重型颅脑损伤后甘露醇、呋塞米和白蛋白降颅压作用的前瞻性多中心随机对照研究

Multicentric prospective randomized controlled study of efficacy of mannitol, furosemide and albnmin ill reducing intracranial pressure in patients with severe brain injury

目的比较甘露醇、呋塞米和白蛋白的不同配伍使用方式在451例重型颅脑损伤（sTBI）患者降颅压治疗过程中降颅压作用的效果。方法5家医院神经外科收治符合标准的sTBI患者451例，随机分为5组，观察期间全部进行持续颅内压监测，连续观察甘露醇、呋塞米和白蛋白5种配伍方式对颅内压、电解质、红细胞压积（HCT）和肾功能指标的影响。结果甘露醇或呋塞米单独使用后1—3h内均可使颅压明显降低（P〈0．05）；半量甘露醇加呋塞米或白蛋白的配伍方法降颅内压作用较强，颅内压降低幅度较大，与全量甘露醇、半量甘露醇及甘露醇和呋塞米交替使用的降颅压作用及持续时问比较，差异有统计学意义（P〈0．05）；甘露醇和呋塞米交替使用后电解质异常的发生率高于其他配伍组（P〈0．05）；全量甘露醇，治疗后颅内压反跳发生率显著高于其他配伍组（P〈0．05）；配伍使用白蛋白的患者，肾功能指标异常的发生率显著高于甘露醇和呋塞米交替使用组及半量甘露醇和呋塞米联用组（P〈0．05）。电解质和肾功能指标的异常多是可逆的。结论半量甘露醇＋呋塞米降颅内压的方法较为合理，半量甘露醇联合中、大剂量白蛋白也具有一定的优势。

Objective To compare the effect of different combinatio of mannitol, furosemide and albumin in reducing intracranial pressure in 451 patients with severe traumatic brain injury （sTBI）. Methods A total of 451 patients with an admission Glasgow Coma Scale of or less from 5 medical centers were randomly divided into 5 groups, ie, Group A （250 ml 20% mannitol each time as control）, Group B （125 ml 20% mannitol each time）, Group C （alternate use of 250 ml 20% mannitol each time or 40 mg furosemide）, Group D （alternate use of 125 ml 20% mannitol each time and 20 mg furosemide） and Group E （alternate use of 125 ml 20% mannitol and moderate or large dose of albumin）. We monitored intracranial pressure continuously and observed the changes of intracranial pressure, electrolytes, hematocrit and renal function after use of 5 combinations of mannitol, furosemide and albumin. Results Mannitol and furosemide could independently reduce intracranial pressure after 1-3 hours （ P 〈 0.05 ）. Semis mannitol plus furosemide or albumin could more significantly reduce intracranial pressure, with statistical difference compared with full dose of mannitol, semis mannitol and alternate use of mannitol and furosemide in aspect of intracranial pressure reduction and persistence time （ P 〈 0.05 ）. Alternate use of mannitol and furosemide begot higher incidence rate of electrolyte abnormality, compared with the other com- binations （P 〈 0.05）. Rebound rate of intracranial pressure was higher in full dose of mannitol than other combinations （P 〈 0.05）. Incidence of renal function abnormality was higher in combination involved albumin than alternative use of mannitol and furosemide as well as combination of semis mannitol and furosemide （ P 〈 0. 05 ）. Abnormality of electrolyte and renal function was reversible. Conclusion The use of 125 ml 20% mannitol each time plus 20 mg furosemide is more reasonable than other combinations. Meanwhile, semis mannitol combined with moderate or large dose of albumin has certain advantages too.