脑出血指南知识讲座培训课件

1、脑出血指南知识讲座脑出血指南知识讲座A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association给予来自美国心脏协会/美国卒中协会的卫生保健专业人员的指南脑出血指南知识讲座2A Guideline for Healthcare Pro一、Emergency Diagnosis and Assessment of ICH and Its Causes Recommendations关于脑出血的紧急诊断和评估的建议脑出血指南知识讲座3一、Emergen

2、cy Diagnosis and Asse1. Rapid neuroimaging with CT or MRI is recommended to distinguish ischemic stroke p1 from ICHp2 (Class I; Level of Evidence: A). (Unchanged from the previous guideline)CT或MRI（核磁共振成像）的快速成像便于很好地区分缺血性中风和脑出血（出血性脑中风）。（与先前的指南并无差异）脑出血指南知识讲座41. Rapid neuroimaging with CT 2. CT angiogra

3、phy and contrast-enhanced CTp3 may be considered to help identify patients at risk for hematoma expansion (Class IIb; Level of Evidence: B), CT血管造影术和强化CT或许可以辅助鉴别有血肿扩散危险的病人and CT angiography, CT venography, contrast-enhanced CT, contrast-enhanced MRI, magnetic resonance angiography, and magnetic reso

4、nance venography can be useful to evaluate for underlying structural lesions, including vascular malformations and tumors when there is clinical or radiological suspicion (Class IIa;Level of Evidence: B). (New recommendation)同时，CT血管造影术、CT静脉造影术、加强CT、加强MRI（核磁共振）、磁共振血管造影、磁共振静脉造影，可以检查到潜在的结构损伤，包括临床上或放射学上

5、怀疑的血管畸形和肿瘤。（新推荐）脑出血指南知识讲座52. CT angiography and contrast二、Medical Treatment for ICH Recommendations 关于脑出血内科治疗的建议p4 脑出血指南知识讲座6二、Medical Treatment for ICH Re1. Patients with a severe coagulation factor deficiency or severe thrombocytopenia should receive appropriate factor replacement therapy or plate

6、lets, respectively (Class I;Level of Evidence: C). (New recommendation)严重缺乏凝血因子或者说有严重血小板减少症的病人，应该适当地接受外来因子或者血小板来进行治疗。（新推荐）脑出血指南知识讲座71. Patients with a severe coag2. Patients with ICH whose INRp5 is elevated due to OACsp6 should have their warfarin withheld, receive therapy to replace vitamin Kdepend

7、ent factors and correct the INR, and receive intravenous vitamin K (Class I; Level of Evidence: C). 对于那些由口服抗凝剂OACsp7 导致INR（国际标准化比值）升高的脑出血病人，不应该再用华法令，而该接受上述治疗来取代维生素K依赖性因子，同时，该改善INR水平、接受静脉内维生素K治疗。PCCsp8 血浆凝固剂have not shown improved outcome compared with新鲜冷冻血浆 FFPp9 but may have fewer complications com

8、pared with FFP and are reasonable to consider as an alternative to FFP (Class IIa; Level of Evidence: B). 与新鲜血浆相比，血液凝固剂并没有显示出明显改善的治疗成果，但是可能并发症更少，是值得考虑的新鲜血浆替代物。脑出血指南知识讲座82. Patients with ICH whose INRrFVIIap10 does not replace all clotting factors, and although the INR may be lowered, clotting may no

9、t be restored in vivo; therefore, rFVIIa is not routinely recommended as a sole agent for OAC reversal in ICH (Class III; Level of Evidence: C). (Revisedfrom the previous guideline).重组凝血因子VII并不能替代所有的凝结因子；虽然INR可能会被降低，但是体内的血凝块并不能消除。所以，并不推荐把rFvlla作为脑出血病人OAC逆转的唯一药剂。（由先前指南修订）脑出血指南知识讲座9rFVIIap10 does not

10、replace a3. Although rFVIIa can limit the extent of hematoma expansion in noncoagulopathic ICH patients, thereis an increase in thromboembolic risk with rFVIIa and no clear clinical benefit in unselected patients. Thus rFVIIa is not recommended in unselected patients. (Class III; Level of Evidence:

11、A). (New recommendation) Further research to determine whether any selected group of patients may benefitfrom this therapy is needed before any recommendation for its use can be made. 虽然重组凝血因子VII可以限制非凝血异常性脑出血病人血肿扩大，但是应用rFVlla 时发生血栓的危险性却增加了，同时，对于随机选定的患者没有明显的临床利益。（新推荐）在可以得出有关其应用的任何推荐之前，需要做更深层次的研究来验证是否

12、任何被选定的病人群体都可以从这种治疗获益。脑出血指南知识讲座103. Although rFVIIa can limit t4. The usefulness of platelet transfusions in ICH patients with a history of antiplatelet use is unclear and is considered investigational (Class IIb; Level of Evidence: B). (New recommend)对于有抗血小板治疗病史的脑出血病人，给予输液血小板治疗的有效性并不清楚、有待于研究。（新推荐）5.

