isishwankathelo
IBhunga lokuVuselela iNgxaki yaseYurophu (i-ERC) kunye ne-European Society of Critical Care Medicine (i-ESICM) zisebenzisane ukuphuhlisa ezi zikhokelo zokhathalelo emva kokuvuselelwa kwabantu abadala, ngokuhambelana ne-2020 International Consensus on the Science and Treatment of CPR. Izihloko ezigutyungelweyo ziquka isifo sokubanjwa kwentliziyo emva kokuvuselelwa, ukuxilongwa kwezizathu zokubanjwa kwentliziyo, ulawulo lwe-oxygen kunye nomoya, ukufakwa kwe-coronary infusion, ukujonga nokulawula i-hemodynamic, ulawulo lokuxhuzula, ulawulo lobushushu, ulawulo lonyango olunzulu ngokubanzi, ukuqikelela kwangaphambili, iziphumo zexesha elide, ukuvuselelwa, kunye nokunikezelwa kwamalungu omzimba.
Amagama angundoqo: Ukubanjwa yintliziyo, ukhathalelo lokuvuselela emva kotyando, ukuxela kwangaphambili, izikhokelo
Intshayelelo kunye nobubanzi
Ngowama-2015, iBhunga le-European Resuscitation Council (ERC) kunye ne-European Society of Critical Care Medicine (ESICM) basebenzisana ukuphuhlisa izikhokelo zokuqala zokhathalelo emva kokuvuselelwa, ezapapashwa kwiResuscitation and Critical Care Medicine. Ezi zikhokelo zokhathalelo emva kokuvuselelwa zahlaziywa ngokubanzi ngo-2020 kwaye zibandakanya isayensi epapashwe ukusukela ngo-2015. Izihloko ezigutyungelweyo ziquka isifo sokubanjwa kwentliziyo emva kokuhlaselwa sisifo, ulawulo lwe-oxygen kunye nomoya, iithagethi ze-hemodynamic, ukufakwa kwe-coronary, ulawulo lobushushu olujoliswe kuko, ulawulo lokuxhuzula, i-prognosis, ukuvuselelwa, kunye neziphumo zexesha elide (Umfanekiso 1).
Isishwankathelo sotshintsho olukhulu
Unyango olukhawulezileyo emva kokuvuselelwa:
• Unyango emva kokuvuselelwa luqala kwangoko emva kweROSC eqhubekayo (ukubuyiselwa kokujikeleza kwegazi okuzenzekelayo), nokuba indawo iphi na (Umfanekiso 1).
• Xa umntu enesifo sentliziyo engaphandle kwesibhedlele, cinga ngokuya kwiziko lonyango lokubanjwa kwentliziyo. Fumanisa unobangela wokubanjwa kwentliziyo.
• Ukuba kukho ubungqina beklinikhi (umz., ukungazinzi kwe-hemodynamic) okanye ubungqina be-ECG bokunqongophala kwentliziyo, kwenziwa i-coronary angiography kuqala. Ukuba i-coronary angiography ayichongi isilonda esibangela oko, kwenziwa i-CT encepography kunye/okanye i-CT pulmonary angiography.
• Ukuchongwa kwangethuba kweengxaki zokuphefumla okanye zemithambo-luvo kungenziwa ngokwenza ii-CT scans zobuchopho nesifuba ngexesha lokulaliswa esibhedlele, ngaphambi okanye emva kwe-coronary angiography (jonga iCoronary Reperfusion).
• Yenza i-CT yengqondo kunye/okanye i-angiography yemiphunga ukuba kukho iimpawu okanye iimpawu ezibonisa imbangela yemithambo-luvo okanye yokuphefumla ngaphambi kokuba i-asystole ifumaneke (umz., intloko ebuhlungu, isifo sokuwa, okanye ukungasebenzi kakuhle kwemithambo-luvo, ukuphefumla okufutshane, okanye i-hypoxemia ebhalwe kwizigulana ezineemeko zokuphefumla ezaziwayo).
1. Indlela yomoya kunye nokuphefumla
Ulawulo lwendlela yomoya emva kokujikeleza kwegazi okuzenzekelayo lubuyiselwe
• Inkxaso yomoya kunye neyokuphefumla kufuneka iqhubeke emva kokubuyela kwimeko yesiqhelo yokujikeleza kwegazi (ROSC).
