摘要
背景:
颅内感染是神经外科的常见并发症,而且致残率和死亡率都很高。
由于血脑屏障的存在,常规静脉给药对某些中枢神经系统疾病难以达到良好的疗效。而脑脊液与脑组织之间仅有室管膜或软膜阻隔,物质交换更容易,易取得更好的疗效。
目前,我国临床医生行脑脊液置换术、鞘内药物注射时,仍用生理盐水,从理论上讲,用生理盐水取代脑脊液对已有损伤的脑组织将造成新的损伤。因此,应用类似于脑脊液的人工脑脊液取代生理盐水,能在最大程度上起到保护神经组织的作用。
亚低温治疗对脑组织的保护作用已得到许多临床和实验证实,配合治疗颅内感染效果良好。
目的:
寻求颅内感染的最佳治疗方案。
方法:
选择符合一定条件的患者共31名,随机分为处理组1(亚低温配合脑室内人工脑脊液置换治疗)、处理组2(运用脑室内人工脑脊液置换治疗,不配合亚低温治疗)、处理组3(单纯亚低温治疗)和处理组4(脑室内生理盐水置换治疗)。间断监测颅内压并辅以亚低温治疗,监测指标:体温、血常规、脑脊液压力、生化及常规。观察项目为:感染控制时间、临床症状改善时间、平均住院日,并对患者进行预后评级和安全性评价。比较以上观察项目在各组之间的差别。
结果:
我们发现(1)亚低温配合脑室内人工脑脊液置换治疗对重症颅内感染其预后明显优于单纯予脑室内人工脑脊液置换治疗;(2)脑室内人工脑脊液置换治疗重症颅内感染其预后明显优于常规治疗手段;(3)人工脑脊液置换治疗重症颅内感染其预后优于生理盐水脑脊液置换治疗。
结论:亚低温配合脑室内人工脑脊液置换治疗重症颅内感染优于以往常规治疗手段,人工脑脊液的使用可明显降低生理盐水置换所带来的对脑组织的再损伤,改善临床预后。
Background:Intracranial infection is a common complication of neurosurgery, it has high mutilation rates and mortality rates.Due to blood brain barriers, routine vein administration could hardly gain satisfactory therapeutic effects in some CNS diseases. There is only ependyma or piamater between the cerebralspinal fluid and brain tissue, so it is easier for matter exchange and therapeutic effects would be more optimal.At present, clinical doctors still use normal sodium in cerebrospinal fluid replacement and intraspinal injection of medication, but this will induce secondary damages to the injured brain tissue. Because of this, using artificial cerebrospinal fluid replacing normal sodium mayhave better protective effects on central nervous system (CNS).Although studies have approved the protective effects of moderate hypothermia treatment on the brain tissue, cerebrospinal fluid replacement combined with the moderate hypothermia treatment will gain more better effects on intracranial infection diseases. Objective :To explore the best treatment for intracranial infection. Methods:Patients were randomly divided into 4 groups, the experimental group l(artificial cerebrospinal fluid replacement combined with the moderate hypothermia treatment), the experimental group 2 (only artificial cerebrospinal fluid replacement) , experimental group 3(only the moderate hypothermia treatment) and experimental group 4 (only normal sodium replacement). Monitoring indexes as follows: body temperature (BT), routine blood test, the pressure of cerebralspinal fluid, the routine tests and biochemistry tests of cerebralspinal fluid. Observing items: the time of infection control, the time of clinical symptom improvement and the mean hospitalization time. At last,evaluating prognosis and safety, Comparing the differences in the 4 experimental groups. Results:(1) Artificial cerebrospinal fluid replacement combined with the moderate hypothermia treatment is significantly better than artificial cerebrospinal fluid replacement alone;(2) Artificial cerebrospinal fluid replacement is significantly superior to the conventional therapy;
(3) Artificial cerebrospinal fluid replacement is significantly superior to normal sodiumreplacement.Conclusion:Artificial cerebrospinal fluid replacement combined with the moderate hypothermia treatment has more advantages over conventional therapy, replacement normal sodium with artificial cerebrospinal fluid can provide maximum extent protections for CNS and better clinical prognosis.
引文
1.张天锡.继发性颅内化脓性感染的抗生素治疗.国外医学.神经病学神经外科学册,1986,13(3):122.
2.赵志刚,陈旭,彭名炜.对300例神经外科患者抗生素应用调查分析.中华医院感染学杂志,1997,7(4):243.
