一頭部外傷病患使用低體溫治療之呼吸照護經驗

Clinical Experience of Traumatic Head Injury Treating with Target Temperature Management

陳宜貞(Yi-Chen Chen) ； 鄭瓊琪(Chiung-Chi Cheng) ； 龔瑞琛(Sui-Sum Kung) ； 王荔雲(Li-Yun Wang) ； 蔡忠榮(Jong-Rung Tsai) ； 許端容(Tuan-Jung Hsu)

《呼吸治療》 11卷1期 (2012/01) Pp. 37-43

https://doi.org/10.6269/JRT.2012.11.1.04

摘要

低溫療法早已行之數年，對於它的療效與相關合併症一直存在許多爭議。2011年美國重症醫學會認為低溫療法（Hypothermia therapy）對重症及頭部外傷病患目前仍無明確之治療效果，因而提出不能使用“therapy＂這字，而是以“目標温度管理策略＂（Target Temperature Management簡稱TTM），來取代原本的＂低溫療法＂用詞。目標温度管理策略的定義是降低患者體溫達到設定目標溫度，可以減緩組織新陳代謝、減少氧氣和葡萄糖需求、抑制發炎反應以及延緩細胞凋亡．．．來達到治療效果；文獻報告中曾指出有些溺到冰冷水中的患者，救活後意識仍可完全清醒。頭部外傷病人會因發燒而提高死亡率。基於上述觀察可推論低體溫對神經有保護效果，高體溫則會提高死亡率。因此臨床上會利用降低病患體溫來治療嚴重頭部外傷與經急救回復生命徵象的到院前已死亡病人。本文個案因嚴重蜘蛛膜下與硬腦膜下出血進而引發嚴重腦水腫意識重度昏迷、生命岌岌可危，雖然經過神經外科醫師緊急手術搶救，顱內壓仍居高不下，為避免腦細胞凋亡、神經受損傷而使用＂目標温度管理策略＂。最後個案意識雖未完全清醒，但昏迷指數（Glasgow ComaScale 簡稱GCS）E1VEM1（E：Eyes；V：Verbal；M：Motor）已進步到E4VTM2，生命徵象穩定且呼吸器脫離成功；因此將照顧經驗寫出，與大家分享這類病人的照顧方式。（呼吸治療2012；11（1）37-43）

關鍵字

目標温度管理策略 ； 低溫療法 ； 呼吸治療 ； 腦部外傷

並列摘要

Hypothermia therapy had been used for decades. However, there are still many controversies about the effects and complications of hypothermia therapy. In 2011, American society of critical care had claimed that ”hypothermia therapy” should not be used anymore because no significant evidences support hypothermia therapy can be used to treat critical ill and head injury patients. Target temperature management (TTM) is the more accurate term. The definition of target temperature management is to lower body temperature to target treatment temperature. Lower the body temperature can decrease the rate of metabolism, the requirement of glucose and oxygen and inhibit the inflammation response and delay the cellular apoptosis. Through these effects, target temperature management can provide therapeutic effect. Previous reports had shown patients who submerged in the cold ice water had better consciousness recovery after resuscitation. Fever can increase the mortality of traumatic head injury patients. These observations provided hypothesis that hypothermia had protective effect for central nervous system. Therefore, clinicians usually treated severe head injury and outside hospital cardiac arrest patients with decreasing body temperature method. We present a case with severe subarachnoid, subdural hemorrhage, brain edema and deep coma due to traffic accident. Although emergency operation is done, the intracranial pressure is still very high. To avoid further brain damage, we treated the patient with target temperature therapy. Fortunately, conscious level（Glasgow Coma Scale）was recovery gradually from E1VEM1 to E4VTM2. Patient became stable and successful weaned from mechanical ventilator after target temperature therapy. We share the experience of target temperature therapy and review the target temperature therapy articles.

並列關鍵字

Target Temperature Management ； Hypothermia therapy ； Respiratory care ； Traumatic Head Injury