危重病患者亚低温复温的护理进展

本文旨在研究危重病患者临床应用亚低温复温的方法、护理措施及并发症等方面的国内外护理现状,对已有的护理研究进展加以归纳和总结,改善亚低温复温的流程及操作规范,降低患者的致残率与死亡率,提高其生存质量,减轻患者及其家属的精神负担,进一步完善临床护理工作,提高护理质量.     

不同复温速度对亚低温治疗新生儿缺氧缺血性脑病的影响

目的探讨不同复温速度对亚低温治疗新生儿缺氧缺血性脑病（HIE）的影响。方法研究对象为36例亚低温治疗的HIE患儿,随机分为Ⅰ组（n=12,复温速度0.2 ℃/h）、Ⅱ组（n=12,复温速度0.3 ℃/h）及Ⅲ组（n=12,复温速度0.4 ℃/h）。治疗过程中动态监测心率、血压、脉氧饱和度,每日测定血糖、血象、肝肾功能、血钾,并于完成治疗后7、14、28 d根据NBNA评分评定短期疗效,生后3个月及6个月行Bayley婴儿发育量表评估中期疗效。结果（1）复温达标时Ⅲ组血糖明显高于Ⅰ组及Ⅱ组,差异有统计学意义（P<0.05）;Ⅲ组复温达标时血糖高于复温前,差异有统计学意义（P<0.05）;（2）平均动脉压波动：Ⅲ组平均动脉压波动大于Ⅰ组和Ⅱ组,差异有统计学意义（P<0.05）;（3）NBNA评分：生后7、14、28 dⅠ组及Ⅱ组NBNA评分明显高于Ⅲ组,差异有统计学意义（P<0.05）;（4）生后3 月及6 月Ⅰ组神经发育指数、心理运动发育指数均高于Ⅱ组及Ⅲ组,差异有统计学意义（P<0.05）。结论亚低温治疗时较慢的复温速度可维持更稳定平均动脉压及血糖水平,有利于改善脑灌注及代谢,起到保护神经功能并改善HIE预后,复温速度过快可能会增加血压波动及高血糖等不良反应的发生。      

亚低温治疗急性脑梗死不同复温速率的比较

目的比较亚低温治疗急性脑梗死时，不同复温速率对局灶性脑缺血大鼠颅内压、脑梗死体积及脑组织含水量的影响。方法采用改良线栓法制备大鼠大脑中动脉闭塞（MCAO）模型，手术后即时诱导亚低温（33．5℃），持续24h后开始复温。将32只SD大鼠随机分为1℃／h复温组、0．5℃／h复温组、0．2℃／h复温组和0．1℃／h复温组。复温过程中监测颅内压，复温结束后比较各组脑梗死体积和脑组织含水量。结果刚开始复温（33．5℃）时，4组大鼠颅内压间差异无统计学意义（P〉0．05）。肛温上升到34．5℃时，1℃／h复温组颅内压高于其它3组，差异有统计学意义（P〈0．05）。肛温升至35．5℃时，0．5℃／h复温组也显著高于0．2℃／h复温组和0．1℃／h复温组，差异有统计学意义（P〈0．05）。复温结束（36．5℃）后，4组颅内压都显著升高，与复温前相比差异有统计学意义（P〈0．05），1℃／h复温组和0．5℃／h复温组大鼠脑梗死体积及脑组织含水量都明显高于0．2℃／h复温组和0．1℃／h复温组，差异有统计学意义（P〈0．05），0．2℃／h复温组和0．1℃／h复温组间差异无统计学意义（P〉0．05）。结论复温过快可引起颅内压上升过快，以致脑梗死体积和脑组织含水量增加。复温过程中应控制复温速率，以0．2℃／h的速率复温最佳。     

