重症监护环境下心搏骤停患者的复苏后管理:循证指南依从性的回顾性分析

Post resuscitation management of cardiac arrest patients in the critical care environment: a retrospective audit of compliance with evidence based guidelines

背景:循证的复苏后护理与患者出院后的生存及功能状态之间有明确的关系。澳大利亚复苏委员会(ARC)推荐采用程序化的护理,以提高患者心搏骤停后的存活机会。卫生服务机构有义务确保程序化的复苏后护理是及时的和循证的。目的 :本研究的目的是,对于院外或在急诊科发生心搏骤停经复苏后存活的患者,从急诊科转入重症监护室后,在患者自主循环恢复的首个24小时内,检查患者的复苏后护理遵循最佳操作指南的情况。方法:在澳大利亚墨尔本的两家医疗机构,对满足心搏骤停后存活标准的患者的病历进行回顾性分析。考察的指标为:原发性心搏骤停特征、氧合和通气管理、心血管护理、神经系统护理和患者预后。结果 :本研究有4项主要发现:(i)在首个24小时内的复苏后管理中,吸入气中的氧浓度分数(FIO2)为100%以及高氧血症常见;(ii)心脏护理有差异,及时给予12导联心电图监测,大部分患者的收缩压(SBP)高于100 mm Hg,但转入心导管实验室的时间延迟;(iii)神经护理不足,包括高血糖发生率高,以及高达50%的患者未提供低温治疗;(iv)患者入院后24小时内的院内病死率与复苏后护理的特定因素有关。结论 :有必要设定贯穿患者就医全过程的循证的,适合特定环境的指南,来指导复苏后护理。在实践中依赖国家级指南不一定能使其转化为健康机构内的循证实践。因此,迫切需要具体实施措施以确保指南的有效实施。

Background： There is a clear relationship between evidence-based post resuscitation care and survival and functional status at hospital discharge. The Australian Resuscitation Council （ARC） recommends protocol driven care to enhance chance of survival following cardiac arrest. Healthcare providers have an obligation to ensure protocol driven post resuscitation care is timely and evidence based. Objective： The aim of this study was to examine adherence to best practice guidelines for post resuscitation care in the first 24 h from Return of Spontaneous Circulation for patients admitted to the intensive care unit from the emergency department having suffered out of hospital or emergency department cardiac arrest and survived initial resuscitation. Methods： A retrospective audit of medical records of patients who met the criteria for survivors of cardiac arrest was conducted at two health services in Melbourne, Australia. Criteria audited were： primary cardiac arrest characteristics, oxygenation ＆ ventilation management, cardiovascular care, neurological care and patient outcomes. Results： The four major findings were： （i） use of fraction of inspired oxygen （FIO2） of 1.0 and hyperoxia was common during the first 24 h of post resuscitation management, （ii） there was variability in cardiac care, with timely 12 lead Electrocardiograph and majority of patients achieving systolic blood pressure （SBP） greater than 100 mmHg, but delays in transfer to cardiac catheterisation laboratory, （iii） neurological care was suboptimal with a high incidence of hyperglycaemia and failure to provide therapeutic hypothermia in almost 50% of patients and （iv） there was an association between in-hospital mortality and specific elements of post resuscitation care during the first 24 h of hospital admission. Conclusion： Evidence- based context-specific guidelines for post resuscitation care that span the whole patient journey are needed. Reliance on national guidelines does not necessarily translate to evidence based care at a local level, so strategies to ensure effective guideline implementation are urgently required.