机械通气辅助及血压调控对重症颅脑损伤患者脑氧代谢的

1、机械通气辅助及血压调控对重症颅脑损伤患者脑氧代谢的影响解温品1 高鸿2 林恩德1 刁宏山1 史亮1 方军1 朱凯敏1（作者单位：1，武警上海总队医院麻醉科；2，贵阳医学院附属医院麻醉科）中文摘要目的 观察机械通气辅助及血压调控对重症颅脑损伤患者脑氧代谢的影响。方法 入选本试验的56例颅脑外伤患者，术前均经CT诊断和GCS (glasgow coma scale) 评分，符合重症颅脑外伤标准（3GCS8），并均需急诊手术和进入重症监护病房监测治疗，且除外心、肺、肝、肾等重要脏器合并症及重度休克、感染、糖尿病、高血压等全身性疾患，除外术后三天内自主呼吸仍不能恢复循环功能仍不能稳定者。随机分为两组（

2、n=28）：对照组（组）和治疗组（组）。常规行气静复合全身麻醉，且在术毕均带气管导管回ICU，按颅脑损伤治疗常规给予治疗，同时对治疗组采用机械通气及血压控制的方式治疗。观察两组患者麻醉前(T0)、诱导后1h(T1)、术毕即刻（T2）、术后6h (T3)、术后12h(T4)、术后24h (T5)、术后48h (T6)及术后72h (T7)的收缩压（SBP）、舒张压（DBP）、平均动脉压（MAP）、心率（HR），并在相应时间抽取桡动脉和颈内静脉球处血液行血气分析, 再根据Fick公式计算颈内静脉球处血氧含量（CjvO2）、桡动脉血氧含量（CaO2）、脑氧摄取率（ERO2）。并在伤后3个月根据格拉斯

3、哥预后积分(Giasgow Outcome Scale, GOS)判定病人预后。结果 两组患者的呼吸循环情况术前、术中及术毕即刻比较没有显著性差异（p0.05），但术后各时点比较有非常显著性差异（p0.01）。两组患者的脑氧摄取率组间术前、术中及术毕即刻比较没有显著性差异（p0.05），但在各时点比较有非常显著性差异（p0.01）；而组内比较，两组在术中及术毕即刻与术前相比有非常显著性差异（p0.01），但对照组在术后各时点与术前相比无显著性差异（p0.05），而治疗组有非常显著性差异（p0.01）。两组患者伤后3个月的预后积分检验，死亡率有显著性差异(p0.05)，而且治疗组的生存质量明显好

4、于对照组(p0.05)。结论 机械通气辅助及血压调控可以使重症颅脑损伤患者的血流动力学更加平稳且维持在较低代谢水平，而对照组存在不同程度的低氧血症/高碳酸血症，同时它还使脑氧摄取率明显降低，3月后的预后明显改善。关键词 机械通气；血压,调控；重症颅脑损伤；脑氧代谢；血流动力学AbstractEffects of mechanical ventilation together with blood pressure under control on cerebral oxygen metabolism in severe traumatic brain injury patients. XIE

5、Wen-pin，GAO Hong , AN Yu-wen , et al. Department of Anesthesiology, Affiliated Hospital, Guiyang Medical College, Guiyang 550004, Guizhou Province, China.Objective To investigate the effects of mechanical ventilation together with blood pressure under control on cerebral oxygen metabolism in patient

6、s with severe traumatic brain injury (STBI). Methods Fifty six patients with severe traumatic brain injury (3GCS8) needed emergency operation, except the patients with heart, lung, liver, kidney, severe shock, infections, diabetes or other systemic diseases, and except the patients who did not resto

7、red in breathing independently and circulation within three days. They were randomly divided into the control group (I group, n=28) and the therapy group (II group, n=28). In I group, patients were treated according to conventional therapy. In II group, patients were treated by mechanical ventilatio

8、n together with blood pressure under control. The SBP, DBP, MAP, HR were observed before narcosis (T0), 1 hour after induction (T1), immediately after surgery(T2), postoperative 6 hour (T3), 12 hour(T4), 12 hour(T5), 12 hour(T6) and 12 hour(T7). At the same time blood was collected from radial arter

9、y and jugular bulb venous for blood gas analysis, and the oxygen content of artery (CaO2 ), oxygen content of jugular venous(CjvO2 ) and cerebral metabolic rate for oxygen(CERO2 ) were calculated. The prognosis of patients were determined according to the Giasgow Outcome Scale(GOS) after three month

10、s. Results The oxygen supply was significantly better after general anesthesia induction, cerebral oxygen metabolic rate was lower than before anesthesia induction in the two groups, but CERO2 was more significantly decreased at postoperative in II group than in I group (P0.01), the hemodynamics was

11、 more stable in II group than in I group. 0.05). According to GOS scores at the 3th month after treatment, the living quality in the II group is better than that in the I group (p0.05). The death rate is significantly different between the two groups (p0.05). Conclusion There is more significant effect on hemodynamics stably in patients with STBI when treated by mechanical ventilation together with blood pressure under control than according to conventional therapy, and it can more significantly decrease the CE