两种气管内吸痰方法对重型颅脑损伤患者颅内压的影响

患者气管内吸痰可以改善通气,减少C02潴留,是颅脑损伤患者的重要护理措施之一。颅内压( intracranial pressure,ICP)、脑灌注压(cerebral perfusion pressure,CPP)、平均动脉压(mean artery pressure,MAP)是监护重型颅脑损伤患者病情的重要指标,由于气管内吸痰( endotracheal suction,ETS)刺激气管可引起静脉系统压力升高,可能使重型颅脑伤患者处于颅内高压及脑缺血状态,致残率、致死率高。本研究分别观察开放式吸痰法(open ETS)与密闭式吸痰法(closed ETS)对重型颅脑伤患者的平均动脉压( MAP)、颅内压(ICP)、脑灌注压(CPP)以及血氧饱和度等脑代谢的影响,比较两种气管内吸痰在临床应用的合理性,报道如下。     

脑氧代谢监测在颅内高压行气管内吸引术中的意义

目的研究气管内吸引术 (endotrachealsuctioning ,ETS)对兔急性脑内血肿致颅内高压状态下脑氧代谢的影响及其意义。方法实验动物麻醉后行气管切开插管 ,呼吸机辅助呼吸 ,并随机分成两组 ,对照组 (n =10 )和颅内高压组 (n =10 ) ,利用微泵注射自体血法建立兔急性脑内血肿模型。行开放式气管内吸引术 ,吸引负压 10 .0kPa ,吸引时程 10s。分别于吸引前、中、后 15min内动态监测ICP、MAP、CPP变化 ,同时运用颈内静脉插管技术及外周血气分析观察SjvO2 、CEO2 、AVDO2 变化。结果两组动物ETS后ICP均有短暂升高 (P <0 .0 5 ) ,而MAP基本不变。颅内高压组ETS后即时SjvO2 下降至 76 .9± 5 .3% (P <0 .0 1) ,CEO2 、AVDO2 明显上升 (P <0 .0 1) ,CPP下降 (P <0 .0 5 )。结论颅内高压状态下进行开放式气管内吸引术可引起脑缺血、缺氧反应 ,而短暂的ICP升高并无特异性。因此 ,在ETS时需重视脑氧继发性损害 ,SjvO2 监测有助于早期发现脑缺血、缺氧。     

两种气管内吸引术在颅内高压动物中的应用比较

目的 :研究颅内高压状态下开放式气管内吸引术 (Openendotrachealsuctioning,OpenETS)与闭合式气管内吸引术 (Closedendotrachealsuctioning ,ClosedETS)对平均动脉压 (MAP)、颅内压 (ICP)、脑灌注压 (CPP)和脑氧代谢等方面的影响及其意义。方法 :实验动物随机分成OpenETS组 (n =10 )和ClosedETS组 (n =10 ) ,麻醉后行气管切开插管 ,呼吸机辅助呼吸。利用微泵注射自体血法建立兔急性脑内血肿模型 ,待ICP稳定在较高水平后 ,分别进行两种气管内吸引术。于吸引前、后动态监测MAP、ICP、CPP变化 ,同时运用颈内静脉插管技术及外周血气分析观察颈静脉氧饱和度 (SjvO2 )、脑氧摄取率 (CEO2 )、脑动静脉氧差(AVDO2 )变化。结果 :两组动物吸引后即时MAP均升高 ,OpenETS组较ClosedETS组明显 (P <0 .0 5 )。吸引后即时ICP均短暂升高 ,两组变化趋势基本相同 ,大多于 5min内回落 ,其回复较SjvO2 快。吸引后即时OpenETS组SjvO2 下降至 76 .9%± 5 .3 %(P <0 .0 1) ,CEO2 、AVDO2 明显上升 (P <0 .0 1) ,CPP下降 (P <0 .0 1) ;而ClosedETS组SjvO2 上升 (P <0 .0 5 ) ,CEO2 、AVDO2 下降(P <0 .0 5 ) ,CPP变化无统计学意义。结论 :颅内高压状态下OpenETS可引起脑缺血、缺氧反应 ,而ClosedETS不损害脑灌注并维持足够脑氧     

