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NEJM社论:心脏骤停时持续胸外按压OR间歇按压?

2015-11-22 医学论坛网 医学论坛网

《新英格兰医学杂志》(NEJM)9日在线发表的一项大型随机对照研究(ROC)显示,在对心脏骤停患者进行心肺复苏过程中,持续胸外按压相较间歇性胸外按压并没有给患者带来额外获益。在NEJM同期社论中,作者Rudolph W. Koster认为,若新近发表的2015美国心脏协会(AHA)心肺复苏指南纳入这一研究结果,指南委员会或将保留之前因通气而进行间歇性胸外按压的推荐,并可能将这一推荐等级上升至IIa

《新英格兰医学杂志》(NEJM)9日在线发表的一项大型随机对照研究(ROC)显示,在对心脏骤停患者进行心肺复苏过程中,持续胸外按压相较间歇性胸外按压并没有给患者带来额外获益。

在NEJM同期社论中,作者Rudolph W. Koster认为,若新近发表的2015美国心脏协会(AHA)心肺复苏指南纳入这一研究结果,指南委员会或将保留之前因通气而进行间歇性胸外按压的推荐,并可能将这一推荐等级上升至IIa级推荐。

2015年AHA新近发表的心肺复苏指南纳入了一IIb级新推荐,即EMS在启动心肺复苏时,在患者被动给氧情况下,前3个200次持续的胸外按压是合理的。但在同期发布的欧洲心肺复苏理事会(ERC)心肺复苏指南中,并没有作出这一推荐。

AHA所作出的上述推荐是基于下列一项大型研究及其类似的研究结果。持续胸外按压的潜在益处已在历史对照性观察研究中获得检验。在其中一项最大型的研究中,研究人员同时采用了一些诸如“护理包”(bundle of care)的急救措施。

在3个200次的胸外按压中,胸外按压仅在心律分析和除颤时中断。此外,这一护理包还包括单次电击除颤方案(此前允许3次电击),以及在3个200次胸外按压时,心律、脉搏检查,延迟插入先进气道设备及在被动给氧代替正压通气达6分钟的情况下,均不中断胸外按压。

研究人员发现,实施上述护理包使得患者至出院时生存率从1.8%显著提高至5.4%;而在那些见过有心脏骤停和室颤的患者中,这一比例则从4.7%提升到了17.6%。

相关动物实验、回顾性队列研究及美国亚利桑那州全州前瞻性研究均显示,持续胸外按压可能提高患者生存率。Koster同时指出,开展心脏骤停患者的随机试验很困难,而且所需要的大量资源难于获得。

那么,为何ROC研究与此前所显示的持续胸外按压能带来明显生存获益的观察性研究结果截然相反?Koster认为:首先,在“护理包”研究中,其他措施而非持续胸外按压可能是导致生存率提高的改变因素。

其次,在ROC研究中,对照组的平均胸外按压分数已经高达0.77,相较干预组中0.83的胸外按压分数并未低多少,两者均远高于AHA和ERC心肺复苏指南所推荐的胸外按压分数高于0.60的目标值,已知胸外按压是间歇性胸外按压的重要指标;再次,因通气间歇胸外按压可能并没有当前所认为的那么重要,对生存率起着那么大的决定作用。

