不同时程亚低温治疗在重型颅脑损伤患者中的疗效比较
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摘要
目的:探讨不同时程亚低温治疗在重型颅脑损伤(severe traumatic brain injury,sTBI)患者中的临床疗效差异。方法:采用前瞻性研究方法选取安徽医科大学第三附属医院本部及滨湖院区ICU在2016年8月至2017年12月收治的90例sTBI患者为研究对象,按照患者入院顺序随机分为常规组(A组,n=30)、长时间亚低温组(B组,n=30)、短时间亚低温组(简称C组,n=30)。A组仅给予基础治疗;B组在A组基础上入院后立即行亚低温治疗,体温控制在33～35℃,持续5 d;C组在A组基础上入院后立即行亚低温治疗,体温控制在33～35℃,持续2 d,比较3组患者治疗6 d后的临床疗效差异。结果:3组患者治疗前的颅内压(intracranial pressure,ICP)差异无统计学意义(P>0.05);治疗第6天,差异有统计学意义(P<0.05),且C组高于B组(P<0.05)。3组患者第6天的APACHE II评分差异有统计学意义(P<0.05),且C组高于B组(P<0.05)。在并发症发生率方面,A组高于其他2组(P<0.05),C组高于B组(P>0.05)。在28d病死率方面,A组高于其他2组(P<0.05),C组高于B组(P>0.05)。结论:亚低温治疗在sTBI患者治疗中的效果显著,与短时间亚低温治疗相比,长时间亚低温治疗虽不能显著降低患者短时间内病死率,但能显著降低ICP、远期死亡风险,对并发症发生率增加没有显著影响。
Objective: To study the clinical effect of mild hypothermia therapy with different durations in patients with severe traumatic brain injury(sTBI). Methods: A total of 90 patients with sTBI admitted to ICU of The First People's Hospital of Hefei and Binhu Hospital from August 2016 to December 2017 were selected prospectively as the subjects, and all patients were randomly divided into a long-term mild hypothermia group(group A, n=30), a shortterm mild hypothermia group(group B, n=30), and a conventional group(group C, n=30). Group A was given only basic treatment. Group B was treated with mild hypothermia after admission and the body temperature was controlled at 33–35 ℃, lasting 5 days. The group C was treated with mild hypothermia after admission and the temperature was controlled at 33–35 ℃ for 2 days. The clinical effects of the 3 groups were compared in the 6 th day. Results: There was no significant difference in intracranial pressure(ICP) between the three groups before treatment(P>0.05), and the ICP was statistically significant on the 6 th day after injury(P<0.05). The APACHE II scores of the 3 groups on the 6 th day after injury were statistically significant(P<0.05), and the group C on the6 th day after injury was higher than that of the group B(P<0.05). The incidence of complications in the group A was higher than that in the group B and the group C(P<0.05). The incidence of complications in the group C was higher than that in group B(P>0.05), but the mortality in the group A was higher than that in the group B(P<0.05).The mortality rate in the group C was higher than that in the group B(P>0.05). Conclusion: The effect of mild hypothermia therapy on patients with sTBI is significant. Although long-term mild hypothermia therapy could not reduce the mortality rate significantly in a short period of time, it could reduce ICP and the risk of long-term death significantly. The incidence of patient complications is no significant increase.
Objective: To study the clinical effect of mild hypothermia therapy with different durations in patients with severe traumatic brain injury(sTBI). Methods: A total of 90 patients with sTBI admitted to ICU of The First People's Hospital of Hefei and Binhu Hospital from August 2016 to December 2017 were selected prospectively as the subjects, and all patients were randomly divided into a long-term mild hypothermia group(group A, n=30), a shortterm mild hypothermia group(group B, n=30), and a conventional group(group C, n=30). Group A was given only basic treatment. Group B was treated with mild hypothermia after admission and the body temperature was controlled at 33–35 ℃, lasting 5 days. The group C was treated with mild hypothermia after admission and the temperature was controlled at 33–35 ℃ for 2 days. The clinical effects of the 3 groups were compared in the 6 th day. Results: There was no significant difference in intracranial pressure(ICP) between the three groups before treatment(P>0.05), and the ICP was statistically significant on the 6 th day after injury(P<0.05). The APACHE II scores of the 3 groups on the 6 th day after injury were statistically significant(P<0.05), and the group C on the6 th day after injury was higher than that of the group B(P<0.05). The incidence of complications in the group A was higher than that in the group B and the group C(P<0.05). The incidence of complications in the group C was higher than that in group B(P>0.05), but the mortality in the group A was higher than that in the group B(P<0.05).The mortality rate in the group C was higher than that in the group B(P>0.05). Conclusion: The effect of mild hypothermia therapy on patients with sTBI is significant. Although long-term mild hypothermia therapy could not reduce the mortality rate significantly in a short period of time, it could reduce ICP and the risk of long-term death significantly. The incidence of patient complications is no significant increase.