颈内静脉氧饱和度与脑灌注压在重型颅脑损伤中的意义

目的 评估颈内静脉氧饱和度(SjvO2)作为重型颅脑损伤的预后指标及与脑灌注压(CPP)的相关性. 方法 回顾性分析2006年10月至2008年5月上海市闵行区中心医院收治的32例重型颅脑损伤患者,每6 h测定一次颈静脉搏氧饱和度,持续监测平均动脉压(MAP)及颅内压(ICP). 结果 SjvO2与重型颅脑损伤预后显著相关,SjvO2≤50%或SjvO2≥75%发作2次以上提示预后不良.在CPP＜70 mm Hg,SjvO2与CPP有显著的相关性,而CPP≥70 mm Hg组患者中,SjvO2与CPP无明显相关性. 结论 SjvO2与CPP监测相结合,能较可靠地反映脑供血及脑代谢状况,对重型颅脑损伤的治疗有指导意义.     

高渗盐水治疗重型颅脑创伤合并休克的疗效研究

目的探讨高渗盐水对重型颅脑创伤合并休克患者的治疗疗效。方法回顾性分析88例严重颅脑创伤合并休克患者的病例资料,根据治疗方案分为两组:A组38例,采用7.5%高渗盐水治疗;B组50例,采用20%甘露醇治疗,监测两组入院后用药4h内各患者颅内压(ICP)、平均动脉压(MAP)、脑灌注压(CPP)和血钠浓度等的变化及评估患者远期的转归。结果 A组和B组比较,用药即时、0.5h、1h时ICP差异均无统计学意义(t分别=-1.92、1.32、0.28,P均>0.05),但A组用药2h和4h时ICP明显低于B组,差异均有统计学意义(t分别=-5.79、-9.32,P均<0.05),且A组患者CPP明显高于B组,差异均有统计学意义(t分别=8.08、7.60,P均<0.05)。两组用药2h内的血钠浓度差异均无统计学意义(t分别=0.86、0.50、0.43、1.83、1.20,P均>0.05)。在远期转归上,两组在6h内死亡率、28d存活率、院内感染率及需处理的高钠血症发生率上差异均无统计学意义(χ2分别=0.54、1.09、0.02、0.12,P均>0.05)。结论重型颅脑创伤合并休克患者早期应用7.5%高渗盐水,不仅能够安全有效地降低ICP,还能够提高患者CPP,有利于休克病人的复苏。     

动态脑灌注压监护在重型颅脑损伤患者治疗中的应用

目的探讨动态脑灌注压（CPP）监护在重型颅脑损伤患者治疗中的应用与意义。方法选择伤后72 h内首诊入院的重型颅脑损伤患者120例随机分为非监护组和监护组各60例。监护组其中伤后〈24 h内入院36例,伤后24～72 h入院24例,进行持续CPP和同步生理监护,以患者入院时的CPP值分为A组（CFP≥9.33 kPa）和B组（CPP〈9.33 kPa）,根据监测指标的变化给予早期临床干预。结果伤后24 h内入院的监护组中,B组患者平均动脉压（MABP）为8.33±1.08 kPa、血液PaO27.88±2.78 kPa,明显低于A组的MABP12.68±1.13 kPa和PaO212.22±2.33 kPa,经统计学比较差异有显著性意义（P〈0.05）;伤后24、72 h入院的监护组中,B组颅内压（ICP）为4.04±0.12 kPa,较A组2.55±0.09 kPa明显增高（P〈0.05）。结论重型颅脑损伤后的早期动态CPP监护,有助于病情变化的正确判断,可为疾病的正确治疗、护理及判断其预后提供依据。     

