《循环》：阿片类药物过量引起的心脏骤停与一般心脏骤停不同

编辑翻译：菁菁

译文校对：奇奇

文献在2021年2月最新的美国医学学术期刊《循环》（Circulation）首次刊发。该文献呈现了美国心脏协会对阿片类药物相关心脏骤停的机制和治疗方法的最新研究。

根据美国心脏协会的科学声明，由阿片类药物过量引起的医院外心脏骤停是25至64岁成年人死亡的重要原因。美国心脏协会是美国最大的自愿性健康组织，致力于维护所有人的心脑健康。这一声明于2021年3月8日发表在该协会的重要杂志《循环》上。

在美国，阿片类药物使用混乱估计每年影响200万人，并花费超过780亿美元的医疗保健费用。阿片滥用的历史已经超过三十年。在2018年，每天约有128人因阿片类药物使用混乱而死亡，其中大多数是25至55岁的成年人。在2016年的阿片类药物过量的案例中，约有15%需要紧急医疗服务，包括心脏骤停。 

阿片类药物相关的院外心脏骤停与其他形式的心脏骤停的不同之处在于身体功能的改变方式和呈现方式。阿片类药物包括处方药，以及仅限于医院使用的非医学类和合成类阿片类药物，例如海洛因和芬太尼。在阿片类药物使用不当的情况下，它们经常与酒精或其他有毒物质混合，这会增加服用过量的风险。

科学声明撰写小组的首席作者兼副主席、医学博士Cameron Dezfulian说：“对于阿片类药物相关医院外心脏骤停的预防和治疗，这项循证医学审查非常有价值，它主要影响成年人。而且，与经常被研究的成人院外突发性心脏骤停相比，这种类型的心脏骤停有着根本的不同。因此人们需要注意一些重要的科学因素。”

科学声明定义了阿片类药物相关心脏骤停的特征，解释了这一症状如何影响机体功能，并提供了关于治疗方法的指导。

Dezfulian是贝勒医学院儿科重症医学的高级教授，同时也是休斯顿德克萨斯儿童医院成人先天性心脏病重症监护病房的医学主任。他解释说，在阿片类药物相关的心脏骤停中，缺氧发生在心脏骤停之前并对脑损伤具有重要意义。没有氧气，在心脏停止运动之前几分钟内，大脑就会受到损害。这些发现表明需要进一步研究，以了解和治疗由阿片类药物相关心脏骤停引起的这些并发症，特别是需要研究潜在的脑损伤和探索可保护大脑的治疗方法。

纳洛酮是应对过量用药的首选紧急治疗方法，可以迅速、有效地逆转阿片类药物引起的呼吸抑制或通气不足。紧急医疗服务人员、训练有素的非医学人士和一般公众（在紧急调度员指示下）可以使用纳洛酮来预防心脏骤停。传统的心肺复苏术（包括气道和急救呼吸支持）也可能有效。

然而，经历过阿片类药物相关院外心脏骤停的人，更有可能独自在家，或在私人环境中生活，少有人亲眼目睹其心脏骤停和行为的早期迹象。还有证据表明，由于阿片类药物中毒的污名化，以及对持有阿片类药物的人进行刑事指控的可能性，导致了阿片类药物相关心脏骤停报告不足。

“要改善与阿片类药物过量有关的心脏骤停后的临床结局，需要另一个人（即公众或急诊人员）的干预，即迅速做出紧急反应，使用纳洛酮或CPR通气并实施压迫治疗，” Dezfulian说，“及时使用纳洛酮可以预防从呼吸到心脏骤停的发展。当前，越来越多地将这种救生药物作为预防阿片类药物相关心脏骤停的一种方法。”

阿片类药物通常会在体内停留数天。因此，在尝试预测结果时，耐心至关重要。该声明建议推迟放弃治疗的相关决策，直到患者系统的药物清除为止，特别是直到：

自发循环恢复和体温正常后至少72小时；

有毒物质及其代谢产物已清除；

ICU镇静剂和镇痛药已清除。

在与阿片类药物滥用和阿片类药物相关医院外心脏骤停的斗争中，教育也发挥着重要作用。

“开展针对性教育活动、向可能有或目睹阿片类药物过量的人提供阿片类药物使用教育和预防信息，分发纳洛酮，开展常规心肺复苏培训（包括抢救呼吸），有助于预防和改善与阿片类药物相关的医院外心脏疾病治疗。”

“除了与预防阿片类药物滥用、挽救患者生命相关的广泛公众教育和法律政策改革，还应提供更多药物治疗资源，以改善年轻或健康人群的康复情况。”

英文原文

Cardiac Arrest from Opioid Overdose Has Unique Features Affecting Prevention and Treatment

Out-of-hospital cardiac arrests triggered by opioid overdose are a significant cause of death among adults 25 to 64, according to a scientific statement from the American Heart Association, the nation's largest voluntary health organization focused on heart and brain health for all. The statement published today in the Association's flagship journal Circulation.

