重度颅脑外伤患者强化胰岛素治疗效果及其预后分析

目的探讨强化胰岛素治疗对重度颅脑外伤患者的效果及其预后。方法将重度颅脑外伤患者49例随机分成强化胰岛素治疗组25例和传统胰岛素治疗组24例;除胰岛素应用存在差别,其余疗法均相同。研究分析术后感染、院内病死率以及随访6个月后GCS评分情况等。结果两组患者在感染、随访6个月时GOS评分及重症监护时间方面的差异具有统计学意义(P0.05);两组数据相比,差异有统计学意义(P0.01);两组在其他方面(诸如病死率、低血糖等)的数据比较均无统计学意义(P0.01)。结论结论强化胰岛素治疗可减少患者感染、重症监护室入住时间及提升神经功能恢复,提高重症颅脑损伤患者预后水平。     

腰椎穿刺脑脊液置换术对颅脑损伤伴蛛网膜下腔出血治疗经验

【摘要】〓目的〓总结腰椎穿刺脑脊液置换术对重型颅脑损伤伴蛛网膜下腔出血的治疗体会。方法〓选取2012年1月~2014年3月间55例重型颅脑损伤伴蛛网膜下腔出血患者接受腰椎穿刺脑脊液置换术作为研究组,另选择同期接受常规救治的该类患者作为对照。对比两组血性脑脊液的清除时间、并发症发生率及临床疗效。结果〓研究组血性脑脊液的清除时间为8.13±1.25 d,对照组为 9.37±1.49 d(P<0.05);研究组脑梗死、脑积水、癫痫发生率分别为0、1.82%、3.64%。对照组分别为9.09%、12.73%、14.55%(P<0.05);研究组患者GOS评定良好率为52.73%,对照组为25.45%(P<0.01);研究组疗效GOS评定重残率、植物生存率及死亡率分别为14.55%、1.82%、0,对照组分别为30.91%、14.55%、7.27%(P<0.05)。结论〓腰椎穿刺脑脊液置换术治疗重型颅脑损伤伴蛛网膜下腔出血可加快血性脑脊液的清除,并降低并发症发生率,同时还能有效的改善预后,临床疗效满意。     

2型糖尿病患者胆道术后的胰岛素强化治疗

目的：探讨胰岛素强化治疗对2型糖尿病患者胆道术后的临床疗效。方法：72例胆道术后合并2型糖尿病患者随机分为强化治疗组和对照组各36例。强化治疗组给予强化胰岛素治疗,使血糖控制在4.4～6.1mmol/L;对照组给予常规胰岛素治疗,使血糖控制在10.0～11.1mmol/L。比较两组空腹血糖（FBG）、炎性指标及预后等。结果：强化治疗组FBG、体温、WBC明显低于对照组,抗生素使用天数、院内感染发生率、重症监护天数及术后并发症明显少于对照组,但低血糖发生率显著高于对照组,差异有统计学意义（P〈0.05）。结论：糖尿病患者胆道术后强化胰岛素治疗,可降低炎性反应,并减少抗生素用量及重症监护天数,降低术后并发症,但低血糖发生率较高。     

重型颅脑损伤并发高血糖救治分析及临床对比研究

目的对比观察控制血糖对重型颅脑损伤并发高血糖患者预后的影响。方法共收治重型颅脑损伤并发高血糖患者126例,分为2组:常规对照组(A)71例;运用胰岛素等治疗组(B)55例。结果重型颅脑损伤治疗组较对照组预后明显提高,特重型颅脑损伤2组病例的疗效无明显差异,2组病死率无明显差异。结论重型颅脑损伤并发高血糖患者控制血糖后恢复良好率提高,致残率下降,对特重型组及降低病死率方面,目前还不能认为有明确治疗效果,尚待进一步研究。     

亚低温治疗重型颅脑损伤的临床体会

目的 探讨亚低温脑保护疗法对救治重型颅脑损伤的疗效。方法 将132例重型颅脑损伤随机平均分为治疗组与对照组，进行对比分析，并且前瞻性分析两组疗效。结果 治疗组66例患者，存活率为77．3％，恢复良好率54．5％（36／66），病死率18．2％（12／66）。疗效明显优于对照组，未发生相关的并发症。结论 亚低温治疗能显著降低重型颅脑损伤患者的死亡率，改善颅脑损伤患者神经功能预后，并具有安全、显著降低病死率及癫痫发生率等优点。     

