Implementation status and prognosis of "chain of survival" for patients with cardiac arrest
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摘要: 目的 从2020美国心脏协会《心肺复苏(CPR)及心血管急救(ECC)指南》“生存链”视角，了解心脏骤停(CA)患者心肺复苏术(CPR)中“生存链”的实施现状，分析影响预后的因素。方法 选取沧州市急救中心2019年1月-2021年6月启动CPR救治流程进行CA抢救的成年患者作为研究对象，分为院内组与院外组，比较2组CA患者CPR“生存链”完成质量情况，分析影响患者预后的因素。结果 共纳入226例患者，院内组89例，院外组137例。心源性疾病是导致CA的主要病因，共131例(57.96%)，其次分别为创伤38例(16.81%)、呼吸系统疾病26例(11.50%)、急性脑血管病11例(4.87%)等。与院外组相比，院内组年龄、初始心律、建立高级气道、目标体温管理比较均差异无统计学意义。院内组CA至心肺复苏时间 < 5 min的比例(74.2% vs 5.8%，P< 0.01)、目击者实施胸外按压的比例(77.5% vs 6.6%，P< 0.01)、抢救过程中实施电除颤的比例(42.7% vs 8.8%，P< 0.01)、使用肾上腺素剂量 < 5 mg的比例(83.1% vs 17.5%，P< 0.01)、心肺复苏至自主循环恢复时间 < 30 min的比例(78.7% vs 20.4%，P< 0.01)均高于院外组。预后方面，院内组自主循环恢复的比例(62.9% vs 16.1%，P< 0.01)与院外组相比差异有统计学意义。存活出院比例(16.1% vs 13.6%，P>0.05)，良好神经系统功能存活出院患者的比例(8.9% vs 9.1%，P>0.05)，2组比较差异无统计学意义。Logistic回归分析显示，CA地点为医院内和初始心律为可电击心律是自主循环恢复和存活出院的保护因素。结论 院内CA患者自主循环恢复比例明显高于院外患者，院外CA患者开始胸外按压时间和首次接受电击时间晚是“生存链”实施中的主要问题。CPR须向普通群众普及，落实“生存链”的各环节是提高CA患者生存率、改善预后的关键。Abstract: Objective This paper aimed to investigate the implementation of the "chain of survival" in cardiopulmonary resuscitation for patients with cardiac arrest(CA) from the perspective of 2020 AHA guidelines for cardiopulmonary resuscitation(CPR) and ECC, and to analyze the prognostic factors.Methods Adult patients with CA who underwent the treatment process of CPR in the Emergency Department and Critical Medicine Department of Cangzhou People's Hospital from January 2019 to June 2021 were selected as the research object.They were divided into in-hospital and out-of-hospital group.The completion quality of CPR "chain of survival" in patients with CA in the two groups were compared, and the factors affecting the prognosis of patients were analyzed.Results A total of 226 patients were included in this study. There were 89 cases in the in-hospital group and 137 cases in the out-of-hospital group.Cardiogenic diseases were the main cause of CA, accounting for 131 cases (57.96%), followed by trauma in 38 cases (16.81%), respiratory diseases in 26 cases (11.50%) and acute cerebrovascular diseases in 11 cases (4.87%).There were no significant differences in age, the earliest monitored heart rhythm, the establishment of advanced airway and target temperature management between the in- and out-of-hospital groups.The proportion of patients in the in-hospital group were higher than those in the out-of-hospital group both in time from CA to CPR less than 5 minutes (74.2% vs 5.8%,P< 0.01), external chest compression by witnesses (77.5% vs 6.6%,P< 0.01), electric defibrillation during rescue (42.7% vs 8.8%,P< 0.01), and adrenaline dose less than 5 mg (83.1% vs 17.5%,P< 0.01).The proportion of patients whose recovery time from CPR to spontaneous circulation less than 30 minutes (78.7% vs 20.4%,P< 0.01) was also higher in the in-hospital group, too. In prognosis, there were significant differences in the proportion of spontaneous circulation recovery (62.9% vs 16.1%,P< 0.01).The proportion of patients who survived to discharge (16.1% vs 13.6%,P>0.05), the proportion of patients who survived to discharge with good neurological function (8.9% vs 9.1%,P>0.05), there was no significant difference between the two groups.Logistic regression analysis showed that the location of cardiac arrest was in the hospital and the earliest monitored rhythm was electric shock rhythm, which was the protective factor for the recovery of autonomic circulation and survival and discharge.Conclusion The proportion of spontaneous circulation recovery of patients with CA in the in-hospital group was significantly higher than that in the out-of-hospital group.The main problems in the implementation of "chain of survival" were the late start time of external chest compression and the first time of receiving electrical shocks in patients with CA out of hospital. CPR must be popularized to the public. The implementation of all links of the "chain of survival" is the key to improve the survival rates and prognosis of patients with CA.
