Maciel Carolina B, Barden Mary M, Greer David M
Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Stroke Service, Directory of Medical Studies, Yale School of Medicine, P.O. Box 208018, New Haven, CT, 06520, USA.
Curr Treat Options Cardiovasc Med. 2017 Jul;19(7):52. doi: 10.1007/s11936-017-0548-0.
Surviving cardiac arrest (CA) requires a longitudinal approach with multiple levels of responsibility, including fostering a culture of action by increasing public awareness and training, optimization of resuscitation measures including frequent updates of guidelines and their timely implementation into practice, and optimization of post-CA care. This clearly goes beyond resuscitation and targeted temperature management. Brain-directed physiologic goals should dictate the post-CA management, as accumulating evidence suggests that the degree of hypoxic brain injury is the main determinant of survival, regardless of the etiology of arrest. Early assessment of the need for further hemodynamic and electrophysiologic cardiac interventions, adjusting ventilator settings to avoid hyperoxia/hypoxia while targeting high-normal to mildly elevated PaCO, maintaining mean arterial blood pressures >65 mmHg, evaluating for and treating seizures, maintaining euglycemia, and aggressively pursuing normothermia are key steps in reducing the bioenergetic failure that underlies secondary brain injury. Accurate neuroprognostication requires a multimodal approach with standardized assessments accounting for confounders while recognizing the importance of a delayed prognostication when there is any uncertainty regarding outcome. The concept of a highly specialized post-CA team with expertise in the management of post-CA syndrome (mindful of the brain-directed physiologic goals during the early post-resuscitation phase), TTM, and neuroprognostication, guiding the comprehensive care to the CA survivor, is likely cost-effective and should be explored by institutions that frequently care for these patients. Finally, providing tailored rehabilitation care with systematic reassessment of the needs and overall goals is key for increasing independence and improving quality-of-life in survivors, thereby also alleviating the burden on families. Emerging evidence from multicenter collaborations advances the field of resuscitation at an incredible pace, challenging previously well-established paradigms. There is no more room for "conventional wisdom" in saving the survivors of cardiac arrest.
心脏骤停（CA）患者的存活需要一种具有多层次责任的纵向方法，包括通过提高公众意识和培训来营造积极行动的文化氛围，优化复苏措施（包括频繁更新指南并及时将其应用于实践），以及优化心脏骤停后的护理。这显然超出了复苏和目标温度管理的范畴。鉴于越来越多的证据表明，无论心脏骤停的病因如何，缺氧性脑损伤的程度是生存的主要决定因素，因此应以脑导向的生理目标来指导心脏骤停后的管理。早期评估进一步进行血流动力学和电生理心脏干预的必要性，调整呼吸机设置以避免高氧/低氧，同时将动脉血二氧化碳分压（PaCO）目标设定为略高于正常至轻度升高，维持平均动脉血压>65 mmHg，评估并治疗癫痫发作，维持血糖正常，并积极追求体温正常，这些都是减少继发于脑损伤的生物能量衰竭的关键步骤。准确的神经预后评估需要采用多模式方法，进行标准化评估并考虑混杂因素，同时认识到在结果存在任何不确定性时进行延迟预后评估的重要性。组建一支高度专业化的心脏骤停后团队，该团队在管理心脏骤停后综合征（在复苏后早期牢记脑导向的生理目标）、目标温度管理（TTM）和神经预后评估方面具有专业知识，为心脏骤停幸存者提供全面护理，这可能具有成本效益，并且经常诊治这些患者的机构应进行探索。最后，提供量身定制的康复护理，并对需求和总体目标进行系统重新评估，这是提高幸存者独立性和改善生活质量的关键，从而也减轻了家庭的负担。多中心合作的新证据正以前所未有的速度推动复苏领域的发展，挑战着先前已确立的范例。在挽救心脏骤停幸存者方面，“传统观念”已无立足之地。