引文
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12.吴隆飞,吴迪,刘向荣.脑动脉选择性亚低温治疗缺血性卒中的研究进展[J].中国脑血管病杂志,2017,14(3):155-158.WU Longfei,WU Di,LIU Xiangrong.Research progress in selective hypothermia for ischemic stroke in cerebral arteries[J].Chinese Journal of Cerebrovascular Diseases,2017,14(3):155-158.
13.中华医学会神经病学分会神经重症协作组.神经重症低温治疗中国专家共识[J].中华神经科杂志,2015,48(6):453-458.Chinese Society of Neurology,Department of Neurological Severe Counseling Group.Chinese expert consensus on hypothermia treatment of neurological severe disease[J].Chinese Journal of Neurology,2015,48(6):453-458.
14.黄良珍,刘朝晖,彭浩,等.去骨瓣减压联合血管重建术对重型颅脑损伤患者脑灌注的影响[J].解放军医学杂志,2015,40(11):934-937.HUANG Liangzhen,LIU Zhaohui,PENG Hao,et al.Effects of decompressive craniectomy combined with revascularization on cerebral perfusion in patients with severe craniocerebral injury[J].Medical Journal of Chinese People’s Liberation Army,2015,40(11):934-937.
15.Howes D,Gray SH,Brooks SC,et al.Canadian Guidelines for the use of targeted temperature management(therapeutic hypothermia)after cardiac arrest:a joint statement from The Canadian Critical Care Society(CCCS),Canadian Neurocritical Care Society(CCCS),and the Canadian Critical Care Trials Group(CCCTG)[J].Resuscitation,2015,98:48-63.
16.Madden LK,Hill M,May TL,et al.The implementation of targeted temperature management:an evidence-based guideline from the Neurocritical Care Society[J].Neurocrit Care,2017,27(3):468-487.
17.李慧,蔡忠林,周杰,等.脑保护策略中低温治疗的研究进展[J].临床急诊杂志,2017,18(6):478-480.LI Hui,CAI Zhonglin,ZHOU Jie,et al.Research progress in cryotherapy in brain protection strategies[J].Journal of Clinical Emergency Call,2017,18(6):478-480.
18.江基尧,朱诚.国外亚低温与脑损伤的研究进展[J].国外医学(神经病学神经外科学分册),1993,22(1):4-7.JIANG Jiyao,ZHU Cheng.Research progress on hypothermia and brain injury in foreign countries[J].Foreign Medical Sciences Section on Neurology&Neurosurgery,1993,22(1):4-7.
19.王晶,陈翀,李晓红.低温脑保护的分子学机制[J].天津医药,2017,45(8):845-850.WANG Jing,CHEN Chong,LI Xiaohong.Molecular Mechanism of low temperature brain protection[J].Tianjin Medical Journal,2017,45(8):845-850.
2.Carney N,Totten AM,O’Reilly C,et al.Guidelines for the management of severe traumatic brain injury,fourth edition[J].Neurosurgery,2017,80(1):6-15.
3.Cecil S,Chen PM,Callaway SE,et al.Traumatic brain injury:advanced multimodal neuromonitoring from theory to clinical practice[J].Crit Care Nurse,2011,31(2):25-36.
4.只达石,张赛.亚低温治疗急性重型颅脑损伤的临床疗效[J].中华神经外科杂志,2000,16(4):239-242.ZHI Dashi,ZHANG Sai.Clinical efficacy of mild hypothermia in the treatment of acute severe brain injury[J].Chinese Journal of Neurosurgery,2000,16(4):239-242.
5.Farag E,Manno EM,Kurz A.Use of hypothermia for traumatic brain injury:point of view[J].Minerva Anestesiol,2011,77(3):366-370.
6.孙一睿,胡锦,周良辅.低温疗法对脑保护作用的研究进展[J].中华神经外科杂志,2016,32(11):1182-1185.SUN Yirui,HU Jin,ZHOU Liangfu.Research progress of hypothermia on brain protection[J].Chinese Journal of Neurosurgery,2016,32(11):1182-1185.
