提示: 手机请竖屏浏览!

撤除患者生命维持措施后的心脏活动恢复情况
Resumption of Cardiac Activity after Withdrawal of Life-Sustaining Measures


Sonny Dhanani ... 其他 • 2021.01.28
相关阅读
• 按照循环系统标准判定死亡之后,器官捐献的合适时机

摘要


背景

根据循环系统标准判定死亡之后,器官捐献之前所要求的最短无脉搏时间尚未经过充分研究。

 

方法

我们在三个国家的20个重症监护病房开展了一项前瞻性观察性研究;本研究在按照计划撤除生命维持措施后死亡的成人中评估了心脏电活动和脉搏活动的恢复率和恢复时间。本研究计划在判定患者死亡后对其进行30分钟监测。床旁临床医师前瞻性报告心脏活动恢复情况。此外我们记录并回顾性评估了连续的血压和心电图(ECG)波形,以确认床旁观察结果,并确定是否有更多心脏活动恢复的情况。

 

结果

共计1,999例患者接受了筛选,631人被纳入本研究。在5例患者(1%)中,临床报告的心脏活动、呼吸运动或这两者恢复情况得到了波形分析结果的确认。对480例患者的ECG和血压波形所做的回顾性分析发现,67例(14%)患者在无脉搏一段时间后心脏活动恢复,其中包括床旁临床医师报告的5例患者。从无脉搏至心脏活动恢复的最长间隔时间为4分20秒。19%患者的最后一个QRS波群与最后一次动脉搏动吻合。

 

结论

根据波形的回顾性分析结果,撤除患者的生命维持措施后,14%的患者在无脉搏后短暂恢复了至少一个周期的心脏活动;床旁评估仅发现了其中的1%。上述事件发生在无脉搏后4分20秒内(由加拿大卫生研究院[Canadian Institutes for Health Research]等资助)。





