重型创伤性脑损伤后慢性意识障碍患者术后短期意识水平改善的相关影响因素

Factors affecting postoperative short‑term improvement of consciousness level in patients with prolonged disorders of consciousness after severe traumatic brain injury

目的探讨重型创伤性脑损伤(sTBI)后慢性意识障碍患者术后短期意识水平改善的影响因素。方法采用病例对照研究分析2021年9月至2022年9月首都医科大学附属北京天坛医院和中国人民解放军总医院第七医学中心收治的55例sTBI后慢性意识障碍患者的临床资料,其中男33例,女22例;年龄13~68岁[(43.0±15.5)岁]。应用改良昏迷恢复量表(CRS⁃R)评估所有患者术前、术后48 h内意识水平,其中术前植物状态33例,微意识状态22例。术后26例意识改善(意识改善组),其余29例意识水平与术前相比未改善(意识未改善组)。记录两组患者性别、年龄、致伤原因、入院时格拉斯哥昏迷评分(GCS)、病程、术前意识水平、手术方式、手术时间、术中补液量、术中尿量、术中出血量、美国麻醉医师协会分级、术中镇痛方案及镇静维持用药等指标。采用单因素分析评估上述指标与sTBI后慢性意识障碍患者术后短期意识水平改善的相关性。采用多因素Logistic回归分析确定sTBI后慢性意识障碍患者术后短期意识水平改善的独立影响因素。结果单因素分析结果显示,入院时GCS、病程、术前意识水平及镇痛方案与sTBI后慢性意识量患者术后短期意识水平改善有一定的相关性(P均<0.05);而性别、年龄、致伤原因、手术方式、手术时间、术中补液量、术中尿量、术中出血量、美国麻醉医师协会分级、镇静维持用药与sTBI后慢性意识障碍患者术后短期意识水平改善不相关(P均>0.05)。多因素Logistic回归分析结果表明,入院时GCS≥7分(OR=0.06,95%CI 0.01,0.36,P<0.01)、术前微意识状态(OR=0.09,95%CI 0.02,0.40,P<0.01)及术中舒芬太尼联合瑞芬太尼镇痛(OR=0.07,95%CI 0.01,0.43,P<0.01)与术后短期意识水平改善显著相关。结论入院时GCS≥7分、术前微意识状态及术中使用舒芬太尼联合瑞芬太尼镇痛是影响sTBI后慢性意识障碍患者术后短期意识水平改善的因素。

Objective To investigate the factors affecting postoperative short⁃term improvement of consciousness level in patients with prolonged disorders of consciousness after severe traumatic brain injury(sTBI).Methods A case⁃control study was conducted to analyze the clinical data of 55 patients with prolonged disorders of consciousness after sTBI admitted to Beijing Tiantan Hospital Affiliated to Capital Medical University and Seventh Medical Center of PLA General Hospital from September 2021 to September 2022.There were 33 males and 22 females,with the age range of 13⁃68 years[(43.0±15.5)years].All patients were assessed for the consciousness level using the coma recovery scale⁃revision(CRS⁃R)preoperatively and within 48 hours postoperatively.A total of 33 patients were observed in vegetative state and 22 in minimally conscious state preoperatively.The consciousness level was found to be improved in 26 patients(consciousness⁃improved group),but not improved in the remaining 29 patients(consciousness⁃unimproved group).Indicators were documented including gender,age,cause of injury,Glasgow coma score(GCS)on admission,course of injury,preoperative consciousness level,operation mode,operation time,intraoperative fluid replenishment,intraoperative urine volume,intraoperative bleeding volume,American Society of Anesthesiologists grade,analgesic regimen and sedation maintenance drugs.A univariate analysis was conducted first to assess those indicators′correlation with postoperative short⁃term improvement of consciousness level in patients with prolonged disorders of consciousness after sTBI.Multivariate Logistic regression analysis was then used to determine the independent risk factors for their postoperative short⁃term improvement of consciousness level.Results Univariate analysis showed that GCS on admission,course of injury,preoperative consciousness level and analgesic regimen were correlated with short⁃term improvement of postoperative consciousness level in patients with prolonged disorders of consciousness after sTBI(all P<0.05),whereas gender,age,cause of injury,operation mode,operation time,intraoperative fluid replenishment,intraoperative urine volume,intraoperative bleeding volume,American Society of Anesthesiologists grade and sedation maintenance drugs showed no relation to the improvement of postoperative consciousness level(all P>0.05).Multivariate Logistic regression analysis showed that the GCS≥7 points on admission(OR=0.06,95%CI 0.01,0.36,P<0.01),preoperative minimally conscious state(OR=0.09,95%CI 0.02,0.40,P<0.01)and intraoperative use of Sufentanil combined with Remifentanil(OR=0.07,95%CI 0.01,0.43,P<0.01)were significantly correlated with postoperative improvement of consciousness level.Conclusion The GCS on admission(≥7 points),preoperative minimally conscious state and intraoperative use of Sufentanil combined with Remifentanil are independent risk factors affecting short⁃term postoperative improvement of consciousness level in patients with prolonged disorders of consciousness after sTBI.