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有不可电击复律心律的心脏停搏患者的目标体温管理
Targeted Temperature Management for Cardiac Arrest with Nonshockable Rhythm


Jean-Baptiste Lascarrou ... 心脑血管疾病 • 2019.12.12
相关阅读
• 出现不可电击复律心律的心脏停搏患者的低温治疗 • 儿童院内心脏停搏后的低温治疗 • 心搏骤停后的目标体温管理的体温应设定为多少

不可除颤心律心脏骤停患者轻度低温治疗

 

郑雯,徐峰,陈玉国*

山东大学齐鲁医院急诊科

*通讯作者

 

2019年12月12日,法国Jean-Baptiste Lascarrou教授及其研究团队在《新英格兰医学杂志》(NEJM)正式发表了HYPERION研究结果(10月2日在线发表),证实了轻度低温治疗在不可除颤心律心脏骤停(cardiac arrest,CA)患者中的有效性1

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摘要


背景

对于院外心脏停搏且心肺复苏成功后持续昏迷的成人,目前推荐采用中度低温治疗来改善神经系统结局。然而,对于有不可电击复律心律(心脏无收缩或无脉性电活动)的患者而言,中度低温治疗的有效性仍有争议。

 

方法

我们开展了一项开放标签、随机、对照试验,在发生心脏停搏且有不可电击复律心律,并且心肺复苏成功后被送入重症监护病房(ICU)的昏迷患者中比较了中度低温治疗(前24小时期间33℃)与常温治疗(37℃)。主要结局是随机分组后第90日时神经系统结局良好的生存率,神经系统结局应用脑功能分类(Cerebral Performance Category,CPC)量表(范围为1~5分,评分较高表示失能较严重)进行评估。我们将良好的神经系统结局定义为CPC评分1分或2分。我们对结局进行了盲法评估。此外还评估了死亡率和安全性。

 

结果

从2014年1月至2018年1月,25个ICU的共计584例患者经随机分组,其中581例患者被纳入分析(3例患者撤回知情同意)。第90日时,低温组284例患者中的29例(10.2%)存活且CPC评分为1分或2分,而常温组为297例患者中的17例(5.7%)(差异,4.5个百分点;95%置信区间[CI],0.1~8.9;P=0.04)。低温组和常温组的90日死亡率无显著差异(分别为81.3%和83.2%;差异,-1.9个百分点;95% CI,-8.0~4.3)。预先设定的不良事件的发生率无显著组间差异。

 

结论

在发生心脏停搏且有不可电击复律心律,并且心肺复苏成功的昏迷患者中,持续24小时的33℃中度低温治疗与常温治疗相比提高了90日时神经系统结局良好的存活患者百分比(由法国卫生部[French Ministry of Health]等资助;HYPERION在ClinicalTrials.gov注册号为NCT01994772)。





