脉搏指数连续心排血量与颅内压联合监测在重型颅脑损伤患者治疗中的应用价值

Pulse index continuous cardiac output combined with intracranial pressure monitoring in patients with severe craniocerebral injury

目的探讨脉搏指数连续心排血量(PICCO)与颅内压联合监测在重型颅脑损伤患者治疗中的应用价值。方法前瞻性选择湖州市第一人民医院(湖州师范学院附属第一医院)神经外科自2015年2月至2019年2月采用控制性减压手术治疗的138例重型颅脑损伤患者,根据患者家属意愿,术后应用PICCO与颅内压联合监测进行液体管理72例(治疗组),应用中心静脉压与颅内压联合监测进行液体管理66例(对照组)。统计比较2组患者术后1周时颅内压和脑灌注压,术后新发外伤性脑梗死、神经源性肺水肿等并发症的发生率,患者的住院时间、费用及抗菌药物使用强度,术后2周时格拉斯哥昏迷量表(GCS)评分,伤后6个月采用格拉斯哥预后量表(GOS)评价患者的预后。结果退出研究者7例(其中对照组3例、治疗组4例),2组患者中途退出率差异无统计学意义(P>0.05)。最终131例患者纳入统计分析,其中对照组63例、治疗组68例。治疗组患者术后1周颅内压低于对照组,脑灌注压高于对照组,差异均有统计学意义(P<0.05)。治疗组患者术后新发外伤性脑梗死、神经源性肺水肿及肺部感染,术后头皮渗液、颅内感染的发生率均较对照组明显降低,差异均有统计学意义(P<0.05)。治疗组患者的住院时间、费用及抗菌药物使用强度均较对照组低,差异均有统计学意义(P<0.05)。术后2周治疗组患者的GCS评分[(11.88±1.78)分]明显高于对照组[(8.06±1.12)分],差异有统计学意义(P<0.05)。治疗组患者的预后良好率(76.5%)较对照组(54.0%)明显提高,死亡率(5.9%)较对照组(17.5%)明显降低,差异均有统计学意义(P<0.05)。结论PICCO与颅内压联合监测能有效地改善重型颅脑损伤患者的颅内压,优化脑灌注,减少外伤性脑梗死、神经源性肺水肿等并发症的发生,从而改善患者预后;能降低患者暴露于抗菌药物的广度和强度、减少患者住院时间和费用,从而减轻家庭及社会负担。

Objective To explore the value of pulse index continuous cardiac output(PICCO)combined with intracranial pressure monitoring in patients with severe craniocerebral injury.Methods One hundred and thirty-eight patients with severe craniocerebral injury accepted controlling decompression surgical treatment in our hospital from February 2015 to February 2019 were prospectively chosen.According to patients'families will,postoperative application of PICCO combined with intracranial pressure monitoring for fluid management was performed in 72 patients(treatment group)and application of central venous pressure combined with intracranial pressure monitoring for fluid management was performed in 66 patients(control group).All patients were adjusted according to the monitoring results.The intracranial pressure and cerebral perfusion pressure one week after surgery,incidences of new traumatic cerebral infarction,neurogenic pulmonary edema,pulmonary infection,scalp exudation,and intracranial infection,average hospitalization days,total hospitalization costs,intensity of antimicrobial use,and Glasgow coma scale scores two weeks after operation were compared and analyzed between the two groups.Glasgow outcome scale was used to evaluate the prognoses of the patients 6 months after injury.Results There were 7 patients(3 from the control group and 4 from the treatment group)dropped out of the study due to various reasons and 131 patients(63 from the control group and 68 from the treatment group)included in the final statistical analysis;there was no significant difference in drop-out rate of the two groups(P>0.05).The intracranial pressure in the treatment group([14.28±2.98]mmHg)was significantly lower than that in the control group([18.99±2.78]mmHg)and cerebral perfusion pressure([66.72±2.25]mmHg)was significantly higher than that in the control group([52.96±3.12]mmHg)one week after operation(P<0.05).During hospitalization,the incidences of new traumatic cerebral infarction,neurogenic pulmonary edema,pulmonary infection,scalp exudation and intracranial infection in the treatment group(8.8%,13.2%,11.8%,7.4%,and 2.9%)were significantly lower than those in the control group(22.2%,27.0%,25.4%,19.0%,and 12.7%,P<0.05).The average hospitalization days,total hospitalization expenses and intensity of antimicrobial use in the treatment group were significantly shorter/lower than those in the control group(P<0.05).Glasgow coma scale scores(11.88±1.78)and good recovery rate(76.5%)in the treatment group were significantly higher than those in the control group(8.06±1.12,54.0%)two weeks after operation(P<0.05).Good recovery rate(76.5%)in the treatment group was significantly higher than that in the control group(54.0%,P<0.05).The mortality rate(5.9%)was significantly lower than that in the control group(17.5%,P<0.05).Conclusion PICCO combined with intracranial pressure monitoring can effectively improve intracranial pressure,optimize cerebral perfusion,reduce complications such as traumatic cerebral infarction,neurogenic pulmonary edema,pulmonary infection and intracranial infection in patients with severe craniocerebral injury,thereby improving prognosis and reducing mortality;besides that,it can reduce patients'exposure to anti-brain infection,and the breadth and intensity of bacterial drugs can reduce the length of hospitalization and total cost of hospitalization,thereby reducing the burden of family and society.