Grathwohl Kurt W, Black Ian H, Spinella Phillip C, Sweeney Jason, Robalino Joffre, Helminiak Joseph, Grimes Jamie, Gullick Richard, Wade Charles E
Anesthesiology/Critical Care Medicine, San Antonio Uniformed Services Health Education Consortium, San Antonio, Texas 78234, USA.
Anesthesiology. 2008 Jul;109(1):44-53. doi: 10.1097/ALN.0b013e31817c02e3.
Traumatic brain injury is a leading cause of death and severe neurologic disability. The effect of anesthesia techniques on neurologic outcomes in traumatic brain injury and potential benefits of total intravenous anesthesia (TIVA) compared with volatile gas anesthesia (VGA), although proposed, has not been well evaluated. The purpose of this study was to compare TIVA versus VGA in patients with combat-related traumatic brain injury.
The authors retrospectively reviewed 252 patients who had traumatic brain injury and underwent operative neurosurgical intervention. Statistical analyses, including propensity score and matched analyses, were performed to assess differences between treatment groups (TIVA vs. VGA) and good neurologic outcome.
Two hundred fourteen patients met inclusion criteria and were analyzed; 120 received VGA and 94 received TIVA. Good neurologic outcome (Glasgow Outcome Score 4-5) and decreased mortality were associated with TIVA compared with VGA (75% vs. 54%; P = 0.002 and 5% vs. 16%; P = 0.02, respectively). Multivariate logistic regression found admission Glasgow Coma Scale score of 8 or greater (odds ratio, 13.3; P < 0.001) and TIVA use (odds ratio, 2.3; P = 0.05) to be associated with good neurologic outcomes. After controlling for confounding factors using propensity analysis and repeated one-to-one matching of patients receiving TIVA with those receiving VGA with regard to Injury Severity Score, Glasgow Coma Scale score, base deficit, Head Abbreviated Injury Score, and craniectomy or craniotomy, the authors could not find an association between treatment and neurologic outcome.
Total intravenous anesthesia often including ketamine was not associated with improved neurologic outcome compared with VGA. Multiple confounders limit conclusions that can be drawn from this retrospective study.
创伤性脑损伤是死亡和严重神经功能残疾的主要原因。尽管有人提出麻醉技术对创伤性脑损伤神经功能结局的影响以及与挥发性气体麻醉（VGA）相比全静脉麻醉（TIVA）的潜在益处，但尚未得到充分评估。本研究的目的是比较TIVA与VGA在与战斗相关的创伤性脑损伤患者中的效果。
作者回顾性分析了252例创伤性脑损伤并接受神经外科手术干预的患者。进行了包括倾向评分和匹配分析在内的统计分析，以评估治疗组（TIVA与VGA）之间的差异以及良好的神经功能结局。
214例患者符合纳入标准并进行了分析；120例接受VGA，94例接受TIVA。与VGA相比，TIVA与良好的神经功能结局（格拉斯哥结局评分4 - 5分）和降低的死亡率相关（分别为75%对54%；P = 0.002和5%对16%；P = 0.02）。多因素逻辑回归发现入院时格拉斯哥昏迷量表评分为8分或更高（比值比，13.3；P < 0.001）和使用TIVA（比值比，2.3；P = 0.05）与良好的神经功能结局相关。在使用倾向分析控制混杂因素并对接受TIVA的患者与接受VGA的患者在损伤严重程度评分、格拉斯哥昏迷量表评分、碱缺失、头部简明损伤评分以及颅骨切除术或开颅手术方面进行重复的一对一匹配后，作者未发现治疗与神经功能结局之间存在关联。
与VGA相比，常包括氯胺酮的全静脉麻醉与改善神经功能结局无关。多种混杂因素限制了从这项回顾性研究中得出的结论。
