视神经鞘直径对非原发性脑损伤危重患者神经预后的预测价值  

Optic nerve sheath diameter for neurological prognosis in critically ill patients without primary brain injury

作　　者：支海君[1] 崔晓雅 李勇[1] 张凤伟 贾春梅[1] Zhi Haijun;Cui Xiaoya;Li Yong;Zhang Fengwei;Jia Chunmei(Emergency Department,Cangzhou Central Hospital,Cangzhou 061000,China)

机构地区：[1]沧州市中心医院急诊医学部,沧州061000

出　　处：《中华急诊医学杂志》2023年第9期1215-1220,共6页Chinese Journal of Emergency Medicine

基　　金：河北省卫生健康委科研基金项目(20211507);睿E(睿意)急诊医学研究专项基金项目(R2020019)。

摘　　要：目的探讨入ICU 24 h内及第3天的视神经鞘直径(optic nerve sheath diameter,ONSD)对非原发性脑损伤危重患者短期神经功能预后的预测价值。方法采用前瞻性观察性研究方法,纳入于2021年1月至2022年4月入住沧州市中心医院急诊重症监护室(intensive care unit,ICU)的非原发性脑损伤危重患者作为研究对象。排除标准:年龄<18岁;有视神经疾病或视神经损伤;既往有神经系统疾病或精神疾病导致意识障碍或交流困难;存在原发性脑损伤;住ICU时间<3 d;入组28 d内死亡或失访。于入ICU 24 h内及入ICU第3天应用医学超声仪进行ONSD超声测量,于ICU住院期间每日评估意识状态,格拉斯哥昏迷评分(Glasgow Coma scale,GCS)为15分且ICU意识模糊评估量表(confusion assessment method intensive care unit,CAM-ICU)为阴性定义为无意识障碍,GCS<15分或CAM-ICU为阳性定义为存在意识障碍。依据入组28 d的意识状态分为非意识障碍组及意识障碍组,比较两组间各指标的差异。通过单因素及多因素COX回归分析28 d神经功能预后的影响因素,绘制Kaplan-Meier生存曲线分析ONSD与28 d神经功能预后的关系。结果共纳入61例非原发性脑损伤危重患者(非意识障碍组48例,意识障碍组13例)。意识障碍组患者较非意识障碍组入ICU GCS更低[7(4,8)分vs.8(6,14)分,P<0.05],机械通气时间[28(15,28)d vs.10(4,14)d,P<0.001]及住ICU时间更长[28(28,28)d vs.12(7,20)d,P<0.001]。两组间入ICU 24 h内ONSD[(5.75±0.53)mm vs.(5.45±0.60)mm,P=0.114]及第3天的ONSD[(5.54±0.64)mm vs.(5.22±0.65)mm,P=0.124]差异无统计学意义。多因素Cox回归分析显示,应用机械通气、ICU时的GCS及入ICU第3天ONSD是其独立影响因素。Kaplan-Meier生存分析显示,入ICU第3天ONSD<5.30 mm的患者具有更好的28 d神经功能预后;即使在入ICU 24 h ONSD≥5.30 mm的患者中,第3天ONSD降至5.30 mm以下者的28 d神经功能预后显著优于第3天ONSD≥5.30 mm者(P=0.042)。结论入ICU 24Objective To explore the predictive value of bedside ultrasound monitoring of optic nerve sheath diameter(ONSD)for short-term neurological prognosis in critically ill patients without primary brain injury.Methods An observational prospective study was conducted to enroll critically ill patients without primary brain injury admitted to the emergency intensive care unit(ICU)of Cangzhou Central Hospital from January 2021 to April 2022.The exclusion criteria were as follows:age<18,combined ocular and optic nerve pathology or injuries,impaired consciousness due to prior neuropathy,primary brain injury,ICU stay<3 days,death or loss of follow-up within 28 days.Bedside ultrasound measurements of ONSD were performed within 24 hours of ICU admission and on day 3 of ICU admission.The consciousness status was assessed daily during ICU hospitalization.If the Glasgow Coma Scale(GCS)is 15 and the confusion assessment method intensive care unit(CAM-ICU)is negative,the consciousness status will be defined as nonconsciousness disorder.While if the GCS score is less than 15 or the CAM-ICU is positive,the consciousness status will be defined as consciousness disorder.According to the status of consciousness at 28 days,patients were divided into a nonconscious disorder group and a conscious disorder group,and the difference in each index was compared between the two groups.Univariate and multivariate Cox regression were used to analyze the factors influencing 28-day neurological function prognosis,and a Kaplan‒Meier survival curve was plotted to analyze the relationship between ONSD and 28-day neurological function prognosis.Results Sixty-one critically ill patients without primary brain injury(48 in the nonconscious disorder group and 13 in the conscious disorder group)were recruited.Compared to patients in the unconscious disorder group,those in the conscious disorder group had lower GCS upon ICU admission[7(4,8)vs.8(6,14),P<0.05],longer length of mechanical ventilation(MV)[28(15,28)days vs.10(4,14)days,P<0.001],and longer length

关 键 词：急性脑功能障碍 床旁超声 视神经鞘直径 重症监护室 非原发性脑损伤 

分 类 号：R651.15[医药卫生—外科学]