Post-cardiac arrest syndrome:Mechanisms and evaluation of adrenal insufficiency

Cardiac arrest is one of the leading causes of death and represents maximal stress in humans. After restoration of spontaneous circulation, post-cardiac arrest syndrome is the predominant disorder in survivors. Besides the post-arrest brain injury, the post-resuscitation myocardial stunning, and the systemic ischemia/reperfusion response, this syndrome is characterized by adrenal insufficiency, a disorder that often remains undiagnosed. The pathophysiology of adrenal insufficiency has not been elucidated. We performed a comprehensive search of three medical databases in order to describe the major pathophysiological disturbances which are responsible for the occurrence of the disorder. Based on the available evidence, this article will help physicians to better evaluate and understand the hidden yet deadly post-cardiac arrest adrenal insufficiency.

Brugada syndrome associated with out-of-hospital cardiac arrest: A case report

BACKGROUND Brugada syndrome(BrS)is an inherited disease characterized by an electrocardiogram(ECG)with a coved-type ST-segment elevation in the right precordial leads(V1-V3),which predisposes to sudden cardiac death(SCD)due to polymorphic ventricular tachycardia or ventricular fibrillation in the absence of structural heart disease.We report the case of a 29-year-old man with out-ofhospital cardiac arrest.BrS is associated with a high incidence of SCD in adults,and increasing the awareness of BrS and prompt recognition of the Brugada ECG pattern can be lifesaving.CASE SUMMARY A 29-year-old man suffered from out-of-hospital cardiac arrest,and after defibrillation,his ECG demonstrated a coved-type elevated ST segment in V1 and V2.These findings were compatible with type 1 Brugada pattern,and ECG of his brother showed a type 2 Brugada pattern.The diagnosis was BrS,NYHF IV,multiple organ dysfunction syndrome,sepsis,and hypoxic ischemic encephalopathy.The patient had no arrhythmia episodes after discharge throughout a follow-up period of 36 mo.CONCLUSION Increasing awareness of BrS and prompt recognition of the Brugada ECG pattern can be lifesaving.

Cardiac arrest after graft reperfusion during liver transplantation

BACKGROUND: Cardiac arrest ( CA) during orthotopic liver transplantation (OLT) is rare but it threatens the lives of patients. The cause of perioperitive CA is not fully understood. We reported the occurrence of CA in 5 patients after unclamping of the vena cava and investigated the relationship between CA and associated variables. METHODS: Five patients with CA after graft reperfusion during OLT in our unit from November 1996 to September 2003 were retrospectively reviewed. Analyzed data included donor and recipient demographic data, and recipient operative and postoperative events. RESULTS: Five (2.1%) of 240 patients undergoing OLT experienced CA 5 minutes after graft reperfusion. Two patients died of resuscitation failure. Hyperkalemia and metabolic acidosis after revascularization were observed in some patients. The five patients had hypothermia and hypocalce-mia, and one had pulmonary embolism. CONCLUSIONS: CA is one of the syndromes after reperfusion. Many factors such as hyperkalemia, acidosis or pulmonary embolism combined with hypothermia and hy-pocalcemia during the operation seem to contribute to the occurrence of CA.

Neuronal injury and tumor necrosis factor-alpha immunoreactivity in the rat hippocampus in the early period of asphyxia-induced cardiac arrest under normothermia

Low survival rate occurs in patients who initially experience a spontaneous return of circulation after cardiac arrest（CA）. In this study, we induced asphyxial CA in adult male Sprague-Daley rats, maintained their body temperature at 37 ± 0.5°C, and then observed the survival rate during the post-resuscitation phase. We examined neuronal damage in the hippocampus using cresyl violet（CV） and Fluore-Jade B（F-J B） staining, and pro-inflammatory response using ionized calcium-binding adapter molecule 1（Iba-1）, glial fibrillary acidic protein（GFAP）, and tumor necrosis factor-alpha（TNF-α） immunohistochemistry in the hippocampus after asphyxial CA in rats under normothermia. Our results show that the survival rate decreased gradually post-CA（about 63% at 6 hours, 37% at 1 day, and 8% at 2 days post-CA）. Rats were sacrificed at these points in time post-CA, and no neuronal damage was found in the hippocampus until 1 day post-CA. However, some neurons in the stratum pyramidale of the CA region in the hippocampus were dead 2 days post-CA. Iba-1 immunoreactive microglia in the CA1 region did not change until 1 day postCA, and they were activated（enlarged cell bodies with short and thicken processes） in all layers 2 days postCA. Meanwhile, GFAP-immunoreactive astrocytes did not change significantly until 2 days post-CA. TNF-α immunoreactivity decreased significantly in neurons of the stratum pyramidale in the CA1 region 6 hours post-CA, decreased gradually until 1 day post-CA, and increased significantly again 2 days post-CA. These findings suggest that low survival rate of normothermic rats in the early period of asphyxia-induced CA is related to increased TNF-α immunoreactivity, but not to neuronal damage in the hippocampal CA1 region.

