儿童重型创伤性脑损伤的颅内压及脑灌注压治疗阈值研究

Intervention thresholds of intracranial pressure and cerebral perfusion pressure in children with severe traumatic brain injury

目的研究儿童重型创伤性脑损伤(severe traumatic brain injury, STBI)颅内压及脑灌注压的临床特点及治疗阈值。方法前瞻性研究2014年6月至2018年6月重庆医科大学附属儿童医院神经外科收治的STBI患儿,术后每小时监测患儿颅内压和动脉血压。根据文献报道,预估不同年龄组患儿的理论颅内压和脑灌注压阈值,分别计算患儿各阈值的压力时间指数(pressure-time index,PTI)。采用受试者工作特征曲线(ROC)评估PTI的预测能力,根据各个年龄组患儿在不同理论阈值水平时的PTI值与伤后6个月时的GOS评分,计算ROC曲线下面积(area under curve, AUC),取最大AUC相应的理论颅内压和脑灌注压阈值作为该年龄组患儿的颅内压和脑灌注压治疗阈值。结果本研究共纳入STBI患儿115例,<2岁组25例,2~7岁组52例,>7岁组38例。年龄相关的颅内压阈值:<2岁组为14.4 mmHg,2~7岁组为20.0 mmHg,>7岁组为21.6 mmHg;年龄相关的脑灌注压阈值:<2岁组为45.0 mmHg,2~7岁组为55.0 mmHg,>7岁组为55.0 mmHg。结论不同年龄阶段的STBI患儿的颅内压和脑灌注压治疗阈值不同,推荐儿童重型TBI颅内压治疗阈值:<2岁为14.4 mmHg,2~7岁为20.0 mmHg,>7岁为21.6 mmHg;脑灌注压治疗阈值:<2岁为45.0 mmHg,≥2岁为55.0 mmHg。

Objective To analyze the clinical characteristics of changes in intracranial pressure(ICP)and cerebral perfusion pressure(CPP)and determine their intervention thresholds in children with severe traumatic brain injury(STBI).Methods This prospective observational study was conducted among the children with STBI admitted in the Children’s Hospital of Chongqing Medical University between June,2014 and June 2018.ICP and CPP of the children were dynamically monitored at every hour after the operation.The theoretical thresholds of ICP and CPP were adopted from literature,and the pressure-time indexes(PTIs)for these thresholds were calculated and their predictive ability was assessed using the receiver operating characteristic(ROC)curve.For children in different age groups(<2 years,2-7 years and>7 years),the area under the ROC curve(AUC)was calculated according to the PTIs for each theoretical threshold and Glasgow Outcome Scale score at 6 months after the trauma.The theoretical thresholds corresponding to the maximum AUC was determined to be the optimal thresholds.Results A total of 115 children with STBI were included in this study.For children aged<2 years(25 cases),2-7 years(52 cases)and>7 years(38 cases),the age-specific thresholds of ICP was 14.4,20.0 and 21.6 mmHg,and those of CPP was 45.0,55.0 and 55.0 mmHg respectively.Conclusion The intervention thresholds of ICP and CPP differ among the STBI chidren at different ages.In children with STBI aged<2 years,2-7 years and>7 years,we recommend postoperative ICP of 14.4,20.0 and 21.6 mmHg,and CCP of 45.0,55.0 and 55.0 mmHg respectively,as the thresholds for initiating interventions.