插入式腹部提压心肺复苏对心搏骤停患者血流动力学及氧代谢的影响

Effects of interposed abdominal pulling-pressing cardiopulmonary resuscitation on hemodynamics and oxygen metabolism in patients with cardiac arrest

目的探讨插入式腹部提压心肺复苏(IAPP-CPR)与标准心肺复苏(S-CPR)对心搏骤停患者血流动力学及氧代谢的影响,以评价IAPP-CPR的救治效果。方法选择2017年1月至2019年1月在连云港市第一人民医院重症医学科(ICU)住院的心搏骤停时间<30 min且有S-CPR适应证的心搏骤停患者,根据患者是否存在IAPP-CPR适应证分为IAPP-CPR组和S-CPR组。S-CPR组按照2015年美国心脏协会(AHA)CPR指南操作;IAPP-CPR组在S-CPR基础上,于胸外按压放松期进行腹部提压(幅度4~5 cm、频率100~120次/min、提压时间比1∶1)。记录两组患者复苏期间血流动力学变化,以及复苏成功患者复苏30 min后血流动力学、氧代谢、动脉血气分析指标和预后。结果研究期间共入选77例患者,排除中途放弃治疗和退出患者24例,最终53例患者纳入分析,S-CPR组28例、IAPP-CPR组25例。①两组患者复苏期间心率(HR)、平均动脉压(MAP)、冠状动脉灌注压(CPP)均呈上升趋势,以IAPP-CPR组升高更为显著。②复苏成功患者血流动力学:IAPP-CRP组复苏成功患者16例、S-CRP组13例。IAPP-CPR组复苏成功患者复苏30 min后MAP、CPP、全心射血分数(GEF)、每搏量(SV)均明显高于S-CPR组〔MAP(mmHg,1 mmHg=0.133 kPa):52.88±3.11比39.39±4.62,CPP(mmHg):36.56±6.89比29.61±6.92,GEF:0.217±0.036比0.178±0.027,SV(mL):38.43±5.25比32.92±8.28,均P<0.05〕;而两组中心静脉压(CVP)和HR比较差异无统计学意义。③复苏成功患者氧代谢:IAPP-CPR组复苏成功患者复苏30 min后心排血量(CO)、动脉血氧含量(CaO2)、氧输送(DO2)、氧消耗(VO2)均明显高于S-CPR组〔CO(L/min):2.23±0.38比1.99±0.29,CaO2(mL/L):158.0±11.8比141.4±8.2,DO2(mL/L):245.8±29.9比209.1±28.0,VO2(mL/L):138.2±24.9比112.8±18.1,均P<0.05〕。④复苏成功患者动脉血气分析:IAPP-CPR组复苏成功患者复苏30 min后pH值、动脉血氧分压(PaO2)、动脉血二氧化碳分压(PaCO2)、氧合指数(PaO2/FiO2)、中心静脉血氧饱和度(ScvO2)均明显高于S-CPR组〔pH值:7.13±0.22比7.00±0.23,PaO2(mmHg):73.68±13.80比65.32±15.32,PaCO2(mmHg):36.24±11.77比29.12±7.82,PaO2/FiO2(mmHg):73.68±13.80比65.32±15.32,ScvO2:0.628±0.074比0.589±0.066,均P<0.05〕,血乳酸(Lac)明显低于S-CPR组(mmol/L:9.80±4.28比12.18±3.63,P<0.05)。⑤IAPP-CPR组患者心搏骤停至自主循环恢复(ROSC)时间较S-CPR组明显缩短(min:10.63±2.94比14.54±3.84,P<0.01),ROSC率、CPR成功率、28 d存活率均明显高于S-CPR组〔64.0%(16/25)比46.4%(13/28),60.0%(15/25)比28.6%(8/28),52.0%(13/25)比21.4%(6/28),均P<0.05〕;IAPP-CPR组与S-CRP组肋骨骨折发生率比较差异无统计学意义〔92.0%(23/25)比89.3%(25/28),P>0.05〕,且均未见腹腔出血表现。结论与S-CPR比较,IAPP-CPR在复苏期间及复苏成功后能产生更好的血流动力学效应,复苏30 min后氧代谢及动脉血气分析指标更佳,ROSC率、CPR成功率、28 d存活率更高,且两种复苏方法并发症无明显差异。

