实践指南更新建议摘要：意识障碍：美国神经病学学会指南制定、传播和实施小组委员会；美国康复医学学会；以及国家残疾、独立生活和康复研究所在此报告。
Practice guideline update recommendations summary: Disorders of consciousness: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology; the American Congress of Rehabilitation Medicine; and the National Institute on Disability, Independent Living, and Rehabilitation Research.
机构信息
From the Department of Physical Medicine and Rehabilitation (J.T.G.), Spaulding Rehabilitation Hospital and Harvard Medical School; Department of Psychiatry (J.T.G.), Massachusetts General Hospital, Boston; Department of Neurology (D.I.K.), Boston University School of Medicine; Braintree Rehabilitation Hospital (D.I.K.), MA; Department of Neurology and Neuroscience (N.D.S.), Weill Cornell Medical College, New York, NY; Moss Rehabilitation Research Institute (J.W.), Elkins Park, PA; Bronson Neuroscience Center (E.J.A.), Bronson Methodist Hospital, Kalamazoo, MI; Department of Pediatrics, Division of Child Neurology (S.A.), Loma Linda University School of Medicine, CA; Department of Neurology (R.B.), University of Rochester Medical Center, NY; Indiana University Department of Physical Medicine & Rehabilitation (F.M.H.), University of Indiana School of Medicine, Indianapolis; Coma Science Group-GIGA Research and Department of Neurology (S.L.), Sart Tillman Liège University & University Hospital, Liège, Belgium; Department of Neurology (G.S.F.L.), Uniformed Services University of Health Sciences, Bethesda; Department of Neurology (G.S.F.L.), Johns Hopkins University, Baltimore, MD; James A. Haley Veterans' Hospital (R.N.-R.), US Department of Veterans Affairs, Tampa, FL; Crawford Research Institute (R.T.S.), Shepherd Center, Atlanta, GA; Center for Rehabilitation Science and Engineering, Department of Physical Medicine & Rehabilitation (R.T.S.), Virginia Commonwealth University School of Medicine, Richmond; Division of Physical Medicine & Rehabilitation (S.Y.), University of Mississippi School of Medicine; Brain Injury Program (S.Y.), Methodist Rehabilitation Center, Jackson, MS; Heart Rhythm Society (T.S.D.G.), Washington, DC; Department of Neurology (G.S.G.), University of Kansas Medical Center, Kansas City; and Department of Neurology (M.J.A.), University of Florida College of Medicine, Gainesville.
出版信息
Neurology. 2018 Sep 4;91(10):450-460. doi: 10.1212/WNL.0000000000005926. Epub 2018 Aug 8.
OBJECTIVE
To update the 1995 American Academy of Neurology (AAN) practice parameter on persistent vegetative state and the 2002 case definition on minimally conscious state (MCS) and provide care recommendations for patients with prolonged disorders of consciousness (DoC).
METHODS
Recommendations were based on systematic review evidence, related evidence, care principles, and inferences using a modified Delphi consensus process according to the AAN 2011 process manual, as amended.
RECOMMENDATIONS
Clinicians should identify and treat confounding conditions, optimize arousal, and perform serial standardized assessments to improve diagnostic accuracy in adults and children with prolonged DoC (Level B). Clinicians should counsel families that for adults, MCS (vs vegetative state [VS]/unresponsive wakefulness syndrome [UWS]) and traumatic (vs nontraumatic) etiology are associated with more favorable outcomes (Level B). When prognosis is poor, long-term care must be discussed (Level A), acknowledging that prognosis is not universally poor (Level B). Structural MRI, SPECT, and the Coma Recovery Scale-Revised can assist prognostication in adults (Level B); no tests are shown to improve prognostic accuracy in children. Pain always should be assessed and treated (Level B) and evidence supporting treatment approaches discussed (Level B). Clinicians should prescribe amantadine (100-200 mg bid) for adults with traumatic VS/UWS or MCS (4-16 weeks post injury) to hasten functional recovery and reduce disability early in recovery (Level B). Family counseling concerning children should acknowledge that natural history of recovery, prognosis, and treatment are not established (Level B). Recent evidence indicates that the term chronic VS/UWS should replace permanent VS, with duration specified (Level B). Additional recommendations are included.
目的
更新 1995 年美国神经病学学会 (AAN) 关于持续性植物状态的实践参数和 2002 年关于最小意识状态 (MCS) 的病例定义，并为持续性意识障碍 (DOC) 患者提供护理建议。
方法
建议基于系统评价证据、相关证据、护理原则以及根据 AAN 2011 流程手册（经修订）使用改良 Delphi 共识流程进行的推断。
建议
临床医生应识别和治疗混杂情况，优化觉醒，并进行连续标准化评估，以提高成人和儿童持续性意识障碍的诊断准确性 (B 级)。临床医生应告知家属，对于成年人来说，MCS（与植物状态 [VS]/无反应觉醒综合征 [UWS] 相比）和创伤性（与非创伤性相比）病因与更好的结果相关 (B 级)。当预后不佳时，必须讨论长期护理问题 (A 级)，承认预后并非普遍不佳 (B 级)。结构 MRI、SPECT 和昏迷恢复量表修订版可协助成人预测预后 (B 级)；没有证据表明在儿童中可以提高预后准确性的测试。始终应评估和治疗疼痛 (B 级)，并讨论支持治疗方法的证据 (B 级)。对于创伤性 VS/UWS 或 MCS（损伤后 4-16 周）的成年人，临床医生应开氨苯甲异恶唑（100-200mg，bid），以促进功能恢复并在恢复早期减少残疾 (B 级)。关于儿童的家庭咨询应承认恢复的自然史、预后和治疗尚未确定 (B 级)。最近的证据表明，慢性 VS/UWS 的术语应替代永久性 VS，并指定持续时间 (B 级)。此外还有其他建议。
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