McKinley B A, Parmley C L, Tonneson A S
Department of Anesthesiology, University of Texas-Houston Medical School, 77030, USA.
J Trauma. 1999 Feb;46(2):271-9. doi: 10.1097/00005373-199902000-00013.
To test a standardized protocol for management of intracranial pressure (ICP) after severe head injury (i.e., traumatic brain injury), consistent with published guidelines.
We compared prospective use of a standardized protocol for ICP management in 12 patients with severe head injuries and retrospective ICP management using preprinted hospital orders in combination with ad hoc physician orders in 12 historical control patients with severe head injuries. With the standardized protocol, flow-chart decision logic diagrams were applied at patient bedside by critical care practitioners, with nursing shift review.
ICP and its variation during the first 6 intensive care unit days was less for the standardized protocol- than for the preprinted order-managed group (p <0.001), indicating better process control with the standardized protocol. ICP exceeded 25 mm Hg for less time for the standardized protocol group (182 hours; 15+/-23 hours/patient) than for prescribed order group (429 hours; 36+/-28 hours/patient) (p = 0.03). On average, ICP exceeded 20 mm Hg for 2.3 days for the standardized protocol-managed group and for 4.7 days for the prescribed order-managed group. Cerebral perfusion pressure was significantly greater and its variation less for the standardized protocol- than for the preprinted order-managed group. Fewer interventions were made for ICP management for the standardized protocol- than for the preprinted order-managed patients (601 vs. 876), suggesting more effective nursing time using the standardized protocol.
ICP management was more consistent, and intracranial hypertension was better controlled, in patients managed according to a standardized, data-driven protocol for escalation and weaning of therapies in response to immediate patient needs. We recommend computerized implementation and a randomized clinical trial to compare the protocol with prescribed orders.
根据已发表的指南，测试一种用于重型颅脑损伤（即创伤性脑损伤）后颅内压（ICP）管理的标准化方案。
我们比较了12例重型颅脑损伤患者前瞻性使用标准化ICP管理方案与12例历史对照重型颅脑损伤患者回顾性使用预印医院医嘱结合临时医生医嘱进行ICP管理的情况。采用标准化方案时，由重症护理人员在患者床边应用流程图决策逻辑图，并进行护理班次复查。
在重症监护病房的头6天内，标准化方案组的ICP及其波动幅度低于预印医嘱管理组（p<0.001），表明标准化方案的过程控制更好。标准化方案组ICP超过25 mmHg的时间（182小时；15±23小时/患者）少于医嘱组（429小时；36±28小时/患者）（p = 0.03）。标准化方案管理组平均ICP超过20 mmHg的时间为2.3天，医嘱管理组为4.7天。标准化方案组的脑灌注压显著更高，其波动幅度更小。标准化方案组针对ICP管理的干预措施少于预印医嘱管理的患者（601次对876次），这表明使用标准化方案能更有效地利用护理时间。
对于根据标准化、数据驱动的方案进行治疗升级和撤机以满足患者即时需求的患者，ICP管理更加一致，颅内高压得到更好控制。我们建议通过计算机化实施并开展一项随机临床试验，以将该方案与医嘱进行比较。
