Ziegenfuss T, Wiercinski A
Klinik für Anaesthesiologie und Intensivmedizin, Universitätskliniken des Saarlandes, Homburg.
Zentralbl Chir. 1996;121(11):963-78.
Multiple trauma often leads to systemic inflammatory reaction and multiple organ dysfunction. Modulation of this response may be promising. Several pharmacologic approaches, such as antioxidants (e.g. superoxidedismutase), calcium channel blockers (e.g. diltiazem), cytokines (e.g. interferone gamma), and modulators of intracellular signal transduction pathways (e.g. pentoxiphylline) have been shown to improve outcome in experimental models and/or in clinical pilot studies. However, up to now no definitive evidence has been provided in prospective, randomized, and blinded "intention to treat" trials that these agents are able to reduce mortality and morbidity of the traumatized patient. Hence, supportive care of failing organs, treatment of hypoxemia and maintenance of an appropriate systemic blood pressure remain the mainstay of critical care therapy. Widely accepted therapeutic measures are (i) immediate treatment of hypoxia by administration of oxygen and ventilatory support, if needed, to maintain an oxygen tension of 60 mmHg or higher (ii) maintenance of adequate oxygen content by transfusion of red packed cells in order to restore a hematocrit of 23-30% (iii) treatment of hypovolemia by infusion of crystalloids, colloids and blood products (iv) normoventilation and restoration of a normal or elevated blood pressure in patients with severe head injury (v) immobilisation and early administration of methylprednisolone in patients with spinal cord injury (vi) analgesia by administration of opioids, non-steroidal antiinflammatory drugs, or ketamine (vii) sedation with benzodiazepines, gamma-hydroxbutyrate or propofol (viii) early enteral nutrition (ix); antibiotic therapy of infections (x) pressure controlled ventilation in patients with acute lung injury (xi) continuous veno-venous hemofiltration in patients developing acute renal failure and (xii) early surgical interventions to control bleeding and/or to evacuate intracerebral hematomas.
多发伤常导致全身炎症反应和多器官功能障碍。调节这种反应可能具有前景。几种药理学方法，如抗氧化剂（如超氧化物歧化酶）、钙通道阻滞剂（如地尔硫䓬）、细胞因子（如干扰素γ）以及细胞内信号转导途径调节剂（如己酮可可碱），已显示在实验模型和/或临床前期研究中可改善预后。然而，迄今为止，在前瞻性、随机、双盲的“意向性治疗”试验中，尚未提供确凿证据表明这些药物能够降低创伤患者的死亡率和发病率。因此，对功能衰竭器官的支持性治疗、低氧血症的治疗以及维持适当的全身血压仍然是重症监护治疗的主要支柱。广泛接受的治疗措施包括：（i）若需要，通过给予氧气和通气支持立即治疗缺氧，以维持氧分压在60mmHg或更高；（ii）通过输注红细胞来维持足够的氧含量，以恢复血细胞比容至23 - 30%；（iii）通过输注晶体液、胶体液和血液制品治疗低血容量；（iv）对重度颅脑损伤患者进行正常通气并恢复正常或升高的血压；（v）对脊髓损伤患者进行固定并早期给予甲基泼尼松龙；（vi）通过给予阿片类药物、非甾体类抗炎药或氯胺酮进行镇痛；（vii）使用苯二氮䓬类药物、γ-羟基丁酸或丙泊酚进行镇静；（viii）早期肠内营养；（ix）感染的抗生素治疗；（x）对急性肺损伤患者进行压力控制通气；（xi）对发生急性肾衰竭的患者进行持续静脉-静脉血液滤过；以及（xii）早期手术干预以控制出血和/或清除脑内血肿。
