亚低温救治重型颅脑损伤的临床研究

Clinical Study of Treatment of Severe Brain Injury with Mild Hypothermia

目的研究亚低温救治重型颅脑损伤的治疗机制和效果。方法67例重型颅脑损伤病人随机分为亚低温组35例和对照组32例。亚低温组于伤后3～24h内,平均(12±3.3)h接受亚低温治疗,直肠温度(RT)控制在31.3～34.7℃,平均(33.7±1.1)℃持续7～14d,平均(171±25.3)h。同时监测生命体征、ICP、CPP、血SOD和血MDA、脑葡萄糖摄取、血糖、血乳酸、血气、血电解质和并发症。对照组RT控制在38℃以内,其它治疗同亚低温组。两组患者均于伤后3月根据GOS评定疗效。结果亚低温治疗组和对照组相比,亚低温治疗后36h两组ICP和CPP无显著差异。治疗120h开始亚低温组ICP明显降低(P<0.05),而CPP明显升高(P<0.05)。治疗36h后亚低温组血MDA明显低于对照组(P<0.05),而血SOD则明显高于对照组(P<0.05)。亚低温组和对照组治疗72h脑葡萄糖摄取分别为(6.33±0.2)mg%和(8.71±0.3)mg%,亚低温组明显低于对照组(P<0.05);复温后(第14天)分别为(12.7±0.5)mg%和(9.91±0.4)mg%,亚低温组则明显高于对照组(P<0.05)。治疗36h后亚低温组血糖明显低于对照组(P<0.05),血乳酸亦明显低于对照组(P<0.05)。治疗后3个月GOS评分,亚低温组良好率62.9%(22/35)、中残率8.6%(3/35)、重残率11.4%(4/35)、植物生存5.7%(2/35)、死亡率11.4%(4/35),对照组分别为40.

Objective To investigate the clinical effect of mild hypothermia on patients with severe brain injury and its mechanism.Methods Sixty-seven patients with severe brain injury(GCS7～4on admission)were randomly divided into hypothermic group(n=35)and control group(n=32).Hypothermia was induced within3～24hours after the injury.Rectal temperature was maintained at31.3～34.7℃for7～14days in the hypothermic group.The vital signs,intracranial pressure(ICP),cerebral perfusion pressure(CPP),serum superoxide dismutase(SOD),serum malonolialodehyde(MDA),cerebral extraction of glucose(CEG),blood glucose,lactale and electrolytes were determined.The rectal temperature was less than38℃in control group.The outcomes of the patients(GOS)between the two groups were compared by after three months of treatment.Results There were in significant difference in ICP and CPP between the two groups36hours after the treatment,but ICP significantly decreased and CPP significantly increased120hours after the treatment in the hypothermin group compared with the control group(P<0.05).MDA significantly decreased and SOD significantly increased compared with the control group36hours after the treatment (P<0.05).CEG was significantly lower(P<0.05)in the hypothermin group(6.33mg%±0.20mg%)than that in the control group(8.71mg%±0.30mg%)72hours after the treatment,but CEG became significantly higher(P<0.05)in the hypothermin group(12.7mg%±0.50mg%)than that in the control group(9.9mg%±0.4mg%)after rewarming.The good outcome was achieved in22(22/35)patients,moderate disablity in3(3/35),severe disablity in4(4/35)and vegetative subsistence in2(2/35)and4patients died(4/35),and in the control group40.6%(13/32)patients were good,18.7%(6/32)moderately disabled,3.1%(1/32)severely disabled and6.3%(2/32)vegetative subsistence and31.3%(10/32)died.There was insignificant difference in the complications between the two groups.Conclusions Mild hypothermia can effectively and saferly prevent from further brain damage in the patients with severe brain injury.Mortality can be reduced and outcome improved by mild hypothermia reducing ICP,lipid peroxidation,and brain metabolism,and lightening acidosis.[