间歇性停用肌肉松弛剂对亚低温治疗的颅脑损伤患者复温后肺部感染的影响

目的探讨间歇性停用肌肉松弛剂降低重型颅脑损伤患者在亚低温治疗复温后肺部感染发生率的作用。方法便利抽样法选取2007年10月至2010年11月在上海市第七人民医院神经外科进行亚低温治疗的重型颅脑损伤患者90例为研究对象,按随机数字表将其分为观察组(n=49)和对照组(n=41),两组患者均采用常规的亚低温治疗方法。观察组患者在亚低温治疗期间根据医嘱每6h停用肌肉松弛剂罗库溴铵30min,对照组患者按照常规持续使用。观察两组患者在复温1周后肺部感染的发生率。结果两组患者亚低温治疗复温1周后肺部感染的发生率分别为16.3%、46.3%,对照组高于观察组,差异有统计学意义(P<0.01)。结论间歇性停用肌肉松弛剂可降低亚低温治疗的重型颅脑损伤患者复温后肺部感染的发生率。     

降温床用于颅脑外伤亚低温治疗的护理对照研究

研究降温床对颅脑外伤患者进行亚低温治疗的疗效、不良反应、护理要点.154例重型颅脑损伤及92例特重型颅脑损伤,分别随机分为亚低温组与对照组,监测项目:心电、呼吸、血压、血氧饱和度、电解质、血液粘膜测定、血小板计数、白陶土部分凝血活酶时间、意识、格拉斯哥昏迷评分(GCS)、瞳孔,注意有无冻伤、褥疮等不良反应发生.对于GCS＞3的患者不良反应少,GCS=3患者中存在复温困难的现象.降温床行亚低温治疗能显著提高重型颅脑损伤的存活率,它为临床治疗重型颅脑损伤提供了一种新的途径.     

降温床用于颅脑外伤亚低温治疗的护理对照研究

研究降温床对颅脑外伤患者进行亚低温治疗的疗效、不良反应、护理要点。154例重型颅脑损伤及92例特重型颅脑损伤,分别随机分为亚低温组与对照组,监测项目：心电、呼吸、血压、血氧饱和度、电解质、血液粘膜测定、血小板计数、白陶土部分凝血活酶时间、意识、格拉斯哥昏迷评分（GCS）、瞳孔,注意有无冻伤、褥疮等不良反应发生。对于GCS＞3的患者不良反应少,GCS＝3患者中存在复温困难的现象。降温床行亚低温治疗能显著提高重型颅脑损伤的存活率,它为临床治疗重型颅脑损伤提供了一种新的途径。     

亚低温在重症颅脑创伤患者中的应用

目的 探讨亚低温在重症颅脑创伤患者中应用的疗效和安全性.方法 将44例重症颅脑创伤患者随机分为亚低温组(n=22)和对照组(n=22),对照组按照脑创伤常规治疗,亚低温组在此基础上给予亚低温治疗.亚低温治疗过程中动态监测颅内压、心率、血压、脉氧饱和度,每日测定血糖、血细胞分析、血气分析、凝血功能、肝肾功能、电解质,并进行GCS评分,于伤后3个月根据GOS分级评定疗效.结果 亚低温维持12、24 h及复温后24 h,颅内压显著低于对照组;复温后24、48、72 h GCS评分显著高于对照组;3个月时治愈率明显高于对照组,死亡率明显低于对照组;亚低温治疗过程中心率、血小板、血钾降低,血糖升高,与对照组比较差异有统计学意义,给予相应治疗后无不良后果.结论 在重症颅脑创伤患者中,亚低温是一种安全、有效的治疗措施.     

亚低温治疗重症颅脑损伤的护理

当深部体温〈35℃时称作亚低温，它是利用对中枢神经系统具有抑制作用的镇静药物，使患者进人睡眠状态，再配合物理降温使患者体温处于一种可控性的低温状态，从而使中枢神经系统处于抑制状态，并降低高热对脑组织的损害，保护血一脑脊液屏障，减轻脑缺氧、脑水肿，降低颅内压，改善预后。2005年9月-2007年6月我科使用亚低温治疗35例重症颅脑损伤患者，取得了良好的效果，现将其应用及护理体会报告如下。[第一段]     

