心搏骤停后综合征预后相关影响因素的分析

An analysis of relevant factors influencing the prognosis of post cardiac arrest syndrome

目的：分析影响心搏骤停后综合征（PCAS）发生和死亡的相关危险因素，为综合提高心搏骤停患者的抢救成功率提供防治依据。方法采用单中心回顾性研究，依据心肺复苏（CPR）评估Utstein模式，统一设计观察表收集患者的临床资料。调查对象为2008年1月至2014年6月吉林大学第一医院重症加强治疗病房（ICU）收治的心搏骤停后自主循环恢复（ROSC）＞24 h的患者，采用多元logistic回归分析对PCAS发生和死亡的相关危险因素进行筛选和检验。结果①93例复苏成功患者入选，其中83例发生全身炎症反应综合征（SIRS），75例发展为PCAS（80.65%），死亡49例；未发生PCAS的18例患者全部存活。②心搏骤停患者的年龄、性别、既往有无慢性疾病史、心搏骤停地点、心搏骤停心律类型、肾上腺素用量等因素对PCAS的发生无明显影响；而电除颤＞3次（χ2＝10.806，P＝0.001）、复苏后发生SIRS（χ2＝46.687，P＜0.001）、昏倒至除颤时间＞5 min（χ2＝6.429，P＝0.011）、昏倒至徒手复苏时间＞5 min（χ2＝4.638，P＝0.031）、昏倒至复苏药物使用时间＞5 min（χ2＝4.190，P＝0.041）、ROSC时间＞10 min（χ2＝20.042，P＜0.001）时，PCAS的发生率相对较高。双变量相关性分析结果显示，昏倒至徒手复苏时间、昏倒至复苏药物使用时间与ROSC时间之间两两相关（r1＝0.677、r2＝0.481、r3＝0.617，均P＜0.001）。③电除颤次数、肾上腺素用量、昏倒至除颤时间对PCAS患者的预后无明显影响；而昏倒至徒手复苏时间＞5 min（χ2＝10.792，P＝0.001）、昏倒至复苏药物使用时间＞5 min（χ2＝13.841，P＜0.001）、 ROSC时间＞10 min（χ2＝36.451，P＜0.001）、器官功能障碍数≥4个（χ2＝28.287，P＜0.001）、动脉血乳酸＞2 mmol/L（χ2＝28.926，P＜0.001）、急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分＞15分（χ2＝33.558，P＜0.001）时，PCAS患者的病死率相对较高。多元logistic回归分析显示：影响预后的危险因素是ROSC时间〔调整后优势比（OR）＝36.643，95%可信区间（95%CI）＝2.382～563.767，P＝0.010〕、器官功能障碍数（OR＝9.010，95%CI＝1.140～71.199，P＝0.037）、APACHEⅡ评分（OR＝10.001，95%CI＝1.336～74.893，P＝0.025）。结论 ROSC时间、发生器官功能障碍数及APACHEⅡ评分是PCAS患者预后的独立预测因素。心搏骤停后努力缩短相关操作的救治时间，尽快恢复自主循环，防治复苏后SIRS和保护多器官功能，可改善患者预后。

ObjectiveTo investigate the relevant factors influencing the incidence and mortality of post cardiac arrest syndrome （PCAS）, and to provide the basis of improvement of resuscitation rate.Methods A single center retrospective study of cardiopulmonary resuscitation （CPR） according to Utstein model was conducted. A clinical case report form was designed to collect clinical data. The clinical data of patients whose spontaneous circulation was restored （ROSC）〉 24 hours in intensive care unit （ICU） of the First Hospital of Jilin University from January 2008 to June 2014 were collected and analyzed. The relevant risk factors of the incidence and mortality rate of PCAS were screened and analyzed by multivariate logistic regression analysis.Results① Successful CPR was achieved in 93 patients, of whom 83 patients were shown to have systemic inflammatory response syndrome （SIRS）, and 75 patients suffered from PCAS （80.65%）. Among them 49 died, and 18 patients who did not suffer from PCAS survived.② The age, gender, history of previous chronic disease, site of occurrence of cardiac arrest, type of rhythm when cardiac arrest occurred, and dosage of adrenaline showed no significant influence on the incidence of PCAS. The incidence of PCAS was elevated when defibrillation was done more than 3 times （χ2= 10.806,P= 0.001）, SIRS occurred after ROSC （χ2= 46.687,P〈 0.001）, interval between collapse and first defibrillation over 5 minutes （χ2 = 6.429,P = 0.011）, interval between collapse and CPR longer than 5 minutes （χ2 = 4.638,P = 0.031）, interval between collapse and administration of first resuscitation medication〉 5 minutes （χ2 = 4.190,P = 0.041）, and ROSC time was longer than 10 minutes （χ2 = 20.042,P〈 0.001）. Bivariate correlation showed that interval between collapse and CPR, interval between collapse and administration of first resuscitation medications, and ROSC time were all correlated （r1 = 0.677,r2 = 0.481,r3 = 0.617, allP〈 0.001）.③ There were no significant relations between the prognosis of PCAS patients and times of defibrillation, the amount of adrenaline used, and interval between collapse and first defibrillation. The mortality rate of PCAS was relatively elevated when interval between collapse and CRP was longer than 5 minutes （χ2 = 10.792,P = 0.001）, interval between collapse and administration of first resuscitation medications was longer than 5 minutes （χ2 = 13.841,P〈 0.001）, ROSC time〉 10 minutes （χ2 = 36.451,P〈 0.001）, the number of dysfunction organ≥ 4 （χ2 = 28.287,P〈 0.001）, arterial blood lactate levels〉 2 mmol/L （χ2 = 28.926, P〈 0.001）, and acute physiology and chronic health evaluationⅡ （APACHEⅡ） score〉 15 （χ2 = 33.558,P〈 0.001）. Multivariate logistic regression analysis showed that the risk factors affecting the prognosis were ROSC time [odds ratio （OR） after adjustment = 36.643, 95% confidence interval （95%CI） = 2.382-563.767,P = 0.010], the number of organs with dysfunction （OR = 9.010, 95%CI = 1.140-71.199,P = 0.037）, and APACHEⅡ score （OR = 10.001, 95%CI =1.336-74.893,P = 0.025）.Conclusions ROSC time, the number of organs with dysfunction, and APACHEⅡ score were independent predictors of PCAS prognosis. Efforts should be given to shorten the rescue time, to shorten the time for restoring the spontaneous circulation, to prevent and treat SIRS after ROSC, and to protect the function of organs, in order to improve the prognosis of patients with PCAS.