isifinyezo
I-European Resuscitation Council (ERC) kanye ne-European Society of Critical Care Medicine (ESICM) babambisene ukuthuthukisa lezi ziqondiso zokunakekelwa ngemva kokuvuselelwa kwabadala, ngokuhambisana ne-International Consensus ka-2020 International on the Science and Treatment of CPR. Izihloko ezihlanganisiwe zifaka phakathi i-post-cardiac arrest syndrome, ukuxilongwa kwezimbangela zokuma kwenhliziyo, ukulawulwa komoya-mpilo kanye nokuphefumula, ukufakwa kwe-coronary, ukuqapha kanye nokuphathwa kwe-hemodynamic, ukulawulwa kokuxhuzula, ukulawulwa kokushisa, ukuphathwa kokunakekelwa okujulile okuvamile, ukubikezela, imiphumela yesikhathi eside, ukuvuselelwa, kanye nokunikelwa kwezitho zomzimba.
Amagama angukhiye: Ukuboshwa kwenhliziyo, ukunakekelwa kokuvuselelwa ngemva kokuhlinzwa, ukubikezela, iziqondiso
Isingeniso kanye nobubanzi
Ngo-2015, i-European Resuscitation Council (ERC) kanye ne-European Society of Critical Care Medicine (ESICM) babambisana ukuthuthukisa iziqondiso zokuqala zokunakekelwa ngemva kokuvuselelwa, ezanyatheliswa ku-Resuscitation and Critical Care Medicine. Lezi ziqondiso zokunakekelwa ngemva kokuvuselelwa zabuyekezwa kabanzi ngo-2020 futhi zafaka isayensi eyanyatheliswa kusukela ngo-2015. Izihloko ezihlanganisiwe zifaka phakathi i-post-cardiac arrest syndrome, i-oxygen kanye ne-ventilation control, i-hemodynamic target, i-coronary infusion, i-target rate rate management, i-seizure control, i-prognosis, i-rehabilitation, kanye nemiphumela yesikhathi eside (Isithombe 1).
Isifinyezo sezinguquko ezinkulu
Ukunakekelwa okusheshayo ngemva kokuvuselelwa:
• Ukwelashwa ngemva kokuvuselelwa kuqala ngokushesha ngemva kwe-ROSC eqhubekayo (ukululama kokujikeleza kwegazi okuzenzakalelayo), kungakhathaliseki indawo (Isithombe 1).
• Uma unesifo senhliziyo ungaphandle kwesibhedlela, cabanga ngokuya esikhungweni sokwelapha ukuhlaselwa yinhliziyo. Thola imbangela yokuhlaselwa yinhliziyo.
• Uma kukhona ubufakazi bezokwelapha (isib. ukungazinzile kwe-hemodynamic) noma ubufakazi be-ECG bokushaqeka kwenhliziyo, kwenziwa i-coronary angiography kuqala. Uma i-coronary angiography ingabonisi isilonda esibangela, kwenziwa i-CT encepography kanye/noma i-CT pulmonary angiography.
• Ukuhlonza kusenesikhathi izinkinga zokuphefumula noma zezinzwa kungenziwa ngokwenza ukuhlolwa kwe-CT kobuchopho nesifuba ngesikhathi sokulaliswa esibhedlela, ngaphambi noma ngemva kwe-coronary angiography (bheka i-Coronary Reperfusion).
• Yenza i-CT yobuchopho kanye/noma i-angiography yamaphaphu uma kunezibonakaliso noma izimpawu ezibonisa imbangela yezinzwa noma yokuphefumula ngaphambi kwe-asystole (isb., ikhanda elibuhlungu, isithuthwane, noma ukuntuleka kwezinzwa, ukuphefumula okufushane, noma i-hypoxemia ebhalwe ezigulini ezinezimo zokuphefumula ezaziwayo).
1. Indlela yokuphefumula kanye nokuphefumula
Ukuphathwa komoya ngemva kokujikeleza kwegazi okuzenzakalelayo sekubuyiselwe esimweni sako
• Ukusekelwa komoya kanye nokuphefumula kufanele kuqhubeke ngemuva kokululama kokujikeleza kwegazi okuzenzakalelayo (ROSC).
