重症动脉瘤性蛛网膜下腔出血的监护治疗及疗效分析  

Critical care manaRement and analysis of clinical outcomes for patients with severe aneurysmal subarachnoid hemorrhage

作　　者：王宁[1] 徐跃峤[1] 曲鑫 程玮涛[1] 陈文劲[1] 齐猛[1] 张雷 谢华勰 温晓辉[3] 吴佳宁[4] 

机构地区：[1]首都医科大学宣武医院神经外科重症监护室,北京100063 [2]广西壮族自治区玉林市红十字会医院重症医学科 [3]四川省遂宁市中心医院重症医学科 [4]哈尔滨医科大学附属第一医院神经外科

出　　处：《中华神经外科杂志》2018年第2期139-143,共5页Chinese Journal of Neurosurgery

基　　金：国家自然科学基金（81541120,81372473）;首都临床特色应用研究与成果推广（Z151100004015095）

摘　　要：目的 探讨重症动脉瘤性蛛网膜下腔出血（aSAH）患者行重症监护的治疗方法和疗效.方法 回顾性纳入首都医科大学宣武医院神经外科重症监护室2015年3月至2017年3月收治的160例重症aSAH患者,所有患者均在多模态监测下采用阶梯状集束化方法治疗.存活患者出院30 d后行门诊或电话随访,随访内容为格拉斯哥预后评级（GOS）.统计所有患者的并发症发生率,并分析影响其预后的危险因素.结果 160例患者在重症监护室的时间为9-42d,平均（16.9±7.5）d.其中38.1％（61/160）的患者出现脑血管痉挛,25.0％ （40/160）出现脑梗死,60.6％ （97/160）出现肺感染,31.3％（50/160）出现肝功能异常,58.8％（94/160）出现低蛋白血症,51.9％ （83/160）出现贫血,78.1％ （125/160）出现电解质紊乱.经分析发现随着Hunt-Hess分级增高,大多数并发症的发生率增加（包括：肝功能异常、低蛋白血症、贫血和电解质紊乱,均P〈0.05）.住院期间死亡10例.存活的150例患者均获得随访,随访期间4例死亡.本组患者整体预后良好率为41.3％ （66/160）,预后不良率为58.7％（94/160）.多因素Logistic回归分析结果显示,Hunt-Hess分级（OR =0.117,95％ CI：0.054 -0.252,P〈0.001）和电解质紊乱（OR=0.306,95％ CI：0.108 -0.867,P=0.026）是影响患者预后的主要危险因素.结论 在神经外科重症监护室采用阶梯状集束化方法可改善重症aSAH患者的预后.Objective To explore the clinical outcomes and therapeutic methods of neurosurgical intensive care for patients with severe aneurysmal subarachnoid hemorrhage （aSAH）.Methods The clinical data of 160 patients with severe aSAH were retrospectively analyzed who were admitted to Neurosurgical ICU of Neurosurgery Department at Xuanwu Hospital of Capital Medical University from March 2015 to March 2017.All patients were treated with bundle therapy based on step-wise protocol under multimodal monitoring to protect brain against damage.The follow-up was carried on at outpatient department or by phone at 30 d after discharge.The incidence of complications during treatment and GOS （glasgow outcome scale） were documented.The incidence of complications and the risk factors related to the prognosis were analyzed.Results The length of stay （LOS） of 160 patients at ICU was 9-42 d （mean：16.9 ± 7.5 d）.In this series,cerebral vasospasm were reported in 38.1% （61/160） of the patients,cerebral infarction in 25% （40/160）,pulmonary infection in 60.6% （97/160）,abnormal liver function in 31.3% （50/160）,hypoproteinemia in 58.8% （94/160）,anemia in 51.9% （83/160）,and electrolyte imbalance in 78.1% （125/160） of the patients.The incidence of most complications,including lung infection,liver dysfunction,hypoproteinemia and anemia,was elevated with the increase of Hunt-Hess scale （P 〈 0.05）.10 deaths during hospitalization.150 patients were followed up,4 deaths during follow-up.Among 160 patients,41.3% （66/160） had favorable ourcomes and 58.7% （94/160） had unfavorable ourcomes.Multivariate Logistic regression analysis showed that Hunt-Hess scale （OR =0.117,95% CI：0.054-0.252,P 〈0.001） and electrolyte disturbance （OR =0.306,95% CI：0.108-0.867,P =0.026） were major risk factors related to the prognosis of patients.Conclusion The bundle therapy based on step-wise protocol under multimodal monitoring could help improve the outcomes of patients with severe aSAH at neurosurgic

关 键 词：蛛网膜下腔出血 颅内动脉瘤 重症监护 治疗结果 预后 

分 类 号：R743.35[医药卫生—神经病学与精神病学]