“当然,随机试验是研究因果关系的最佳工具。” Koster写道。

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  1. [GetPortalCommentsPageByObjectIdResponse(id=1651255, encodeId=514116512551d, content=<a href='/topic/show?id=6f9c564499c' target=_blank style='color:#2F92EE;'>#按压#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=87, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56449, encryptionId=6f9c564499c, topicName=按压)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=0a7424147894, createdName=lisa446, createdTime=Thu Dec 03 23:00:00 CST 2015, time=2015-12-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=44021, encodeId=de544402193, content=持续, beContent=null, objectType=article, channel=null, level=null, likeNumber=144, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20161017/IMG5804CC6615D212822.jpg, createdBy=39cf1666406, createdName=星海孤魂, createdTime=Sat Nov 28 15:23:00 CST 2015, time=2015-11-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1630468, encodeId=4211163046868, content=<a href='/topic/show?id=dbd084102dd' target=_blank style='color:#2F92EE;'>#胸外按压#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84102, encryptionId=dbd084102dd, topicName=胸外按压)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=082221527772, createdName=dongjia2017, createdTime=Tue Nov 24 14:00:00 CST 2015, time=2015-11-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=43609, encodeId=2cd2436099a, content=持续按压, beContent=null, objectType=article, channel=null, level=null, likeNumber=112, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=3b2c1627329, createdName=owlhealth, createdTime=Tue Nov 24 01:33:00 CST 2015, time=2015-11-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=43578, encodeId=1536435e836, content=我觉得还是持续按压的好,虽然对身体的损伤会更多一些, beContent=null, objectType=article, channel=null, level=null, likeNumber=137, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://login.medsci.cn/upload/avatar/e3b78fdf1c4d3e2e9ec6e03f643df0e2/6ca494c7b27a25fdde0721c5dac778d7.jpg, createdBy=2e441664544, createdName=鲜花飞鸟, createdTime=Mon Nov 23 10:49:00 CST 2015, time=2015-11-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=43560, encodeId=6ebc4356084, content=在对心脏骤停患者进行心肺复苏过程中,持续胸外按压相较间歇性胸外按压并没有给患者带来额外获益, beContent=null, objectType=article, channel=null, level=null, likeNumber=96, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20201205/e96b3d935daf4e258fba69d60175f0ab/b6d3ee4a3a414b8eafaf7c5e905937a2.jpg, createdBy=ad4b83208, createdName=vpssa, createdTime=Mon Nov 23 09:18:00 CST 2015, time=2015-11-23, status=1, ipAttribution=)]
    2015-12-03 lisa446
  2. [GetPortalCommentsPageByObjectIdResponse(id=1651255, encodeId=514116512551d, content=<a href='/topic/show?id=6f9c564499c' target=_blank style='color:#2F92EE;'>#按压#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=87, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56449, encryptionId=6f9c564499c, topicName=按压)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=0a7424147894, createdName=lisa446, createdTime=Thu Dec 03 23:00:00 CST 2015, time=2015-12-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=44021, encodeId=de544402193, content=持续, beContent=null, objectType=article, channel=null, level=null, likeNumber=144, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20161017/IMG5804CC6615D212822.jpg, createdBy=39cf1666406, createdName=星海孤魂, createdTime=Sat Nov 28 15:23:00 CST 2015, time=2015-11-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1630468, encodeId=4211163046868, content=<a href='/topic/show?id=dbd084102dd' target=_blank style='color:#2F92EE;'>#胸外按压#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84102, encryptionId=dbd084102dd, topicName=胸外按压)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=082221527772, createdName=dongjia2017, createdTime=Tue Nov 24 14:00:00 CST 2015, time=2015-11-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=43609, encodeId=2cd2436099a, content=持续按压, beContent=null, objectType=article, channel=null, level=null, likeNumber=112, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=3b2c1627329, createdName=owlhealth, createdTime=Tue Nov 24 01:33:00 CST 2015, time=2015-11-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=43578, encodeId=1536435e836, content=我觉得还是持续按压的好,虽然对身体的损伤会更多一些, beContent=null, objectType=article, channel=null, level=null, likeNumber=137, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://login.medsci.cn/upload/avatar/e3b78fdf1c4d3e2e9ec6e03f643df0e2/6ca494c7b27a25fdde0721c5dac778d7.jpg, createdBy=2e441664544, createdName=鲜花飞鸟, createdTime=Mon Nov 23 10:49:00 CST 2015, time=2015-11-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=43560, encodeId=6ebc4356084, content=在对心脏骤停患者进行心肺复苏过程中,持续胸外按压相较间歇性胸外按压并没有给患者带来额外获益, beContent=null, objectType=article, channel=null, level=null, likeNumber=96, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20201205/e96b3d935daf4e258fba69d60175f0ab/b6d3ee4a3a414b8eafaf7c5e905937a2.jpg, createdBy=ad4b83208, createdName=vpssa, createdTime=Mon Nov 23 09:18:00 CST 2015, time=2015-11-23, status=1, ipAttribution=)]
    2015-11-28 星海孤魂

