腹部提压心肺复苏急救仪的临床应用研究

发布时间：2018-05-22 07:43

本文选题：心肺复苏 + 腹部　；参考：《南方医科大学》2016年硕士论文

【摘要】：研究背景与目的心脏骤停(Cardiac Arrest,CA)是指各种原因引起的心肌细胞收缩及舒张运动的突然停止,继而导致心脏丧失射血功能,从而引起人体的所有组织器官出现骤然的严重缺血、缺氧以及功能丧失。其主要临床表现为患者突然意识丧失,不能触及大动脉搏动,以及听诊心音消失,伴或者不伴有自主呼吸的停止,并导致全身所有脏器及组织因缺血、缺氧而发生衰竭并最终死亡。导致心脏骤停的原因很多,而较常见的根据病因分类则可分为：1、心源性因素导致的心脏骤停：包括冠状动脉粥样硬化性心脏病、各种类型的心肌病、先天性心脏病及心肌炎等；2、肺源性因素导致的心脏骤停：包括各种原因导致的窒息、肺栓塞及过度应用阿片类药物引起的呼吸抑制等；3、脑源性因素导致的心脏骤停：包括脑卒中、脑部创伤及各种原因引起的脑疝等；4、其他原因导致的心脏骤停：如电解质紊乱、中毒、低体温及触电等。在所有引起心脏骤停的病因中,心源性因素是最常见也是最重要的原因,约占心脏骤停患者总数的一半以上。心脏呼吸骤停具有较高的发生率,美国每年约有42万人、欧洲每年约有28万人发生心脏骤停,我国每年至少有50万人死于心脏骤停。而在复苏结果上,尽管过去10-15年里,随着医院参与美国心脏病协会的遵循指南-复苏项目,院内心肺复苏(Cardiopulmonary Resuscitation,CPR)的结果有了很大改善,但成人出院生存率也只从2000年的13.7%提高到2009年的22.3%,儿童出院生存率也仅从2000年1/1.3%提高到2009年的39.4%。在我国,心肺复苏的成功率大约为5-50%,平均复苏成功率约为6%。随着我国社会人口结构逐渐加速进入老龄化社会,心脑血管发病率正呈现逐年上升趋势,心脏骤停及猝死患者的人数也会随之增加。由于心脏骤停和心脏性猝死具有发病突然、进展迅速及不易预测的特点,因而一旦患者发生心脏骤停,第一目击者采取正确的方式对患者实施有效的心肺复苏,将有利于患者的预后。为了进一步改善心肺复苏效果,提高患者自主循环恢复率,自现代心肺复苏技术及理论于上世纪60年代起应用于临床后,大量以提升心肺复苏效率的有益研究被国内外学者提出并进行研究,以便能进一步提升心脏骤停后患者自主循环恢复率,改善患者预后,挽救更多患者生命。依托于不断产出的有关心肺复苏方面的文献以及资料,以大量循证医学证据为依据,美国心脏病协会心血管急救委员会每5年进行一次心肺复苏的指南更新,并于2015年发布新一版的指南,本次指南再一次强调了早期建立循环的重要性,并强调快速有力实施胸外按压,尽量减少不必要的停顿与中断,以免过多中断按压,导致冠状动脉和脑动脉等重要器官出现血液供应中断,降低心肺复苏成功率。同时还一如既往的强调及时有效的初级心肺复苏,以便在等待专业急救队伍抵达前为患者赢得更多抢救时间,并为实施高级心肺复苏奠定基础。但对比既往的指南,心肺复苏的操作要求也更加苛刻,对有效的心肺复苏给出了更加明确的界限,如按压深度限定为5-6cm,按压频率控制在100-120次／分钟,在缺少反馈装置的前提下,对于专业急救人员实施如此精确的复苏尚有难度,更何况非长期从事急救复苏的医学从业人员,而向社区和普通群众推广该复苏方式则更显得有些繁琐与困难。且胸外心脏按压方式始终无法克服需要中断按压给予有效通气的弊端,只能通过更严格的要求专业急救人员弥补并减少复苏过程中的中断对复苏质量造成的影响。为提高患者冠脉及大脑血流灌注,增加按压深度是有效方法,但在增加了对患者胸廓的按压深度后,导致患者胸骨骨折的风险也将随之增加。过深程度的胸外心脏按压将会引起患者胸骨、肋骨等发生骨折,从而使得胸廓的完整性受到破坏,并导致胸腔的泵机制失能,进而严重影响心肺复苏的效率。更甚者导致胸骨及肋骨的完全骨折,间接导致严重的肺部、肝脏和其他组织、器官的损伤,威胁患者生命。且胸廓本身缺陷或损伤的心脏骤停患者无法实施胸外心脏按压,这也是此类患者救治的难题。鉴于此,依托于腹部的心肺复苏技术在长期的研究中得到了一定的应用与发展,先后有Ralston在实验中发现,采用插入式腹部心肺复苏法(Interposed Abdominal Compression Cardiopulmonary Resuscitation,IAC-CPR)可以起到增加动脉压的效果,随后Barranco及Berryman的研究也验证了腹部按压法在升高动脉压上的作用,而Einagle等人的研究则发现,腹部按压技术在心肺复苏时可以增加颈动脉血流的效果,为腹部按压技术改善脑灌注提供了支持依据,之后Tang等人的研究发现腹部压-松的方式可以起到增加心排出量的作用,Andrea等人根据其研究结果,更是认为在心脏骤停时,腹部是人体的第二心脏,但以上研究都是基于对腹部的按压过程,却忽视了对腹部提拉所能产生的效果。腹部提压心肺复苏急救仪就是根据“胸泵”、“腹泵”、“心泵”的机制,采用主动按压与提拉相结合的方法,通过对患者腹部加压和提拉引起腹腔压力变化启动“腹泵”,再利用膈肌在连接胸腔与腹腔的活塞作用,将腹腔压力变化通过膈肌的位移传导到胸腔,引起胸腔压力变化,间接启动“胸泵”,随后利用心脏与膈肌的解剖关系产生“心泵”的效果而进行心肺复苏的一种新技术,该项技术动物实验中已取得了明显的应用效果,所以我们采用腹部提压心肺复苏急救仪,选取有胸外按压禁忌症的心脏呼吸骤停患者进行腹部提压法与传统心肺复苏术的对比研究,对所有接受复苏患者自主循环恢复(Restoration of Spontaneous Circulation,ROSC)情况、血气变化及仪器使用情况进行观察。研究方法1入组条件(1)美国心脏病协会指南标准：①神志丧失；②心音、颈动脉、股动脉搏动消失；③叹息样呼吸；④瞳孔散大,对光反射减弱或消失。(2)体重40-150kg的成年人,性别不限；(3)患者近亲属及其法定代理人知情同意并签署《知情同意书》；(4)有胸廓畸形、外伤等体征的患者。2病例排除标准如遇下列任何情况之一排除：(1)无复苏的适应症；(2)腹部外伤、膈肌破裂、腹腔脏器出血、腹主动脉瘤及腹腔巨大肿物等；(3)患者近亲属不同意使用腹部提压心肺复苏急救仪进行救治；(4)患者有明显的可能会影响到疗效评价的其他疾病者(慢性消耗性疾病如恶性肿瘤、严重的结核性疾病等)。3临床干预措施将符合条件的患者经分组后分别采用腹部提压心肺复苏及标准胸外按压心肺复苏救治。所有患者均行经口气管插管(驼人医疗器械公司,中国)、呼吸气囊辅助呼吸(驼人医疗器械公司,中国)、心电监测(飞利浦,荷兰)、0.9%氯化钠注射液(石家庄四药有限公司,中国)建立两路静脉通路(0.9%氯化钠注射液250ml×2快速静滴),需要除颤者给予除颤(飞利浦,荷兰)。4终止抢救标准：符合美国心脏病协会指南标准：(1)出现自主的大动脉搏动；(2)面色出现转润；(3)出现自主呼吸；(4)瞳孔出现由大变小并有对光反射现象,出现眼球活动或四肢抽动；(5)经持续规范抢救30min以上,患者仍未出现心搏和自主呼吸,在得到患者家属充分知情并同意后终止抢救。