原发性肝癌术后低体温患者个体因素对复温速度的影响

目的：探讨在复温措施和治疗方案相同的情况下,原发性肝癌术后低体温患者自身因素对复温速度的影响。方法回顾性分析120例原发性肝癌术后低体温患者91例的复温过程,对可能影响体温恢复的个体因素,包括性别、年龄、身高、体质量、体重指数、体表面积、体表面积／体质量、术中出血量、手术时间、肿瘤直径等因素进行单因素分析,选取有统计学意义的因素进行多因素Logistic回归分析。结果单因素分析显示,体质量、体重指数、体表面积、体表面积／体重、肿瘤直径有统计学意义（P＜0．05）,进一步多因素Logistic回归分析表明,患者的体重指数与肿瘤直径是影响复温速度的个体因素。结论患者的体重指数和肿瘤大小可影响原发性肝癌术后低体温患者的复温速度,提示临床应加强对低体重指数及大肝癌术后低体温患者的复温护理,并根据患者的体重指数和肿瘤直径选择个性化的复温措施,提高复温效果。     

亚低温治疗重症颅脑损伤的护理

当深部体温〈35℃时称作亚低温，它是利用对中枢神经系统具有抑制作用的镇静药物，使患者进入睡眠状态，再配合物理降温使患者体温处于一种可控性的低温状态，从而使中枢神经系统处于抑制状态，并降低高热对脑组织的损害，保护血一脑脊液屏障，减轻脑缺氧、脑水肿，降低颅内压，改善预后。2004年5月～2005年6月我科使用亚低温治疗15例重症颅脑损伤患者，取得了良好的效果，现将其应用及护理体会报告如下。     

重型颅脑损伤患者开颅术后亚低温治疗作用的研究

目的研究重型颅脑损伤患者开颅术后亚低温治疗的作用。方法80例重型颅脑损伤患者开颅术后被随机分成两组：脑亚低温组（A组）和常温组（B组）。利用亚低温治疗仪,对控制目标温度在脑温33—35℃,亚低温治疗4d后自然复温。具有相似性质病例的B组,使用亚低温外的常规治疗。监测两组病例的生命体征、颅内压、静脉血超氧化物歧化酶（SOD）含量、GOS评分及并发症,进行分析。结果（1）两组在24、48、72h的平均颅内压分别为（23．49±2．38）mmHg、（24．68±1．71）mmHg、（22．51±2．44）mmHg和（25．87±2．18）mmHg、（25．90±1．86）mmHg、（24．57±3．95）mmHg,前者较后者降低（P分别为0．000,0．0130及0．003）;（2）两组在3d和7d的平均SOD含量分别为（533．0±103．4）μg/L、（600．5±82．9）μg/L和（458．7±68．1）μg/L、（497．0±57．3）μg/L,前者较后者明显升高（P=0．000）;（3）1年后两组恢复良好率（GOS评分）分别为70．0％和47．5％,（P=0．041）。两组并发症的发生率（包括肺部感染）分别为57．5％和32．5％（P=0．025）,处理后未见严重后果发生。结论亚低温治疗为重型颅脑损伤患者开颅术后的一种安全有效的治疗措施。     

Effects of therapeutic mild hypothermia on patients with severe traumatic brain injury after craniotomy

PURPOSE: We investigated the effects of therapeutic mild hypothermia on patients with severe traumatic brain injury after craniotomy (TBI). METHODS: Eighty patients with severe TBI after unilateral craniotomy were randomized into a therapeutic hypothermia group with the brain temperature maintained at 33 degrees C to 35 degrees C for 4 days, and a normothermia control group in the intensive care unit. Vital signs, intracranial pressure, serum superoxide dismutase level, Glasgow Outcome Scale scores, and complications were prospectively analyzed. RESULTS: The mean intracranial pressure values of the therapeutic hypothermia group at 24, 48, and 72 hours after injury were much lower than those of the control group (23.49 +/- 2.38, 24.68 +/- 1.71, and 22.51 +/- 2.44 vs 25.87 +/- 2.18, 25.90 +/- 1.86, and 24.57 +/- 3.95 mm Hg; P = .000, .000, and .003, respectively). The mean serum superoxide dismutase levels of the therapeutic hypothermia group at days 3 and 7 were much higher than those of the control group at the same time point (533.0 +/- 103.4 and 600.5 +/- 82.9 vs 458.7 +/- 68.1 and 497.0 +/- 57.3 mug/L, respectively; P = .000). The percentage of favorable neurologic outcome 1 year after injury was 70.0% and 47.5%, respectively (P = .041). Complications, including pulmonary infections (57.5% in the therapeutic hypothermia group vs 32.5% in the control group; P = .025) were managed without severe sequelae. CONCLUSIONS: Therapeutic mild hypothermia provides a promising way in the intensive care unit for patients with severe TBI after craniotomy.     

