脑电双频指数镇痛镇静联合液压耦合颅内压监测在重型颅脑损伤中的应用研究

Application of analgesia and sedation under BIS monitoring combined with hydraulic coupling intracranial pressure monitoring in severe craniocerebral injury

目的探讨脑电双频指数(BIS)镇痛镇静联合液压耦合颅内压(ICP)监测在重型颅脑损伤(sTBI)中的临床应用价值。方法①采用前瞻性自身平行对照研究方法,选择2020年12月至2021年7月湖州市第一人民医院重症监护病房(ICU)收治的32例sTBI开颅术后患者作为研究对象,同时应用Codman监测系统和液压耦合监测系统监测ICP值,比较两者的差异及相关性。②采用前瞻性随机对照研究方法,选择2021年8月至2022年8月湖州市第一人民医院ICU收治的108例sTBI开颅术后患者,按随机数字表法分为3组,所有患者均予脑外科术后诊疗常规,并在此基础上,A组(35例)辅以Codman监测系统监测ICP值,B组(40例)辅以液压耦合监测系统监测ICP值,C组(33例)通过BIS指导镇痛镇静并联合液压耦合监测系统监测ICP值。比较3组患者治疗后ICP、脑脊液引流时间、ICP监测时间、ICU住院时间、并发症发生情况以及术后6个月格拉斯哥预后评分(GOS)等指标。此外,对于B组和C组患者根据波形进行再次分组,若P_(1)=P_(2)或P_(2)、P_(3)低则为代偿组;若圆形波或P_(2)>P_(1)则为失代偿组,比较两组患者术后6个月GOS评分。结果①同一患者分别采用Codman监测系统与液压耦合监测系统测得的ICP值差异无统计学意义(mmHg:11.94±1.76比11.88±1.90,t=0.150,P=0.882;1 mmHg≈0.133 kPa),Bland-Altman分析显示,两种方法测量ICP值95%一致性界限(95%LoA)为-4.55~4.68 mmHg,且所有的点均落在95%LoA内,表明两种测量方法具有良好的相关性。②3组sTBI患者脑脊液引流时间、ICP监测时间、ICU住院时间以及颅内感染、颅内再出血、外伤型脑积水、脑脊液漏、意外拔管等并发症发生率差异均无统计学意义(P>0.05或P>0.017)。C组治疗后ICP值显著低于A组和B组(mmHg:20.94±2.37比25.86±3.15、26.40±3.09,均P<0.05),肺部感染发生率(9.1%比45.7%、42.5%)、癫痫发作发生率(3.0%比31.4%、30.0%)、再次手术率(3.0%比31.4%、40.0%)、术后6个月预后不良发生率(33.3%比65.7%、65.0%)均显著低于A组和B组(均P<0.017)。此外,根据液压耦合波形判断,代偿组35例患者术后6个月GOS评分显著高于失代偿组38例患者(分:4.03±1.18比2.39±1.50,t=5.153,P<0.001)。结论液压耦合监测系统测量ICP值具有较好的准确性和一致性,且比传统ICP监测方式能更好显示ICP波形变化,对预后有较好地预测价值,可替代Codman监测精确指导临床工作;另外可通过BIS监测下的镇痛镇静联合液压耦合ICP监测辅助评估并及时干预,有效降低ICP,减少并发症,改善预后,具有较高的临床应用价值。

Objective To investigate the clinical value of analgesia and sedation under bispectral index(BIS)monitoring combined with hydraulic coupled intracranial pressure(ICP)monitoring in severe craniocerebral injury(sTBI).Methods①A prospective self-controlled parallel control study was conducted.A total of 32 patients with sTBI after craniotomy admitted to the intensive care unit(ICU)of the First People's Hospital of Huzhou from December 2020 to July 2021 were selected as the research objects.ICP was monitored by Codman monitoring system and hydraulically coupled monitoring system,and the difference and correlation between them were compared.②A prospective randomized controlled study was conducted.A total of 108 sTBI patients admitted to the ICU of the First People's Hospital of Huzhou from August 2021 to August 2022 were selected patients were divided into 3 groups according to the random number table method.All patients were given routine treatment after brain surgery.On this basis,the ICP values of the patients in group A(35 cases)were monitored by Codman monitoring system,the ICP values of the patients in group B(40 cases)were monitored by hydraulic coupling monitoring system,and the ICP values of the patients in group C(33 cases)were monitored combined with hydraulic coupling monitoring system,and the analgesia and sedation were guided by BIS.The ICP after treatment,cerebrospinal fluid drainage time,ICP monitoring time,ICU stay time,complications and Glasgow outcome score(GOS)at 6 months after surgery were compared among the 3 groups.In addition,patients in group B and group C were further grouped according to the waveforms.If P_(1)=P_(2)wave or P_(2)and P_(3)wave were low,they were classified as compensatory group.If the round wave or P_(2)>P_(1)wave was defined as decompensated group,the GOS scores of the two groups at 6 months after operation were compared.Results①There was no significant difference in ICP values measured by Codman monitoring system and hydraulic coupling monitoring system in the same patient(mmHg:11.94±1.76 vs.11.88±1.90,t=0.150,P=0.882;1 mmHg≈0.133 kPa).Blan-altman analysis showed that the 95%consistency limit(95%LoA)of ICP values measured by the two methods was-4.55 to 4.68 mmHg,and all points fell within 95%LoA,indicating that the two methods had a good correlation.②There were no significant differences in cerebrospinal fluid drainage time,ICP monitoring time,ICU stay time,and incidence of complications such as intracranial infection,intracranial rebleeding,traumatic hydrocephalus,cerebrospinal fluid leakage,and accidental extubation among the 3 groups of sTBI patients(P>0.05 or P>0.017).The ICP value of group C after treatment was significantly lower than that of group A and group B(mmHg:20.94±2.37 vs.25.86±3.15,26.40±3.09,all P<0.05),the incidence of pulmonary infection(9.1%vs.45.7%,42.5%),seizure(3.0%vs.31.4%,30.0%),reoperation(3.0%vs.31.4%,40.0%),and poor prognosis 6 months after operation(33.3%vs.65.7%,65.0%)were significantly lower than those in group A and group B(all P<0.017).According to the hydraulic coupling waveform,GOS scores of 35 patients in the compensated group were significantly higher than those of 38 patients in the decompensated group 6 months after operation(4.03±1.18 vs.2.39±1.50,t=5.153,P<0.001).Conclusions The hydraulic coupled intracranial pressure monitoring system has good accuracy and consistency in measuring ICP value,and it can better display ICP waveform changes than the traditional ICP monitoring method,and has better prediction value for prognosis evaluation,which can replace Codman monitoring to accurately guide clinical work.In addition,analgesia and sedation under BIS monitoring combined with hydraulic coupled ICP monitoring can effectively reduce ICP,reduce the incidence of complications,and improve the prognosis,which has high clinical application value.