亚低温治疗重型颅脑损伤的监测及护理

探讨亚低温治疗重型颅脑损伤的监护重点和并发症防治.对96例重型颅脑损伤患者在常规治疗的基础上,加用亚低温治疗并进行回顾性分析.亚低温治疗前后比较及亚低温治疗组与对照组比较,神经功能明显改善,颅内压、体温明显降低,疗效明显增高.亚低温是重型颅脑损伤患者的重要治疗方法.在护理上总结了亚低温治疗的降温与复温方法,冬眠药物的作用与体温控制,监护重点及并发症的防治.     

亚低温治疗重型颅脑损伤的监测和护理

目的探讨重型颅脑损伤亚低温治疗和监测方法,并发症的预防和护理。方法通过对41例重型颅脑损伤患者实施亚低温治疗及监护,观察治疗过程中的并发症、死亡率。并与未使用亚低温治疗的3 8例重型颅脑损伤患者作一简要对照。结果亚低温治疗组死亡率明显低于未使用亚低温治疗组。结论亚低温治疗及监护能明显提高重型颅脑损伤病人的治疗效果,且设备简单,易于推广。     

21例重型颅脑损伤病人亚低温治疗的实施和护理

对21例重型颅脑损伤病人在常规治疗的基础上，加用亚低温治疗，通过探讨它的实施方法、监护重点及并发症防治，总结出该组病人的监测与护理要点。     

21例重型颅脑损伤病人亚低温治疗的实施和护理

对21例重型颅脑损伤病人在常规治疗的基础上,加用亚低温治疗,通过探讨它的实施方法、监护重点及并发症防治,总结出该组病人的监测与护理要点。     

亚低温治疗对重型颅脑损伤患者免疫系统的影响研究

目的 探讨亚低温治疗重型颅脑损伤的临床疗效及其对颅脑损伤患者免疫功能的影响。方法 重型颅脑外伤患者62例，随机分为亚低温治疗组(亚低温组)和对照组，亚低温组32例，伤后24h内采用亚低温治疗，直肠温度控制在32～35℃；对照组30例，采用传统的物理及化学方法降温使直肠温度控制在37．8～38．5℃，余治疗方法同亚低温组，比较两组患者的并发症发生率和预后情况。同时检测两组患者治疗后T淋巴细胞转化功能、自然杀伤细胞活性，并采用流式细胞术检测外周血T淋巴细胞亚群的动态变化。结果 与对照组比较，亚低温组患者伤后早期颅内压明显下降，血电解质及酸碱平衡均未出现明显紊乱，并发症发生率及病死率明显下降，优良率提高，预后显著改善；同时T淋巴细胞转化率、自然杀伤细胞活性及CD4^ 、CD8^ T淋巴细胞均显著升高。结论 亚低温治疗对于重型颅脑损伤患者安全有效，可降低并发症发生率及病死率，明显提高患者生存质量。亚低温对颅脑伤患者免疫功能具有保护作用。     

亚低温治疗重型颅脑损伤的新进展及监护

亚低温治疗作为重型颅脑损伤的治疗手段之一起自 80年代中后期。大量的动物实验及多个小样本、单中心试验的结果肯定了它在治疗重型颅脑损伤中的作用 ,因而逐渐被各国神经外科医生所认识并使用。但是自 2 0 0 1年以来对这种治疗方法有效性的争论逐渐增多。现将国内外亚低温治疗重型颅脑损伤的研究进展及相关监护问题综述如下。亚低温治疗效果临床采用亚低温治疗重型颅脑损伤通常将温度控制在32～ 35℃。在这种体温范围内 ,机体各器官功能正常 ,无严重并发症。大量的动物实验和临床应用的研究结果表明 ,亚低温治疗对颅脑损伤具有肯定的治疗效…     