作者信息

Jean-Baptiste Lascarrou, M.D., Hamid Merdji, M.D., Ph.D., Amélie Le Gouge, M.Sc., Gwenhael Colin, M.D., Guillaume Grillet, M.D., Patrick Girardie, M.D., Elisabeth Coupez, M.D., Pierre-François Dequin, M.D., Ph.D., Alain Cariou, M.D., Ph.D., Thierry Boulain, M.D., Noelle Brule, M.D., Jean-Pierre Frat, M.D., Ph.D., Pierre Asfar, M.D., Ph.D., Nicolas Pichon, M.D., Mickael Landais, M.D., Gaëtan Plantefeve, M.D., Jean-Pierre Quenot, M.D., Ph.D., Jean-Charles Chakarian, M.D., Michel Sirodot, M.D., Stéphane Legriel, M.D., Julien Letheulle, M.D., Didier Thevenin, M.D., Arnaud Desachy, M.D., Arnaud Delahaye, M.D., Vlad Botoc, M.D., Sylvie Vimeux, M.D., Frederic Martino, M.D., Bruno Giraudeau, Ph.D., and Jean Reignier, M.D., Ph.D. for the CRICS-TRIGGERSEP Group*
From Médecine Intensive Réanimation, University Hospital Center, Nantes (J.-B.L., N.B., J.R.), the Paris Cardiovascular Research Center, INSERM Unité 970 (J.-B.L., A.C.), the Medical Intensive Care Unit, Cochin University Hospital Center (A.C.), and the AfterROSC Network (J.-B.L., A.C., N.P., S.L.), Paris, Université de Strasbourg, Faculté de Médecine (H.M.), Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, Service de Médecine Intensive Réanimation (H.M.), and Unité Mixte de Recherche (UMR) 1260, Regenerative Nano Medecine, INSERM, Fédération de Médecine Translationnelle de Strasbourg, Université de Strasbourg (H.M.), Strasbourg, INSERM Centres d’Investigation Clinique (CIC) 1415, Centre Hospitalier Régional Universitaire de Tours (A.L.G., B.G.), the Medical Intensive Care Unit, University Hospital Center (P.-F.D.), INSERM UMR 1100–Centre d’Etude des Pathologies Respiratoires, Tours University (P.-F.D.), and Université de Tours (B.G.), Tours, the Medical–Surgical Intensive Care Unit, District Hospital Center, La Roche-sur-Yon (G.C.), the Medical Intensive Care Unit, South Brittany General Hospital Center, Lorient (G.G.), Médecine Intensive Réanimation, Centre Hospitalier Universitaire Lille, and Université de Lille, Faculté de Médicine, Lille (P.G.), the Medical Intensive Care Unit, University Hospital Center, Clermond-Ferrand (E.C.), the Medical Intensive Care Unit, Regional Hospital Center, Orleans (T.B.), the Medical Intensive Care Unit, University Hospital Center, INSERM CIC 1402, Équipe ALIVE, and Université de Poitiers, Faculté de Médecine et de Pharmacie de Poitiers, Poitiers (J.-P.F.), the Medical Intensive Care Unit, University Hospital Center, Angers (P.A.), Service de Réanimation Polyvalente, University Hospital Center, and CIC 1435, University Hospital Center, Limoges (N.P.), the Medical–Surgical Intensive Care Unit, General Hospital Center, Le Mans (M.L.), the Medical–Surgical Intensive Care Unit, General Hospital Center, Argenteuil (G.P.), the Medical Intensive Care Unit, University Hospital Center, Dijon (J.-P.Q.), the Medical–Surgical Intensive Care Unit, General Hospital Center, Roanne (J.-C.C.), the Medical–Surgical Intensive Care Unit, General Hospital Center, Annecy (M.S.), the Medical–Surgical Intensive Care Unit, Versailles Hospital, Versailles (S.L.), the Medical–Surgical Intensive Care Unit, General Hospital Center, Saint Brieuc (J.L.), the Medical–Surgical Intensive Care Unit, General Hospital Center, Lens (D.T.), the Medical–Surgical Intensive Care Unit, General Hospital Center, Angouleme (A. Desachy), the Medical–Surgical Intensive Care Unit, General Hospital Center, Rodez (A. Delahaye), the Medical–Surgical Intensive Care Unit, General Hospital Center, Saint Malo (V.B.), the Medical–Surgical Intensive Care Unit, General Hospital Center, Montauban (S.V.), and the Medical Intensive Care Unit, University Hospital Center, Point-a-Pitre (F.M.) — all in France. Address reprint requests to Dr. Lascarrou at the Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire, 30 Blvd. Jean Monnet, 44093 Nantes CEDEX 1, France, or at jeanbaptiste.lascarrou@chu-nantes.fr. *Lists of the investigators in the HYPERION trial and the members of the Clinical Research in Intensive Care and Sepsis (CRICS) Group are provided in the Supplementary Appendix, available at NEJM.org.

 

参考文献

1. Nolan JP, Soar J, Cariou A, et al. European Resuscitation Council and European Society of Intensive Care Medicine guidelines for post-resuscitation care 2015: section 5 of the European Resuscitation Council guidelines for resuscitation 2015. Resuscitation 2015;95:202-222.