A Case of Two Cardiac Arrests in a Pregnant Woman with Severe Covid-19 Pneumonia

Background: COVID-19 pneumonia increases the risk for pregnant women and the fetuses that often require intensive therapy. In addition to obvious therapeutic targets, ICU staff has to control the psycho-emotional conditions of COVID-19 patients, e.g. intensive care unit syndrome and post-intensive care syndrome. Case presentation: Patient M., Uzbek, 24 years old, gravida 1 (27 weeks) was admitted to the Maternity Department of Zangiota hospital on 19.07.2021 with the diagnosis of extremely severe COVID-19 pneumonia and respiratory failure with psychomotor agitation. On day 4 her general condition deteriorated due to the progression of pneumonia and involvement of abdominal organs associated with 27-week pregnancy. On that day the fetus had no signs of life, and the caesarean delivery was performed;the child was stillborn. For the next two weeks the patient had been in medical coma due to the progression of respiratory and multi-organ failure. The patient had two separate cardiac arrests. Cardio-pulmonary resuscitation was successful. By day 20, the dynamics of her cardiac activity has been completely restored. The brain function restored to 15 on the Glasgow Coma Scale. Conclusion: Special measures of prevention and treatment of multi-organ failure, intensive care unit syndrome and post-intensive care syndrome should be taken in an ICU for pregnant women with COVID-19 pneumonia.

2024年《女性心脏急症管理》临床声明解读

心脏急症发病迅速,严重威胁患者的身体健康和生命安全。长期以来,由于性别偏见、症状不典型等原因,女性心脏急症存在研究不足,诊断、治疗不及时的问题,且心脏急症在病理生理机制、危险因素及管理和结局方面存在明显的性别差异。在我国,女性心脏急症发病率高、研究起步晚,且目前尚无针对女性心脏急症的权威指南发布,故加强女性心脏急症管理十分迫切。本文组织全科医学、心血管和急诊医学临床医生对急性心血管护理协会等机构发布的2024年《女性心脏急症管理》临床声明进行解读,以期规范女性心脏急症的诊疗,改善健康结局。

Therapeutic Effects of Shenfu Injection(参附注射液) on Post-Cardiac Arrest Syndrome

Survival rates after cardiac arrest have not changed substantially over the past 5 decades. Post- cardiac arrest （CA） syndrome （PCAS） is the primary reason for the high mortality rate after successful restoration of spontaneous circulation （ROSC）. Intravenous administration of Shenfu Injection （参附注射液, SFI） may attenuate post-CA myocardial dysfunction and cerebral injury, inhibit systemic ischemiaJreperfusion responses, and treat underlying diseases. In this article, we reviewed the therapeutic effects of SFI in PCAS. SFI might be useful in the treatment of PCAS, incorporating the multi-link and muff-target advantages of Chinese medicine into PCAS management. Further experimental and clinical research to verify the therapeutic effects of SFI in PCAS is required.

Clinical significance of lactate in acute cardiac patients

Lactate, as a metabolite of easy and quick assessment, has been studied over time in critically ill patients in order to evaluate its prognostic ability. The present review is focused on the prognostic role of lactate levels in acute cardiac patients(that is with acute coronary syndrome, cardiogenic shock, cardiac arrest, non including post cardiac surgery patients). In patients with STelevation myocardial infarction treated with mechanical revascularization, hyperlactatemia identified a subset of patients at higher risk for early death and in-hospital complications, being strictly related mainly to hemodynamic derangement. The prognostic impact of hyperlactatemia on mortality has been documented in patients with cardiogenic shock and in those with cardiac arrest even if there is no cut-off value of lactate to be associated with worse outcome or to guide resuscitation or hemodynamic management. Therapeutic hypothermia seems to affect per se lactate values which have been shown to progressively decrease during hypothermia. The mechanism(s) accounting for lactate levels during hypothemia seem to be multiple ranging from the metabolic effects of reduced temperatures to the hemodynamic effects of hypothermia(i.e., reduced need of vasopressor agents). Serial lactate measurements over time, or lactate clearance, have been reported to be clinically more reliable than lactate absolute value also in acute cardiac patients. Despite differences in study design, timing of lactate measurements and type of acute cardiac conditions(i.e., cardiogenic shock, cardiac arrest, refractory cardiac arrest), available evidence strongly suggests that higher lactate levels can be observed on admission in non-survivors and that higher lactate clearance is associated with better outcome.