亚低温疗法在重型颅脑损伤的临床应用及护理

目的 探讨亚低温疗法在重型颅脑损伤的临床应用疗效观察和有效的护理方法。方法应用北京康诺技术发展公司生产的“KN01康诺降温毯”作亚低温治疗技术，对30例重型颅脑损伤患者早期实施亚低温疗法，配合有效的护理方法。结果重型颅脑损伤患者应用亚低温疗法配合有效的护理方法能明显提高抢救成功率、治疗效果及预后水平，提高患者的生存质量和良好的社会适应能力。减轻重型颅脑损伤患者的神经功能缺损，降低死亡率和残障率，不产生任何严重并发症。结论重型颅脑损伤患者早期应用亚低温疗法配合有效的护理方法疗效显著，既安全又有效且无严重并发症发生，临床切实可行。     

亚低温治疗重型颅脑损伤病人常见并发症的监护

目的 探讨亚低温治疗重型颅脑损伤病人常见并发症及其监护措施。方法 对25例重型颅脑损伤病人入院后或急诊手术后立即采用半导体降温毯行亚低温治疗,温度设定为33～35℃,同时微量泵输入冬眠合剂,给予呼吸机辅助内呼吸,降温维持2～3日,对其中3例颅内压高达38mmHg以上者降温时间延长至5～8日、复温采用自然复温法。治疗监护常见并发症,如颅内高压、感染、心律失常、电解质紊乱、应激性溃疡、癫痫等。结果 通过对常见并发症的监护,采用预见性护理,降低了重型颅脑损伤病人的病死率(28％)。结论 加强亚低温治疗重型颅脑损伤病人常见并发症的监护,做好预见性护理,是提高亚低温治疗成功率,降低重型颅脑损伤病死率,提高患者生存质量的重要措施之一。     

重型颅脑损伤术后亚低温治疗的早期监护

回顾性分析74例重型颅脑损伤患者术后亚低温治疗过程中的早期监护要点、护理内容及处理方法，通过制定及实施合理的早期监护方案，对生命体征、呼吸功能、意识障碍、消化系统等重点监护及处理，并随时发现病情变化，提供临床及时调整治疗方案，结合常规基础治疗使亚低温对重型颅脑损伤术后的治疗达到最佳效果，有利于病情转归。提高生存率和生活质量，降低死亡率和病残率。     

亚低温治疗重度颅脑损伤的疗效分析

目的：探讨亚低温治疗对重度颅脑损伤的临床疗效。方法：对1999年1月－2000年6月收治的58例重型颅脑损伤患者在常规治疗的基础上采用亚低温治疗，作为治疗组。随机抽取1995年7月－1997年7月期间常规治疗的58例重型颅脑损伤患者，作为对照组，与之比较。并对两组中的原发性脑干损伤的患者的疗效进行对比分析。结果；两组在颅内压，体温，心率，血糖，死亡率等指标方面有显著差异。结论：亚低温能降低重型颅脑损伤患者的死亡率，降低颅内压，抑制伤后早期高血糖，对原发性脑干损伤有明显的治疗效果，可提高生存率。     

