Effect of intracranial pressure monitoring and targeted intensive care on functional outcome after severe head injury
Effect of intracranial pressure monitoring and targeted intensive care on functional outcome after severe head injury
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DOI：
10.1097/01.ccm.0000181300.99078.b5
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发表时间：
2005-10-01
影响因子：
8.8
通讯作者：
Kalkman, CJ
中科院分区：
文献类型：
--
作者：
Cremer, OL;van Dijk, GW;Kalkman, CJ
目的：重型颅脑损伤后的高颅压与病死率有关，但没有可靠的证据表明监测颅内压(ICP)和针对性地管理脑灌注压(CPP)可以改善预后，尽管该领域的专家普遍建议。设计：回顾队列研究，并对结果进行前瞻性评估。背景：1996年至2001年，荷兰的两个I级创伤中心。患者：333名存活并昏迷24小时的患者，共685例重型颅脑损伤患者。干预：在A中心(支持性重症监护)，平均动脉压维持在大约90 mm Hg，治疗干预基于临床观察和计算机断层扫描结果。在中心B(ICP/CPP-针对性重症监护)，管理的目标是维持ICP<；20 mm Hg和CPP>；70 mm Hg。每一个创伤中心的分配完全基于事故发生的地点。测量和主要结果：我们在>；=12个月后测量了扩展的格拉斯哥结果量表。患者特征在两个中心之间很好地平衡。A、B中心分别有122例(0%)和142例(67%)患者接受了颅内压监测。住院死亡率分别为41例(34%)和69例(33%；p=.87)。在ICP/CPP靶向治疗后，获得更有利的功能结果的优势比为0.95(95%可信区间，0.62-1.44)。在对潜在的混杂因素进行调整后，这一结果仍然存在。镇静剂、血管加压药、甘露醇和巴比妥类药物在中枢B区使用频率更高(均p
Objective: Intracranial hypertension after severe head injury is associated with case fatality, but there is no sound evidence that monitoring of intracranial pressure (ICP) and targeted management of cerebral perfusion pressure (CPP) improve outcome, despite widespread recommendation by experts in the field. The purpose was to determine the effect of ICP/CPP-targeted intensive care on functional outcome and therapy intensity levels after severe head injury.Design: Retrospective cohort study with prospective assessment of outcome.Setting: Two level I trauma centers in The Netherlands from 1996 to 2001.Patients: Three hundred thirty-three patients who had survived and remained comatose for > 24 hrs, from a total of 685 consecutive severely head-injured adults.Interventions: In center A (supportive intensive care), mean arterial pressure was maintained at approximately 90 mm Hg, and therapeutic interventions were based on clinical observations and computed tomography findings. In center B (ICP/CPP-targeted intensive care), management was aimed at maintaining ICP < 20 mm Hg and CPP > 70 mm Hg. Allocation to either trauma center was solely based on the site of the accident.Measurements and Main Results: We measured extended Glasgow Outcome Scale after >= 12 months. Patient characteristics were well balanced between the centers. ICP monitoring was used in zero of 122 (0%) and 142 of 211 (67%) patients in centers A and B, respectively. In-hospital mortality rate was 41 (34%) vs. 69 (33%; p =.87). The odds ratio for a more favorable functional outcome following ICP/CPP-targeted therapy was 0.95 (95% confidence interval, 0.62-1.44). This result remained after adjustment for potential confounders. Sedatives, vasopressors, mannitol, and barbiturates were much more frequently used in center B (all p