JAMA | OriginalInvestigation | CARING FOR THE CRITICALLY ILL PATIENT
Association Between Therapeutic Hypothermia and Survival After In-Hospital Cardiac Arrest
Paul S. Chan, Robert A. Berg, Yuanyuan Tang, et al.
JAMA 2016; 316(13): 1375-1382.
doi:10.1001/jama.2016.14380
Importance 背景
Therapeutic hypothermia is used for patients following both out-of-hospital and in-hospital cardiac arrest. However, randomized trials on its efficacy for the in-hospital setting do not exist, and comparative effectiveness data are limited.
治疗性低温用于院外及院内心跳骤停患者的治疗。然而，在院内实施治疗性低温的疗效缺乏随机临床试验，疗效比较的资料也非常有限。
Objective 目的
To evaluate the association between therapeutic hypothermia and survival after in-hospital cardiac arrest.
评估治疗性低温与院内心跳骤停后生存率的相关性。
Design, Setting, and Patients 设计，场景及患者
In this cohort study, within the national Get With the Guidelines–Resuscitation registry, 26?183 patients successfully resuscitated from an in-hospital cardiac arrest between March 1, 2002, and December 31, 2014, and either treated or not treated with hypothermia at 355 US hospitals were identified. Follow-up ended February 4, 2015.
在这项队列研究中，我们采用了全国Get With the Guidelines–Resuscitation登记研究资料，2002年3月1日至2014年12月31日期间，美国355家医院中共计26183名患者发生院内心跳骤停后得到成功复苏，其中包括接受或不接受低温治疗的患者。随访期截止到2015年2月4日。
Exposure 暴露
Induction of therapeutic hypothermia.
实施治疗性低温。
Main Outcomes and Measures 主要预后指标
The primary outcome was survival to hospital discharge. The secondary outcome was favorable neurological survival, defined as a Cerebral Performance Category score of 1 or 2 (ie, without severe neurological disability). Comparisons were performed using a matched propensity score analysis and examined for all cardiac arrests and separately for nonshockable (asystole and pulseless electrical activity) and shockable (ventricular fibrillation and pulseless ventricular tachycardia) cardiac arrests.
主要预后指标为住院存活率。次要预后指标为神经系统功能良好（定义为脑功能分级评分1或2分，即没有严重的神经系统障碍）。采用匹配倾向性评分分析，对所有心跳骤停患者进行比较，并对无需电除颤（心搏停止，无脉电活动）及需电除颤（室颤及无脉室性心动过速）的心跳骤停进行单独分析。
Results 结果
Overall, 1568 of 26?183 patients with in-hospital cardiac arrest (6.0%) were treated with therapeutic hypothermia; 1524 of these patients (mean [SD] age, 61.6 [16.2] years; 58.5% male) were matched by propensity score to 3714 non–hypothermia-treated patients (mean [SD] age, 62.2 [17.5] years; 57.1% male). After adjustment, therapeutic hypothermia was associated with lower in-hospital survival (27.4% vs 29.2%; relative risk [RR], 0.88 [95% CI, 0.80 to 0.97]; risk difference, ?3.6% [95% CI, ?6.3% to ?0.9%]; P?=?.01), and this association was similar (interaction P?=?.74) for nonshockable cardiac arrest rhythms (22.2% vs 24.5%; RR, 0.87 [95% CI, 0.76 to 0.99]; risk difference, ?3.2% [95% CI, ?6.2% to ?0.3%]) and shockable cardiac arrest rhythms (41.3% vs 44.1%; RR, 0.90 [95% CI, 0.77 to 1.05]; risk difference, ?4.6% [95% CI, ?10.9% to 1.7%]). Therapeutic hypothermia was also associated with lower rates of favorable neurological survival for the overall cohort (hypothermia-treated group, 17.0% [246 of 1443 patients]; non–hypothermia-treated group, 20.5% [725 of 3529 patients]; RR, 0.79 [95% CI, 0.69 to 0.90]; risk difference, ?4.4% [95% CI, ?6.8% to ?2.0%]; P?
26183名院内心跳骤停的患者中，有1568名(6.0%)接受治疗性低温；其中1524名患者 （平均[SD]年龄，61.6 [16.2]岁，58.5%为男性）根据倾向性评分与3714名非低温治疗患者（平均[SD]年龄，62.2 [17.5]岁; 57.1% 为男性）进行匹配。校正后，治疗性低温伴随住院存活率降低(27.4% vs 29.2%; 相对危险度 [RR], 0.88 [95% CI, 0.80 to 0.97]; 风险差异，?3.6% [95% CI, ?6.3% to ?0.9%]; P?=?.01），无需电除颤者(22.2% vs 24.5%; RR, 0.87 [95% CI, 0.76 to 0.99]; 风险差异 ?3.2% [95% CI, ?6.2% to ?0.3%]) 以及需电除颤者(41.3% vs 44.1%; RR, 0.90 [95% CI, 0.77 to 1.05]; 风险差异, ?4.6% [95% CI, ?10.9% to 1.7%])也呈现相似的相关性（交互作用P?=?.74）。对于全部队列患者，治疗性低温还伴随神经系统功能良好的比例较低（低温治疗组17.0% [246/1443]；非低温治疗组20.5% [725 of 3529 patients]; RR, 0.79 [95% CI, 0.69 to 0.90]，风险差异, ?4.4% [95% CI, ?6.8% to ?2.0%]; P?<>
Conclusions and Relevance 结论及意义
Among patients with in-hospital cardiac arrest, use of therapeutic hypothermia compared with usual care was associated with a lower likelihood of survival to hospital discharge and a lower likelihood of favorable neurological survival. These observational findings warrant a randomized clinical trial to assess efficacy of therapeutic hypothermia for in-hospital cardiac arrest.
对于院内心跳骤停患者，与常规治疗相比，治疗性低温与较低的住院存活率及较低的神经系统功能良好比例相关。基于这些观察结果，有必要进行随机临床试验，以评价治疗性低温对于院内心跳骤停的疗效。
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