The prognostic value of neuron-specific enolase in head trauma patients

In recent years, in addition to neurological examination and neuroradiologic examinations, attempts have been made to assess the severity of post-traumatic brain injury and to obtain an early idea of patient prognosis using biochemical markers with a high degree of brain tissue specificity. One such enzyme is neuron-specific enolase (NSE). This study investigates the correlation between serum NSE levels, Glasgow Coma Score, and prognosis measured by Glasgow Outcome Scores in head trauma patients. This was a prospective study conducted with 80 trauma patients presenting to the Emergency Department. Patients were divided into four groups. The first group consisted of patients with general body trauma, but no head trauma. The second group had minor head trauma. The third group had moderate head trauma, and the fourth group had severe head trauma. The relationship between subjects' admission NSE levels and admission and discharge Glasgow Coma Scores (GCS) and Glasgow Outcome Scores (GOS) 1 month later was examined. A receiver operating characteristic (ROC) analysis was performed using a serum NSE cutoff level of 20.52 ng/mL and a GOS of 3 or less as the definition of poor neurologic outcome. There was a significant difference in the NSE levels between group 1 (general trauma) and group 3 (moderate head trauma). There was also a statistically significant difference in NSE levels between group 1 (general trauma) and group 4 (severe head trauma) (p < 0.05). There was a statistically significant inverse relationship between NSE levels and GOS as determined within groups 3 (moderate) and 4 (severe head trauma) (p < 0.05). When NSE levels were compared with admission GCS, it was found that GCS fell as NSE levels rose. There was no significant correlation between NSE and GCS within groups 3 (moderate) or 4 (severe). There was a statistically significant correlation within group 2 (mild) (p < 0.05). By ROC analysis, serum NSE was 87% sensitive and 82.1% specific in predicting poor neurologic outcome in the study patients. The area under the curve was 0.931. This study shows that initial serum NSE levels in moderate and severe head trauma patients correlate inversely with GOS 1 month later, but only within the moderate and severe head trauma groups. However, serum NSE was 87% sensitive and 82.1% specific in predicting poor neurologic outcome in all of the study patients. This derived cutoff value now needs to be prospectively validated.     

颞肌部分切除术在重型颅脑损伤患者治疗中的应用

目的：探讨去标准外伤大骨瓣减压＋颞肌部分切除术在重型颅脑损伤患者治疗中的应用价值。方法：将2010年1月至2012年10月收治的重型颅脑损伤患者62例随机分成对照组和观察组各31例．观察组采用去标准外伤大骨瓣减压＋颞肌部分切除术治疗,对照组采用去标准外伤大骨瓣减压术治疗,比较两组的疗效。结果：与对照组相比,治疗组术后并发症、病死率、致残率明显下降,术后生活自理能力明显提高,P均〈0．05。结论：去外伤大骨瓣减压＋颞肌部分切除术可提高重型颅脑损伤患者的抢救成功率及治愈率。     

亚低温治疗重型颅脑损伤的应用价值

目的观察亚低温脑保护对救治重型颅脑损伤的效果。方法采用前瞻性研究方法，将40例重型颅脑损伤病人随机分为亚低温组和对照组，各20例。对照组给予控制血压、脱水、营养脑细胞等常规治疗，亚低温组采用33℃～35℃亚低温下给予控制血压、脱水、营养脑细胞等治疗。结果亚低温组20例恢复良好6例（30．00％），死亡6例（30．00％）；对照组恢复良好3例（15．00％），死亡9例（45．00％）。亚低温组疗效明显优于对照组。结论亚低温能显著降低重型颅脑损伤的死亡率，改善颅脑损伤病人神经功能预后。     

Motor vehicle crashes: the association of alcohol consumption with the type and severity of injuries and outcomes

The effect of alcohol ingestion on short-term outcomes for trauma patients is indeterminate. Experimental and clinical reports often conflict. The objective of this study was to investigate the prevalence of positive alcohol screens, the effect of alcohol ingestion on injury patterns, severity, and outcomes in patients who were involved in motor vehicle crashes (MVC). MVC patients aged > 10 years treated in any of the 13 trauma centers in Los Angeles County during the calendar year 2003 were studied. All patients underwent routine alcohol screening on admission. The alcohol negative group ("no ETOH") had a blood alcohol level (BAL) of < or = 0.005 g/dL. Low and high alcohol groups ("low ETOH" and "high ETOH") had a BAL of > 0.005 g/dL to < 0.08 g/dL and > or = 0.08 g/dL, respectively. Logistic regression was performed to compare injury severity, complications, survival, and length of hospital stay among the three groups. Of the 3025 patients studied, 2013 (67%) were in the no ETOH group, 216 (7%) were in the low ETOH group, and 796 (26%) were in the high ETOH group. Levels were not associated with injury severity, Emergency Department hypotension, or Intensive Care Unit length of stay. Patients with an injury severity score > 15 and a high BAL had a higher incidence of severe head trauma (head abbreviated injury score > 3) and increased incidence of sepsis. However, in this group of severely injured, the high ETOH group had a significantly better survival rate than patients in the no ETOH group (adjusted odds ratio 0.41, 95% confidence interval 0.16-0.94, p = 0.05). Severely injured MVC victims with a high BAL have a higher incidence of severe head trauma and septic complications than no ETOH patients. However, the high ETOH group had superior adjusted survival rates.     

