小儿严重创伤中的脑氧合：其与创伤严重程度及预后的相关性。

Cerebral oxygenation in major pediatric trauma: its relevance to trauma severity and outcome.

作者信息

Narotam Pradeep K, Burjonrappa Sathyaprasad C, Raynor Stephen C, Rao Malini, Taylon Charles

机构信息

Division of Neurosurgery and Trauma, Creighton University Medical Center, Omaha, NE 68131, USA.

出版信息

J Pediatr Surg. 2006 Mar;41(3):505-13. doi: 10.1016/j.jpedsurg.2005.11.069.

DOI:10.1016/j.jpedsurg.2005.11.069

PMID:16516625

Abstract

INTRODUCTION

Trauma is the commonest cause of death in the pediatric population, which is prone to diffuse primary brain injury aggravated by secondary insults (eg, hypoxia, hypotension). Standard monitoring involves intracranial pressure (ICP) and cerebral perfusion pressure, which do not reflect true cerebral oxygenation (oxygen delivery [Do(2)]). We explore the merits of a brain tissue oxygen-directed critical care guide.

METHODS

Sixteen patients with major trauma (Injury Severity Score, >16/Pediatric Trauma Score [PTS], <7) had partial pressure of brain tissue oxygen (Pbto(2)) monitor (Licox; Integra Neurosciences, Plainsboro, NJ) placed under local anesthesia using twist-drill craniostomy and definitive management of associated injuries. Pbto(2) levels directed therapy intensity level (ventilator management, inotrops, blood transfusion, and others). Patient demographics, short-term physiological parameters, Pbto(2), ICP, Glasgow Coma Score, trauma scores, and outcomes were analyzed to identify the patients at risk for low Do(2).

RESULTS

There were 10 males and 6 females (mean age, 14 years) sustaining motor vehicle accident (14), falls (1), and assault (1), with a mean Injury Severity Score of 36 (16-59); PTS, 3 (0-7); and Revised Trauma Score, 5.5 (4-11). Eleven patients (70%) had low Do(2) (Pbto(2), <20 mm Hg) on admission despite undergoing standard resuscitation affected by fraction of inspired oxygen, Pao(2), and cerebral perfusion pressure (P = .001). Eubaric hyperoxia improved cerebral oxygenation in the low-Do(2) group (P = .044). The Revised Trauma Score (r = 0.65) showed moderate correlation with Pbto(2) and was a significant predictor for low Do(2) (P = .001). In patients with Pbto(2) of less than 20 mm Hg, PTS correlated with cerebral oxygenation (r = 0.671, P = .033). The mean 2-hour Pbto(2) and the final Pbto(2) in survivors were significantly higher than deaths (21.6 vs 7.2 mm Hg [P = .009] and 25 vs 11 mm Hg [P = .01]). Although 4 of 6 deaths were from uncontrolled high ICP, PTS and 2-hour low Do(2) were significant for roots for mortality.

CONCLUSIONS

Pbto(2) monitoring allows for early recognition of low-Do(2) situations, enabling appropriate therapeutic intervention.

摘要

引言

创伤是儿童群体中最常见的死亡原因，儿童易发生弥漫性原发性脑损伤，并因继发性损伤（如缺氧、低血压）而加重。标准监测包括颅内压（ICP）和脑灌注压，但这些并不能反映真正的脑氧合情况（氧输送[Do(2)]）。我们探讨了一种以脑组织氧为导向的重症监护指南的优点。

方法

16例严重创伤患者（损伤严重度评分>16/儿童创伤评分[PTS]<7）在局部麻醉下通过锥孔钻颅术置入脑组织氧分压（Pbto(2)）监测仪（Licox；Integra Neurosciences，新泽西州普林斯顿），并对相关损伤进行确定性处理。Pbto(2)水平指导治疗强度水平（呼吸机管理、血管活性药物、输血等）。分析患者的人口统计学数据、短期生理参数、Pbto(2)、ICP、格拉斯哥昏迷评分、创伤评分及预后，以确定存在低Do(2)风险的患者。

结果

患者共10例男性和6例女性（平均年龄14岁），受伤原因包括机动车事故（14例）、跌倒（1例）和袭击（1例），平均损伤严重度评分为36（16 - 59）；PTS为3（0 - 7）；改良创伤评分5.5（4 - 11）。11例患者（70%）入院时尽管接受了标准复苏，但仍存在低Do(2)（Pbto(2)<20 mmHg），这受到吸入氧分数、动脉血氧分压（Pao(2)）和脑灌注压的影响（P = 0.001）。常压高氧改善了低Do(2)组的脑氧合（P = 0.044）。改良创伤评分（r = 0.65）与Pbto(2)呈中度相关，是低Do(2)的显著预测指标（P = 0.001）。在Pbto(2)小于20 mmHg的患者中，PTS与脑氧合相关（r = 0.671，P = 0.033）。幸存者的平均2小时Pbto(2)和最终Pbto(2)显著高于死亡者（分别为21.6 vs 7.2 mmHg [P = 0.009]和25 vs 11 mmHg [P = 0.01]）。虽然6例死亡患者中有4例死于无法控制的高ICP，但PTS和2小时低Do(2)是死亡的重要根源。