Page 15 - 麻醉与监护论坛2015年第7期

Review and CME Lecture
metabolic enzymes in the body, playing an important role
in the contraction and conduction of neuromuscular and
myocardial cells and the adjustment of smooth muscles in
blood vessels, tracheas and bronchia. Studies have shown
that hypomagnesemia (serum magnesium <0.74mmol/L)
is closely related to arrhythmia, vascular spasm and the high
incidence of cardiac arrest and acute myocardial infarction
caused by congestive heart failure .[5-8] 45% of patients
with myocardial infarction suffer from hypomagnesemia
[9]. As myocardial electrophysiological activity requires
the participation of magnesium, sodium pump fails if
magnesium is deficient so as to affect myocardial resting
potential, elevating the excitement of atrioventricular node.
Therefore, hypomagnesemia is the primary cause of cardiac
arrest in the case, and myocardial infarction may be the
secondary on the basis of arrest, but we could not rule out an experienced ischemia require more glucose to use direct.
earlier myocardial infarction induced by hypomagnesemia
and physiological hypercoagulative state of a pregnant
woman.
Optimize the brain protection treatment
The incidence of brain injury post-resuscitation is
particularly high. Studies have revealed that among the
patients after successful resuscitation who finally died
in the ICU, 68% of the patients who die from brain
injury were resuscitated outside the hospital, and 23%
were resuscitated inside the hospital .[10] Therefore, the
difference between MODS caused by PRS and that caused
by other reasons is that PRS require more emphasis on
the protection of the nervous system, so we should take
brain protection at first in treatment strategies:①The
brain topical treatment measures: Include the ice caps to
maintain a state of mild hypothermia, or the decrease of
intracranial pressure and sedation measure to alleviate
epilepsy, or the promotion of brain cell metabolism. Mild
hypothermia treatment (32~34℃) is an effective means
of cerebral protection, which can reduce the cerebral
metabolic rate of 8% by decreasing each 1℃ of brain
temperature. Mild hypothermia also inhibits apoptosis,
reducing the generation of inflammatory cytokines and
free radicals. Mild hypothermia can be implemented by ice
caps, intravenous infusion of ice saline water, or the CRRT
treatment. Recent research shows that you may try to reduce
brain temperature by infiltrating the throat with the ice
saline water [11].② Strengthen extracerebral organ support
Laboratory RanedvieCwlinaincadlCInMvEesLteigcatutiroen 25
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treatment: There presents self-regulatory mechanism in
normal human to protect cerebral perfusion under various
states of blood pressure, but the mechanism was lost post-
resuscitation. Cerebral perfusion mainly dependents on
arterial blood pressure, so it is critical to protect cerebral
perfusion after the restoration of spontaneous circulation,
while the maintenance of a normal or even high blood
pressure at the initial stage of resuscitation will contribute
to the rehabilitation of the central nervous system. ③ the
level of glycemic control: there are some controversies
about the control of blood glucose level in the treatment
of the PRS. Certain clinical studies show that mild high
blood glucose levels (6.44~7.94mmol/L) is conducive to
the rehabilitation of the nervous system, especially in 12h
after the resuscitation[12], because the central nervous cells
Thus, we are not in favor of strict glycemic control in
patients after resuscitation clinically.
Stabilize hemodynamics
After the restoration of spontaneous circulation,
most patients will experience hemodynamic disturbances
due to initial cardiovascular instability and ultimately
die, representing as hypotension, cardiogenic shock and
severe arrhythmia. Therefore, the occurrence of PRS
could be reduced by supplying blood volume, stabilizing
blood pressure, modifying microcirculation perfusion and
alleviating vascular spasm in viscera after initial effective
resuscitation. The acid-base equilibrium and electrolyte
imbalance are needed to improve particularly, and the
risk of cardiac arrest once more due to acute myocardial
infarction after ischemia and hypoxia should be taken
care of. In this case, the patient suffered from myocardial
infarction after the first cardiac arrest, and experienced
for a second time in the condition of unrectified blood
magnesium, suggesting hemodynamics of patients after
cardiac arrest were extremely unstable, and any minor
incentives were likely to lead to another cardiac arrest,
attention should be paid clinically.
Controlled ventilation strategies
There are different degrees of respiratory dysfunction
in the process of cardiopulmonary resuscitation, and part
of patients still need respiratory support. A reasonable
respiration method will directly affect the successful rate
of CRP and the prognosis. Hypoxemia and hypercapnia
FAM 2013 Jan/Feb Vol.20 Issue 1