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表 1 CA患者流行病学特征和生存链各环节实施情况
例(%) 项目 院内组(n=89) 院外组(n=137) χ2 P 一般资料 男 57(64.0) 94(68.6) 0.51 0.478 年龄>65岁 43(48.3) 79(57.7) 1.67 0.196 CA原因 心源性 44(49.4) 87(63.5) 4.38 0.036 非心源性疾病a) 45(50.6) 50(36.5) 胸外按压时间/min CA-CPR < 5 66(74.2) 8(5.8) 114.34 < 0.01 CA-CPR>5 23(25.8) 129(94.2) 目击者实施胸外按压 69(77.5) 9(6.6) 110.96 < 0.01 初始心律 可电击心律 11(12.4) 9(6.6) 2.20 0.134 非可电击心律 78(87.6) 128(93.4) 抢救过程中实施电除颤 38(42.7) 12(8.8) 36.07 < 0.01 建立高级气道 是 79(88.8) 130(95.6) 2.91 0.088 否 10(11.2) 7(4.4) 使用肾上腺素/mg < 5 74(83.1) 24(17.5) 94.61 < 0.01 >5 15(16.9) 113(82.5) CA-ROSC/min < 30 70(78.7) 28(20.4) 74.44 < 0.01 >30 19(21.3) 109(79.6) TTM 3(3.4) 6(4.4) 0.14 0.705 转归 ROSC 56(62.9) 22(16.1) 52.42 < 0.01 存活出院 9(16.1) 3(13.6) 0.01 0.908 良好神经系统功能存活出院 5(8.9) 2(9.1) 0.17 0.676 注：a)非心源性疾病包括脑血管病、呼吸衰竭、消化道出血、内分泌和电解质代谢紊乱、脓毒症、创伤、窒息、中毒等。 
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表 2 CA患者ROSC相关因素Logistic回归分析
相关因素 B S.E Wald P OR 95%CI 下限 上限 年龄>65岁 -1.034 0.361 8.203 0.004 0.356 0.175 0.722 病因为心源性 0.305 0.386 0.626 0.429 1.357 0.637 2.890 CA地点为院内 2.405 0.360 44.558 < 0.001 11.081 5.468 22.453 初始心律为可电击心律 1.624 0.482 11.346 0.001 5.072 1.972 13.046 常量 -1.732 0.370 21.944 < 0.001 0.177
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表 3 CA患者存活出院相关因素Logistic回归分析
相关因素 B S.E Wald P OR 95%CI 下限 上限 年龄>65岁 -1.004 0.773 1.690 0.194 0.366 0.081 1.665 病因为心源性 -1.390 0.892 2.429 0.119 0.249 0.043 1.430 CA地点为院内 2.504 1.077 5.403 0.020 12.234 1.481 101.072 初始心律为可电击心律 2.708 0.856 9.997 0.002 14.995 2.799 80.330 常量 -4.432 1.094 16.413 < 0.001 0.012
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[1] Eumar RW, Shuster M, Callaway CW, et al. Part 1: executive summary: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care[J]. Circulation, 2015, 132(18 Suppl 2): S315-367.
[2] Sasson C, Rogers MAM, Dahl J, et al. Predictors of survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis[J]. Circ Cardiovasc Qual Outcomes, 2010, 3(1): 63-81. doi: 10.1161/CIRCOUTCOMES.109.889576
[3] American Heart Association. 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care[J]. Circulation, 2020, 142(16_Suppl_2): S337-S604.
[4] 心肺复苏后昏迷患者早期神经功能预后评估专家共识组. 心肺复苏后昏迷患者早期神经功能预后评估专家共识[J]. 中华急诊医学杂志, 2019, 28(2): 156-161.
