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Cerebral Perfusion Pressure Guided Management in Severe Head Injury: Analysis of 24 Cases

以腦灌流壓為導向治療嚴重顱腦損傷之24個病例分析

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摘要


由 2001 年五月至 2002 年十一月,共有 24 位(15男及8女,平均年齡38±11.7 歲),昏迷指數小於或等於七,住入奇美醫院加護病房。他們均接受顱骨切除減壓清除血塊手術,術後並採用以大腦灌流壓為導向的治療方法,給予擴張血管內容積之輸液 ( hydroxyethyl starch , albumin)、血管增壓劑(norepi - nephrine , dopamin)、鎮定劑( Propofol )、肌肉鬆弛劑(tracrium besylate)、輕微過度換氣及甘露醇;以維持大腦灌流壓至少在 70 毫米汞柱,平均動脈壓平均維持在 97.1±11.3 毫米汞柱,顱內壓平均維持在 21.7±7.1 毫米汞柱,大腦灌流壓平均維持在 75.4±10.0 毫米汞柱;中心靜脈壓平均維持在 8.6±2.7 毫米汞柱,每天輸入量平均為 8096±2338.6 毫升,輸出量平均為 SOn 士 3008 毫升。主要併發症包括:肺炎(58 %)、肋膜腔積水(16.7 %)、成人呼吸窘迫症( 16.7 %)、高血鈉(41 . 7 %)、延遲性顱內出血 ( 12.5%)。出院時之預後指數平均 3.4±1.7,死亡率為 25 %,良好預後為 5833 %,沒有任何病人死亡於無法控制之顱內高壓。此結果顯示,維持腦灌流壓在70毫米汞柱以上大體上能降低死亡率,對於存活者生活品質也相對提高。同時,以此方法治療時,也要留意併發症之發生。

關鍵字

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並列摘要


Objective: Cerebral perfusion pressure (CPP)-guided management has become a popular treatment for severe head injury. This paper reports our experience with this disease at Chi-Mei Medical Center. Patients and Methods: From May 2001 through November 2002, 24 patients (15 male and 9 female; 38±11.7 years: mean±STD:) with Glasgow Coma Scale (GCS) scores of 7 were admitted to the Neurosurgical Intensive Care Unit (GCS: 5.3 ± 1.3) of Chi-Mei Medical Center. They were managed with decompressive craniectomy, vascular volume expansion (hydroxyethyl starch or albumin), systemic vasopressors (norepinephrine bitartrate or dopamine), sedation (propofol), muscle relaxation (atracurium besylate), mannitol and mild hyperventilation to maintain a minimum cerebral perfusion pressure (CPP) of at least 70 mmHg. Results: The mean arterial pressure was 97.1±11.3 mmHg, mean intracranial pressure (ICP) was 21.7±7.1 mmHg, mean central venous pressure was 8.6±2.7 minHg and the mean CPP was 75.4 ± 10.0mmHg. The fluid intake was 8,096 ± 2,338.6 mE/day and output was 8,011.1± 3,008 mE/day. The major complications were pneumonia (58%), pleural effusion (16.7%), adult respiratory distress syndronie (16.7%), hypernatremia (41.7%) and delayed intracranial hemorrhage (12.5%). The mean Glasgow outcome score was 3.4 ±1.7 at discharge. The overall mortality rate was 25% and the favorable outcome rate was 58.3%. No patient died of uncontrolled ICP. Conclusions: These results suggest that maintenance of CPP above 70 mmHg reduced mortality and improved the quality of survival following severe traumatic head injury. Nonetheless, one must keep in mind the simultaneous complications of CPP guided management of severe traumatic head injury.

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