• Iziguli eziye zaba nokuma kwenhliziyo okwesikhashana, ukubuyela ngokushesha ekusebenzeni okuvamile kobuchopho, kanye nokuphefumula okuvamile kungenzeka kungadingi ukufakwa kwe-endotracheal intubation, kodwa kufanele zinikezwe umoya-mpilo ngemaski uma ukugcwala komoya-mpilo wazo emithanjeni kungaphansi kwama-94%.
• Ukufakwa kwe-endotracheal intubation kufanele kwenziwe ezigulini ezihlala zi-comatose ngemva kwe-ROSC, noma ezigulini ezinezinye izinkomba zezokwelapha zokupholisa kanye nokuphefumula ngomshini, uma ukufakwa kwe-endotracheal intubation kungenziwa ngesikhathi se-CPR.
• Ukufakwa kwe-endotracheal intubation kufanele kwenziwe ngumuntu onolwazi onesilinganiso esiphezulu sempumelelo.
• Ukubekwa kahle kwepayipi le-endotracheal kumele kuqinisekiswe nge-waveform capnography.
• Uma kungekho ama-intubator anolwazi, kunengqondo ukufaka i-supraglottic airway (SGA) noma ukugcina i-airway usebenzisa amasu ayisisekelo kuze kube yilapho kutholakala i-intubator enekhono.
Ukulawulwa komoya-mpilo
• Ngemva kwe-ROSC, kusetshenziswa i-oxygen engu-100% (noma etholakalayo kakhulu) kuze kube yilapho ukugcwala kwe-oxygen emithanjeni noma ukucindezela okuyingxenye kwe-oxygen emithanjeni kungalinganiswa ngokuthembekile.
• Uma ukugcwala komoya-mpilo emithanjeni sekulinganiswe ngokuthembekile noma inani legesi yegazi emithanjeni lingatholakala, umoya-mpilo ophefumulelwe uyalinganiswa ukuze kufezwe ukugcwala komoya-mpilo emithanjeni okungu-94-98% noma ingcindezi engaphelele yomoya-mpilo (PaO2) emithanjeni engu-10 kuya ku-13 kPa noma engu-75 kuya ku-100 mmHg (Isithombe 2).
• 避免ROSC后的低氧血症(PaO2 <8 kPa或60 mmHg).
• Gwema i-hyperxemia ngemva kwe-ROSC.
Ukulawula ukuphefumula
• Thola amagesi egazi emithanjeni bese usebenzisa ukuqapha kwe-CO2 kokuphela kolwandle ezigulini eziphefumula ngomshini.
• Ezigulini ezidinga ukuphefumula ngomshini ngemva kwe-ROSC, lungisa ukuphefumula ukuze kufinyelelwe ukucindezela okuvamile kwe-carbon dioxide (PaCO2) kwemithambo yegazi okungu-4.5 kuya ku-6.0 kPa noma okungu-35 kuya ku-45 mmHg.
• I-PaCO2 ivame ukubhekwa ezigulini ezelashwa ngokulawulwa kokushisa okuqondiwe (TTM) ngoba i-hypocapnia ingase ivele.
• Amanani egesi egazini ahlala elinganiswa kusetshenziswa izindlela zokulungisa izinga lokushisa noma ezingezona izinga lokushisa ngesikhathi se-TTM kanye namazinga okushisa aphansi.
• Sebenzisa isu lokungenisa umoya elivikela amaphaphu ukuze ufinyelele umthamo womoya ofanele ongu-6 - 8 ml/kg.
2. Ukujikeleza kwegazi kwenhliziyo
Ukuphinda kufakwe uketshezi
• Iziguli ezindala ezine-ROSC ngemuva kokusolwa kokuma kwenhliziyo kanye nokuphakama kwe-ST-segment ku-ECG kufanele zihlolwe ngokushesha elabhorethri yokuhlolwa kwe-catheterization yenhliziyo (i-PCI kufanele yenziwe ngokushesha uma kuboniswe).
