课件：神经科危重病的监护治疗.ppt

* * * PEEP对ICP的影响 PEEP是否影响ICP？ 影响ICP的PEEP水平？ 何种患者的ICP易受到PEEP的影响？ PEEP对ICP影响的其他方式 进一步研究的途径 * ICP随颅内容积的变化趋势 * 12只实验兔，随机分为PEEP 0和10cmH2O 硬脑膜下注水 * 文献报道不统一 10 – 12 cmH2O以下影响不明显 建立容量和ICP监测 应用PEEP前首先补充血容量 避免MAP下降导致的CPP降低 * * J Neurosurg. 1991 Nov;75(5):731-9. Adverse effects of prolonged hyperventilation in patients with severe head injury: a randomized clinical trial.Muizelaar JP, Marmarou A, Ward JD, Kontos HA, Choi SC, Becker DP, Gruemer H, Young HF.Division of Neurological Surgery, Medical College of Virginia, Richmond.There is still controversy over whether or not patients should be hyperventilated after traumatic brain injury, and a randomized trial has never been conducted. The theoretical advantages of hyperventilation are cerebral vasoconstriction for intracranial pressure (ICP) control and reversal of brain and cerebrospinal fluid (CSF) acidosis. Possible disadvantages include cerebral vasoconstriction to such an extent that cerebral ischemia ensues, and only a short-lived effect on CSF pH with a loss of HCO3-buffer from CSF. The latter disadvantage might be overcome by the addition of the buffer tromethamine (THAM), which has shown some promise in experimental and clinical use. Accordingly, a trial was performed with patients randomly assigned to receive normal ventilation (PaCO2 35 +/- 2 mm Hg (mean +/- standard deviation): control group), hyperventilation (PaCO2 25 +/- 2 mm Hg: HV group), or hyperventilation plus THAM (PaCO2 25 +/- 2 mm Hg: HV + THAM group). Stratification into subgroups of patients with motor scores of 1-3 and 4-5 took place. Outcome was assessed according to the Glasgow Outcome Scale at 3, 6, and 12 months. There were 41 patients in the control group, 36 in the HV group, and 36 in the HV + THAM group. The mean Glasgow Coma Scale score for each group was 5.7 +/- 1.7, 5.6 +/- 1.7, and 5.9 +/- 1.7, respectively; this score and other indicators of severity of injury were not significantly different. A 100% follow-up review was obtained.