[5] Elliott VJ, Rodgers DL, Brett SJ. Systematic review of quality of life and other patient-centred outcomes after cardiac arrest survival[J]. Resuscitation, 2011, 82: 247-256. doi: 10.1016/j.resuscitation.2010.10.030
[6] Berdowski J, Berg RA, Tijssen JGP, et al. Global incidences of out-of-hospital cardiac arrest and survival rates: Systematic review of 67 prospective studies[J]. Resuscitation, 2010, 81: 1479-1487. doi: 10.1016/j.resuscitation.2010.08.006
[7] 张重阳, 张风云, 王耀辉, 等. 基于Utstein模式下秦皇岛地区院外心搏骤停旁观者心肺复苏的现状分析[J]. 中华危重病急救医学, 2020, 32(9): 1096-1100. doi: 10.3760/cma.j.cn121430-20200714-00520
[8] Deakin CD. The chain of survival: Not all links arc equal[J]. Resuscitation, 2018, 126: 80-82. doi: 10.1016/j.resuscitation.2018.02.012
[9] Adnet F, Triba MN, Borron SW, et al. Cardiopulmonary resuscitation duration and survival in out-of-hospital cardiac arrest patients[J]. Resuscitation, 2017, 111: 74-81. doi: 10.1016/j.resuscitation.2016.11.024
[10] 陈小凤, 季娟娟, 孙涛, 等. 院内心搏骤停患者心肺复苏预后相关因素分析[J]. 中国急救复苏与灾害医学杂志, 2020, 15(12): 1366-1370. doi: 10.3969/j.issn.1673-6966.2020.12.010
[11] 蓝洲, 陀鹏, 赵旋, 等. 胸腹联合心肺复苏在急诊心搏骤停患者救治中的应用分析[J]. 临床急诊杂志, 2021, 22(7): 458-462. https://www.cnki.com.cn/Article/CJFDTOTAL-ZZLC202107004.htm
[12] Panchal AR, Berg KM, Cabanas JG, et al. 2019 American Heart Association Focused Update on Systems of Care: Dispatcher-Assisted Cardiopulmonary Resuscitation and Cardiac Arrest Centers: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care[J]. Circulation, 2019, 140(24): e895-e903.
[13] 薛继可, 冷巧云, 高玉芝, 等. 急诊科心搏骤停患者心肺复苏预后的影响因素[J]. 中华急诊医学杂志, 2013, 22(1): 28-34. https://cpfd.cnki.com.cn/Article/CPFDTOTAL-ZHYX201307001010.htm
[14] Kim F, Nichol G, Maynard C, et al. Effect of prehospital induction of mild hypothermia on survival and neurological status among adults with cardiac arrest: a randomized clinicaltrial[J]. JAMA, 2014, 311(1): 45-52. doi: 10.1001/jama.2013.282173
[15] Uber A, Sadler RC, Chassee T, et al. Bystander cardiopulmonary resuscitation is clustered and associated with neighborhood socioeconomic characteristics: a geospatial analysis of Kent County, Michigan[J]. Acad Emerg Med, 2017, 24(8): 930-939. doi: 10.1111/acem.13222
[16] 张东, 赵淑杰, 李南, 等. 心搏骤停后综合征预后相关影响因素的分析[J]. 中华危重病急救医学, 2015, 27(3): 175-179. https://cdmd.cnki.com.cn/Article/CDMD-10366-1013337964.htm
[17] 黄煜, 何庆. 2020 AHA心肺复苏指南解读(三)——成人基础和高级生命支持(中)[J]. 心血管病学进展, 2020, 41(12): 1338-1344. https://www.cnki.com.cn/Article/CJFDTOTAL-XXGB202103021.htm
[18] 李宗浩, 葛鑫. 自动体外除颤器AED和心肺复苏术[J]. 中国急救复苏与灾害医学杂志, 2020, 15(8): 885-891. https://www.cnki.com.cn/Article/CJFDTOTAL-SZZX201713085.htm
[19] 黄燕梅, 张婉婉, 张永恕, 等. 院外心脏骤停初始可除颤心律的流行病学预测因素分析[J]. 中华急诊医学杂志, 2019, 28(10): 1296-1300.
