早期气管切开联合过度通气在重型颅脑损伤中的临床应用价值

目的探讨早期气管切开联合轻~中度过度通气在治疗重型颅脑损伤（sTBI）中的临床应用价值。方法将80例sTBI患者（GCS评分3~8分）随机分为观察组和对照组各40例。观察组患者入院后24 h内行经皮气管切开并呼吸机短时间内维持轻~中度过度通气（HV）,监测呼气末二氧化碳分压（PetCO2）,使PetCO2维持在27~32 mmHg,30 min/次,4次/d（Q6h）,持续7 d。对照组患者入院后持续面罩中流量供氧,出现呼吸衰竭时再行经皮气管切开及机械通气（未进行过度通气）。全部80例患者均予防治感染、脱水降颅压、脑保护、营养支持等对症支持治疗（有手术指征者及时行手术治疗）,连续观察患者伤后第1~7天颅内压（ICP）的变化,所有病例于伤后6个月时根据GOS评估法判断疗效,分为良好、中残、重残、植物生存和死亡。结果观察组经过轻~中度过度通气后能使sTBI患者的ICP迅速下降,与对照组比较差异有统计学意义（P〈0.O1）。观察组与对照组患者半年后预后在良好、中残、重残、植物生存方面比较差异有统计学意义（P〈0.05）,病死率比较差异无统计学意义（P〉0.05）。结论早期气管切开联合轻~中度过度通气在治疗sTBI中有利于降低颅内压,改善重症患者伤后6个月的生存质量。

Clinical research on early tracheotomy combined with hyperventilation in severe traumatic brain injury

Objective To discuss the clinical value of early tracheotomy combined with hyperventilation in severe traumatic brain injury（sTBI）.Methods Eighty patients with sTBI（GCS 3 ~ 8） were randomly divided into the observation group and the control group.Within 24 h after admission the observation group＇ s patients received percutaneous tracheostomy,and in a short time maintained the light to moderate hyperventilation with ventilator.Monitoring the end-tidal carbon dioxide partial pressure（PetCO 2）,the PetCO 2 was maintained at 27 ~ 32 mmHg,each time for 30 min,4 times a day,for 7 days.Continuous moderate oxygen supply via face mask was used in control group＇ s patients after admission until respiratory failure comes out,then the percutaneous tracheostomy and mechanical ventilation（not hyperventilation was performed）.All of the 80 patients received the treatment of preventing infections,reducing the intracranial pressure,cerebral protection,nutritional supporting and other symptomatic and supportive therapy.Within 7 days the changes of intracranial pressure（ICP） in the patients were continuously observed and 6 months after injury,the efficacy was evaluated according to GOS valuation method including 5 grades： good,moderate disability,severe disability,vegetative state,and death.Results ICP decreased more rapidly in the observation group than the control group,and the difference was statistically significant（P 0.01）.After 6 months there were significant differences between the two groups in good,moderate disability,severe disability,vegetative state（P 0.05）,without statistically significant difference in mortality rate（P 0.05）.Conclusion The early tracheotomy combined with mild to moderate hyperventilation may be beneficial to decreasing ICP,and improving the survival quality for patients within 6 months after sTBI.