7.Suehiro E,Koizumi H,Fujisawa H,et a1.Diverse effects of hypothermia therapy in patients with severe traumatic brain injury based on the computed tomography classification of the traumatic coma data bank[J].J Neurotrauma,2015,32(5):353-358.
8.Tisherman SA.Targeted temperature management after cardiac arrest:when,how deep,how long?[J].J Thorac Dis,2017,9(12):4840-4843.
9.苏海,苏祖禄,贺学农,等.中性粒细胞弹性蛋白酶抑制剂对颅脑创伤大鼠血脑屏障通透性和脑水肿的影响[J].重庆医学,2014,43(26):3458-3460.SU Hai,SU Zulu,HE Xuenong,et al.Effects of neutrophil elastase inhibitor on blood-brain barrier permeability and brain edema in rats with craniocerebral trauma[J].Chongqing Medical Journal,2014,43(26):3458-3460.
10.刘伟明,张擎,倪明,等.中国神经外科指南(共识)的整体评价[J].中华医学杂志,2015,95(15):1122-1126.LIU Weiming,ZHANG Qing,NI Ming,et al.Overall evaluation of Chinese neurosurgical guidelines(consensus)[J].National Medical Journal of China,2015,95(15):1122-1126.
11.季雪亮,隋岩永,郭克光.亚低温脑保护在重型颅脑损伤治疗中的应用效果分析[J].中外医疗,2017,36(13):22-24.JI Xueliang,SUI Yanyong,GUO Keguang.Analysis of the application effect of mild hypothermia brain protection in the treatment of severe brain injury[J].Friend of Chemical Industry,2017,36(13):22-24.
12.吴隆飞,吴迪,刘向荣.脑动脉选择性亚低温治疗缺血性卒中的研究进展[J].中国脑血管病杂志,2017,14(3):155-158.WU Longfei,WU Di,LIU Xiangrong.Research progress in selective hypothermia for ischemic stroke in cerebral arteries[J].Chinese Journal of Cerebrovascular Diseases,2017,14(3):155-158.
13.中华医学会神经病学分会神经重症协作组.神经重症低温治疗中国专家共识[J].中华神经科杂志,2015,48(6):453-458.Chinese Society of Neurology,Department of Neurological Severe Counseling Group.Chinese expert consensus on hypothermia treatment of neurological severe disease[J].Chinese Journal of Neurology,2015,48(6):453-458.
14.黄良珍,刘朝晖,彭浩,等.去骨瓣减压联合血管重建术对重型颅脑损伤患者脑灌注的影响[J].解放军医学杂志,2015,40(11):934-937.HUANG Liangzhen,LIU Zhaohui,PENG Hao,et al.Effects of decompressive craniectomy combined with revascularization on cerebral perfusion in patients with severe craniocerebral injury[J].Medical Journal of Chinese People’s Liberation Army,2015,40(11):934-937.
15.Howes D,Gray SH,Brooks SC,et al.Canadian Guidelines for the use of targeted temperature management(therapeutic hypothermia)after cardiac arrest:a joint statement from The Canadian Critical Care Society(CCCS),Canadian Neurocritical Care Society(CCCS),and the Canadian Critical Care Trials Group(CCCTG)[J].Resuscitation,2015,98:48-63.
16.Madden LK,Hill M,May TL,et al.The implementation of targeted temperature management:an evidence-based guideline from the Neurocritical Care Society[J].Neurocrit Care,2017,27(3):468-487.
17.李慧,蔡忠林,周杰,等.脑保护策略中低温治疗的研究进展[J].临床急诊杂志,2017,18(6):478-480.LI Hui,CAI Zhonglin,ZHOU Jie,et al.Research progress in cryotherapy in brain protection strategies[J].Journal of Clinical Emergency Call,2017,18(6):478-480.
18.江基尧,朱诚.国外亚低温与脑损伤的研究进展[J].国外医学(神经病学神经外科学分册),1993,22(1):4-7.JIANG Jiyao,ZHU Cheng.Research progress on hypothermia and brain injury in foreign countries[J].Foreign Medical Sciences Section on Neurology&Neurosurgery,1993,22(1):4-7.
19.王晶,陈翀,李晓红.低温脑保护的分子学机制[J].天津医药,2017,45(8):845-850.WANG Jing,CHEN Chong,LI Xiaohong.Molecular Mechanism of low temperature brain protection[J].Tianjin Medical Journal,2017,45(8):845-850.