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背景:亚低温对重型颅脑损伤患者的治疗作用已被人们所认识,但其机制尚需进一步证实。目前对于重型颅脑损伤后及亚低温治疗过程中脑组织氧代谢状态的改变,尚未见到相应报道。目的:观察重型颅脑损伤患者亚低温治疗过程中的脑氧代谢变化规律, 揭示亚低温治疗的作用。设计:以患者为观察对象的析因设计。单位:天津市环湖医院亚低温治疗中心。对象:选择1998-08／2000-01在天津市环湖医院亚低温治疗中心就诊的重型颅脑损伤患者13例。男11例,女2例;年龄18-65岁。脑挫裂伤并硬膜下血肿6例,硬膜外血肿1例,蛛网膜下腔出血4例,弥漫性轴索损伤2例;保守治疗7例,手术清除血肿同时行内／外减压术6例。方法:所有患者在亚低温治疗室内应用体温调节毯进行全身降温,同时给予冬眠肌松合剂(生理盐水500 mL+氯丙嗪100 mg+异丙嗪100 mg+ 卡肌宁400 mg)持续静滴。采用Neurotrend-7TM多参数监测系统持续监测脑组织氧分压、二氧化碳分压、pH值及脑温,比较治疗前后指标的变化。并对患者脑氧代谢与格拉斯哥昏迷量表(总分15分,正常为15分, 分数越低意识障碍程度越深)及格拉斯哥预后评分进行相关性分析。主要观察指标:持续监测脑组织氧分压、二氧化碳分压、pH值及脑温。结果:13例患者均进入结果分析。①脑氧代谢的变化趋势:氧分压亚低温后18 h明显高于降温前[(2．23±1．29,1．29±0．57)kPa,t=2．449,P<0．05]。二氧化碳分压亚低温后6 h明显低于降温前[(7．32±0．92,7．75+1．07)kPa, t=2．446,P<0．05]。pH值达低温时明显高于降温前[(7．06±0．15,6．83±0．20), t=5．164,P<0．05]。颅内压达低温时明显低于降温前[(2．03±1．01, 2．57±0．93)kPa,t=2．948,P<0．05]。脑灌注压亚低温后6 h明显高于降温前[(9．40±1．80,7．80±1．59)kPa,t=2．365,P<0．05]。②重型颅脑损伤患者脑氧代谢与格拉斯哥预后评分的相关关系:二氧化碳分压在低温24 h时的数值与格拉斯哥预后评分呈负相关(r=-0．699,P<0．05)。治疗前后脑氧代谢指标的变化与格拉斯哥预后评分呈正相关。结论:脑氧代谢持续监测安全、有效,有利于早期发现重型颅脑损伤后脑组织缺氧及酸中毒。亚低温治疗能有效缓解重型颅脑损伤后的脑组织缺氧及酸中毒,从而改善患者预后。
BACKGROUND: The therapeutic effect of mild hypothermia on patients with severe traumatic brain injury has been recognized, but the mechanism needs to be further confirmed. At present, there is no corresponding report about the change of oxygen metabolism state in brain tissue after severe craniocerebral injury and mild hypothermia. Objective: To observe the changes of cerebral oxygen metabolism during mild hypothermia in patients with severe craniocerebral injury and to reveal the effect of mild hypothermia. Design: Factorial design with patient as object of observation. Unit: Tianjin Huanhu Hospital hypothermia treatment center. PARTICIPANTS: Thirteen patients with severe traumatic brain injury who were treated in the mild hypothermia treatment center of Tianjin Huanhu Hospital from August 1998 to January 2000 were selected. 11 males and 2 females; aged 18-65 years old. Cerebral contusion and subdural hematoma in 6 cases, 1 case of epidural hematoma, 4 cases of subarachnoid hemorrhage, diffuse axonal injury in 2 cases; conservative treatment of 7 cases, surgical removal of hematoma while undergoing internal / external decompression 6 cases. Methods: All patients in the mild hypothermia treatment room thermostat blanket body cooling, while giving hibernating muscle relaxant (saline 500 mL + chlorpromazine 100 mg + promethazine 100 mg + card muscle Ning 400 mg) intravenous infusion. The Neurotrend-7TM multi-parameter monitoring system was used to continuously monitor changes of oxygen partial pressure, carbon dioxide partial pressure, pH value and brain temperature in brain tissue. The changes of indexes before and after treatment were compared. The correlation between brain oxygen metabolism and Glasgow coma scale (15 points in total, 15 points in normal, the lower the level of consciousness disorder) and Glasgow prognostic score were analyzed. MAIN OUTCOME MEASURES: Continuous monitoring of brain oxygen tension, carbon dioxide partial pressure, pH and brain temperature. Results: All 13 patients entered the result analysis. ①The trend of cerebral oxygen metabolism: The oxygen partial pressure was significantly higher at 18 h after mild hypothermia than before [(2.23 ± 1.29, 1.29 ± 0.57) kPa, t = 2.449, P <0 .05]. Carbon dioxide partial pressure 6 h after mild hypothermia was significantly lower than before [(7.32 ± 0.92,7.75 + 1.07) kPa, t = 2.446, P <0.05]. The pH value at low temperature was significantly higher than before [(7.06 ± 0.15,6.83 ± 0.20), t = 5.164, P <0.05]. Intracranial pressure was significantly lower than that before hypothermia [(2.03 ± 1.01, 2.57 ± 0.93) kPa, t = 2.948, P <0.05]. Six hours after hypothermia, the cerebral perfusion pressure was significantly higher than that before hypothermia [(9.40 ± 1.80, 7.80 ± 1.59) kPa, t = 2.365, P <0.05]. ② The relationship between cerebral oxygen metabolism and Glasgow prognostic score in patients with severe craniocerebral injury: There was a negative correlation between the partial pressure of carbon dioxide at 24 h and the Glasgow prognostic score (r = -0.699, P <0.05). The change of cerebral oxygen metabolism index before and after treatment was positively correlated with the Glasgow prognostic score. Conclusion: Continuous monitoring of cerebral oxygen metabolism is safe and effective, which is beneficial to the early detection of hypoxia and acidosis after severe craniocerebral injury. Mild hypothermia treatment can effectively alleviate the brain tissue hypoxia and acidosis after severe craniocerebral injury, thereby improving the prognosis of patients.