等渗透剂量的15高渗盐水和20甘露醇治疗重型颅脑损伤合并颅内高压的对比研究

摘要

目的：比较等渗透剂量的15%高渗盐水（HTS）和20%甘露醇治疗重型颅脑损伤合并颅内高压的疗效。方法重型颅脑损伤患者出现颅内高压事件时，随机交替接受0.42 ml/kg 15%HTS与2 ml/kg 20%甘露醇的降颅压治疗。药物经深静脉20 min以上快速滴注完成。在药物开始使用至颅内压（ICP）回升到20 mmHg期间，连续监测患者ICP，平均动脉压（MAP）、脑灌注压（CPP）及中心静脉压（CVP）。记录有效降颅压持续时间、ICP最大降幅及其时间；用药前及用药后1、3 h抽血查血钠浓度和血浆渗透压。结果静脉快速滴注15%HTS和20%甘露醇两者均可显著降低ICP（P<0.05），15%HTS在用药后23.6±7.1 min ICP降至最低点，最大降幅为9.3±3.1 mmHg，其有效降颅压时间为5.3±2.1 h。20%甘露醇在28.7±9.3 min ICP降至最低点，降幅为8.7±2.3 mmHg，有效降颅压时间持续4.5±2.3 h。两者的起效时间、作用持续时间及ICP降幅均无统计学差异（P>0.05）。CPP较用药前相比均有显著上升（P<0.05），使用15%HTS治疗后较20%甘露醇后CPP上升更显著（P<0.05）。两组MAP、血钠及渗透压变化无统计学差异（P>0.05）。结论渗透剂量的15%HTS与20%甘露醇在降颅压起效时间、最大降幅及持续降颅压时间上无显著差异，两者均可作为降低ICP的一线治疗药物。%Objective To compare the effects of 15%hypertonic saline and 20%mannitol in doses of similar osmotic burden for treatment of intracranial hypertension in patients with severe traumatic brain injury. Methods We used an alternating treatment protocol to compare the effects of hypertonic saline with that of mannitol given for episodes of increased intracranial pressure (ICP) in patients with severe brain injury. Standard guidelines for the management of severe traumatic brain injury were followed. For episodes of increased ICP, 20% mannitol (2 ml/kg, infused for over 20 min) and 15% saline (0.42 ml/kg, administered as a bolus via a central venous catheter) of similar osmotic burden were given alternately, with the choice of agent for the initial hypertensive event determined on a randomized basis. Reduction of ICP and duration of the action were recorded after each event. Results The data were collected from 33 patients with 237 hypertensive events. The mean decrease in ICP was 8.7 mm Hg at 28.7±9.3 min after mannitol treatment as compared with 9.3 mm Hg at 23.6±7.1 min after treatment with hypertonic saline (P>0.05). The mean duration of the effect was 270 min for mannitol and 318 min for hypertonic saline (P>0.05). Conclusion Treatment with 15% hypertonic saline and 20% mannitol in doses of similar osmotic burden produces similar effects in management of increased ICP in patients with severe traumatic brain injury in terms of the time of action onset, maximum ICP reduction, and duration of action.