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目的探讨早期机械通气联合亚低温在重型颅脑损伤(STBI)患者治疗中的应用及其临床效果。方法选择116例STBI患者,随机分为对照组及治疗组,对照组依据病情给予呼吸支持,治疗组给予早期机械通气联合亚低温治疗,两组患者均依据病情给予外科治疗或保守治疗,连续监测两组患者脑灌注压(CPP)、颈静脉血氧饱和度(SjvO2)、脑组织氧分压(PbtO2)、脑动静脉氧压差(AVDO2)及脑组织摄氧率(CERO2),比较两组间不同时间点的差异。并对患者预后进行随访,比较患者康复情况。结果两组患者治疗前CPP、SjvO2、PbtO2、AVDO2及CERO2无差异,治疗后6、12、24、48 h及72 h,治疗组CPP分别为(67.0±7.2)、(65.9±7.4)、(71.4±9.1)、(78.2±12.6)、(75.9±10.7)mm Hg,对照组CPP分别为(55.4±6.9)、(55.4±6.9)、(49.6±5.6)、(51.9±8.0)、(56.4±7.8)mm Hg,治疗后各时间点治疗组CPP高于对照组(6 h t=4.31,P=0.006;12 h t=5.25,P=0.003;24 h t=7.10,P=0.000;48 h t=10.39,P=0.000;72 h t=5.10,P=0.002),治疗组SjvO2分别为(0.48±0.11)%、(0.52±0.16)%、(0.56±0.12)%、(0.54±0.12)%、(0.58±0.14)%,对照组SjvO2分别为(0.40±0.11)%、(0.38±0.12)%、(0.36±0.14)%、(0.32±0.13)%、(0.38±0.11)%,治疗组各时间点SjvO2高于对照组(6 h t=4.28,P=0.005;12 h t=4.79,P=0.004;24 h t=4.29,P=0.005;48 h t=3.84,P=0.009;t=4.26,P=0.005),治疗组PbtO2分别为(34.7±4.0)%、(35.2±3.8)%、(37.6±3.2)%、(39.2±4.1)%、(40.6±3.7)%,对照组PbtO2分别为(31.2±3.1)%、(28.4±3.3)%、(30.6±3.6)%、(29.5±3.9)%、(33.6±4.0)%,治疗后各时间点治疗组PbtO2高于对照组(6 h t=4.10,P=0.009;12 h t=3.82,P=0.010;24 h t=11.03,P=0.000,48 h t=6.14,P=0.002;72 h t=3.17,P=0.012),治疗组AVDO2分别为(3.84±0.33)、(3.34±0.35)、(3.28±0.29)、(3.16±0.22)、(3.19±0.34)mm Hg,对照组AVDO2分别为(4.92±0.51)、(5.30±0.47)、(5.46±0.35)、(5.31±0.40)、(5.38±0.51)mm Hg,各时间点治疗组AVDO2低于对照组(6 h t=6.02,P=0.002;12 h t=4.06,P=0.007;24 h t=8.02,P=0.001;48 h t=4.09,P=0.008;72 h t=4.11,P=0.007)。治疗组CERO2分别为(30.1±7.6)%、(22.4±6.5)%、(21.6±5.4)%、(20.4±4.6)%、(18.2±3.7)%,对照组CERO2分别为(4.92±0.51)%、(5.30±0.47)%、(5.46±0.35)%、(5.31±0.40)%、(5.38±0.51)%,治疗组各时间点CERO2低于对照组(6 h t=3.57,P=0.011;12 h t=5.10,P=0.004;24 h t=5.20,P=0.003;48 h t=5.77,P=0.003;72 h t=6.20,P=0.002)。两组患者随访6个月后,治疗组疗效优于对照组(Z=2.073,P=0.038)。结论早期机械通气联合亚低温能够改善STBI患者氧供,降低脑组织氧耗及神经损伤,改善预后,具有较好的临床效果。
Objective To investigate the application of early mechanical ventilation combined with mild hypothermia in the treatment of patients with severe craniocerebral injury (STBI) and its clinical effect. Methods One hundred and sixty-six patients with STBI were randomly divided into control group and treatment group. The control group received respiratory support according to the condition. The treatment group received early mechanical ventilation combined with mild hypothermia. Both groups were given surgical treatment or conservative treatment according to the condition, The CPP, SjvO2, PbtO2, AVDO2 and CERO2 of two groups were compared, Differences between groups at different time points. And follow-up of patients with prognosis, rehabilitation of patients compared. Results