多中心前瞻性队列研究：蛛网膜下腔出血后容量管理：根据蛛网膜下腔出血和脑血管痉挛的严重程度的血液动力学变化。
Multicenter prospective cohort study on volume management after subarachnoid hemorrhage: hemodynamic changes according to severity of subarachnoid hemorrhage and cerebral vasospasm.
机构信息
Department of Neurosurgery and Clinical Neuroscience, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan.
出版信息
Stroke. 2013 Aug;44(8):2155-61. doi: 10.1161/STROKEAHA.113.001015. Epub 2013 Jun 4.
BACKGROUND AND PURPOSE
Systemic circulation management has not been established for patients with poor grade aneurysmal subarachnoid hemorrhage (SAH) or delayed cerebral ischemia (DCI) after SAH. The aims of the study were to examine hemodynamic variables in these patients and to establish treatment strategies.
METHODS
A multicenter prospective cohort study of hemodynamic variables from days 1 to 14 was performed using a transpulmonary thermodilution system (PiCCO Plus). Parameters were analyzed by Mann-Whitney test. Multivariate analysis was performed to identify parameters involved in onset of DCI.
RESULTS
The subjects were 204 patients, including 138 with poor grade SAH (World Federation of Neurological Surgeons grades IV and V) and 52 who developed DCI. The extravascular lung water index, pulmonary vascular permeability index, and systemic vascular resistance index were significantly greater in patients with poor grade SAH compared with those with good grade SAH (World Federation of Neurological Surgeons I-III) on day 2 (P=0.049, P=0.039, and P=0.038). Cardiac index was significantly lower in patients with poor grade SAH on days 1 and 2 (P=0.027 and P=0.011). In patients with DCI, the global end-diastolic volume index was significantly lower than in those without DCI on days 3 to 5 (P=0.0053; P=0.048; and P=0.048). In multivariate analysis, median global end-diastolic volume index, cardiac index, and systemic vascular resistance index at an early stage of SAH (days 3-6) were independently related to onset of DCI (P=0.023, P=0.013, and P=0.003).
CONCLUSIONS
Patients with poor grade SAH developed heart failure-like afterload mismatch at an early stage, and those with DCI had decreased global end-diastolic volume index (hypovolemia) in the early stage of SAH.
CLINICAL TRIAL REGISTRATION URL
http://www.clinicaltrials.gov. Unique identifier: UMIN000003794.
背景与目的
对于患有较差级别动脉瘤性蛛网膜下腔出血（SAH）或 SAH 后迟发性脑缺血（DCI）的患者，尚未建立全身循环管理。本研究旨在检查这些患者的血流动力学变量并建立治疗策略。
方法
使用经肺温度稀释系统（PiCCO Plus）对 1 至 14 天的血流动力学变量进行了一项多中心前瞻性队列研究。采用曼-惠特尼检验对参数进行分析。采用多变量分析来确定与 DCI 发生相关的参数。
结果
受试者为 204 例患者，其中 138 例为较差级别 SAH（世界神经外科学联合会四级和五级），52 例发生 DCI。在第 2 天，较差级别 SAH 患者的血管外肺水指数、肺血管通透性指数和全身血管阻力指数明显大于较好级别 SAH 患者（世界神经外科学联合会 I-III 级）（P=0.049，P=0.039 和 P=0.038）。在第 1 天和第 2 天，较差级别 SAH 患者的心指数明显较低（P=0.027 和 P=0.011）。在 DCI 患者中，在第 3 至 5 天，整体舒张末期容积指数明显低于无 DCI 患者（P=0.0053；P=0.048；和 P=0.048）。多变量分析显示，SAH 早期（第 3-6 天）的中位数整体舒张末期容积指数、心指数和全身血管阻力指数与 DCI 的发生独立相关（P=0.023、P=0.013 和 P=0.003）。
结论
患有较差级别 SAH 的患者在早期发生心力衰竭样后负荷不匹配，而患有 DCI 的患者在 SAH 的早期阶段出现整体舒张末期容积指数（低血容量）降低。
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