重型颅脑损伤病人体位变化对颅内压及脑灌注压的影响

[目的]分析重型颅脑损伤病人体位变化对颅内压(ICP)和脑灌注压(CPP)的影响.[方法]取12种不同体位,统计比较各种体位变化前后ICP、CPP变化.[结果]仰卧位头部抬高45°、仰卧屈膝位30°及45°可使颅内压明显降低,而左侧卧位头部抬高15°、右侧卧位头部抬高15°后颅内压则明显升高.左侧卧位头部抬高30°脑灌注压明显下降.[结论]不同体位可显著影响重型颅脑损伤病人颅内压和脑灌注压的变化.     

重型颅脑损伤术后患者动态脑灌注压的监测及其护理

目的:探讨与分析重型颅脑损伤术后患者动态脑灌注压(CPP)监测的临床应用价值和护理要点。方法:选择首诊入院的符合重型颅脑损伤纳入标准的患者110例,并随机分别为非监护组和监护组各55例。非监护组采取常规治疗;监护组进行持续动态脑灌注压监测和同步生理监护,根据监测指标的变化采取相应早期临床干预治疗。结果:监护组治疗前后平均ICP分别为5.72和1.75,治疗前后差异具有显著统计学意义(P<0.01);监护组治疗前后平均CPP分别为6.01和9.86,治疗前后差异具有统计学意义(P<0.05);监护组治疗并发症和常规组并发症发生率差异具有显著统计学意义(P<0.01);监护组治疗疗效和常规组疗效比较差异具有显著统计学意义(P<0.01)。结论:重型颅脑损伤后的早期动态CPP监护可作为病情变化的判断指征,为重型颅脑损伤的正确治疗提供论据,可降低重型颅脑损伤术后的致残率和死亡率。合理细致的护理对于进行动态CPP监护患者的治疗有至关重要的作用,保证其顺利实施。     

早期机械通气对严重颅脑创伤患者颅内压和脑代谢的影响

目的　观察早期机械通气及开颅探查术对严重颅脑创伤患者颅内压 (ICP)、脑灌注压 (CPP)、颈内静脉血氧饱和度 (SjvO2 )及动脉 -颈内静脉血乳酸浓度之差 (VADL)的影响。方法　重型颅脑损伤患者 2 1例 ,入院后给予早期机械通气治疗 ,并在明确诊断后 1h内行开颅探查颅内血肿清除 +去骨瓣减压术。分别于气管插管机械通气前、通气后 10min、通气后 30min、开颅前、开颅后 5个时相点通过侧脑室置管监测ICP ,计算CPP ;同时分别抽取动脉、颈内静脉血行血气分析及乳酸测定。结果　与机械通气前相比 ,机械通气后 10minICP显著降低 (P <0 0 5 ) ,CPP显著升高 (P <0 0 5 ) ,SjvO2 、VADL无显著变化。机械通气后 30min和开颅前ICP、VADL显著升高 (P <0 0 1和P <0 0 5 ) ,CPP、SjvO2 显著降低 (P <0 0 5 ) ,开颅后ICP、VADL较开颅前显著下降 (P <0 0 1和P <0 0 5 ) ,CPP、SjvO2 显著升高 (P <0 0 1)。结论　长时间机械通气治疗不能降低重型颅脑损伤患者ICP、改善脑代谢 ;及时行开颅探查颅内血肿清除术是降低ICP、改善脑代谢的有效方法。     