适宜复温速率对重型颅脑损伤亚低温治疗患者的效果研究

目的探讨重型颅脑损伤患者亚低温治疗过程中适宜的复温速率对其治疗效果的影响。方法将31例亚低温治疗的重型颅脑损伤患者随机分为3组,复温速率分别控制为0.05℃/h、0.05~0.09℃/h和0.10~0.25℃/h。收集复温过程中患者生命体征、颅内压变化、格拉斯哥评分及并发症等资料进行评定。结果患者复温达36.5℃时,复温速率0.10℃/h组患者的颅内压值明显高于其他两组(P0.05);3组患者格拉斯哥评分、生命体征及检验结果、并发症的差异无统计学意义(P0.05)。结论重型颅脑损伤患者亚低温治疗复温速率应控制于0.10℃/h以下。     

Hyperbaric oxygen therapy for traumatic brain injury: a systematic review of the evidence

OBJECTIVE: To identify the benefits and harms of hyperbaric oxygen therapy (HBOT) to treat traumatic brain injury (TBI). DATA SOURCES: MEDLINE, EMBASE, the Cochrane Library, HealthSTAR, CINAHL, MANTIS, professional society databases, and reference lists. Databases were searched from inception through December 2003. STUDY SELECTION: We included English-language studies of patients with TBI given HBOT and evaluating functional health outcomes. DATA EXTRACTION: Data were abstracted by 1 reviewer and checked by a second. Study quality was rated as good, fair, or poor. DATA SYNTHESIS: Two fair-quality randomized controlled trials of patients with severe brain injury reported conflicting results. One found no difference in mortality (48% HBOT vs 55% control) or morbidity at 1 year. In young patients with brainstem contusion, significantly more regained consciousness at 1 month with HBOT (67%) than control (11%) (P<.03). The other found a significant decrease in mortality in the HBOT group at 1 year (17%) compared with controls (31%) (P=.037). This decrease in mortality was accompanied by an increase in proportion of patients with severe disability. Patients with intracranial pressure (ICP) greater than 20 mmHg or a Glasgow Coma Scale score of 4 to 6 had significantly lower mortality at 1 year than controls. Five observational studies did not provide better evidence of effectiveness or adverse events. Two indicated a potential for initially reducing elevated ICP in some patients. However, rebound elevations higher than pretreatment levels occurred in some patients. Adverse events, including seizures, pulmonary symptoms, and neurologic deterioration, were reported; however, no study systematically assessed adverse events, and none reported adverse events in control groups. CONCLUSIONS: The evidence for HBOT for TBI is insufficient to prove effectiveness or ineffectiveness, and more high-quality studies are needed. The evidence indicates that there is a small chance of a mortality benefit, which may depend on subgroup selection. The effect on functional status and the incidence and clinical significance of adverse effects are unclear.     

