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#1
23.08.2005, 16:54
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Пост-резуститационный период
Глубоко уважаемые коллеги!
Очень бы хотелось узнать о ваших подходах к ведению больных в пост-резуститационном периоде, а именно о методах уменьшения постаноксического повреждения головного мозга (возможности ИВЛ, фармтерапии, прогноз, диуретики, седативные) буду признателен за ссылки на данную тему. P.S. имею ввиду пациентов с первичной остановкой сердечной деятельности (ЖТ, ФЖ) т.е. относительно сохранных. 
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#2
27.08.2005, 02:11
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Цитата:
Cardiac Resuscitation From ACS Surgery: Principles & Practice Posted 07/26/2005 Terry J. Mengert, MD The chain of survival and the primary and secondary surveys of cardiac resuscitation are described. Cardiac resuscitation based on rhythm findings, immediate postresuscitation care, and ending a resuscitation attempt are discussed. Comparison of Vasopressin and Epinephrine in Cardiac Arrest Persons in cardiac arrest (which can result from pulseless ventricular tachycardia [VT], ventricular fibrillation [VF], pulseless electrical activity [PEA], or asystole) require a vasopressor for as long as they remain pulseless. Typically, 1 mg of epinephrine is administered intravenously every 3 to 5 minutes. Epinephrine stimulates adrenergic receptors, which leads to vasoconstriction and optimization of cardiopulmonary resuscitation (CPR) -- generated blood flow to the heart and brain. Vasopressin (40 units I.V. once only) is a reasonable alternative to epinephrine, at least initially. Vasopressin in the recommended dose is a potent vasoconstrictor. It also has the theoretical advantage over epinephrine of not increasing myocardial oxygen consumption or lactate production in the arrested heart. Despite its potential advantages, however, in a study of 200 inpatient cardiac arrest patients, vasopressin did not provide a better survival rate than epinephrine. Vasopressin was also found to be comparable to epinephrine in out-of-hospital cardiac arrests when the rhythm was VF or PEA but superior to epinephrine for patients in asystole.[1,2] Priming the Pump Ongoing research suggests that the duration of VF is a consideration in deciding whether to defibrillate as soon as a defibrillator is available or to perform CPR for a brief period first to 'prime the pump' before proceeding to defibrillation. In the porcine model in the setting of prolonged VF (> 10 minutes), CPR before countershock provides several physiologic benefits.[1] Studies have found that patients with VF of longer than 5 minutes' duration had better return of spontaneous circulation, survival to hospital discharge, and 1-year survival if ambulance personnel provided 3 minutes of CPR before performing defibrillation than if ambulance personnel performed defibrillation immediately upon arriving at the scene; however, some experts question the validity of these results, on the basis of study design.[2,3] Initiating Defibrillation When the automated external defibrillator or monitor-defibrillator arrives, it should be attached to the patient in an appropriate manner, and the patient's rhythm should be analyzed; if the patient is in VF or pulseless VT, a defibrillatory shock should be rapidly applied (see Table 1 and Table 2 ). If required, two additional shocks may be administered sequentially. The importance of rapid access to defibrillation cannot be overemphasized. In a patient who is dying from a shockable rhythm, the chance of survival declines by 7% to 10% for every minute that defibrillation is delayed. When Spontaneous Circulation Does Not Return The most challenging part of cardiac resuscitation management in general is the problem-solving required when spontaneous circulation does not return despite appropriate initial interventions. This situation poses a critical question to the resuscitators: Why is this patient dying right now? The intellectual challenge of that question, which the resuscitators must try to answer expeditiously and at the bedside, is compounded by the emotional intensity that pervades most cardiac resuscitations. The solvable problems that may interfere with resuscitation can be grouped into three broad categories: technical, physiologic, and anatomic. Technical problems consist of difficulties with the resuscitators' equipment or skills; such difficulties include ineffective CPR, inadequate oxygenation and ventilation, endotracheal tube complications, intravenous access difficulties, and monitor-defibrillator malfunction or misuse. The physiologic and anatomic problems consist of life-threatening but potentially treatable conditions that may have led to the cardiac arrest in the first place. This differentiation between physiology and anatomy is admittedly artificial, given that physiology is always involved in a cardiac arrest, but it has some usefulness as a teaching and problem-solving tool. Physiologic problems classically include hypoxia, acidosis, hyperkalemia, severe hypokalemia, hypothermia, hypoglycemia, and drug overdose. Anatomic problems are hypovolemia/hemorrhage, tension pneumothorax, cardiac tamponade, myocardial infarction, and pulmonary embolism. Whenever possible, the patient's medical and surgical history and the circumstances and symptoms immediately before the cardiac arrest should be sought from family