早期肠内营养支持对重型颅脑损伤患者的临床研究

目的研究重型颅脑损伤患者实施早期肠内营养支持的临床效果。方法选择2018年7月至2019年6月本院收治的重型颅脑损伤60例患者,根据时间先后分为对照组与实验组,各为30例。其中对照组采用肠外营养支持,实验组采用早期肠内营养支持,对比2组患者治疗前后营养指标、血清免疫指标、预后指标及并发症情况。结果①实验组白蛋白、总蛋白、血红蛋白高于对照组。②实验组免疫球蛋白G、免疫球蛋白A、免疫球蛋白M高于对照组,免疫球蛋白E水平较低,与正常值比较更接近正常标准。实验组治疗7天后、治疗15天后格拉斯哥昏迷指数高于对照组。③实验组腹泻、消化系统出血、泌尿系感染、肺部感染并发症发生比例(7.14%)低于对照组(32.14%)。结论重型颅脑损伤患者通过早期肠内营养支持效果确切,患者营养指标得以显著提升,且有助于其免疫系统功能恢复,并发症发生率较低,患者预后效果显著。     

经颅多普勒超声检查对重型颅脑损伤预后的判断价值

【摘要】〓目的〓探讨经颅多普勒超声检查(TCD)对重型颅脑损伤患者预后的判断价值。方法〓以2013 年2月至2014年10月在我院进行治疗的62例重型颅脑损伤患者作为病例组,并收集患者受伤后(术后)第1、3、7、14、21 d大脑中动脉的血流数据,以大脑中动脉收缩期血流速度(Vs)、舒张期血流速度(Vd)、博动指数(PI)作为观察指标;将同时期在我院接受TCD检查的健康44名对象作为对照组;将两组数据进行对比。结果〓患者受伤后(术后)第1 d脑血流速度即可发生改变;Vs和Vd值在第7 d降至最低,随后逐级恢复;PI指标则与脑血流速度变化趋势相反;第7 d的Vs是颅脑损伤的一个保护性因素。结论〓通过TCD检测的脑血流速度能反映重型颅脑损伤患者的颅内压力变化及预后情况,对颅脑损伤的治疗具有指导价值。     

早期使用胰岛素泵治疗重型颅脑损伤高血糖反应对患者预后的影响

目的观察早期使用胰岛素泵治疗重型颅脑损伤高血糖反应对患者预后的影响。方法测定重型颅脑损伤患者入院时的血糖，随机分成胰岛素泵治疗组和常规胰岛素强化治疗组，观察1个月后的疗效。结果重型颅脑损伤后血糖水平显著升高，其与格拉斯哥昏迷记分（GCS），预后差异有高度统计学意义（P〈0．01），胰岛素泵治疗组预后与对照组相比差异有高度统计学意义（P〈0．01）。结论测定血糖有助于了解颅脑损伤的严重程度，估计患者的预后，用胰岛素泵治疗重型颅脑损伤高血糖反应能改善患者预后。     

盐酸氨溴索对控制重型颅脑损伤患者肺部感染的临床研究

目的探讨盐酸氨溴索对控制重型颅脑损伤患者肺部感染的作用.方法选取GCS3～8分颅脑损伤患者60例,随机分两组,其中30例(治疗组)加用盐酸氨溴索治疗,另30例(对照组)未予盐酸氨溴索.所有患者其他治疗措施均基本相同.结果治疗组肺部感染发生率及死亡率明显低于对照组(P( )0.05).结论盐酸氨溴索对控制重型颅脑损伤患者肺部感染有较好的临床疗效,值得临床推广应用.     