In the U.S., opioid use disorder affects an estimated 2 million people each year and costs more than $78 billion in health care expenses. The opioid epidemic, which spans more than three decades, accounted for approximately 128 deaths a day in 2018, mostly among adults ages 25 to 55. And, more than 15% of the opioid overdose emergency medical service cases in 2016 included cardiac arrest.

Opioid-associated out-of-hospital cardiac arrest differs from other forms of cardiac arrest in terms of how it abnormally changes body functions and the different ways it presents. Opioids include prescription medications, as well as nonmedical and synthetic opioids restricted to hospitals such as heroin and fentanyl, respectively. In the case of opioid use disorder, they are frequently mixed with alcohol or other toxic substances, which increases the risk of overdose.

Cameron Dezfulian, M.D., FAHA, lead author and vice chair of the scientific statement writing group, said, "This evidence-based review is valuable to help improve prevention and treatment of opioid-associated out-of-hospital cardiac arrest, which primarily affects people in the prime of adult life. And, there are important scientific elements to be aware of since this type of cardiac arrest is fundamentally different from adult out-of-hospital sudden cardiac arrests, which have been more often studied."

The scientific statement defines the unique features of opioid-associated cardiac arrest, explains how body functions are affected and provides guidance on treatment options.

Dezfulian, who is senior faculty in pediatric critical care medicine at Baylor College of Medicine and medical director of the Adult Congenital Heart ICU at Texas Children's Hospital in Houston, explains that in opioid-associated cardiac arrest, hypoxia (oxygen deficiency) happens before the heart stops and has important implications for brain injury. Without oxygen, the brain is damaged within minutes even before the heart stops. These findings point to the need for further research to understand and appropriately treat these complications that result from opioid-associated cardiac arrest, especially potential brain injury and possible use of treatments that can protect the brain.

Naloxone, an urgent first treatment for overdose, can rapidly and effectively reverse respiratory depression or hypoventilation caused by opioids. Emergency medical services responders, trained laypeople and the general public (with the support of 911 emergency dispatcher instructions) can administer naloxone to prevent cardiac arrest. Traditional CPR including airway and rescue breathing support can also be effective.

Yet people who experience opioid-associated out-of-hospital cardiac arrest are more likely to be alone at home or in a private setting—away from someone who would witness the early signs of cardiac arrest and act. There is also evidence of underreporting due to the stigma associated with opioid poisoning and the potential for criminal charges to others in possession of opioids.

"Optimizing outcomes after cardiac arrest associated with opioid overdose requires recognition of distress by another person—the lay public or emergency dispatchers, prompt emergency response, and treatment with naloxone or CPR ventilation coupled with compressions," said Dezfulian. Prompt naloxone use can prevent progression from respiratory to cardiac arrest; increasing access to this life-saving drug is one way to prevent opioid-associated cardiac arrests.

Because opioids often remain in the body for several days, when it comes to attempting to predict outcomes, patience is critical. The statement recommends delaying decisions about stopping life-saving efforts until there has been time for the medications to clear from the patient's system, specifically until:at least 72 hours after the return of spontaneous circulation and normothermia (normal body temperature);toxic substances and their metabolites have cleared; and ICU-administered sedatives and analgesics have cleared.

Education may be another critical component in the fight against opioid overdose and opioid-associated out-of-hospital cardiac arrest.

"Targeted educational campaigns providing opioid use disorder education and prevention information, naloxone distribution and conventional CPR training, including rescue breathing, to those likely to have or witness an opioid overdose could help prevent and improve treatment of opioid-associated out-of-hospital cardiac arrest," Dezfulian said. "Along with broader public education, legal reforms and policies aimed at preventing opioid-associated cardiac arrest can save lives and should include resources for medication treatment in order to improve recovery for a generally young otherwise healthy segment of our population."

参考文献：

Cameron Dezfulian et al,Opioid-Associated Out-of-Hospital Cardiac Arrest:Distinctive Clinical Features and Implications for Health Care and Public Responses: A Scientific Statement From the American Heart Association,Circulation (2021). 

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