作者信息

Sonny Dhanani, M.D., Laura Hornby, M.Sc., Amanda van Beinum, M.Sc., Nathan B. Scales, Ph.D., Melanie Hogue, M.Sc., Andrew Baker, M.D., Stephen Beed, M.D., J. Gordon Boyd, M.D., Ph.D., Jennifer A. Chandler, L.L.B., L.L.M., Michaël Chassé, M.D., Ph.D., Frederick D’Aragon, M.D., Ph.D., Cameron Dezfulian, M.D., Christopher J. Doig, M.D., Frantisek Duska, M.D., Ph.D., Jan O. Friedrich, M.D., D.Phil., Dale Gardiner, M.D., Teneille Gofton, M.D., Dan Harvey, M.D., Christophe Herry, Ph.D., George Isac, M.D., Andreas H. Kramer, M.D., Demetrios J. Kutsogiannis, M.D., David M. Maslove, M.D., Maureen Meade, M.D., Sangeeta Mehta, M.D., Laveena Munshi, M.D., Loretta Norton, Ph.D., Giuseppe Pagliarello, M.D., Tim Ramsay, Ph.D., Katerina Rusinova, M.D., Ph.D., Damon Scales, M.D., Ph.D., Matous Schmidt, M.D., Andrew Seely, M.D., Ph.D., Jason Shahin, M.D., C.M., Marat Slessarev, M.D., Derek So, M.D., Heather Talbot, B.Ed., Walther N.K.A. van Mook, M.D., Ph.D., Petr Waldauf, M.D., Matthew Weiss, M.D., Jentina T. Wind, R.N., Ph.D., and Sam D. Shemie, M.D. for the Canadian Critical Care Trials Group and the Canadian Donation and Transplantation Research Program*
From the Children’s Hospital of Eastern Ontario (S.D.), Children’s Hospital of Eastern Ontario Research Institute (S.D., L.H., A. van Beinum, M.H., H.T.), Faculty of Medicine (S.D.) and Centre for Health Law, Policy, and Ethics (J.A.C.), University of Ottawa, Canadian Blood Services (L.H., S.D.S.), Carleton University (A. van Beinum), the Dynamical Analysis Lab (N.B.S., C.H., A.S.), Clinical Epidemiology Program (N.B.S., C.H., A.S.), and Clinical Epidemiology Program Methods Centre (T.R.), Ottawa Hospital Research Institute, the Departments of Critical Care and General Surgery (G.P.) and Surgery (A.S.) and Division of Thoracic Surgery (A.S.), Ottawa Hospital, and Interventional Cardiology Program, University of Ottawa Heart Institute (D. So), Ottawa, the Department of Critical Care, Trauma and Neurosurgery Program, St. Michael’s Hospital (A. Baker), Li Ka Shing Knowledge Institute, Unity Health–St. Michael’s Hospital (J.O.F., D. Scales), University of Toronto (J.O.F.), Mount Sinai Hospital (S.M., L.M.) and Interdepartmental Division of Critical Care Medicine (S.M., L.M., D. Scales), University of Toronto, Department of Critical Care Medicine, Sunnybrook Health Sciences Centre (D. Scales), and the Canadian Donation and Transplantation Research Program (H.T.), Toronto, the Departments of Critical Care and Anesthesia, Dalhousie University, Halifax, NS (S.B.), the Departments of Medicine and Critical Care Medicine, Queen’s University, Kingston, ON (J.G.B., D.M.M.), the Department of Medicine (Critical Care), Research Centre of the University of Montreal Hospital (M.C.), the Department of Critical Care, Division of Pulmonary Medicine, McGill University (J.S.), McGill University Health Centre and Research Institute (J.S., S.D.S.), Transplant Québec (M.W.), and the Division of Critical Care, Montreal Children’s Hospital (S.D.S.), Montreal, the Department of Anesthesiology, Université de Sherbrooke and Centre de Recherche du Centre Hospitalier Universitaire (CHU) de Sherbrooke, Sherbrooke, QC (F. D’Aragon), the Departments of Critical Care Medicine, Community Health Sciences, and Medicine, Cumming School of Medicine (C.J.D.), and the Departments of Critical Care Medicine and Clinical Neurosciences (A.H.K.), University of Calgary, and Calgary Zone, Alberta Health Services (C.J.D.), Calgary, the Department of Clinical Neurological Sciences, London Health Sciences Centre (T.G.), Schulich School of Medicine and Dentistry (T.G.), the Department of Psychology, King’s University College (L.N.), and the Department of Medicine and the Brain and Mind Institute (M. Slessarev), Western University, London, ON, the Division of Critical Care, Departments of Medicine and Anesthesia, University of British Columbia, Vancouver (G.I.), the Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton (D.J.K.), the Department of Medicine, McMaster University, and Hamilton Health Sciences Centre, Hamilton, ON (M.M.), and the Division of Pediatric Intensive Care, CHU de Québec, Centre Mère-Enfant Soleil, and the Department of Pediatrics, Faculté de Médecine, Université Laval, Quebec City, QC (M.W.) — all in Canada; Safar Center for Resuscitation Research, Critical Care Medicine Department, University of Pittsburgh School of Medicine, Pittsburgh (C.D.); Charles University, Third Faculty of Medicine and FNKV University Hospital (F. Duska, M. Schmidt, P.W.), and the Department of Palliative Medicine, First Faculty of Medicine, Charles University and General University Hospital (K.R.), Prague, Czech Republic; NHS Blood and Transplant, Bristol (D.G., D.H.), and Adult Critical Care, Nottingham University Hospitals NHS Trust, Nottingham (D.G., D.H.) — both in the United Kingdom; and the Department of Intensive Care Medicine, Maastricht University Medical Center, and the School of Health Professions Education, Maastricht University (W.N.K.A.M.), and the Heart and Vascular Center, Maastricht University Medical Center (J.T.W.), Maastricht, the Netherlands. Address reprint requests to Dr. Dhanani at Children’s Hospital of Eastern Ontario, 401 Smyth Rd., Ottawa, ON K1M 1N8, Canada, or at sdhanani@cheo.on.ca. *The members of the site research groups are listed in the Supplementary Appendix, available at NEJM.org.