    持续

    0

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  4. [GetPortalCommentsPageByObjectIdResponse(id=1651255, encodeId=514116512551d, content=<a href='/topic/show?id=6f9c564499c' target=_blank style='color:#2F92EE;'>#按压#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=87, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56449, encryptionId=6f9c564499c, topicName=按压)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=0a7424147894, createdName=lisa446, createdTime=Thu Dec 03 23:00:00 CST 2015, time=2015-12-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=44021, encodeId=de544402193, content=持续, beContent=null, objectType=article, channel=null, level=null, likeNumber=144, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20161017/IMG5804CC6615D212822.jpg, createdBy=39cf1666406, createdName=星海孤魂, createdTime=Sat Nov 28 15:23:00 CST 2015, time=2015-11-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1630468, encodeId=4211163046868, content=<a href='/topic/show?id=dbd084102dd' target=_blank style='color:#2F92EE;'>#胸外按压#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84102, encryptionId=dbd084102dd, topicName=胸外按压)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=082221527772, createdName=dongjia2017, createdTime=Tue Nov 24 14:00:00 CST 2015, time=2015-11-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=43609, encodeId=2cd2436099a, content=持续按压, beContent=null, objectType=article, channel=null, level=null, likeNumber=112, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=3b2c1627329, createdName=owlhealth, createdTime=Tue Nov 24 01:33:00 CST 2015, time=2015-11-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=43578, encodeId=1536435e836, content=我觉得还是持续按压的好,虽然对身体的损伤会更多一些, beContent=null, objectType=article, channel=null, level=null, likeNumber=137, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://login.medsci.cn/upload/avatar/e3b78fdf1c4d3e2e9ec6e03f643df0e2/6ca494c7b27a25fdde0721c5dac778d7.jpg, createdBy=2e441664544, createdName=鲜花飞鸟, createdTime=Mon Nov 23 10:49:00 CST 2015, time=2015-11-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=43560, encodeId=6ebc4356084, content=在对心脏骤停患者进行心肺复苏过程中,持续胸外按压相较间歇性胸外按压并没有给患者带来额外获益, beContent=null, objectType=article, channel=null, level=null, likeNumber=96, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20201205/e96b3d935daf4e258fba69d60175f0ab/b6d3ee4a3a414b8eafaf7c5e905937a2.jpg, createdBy=ad4b83208, createdName=vpssa, createdTime=Mon Nov 23 09:18:00 CST 2015, time=2015-11-23, status=1, ipAttribution=)]
    2015-11-24 owlhealth

