Tuğba CİMİLLİ ÖZTÜRK, Fatma SARI DOĞAN, Ebru ÜNAL AKOĞLU

Hipotermide Kan Gazlarında Gözlenen Değişiklikler Ve Solunumsal Tedavi Hedefleri: Alfa-STAT Ve pH-STAT Yaklaşımları

Acil Tıp pratiğinde hipotermi vakaları genellikle soğuk ile ilişkili çevresel kazalar ile birlikte görülür. Vakaların vücut ısıları farklılık gösterir ve tedavide nihai hedef normal vücut sıcaklığına ulaşmaktır. Terapötik hipotermi veya daha çok kabul gören ismi ile ‘Hedeflenmiş Sıcaklık Yönetimi’ ise kardiyak arrest sonrası nörolojik fonksiyonlarda ve hayatta kalma oranında artış sağlayabildiği düşünülen nöroprotektif bir tedavi yöntemidir. Kardiyak arrest sonrası her ne kadar hedef değerler ve uygulama süresi netlik kazanmamış olsa da ilk saatlerde uygulanmaya başlayan hastalarda standart tedavi uygulananlara göre daha iyi nörolojik sonlanımın gözlendiği bilinmektedir. Dolayısıyla önümüzdeki günlerde acil servislerde ‘Hedeflenmiş Sıcaklık Yönetimi’nin daha yaygın uygulanması kaçınılmaz olacaktır. Hipotermi uygulanan hastalarda kan gazlarında gözlenen değişikliklerin yorumlanması ve hücresel fizyolojik süreçleri normal seyrinde yürütmek için uygulanması gereken solunumsal tedavi stratejileri ise uzun yıllardır tartışılmaya devam eden ve üzerinde bir konsensüse varılamamış önemli sorunlardır. Bu derlemede, hipotermide insan vücudunda ortaya çıkan fizyolojik süreçler ve bunun kan gazlarına olan yansımaları değerlendirilmiş ve aynı zamanda bu hasta grubunda uygulanan ve birbirine tamamen zıt hedefleri olan ‘Alfa-Stat’ ve pH-Stat’ solunumsal tedavi yöntemleri tartışılmıştır.

Changes in Blood Gases in Hypothermia and Respiratory Treatment Goals: Alpha-STAT and pH-STAT Approaches

In Emergency Medicine practice, hypothermia cases are generally seen with environmental accidents related to cold injuries. The body temperatures of the cases differ and the ultimate goal in treatment is to reach normal body temperature. Therapeutic Hypothermia, or "Targeted Temperature Management", is a neuroprotective treatment method that is thought to increase neurological functions and survival rate after cardiac arrest. Although the target values and duration of therapy after cardiac arrest have not been clarified, it is known that better neurological outcome is observed compared to those who received standard therapy in the first hours. Therefore, it will be inevitable to apply "Targeted Temperature Management" more widely in emergency services in the coming days. Interpretation of changes in blood gases observed in patients with hypothermia and respiratory therapy strategies that should be applied to carry out cellular physiological processes in a normal course are important problems that have been discussed for many years and there is still no consensus. In this review, physiological processes occurring in the human body in hypothermia and their reflections on blood gases are evaluated and at the same time, 'Alpha-Stat' and pH-Stat' respiratory treatment strategies, which have completely opposite goals are discussed.

