Жолтый Ангел писал(а):
irene писал(а):
Терапевтическая гипотермия используется зарубежом всё активнее.
Ну нам-то Вы не рекомендуете её применять? Ведь Боткин про неё не писал, в советское время не применялась.
Гипотермия применялась в СССР активно, как и во всём мире, во второй половине 20 века. Были фабричные холодовые установки("Флюидокраниотерм», «Криоэлектроника-7»), разные шлемы. На Украине сохранился криоцентр (там по сей день интересные работы). Потом интерес пропал, но последние 5 лет возобновился. Много экспериментальных работ. Особенно по детству и г/м. Преимущество перед фармакологией.
Из хорошо написанного (Medscape) - статья
Therapeutic Hypothermia Mark E Brauner, Michael R Sayre, Updated: Dec 22, 2008
О гипотермии в СЛР.
Summary of 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care regarding the use of hypothermia
• Unconscious adult patients with return of spontaneous circulation after out-of-hospital cardiac arrest should be cooled to 32-34ºC for 12-24 hours when initial rhythm was ventricular fibrillation (VF) (class IIa).
• Similar therapy may be beneficial for patients with non-VF arrest out-of-hospital or with in-hospital arrest (class IIb).
• Hemodynamically stable patients with spontaneous mild hypothermia (>33ºC) after resuscitation from cardiac arrest should not be actively rewarmed.
Patient Selection
Inclusion criteria
Patients who have been shown to benefit from induced hypothermia include the following:
• Intubated patients with treatment initiated within a 6-hour post cardiac arrest (nonperfusing ventricular tachycardia [VT] or VF) time window
• Those able to maintain a systolic blood pressure >90 mm Hg, with or without pressors, after cardiopulmonary resuscitation (CPR)
• Those in a coma at the time of cooling. Coma is defined as not following commands. Brainstem reflexes and pathological/posturing movements are permissible. Patients with a Glasgow Coma Score (GCS) of 3 are eligible for hypothermia.
Exclusion criteria
Exclusion criteria are in part based on theoretical increases in risk. Many studies have reported increased but nonsignificant increases in risk. Patients for whom hypothermia may carry increased risk include those with the following conditions:
• Recent major surgery within 14 days - Hypothermia may increase the risk of infection and bleeding.
• Systemic infection/sepsis - Hypothermia may inhibit immune function and is associated with a small increase in risk of infection.
• Patients in a coma from other causes (drug intoxication, preexisting coma prior to arrest)
• Patients with a known bleeding diathesis or with active ongoing bleeding - Hypothermia may impair the clotting system. Check prothrombin time/partial thromboplastin time (PT/PTT), fibrinogen value, and D-dimer value at admission. (Note: Patients may receive chemical thrombolysis, antiplatelet agents, or anticoagulants if deemed necessary in the treatment of the primary cardiac condition.)
• Patients with a valid do not resuscitate order (DNR)
Induced hypothermia after pulseless electrical activity (PEA), asystolic, or in-hospital arrest has not been fully studied, but it may be applied at the discretion of the treating physicians. The physician should consider the most likely etiology of the cardiac arrest. For example, patients with PEA arrest due to septic shock may be poor candidates for hypothermia. Although their brain might benefit, the impairment to the immune system from hypothermia may be more significant.
Data from a June 2007 study of prehospital hypothermia examined secondary results of clinical outcomes. Among 125 patients total, 74 had non-VF arrest, that is PEA (n=34), asystole (n=39), or unknown rhythm (n=1). In the non-VF group, the survival to hospital discharge was worse in the cooled group (6%) than in the noncooled group (20%). This study was not intended or powered to detect differences in clinical outcome at discharge, but it raises concern with treating patients with PEA or asystole and ROSC with hypothermia in the prehospital setting. Other preliminary data suggest that the indications for hypothermia will broaden considerably in the future. Induced hypothermia is not recommended for patients with an isolated respiratory arrest.