13、 Patients with ICH should have intermittent pneumatic compressionp11 for prevention of venous thromboembolism in addition to elastic stockingsp12 (Class I;Level of Evidence: B). (Unchanged from the previousguideline)为了预防脑出血病人出现下肢静脉栓塞p13 ，除了下肢要穿弹力袜子、也要进行间歇性的充气压迫治疗（与先前的指南并无差异） 脑出血指南知识讲座114. The useful

14、ness of platelet 6. After documentation of cessation of bleeding, lowdose subcutaneous low-molecular-weight heparin or unfractionated heparin may be considered for prevention of venous thromboembolism in patients with lack of mobility after 1 to 4 days from onset (ClassIIb; Level of Evidence: B). (R

15、evised from the previousguideline)在确定病人出血停止后，皮下注射低剂量的低分子量的肝素或者肝素，可能用于防止病人发病后1到4天后发生静脉栓塞。（由先前指南修订）脑出血指南知识讲座126. After documentation of cess三、Blood Pressure Recommendations（有关血压方面的建议）1. Until ongoing clinical trials of BP intervention for ICH are completed, physicians must manage BP on the basis of th

16、e present incomplete efficacy evidence.Current suggested recommendations for target BP in various situations are listed in Table 6 and may be considered (Class IIb; Level of Evidence: C). (Unchangedfrom the previous guideline)在正在进行的脑出血病人血压干预临床试验完成之前，医师必须依据目前不完善的循证医学证据的基础，来适当控制血压。目前，对于不同情况下所推荐的血压处理方法

17、，请见表6，值得借鉴。（与先前的指南并无差异）脑出血指南知识讲座13三、Blood Pressure Recommendatio2. In patients presenting with a systolic BP of 150 to 220 mm Hg, acute lowering of systolic BP to 140 mm Hg is probably safe (Class IIa; Level of Evidence: B). (New recommendation)对于收缩压在150到220mmHg之间的病人，收缩压迅速降低到140mmHg或许是安全的。（新推荐）脑出血指南

18、知识讲座142. In patients presenting with四、Inpatient Managementp14 and Prevention of Secondary Brain Injury Recommendations关于住院病人的处理治疗和预防二次脑损伤的建议脑出血指南知识讲座15四、Inpatient Managementp14 an1. Initial monitoring and management of ICH patients should take place in an intensive care unit with physician and nursi

19、ng neuroscience intensive care expertise (Class I; Level of Evidence: B). (Unchanged from the previous guideline）脑出血病人最初的监测和管理，应该在一个拥有神经科学重专业护理人员和内科医生的加强治疗中心ICU。（与先前的指南并无差异）脑出血指南知识讲座161. Initial monitoring and manaManagement of Glucose（血糖控制）1. Glucose should be monitored and normoglycemia is recomme

20、nded (Class I: Level of Evidence: C). (New recommendation)应该监测血糖，保证血糖的正常。（新推荐）脑出血指南知识讲座17Management of Glucose（血糖控制）脑出血Seizures and Antiepileptic Drugsp15 （控制惊厥及抗癫痫药物）1. Clinical seizures should be treated with antiepileptic drugs (Class I; Level of Evidence: A). (Revised from the previous guideline

21、) Continuous EEGp16 monitoring is probably indicated in ICH patients with depressed mental status out of proportion to the degree of brain injury (Class IIa; Level of Evidence: B). Patients with a change in mental status who are found to have electrographic seizures on EEG should be treated with ant

22、iepileptic drugs (Class I; Level of Evidence: C). Prophylactic anticonvulsant medication should not be used (Class III; Level of Evidence:B). (New recommendation）临床的癫痫发作应该给予抗癫痫药物；（一级推荐A级证据）对那些精神状态抑制与脑损伤程度不相符合的脑出血病人，进行持续的脑电图监视可能会有一定的诊断预警作用。p17 那些发现有脑电图痫性异常的精神状态改变的病人，应该用抗癫痫药物（C级证据一级推荐）；不建议预防性应用抗痉挛剂。（新

23、推荐）脑出血指南知识讲座18Seizures and Antiepileptic Dru六、Procedures/Surgery Recommendations（关于手术程序的建议）脑出血指南知识讲座19六、Procedures/Surgery Recommend1. Patients with a GCSp18 score of 30 mL and within 1 cm of the surface, evacuation of supratentorialp28 ICH by standard craniotomy might be considered(Class IIb; Level

