一种用于重型颅脑损伤多模态监测的床边单毛刺孔方法
Summary
介绍了一种利用床边单孔技术记录重型颅脑损伤患者多模态监测信号的方法。
Abstract
颅内压监测 (ICP) 是包括创伤性脑损伤在内的严重急性脑损伤患者重症监护管理的基石。虽然比较方案中的海拔是常见的, 但关于这些比较方案海拔的测量和处理数据相互矛盾。人们日益认识到, 脑组织供求平衡的变化至关重要, 因此需要测量多种模式。方法不是标准的, 因此本文提供了一个床边的描述, 单一的毛孔方法, 以多方式监测, 允许通过探针, 旨在测量不仅 ICP, 但脑组织氧气, 血液流动,颅内脑电图。介绍了患者选择标准、手术程序以及在重症监护期间固定探头的实际注意事项。这种方法是易于执行, 安全, 有保障, 和灵活的采用各种多方式监测方法, 旨在检测或防止继发脑损伤。
Introduction
严重的脑损伤, 如创伤性脑损伤 (TBI) 或蛛网膜下腔出血, 可能导致昏迷, 这是一种临床状态, 患者对其环境没有反应。神经外科医生和神经强化者严重依赖临床神经检查, 但严重的脑损伤可能会导致无法检测到与大脑生理环境有关的变化: 颅内压升高 (ICP), 减少脑血流, 或非惊厥癫痫发作和扩散去极化。这些生理障碍可导致进一步的损伤, 称为继发性脑损伤。
严重创伤性脑损伤后, ICP 的升高很常见, 可能导致血液流动减少, 从而导致继发性脑损伤和神经恶化。ICP 中的升高记录在89% 的患者中, 1 和神经恶化发生在四分之一, 死亡率从9.6% 上升到 56.4%2。因此, ICP 的测量是继发性脑损伤发展最常用的生物标志物, 有大脑创伤基金会3的 iib 推荐。
ICP 的测量是50多年前首创的,4使用导管, 导管是通过一个麻钻颅骨造口术引入 (通常被互换称为一个毛孔), 通常创建在额骨在瞳孔中线刚刚前到冠状缝合线, 并通过进入心室。然而, 这些外心室引流导管 (Evd) 需要中线解剖, 这并不总是存在后, 严重的脑损伤, 和错位可能会损害深部结构, 如丘脑。虽然 evd 允许引流脑脊液作为一个潜在的治疗方案, 但 evd 的出血率平均为 6-7% 5,6.
通过毛孔引入骨髓内压力监测仪, 是出血率为 3-5%7,8 的常见替代品和辅助剂。这些较小的探头位于头骨内表下2-3 厘米处, 可连续测量压力, 但没有像 Evd 那样排出脑脊液的选项。现有的队列研究9和 meta 分析10,11表明将 icp 作为继发性脑损伤的标志物可以提高生存率;然而, 一项随机对照试验比较了 ICP 的治疗基于神经检查单独与测量 icp 未能证明效益 12。
神经外科和神经重症监护的进展使人们认识到, 大脑生理学比单独的 ICP 要复杂得多。研究表明, 大脑 13损伤后, 大脑内的自我调节功能受损, 导致区域脑血流调节的变化。此外, 使用颅内脑电图 (ieeg) 电极的记录, 可以识别非惊厥发作的负担14和扩散的去极化15 。改善脑组织氧 (PbtO2) 的策略被证明是治疗的目标, 并在大型多中心第二阶段临床试验16中被证明是可行的。
本文介绍了一种技术, 允许同时测量多种模式–包括 ICP、PbtO2、rCBF 和 iEEG–在需要密集的严重急性脑损伤患者的床边放置一个简单的单毛孔孔护理。包括患者的选择和手术方法, 这项技术包括在内。这项技术特别允许放置多个探针, 以提供有针对性的监测多个生理参数, 这可能提供一个更敏感和具体的预警系统的继发性脑损伤。
Protocol
Representative Results
Discussion
本文提供了一种将多探针引入急性脑损伤后大脑的方法的实用元素, 以促进多模态方法对继发性脑损伤背后的生理理解。现有的脑外伤基金会指南建议在创伤后的特定患者中使用颅内压监测 (IIb 级)3, 尽管有证据表明, 即使在大容量 i 级创伤下, 也可以不同地进行这种监测中心19,20。这在一定程度上可能是由于技术 (心室引流与实质探针<em…
Disclosures
The authors have nothing to disclose.
Acknowledgements
作者希望感谢 Norberto Andaluz 博士 (路易斯维尔大学) 在率先采用这一技术方面发挥的领导作用。我们还要感谢神经外科居民的辛勤工作, 他们完善了这项技术, 并感谢神经危重护理护理人员为了病人的利益而采用了这一新技术。
Materials
| Cranial Access Kit | Integra LifeSciences | NA | Cranial Access kit |
| Neurovent PTO | Qflow 500 | NA | ICP/PBtO2 catheter |
| Qflow 500 Perfusion Probe | Hemedex, Inc | #H0000-1600 | rCBF catheter |
| Qflow 500 Titanium Bolt | Hemedex, Inc | #H0000-3644 | Cranial access bolt |
| Spencer Depth Electrode | Ad-Tech Medical Instrument Corporation | NA | iEEG |
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