1、心肺復(fù)蘇后亞低溫治療河北醫(yī)科大學(xué)第三醫(yī)院急診科秦延軍2016-9-24目錄1.心跳驟停流行病學(xué)2.亞低溫與指南3. 最佳目標(biāo)溫度4.亞低溫并發(fā)癥及處理心跳驟停病死率高心臟驟停的存活率低，據(jù)統(tǒng)計(jì)，院外存活率6%，院內(nèi)18%，平均18 years),in cardiac arrest on EMS arrival, had IV access establishedwere still in cardiac arrest after initial resuscitation treatments.排除標(biāo)準(zhǔn)in cardiac arrest as a result of trauma (inclu

2、ding hanging), suspected intra-cranial bleeding, females who were known or suspected to be pregnant, already hypothermic (34.5C), or in-patients in a hospital.Randomization and Intervention隨機(jī) an opaque envelope containing computer-generated random treatment allocation處理 a rapid infusion of 30mL/kg c

3、old saline (maximum 2L) via a peripheral intravenous cannula, or continued standard care.停止輸液條件reached 33C or if pulmonary edema was suspectedOutcomesThe primary outcome measure was survival at hospital dischargeSecondary outcome measures were the proportion of patients in shockable and non-shockabl

4、e rhythms with ROSC快速輸液使右房壓增加，降低了冠脈灌注壓，且可以導(dǎo)致肺水腫心臟溫度低使得對(duì)除顫反應(yīng)性差，這一點(diǎn)有爭(zhēng)議低溫持續(xù)的時(shí)間和復(fù)溫目標(biāo)溫度持續(xù)時(shí)間至少24h復(fù)溫速度控制在0.25-0.5/h復(fù)溫后溫度應(yīng)控制在37.5以下，至少維持到復(fù)蘇后72hDOI 10.1186/s13049-015-0121-3并發(fā)癥處理寒顫：處理：鎮(zhèn)靜藥、麻醉藥，鎂，肌松藥，皮膚保暖高血糖：低溫降低胰島素敏感性及胰島素的分泌，血糖增高，需要強(qiáng)化胰島素治療復(fù)溫時(shí)注意低血糖發(fā)生低鉀血癥：低溫導(dǎo)致細(xì)胞外鉀離子轉(zhuǎn)移至細(xì)胞內(nèi)；導(dǎo)致腎小管功能障礙，分泌鉀增多凝血功能障礙感染風(fēng)險(xiǎn)增加低溫對(duì)凝血的影響盡管輕到

5、中度低溫對(duì)患者凝血系統(tǒng)有影響，與低溫有關(guān)的出血風(fēng)險(xiǎn)非常低。對(duì)于伴有中到重度酸中毒的患者出血風(fēng)險(xiǎn)增加。如果溫度控制35C，低溫對(duì)患者無影響，即使患者具有較高出血風(fēng)險(xiǎn)在此溫度都很安全Kees H Polderman.Hypothermia and coagulation. Critical Care 2012, 16(Suppl 2):A20Hypothermia and coagulation， Critical Care 2012低溫與感染低溫抑制細(xì)胞和體液免疫肺部感染常見，心肺復(fù)蘇、急診氣管插管、機(jī)械通氣有關(guān)，這些可以引起血行感染和導(dǎo)管感染。研究發(fā)現(xiàn)這些感染并沒有增加病死率。Mongardon N. Infectious complications in out-of-hospital cardiac arrest patients in the therapeutic hypothermia era. Crit Care Med. 2011;39:13591364Tsai MS. Infections in the survivors of out-of-hosp