24、 of Evidence: B). (Revised from the previous guideline)对于那些血肿体积大于30ml 、靠近脑表面小于1cm的脑叶出血的病人，可以考虑用标准的开颅手术治疗幕上脑出血。（由先前指南修订） 脑出血指南知识讲座253. For patients presenting wit4. The effectiveness of minimally invasive clot evacuation utilizing either stereotacticp29 or endoscopic aspiration with or without thromb

25、olytic usage is uncertain and is considered investigational (Class IIb; Level of Evidence: B). (New recommendation)应用辅用溶栓剂或者不用溶栓剂的的立体定位方法或者内窥抽吸法，来尽可能地清除的血凝块的疗效并不确定、尚值得探究。脑出血指南知识讲座264. The effectiveness of minima5. Although theoretically attractive, no clear evidence at present indicates that ultra-e

26、arly removal of supratentorialp30 ICH improves functional outcome or mortality rate. Very early craniotomy may be harmful due to increased risk of recurrent bleeding (Class III; Level of Evidence: B). (Revised from the previous guideline)虽然理论上很有吸引性，但是目前没有明确的证据表明，尽早清除幕上脑出血血肿能够改善脑功能、降低死亡率。过早的开颅手术增加了再发

27、性脑出血的风险，因而可能会对病人有害。（由先前指南修订） 脑出血指南知识讲座275. Although theoretically attr九、Outcome Prediction and Withdrawal of Technological Support Recommendation脑出血指南知识讲座28九、Outcome Prediction and Withd1. Aggressive full care early after ICH onset and postponement of new DNR ordersp31 until at least the second full

28、 day of hospitalization is probably recommended(Class IIa; Level of Evidence: B). Patients with preexisting DNR orders are not included in this recommendation. Current methods of prognostication in individual patients early after ICH are likely biased by failure to account for the influence of withd

29、rawal of support and early DNR orders. Patients who are given DNR status at any point should receive all other appropriate medical and surgical interventions unless otherwise explicitly indicated.(Revised from the previous guideline)在脑出血发生后无法复苏的延缓期中，至少到住院治疗第二天之前，都应该采用早期迅速而全面的护理。那些先前存在无法复苏情况的病人并不包括在这

30、推荐之内。目前对特定脑出血病人早期进行预测的方法p32 可能是有失偏颇的，因为不能说明停止使用有效药物后对病人的影响和早期的无法复苏情况。任何被医生定为无法复苏的病人都应该接受所有其他形式的药物和手术干预，除非有其明确的原因。脑出血指南知识讲座291. Aggressive full care early 十、Prevention of Recurrent ICH Recommendations关于预防再发性脑出血的建议脑出血指南知识讲座30十、Prevention of Recurrent ICH 1. In situations where stratifying a patients r

31、isk of recurrent ICH may affect other management decisions, it is reasonable to consider the following risk factors for recurrence: lobar location of the initial ICH, older age, ongoing anticoagulation, presence of the apolipoprotein E 2 or 4 alleles, and greater number of microbleeds on MRI p33 (Cl

32、ass IIa; Level of Evidence: B). (New recommendation)把病人再发性脑出血的风险进行分类可能会影响其他治疗决定的状态，应该考虑如下引起复发的危险因子：原发性脑叶出血的位置，老年人，正在进行的抗凝治疗，载脂脂蛋白E2或者E4等位基因的存在，以及核磁共振成像显现的大量微出血。（新推荐）脑出血指南知识讲座311. In situations where stratif2. After the acute ICH period, absent medical contraindications, BP should be well controlled,

33、 particularly for patients with ICH location typical of hypertensive vasculopathy (Class I; Level of Evidence: A).(New recommendation)在脑出血急性期之后，没有医学上的禁忌症的时候，应该好好控制血压，尤其对于那些脑出血部位在高血压导致的血管病变的病人。3. After the acute ICH period, a goal target of a normal BP of 140/90 (130/80 if diabetes or chronic kidney

34、disease) is reasonable (Class IIa; Level of Evidence: B). (New recommendation)在脑出血急性期之后，血压应该控制在收缩压低于140mmHg、舒张压低于90mmHg的水平（如果有糖尿病或者慢性肾病的病人，是低于13080）。（新推荐）脑出血指南知识讲座322. After the acute ICH period,4. Avoidance of long-term anticoagulation as treatment for nonvalvular atrial fibrillation is probably re

35、commended after spontaneous lobar ICH because of the relatively high risk of recurrence (Class IIa; Level of Evidence: B). Anticoagulation after nonlobar ICH and antiplatelet therapy after all ICH might be considered, particularly when there are definite indications for these agents (Class IIb; Level of Evidence:B). (Unchanged from the previous guideline)因为存在复发相关的高风险，对于非瓣膜