不同浓度高渗盐水对颅脑损伤患者颅高压的影响
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摘要
目的探讨不同浓度高渗盐水对颅脑损伤患者的颅高压治疗效果及其预后的影响。方法选取2018年3月至2019年2月间入住我院重症医学科的颅脑损伤患者60例,随机分为A、B、C三组(各20例)。A组:3%的高渗盐水150mL静脉注射,每6h1次,0.5mL/kg·h;B组:10%的高渗盐水0.8mL/kg静脉注射,每6h1次,200mL/h;C组:20%甘露醇0.5g/kg静脉滴注,比较三组患者治疗前、治疗后0.5、1、2、3、6h颅内压(intracranial pressure,ICP)、平均动脉压(mean arterial pressure,MAP)、脑灌注压(cerebral perfusion pressure,CPP)水平变化,比较治疗前、治疗后6h血钠、血浆渗透压,降颅压显效时间、持续时间以及患者预后情况。结果治疗前三组患者ICP、MAP、CPP均无显著性差异(P>0.05),治疗后三组患者ICP均得到有效控制,A组患者治疗后3h ICP开始上升,而B、C组患者治疗后2h后ICP开始上升,差异具有统计学意义(P<0.05)。治疗后3h内三组患者MAP、CPP均显著上升,且A、B组患者上升幅度更显著,差异具有统计学意义(P<0.05)。而治疗后6h,三组患者MAP、CPP与治疗前无统计学差异(P>0.05),治疗前、治疗后6h三组患者血钠、血浆渗透压差异无统计学差异(P>0.05),C组患者降颅压显效时间显著延长,A组患者降颅压持续时间显著延长,差异具有统计学意义(P<0.05),A、B组患者预后优于C组,差异具有统计学意义(P<0.05),而A、B组患者预后无显著性差异(P>0.05),三组患者不良反应发生率差异无统计学意义(χ~2=5.536,P=0.765)。结论高渗盐水、甘露醇治疗重型颅脑损伤患者能够有效降低患者的颅内压,在降压效果和持续时间方面,3%高渗盐水的作用更显著,治疗过程中要严格控制药物的输注速度、密切实时监测血钠、血浆渗透的改变,减少不良反应的发生,建议在临床上推广。
Objective To investigate the effect of different concentrations of hypertonic saline and 20% mannitol on intracranial hypertension and prognosis in patients with craniocerebral injury.Methods Sixty patients with craniocerebral injury who were admitted to the Department of Critical Care Medicine from March 2018 to February 2019 were randomly divided into three groups: A, B, and C(20 cases each). Group A: 3% high Infiltration of saline 150 mL Intravenous injection, once every 6 hours 0.5 mL/kg·h; Group B: 10% hypertonic saline 0.8 mL/kg Intravenous injection, once every 6 hours 200 mL/h; Group C: 20% mannitol 0.5 g/kg intravenous injection. The intracranial pressure(ICP), mean arterial pressure(MAP), and cerebral perfusion pressure(CPP) at 0.5、1、2、3、6 h before and after treatment were compared among the three Group. The blood sodium, plasma osmotic pressure, reduction of intracranial pressure effective time and duration, prognosis at 6 h before and after treatment were also compared.Results There were no significant differences in ICP, MAP, and CPP among the three groups before treatment(P>0.05). After treatment,the ICP were effectively controlled in the three groups. The ICP in group A began to increase at 3 h after treatment, while the ICP of patients in group B and C began to increase at 2 h after treatment. The difference had statistically significant(P<0.05). The MAP and CPP of the three groups increased significantly within 3 hours after treatment,and the increase was more significant in the A and B groups, the difference was statistically significant(P<0.05). There was no significant difference in MAP and CPP between the three groups after treatment(P>0.05). There was no significant difference in blood sodium and plasma osmotic pressure between the three groups before treatment and 6 hours after treatment(P>0.05). The effective time of intracranial pressure was significantly prolonged in the group. The duration of intracranial pressure was significantly prolonged in group A(P<0.05). The prognosis of patients in group A and B was better than that in group C. The difference was statistically significant(P<0.05), and there was no significant difference in the prognosis between the A and B groups(P>0.05). There was no significant difference in the incidence of adverse reactions between the three groups(χ~2=5.536, P=0.765).Conclusion Hypertonic saline and mannitol has effective role in the treatment of patients with severe head injury by reducing the intracranial pressure. In the aspect of antihypertensive effect and duration, the effect of 3% hypertonic saline is the most significant. During the treatment, the infusion rate of the drug should be strictly controlled, and the changes of blood sodium and plasma permeation should be closely monitored in real time. To reduce the occurrence of adverse reactions, it is recommended to promote in the clinic.
