不同头高位对aSAH患者术后颅内压及脑灌注压的影响

Effects of different head heights on intracranial pressure and cerebral perfusion pressure in postoperative aneurysmal subarachnoid hemorrhage patients

目的探讨不同头高位对动脉瘤性蛛网膜下腔出血(aSAH)患者术后颅内压和脑灌注压的影响。方法纳入66例2020年9月至2021年4月我院重症医学科aSAH术后患者,依次将床头抬高0°、10°、20°、30°、40°,每种体位保持15 min,待稳定后记录患者血压、心率、呼吸、脉搏血氧饱和度、颅内压,计算出相应平均动脉压和脑灌注压。并收集患者的预后相关指标,包括压力性损伤、住院病死率、出院时格拉斯哥预后评分。结果在床头抬高0°、10°、20°、30°、40°时,颅内压分别为(17.76±5.54)、(16.77±5.58)、(15.94±5.85)、(14.94±5.26)、(14.35±5.33)mmHg(1 mmHg=0.133 kPa),脑灌注压分别为(79.31±12.08)、(80.17±10.07)、(81.94±11.96)、(81.92±12.48)、(82.53±12.30)mmHg,平均动脉压分别为(97.07±11.17)、(96.94±9.43)、(97.88±10.57)、(96.86±11.56)、(96.87±10.89)mmHg。头高位从0°增加到30°时,颅内压显著下降,差异有统计学意义(两两比较,P=0.001,P=0.050,P=0.033),但在30°与40°时,差异无统计学意义(P=0.507)。头高位从0°增加到40°时,脑灌注压呈升高趋势,差异有统计学意义(P=0.031),但两两比较,差异无统计学意义(均P>0.05)。平均动脉压随着头高位角度的增高并没有明显变化,差异无统计学意义(P=0.826)。患者在不同头高位下的收缩压、舒张压、心率、呼吸、脉搏血氧饱和度等生命体征比较,差异均无统计学意义(均P>0.05)。所有患者ICU住院期间均未发生压力性损伤。结论对aSAH术后患者,床头抬高至30°~40°是控制颅内压升高、保证有效脑灌注压的安全有效的治疗性体位。对初始颅内压较高的患者,床头抬高至40°可降低颅内压,且无需担心压力性损伤的发生。

Objective To investigate the effects of different bedside angle on postoperative intracranial pressure and cerebral perfusion pressure in aSAH patients.Methods 66 postoperative aSAH patients in the intensive care unit of Beijing Tiantan Hospital,Capital Medical University from September 2020 to April 2021 were selected as the research objects.The patients in a supine position at rest and raise the bedside angle by 0°,10°,20°,30°and 40°)were kept in turn.Each position was held for 15 minutes,in which blood pressure,heart rate,respiration rate,pulse oxygen saturation and intracranial pressure were recorded after the data was stable.The average arterial pressure and cerebral perfusion pressure were calculated correspondingly.Prognostic related parameters including pressure injuries,hospital mortality,and Glasgow score at discharge,were also collected.Results When the bedside angle were elevated at 0°,10°,20°,30°and 40°,the intracranial pressure values were(17.76±5.54),(16.77±5.58),(15.94±5.85),(14.94±5.26),(14.35±5.33)mmHg(1 mmHg=0.133 kPa);the cerebral perfusion pressure were(79.31±12.08),(80.17±10.07),(81.94±11.96),(81.92±12.48),(82.53±12.30)mmHg,and the mean arterial pressure were(97.07±11.17),(96.94±9.43),(97.88±10.57),(96.86±11.56),(96.87±10.89)mmHg,respectively.The intracranial pressure decreased significantly with the increase of bedside angle from 0°to 30°(pairwise comparison showed P=0.001,P=0.050 and P=0.033),there was no significant difference in intracranial pressure between 30°and 40°(P=0.507).The cerebral perfusion pressure had a growing trend with the increase of the bedside angle from 0°to 40°(P=0.031),but there was no significant difference in all of pairwise comparison(P>0.05).Mean arterial pressure did not change significantly with the increase of the degree of head elevation(P>0.05).There was no statistically significant difference in vital signs of systolic blood pressure,diastolic blood pressure,heart rate,respiration rate and pulse oxygen saturation at different degrees of head elevations(P>0.05).No pressure injury occurred in all patients during their ICU stay.Conclusions It may be a safe and effective therapeutic position to maintain the bedside angle at 30°-40°in aSAH patients to control intracranial pressure and ensure adequate cerebral perfusion.For patients with initially high intracranial pressure,raising the bedside angle to 40°may reduce intracranial pressure without increasing risks of pressure injuries.