早期气管切开联合过度通气在重型颅脑损伤中的临床应用价值

摘要

目的探讨早期气管切开联合轻～中度过度通气在治疗重型颅脑损伤（sTBI）中的临床应用价值。方法将80例sTBI患者（GCS评分3～8分）随机分为观察组和对照组各40例。观察组患者入院后24 h内行经皮气管切开并呼吸机短时间内维持轻～中度过度通气（HV），监测呼气末二氧化碳分压（PetCO2），使PetCO2维持在27～32 mmHg，30 min/次，4次/d（Q6h），持续7 d。对照组患者入院后持续面罩中流量供氧，出现呼吸衰竭时再行经皮气管切开及机械通气（未进行过度通气）。全部80例患者均予防治感染、脱水降颅压、脑保护、营养支持等对症支持治疗（有手术指征者及时行手术治疗），连续观察患者伤后第1～7天颅内压（ICP）的变化，所有病例于伤后6个月时根据GOS评估法判断疗效，分为良好、中残、重残、植物生存和死亡。结果观察组经过轻～中度过度通气后能使sTBI患者的ICP迅速下降，与对照组比较差异有统计学意义（P＜0.O1）。观察组与对照组患者半年后预后在良好、中残、重残、植物生存方面比较差异有统计学意义（P＜0.05），病死率比较差异无统计学意义（P＞0.05）。结论早期气管切开联合轻～中度过度通气在治疗sTBI中有利于降低颅内压，改善重症患者伤后6个月的生存质量。%Objective To discuss the clinical value of early tracheotomy combined with hyperventilation in severe traumatic brain injury(sTBI).Methods Eighty patients with sTBI (GCS 3~8) were randomly divided into the observation group and the control group .Within 24 h after admission the observation group′s patients received percutaneous tracheostomy,and in a short time maintained the light to moderate hyperventilation with ventilator .Moni-toring the end-tidal carbon dioxide partial pressure (PetCO2 ),the PetCO2 was maintained at 27~32 mmHg,each time for 30 min,4 times a day,for 7 days.Continuous moderate oxygen supply via face mask was used in control group ′s patients after admission until respiratory failure comes out ,then the percutaneous tracheostomy and mechanical venti-lation(not hyperventilation was performed ).All of the 80 patients received the treatment of preventing infections , re-ducing the intracranial pressure , cerebral protection, nutritional supporting and other symptomatic and supportive therapy.Within 7 days the changes of intracranial pressure (ICP) in the patients were continuously observed and 6 months after injury, the efficacy was evaluated according to GOS valuation method including 5 grades:good, moder-ate disability, severe disability, vegetative state, and death.Results ICP decreased more rapidly in the observation group than the control group, and the difference was statistically significant (P<0.01).After 6 months there were significant differences between the two groups in good , moderate disability, severe disability, vegetative state(P<0.05),without statistically significant difference in mortality rate (P>0.05).Conclusion The early tracheotomy combined with mild to moderate hyperventilation may be beneficial to decreasing ICP , and improving the survival quality for patients within 6 months after sTBI.