关键词： 艾司洛尔   体外循环   心脏手术   心肌顿抑  

摘要： 目的:研究艾司洛尔(Esmolol)对体外循环心脏手术后心脏复苏的影响.方法:24例拟行心脏瓣膜置换术的患者,随机分为两组,每组12例.Esmolol组(Esm组)于手术开始时静脉持续输注Esmolol 100μ g·kg<'-1>·min<'-1>直至开放主动脉后1分钟,并于体外循环机内预充Esmolol 1mg·kg<'-1>.对照组(contr组)于同一时期内输注复方氯化钠液(Ringer's)0.***.kg<'-1>.min<'-1>.记录病人术前基本情况和手术情况,于术前及复温后抽静脉血测血浆香草扁桃酸(Vanillymandelic acid,VMA)浓度,于术前及术后12小时抽静脉血测血浆磷酸肌酸激酶(CK)和磷酸肌酸激酶同功酶(CK-B)浓度,记录病人心脏复跳方式并于停体外循环后血压平稳时记录多巴胺的维持剂量,同时抽中心静脉血测其血氧饱和度(S<,CV>O<,2>).结果:两组病人组间比较基本情况和手术情况,术前及术后12小时血浆的CK、CK-B,术前及复温20分钟后血浆VMA及复跳方式均无明显差异;停体外循环后血压平衡时Esm组多巴胺的维持剂量显著小于Contr组(P<0.01),Esm组S<,cvo2>显著高于Contr组(P<0.01).两组病人组内比较术后12小时血浆CK、CK-MB均高于术前,复温后血浆VMA均高于术前.结论:心脏瓣膜置换术中持续输注艾司洛尔100μg·kg<'-1>·min<'-1>能改善体外循环心脏手术后心脏复苏的质量,但不能抑制体外循环引起的内源性儿茶酚胺的分泌,也不能消除体外循环心脏手术引起的心肌损害.

关键词： 心脏骤停   纳络酮   心肺复苏   平均动脉压  

摘要： 心脏骤停是由各种原因所导致的突然心泵功能丧失，即有效的心脏收缩停止，患者意识丧失和抽搐，大动脉触不到搏动的一种状态。心脏骤停占急诊病人死亡率的首位，每年全世界约数百万人发生心脏骤停。随着心肺复苏技术的发展，心脏骤停后心肺复苏水平已有明显提高，但由于脑组织对缺血的耐受性较差，易引起不可逆损害，研究证明，若完全性缺氧6s可致神经元代谢受损，15s可致短暂昏迷，2min便有脑活动停止，5min则有脑不可逆损伤[2]。所以虽然部分病人心肺复苏成功，但终因不可逆性脑损伤而致死亡或残留严重后遗症，导致脑复苏失败而影响了心脏骤停后整个心肺复苏水平。心脏骤停后复苏的成功并非仅指心跳和呼吸的恢复，重要的是恢复智能和生活能力，因此，心肺复苏是决定预后的基础，脑复苏则是决定预后的关键。 目前国内外一致认为肾上腺素为抢救心脏骤停时的首选药物，在动物实验中，大剂量肾上腺素能有效提高主动脉舒张压和冠脉血流，随着肾上腺素剂量的增加，局部心肌血流和脑血流也随之增加。 chouxc等研究结果显示大剂量肾上腺素（5mg）的重复给药，优于标准剂量肾上腺素（1mg）的重复给药，较高剂量的肾上腺素能够明显改善血液动力学，提高复苏的成功率[8]，但随着肾上腺素剂量的增加，脑组织缺血缺氧的损害程度也在增加。大剂量的肾上腺素有利于循环的建立，但不利于脑组织的复苏。我们设想在抢救心脏骤停时加用其它药物辅助治疗，以改善因肾上腺素剂量较大所致的脑缺血状态，有效保护脑细 ＜WP=32＞ 胞，在不影响心肺脑复苏的前提下，减轻抢救药对脑组织的损害。 纳络酮是体内阿片受体的纯拮抗剂，可通过特异性地阻断β内啡肽而具有较为广泛的药理效用。 陈天铎等前瞻性观察β-ＥＰ拮抗剂纳络酮在复苏中的作用，心脏骤停病人血中β-ＥＰ含量较正常人明显提高，结果提示，纳络酮组自主呼吸恢复率和复苏成功率明显提高，能增加脑缺血区血流量，减轻脑水肿，从多个环节促进了心肺脑诸器官复苏。但目前纳络酮用于CPR的有限报道中，只比较了对存活率和脑血流的影响，而不同剂量的纳洛酮对脑复苏的影响尚不清楚，本文就这一问题进行了探讨。 采用大鼠窒息缺氧的方法制备心脏骤停动物模型，将Wistar 大鼠40只，随机分成四组，评价不同剂量纳洛酮对于心脏骤停后血液动力学的影响，同时观察不同剂量纳洛酮治疗后脑组织的病理改变，为临床探索脑复苏的方法提供实验依据。 主要结果如下： 一、不同剂量纳络酮对MAP的影响 本试验可以看到在窒息5分钟后所有大鼠动脉血压均消失或QRS波＜40次/min ，CPR 后5分钟各组的MAP均明显增高，保证了脑组织的有效灌注压，此后30min、60min、120min时各纳络酮组MAP均高于NE组， SN组、MN组及LN组与NE组比较均有显著差异（P﹤0.05），提示纳络酮有增高MAP的作用，且随着纳络酮剂量的增加，MAP增加更明显。可以说心脏骤停复苏时大剂 ＜WP=33＞ 量纳络酮升高MBP的作用优于小剂量及中剂量的纳络酮。 二、不同剂量纳络酮对脑的影响 本试验HE染色示肾上腺素常规复苏组海马神经细胞缺血性改变明显，细胞变小、有固缩，核呈三角形、条形、有固缩，核仁浓缩。虽然大剂量肾上腺素可提高心肺复苏成功率，但可加重脑损害，不利于脑复苏。在大剂量肾上腺素的基础上加用不同剂量的纳络酮可见小、中剂量的纳络酮组仍可见部分细胞固缩，核仁浓染，但缺血性改变较轻，常规复苏组+大剂量纳络酮组仅有极少数细胞固缩，基本为正常细胞。从病理的结果可以看到大剂量纳络酮对脑细胞有明显的保护作用。 综合以上结果，我们可以得到以下的结论： 1.心肺脑复苏时纳络酮可明显提高MBP水平，维持了较好的脑内稳态，有利于维持有效的循环灌注压，大剂量纳络酮升高MBP的作用优于小剂量及中剂量的纳络酮。 2.我们的光镜结果表明心肺复苏时大剂量肾上腺素可加重脑组织的缺氧性损害，在肾上腺素的基础上加用纳络酮可减轻脑细胞的缺氧性损害，大剂量纳络酮组的脑保护作用优于小、中纳络酮组。