5观察指标(1)主要评价指标：自主循环恢复率(自主循环恢复率评价标准：恢复窦性或室上性心律,平均动脉压≥60mmHg,维持≥20分钟)(2)次要评价标准：患者复苏前、复苏过程中和复苏后不同时间段的血压、心率、动脉血气,并依此计算平均动脉压。记录自主循环恢复后30min及60min存活率。对仪器的安全性、便携性及稳定性作出评价。入院后的进一步救治均按照美国心脏病协会指南执行。结果本研究共入组101例病人,经过进一步筛选及对不符合要求病例的剔除,最后有83例纳入分析,分别是腹部提压心肺复苏(Abdominal Lifting and Compression Cardiopulmonary Resuscitation,ALP-CPR)组40例,标准心肺复苏(Standard Cardiopulmonary Resuscitation,STD-CPR)组43例。两组患者的年龄、性别、心脏骤停时间、体重、身高及身体质量指数(Body Mass Index,BMI)均无明显统计学差异,患者出现心脏骤停后的平均动脉压(Mean Arterial Pressure,MAP)及血气结果均无明显统计学差异。1 实施ALP-CPR及STD-CPR均可使患者获得较基础值明显增高的平均动脉压,并维持在一定水平,但采用STD-CPR组的患者MAP升高幅度较ALP-CPR高,两者之间差异有统计学意义(P=0.001)。就血气分析结果而言,复苏过程中ALP-CPR较STD-CPR组具有更高的PO2及乳酸(Lactic Acid,LAC)水平,但PH、PCO水平ALP-CPR则更低,差异均具有明显统计学意义,而SPO2水平上两种复苏方法无明显统计学差异；结合表4的结果可以发现,ALP-CPR组SPO2、PO2水平上升,且PCO：水平下降,而STD-CPR组患者SPO：的水平虽较基础值出现上升趋势,但该组患者PO：水平呈现下降趋势,而PCO：水平呈现上升趋势,LAC及PH则两组患者均呈现下降的趋势,比较两组患者SPO：较基础值增加的水平也无明显统计学差异。2两种复苏方式按照性别进行二次分组并做统计学分析,按照性别划分后的四组间MAP、PO2、PCO以及LAC水平均具有明显的统计学差异(P0.05),而PH、SPO。的变化情况则均无明显统计学差异。将具有统计学差异的结果分别进行多重比较后可以发现,对于同一组内不同性别间比较,除STD-CPR组在P02和PCO2存在组内不同性别间差异外,其余指标均不存在不同性别间的差异。而在不同组之间,在MAP、PO2及PCO：分压三项指标上,ALP-CPR组的女性与STD-CPR组的男性之间存在统计学差异。而在LAC的结果中,ALP-CPR组中女性与STD-CPR组中女性以及男性均具有统计学差异,而ALP-CPR组中男性与STD-CPR组中女性以及男性比较,则均未出现明显统计学差异。3两种复苏方式按照年龄进行二次分组并进行统计学分析,按照年龄划分后的四组间MAP、SPO2及LAC均具有明显的统计学差异(P0.05),而PH、P0：及PC02均无明显统计学差异。将具有统计学差异的指标进行多重比较可以发现(见表8),对于同一组内不同年龄间比较,除STD-CPR组在MAP和SPO2以及65y的两组复苏方式的MAP存在差异外,其余指标均无明显统计学意义。4 两组的ROSC率、ROSC后30min和60min均无明显统计学差异,但ALP-CPR组的ROSC率及ROSC后30min和60min的存活率均高于STD-CPR组,且ALP-CPR组ROSC后及ROSC后30min和60min较STD-CPR组优势比越来越明显。5 在复苏过程中,腹部提压复苏仪的稳定性、安全性及便携性均得到所有参与人员的充分肯定,试验过程中均未出现明显不良反应。结论腹部提压心肺复苏急救仪在除胸部外的区域提供了复苏手段,并能兼顾心脏骤停患者的不间断循环及有效的通气,为心肺复苏开辟了新的途径,为合并心脏按压相对禁忌症患者的急救提供了一种安全有效的手段。
[Abstract]:Background and objective Cardiac Arrest (CA) refers to the sudden stop of cardiac contractile and diastolic movement caused by various causes, which leads to the loss of blood function of the heart, which causes sudden severe ischemia in all tissues and organs of the human body, and the loss of oxygen and function. The main clinical manifestation is the sudden consciousness of the patients. Loss, failure to touch the pulsation of the large artery, and the disappearance of the sound of the auscultation, with or without the stop of spontaneous breathing, and leading to the failure of all organs and tissues of the body due to ischemia and hypoxia and eventually death. The causes of cardiac arrest are many, and the more common classification according to the cause of the disease can be divided into 1, cardiogenic factors leading to the heart. Sudden stop: including coronary atherosclerotic heart disease, various types of cardiomyopathy, congenital heart disease, and myocarditis; 2, cardiac arrest caused by pulmonary factors: asphyxia caused by various causes, pulmonary embolism, and excessive use of opioid induced inhibition of respiration; 3, cardiac arrest caused by brain origin factors: package Cerebral apoplexy, brain trauma, and various causes of cerebral hernia; 4, other causes of cardiac arrest, such as electrolyte