members, bystanders, or hospital staff as the resuscitation proceeds. This information may contain important clues to the principal arrest problem and how it may be expeditiously treated. For example, a patient who presents to an emergency department with chest pain and then suffers a VF cardiac arrest is probably dying of a massive myocardial infarction, pulmonary embolism, or aortic dissection, with tension pneumothorax or cardiac tamponade also being possibilities. Specific questions to consider include the following: Does the patient have risk factors for heart disease, pulmonary embolism, or aortic disease? What was the quality of the patient's pain and its radiation before the cardiac arrest? What were the prearrest vital signs and physical examination findings? What did the prearrest ECG show (if available)? Can any of this information be used now, at the bedside, to dictate the needed resuscitation interventions during the D phase of the secondary survey? For example, if the prearrest ECG showed prominent ST segment elevation in leads V1 through V4 consistent with a large anterior myocardial infarction, if the patient's resuscitation is failing despite appropriate interventions, and if there appear to be no technical problems hampering the resuscitation, a working diagnosis of massive myocardial infarction can be made; intravenous thrombolytic therapy may then be a reasonable and needed step in such a resuscitation. Thoughtful consideration of the possible reasons why a resuscitation is failing will regularly push the code-team captain's and resuscitation team's expertise and clinical skills to the limits. Nevertheless, the failure to consider these formidable issues will deprive the patient of an optimal opportunity to survive the cardiac arrest. Optimizing Postresuscitation Management Research to determine optimal postresuscitation management strategies to improve neurologic outcome and survival to hospital discharge is ongoing. Hyperthermia and hyperglycemia compromise postresuscitation neurologic outcome, whereas mild to moderate induced hypothermia appears to improve neurologic outcome and decrease mortality.[1-3] For more information, visit . to ACS Surgery: Principles and Practice. References Wenzel V, Krismer AC, Arntz HR, et al: A comparison of vasopressin and epinephrine for out-of-hospital cardiopulmonary resuscitation. N Engl J Med 350:105, 2004 [PMID 14711909] McIntryre KM: Vasopressin in asystolic cardiac arrest. N Engl J Med 350:179, 2004 [PMID 14711918] Berg RA, Hilwig RW, Kern KB, et al: Precountershock cardiopulmonary resuscitation improves ventricular fibrillation median frequency and myocardial readiness for successful defibrillation from prolonged ventricular fibrillation: a randomized, controlled swine study. Ann Emerg Med 40:563, 2002 [PMID 12447331] Wik L, Hansen TB, Fylling F, et al: Delaying defibrillation to give basic cardiopulmonary resuscitation to patients with out-of-hospital ventricular fibrillation. JAMA 289:1389, 2003 [PMID 12636461] Weisfeldt ML, Becker LB: Resuscitation after cardiac arrest: a 3-phase time sensitive model. JAMA 288:3035, 2002 [PMID 12479769] Moghissi E: Hospital management of diabetes: beyond the sliding scale. Cleve Clin J Med 71:801, 2004 [PMID 15529485] Bernard SA, Gray TW, Buist MD, et al: Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med 346:557, 2002 [PMID 11856794] Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. The Hypothermia after Cardiac Arrest Study Group. N Engl J Med 346:549 Terry J. Mengert, MD, University of Washington School of Medicine ACS Surgery. 2005; ©2005 WebMD Inc. All rights reserved.
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#3
29.01.2007, 02:05
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Вот и мои 5 копеек. Сугубо про ДГЭ.
Использую мексидол в дозе 400-600 мг и ГОМК. Собственно, другого и нет ничего. Сразу после восстановления сердечной деятельности. Даже если пытается восстановить спонтанное дыхание (бывает это крайне редко, как, впрочем, и успешная ресуститация вне стационара, особенно, если смерть не "твоя", а тебя зовут в помощь) - ИВЛ в режиме IPPV 100% кислородом. Исключение - реанимация при фибрилляции. Тут, если дефибрилляция была успешна - как правило, кроме седации, инсуффляции кислорода и мониторинга до доставки в стационар ничего не требуется.
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#4
29.01.2007, 13:15
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Цитата:
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#5
29.01.2007, 22:25
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Да, это догоспитальный этап.
Других средств-церебропротекторов у нас. А вы считаете, что пациент после СЛР в них не нуждается?
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#6
29.01.2007, 22:37
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ИМХО, конечно, но если я не начну защиту мозга пациента сразу после реанимации, то в стационаре, несмотря на вполне функционирующие остальные органы, получат либо очередного органного донора, либо "растение".
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#7
29.01.2007, 23:06
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Цитата:
 Да, я считаю, что пациент после СЛР ни в них, ни в других "церебропротекторах" не нуждается. Посмотрите ссылки на мировые рекомендации по СЛР - там нет даже упоминания ни о чем подобном. Экспериментировать нужно на животных...
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Комбинированный вид
