PETCO2对腹部提压CPR救治效果及血清S100B蛋白对脑功能预测价值的研究

Predictive value of partial pressure of end-tidal carbon dioxide on the effect of active abdominal compression-decompression cardiopulmonary resuscitation and serum S100B protein on cerebral function

目的探讨呼气末二氧化碳分压（PETCO2）对腹部提压心肺复苏（AACD-CPR）的复苏效果及血清S100B蛋白对成功复苏患者脑功能的预测价值。方法选择2014年9月至2017年12月南方医科大学附属郑州人民医院收治的实施AACD-CPR的142例院内心搏骤停（IHCA）成人患者，根据自主循环恢复（ROSC）与否将患者分为成功组和失败组；再根据复苏成功后1个月格拉斯哥-匹兹堡脑功能（CPC）分级将复苏成功患者分为预后良好组（CPC 1～2级）和预后不良组（CPC 3～5级）。分析患者复苏过程中血流动力学、动脉血气指标、PETCO2、血清S100B蛋白水平的变化（以25例健康者S100B蛋白水平作为正常参考值）；用受试者工作特征曲线（ROC）分析PETCO2对AACD-CPR的复苏效果及血清S100B蛋白对成功复苏患者脑功能的预测价值。结果①根据传统定性指标如触及大动脉搏动、口唇及四肢末梢变红润、可见胸廓自行上下起伏、瞳孔较前缩小、对光反射存在等判断，142例IHCA患者成功复苏54例；通过PETCO2指导CPR，最后成功复苏57例，两者对比差异无统计学意义（χ2＝0.133，P＝0.715）。142例IHCA患者随AACD-CPR的进行，动脉血氧分压（PaO2）、动脉血二氧化碳分压（PaCO2）均有不同程度改善；ROSC 20 min时心率（HR）、平均动脉压（MAP）、PaO2、PaCO2均较复苏过程中进一步改善。复苏开始时，成功组和失败组PETCO2约为10 mmHg（1 mmHg＝0.133 kPa）；成功组PETCO2随CPR的进行逐渐上升到20 mmHg以上，而失败组则在2～5 min内稍升高后逐渐下降至20 mmHg以下，两组CPR各时间点PETCO2比较差异有统计学意义。用CPR 20 min PETCO2预测复苏结局的ROC曲线下面积（AUC）为0.969，95%可信区间（95%CI）为0.943～0.995（P＝0.000），最佳临界值为24.25 mmHg时，敏感度为90.7%，特异度为96.6%。②预后良好组和预后不良组ROSC 0.5 h时S100B蛋白水平均较健康对照组明显升高，而预后不良组与预后良好组间比较差异无统计学意义。预后不良组S100B蛋白于ROSC 3～6 h内达峰值，然后逐渐降低，至ROSC 72 h时仍显著高于健康对照组；预后良好组S100B蛋白则逐渐降低，并于ROSC 72 h内恢复至正常范围。用ROSC 3 h血清S100B蛋白水平预测脑功能预后不良的AUC为0.925，95%CI为0.867～0.984（P＝0.000），最佳临界值为1.215 μg/L时，敏感度为85.2%，特异度为85.5%。结论PETCO2可作为预测IHCA患者AACD-CPR成功与否的客观评判指标，血清S100B水平可作为预测复苏成功患者脑功能预后不良的客观指标，两者对临床治疗具有一定的参考和指导意义。

ObjectiveTo explore the predictive value of partial pressure of end-tidal carbon dioxide （PETCO2） on the effect of active abdominal compression-decompression cardiopulmonary resuscitation （AACD-CPR） and serum S100B protein on cerebral function.Methods142 adult patients with in-hospital cardiac arrest （IHCA） AACD-CPR in Zhengzhou People＇s Hospital, Affiliated Southern Medical University from September 2014 to December 2017 were enrolled. Patients were divided into successful group and failure group according to restoration of spontaneous circulation （ROSC） or not; and then according to Glasgow-Pittsburgh cerebral performance categories （CPC） one month after ROSC, the successful group was divided into good prognosis group （CPC 1-2） and poor prognosis group （CPC 3-5） further. The variations of hemodynamic, arterial blood gas index, PETCO2 and serum S100B protein level （25 healthy subjects as normal S100B protein level reference value） during the recovery were analyzed. The predictive value of PETCO2 on the effect of AACD-CPR and serum S100B protein on cerebral function of successful resuscitation patients were analyzed by receiver operating characteristic curve （ROC）.Results① According to the traditional qualitative indexes, such as pulsation of the large artery, redness of lips and extremities, spontaneous fluctuation of chest, narrowing of pupil, existence of shallow reflex, etc, 54 in 142 patients with IHCA were successfully resuscitated; 57 cases were successfully resuscitated through the guidance of PETCO2, there was no significant difference between the two groups （χ2 = 0.133, P = 0.715）. With the AACD-CPR, 142 CA patients＇ arterial partial pressure of oxygen （PaO2）, arterial blood carbon dioxide partial pressure （PaCO2） were all improved with different degrees; heart rate （HR）, mean arterial pressure （MAP）, PaO2 and PaCO2 were further improved at 20 minutes after ROSC. At beginning of AACD-CPR, PETCO2 of both groups were about 10 mmHg （1 mmHg = 0.133 kPa）. PETCO2 was gradually rising to above 20 mmHg in successful group during AACD-CPR process; the failed group increased slightly within 2-5 minutes, then gradually decreased to below 20 mmHg, there was a significant difference in PETCO2 between the two groups at each time. The area under the ROC （AUC） of PETCO2 at CPR 20 minutes in predicting the outcome of the resuscitation was 0.969, 95% confidence interval （95%CI） was 0.943-0.995 （P = 0.000）, when the cut-off value of PETCO2 was 24.25 mmHg, the sensitivity was 90.7%, and the specificity was 96.6%. ② The level of serum S100B protein at 0.5 hour after ROSC in the good prognosis group and the poor prognosis group were significant higher than that of the normal control group; there was no significant difference between poor prognosis group and good prognosis group. S100B protein concentration of the poor prognosis group reached the peak within 3-6 hours, then gradually decreased, and was higher than that of the normal control group at ROSC 72 hours; the good prognosis was gradually decreased and recovered to normal control group within ROSC 72 hours. The AUC of S100B at 3 hours after ROSC on cerebral function prognosis prediction was 0.925, 95%CI was 0.867-0.984 （P = 0.000）, when the cut-off value of S100B protein was 1.215 μg/L, the sensitivity was 85.2%, and the specificity was 85.5%.ConclusionThe variation of PETCO2 can be used as an objective index to predict the success of AACD-CPR, and serum S100B protein can be used as an objective clinical index to predict cerebral function after AACD-CPR, both of which have some reference and guiding significance for clinical treatment.