• Ukuhlolwa kwelabhorethri okuphuthumayo kokufakwa kwe-catheter yenhliziyo kufanele kucatshangelwe ezigulini ezine-ROSC ezine-cardiac arrest yangaphandle kwesibhedlela (OHCA) ezingenayo i-ST-segment elevation ku-ECG futhi okulinganiselwa ukuthi zinamathuba aphezulu okuvaleka kwemithambo yenhliziyo (isb., iziguli ezine-hemodynamic kanye/noma ezingazinzile ngogesi).
Ukuqapha nokuphatha i-Haemodynamic
• Ukuqapha okuqhubekayo komfutho wegazi nge-ductus arteriosus kufanele kwenziwe kubo bonke iziguli, futhi ukuqapha ukuphuma kwenhliziyo kunengqondo ezigulini ezingazinzile ngenxa yokungasebenzi kahle kwegazi.
• Yenza i-echocardiogram kusenesikhathi (ngokushesha ngangokunokwenzeka) kubo bonke iziguli ukuze kutholakale noma yiziphi izimo zenhliziyo eziyisisekelo futhi kulinganiswe izinga lokungasebenzi kahle kwenhliziyo.
• Gwema ukwehla komfutho wegazi (< 65 mmHg). Qondisa umfutho wegazi ojwayelekile (MAP) ukuze uthole umphumela ofanele womchamo (> 0.5 mL/kg*h kanye ne-lactate evamile noma encishisiwe (Isithombe 2).
• I-Bradycardia ingashiywa ingelashwa ngesikhathi se-TTM kuma-33°C uma umfutho wegazi, i-lactate, i-ScvO2, noma i-SvO2 zanele. Uma kungenjalo, cabanga ngokwandisa izinga lokushisa eliqondiwe, kodwa kungabi ngaphezu kwama-36°C.
• Ukugcinwa kokugeleza kwegazi ngoketshezi, i-norepinephrine, kanye/noma i-dobutamine kuye ngesidingo somthamo wemithambo yegazi, ukuqina kwemithambo yegazi, noma ukufinyela kwemisipha esigulini ngasinye.
• Gwema i-hypokalemia, ehlotshaniswa nokuphazamiseka kwe-ventricular arrhythmias.
• Uma ukuvuselelwa koketshezi, ukufinyela kwemisipha, kanye nokwelashwa ngemithambo yegazi kunganele, ukwesekwa kokujikeleza kwegazi ngomshini (isb., iphampu yebhaluni ye-intra-aortic, idivayisi yokusiza i-ventricular yangakwesobunxele, noma i-oxygenation ye-extracorporeal membrane ye-arteriovenous) kungacatshangelwa ekwelapheni ukushaqeka okuqhubekayo kwenhliziyo okubangelwa ukwehluleka kwe-ventricular yangakwesobunxele. Amadivayisi okusiza i-ventricular yangakwesobunxele noma i-oxygenation ye-extracorporeal endovascular kufanele futhi kucatshangelwe ezigulini ezine-haemodynamically unstable coronary syndrome (ACS) kanye ne-recurrent ventricular tachycardia (VT) noma i-ventricular fibrillation (VF), naphezu kwezinketho zokwelapha ezifanele.
3. Umsebenzi wokunyakaza (ukuthuthukisa ukululama kwezinzwa)
Lawula ukuquleka
• Sincoma ukusetshenziswa kwe-electroencephalogram (EEG) ukuxilonga i-electrospasms ezigulini ezine-clinical dynamics kanye nokuqapha impendulo yokwelashwa.
• Ukuze kwelashwe ukuxhuzula ngemva kokumiswa kwenhliziyo, siphakamisa i-levetiracetam noma i-sodium valproate njengemithi yokuqala yokulwa nokuxhuzula ngaphezu kwemithi yokudambisa.