• Izigulane eziye zaphelelwa yintliziyo okwethutyana, zabuyela kwangoko ekusebenzeni kwengqondo okuqhelekileyo, kwaye zaphefumla ngendlela eqhelekileyo zisenokungadingi ukufakwa kwe-endotracheal intubation, kodwa kufuneka zinikwe ioksijini ngemaski ukuba ukugcwala kweoksijini kwimithambo yazo kungaphantsi kwama-94%.
• Ukufakwa kwe-endotracheal intubation kufuneka kwenziwe kwizigulana ezihlala zikho emva kwe-ROSC, okanye kwizigulana ezinezinye iimpawu zonyango zokuthomalalisa kunye nokuphefumla ngomatshini, ukuba ukufakwa kwe-endotracheal intubation akwenziwanga ngexesha le-CPR.
• Ukufakwa kwe-endotracheal intubation kufuneka kwenziwe ngumntu onamava oqhuba i-endotracheal onezinga eliphezulu lempumelelo.
• Ukubekwa ngokuchanekileyo kwetyhubhu ye-endotracheal kufuneka kuqinisekiswe nge-waveform capnography.
• Ukuba akukho zi-intubators ezinamava, kusengqiqweni ukufaka i-supraglottic airway (SGA) okanye ukugcina indlela yomoya usebenzisa iindlela ezisisiseko de kubekho i-intubator enobuchule.
Ulawulo lweoksijini
• Emva kweROSC, i-100% (okanye ekhoyo kakhulu) ioksijini isetyenziswa de kube kukwazi ukulinganiswa ngokuthembekileyo ioksijini emithanjeni okanye uxinzelelo oluncinci lweoksijini emithanjeni.
• Nje ukuba ukugcwala kweoksijini kwimithambo yegazi kunokulinganiswa ngokuthembekileyo okanye ixabiso legesi yegazi kwimithambo yegazi linokufunyanwa, ioksijini ephefumlelweyo iyalinganiswa ukuze kufunyanwe ukugcwala kweoksijini kwimithambo yegazi engama-94-98% okanye uxinzelelo lweoksijini oluyinxenye yemithambo yegazi (PaO2) oluyi-10 ukuya kwi-13 kPa okanye i-75 ukuya kwi-100 mmHg (Umfanekiso 2).
• 避免ROSC后的低氧血症(PaO2 < 8 kPa或60 mmHg).
• Kuphephe uxinezeleko olukhulu emva kokusebenzisa i-ROSC.
Ulawulo lomoya ophumayo
• Fumana iigesi zegazi eziphuma kwimithambo yegazi kwaye usebenzise ukujonga i-CO2 ekupheleni kolwandle kwizigulana ezisebenzisa umoya opholileyo.
• Kwizigulane ezifuna umoya ongenisiweyo emva kweROSC, lungisa umoya ongenisiweyo ukuze ufumane uxinzelelo oluqhelekileyo lwe-arterial partial pressure ye-carbon dioxide (PaCO2) ye-4.5 ukuya kwi-6.0 kPa okanye i-35 ukuya kwi-45 mmHg.
• I-PaCO2 ijongwa rhoqo kwizigulana ezinyangwa ngolawulo lobushushu olujoliswe kuzo (TTM) kuba i-hypocapnia inokubakho.
• Amaxabiso egesi yegazi ahlala elinganiswa kusetyenziswa iindlela zokulungisa ubushushu okanye ezingezizo ezobushushu ngexesha le-TTM kunye nobushushu obuphantsi.
• Sebenzisa icebo lokukhusela imiphunga ukuze ufumane ubunzima bomzimba obuyi-6 ukuya kwi-8 ml/kg efanelekileyo.
2. Ukujikeleza kwegazi kwimithambo yegazi
Ukuphinda kufakwe igazi emzimbeni
• Izigulane zabantu abadala ezine-ROSC emva kokurhanelwa kokuma kwentliziyo kunye nokuphakama kwe-ST-segment kwi-ECG kufuneka ziphononongwe ngokukhawuleza kwilebhu yokuhlolwa kwe-cardiac catheterization (i-PCI kufuneka yenziwe ngoko nangoko ukuba kubonisiwe).
