颅内高压药物治疗后的颅内压反应。

Intracranial pressure response after pharmacologic treatment of intracranial hypertension.

机构信息

From the Shock Trauma Anesthesia Research Organized Research Center (K.C., S.Y., P.F.H., H.H.C., B.B., T.M.S., D.M.S.), University of Maryland School of Medicine; and R Adams Cowley Shock Trauma Center (K.C., S.Y., P.F.H., H.H.C., B.B., T.M.S., D.M.S.), Baltimore, Maryland; and Duke University School of Medicine (K.C.), Durham, North Carolina.

出版信息

J Trauma Acute Care Surg. 2014 Jul;77(1):47-53; discussion 53. doi: 10.1097/TA.0000000000000270.

DOI:10.1097/TA.0000000000000270

PMID:24977754

Abstract

BACKGROUND

The accepted treatment of increased intracranial pressure (ICP) in patients experiencing severe traumatic brain injury is multimodal and algorithmic, obscuring individual effects of treatment. Using continuous vital signs monitoring, we sought to measure treatment effect and ascertain the accuracy of manual data recording.

METHODS

Patients older than 17 years, admitted and requiring ICP monitoring between 2008 and 2010 at a high-volume urban trauma center, were retrospectively evaluated. Timing and dose of ICP-directed therapy were recorded from paper and electronic medical records. ICP data were collected automatically at 6-second intervals and from manual charts. A statistical mixed model was applied to all data to account for multiple sampling.

RESULTS

A total of 117 patients met inclusion criteria; 450 treatments were administered when nursing records indicate an ICP greater than 20 mm Hg, while 968 treatments were given when ICP was greater than 20 mm Hg by automated data. Pharmacologic treatments identified include hypertonic saline (HTS), mannitol, barbiturates, and dose escalations of propofol or fentanyl infusions. Treatment with HTS resulted in the largest ICP decrease of the treatments examined, with a 1-hour ICP reduction of 8.8/9.9 mm Hg (for a small/large dose) according to manual data and a reduction of 3.0/2.4 mm Hg according to automated data. Propofol and fentanyl escalations resulted in smaller but significant ICP reductions. Mannitol (n = 8) resulted in statistically insignificant trends down in the first hour but rebounded by the second hour after administration. The average ICP in the hour before medication administration was higher for barbiturates (27 mm Hg) and mannitol (32 mm Hg) than for the other interventions (18-19 mm Hg).

CONCLUSION

ICP fell after administration of HTS, mannitol, or barbiturates and showed continued improvement after 2 hours. ICP fell initially after treatment with short-acting propofol and fentanyl but trended back up after 2 hours. Manually recorded data consistently overestimated treatment effectiveness. Automated data collection gives a more accurate assessment of patient status and responsiveness to treatment.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

摘要

背景

目前，对于严重创伤性脑损伤患者颅内压（ICP）升高的治疗方法是多模式和算法化的，这掩盖了治疗的个体效果。通过使用连续生命体征监测，我们试图测量治疗效果并确定手动数据记录的准确性。

方法

我们回顾性评估了 2008 年至 2010 年在一家大容量城市创伤中心住院并需要 ICP 监测的年龄大于 17 岁的患者。从纸质和电子病历中记录 ICP 靶向治疗的时间和剂量。ICP 数据以 6 秒的间隔自动采集，并从手动图表中采集。应用统计混合模型对所有数据进行分析，以考虑多次采样。

结果

共有 117 例患者符合纳入标准；当护理记录显示 ICP 大于 20mmHg 时，给予了 450 次治疗，而当自动数据显示 ICP 大于 20mmHg 时，给予了 968 次治疗。确定的药物治疗包括高渗盐水（HTS）、甘露醇、巴比妥类药物，以及异丙酚或芬太尼输注的剂量升级。在所检查的治疗中，HTS 治疗导致 ICP 下降最大，根据手动数据，1 小时 ICP 下降 8.8/9.9mmHg（小/大剂量），根据自动数据下降 3.0/2.4mmHg。异丙酚和芬太尼升级导致较小但有统计学意义的 ICP 下降。给予甘露醇 8 例，在给药后第 1 小时内呈统计学意义的 ICP 下降趋势，但在第 2 小时后反弹。给药前 1 小时的平均 ICP 为：巴比妥类药物（27mmHg）和甘露醇（32mmHg）高于其他干预措施（18-19mmHg）。