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Внедрение, проблемы ресурса и ревизия

8.1 Местное выполнение

Есть сообщения, что внедрение умеренной гипотермии после остановки сердца отстает в большей части развитого мира – несколько обзоров последних двух лет сообщают,

что только приблизительно 25% ОИТ когда-либо использовали эту терапию [3]. [215-218]

Однако, об успешном внедрение гипотермии сейчас сообщают много центров [2 +]. [15 38 39 59 114 219]

‘

Алгоритм помощи после остановки сердца включает [4]: [12]

1. Ранняя коронарная реперфузия и нормализация гемодинамики

2. Контроль вентиляции

3. Контроль за глюкозой крови

4. Температурный контроль

5. Лечение судорожных приступов.

Местное внедрение алгоритма лечения после остановки сердца требует сотрудничества

врачей и медсестер нескольких специальностей, в частности, специалистов, работающих в области интенсивной терапии и реанимации, экстренной медицинской помощи и кардиологии. Адаптация местных протоколов оказания помощи должна быть проведена совместно представителями всех этих дисциплин.

8.2 Привлечение ресурса

Многие из вмешательств, применяемых в постреанимационный период, не требуют

дорогого оборудования. У более дорогих систем охлаждения есть небольшие преимущества, но они, в любом случае, не являются существенными. Достижение адекватного среднего артериального давления и контроль глюкозы крови - также относительно недорогие вмешательства. В некоторые системах здравоохранения отсутствие интервенционных систем кардиологии мешает осуществлению своевременного ЧКВ в первые 24 часа, но в большинстве случаев возможно достигнуть ранней реперфузии посредством тромболитической терапии. Использование гипотермии не должно значительно увеличивать продолжительность пребывания в ОИТ. Данные, подтверждающие это, ожидаются.

8.3 Ключевые пункты для ревизии

Оказание помощи после остановки сердца должно быть предметом регулярной ревизии. Результат лечения пациентов, поступивших в ОИТ после остановки сердца, должен быть предметом регулярной и непрерывной ревизии.

8.4 Рекомендации для исследования

Следующие ключевые вопросы исследований, касающиеся послереанимационного периода, должны быть адаптированы из данных, собранных рабочими группами AHA/ILCOR [4]. [10 220].

8.4.1 Эпидемиология

Изучение и контроль тенденций прогноза после остановки сердца в Великобритании.

8.4.2 Патофизиология

1. Механизмы и время течения комы после остановки сердца

2. Механизмы и продолжительность нейродегенерации после остановки сердца

3. Механизмы и продолжительность миокардиальной дисфункции после остановки сердца

4. Механизмы и продолжительность доставки кислорода и его утилизации после остановки сердца

5. Роль внутрисосудистой коагуляции в дисфункции и недостаточности органов после остановки сердца

6. Механизм, продолжительность и значение надпочечниковой недостаточности после остановки сердца.

8.4.3 Терапия

1. Оптимальное применение терапевтической гипотермии у пациента после остановки сердца.

a. Какая польза для пациентов?

b. Оптимальная целевая температура, начало, продолжительность, и уровень нагревания

c. Самая эффективная техника охлаждения – внешняя или внутренняя

d. Показания для использования миорелаксантов

2. Показания для раннего чрезкожного коронарного вмешательства

3. Оптимальная терапия миокардиальной дисфункции после остановки сердца:

a. медикаментозная

b. механическая

4. Клиническая польза контролируемой реоксигенации

5. Клиническая польза достижения ранней оптимизации гемодинамики

6. Оптимальные цели (параметры и целевые диапазоны) для ранней оптимизации гемодинамики:

a. Среднее артериальное давление

b. Центральное венозное давление

c. Насыщение кислородом центральной венозной крови и смешанной венозной крови

d. Концентрация гемоглобина и переливание крови

e. Концентрация лактата

f. Диурез

g. Доставка кислорода

h. Другое.

7. Клиническая польза контроля за глюкозой и оптимального целевого диапазона глюкозы.

8. Роль высоко-объемного гемодиализа

9. Роль ранней глюкокортикоидной терапии

10. Роль профилактического назначения антиконвульсантов

11. Роль определенного периода седации и вентиляции

12. Роль нейропротективных препаратов.

8.4.4 Прогноз

1. Оптимальная схема принятия решения для определения нецелесообразности дальнейшего продолжения лечения

2. Воздействие терапевтической гипотермии на достоверность предсказания

нецелесообразности.

8.4.5 Педиатрия

1. Доказательства возможности применения для детей знаний, упомянутых выше

2. Роль экстракорпоральной мембранной оксигенации в терапии остановки сердца у детей и в ведении детей после остановки.

8.4.5 Барьеры

1. Наиболее эффективный подход для осуществления терапевтической гипотермии и

оптимизация помощи пациентам после остановки сердца

2. Ценность региональной помощи после остановки сердца специализированными центрами.

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