Objective To investigate the effect of different concentrations of hypertonic saline and 20% mannitol on intracranial hypertension and prognosis in patients with craniocerebral injury.Methods Sixty patients with craniocerebral injury who were admitted to the Department of Critical Care Medicine from March 2018 to February 2019 were randomly divided into three groups: A, B, and C(20 cases each). Group A: 3% high Infiltration of saline 150 mL Intravenous injection, once every 6 hours 0.5 mL/kg·h; Group B: 10% hypertonic saline 0.8 mL/kg Intravenous injection, once every 6 hours 200 mL/h; Group C: 20% mannitol 0.5 g/kg intravenous injection. The intracranial pressure(ICP), mean arterial pressure(MAP), and cerebral perfusion pressure(CPP) at 0.5、1、2、3、6 h before and after treatment were compared among the three Group. The blood sodium, plasma osmotic pressure, reduction of intracranial pressure effective time and duration, prognosis at 6 h before and after treatment were also compared.Results There were no significant differences in ICP, MAP, and CPP among the three groups before treatment(P>0.05). After treatment,the ICP were effectively controlled in the three groups. The ICP in group A began to increase at 3 h after treatment, while the ICP of patients in group B and C began to increase at 2 h after treatment. The difference had statistically significant(P<0.05). The MAP and CPP of the three groups increased significantly within 3 hours after treatment,and the increase was more significant in the A and B groups, the difference was statistically significant(P<0.05). There was no significant difference in MAP and CPP between the three groups after treatment(P>0.05). There was no significant difference in blood sodium and plasma osmotic pressure between the three groups before treatment and 6 hours after treatment(P>0.05). The effective time of intracranial pressure was significantly prolonged in the group. The duration of intracranial pressure was significantly prolonged in group A(P<0.05). The prognosis of patients in group A and B was better than that in group C. The difference was statistically significant(P<0.05), and there was no significant difference in the prognosis between the A and B groups(P>0.05). There was no significant difference in the incidence of adverse reactions between the three groups(χ~2=5.536, P=0.765).Conclusion Hypertonic saline and mannitol has effective role in the treatment of patients with severe head injury by reducing the intracranial pressure. In the aspect of antihypertensive effect and duration, the effect of 3% hypertonic saline is the most significant. During the treatment, the infusion rate of the drug should be strictly controlled, and the changes of blood sodium and plasma permeation should be closely monitored in real time. To reduce the occurrence of adverse reactions, it is recommended to promote in the clinic.
引文
[1] 陈珑.不同剂量高渗盐水治疗颅脑损伤时对血生化及渗透压的影响研究[J].中围医学创新,2013,10(7):132-133.
[2] HORN P,MUNCH E,VAJKOCZY P,et al.Hypertonic saline solution for control of elevated intracranial pressure in patients with exhausted response to mannitol and barbiturates[J].Neurol Res,2016,21(8):758-764.
[3] 周冬青,谢海,马乃全,等.颅内高压患者术中应用3%高渗盐水与20%甘露醇后血流动力学的变化[J].中华实验外科杂志,2012,29(7):1396-1398.
[4] 江基尧.颅脑创伤临床救治指南[M].上海:第军医大学出版社,2015.
[5] DASILVA J C,DELIMA F M,VALENCA M M,et al.Hypertonic saline more efficacious than mannitol in lethal intracranial hypertension model[J].Neurol Res,2018,32(2):139-143.
[6] ICHAI C,ARMANDO G,ORBAN J C,et al.Sodium lactate versus mannitol in the treatment of intracranial hypertensive episodes in severe traumatic brain-injured patients[J].Intensive Care Med,2015,35(3):471-479.
[7] ROBERTS I,YATES D,SANDERCOCK P,et al.Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury(MRC CRASH trial)randomised placebo-controlled trial[J].Lancet,2014,364(9442):1321-1328.
[8] TREGGIARI M M,CHUTV N,YANEZ N D,et al.Role of intracranial pressure values and patterns in predicting outcome in traumatic brain injury:a systematic review[J].Neurocrit Care,2017,6(2):104-12.
[9] WERE M L,NEMANI V M,MEEKER M,et al.Effects of 23.4% sodium chloride solution in reducing intracranial pressure in patients with traumatic brain injury:a preliminary study[J].Neurosurgery,2015,57(4):727-736.