disturbance, poisoning, hypothermia, and electrical shock. Cardiogenic factors are the most common and most important cause of all causes of cardiac arrest, accounting for more than half of the total cardiac arrest. The sudden stop has a high incidence of about 420 thousand people in the United States each year, and about 280 thousand people in Europe have cardiac arrest every year. At least 500 thousand people die from cardiac arrest every year in our country. In the recovery results, although the hospital has been involved in the guidelines of the American Heart Association for the past 10-15 years, hospital heart resuscitation (Cardiopulmonary The results of Resuscitation, CPR) have been greatly improved, but the survival rate of adult discharge has increased only from 13.7% in 2000 to 22.3% in 2009. The survival rate of children's discharge is also increased from 1/1.3% in 2000 to 39.4%. in 2009 in China. The success rate of cardiopulmonary resuscitation is about 5-50%, and the average recovery success rate is about 6%. with the social population structure of our country. The incidence of cardiovascular and cerebrovascular diseases is on the rise year by year, and the number of patients with sudden cardiac arrest and sudden death will increase. Sudden cardiac arrest and sudden cardiac death have the characteristics of sudden onset, rapid progress and unpredictable. The effective cardiopulmonary resuscitation will be beneficial to the patient's prognosis. In order to further improve the effect of cardiopulmonary resuscitation and improve the recovery rate of patients' autonomic circulation, a lot of beneficial studies on improving the efficiency of cardiopulmonary resuscitation have been studied by scholars both at home and abroad after the application of modern cardiopulmonary resuscitation Technology and theory in 60s. In order to further improve the recovery rate of autonomic circulation after cardiac arrest, improve the prognosis and save more of the patient's life. Relying on the continuous production of literature and data concerned with pulmonary resuscitation, based on a large number of evidence-based medical evidence, the cardiovascular emergency committee of the American Heart Association for heart disease carries out one heart every 5 years. The guidelines for pulmonary resuscitation were updated and a new edition of the guide was issued in 2015. This guide once again emphasizes the importance of early cycle building, and emphasizes the rapid and effective implementation of external pressure, minimized unwanted pause and interruption, so as to avoid overpressure and lead to blood supply interruptions in important organs such as the coronary and cerebral arteries. Reduce the success rate of cardiopulmonary resuscitation. It also emphasizes timely and effective primary cardiopulmonary resuscitation so as to win more rescue time for patients before waiting for the professional first aid team to arrive and lay the foundation for the implementation of advanced cardiopulmonary