3. Clmenza JW, Kaltman SI,Diamond DL. Craniofasial trauma and cerebrospinal fluid leakage: aretrospective clinical studay. [J] Oral Maxillofac Surg,1995,53:1004.
4. Korinek AM. Risk factors for neurosurgical site infections after craniotomy: a prospective multicenter study of 2944 patients[J]. Neurosurgery, 1997, 41 (5): 1079-1081.
5. Infections in neurosurgery working party of the British society for antimicrobial chemotherapy. Antimicrobial prophylaxis in neurosurgery and after head injury [J]. L ancet, 1994, 349 (9065): 1574-1581
6. Morrow BA, Starcevic VP, Keil LC and Seve Am WB. Intracranial hypertension after cerebroventdcular infusions in conscious rats [J] Physiol Regulatory Integrative Comp Physiol, May 1990;258: 1170.
7. Morrow BA, Starcevic VP, Keil LC and Severs WB. Dexamethasone and ergonovine effects on cerebrospinal fluid pressure in conscious rats [J].Pharmacology, Sep 1994;49(3): 199-204.
8. Grady PA and Blaumanis OR. Cerebral venous blood gas tensions in elevated intracranial pressure[J]. Stroke, Sep 1986;17: 946.
9. Lin Y, Tsuchihashi T, Matsumura K, Fukuhara M, Ohya Y, Fujii K, and Iida M. Central cardiovascular action of urotensin Ⅱ in spontaneously hypertensive rats.Hypertens Res, Oct 2003;26(10): 839-45.
10. Kaiser AB,M cGee ZA. Am inoglyco side therapy of gram-negative bacillary meningitis. N Engl J Med, 1975, 293 (24): 1215-1220.
11.尚爱加,程东源,周定标.清洁开颅手术后颅内感染的治疗[J].中华医院感染学杂志,2002;02:22-24。
12.乔丽琴;王志明;闫淑英.颅脑手术后颅内感染的成因及治疗[J].中国综合临床,2002;11:975-976.
13.吴锋.鞘内注射治疗颅内感染的临床进展[J]..中国综合临床,2002;12(18):1059-1060.
14.刘窗溪,万登济,李健龙,等.颅脑手术后颅内感染临床分析[J].中华医院感染学杂志,2000,10(1):426.
15.王秉玉,陈若平,侍行文,等.脑室外引流方法与感染[J].上海第二医科大学学报,2000,17(1):40-41.
16. Pons VG, Denlinger SL, Guglielmo BJ, et al. Ceftizoxime versus vancomycin and gentamicin in neurosurgical prophylaxis: Arandomized prospective blinded clinical study[J]. Neurosurgery, 1993,33: 416.
17.江基尧,朱诚.国外亚低温与脑损伤的研究进展.国外医学·神经病学神经外科学分册,1993,20:4.
18. Dietrich WD.The importance of brain temperature in cerebral injury.J Neurotrauma. 1992,9: S457.
19. Hoffman WE,Werner C,Baughman VL, et al.Postischemic treatment with hypothermia improves outcome from incomplete cerebral ischemia in rats.J Neurosurg Anesthesiol,1991,3: 34.
20. Kariebe H,Zarow GJ,Weistein PR.Use of mild hypothermia vesus mannitol to reduce infarct size after temporary middle cerebral artery occlusioninrat.J Neurosurg,1995,83: 93.
21. Jiang JY, Lyeth BG,Clifton GL, et al.Relationship between body and brain temperature intraumatically brain-injured rodents.J Neurosurg,1991,74: 492.
22. Lyeth BG,Jiang JY, Liu S,et al.Behavioral protection by moderate hypothermia in itiated after experimental traumatic braininjury.J Neurotrauma,1993,10: 57.
23. Pomeranz S,Safar P, Radovsky A, et al.The effect of suscitative moderate hypothermia following epidural brain compression on cerebral damage in a canine outcome model.J Neurosurg,1993,79: 241.
24. Marion DW, White MJ.Treatment of experimental brain injury with moderate hypothermia and 21-aminostedods.J Neurotrauma,1996,13:139.
25. Shiozaki T, Sugimoto H,Taneda M,et al.Effect of mild hypothermia on uncontrol lable intracranial hypertension after severe head injury.J Neurosurg,1993,79: 363
26. Marion DW, Obrist WD,Carlier PM,et al.The use of moderate therapeutic hypothermia for patients with severe head injuries:Apreliminaryreport.J Neurosurg,1993,79: 354.
27. Clifton GL, Barrodale P, Plenger P, et al.Aphase study of moderate hypothermia in severe braininjury.J Neurotrauma,1993,10: 263.
