在何种意识水平下适合对院外心脏骤停患者采用轻度治疗性低温：一项回顾性、历史性队列研究。
At what level of unconsciousness is mild therapeutic hypothermia indicated for out-of-hospital cardiac arrest: a retrospective, historical cohort study.
机构信息
Senri Critical Care Medical Center, Osaka Saiseikai Senri Hospital, 1-1-6 Tsukumodai, Suita City, Osaka Japan.
出版信息
J Intensive Care. 2015 Sep 11;3(1):38. doi: 10.1186/s40560-015-0104-5. eCollection 2015.
BACKGROUND
Appropriate patient selection is very important when initiating mild therapeutic hypothermia (MTH) for patients following out-of-hospital cardiac arrest, and the extent of unconsciousness at implementation must be defined in such cases. However, there are no clear standards regarding the level of unconsciousness at which MTH would be beneficial. The effects of MTH in patients with different degrees of unconsciousness according to the motor response score of the Glasgow Coma Scale (GCS) were investigated.
METHODS
The subjects consisted of witnessed non-traumatic adult out-of-hospital cardiac arrest patients admitted to our institute from April 2002 to August 2011. The patients were divided into six groups according to the GCS motor response score: 1 (GCS M1), 2 (GCS M2), 3 (GCS M3), 4 (GCS M4), 5 (GCS M5), and 6 (GCS M6). The neurological outcome was evaluated at 30 days after hospital admission using the Cerebral Performance Category. Chi-squared Automatic Interaction Detection (CHAID) analysis was performed to estimate the threshold GCS M level where therapeutic hypothermia is indicated. Odds ratios were then calculated by multiple logistic-regression analysis using factors including GCS M5-6 and MTH.
RESULTS
A total of 289 patients were enrolled in this study. CHAID analysis demonstrated two points of significant increase in percentage of good recovery at 30 days after admission, dividing the GCS M categories into three groups. Patients classified with a GCS motor response score of 5 or higher had the highest percentage of good recovery. The odds ratio for good recovery (CPC1-2) was 2.901 (95 % CI 1.460-5.763, P = 0.002) for MTH, and that for GCS M5-6 was 159.835 (95 % CI 33.592-760.513, P < 0.001).
CONCLUSIONS
MTH may be unnecessary in patients with a GCS motor response score of 5 or higher. Consequently, because there are post cardiac arrest patients with a GCS motor response score of 4 or lower who benefit from MTH, MTH may be limited to patients with a GCS motor response score of 4 or lower.
背景
在对院外心脏骤停患者进行轻度治疗性低体温治疗（MTH）时，患者的选择非常重要，并且在这种情况下必须定义实施时的无意识程度。然而，对于 MTH 在何种程度的无意识状态下会有益处，目前尚无明确的标准。本研究旨在调查根据格拉斯哥昏迷量表（GCS）运动反应评分（M），不同程度无意识的患者接受 MTH 的效果。
方法
本研究纳入了 2002 年 4 月至 2011 年 8 月期间我院收治的有目击者的非创伤性成人院外心脏骤停患者。根据 GCS 运动反应评分，患者被分为六组：1（GCS M1）、2（GCS M2）、3（GCS M3）、4（GCS M4）、5（GCS M5）和 6（GCS M6）。入院后 30 天采用脑功能分类量表（Cerebral Performance Category）评估神经功能预后。采用卡方自动交互检测（CHAID）分析估计治疗性低体温的 GCS M 水平阈值。然后使用包括 GCS M5-6 和 MTH 在内的多个 logistic 回归分析计算比值比（ORs）。
结果
本研究共纳入 289 例患者。CHAID 分析表明，入院后 30 天的良好恢复率有两个显著增加的百分比，将 GCS M 分类分为三组。GCS 运动反应评分为 5 或更高的患者具有最高的良好恢复率。MTH 的良好恢复（CPC1-2）的优势比（OR）为 2.901（95%CI 1.460-5.763，P=0.002），GCS M5-6 的 OR 为 159.835（95%CI 33.592-760.513，P<0.001）。
结论
对于 GCS 运动反应评分 5 或更高的患者，MTH 可能是不必要的。因此，由于存在 GCS 运动反应评分 4 或更低的心脏骤停后患者受益于 MTH，MTH 可能仅限于 GCS 运动反应评分 4 或更低的患者。
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