• Sincoma ukuthi ungasebenzisi ukuvimbela ukuxhuzula okuvamile ezigulini ezilandela ukumiswa kwenhliziyo.
Ukulawula izinga lokushisa
• Kubantu abadala abangasabeli ku-OHCA noma ekumisweni kwenhliziyo esibhedlela (noma yisiphi isigqi senhliziyo sokuqala), siphakamisa ukuphathwa kokushisa okuqondiwe (i-TTM).
• Gcina izinga lokushisa eliqondiwe lihlala liphakathi kuka-32 no-36 °C okungenani amahora angu-24.
• Ezigulini ezihlala zi-comatose, gwema umkhuhlane (> 37.7°C) okungenani amahora angu-72 ngemva kwe-ROSC.
• Ungasebenzisi isisombululo esibandayo ngaphambi kokuya esibhedlela ukuze wehlise izinga lokushisa lomzimba. Ukuphathwa Kokunakekelwa Okujulile Okuvamile – Ukusetshenziswa kwemithi yokudambisa esebenza ngokushesha kanye nama-opioid.
• Ukusetshenziswa njalo kwemithi yokuvimba imisipha kuyagwenywa ezigulini ezine-TTM, kodwa kungacatshangelwa ezimweni zokubanda okukhulu ngesikhathi se-TTM.
• Ukuvimbela izilonda zokucindezeleka kunikezwa njalo ezigulini ezinesifo senhliziyo.
• Ukuvimbela 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（<4 mg）<4.0).
• Qala ukudla okunomsoco okuphansi (ukudla okunomsoco) ngesikhathi se-TTM bese ukhulisa ngemva kokufudumeza kabusha uma kudingeka. Uma kusetshenziswa i-TTM engu-36°C njengokushisa okuqondiwe, izinga lokuphakelwa kokudla okunomsoco lingakhuphuka kusenesikhathi ngesikhathi se-TTM.
• Asikukhuthazi ukusetshenziswa njalo kwama-antibiotic okuvimbela.
4. Ukubikezela okuvamile
Iziqondiso ezijwayelekile
• Asincomi ama-antibiotic okuvimbela iziguli eziqulekile ngemva kokuvuselelwa ngenxa yokuma kwenhliziyo, futhi ukubikezela i-neuroprognosis kufanele kwenziwe ngokuhlolwa kwezokwelapha, i-electrophysiology, ama-biomarker, kanye ne-imaging, kokubili ukwazisa izihlobo zesiguli kanye nokusiza odokotela ukuthi bahlose ukwelashwa ngokusekelwe emathubeni esiguli okuthola ukululama okunenjongo kwemizwa (Isithombe 3).
• Akukho sibikezeli esisodwa esinembile ngokuphelele. Ngakho-ke, sincoma isu lokubikezela imizwa ngezindlela eziningi.
• Uma kubikezelwa imiphumela emibi yezinzwa, kudingeka ukucacisa okuphezulu nokunemba ukuze kugwenywe izibikezelo ezingamanga zokuphelelwa yithemba.
• Ukuhlolwa kwezinzwa zezokwelapha kubalulekile ukuze kutholakale isibikezelo. Ukuze kugwenywe izibikezelo ezingelona iqiniso ngephutha, odokotela kufanele bagweme ukudida imiphumela yokuhlolwa engadidaniswa yimithi yokudambisa kanye neminye imithi.
• Ukuhlolwa kwezokwelapha kwansuku zonke kuyakhuthazwa lapho iziguli zelashwa nge-TTM, kodwa ukuhlolwa kokugcina kokubikezela kufanele kwenziwe ngemva kokuvuselelwa.
• Odokotela kumele baqaphele ingozi yokuthambekela kokuprofetha okubangelwa yibo, okwenzeka lapho kusetshenziswa imiphumela yokuhlolwa kwenkomba ebikezela imiphumela emibi ezinqumweni zokwelapha, ikakhulukazi maqondana nezindlela zokwelapha ezisekela impilo.