Admission hypothermia and outcome after major trauma

OBJECTIVE: Uncontrolled exposure hypothermia is believed to be deleterious in the setting of major trauma. Prevention of hypothermia in the injured patient is currently practiced in both prehospital and in-hospital settings. However, this standard is based on studies of limited patient series that were not designed to identify the independent relationship between hypothermia and mortality. Recent studies suggest that therapeutically applied hypothermia may benefit selected patient subsets. The goal of this study was to evaluate the independent association between admission hypothermia and mortality after major trauma, with adjustment for clinical confounders. DESIGN: Retrospective analysis of a statewide trauma registry. The primary outcome was death at hospital discharge. The key exposure was hypothermia, defined as body temperature /=16 yrs of age for the years 2000-2002. Transferred patients were excluded. Patients were excluded if temperature or route of temperature measurement was not known. Both the full cohort and a subset with isolated severe head injury were evaluated. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 38,520 patients, 1,921 (5.0%) were hypothermic at admission. Admission hypothermia was independently associated with increased odds of death in both the full cohort (odds ratio, 3.03; 95% confidence interval, 2.62-3.51) and the subset with isolated severe head injury (2.21; 1.62-3.03), with adjustment for age, severity and mechanism of injury, and route of temperature measurement. CONCLUSIONS: Admission hypothermia is independently associated with increased adjusted odds of death after major trauma. The increase in mortality is not completely attributable to physiologic presentation or injury pattern or severity.     

Effects of therapeutic hypothermia on intracranial pressure and outcome in patients with severe head injury

OBJECTIVE: Therapeutic hypothermia may improve outcome in patients with severe head injury, but clinical studies have produced conflicting results. We hypothesised that the severe side effects of artificial cooling might have masked the positive effects in earlier studies, and we treated a large group of patients with severe head injury with hypothermia using a strict protocol to prevent the occurrence of cooling-induced side effects. DESIGN: Prospective clinical trial. SETTING: University teaching hospital. PATIENTS: Hundred thirty-six consecutive patients admitted to our hospital with severe head injury (Glasgow Coma Scale (GCS) < or =8). MEASUREMENTS AND RESULTS: Patients included are the 136 patients with a GCS of 8 or less on admission in whom intracranial pressure (ICP) remained above 20 mmHg in spite of therapy according to a step-up protocol. Those who responded to the last step of our protocol (barbiturate coma) constituted the control group (n=72). Those who did not respond to barbiturate coma (n=64) were treated with moderate hypothermia (32-34 degrees C). Average APACHE II scores were higher (28.9+/-14.4 vs 25.2+/-12.1, p<0.01) and average GCS at admission slightly lower (5.37+/-1.8 vs 5.9+/-2.1, p<0.05) in the hypothermia group, indicating greater severity of illness and more severe neurological injury. Predicted mortality was 86% for the hypothermia group versus 80% in controls (p<0.01). Actual mortality rates were significantly lower: 62% versus 72%; the difference in mortality between hypothermic patients and controls was significant (p<0.05). The number of patients with good neurological outcome was also higher in the hypothermia group: 15.7% versus 9.7% for hypothermic patients versus controls, respectively (p<0.02). These differences were explained almost entirely by the subgroup of patients with GCS of 5 or 6 at admission (mortality 52% vs 76%, p<0.01; good neurological outcome 29% vs 8%, p<0.01). CONCLUSIONS: Artificial cooling can significantly improve survival and neurological outcome in patients with severe head injury when used in a protocol with great attention to the prevention of side effects. Because there is likely to have been bias against the hypothermia group in this study, the positive effects of hypothermia might even have been underestimated. In addition, our results confirm the value of therapeutic hypothermia in treating refractory intracranial hypertension.     

