围术期脑保护的研究进展演示教学.pptx

围术期脑保护的研究进展解轶 2012年3月1 生理性的脑保护1． 1 选择性脑降温1． 2 控制血糖1． 3 控制血压和保证氧供1. 4 血红蛋白浓度1． 1 选择性脑降温选择性脑降温是指在离头部较近处加强热量散发，使颅内温度低于躯体温度，可以避免全身低温所带来的不利影响，同时又能有效地改善缺血缺氧性脑损伤。脑保护机制不仅与降低脑代谢率有关，还涉及抑制缺血缺氧诱发的“瀑布式反应”的进展，如抑制谷氨酸释放、减少自由基生成、抑制凋亡、保护血脑屏障等，并且可为其他治疗措施延长治疗时间窗。The National Acute Brain Injury Study: Hypothermia II was a randomized multicenter trial in which 97 patients with moderate-to-severe TBI received either normothermia or total-body hypothermia to 33°C for 48 hours. The primary outcome measure was the rate of poor outcome (ie, GOS showing severe disability, vegetative state, or death). This trial was terminated prematurely due to futility. There was no difference in the rate of poor outcome (60% vs. 45% for hypothermia and normothermia, respectively; P=0.67) or death (23% vs. 14%, P=0.52). Very early hypothermia induction in patients with severe brain injury (the National Acute Brain Injury Study: Hypothermia II): a randomised trial. Lancet Neurol. 2011;10:131–139.不过有一点可以肯定: 围术期高热会使临床结局变得更差1． 2 控制血糖大量研究证实，围术期控制血糖有助于改善患者神经功能预后。在一些危重和心脏手术患者中，严格控制围术期的血糖水平可以降低脑缺血发病率和病死率。围术期持续高血糖可增加缺血性脑损伤的范围，使得临床结局更差。McGirt 的研究发现，血糖＞ 11． 11 mmol /L ( 无论患者是否患有糖尿病) 可使颈动脉内膜剥脱术围术期脑卒中发生率增高。但是严格的血糖控制( 4． 44～ 6． 11 mmol /L) 可能会增加低血糖的风险。 Sui reported data from 43,933 men who underwent a comprehensive preventative medical between 1971 and 2002 （were free of myocardial infarction, stroke, cancer, or known diabetes mellitus）They were followed until either stroke, death, or the study end date (December 31, 2004) occurred. BG concentrations were stratified into 3 groups: (1) normal (80 to 109 mg/dL); (2) impaired (110 to 125 mg/dL); and (3) diabetes mellitus (=126 mg/dL). Nonfatal stroke rate was 10.3, 11.8, and 18.0 per 10,000 person-years in the 3 groups (P=0.002). Fatal stroke, with stroke rates of 2.1, 3.4, and 4.0 per 10,000 person-years (P=0.008). For fasting plasma glucose concentrations 110 mg/dL, each 10 mg/dL increase in serum glucose concentration was associated with a 6% greater risk of fatal strok