左西孟旦在心脏骤停中的应用进展

心脏骤停(CA)严重危害人类健康,目前有效治疗手段十分匮乏,所以探索新的治疗方法一直是心肺复苏(CPR)领域的热点。左西孟旦作为新型正性肌力药物,在不增加心肌耗氧量的同时通过钙增敏作用增强心肌收缩力,通过激活平滑肌及线粒体三磷酸腺苷敏感性钾通道(KATP)改善脏器灌注和细胞代谢功能。基于增强心肌收缩力、改善脏器血供、减轻线粒体损伤等机制,本研究就左西孟旦在CA治疗中的研究进展作一综述。

两种早期预警评分系统对急性冠状动脉综合征患者发生心搏骤停的预测效果分析

目的探讨两种早期预警评分系统对急性冠状动脉综合征患者发生心搏骤停的预测效果。方法采取回顾性病例-对照研究,便利选取2018年12月至2022年12月因急性冠状动脉综合征入某医院急诊科进行治疗的300例患者作为研究对象,按入院24 h后是否发生心搏骤停分为病例组(158例)和对照组(142例)。病例组收集患者在心搏骤停发生前30 min、1 h、2 h、4 h、8 h、16 h、24 h的生命体征,并带入改良早期预警评分量表和重要性早期预警评分量表;对照组随机选择24 h内具有完整资料的时间点与病例组相对应,收集内容及方法同病例组。结果病例组患者心搏骤停前30 min至24 h各个时间点,两个量表评分均明显高于对照组(P<0.05)。心搏骤停前8 h,改良早期预警评分的ROC曲线下面积为0.642,具有较低的预测效能,重要性早期预警评分的ROC曲线下面积为0.783,预测效能中等。心搏骤停发生前的8 h内,重要性早期预警评分的ROC曲线下面积均>0.7,且各值比较差异均无统计学意义(P>0.05)。重要性早期预警评分对各种类型的急性冠状动脉综合征患者发生心搏骤停的ROC曲线下面积均>0.7。结论重要性早期预警评分比改良早期预警评分具有更高的预测效能,能够提前8 h预测心搏骤停的发生,且对各种类型的急性冠状动脉综合征患者均有良好的预测效果,建议临床推广应用。

心搏骤停后综合征的治疗方法研究进展

心搏骤停后综合征(PCAS)是心搏骤停的严重并发症,致死、致残率极高。如何采用及时有效的治疗措施提高PCAS患者的救治成功率已成为急诊医学界关注和研究的热点问题之一。目前,PCAS的治疗措施主要包括呼吸支持、循环支持、脑保护、冠状动脉血运重建等。本文对当前PCAS的主要治疗方法进行总述,以期为临床医生救治此类患者和开展进一步的研究提供参考。

急性冠状动脉综合征导致心脏骤停的预警因素研究进展

急性冠状动脉综合征(ACS)的发病率在我国目前仍呈上升趋势,危重者可发生心脏骤停,心脏骤停后死亡率极高。积极评估患者病情变化,预警心脏骤停的发生,及时给予临床干预,可降低死亡率。目前临床评估方法主要靠预警因素。本文主要从分子生物学、一般临床特征、实验室及辅助检查指标、预警模型及评分等方面对ACS导致心脏骤停的预警因素进行综述。

心房颤动伴长间歇的治疗策略:共识与争议

心房颤动(房颤)是心血管疾病中最为常见的心律失常,其常与病态窦房结综合征并存且相互作用。既往临床上对于有症状的房颤伴长间歇治疗多倾向于植入心脏起搏器联合抗心律失常药物,但近年来越来越多的研究表明,与植入起搏器相比,射频消融能降低房性心动过速相关心律失常的住院率、有效控制房颤,改善患者预后及心力衰竭住院率。但同时部分患者存在固有窦房结功能障碍(SND),且SND可在部分患有房颤的患者中逐渐进展及加重。因此,房颤伴长间歇患者的一线治疗策略仍存在争议。本文以房颤伴长间歇治疗策略的选择进行综述。

