Department of Emergency Medicine, Loma Linda University, Loma Linda, CA, USA.
Shock. 2011 Apr;35(4):360-6. doi: 10.1097/SHK.0b013e318204c106.
Patients who present to the emergency department (ED) with return of spontaneous circulation after cardiac arrest generally have poor outcomes. Guidelines for treatment can be complicated and difficult to implement. This study examined the feasibility of implementing a care bundle including therapeutic hypothermia (TH) and early hemodynamic optimization for comatose patients with return of spontaneous circulation after out-of-hospital cardiac arrest. The study included patients over a 2-year period in the ED and intensive care unit of an academic tertiary-care medical center. The first year (prebundle) provided a historical control, followed by a prospective observational period of bundle implementation during the second year. The bundle elements included (a) TH initiated; (b) central venous pressure/central venous oxygen saturation monitoring in 2 h; (c) target temperature in 4 h; (d) central venous pressure greater than 12 mmHg in 6 h; (e) MAP greater than 65 mmHg in 6 h; (f) central venous oxygen saturation greater than 70% in 6 h; (g) TH maintained for 24 h; and (h) decreasing lactate in 24 h. Fifty-five patients were enrolled, 26 patients in the prebundle phase and 29 patients in the bundle phase. Seventy-seven percent of bundle elements were completed during the bundle phase. In-hospital mortality in bundle compared with prebundle patients was 55.2% vs. 69.2% (P = 0.29). In the bundle patients, those patients who received all elements of the care bundle had mortality 33.3% compared with 60.9% in those receiving some of the bundle elements (P = 0.22). Bundle patients tended to achieve good neurologic outcome compared with prebundle patients, Cerebral Performance Category 1 or 2 in 31 vs. 12% patients, respectively (P = 0.08). Our study demonstrated that a post-cardiac arrest care bundle that incorporates TH and early hemodynamic optimization can be implemented in the ED and intensive care unit collaboratively and can achieve similar clinical benefits compared with those observed in previous clinical trials.
在心跳骤停后自主循环恢复的患者一般预后较差。治疗指南可能比较复杂且难以实施。本研究旨在探讨昏迷心跳骤停后自主循环恢复患者应用治疗性低温和早期血流动力学优化治疗包的可行性。该研究纳入了在一所学术性三级医疗中心的急诊科和重症监护病房中，两年期间的患者。第一年（预治疗包阶段）为历史对照，第二年为治疗包实施的前瞻性观察阶段。治疗包的内容包括：（a）开始降温；（b）在 2 小时内进行中心静脉压/中心静脉血氧饱和度监测；（c）在 4 小时内达到目标温度；（d）在 6 小时内中心静脉压大于 12mmHg；（e）在 6 小时内平均动脉压大于 65mmHg；（f）在 6 小时内中心静脉血氧饱和度大于 70%；（g）维持 24 小时低温；和（h）24 小时内降低血乳酸。共纳入 55 例患者，预治疗包阶段 26 例，治疗包阶段 29 例。在治疗包阶段，有 77%的治疗包内容得到完成。治疗包组和预治疗包组的院内死亡率分别为 55.2%和 69.2%（P = 0.29）。在治疗包患者中，接受所有治疗包内容的患者死亡率为 33.3%，而仅接受部分治疗包内容的患者死亡率为 60.9%（P = 0.22）。与预治疗包组相比，治疗包组患者的神经功能预后良好（Cerebral Performance Category 1 或 2），分别为 31%和 12%（P = 0.08）。本研究表明，纳入治疗性低温和早期血流动力学优化的心脏骤停后治疗包可以在急诊科和重症监护病房中协作实施，并且可以达到与以往临床试验相似的临床获益。