Cooling Methods
Mild hypothermia is induced by using surface, internal, or a combination of cooling methods. Thermal heat-exchange cooling pads using water or gel may have superior rate of cooling (1.33°C/h for water and 1.04°C/h for gel) compared with cooling with 30 mL/kg iced saline plus ice packs (0.31°C/h). Endovascular cooling may obviate the need for paralysis and provide very tight temperature control.
Surface cooling with ice packs
This method is inexpensive and represents an appropriate way to initiate cooling. However, it can be messy and is less than optimal in the rate of cooling and target temperature maintenance. Practically, ice packs are placed in anatomic areas that have large heat-exchange capability (the head, neck, axillae, and groin) and are replaced when the ice packs have substantially melted. In addition to ice packs, evaporative cooling with fans has been used. The average temperature drop using ice packs is moderately slow and highly variable and is reported to be 0.03-0.98°C per hour.
Surface cooling with blankets or surface heat-exchange device and ice
Conventional surface cooling blankets are also suboptimal because of poor surface contact with the patient's skin. However, a combination of water-circulating cooling device and ice packs are effective at rapidly cooling patients and are fair at maintaining target temperature. Many clinical studies have used this combination. The patient is sandwiched between 2 blankets or the cooling device's heat-exchange pads are placed and then ice packs are applied. When the target temperature is achieved, the ice packs are removed and the blanket or device is used to maintain the target temperature. Newer medical devices are on the market that have adhesive gel that facilitates heat exchange and are considerably more effective in the rate and maintenance of cooling
Рис 1. This is the Alsius CoolGard 3000. It is used in conjunction with the endovascular cooling catheter below.
Рис 2. Media file 2: This is the Alsius Fortius 9.3 Fr endovascular cooling catheter
Рис 3. This is the Arctic Sun heat-exchange devise. It is used with the cooling pads as depicted below.
Surface cooling helmet
Hachimi-Idrissi et al used a helmet cooling device in their human clinical study. The soft bonnetlike helmet contained a solution of aqueous glycerol that facilitated heat exchange. This method works, but it may be slower than other methods.
Internal cooling methods using catheter-based technologies
Two devices are currently available for use: Celsius Control System (Innercool, Inc, San Diego, CA) and Cool Line System (Alsius, Inc, Irvine, CA). These technologies are also referred to as endovascular heat-exchange catheters. Heat exchange occurs between cooled saline that passes through the heat exchange portion of the catheter (in a coil with large surface area for heat exchange) and the blood that flows over the outer surface of the catheter. Endovascular cooling and rewarming is reported to be faster (1.46°C32 , 1.59°C/h29 ) and better at maintaining target temperature. These devices are generally placed in the femoral vein and are associated with a low rate of complications. Guluma et al reported endovascular cooling along with buspirone and surface warming to allow mild therapeutic hypothermia without shivering and avoiding the need for chemical paralysis. Extremely tight temperature control was also documented. Thus, intravascular cooling allows:
• Most rapid cooling
• Tightest control of target temperature
• Minimization of shivering and possible increase in the patient's comfort as cutaneous warming is permitted
• Opportunity to avoid need for chemical paralysis of the patient
Internal cooling methods using infusion of cold fluids
Many have studied the effect of cold fluid infusion for the induction of mild-to-moderate hypothermia in humans. The rates of induction are variable but otherwise considered to be rapid. Cold fluid infusion with concomitant use of cooling blankets has also been shown to be efficacious. Typical infusion volume is either 30 mL/kg or 2 L of fluid using either normal saline or lactated Ringer solution. In the several studies that have investigated cold fluid infusion, there has not been an association with increased venous pressure, left atrial filling pressures, pulmonary pressures, pulmonary edema, cardiac arrhythmia, or other major complications.
PS. Приношу извинения, обидеть не хотела, похоже, занесло.
С уважением. Irene
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), кое-что позитивного проделано при энцефалопатии у новорожденных (кто бы сомневался, они до года пойкилотермные, как ящерицы, гипофиз милипусенький). Конечно, хорошо бы при остановке сердца охлаждать (как в Европе). Но - низзя. Пока рано.
А где Вы видели дискуссию?
На Медскейпе не интересно.