• Inhloso yokuhlolwa kwe-Neuroprognosis Index ukuhlola ubukhali bokulimala kobuchopho okungena-hypoxic-ischemic. Ukubikezela i-neuroprognosis kungenye yezici eziningana okufanele uzicabangele lapho uxoxa ngamakhono omuntu okululama.
Ukubikezela kwamamodeli amaningi
• Qala ukuhlolwa kokubikezela ngokuhlolwa okunembile kwezokwelapha, okwenziwa kuphela ngemva kokuba izici ezinkulu ezididayo (isb., ukuthulisa okusele, i-hypothermia) sezikhishiwe (Isithombe 4)
• Uma kungekho ziphazamiso, iziguli ezine-comatose ezine-ROSC ≥ M≤3 zingakapheli amahora angu-72 cishe zizoba nemiphumela emibi uma kukhona izibikezelo ezimbili noma ngaphezulu ezilandelayo: akukho pupillary corneal reflex kumahora angu-≥ angu-72, ukungabikho kwe-bilateral N20 SSEP ≥ amahora angu-24, i-high-grade EEG > amahora angu-24, i-specific neuronal enolase (NSE) > 60 μg/L amahora angu-48 kanye/noma amahora angu-72, i-state myoclonus ≤ amahora angu-72, noma i-diffuse brain CT, i-MRI kanye nokulimala okukhulu kwe-hypoxic. Iningi lalezi zimpawu lingaqoshwa ngaphambi kwamahora angu-72 e-ROSC; Kodwa-ke, imiphumela yazo izohlolwa kuphela ngesikhathi sokuhlolwa kokubikezela kwezokwelapha.
Ukuhlolwa kwezokwelapha
• Ukuhlolwa kwezokwelapha kungahle kuphazanyiswe yimithi yokudambisa ukucindezeleka, ama-opioid, noma imithi yokuphumula imisipha. Ukudida okungenzeka ngokudambisa ukucindezeleka okusele kufanele kucatshangelwe futhi kukhishwe.
• Ezigulini ezihlala zise-coma emahoreni angu-72 noma kamuva ngemva kwe-ROSC, ukuhlolwa okulandelayo kungase kubikezele ukubikezela okubi kakhulu kwezinzwa.
• Ezigulini ezihlala zi-comatose emahoreni angu-72 noma kamuva ngemva kwe-ROSC, ukuhlolwa okulandelayo kungabikezela imiphumela emibi yezinzwa:
– Ukungabikho kokukhanya okujwayelekile kwe-pupillary okubili
- I-quantitative pupilometry
- Ukulahlekelwa yi-corneal reflex kuzo zombili izinhlangothi
– I-Myoclonus zingakapheli amahora angu-96, ikakhulukazi i-state myoclonus zingakapheli amahora angu-72
Sincoma futhi ukuqopha i-EEG lapho kukhona i-myoclonic tics ukuze kutholakale noma yimuphi umsebenzi we-epileptiform ohambisanayo noma ukuhlonza izimpawu ze-EEG, njengokusabela kwangemuva noma ukuqhubeka, okuphakamisa amathuba okululama kwezinzwa.
i-neurophysiology
• I-EEG (i-electroencephalogram) yenziwa ezigulini ezilahlekelwa ukwazi ngemva kokumiswa kwenhliziyo.
• Amaphethini e-EEG anobungozi kakhulu afaka phakathi izizinda zokucindezela lapho kukhona noma kungekho ukuphuma kwegazi ngezikhathi ezithile kanye nokucindezela okuqhumayo. Sincoma ukusebenzisa la maphethini e-EEG njengesibonakaliso sokubikezela okubi ngemva kokuphela kwe-TTM kanye nangemva kokudambisa.
• Ukuba khona kokuquleka okuqondile ku-EEG emahoreni okuqala angu-72 ngemva kwe-ROSC kuyinkomba yokubikezela okubi.
• Ukuntuleka kwempendulo yangemuva ku-EEG kuyinkomba yokubikezela okubi ngemva kokumiswa kwenhliziyo.
