arrest, according to new research.

"Healthcare providers need to monitor how the patient is responding to the resuscitation effort," said lead investigator Robert Sutton, MD, from the University of Pennsylvania School of Medicine and the Children's Hospital of Philadelphia.

In fact, they might "need to change their approach if they are not getting good patient physiology during the CPR that they are providing," he told Medscape Medical News here at the Society of Critical Care Medicine 44th Critical Care Congress.

Most in-hospital cardiac arrests occur in the intensive care unit, where blood pressure and carbon dioxide are already closely monitored. Despite that, CPR efforts are typically made in a uniform manner and are not adjusted to those readings.

When the measures are used, CPR is more closely responsive to the patient's immediate needs, Dr Sutton explained.

"This monitoring is a form a personalized medicine; these monitors are a rough approximation of blood flow during CPR," he said. "And we think better blood flow during CPR equates to better patient outcome."

We think better blood flow during CPR equates to better patient outcome.

Dr Sutton has been involved in previous animal studies that showed that the titration of resuscitation efforts according to the individual's physiology can save lives.

In this study, his team evaluated 245,300 CPR events reported in the Get With the Guidelines – Resuscitation registry of all in-hospital CPR events from 2000 to 2012.

In an analysis of diastolic blood pressure, 11,259 of 16,301 (69%) CPR events resulted in a return of spontaneous circulation, and in 4212 (26%) events, diastolic blood pressure was used to monitor the quality of CPR.

In an analysis of end tidal carbon dioxide, 30,980 of 47,135 (66%) CPR events resulted in a return of spontaneous circulation, and in 1648 (3.5%) events, end tidal carbon dioxide was used to monitor quality.

Events in which an arterial catheter was not used or an invasive airway was in place at the time of the cardiac arrest were excluded from the study.

The return of spontaneous circulation was better when diastolic blood pressure was used to monitor CPR than when it was not after adjustment for potential confounders such as age, sex, race, year of arrest, first pulseless rhythm, and duration of arrest (odds ratio [OR], 1.23, 95% confidence interval [CI], 1.12 - 1.36; P < .001).

The same was true for end tidal carbon dioxide (OR, 1.25; 95% CI, 1.10 - 1.43; P < .001).

The association between a return to spontaneous circulation and end tidal carbon dioxide was stronger when the end tidal carbon dioxide achieved was above 10 mm Hg than when it was not (P < .001).

These findings underscore the value of guidance from diastolic blood pressure and end tidal carbon dioxide measures and in CPR decision-making, Dr Sutton said.

"Clinicians may need to push faster, slower, harder, or less hard," he explained. "But the determining factor should be the individual patient, not what works with most patients."

New Targets

"Monitoring has not been emphasized or made a priority in our existing basic and advanced life support classes, likely because there was little human data showing that such a resuscitation approach would improve outcomes over our standard methods," Dr Sutton said. "This study will hopefully begin to change our focus."

This is "an important study because it adds to the body of literature on CPR quality," said Alexandre Rotta, MD, from University Hospitals Rainbow Babies & Children's Hospital in Cleveland.

"For a few years now we have known that not every CPR is effective and that there is significant operator variability in delivering CPR," he told Medscape Medical News.

"The strength of this study is in the large sample," he added.

Although the study has some important limitations, such as its retrospective nature, it nevertheless should spur much-needed additional research, said Dr Rotta.

"It is difficult, if not impossible, to discern whether patients who achieved a higher diastolic blood pressure and higher end tidal carbon dioxide did so because adjustments were made to the CPR process during resuscitation, or whether these patients simply had higher diastolic blood pressure and end tidal carbon dioxide, which have been known for years to be associated with better outcomes," he explained.

"This question can only be answered by a prospective study," he added. "The current study provides enough intriguing evidence to justify such a trial using these two candidate variables as targets during CPR."

Dr Sutton's work is supported by a National Institutes of Health award, he is a member of the Get With the Guidelines – Resuscitation Pediatrics Task Force, and he has received speakers honoraria from Zoll Medical. Dr Rotta has disclosed no relevant financial relationships.

Society of Critical Care Medicine (SCCM) 44th Critical Care Congress: Abstract 225. Presented January 18, 2015.

    
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