气管插管脑损伤患者的早期神经唤醒试验:长期的单中心经验报告
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摘要
背景:入院前处理中,在初始影像学检查前,严重创伤性脑损伤(TBI)均需要气管插管、镇静和机械通气。初始影像评估后,随即以早期的神经唤醒试验(ENWT)给予快速的神经学复评。这一管理策略给予了早期的参考临床检查,将与后续检查对比。目的 :本研究旨在描述经历过ENWT患者的临床特点,并明确ENWT失败的原因。方法 :我们进行了一项观察性的回顾性单中心研究,纳入创伤中心收治的所有TBI患者。ENWT是指在TBI后24小时内暂停镇静。研究数据涵盖了患者特点、CT扫描结果及患者转归,患者转归数据来自ICU收治的所有气管插管的TBI患者的预估。从患者档案中检索ENWT的特点和失败的原因。建立了多元Logistic回归模型,以确定ENWT失败的危险因素。结果 :7年中,所收治的242例气管插管TBI患者均纳入此研究。96例患者接受了ENWT,占患者总数的40%;其中38例(39.5%)患者中止了ENWT,主要原因是神经系统恶化(27例,71%)或呼吸窘迫(10例,26%)。ENWT失败的重要预测因子是:第1次影像检查显示硬膜下血肿厚度>5 mm(OR=3.2,95%CI为1.01~10.28),以及初始GCS评分<5(OR=7.4,95%CI为1.92~28.43)。ENWT成功的患者,1年的预后不良率低于ENWT失败或未实施ENWT的患者,三者的预后不良率分别为4%、48%和49%(P<0.0001)。结论 :对纳入研究的40%的患者实施了ENWT,成功率为60.5%。硬膜下血肿厚度>5 mm或初始GCS评分<5的患者,预期ENWT可能会失败。
Background: In prehospital setting, a severe traumatic brain injury(TBI) requires tracheal intubation, sedation and mechanical ventilation pending the initial imagery. An early neurological wake-up test(ENWT), soon after the initial imaging assessment, allows a rapid neurological reassessment. This strategy authorises an initial clinical examination of reference with which will be compared the later examinations. Objective: The main objective of this study was to describe the characteristics of the patients who underwent an ENWT, and to determine its causes of failure. Methods: We conducted a retrospective, observational, single-centre study including all intubated TBI admitted in the trauma centre. An ENWT was defined as cessation of sedation within 24 h after TBI. Data concerning patient characteristics, CT-scan results, and outcomes were extracted from a prospective register of all intubated TBI admitted in the ICU. Characteristic of ENWT and causes of failure were retrieved from patient files. A multivariate logistic regression model was developed to determine the risk factors of ENWT failure. Results: During 7 years, 242 patients with intubated TBI were included. An ENWT was started in 96 patients, for an overall rate at 40%. The ENWT was stopped in 38 patients(39.5%), mostly due to neurological deterioration in 27 cases(71%) or respiratory distress in 10 cases(26%). Significant predictors of ENWT failure were: the presence of subdural hematoma with a thickness >5 mm on first imagery(OR=3.2; 95%CI [1.01-10.28]), and an initial GCS score <5(OR=7.4; 95%CI [1.92-28.43]). Prevalence of poor outcome at 1 year was lesser in patients with successful ENWT compared to those with failure or absence of ENWT: 4% vs. 48% and 49%(P<0.0001). Conclusion: The ENWT is achieved in 40% of patients, with a success rate of 60.5%. In presence of a subdural hematoma with a thickness >5 mm or an initial GCS score <5, an ENWT failure may be expected.
Background: In prehospital setting, a severe traumatic brain injury(TBI) requires tracheal intubation, sedation and mechanical ventilation pending the initial imagery. An early neurological wake-up test(ENWT), soon after the initial imaging assessment, allows a rapid neurological reassessment. This strategy authorises an initial clinical examination of reference with which will be compared the later examinations. Objective: The main objective of this study was to describe the characteristics of the patients who underwent an ENWT, and to determine its causes of failure. Methods: We conducted a retrospective, observational, single-centre study including all intubated TBI admitted in the trauma centre. An ENWT was defined as cessation of sedation within 24 h after TBI. Data concerning patient characteristics, CT-scan results, and outcomes were extracted from a prospective register of all intubated TBI admitted in the ICU. Characteristic of ENWT and causes of failure were retrieved from patient files. A multivariate logistic regression model was developed to determine the risk factors of ENWT failure. Results: During 7 years, 242 patients with intubated TBI were included. An ENWT was started in 96 patients, for an overall rate at 40%. The ENWT was stopped in 38 patients(39.5%), mostly due to neurological deterioration in 27 cases(71%) or respiratory distress in 10 cases(26%). Significant predictors of ENWT failure were: the presence of subdural hematoma with a thickness >5 mm on first imagery(OR=3.2; 95%CI [1.01-10.28]), and an initial GCS score <5(OR=7.4; 95%CI [1.92-28.43]). Prevalence of poor outcome at 1 year was lesser in patients with successful ENWT compared to those with failure or absence of ENWT: 4% vs. 48% and 49%(P<0.0001). Conclusion: The ENWT is achieved in 40% of patients, with a success rate of 60.5%. In presence of a subdural hematoma with a thickness >5 mm or an initial GCS score <5, an ENWT failure may be expected.
引文