体温干预下头颈部降温对脑外伤患者耳蜗温度的影响
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摘要
目的通过观察耳蜗温度的变化,研究头颈部降温配合体温管理对脑外伤患者颅脑亚低温治疗效能。方法选取重度颅脑外伤患者33例,其中保守治疗患者16例和颅脑手术后患者17例,按入组先后顺序随机分为头颈降温组(18例)和单纯冰帽组(15例),分别在降温前及开始后1、2、4、8、9 h记录肛温和耳蜗温度,并对体温过低和发热进行干预。降温过程监测血压、心率及寒战等异常情况。统计学分析头颈部降温方法的颅脑降温效能,并分析手术后头部敷料包扎对颅脑降温效果的影响。结果单纯冰帽组耳蜗温度下降缓慢且耳蜗温度下降仅0.4～0.7℃,而头颈降温组耳蜗温度在3～4 h达到可靠的降温效果,降温幅度接近2.5℃,两组差异有统计学意义(P<0.05)。头颅手术后敷料包扎可以显著削弱头颈部降温的作用,但降温强度仍能接近1.5℃,与冰帽降温比较差异仍有统计学意义(P<0.05)。结论头颈部降温,可以显著改善单纯冰帽的颅脑降温效能,结合体温管理,可以有效维持核心体温稳定。
引文
[1] Lewis SR,Evans DJ,Butler AR,et al.Hypothermia for traumatic brain injury[J].Cochrane Database Syst Rev,2017,9:CD001048.
[2] Cooper DJ,Nichol AD,Bailey M,et al.Effect of Early Sustained Prophylactic Hypothermia on Neurologic Outcomes Among Patients With Severe Traumatic Brain Injury:The POLAR Randomized Clinical Trial[J].JAMA,2018,320(21):2211-2220.
[3] Harris OA,Muh CR,Surles MC,et al.Discrete cerebral hypothermia in the management of traumatic brain injury:a randomized controlled trial[J].J Neurosurg,2009,110(6):1256-1264.
[4] Nelson DA,Nunneley SA.Brain temperature and limits on transcranial cooling in humans:quantitative modeling results[J].Eur J Appl Physiol Occup Physiol,1998,78(4):353-359.
[5] Kallmünzer B,Beck A,Schwab S,et al.Local head and neck cooling leads to hypothermia in healthy volunteers[J].Cerebrovasc Dis,2011,32(3):207-210.
[6] Li H,Chen RK,Tang Y,et al.An experimental study and finite element modeling of head and neck cooling for brain hypothermia[J].J Therm Biol,2018,71:99-111.
[7] Giuliani E,Magnoni S,Fei M,et al.A Novel Cooling Device for Targeted Brain Temperature Control and Therapeutic Hypothermia:Feasibility Study in an Animal Model[J].Neurocrit Care,2016,25(3):464-472.
[8] Maissan IM,Ketelaars R,Vlottes B,et al.Increase in intracranial pressure by application of a rigid cervical collar:a pilot study in healthyvolunteers[J].Eur J Emerg Med,2018,25(6):e24-e28.
[9] Sparke A,Voss S,Benger J.The measurement of tissue interface pressures and changes in jugular venous parameters associated with cervical immobilisation devices:a systematic review[J].Scand J Trauma Resusc Emerg Med,2013,21:81.
[10] Feng H,Jin Z,He W,et al.Cerebral venous outflow participates in perihematomal edema after spontaneous intracerebral hemorrhage:A cross-sectional study[J].Medicine (Baltimore),2018,97(35):e12034.
[11] Bommadevara M,Zhu L.Temperature difference between the body core and arterial blood supplied to the brain during hyperthermia or hypothermia in humans[J].Biomech Model Mechanobiol,2002,1(2):137-149.
[12] 张海峰.医用冰帽对头部径向温度分布的影响[J].中国科学技术大学学报,2008,38(4):410-413.
