1、Therapeutic hypothermia in PostCardiac Arrest Care2015 VS 2010心脏骤停的流行病学心脏骤停的流行病学400,000 骤停骤停/每年在每年在 U.S.A医院医院3/4 门急诊门急诊1/4 住院患者住院患者 hypoxemia ischemia reperfusion multiple organ systems Influence of cardiac arrest and resuscitation*低温治疗：是一种以物理方法物理方法将患者的体温体温降低到预期水平而达到治疗疾病目的的方法。低温疗法是荷兰物理学家卡曼林昂内斯（1853-
2、1926）发明的，被誉为“低温学之父。”低温治疗的分类低温治疗的分类分类英文名称目标温度轻度低温mild hypothermia3335亚低温亚低温(mild hypothermia)，亚低温状态下，对心脑肺的保护作用与深度低温相似，但无明显不良反应中度低温moderate hypothermia2832深度低温profound hypothermia172728以下低温容易引起低血压和心律失常等并发症，目前较少使用超深度低温ultraprofound hypothermia16低温治疗作用机制的新观念低温治疗作用机制的新观念 降低脑的代谢水平，减低氧耗，改善并恢复能量供给；抑制氧自由基产生，
3、减轻氧化应激损伤；下调炎症介质的产生和炎症细胞的集聚，减轻炎症损伤；减低神经细胞及心肌细胞凋亡。IntensiveCareMed.1996,22(11):1191-6.心肺复述后病人颅脑损伤及重型颅脑手术后病人低温麻醉病人高热惊厥或超高热病人感染中毒性休克早期病人及颅内感染病人急性重症脑血管病心肺复苏后病人心肺复苏后病人Bladder Temperature in the Normothermia and Hypothermia Groups.The T bars indicate the 75th percentile in the normothermia group and the 25
4、th percentile in the hypothermia group.The target temperature in the hypothermia group was 32 to 34,and the duration of cooling was 24 hours.Only patients with recorded temperatures were included in the analysis.N Engl J Med.2002,346(8):557-563.The 2010 Guidelines advised hypothermia(32C to 34C)Afte
5、r 6 months:75 of the 136(55%)in hypothermia group had better favorable neurologic outcome than normothermia group(39%).After 6 months:Rate of death(41%)in the hypothermia is 14%lower than in the normothermia group(55%).The 2010 Guidelines advised hypothermia duration temperature 12 to 24 hours N Eng
6、l J Med.2002,346(8):549-556.hypothermia(33C maintained 12 hours)VS normothermia.The 2015 Guidelines advised hypothermia(32C to 36C)N Engl J Med.2013,369(23):2197-2206.2015 Guidelines advised hypothermia at least 24 hours N Engl J Med.2013,369(23):2197-2206.（cerebral performance categorycerebral perf
7、ormance category，CPCCPC）脑功能脑功能功能分类功能分类 敏感性较差 1.好的脑功能：有意识，灵敏，和能够工作并且正常生活。可能有轻微心理或者神经病学缺陷(轻度的语言障碍，轻瘫或者轻微脑神经异常).2.中度脑残疾：有意识。在一保护的环境有足够脑功能胜任部分工作或者能进行独立日常生活活动(如穿，乘公共交通，食品准备).这样的病人可能有半身不遂，发作，共济失调，构语障碍，言语障碍或者永久记忆或者精神变化 3.严重脑残疾：有意识；因为受损的大脑功能病人依靠其他人得到日常帮助(在一个机构里或者在家需要特别的家庭帮助)。至少已经有认知限制。这个种类包括大范围脑的不正常，病人能行走但是
8、有严重的记忆混乱或者痴呆不能独立生存，那些全身瘫痪并且只能用眼睛交流的人，如同闭锁综合症。4.昏迷/植物的状态：没有意识，没意识到环境，没有认知。没有文字和或心理与环境的相互作用。5.脑死亡。JAMA.2006,295(1):50-57Follow-up and Outcomes序贯器官衰竭估计评分序贯器官衰竭估计评分(SOFA)每一变量的分值均为每一变量的分值均为03分，总分分，总分09分。分。分值越大，表明细胞受损分值越大，表明细胞受损/脏器功能受损越重，预后也越差脏器功能受损越重，预后也越差 Cardiovascular component of Sequential Organ Fai
9、lure Assessment score Day 1 to 3Serious adverse events excluding deathPatients were excluded due to exclusion criteria 13 known bleeding diathesis 15 suspected or confirmed acute intracranial bleeding 5 suspected or confirmed acute strokeSeizures might be preferred lower temperaturesNeurol Res.2013,
10、35(2):163-168.cerebral edema might be preferred lower temperaturesAm Heart J.2012,163(4):541-548.cooling defined as a temperature less than 34.5 C within 8 h Higher temperatures might be preferred in bleeding J Trauma.1998 May;44(5):846-54.Rewarming maintain the body temperature After 28 hours,gradu
11、al rewarming to 37C in hourly increments of 0.5C was commenced in both groups.At 36 hours,mandatory sedation was discontinued or tapered.After the intervention period,the intention was to maintain the body temperature for unconscious patients below 37.5C until 72 hours after the cardiac arrest,with
12、the use of fever-control measures at the discretion of the sites.rebound hyperthermia A newly described phenomenon is known as“rebound hyperthermia”,which is defined as a core body temperature of 38.5 C or greater within 24 h of cessation of THAvoidance of Hyperthermia fever Am Heart J 2012;163:541-
13、8.Association of rebound hyperthermia with mortalityCirculation 2011;124:206-14.Risk factors for rebound hyperthermiaCrit Care Med 2009;37:1101-20.The presence of rebound hyperthermia is associated with anincreased risk of in-hospital mortality.40 of the 99(40.4%)patients without rebound hyperthermi
14、a experienced any cause in-hospital death.This is compared to 27 of the 42(64.3%)patients who experienced rebound hyperthermia(OR:2.66;95%CI:1.265.61;p=0.011).The risk of rebound hyperthermia.Resuscitation 2013;84:927-34.Treat fever until at least 72 hrs after cardiac arrest.Reasons for early rewarm
15、ing Arrhythmia(severe bradycardia,recurrent ventricular fibrillation)Severe circulatory instability Bleeding Uncontrolled lactate rise conclusion selecting and maintaining a constant temperature between 32C and 36C during TTM(Class I).TTM be maintained for at least 24 hours after achieving target temperature(Class IIa).