28. Sutherland GR,Lesiuk H,Hazendon kP, et al.Magnetic resonance imaging and 31P magnetic resonance spectroscopy study of the effect of temperature on ischemic brain injury.J CanSciNeurol,1992,19: 317.
29. Jiang JY, Lyeth BG,Kapasi MZ, et al.Moderate hypothermia reduces blood-brain-barrier disruption following truamatic-brain injury in the rat.ActaNeuropathol,1992,84: 495.
30.Smith SL,Hall ED. Mild pertraumatic and posttraumatic hypothermia attenuates blood brain barrier damage following controlled cortical impact injury in ratsJ Neurotrauma,1996,13 : 1.
31.Lo EH,Stcinberg GK.Effects of hypothermia on evokedpotentials,magnetic resonance imaging, and blood flow in focal ischemia in rabbits.Stroke,1992,23 : 8892.
32.Lyeth BG,Jiang JY,Robinson SE,et al.Hypothermia blunts acety lcholine increase in CSF of traumatically brain injured rasts.MolChem Neuropathol,1993,18 .' 247.
33.Hamaski T, Karoda H, Mori T. Temperature dependency of calicium-induced reperfusion injury in the isolate rat heart. Ann Thorac Surg, 1988,45:306-312 .
34.Sammel S, Tisherman MD, Aurelio Rodriguez, et al. Therapeutic hypothermia in traumatology. Surg Clin North Am, 1999, Dec:79(6).
35.Villar J. Therapeutic hypothermia in the acute respiratory distress syndrome and septic shock .In Proceedings of Society of Critical Care Medicine Synposium, San Francisco ,1999, pp731-733.
36.Villar J, Slutsky AS. Effects of induced hypothermia in patients with septic adult respiratory distress syndrome .Resuscitation, 1993,26:183-19.
37.Von Eiselsberg AF, Ranzi E.Uber die chirurgische Behandlung der Him und Ruckenmarkstumoren. Arch Klin Chir 1913,102:309-468.
38.Tooth HH.The treatment of tumours of the brain,and the indications for operations. Trans 1st Cong Med London 1913,8:203-299.
39.O1ive crona H.Die Parasagittalen Meningeome.Leipzig:Georg Thieme, 1934,ppl41-143.
40.Cushing H, Eisenhart L.Meningiomas, Their Classification,Regional Behaviour,Life History and Surgical end Results.Springfield,IL: Charle C Thomas,1938,733-734.
41.Cairns H. Bacterial infections during intracranial operations Lancet 1939,1:1193-1198.
42.Woodall B,Neill RG, Dratz HM.Ultravioet radiation as an adjunct in the control of post-operative neurosurgical infention. Ann surg 1949,129:820-825.
43.Wright RLPostoperative Craniotomy Infentions.Spingfield,IL:Charles C Thomas,1996.
44.Skultety Fm,Nishioka H.Report on the cooperative study of intracranial aneurysms and subarachnoid hemorrhage:section ⅧI,part 2.The results of intracranial suigery in the treatment of aneurysms.J Neruosurg 1966,25:683-704.
45.Balch RE.Wound infection complicating neurosurgical procedures . J Neruosurg 1966,25:683-704.
46.Green JR, Kanshepolsky J , Turkian B.Incidence and singnificance of central nervous system infection in neurosurgical patients.Adv Neurol 1974,6:223-228.
47.Chou SN, Erickson DL.Craniotomy infentions.Clin Neurosurg 1976,23:357-362.
48.Cruse PJE. I nfection surveillance.South Med J1977 ,70:48.
49.Quadery LA, Medlery AV,Miles J. Factors affecting the incidence of wound infection in neurosurgery. Acta Neurochir 1977,39:133-141.
50.Lhan RC,Thompson GB.Morbidity,mortality,andqulity of life following surgery
for intracranial meningioma. J Neurosury 1984,60:52-60.
51. Jomin M, Lesoin F, Lozes G.500 uptured and operated intracraninl arterial aneurysm. J Serg Neurol 1984,21:13-18.
52. Vlahov D,Montgomery E, Tenney JN,et al.Neurosurgical wound infections:Methodological and clinical factors affecting calculations of infection rates.J Neurosurg Nurs 1984,16:128-133.
53. Blomstd GC. Infections in neurosurgery:a retrospective study of 1143 patients and 1517 operations. J Acte Neurochir.1985,78:81-90.
54. Tenney JH, Vlahov D,Salcman M,et al.Wide variation in risk of wound infection following clean neurosurgery:implications for perioperative antibiotic prophylaxis.J Neurosurg 1985,62:243-247.