经颅多普勒在颅内感染和脑出血初期颅高压的对比研究

目的观察经颅多普勒(TCD)频谱参数在颅内感染和脑出血患者初期颅高压的相关变化,进而预测颅内压(ICP)和脑灌注压(CPP)并比较TCD预测的准确性。方法对42例颅内感染患者128次腰穿和45例脑出血患者138次腰穿测压前均行TCD检查并记录血压。结果随着ICP升高,颅内感染和脑出血TCD均表现出高阻力血流频谱,收缩期血流速度(Vs)无明显变化,舒张期血流速度(Vd)减慢,血管博动指数(PI)增大。颅内感染颅内动脉血流速度明显快于脑出血(P<0.01),平均动脉压、脑灌注压明显低于脑出血(P<0.01)。颅内感染TCD参数、平均动脉压(MAP)与ICP、CPP的回归方程分别为:ICPe=1.026 17.165×PI;CPPe=1.411-17.091×PI 0.971×MAP。预测和实测ICP、CPP相关系数分别为0.594、0.910。ICP预测差值在5mmHg内阳性预测率为63.28%,CPP为62.5%。脑出血TCD相关参数与ICP、CPP的逐步回归方程分别为:ICPe=-7.096 20.474×PI 0.053×MAP;CPPe=7.096-20.474×PI 0.947×MAP。预测和实测ICP、CPP相关系数分别为0.796、0.977,预测差值在5mmHg内阳性预测率均为89.91%。结论颅内感染多合并炎性血管痉挛,根据特征性TCD频谱参数改变可较准确预测ICP、CPP,对脑出血的预测准确性好于颅内感染。     

不同吸痰深度对重型颅脑损伤机械通气患者颅内压力的影响

目的 研究不同吸痰深度对重型颅脑损伤机械通气患者颅内压(ICP)和呼吸机相关性肺炎(VAP)发生率的影响.方法 选取重症监护病房58例行机械通气及ICP监护的患者,分为3组,A组、B组、C组分别采取浅吸痰、改良深部吸痰、深部吸痰 3种吸痰方式,分析3组吸痰前后ICP数值变化、吸痰间隔时间和频率;分析机械通气7d内的VAP发生率.结果 A组对ICP影响最小,吸痰间隔最短,吸痰频率最高,VAP发生率60.0％.B组在吸痰瞬间ICP升高,但平均ICP高峰＜20mmHg(1 mmHg=0.133kPa),并在2min内回复基线水平,吸痰间隔较长,吸痰频率较低,VAP发生率为26.3％.C组在吸痰瞬间ICP最高,达(22.63±4.02) mmHg,需5min回复基线水平,吸痰间隔最长,吸痰频率最低,VAP发生率为21.1％.结论 针对重型颅脑损伤患者的气道管理,改良深部吸痰是一种比较安全有效的选择.     

Cardiopulmonary and intracranial pressure changes related to endotracheal suctioning in preterm infants

Although endotracheal (ET) suctioning is performed frequently in sick newborn infants, its effects on cardiorespiratory variables and intracranial pressure (ICP) have not been thoroughly documented in neonates greater than 24 h who were not paralyzed while receiving mechanical ventilation. This study evaluates these changes in preterm infants who required ventilatory assistance. We measured transcutaneous PO2 and PCO2 (PtcO2 and PtcCO2, respectively), intra-arterial BP, heart rate, ICP, and cerebral perfusion pressure (CPP) before, during, and for at least 5 min after ET suctioning in 15 low birth weight infants less than 1500 g and less than or equal to 30 days of age. One infant was studied twice. A suction adaptor was used to avoid disconnecting the patient from the ventilator and to attempt to minimize hypoxemia and hypercapnia during suctioning. The patients were studied in the supine position and muscle relaxants were not used. PtcO2 decreased 12.1% while PtcCO2 increased 4.7% 1 min after suctioning; however, greater increases in mean BP (33%) and ICP (117%) were observed during suctioning. CPP also increased during the procedure. ICP returned to baseline almost immediately, whereas BP remained slightly elevated 1 min after suctioning. Our findings demonstrate that ET suctioning significantly increases BP, ICP, and CPP in preterm infants on assisted ventilation in the first month of life. These changes appear to be independent of changes observed in oxygenation and ventilation.     

