分段式不同阈值颅内压控制在重型颅脑损伤患者治疗中的临床意义

Intracranial pressure control with different thresholds in management of patients with severe traumatic brain injury

目的探索分段式不同阈值颅内压（ICP）控制对颅脑损伤（TBI）患者治疗的临床意义。方法收集2012年3月至2015年3月救治的重型TBI患者188例，其中2014年1月至2015年3月收治的92例患者设为试验组，采用分段式不同阈值控制ICP；而2012年3月至2013年12月收治的96例患者设为历史对照组，采用传统的单一阈值控制ICP。评估两组患者6个月格拉斯哥预后评分（GOS）、病死率、降ICP治疗措施使用情况、病程中神经功能恶化的发生率、并发症发生率、患者ICU住院时间及总住院时间的差异。结果两组患者发生神经功能恶化的比例无统计学差异（P〉O．05），两组患者的高渗治疗时间和行脑室外引流时间均无统计学差异（均P〉O05），但试验组患者中行过度通气、去大骨瓣减压术及亚低温治疗的比例均显著低于历史对照组（均P〈005），试验组患者的6个月预后良好率为500％，显著高于历史对照组患者的28．1％（P〈0．01）。logistic多因素分析显示，试验组患者6个月预后良好的可能性显著高于历史对照组（OR=2．56，95％CI：129～511）。另外，试验组患者的总住院时间（P〈0．01）和ICU住院时间（P〈0.01）也均低于历史对照组，而且肺部感染、脑积水、肾功能不全和弥散性血管内凝血（DIC）的发病率均显著低于历史对照组（均P〈0.05）。结论分段式不同阈值ICP控制可以安全有效的减少TBI患者二线降颅压措施的使用、住院时间及并发症的发生，并且改善患者预后。

Objective To evaluate the intracranial pressure（ICP） control with different thresholds in management of patients with severe traumatic brain injury （TBI）. Methods One hundred and eighty eight patients with TBI were included in the study, including 92 cases treated with different threshold ICP control from January 2014 to March 2015 （study group） and 96 cases treated with traditional single threshold ICP control from March 2012 and December 2013 （control group）. The 6-month GOS scores, mortality, the extent of ICP control, the incidence of neurological deterioration, the incidence of complications, the length of ICU stay and the length of hospital stay were compared between the two groups. Results There were no significant differences in incidence of neurological deterioration（P〉0.05）, days of hypertonic treatment（P〉0.05） and days of external ventricular drainage （P〉0.05） between two groups. The hyperventilation （P〈0.05）, the decompressive craniectomy （P〈0.01） and mild hypothermia （P〈0.05） in study group were significantly lower than those in control group. The proportion of favorable outcome at 6 months in study group was 50.0%, which was significantly higher than that in control group （28.1%, P〈0.01）. Multivariate logistic analysis showed that the different threshold ICP control was associated with favorable outcome （OR=2.56, 95%CI： 1.29-5.11）. In addition, the length of hospital stay （P〈0.01） and length of ICU stay （P〈0.01） in study group were lower than those in control group. The incidence of pulmonary infection, hydrocephalus, renal dysfunction and disseminated intravascular coagulation （DIC） in study group was also significantly lower than that in control group （all P〈0.05）. Conclusion Different ICP threshold control is safe and effective for management of patients with severe TBI.