Interpretation of the 2022 ERC-ESICM clinical practice guidelines for temperature control in adults after cardiac arrest
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摘要: 基于随机对照试验、系统评价和荟萃分析，心脏骤停复苏后患者使用目标温度管理(TTM)进行温度控制已得到专家协会的认可和国际临床实践指南的推荐。近期TTM-2试验报告指出具有任何初始心律的1850例院外心脏骤停(OHCA)昏迷患者温度控制在33℃与仅在患者发热(>37.7℃)时进行干预，6个月的病死率或神经功能结局没有差异，故欧洲复苏委员会(ERC)和欧洲危重病医学会(ESICM)更新了温度控制的临床实践指南，为具有任何初始节律的院内或院外心脏骤停复苏后昏迷的成人患者提供基于循证的体温控制指导。本文对其重点内容进行解读，为国内临床医师更好的学习和了解最新进展。Abstract: Based on randomized controlled trials, systematic reviews, and meta-analyses, the use of temperature control with target temperature management(TTM) in patients after resuscitation from cardiac arrest has been endorsed by expert associations and recommended by international clinical practice guidelines. The recent TTM-2 trial reported that there was no difference in 6 months-mortality or neurological outcomes in 1850 out-of-hospital cardiac arrest (OHCA) coma patients with any initial rhythm between temperature control at 33℃ and intervention only in patients with fever, defined as body temperature>37.7℃. Therefore, the European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have updated clinical practice guidelines to provide evidence-based guidance on temperature control in adults patients who are comatose after resuscitation from either in-hospital or out-of-hospital cardiac arrest with any initial cardiac rhythm. This paper interprets the key contents in order to better learn and understand the latest progress for domestic clinicians.
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Key words:
- cardiac arrest /
- coma /
- hypothermia /
- clinical practice guideline /
- guideline interpretation
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表 1 ILCOR系统评价的PICO原则
研究对象 干预措施 对照设计 结局指标 院内或院外心脏骤停的成人患者 目标体温为32~34℃时的温度控制 对体温正常或预防发热的温度控制 任何临床结果 特定的TTM持续时间(如48 h) 不同的TTM持续时间(如24 h) 特定的TTM降温方法(如体表降温) 不同的TTM降温方法(如血管内降温) 特定目标温度下的TTM(如33℃) 不同目标温度下的TTM(如36℃) 在特定时间点之前前诱导TTM(如院前或心脏骤停期间，即恢复自主循环之前) 在特定时间点之后诱导TTM 具有特定复温速率的TTM 具有不同的复温速率或无复温速率的TTM 注：PICO临床结果包括但不一定限于ROSC、入院28 d、入院30 d、出院时的生存率或良好神经功能结局，以及出院后28 d、30 d、90 d、180 d、1年的生存率或良好神经功能结局。ILCOR的ALS工作组以生存率和长期神经功能结局为重点进行了先验排序。 
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表 2 ERC-ESICM对成人心脏骤停后温度控制的建议
推荐强度及质量等级 建议 最佳实践声明 对于心脏骤停ROSC后处于昏迷状态的患者，推荐持续监测核心温度 弱推荐，低质量证据 对于心脏骤停后处于昏迷状态的患者，推荐积极预防发热(>37^7℃) 最佳实践声明 对于心脏骤停后处于昏迷状态的患者，推荐积极预防发热至少72 h 最佳实践声明 温度控制可以通过让患者暴露在环境中，使用解热药物，如果无法达标，可以使用目标温度为37^5℃的冷却装置 最佳实践声明 目前没有足够的证据支持或反对在心脏骤停患者亚群中控制32~36℃的温度或进行早期降温，未来的研究可能有助于阐明这一点。不推荐对ROSC后处于轻度低温状态的昏迷患者进行复温以达到常温 强反对，中等质量证据 不推荐ROSC后立即快速输注大量冷静脉液体进行院前降温
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表 3 未来心脏骤停后温度控制研究关注的问题
序号 关注研究的问题 1 尚未有正常体温/预防发热与无体温控制进行比较的试验 2 关于IHCA后温度控制的潜在益处的证据有限。一个多中心随机对照试验(No：NCT00457431)对IHCA复苏患者进行体温控制、低温和常温的比较，其结果尚未归 3 低温治疗在临床上可能有效的治疗窗口 4 温度控制的最佳持续时间 5 温度控制的临床效果是否取决于根据脑损伤的严重程度所提供适当的变量(目标温度和持续时间) 6 是否存在能从低温控制中获益的心脏骤停后特定人群 7 心脏骤停后患者的最佳镇静策略
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