持续颅内压及脑组织氧分压监测在重度颅脑损伤患者治疗中的应用  

Application of continuous monitoring of intracranial pressure and brain oxygen partial pressure in the treatment of patients with severe craniocerebral injury

作　　者：王忠 张瑞剑 韩志桐 王俊青 吴日乐 赵卫平 张晓军 包金岗 杨蔚然 张之龙 Wang Zhong;Zhang Ruijian;Han Zhitong;Wang Junqing;Wu Rile;Zhao Weiping;Zhang Xiaojun;Bao Jingang;Yang Weiran;Zhang Zhilong(Department of Neurosurgery,People's Hospital of Inner Mongolia Autonomous Region,Hohhot 010017,Inner Mongolia Autonomous Region,China)

机构地区：[1]内蒙古自治区人民医院神经外科,呼和浩特010017

出　　处：《中华危重病急救医学》2021年第4期449-454,共6页Chinese Critical Care Medicine

基　　金：内蒙古自治区卫生计生科研计划项目(201701009);内蒙古自治区科技厅资助项目(201502107);内蒙古自治区关键技术攻关计划项目(2019GG051)。

摘　　要：目的探讨持续颅内压(ICP)及脑组织氧分压(PbtO_(2))监测指导治疗对重型颅脑损伤患者预后的影响。方法采用前瞻性随机对照研究方法,选择内蒙古自治区人民医院神经外科重症监护病房(NICU)2017年1月至2020年5月收治的格拉斯哥昏迷评分(GCS)4~8分的重度颅脑损伤患者,通过随机数字表法将患者分成ICP监测组和ICP+PbtO_(2)监测组。ICP监测组患者接受ICP监测,给予传统的控制ICP和脑灌注压(CPP)治疗,治疗目标为ICP<20 mmHg(1 mmHg=0.133 kPa)、CPP>60 mmHg;ICP+PbtO_(2)监测组患者同时使用ICP和PbtO_(2)监测,在给予控制ICP和CPP治疗基础上,联合进行氧流量调节,维持PbtO_(2)>20 mmHg,ICP治疗目标与ICP监测组相同。记录两组患者监测治疗期间ICP与PbtO_(2)的平均值,同时记录CPP、GCS评分和动脉血气分析结果;采用格拉斯哥预后评分(GOS)评估两组伤后3个月和6个月预后,GOS评分>3分为预后良好。绘制Kaplan-Meier生存曲线,分析两组患者伤后3个月和6个月累积生存率。采用线性回归分析进一步评价PbtO_(2)与GOS评分之间的关系。结果最终共70例重度颅脑损伤患者纳入分析,有34例患者接受ICP联合PbtO_(2)监测指导治疗,36例患者接受单独ICP监测指导治疗。ICP+PbtO_(2)监测组平均ICP较ICP监测组显著降低(mmHg:13.4±3.2比18.2±8.3,P<0.01);尽管两组平均CPP均>60 mmHg,但ICP+PbtO_(2)监测组平均CPP明显高于ICP监测组(mmHg:82.1±10.5比74.5±11.6,P<0.01);ICP+PbtO_(2)监测组与ICP监测组平均GCS评分和平均动脉血二氧化碳分压(PaCO_(2))差异均无统计学意义〔GCS评分(分):5.3±2.3比5.2±2.2,PaCO_(2)(mmHg):33.5±4.8比32.6±5.2,均P>0.05〕;ICP+PbtO_(2)监测组平均动脉血氧分压(PaO_(2))明显高于ICP监测组(mmHg:228.4±93.6比167.3±81.2,P<0.01)。与ICP监测组相比,ICP+PbtO_(2)监测组患者伤后3个月和6个月预后良好率显著升高(3个月:67.6%比38.9%,6个月:70.6%比41.7%,均P<0.05)。Kaplan-Meier生存曲线显示,Objective To investigate the effects of continuous monitoring intracranial pressure(ICP)and brain oxygen partial pressure(PbtO_(2))on the prognosis of patients with severe craniocerebral injury.Methods A prospective randomized controlled trial was conducted.Seventy patients with severe craniocerebral injury with a Glasgow coma score(GCS)4-8 admitted to the neurosurgical intensive care unit(NICU)of the People's Hospital of Inner Mongolia Autonomous Region from January 2017 to May 2020 were enrolled,and they were divided into ICP monitoring group and ICP+PbtO_(2)monitoring group by random number table.Patients in ICP monitoring group received ICP monitoring and were given traditional treatment of controlling ICP and cerebral perfusion pressure(CPP),the therapeutic target was ICP<20 mmHg(1 mmHg=0.133 kPa)and CPP>60 mmHg.Patients in ICP+PbtO_(2)monitoring group were given ICP and PbtO_(2)monitoring at the same time,and oxygen flow was adjusted on the basis of controlling ICP and CPP to maintain the PbtO_(2)>20 mmHg,and the therapeutic target of ICP and CPP was the same as the ICP monitoring group.ICP and PbtO_(2)values were recorded during monitoring in the two groups,the results of CPP,GCS and arterial blood gas analysis were recorded,and the prognosis at 3 months and 6 months after injury was compared by Glasgow outcome scale(GOS)score between the two groups.GOS score>3 was considered as good prognosis.Kaplan-Meier survival curve was drawn,and the 3-month and 6-month cumulative survival rates of the two groups were analyzed.Linear regression analysis was used to further evaluate the relationship between PbtO_(2)and GOS score.Results Finally,a total of 70 patients with severe craniocerebral injury were enrolled in the analysis,34 patients received ICP combined with PbtO_(2)monitoring and guided therapy,and 36 patients received ICP monitoring alone.The average ICP of ICP+PbtO_(2)monitoring group was significantly lower than that of ICP monitoring group(mmHg:13.4±3.2 vs.18.2±8.3,P<0.01).Although the CPP in both grou

关 键 词：颅内压 脑组织氧分压 重度颅脑损伤 格拉斯哥预后评分 

分 类 号：R651.15[医药卫生—外科学]