延长院内CPR可提高存活率且不损害神经功能

《柳叶刀》9月4日发表的一项研究报告显示，系统性延长院内心脏骤停患者心肺复苏(CPR)时间可改善患者存活率，且对神经功能状态无不良影响(Lancet 2012 Sept. 4 [doi:10.1016/S0140-6736(12)60862-9])。

密歇根大学安娜堡分校心血管医学部的Zachary D. Goldberger博士及其同事报告称，对美国435家医院8年多时间内救治的64,339例院内心脏骤停患者的研究表明，患者存活率获益独立于其他多项患者因素。重要的是，患者神经功能没有受到复苏时间的影响，CPR时间≥30分钟的存活患者的神经功能完整性与CPR时间＜15分钟的存活患者一致。较长时间复苏与自主循环恢复率和出院存活率增加相关。

 


研究者指出，现行复苏指南并没有涉及何时停止复苏努力的问题，也没有足够的数据来指导实践。“如果患者经过短时间复苏尚未恢复自主循环，考虑到这些患者总体预后不佳，医生通常不愿再继续尝试。”为此，研究者利用收录院内心脏骤停病例最多的遵循复苏指南(GWTG)数据库，对上述问题进行了考察。患者复苏抢救结束后，总计31,198例(48.5%)恢复自主循环，33,141 例(51.5%)死亡。

结果显示，约80%的出院存活患者神经功能状态良好。状态良好率不因复苏时间长短不同而存在显著差异：复苏时间＜15分钟者的神经良好状态率为80.0%，而复苏时间＞30分钟者为78.4%。正如预期的那样，由于缺乏统一标准，医院之间复苏时间差异较大。总体上，中位复苏时间为17分钟；复苏时间处于最低四分位数的患者中位复苏时间为16分钟，而最高四分位数患者为25分钟。复苏时间较长的院内患者总存活率和出院存活率均显著高于复苏时间较短患者。

研究者指出，上述结果表明，复苏操作规范化和确认最短复苏时间将有助于改善患者存活率。延长复苏时间10或15 分钟可能对复苏资源略有影响，但可改善结局。研究者也承认，上述数据尚不能提供具体的复苏临界时间，也难以预测，特别是考虑到这是一项观察性研究。此外，胸外按压质量和各家医院能否开展经皮介入治疗等对复苏时间确有影响的多项变量也未在该项研究中加以分析。还应注意的是，该项研究没有分析复苏存活者长期结局，而危重患者存活受益时间的长短应该是评判复苏措施有效性的最终指标。

该研究由美国心脏协会(AHA)、Robert Wood Johnson基金会和美国国立心肺血液研究所(NHLBI)资助。Goldberger报告无相关利益冲突，他的一位同事报告与美敦力公司和联合健康保险公司(UHC)存在经济利益关系。

随刊述评：不妨稍微延长复苏时间

Jerry P. Nolan 博士和 Jasmeet Soar博士指出，上述结果应该可以打消医生们对延长复苏时间“可能显著增加存活者严重神经功能损伤”的疑虑。如果心脏骤停原因具有潜在可逆性，稍加延长复苏时间或许值得尝试(Lancet 2012 Sept. 4 [doi:10.1016/S0140-6736(12)61182-9])。

Nolan博士供职于英国巴斯NHS基金会皇家联合医院，并担任《复苏》杂志主编。Soar博士供职于英国布里斯托的布里斯托北部NHS基金会斯托邵斯密医院，并担任《复苏》杂志编委。他们均报告无相关利益冲突。

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By: MARY ANN MOON, Cardiology News Digital Network

Systematically lengthening the duration of resuscitation efforts for patients who have in-hospital cardiac arrests could improve survival with no adverse impact on neurological status, according to a reportpublished Sept. 4 in The Lancet.

In a study of 64,339 patients who had in-hospital cardiac arrests at 435 U.S. hospitals over an 8-year period, this survival benefit was independent of numerous patient factors, wrote Dr. Zachary D. Goldberger of the division of cardiovascular medicine, University of Michigan, Ann Arbor, and his associates.

Importantly, they wrote, neurologic status was not affected by the duration of resuscitation efforts, so patients revived after relatively long CPR attempts of 30 minutes or more were as neurologically intact as were those revived after brief attempts of less than 15 minutes.

