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醫生可能過早放棄心肺復蘇搶救

Doctors May Be Ending CPR Efforts Too Soon, Study Says
醫生可能過早放棄心肺復蘇搶救

When a hospital patient goes into cardiac arrest, one of the most difficult questions facing the medical team is how long to continue cardiopulmonary resuscitation. Now a new study involving hundreds of hospitals suggests that often doctors may be giving up too soon.

當一名住院患者的心臟驟停時,醫療團隊面臨的最棘手難題之一是,應該給患者實施多長時間的心肺復蘇術(cardiopulmonary resuscitation,簡稱CPR)?,F在,一項涉及數百家醫院的新研究似乎表明,醫生們可能經常過早放棄了搶救。

The study found that patients have a better chance of surviving in hospitals that persist with CPR for just nine minutes longer, on average, than hospitals where efforts are halted earlier.

該研究發現,在那些實施CPR的時間平均比更早停止搶救的醫院長9分鐘的醫院,患者存活的機會更大。
 

2010年,布魯克林的瑪摩利醫院(Maimonides Medical Center)醫護人員正在搶救一名心跳驟停的患者。

There are no clear, evidence-based guidelines for how long to continue CPR efforts.

對于CPR搶救應該持續多長時間,目前并沒有明確的、基于證據的指引。

The findings challenge conventional medical thinking, which holds that prolonged resuscitation for hospitalized patients is usually futile and that when patients do survive, they often suffer permanent neurological damage. To the contrary, the researchers found that patients who survived prolonged CPR and left the hospital fared as well as those who were quickly resuscitated.

這項發現挑戰了傳統的醫學觀念,即對住院患者實施長時間的心肺復蘇術通常沒有意義,即使患者得以生還,他們也往往會遭受永久性的神經損傷。研究人員發現,實際情況與此相反,經過長時間CPR搶救后復蘇并出院的患者,和那些快速復蘇的患者一樣健康。

The study, published online Tuesday in The Lancet, is one of the largest of its kind and one of the first to link duration of CPR efforts with survival rates. It should prompt hospitals to review their practices and to consider changes if their resuscitation efforts fall short, several experts said.

這項研究于本周二發表在《柳葉刀》(The Lancet)雜志的網站上,其規模在同類研究中名列前茅,也是把CPR搶救時間與患者存活率聯系起來的首批研究之一。數名專家表示,它應當促使醫院審查各自的搶救程序,并在搶救時間偏短的情況下考慮做出改變。

Between one and five of every 1,000 hospitalized patients suffer a cardiac arrest. Generally they are older and sicker than non-hospital patients who suffer cardiac arrest, and their outcomes are generally poor, with fewer than 20 percent surviving to be discharged from the hospital.

每1000名住院患者中,就有一到五名會遭遇心臟驟停。通常而言,這些患者比沒住院的心臟驟?;颊吣昙o更大、也更體弱。他們的結局一般不佳,只有不到20%能夠復蘇并出院。

Dr. Zachary D. Goldberger, lead author of the new study, and his colleagues gathered data from the world’s largest registry of in-hospital cardiac arrest, maintained by the American Heart Association, identifying 64,339 patients who went into cardiac arrest at 435 hospitals in the United States between 2000 and 2008.

這項新研究的首席作者是扎卡里·D·戈德伯格(Zachary D. Goldberger)醫生。他和同事們從美國心臟協會(American Heart Association)保持的全球最大住院患者心臟驟停病例數據庫收集數據,從中辨別出逾6.4萬名在2000年到2008年期間在美國435家醫院發生心臟驟停的患者。

The researchers examined adult hospital patients in regular beds or intensive care units, excluding patients in the emergency room or who suffered arrest during procedures. They calculated the median duration of resuscitation efforts for the non-survivors rather than the survivors, in order to measure a hospital’s tendency to engage in more prolonged resuscitation efforts.

研究人員查看了住在普通病房和重癥監護室的成年住院患者,并剔除了在急診室或手術中遭遇心臟驟停的患者。他們計算了死亡患者(而非幸存患者)接受心肺復蘇搶救時間的中值,目的是衡量相關醫院實施更長時間CPR搶救的傾向性。

One of the first surprises was the significant variation in duration of CPR among the hospitals, ranging from a median of 16 minutes in hospitals spending the least amount of time trying to revive patients to a median of 25 minutes among those spending the most — a difference of more than 50 percent.