[13] Diao C,Zhu L,Wang H.Cooling and rewarming for brain ischemia or injury:theoretical analysis[J].Ann Biomech Eng,2002,31(3):346-353.
[14] T?mte ?,Dr?gni T,Mangschau A,et al.A comparison of intravascular and surface cooling techniques in comatose cardiac arrest survivors[J].Crit Care Med,2011,39(3):443-449.
[15] Pittl U,Schratter A,Desch S,et al.Invasive versus noninvasive cooling after in- and out-of-hospital cardiac arrest:a randomized trial[J].Clin Res Cardiol,2013,102:607-614.
[16] Nielsen N,Wetterslev J,Cronberg T,et al.Targeted temperature management at 33℃ versus 36℃ after cardiac arrest[J].New England J Med,2013,369(23):2197-2206.
[17] Metz C,Holzschuh M,Bein T,et al.Moderate hypothermia in patients with severe head injury:cerebral and extracerebral effects[J].J Neurosurg,1996,85(4):533-541.
[18] Pérez-Bárcena J,Llompart-Pou JA,Homar J,et al.Pentobarbital versus thiopental in the treatment of refractory intracranial hypertension in patients with traumatic brain injury:A randomized controlled trial[J].Crit Care,2008,12(4):R112.
[19] Jacob S,Khan A,Jacobs ER,et al.Prolonged hypothermia as a bridge to recovery for cerebral edema and intracranial hypertension associated with fulminant hepatic failure[J].Neurocritical Care,2009,11(2):242-246.
[20] Wang CH,Lin YT,Chou HW,et al.Novel approach for independent control of brain hypothermia and systemic normothermia:cerebral selective deep hypothermia for refractory cardiac arrest[J].J Neurointerv Surg,2017,9(8):e32.
[21] Sakoh M,Gjedde A.Neuroprotection in hypothermia linked to redistribution of oxygen in brain[J].Am J Physiol Heart Circ Physiol,2003,285(1):H17-H25.
[22] Lemiale V,Huet O,Vigué B,et al.Changes in cerebral blood flow and oxygen extraction during post resuscitation syndrome[J].Resuscitation,2008,76(1):17-24.
[23] Monson KL,Converse MI,Manley GT,et al.Cerebral blood vessel damage in traumatic brain injury[J].Clin Biomech (Bristol,Avon),2018,19:S0268-0033(18)30125-6.
[24] Ogami K,Dofredo M,Moheet AM,et al.Early and Severe Symptomatic Cerebral Vasospasm After Mild Traumatic Brain Injury[J].World Neurosurg,2017,101:813.e11-813.e14.
[25] Carre E,Ogier M,Boret H,et al.Metabolic crisis in severely head-injured patients:is ischemia just the tip of the iceberg?[J].Front Neurol,2013,4:146.
[2] Cooper DJ,Nichol AD,Bailey M,et al.Effect of Early Sustained Prophylactic Hypothermia on Neurologic Outcomes Among Patients With Severe Traumatic Brain Injury:The POLAR Randomized Clinical Trial[J].JAMA,2018,320(21):2211-2220.
[3] Harris OA,Muh CR,Surles MC,et al.Discrete cerebral hypothermia in the management of traumatic brain injury:a randomized controlled trial[J].J Neurosurg,2009,110(6):1256-1264.
[4] Nelson DA,Nunneley SA.Brain temperature and limits on transcranial cooling in humans:quantitative modeling results[J].Eur J Appl Physiol Occup Physiol,1998,78(4):353-359.
[5] Kallmünzer B,Beck A,Schwab S,et al.Local head and neck cooling leads to hypothermia in healthy volunteers[J].Cerebrovasc Dis,2011,32(3):207-210.
[6] Li H,Chen RK,Tang Y,et al.An experimental study and finite element modeling of head and neck cooling for brain hypothermia[J].J Therm Biol,2018,71:99-111.
[7] Giuliani E,Magnoni S,Fei M,et al.A Novel Cooling Device for Targeted Brain Temperature Control and Therapeutic Hypothermia:Feasibility Study in an Animal Model[J].Neurocrit Care,2016,25(3):464-472.