益生菌对重型颅脑伤大鼠肠道菌群、消化酶及肠动力的影响

目的 探讨益生菌对重型颅脑伤大鼠肠道菌群、肠消化酶及小肠推进率的影响.方法 建立重型颅脑损伤大鼠模型.将SD大鼠随机分为A肠内营养组(三九全营素)、B益生菌组(三九全营素+益生菌)、C假手术组(正常饮食),于创伤后第3、7、14天留取肠黏膜、粪便标本,检测肠道消化酶、肠道菌群及小肠推进率的变化.结果 A组、B组同C组相比,乳杆菌、双歧杆菌的含量在创伤后2周内明显降低,而大肠杆菌数量则显著增加.A组同B组相比,双歧杆菌的数量在创伤后各时相点偏低,而大肠杆菌的水平则较高.A、B组的乳杆菌含量在创伤后7 d已无差异.2组致伤大鼠小肠二糖酶、Na+-K+-ATP酶的水平在创伤后2周内与假手术组相比显著降低,虽然B组的消化酶含量在各时相点均高于A组,但2组间无差异.同C组相比,A、B组的小肠推进率在颅脑损伤后2周内明显降低,但2组之间无差异.结论 益生菌可以改善重型颅脑伤后肠道的菌群紊乱,调节肠消化酶的活性,从而减轻小肠的吸收障碍.     

益生菌对重型颅脑伤大鼠肠道菌群、消化酶及肠动力的影响

目的探讨益生菌对重型颅脑伤大鼠肠道菌群、肠消化酶及小肠推进率的影响。方法建立重型颅脑损伤大鼠模型，将SD大鼠随机分为A肠内营养组（三九全营素）、B益生菌组（三九全营素＋益生菌）、C假手术组（正常饮食），于创伤后第3、7、14天留取肠黏膜、粪便标本，检测肠道消化酶、肠道菌群及小肠推进率的变化。结果A组、B组同C组相比，乳杆菌、双歧杆菌的含量在创伤后2周内明显降低，而大肠杆菌数量则显著增加。A组同B组相比，双歧杆菌的数量在创伤后各时相点偏低，而大肠杆菌的水平则较高。A、B组的乳杆菌含量在创伤后7d已无差异。2组致伤大鼠小肠二糖酶、Na^＋-K^＋-ATP酶的水平在创伤后2周内与假手术组相比显著降低，虽然B组的消化酶含量在各时相点均高于A组，但2组间无差异。同C组相比，A、B组的小肠推进率在颅脑损伤后2周内明显降低，但2组之间无差异。结论益生菌町以改善重型颅脑伤后肠道的菌群紊乱，调节肠消化酶的活性，从而减轻小肠的吸收障碍。     