Reliability of peak cardiorespiratory responses in patients with moderate to severe traumatic brain injury

OBJECTIVE: To examine the test-retest reliability of acute physiologic responses in patients with traumatic brain injury (TBI). DESIGN: Repeated measures within 1 week. SETTING: Brain injury rehabilitation program and community rehabilitation hospital. PARTICIPANTS: Thirty-six inpatients or their legal guardians. INTERVENTIONS: Each patient performed a symptom-limited incremental cycle ergometer test to voluntary fatigue on 2 separate occasions within 1 week. MAIN OUTCOME MEASURES: Peak values of power output and cardiorespiratory responses measured with a metabolic cart interfaced with an electrocardiogram. RESULTS: Intraclass correlations between the 2 trials were as follows: power output,.96; absolute oxygen uptake,.98; relative oxygen uptake,.97; heart rate,.82; ventilation rate,.96; and respiratory exchange ratio,.81. Bland-Altman plots showed that all data points were within the 95% confidence limits of the mean value of the 2 trials for each variable. CONCLUSIONS: The reliability of the peak cardiorespiratory responses during non-weight-bearing exercise was high in patients with TBI in a controlled laboratory setting. Therefore, aerobic exercise programs can be accurately prescribed, and changes resulting from such interventions can be confidently evaluated in this population.     

高渗盐水复苏对急性脑损伤伴失血性休克患者颅内压脑氧代谢的影响

目的　研究高渗盐水 (HTS)复苏对急性脑损伤伴失血性休克患者颅内压、脑氧代谢的影响。方法　 4 6例急性脑损伤伴失血性休克患者随机分为 3组 :HTS治疗组、甘露醇 (MT)治疗组和平衡液对照组。在平衡液复苏基础上 ,分别在 15min内快速静脉输入 7 5 %HTS 4mL/kg和 2 0 %MT 0 5g/kg。于治疗后 15、30、6 0、12 0min通过侧脑室置管监测颅内压 (ICP) ,计算脑灌注压 (CPP) ;同时分别抽取动脉、颈内静脉球部血行血气分析 ,监测颈静脉血氧饱和度 (SjvO2 )及脑动静脉氧含量差 (Da -jvO2 )。结果　与对照组比较 ,HTS能明显降低ICP ,增加CPP ,改善脑氧供需平衡 (P <0 0 1) ;与MT组比较 ,HTS组降低ICP幅度与其相似(P >0 0 5 ) ,而降ICP作用维持时间较长 ,于治疗后 12 0minICP、CPP值与MT组比较差异有显著意义 (P <0 0 1)。结论　HTS降低ICP效果确切 ,且维持时间较长 ,同时可改善脑氧代谢 ,适于急性脑损伤伴失血性休克患者的急救治疗     

局灶亚低温对创伤性脑损伤后大鼠脑组织炎症反应的影响

目的 观察创伤性脑损伤后早期应用局灶亚低温治疗对脑组织炎症反应的影响,探讨其治疗创伤性脑损伤的机制.方法 采用自由落体撞击模型,63只雄性Sprague Dawley大鼠随机分为对照组、颅脑外伤组及局灶亚低温组(使用25℃水降温),每组再根据伤后不同生存时间随机分为3个亚组(每组7只).取伤灶脑组织检测髓过氧化物酶(MPO)活性,做细胞间黏附分子-1(ICAM-1)免疫组化染色,光镜下计数ICAM-1阳性血管数.数据的统计采用SPSS 10.0软件行SNK-q检验.结果 局灶亚低温组各时间点伤灶区ICAM-1阳性血管数均明显低于颅脑外伤组相应时间点(P<0.01).局灶亚低温组各时间点MPO活性均明显低于颅脑外伤组相应时问点(P<0.01).结论 局灶亚低温可减少伤灶区ICAM-1的表达及中性粒细胞浸润,这可能是其治疗创伤性脑损伤的机制之一.     