    持续按压

    0

  5. [GetPortalCommentsPageByObjectIdResponse(id=1651255, encodeId=514116512551d, content=<a href='/topic/show?id=6f9c564499c' target=_blank style='color:#2F92EE;'>#按压#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=87, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56449, encryptionId=6f9c564499c, topicName=按压)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=0a7424147894, createdName=lisa446, createdTime=Thu Dec 03 23:00:00 CST 2015, time=2015-12-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=44021, encodeId=de544402193, content=持续, beContent=null, objectType=article, channel=null, level=null, likeNumber=144, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20161017/IMG5804CC6615D212822.jpg, createdBy=39cf1666406, createdName=星海孤魂, createdTime=Sat Nov 28 15:23:00 CST 2015, time=2015-11-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1630468, encodeId=4211163046868, content=<a href='/topic/show?id=dbd084102dd' target=_blank style='color:#2F92EE;'>#胸外按压#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84102, encryptionId=dbd084102dd, topicName=胸外按压)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=082221527772, createdName=dongjia2017, createdTime=Tue Nov 24 14:00:00 CST 2015, time=2015-11-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=43609, encodeId=2cd2436099a, content=持续按压, beContent=null, objectType=article, channel=null, level=null, likeNumber=112, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=3b2c1627329, createdName=owlhealth, createdTime=Tue Nov 24 01:33:00 CST 2015, time=2015-11-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=43578, encodeId=1536435e836, content=我觉得还是持续按压的好,虽然对身体的损伤会更多一些, beContent=null, objectType=article, channel=null, level=null, likeNumber=137, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://login.medsci.cn/upload/avatar/e3b78fdf1c4d3e2e9ec6e03f643df0e2/6ca494c7b27a25fdde0721c5dac778d7.jpg, createdBy=2e441664544, createdName=鲜花飞鸟, createdTime=Mon Nov 23 10:49:00 CST 2015, time=2015-11-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=43560, encodeId=6ebc4356084, content=在对心脏骤停患者进行心肺复苏过程中,持续胸外按压相较间歇性胸外按压并没有给患者带来额外获益, beContent=null, objectType=article, channel=null, level=null, likeNumber=96, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20201205/e96b3d935daf4e258fba69d60175f0ab/b6d3ee4a3a414b8eafaf7c5e905937a2.jpg, createdBy=ad4b83208, createdName=vpssa, createdTime=Mon Nov 23 09:18:00 CST 2015, time=2015-11-23, status=1, ipAttribution=)]
    2015-11-23 鲜花飞鸟

    我觉得还是持续按压的好,虽然对身体的损伤会更多一些

    0

  6. [GetPortalCommentsPageByObjectIdResponse(id=1651255, encodeId=514116512551d, content=<a href='/topic/show?id=6f9c564499c' target=_blank style='color:#2F92EE;'>#按压#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=87, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56449, encryptionId=6f9c564499c, topicName=按压)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=0a7424147894, createdName=lisa446, createdTime=Thu Dec 03 23:00:00 CST 2015, time=2015-12-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=44021, encodeId=de544402193, content=持续, beContent=null, objectType=article, channel=null, level=null, likeNumber=144, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20161017/IMG5804CC6615D212822.jpg, createdBy=39cf1666406, createdName=星海孤魂, createdTime=Sat Nov 28 15:23:00 CST 2015, time=2015-11-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1630468, encodeId=4211163046868, content=<a href='/topic/show?id=dbd084102dd' target=_blank style='color:#2F92EE;'>#胸外按压#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84102, encryptionId=dbd084102dd, topicName=胸外按压)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=082221527772, createdName=dongjia2017, createdTime=Tue Nov 24 14:00:00 CST 2015, time=2015-11-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=43609, encodeId=2cd2436099a, content=持续按压, beContent=null, objectType=article, channel=null, level=null, likeNumber=112, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=3b2c1627329, createdName=owlhealth, createdTime=Tue Nov 24 01:33:00 CST 2015, time=2015-11-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=43578, encodeId=1536435e836, content=我觉得还是持续按压的好,虽然对身体的损伤会更多一些, beContent=null, objectType=article, channel=null, level=null, likeNumber=137, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://login.medsci.cn/upload/avatar/e3b78fdf1c4d3e2e9ec6e03f643df0e2/6ca494c7b27a25fdde0721c5dac778d7.jpg, createdBy=2e441664544, createdName=鲜花飞鸟, createdTime=Mon Nov 23 10:49:00 CST 2015, time=2015-11-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=43560, encodeId=6ebc4356084, content=在对心脏骤停患者进行心肺复苏过程中,持续胸外按压相较间歇性胸外按压并没有给患者带来额外获益, beContent=null, objectType=article, channel=null, level=null, likeNumber=96, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20201205/e96b3d935daf4e258fba69d60175f0ab/b6d3ee4a3a414b8eafaf7c5e905937a2.jpg, createdBy=ad4b83208, createdName=vpssa, createdTime=Mon Nov 23 09:18:00 CST 2015, time=2015-11-23, status=1, ipAttribution=)]
    2015-11-23 vpssa

    在对心脏骤停患者进行心肺复苏过程中,持续胸外按压相较间歇性胸外按压并没有给患者带来额外获益

    0

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