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奥地利重度创伤性脑损伤VI:基于指南管理的效果

Severe traumatic brain injury in Austria VI: effects of guideline-based management.

作者信息

Rusnak Martin, Janciak Ivan, Majdan Marek, Wilbacher Ingrid, Mauritz Walter

机构信息

INRO (International Neurotrauma Research Organisation), Vienna, Austria.

出版信息

Wien Klin Wochenschr. 2007 Feb;119(1-2):64-71. doi: 10.1007/s00508-006-0765-0.

DOI:10.1007/s00508-006-0765-0
PMID:17318752
Abstract

OBJECTIVES

The goal of this paper is to report relations between health outcomes and implementation of individual recommendations of the guidelines.

PATIENTS AND METHODS

Data sets from 405 patients included by 5 Austrian hospitals were available. The analysis focused on the compliance of treatment modalities to TBI guidelines recommendations. Compliance was evaluated based on scores developed specifically for this purpose. To evaluate the relations between the TBI guidelines compliance and outcomes the estimation of odds ratios was computed using multiple as well as logistic regression with age, ISS and initial GCS used to control confounding.

RESULTS

The option on prehospital resuscitation was followed in 84%, the guideline on early resuscitation was followed in 79%. The guideline on intracranial pressure treatment threshold was the most closely followed one (89%). The option on cerebral perfusion pressure was followed in less than 30% of patients. Only the scores on resuscitation of blood pressure and oxygenation and on cerebral perfusion pressure were positively and statistically significantly related to ICU survival. Positive relations were also found for adherence to the recommendations on the type of monitoring, hyperventilation (guideline), prophylactic use of anti-seizure drugs, and the total of scores. The other recommendations were negatively related to ICU survival, but computed odds ratios were statistically not significant. Analysis of relations between compliance scores and length of ICU and hospitals stay in survivors showed that adherence to the recommendations on type of monitoring was related to a reduction of length of stay in ICU and hospital, adherence to the hyperventilation guideline was related to shortened ICU, but increased hospital stay, and adherence to the guideline on mannitol was related to reduced days in hospital, but not to days in ICU. Implementing the standard on corticosteroid use was related to a reduction of days both in hospital and ICU. Using the standard on prophylactic use of anti-seizure drugs was related to a reduction in ICU days. If all the recommendations were closely followed an increase of days in ICU would be observed, while the length of stay in hospital would be reduced.

CONCLUSIONS

The relatively strong relation between initial resuscitation in the hospital and ICU survival provides a firm basis for future efforts of emergency teams. The positive influence of some of the recommendations on reduction of ICU or hospital days may provide economic incentives to promote guidelines implementation.

摘要

目的

本文旨在报告健康结局与指南中各项建议实施情况之间的关系。

患者与方法

可获取来自奥地利5家医院纳入的405例患者的数据集。分析聚焦于治疗方式对创伤性脑损伤(TBI)指南建议的依从性。依从性基于为此专门制定的评分进行评估。为评估TBI指南依从性与结局之间的关系,使用多元及逻辑回归计算比值比估计值,以年龄、损伤严重度评分(ISS)和初始格拉斯哥昏迷评分(GCS)控制混杂因素。

结果

84%的患者遵循了院前复苏选项,79%的患者遵循了早期复苏指南。颅内压治疗阈值指南是遵循程度最高的一项(89%)。不到30%的患者遵循了脑灌注压选项。仅血压和氧合复苏以及脑灌注压的评分与重症监护病房(ICU)存活呈正相关且具有统计学意义。在监测类型、过度通气(指南)、预防性使用抗癫痫药物以及总评分等建议的依从性方面也发现了正相关关系。其他建议与ICU存活呈负相关,但计算出的比值比无统计学意义。对存活患者的依从性评分与ICU住院时长及住院时间之间关系的分析表明,遵循监测类型建议与ICU及住院时长的缩短相关,遵循过度通气指南与ICU住院时长缩短相关,但住院时间增加,遵循甘露醇指南与住院天数减少相关,但与ICU天数无关。实施皮质类固醇使用标准与住院及ICU天数的减少相关。使用预防性抗癫痫药物标准与ICU天数的减少相关。如果严格遵循所有建议,会观察到ICU住院天数增加,而住院时间会减少。

结论

医院初始复苏与ICU存活之间相对较强的关系为急救团队未来的工作提供了坚实基础。部分建议对减少ICU或住院天数的积极影响可能为促进指南实施提供经济激励。

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Severe traumatic brain injury in Austria I: introduction to the study.奥地利的重度创伤性脑损伤 I:研究介绍
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