长时程亚低温与短时程亚低温治疗重型颅脑损伤的比较研究

Effect of long-term and short-term mild hypothermia in severe traumatic brain injury:a comparative study

目的探讨不同时程亚低温治疗对重型颅脑损伤(STBI)患者疗效及并发症的影响.方法采用回顾性调查研究方法,选择2010年1月至2018年12月在甘肃省中医药大学第三附属医院住院并接受亚低温治疗的132例STBI患者作为研究对象.根据亚低温持续治疗的天数将患者分为2 d亚低温治疗组、5 d亚低温治疗组和14 d亚低温治疗组.比较3组患者亚低温治疗后10 d、30 d的格拉斯哥昏迷评分(GCS);30 d的致残率和病死率;昏迷时间;凝血酶原时间(PT)、活化部分凝血活酶时间(APTT)、纤维蛋白原(Fib)、D-二聚体;30 d内血压下降、胃肠动力减弱、感染、头皮不愈合、脑脊液漏等并发症的发生率.结果132例STBI患者中,亚低温持续治疗2 d者44例、5 d者45例、14 d者43例,3组患者性别、年龄、治疗前GCS评分、受伤至入院时间等一般资料比较差异均无统计学意义.与亚低温持续治疗2 d组比较,5 d、14 d组患者亚低温治疗后10 d和30 d的GCS评分明显升高(分:11.61±2.23、10.17±2.03比6.79±1.49,13.15±2.53、11.24±2.24比8.79±1.59),昏迷时间明显缩短(d:5.79±1.89、5.45±1.72比13.65±2.73),30 d的致残率和病死率明显下降〔13.33%(6/45)、11.63%(5/43)比22.73%(10/44),17.78%(8/45)、16.28%(7/43)比31.82%(14/44)〕,PT、APTT明显缩短(s:20.14±4.12、22.54±3.56比30.67±5.19,35.14±12.41、38.59±13.54比56.67±10.62),Fib明显升高(g/L:1.84±0.25、1.98±0.27比0.67±0.12),D-二聚体明显降低(mg/L:53.10±19.84、49.20±20.13比102.60±20.13),差异均有统计学意义(均P<0.05);而5 d治疗组与14 d治疗组上述各指标差异均无统计学意义(均P>0.05).亚低温持续治疗14 d组并发症发生率明显高于2 d、5 d组〔血压下降:55.56%(20/36)比36.67%(11/30)、35.14%(13/37),胃肠动力减弱:72.22%(26/36)比46.67%(14/30)、45.95%(17/37),泌尿系感染:52.78%(19/36)比36.67%(11/30)、35.14%(13/37),肺部感染:47.22%(17/36)比36.67%(11/30)、37.84%(14/37),头皮不愈合:5.56%(2/36)比0%(0/30)、0%(0/37),脑脊液漏:5.56%(2/36)比0%(0/30)、0%(0/37),均P<0.05〕,而2 d组与5 d组间并发症发生率比较差异则无统计学意义(均P>0.05).结论STBI患者亚低温治疗的最佳时程为发病后5 d内,持续治疗5 d可缩短患者昏迷时间,降低病死率和致残率;过短时间的亚低温治疗不能有效预防继发性脑损伤,而过长时间的亚低温治疗可影响患者损伤组织的修复,不利于机体功能的恢复,且易出现并发症.

Objective To explore the effects of different mild hypothermia therapy time on the efficacy and complications of patients with severe traumatic brain injury(STBI).Methods A retrospective research method was used.132 patients with STBI given mild hypothermia therapy admitted to the Third Affiliated Hospital of Gansu University of Traditional Chinese Medicine from January 2010 to December 2018 were enrolled.According to the days of mild hypothermia therapy,the patients were divided into 2-day mild hypothermia treatment group,5-day mild hypothermia treatment group and 14-day mild hypothermia treatment group.Glasgow coma score(GCS)after treatment of 10 days and 30 days,30-day disability rate and mortality,coma time,prothrombin time(PT),activated partial thromboplastin time(APTT),fibrinogen(Fib),D-dimer,and the incidence of complications such as decreased blood pressure,decreased gastrointestinal motility,infection,nonunion of scalp,cerebrospinal fluid leakage,etc.were compared among three groups.Results Among the 132 patients with STBI,there were 44 cases in the 2-day mild hypothermia treatment group,45 cases in 5-day mild hypothermia treatment group,and 43 cases in 14-day mild hypothermia treatment group.There was no significant difference in gender,age,GCS score before treatment or time from injury to admission among three groups.Compared with 2-day mild hypothermia treatment group,the GCS score 10 days and 30 days after treatment in 5-day mild hypothermia treatment group and 14-day mild hypothermia treatment group were significantlyhigher(11.61±2.23,10.17±2.03 vs.6.79±1.49;13.15±2.53,11.24±2.24 vs.8.79±1.59),the coma time were shorten(days:5.79±1.89,5.45±1.72 vs.13.65±2.73),and 30-day disability rate and mortality were significantly decreased[13.33%(6/45),11.63%(5/43)vs.22.73%(10/44);17.78%(8/45),16.28%(7/43)vs.31.82%(14/44)],PT and APTT were reduced obviously(s:20.14±4.12,22.54±3.56 vs.30.67±5.19;35.14±12.41,38.59±13.54 vs.56.67±10.62),Fib rose obviously(g/L:1.84±0.25,1.98±0.27 vs.0.67±0.12),and D-dimer reduced obviously(mg/L:53.10±19.84,49.20±20.13 vs.102.60±20.13),with statistically significant differences(all P<0.05).But there was no significant difference in above indicators between the 5-day mild hypothermia treatment group and 14-day mild hypothermia treatment group(all P>0.05).The incidence of complications in 14-day mild hypothermia group was significantly higher than those in 2-day mild hypothermia group and 5-day mild hypothermia group[decrease of blood pressure:55.56%(20/36)vs.36.67%(11/30),35.14%(13/37);weakening of stomach intestinemotive power:72.22%(26/36)vs.46.67%(14/30),45.95%(17/37);urethral infection:52.78%(19/36)vs.36.67%(11/30),35.14%(13/37);lungs infection:47.22%(17/36)vs.36.67%(11/30),37.84%(14/37);disunion of scalp:5.56%(2/36)vs.0%(0/30),0%(0/37);leak of cerebrospinal fluid:5.56%(2/36)vs.0%(0/30),0%(0/37),all P<0.05],but there was no significant difference between the 2-day mild hypothermia treatment group and 5-day mild hypothermia treatment group(all P>0.05).Conclusions The optimal time frame for mild hypothermia treatment in patients with STBI is 5-day,which shortens the coma time,and reduces the mortality and the disability rate.The shorter mild temperature time cannot effectively prevent secondary brain injury.However,the prolonged period of mild temperature will affect the repair of the patient's injury tissue,which is not conducive to the recovery of patient's mechanical function and is prone to complications.