序惯性人工气道救治重症脑损伤的效果观察

Observation of the effect from the use of sequential inertial artificial airway in the treatment of severe brain injury

目的探讨序贯性人工气道救治重症脑损伤患者的临床效果。方法回顾性分析石河子大学医学院第一附属医院2014-04至2016-12收治的83例重症脑损伤患者的临床资料,根据纳入与排除标准,筛选出48例作为研究对象。按气道开放实施方法的不同将其分成观察组(n=24)和对照组(n=24)。所有患者均达到了常规脱机标准,给予观察组序贯气道开放法治疗,操作方法为在气管切开,导管置入气管内之前仍要维持气管插管,待气管切开,导管得到正确放置后再将气管插管拔除,整个过程采用呼吸机辅助通气;对照组在气管切开造口的整个过程中始终不使用呼吸机辅助通气,仅维持5~8 L/min速度给予患者吸氧。比较两组的手术操作时间、生命体征、术后神经元特异性烯醇化酶(neuron specific enolase,NSE)水平、血气分析指标。结果 (1)组内比较:与切开气管前比较,对照组在气管切开术后心率(heart rate,HR)、呼吸频率(respiratory rate,RR)、收缩压(systolic blood pressure,SBP)、舒张压(diastolic blood pressure,DBP)水平均明显升高,但脉搏血氧饱和度(saturation of pulse oximetry,SpO_2)显著下降;观察组在气管切开术后HR、RR、SpO_2水平均明显升高,但DBP显著降低。组间比较:两组气管切开术前急性生理与慢性健康(acute physiology and chronic health evaluation-Ⅱ,APACHE-Ⅱ)评分、HR、RR、BP、SpO_2变化水平比较,差异均无统计学意义;观察组气管切开术后HR、RR、SBP、DBP、SpO_2水平优于对照组,差异均具有统计学意义(t=-3.310,P=0.002;t=-2.390,P=0.022;t=-4.798,P<0.001;t=-3.716,P=0.001;t=10.209,P<0.001)。(2)组内比较:观察组气管切开后动脉二氧化碳分压(partial pressure of carbon dioxide in artery,PaCO_2)水平呈持续下降趋势;对照组气管切开后血氧分压(partial pressure of oxygen,PaO_2)水平显著降低。组间比较:气管切开前两组pH、PaO_2、PaCO_2和血清NSE水平比较,差异均无统计学意义;观察组气管切开术后pH、PaO_2、Pa CO2和血清NSE水平均优于对照组,差异均具有统计学意义(t=8.507,P<0.001;t=7.074,P<0.001;t=-14.605,P<0.001;t=-3.090,P=0.003)。结论重症脑损伤患者的救治过程中采取序贯性人工气道开放术可提高治疗安全性,有效改善患者治疗效果,提高救治成功率,具有临床推广意义。

Objective The objective of this study was to investigate the clinical effect of sequential artificial airway when used in the treatment of patients with severe brain injury. Methods A sample of 83 patients with severe brain injury treated in the First Affiliated Hospital of the Medical College, Shihezi University from April 2014 to December 2016 were retrospectively analyzed. Based on the inclusion and exclusion criteria, 48 eases were included in this study. The sample was divided into the observation group （n=24） and control group （n=24） based on the different methods used for opening the airway. All the patients had reached the conventional offline standard, the observation group was given sequential airway opening therapy whose method of operation was tracheotomy. The endotracheal tube should be maintained before the endotracheal tube was inserted, and then the tracheal intubation can be removed after the catheter was properly placed, and the mechanical ventilation was used in the whole process. The control group received only passive oxygen administration at 5-8 L/rain during the traeheotomy procedure. The operation time, vital signs, neuron specific enolase （NSE） levels and blood gas analysis indexes were compared between the two groups. Results （1） Comparison within groups： in the control group, the heart rate （HR）, respiratory rate （RR）, systolic blood pressure （SBP） and diastolic blood pressure （DBP） were significantly increased and the SpO2 levels were significantly decreased after the traeheotomy as compared to those before tracheotomy; the HR, RR and SpO2 after tracheotomy were significantly increased, while DBP was decreased significantly. Comparison between groups： the acute physiology and chronic health evaluation Ⅱ（APACHE-Ⅱ ）, HR, RR,BP, SpO2 levels of two groups were compared, and there were no significant differences; the HR, RR, SBP, DBP, SpO2 levels of observation group after tracheotomy were better than those of control group （t=-3.310, P=0.002; t=-2.390, P=0.022; t=-4.798, P〈0.001 ; t=-3.716, P=0.001 ; t=10.209, P〈0.001）. （2） Comparison within groups： the level of partial pressure of carbon dioxide in artery （PaCOz） in the observation group was decreased continuously after tracheotomy, and the level of partial pressure of oxygen （PaO2） in the control group was significantly decreased after tracheotomy. Comparison between groups： before tracheotomy, the levels of pH, PaO2, PaCO2 and serum NSE of two groups were compared, and there were no significant differences; the pH, PaO2, PaCO2, serum NSE levels in the observation group after tracheotomy were better than those in the control group （t=8.507, P 〈 0.001 ; t=7.074, P 〈 0.001 ; t= - 14.605, P 〈 0.001 ; t= - 3.090, P=0.003）. Conclusions In the treatment of severe brain injury, sequential artificial airway opening surgery can improve the safety of treatment, the treatment effect of the patients and the success rate of treatment, and has important clinical significance.