早期应用纳洛酮对重型颅脑损伤患者内皮素及神经功能的影响

目的 探讨早期应用纳洛酮对重型颅脑损伤患者内皮素及神经功能的影响及意义。方法 采用按随机配对实验法，将82例重型颅脑损伤患者分为纳洛酮治疗组和对照组，在伤后不同时间予GCS评分、血ET测定、运动功能积分、及GOS预后评定。结果 纳洛酮治疗组的各项指标均较对照组明显改善，两组差异有显著性（P〈0.05）。结论 早期应用纳洛酮治疗重型颅脑损伤，具有改善脑血流、脑代谢，保护脑细胞，改善脑干的缺血缺氧状态，从而利于神经功能恢复，并明显改善预后。     

Intensive insulin therapy in brain injury: a meta-analysis

Many studies have addressed the question of whether intensive insulin therapy (IIT) provides better outcomes for brain-injured patients than does conventional insulin therapy (CIT), with conflicting results. We performed a systematic review and meta-analysis of the literature to estimate the effect of IIT on patients with brain injury. We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and citations of key articles and selected "all randomized controlled trials" (RCTs) comparing the effect of IIT to CIT among adult patients with acute brain injury (traumatic brain injury, stroke, subarachnoid hemorrhage, and encephalitis). Of the 2807 studies, we identified 9 RCTs with a total of 1160 patients for analysis. IIT did not appear to decrease the risk of in-hospital or late mortality (RR=1.04, 95% CI=0.75, 1.43 and RR=1.07, 95%CI=0.91, 1.27 respectively). No significant heterogeneity was found (I(2)=0.0%). IIT also did not have a protective effect on long-term neurological outcomes (LTNO) (RR=1.10, 95% CI=0.96, 1.27). IIT, however, did decrease the rate of infections (RR=0.76, 95% CI=0.58, 0.98). Heterogeneity was present (I(2)=64%), which was eliminated upon sensitivity analysis bringing the RR to 0.66 (95% CI=0.55, 0.80, I(2)=0%). IIT increased the rate of hypoglycemic episodes (RR=1.72, 95% CI=1.20, 2.46) however there was intractable heterogeneity present (I(2)=89%), which did not resolve upon sensitivity analysis. We found no evidence of publication bias by Egger's test (p=0.50). To conclude, IIT has no mortality or LTNO benefit to patients with brain injury, but is beneficial at decreasing infection rates.     

Intensive insulin therapy in mixed medical/surgical intensive care units: benefit versus harm

Intensive insulin therapy (IIT) improves the outcome of prolonged critically ill patients, but concerns remain regarding potential harm and the optimal blood glucose level. These questions were addressed using the pooled dataset of two randomized controlled trials. Independent of parenteral glucose load, IIT reduced mortality from 23.6 to 20.4% in the intention-to-treat group (n = 2,748; P = 0.04) and from 37.9 to 30.1% among long stayers (n = 1,389; P = 0.002), with no difference among short stayers (8.9 vs. 10.4%; n = 1,359; P = 0.4). Compared with blood glucose of 110-150 mg/dl, mortality was higher with blood glucose >150 mg/dl (odds ratio 1.38 [95% CI 1.10-1.75]; P = 0.007) and lower with <110 mg/dl (0.77 [0.61-0.96]; P = 0.02). Only patients with diabetes (n = 407) showed no survival benefit of IIT. Prevention of kidney injury and critical illness polyneuropathy required blood glucose strictly <110 mg/day, but this level carried the highest risk of hypoglycemia. Within 24 h of hypoglycemia, three patients in the conventional and one in the IIT group died (P = 0.0004) without difference in hospital mortality. No new neurological problems occurred in survivors who experienced hypoglycemia in intensive care units (ICUs). We conclude that IIT reduces mortality of all medical/surgical ICU patients, except those with a prior history of diabetes, and does not cause harm. A blood glucose target <110 mg/day was most effective but also carried the highest risk of hypoglycemia.     

Tight perioperative glycemic control using an artificial endocrine pancreas

Van den Berghe et al. reported in 2001 that tight glycemic control (maintaining blood glucose levels at 80–110 mg/dl) improved morbidity and mortality in the surgical intensive care unit. This method was termed intensive insulin therapy (IIT), and it is now being adopted worldwide for perioperative care. Recent evidence has suggested that perioperative hyperglycemia significantly contributes to the development of postoperative infection (POI). Many professional societies therefore now recommend IIT over conventional standard glycemic control measures for critically ill adult patients to minimize infectious complications. However, IIT carries a risk of inducing hypoglycemia, which is linked to serious neurological events. We recently demonstrated that achieving perioperative tight glycemic control using an artificial endocrine pancreas for surgical patients was a safe and effective method for decreasing the incidence of POI without increasing the risk of hypoglycemia. We herein review the benefits and requirements of tight glycemic control in surgery, with a focus on infection control. Strict perioperative glycemic control using a closed-loop artificial endocrine pancreas system is recommended for safe and effective performance of IIT.     

