John Hopkins University, Baltimore, MD, United States of America.
Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States of America.
Am J Emerg Med. 2019 Sep;37(9):1665-1671. doi: 10.1016/j.ajem.2018.11.041. Epub 2018 Nov 29.
Spontaneous intracranial hemorrhage (sICH) that increases intracranial pressure (ICP) is a life-threatening emergency often requiring intubation in Emergency Departments (ED). A previous study of intubated ED patients found that providing ≥5 interventions after initiating mechanical ventilation (pMVI) reduced mortality rate. We hypothesized that pMVIs would lower blood pressure variability (BPV) in patients with sICH and thus improve survival rates and neurologic outcomes.
We performed a retrospective study of adults, who were transferred to a quaternary medical center between 01/01/2011 and 09/30/2015 for sICH, received an extraventricular drain during hospitalization. They were identified by International Classification of Diseases, version 9 (430.XX, 431.XX), and procedure code 02.21. Outcomes were BPV indices, death, and being discharged home.
We analyzed records from 147 intubated patients transferred from 40 EDs. Forty-one percent of patients received ≥5 pMVIs and was associated with lower median successive variation in systolic blood pressure (BP) (31,[IQR 18-45) compared with those receiving 4 or less pMVIs (38[IQR 16-70]], p = 0.040). Three pMVIs, appropriate tidal volume, sedative infusion, and capnography were significantly associated with lower BPV. In addition to clinical factors, BP (OR 26; 95% CI 1.2, >100) and chest radiography (OR 0.3; 95% CI 0.09, 0.9) were associated with mortality rate. Use of quantitative capnography (OR 8.3; 95%CI, 4.7, 8.8) was associated with increased likelihood of being discharged home.
In addition to disease severity, individual pMVIs were significantly associated with BPV and patient outcomes. Emergency physicians should perform pMVIs more frequently to prevent BPV and improve patients' outcomes.
自发性颅内出血（sICH）导致颅内压（ICP）升高，常需要在急诊室（ED）进行插管。先前一项关于插管 ED 患者的研究发现，在开始机械通气后实施≥5 项干预措施可降低死亡率。我们假设，sICH 患者的机械通气后干预（pMVIs）会降低血压变异性（BPV），从而提高生存率和神经功能结局。
我们对 2011 年 1 月 1 日至 2015 年 9 月 30 日期间因 sICH 转至四级医疗中心的成年人进行了回顾性研究，这些患者在住院期间接受了脑室外引流。通过国际疾病分类，第 9 版（430.XX，431.XX）和程序代码 02.21 对他们进行了识别。结果为 BPV 指数、死亡和出院回家。
我们分析了从 40 个 ED 转来的 147 名插管患者的记录。41%的患者接受了≥5 项 pMVIs，与接受 4 项或更少 pMVIs 的患者相比，收缩压（BP）的中位连续变化较小（31[IQR 18-45]与 38[IQR 16-70]，p=0.040）。3 项 pMVIs，即适当的潮气量、镇静剂输注和二氧化碳描记术与较低的 BPV 显著相关。除临床因素外，BP（OR 26；95%CI 1.2，>100）和胸部 X 线（OR 0.3；95%CI 0.09，0.9）与死亡率相关。使用定量二氧化碳描记术（OR 8.3；95%CI，4.7，8.8）与更有可能出院回家相关。
除疾病严重程度外，个别 pMVIs 与 BPV 和患者结局显著相关。急诊医师应更频繁地进行 pMVIs，以防止 BPV 并改善患者结局。
