3％高渗氯化钠在重型颅脑损伤术后患者中的应用

Application of 3% hypertonic saline in patients with severe craniocerebral injury after operation

目的：±探讨3％高渗氯化钠（HS）在重型颅脑损伤术后患者中的应用。方法将68例重型颅脑损伤术后患者按照随机数字表法分为HS组和对照组，每组34例，对照组20％甘露醇125ml每6h或每8h1次，而HS组在常规甘露醇治疗的基础上加用3％HS130ml，每8h或每12h1次，与甘露醇交替使用，快速静脉滴注。分别于第1天6、12、24h内，第2天24h内，第3天24h内，第5天24h内统计颅内压（ICP）、平均动脉压（MAP）、中心静脉压（CVP）。第1天12、24h内，第2天24h内，第3天24h内，第5天24h内统计血钠水平，计算血浆渗透浓度。第1天24h内、第3天24h内、第5天24h内统计格拉斯哥昏迷量表（GCS）评分。结果HS组在各时间点ICP均小于对照组，差异有统计学意义（P＜0．05）；两组在第1、2天各时间点ICP变化趋势不明显（P＞0．05），但第3、5天24h内，两组ICP均较第1、2天各时间点明显上升（P＜0．05）。HS组在第1天6、12、24h内和第2天24h内MAP和CVP分别为（87．984±5．03）、（88．564±5．36）、（87．04±6．90）、（90．034±5．19）mmHg（1mmHg=0．133kPa）和（9．234±1．24）、（9．67±1．35）、（10．214±1．38）、（10．564±1．96）mmHg，均高于对照组的（77．98±5．09）、（79．98±6．09）、（80．984±5．27）、（81．98±4．32）mmHg和（7．154±2．01）、（8．32±1．53）、（8．67±1．89）、（9．224±2．03）mmHg，差异有统计学意义（P＜0．05），但第3、5天24h内两组比较差异无统计学意义（P〉0．05）。HS组在各时间点血钠及血浆渗透浓度均高于对照组（P＜0．05）。HS组第1、3、5天24h内GCS评分分别为（4．21±2．31）、（5．44±2．46）、（7．23±1．64）分，对照组分别为（4．144±2．10）、（5．154±2．31）、（7．314±2．12）分，两组第5天24h内GCS评分均明显高于第1天24h内（P＜0．05），但两组间比较差异无统计学意义（JP＞0．05）。结论加用3％HS可以更加有效地降低ICP，改善脑灌注，且不良反应少，可以作为重型颅脑损伤术后患者的一线用药。

[Abstract] Objective To study the application of 3% hypertonic saline （HS） in patients with severe craniocerebral injury after operation. Methods Sixty-eight cases with severe craniocerebral injuryafter operation were divided by random digits table method into HS group and control group with 34 cases each.The patients in control group were treated with 125 ml 20% mannitol every 6 hours or 8 hours. The patients in HS group were given conventional mannitol and added with 130 ml 3% HS every 12 hours or 8 hours through fast intravenous drip alternated with mannitol. The levels of intracranial pressure （ICP）, mean arterial pressure （MAP）, central venous pressure （CVP） were recorded within 6 hours, 12 hours, 24 hours of the 1st day, 24 hours of the 2nd day, 24 hours of the 3rd day, 24 hours of the 5th day. The Na^± level of blood serum and the plas±ma osmotic pressure were recorded and calculated within 12 hours, 24 hours of the 1st day,24 hours of the 2nd day,24 hours of the 3rd day,24 hours of the 5th day. The Glasgow coma scale（GCS） score was accounted within 24 hours of the 1st day, 24 hours of the 3rd day ,24 hours of the 5th day. Results Compared with control group,the level of ICP in HS group decreased at every time point （P 〈 0.05 ）. The tendency of ICP in two groups was not significant on the 1st and 2nd day （P 〉 0.05）,but the level of ICP within 24 hours of the 3rd and 5th day obviously increased compared with those of the 1st and 2nd day （P〈 0.05 ）. The levels of MAP and CVP in HS group were significantly higher than those in control group within 6 hours, 12 hours and 24 hours of the 1 st day and 24 hours of the 2nd day [ （87.98 ± 5.03 ）, （88.56 ± 5.36）, （87.04 ± 6.90）, （90.03 ± 5.19） mm Hg （1 mm Hg = 0.133 kPa） vs. （77.98 ± 5.09）, （79.98 ± 6.09）, （80.98 ± 5.27 ）, （81.98 ± 4.32） mm Hg and （9.23 ± 1.24）, （9.67 ± 1.35 ）, （10.21 ± 1.38 ）, （ 10.56 ± t .96） mm Hg vs. （ 7.15 ± 2.01 ）, （ 8.32 _± 1.53 ）, （ 8.67 ± 1.89 ）, （ 9.22 ± 2.03 ） mm Hg ] （P 〈 0.05 ）, but the values within 24 hours of the 3rd and 5th day between two groups had no significant differences （P 〉 0.05 ）. The Na± level of blood serum and the plasma osmotic pressure in HS group at every time point was obviously higher than that in control group （P 〈 0.05 ）. The GCS scores within 24 hours of the 1 st, 3rd and 5th day in HS group were （4.21 ± 2.31 ）, （5.44 ± 2.46）, （7.23 ± 1.64） scores,respectively,while the scores in control group were （4.14 ± 2.10）, （5.15 ± 2.31 ）, （7.31 ± 2.12） scores,respectively;the score within 24 hours of the 5th day in two groups was obviously higher than that of the 1 st day respectively （P 〈 0.05 ）, but the scores between two groups had no statistical significance （P〉 0.05 ）. Conclusions Adding 3% HS is more effective to decrease ICP,improve the brain pcrfusion and reduce the adverse reactions. 3% HS can be used as the first-line therapy for patients with severe craniocerebral injury after operation.