Progressive artificial endocrine pancreas: The era of novel perioperative blood glucose control for surgery

Strict glycemic control needs to be maintained in critically ill surgical patients to reduce the mortality and morbidity due to hyperglycemia and associated infection. However, conventional intensive insulin therapy (IIT), which consists of intermittent blood glucose measurement and manually controlled infusions of insulin, tends to induce hypoglycemia and glucose variability. Many randomized clinical trials have been conducted to improve the efficacy of IIT, although some of these were stopped owing to frequent hypoglycemia. In pursuing safe and strict glycemic control for critically ill surgical patients, we found that a closed-loop glycemic control system was able to maintain appropriate blood glucose levels without hypoglycemia in more than 400 clinical cases. Considering the need for the perioperative and intensive care environment, a well-established artificial pancreas was modified into a new closed-loop glycemic control system, called the progressive artificial pancreas. The new device is slim in shape and shows clinical compatibility with the conventional artificial pancreas. We herein review this new closed-loop glycemic control system and the expectations for its future application in critically ill surgical patients.     

替代剂量的甲泼尼龙治疗急性中重型颅脑创伤后肾上腺皮质功能减低的应用

目的研究急性重型颅脑创伤病人中替代剂量地使用甲泼尼龙（methvlprednisn10ne）联合甘露醇能否改善患者预后状况。方法将74位：急性中重型颅脑外伤病人随机均分成A（GCS=7．57±2．97）、B（GCS=7．81±2,85）两组,然后按照GCS标准再将每组颅脑外伤病人按病情轻重分为中．重型两个亚组（即A1（中型颅脑损伤17人,GCS=10．35±1．13）、A2（重型颅脑损伤20人,GCS=5．20~1．75）、B1（中型颅脑损伤18人,GCS=i0．33-±1．11）、B2（重型颅脑损伤19人,GCS=5．42±1．70））,实验组A组病人在创伤后给予甲泼尼龙（1．0mg·kg。·d。）治疗。对照组B组病人给予同时间同样剂量的安慰剂治疗,疗程均为lO天,其余诊疗经过,如手术及手术方式、营养支持治疗、脱水治疗以及其他用药、护理等情况无明显差异。结果经过治疗,实验组A1亚组病人10天后8例GCS评分≥12分,5例GCS评分9～12分,3例GCS评分3～8分,1例死亡．死亡率5．82％,GCS=11．697±-3．40,与治疗前相比GCS评分未见明显统计学差异（P〉0．05）;实验组A2亚组病人10天后5例GCS评分≥12分,6例GCS评分9～12分,4例GCS评分3～8分,5例死亡,死亡率25．00％,GCS=10．46±3．30,与治疗前GCS相比具有统计学差异（P〈0．01）;对照组B1亚组病人10天后6例GCS评分≥12分,8例GCS评分9～12分。2例GCS评分3～8分,2例死亡,死亡率11．11％,GCS=11．06±2．56,与治疗前GCS相比无统计学差异（p〉0．05）;对照组B2亚组病人10天后2例GCS评分≥12分,5例GCS评分9～12分．6例GCS评分3-8分,7例死亡,死亡率36．84％,GCS=8．15±3．28,与治疗前GCS相比有统计学差异（P〈0．01）;治疗10天后A1组病人与B1组病人GCS评分比较不具有显著统计学差异（P〉0．05）．A2组病人与B2组病人GCS评分比较具有显著统计学差异（P〈0．05）。结论在中型颅脑创伤病人的治疗中使用替代剂量的甲泼尼龙不能显著改善预后,但也不会使病情恶化;而在重型颅脑创伤病人的治疗中使用替代剂量的甲泼尼龙与未使用者相比能显著改善患者预后状况。     

