Department of Critical Care, Maine Medical Center, Portland, ME.
Division of Clinical Decision Making, Tufts Medical Center, Boston, MA.
Crit Care Med. 2018 Oct;46(10):e975-e980. doi: 10.1097/CCM.0000000000003301.
Sedation and neuromuscular blockade protocols in patients undergoing targeted temperature management after cardiac arrest address patient discomfort and manage shivering. These protocols vary widely between centers and may affect outcomes.
Consecutive patients admitted to 20 centers after resuscitation from cardiac arrest were prospectively entered into the International Cardiac Arrest Registry between 2006 and 2016. Additional data about each center's sedation and shivering management practice were obtained via survey. Sedation and shivering practices were categorized as escalating doses of sedation and minimal or no neuromuscular blockade (sedation and shivering practice 1), sedation with continuous or scheduled neuromuscular blockade (sedation and shivering practice 2), or sedation with as-needed neuromuscular blockade (sedation and shivering practice 3). Good outcome was defined as Cerebral Performance Category score of 1 or 2. A logistic regression hierarchical model was created with two levels (patient-level data with standard confounders at level 1 and hospitals at level 2) and sedation and shivering practices as a fixed effect at the hospital level. The primary outcome was dichotomized Cerebral Performance Category at 6 months.
Cardiac arrest receiving centers in Europe and the United states from 2006 to 2016 PATIENTS:: Four-thousand two-hundred sixty-seven cardiac arrest patients 18 years old or older enrolled in the International Cardiac Arrest Registry.
None.
The mean age was 62 ± 15 years, 36% were female, 77% out-of-hospital arrests, and mean ischemic time was 24 (± 18) minutes. Adjusted odds ratio (for age, return of spontaneous circulation, location of arrest, witnessed, initial rhythm, bystander cardiopulmonary resuscitation, defibrillation, medical history, country, and size of hospital) was 1.13 (0.74-1.73; p = 0.56) and 1.45 (1.00-2.13; p = 0.046) for sedation and shivering practice 2 and sedation and shivering practice 3, respectively, referenced to sedation and shivering practice 1.
Cardiac arrest patients treated at centers using as-needed neuromuscular blockade had increased odds of good outcomes compared with centers using escalating sedation doses and avoidance of neuromuscular blockade, after adjusting for potential confounders. These findings should be further investigated in prospective studies.
心脏骤停后行目标体温管理的患者镇静和神经肌肉阻滞方案可解决患者的不适并控制寒战。这些方案在各中心之间差异很大，可能会影响结局。
2006 年至 2016 年，连续 20 个中心的心脏骤停复苏后患者前瞻性纳入国际心脏骤停注册研究。通过调查获得每个中心镇静和寒战管理实践的其他数据。镇静和寒战实践分为镇静剂量递增和最小或无神经肌肉阻滞（镇静和寒战实践 1）、镇静联合持续或计划神经肌肉阻滞（镇静和寒战实践 2）或按需镇静联合神经肌肉阻滞（镇静和寒战实践 3）。良好结局定义为意识状态评分（Cerebral Performance Category，CPC）为 1 或 2 分。采用具有 2 个层次（第 1 层为患者水平数据和标准混杂因素，第 2 层为医院）的逻辑回归层次模型，并将镇静和寒战实践作为医院水平的固定效应。主要结局为 6 个月时 CPC 二分法。
欧洲和美国的心脏骤停收治中心，2006 年至 2016 年。
4267 例年龄 18 岁或以上的国际心脏骤停注册研究患者。
无。
平均年龄为 62±15 岁，36%为女性，77%为院外心脏骤停，平均缺血时间为 24（±18）分钟。调整后的优势比（年龄、自主循环恢复、骤停位置、目击者、初始节律、旁观者心肺复苏、除颤、既往史、国家和医院规模）分别为 1.13（0.74-1.73；p=0.56）和 1.45（1.00-2.13；p=0.046），镇静和寒战实践 2 和镇静和寒战实践 3 分别参照镇静和寒战实践 1。
调整潜在混杂因素后，与使用递增镇静剂量和避免神经肌肉阻滞的中心相比，使用按需神经肌肉阻滞的中心患者的良好结局的可能性更高。这些发现应在前瞻性研究中进一步探讨。