 

参考文献

1. Youngner SJ, Arnold RM. Ethical, psychosocial, and public policy implications of procuring organs from non-heart-beating cadaver donors. JAMA 1993;269:2769-2774.

2. Greer DM, Shemie SD, Lewis A, et al. Determination of brain death/death by neurologic criteria: the World Brain Death Project. JAMA 2020 August 3 (Epub ahead of print).

3. Smith M, Dominguez-Gil B, Greer DM, Manara AR, Souter MJ. Organ donation after circulatory death: current status and future potential. Intensive Care Med 2019;45:310-321.

4. Dhanani S, Hornby L, Ward R, Shemie S. Variability in the determination of death after cardiac arrest: a review of guidelines and statements. J Intensive Care Med 2012;27:238-252.

5. Weiss MJ, Hornby L, Witteman W, Shemie SD. Pediatric donation after circulatory determination of death: a scoping review. Pediatr Crit Care Med 2016;17(3):e87-e108.

6. Boucek MM, Mashburn C, Dunn SM, et al. Pediatric heart transplantation after declaration of cardiocirculatory death. N Engl J Med 2008;359:709-714.

7. Bernat JL. The boundaries of organ donation after circulatory death. N Engl J Med 2008;359:669-671.

8. Curfman GD, Morrissey S, Drazen JM. Cardiac transplantation in infants. N Engl J Med 2008;359:749-750.

9. Hornby K, Hornby L, Shemie SD. A systematic review of autoresuscitation after cardiac arrest. Crit Care Med 2010;38:1246-1253.

10. Hornby L, Dhanani S, Shemie SD. Update of a systematic review of autoresuscitation after cardiac arrest. Crit Care Med 2018;46(3):e268-e272.

11. Dhanani S, Hornby L, Ward R, et al. Vital signs after cardiac arrest following withdrawal of life-sustaining therapy: a multicenter prospective observational study. Crit Care Med 2014;42:2358-2369.

12. Cook DA, Widdicombe N. Audit of ten years of donation after circulatory death experience in Queensland: observations of agonal physiology following withdrawal of cardiorespiratory support. Anaesth Intensive Care 2018;46:400-403.

13. Sheth KN, Nutter T, Stein DM, Scalea TM, Bernat JL. Autoresuscitation after asystole in patients being considered for organ donation. Crit Care Med 2012;40:158-161.

14. van Beinum A, Talbot H, Hornby L, Fortin MC, Dhanani S. Engaging family partners in deceased organ donation research — a reflection on one team’s experience. Can J Anaesth 2019;66:406-413.

15. Bravi A, Longtin A, Seely AJ. Review and classification of variability analysis techniques with clinical applications. Biomed Eng Online 2011;10:90-90.

16. Seely AJE, Bravi A, Herry C, et al. Do heart and respiratory rate variability improve prediction of extubation outcomes in critically ill patients? Crit Care 2014;18:R65-R65.

17. Higgins JPT, Green S, eds. Cochrane handbook for systematic reviews of interventions, version 5.1.0. London: Cochrane Collaboration, 2011.

18. Newcombe R, Altman D. Proportions and their differences. In: Altman D, Machin D, Bryant T, Gardner M, eds. Statistics with confidence. 2nd ed. London: BMJ Books, 2000:45-56.

19. R: a language and environment for statistical computing. Vienna: R Foundation for Statistical Computing, 2019 (https://www.r-project.org/. opens in new tab).

20. Agresti A, Coull BA. Approximate is better than “exact” for interval estimation of binomial proportions. Am Stat 1998;52:119-126.

21. Clopper CJ, Pearson ES. The use of confidence or fiducial limits illustrated in the case of the binomial. Biometrika 1934;26:404-413.

22. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. PLoS Med 2007;4(10):e296-e296.

服务条款 | 隐私政策 | 联系我们