在重度创伤性脑损伤儿童中使用神经肌肉阻滞剂对急性并发症发生率和预后的影响：一项治疗性低温随机对照试验的二次分析
Effect of administration of neuromuscular blocking agents in children with severe traumatic brain injury on acute complication rates and outcomes: a secondary analysis from a randomized, controlled trial of therapeutic hypothermia.
作者信息
Chin Katherine H, Bell Michael J, Wisniewski Stephen R, Balasubramani Goundappa K, Kochanek Patrick M, Beers Sue R, Brown S Danielle, Adelson P David
机构信息
1Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA. 2Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA. 3Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA 4Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA. 5Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA. 6Barrow Neurological Institute of Phoenix Children's Hospital, Phoenix, AZ.
出版信息
Pediatr Crit Care Med. 2015 May;16(4):352-8. doi: 10.1097/PCC.0000000000000344.
OBJECTIVE
To evaluate the association between neuromuscular blocking agents and outcome, intracranial pressure, and medical complications in children with severe traumatic brain injury.
DESIGN
A secondary analysis of a randomized, controlled trial of therapeutic hypothermia.
SETTING
Seventeen hospitals in the United States, Australia, and New Zealand.
PATIENTS
Children (< 18 yr) with severe traumatic brain injury.
INTERVENTIONS
None for this secondary analysis.
MEASUREMENTS AND MAIN RESULTS
Children received neuromuscular blocking agent on the majority of days of the study (69.6%), and the modified Pediatric Intensity Level of Therapy scores (modified by removing neuromuscular blocking agent administration from the score) were increased on days when neuromuscular blocking agents were used (9.67 ± 0.21 vs 5.48 ± 0.26; p < 0.001). Children were stratified into groups based on exposure to neuromuscular blocking agents (group 1 received neuromuscular blocking agents each study day; group 2 did not). Group 1 had increased number of daily intracranial pressure readings more than 20 mm Hg (4.4 ± 1.1 vs 2.4 ± 0.5;p = 0.015) and longer ICU and hospital length of stay (p = 0.003 and 0.07, respectively, Kaplan-Meier). The Glasgow Outcome Score-Extended for Pediatrics at hospital discharge and 3, 6, and 12 months after traumatic brain injury and medical complications observed during the acute hospitalization were similar between groups.
CONCLUSIONS
Administration of neuromuscular blocking agents was ubiquitous and daily administration of neuromuscular blocking agents was associated with intracranial hypertension but not outcomes-likely indicating that increased injury severity prompted their use. Despite this, neuromuscular blocking agent use was not associated with complications. A different study design-perhaps using randomization or methodologies-of a larger cohort will be required to determine if neuromuscular blocking agent use is helpful after severe traumatic brain injury in children.
目的
评估神经肌肉阻滞剂与重度创伤性脑损伤患儿的预后、颅内压及医疗并发症之间的关联。
设计
对一项治疗性低温随机对照试验的二次分析。
地点
美国、澳大利亚和新西兰的17家医院。
患者
重度创伤性脑损伤患儿（<18岁）。
干预措施
本次二次分析未采取干预措施。
测量指标及主要结果
在研究的大多数日子里（69.6%），患儿接受了神经肌肉阻滞剂治疗，使用神经肌肉阻滞剂的日子里，改良的儿科治疗强度水平评分（通过从评分中去除神经肌肉阻滞剂的使用进行改良）有所增加（9.67±0.21对5.48±0.26；p<0.001）。根据神经肌肉阻滞剂的使用情况将患儿分层（第1组在每个研究日接受神经肌肉阻滞剂治疗；第2组未接受）。第1组每日颅内压读数超过20mmHg的次数更多（4.4±1.1对2.4±0.5；p=0.015），重症监护病房（ICU）和住院时间更长（分别为p=0.003和0.07，Kaplan-Meier法）。两组在创伤性脑损伤后出院时、3个月、6个月和12个月的儿科扩展格拉斯哥预后评分以及急性住院期间观察到的医疗并发症相似。
结论
神经肌肉阻滞剂的使用很普遍，每日使用神经肌肉阻滞剂与颅内高压相关，但与预后无关——这可能表明损伤严重程度增加促使了其使用。尽管如此，神经肌肉阻滞剂的使用与并发症无关。需要不同的研究设计——或许采用随机化或更大队列的方法——来确定神经肌肉阻滞剂在儿童重度创伤性脑损伤后是否有用。
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