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[JAMA在线发表]:院内心跳骤停成年患者心肺复苏期间气管插管与低存活率相关
2017年02月11日 时讯速递, 进展交流 评论数 1

JAMA | Original Investigation | CARING FOR THE CRITICALLY ILL PATIENT

Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival

Lars W. Andersen, Asger Granfeldt,CliftonW. Callaway, et al.

JAMA. doi:10.1001/jama.2016.20165

Published online January 24, 2017.

IMPORTANCE 背景

Tracheal intubation is common during adult in-hospital cardiac arrest, but little is known about the association between tracheal intubation and survival in this setting.

院内心跳骤停成年患者经常接受气管插管,但气管插管与存活之间的关系却鲜有了解。

OBJECTIVE 目的

To determine whether tracheal intubation during adult in-hospital cardiac arrest is associated with survival to hospital discharge.

确定院内心跳骤停的成年患者气管插管与出院存活之间的相关性。

DESIGN, SETTING, AND PARTICIPANTS 设计,场景及人群

Observational cohort study of adult patients who had an in-hospital cardiac arrest from January 2000 through December 2014 included in the Get With The Guidelines–Resuscitation registry, a US-based multicenter registry of in-hospital cardiac arrest. Patients who had an invasive airway in place at the time of cardiac arrest were excluded. Patients intubated at any given minute (from 0-15 minutes) were matched with patients at risk of being intubated within the same minute (ie, still receiving resuscitation) based on a time-dependent propensity score calculated from multiple patient, event, and hospital characteristics.

遵从指南—复苏登记(Get With The Guidelines–Resuscitation registry)数据库是美国院内心跳骤停的多中心注册研究。对其中2000年1月至2014年12月间发生院内心跳骤停成年患者进行观察性队列研究。排除那些在发生心跳骤停时已经留置有创人工气道的患者。根据对患者、事件及医院多个特征计算的时间依赖倾向性评分,将任何特定时间(0-15分钟)接受气管插管的患者与在同一时间有插管风险(仍接受复苏)的患者进行匹配。

EXPOSURE 暴露

Tracheal intubation during cardiac arrest.

心跳骤停期间气管插管。

MAIN OUTCOMES AND MEASURES 主要预后指标

The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation (ROSC) and a good functional outcome. A cerebral performance category score of 1 (mild or no neurological deficit) or 2 (moderate cerebral disability) was considered a good functional outcome.

主要预后指标为出院存活。次要预后指标包括自主循环恢复(ROSC)及功能预后良好。脑功能分级1级(轻度或无神经系统异常)或2级(中度脑功能障碍)提示功能预后良好。

RESULTS 结果

The propensity-matched cohort was selected from 108 079 adult patients at 668 hospitals. The median age was 69 years (interquartile range, 58-79 years), 45 073 patients (42%) were female, and 24 256 patients (22.4%) survived to hospital discharge. Of 71 615 patients (66.3%) who were intubated within the first 15 minutes, 43 314 (60.5%) were matched to a patient not intubated in the same minute. Survival was lower among patients who were intubated compared with those not intubated: 7052 of 43 314 (16.3%) vs 8407 of 43 314 (19.4%), respectively (risk ratio [RR] = 0.84; 95%CI, 0.81-0.87; P < .001). The proportion of patients with ROSC was lower among intubated patients than those not intubated: 25 022 of 43 311 (57.8%) vs 25 685 of 43 310 (59.3%), respectively (RR = 0.97; 95%CI, 0.96-0.99; P < .001). Good functional outcome was also lower among intubated patients than those not intubated: 4439 of 41 868 (10.6%) vs 5672 of 41 733 (13.6%), respectively (RR = 0.78; 95%CI, 0.75-0.81; P < .001). Although differences existed in prespecified subgroup analyses, intubation was not associated with improved outcomes in any subgroup.

在668家医院的108079名成年患者中选择了倾向性评分匹配的队列。中位年龄为 69 岁(四分位区间 58-79 岁), 45073 名患者 (42%) 为女性, 24256 名患者 (22.4%) 出院存活。在最初15分钟内接受气管插管的 71615 名患者 (66.3%) 中,43314 名患者 (60.5%) 与同一时间未接受插管的患者进行匹配。与未插管患者相比,接受气管插管的患者存活率较低,分别为 7052/43314 (16.3%) vs 8407/43314 (19.4%)(风险比 [RR] 0.84; 95%CI, 0.81-0.87; P < .001)。插管患者ROSC比例低于未插管患者:分别为 25022/43311 (57.8%) vs 25685/43310 (59.3%) (RR 0.97; 95%CI, 0.96-0.99; P < .001)。插管患者良好功能预后比例较低:分别为4439/41868 (10.6%) vs 5672/41733 (13.6%) (RR 0.78; 95%CI, 0.75-0.81; P < .001)。尽管预先确定的亚组分析结果存在差异,但任何一个亚组中气管插管均不伴随预后改善。

CONCLUSIONS AND RELEVANCE 结论与意义

Among adult patients with in-hospital cardiac arrest, initiation of tracheal intubation within any given minute during the first 15 minutes of resuscitation, compared with no intubation during that minute, was associated with decreased survival to hospital discharge. Although the study design does not eliminate the potential for confounding by indication, these findings do not support early tracheal intubation for adult in-hospital cardiac arrest.

对于院内发生心跳骤停的成年患者,在复苏最初15分钟内任何时间进行气管插管,与同一时间不进行插管相比,伴随出院存活率降低。尽管研究设计无法消除混杂因素的影响,但是,这些发现不支持发生院内心跳骤停的成年患者早期进行气管插管。

 

目前有 1 条留言 其中:访客:1 条, 博主:0 条

  1. lengdao1973 : 2017年02月12日17:45:05  -49楼

    确实很意外,颠覆了三观!但是仅仅罗列了数据与分析结果,没有分析的原因说明不了问题。难道是为了气管插管影响了有效复苏?还是插管后的呼吸机应用导致了死亡的增加?

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