2. Frydland M, Kjaergaard J, Erlinge D, et al. Target temperature management of 33°C and 36°C in patients with out-of-hospital cardiac arrest with initial non-shockable rhythm — a TTM sub-study. Resuscitation 2015;89:142-148.

3. Bradley SM, Liu W, McNally B, et al. Temporal trends in the use of therapeutic hypothermia for out-of-hospital cardiac arrest. JAMA Netw Open 2018;1(7):e184511-e184511.

4. Proceedings of Réanimation 2019, the French Intensive Care Society International Congress. Ann Intensive Care 2019;9:Suppl 1:1-153.

5. Khera R, Humbert A, Leroux B, et al. Hospital variation in the utilization and implementation of targeted temperature management in out-of-hospital cardiac arrest. Circ Cardiovasc Qual Outcomes 2018;11(11):e004829-e004829.

6. Testori C, Sterz F, Behringer W, et al. Mild therapeutic hypothermia is associated with favourable outcome in patients after cardiac arrest with non-shockable rhythms. Resuscitation 2011;82:1162-1167.

7. Perman SM, Grossestreuer AV, Wiebe DJ, Carr BG, Abella BS, Gaieski DF. The utility of therapeutic hypothermia for post-cardiac arrest syndrome patients with an initial nonshockable rhythm. Circulation 2015;132:2146-2151.

8. Vaahersalo J, Hiltunen P, Tiainen M, et al. Therapeutic hypothermia after out-of-hospital cardiac arrest in Finnish intensive care units: the FINNRESUSCI study. Intensive Care Med 2013;39:826-837.

9. Dumas F, Grimaldi D, Zuber B, et al. Is hypothermia after cardiac arrest effective in both shockable and nonshockable patients? Insights from a large registry. Circulation 2011;123:877-886.

10. Chan PS, Berg RA, Tang Y, Curtis LH, Spertus JA. Association between therapeutic hypothermia and survival after in-hospital cardiac arrest. JAMA 2016;316:1375-1382.

11. Mader TJ, Nathanson BH, Soares WE III, Coute RA, McNally BF. Comparative effectiveness of therapeutic hypothermia after out-of-hospital cardiac arrest: insight from a large data registry. Ther Hypothermia Temp Manag 2014;4:21-31.

12. Myat A, Song K-J, Rea T. Out-of-hospital cardiac arrest: current concepts. Lancet 2018;391:970-979.

13. Bougouin W, Lamhaut L, Marijon E, et al. Characteristics and prognosis of sudden cardiac death in Greater Paris: population-based approach from the Paris Sudden Death Expertise Center (Paris-SDEC). Intensive Care Med 2014;40:846-854.

14. Argaud L, Cour M, Dubien PY, et al. Effect of cyclosporine in nonshockable out-of-hospital cardiac arrest: the CYRUS randomized clinical trial. JAMA Cardiol 2016;1:557-565.

15. Kirkegaard H, Søreide E, de Haas I, et al. Targeted temperature management for 48 vs 24 hours and neurologic outcome after out-of-hospital cardiac arrest: a randomized clinical trial. JAMA 2017;318:341-350.

16. Lascarrou JB, Meziani F, Le Gouge A, et al. Therapeutic hypothermia after nonshockable cardiac arrest: the HYPERION multicenter, randomized, controlled, assessor-blinded, superiority trial. Scand J Trauma Resusc Emerg Med 2015;23:26-26.

17. Lascarrou JB, Le Gouge A, Dimet J, et al. Neuromuscular blockade during therapeutic hypothermia after cardiac arrest: observational study of neurological and infectious outcomes. Resuscitation 2014;85:1257-1262.

18. Ely EW, Truman B, Shintani A, et al. Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). JAMA 2003;289:2983-2991.

19. Peberdy MA, Callaway CW, Neumar RW, et al. Post-cardiac arrest care: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2010;122:Suppl 3:S768-S786.

