急性特重型颅脑损伤救治体会

特重型颅脑伤由于伤情特种、恶变极快，传统治疗的死亡率一直很高，是临床救治的难题。作者2004年12月-2009年12月收治格拉斯哥昏迷评分（GCS）3～5分的特重型颅脑伤106例（观察组），并与前期（2000年6月-2003年12月）收治的69例（对照组）特重型颅脑伤的救治结果进行对比，着重分析了影响预后的因素，提出了一些新的救治经验。     

急性特重型颅脑损伤救治体会

特重型颅脑伤由于伤情特种、恶变极快,传统治疗的死亡率一直很高,是临床救治的难题.作者2004年12月～2009年12月收治格拉斯哥昏迷评分(GCS)3～5分的特重型颅脑伤106例(观察组),并与前期(2000年6月～2003年12月)收治的69例(对照组)特重型颅脑伤的救治结果进行对比,着重分析了影响预后的因素,提出了一些新的救治经验.     

123例颅脑损伤致急性脑疝患者的救治

目的探讨外伤性急性脑疝患者的救治。方法回顾性分析2003年1月到2005年9来本院就诊的123例急诊手术患者的资料,总结救治颅脑损伤所致急性脑疝的术前准备、手术方式及术后管理的最佳方法。结果本组患者抢救成功率为77.2%,恢复正常生活者52.9%,病死率22.8%。结论开通“绿色通道”,争分夺秒做好术前准备,维护好生命体征,尽早手术充分减压,清除血肿,恢复脑疝,消除水肿等是成功救治急性脑疝患者的关键。     

急性颅脑损伤患者凝血功能异常的临床意义

回顾性分析我院2012年3月-2013年5月期间收治的急性颅脑损伤患者78例的临床资料,统计分析入院时凝血酶原时间（PT）、凝血酶时间（TT）、活化部分凝血酶时间（APTT）、纤维蛋白原（Fg）、血小板计数（PLT）、D-二聚体（DD）水平和病情严重程度的关系。结果患者的PT、APTT、DD水平明显高于健康人群的正常水平（P＜0.05）,Fg、PLT明显低于正常水平（P＜0.05）;随着病情进展性加重,PT、TT、APTT、DD水平依次增高,Fg、PLT依次降低（P＜0.05）。急性颅脑损伤患者凝血功能异常程度和病情严重程度密切相关,临床上早期监测患者凝血功能有助于准确判断病情的严重程度,预测预后,制定科学有效的治疗方法,改善患者的预后。     

重型颅脑损伤开颅术中的急性脑膨出

重型颅脑损伤开颅术中出现的急性脑膨出,是临床常遇到的棘手问题。其病因复杂,处理困难,预后较差。我院于1987年5月～1993年8月间共收治83例,占同期脑损伤开颅手术(520例)的16％,现结合临床报告分析如下。     

测定神经降压素含量对急性颅脑损伤患者预后的评价

目的：探讨急性颅脑损伤患者神经降压素含量变化及临床意义。方法：采用放免法动态测定51例急性颅脑损伤患者血浆及脑脊液神经降压素含量，以观察神经降压素水平在颅脑损伤组和正常对照组中的变化。结果：颅脑损伤患者急性期血浆及脑脊液神经降压素含量显著高于对照组，且与病情轻重程度明显相关。结论：神经降压素参与急性颅脑损伤后继发性病理生理损害；血浆或脑脊液神经降压素动态含量，可能成为判断急性颅脑损伤患者预后的重要因素。     

急性颅脑损伤1100例的护理体会

2001年1月-2004年12月，我院收治1100例急性颅脑损伤患。现将护理体会报告如下。     

急性颅脑损伤54例护理体会

目的：探讨急性颅脑损伤患者的护理方法。方法：制订详细的护理措施，争取时间配合医生进行积极抢救，注重急性期的病情观察及护理以及恢复期的康复护理。结果：本组病例治愈39例，好转9例，死亡6例。结论：对急性颅脑损伤患者争取时间积极抢救，严密的病情观察，正确的护理措施，可有效地减少并发症的发生，降低病死率。     

Cerebral blood flow and metabolism in severe brain injury: the role of pressure autoregulation during cerebral perfusion pressure management

