心肺復(fù)蘇后心功能不全zs

1、心肺復(fù)蘇后心功能障礙心肺復(fù)蘇后心功能障礙 一切惡果的始作俑者？一切惡果的始作俑者？心肺復(fù)蘇后治療仍面臨巨大挑戰(zhàn)心肺復(fù)蘇后治療仍面臨巨大挑戰(zhàn)1.Safar P: Resuscitation from clinical death: pathophysiologic limits and therapeutic potentials. Crit Care Med 1988, 16:923941.2.Keenan SP, Dodek P, Martin C, Priestap F, Norena M, Wong H. Variation in length of intensive care uni

2、t stay after cardiac arrest: where you are is as important as who you are. Crit Care Med 2007;35:83641.3.Nolan JP, Laver SR, Welch CA, Harrison DA, Gupta V, Rowan K. Outcome following admission to UK intensive care units after cardiac arrest: a secondary analysis of the ICNARC Case Mix Programme Dat

3、abase. Anaesthesia 2007;62:120716.4.Herlitz J, Engdahl J, Svensson L, Angquist KA, Silfverstolpe J, Holmberg S. Major differences in 1-month survival between hospitals in Sweden among initial survivors of out-of-hospital cardiac arrest. Resuscitation 2006;70:4049.5.Langhelle A, Tyvold SS, Lexow K, H

4、apnes SA, Sunde K, Steen PA. In-hospital factors associated with improved outcome after out-of-hospital cardiac arrest. A comparison between four regions in Norway. Resuscitation 2003;56:24763.6.Mashiko K, Otsuka T, Shimazaki S, et al. An outcome study of out-of-hospital cardiac arrest using the Uts

5、tein templatea Japanese experience. Resuscitation 2002;55:2416.NationsMortality rateyearCanada265%2007UK371.4%2007Sweden458-86%2006Norway554-70%2003Japan690%2002ROSC患者存在血流動(dòng)力學(xué)不穩(wěn)定患者存在血流動(dòng)力學(xué)不穩(wěn)定復(fù)蘇后心功能障礙心臟驟停后休克狀態(tài)死亡率復(fù)蘇復(fù)蘇后心功能不全的變變化與預(yù)與預(yù)后密切相關(guān)關(guān)Manuel Ruiz-Bailn, Eduardo Aguayo de Hoyos, Silvia Ruiz-Navarro, et

6、 al. Reversible myocardial dysfunction after cardiopulmonary resuscitation. Resuscitation 2005;66:175-181.GroupNDieCauseMyocardial dysfunction209Shock and MOF(8) Cerebral death(1) Myocardial function93Cerebral death(2)Hemorrhagic shock(1)心因性心臟驟臟驟停ROSC后的心功能研研究GroupNInvasive monitoringNo hemodynamic i

7、nstability75NoHemodynamic instability73YesI. Laurent, M. Monchi, J.D. Chiche, et al. Reversible myocardial dysfunction in survivors of out-of-hospital cardiac arrest. J Am Coll Cardiol 2002;40:21102116I. Laurent, M. Monchi, J.D. Chiche, et al. Reversible myocardial dysfunction in survivors of out-of

8、-hospital cardiac arrest. J Am Coll Cardiol 2002;40:21102116心因性心臟驟臟驟停ROSC后的心功能研研究I. Laurent, M. Monchi, J.D. Chiche, et al. Reversible myocardial dysfunction in survivors of out-of-hospital cardiac arrest. J Am Coll Cardiol 2002;40:21102116死亡率與與心功能持續(xù)續(xù)障礙相關(guān)關(guān)心因性心臟驟臟驟停ROSC后的心功能研研究復(fù)蘇復(fù)蘇后心功能不全 是一切麻煩煩的制造者！心