中医药治疗复苏后综合征的研究进展

复苏后综合征(PRS)是心脏骤停经过复苏恢复自主循环后,机体因长时间缺血以及缺血再灌注损伤,导致多器官功能不全或衰竭等一系列复杂病理生理过程。随着心脏骤停患者的增多,PRS也成为临床难题。中医药用于治疗PRS具有一定优势,并在治疗研究上取得了一定成果。本文就近年来中医药治疗PRS的研究进展进行综述。

心脏骤停后综合征动物模型的建立

目的 建立一种稳定的、能进行心脏骤停后综合征研究的动物模型.方法 大耳白兔30只,随机分为3组,每组10只.兔麻醉后逆行气管插管、右侧股动脉插管,静脉注射司可林后,在呼气末夹闭气管插管,当达到心脏骤停标准后,分别维持4、5、6 min,然后开始进行常规心肺复苏,观察动脉血压变化、复苏后综合征发生情况和生存时间.结果 夹闭气管插管后5～7 min内,所有兔均达到心脏骤停标准.心脏骤停持续4、5、6 min组心肺复苏即刻成功率分别为100%、86%、77%,24 h存活率分别为100%、63%、27%,兔存活时间分别为（120.00±0.00）h,（58.00±41.52）h,（28.00±39.80）h,差异有统计学意义（P＜0.01）.复苏后综合征发生情况则随心搏停止持续时间的延长而加重.结论 兔心脏骤停持续时间以5 min为适宜,心肺复苏成功率及复苏成功后24 h生存率高.该模型稳定,可重复性好,可作为心脏骤停后综合征研究的动物模型.

降钙素原浓度监测在心脏停搏后综合征患者早期救治中的价值和意义

目的观察心脏停搏后综合征（PCAS）患者早期降钙素原（PCT）浓度的动态变化，探讨PCT水平对PCAS患者救治的临床价值和意义。方法回顾性分析东莞市第五人民医院重症医学科2012年1月至2014年12月收治的73例PCAS患者的临床资料，以心肺复苏（CPR）后当天的PCT水平分为类脓毒症组（PCT≥10μL，46例）和非类脓毒症组（PCT〈10μg/L，27例），比较两组入院7d感染发生率。以入院7d内是否并发感染分为感染组（17例）和非感染组（56例），比较两组入院当天的PCT水平。以28d预后分为存活组（50例）和死亡组（23例），比较两者间PCT的变化，并对所有患者进行急性生理学与慢性健康状况评分系统Ⅱ（APACHEH）评分，分析PCT与APACHEⅡ评分的相关性。结果入院当天类脓毒症组感染发生率与非类脓毒症组差异无统计学意义[23．9％（11／46）比22．2％（6／27），P〉0．05]；感染组与非感染组PCT水平差异无统计学意义[μL：16．80（7．85，38．80）比9．30（1．48，31．15），P〉0．05]；死亡组PCT明显高于存活组[μL：33．20（32．00，46．00）比5．12（0．50，16．35），P〈0．01]，死亡组和存活组随时间延长开始升高，并于入院1d时达峰值[58．30（47．26，76．40）和8．75（1．22，30．87）]，然后缓慢下降，但死亡组较存活组下降缓慢，5d起降到正常水平，6d时死亡组PCT仍明显高于存活组[1．20（1．02，6．40）比0．46（0．05，1．20），P〈0．01]。Pearson相关分析显示：PCT与APACHEⅡ评分呈正相关性（r=0．447，P〈0．01）。结论早期动态监测PCT水平对指导判断PCAS患者的病情严重程度及预后有一定的作用，但PCAS患者早期PCT浓度升高与感染相关性差，不能单纯根据PCT来判断PCAS患者早期发生感染。

