Joseph D'Andrea K, Dutton Richard P, Aarabi Bizhan, Scalea Thomas M
Program in Trauma, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA.
J Trauma. 2004 Oct;57(4):687-93; discussion 693-5. doi: 10.1097/01.ta.0000140645.84897.f2.
Increases in intra-abdominal pressure (IAP) can cause increases in intracranial pressure (ICP). Recently, we noticed that abdominal fascial release could be useful in treating intracranial hypertension (ICH) after traumatic brain injury (TBI). We added this as an option in our treatment of TBI.
In our institution, ICH is treated with an algorithm using osmolar therapy, CSF drainage and barbiturates. Patients with refractory ICH have routine measurement of IAP. If elevated, consideration is given to decompressive laparotomy. We retrospectively reviewed all patients admitted from January 2000 through July 2003 who had abdominal decompression to treat refractory ICH.
From 1/00 to 7/03, 17 patients underwent decompressive laparotomy for intractable ICH. Thirteen male and 4 females all sustained blunt injury. All had failed maximal therapy including 14 who had had decompressive craniectomy. Mean ICP was 30 +/- 8.1 mmHg (range 20-40 mmHg) before decompression. No patients had evidence of abdominal compartment syndrome (ACS). Before decompression mean IAP was 27.5 (+/- 5.2) mmHg (range 21-35 mmHg). After abdominal decompression ICP dropped precipitously by at least 10 mmHg to a mean of 17.5 (+/- 3.2) mmHg (range 10-25 mmHg). In 6 patients the decrease in ICP was transient. All died. The remaining 11 had sustained decreases in ICP. All survived, made neurologic recovery and were discharged to a rehabilitation facility.
Decompressive laparotomy can be a useful adjunct in the treatment of ICH failing maximal therapy following TBI. More work will need to be done to precise the exact indications for this therapy.
腹内压（IAP）升高可导致颅内压（ICP）升高。最近，我们注意到腹部筋膜松解术可能有助于治疗创伤性脑损伤（TBI）后的颅内高压（ICH）。我们将此作为TBI治疗的一种选择。
在我们机构，ICH采用包括渗透压疗法、脑脊液引流和巴比妥类药物的治疗方案。难治性ICH患者常规测量IAP。如果IAP升高，则考虑进行减压剖腹术。我们回顾性分析了2000年1月至2003年7月期间因难治性ICH接受腹部减压治疗的所有患者。
2000年1月至2003年7月，17例患者因难治性ICH接受了减压剖腹术。其中13例男性和4例女性均为钝性损伤。所有患者均接受了最大程度的治疗但均告失败，其中14例曾行减压颅骨切除术。减压前平均ICP为30±8.1 mmHg（范围20 - 40 mmHg）。所有患者均无腹腔间隔室综合征（ACS）的证据。减压前平均IAP为27.5（±5.2）mmHg（范围21 - 35 mmHg）。腹部减压后ICP急剧下降至少10 mmHg，平均降至17.5（±3.2）mmHg（范围10 - 25 mmHg）。6例患者ICP下降为短暂性。所有6例均死亡。其余11例患者ICP持续下降。所有患者均存活，神经功能恢复，出院后进入康复机构。
减压剖腹术可作为TBI后最大程度治疗失败的ICH患者的一种有效辅助治疗方法。需要做更多工作以明确该治疗的确切适应症。