• Uvavanyo olukhawulezileyo lwelabhoratri ye-cardiac catheterization kufuneka luqwalaselwe kwizigulane ezine-ROSC ezine-cardiac arrest yangaphandle kwesibhedlele (OHCA) ezingenalo i-ST-segment elevation kwi-ECG kwaye kuqikelelwa ukuba zinamathuba aphezulu okuvaleka kwemithambo yentliziyo (umz., izigulane ezine-hemodynamic kunye/okanye ezingazinzanga ngombane).
Ukubeka esweni nolawulo lwe-Haemodynamic
• Ukuhlolwa rhoqo koxinzelelo lwegazi nge-ductus arteriosus kufuneka kwenziwe kubo bonke abaguli, kwaye ukubekwa kweliso lokukhupha kwentliziyo kufanelekile kwizigulane ezingazinzanga ngokwe-hemodynamics.
• Yenza i-echocardiogram kwangoko (ngokukhawuleza kangangoko kunokwenzeka) kubo bonke abaguli ukuze kuchongwe naziphi na iimeko zentliziyo ezingaphantsi kunye nokulinganisa ukungasebenzi kakuhle kwentliziyo.
• Kuphephe ukuncipha kwe-hypotension (< 65 mmHg). Jonga uxinzelelo oluphakathi lwemithambo yegazi (MAP) ukuze ufumane imveliso eyaneleyo yomchamo (> 0.5 mL/kg*h kunye ne-lactate eqhelekileyo okanye enciphileyo (Umfanekiso 2).
• I-Bradycardia ingashiywa inganyangwa ngexesha le-TTM kuma-33°C ukuba uxinzelelo lwegazi, i-lactate, i-ScvO2, okanye i-SvO2 zanele. Ukuba akunjalo, cinga ngokunyusa ubushushu obujoliswe kubo, kodwa bungadluli kuma-36°C.
• Ukugcinwa koxinzelelo lomoya olusebenzisa ulwelo, i-norepinephrine, kunye/okanye i-dobutamine kuxhomekeke kwimfuneko yomthamo wemithambo yegazi, ukuqina kwemithambo yegazi, okanye ukuqiniswa kwemisipha kwisigulana ngasinye.
• Kuphephe i-hypokalemia, enxulunyaniswa ne-ventricular arrhythmias.
• Ukuba ukuvuselelwa kolwelo, ukuqiniswa kwemisipha, kunye nonyango olusebenzisa imithambo yegazi alwanelanga, inkxaso yokujikeleza kwegazi ngoomatshini (umz., ipompo yebhaluni ye-intra-aortic, isixhobo sokuncedisa i-ventricular yasekhohlo, okanye i-oxygenation ye-extracorporeal membrane ye-arteriovenous) zinokuqwalaselwa kunyango loxinzelelo oluqhubekayo lwentliziyo olubangelwa kukusilela kwe-ventricular yasekhohlo. Izixhobo zokuncedisa i-ventricular yasekhohlo okanye i-oxygenation ye-extracorporeal endovascular nazo kufuneka ziqwalaselwe kwizigulana ezine-haemodynamically unstable acute coronary syndrome (ACS) kunye ne-recurrent ventricular tachycardia (VT) okanye i-ventricular fibrillation (VF), nangona kukho iindlela zonyango ezifanelekileyo.
3. Umsebenzi womzimba (ukuphucula ukubuyiselwa kwemithambo-luvo)
Lawula ukuxhuzula
• Sicebisa ukusetyenziswa kwe-electroencephalogram (EEG) ukuxilonga i-electrospasms kwizigulane ezine-clinical dyvulsions kunye nokujonga indlela ezisabela ngayo kunyango.
• Ukuze kunyangwe ukuxhuzula emva kokuba intliziyo imile, sicebisa i-levetiracetam okanye i-sodium valproate njengeyeza lokuqala zokulwa nokuxhuzula ukongeza kumayeza okuthomalalisa.
• Sicebisa ukuba singasebenzisi uthintelo lokuxhuzula rhoqo kwizigulana emva kokuba intliziyo imile.