关键词： heart arrest   cardiopulmonary resuscitation   drugs   contractility   PROLONGED VENTRICULAR-FIBRILLATION   CHRONIC HEART-FAILURE   SURVIVORS   DEFIBRILLATION   DOBUTAMINE   COUNTERSHOCK   AMRINONE  

摘要： Background - Left ventricular (LV) dysfunction with a low cardiac index after successful CPR contributes to early death attributable to multiorgan failure, and an effective treatment has not been identified. The purpose of this study was to investigate the use of milrinone, a selective phosphodiesterase III inhibitor, as treatment for LV dysfunction after resuscitation. Methods and Results - Ventricular fibrillation (VF) was induced electrically in 32 swine. After 5 minutes of VF, CPR was initiated and animals were randomized to receive either saline ( control group, n = 16) as a bolus and infusion or milrinone 50 mug/kg as a bolus and then 0.5 mug/kg per min for 60 minutes ( treatment group, n = 16). After 2 minutes of CPR ( total VF time, 7 minutes), countershocks were given. Coronary perfusion pressures during CPR were similar for the groups ( 24 +/- 2 versus 21 +/- 4 mm Hg). All animals were defibrillated; 6 of 16 control animals developed refractory postcountershock pulseless electrical activity compared with 0 of 16 treated animals ( P = 0.018). At 30 minutes after restoration of spontaneous circulation, stroke volume ( 16 +/- 3 versus 26 +/- 7 mL, P < 0.01) and LV dp/dt ( 793 +/- 197 versus 1108 +/- 316 mm Hg/s, P < 0.02) were higher in the treatment group. Similar differences were observed 60 minutes after restoration of spontaneous circulation. Significant differences in heart rates between groups were not observed, and peripheral vascular resistance was significantly greater in the control group 30 and 60 minutes after resuscitation. Conclusions - Milrinone facilitates resuscitation from prolonged VF and attenuates LV dysfunction after resuscitation without worsening major determinants of myocardial oxygen demand.

关键词： 阿米替林   抗抑郁药   不良反应   心脏停跳   呼吸停止   心肺复苏   脑复苏  

摘要： 患者女性,30岁.原有精神分裂症病史5年,于2001年11月1日下午自服阿米替林25mg×200片后20分钟来诊.

关键词： 心肺复苏   抢救护理   静脉给药   按压法   无脉搏室速   加压素   急诊科   心脏骤停   临床急救   心脏复苏  

关键词： Q-T间期   心脏聚停   心肺复苏   心电图   患者   血压   ICD   酮病   降温   病史  

摘要： 1临床资料患者女性,46岁,既往有甲亢病史5年,阵发性房颤间歇服用胺磺酮病史1年.于2002年8月19日上午10时因家人去世,过度悲伤,突然意识丧失,晕倒在地,口唇发绀,呼之不应,小便失禁,无抽搐,5分钟后家人急送我院急救中心,查体:血压为零,大动脉搏动消失,呼吸停止,双侧瞳孔等大等圆,约4mm,固定,对光反射消失,心电图示:室颤,立即给予体外非同步电除颤,300J 2次,200J 3次,心电监护示:窦性心动过速,T波倒置,同时给予气管插管、吸氧、气囊人工呼吸,多巴胺40mg静推,多巴胺400mg、间羟胺60mg静点,测血压24/16KPa,去除升压药,患者仍处于昏迷状态,给予冰帽降温,甘露醇脱水.

