院外心脏骤停中从AED过渡到手动除颤的能量递增方案依从性及临床结局分析

　　本研究针对OHCA（院外心脏骤停）患者从AED（自动体外除颤仪）过渡至手动除颤时能量递增方案执行率低的问题，通过分析827例病例数据，发现EMS（急救医疗服务）人员对能量调整的依从性仅为20.3%，且未发现依从性与ROSC（自主循环恢复）或30天生存率等临床结局存在显著关联。该研究为优化除颤能量设置和培训策略提供了重要实证依据。

　　

当一个人的心脏突然停止有效跳动，每一秒的延迟都可能意味着生与死的差别。在院外心脏骤停（OHCA）的紧急情况下，除颤是恢复心脏正常节律的关键干预措施。目前，欧洲复苏委员会（ERC）指南推荐采用能量递增方案进行除颤，即首次电击使用较低能量（如150J或200J），后续电击则使用最高能量（如360J）。这一建议基于部分研究显示，对于需要多次电击的患者，递增能量可能比固定低能量方案带来更好的 outcomes。然而，在现实世界的急救现场，情况往往更为复杂。当患者已经接受了自动体外除颤仪（AED）的电击后，急救医疗服务（EMS）人员在使用手动除颤仪进行首次电击时，需要手动将能量从默认的200J调整至360J，以遵循能量递增协议。这个看似简单的操作，在分秒必争、高压力的急救环境中是否被严格执行？如果执行率低，又是否会影响患者的生存机会？这些问题的答案，对于优化急救协议、设备设置和人员培训都具有重要意义。

为了回答这些问题，由Frans Dammers和Bas J. Verkaik等研究人员开展了一项深入的研究，其成果发表在《Resuscitation》上。该研究利用荷兰阿姆斯特丹地区的前瞻性ARREST（AmsteRdam REsuscitation STudies）注册系统数据，分析了2017年1月至2023年7月期间827例成年OHCA患者，这些患者均具有可电击心律（心室颤动VF或室性心动过速VT），并且在接受至少一次AED电击后，又接受了至少一次手动除颤仪电击。研究的主要目的是评估EMS人员对能量递增协议的依从性（即手动将首次手动除颤能量设置为360J），并探讨其与临床结局（如ROSC、30天生存率等）的关联。

研究采用的关键技术方法包括：利用专门的CODE-STAT reviewer软件（v10.1）对LIFEPAK 15除颤仪记录的数据进行详细分析，包括电击前和电击后的心律、能量水平以及ROSC的发生；基于Utstein风格模板的系统性数据收集，涵盖从调度中心、救护车服务到医院的多源数据；以及运用多变量逻辑回归、负二项回归等统计方法，调整了性别、年龄、是否目击骤停、 bystander CPR（旁观者心肺复苏）等协变量，以控制潜在混杂因素的影响。

主要结果

主要结局

在827例符合分析条件的病例中，EMS人员对能量递增协议的依从性仅为20.3%（168例），即仅有约五分之一的患者在从AED过渡到手动除颤时，其首次电击能量被正确设置为360J。这一低依从性凸显出现行指南在实际操作中存在显著的执行差距。

基线特征

患者的平均年龄为65.4岁，女性占15.4%。多变量分析显示，没有任何基线特征（如性别、年龄、骤停地点、是否目击、 bystander CPR、使用机械胸外按压装置、AED电击次数等）与依从性有显著关联。单变量分析中，仅年龄和接受多次AED电击与依从性有微弱关联（年龄较大者和接受更多AED电击者依从性略高），但经过多变量调整后，这些关联均不再显著。

次要结局

重要的是，无论EMS人员是否遵循能量递增协议，患者的临床结局均未表现出统计学上的显著差异。具体而言：

• •
  可电击心律终止：首轮手动除颤电击成功终止可电击心律的比例在依从组为82.7%，非依从组（使用200J）为79.1%，两者无显著差异。
• •
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