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1. Dow J, Giesbrecht GG, Danzl DF, et al. Wilderness Medical Society Clinical Practice guidelines for the out-of-hospital evaluation and treatment of accidental hypothermia: 2019 update. Wilderness & environmental medicine. 2019;30(4):47- 69.
2. Paddock MT. Cold Injuries. In:Tintinalli JEed. Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY:McGraw-Hill;2016:1353-1357.
3. Zafren K, Danzl DF. Frostbite and non-freezing cold injuries. In: Walls RM ed. Rosen’s Emergency Medicine Consepts and Clinical Practise. 9th ed. Philedelphia, PA:Elsevier, Inc;2018:1735-1742.
4. Panchal AR, Bartos JA, Cabañas JG, et al. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142:366-468.
5. Lascarrou JB, Merdji H, Le Gouge A, et al. Targeted temperature management for cardiac arrest with nonshockable rhythm. New England Journal of Medicine. 2019:12;381(24):2327-37.
6. Algarni KD, Yanagawa B, Rao V, et al. Profound hypothermia compared with moderate hypothermia in repair of acute type A aortic dissection. The Journal of thoracic and cardiovascular surgery. 2014:148(6):2888-94.
7. Moler FW, Silverstein FS, Holubkov R, et al. Therapeutic hypothermia after in-hospital cardiac arrest in children. New England Journal of Medicine. 2017;376(4):318-29.
8. Kurisu K, Kim JY, You J, et al. Therapeutic Hypothermia and Neuroprotection in Acute Neurological Disease. Curr Med Chem. 2019;26(29):5430-5455. doi:10.2174/0929867326666190506124836
9. Brown D. Hypotermia. In: Tintinalli JE ed. Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY:McGrawHill;2016:1357-1365.
10. Severinghaus JW. The invention and development of blood gas analysis apparatus. Anesthesiology. 2002;97(1):253-6.
11. Shapiro BA. Temperature correction of blood gas values. Respiratory Care Clinics of North America. 1995;1(1):69-76.
12. Mohammadhoseini E, Safavi E, Seifi S,et al. Effect of sample storage temperature and time delay on blood gases, bicarbonate and pH in human arterial blood samples. Iranian Red Crescent Medical Journal. 2015;17(3).
13. Theodore AC, Manaker S, Hollingsworth H. Arterial blood gases. In:UpToDate 2018. UpToDate, Waltham (MA). https://www.uptodate.com/contents/arterial-blood-gases#H6 adresinden 17.01.2021 tarihinde erişilmiştir.
14. Bacher A. Effects of body temperature on blood gases. Intensive care medicine. 2005;31(1):24-7.
15. Andritsch RF, Muravchick S, Gold MI. Temperature Correction of Arterial Blood-Gas Parameters. A Comparative Review of Methodology. Anesthesiology: The Journal of the American Society of Anesthesiologists. 1981;55(3):311-6.
16. Severinghaus JW, Astrup P, Murray JF. Blood gas analysis and critical care medicine. American journal of respiratory and critical care medicine. 1998;157(4):114-22.
17. Ashwood ER, Kost G, Kenny M. Temperature correction of bloodgas and pH measurements. Clinical chemistry. 1983; 29(11):1877-85.
18. Higgins, Chris. "Temperature correction of blood gas and pH measurement-an unresolved controversy." https://acutecaretesting.org/en/articles/temperaturecorrection-of-blood-gas-and-ph-measurement--an-unresolvedcontroversy adresinden 17.01.2021 tarihinde erişilmiştir.
19. Abdul Aziz KA, Meduoye A. Is pH-stat or alpha-stat the best technique to follow in patients undergoing deep hypothermic circulatory arrest? Interactive cardiovascular and thoracic surgery. 2010;10(2):271-82.
20. Reeves RB. An imidazole alphastat hypothesis for vertebrate acid-base regulation: Tissue carbon dioxide content and body temperature in bullfrogs. Respiration Physiology.1972;14(1- 2):219-236.
21. Duebener LF, Hagino I, Sakamoto T, et al. Effects of pH management during deep hypothermic bypass on cerebral microcirculation: alpha-stat versus pH-stat. Circulation. 2002;106(12-suppl-1):I-103.
22. Jacobsen CF, Leonis J, Linderstrøm-Lang K, et al. The pH-stat and its use in biochemistry. Methods of Biochemical Analysis. 1957;4:171-210.
23. Alston TA. Blood gases and pH during hypothermia: the "-stats". Int Anesthesiol Clin 2004; 42,4: 73-80.
24. Priestley MA, Golden JA, O'Hara IB, et al. Comparison of neurologic outcome after deep hypothermic circulatory arrest with alpha-stat and pH-stat cardiopulmonary bypass in newborn pigs. The Journal of Thoracic and Cardiovascular Surgery. 2001;121(2):336-43.
25. Li ZJ, Yin XM, Ye J. Effects of pH management during deep hypothermic bypass on cerebral oxygenation: alpha-stat versus pH-stat. Journal of Zhejiang University-SCIENCE A. 2004;5(10):1290-7.
26. Kollmar R, Georgiadis D, Schwab S. Alpha-stat versus pH-stat guided ventilation in patients with large ischemic stroke treated by hypothermia. Neurocritical care. 2009;10(2):173-80.
27. Eastwood GM, Suzuki S, Lluch C,et al. A pilot assessment of alpha-stat vs pH-stat arterial blood gas analysis after cardiac arrest. Journal of critical care. 2015;30(1):138-144. https://doi.org/10.1016/j.jcrc.2014.09.022.
28. Bellinger DC, Wypij D, du Plessis AJ, et al. Developmental and neurologic effects of alpha-stat versus pH-stat strategies for deep hypothermic cardiopulmonary bypass in infants. The Journal of thoracic and cardiovascular surgery. 2001;121(2):374- 83.
29. Voicu S, Deye N, Malissin I, et al. Influence of α-stat and pH-stat blood gas management strategies on cerebral blood flow and oxygenation in patients treated with therapeutic hypothermia after out-of-hospital cardiac arrest: a crossover study. Critical care medicine. 2014;42(8):1849-61.
30. Jakkula P, Reinikainen M, Hästbacka J, et al. Targeting two different levels of both arterial carbon dioxide and arterial oxygen after cardiac arrest and resuscitation: a randomised pilot trial. Intensive care medicine. 2018;44(12):2112-21-44.