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学科主题: 内科学
题名:
心脏骤停生存链实施现状和预后因素分析
作者: 郑康
答辩日期: 2016-11-24
导师: 高炜
专业: 内科学
授予单位: 北京大学
授予地点: 北京大学第三临床医学院
学位: 博士
关键词: 心脏骤停 ; 生存链 ; 自主循环恢复 ; 生存率
其他题名: Investigation on implementation of chain of survival and prognostic factors in cardiac arrest patients
分类号: R541.6
摘要:

目的:了解心脏骤停患者心肺复苏过程中“生存链”的实施现状,比较临床实践和心肺复苏指南间的差距,分析影响心脏骤停患者预后的因素。

方法:收集2012年1月至2015年12月在北京大学第三医院和首都医科大学附属北京友谊医院急诊科救治的符合入选标准的心脏骤停成年患者临床资料进行分析。比较院外心脏骤停(OHCA组)和院内心脏骤停(IHCA组)患者人口学资料、心脏骤停的发生地点、病因、心肺复苏过程中“生存链”的实施情况、生存率和神经系统功能,分析影响患者预后的因素。

结果:

研究共纳入符合入选标准的患者1,330例,男性占68.2%,平均年龄63.1±17.2岁,所有患者中导致心脏骤停的病因中居前三位的依次为非心源性内科病因(如急性脑血管病、重症感染、消化道出血等),心源性病因和窒息。经过心肺复苏后27.8%的患者恢复自主循环,7.6%的患者存活出院,随访6个月有4.8%的患者存活。

根据心脏骤停发生地点将患者分为OHCA组(547例)与IHCA组(783例)进行亚组分析,结果显示:

①亚组患者基本资料的比较:OHCA组的平均年龄更低(60.9±18.7 vs. 64.7±15.8, p<0.001)、心源性病因比例更高(58.5% vs. 26.6%, p<0.001)。两组中男性所占比例无差异(69.5% vs. 67.3%, p=0.404)。

②心脏骤停的监测、识别和启动应急反应系统的比较:OHCA组的医务人员接触患者时间小于5分钟的比例更低(14.3% vs. 97.7%, p<0.001)、非医务人员目击心脏骤停的比例更高(71.5% vs. 3.8%, p<0.001)。两组中心脏骤停前出现预警症状者的比例(70.8% vs. 67.6%,p=0.225)无差异。

③即时高质量心肺复苏的比较:OHCA组的目击者实施有效心肺复苏的比例更低(13.5% vs. 95.7%, p<0.001)、5分钟内开始有效心肺复苏的比例更低(15.2% vs. 97.2%, p<0.001)。两组中使用反馈监测系统或ETCO2监测心肺复苏质量的例数均为0。

④快速除颤的比较:OHCA组的初始心律为可电击心律的比例更低(8.2% vs. 12.5%, p=0.013)、5分钟内完成首次电复律的比例更低(9.1% vs. 76.7%, p<0.001)。非医务人员使用自动体外除颤器实施电复律的例数为0。

⑤高级生命支持技术实施的比较:OHCA组经骨髓腔给予肾上腺素的比例更高(1.1% vs. 0.3%, p=0.030)、5分钟内给予首剂肾上腺素的比例更低(14.3% vs. 97.7%, p<0.001)、心肺复苏过程中建立高级气道的比例更高(82.7% vs. 73.8%, p<0.001)、10分钟内建立高级气道的比例更低(5.9% vs. 92.9%, p<0.001)。两组中肾上腺素的使用率、给药剂量为1mg/次的比例均为100%,实施ECPR的例数均为0。

⑥心脏骤停后综合征治疗的比较:两组中自主循环恢复的患者使用血管活性药物(85.7% vs.75.3%, p=0.138)、心源性病因患者接受急诊冠脉造影的比例(15.9% vs. 24.4%, p=0.195)、有创机械通气(93.3% vs. 93.6%, p=0.899)、目标温度管理(39.1% vs. 45.6%, p=0.256)的比例无差异。

⑦预后指标的比较分析:OHCA组自主循环恢复率更低(21.8% vs. 32.1%,p<0.001)、6个月生存率更低(3.3% vs. 5.9%, p=0.030)、出院时(0.7% vs. 3.7%, p=0.001)和6个月(0.9% vs. 3.4%, p=0.003)时神经功能恢复良好率更低。两组的出院存活率(7.1% vs. 7.9%,p=0.593)无差异。

预后相关因素Logistic回归分析结果显示:

①OHCA组自主循环恢复相关因素:年龄≥60岁(OR=2.452, 95%CI: 1.514-3.969, p<0.001)、医务人员接触时间小于5分钟(OR=1.782, 95%CI: 1.106-3.125, p=0.044)、心脏骤停发生前拨打急救电话(OR=2.707, 95%CI: 1.635-4.482, p<0.001)和初始心律为可电击心律(OR=4.524, 95%CI: 2.280-8.975, p<0.001)是有利因素,而性别为男性(OR=0.449, 95%CI: 0.316-0.789, p=0.003)是不利因素。