乌司他丁干预治疗对复苏后多器官功能障碍综合征防治效果的临床观察

目的观察心搏骤停成功复苏后自主循环恢复（ROSC）时间超过10min的患者早期应用乌司他丁干预治疗效果，为提高心搏骤停复苏后多器官功能障碍综合征（PR—MODS）防治水平提供新的思路。方法采用回顾性分析方法对40例心搏骤停成功复苏且ROSC时间超过10min的患者，以是否使用乌司他丁干预治疗进行分组，比较两组患者脏器功能受累水平、PR—MODS发生率及最终存活率。结果ROSC即刻检测结果显示，无论是否采用乌司他丁治疗，两组患者重要脏器受损指标水平、危重病病情预测指标水平均明显升高，两者无明显差异；乌司他丁治疗组24h、48h、72h检测结果显示，上述指标水平明显优于常规治疗组，且与时间呈正相关；ROSC72h脏器受累平均数目也低于常规治疗组，但PR—MODS发生率及最终存活率差异无统计学意义。结论早期应用乌司他丁干预治疗对PR—MODS形成具有一定的干预作用，但选用的治疗剂量和给药方法尚有待进一步探讨。

心脏骤停后综合征优化治疗的临床观察

目的探讨心脏骤停后综合征(PCAS)优化治疗对心脏骤停患者的影响。方法选取2009年10月～2011年8月所有院内外心脏骤停后、成功复苏且复苏时间小于30 min并于6 h之内进入广东省佛山市第一人民医院重症监护病房(ICU)的成年患者入选行PCAS优化治疗。与之相比较的是2005年7月～2007年6月广东省佛山市第一人民医院收入ICU的符合相同条件的PCAS患者。研究两组患者在ICU内治疗期间并发症的发生率、神经功能及死亡率等情况。结果干预组共入选48例患者,其中伴有良好神经功能预后的为23例(48%),与对照组(11例,21%)比较,差异有统计学意义(P<0.05)。在ICU治疗期间,肺炎、脓毒症、心律失常和癫痫等并发症的发生率两组比较。差异无统计学意义(P>0.05)。结论 PCAS优化治疗方案的实施能够有效地改善心脏骤停后综合征患者的神经功能和预后。

心脏骤停后综合征的治疗进展

心脏骤停是临床最危急的病症，如不及时救治短时间内可致患者死亡。随着建立在大量临床干预研究及新技术发展基础上的心肺复苏指南的不断更新，自主循环恢复（ROSC）比率大幅度提高，但目前心脏骤停患者存活率仍然很低。心脏骤停后综合征（PCAS）为心脏骤停患者ROSC后较长时间严重的全身缺血一再灌注综合征，涉及一系列复杂的病理生理改变，包括心脏骤停后脑损伤、心脏骤停后心肌功能异常、全身缺血一再灌注损伤和持续的致病因素。目前，对PCAS的处理已成为改善心脏骤停生存链的重要一环，逐渐为广大临床医务人员所重视。对心肺复苏恢复自主循环的患者最迫切治疗是优化全身血液灌注，维持各器官系统功能。对疑有急性冠状动脉综合征（ACS）患者应早期行经皮冠状动脉介入术（PCI）治疗。维持适当通气并保证动脉氧饱和度在94％～96％。临床亚低温治疗是目前唯一临床证实有效的脑保护技术，对PCAS后昏迷患者应尽早实施。对高血糖的PCAS患者应使用胰岛素控制血糖在正常范围。对于行机械通气及亚低温治疗的患者给予镇静剂可以降低氧耗并加快低温诱导。关于神经保护药物及激素应用疗效还有待于进一步研究。

大承气汤降低心脏骤停后综合征兔血清类胰蛋白酶及炎性细胞因子的水平

目的观察大承气汤对心脏骤停后综合征(PCAS)兔血清肥大细胞类胰蛋白酶和单核细胞趋化蛋白-1(MCP-1)、白细胞介素8(IL-8)水平的影响。方法大耳白兔30只,随机分为假手术组、模型组、大承气汤组。采用窒息性心脏骤停制备兔PCAS模型。大承气汤组在自主循环恢复后15 min给予大承气汤每日15 g/kg灌胃(分2次使用)。分别在0、24、48、72 h观察反映器官功能的检测指标,采用ELISA测定兔血清类胰蛋白酶、MCP-1、IL-8的水平。结果大承气汤可明显减轻心、脑、肝、肾功能障碍。PCAS模型组血清类胰蛋白酶、MCP-1和IL-8含量均明显高于假手术组(P<0.01)。大承气汤组血清类胰蛋白酶含量(6 h)、MCP-1含量(6、24、48 h)和IL-8含量(6、24 h)均明显低于PCAS模型组(P<0.05或P<0.01)。结论大承气汤可降低PCAS兔血清类胰蛋白酶、MCP-1、IL-8的水平。