церебральное перфузионное давление при СЛР

[efns]

Коллеги, позвольте уточнить. Инвазивные данные по ВЧД при СЛР имеются в литературе? Отмечается ревербирующий кровоток в сонных артериях при СЛР? И последнее - мозговой кровоток , ЦПД при СЛР настолько мал, что репефузионное поражение мозга неизбежно. Данные Koehier RC, Michael JR. Cardiopulmonary resuscitation, brain blood flow, and neurologic recovery. Cnt Care CIm 1985: 1:205-222., приведенные в этой работе свидетельствуют о 5% мозгового кровотока (от нормы) при СЛР.

[Dr.Vad]

по ВЧД при СЛР:

Intensive Care Med. 2003 Jun;29(6):1016-9. Epub 2003 Mar 28.
Cerebral perfusion pressure and cerebral tissue oxygen tension in a patient during cardiopulmonary resuscitation.
Imberti R, Bellinzona G, Riccardi F, Pagani M, Langer M.
Servizio di Anestesia e Rianimazione II, IRCCS Policlinico S. Matteo, 27100, Pavia, Italy.

OBJECTIVE: To report on the effects of cardiopulmonary resuscitation (CPR) instituted immediately after a cardiac arrest on cerebral perfusion pressure (CPP) and cerebral tissue oxygen tension (PbrO(2)).

DESIGN: Case report.

SETTING: ICU of a university hospital.

PATIENT: A head-injured 17-year-old man submitted to multimodal neurological monitoring underwent sudden cardiac arrest and successful CPR.

INTERVENTIONS: External chest compression, 100% oxygen ventilation, volume expansion and standard ACLS protocols.

MEASUREMENTS AND RESULTS: Heart rate, ECG, mean arterial blood pressure (MABP), ETCO(2), PaO(2), intracranial pressure (ICP), CPP and PbrO(2) were continuously monitored during CPR and data recorded at 15-s intervals by a dedicated personal computer. At the onset of the cardiac arrest, PbrO(2) decreased to zero. The institution of CPR resulted in a progressive increase of MABP, CPP and PbrO(2). Assuming, on the basis of previous experimental and clinical reports, 8 mmHg PbrO(2) as a possible ischaemic/hypoxic threshold value, during the first 6.5 min of CPR, PbrO(2) values were below this threshold (range 0-7 mmHg) and CPP values were <25 mmHg for 81.5% of the time. In the following 5.5 min, more efficient CPR generated CPP values >25 mmHg for 77.3% of the time. These values were associated with a PbrO(2) >8 mmHg (range 8-28 mmHg) at all times.

CONCLUSIONS: In the clinical setting of a witnessed cardiac arrest, immediate institution of CPR can be effective in generating PbrO(2) values above a supposed ischaemic/hypoxic threshold when CPP is >25 mmHg. PbrO(2) monitoring by the Licox system is sensitive and reliable, even at low values, and can be suitable for evaluating cerebral oxygenation during experimental CPR.


Intensive Care Med. 1987;13(4):256-9.
Intracranial pressure following cardiopulmonary resuscitation.
Sakabe T, Tateishi A, Miyauchi Y, Maekawa T, Matsumoto M, Tsutsui T, Takeshita H.

Intracranial pressure (ICP) was measured in six patients following cardiopulmonary resuscitation (CPR). The causes of cardiac arrest were respiratory or circulatory problems and the primary intracranial pathology was not detected. The measurement of ICP started 3 to 10 h following CPR except one patient in whom it started on the day 7. Duration of ICP measurement ranged from 2 to 7 days. In five out of six patients, ICP persistently remained below 20 mmHg. In the remaining one patient, ICP elevation associated with seizure activity was observed and ICP ultimately increased to 57 mmHg. Among these, four patients died and two remained in a persistent vegetative state. These results suggest that ICP following CPR does not necessarily increase if the patient has no primary intracranial pathology or seizures.

по теме в полной версии:

Management of Brain Injury After Resuscitation From Cardiac Arrest
[Ссылки доступны только зарегистрированным пользователям ]

[efns]

Уважаемый Вадим Вадимович, благодарю. Вопрос. СЛР проводилась по протоколу, а если на улице, в общественном месте, ....INTERVENTIONS: External chest compression, 100% oxygen ventilation.... 100% кислородным при дыхании рот в рот не обеспечим? И еще, по ВЧД -Rogers MC, Nugent SK, Stidham GL. Effects of closedchest cardiac massage on intracranial pressure, Crit Care
Med 1979; 7: 454-6. несколько в другой плоскости выполнена, мне кажется она более объективно дает состояние ВЧД при СЛР. Как быть с утверждением аксиомой - CPR does not "bring anyone back"(CPR statistics". American Heart Association. Retrieved 2007-06-14).Спасибо.