醫院實施CPR的時間長短差異之大,是首批意外發現之一。在搶救患者持續時間最短的醫院,這個中值是16分鐘,而持續時間最長的醫院的中值是25分鐘——差異高達50%。

The researchers initially thought they would find that some patients were being subjected to protracted resuscitation efforts in vain, said the senior author, Dr. Brahmajee Nallamothu, an associate professor at the University of Michigan and a cardiologist at the Ann Arbor VA Medical Center.

該研究的資深作者布拉馬基·納拉莫蘇(Brahmajee Nallamothu)醫生表示,研究人員最初以為,他們將發現一些患者被無意義地實施長時間的心肺復蘇術。納拉莫蘇是密歇根大學(University of Michigan)副教授,弗吉尼亞安娜堡醫學中心(Ann Arbor VA Medical Center)心臟病專家。

But as it turned out, those extra minutes made a positive difference. Patients in hospitals with the longest CPR efforts were 12 percent more likely to survive and go home from the hospital than those with the shortest times.

但研究結果顯示,那幾分鐘的延長搶救產生了積極的效果。CPR搶救時間最長的醫院的患者存活和出院的幾率,比搶救時間最短的醫院的患者高出12%。

Dr. Nallamothu and his colleagues also found that “survivors at hospitals where attempts continued for longer didn’t seem to have more neurological difficulties at the time of discharge,” he said.

納拉莫蘇醫生說,他和他的同事還發現,“在醫院接受更長時間CPR搶救的幸存者在出院時,似乎并沒有更嚴重的神經功能問題。”

The patients who got the most added benefit from prolonged CPR were those whose conditions do not respond to defibrillation, or being shocked The extra time spent on prolonged CPR may give doctors time to analyze the situation and try different interventions, they said.

長時間CPR搶救的最大受益者是那些對心臟除顫或電擊沒有反應的患者。研究人員表示,延長CPR搶救時間,可能讓醫生有時間分析患者情況,嘗試不同的干預方案。

“You can keep circulating blood and oxygen using CPR for sometimes well over 30 minutes and still end up with patients who survive and, importantly, have good neurological survival,” said Dr. Jerry P. Nolan, a consultant in anesthesia and critical care medicine at Royal United Hospital NHS Trust in Bath, England, who wrote a commentary accompanying the article.

“有時,你可以利用遠遠超過30多分鐘的CPR搶救,持續給患者輸氧和保持血液循環,患者最終還是有可能生存,而且更重要的是,他們的神經功能完好,”位于英格蘭巴斯、隸屬英國國民醫療保健服務(NHS)體系的皇家聯合醫院(Royal United Hospital)的麻醉及危重病醫學顧問醫師杰里·P·諾蘭(Jerry P. Nolan)醫生說道,他為這篇論文寫了評語。

Dr. Stephen J. Green, associate chair of cardiology at North Shore-Long Island Jewish Health System, who was not involved in the study, said hospitals might have to modify their practices in light of the new research.

北岸—長島猶太裔衛生系統(North Shore-Long Island Jewish Health System)心臟病學副主任、未參加這項研究的斯蒂芬·J·格林(Stephen J. Green)醫生表示,根據這項新研究,醫院可能必須修訂各自的程序。

“You don’t want to be on the low end of this curve,” Dr. Green said. “Hospitals that are outliers should reassess what they’re doing and think about extending the duration of their CPR.”

“你不想處于這條曲線的底端,”格林醫生說,“目前搶救時間偏短的醫院應該重新評估他們的程序,考慮延長實施CPR的時間。”

Still, he and other experts worried that the new findings could lead to protracted efforts to resuscitate patients for whom it is inappropriate because they are at the end of their lives or for other reasons.

但話說回來,格林醫生和其他專家擔憂,新發現可能導致醫院對某些因生命即將終結或其他原因而不適合的患者實施長時間搶救。

“There isn’t going to be a magic number,” Dr. Green said. “If you’re in there 10 to 15 minutes, you need to push higher, but as you get up higher and higher, you get to the point of very little return.”

“不會出現一個神奇數字,”格林醫生說。“如果你目前的搶救時間是10到15分鐘,那么你需要延長時間,但是當你延長到一定程度時,你就會達到產生不了什么回報的水平了。”

The study authors acknowledge that their research does not indicate that longer CPR is better for every patient.

研究作者承認,他們的研究并未顯示,延長CPR搶救對每一位患者都有益。

“The last thing we want is for the take-home message to be that everyone should have a long resuscitation,” Dr. Goldberger said. “We’re not able to identify an optimal duration for all patients in the hospital.”

“我們最不愿意看到的結論是,每個人都該得到長時間的復蘇搶救,”戈德伯格說,“我們無法針對所有住院患者確定一個最優的搶救時間。”
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