关键词： cardiac arrest   cardiopulmonary resuscitation   treatment   PORCINE MODEL   VENTRICULAR-FIBRILLATION   LIFE-SUPPORT   VALVE   HYPOTHERMIA   GUIDELINES   SURVIVAL  

摘要： Background-Active compression-decompression (ACD) CPR combined with an inspiratory impedance threshold device (ITD) improves vital organ blood flow during cardiac arrest. This study compared survival rates with ACD+ITD CPR versus standard manual CPR (S-CPR). Methods and Results-A prospective, controlled trial was performed in Mainz, Germany, in which a 2-tiered emergency response included early defibrillation. Patients with out-of-hospital arrest of presumed cardiac pathogenesis were sequentially randomized to ACD+ITD CPR or S-CPR by the advanced life support team after intubation. Rescuers learned which method of CPR to use at the start of each work shift. The primary end point was 1-hour survival after a witnessed arrest. With ACD+ITD CPR (n=103), return of spontaneous circulation and 1- and 24-hour survival rates were 55%, 51%, and 37% versus 37%, 32%, and 22% with S-CPR (n=107) (P=0.016, 0.006, and 0.033, respectively). One- and 24-hour survival rates in witnessed arrests were 55% and 41% with ACD+ITD CPR versus 33% and 23% in control subjects (P=0.011 and 0.019), respectively. One- and 24-hour survival rates in patients with a witnessed arrest in ventricular fibrillation were 68% and 58% after ACD+ITD CPR versus 27% and 23% after S-CPR (P=0.002 and 0.009), respectively. Patients randomized greater than or equal to10 minutes after the call for help to the ACD+ITD CPR had a 3 times higher 1- hour survival rate than control subjects (P=0.002). Hospital discharge rates were 18% after ACD+ITD CPR versus 13% in control subjects (P=0.41). In witnessed arrests, overall neurological function trended higher with ACD+ITD CPR versus control subjects (P=0.07). Conclusions-Compared with S-CPR, ACD+ITD CPR significantly improved short-term survival rates for patients with out-of-hospital cardiac arrest. Additional studies are needed to evaluate potential long-term benefits of ACD+ITD CPR.

关键词： 心脏骤停   心脏复苏   除颤心电监护仪   第一时间  

摘要： 随着科学技术的发展,越来越多的医疗仪器应于临床,使临床诊疗工作更加科学、有效.为了探究除颤心电监护仪这一电技术仪器在心脏骤停第一时间内对心肺复苏成功率的影响.我们用进口除颤心电监护仪对34例心脏骤停患者进行电击除颤,并与单纯人工通气加胸外心脏按压及药物复苏组进行比较,其结果报道如下.

关键词： 肾上腺素   心脏复苏   冠状动脉   抢救措施  

关键词： heart arrest   survival   cardiopulmonary resuscitation   AMERICAN-HEART-ASSOCIATION   UTILITIES INDEX   SUPPORT OPALS   SYSTEM   CARE   MULTIATTRIBUTE   PROFESSIONALS   METHODOLOGY   RELIABILITY   RATIONALE  

摘要： Background - This study evaluated the prehospital factors associated with better health-related quality of life for survivors of out-of-hospital cardiac arrest. Methods and Results - This prospective, 20-community, cohort study involved consecutive, adult out-of-hospital cardiac arrest patients who survived to 1 year. Patients were contacted by telephone and evaluated for the Health Utilities Index Mark III (HUI3), which describes health as a utility score on a scale from 0 ( dead) to 1.0 ( perfect health). The 8091 cardiac arrest patients had overall survival rates of 5.2% to hospital discharge and 4.0% to 1 year. We successfully contacted and evaluated 268 of 316 (84.8%) of known 1-year survivors. The median HUI3 score was 0.80 (interquartile range, 0.50 to 0.97), which compares well with age-adjusted values for the general population (0.83). Logistic regression identified 2 factors independently associated with very good quality of life ( HUI3 > 0.90) and their odds ratios (95% CIs), as follows: age 80 years or older, 0.3 (0.1 to 0.84), and citizen-initiated cardiopulmonary resuscitation (CPR), 2.0 (1.2 to 3.4) ( Hosmer-Lemeshow goodness-of-fit statistic, 0.74). Conclusions - This study is the largest ever conducted for out-of-hospital cardiac arrest survivors, clearly shows that these patients have good quality of life, and is the first to demonstrate that citizen-initiated CPR is strongly and independently associated with better quality of life. These results emphasize the importance of optimizing community citizen CPR readiness. Given the low rate of citizen-initiated CPR in many communities, we believe that local and national initiatives should vigorously promote the practice of bystander CPR.