Objective: To ascertain if norepinephrine can be used as part of the cerebral perfusion pressure (CPP) management to increase arterial blood pressure (MAP) without causing cerebral hyperemia after severe head injury (HI).¶Design: Prospective, interventional study.¶Setting: Intensive care unit in a university hospital.¶Patients: Twelve severely HI patients; median Glasgow Coma Scale was 6 (range 3–8).¶Interventions: CPP management ( = 70 mmHg). Pressure autoregulation (assessed by norepinephrine infusion) was defined intact if %CPP/%CVR ≤ 2.¶Results: Cerebral blood flow (CBF: Xe¹³³ inhalation technique), jugular bulb oxygen saturation (SjO₂) and transcranial Doppler (TCD) were recorded during the test. Norepinephrine increased CPP by 33 % ( ± 4). Autoregulation was found to be intact in ten patients and defective in two. In the ten patients with preserved autoregulation, CBF decreased from 31 ± 3 to 28 ± 3 ml/100 g/min; in the two patients with impaired autoregulation CBF increased respectively from 16 to 35 and from 21 to 70 ml/100 g/min. SjO₂ did not change significantly from baseline. TCD remained within the normal range.¶Conclusions: During CPP management norepinephrine can be used to increase MAP without potentiating hyperemia if pressure autoregulation is preserved. The assessment of pressure autoregulation should be considered as a guide for arterial pressure-oriented therapy after HI.     

Sustained moderate reductions in arterial CO<Subscript>2</Subscript> after brain trauma Time-course of cerebral blood flow velocity and intracranial pressure

Objective In healthy volunteers cerebral blood flow starts to recover towards baseline within a few minutes of continued hyperventilation due to normalisation of perivascular pH. We investigated the time-course of changes in middle cerebral artery mean flow velocity (FVm) and intracranial pressure (ICP) in head-injured patients during sustained moderate reductions in arterial partial pressure of CO₂ (PaCO₂).Design Observational study.Patients Twenty-seven sedated, mechanically ventilated patients with severe head injury.Interventions Measurements were made during and after routine determination of CO₂-reactivity: an acute 20% increase in respiratory minute volume was followed by a 10-min stabilisation period and 50 min of continued moderate hyperventilation at a constant PaCO₂ (>3.5 kPa).Measurements and results FVm was monitored with transcranial Doppler, ICP was monitored with intraparenchymal probes. During the 50-min period with stable PaCO₂ FVm increased in 36% of patients. All other patients showed a decline in FVm over the same time period. Overall FVm recovery was –0.03±0.14%·min^-1. The time-course of ICP changes was significantly different from that of FVm, with ICP reaching its lowest value earlier than FVm (23±12 vs 37±20 min; P = 0.001) and returning more rapidly towards baseline than FVm (0.23±0.23 vs –0.03±0.14%·min^-1; P< 0.0001).Conclusions Head-injured patients may adapt differently to hyperventilation than healthy volunteers. Potentially harmful reductions in cerebral blood flow may persist beyond the duration of useful ICP reduction.Grant information: L. Steiner was supported by a grant from the Margarete und Walter Lichtenstein-Stiftung (Basel, Switzerland), a Myron B. Laver Grant (Department of Anaesthesia, University of Basel, Switzerland), by the Swiss National Science Foundation, and was recipient of an Overseas Research Student Award (Committee of Vice-Chancellors and Principals of the Universities of the United Kingdom). A. Johnston was recipient of a grant from Codman. J. Coles was a Wellcome Research Training Fellow. This work was further supported by a grant from the Medical Research Council (Grant No. G9439390, ID 56833).     

急性颅脑损伤并外伤性脑梗死18例临床分析

目的 探讨急性颅脑损伤后外伤性脑梗死发病原因、临床特点及治疗结果。方法 对18例急性颅脑损伤后外伤性脑梗死患者,根据梗死面积决定采取保守治疗或手术治疗。结果 出现脑梗死的病人根据梗死面积及颅内压情况决定采取保守治疗或手术治疗。按格拉斯哥预后评分（GOS）判断预后的标准,恢复良好3例,中残6例,重残4例,死亡5例。结论 急性颅脑损伤病人随时可能并发外伤性脑梗死,病死率较高,应该早期预防,早期发现及早期治疗以提高疗效。     

黄芪对急性脑创伤后局部脑皮质血流速度变化的影响

目的:观察脑创伤后黄芪对局部脑皮质血流速度(rCBFV)变化的影响,为黄芪在脑创伤中的应用提供理论依据.方法:以大鼠为实验动物,随机分成正常对照组、盐水对照组和黄芪组;采用改进的Feeney's方法建立颅脑创伤模型,正常对照组5只动物,盐水对照组和黄芪组各35只,均分为创伤后1、3、6、8、12、24和48 h等7个时间点,测定创伤脑组织rCBFV.结果:急性脑创伤早期,rCBFV即呈下降趋势,其中伤后1 h时rCBFV有所下降,伤后24 h时rCBFV下降至最低点,伤后48 h血流速度开始回升.黄芪组各时间点rCBFV下降幅度明显减少,与盐水对照组比较具有统计学意义(P<0.05).结论:黄芪具有明显增加rCBFV的作用,其机制与黄芪的神经血管保护作用有密切关系.     

