Oddo M, Levine J M, Frangos S, Carrera E, Maloney-Wilensky E, Pascual J L, Kofke W A, Mayer S A, LeRoux P D
Neurointensive Care Unit, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania, USA.
J Neurol Neurosurg Psychiatry. 2009 Aug;80(8):916-20. doi: 10.1136/jnnp.2008.156596. Epub 2009 Mar 16.
The impact of osmotic therapies on brain oxygen has not been extensively studied in humans. We examined the effects on brain tissue oxygen tension (PbtO(2)) of mannitol and hypertonic saline (HTS) in patients with severe traumatic brain injury (TBI) and refractory intracranial hypertension.
12 consecutive patients with severe TBI who underwent intracranial pressure (ICP) and PbtO(2) monitoring were studied. Patients were treated with mannitol (25%, 0.75 g/kg) for episodes of elevated ICP (>20 mm Hg) or HTS (7.5%, 250 ml) if ICP was not controlled with mannitol. PbtO(2), ICP, mean arterial pressure, cerebral perfusion pressure (CPP), central venous pressure and cardiac output were monitored continuously.
42 episodes of intracranial hypertension, treated with mannitol (n = 28 boluses) or HTS (n = 14 boluses), were analysed. HTS treatment was associated with an increase in PbtO(2) (from baseline 28.3 (13.8) mm Hg to 34.9 (18.2) mm Hg at 30 min, 37.0 (17.6) mm Hg at 60 min and 41.4 (17.7) mm Hg at 120 min; all p<0.01) while mannitol did not affect PbtO(2) (baseline 30.4 (11.4) vs 28.7 (13.5) vs 28.4 (10.6) vs 27.5 (9.9) mm Hg; all p>0.1). Compared with mannitol, HTS was associated with lower ICP and higher CPP and cardiac output.
In patients with severe TBI and elevated ICP refractory to previous mannitol treatment, 7.5% hypertonic saline administered as second tier therapy is associated with a significant increase in brain oxygenation, and improved cerebral and systemic haemodynamics.
渗透性治疗对脑氧的影响在人体中尚未得到广泛研究。我们研究了甘露醇和高渗盐水（HTS）对重度创伤性脑损伤（TBI）和难治性颅内高压患者脑组织氧分压（PbtO₂）的影响。
对12例连续接受颅内压（ICP）和PbtO₂监测的重度TBI患者进行研究。对于ICP升高（>20 mmHg）的发作，患者接受甘露醇（25%，0.75 g/kg）治疗；如果甘露醇不能控制ICP，则接受HTS（7.5%，250 ml）治疗。连续监测PbtO₂、ICP、平均动脉压、脑灌注压（CPP）、中心静脉压和心输出量。
分析了42次颅内高压发作，分别用甘露醇（n = 28次推注）或HTS（n = 14次推注）治疗。HTS治疗与PbtO₂升高相关（从基线的28.3（13.8）mmHg在30分钟时升至34.9（18.2）mmHg，60分钟时为37.0（17.6）mmHg，120分钟时为41.4（17.7）mmHg；所有p<0.01），而甘露醇不影响PbtO₂（基线30.4（11.4）对28.7（13.5）对28.4（10.6）对27.5（9.9）mmHg；所有p>0.1）。与甘露醇相比，HTS与更低的ICP、更高的CPP和心输出量相关。
在重度TBI且ICP升高且对先前甘露醇治疗无效的患者中，作为二线治疗给予7.5%高渗盐水与脑氧合显著增加以及脑和全身血流动力学改善相关。
