院外心脏骤停后接受亚低温治疗患者中α-稳态和pH-稳态血气管理策略对脑血流量和氧合的影响：一项交叉研究。

Influence of α-stat and pH-stat blood gas management strategies on cerebral blood flow and oxygenation in patients treated with therapeutic hypothermia after out-of-hospital cardiac arrest: a crossover study.

作者信息

Voicu Sebastian, Deye Nicolas, Malissin Isabelle, Vigué Bernard, Brun Pierre-Yves, Haik William, Champion Sebastien, Megarbane Bruno, Sideris Georgios, Mebazaa Alexandre, Carli Pierre, Manivet Philippe, Baud Frédéric J

机构信息

1Medical and Toxicological Intensive Care Department, Lariboisière University Hospital, APHP, Paris, France. 2INSERM U942, Université Paris Diderot, Paris, France. 3Cardiology Department, Lariboisière University Hospital, APHP, Paris, France. 4Department of Anesthesiology and Critical Care, CHU Bicêtre, APHP, Le Kremlin-Bicêtre, France. 5INSERM U705, Université Paris Denis Diderot, Paris, France. 6Department of Anaesthesia and Intensive care, Lariboisière University Hospital, APHP, Paris, France. 7SAMU 75 and Department of Anesthesiology, Necker Hospital, APHP, Paris Descartes University, Medical School, Paris, France. 8Biochemical Laboratory, Lariboisière University Hospital, APHP, Paris, France.

出版信息

Crit Care Med. 2014 Aug;42(8):1849-61. doi: 10.1097/CCM.0000000000000339.

DOI:10.1097/CCM.0000000000000339

PMID:24717455

Abstract

OBJECTIVES

In patients treated with therapeutic hypothermia after out-of-hospital cardiac arrest, two blood gas management strategies are used regarding the PaCO2 target: α-stat or pH-stat. We aimed to compare the effects of these strategies on cerebral blood flow and oxygenation.

DESIGN

Prospective observational single-center crossover study.

SETTING

ICU of University hospital.

PATIENTS

Twenty-one therapeutic hypothermia-treated patients after out-of-hospital cardiac arrest more than 18 years old without history of cerebrovascular disease were included.

INTERVENTIONS

Cerebral perfusion and oxygenation variables were compared in α-stat (PaCO2 measured at 37 °C) versus pH-stat (PaCO2 measured at 32-34 °C), both strategies maintaining physiological PaCO2 values: 4.8-5.6 kPa (36-42 torr).

MEASUREMENTS AND MAIN RESULTS

Bilateral transcranial middle cerebral artery flow velocities using Doppler and jugular vein oxygen saturation were measured in both strategies 18 hours (14-23 hr) after the return of spontaneous circulation. Pulsatility and resistance indexes and cerebral oxygen extraction were calculated. Data are expressed as median (interquartile range 25-75) in α-stat versus pH-stat. No differences were found in temperature, arterial blood pressure, and oxygenation between α-stat and pH-stat. Significant differences were found in minute ventilation (p = 0.006), temperature-corrected PaCO2 (4.4 kPa [4.1-4.6 kPa] vs. 5.1 kPa [5.0-5.3 kPa], p = 0.0001), and temperature-uncorrected PaCO2 (p = 0.0001). No differences were found in cerebral blood velocities and pulsatility and resistance indexes in the overall population. Significant differences were found in jugular vein oxygen saturation (83.2% [79.2-87.6%] vs. 86.7% [83.2-88.2%], p = 0.009) and cerebral oxygen extraction (15% [11-20%] vs. 12% [10-16%], p = 0.01), respectively. In survivors, diastolic blood velocities were 25 cm/s (19-30 cm/s) versus 29 cm/s (23-35 cm/s) (p = 0.004), pulsatility index was 1.10 (0.97-1.18) versus 0.94 (0.89-1.05) (p = 0.027), jugular vein oxygen saturation was 79.2 (71.1-81.8) versus 83.3% (76.6-87.8) (p = 0.033), respectively. However, similar results were not found in nonsurvivors.

CONCLUSIONS

In therapeutic hypothermia-treated patients after out-of-hospital cardiac arrest at physiological PaCO2, α-stat strategy increases jugular vein blood desaturation and cerebral oxygen extraction compared with pH-stat strategy and decreases cerebral blood flow velocities in survivors.

摘要

目的

在院外心脏骤停后接受治疗性低温治疗的患者中，针对动脉血二氧化碳分压（PaCO₂）目标采用了两种血气管理策略：α稳态或pH稳态。我们旨在比较这些策略对脑血流量和氧合的影响。

设计

前瞻性观察性单中心交叉研究。

地点

大学医院重症监护病房。

患者

纳入21例年龄超过18岁、无脑血管疾病史且接受治疗性低温治疗的院外心脏骤停患者。

干预措施

比较α稳态（在37℃测量PaCO₂）与pH稳态（在32 - 34℃测量PaCO₂）时的脑灌注和氧合变量，两种策略均维持生理PaCO₂值：4.8 - 5.6 kPa（36 - 42 torr）。

测量指标及主要结果

自主循环恢复后18小时（14 - 23小时），在两种策略下使用多普勒测量双侧经颅大脑中动脉血流速度，并测量颈静脉血氧饱和度。计算搏动性和阻力指数以及脑氧摄取率。数据以α稳态与pH稳态的中位数（四分位间距25 - 75）表示。α稳态和pH稳态在体温、动脉血压和氧合方面未发现差异。在分钟通气量（p = 0.006）、温度校正后的PaCO₂（4.4 kPa [4.1 - 4.6 kPa] 与5.1 kPa [5.0 - 5.3 kPa]，p = 0.0001）和未校正温度的PaCO₂（p = 0.0001）方面发现显著差异。在总体人群中，脑血流速度以及搏动性和阻力指数未发现差异。颈静脉血氧饱和度（83.2% [79.2 - 87.6%] 与86.7% [83.2 - 88.2%]，p = 0.009）和脑氧摄取率（15% [11 - 20%] 与12% [10 - 16%]，p = 0.01）分别存在显著差异。在存活者中，舒张期血流速度为25 cm/s（19 - 30 cm/s）与29 cm/s（23 - 35 cm/s）（p = 0.004），搏动指数为1.10（0.97 - 1.18）与0.94（0.89 - 1.05）（p = 0.027），颈静脉血氧饱和度分别为79.2（71.1 - 81.8）与83.3%（76.6 - 87.8）（p = 0.033）。然而，在非存活者中未发现类似结果。