纳洛酮对急性颅脑损伤治疗作用的临床观察

目的 观察研究纳洛酮对急性颅脑损伤的治疗作用。方法 ①随机将急性颅脑损伤患者分为纳洛酮治疗组（治疗组）和常规治疗组（对照组），各40例。前者在颅脑伤后12h以内，以常规治疗为基础，再给予纳洛酮12－16mg，静脉滴注，24h维持，连续3d后，剂量改为4.8mg，连续7d,10d为一个疗程。②根据GOS评估，观察两组患者病情预后和血浆β-内啡肽不同时间的含量变化。结果 重型颅脑损伤（GCS3－8分）者，治疗组预后好于对照组（P＜0.05）；治疗组用纳洛酮后血浆β－内啡肽均值较对照组下降明显（P＜0.01）。结论 急性颅脑损伤早期应用纳洛酮，可使颅脑伤后的病残程度降低和治疗效果提高。     

急性脑外伤脑水肿脑脊液谷氨酸与GCS,ICP和CPP的相关关系

目的探讨急性脑外伤病人ＣＳＦ中兴奋性氨基酸谷氨酸（Ｇｌｕ）与ＧＣＳ、ＩＣＰ和ＣＰＰ的相关关系。方法用反向高效液相色谱法动态检测每２４小时采集的ＣＳＦ中Ｇｌｕ含量,评估入院时ＧＣＳ,脑室监护法或腰穿测定ＩＣＰ,ＣＰＰ＝ＭＡＢＰ－ＩＣＰ。结果ＧＣＳ≤８分组ＣＳＦ中Ｇｌｕ显著高于ＧＣＳ＞８分组（Ｐ＜０００１）;ＧＣＳ与Ｇｌｕ峰值显著负相关（γｓ＝－０５７０６,Ｐ＜０００１）。ＩＣＰ＞２６７ｋＰａ（２０ｍｍＨｇ）组Ｇｌｕ峰值明显高于ＩＣＰ≤２６７ｋＰａ组（Ｐ＜００５）;ＩＣＰ也与Ｇｌｕ峰值相关（γｓ＝０３２６０,Ｐ＜００５）。低ＣＰＰ组（ＣＰＰ＜８０ｋＰａ）Ｇｌｕ峰值高于正常ＣＰＰ组（Ｐ＜００５）;但ＣＰＰ与Ｃｌｕ峰值间无统计学相关（γｓ＝０２０１９,Ｐ＞０１）。结论脑外伤越重,Ｇｌｕ诱导的兴奋性毒性作用越明显,继发性脑损害脑水肿也越重,导致的ＩＣＰ升高又使ＣＰＰ下降,恶化脑血供,后者又可诱发Ｇｌｕ释放。说明了ＣＳＦ中Ｇｌｕ与ＧＣＳ、ＩＣＰ和ＣＰＰ之间的内在联系。     

硫酸镁治疗急性重型颅脑损伤的疗效分析

目的研究硫酸镁对急性重型颅脑损伤的临床治疗效果。方法51例急性重型颅脑损伤患者随机分为硫酸镁治疗组(n=25)和对照组(n=26),观察临床效果,并对治疗后第7天脑水肿带、第10天GCS、伤后半年COS和死亡率等指标进行统计学分析。结果两组第7天脑水肿带、第10天GCS评分、半年后COS评分比较均有统计学意义(P＜0．05)。结论早期硫酸镁治疗急性重型颅脑损伤能减轻脑水肿、促进清醒及改善预后。     

持续脑电双频指数监测对急性脑损伤患者预后的评估

目的 探讨持续脑电双频指数(BIS)监测对急性脑损伤患者预后的评估作用.方法 采用回顾性研究方法,选择2009年3月至2010年7月重症监护病房(ICU)急性脑损伤昏迷患者61例,根据预后将患者分为生存组(25例)和死亡组(36例).于入ICU 3 d内或停用镇静剂24 h后持续12 h监测BIS,取其均值(BISmean)、记录BIS最大值(BISmax)和最小值(BISmin).记算患者急性生理学与慢性健康状况评分系统Ⅱ(APACHE Ⅱ)评分、存活概率(PS)、格拉斯哥昏迷评分(GCS),并于监测当日取静脉血检测S100蛋白、神经元特异性烯醇化酶(NSE)水平;分析BISmean与GCS评分、$100蛋白、NSE水平的相关性.结果 ①两组患者性别、年龄、机械通气时间无明显差异.死亡组APACHE Ⅱ评分(分)明显高于生存组(27.36±5.99比23.28±6.69),PS明显低于生存组(0.31±0.17比0.49±0.19),住ICU时间(d)明显短于生存组(6.33±4.48比27.88±54.46),P<0.05或P<0.01.②死亡组BISmean、BISmax、BISmin、GCS均明显低于生存组(BISmean:35.45±28.31比55.91±17.53,BISmax:51.92±34.24比74.84±16.58,BISmin:22.39±24.83比39.68±15.72,GCS评分(分):3.64±1.19比5.60±2.22],P<0.05或P<0.01;血清S100蛋白、NSE水平明显高于生存组[S100蛋白(μg/L):7.54±10.49比1.18±1.57,NSE(μg/L):120.74±109.01比49.83±54.94],均P<0.01.③双变量相关分析显示,BISmean与GCS评分呈显著正相关(r=0.379,P=0.003),与S100蛋白、NSE水平呈显著负相关(r1=-0.418,P1=0.001;r2=-0.290,P2=0.023).结论 BIS监测具有无创、直观、易于操作、可连续监测的特点,可以作为判断急性脑损伤患者预后的早期客观指标.