resuscitation. The recovery gives more clear boundaries, such as the pressure depth of 5-6cm, frequency control at 100-120 / minute, and the difficulty of such precise recovery for professional first-aid workers without feedback devices, not to mention the non long-term medical workers engaged in first aid recovery, and to the community and the ordinary people. The resuscitation approach is more complicated and difficult. And the external cardiac compression method has always been unable to overcome the drawbacks of the need to interrupt effective ventilation, only through more stringent requirements for professional emergency workers to make up for and reduce the effect of interruption on the resuscitation quality in the recovery process. It is an effective method to increase the compression depth, but the risk of the fracture of the sternum will increase after the compression depth of the chest, which will cause the fracture of the patient's sternum, rib and so on. There is a serious impact on the efficiency of cardiopulmonary resuscitation. More serious fractures of the sternum and ribs are caused, which indirectly lead to severe lung, liver and other tissue, organ damage, and threat to the patient's life. The chest pressure is not possible for patients with cardiac arrest or injury of the chest itself. This is also a difficult problem for such patients. Cardiopulmonary resuscitation (CPR) based on the abdomen has been applied and developed in a long period of study. It has been found in the experiment that the insertion of abdominal cardiopulmonary resuscitation (Interposed Abdominal Compression Cardiopulmonary Resuscitation, IAC-CPR) can increase the effect of arterial pressure, followed by Barranco and Berryman. The study also demonstrated the effect of abdominal compression on increasing arterial pressure, and Einagle et al.'s study found that abdominal compression could increase the effect of the carotid artery blood flow during cardiopulmonary resuscitation, providing a support basis for the abdominal compression technique to improve cerebral perfusion, and then Tang et al. The effect of cardiac output, Andrea et al. According to the results of the study, is that the abdomen is the second heart of the human body during cardiac arrest, but the above research is based on the pressing process of the abdomen, but neglects the effect on the abdominal pulling. The mechanism of pump "is to use the combined method of active pressing and pulling to start" abdominal pump "through the change of abdominal pressure and abdominal pressure, and then use the diaphragm to connect the piston of the thoracic cavity with the abdominal cavity. The change of abdominal pressure changes through the diaphragm of the diaphragm to the thoracic cavity, causing the change of the thoracic pressure and indirectly starting the" chest ". "Pump", a new technique for cardiopulmonary resuscitation with the effect of the heart pump on the heart and the diaphragm, which has been used in the animal experiment, so