9、功能不全如何發(fā)發(fā)生？心 1、心肌收縮縮力 2、心臟臟舒張順應(yīng)張順應(yīng)性 3、心率心肌頓頓抑 是指心肌短時(shí)間缺血后不發(fā)生壞死，但引起心肌細(xì)細(xì)胞的結(jié)結(jié)構(gòu)構(gòu)、代謝謝和功能改變變在再灌注后延遲遲恢復(fù)復(fù)的現(xiàn)現(xiàn)象 臨床特征表現(xiàn)為收縮縮功能障礙 持續(xù)數(shù)數(shù)天到數(shù)數(shù)周 復(fù)蘇復(fù)蘇后心功能不全主要是心肌頓頓抑 最早ROSC后30分鐘內(nèi)可監(jiān)測到左室舒張末壓上升（8-10mmHg到20-22mmHg），射血分?jǐn)?shù)顯著下降（55%到20%），呈現(xiàn)低心排和低血壓。 在整個(gè)個(gè)心功能障礙期間間冠脈的血流沒沒有明顯顯下降，提示是一種真種真正的心肌頓頓抑，而非持續(xù)續(xù)的心肌損傷損傷或梗死。 這種功能障礙多是暫時(shí)性的，大多可在72h完全恢

10、復(fù)，但也有低心排持續(xù)數(shù)周到數(shù)月的報(bào)道。復(fù)蘇復(fù)蘇后存在可逆心功能障礙Manuel Ruiz-Bailn, Eduardo Aguayo de Hoyos, Silvia Ruiz-Navarro, et al. Reversible myocardial dysfunction after cardiopulmonary resuscitation. Resuscitation 2005;66:175-181.黑線：全部患者的左室射血分?jǐn)?shù)（29人）；灰線：心肌異常組的左室射血分?jǐn)?shù)（20人）治療療策略 需要強(qiáng)化監(jiān)護(hù)監(jiān)護(hù) 早期血流動(dòng)動(dòng)力學(xué)優(yōu)學(xué)優(yōu)化或EGDT，恢復(fù)復(fù)和維維持全身氧輸氧輸送和氧氧需平衡成

11、功的關(guān)鍵：成功的關(guān)鍵：盡早監(jiān)護(hù)和治療，并在起病數(shù)小時(shí)內(nèi)達(dá)到治療目標(biāo)盡早監(jiān)護(hù)和治療，并在起病數(shù)小時(shí)內(nèi)達(dá)到治療目標(biāo)治療療策略 低血壓的一線干預(yù)措施是通過輸液使右室充盈壓最佳化（CVP 8-12mmHg） 如果輸液使得前負(fù)荷達(dá)標(biāo)，但仍未獲獲得滿滿意的血流動(dòng)動(dòng)力學(xué)學(xué)目標(biāo)標(biāo)，可考慮應(yīng)慮應(yīng)用正性肌力和升壓藥壓藥K.B. Kern, R.W. Hilwig, R.A. Berg, et al. Postresuscitation left ventricular systolic and diastolic dysfunction: treatment with dobutamine. Circulatio

12、n 1997, 95: 26102613正性肌力藥藥物可改善心功能心肌頓頓抑是唯一的麻煩煩制造者？I. Laurent, M. Monchi, J.D. Chiche, et al. Reversible myocardial dysfunction in survivors of out-of-hospital cardiac arrest. J Am Coll Cardiol 2002;40:21102116CI改善情況下仍然需要血管活性藥物維持血流動(dòng)力學(xué)穩(wěn)定改善情況下仍然需要血管活性藥物維持血流動(dòng)力學(xué)穩(wěn)定I. Laurent, M. Monchi, J.D. Chiche, et al.

13、 Reversible myocardial dysfunction in survivors of out-of-hospital cardiac arrest. J Am Coll Cardiol 2002;40:21102116心功能改善不是血流動(dòng)動(dòng)力學(xué)穩(wěn)學(xué)穩(wěn)定的唯一原因心臟驟臟驟停后綜綜合征Jerry P. Nolan, Robert W. Neumar, Christophe Adrie, et al. Post-cardiac arrest syndrome: Epidemiology, pathophysiology, treatment, and prognostication

14、: A Scientific Statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; the Council on Stroke. Resuscitation 2008; 79:350-379心臟驟停后獨(dú)特的病理生理狀態(tài)及臨床表現(xiàn)心臟驟停后綜合征Christophe Adrie, Minou Adib-Conquy, Ivan Laurent, et al. Successful Cardiopulmonary Resuscitation After Cardiac Arrest as a “Sepsis-Like” Syndrome. Ci