Henzler Dietrich, Cooper D James, Tremayne Ann B, Rossaint Rolf, Higgins Alisa
Department of Anesthesiology, University Hospital Aachen, Aachen, Germany.
Crit Care Med. 2007 Apr;35(4):1027-31. doi: 10.1097/01.CCM.0000259526.45894.08.
Survival of patients with severe traumatic brain injury may be improved by minimizing secondary brain injury. We aimed to identify potentially modifiable contributors to secondary brain injury that may persist and adversely affect patient outcome.
Retrospective case control study. Nonsurviving patients with traumatic brain injury were selected and matched 1:1 for age, Glasgow Coma Scale score, Abbreviated Injury Scale: Head (AISHEAD), Revised Trauma Score, and Injury Severity Score with survivors. Potentially modifiable contributors to secondary brain injury were examined and compared in both groups.
A level I trauma center in Melbourne, Australia.
Patients with traumatic brain injury caused by blunt trauma with an AISHEAD >or=4 were identified from a prospective intensive care database.
None.
Between January 1, 1999, and July 30, 2000, 74 patients, including 37 nonsurvivors, were identified. By design, the groups were well matched for injury severity and baseline conditions. In nonsurvivors, mean arterial pressure was similar to that of survivors at hospital arrival but was lower at 4 hrs after arrival (71 +/- 16 vs. 80 +/- 15 mm Hg, p = .016). A mean arterial pressure <or=65 mm Hg during this 4-hr period was associated with a four-fold increase in the odds of nonsurvival (95% confidence interval, 1.25-12.8). Intracranial pressure monitoring and intensive care unit admission tended to be initiated later in nonsurvivors, potentially delaying recognition and management of inadequate cerebral perfusion pressure. In nonsurvivors, hypothermia did not normalize during the first 24 hrs after injury.
In patients with severe traumatic brain injury, lower blood pressure in the first 4 hrs after admission was associated with mortality and may have increased the rate of secondary brain injury. Outcomes of patients with severe traumatic brain injury may potentially be improved by early targeting of the higher mean arterial pressure observed in survivors (mean arterial pressure 80 mm Hg), which may facilitate improved cerebral perfusion. Slower initiation of intracranial pressure monitoring and of intensive care unit admission may also have adversely affected outcomes, whereas persistent hypothermia was associated with nonsurvival.
通过尽量减少继发性脑损伤来提高重型颅脑损伤患者的生存率。我们旨在确定可能持续存在并对患者预后产生不利影响的继发性脑损伤的潜在可改变因素。
回顾性病例对照研究。选择重型颅脑损伤死亡患者，并按年龄、格拉斯哥昏迷量表评分、简明损伤定级标准：头部（AISHEAD）、修正创伤评分和损伤严重度评分与存活患者进行1:1匹配。对两组中继发性脑损伤的潜在可改变因素进行检查和比较。
澳大利亚墨尔本的一家一级创伤中心。
从前瞻性重症监护数据库中识别出由钝性创伤导致AISHEAD≥4的颅脑损伤患者。
无。
在1999年1月1日至2000年7月30日期间，共识别出74例患者，其中37例死亡。根据设计，两组在损伤严重程度和基线条件方面匹配良好。在死亡患者中，入院时平均动脉压与存活患者相似，但入院后4小时较低（71±16 vs. 80±15 mmHg，p = 0.016）。在此4小时期间平均动脉压≤65 mmHg与死亡几率增加四倍相关（95%置信区间，1.25 - 12.8）。颅内压监测和重症监护病房收治在死亡患者中往往启动较晚，可能会延迟对脑灌注压不足的识别和处理。在死亡患者中，伤后最初24小时内体温未恢复正常。
在重型颅脑损伤患者中，入院后最初4小时血压较低与死亡率相关，可能增加了继发性脑损伤的发生率。通过早期将目标设定为存活患者中观察到的较高平均动脉压（平均动脉压80 mmHg），可能有助于改善脑灌注，从而有可能改善重型颅脑损伤患者的预后。颅内压监测和重症监护病房收治启动较慢也可能对预后产生不利影响，而持续性体温过低与死亡相关。
