Aneman Anders, Skrifvars Markus Benedikt, Ameloot Koen
Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District and South Western Sydney Clinical School, University of New South Wales, Sydney, Australia.
The Ingham Institute for Applied Medical Research, Sydney, Australia.
Intensive Care Med Exp. 2024 Aug 13;12(1):70. doi: 10.1186/s40635-024-00657-0.
The European Resuscitation Council 2021 guidelines for haemodynamic monitoring and management during post-resuscitation care from cardiac arrest call for an individualised approach to therapeutic interventions. Combining the cardiac function and venous return curves with the inclusion of the mean systemic filling pressure enables a physiological illustration of intravascular volume, vasoconstriction and inotropy. An analogue mean systemic filling pressure (Pmsa) may be calculated once cardiac output, mean arterial and central venous pressure are known. The NEUROPROTECT trial compared targeting a mean arterial pressure of 65 mmHg (standard) versus an early goal directed haemodynamic optimisation targeting 85 mmHg (high) in ICU for 36 h after cardiac arrest. The trial data were used in this study to calculate post hoc Pmsa and its expanded variables to comprehensively describe venous return physiology during post-cardiac arrest management. A general estimating equation model was used to analyse continuous variables split by standard and high mean arterial pressure groups.
Data from 52 patients in each group were analysed. The driving pressure for venous return, and thus cardiac output, was higher in the high MAP group (p < 0.001) along with a numerically increased estimated stressed intravascular volume (mean difference 0.27 [- 0.014-0.55] L, p = 0.06). The heart efficiency was comparable (p = 0.43) in both the standard and high MAP target groups, suggesting that inotropy was similar despite increased arterial load in the high MAP group (p = 0.01). The efficiency of fluid boluses to increase cardiac output was increased in the higher MAP compared to standard MAP group (mean difference 0.26 [0.08-0.43] fraction units, p = 0.01).
Calculation of the analogue mean systemic filling pressure and expanded variables using haemodynamic data from the NEUROPROTECT trial demonstrated an increased venous return, and thus cardiac output, as well as increased volume responsiveness associated with targeting a higher MAP. Further studies of the analogue mean systemic filling pressure and its derived variables are warranted to individualise post-resuscitation care and evaluate any clinical benefit associated with this monitoring approach.
欧洲复苏委员会2021年关于心脏骤停后复苏护理期间血流动力学监测与管理的指南要求采取个体化的治疗干预方法。将心功能曲线和静脉回流曲线与平均体循环充盈压相结合，能够从生理学角度说明血管内容量、血管收缩和心肌收缩力。一旦知道心输出量、平均动脉压和中心静脉压，就可以计算出模拟平均体循环充盈压（Pmsa）。NEUROPROTECT试验比较了在心脏骤停后36小时内，在重症监护病房将平均动脉压目标设定为65 mmHg（标准组）与早期目标导向血流动力学优化目标设定为85 mmHg（高目标组）的情况。本研究使用该试验数据来事后计算Pmsa及其扩展变量，以全面描述心脏骤停后管理期间的静脉回流生理。使用一般估计方程模型分析按标准和高平均动脉压组划分的连续变量。
对每组52例患者的数据进行了分析。高平均动脉压组的静脉回流驱动压力（进而心输出量）更高（p < 0.001），估计的应激血管内容量在数值上有所增加（平均差异0.27 [-0.014 - 0.55] L，p = 0.06）。标准和高平均动脉压目标组的心脏效率相当（p = 0.43），这表明尽管高平均动脉压组的动脉负荷增加，但心肌收缩力相似（p = 0.01）。与标准平均动脉压组相比，较高平均动脉压组中液体推注增加心输出量的效率更高（平均差异0.26 [0.08 - 0.43]分数单位，p = 0.01）。
利用NEUROPROTECT试验的血流动力学数据计算模拟平均体循环充盈压及其扩展变量，结果表明将较高平均动脉压作为目标与静脉回流增加（进而心输出量增加）以及容量反应性增加相关。有必要对模拟平均体循环充盈压及其派生变量进行进一步研究，以实现复苏后护理的个体化，并评估这种监测方法的任何临床益处。