The CPP, SjvO2, PbtO2, AVDO2 and CERO2 before treatment were not different between the two groups. At 6, 12, 24, 48 and 72 h after treatment, the CPP in the treatment group were (67.0 ± 7.2) and (65.9 ± 7.4) (55.4 ± 6.9), (55.4 ± 6.9), (49.6 ± 5.6), (51.9 ± 8.0) and (56.4 ± 5.10) in the control group were significantly lower than those in the control group (71.4 ± 9.1, 78.2 ± 12.6 and 75.9 ± 10.7 mm Hg, ± 7.8) mm Hg. After treatment, the CPP in the treatment group was significantly higher than that in the control group at 6 ht = 4.31, P = 0.006; 12 ht = 5.25, P = 0.003; 24 ht = 7.10, P = 0.000; 48 ht = , P = 0.000; 72 ht = 5.10, P = 0.002). The levels of SjvO2 in the treatment group were (0.48 ± 0.11)%, (0.52 ± 0.16)%, (0.56 ± 0.12)%, (0.54 ± 0.12)%, ± 0.14%, respectively. The SjvO2 in the control group were (0.40 ± 0.11)%, (0.38 ± 0.12)%, (0.36 ± 0.14)%, (0.32 ± 0.13)% and SjvO2 was higher than the control group (6 ht = 4.28, P = 0.005; 12 ht = 4.79, P = 0.004; 24 ht = 4.29, P = 0.005; 48 ht = 3.84, P = 0.009; The PbtO2 in the treatment group were (34.7 ± 4.0)%, (35.2 ± 3.8)%, (37.6 ± 3.2)%, (39.2 ± 4.1)% and (40.6 ± 3.7)%, respectively ), (28.4 ± 3.3)%, (30.6 ± 3.6)%, (29.5 ± 3.9)% and (33.6 ± 4.0)%, respectively PbtO2 in the treatment group was higher than that in the control group (6 ht = 4.10, P = 0.009; 12 ht = 3.82, P = 0.010; 24 ht = 11.03, P = 0.000, 48 ht = = 0.012). The AVDO2 in the treatment group was (3.84 ± 0.33), (3.34 ± 0.35), (3.28 ± 0.29), (3.16 ± 0.22) and (3.19 ± 0.34) mm Hg, (5.30 ± 0.47), (5.46 ± 0.35), (5.31 ± 0.40) and (5.38 ± 0.51) mm Hg respectively. The AVDO2 in the treatment group at each time point was lower than that in the control group (6 ht = 6.02, P = 0.002; = 4.06, P = 0.007; 24 ht = 8.02, P = 0.001; 48 ht = 4.09, P = 0.008; 72 ht = 4.11, P = 0.007). The CER of the treatment group were (30.1 ± 7.6)%, (22.4 ± 6.5)%, (21.6 ± 5.4)%, (20.4 ± 4.6)%, (18.2 ± 3.7)%, %, (5.30 ± 0.47)%, (5.46 ± 0.35)%, (5.31 ± 0.40)%, (5.38 ± 0.51)% respectively. The CERO2 in the treatment group was lower than that in the control group at 6 ht = 3.57, 12 ht = 5.10, P = 0.004; 24 ht = 5.20, P = 0.003; 48 ht = 5.77, P = 0.003; 72 ht = 6.20, P = 0.002). After 6 months of follow-up, the curative effect of treatment group was better than that of control group (Z = 2.073, P = 0.038). Conclusion Early mechanical ventilation combined with mild hypothermia can improve the oxygen supply of STBI patients, reduce brain tissue oxygen consumption and nerve damage, improve prognosis, and have good clinical effect.