丹麦欧登塞大学医院Jacob E. Møller团队研究了用于院外心脏骤停昏迷幸存者的氧合目标。2022年8月27日出版的《新英格兰医学杂志》发表了这一最新研究成果。

院外心脏骤停昏迷幸存者机械通气的适当氧合目标尚不清楚。

在这项随机试验中，研究组采用2乘2析因设计，以1:1的比例将患有院外心脏骤停的昏迷成人随机分配到动脉氧分压（Pao₂）为9至10 kPa（68至75 mm Hg）的限制性氧目标或Pao₂为13至14 kPa（98至105 mm Hg）的自由氧目标；患者被分配到两个血压目标中的一个（单独报告）。

主要结局是全因死亡或因严重残疾或昏迷而出院（脑功能类别[CPC]为3或4；类别范围为1至5，更高值表示更严重的残疾），以随机化后90天内最先发生的为准。次要结果是48小时的神经元特异性烯醇化酶水平、全因死亡、蒙特利尔认知评估得分（0-30分，得分越高表示认知能力越好）、改良Rankin量表得分（0到6分，得分高表示残疾程度越高）和90天时的CPC。

共有789名患者接受了随机分组。限制性氧目标组394名患者中有126名（32.0%）出现主要结局事件，自由氧目标组395名患者中有134名（33.9%），危险比为0.95。90天时，限制性氧目标组中有113名患者（28.7%）死亡，自由氧目标组中有123名（31.1%）死亡。

两组的中位CPC类别为1；在改良Rankin量表中，限制性氧目标组的中位数为2，自由氧目标组为1；在蒙特利尔认知评估中，两组的中位数均为27分。分组后48小时，限制性氧目标组的神经元特异性烯醇化酶中位数为17μg/L，自由氧目标组为18μg/L。两组不良事件的发生率相似。

研究结果表明，在因心脏骤停复苏后，针对昏迷患者的限制性或自由氧合策略导致相似的死亡或严重残疾或昏迷发生率。

附：英文原文

Title: Oxygen Targets in Comatose Survivors of Cardiac Arrest

Author: Henrik Schmidt, M.D., D.M.Sc.,, Jesper Kjaergaard, M.D., D.M.Sc.,, Christian Hassager, M.D., D.M.Sc.,, Simon Mlstrm, M.D.,, Johannes Grand, M.D., Ph.D.,, Britt Borregaard, Ph.D.,, Laust E. Roelsgaard Obling, M.D.,, Sren Ven, M.D.,, Laura Sarkisian, M.D., Ph.D.,, Dmitry Mamaev, M.D.,, Lisette O. Jensen, M.D., D.M.Sc.,, Benjamin Nyholm, M.D.,, Dan E. Hfsten, M.D., Ph.D.,, Jakob Josiassen, M.D., Ph.D.,, Jakob H. Thomsen, M.D., Ph.D.,, Jens J. Thune, M.D., Ph.D.,, Matias G. Lindholm, M.D., Ph.D.,, Martin A. Stengaard Meyer, M.D.,, Matilde Winther-Jensen, Ph.D.,, Marc Srensen, M.D.,, Martin Frydland, M.D., Ph.D.,, Rasmus P. Beske, M.D.,, Ruth Frikke-Schmidt, M.D., D.M.Sc.,, Sebastian Wiberg, M.D., Ph.D.,, Sren Boesgaard, M.D., D.M.Sc.,, Vibeke Lind Jrgensen, M.D., Ph.D.,, and Jacob E. Mller, M.D., D.M.Sc.

Issue&Volume: 2022-08-27

Abstract:

Background

The appropriate oxygenation target for mechanical ventilation in comatose survivors of out-of-hospital cardiac arrest is unknown.

Methods

In this randomized trial with a 2-by-2 factorial design, we randomly assigned comatose adults with out-of-hospital cardiac arrest in a 1:1 ratio to either a restrictive oxygen target of a partial pressure of arterial oxygen (Pao2) of 9 to 10 kPa (68 to 75 mm Hg) or a liberal oxygen target of a Pao2 of 13 to 14 kPa (98 to 105 mm Hg); patients were also assigned to one of two blood-pressure targets (reported separately). The primary outcome was a composite of death from any cause or hospital discharge with severe disability or coma (Cerebral Performance Category [CPC] of 3 or 4; categories range from 1 to 5, with higher values indicating more severe disability), whichever occurred first within 90 days after randomization. Secondary outcomes were neuron-specific enolase levels at 48 hours, death from any cause, the score on the Montreal Cognitive Assessment (ranging from 0 to 30, with higher scores indicating better cognitive ability), the score on the modified Rankin scale (ranging from 0 to 6, with higher scores indicating greater disability), and the CPC at 90 days.

Results

A total of 789 patients underwent randomization. A primary-outcome event occurred in 126 of 394 patients (32.0%) in the restrictive-target group and in 134 of 395 patients (33.9%) in the liberal-target group (hazard ratio, 0.95; 95% confidence interval, 0.75 to 1.21; P=0.69). At 90 days, death had occurred in 113 patients (28.7%) in the restrictive-target group and in 123 (31.1%) in the liberal-target group. On the CPC, the median category was 1 in the two groups; on the modified Rankin scale, the median score was 2 in the restrictive-target group and 1 in the liberal-target group; and on the Montreal Cognitive Assessment, the median score was 27 in the two groups. At 48 hours, the median neuron-specific enolase level was 17 μg per liter in the restrictive-target group and 18 μg per liter in the liberal-target group. The incidence of adverse events was similar in the two groups.

Conclusions

Targeting of a restrictive or liberal oxygenation strategy in comatose patients after resuscitation for cardiac arrest resulted in a similar incidence of death or severe disability or coma.

DOI: 10.1056/NEJMoa2208686

Source: https://www.nejm.org/doi/full/10.1056/NEJMoa2208686