Pentobarbital Coma For Refractory Intra-Cranial Hypertension After Severe Traumatic Brain Injury: Mortality Predictions and One-Year Outcomes in 55 Patients
Pentobarbital Coma For Refractory Intra-Cranial Hypertension After Severe Traumatic Brain Injury: Mortality Predictions and One-Year Outcomes in 55 Patients
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DOI：
10.1097/ta.0b013e3181de74c7
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发表时间：
2010-08-01
影响因子：
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通讯作者：
May, Addison K.
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文献类型：
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作者：
Marshall, Gary T.;James, Robert F.;May, Addison K.
目的：确定重度创伤性脑损伤（TBI）患者戊巴比妥昏迷（PBC）后存活者死亡率和长期结局的预测因素。这是一项回顾性队列研究，严重TBI患者接受PBC在一级创伤中心和第三大学hospital.Methods：四千九百三十四例患者被送入创伤重症监护室严重TBI（头部简明损伤量表>= 3）1998年4月至2004年12月。611例接受颅内压（ICP）监测，58例接受PBC。3例因颅内占位性病变行开颅手术，均被排除。研究组接受严重TBI的标准化医疗管理，包括阿片类药物、苯二氮卓类药物、抬高床头、避免低血压和高碳酸血症以及高渗治疗（HOsmRx）。此外，55名患者中有31名（56%）接受了脑室内导管放置以进行脑脊液引流。如果常规医疗管理和脑脊液分流术未能控制ICP，则确定患者患有难治性颅内高压（RICH），并开始PBC治疗。在连续脑电图监测下，通过戊巴比妥输注进行PBC，以确保充分的爆发抑制。测量包括血清钠（Na+）和渗透压（Osm）作为PBC启动的指标进行评估，并在控制ICP时估计50%死亡率临界点。使用格拉斯哥结局量表评估随访功能结局，并根据入院格拉斯哥昏迷量表评分和马歇尔计算机断层扫描分类进行分层。在55例PBC患者中，22例（40%）出院时存活。22例患者中有19例获得了长期随访（1年或更长时间）。其中，13例（68%）正常或功能独立（格拉斯哥结局量表评分4或5）。在控制ICP时，血清Na+和Osm与死亡相关（p < 0.05）。50%死亡率临界点为Na+160 mEq/L和Osm 330 mOsm/kg H2O。PBC后的中位最低脑灌注压为42毫米汞柱的幸存者和34毫米汞柱的非幸存者（p = 0.013）。结论：在严重的TBI和RICH患者，出院时的生存率为40%，68%的幸存者在1年或更长时间的良好功能结果，可以实现与PBC后失败的HOsmRx。基于50%死亡率临界点，分析表明HOsmRx的限度为Na+160 mEq/L和Osm 330 mOsm/Kg H2O。PBC术后维持较高的脑灌注压与生存率相关。当RIH的其他治疗方法（如去骨瓣减压术）不可用时，PBC治疗RIH可能更为重要。
Objective: To identify predictors of mortality and long-term outcomes in survivors after pentobarbital coma (PBC) in patients failing current treatment standards for severe traumatic brain injuries (TBI). This is a retrospective cohort study of severe TBI patients receiving PBC at Level I Trauma Center and tertiary university hospital.Methods: Four thousand nine hundred thirty-four patients were admitted to the trauma intensive care unit with severe TBI (head Abbreviated Injury Scale >= 3) between April 1998 and December 2004. Six hundred eleven received intracranial pressure (ICP) monitoring and 58 received PBC. Three patients underwent craniotomy for intracranial mass lesion and were excluded. The study group received standardized medical management for severe TBI including opiates, benzodiazepines, elevation of the head of bed, avoidance of hypotension and hypercapnia and hyperosmolar therapy (HOsmRx). In addition, 31 of 55 patients (56%) underwent placement of intraventricular catheters for cerebrospinal fluid drainage. If routine medical management and cerebrospinal fluid diversion failed to control ICP, then the patient was determined to have refractory intracranial hypertension (RICH) and PBC treatment was initiated. PBC was performed with pentobarbital infusion with continuous electroencephalogram monitoring to ensure adequate burst suppression. The measurements include serum sodium (Na+) and osmolality (Osm) were assessed as indicators for initiation of PBC and to estimate the 50% mortality cut-points when controlling for ICP. Follow-up functional outcomes were assessed using the Glasgow Outcome Scale and stratified according to admission Glasgow Coma Scale score and Marshall computed tomography classification. Of the 55 PBC patients, 22 (40%) survived at discharge. 19 of 22 had long-term follow-up (1 year or more) available. Of these, 13 (68%) were normal or functionally independent (Glasgow Outcome Scale score 4 or 5). Serum Na+ and Osm were associated with death (p < 0.05) when controlling for ICP. The 50% mortality cut-points were Na+ of 160 mEq/L and Osm of 330 mOsm/kg H2O. Median minimum cerebral perfusion pressure after PBC was 42 mm Hg in survivors and 34 mm Hg in nonsurvivors (p = 0.013).Conclusions: In patients with severe TBI and RICH, survival at discharge of 40% with good functional outcomes in 68% of survivors at 1 year or more can be achieved with PBC after failure of HOsmRx. Based on 50% mortality cut-points, analysis suggests the limits of HOsmRx to be Na+ of 160 mEq/L and Osm of 330 mOsm/Kg H2O. Maintenance of higher cerebral perfusion pressure after PBC is associated with survival. PBC treatment of RIH may be even more important when other treatments of RIH, such as decompressive craniectomy, are not available.