亚低温技术和常温技术对脑功能保护的比较与评估

背景亚低温对缺血性损害的脑细胞有显著的保护作用,对脑复苏后的脑功能是否也具有保护作用?目的比较采用亚低温技术和常温技术评估脑复苏3个月时患者神经功能结局评分与生活自理能力评分的差异.设计随机对照实验.单位南京大学医学院附属鼓楼医院急诊中心.对象选择南京鼓楼医院2002-02/10在急诊抢救室经心肺复苏术抢救的患者16例,均为内科系统病变及中毒患者,在院内突发心跳与呼吸停止而进行心肺复苏术.其中男10例,女6例;年龄27～57岁;根据是否采用亚低温技术,将16例患者随机分为两组常温组与亚低温组,每组8例.方法心肺复苏后亚低温组患者立即采用药物+头部冰帽+电子冰毯方法做降温处理,使其脑部温度控制在32～34℃,维持72 h后复温;常温组患者在室温下对症处理.主要观察指标①两组患者复苏后第3,7天的血氧饱和度,血酸碱度,体温,颅内压,平均动脉压和格拉斯格昏迷评分.②复苏后3个月的格拉斯格神经功能结局评分(功能独立为85～100分,中度残疾为74～84分,严重残疾为10～50分,植物状态为＜10分)和生活自理能力评分(采用Bathel指数进行评价,共10项,每项0～15分不等,满分100分,＜60分为不能自理).结果16例患者均进入结果分析.①第3天时亚低温组平均脑温和颅内压均低于常温组[(33.1±0.26)℃,(37.4±18)℃;15.7 mm Hg,19.1 mm Hg,P=-0.027,0.043].血氧饱和度,血酸碱度,平均动脉压和格拉斯格昏迷评分两组基本接近(P＞0.05).②第7天亚低温组的格拉斯格昏迷评分明显高于常温组[(9.1±1.4),(11.2±1.6)分,P=0.032].③3个月后亚低温组格拉斯哥预后量表评分和Barthel指数明显高于常温组[(12.9±1.75),(9.9±1.9)分;(86±6),(52±12)分,P＜0.05～0.01].结论亚低温对早期脑复苏时的颅内压减低有效,尤其对复苏远期神经功能和日常生活活动能力恢复具有良好效果,具有显著的脑功能保护作用.

Comparison and evaluation of brain-functional protection with mild hypothermia technique and normal temperature technique

BACKGROUND: Mild hypothermia can protect cerebral cell from injury induced by ischemia, however, whether it can protect cerebral function after cerebral resuscitation or not?OBJECTIVE: To investigate the differences between neural functional outcome and living self-care ability of patients after 3-month cerebral resuscitation with mild hypothermia technique compared with normal temperature technique.DESIGN: Randomized control study.SETTING: Emergency Center of Gulou Hospital Affiliated to Medical College of Nanjing University.PARTICIPANTS: Totally 16 patients rescued with cardiopulmonary resuscitation were selected from Gulou Hospital of Nanjing between February and October 2002. All patients had systemic lesion and intoxication, and were treated with cardiopulmonary resuscitation because of heartbeat and respiratory arrest. There were 10 males and 6 females aged 27-57 years.According to the application of mild hypothermia or not, 16 cases were divided randomly into normal temperature group and mild hypothermia group with 8 in each group.METHODS: After cardio-pulmonary resuscitation, patients in mild hypothermia group were treated with medicine + caput ice cap + electronic ice blanket method to reduce the temperature. The temperature of brain was kept at 32 to 34 ℃ for 72 hours. Patients in normal temperature group were treated at the room temperature.MAIN OUTCOME MEASURES: ① Blood-oxygen saturation, blood pH value, intracranial pressure, mean arterial pressure and Glascow Coma Scale of patients were measured on the third and seventh day after resuscitation. ② After 3-month resuscitation, Glascow Coma Scale was followed:85-100 points as functional independency, 74-84 as moderate disability,10-50 as severe disability and ＜ 10 as vegetative slate; meanwhile, living self-care ability was measured with Bathel index of 10 items in total. Every item was scored from 0 to 15 points with 100 in total, and ＜ 60 was determined as unable self-care.RESULTS: Totally 16 patients entered the final analysis. ① On the third day, mean cerebral temperature and intracranial pressure in the mild hypothermia group were lower than those in the normal temperature group [(33.1±0.26)℃, (37.4±18)℃; 15.7 mm Hg, 19.1 mm Hg, P=0.027, 0.043]. The two groups were similar in the Score of blood-oxygen saturation, blood pH value, mean arterial pressure and Glascow Coma Scale (P ＞ 0.05). ② On the seventh day, Glascow Coma Scale in the mild hypothermia group was higher than that in the normal temperature group [(9.1±1.4), (11.2±1.6) points,P=0.032]. ③ After 3 months, Glascow Coma Scale and Barthel index in the mild hypothermia group were higher than those in the normal temperature group [(12.9±1.75), (9.9±1.9) points; (86±6), (52±12) points, P ＜ 0.05-0.01].CONCLUSION: Mild hypothermia can decrease intracranial pressure during the early cerebral resuscitation, is especially effective in the recovery of long-term neural function and activity of daily living, and has remarkable protecting effect on cerebral function.