Ulawulo lobushushu
• Kubantu abadala abangasabeliyo kwi-OHCA okanye ekubanjweni kwentliziyo esibhedlele (nasiphi na isigqi sentliziyo sokuqala), sicebisa ulawulo lobushushu olujoliswe ekujoliswe kulo (i-TTM).
• Gcina ubushushu obujoliswe kubo buhlala buphakathi kwama-32 nama-36°C ubuncinane iiyure ezingama-24.
• Kwizigulane ezihlala zikhohlela, phepha umkhuhlane (> 37.7°C) ubuncinane iiyure ezingama-72 emva kokufumana i-ROSC.
• Musa ukusebenzisa isisombululo somkhuhlane ngaphambi kokuba ungeniswe esibhedlele ukuze wehlise ubushushu bomzimba. Ulawulo Olupheleleyo Lonyango Olunzulu – Ukusetyenziswa kwemithi yokuthomalalisa esebenza ngokukhawuleza kunye ne-opioids.
• Ukusetyenziswa rhoqo kwamayeza okuvimba imisipha yemithambo-luvo kuyathintelwa kwizigulane ezine-TTM, kodwa kunokuqwalaselwa kwiimeko zokugodola okukhulu ngexesha le-TTM.
• Uthintelo lwezilonda zoxinzelelo luhlala lunikwa izigulana ezinesifo sentliziyo.
• Ukuthintela i-deep vein thrombosis.
• 如果需要，使用胰岛素输注将血糖定位為7.8-10 mmol/L（140- 180 mg/dL），避免低血糖 mmol（<0 mg）<4.0 mg）<4.
• Qalisa ukutya okunesondlo okunezinga eliphantsi (ukondla okunesondlo) ngexesha le-TTM kwaye wonyuse emva kokufudumeza kwakhona ukuba kuyimfuneko. Ukuba i-TTM engama-36°C isetyenziswa njengobushushu ekujoliswe kubo, izinga lokondla elinesondlo linokunyuka kwangethuba ngexesha le-TTM.
• Asikukhuthazi ukusetyenziswa rhoqo kwee-antibiotics zokuthintela umhlaza.
4. Uqikelelo oluqhelekileyo
Izikhokelo ngokubanzi
• Asicebisi amayeza okuthintela ukugula kwizigulane ezingakwaziyo ukuzenzela nto emva kokuba zivuselelwe emva kokuma kwentliziyo, kwaye kufuneka kwenziwe uvavanyo lwe-neuroprognosis ngokuhlolwa kweklinikhi, i-electrophysiology, ii-biomarkers, kunye ne-imaging, zombini ukwazisa izalamane zesigulana kunye nokunceda oogqirha bajolise kunyango ngokusekelwe kumathuba esigulana okufumana ukuphumla okubalulekileyo kwemithambo-luvo (Umfanekiso 3).
• Akukho sibikezeli sinye sichanekileyo ngokupheleleyo. Ke ngoko, sicebisa icebo lokuqikelela i-neural elisebenzisa iindlela ezininzi.
• Xa kuqikelelwa iziphumo ezingalunganga zemithambo-luvo, kufuneka ukucacisa okuphezulu kunye nokuchaneka ukuze kuthintelwe ukuqikelela okungekho ngqiqweni.
• Uvavanyo lweklinikhi lwe-neurological lubalulekile ukuze kufunyanwe isibikezelo. Ukuze kuthintelwe ukuqikelela okungalunganga okungafanelekanga, oogqirha kufuneka baphephe ukubhidanisa iziphumo zovavanyo ezinokubhidanisa ngamayeza okuthomalalisa kunye namanye amayeza.
• Uvavanyo lweklinikhi lwemihla ngemihla luyakhuthazwa xa izigulane zinyangwa nge-TTM, kodwa uvavanyo lokugqibela lokuxela kwangaphambili kufuneka lwenziwe emva kokuvuselelwa.
• Iingcali zonyango kufuneka ziqaphele umngcipheko wokuzicingela ngokwazo, okwenzeka xa kusetyenziswa iziphumo zovavanyo olubonisa iziphumo ezimbi xa kusenziwa izigqibo zonyango, ingakumbi ngokubhekiselele kunyango oluxhasa ubomi.