20. Becker LB, Aufderheide TP, Geocadin RG, et al. Primary outcomes for resuscitation science studies: a consensus statement from the American Heart Association. Circulation 2011;124:2158-2177.

21. Fayol P, Carrière H, Habonimana D, Preux PM, Dumond JJ. French version of structured interviews for the Glasgow Outcome Scale: guidelines and first studies of validation. Ann Readapt Med Phys 2004;47:142-156. (In French.)

22. Jennett B, Bond M. Assessment of outcome after severe brain damage. Lancet 1975;1:480-484.

23. Robert R, Le Gouge A, Kentish-Barnes N, et al. Terminal weaning or immediate extubation for withdrawing mechanical ventilation in critically ill patients (the ARREVE observational study). Intensive Care Med 2017;43:1793-1807.

24. Lascarrou J, Lacherade J, Martin-Lefèvre L, et al. Intérêt de l’hypothermie thérapeutique dans l’arrêt cardiaque non choquable. Reanimation 2012;21:S193-S194.

25. Peto R, Pike MC, Armitage P, et al. Design and analysis of randomized clinical trials requiring prolonged observation of each patient. I. Introduction and design. Br J Cancer 1976;34:585-612.

26. Bernard SA, Gray TW, Buist MD, et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med 2002;346:557-563.

27. The Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med 2002;346:549-556.

28. Nielsen N, Wetterslev J, Cronberg T, et al. Targeted temperature management at 33°C versus 36°C after cardiac arrest. N Engl J Med 2013;369:2197-2206.

29. Wissenberg M, Lippert FK, Folke F, et al. Association of national initiatives to improve cardiac arrest management with rates of bystander intervention and patient survival after out-of-hospital cardiac arrest. JAMA 2013;310:1377-1384.

30. Testori C, Sterz F, Holzer M, et al. The beneficial effect of mild therapeutic hypothermia depends on the time of complete circulatory standstill in patients with cardiac arrest. Resuscitation 2012;83:596-601.

31. Dankiewicz J, Friberg H, Bělohlávek J, et al. Time to start of cardiopulmonary resuscitation and the effect of target temperature management at 33°C and 36°C. Resuscitation 2016;99:44-49.

32. Mongardon N, Dumas F, Ricome S, et al. Postcardiac arrest syndrome: from immediate resuscitation to long-term outcome. Ann Intensive Care 2011;1:45-45.

33. Hassager C, Nagao K, Hildick-Smith D. Out-of-hospital cardiac arrest: in-hospital intervention strategies. Lancet 2018;391:989-998.

34. Isaacs E, Callaham ML. Ability of laypersons to estimate short time intervals in cardiac arrest. Ann Emerg Med 2000;35:147-154.

35. Maupain C, Bougouin W, Lamhaut L, et al. The CAHP (Cardiac Arrest Hospital Prognosis) score: a tool for risk stratification after out-of-hospital cardiac arrest. Eur Heart J 2016;37:3222-3228.

36. Perkins GD, Ji C, Deakin CD, et al. A randomized trial of epinephrine in out-of-hospital cardiac arrest. N Engl J Med 2018;379:711-721.

37. Hasselqvist-Ax I, Riva G, Herlitz J, et al. Early cardiopulmonary resuscitation in out-of-hospital cardiac arrest. N Engl J Med 2015;372:2307-2315.

38. Zeiner A, Holzer M, Sterz F, et al. Hyperthermia after cardiac arrest is associated with an unfavorable neurologic outcome. Arch Intern Med 2001;161:2007-2012.

39. Makker P, Kanei Y, Misra D. Clinical effect of rebound hyperthermia after cooling postcardiac arrest: a meta-analysis. Ther Hypothermia Temp Manag 2017;7:206-209.

40. Harrington D, D’Agostino RB Sr, Gatsonis C, et al. New guidelines for statistical reporting in the Journal. N Engl J Med 2019;381:285-286.

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