Objective To analyze the effect of interposed abdominal pulling-pressing cardiopulmonary resuscitation(IAPP-CPR)and standard cardiopulmonary resuscitation(S-CPR)on hemodynamics and oxygen metabolism in patients with cardiac arrest,and to evaluate the treatment effect of IAPP-CPR.Methods The patients with cardiac arrest,cardiac arrest time less than 30 minutes,and with S-CPR indications admitted to intensive care unit(ICU)of the First People's Hospital of Lianyungang from January 2017 to January 2019 were enrolled.The patients were divided into IAPP-CPR group and S-CPR group according to whether the patients had IAPP-CPR indication or not.The patients in the S-CPR group were operated according to the 2015 American Heart Association(AHA)CPR guidelines;and the patients in the IAPP-CPR group received the IAPP-CPR on the basis of the S-CRP.During the relaxation period,the patients were subjected to abdominal lifting and compressing with amplitude of 4-5 cm,frequency of 100-120 times/min,and the time ratio of lifting to compressing was 1∶1.Hemodynamic changes during resuscitation were recorded in the two groups.Hemodynamics,oxygen metabolism,arterial blood gas analysis and prognostic indicators were recorded at 30 minutes after successful resuscitation.Results During the study period,77 patients were selected,24 patients were excluded from giving up treatment and quitting,53 patients were enrolled in the analysis finally,with 28 patients in the S-CPR group and 25 in the IAPP-CPR group.①The heart rate(HR),mean arterial pressure(MAP)and coronary perfusion pressure(CPP)showed an upward trend during resuscitation,and a more significant increase was shown in the IAPP-CPR group.②Hemodynamics after successful resuscitation:there were 16 patients with successful resuscitation in the IAPP-CPR group and 13 in the S-CPR group.The MAP,CPP,global ejection fraction(GEF)and stroke volume(SV)of patients with successful resuscitation at 30 minutes after resuscitation in the IAPP-CPR group were significantly higher than those in the S-CPR group[MAP mmHg(1 mmHg=0.133 kPa):52.88±3.11 vs.39.39±4.62,CPP(mmHg):36.56±6.89 vs.29.61±6.92,GEF:0.217±0.036 vs.0.178±0.027,SV(mL):38.43±5.25 vs.32.92±8.28,all P<0.05],but there was no significant difference in central venous pressure(CVP)or HR between the two groups.③Oxygen metabolism after successful resuscitation:the cardiac output(CO),arterial oxygen content(CaO2),oxygen transport(DO2)and oxygen consumption(VO2)of patients with successful resuscitation at 30 minutes after resuscitation in the IAPP-CPR group were significantly higher than those in the S-CPR group[CO(L/min):2.23±0.38 vs.1.99±0.29,CaO2(mL/L):158.0±11.8 vs.141.4±8.2,DO2(mL/L):245.8±29.9 vs.209.1±28.0,VO2(mL/L):138.2±24.9 vs.112.8±18.1,all P<0.05].④Arterial blood gas after successful resuscitation:the values of the pH,arterial oxygen partial pressure(PaO2),arterial partial pressure of carbon dioxide(PaCO2),oxygenation index(PaO2/FiO2)and central venous oxygen saturation(ScvO2)of patients with successful resuscitation at 30 minutes after resuscitation in the IAPP-CPR were significantly higher than those in the S-CPR group[pH value:7.13±0.22 vs.7.00±0.23,PaO2(mmHg):73.68±13.80 vs.65.32±15.32,PaCO2(mmHg):36.24±11.77 vs.29.12±7.82,PaO2/FiO2(mmHg):73.68±13.80 vs.65.32±15.32,ScvO2:0.628±0.074 vs.0.589±0.066,all P<0.05],and the blood lactic acid(Lac)level was significantly lower than that in the S-CPR group(mmoL/L:9.80±4.28 vs.12.18±3.63,P<0.05).⑤The patients in the IAPP-CPR group had a shorter time for cardiac arrest to restoration of spontaneous circulation(ROSC)than that in the S-CPR group(minutes:10.63±2.94 vs.14.54±3.84,P<0.01),and the rate of ROSC,CPR successful rate and 28-day survival rate were significantly higher than those in the S-CPR group[64.0%(16/25)vs.46.4%(13/28),60.0%(15/25)vs.28.6%(8/28),52.0%(13/25)vs.21.4%(6/28),all P<0.05].There was no significant difference in incidence of rib fracture between the IAPP-CPR and S-CPR groups[92.0%(23/25)vs.89.3%(25/28),P>0.05],and no abdominal bleeding was found in both group.Conclusion IAPP-CPR can produce better hemodynamic effect during and after resuscitation than S-CPR,and oxygen metabolism and arterial blood gas analysis parameters at 30 minutes after resuscitation were better than S-CPR,with higher ROSC rate,CPR successful rate and 28-day survival rate,and no significant difference in complications between the two resuscitation methods.