• Injongo yovavanyo lwe-Neuroprognosis Index kukuvavanya ubukhali bokwenzakala kwengqondo okungena-oxygen-ischemic. I-Neuroprognosis yenye yezinto ezininzi ekufuneka ziqwalaselwe xa kuxoxwa ngamathuba omntu okuchacha.
Uqikelelo lwemodeli ezininzi
• Qalisa uvavanyo lokuxela kwangaphambili ngovavanyo oluchanekileyo lweklinikhi, olwenziwa kuphela emva kokuba izinto ezinkulu ezididayo (umz., ukuthomalalisa okushiyekileyo, i-hypothermia) zingafakwanga (Umfanekiso 4)
• Xa kungekho zi-confounders, izigulane ezine-comatose ezine-ROSC ≥ M≤3 zingadlulanga iiyure ezingama-72 zinokuba neziphumo ezimbi ukuba zimbini okanye ngaphezulu kwezi zinto zilandelayo: akukho pupillary corneal reflex kwi-≥ iiyure ezingama-72, ukungabikho kwe-bilateral ye-N20 SSEP ≥ iiyure ezingama-24, i-high-grade EEG > iiyure ezingama-24, i-specific neuronal enolase (NSE) > 60 μg/L iiyure ezingama-48 kunye/okanye iiyure ezingama-72, i-state myoclonus ≤ iiyure ezingama-72, okanye i-diffuse brain CT, i-MRI kunye nokulimala okukhulu kwe-hypoxic. Uninzi lwezi mpawu zinokurekhodwa ngaphambi kweeyure ezingama-72 ze-ROSC; Nangona kunjalo, iziphumo zazo ziya kuvavanywa kuphela ngexesha lovavanyo lweklinikhi.
Uvavanyo lweklinikhi
• Uvavanyo lweklinikhi lunokuphazanyiswa zii-sedative, ii-opioid, okanye iziphumzi zemisipha. Ukuphazamiseka okunokwenzeka ngenxa ye-residual sedation kufuneka kuqwalaselwe kwaye kususwe.
• Kwizigulana ezihlala kwi-coma emva kweeyure ezingama-72 okanye kamva emva kwe-ROSC, olu vavanyo lulandelayo lunokuxela kwangaphambili ukuba isifo semithambo-luvo siya kuba sibi kakhulu.
• Kwizigulane ezihlala zikhohlela emva kweeyure ezingama-72 okanye kamva emva kweROSC, ezi mvavanyo zilandelayo zinokuxela kwangaphambili iziphumo ezibi zemithambo-luvo:
– Ukungabikho kwe-double standard pupillary light reflexes
– I-Quantitative pupilometry
– Ukulahlekelwa yi-corneal reflex kumacala omabini
– I-Myoclonus zingadlulanga iiyure ezingama-96, ingakumbi i-state myoclonus zingadlulanga iiyure ezingama-72
Sikwacebisa ukuba urekhode i-EEG xa kukho i-myoclonic tics ukuze kubonwe nawuphi na umsebenzi we-epileptiform onxulumene nayo okanye kuchongwe iimpawu ze-EEG, ezifana nokuphendula kwangasemva okanye ukuqhubeka, nto leyo ebonisa ukuba kunokwenzeka ukuba ubuchopho bubuyele esiqhelweni.
i-neurophysiology
• I-EEG (i-electroencephalogram) yenziwa kwizigulana ezilahlekelwa zingqondo emva kokuma kwentliziyo.
• Iipateni ze-EEG ezinobungozi kakhulu ziquka imvelaphi yokucinezelwa okunokuphuma okanye okungenazo iintshukumo ezithile kunye nokucinezelwa okuqhumayo. Sicebisa ukuba kusetyenziswe ezi pateni ze-EEG njengophawu lokungafumani ziphumo zilungileyo emva kokuphela kwe-TTM nasemva kokuthomalalisa.
• Ukubakho kwesifo sokuxhuzula esiqinisekileyo kwi-EEG kwiiyure zokuqala ezingama-72 emva kwe-ROSC kubonisa ukuba isifo asikabi nakwenzeka.
• Ukungafumani mpendulo ichanekileyo kwi-EEG kubonisa ukuba umntu akafumani mpendulo ifanelekileyo emva kokuba intliziyo yakhe imile.