we use the abdominal pressure cardiopulmonary resuscitation apparatus and select the patients with cardiac respiratory arrest with pressure contraindication to the abdomen. The comparative study of pressure method and traditional cardiopulmonary resuscitation (CPR) was used to observe all recovery patients' self circulation recovery (Restoration of Spontaneous Circulation, ROSC), blood gas changes and instrument use. Study methods 1 entry conditions (1) guidelines for the American Heart Association: (1) loss of mind; (2) heart sound, carotid artery, and femoral head The arterial pulsation disappeared; (3) the sigh like respiration; (4) the pupil was large and the light reflex was weakened or disappeared. (2) the adult of the body weight 40-150kg was not limited to sex; (3) the close relatives and their legal agents informed consent and signed the "informed consent"; (4) the exclusion criteria for the patients with thoracic deformity and trauma were in any case in the following cases One of the exclusions: (1) no resuscitation indications; (2) abdominal trauma, diaphragmatic rupture, abdominal viscera hemorrhage, abdominal aortic aneurysm and abdominal massive swelling, and (3) the close relatives of the patients did not agree to use abdominal pressure cardiopulmonary resuscitation apparatus for treatment; (4) patients with other diseases (chronic attrition) that could significantly affect the evaluation of the disease (chronic attrition) .3 clinical interventions, such as malignant tumors, serious tuberculous diseases, etc., were treated by abdominal pressure cardiopulmonary resuscitation and standard external pressure cardiopulmonary resuscitation. All patients were treated by oral tracheal intubation (humpman medical device company, China), respiratory airbag auxiliary breathing (hump medical device male) Division, China), ECG monitoring (PHILPS, Holland), 0.9% Sodium Chloride Injection (Shijiazhuang four drugs limited, China) to establish two channels (0.9% Sodium Chloride Injection 250ml x 2 fast drops), defibrillators to defibrillation (PHILPS, Holland).4 termination of rescue standards: compliance with the American Heart Association guidelines: (1) autonomous Great artery pulsation; (2) the appearance of the facial color, (3) the emergence of spontaneous breathing; (4) the pupil appeared from large to light reflection, the occurrence of eye movement or extremities movement; (5) the continuous standardized rescue of 30min, the patients still have no heart beat and spontaneous breathing, after the patient's family is fully informed and agreed to terminate.5 observation after the consent to terminate the observation finger. Standard (1) main evaluation indicators: self circulation recovery rate (independent circulation recovery rate evaluation criteria: restoring sinus or supraventricular rhythm, mean arterial pressure more than 60mmHg, maintaining over 20 minutes) (2) secondary evaluation criteria: the blood pressure, heart rate, arterial blood gas before resuscitation, the