Ghajar J, Hariri R J, Narayan R K, Iacono L A, Firlik K, Patterson R H
Aitken Neurosurgery Laboratory, Department of Surgery, Cornell University Medical College, New York, NY 10021.
Crit Care Med. 1995 Mar;23(3):560-7. doi: 10.1097/00003246-199503000-00023.
This survey was designed to study current practices in the monitoring and treatment of patients with severe head injury in the United States.
The collected data represent answers to telephone interviews of nurse managers, clinical specialists, and staff nurses specializing in neurotrauma care at 277 randomly selected hospitals from a total pool of 624 trauma centers. Overall, 261 (94%) centers participated in the survey. Of the participating centers, 219 (84%) were providers of care for severely head-injured patients. In order to assess reliability and account for differences among respondents, personnel from 40 (15%) centers were resurveyed 6 months later and a different nursing professional was interviewed, although the questions remained the same.
The largest group of respondents came from level I centers (49%), followed by level II (32%) and level III (2%). Thirty-four percent of the surveyed hospitals had a designated neurologic/neurosurgical intensive care unit, and 24% of all units surveyed were under the direction of either a neurosurgeon or a neurologist. Twenty-eight percent of the centers routinely performed intracranial pressure monitoring, while 7% of the centers reported never using this technique. The use of ventriculostomy catheters for intracranial pressure monitoring was employed in 72% of the centers, but cerebrospinal fluid drainage was utilized by only 44% of the hospitals. The percentage of patients who had their intracranial pressure monitored was significantly higher in level I trauma centers and at hospitals that treated larger numbers of severely head-injured patients (15 to 30 patients per month, which represented 15% of the hospitals surveyed). Hyperventilation and osmotic diuretics were used in 83% of centers to reduce intracranial hypertension. The administration of barbiturates was reported in 33% of the units as a treatment for intracranial hypertension. Corticosteroids were used more than half of the time in 64% of trauma centers. Twenty-nine percent of the centers reported aiming for PaCO2 values of < 25 torr (< 3.3 kPa).
The survey data indicate that there is a considerable variation in the management of patients with severe head injury in the United States. The establishment of guidelines for the management of head injury based on available scientific data and moderated by practical and financial considerations may lead to improvement in the standard of care.
本调查旨在研究美国严重颅脑损伤患者监测与治疗的当前实践情况。
收集的数据代表了对624家创伤中心中随机选取的277家医院的护士经理、临床专家以及专门从事神经创伤护理的护士进行电话访谈的答复。总体而言，261家（94%）中心参与了调查。在参与调查的中心中，219家（84%）为严重颅脑损伤患者提供护理。为评估可靠性并考虑受访者之间的差异，6个月后对40家（15%）中心的人员进行了重新调查，并采访了另一名护理专业人员，尽管问题保持不变。
最大的受访者群体来自一级中心（49%），其次是二级中心（32%）和三级中心（2%）。34%的受访医院设有指定的神经科/神经外科重症监护病房，所有受访病房中有24%由神经外科医生或神经科医生指导。28%的中心常规进行颅内压监测，而7%的中心报告从未使用过该技术。72%的中心使用脑室造瘘导管进行颅内压监测，但只有44%的医院进行脑脊液引流。在一级创伤中心以及每月治疗大量严重颅脑损伤患者（每月15至30例患者，占受访医院的15%）的医院中进行颅内压监测的患者百分比显著更高。83%的中心使用过度换气和渗透性利尿剂来降低颅内高压。33%的病房报告使用巴比妥类药物治疗颅内高压。64%的创伤中心超过一半的时间使用皮质类固醇。29%的中心报告目标是使动脉血二氧化碳分压值<25托（<3.3千帕）。
调查数据表明，美国严重颅脑损伤患者的管理存在相当大的差异。根据现有科学数据并结合实际和经济考虑制定颅脑损伤管理指南可能会提高护理标准。
