高渗氯化钠羟乙基淀粉40注射液对重症颅脑损伤患者预后的影响

Effects of hypertonic saline hydroxyethyl starch 40 injection on the prognosis of severe traumatic brain injury

目的研究高渗氯化钠羟乙基淀粉40注射液(HTS-HES)应用于重症颅脑损伤(STBI)患者术中容量治疗的临床疗效,以及对STBI患者长期预后的影响。方法选择因STBI需行手术治疗的患者71例,随机分入常规治疗组(35例)和HTS-HES组(36例)。常规治疗组术中静脉输注醋酸钠林格注射液进行容量治疗;HTS-HES组在手术开始后颅骨打开前静脉输注HTS-HES 250mL,其余治疗方案同常规治疗组。记录两组患者在麻醉诱导前(T0),手术开始静脉输液进行容量治疗前(T1),静脉输液后15min(T2)、30min(T3)和60min(T4),手术结束时(T5),手术结束后24h(T6)各时间点的血流动力学参数。记录术中液体出入量。于术后3和6个月进行随访,评估生存患者的格拉斯格预后评分(GOS评分)、认知功能分级(RLA评分)、功能独立性评定(FIM评分)和工作情况。结果 HTS-HES组术中醋酸钠林格注射液输注量显著少于常规治疗组(P<0.01),术中静脉输注20%甘露醇患者的构成比显著低于常规治疗组(P<0.05)。HTS-HES组患者静脉输注HTS-HES 250mL后,收缩压(SBP)、舒张压(DBP)和中心静脉压(CVP)均呈升高趋势,且T2、T3、T4时间点的SBP和DBP,T2、T3、T4、T5时间点的CVP均显著高于常规治疗组同时间点(P值均<0.05),但两组间心率和呼气末二氧化碳分压的差异均无统计学意义(P值均>0.05)。共43例存活并出院,生存率为60.6%,其中常规治疗组为57.1%(20/35),HTS-HES组为63.9%(23/36)。两组间平均住院时间,术后3和6个月的生存率、GOS评分、RLA评分、FIM评分,以及工作情况构成比的差异均无统计学意义(P值均>0.05)。结论 HTS-HES 250mL用于STBI患者术中容量治疗,促进了患者术中血流动力学稳定,但并未对STBI患者的生存率和术后3和6个月的神经系统功能恢复产生积极影响。

Objective To study the therapeutic effect of hypertonic saline hydroxyethyl starch 40 injection （HTS-HES） for severe traumatic brain injury （STBI） and prognosis. Methods A total of 71 STBI patients were randomly divided into two groups： conventional therapy group （n = 35） and HTS-HES group （n = 36）. Ringer~ s solution was used for fluid expansion during surgery in all patients. HTS-HES （250 mL） was applied in HTS-HES group before opening the skull. Hemodynamic parameters and intraoperative liquid intake and output volume were recorded before anesthesia induction （To）, before HTS-HES injection （T1）, 15 min, 30 min and 60 min after transfusion （T2, T3 and T4）, at the end of surgery （T5）, and 24 h after surgery （T6）. The prognosis （Glasgow outcome score I-GOS~, Rancho Los Amigos ERLA~, functional independence measure EFIM, assessments and working status） was compared between two groups during follow-up （3 months and 6 months after discharge）. Results The consumption of Ringer＇s solution and 20% mannitol in HTS-HES group were significantly less than those in conventional therapy group （P〈0. 01,0.05）. Systolic blood pressure （SBP）, diastolic blood pressure （DBP） and central venous pressure （CVP） were increased after HTS-HES injection. SBP and DBP at T2, T3 andT4 and CVP at ＂1＂2, T3, T4 and T5 in HTS-HES group were significantly higher than those in conventional therapy group （all P〈0.05）. But there were no significant differences in heart rate or partial pressure of carbon dioxide in endexpiratory gas （pet CO2 ） between two groups （both P〈 0.05）. The survival rate was 57. 1% （20/35） in conventional therapy group and 63.9% （23/36） in HTS-HES group, with a total survival rate of 60.6% （43/71）. There were no significant differences in terms of hospital stay, survival rate, the assessment of GOS, RLA or FIM and working status between two groups （all P 〉 0. 05）. Conclusion HTS-HES （250 mL） can improve hemodynamic stability in STBI patients. However, it does not seem to affect survival rate and recovery of postoperative neurological function.