Ryttlefors Mats, Howells Tim, Nilsson Pelle, Ronne-Engström Elisabeth, Enblad Per
Department of Neuroscience, Section of Neurosurgery, Uppsala University Hospital, Uppsala, Sweden.
Neurosurgery. 2007 Oct;61(4):704-14; discussion 714-5. doi: 10.1227/01.NEU.0000298898.38979.E3.
To study the occurrence of secondary insults during neurointensive care of patients with subarachnoid hemorrhage using a computerized multimodality monitoring system and to study the impact of secondary insults on clinical deterioration and functional outcome.
Patients with subarachnoid hemorrhage who were admitted to the neurointensive care unit between January 1999 and December 2002 with at least 120 hours of multimodality monitoring data within the first 240 hours of neurointensive care were included. Data were continuously recorded for intracranial pressure (ICP), cerebral perfusion pressure (CPP), mean arterial blood pressure, systolic blood pressure, oxygen saturation, and temperature. Secondary insult levels were defined as ICP of 20 or greater or 25 or greater; CPP of 60 or lower, 55 or lower, greater than 100, or greater than 110; mean arterial blood pressure of 80 or lower, 70 or lower, 120 or greater, or 130 or greater; systolic blood pressure of 110 or lower, 100 or lower, 180 or greater, or 200 or greater; temperature of 38 degrees C or higher or 39 degrees C or higher; and oxygen saturation of less than 95 or less than 90. Secondary insults were quantified as the proportion of good monitoring time at the insult level. Uni- and multivariate logistic regression analyses were performed with admission and secondary insult variables as explanatory variables and clinical deterioration and independent outcome as the dependent variable, respectively.
Ninety-nine patients (67 women; mean age, 57.8 yr) met the inclusion criteria. In the univariate analysis, ICP of 20 or greater, ICP of 25 or greater, CPP of 60 or less, and CPP of 55 or less increased the risk of clinical deterioration, whereas CPP greater than 100 and systolic blood pressure greater than 180 decreased the risk of clinical deterioration. In the multivariate logistic regression, ICP of 25 or greater and CPP of greater than 100 had an independent effect on clinical deterioration. The occurrence of secondary insults had no significant effect on functional outcome.
Elevated ICP not responding to treatment is predictive of clinical deterioration, whereas high CPP decreases the risk of clinical deterioration. It may be beneficial to not lower spontaneous high CPP in patients with subarachnoid hemorrhage.
使用计算机化多模态监测系统研究蛛网膜下腔出血患者神经重症监护期间二次损伤的发生情况，并研究二次损伤对临床恶化和功能转归的影响。
纳入1999年1月至2002年12月期间入住神经重症监护病房、在神经重症监护的最初240小时内至少有120小时多模态监测数据的蛛网膜下腔出血患者。连续记录颅内压（ICP）、脑灌注压（CPP）、平均动脉血压、收缩压、血氧饱和度和体温。二次损伤水平定义为：ICP为20或更高、25或更高；CPP为60或更低、55或更低、大于100或大于110；平均动脉血压为80或更低、70或更低、120或更高、130或更高；收缩压为110或更低、100或更低、180或更高、200或更高；体温为38℃或更高、39℃或更高；血氧饱和度小于95或小于90。二次损伤以损伤水平下良好监测时间的比例进行量化。分别以入院和二次损伤变量作为解释变量，临床恶化和独立转归作为因变量，进行单因素和多因素逻辑回归分析。
99例患者（67例女性；平均年龄57.8岁）符合纳入标准。在单因素分析中，ICP为20或更高、ICP为25或更高、CPP为60或更低以及CPP为55或更低会增加临床恶化风险，而CPP大于100和收缩压大于180会降低临床恶化风险。在多因素逻辑回归中，ICP为25或更高和CPP大于100对临床恶化有独立影响。二次损伤的发生对功能转归无显著影响。
治疗无效的ICP升高可预测临床恶化，而高CPP可降低临床恶化风险。对于蛛网膜下腔出血患者，不降低自发性高CPP可能有益。