• Ukulahlekelwa yi-cortical N20 potential okubangelwa yi-somatosensory bilateral somatosensory kuyinkomba yokubikezela okubi ngemva kokumiswa kwenhliziyo.
• Imiphumela ye-EEG kanye ne-somatosensory evoked potentials (SSEP) ivame ukucatshangelwa kumongo wokuhlolwa kwezokwelapha kanye nokunye ukuhlolwa. Imithi yokuvimba imisipha yemizwa kumele icatshangelwe lapho kwenziwa i-SSEP.
Ama-biomarker
• Sebenzisa uhla lwezilinganiso ze-NSE kanye nezinye izindlela ukubikezela imiphumela ngemva kokumiswa kwenhliziyo. Amanani aphezulu emahoreni angu-24 kuya kwangu-48 noma emahoreni angu-72, ahlanganiswe namanani aphezulu emahoreni angu-48 kuya kwangu-72, abonisa ukubikezela okubi.
Ukuthwebula izithombe
• Sebenzisa izifundo zokuthatha izithombe zobuchopho ukubikezela imiphumela emibi yezinzwa ngemva kokumiswa kwenhliziyo kanye nezinye izibikezeli ezindaweni ezinolwazi olufanele locwaningo.
• Ukuba khona kwe-generalized cerebral edema, okubonakaliswa ukwehla okuphawulekayo kwesilinganiso se-grey/white matter ku-brain CT, noma ukulinganiselwa okubanzi kokusabalala ku-brain MRI, kubikezela ukubikezela okubi kwe-neurological ngemva kokumiswa kwenhliziyo.
• Okutholakele kwezithombe kuvame ukubhekwa njengokuhlanganiswa nezinye izindlela zokubikezela ukubikezela kwezifo zemizwa.
5. Yeka ukwelashwa okusekela impilo
• Ingxoxo ehlukile yokuhlolwa kokubikezela kokuhoxa kanye nokululama kwezinzwa kokwelashwa okusekela impilo (i-WLST); Isinqumo se-WLST kufanele sicabangele ezinye izici ngaphandle kokulimala kobuchopho, njengobudala, izifo ezihambisana naso, ukusebenza kwezitho zomzimba, kanye nokukhethwa kwesiguli.
Beka isikhathi esanele sokuxhumana, ukubikezela isikhathi eside ngemva kokuma kwenhliziyo
Izinga lokwelashwa ngaphakathi kwethimba linquma futhi • lenze ukuhlolwa kokusebenza ngokomzimba nangokwezihlobo nezihlobo. Ukutholwa kusenesikhathi kwezidingo zokuvuselelwa kokukhubazeka ngokomzimba ngaphambi kokukhululwa kanye nokuhlinzekwa kwezinsizakalo zokuvuselelwa uma kudingeka. (Isithombe 5).
• Hlela ukuvakasha kokulandelela kwabo bonke abasindile ekumisweni kwenhliziyo zingakapheli izinyanga ezi-3 bekhululiwe, okuhlanganisa okulandelayo:
- 1. Ukuhlolwa kwezinkinga zokuqonda.
2. Hlola izinkinga zemizwa kanye nokukhathala.
3. Nikeza ulwazi kanye nokusekela abasindile kanye nemindeni.
6. Ukunikela ngezitho zomzimba
• Zonke izinqumo mayelana nokunikela ngezitho zomzimba kumele zihambisane nezimfuneko zomthetho nezokuziphatha zendawo.
• Ukunikela ngezitho zomzimba kufanele kucatshangelwe kulabo abahlangabezana ne-ROSC futhi abahlangabezana nezindinganiso zokufa kwezinzwa (Isithombe 6).
• Ezigulini eziphefumula ngokuphefumula ezingahlangabezani nezindinganiso zokufa kwezinzwa, ukunikela ngezitho zomzimba kufanele kucatshangelwe ngesikhathi sokuma kokujikeleza kwegazi uma kwenziwa isinqumo sokuqala ukwelashwa kokuphela kokuphila nokuyeka ukwesekwa kokuphila.
Isikhathi sokuthunyelwe: Julayi-26-2024