55. Van EK B,Bakker FP, van Dulken H ,Dijlmans BA.Infections after craniotomy:A retrospective study.J Infect 1986,12:105-109.
56. Rasmussen S, Ohrstrom JK, Westergaard L, Kosteljanetz M.Postoperative infections of osteoplastic compared weth free bone flaps.Br J Neurosurg 1990,4:493-495.
57. Gaillard T, Gilsbach JM.Intra-operative antibiotic prophylaxis in neurosurgery:A prospective randomized,controlled study on cefotiam.Acta Neurochir 1991,113:103-109.
58. Mindermann T,Zimmerli W, Gratzl O:Randomized placebo-controlled trial of single-dose antibiotic prophylaxis with fusidic acid in neurosurgery.Acta Neurochir 1993,121:9-11.
59.柳国良,罗世棋,王涛.开颅术后颅内感染死亡原因及教训.中华神经外科杂志,1995,11(5):291-299.
60.朱士广,杨树源,张建宁.神经外科术后颅内感染及治疗.J中华神经精神疾病杂志.1998,24(4):215-217
61.高建国,张玉荣,上官军发.开颅术后颅内感染原因分析.J宁夏医学杂志,1999,2(9):546-547.
62.刘窗溪,万登济,李健龙,等.颅脑手术后颅内感染临床分析.J中华医院感染学杂志,2000,10(1):4-6.
63.袁源,刘远林,付鹏,等.开颅术后颅内感染临床分析.J中华医院感染学杂志,2001,11(5):363-365.
64. krause PJ,et al.Depressed neutrophil chemotaxis in children suffering blunt trauma.Pediatrics,1994,93:807.
65. wolach B,et al.Some aspects of humoral and neutrophil functions in post-comatose unawareness patients.Brain. Inj,1993,5(5):401.
66.张新忠,史耀亭.脑外伤继发感染与体液免疫抑制.中国急救医学,1997,17(6):12-14.
67.姜绯,岳猛.颅脑术后脑脊液细菌培养及药敏结果分析.J中国医科大学学报 2004 33(5)474.
68. Maier CM,Ahern KB,Cheng ML, et al.Optimal depth and duration of mild hypothermia in a focal model of transient cerebral ischemia[J].Stroke,1998,29:2171-2180.
69. Gundersen Y, Vaagenes P, Pharo A, et al. Moderate hypothermia blunt the infammatory response and reduces organ injury after acute haemorrhage .Acta-Anaestthe-Siol-Scand 2001;45(8):994-1000.
70. R0win ME, Xue V, Irazuztta J.Hypothermia attenuate beta 1 integrin experssion extravasated neutrophils in an animal model of meningitis.Inflammation 2001;25(3):137-144.
71. Wenisch C,Narzt E, Sessler DI,et al.Mild intraoperative hypothermia reduces production of reactive oxygen intermediates by polymorph onuclear leukocytes[J].Anesth Analg,1996,82:810-816.
72. Mizuno T, Kannan Y, Tokunaga M,et al.Role of hypothermia induced by tumor necrosis factor on apoptosis and function of inflammatory nertrophils in mice[J].Am J Physiol,2000,278:R157-R165.
73.解启莲,胡皓夫,安会波.亚低温对全身炎症反应小鼠细胞因子与粘附因子表达的影响及意义.中国危重病急救医学[J].2000,12(10):617-619.
74.王学敏.亚低温在急性呼吸窘迫综合征治疗中的应用前景探讨[J].中国危重病急救医学,2002(12):43.
75. Weinstable C, Richling E,Plainer B,et al.Comparative analysis between epidural and subdural intracranial pressure prossure probes,J Clin Monitor. 1992;8:116-120.
76. Fernandes HM, Bingham K, Chambers IR, et al.Clinical evauluation of the codman microsensor intracranial pressure monitoring system.Acta Neurochir Suppl. 1998;71:44-46.
77. Kanter MJ and Robertson CS.Measurement of intracranial pressure. Intensive Care Word.1990;7:16-9.
78. Hayashi N,Tabb DD,Perry VH,et al.Oyerriding the brain's intrinsic resistance to leukocyte recruitement with intraparenchymal injectuins of recombinant chemokines.Neuroscience.1996;74:283-92.58
79. Miller JD,Garibi J.Intracranial volume/pressure relationships during continuous monitoring of ventricular fluid pressure,in Brock M.Dietz H(eds):Intracranial pressure.Berlin;pringer-Verlag, 1972;pp:270-74.