Hypothalamic-pituitary dysfunction in critically ill patients with traumatic and nontraumatic brain injury

Background A significant number of studies have shown that critically ill patients with brain injury (BI) frequently exhibit abnormal pituitary hormonal responses during the immediate postinjury period.Discussion The elucidation of endocrine alterations depends on the criteria used, the diagnostic tests applied, and the timing of testing in relation to BI. The pattern of the detected hormonal abnormalities shows considerable variability. Altered endocrine responses are due mostly to hypothalamic changes rather than to pituitary dysfunction. Several studies have examined the correlation between hormonal alterations and BI severity, but the results are inconsistent. Furthermore, it remains currently unclear whether and how pituitary abnormalities adversely affect the clinical course of BI patients during the period of critical illness. On the basis of current knowledge, with the exception of clinically significant relative adrenal deficiency and diabetes insipidus, the other endocrine alterations do not seem to require any therapeutic intervention in severely ill BI patients. It is also uncertain whether hormonal abnormalities detected in the early post-BI period persist for the rest of these patients lives.Conclusions In view of current evidence indicating a high incidence of pituitary dysfunction even years following BI it is recommended that repetition of endocrine evaluation should be performed during the rehabilitation phase in all patients.     

Transcranial Doppler ultrasound goal-directed therapy for the early management of severe traumatic brain injury

Objective To evaluate the usefulness of early transcranial Doppler ultrasound (TCD) goal-directed therapy after severe traumatic brain injury initiated before invasive cerebral monitoring is available. Design Prospective, observational clinical study. Setting Surgical intensive care unit, university hospital. Patients and participants Twenty-four severely brain-injured patients. Interventions All patients had TCD measurements immediately on admission (T0) and when invasive cerebral monitoring was available (T1). TCD was considered abnormal when two out of three measured values were outside the following limits: Vm < 30 cm/s, Vd < 20 cm/s, PI  > 1.4. When admission TCD was abnormal, attending physicians modified treatment to increase cerebral perfusion pressure. Measurements and results Admission TCD was performed 18 ± 11 min (T0) after admission, whereas cerebral inasive monitoring was available 242 ± 116 min (T1) after admission. At T0, 11 (46%) patients had abnormal TCD values (group 1) and 13 had normal TCD values (group 2); mean arterial pressure was comparable between groups. All group 1 patients received mannitol and/or norepinephrine. At T1, mean arterial pressure was increased compared to admission in group 1 (105 ± 17 mmHg vs. 89 ± 15 mmHg, p < 0.05) and only two patients had still an abnormal TCD. Although group 1 patients had higher intracranial pressure than those of group 2 (32 ± 13 mmHg vs. 22 ± 10 mmHg, p < 0.01), both cerebral perfusion pressure and jugular venous oxygen saturation were comparable between the groups. Conclusions The use of TCD at hospital admission allows identification of severely brain-injured patients with brain hypoperfusion. In such high-risk patients, early TCD goal-directed therapy can restore normal cerebral perfusion and might then potentially help in reducing the extent of secondary brain injury.     

Measuring medical complexity during inpatient rehabilitation after traumatic brain injury

OBJECTIVE: To compare the performance of 3 severity of illness (SOI) indices--the Comprehensive Severity Index (CSI), All Patient Refined Diagnosis Related Groups Severity of Illness, case-mix group (CMG)--and 5 well-known neurologic parameters, as measures of medical complexity. DESIGN: Retrospective chart review. SETTING: Inpatient rehabilitation center within a level I trauma center. PARTICIPANTS: Consecutive traumatic brain injury (TBI) admissions (N=212). INTERVENTION: Acute inpatient TBI rehabilitation. CSI and neurologic parameters were scored by chart extraction. SOI was based on diagnosis codes by using 3M PC Grouper software, version 15. MAIN OUTCOME MEASURES: Adjusted R 2 was used to predict rehabilitation charges as a proxy of medical complexity. RESULTS: The highest adjusted R 2 values for single variables predicting charges were: CMG .349, CSI .293, duration of posttraumatic amnesia .260. Adjusted R 2 values for the CMG combined with the CSI, 5 neurologic parameters, and SOI to predict charges were .446, .431, and .365, respectively. CONCLUSIONS: The CMG was the best single predictor of rehabilitation charges for TBI. Predictive ability was better when the CMG was combined with the CSI or a combination of the 5 neurologic parameters. A severity index based on objective clinical findings rather than diagnostic codes may have distinct advantages for rehabilitation outcome studies and reimbursement methodology.