"Our most notable result was that long resuscitation attempts might be linked to increased rates of return of spontaneous circulation and survival to discharge," they said.

At present, resuscitation guidelines do not address the issue of when to terminate such efforts, and there are not enough data available to guide practice. "Clinicians are frequently reluctant to continue efforts when return of spontaneous circulation does not occur shortly after initiation of resuscitation, in view of the overall poor prognosis for such patients," the researchers noted.

They examined the issue using information from the Get With The Guidelines-Resuscitation database, the largest registry of in-hospital cardiac arrests in the world. A total of 31,198 patients (48.5%) achieved return of spontaneous circulation, while 33,141 (51.5%) died after termination of resuscitation efforts.

Approximately 80% of patients who survived to hospital discharge had favorable neurologic status. The rate of favorable status did not differ significantly by duration of resuscitation: It was 81.2% for patients in whom resuscitation attempts lasted less than 15 minutes, 80.0% for those in whom resuscitation attempts lasted 15-30 minutes, and 78.4% for those in whom resuscitation attempts lasted longer than 30 minutes.

As expected when there is no consensus on the appropriate duration of resuscitation attempts, the investigators found wide variation among hospitals in this practice.

Overall, the median duration of resuscitation efforts was 17 minutes. When the hospitals were divided into quartiles based on this duration, those in the quartile with the shortest interval had a median duration of 16 minutes, while those in the quartile with the longest interval had a median duration of 25 minutes.

Resuscitation efforts lasted more than 50% longer at hospitals in the longest quartile compared with those in the shortest quartile.

Patients at the hospitals with longer durations of resuscitation efforts had significantly higher overall survival and significantly higher survival to hospital discharge than did those at hospitals with shorter durations of resuscitation efforts, Dr. Goldberger and his colleagues said (Lancet 2012 Sept. 4 [doi:10.1016/S0140-6736(12)60862-9]).

The study findings suggest that standardizing resuscitation procedures and identifying a minimum duration could improve patient survival. "Prolongation of resuscitation attempts by 10 or 15 minutes might have only a slight effect on resources once efforts have already begun, but could improve outcomes," the investigators noted.

"We are unable to provide a specific cutoff from these data and are hesitant to speculate," especially because this was an observational study that cannot establish cause and effect. Moreover, several variables that almost certainly affected the duration of resuscitation efforts were not addressed in this study, such as the quality of chest compressions and the availability at each hospital of percutaneous intervention.

It is even possible that the duration of resuscitation attempts is merely a marker for "more comprehensive care" with longer CPR performed at centers where resuscitation guidelines are reliably implemented, they added.

It should also be noted that this study did not address long-term outcomes in survivors of resuscitation. "The extent to which critically ill patients benefit from survival months to years after cardiac arrest should be the ultimate measure of the usefulness of resuscitation measures," Dr. Goldberger and his associates said.

The study was funded by the American Heart Association, the Robert Wood Johnson Foundation, and the National Heart, Lung, and Blood Institute. Dr. Goldberger reported no financial conflicts of interest, and one of his associates reported ties to Medtronic and United Health Care.

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Try a Little Longer

The findings of Goldberger and colleagues should reassure clinicians that prolonged resuscitation efforts "do not seem to result in a substantial increase in severe neurological injury in survivors," said Dr. Jerry P. Nolan and Dr. Jasmeet Soar.

All hospitals should monitor their cardiac arrests to improve their quality of care. "If the cause of a cardiac arrest is potentially reversible, it might be worthwhile to try [resuscitation] for a little longer," they said.

DR. NOLAN is at the Royal United Hospital NHS Trust in Bath, England, and is editor-in-chief of the journal Resuscitation. DR. SOAR is at Southmead Hospital North Bristol NHS Trust in Bristol, England, and is an editor at the journal Resuscitation. They reported no financial conflicts of interest. These remarks were taken from their editorial comment accompanying Dr. Goldberger’s report (Lancet 2012 Sept. 4 [doi:10.1016/S0140-6736(12)61182-9]).

More Survival, No Neurologic Loss Seen With Longer In-Hospital CPR