渗透性治疗在儿童颅内高压综合征中的应用与研究

Application and research of osmotic therapy in children with intracranial hypertension syndrome

儿童颅内高压(ICH)综合征是临床危急重症,对其正确而有效地治疗,可以降低患儿死亡率、脑损伤和神经后遗症发生率。儿童ICH综合征急性期进行降低颅内压处理,是达到有效治疗该病患儿的关键措施,其中渗透性治疗是临床最常见的降低颅内压措施。目前临床用于儿童ICH综合征急性期降低颅内压的渗透性治疗药物包括:经典渗透性药物甘露醇,其降低颅内压效果确切,临床使用广泛;高渗盐水作为另一种渗透性药物,其降低颅内压效果与甘露醇相当,甚至有研究结果表明,其降低颅内压效果较甘露醇更为显著。此外,高渗盐水在维持ICH综合征患儿脑组织灌注压(CPP)方面,较甘露醇更有效,可通过多种机制发挥脑功能保护作用。从脑功能保护角度,新的研究和指南愈来愈推崇和重视高渗盐水在ICH综合征患儿中的应用,尤其在创伤性脑损伤(TBI)所致ICH综合征患儿中,高渗盐水应作为首先推荐的降低颅内压治疗药物。儿童ICH综合征急性期降低颅内压治疗中,高渗盐水能否取代甘露醇成为首选渗透性药物,或哪些情况下首选高渗盐水,笔者拟就渗透性治疗药物在儿童ICH综合征急性期降低颅内压治疗的历史及其研究现状,甘露醇及高渗盐水降低颅内压的作用机制,甘露醇及高渗盐水在儿童ICH综合征降低颅内压的临床研究最新进展进行阐述,重点比较与分析甘露醇及高渗盐水的治疗作用。

Pediatric intracranial hypertension (ICH) syndrome is a critical and severe pathogenic disorder. An appropriate and effective treatment can reduce its mortality, and decrease incidences of secondary brain injuries and neurologic complications. Timely treatment of intracranial pressure is the key measure in the acute stage of pediatric ICH syndrome, and osmotic therapy is considered as the most common measure to reduce intracranial pressure. Osmotic drugs used in the acute stage of pediatric ICH syndrome include urea, glycerin, sorbitol, mannitol, and hypertonic saline, etc.. Since urea, glycerin and sorbitol are associated with numerous side effects, they are no longer used clinically. Mannitol as the traditionally used osmotic medication has a definitive effect on reducing intracranial pressure, thus it is still widely administrated in clinical practices. Despite that hypertonic saline has a similar effect on reduction of intracranial pressure as mannitol, continuous studies have shown that administration of hypertonic saline yields even better outcomes for reducing intracranial pressure and better maintenance of cerebral perfusion pressure (CPP) compared with the use of mannitol. Moreover, the administration of hypertonic saline may provide protection for brain functions through various mechanisms. From the perspective of protection for brain functions, new studies and guidelines increasingly suggest and pay attention to the application of hypertonic saline in reduction of intracranial pressure, especially, recommend it as the first-line osmotic medcine for traumatic brain injury (TBI)-induced pediatric ICH syndrome. As of today, questions are still remained: could hypertonic saline replace mannitol as the first-line osmotic medcine in reducing intracranial pressure or in which cases should hypertonic saline be preferably selected? This article focuses on the historical and current research progresses of osmotic therapy in reduction of intracranial pressure in the acute stage for children with ICH syndrome, and explores the mechanisms of reduction of intracranial pressure for mannitol and hypertonic saline, and discovers recent clinical status of using mannitol and hypertonic saline as well as comparison between these two medications in treatment of children with ICH syndrome.