②OHCA组存活出院的相关因素:初始心律为可电击心律(OR=15.253, 95%CI: 1.299-179.150, p=0.030)、心源性病因患者接受急诊冠脉造影(OR=9.560, 95%CI: 1.839-49.700, p=0.007)、昏迷患者接受目标温度管理(OR=3.510, 95%CI: 1.417-8.696, p=0.007)是有利因素。

③OHCA组6个月生存的相关因素:初始心律为可电击心律(OR=4.431, 95%CI: 1.284-15.292, p=0.018)是有利因素,而使用血管活性药物(OR=0.251, 95%CI: 0.069-0.916, p=0.036)是不利因素。

④IHCA组自主循环恢复相关因素:出现预警症状(OR=1.791, 95%CI: 1.249-2.567, p=0.002)和实施电复律(OR=2.570, 95%CI: 1.712-3.857, p<0.001)是有利因素,而医务人员接触患者时间小于5分钟(OR=0.301, 95%CI: 0.113-0.803, p=0.016)是不利因素。

⑤IHCA组存活出院的相关因素:心脏骤停发生时有心电监护(OR=6.195, 95%CI: 1.400-27.411, p=0.016)、心源性病因患者接受急诊冠脉造影(OR=32.367, 95%CI: 8.395-124.794, p=<0.001)、昏迷患者接受目标温度管理(OR=3.389, 95%CI: 1.739-6.603, p<0.001)是有利因素。

⑥IHCA组6个月生存的相关因素:心脏骤停发生时有心电监护(OR=7.892, 95%CI: 1.479-42.120, p=0.016)、初始心律为可电击心律(OR=4.363, 95%CI: 1.130-16.845, p=0.033)、心源性病因患者接受急诊冠脉造影(OR=30.500, 95%CI: 5.880-158.195, p<0.001)、昏迷患者接受目标温度管理(OR=2.173, 95%CI: 1.012-4.665, p=0.046)是有利因素。

结论:①本研究显示心脏骤停生存率和神经系统功能预后均明显低于发达国家,OHCA患者的预后更差。②心脏骤停患者救治的实践中,“生存链”的实施情况OHCA实施现状明显低于国外发达国家的水平,IHCA组虽然仍然存在不足,但是与国外的差距不大,基本能达到《指南》要求的水平。尤其是目击者实施有效心肺复苏的比例极低,首次电复律的时间明显延迟。③年龄≥60岁、医务人员接触时间<5分钟、心脏骤停发生前拨打急救电话、初始心律为可电击心律、心源性病因患者接受急诊冠脉造影、昏迷患者接受目标温度管理是OHCA患者预后的有利因素,而性别为男性和使用血管活性药物是不利因素。④心脏骤停发生时有心电监护、心脏骤停前出现预警症状、初始心律为可电击心律、实施电复律、心源性病因患者接受急诊冠脉造影、昏迷患者接受目标温度管理是IHCA患者预后的有利因素。

英文摘要:

Objective: To evaluate the status of implementation of the chain of survival and the gap to the guideline’s recommendations, analysis the prognostic factors of cardiac arrest patients.

Methods: A retrospective analysis of cardiac arrest adult patients admitted to Emergency Department of Peking University Third Hospital and Capital medical university Beijing Friendship Hospital from January 2012 to December 2015. The epidemiology, clinical features, implementations of the chain of survival and outcome were compared between out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) patients, in regard to analysis the predictors for survival.

Results: A total of 1,330 patients (68.2% male and average age were 63.1±17.2 years) Top three causes of cardiac arrest were other medical etiologies, cardiac cause and external asphyxia in sequence. There were 27.8% return of spontaneous circulation, 7.6% survived to disge and 4.8% survived at six months post cardiac arrest.

All patients were divided to two subgroups, OHCA group had 547 patients and IHCA had 783 patients.Compared with OHCA and IHCA group:

①Demographic data: OHCA group had younger average age (60.9±18.7 vs. 64.7±15.8, p<0.001), higher proportion of cardiac cause (58.5% vs. 26.6%, p<0.001). There were no statistical differences in male proportion (69.5% vs. 67.3%, p=0.404).

②Moniter, recognize CA and call for help: OHCA group had lower proportion of medical contact within 5 min (14.3% vs. 97.7%,p<0.001), higher proportion of non-medical staff witness (71.5% vs. 3.8%, p<0.001).  There were no statistical differences in proportion of patients with warning symptoms (70.8% vs. 67.6%,p=0.225).

③Initiate CPR: OHCA group had lower proportion of bystander CPR (13.5% vs. 95.7%, p<0.001), lower proportion of began effective CPR within 5 min (15.2% vs. 97.2%, p<0.001). The number of using audiovisual feedback devices or ETCO2 devices during CPR for optimization of CPR performance was 0.

④Early defibrillation: OHCA group had lower proportion of shockable initial rhythm (8.2% vs. 12.5%, p=0.013), lower proportion of giving first shock in 5 min (9.1% vs. 76.7%, p<0.001). The number of using AED by non-medical staff was 0.

