Prevention of secondary ischemic insults after severe head injury
Prevention of secondary ischemic insults after severe head injury
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DOI：
10.1097/00003246-199910000-00002
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发表时间：
1999-10-01
影响因子：
8.8
通讯作者：
Grossman, RG
中科院分区：
文献类型：
--
作者：
Robertson, CS;Valadka, AB;Grossman, RG
目的：本研究的目的是比较两种急性护理管理策略对严重颅脑损伤患者颈静脉血氧饱和度降低和难治性颅内高压的频率以及长期神经系统结局的影响。设计：随机临床试验。地点：一级创伤医院。患者：189 名因严重颅脑损伤而昏迷入院的成人。干预措施：患者被分配到任一组 在随机分配的时间黑人期间，以脑血行（CBF）为目标或以颅内压（ICP）为目标的管理方案。在 CBF 靶向方案中，脑灌注压保持在 >70 mm Hg，PaCO2 保持在大约 35 托（4.67 kPa）。在 ICP 靶向方案中，脑灌注压保持在 >50 mm Hg，过度通气至 PaCO2 为 25-30 托 (3.33-4.00 kPa)，用于治疗颅内高压。测量和主要结果：CBF 靶向方案将颈静脉去饱和度频率从 50.6% 降低至 30% (p = .006)。即使针对所有显着的混杂因素调整了颈静脉去饱和度的频率，ICP 靶向方案的脑缺血风险仍高出 2.4 倍。尽管继发性缺血性损伤减少，但神经系统结果没有差异。未能改变长期神经系统结果可能归因于两个主要因素。两组均接受规律的颈静脉血氧饱和度治疗，最大限度地减少了 ICP 目标组发生的损伤。 CBF 目标治疗方案的有益效果可能会被成人呼吸窘迫综合征发生频率增加五倍所抵消。结论：通过有针对性的治疗方案，可以预防严重头部损伤后全身因素引起的继发性缺血性损伤。然而，这种管理策略的潜在不利影响可能会抵消这些有利影响。
Objective: The purpose of this study was to compare the effects of two acute-care management strategies on the frequency of jugular venous desaturation and refractory intracranial hypertension and on long-term neurologic outcome in patients with severe head injury.Design: Randomized clinical trial.Setting: Level I trauma hospital.Patients: One hundred eighty-nine adults admitted in coma because of severe head injury.Interventions: Patients were assigned to either cerebral blood Row (CBF)-targeted or intracranial pressure (ICP)-targeted management protocols during randomly assigned time blacks. In the CBF-targeted protocol, cerebral perfusion pressure was kept at >70 mm Hg and PaCO2 was kept at approximately 35 torr (4.67 kPa). In the ICP-targeted protocol, cerebral perfusion pressure was kept at >50 mm Hg and hyperventilation to a PaCO2 of 25-30 torr (3.33-4.00 kPa) was used to treat intracranial hypertension,Measurements and Main Results: The CBF-targeted protocol reduced the frequency of jugular desaturation from 50.6% to 30% (p = .006). Even when the frequency of jugular desaturation was adjusted for all confounding factors that were significant, the risk of cerebral ischemia was 2.4-fold greater with the ICP-targeted protocol. Despite the reduction in secondary ischemic insults, there was no difference in neurologic outcome. Failure to alter long-term neurologic outcome was probably attributable to two major factors. A law jugular venous oxygen saturation was treated in both groups, minimizing the injury that occurred in the ICP-targeted group, The beneficial effects of the CBF-targeted protocol may have been offset by a five-fold increase in the frequency of adult respiratory distress syndrome.Conclusions: Secondary ischemic insults caused by systemic factors after severe head injury can be prevented with a targeted management protocol. However, potential adverse effects of this management strategy may offset these beneficial effects.