Zhou Xiaofen, Chen Han, Yu Rongguo, Zhao Jianxiang, Xu Jingqing, Zhang Yingrui, Yan Wanli
Department of Critical Care Medicine, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou 350001, Fujian, China. Corresponding author: Chen Han, Email:
Zhonghua Wei Zhong Bing Ji Jiu Yi Xue. 2020 Aug;32(8):960-964. doi: 10.3760/cma.j.cn121430-20200130-00148.
To explore the significance of multimodal monitoring in the monitoring and treatment of neurocritical care patients.
104 neurocritical care patients admitted to the department of Critical Care Medicine of Fujian Provincial Hospital from March 2019 to January 2020 were enrolled. Patients were randomly assigned into two groups, with 52 in each group. In the routine monitoring treatment group, heart rate, blood pressure, respiratory rate and the changes in consciousness and pupils were monitored after operation. The patients were treated with routine medicine to reduce intracranial pressure (ICP), maintain proper cerebral perfusion pressure (CPP), balance fluid intake and output, and maintain the airway clear. Patients in the multimodal monitoring treatment group were treated with invasive ICP monitoring, ultrasound to assess brain structure, ultrasound to measure optic nerve sheath diameter (ONSD), transcranial color doppler (TCCD), internal jugular venous blood oxygen saturation monitoring, near-infrared spectroscopy (NIRS), non-invasive cerebral blood oxygen saturation monitoring and quantitative electroencephalogram monitoring. According to the monitoring results, the patients were given targeted treatment with the goal of controlling ICP and improving brain metabolism. The length of intensive care unit (ICU) stay, the incidences of neurological complications (secondary cerebral infarction, cerebral hemorrhage, high intracranial pressure, etc.), and the incidences of poor prognosis [6 months after the onset of Glasgow outcome score (GOS) 1 to 3] were compared between the two groups. Spearman rank correlation analysis of the correlation between invasive ICP and the ICP value which was calculated by TCCD. The receiver operating characteristic (ROC) curve of invasive ICP and pulsatility index of middle cerebral artery (PI) were used to predict poor prognosis.
The length of ICU stay in the multimodal monitoring treatment group was significantly shorter than that of the routine monitoring treatment group (days: 6.27±3.81 vs. 9.61±5.09, P < 0.01), and the incidence of neurological complications was significantly lower than that in the routine monitoring treatment group (9.62% vs. 25.00%, P < 0.05). In the multimodal monitoring treatment group, 37 cases had a good prognosis and 15 cases had a poor prognosis, while the routine monitoring treatment group had a good prognosis in 27 cases and a poor prognosis in 25 cases. The incidence of poor prognosis in the multimodal monitoring treatment group was lower than that of the routine monitoring treatment group (28.85% vs. 48.08%, P < 0.05). In the multimodal monitoring treatment group, the invasive ICP and PI of patients with good prognosis were significantly lower than those of patients with poor prognosis [invasive ICP (mmHg, 1 mmHg = 0.133 kPa): 16 (12, 17) vs. 22 (20, 24), PI: 0.90±0.33 vs. 1.39±0.58, both P < 0.01]. There was no significant difference in resistance index of the middle cerebral artery (RI) between the good prognosis group and the poor prognosis group (0.63±0.12 vs. 0.66±0.15, P > 0.05). There was a positive correlation between the invasive ICP and the ICP value which was calculated by TCCD (r = 0.767, P < 0.001). ROC curve analysis showed that the area under ROC curve (AUC) of invasive ICP for poor prognosis prediction was 0.906, the best cut-off value was ≥ 18 mmHg, the sensitivity was 86.49%, and the specificity was 86.67%. The AUC of PIMCA for poor prognosis prediction was 0.759, the best cut-off value was ≥ 1.12, the sensitivity was 81.08%, and the specificity was 60.00%. The AUC of invasive ICP was greater than PI (Z = 2.279, P = 0.023).
Comprehensive analysis of multimodal monitoring indicators for neurocritical care patients to guide clinical treatment can reduce the length of hospital stay, and reduce the risk of neurosurgery complications and disability; invasive ICP can predict poor prognosis of neurocritical care patients.
探讨多模态监测在神经重症监护患者监测与治疗中的意义。
选取2019年3月至2020年1月福建省立医院重症医学科收治的104例神经重症监护患者。将患者随机分为两组，每组52例。常规监测治疗组术后监测心率、血压、呼吸频率及意识和瞳孔变化。给予患者常规药物治疗以降低颅内压（ICP）、维持适当的脑灌注压（CPP）、平衡液体出入量并保持气道通畅。多模态监测治疗组患者接受有创ICP监测、超声评估脑结构、超声测量视神经鞘直径（ONSD）、经颅彩色多普勒（TCCD）、颈内静脉血氧饱和度监测、近红外光谱（NIRS）、无创脑血氧饱和度监测及定量脑电图监测。根据监测结果，对患者进行针对性治疗，目标是控制ICP并改善脑代谢。比较两组患者重症监护病房（ICU）住院时间、神经并发症（继发性脑梗死、脑出血、高颅内压等）发生率及预后不良发生率[发病6个月后格拉斯哥预后评分（GOS）1至3分]。对有创ICP与TCCD计算的ICP值进行Spearman等级相关分析。采用有创ICP和大脑中动脉搏动指数（PI）的受试者操作特征（ROC）曲线预测预后不良。
多模态监测治疗组ICU住院时间显著短于常规监测治疗组（天数：6.27±3.81 vs. 9.61±5.09，P<0.01），神经并发症发生率显著低于常规监测治疗组（9.62% vs. 25.00%，P<0.05）。多模态监测治疗组37例预后良好，15例预后不良，而常规监测治疗组27例预后良好，25例预后不良。多模态监测治疗组预后不良发生率低于常规监测治疗组（28.85% vs. 48.08%，P<0.05）。多模态监测治疗组中，预后良好患者的有创ICP和PI显著低于预后不良患者[有创ICP（mmHg，1 mmHg = 0.133 kPa）：16（12，17）vs. 22（20，24），PI：0.90±0.33 vs. 1.39±0.58，均P<0.01]。预后良好组与预后不良组大脑中动脉阻力指数（RI）差异无统计学意义（0.63±0.12 vs. 0.66±0.15，P>0.05）。有创ICP与TCCD计算的ICP值呈正相关（r = 0.767，P<0.001）。ROC曲线分析显示，有创ICP预测预后不良的ROC曲线下面积（AUC）为0.906，最佳截断值为≥18 mmHg，灵敏度为86.49%，特异度为86.67%。大脑中动脉搏动指数（PIMCA）预测预后不良的AUC为0.759，最佳截断值为≥1.12，灵敏度为81.08%，特异度为60.00%。有创ICP的AUC大于PI（Z = 2.279，P = 0.023）。
综合分析神经重症监护患者的多模态监测指标以指导临床治疗，可缩短住院时间，降低神经外科并发症及致残风险；有创ICP可预测神经重症监护患者的预后不良。