Abstract：

Objective To discuss the effect of continuous monitoring of bispectral index(BIS)on the prognosis of patients with acute brain injury.Methods A retrospective study was carried out,61 patients with acute brain injury admitted to the intensive care unit (ICU) from March 2009 to July 201 0 were divided into survival group (n=25) and death group (n=36).The BIS was continuously monitored for 12 hours within the first 3 days or 24 hours after stoppage of sedative after admission to ICU.The mean value of BIS (BISmean),the maximal value of BIS(BISmax),and the minimal value of BIS(BISmin)were evaluated.At the same time,the acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score,probability of survival (PS) and Glasgow coma score (GCS) were evaluated.The values of serum S100 protein and neuron-specific enolase (NSE) were determined.The relationship between BISmean and GCS,S100 protein and NSE were respectively analyzed.Results ①There was no significant difference in the sex,age,or duration of mechanical ventilation between two groups.APACHE Ⅱ score in death group was significantly higher than the survival group (27.36±5.99 vs.23.28±6.69),PS was significantly lower than the survival group(0.31±0.17 vs.0.49±0.19),and length of stay in ICU (days) was significantly lower than that of the survival group(6.33±4.48 vs.27.88±54.46),P<0.05 or P<0.01.②BISmean,BISmax,BISmin,GCS in death group were significantly lower than those in the survival group (BISmean:35.45±28.31 vs.55.91±17.53,BISmax:51.92±34.24 vs.74.84±1 6.58,BISmin:22.39±24.83 vs.39.68±15.72,GCS score:3.64±1.19 vs.5.60±2.22),P<0.05 or P<0.01,while serum S100 protein and NSE levels were significantly higher than the survival group(S100 protein(μg/L):7.54±10.49 vs.1.18±1.57,NSE (μg/L):120.74±109.01 vs.49.83±54.94],both P<0.01.③By bivariate analysis,BISmean was positively correlated with GCS(r=0.379,P=0.003),whereas it was found to be negatively correlated with S100 protein and NSE levels(r1=-0.418,P1=0.001;r2=-0.290,P2=0.023).Conclusion BIS monitoring can be applied as an early objective indicator to evaluate the prognosis of the acute brain injured patients with the characteristics of being noninvasive,intuitive,easy-to-manipulate,and non-stop monitoring.     

肺表面活性物质联合布地奈德对急性脑损伤并发呼吸窘迫综合征患者脑血流的影响

目的探讨肺表面活性物质(PS)与布地奈德(BUD)联合治疗对急性脑损伤并发呼吸窘迫综合征(ARDS)患者脑血流及肺功能的影响。方法 64例急性脑损伤合并ARDS患者随机分为观察组及对照组,每组32例。2组患者均行机械通气辅助治疗,对照组在入ICU后30~60 min内给予70 mg/kg的肺表面活性物质,观察组在对照组基础上给予0.25 mg/kg布地奈德联合治疗。比较2组治疗前,治疗后1、3、5、7 d患者搏动指数(PI)、平均血流速度(Vm)、血流阻力指数(RI)、收缩期峰值流速(Vs)、舒张末期血流速度(Vd)。记录2组患者潮气量(VT)、胸肺总顺应性(Crs)、连续呼吸阻力(Raw)。观察2组患者死亡率、脑室周围白质软化(PVL)、脑室周围-脑室内出血(PVH-IVH)发生率。结果观察组治疗3、5、7 d的PI、Vm、RI、Vs、Vd值显著高于对照组(P0.05)。观察组治疗3、5、7 d的VT、Crs显著高于对照组,而Raw显著低于对照组(P0.05)。观察组死亡率、PVL、PVH-IVH发生率显著低于对照组,机械通气时间显著短于对照组(P0.05)。结论 PS联合BUD能有效改善急性脑损伤并发ARDS患者脑血流及肺功能,降低脑损伤发生率,降低患者死亡率。