Can we improve neurological outcomes in severe traumatic brain injury?: Something old (early prophylactic hypothermia) and something new (erythropoietin)

Traumatic brain injury is a leading cause of mortality and long-term morbidity, particularly affecting young people. With our best therapies, one half of the patients with severe traumatic brain injury are never capable of living independently. Two interventions, which have real potential to improve neurological outcomes in patients with traumatic brain injury, are (i) very early induction of prophylactic hypothermia and (ii) exogenous erythropoietin therapy. There is substantial experimental evidence, a plausible biological rationale, and supportive clinical evidence from clinical trials to suggest a possible beneficial effect of prophylactic hypothermia and also for exogenous erythropoietin therapy in severe traumatic brain injury. Despite the recent guidelines and publications recommending these interventions, critical care clinicians should be conservative towards implementing these therapies outside clinical trials due to substantial efficacy and safety concerns. Nevertheless the high morbidity and mortality associated with severe traumatic brain injury (TBI) demands that we investigate the safety and efficacy of these promising potential therapies as a matter of urgency.     

胰岛素强化治疗对糖尿病患者腹腔镜阑尾炎术后疗效的影响

目的:总结胰岛素强化治疗(intensive insulin therapy,IIT)对糖尿病患者腹腔镜阑尾炎术后疗效的影响。方法:将47例拟急症行腹腔镜阑尾切除术的糖尿病患者随机分为IIT组(n=24)与传统胰岛素治疗(conventional insulin treatment,CIT)组(n=23)。观察对比两组患者术后发热时间、抗生素使用时间、术后排气时间、住院时间、住院费用及术后并发症发生率。计量资料采用两独立样本t检验,计数资料采用χ2检验。结果:两组患者均未出现低血糖。术后排气时间、住院时间两组相比差异无统计学意义;但IIT组术后发热时间、抗生素使用时间、住院费用及并发症发生率低于CIT组,差异有统计学意义(P<0.05)。结论:IIT可降低糖尿病患者腹腔镜手术后并发症发生率,减轻炎症反应,节约住院费用,具有临床应用价值。     

标准大骨瓣开颅术结合颅内压监测治疗重型颅脑损伤

目的探讨标准大骨瓣开颅术结合颅内压监测治疗重型颅脑损伤的疗效。方法回顾性分析手术治疗重型颅脑损伤患者78例的临床资料,采用标准大骨瓣减压结合颅内压监测治疗38例患者为A组,采用常规骨瓣减压治疗40例患者为B组。比较两组患者术后6个月的临床疗效。结果 A组患者的临床效果好于B组。两组在术后6个月临床疗效方面比较,差异有统计学意义（P〈0.05）。结论标准大骨瓣开颅术结合颅内压监测显著改善重型颅脑损伤患者的预后。     

Effect of dipeptide of glutamine and alanine on severe traumatic brain injury

OBJECTIVE: To determine the effect of dipeptide of glutamine and alanine on patients with severe traumatic brain injury. METHODS: A total of 46 patients (31 males and 15 females, aged 7-68 years, (47+/-9.6) years on average) with severe traumatic brain injury were randomized into two groups: Group G (n=23) and Group C (n=23). The patients in Group G received nutritional remedy with the dipeptide of glutamine and alanine, whereas the patients in Group C received routine nutritional therapy only. GCS changes, the length of stay in the neurosurgical intensive care unit (NICU), the mortality,the count of lymphocytes, related complications including lung infection and hemorrhage of alimentary tracts, etc, were examined and recorded. RESULTS: The fatality rate and the length of stay in NICU in Group G was lower than these in Group C (P larger than 0.05), but no obvious difference was found in GCS changes of the patients between the two groups (P larger than 0.05). The patients with lung infection and alimentary tract hemorrhage in Group G were less than those in Group C (P larger than 0.05). The count of lymphocytes in Group G was more than that in Group C (P larger than 0.05), but no difference was found in other nutritional data. CONCLUSIONS: Dipeptide of glutamine and alanine can increase the resisting stress and anti-infection ability of patients with severe traumatic brain injury, which can also lower the mortality and shorten the NICU stay.