[8] Maissan IM,Ketelaars R,Vlottes B,et al.Increase in intracranial pressure by application of a rigid cervical collar:a pilot study in healthyvolunteers[J].Eur J Emerg Med,2018,25(6):e24-e28.
[9] Sparke A,Voss S,Benger J.The measurement of tissue interface pressures and changes in jugular venous parameters associated with cervical immobilisation devices:a systematic review[J].Scand J Trauma Resusc Emerg Med,2013,21:81.
[10] Feng H,Jin Z,He W,et al.Cerebral venous outflow participates in perihematomal edema after spontaneous intracerebral hemorrhage:A cross-sectional study[J].Medicine (Baltimore),2018,97(35):e12034.
[11] Bommadevara M,Zhu L.Temperature difference between the body core and arterial blood supplied to the brain during hyperthermia or hypothermia in humans[J].Biomech Model Mechanobiol,2002,1(2):137-149.
[12] 张海峰.医用冰帽对头部径向温度分布的影响[J].中国科学技术大学学报,2008,38(4):410-413.
[13] Diao C,Zhu L,Wang H.Cooling and rewarming for brain ischemia or injury:theoretical analysis[J].Ann Biomech Eng,2002,31(3):346-353.
[14] T?mte ?,Dr?gni T,Mangschau A,et al.A comparison of intravascular and surface cooling techniques in comatose cardiac arrest survivors[J].Crit Care Med,2011,39(3):443-449.
[15] Pittl U,Schratter A,Desch S,et al.Invasive versus noninvasive cooling after in- and out-of-hospital cardiac arrest:a randomized trial[J].Clin Res Cardiol,2013,102:607-614.
[16] Nielsen N,Wetterslev J,Cronberg T,et al.Targeted temperature management at 33℃ versus 36℃ after cardiac arrest[J].New England J Med,2013,369(23):2197-2206.
[17] Metz C,Holzschuh M,Bein T,et al.Moderate hypothermia in patients with severe head injury:cerebral and extracerebral effects[J].J Neurosurg,1996,85(4):533-541.
[18] Pérez-Bárcena J,Llompart-Pou JA,Homar J,et al.Pentobarbital versus thiopental in the treatment of refractory intracranial hypertension in patients with traumatic brain injury:A randomized controlled trial[J].Crit Care,2008,12(4):R112.
[19] Jacob S,Khan A,Jacobs ER,et al.Prolonged hypothermia as a bridge to recovery for cerebral edema and intracranial hypertension associated with fulminant hepatic failure[J].Neurocritical Care,2009,11(2):242-246.
[20] Wang CH,Lin YT,Chou HW,et al.Novel approach for independent control of brain hypothermia and systemic normothermia:cerebral selective deep hypothermia for refractory cardiac arrest[J].J Neurointerv Surg,2017,9(8):e32.
[21] Sakoh M,Gjedde A.Neuroprotection in hypothermia linked to redistribution of oxygen in brain[J].Am J Physiol Heart Circ Physiol,2003,285(1):H17-H25.
[22] Lemiale V,Huet O,Vigué B,et al.Changes in cerebral blood flow and oxygen extraction during post resuscitation syndrome[J].Resuscitation,2008,76(1):17-24.
[23] Monson KL,Converse MI,Manley GT,et al.Cerebral blood vessel damage in traumatic brain injury[J].Clin Biomech (Bristol,Avon),2018,19:S0268-0033(18)30125-6.
[24] Ogami K,Dofredo M,Moheet AM,et al.Early and Severe Symptomatic Cerebral Vasospasm After Mild Traumatic Brain Injury[J].World Neurosurg,2017,101:813.e11-813.e14.
[25] Carre E,Ogier M,Boret H,et al.Metabolic crisis in severely head-injured patients:is ischemia just the tip of the iceberg?[J].Front Neurol,2013,4:146.