蛛网膜下腔出血后外置脑室引流的管理：一项多机构调查
Management of External Ventricular Drains After Subarachnoid Hemorrhage: A Multi-Institutional Survey.
作者信息
Chung David Y, Leslie-Mazwi Thabele M, Patel Aman B, Rordorf Guy A
机构信息
Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, 02114, USA.
Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
出版信息
Neurocrit Care. 2017 Jun;26(3):356-361. doi: 10.1007/s12028-016-0352-9.
BACKGROUND
Patients with aneurysmal subarachnoid hemorrhage (SAH) often develop hydrocephalus requiring an external ventricular drain (EVD). The best available evidence suggests that a rapid EVD wean and intermittent CSF drainage is safe, reduces complications, and shortens ICU and hospital length of stay as compared to a gradual wean and continuous drainage. However, optimal EVD management remains controversial and the baseline practice among neurological ICUs is unclear. Therefore, we sought to determine current institutional practices of EVD management for patients with aneurysmal SAH.
METHODS
An e-mail survey was sent to attending intensivists and neurosurgeons from 72 neurocritical care units that are registered with the Neurocritical Care Research Network or have been previously associated with the existing literature on the management of EVDs in critically ill patients. Only one response was counted per institution.
RESULTS
There were 45 out of 72 institutional responses (63%). The majority of responding institutions (80%) had a single predominant EVD management approach. Of these, 78% favored a gradual EVD weaning strategy. For unsecured aneurysms, 81% kept the EVD continuously open and 19% used intermittent drainage. For secured aneurysms, 94% kept the EVD continuously open and 6% used intermittent drainage. Among continuously drained patients, the EVD was leveled at 18 (unsecured) and 11 cm HO (secured) (p < 0.0001). When accounting for whether the EVD strategy was to enhance or minimize CSF drainage, there was a significant difference in the management of unsecured versus secured aneurysms with 42% using an enhance drainage approach in unsecured patients and 92% using an enhance drainage approach in secured patients (p < 0.0001).
CONCLUSION
Most institutions utilize a single predominant EVD management approach, with a consensus toward a continuously open EVD to enhance CSF drainage in secured aneurysm patients coupled with a gradual weaning strategy. This finding is surprising given that the best available evidence suggests that the opposite approach is safe and can reduce ICU and hospital length of stay. We recommend a critical reassessment of the approach to the management of EVDs. Given the potential impact on patient outcomes and length of stay, more research needs to be done to reach a threshold for practice change, ideally via multicenter and randomized trials.
背景
动脉瘤性蛛网膜下腔出血（SAH）患者常并发脑积水，需要进行脑室外引流（EVD）。现有最佳证据表明，与逐渐撤机和持续引流相比，快速撤机和间歇性脑脊液引流是安全的，可减少并发症，并缩短重症监护病房（ICU）住院时间和住院总时长。然而，最佳的EVD管理仍存在争议，神经ICU的基线实践尚不清楚。因此，我们试图确定动脉瘤性SAH患者EVD管理的当前机构实践。
方法
向72个神经重症监护病房的主治重症医学专家和神经外科医生发送了电子邮件调查，这些病房已在神经重症监护研究网络注册，或此前曾参与过有关重症患者EVD管理的现有文献研究。每个机构只统计一份回复。
结果
72个机构中有45个回复（63%）。大多数回复机构（80%）采用单一的主要EVD管理方法。其中，78%倾向于逐渐撤机策略。对于未夹闭的动脉瘤，81%保持EVD持续开放，19%采用间歇性引流。对于已夹闭的动脉瘤，94%保持EVD持续开放，6%采用间歇性引流。在持续引流的患者中，EVD的水平设定为18（未夹闭）和11cm H₂O（已夹闭）（p<0.0001）。在考虑EVD策略是增强还是减少脑脊液引流时，未夹闭和已夹闭动脉瘤的管理存在显著差异，42%的未夹闭患者采用增强引流方法，92%的已夹闭患者采用增强引流方法（p<0.0001）。
结论
大多数机构采用单一的主要EVD管理方法，对于已夹闭动脉瘤患者，普遍倾向于持续开放EVD以增强脑脊液引流，并采用逐渐撤机策略。鉴于现有最佳证据表明相反的方法是安全的，且可缩短ICU住院时间和住院总时长，这一发现令人惊讶。我们建议对EVD管理方法进行批判性重新评估。鉴于对患者预后和住院时长的潜在影响，需要开展更多研究以达到实践改变的阈值，理想情况下通过多中心随机试验进行。
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