[10] LIU S,LI L,LUO Z,et al.Superior effect of hypertonic saline over mannitol to attenuate cerebral edema in a rabbit bacterial meningitis model[J].Crit Care Med,2011,39(6):1467-1473.
[11] 朱敏,李英斌.高渗盐水与甘露醇治疗高血压脑出血术后颅内高压的临床疗效[J].右江民族医学院学报,2016,38(4):395.
[12] MANGAT H S,HRTL R.Hypertonic saline for the management of raised intracranial pressure after severe traumatic brain injury[J].Annals of the New York Academy of Sciences,2015,25(1345):83-88.
[13] QURESHI M D,SUAREZ M D,BHARDWAJ A,et al.Use of Hypertonic(3%)Saline Infusion in the Treatment of Cerebral Edema:Effect on Intracranial Pressure and Lateral Displacement of the Brain[J].Critical Care Medicine,2016,26(3):440-446.
[14] BATTISON C,ANDREWS P J,GRAHAM C,et al.Randomized,controlled trial on the effect of a 20% mannitol solution and a 7.5% saline/6% dextran solution on increased intraintracranial pressure after brain injury [J].Crit Care Med,2015,33(1):196.
[15] PRABHAKAR H,SINGH G P,ANAND V,et al.Mannitol versushypertonic saline for brain relaxation in patients undergoing craniotomy[J].Sao Paulo Med J,2015,133(2):166-167.
[2] HORN P,MUNCH E,VAJKOCZY P,et al.Hypertonic saline solution for control of elevated intracranial pressure in patients with exhausted response to mannitol and barbiturates[J].Neurol Res,2016,21(8):758-764.
[3] 周冬青,谢海,马乃全,等.颅内高压患者术中应用3%高渗盐水与20%甘露醇后血流动力学的变化[J].中华实验外科杂志,2012,29(7):1396-1398.
[4] 江基尧.颅脑创伤临床救治指南[M].上海:第军医大学出版社,2015.
[5] DASILVA J C,DELIMA F M,VALENCA M M,et al.Hypertonic saline more efficacious than mannitol in lethal intracranial hypertension model[J].Neurol Res,2018,32(2):139-143.
[6] ICHAI C,ARMANDO G,ORBAN J C,et al.Sodium lactate versus mannitol in the treatment of intracranial hypertensive episodes in severe traumatic brain-injured patients[J].Intensive Care Med,2015,35(3):471-479.
[7] ROBERTS I,YATES D,SANDERCOCK P,et al.Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury(MRC CRASH trial)randomised placebo-controlled trial[J].Lancet,2014,364(9442):1321-1328.
[8] TREGGIARI M M,CHUTV N,YANEZ N D,et al.Role of intracranial pressure values and patterns in predicting outcome in traumatic brain injury:a systematic review[J].Neurocrit Care,2017,6(2):104-12.
[9] WERE M L,NEMANI V M,MEEKER M,et al.Effects of 23.4% sodium chloride solution in reducing intracranial pressure in patients with traumatic brain injury:a preliminary study[J].Neurosurgery,2015,57(4):727-736.
[10] LIU S,LI L,LUO Z,et al.Superior effect of hypertonic saline over mannitol to attenuate cerebral edema in a rabbit bacterial meningitis model[J].Crit Care Med,2011,39(6):1467-1473.
[11] 朱敏,李英斌.高渗盐水与甘露醇治疗高血压脑出血术后颅内高压的临床疗效[J].右江民族医学院学报,2016,38(4):395.
[12] MANGAT H S,HRTL R.Hypertonic saline for the management of raised intracranial pressure after severe traumatic brain injury[J].Annals of the New York Academy of Sciences,2015,25(1345):83-88.
[13] QURESHI M D,SUAREZ M D,BHARDWAJ A,et al.Use of Hypertonic(3%)Saline Infusion in the Treatment of Cerebral Edema:Effect on Intracranial Pressure and Lateral Displacement of the Brain[J].Critical Care Medicine,2016,26(3):440-446.
[14] BATTISON C,ANDREWS P J,GRAHAM C,et al.Randomized,controlled trial on the effect of a 20% mannitol solution and a 7.5% saline/6% dextran solution on increased intraintracranial pressure after brain injury [J].Crit Care Med,2015,33(1):196.
[15] PRABHAKAR H,SINGH G P,ANAND V,et al.Mannitol versushypertonic saline for brain relaxation in patients undergoing craniotomy[J].Sao Paulo Med J,2015,133(2):166-167.