[efns]

Уважаемый Вадим Вадимович.
Если это утверждение верно ..."Chest compressions generate blood flow by increasing intra-thoracic pressure and compressing the heart directly. At best, compressions achieve 25% of normal brain and myocardium perfusio."([Ссылки доступны только зарегистрированным пользователям ]) то остается кровоток около 15мм/100г/мин. При таких параметрах мозгового кровотока блокируется не только синаптическая передача, но и стартует свободнорадиакальная агрессия. Грубые реперфузионные изменения неизбежны. Не удается найти валидные данные допплерографии при СЛР.

[Dr.Vad]

Вообще-то, я несколько не в теме, просто ссылки привел...

Если СРЛ на улице, то откуда будут данные по ВЧД или допплеру???

не понятно, как [CPR does not "bring anyone back" "CPR statistics"], если например выживаемость от СРЛ на улице 25%, согласно:

Survival was 25% (49 of 199), not associated with long or short ventilation pauses when controlled for covariates.

Circulation. 2013 Apr 16;127(15):1585-90.
Duration of ventilations during cardiopulmonary resuscitation by lay rescuers and first responders: relationship between delivering chest compressions and outcomes.
Beesems SG, Wijmans L, Tijssen JG, Koster RW.
Msc, Department of Cardiology, Room G4-248, Academic Medical Center, University of Amsterdam, Meibergdreef 9 1105 AZ, Amsterdam, The Netherlands

[Dr.Vad]

Еще, недавняя неплохая статья в полной версии, что делается, чтобы улучшить исход; выживаемость от 13 до 28% в зависимости от исходного состояния/диагноза пациента:

Crit Care Med. 2008 Nov;36(11 Suppl):S397-404.
From laboratory science to six emergency medical services systems: New understanding of the physiology of cardiopulmonary resuscitation increases survival rates after cardiac arrest.

[Ссылки доступны только зарегистрированным пользователям ]

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совсем свежая публикация, что оценка Regional cerebral oxygen saturation быть может поможет оценить благоприятный неврологический исход после СРЛ; выживаемость с хорошим неврологическим исходом 14%:

Resuscitation. 2012 Jan;83(1):46-50.
Regional cerebral oxygen saturation on hospital arrival is a potential novel predictor of neurological outcomes at hospital discharge in patients with out-of-hospital cardiac arrest.
Ito N, Nanto S, Nagao K, Hatanaka T, Nishiyama K, Kai T.
Senri Critical Care Medical Center, Osaka Saiseikai Senri Hospital, 1-1-6 Tsukumodai, Suita, Osaka 565-0862, Japan.

AIM: To investigate the association between regional brain oxygen saturation (rSO(2)) on hospital arrival and neurological outcomes at hospital discharge in patients with out-of-hospital cardiac arrest (OHCA).

METHODS: A prospective cohort study was conducted, registering 179 patients with OHCA who were referred to Senri Critical Care Medical Centre between April 2009 and June 2010. Of these patients, 92 met the inclusion criteria. The primary end point was "neurological outcomes" at hospital discharge according to the "Utstein style" guidelines.

RESULTS: The overall rate of good neurological outcome at hospital discharge was 14% (n=13). Sixty-one patients with rSO(2) ≤25% showed poor neurological outcome in the receiver operating curve analysis (optimal cut-off point, 25%; sensitivity, 0.772; specificity, 1.000; positive predictive value, 1.000; area under the curve (AUC), 0.919; p<0.0001). The AUC for rSO(2) was greater than that for base excess (p=0.0461) or lactate (p=0.0128) measured on hospital arrival. Since rSO(2) >40% was previously collated with good neurological outcome after cardiovascular surgery, we categorised our patients into three groups in a post hoc analysis: patients with rSO(2) ≤25% (n=61); patients with rSO(2) 26-40% (n=9) and patients with rSO(2) >40% (n=22). Patients with good neurological outcome were as follows: 0 (0%)/61 with rSO(2) ≤25%; two (22.2%)/9 with rSO(2) 26-40% and 11 (50.0%)/22 with rSO(2) >40% (p<0.0001).

CONCLUSION: rSO(2) on hospital arrival may help predict neurological outcomes at hospital discharge in patients with OHCA.

и ред. комментарий к ней:

Resuscitation. 2012 Jan;83(1):11-2.
Cerebral oximetry - the holy grail of non-invasive cerebral perfusion monitoring in cardiac arrest or just a false dawn?
Parnia S.

[efns]

Уважаемый Вадим Вадимович. Благодарю. Посмотрю.
EFNS