1、心肺复苏后心功能障碍 一切恶果的始作俑者？,心肺复苏后治疗仍面临巨大挑战,1.Safar P: Resuscitation from clinical death: pathophysiologic limits and therapeutic potentials. Crit Care Med 1988, 16:923941.2.Keenan SP, Dodek P, Martin C, Priestap F, Norena M, Wong H. Variation in length of intensive care unit stay after cardiac arrest: whe
2、re you are is as important as who you are. Crit Care Med 2007;35:83641.3.Nolan JP, Laver SR, Welch CA, Harrison DA, Gupta V, Rowan K. Outcome following admission to UK intensive care units after cardiac arrest: a secondary analysis of the ICNARC Case Mix Programme Database. Anaesthesia 2007;62:12071
3、6.4.Herlitz J, Engdahl J, Svensson L, Angquist KA, Silfverstolpe J, Holmberg S. Major differences in 1-month survival between hospitals in Sweden among initial survivors of out-of-hospital cardiac arrest. Resuscitation 2006;70:4049.5.Langhelle A, Tyvold SS, Lexow K, Hapnes SA, Sunde K, Steen PA. In-
4、hospital factors associated with improved outcome after out-of-hospital cardiac arrest. A comparison between four regions in Norway. Resuscitation 2003;56:24763.6.Mashiko K, Otsuka T, Shimazaki S, et al. An outcome study of out-of-hospital cardiac arrest using the Utstein templatea Japanese experien
5、ce. Resuscitation 2002;55:2416.,ROSC患者存在血流动力学不稳定,复苏后心功能不全的变化与预后密切相关,Manuel Ruiz-Bailn, Eduardo Aguayo de Hoyos, Silvia Ruiz-Navarro, et al. Reversible myocardial dysfunction after cardiopulmonary resuscitation. Resuscitation 2005;66:175-181.,心因性心脏骤停ROSC后的心功能研究,I. Laurent, M. Monchi, J.D. Chiche, et
6、al. Reversible myocardial dysfunction in survivors of out-of-hospital cardiac arrest. J Am Coll Cardiol 2002;40:21102116,I. Laurent, M. Monchi, J.D. Chiche, et al. Reversible myocardial dysfunction in survivors of out-of-hospital cardiac arrest. J Am Coll Cardiol 2002;40:21102116,心因性心脏骤停ROSC后的心功能研究,
7、I. Laurent, M. Monchi, J.D. Chiche, et al. Reversible myocardial dysfunction in survivors of out-of-hospital cardiac arrest. J Am Coll Cardiol 2002;40:21102116,死亡率与心功能持续障碍相关,心因性心脏骤停ROSC后的心功能研究,复苏后心功能不全 是一切麻烦的制造者！,心功能不全如何发生？,心功能的影响因素 1、心肌收缩力 2、心脏舒张顺应性 3、心率,1、心肌坏死（不可逆缺血）2、心肌顿抑（可逆缺血）,心肌顿抑,是指心肌短时间缺血后不发生
8、坏死，但引起心肌细胞的结构、代谢和功能改变在再灌注后延迟恢复的现象临床特征表现为收缩功能障碍持续数天到数周,复苏后心功能不全主要是心肌顿抑,最早ROSC后30分钟内可监测到左室舒张末压上升（8-10mmHg到20-22mmHg），射血分数显著下降（55%到20%），呈现低心排和低血压。在整个心功能障碍期间冠脉的血流没有明显下降，提示是一种真正的心肌顿抑，而非持续的心肌损伤或梗死。这种功能障碍多是暂时性的，大多可在72h完全恢复，但也有低心排持续数周到数月的报道。,复苏后存在可逆心功能障碍,Manuel Ruiz-Bailn, Eduardo Aguayo de Hoyos, Silvia Ru
9、iz-Navarro, et al. Reversible myocardial dysfunction after cardiopulmonary resuscitation. Resuscitation 2005;66:175-181.,黑线：全部患者的左室射血分数（29人）；灰线：心肌异常组的左室射血分数（20人）,治疗策略,需要强化监护早期血流动力学优化或EGDT，恢复和维持全身氧输送和氧需平衡,成功的关键：尽早监护和治疗，并在起病数小时内达到治疗目标,治疗策略,低血压的一线干预措施是通过输液使右室充盈压最佳化（CVP 8-12mmHg）如果输液使得前负荷达标，但仍未获得满意的血流动力
10、学目标，可考虑应用正性肌力和升压药,K.B. Kern, R.W. Hilwig, R.A. Berg, et al. Postresuscitation left ventricular systolic and diastolic dysfunction: treatment with dobutamine. Circulation 1997, 95: 26102613,正性肌力药物可改善心功能,心肌顿抑是唯一的麻烦制造者？,I. Laurent, M. Monchi, J.D. Chiche, et al. Reversible myocardial dysfunction in sur
11、vivors of out-of-hospital cardiac arrest. J Am Coll Cardiol 2002;40:21102116,CI改善情况下仍然需要血管活性药物维持血流动力学稳定,I. Laurent, M. Monchi, J.D. Chiche, et al. Reversible myocardial dysfunction in survivors of out-of-hospital cardiac arrest. J Am Coll Cardiol 2002;40:21102116,心功能改善不是血流动力学稳定的唯一原因,心脏骤停后综合征,Jerry P
12、. Nolan, Robert W. Neumar, Christophe Adrie, et al. Post-cardiac arrest syndrome: Epidemiology, pathophysiology, treatment, and prognostication: A Scientific Statement from the International Liaison Committee on Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; t
13、he Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; the Council on Stroke. Resuscitation 2008; 79:350-379,Christophe Adrie, Minou Adib-Conquy, Ivan Laurent, et al. Successful Cardiopulmonary Resuscitation After Cardiac Arrest as a “Sepsis-Like” Syndrome. Circulation 2002;106:562-568,ROSC后机体存在缺血再灌注反应一个类似脓毒症中瀑布样炎症反应,循环着的炎症介质可能导致心肌功能受损心肌顿抑！,心肌顿抑，心功能受损也是受害者？,总结,ROSC后存在心功能障碍心功能障碍影响预后，得到纠正可改善预后传统复苏不能纠正，ECLS可改善，提示心外因素影响全身性炎症反应，可引起心功能受损，继而血流动力学紊乱心肺复苏后的监护治疗有重大临床意义,谢谢聆听,
