嚴重頭部外傷病患最適當腦灌流壓之臨床研究

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Clinical research for evaluation of optimal cerebral perfusion ressure in severe traumatic brain injury

中文摘要

頭部外傷是外傷中最致命也是導致失能的最主要因素， 2000 年的準則提出以 CPP orientated treatment ，認為腦灌流壓大於 70mmHg 才足以維持適當的腦灌流壓，但2003 年則反而提出只要大於 60mmHg 即可防止腦部缺氧 6，更可減少因過度使用升壓劑或輸液來維持腦灌流壓而造成併發症（如ARDS）。由此可見如何取得適當的腦灌流壓值來防止腦部的缺血，並避免併發症至今仍是很值得再去探討的。

本研究共搜集自91 年 1 月 1 日至 94 年 3 月 31 日期間，共收集八家醫院之嚴重頭部外傷患者305 例，有效回收問卷 283 份。男女比為 3：1 (圖 1 )，男性死亡人數有108 人（50.9％）但未達統計上顯著差異（P:0.288）。各年齡層之死亡率雖無明顯之統計學之差異。進一步將入院診斷與預後結果做卡方檢定，以硬腦膜外出血者結果預後最好。入院時之昏迷指數越高則死亡率越低且神經功能恢復越好結論1. 入院診斷以硬腦膜外出血者結果預後最好。2. GCS 越高則死亡率越低且神經功能恢復越好。本研究結果發現顱內壓監測器的置入有助於患者之治療，可使患者有較好的預後。將顱內壓控制在20mmHg 以下，患者有較低的死亡率及失能程度ICP 大於 20mmHg 以上之病患將 CPP 閾值設定為 60 mmHg 只可改善存活率（P<0.001），但仍不能改善 GOS。可見 ICP 大於 20mmHg 之病患，其 CPP 只要能大於 60mmHg 其存活率將會大為提昇。在腦幹受損 GCS : 3-5 分的病人特別去執行CPP 使其大於 70 mmHg，可明顯改善存活率及並可改善 GOS，也就是說昏迷指數越低，越需要高的 CPP 值。小於 65 歲的人需要積極維持 CPP 大於60mmHg 有明顯改善存活率及 GOS；大於 65 歲的人，可能因為維持 CPP 而產生更多的併發症，進而影響預後。

英文摘要

The traumatic brain injury is the most main factor to cause die and lose ability.

The cerebral pressure perfusion (CPP) orientated treatment was suggested to maintain the proper CCP greater than 70mmHg in 2000 guideline. But in 2003, greater than 60mmHg will propose instead that to prevent brain ischemic change, and decrease the complications which cause by using inotropic medications or the infusion fluids to maintain the CCP (such as ARDS). Therefore, how to obtain the optimal CCP to prevent brain ischemic change, and avoid the complication from being very worth probing into again so far.

This research was collected from the 1st of January, 2002 to March 31, 2005 altogether, collect to 305 severe traumatic brain injury patients of eight hospitals

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altogether, retrieve 283 questionnaires effectively. Men and women are to 3: 1, male death toll have not reaching on counting showing by differencing but 108 (50.9%) (P=0.288). Although the mortality of all ages has no difference of obvious statistics. Admitted to hospital and diagnose that runs the K squire to assay with the prognosis result further, epidura hemorrhage (EDH) is the best result. High G.C.S. within 6 hours in admission will be good neurologic outcome and low mortality rate.

Conclusion. The diagnosis of EDH upon admission into hospital is the best result.

The higher GCS is lower mortality rate and good neural functional outcome. This result of study finds that the patient's with intracranial monitor can make the patient have better prognosis. Limit ICP below to 20mmHg, the patient has lower death rate and good neurologic functional outcome.

It is obvious that ICP is greater than the patient of 20mmHg, its CPP can only be greater than 60mmHg its survival rate and greatly promote. In damaged of brain stem: GCS 3-5 points of patients especially goes to carry out CPP to make it greater than 70 mmHg, can obviously improve the survival rate and and can improve neurologic functional outcome (GOS 0 , that is to say that the index is the lower G.C.S. , need high CPP value . The person smaller than 65 years old needs to keep CPP greater than 60mmHg to obviously improve survival rate and GOS actively; Greater than the person for 65 years, may produce more complications because of maintaining CPP, and then influence the prognosis.