recovery process and the resuscitation, and the calculation of the average artery. The safety, portability and stability of the instrument were evaluated after the recovery of 30min and 60min. The further treatment after admission was carried out in accordance with the American Heart Association guidelines. Results 101 patients were enrolled in the study. After further screening and rejection of the incompatible cases, 83 were finally included in the study. Analysis, 40 cases of Abdominal Lifting and Compression Cardiopulmonary Resuscitation, ALP-CPR group, 43 cases of standard cardiopulmonary resuscitation (Standard Cardiopulmonary Resuscitation, STD-CPR) group. Age, sex, cardiac arrest time, weight, height and body mass index (Body) in the two groups. There was no significant difference in statistical difference. There was no significant difference in the average arterial pressure (Mean Arterial Pressure, MAP) and blood gas results after cardiac arrest..1 implementation ALP-CPR and STD-CPR can make the patients gain a higher average arterial pressure than the basic value, and maintain a certain level, but the MAP elevation of the patients in the STD-CPR group is used. The difference between the two was higher than that of ALP-CPR (P=0.001). As for the results of blood gas analysis, ALP-CPR had higher PO2 and lactic acid (Lactic Acid, LAC) than that of the STD-CPR group during the recovery process, but PH, PCO ALP-CPR was lower, and the difference had obvious sense of integration, while the two resuscitation methods on the SPO2 level were not statistically significant. Difference; with the results of Table 4, it was found that the level of SPO2 and PO2 increased in group ALP-CPR, and PCO: the level decreased, while the level of SPO in group STD-CPR was higher than the basic value, but the level of PO in this group was declining, while PCO: the level of SPO was on the rise, and both LAC and PH were decreased in the two groups, compared to two. Group SPO: there was no significant difference in the level of the base value..2 two resuscitation methods were divided into two groups according to sex and made statistical analysis. The levels of MAP, PO2, PCO and LAC after sex division were statistically significant (P0.05), but there was no significant difference in the change of PH and SPO.. After multiple comparison of the results with statistical differences, we can find that in the same group, the difference between the same sex differences between the STD-CPR group and the group of P02 and PCO2 in the same group does not exist in the other indexes, but there are three indexes in the MAP, PO2 and PCO: ALP-CPR group among the different groups. There was a statistically significant difference between the women in the group STD-CPR and those in the group LAC, while in the ALP-CPR group, the women in the ALP-CPR group and the women in the group were male.
【学位授予单位】：南方医科大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R459.7

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