创伤患者单核细胞人类白细胞抗原DR的表达及其对感染并发症的预测价值

目的 探讨创伤患者单核细胞人类白细胞抗原DR(HLA-DR)抗原分子的表达变化规律，及其对伤后感染并发症的预测价值。方法 应用流式细胞仪连续监测54例创伤患者伤后单核细胞HLA-DR抗原分子的表达，并根据创伤严重程度分组进行分析。另对34例严重创伤患者，根据其感染发生与否及严重程度分组进行分析。结果 创伤患者伤后单核细胞表达HLA-DR的阳性细胞率和平均荧光强度均出现降低，以伤后2d达到低谷，之后逐渐恢复；与健康对照相比，中度和重度创伤患者单核细胞HLA-DR抗原分子出现明显的低表达；轻度创伤患者与健康对照相比，重度与中度创伤患者相比，HLA-DR的表达变化均无明显的差异。另外，严重创伤患者单核细胞HLA-DR的表达变化与感染并发症发生与否及严重程度有明显的相关性；非感染患者伤后2d单核细胞HLA-DR的表达降到最低，随后逐渐恢复正常；局部感染患者伤后前4d单核细胞HLA-DR的表达明显低于非感染患者，6d后逐渐恢复正常；并发全身感染患者，伤后单核细胞HLA-DR的表达阳性细胞率于伤后1～14d，平均荧光强度于伤后2～14d均明显低于局部感染患者。死亡的2例患者，单核细胞HLA-DR的表达持续低下直至死亡。结论 严重创伤患者单核细胞HLA-DR分子表达量明显降低，且HLA-DR的表达变化与患者感染并发症的发生、发展及预后有明显的关系。     

Hypomagnesemia and hypophosphatemia at admission in patients with severe head injury

OBJECTIVE: Low serum levels of electrolytes such as magnesium (Mg), potassium (K), calcium (Ca), and phosphate (P) can lead to a number of clinical problems in intensive care unit (ICU) patients, including hypertension, coronary vasoconstriction, disturbances in heart rhythm, and muscle weakness. Loss of these electrolytes can be caused, among other things, by increased urinary excretion. Cerebral injury can lead to polyuresis through a variety of mechanisms. We hypothesized that patients with cranial trauma might be at risk for electrolyte loss through increased diuresis. The objective of this study was to assess levels of Mg, P, and K at admission in patients with severe head injury. DESIGN: We measured plasma levels of Mg, P, K, Ca, and sodium at admission in 18 consecutive patients with severe head injury admitted to our ICU (group 1). As controls, we used 19 trauma patients with two or more bone fractures but no significant cranial trauma (group 2). SETTING: University teaching hospital. PATIENTS: Eighteen patients with severe head injury admitted to our surgical ICU (group 1) and 19 controls (trauma patients with no significant cranial trauma; group 2). MAIN RESULTS: Electrolyte levels at admission (group 1 vs. group 2; mean +/- SD, units: mmol/L) were as follows. Mg, 0.57 +/- 0.17 (range, 0.24-0.85) vs. 0.88 +/- 0.21 (range, 0.66-1.42 mmol/L; p < .01). P, 0.56 +/- 0.15 (range, 0.20-0.92) vs. 1.11 +/- 0.15 (range, 0.88-1.44 mmol/L; p < .01). K, 3.54 +/- 0.59 (range, 2.4-4.8) vs. 4.07 +/- 0.45 (range, 3.6-4.8 mmol/L; p < .02). Ca, 2.02 +/- 0.24 (range, 1.45-2.51) vs. 2.14 +/- 0.20 (range, 1.88-2.46; p = NS). In group 1, 12/18 patients had Mg levels <0.70 mmol/L vs. 2/19 patients in group 2 (p < .01); in group 1, 11/18 patients had P levels below 0.60 mmol vs. 0/19 patients in group 2 (p < .01). Moderate hypokalemia (K levels, <3.6 mmol/L) was present in 8/18 patients in group 1 vs. 1/19 patients in group 2 (p < .01). Severe hypokalemia (K levels, < or =3.0) was present in 4/18 patients in group 1 vs. 0/19 patients in group 2 (p < .05). CONCLUSION: We conclude that patients with severe head injury are at high risk for the development of hypomagnesemia, hypophosphatemia, and hypokalemia. One of the causes of low electrolyte levels in these patients may be an increase in the urinary loss of various electrolytes caused by neurologic trauma. Mannitol administration may be a contributing factor. Intensivists should be aware of this potential problem. If necessary, adequate supplementation of Mg, P, K, and Ca should be initiated promptly.