南方医科大学学报

南方医科大学学报 ›› 2021, Vol. 41 ›› Issue (1): 111-115.doi: 10.12122/j.issn.1673-4254.2021.01.16

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限制性液体管理策略对重型颅脑损伤患者的临床效果：51例前瞻性随机对照临床试验

赵士兵，徐德才，李 锐，邹 琪，陈真真，汪华学，何先弟   

  • 出版日期:2021-01-26 发布日期:2021-01-26

Clinical efficacy of restrictive fluid management in patients with severe traumatic brain injury

  • Online:2021-01-26 Published:2021-01-26

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摘要：

目的 探讨限制性液体管理策略对重型颅脑损伤患者的应用效果。方法 采用前瞻性随机对照研究，选择蚌埠医学院第一附属医院2019年1月~2020年6月收治的预计ICU住院时间≥7 d的重型颅脑损伤术后患者，按随机数字表法，分为治疗组（行限制性液体管理策略，n=25），对照组（行常规液体管理策略，n=26）。收集手术时间、术中液体平衡数据，分别在术后入ICU时和入ICU 1、3、7 d行超声测量视神经鞘直径（ONSD）、大脑中动脉搏动指数（MCA-PI）、下腔静脉直径（IVC），并收集相应时间点格拉斯哥昏迷评分（GCS）、神经元特异性烯醇化酶（NSE）、瞳孔直径、平均动脉压、心率、累计液体平衡等资料，记录机械通气时间、ICU住院时间和28 d病死率。结果 两组患者在手术时间、术中液体平衡、入ICU时ONSD、MCA-PI、IVC等方面差异没有统计学意义（P>0.05）。累计液体平衡：两组1 d均为正平衡，3~7 d为负平衡，相同时间点，治疗组负平衡量显著大于对照组（P<0.05），且随治疗时间延长，负平衡量不断加大。ONSD、MCA-PI 均呈现先高后低的趋势，两组1 d就较基线增大（P<0.05），组间无差异（P>0.05），3 d达到峰值，7 d下降，相同时间点治疗组明显低于对照组（P<0.05）。NSE在1 d两组无差异（P>0.05），在3 d升高到峰值，对照组更高（P<0.05），7 d治疗组回落至1 d水平，对照组仍高于1 d。两组28 d病死率无明显差异（P>0.05），治疗组机械通气时间、ICU住院时间、气管切开数量均少于对照组（P<0.05）。 结论 应用限制性液体管理策略能更好地实现液体负平衡，减轻脑水肿，降低ONSD、MCA-PI，改善NSE、GCS等预后指标，减少机械通气时间和ICU住院时间，降低气管切开率，但对28 d病死率无影响。

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Abstract:

Objective To investigate the effects of restrictive fluid management in patients with severe traumatic brain injury (sTBI). Methods Between January, 2019 and June, 2020, we randomly assigned 51 postoperative patients (stay in the ICU of no less than 7 days) with sTBI into treatment group (n=25) with restrictive fluid management and the control group (n=26) with conventional fluid management. The data of optic nerve sheath diameter (ONSD), middle cerebral artery pulsatility index (MAC- PI), neuron-specific enolase (NSE) level, inferior vena cava (IVC) diameter, Glascow Coma Scale (GCS) score, mean arterial blood pressure, heart rate, and fluid balance of the patients were collected at ICU admission and at 1, 3 and 7 days after ICU admission, and the duration of mechanical ventilation, ICU stay, and 28-day mortality were recorded. Results The cumulative fluid balance of the two groups were positive on day 1 and negative on days 3 and 7 after ICU admission; at the same time points, the patients in the treatment group had significantly greater negative fluid balance than those in the control group (P<0.05). In both of the groups, the ONSD and MCA-PI values were significantly higher on day 1 than the baseline (P<0.05), reached the peak levels on day 3, and decreased on day 7; at the same time point, these values were significantly lower in the treatment group than in the control group (P<0.05). No significant difference was found in NSE level on day 1 between the two groups (P>0.05); on day 3, NSE level reached the peak level and was significantly higher in the control group (P<0.05); on day 7, NSE level was lowered the level of day 1 in the treatment group but remained higher than day 1 level in the control group. The 28-day mortality rate did not differ significantly between the two groups (16.00% vs 23.08%, P>0.05); the duration of mechanical ventilation, length of ICU stay, and the number of tracheotomy were all significantly shorter or lower in the treatment group than in the control group (P<0.05). Conclusions Restrictive fluid management can reduce cerebral edema and improve the prognosis but does not affect the 28-day mortality of patients with sTBI.

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