• Ukulahleka kwe-cortical N20 potential okubangelwa zi-somatosensory ezibangelwa zi-bilateral somatosensory yimbonakaliso yokuba i-prognosis ayilunganga emva kokuma kwentliziyo.
• Iziphumo ze-EEG kunye ne-somatosensory evoked potentials (SSEP) zihlala ziqwalaselwa xa kujongwa uvavanyo lweklinikhi kunye nezinye iimvavanyo. Amayeza okuthintela imisipha kufuneka aqwalaselwe xa kusenziwa i-SSEP.
Iimpawu zebhayoloji
• Sebenzisa uluhlu lweemilinganiselo ze-NSE kunye nezinye iindlela zokuqikelela iziphumo emva kokuma kwentliziyo. Amaxabiso aphezulu kwiiyure ezingama-24 ukuya kuma-48 okanye iiyure ezingama-72, kunye namaxabiso aphezulu kwiiyure ezingama-48 ukuya kuma-72, abonisa ukuba i-prognosis ayilunganga.
Ukufota
• Sebenzisa izifundo zokujonga ubuchopho ukuqikelela iziphumo zemithambo-luvo ezingalunganga emva kokuma kwentliziyo kunye nezinye izinto ezixela kwangaphambili kwiindawo ezinamava ophando afanelekileyo.
• Ukubakho kwe-generalized cerebral edema, okubonakaliswa kukwehla okuphawulekayo komlinganiselo we-grey/white matter kwi-brain CT, okanye umda wokusasazeka ngokubanzi kwi-brain MRI, kuxela kwangaphambili ukuba isifo se-neurological prognosis asilunganga emva kokuma kwentliziyo.
• Iziphumo zomfanekiso-ngqondweni zihlala ziqwalaselwa kunye nezinye iindlela zokuqikelela uqikelelo lwesifo semithambo-luvo.
5. Yeka unyango oluxhasa ubomi
• Ingxoxo eyahlukileyo malunga novavanyo lokuxela kwangaphambili malunga nokurhoxa kunye nokubuyiselwa kwe-neurological of life-sustaining therapy (WLST); Isigqibo se-WLST kufuneka siqwalasele ezinye iinkalo ngaphandle kokwenzakala kwengqondo, njengobudala, izifo ezihambisana noko, ukusebenza kwamalungu omzimba, kunye nokukhethwa kwesigulana.
Beka ixesha elaneleyo lokunxibelelana, ixesha elide emva kokubanjwa kwentliziyo
Inqanaba lonyango kwiqela limisela kwaye • lenza uvavanyo lomsebenzi ngokwasemzimbeni nangaphandle kolwasekhaya kunye nezalamane. Ukufunyanwa kwangoko kweemfuno zokuvuselelwa komzimba ngaphambi kokukhululwa emsebenzini kunye nokunikezelwa kweenkonzo zokuvuselelwa xa kuyimfuneko. (Umfanekiso 5).
• Lungiselela utyelelo lokulandelela bonke abasindileyo ekubanjweni yintliziyo zingadlulanga iinyanga ezi-3 emva kokukhululwa, kuquka oku kulandelayo:
- 1. Uvavanyo lweengxaki zengqondo.
2. Hlola iingxaki zeemvakalelo kunye nokudinwa.
3. Nika ulwazi nenkxaso kwabasindileyo nakwiintsapho.
6. Ukunikela ngamalungu omzimba
• Zonke izigqibo malunga nokunikela ngezitho zomzimba kufuneka zihambelane neemfuno zomthetho nezokuziphatha zasekuhlaleni.
• Ukunikela ngezitho zomzimba kufanele kuthathelwe ingqalelo kwabo bahlangabezana neROSC kwaye bahlangabezana nemigangatho yokufa kwemithambo-luvo (Umfanekiso 6).
• Kwizigulane eziphefumlelwe ngumoya ezingahlangabezaniyo nemigangatho yokufa kwemithambo-luvo, ukunikela ngamalungu omzimba kufuneka kuqwalaselwe ngexesha lokuma kwegazi ukuba kwenziwe isigqibo sokuqala unyango lokuphela kobomi kunye nokuyeka inkxaso yobomi.
Ixesha leposi: Julayi-26-2024