⑤Advanced life support: OHCA group had higher proportion of administered epinephrine by intraosseous (1.1% vs. 0.3%, p=0.030), lower proportion of administered first epinephrine in 5 min (14.3% vs. 97.7%, p<0.001), higher proportion of placing advanced airway during CPR (82.7% vs. 73.8%, p<0.001), higher proportion of placing advanced airway in 10 min (5.9% vs. 92.9%, p<0.001). Proportion of epinephrine using and epinephrine dose was 1mg per time were 100.0%, and the number of using ECPR was 0.

⑥Post-cardiac arrest syndrome treatment: There were no statistical differences in using vasopressors (85.7% vs.75.3%, p=0.138), emergency coronary angiography in cardiac cause patients(15.9% vs. 24.4%, p=0.195), mechanical ventilation (93.3% vs. 93.6%, p=0.899) and targeted temperature management in coma patients(39.1% vs. 45.6%, p=0.256).

⑦Outcome: OHCA group had lower rate of restoration of spontaneous circulation (21.8% vs. 32.1%,p<0.001), lower survival rate at six months (3.3% vs. 5.9%, p=0.030), good neurological outcome at disge(0.7% vs. 3.7%, p=0.001) and at six months (0.9% vs. 3.4%, p=0.003). There were no statistical differences in survival rate at disge(7.1% vs. 7.9%,p=0.593).

According to the results of logistic regression analysis:

①Age≥60 years(OR=2.452, 95%CI: 1.514-3.969, p<0.001), medical contact in 5 min(OR=1.782, 95%CI: 1.106-3.125, p=0.044), call before cardiac arrest (OR=2.707, 95%CI: 1.635-4.482, p<0.001)and shockable initial rhythm(OR=4.524, 95%CI: 2.280-8.975, p<0.001) were the favorable predictors for return of spontaneous circulation in OHCA group, but male(OR=0.449, 95%CI: 0.316-0.789, p=0.003) was the unfavorable predictors.

②Shockable initial rhythm(OR=15.253, 95%CI: 1.299-179.150, p=0.030), emergency coronary angiography in cardiac cause patients(OR=9.560, 95%CI: 1.839-49.700, p=0.007) and targeted temperature management in coma patients(OR=3.510, 95%CI: 1.417-8.696, p=0.007)were the favorable predictors for survival to disge in OHCA group.

③Shockable initial rhythm(OR=4.431, 95%CI: 1.284-15.292, p=0.018) was the favorable predictors for survival at six months post cardiac arrest in OHCA group, but using vasopressors(OR=0.251, 95%CI: 0.069-0.916, p=0.036) was the unfavorable predictors.

④Warning symptoms before cardiac arrest(OR=1.791, 95%CI: 1.249-2.567, p=0.002) and giving shock(OR=2.570, 95%CI: 1.712-3.857, p<0.001) were the favorable predictors for return of spontaneous circulation in IHCA group, but medical contact in 5 min(OR=0.301, 95%CI: 0.113-0.803, p=0.016) was the unfavorable predictors.

⑤Monitering when cardiac arrest(OR=6.195, 95%CI: 1.400-27.411, p=0.016), emergency coronary angiography in cardiac cause patients(OR=32.367, 95%CI: 8.395-124.794, p=<0.001) and targeted temperature management in coma patients(OR=3.389, 95%CI: 1.739-6.603, p<0.001) were the favorable predictors for survival to disge in IHCA group.

⑥Monitering when cardiac arrest(OR=7.892, 95%CI: 1.479-42.120, p=0.016), shockable initial rhythm(OR=4.363, 95%CI: 1.130-16.845, p=0.033),emergency coronary angiography in cardiac cause patients(OR=30.500, 95%CI: 5.880-158.195, p<0.001) and targeted temperature management in coma patients(OR=2.173, 95%CI: 1.012-4.665, p=0.046) were the favorable predictors for survival at six months post cardiac arrest in IHCA group.

Conclusion: ①The survival and neurological outcome of cardiac arrest patients in our study were poor than developed coutries, especially in OHCA group. ②Implementation of chain of survival in IHCA group was similar with the developed countries and met the CPR guideline’s requierments. The major problems in OHCA group were the later medical contact, later high quality CPR, later defibrillation and rare bystander CPR. And OHCA group had obvious gap with CPR guideline requirements. ③Age≥60 years, medical contact in 5 min, call before cardiac arrest, shockable initial rhythm, emergency coronary angiography in cardiac cause patients and targeted temperature management in coma patients were the favorable predictors for prognosis in OHCA group, male and using vasopressors were the unfavorable predictors.④Monitering when cardiac arrest, warning symptoms before cardiac arrest, shockable initial rhythm, giving shock, emergency coronary angiography in cardiac cause patients and targeted temperature management in coma patients were the favorable predictors for prognosis in IHCA group.

语种: 中文
相关网址: 查看原文
内容类型: 学位论文
URI标识: http://ir.bjmu.edu.cn/handle/400002259/124740
Appears in Collections:北京大学第三临床医学院_学位论文

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作者单位: 北京大学第三临床医学院

Recommended Citation:
郑康. 心脏骤停生存链实施现状和预后因素分析[D]. 北京大学第三临床医学院. 北京大学. 2016.
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