[20] Pandak T, Teufel N, Bartonicek D, et al. European resuscitation council guidelines for resuscitation 2015[J]. Lijec Vjesn, 2016, 138(11-12): 305-321.
[21] Nolan JP, Soar J, Smith GB, et al. Incidence and outcome of in hospital cardiac arrest in the United Kingdom National Cardiac Arrest Audit[J]. Resuscitation, 2014, 85(8): 987-992.
[22] Couper K, Kimani PK, Gale CP, et al. Patient, health service factors and variation in mortality following resuscitated out-of-hospital cardiac arrest in acute coronary syndrome: Analysis of the Myocardial Ischaemia National Audit Project[J]. Resuscitation, 2018, 124: 49-57.
[23] Barry T, Doheny MC, Masterson S, et al. Community first responders for out-of-hospital cardiac arrest in adults and children[J]. Cochrane Database Syst Rev, 2019(7): CD012764.
[24] Huang Y, He Q, Yang LJ, et al. Cardiopulmonary resuscitation(CPR)plus delayed defibrillation versus immediate defibrillation for out-of-hospital cardiac arrest[J]. Cochrane Database Syst Rev, 2014(9): CD009803.
[25] Perkins GD, Handley AJ, Koster RW, et al. European Resuscitation Council Guidelines for Resuscitation 2015: Section 2. Adult basic life support and automated external defibrillation[J]. Resuscitation, 2015(95): 81-99.
[26] Zègre-Hemsey JK, Bogle B, Cunningham CJ, et al. Delivery of automated external defibrillators(AED)by drones: implications for emergency cardiac care[J]. Curr Cardiovasc Risk Rep, 2018, 12: 25.
[27] 骆丁, 张娜, 郑源, 等. 自动体外除颤仪的配置现状及实施研究进展[J]. 中国急救医学, 2021, 14(2): 182-185. https://www.cnki.com.cn/Article/CJFDTOTAL-ZJJY202102018.htm
[28] 朱威, 徐佳, 陆远强. 《2020年美国心脏协会心肺复苏及心血管急救指南》成人生命支持部分建议内容分析[J]. 中华危重症医学杂志(电子版), 2020, 13(5): 379-381. https://www.cnki.com.cn/Article/CJFDTOTAL-ZWZD202005014.htm
[29] 孙慧, 杜贤进. 创伤性心搏骤停患者心肺复苏的研究进展[J]. 临床急诊杂志, 2020, 21(9): 752-757. https://www.cnki.com.cn/Article/CJFDTOTAL-ZZLC202009016.htm
[30] JouffIoy R, Soode A, AlexaⅡdre P, et al. Epinephrine administration in non-shockable out-of-hospital cardiac arrest[J]. Am J Emerg Med, 2019, 37(3): 387-390.
[31] 赵梦龙, 郭凯, 张源波, 等. 心脏骤停自主循环恢复患者预后的多因素Cox生存分析[J]. 中国急救医学, 2017, 37(2): 149-152.
[32] 冯梦云, 尚桂莲. 心脏骤停后低温治疗时间窗的研究进展[J]. 临床急诊杂志, 2021, 22(3): 216-221. https://www.cnki.com.cn/Article/CJFDTOTAL-ZZLC202103015.htm
[33] Myat A, Song KJ, Rea T. Out-of-hospital cardiac arrest: current concepts[J]. Lancet, 2018, 391(10124): 970-979.
[34] Sonder P, Janssens GN, Beishuizen A, et al. Efficacy different cooling technologies for therapeutic temperature management: A prospective intervention study[J]. Resuscitation, 2018, 124: 14-20.
[35] Arrich J, Holzer M, Havel C, et al. Hypothermia for neuroprotection in adults after cardiopulmonary resuscitation[J]. Cochrane Database Syst Rev, 2016, 2: CD004128.
[36] 李双磊, 吴远斌, 龚志云, 等. 心脏骤停患者心肺复苏后神经系统的维护[J]. 中国体外循环杂志, 2019, 17(4): 249-256. https://www.cnki.com.cn/Article/CJFDTOTAL-TWXH201904017.htm
[37] Sanson G, Verduno J, Zambon M, et al. Emergency medical service treated out-of-hospital cardiac arrest: Identification of weak links in the chain-of-survival through an epidemiological study[J]. Eur J Cardiovasr Nur, 2016, 15(5): 328-336.
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