连续性血液滤过治疗脑外伤术后难治性急性脑膨出的疗效观察

The effect of continuous hemofiltration in the treatment of traumatic patients with refractory acute cephalocele after craniotomy

目的探讨连续性血液滤过技术对脑外伤术后难治性急性脑膨出的疗效和可能的机制。方法对9例急性脑外伤开颅术后出现难治性急性脑膨出患者给予连续性静-静脉血液滤过（CVVH）治疗。观察患者治疗前后生命体征、电解质、血气、生化指标和凝血功能变化及预后。结果①开始CVVH治疗越晚，患者出现体温、呼吸频率、心率、血压、血气异常的程度越明显，延迟12h则出现显著异常；CVVH治疗后12h内上述异常可得到纠正且维持稳定。患者体温一直维持在亚低温水平，血乳酸水平随CVVH时间延长不断降低，但凝血功能无明显变化。②脑膨出后至开始CVVH治疗时间2～16h，平均（5．4±5．1）h；CVVH疗程23～129h，平均（75．7±34．3）h；CVVH期间液体净平衡量（NVLB）-1．2～3．1L，平均（0．76±1．46）L；CVVH治疗前及治疗72h后脑组织膨出骨窗高度（HEOSW，mm）分别为51．8±10．0和51．0±10．0。NVLB和HEOSW与患者预后无明显相关。③4例患者存活，其中2例显效，随访3个月格拉斯哥预后评分（GOS）〉12分；2例有效，3个月后GOS8分，呈植物生存；另5例于停止CVVH后9～35d死于呼吸衰竭和多器官功能障碍综合征（MODS）。结论CVVH对难治性急性脑膨出具有一定疗效且安全，患者的直接死因并非是脑膨出而是并发症；治疗效果与急性脑膨m发生后开始进行CVVH的时机及CVVH疗程有关，与CVVH期间液体负平衡量及HEOSW无明显相关；CVVH的主要作用并非是单纯颅脑脱水，它在调节水、电解质、酸碱平衡和体温方面确有疗效。

Objective To investigate the effect and the possible mechanism of continuous hemofihration in the treatment of traumatic patients with refractory acute cephalocele. Methods Continuous venous-venous hemofiltration （ CVVH ） was applied to 9 traumatic patients with refractory acute cephalocele after craniotomy. The changes in patients＇ physical signs, electrolytes, blood gas analysis, biochemical and blood clotting indexes as well as the outcome were observed. Results （1） The later the CVVH started, the worse the disorders became such as unstable body temperature, respiratory rate, heart rate, blood pressure and abnormal blood gas analysis. The most significant abnormality emerged with a delay of 12 hours. The above abnormalities returned to normal and kept stable within 12 hours of CVVH. CVVH maintained body temperature in hypothermic state, and serum lactic acid was kept at a low level without disturbance of blood coagulation function. （2） The duration between occurrence of cephalocele and beginning of CVVH was 2-16 hours, with a mean of （5.4 ±5.1 ） hours, the duration of CVVH was 23-129 hours, with a mean of （75.7 ±34.3） hours, and the net volume of liquid balance （NVLB） was -1.2-3.1 L, with a mean of （0.76 ±1.46 ） L. Height of encephalocele over skull window （HEOSW, mm） was 51.±＋ 10.0 and 51.0 ±10.0 before and 72 hours after CVVH. NVLB and HEOSW did not show obvious correlation with the prognosis of the patients. （3） Four patients survived, and 2 patients showed satisfactory outcome with Glasgow outcome scale （GOS） over 12 after follow-up for 3 months, and 2 patients showed improvement with GOS of 8 but in vegetative state 3 months later. Five patients died of respiratory failure and multiple organ dysfunction syndrome （MODS） 9-35 days after the termination of CVVH. Conclusions CVVH was safe and effective in certain extent in the treatment of refractory acute cephalocele. The direct causes of death of the patients were complications instead of the cephalocele itself. The outcomes of the patients were related to the time of beginning of CVVH and the duration of CVVH, and there was nothing to do with the NVLB and the HEOSW. The study implicated that the effect of CVVH on these patients was not brain-dehydration solely. It also exerted certain effect on regulating water-electrolyte balance, acid-base balance and body temperature.