密闭式吸痰在重度颅脑外伤患者中的临床应用

目的观察密闭式吸痰对重度颅脑外伤患者血氧饱和度的影响。方法选择53例重度颅脑外伤患者并应用机械通气辅助呼吸的危重病人,随机分为密闭式吸痰组和开放式吸痰组,比较两组吸痰前后1min,经皮血氧饱和度（SpO2）的变化。结果开放式吸痰组吸痰后较吸痰前SpO2有明显下降,差异具有显著性（P〈0.05）,密闭式吸痰组SpO2吸痰前后比较差异无统计学意义（P〉0.05）;两组SpO2吸痰前比较差异无显著性（P〉0.05）,吸痰后开放式吸痰组SpO2低于密闭式吸痰组,差异具有显著性（P〈0.01）。结论密闭式吸痰不影响重性颅脑外伤患者氧合作用,可避免吸痰造成患者颅内压的波动,适用于重性颅脑外伤患者。     

肺复张对急性呼吸窘迫综合征患者开放吸痰后氧合及血流动力学的影响

目的研究肺复张（LR）对急性呼吸窘迫综合征（ARDS）患者开放吸痰（ETS）后的治疗价值。方法选择20例需要机械通气的ARDS／急性肺损伤（ALI）患者，在标准通气稳定30min后按流程随机分组。ETs＋LR组在ETs后立即实施LR，60min后行第2次ETS，但不实施LR；ETS—LR组在ETS后不实施LR，60min后行第2次ETS，并立即实施LR。监测实验过程中各时间点的动脉血氧分压（PaO2）及血流动力学参数，如中心静脉压（CVP）、心率（HR）、平均动脉压（MAP）。结果所有患者血流动力学参数基本稳定，无心律失常发生。患者实施ETS后PaO2显著下降，ETS前后比较差异有显著性（P均〈0．05）；ETS后实施与不实施LR比较，在5和15min时PaO2差异有显著性（P均〈0．05）。结论ARDS／ALI患者在ETS后立即予以LR，患者可以耐受，其血流动力学未受到显著干扰，且可以迅速改善低氧血症。     

The effects of lidocaine on intracranial hypertension.

In head-injured adults sudden increases in intracranial pressure (ICP) frequently occur in response to noxious stimuli, such as endotracheal suctioning (ETS). Transient increased ICP may have potentially harmful effects upon head-injured patients. One intervention clinicians believe to be efficacious in blunting ICP response to ETS is administration of lidocaine hydrochloride. This article critiques studies that examined effects of lidocaine in attenuating the ICP response to suctioning and similar stimuli. The literature to date, while providing conflicting results, does demonstrate tentative support for the use of lidocaine prior to ETS as a means of attenuating a rise in ICP. Support was found for the intratracheal route of administration. Additionally when intratracheal lidocaine was coupled with muscle relaxants or other anesthetic agents administered at appropriate times prior to suctioning, large rises in ICP may be effectively blunted.     

Comparison of open and closed suction on safety,efficacy and nursing time in a paediatric intensive care unit

BackgroundEndotracheal suctioning (ETS) is one of the most common procedures performed in the paediatric intensive care. The two methods of endotracheal suctioning used are known as open and closed suction, but neither method has been shown to be the superior suction method in the Paediatric Intensive Care Unit (PICU).PurposeThe primary purpose was to compare open and closed suction methods from a physiological, safety and staff resource perspective.MethodsAll paediatric intensive care patients with an endotracheal tube were included. Between June and September 2011 alternative months were nominated as open or closed suction months. Data were prospectively collected including suction events, staff involved, time taken, use of saline, and change from pre-suction baseline in heart rate (HR), mean arterial pressure (MAP) and oxygen saturation (SpO₂). Blocked or dislodged ETTs were recorded as adverse events.FindingsClosed suction was performed more often per day (7.2 vs 6.0, p < 0.01), used significantly less nursing time (23 vs 38 min, p < 0.01) and had equivalent rates of adverse events compared to open suction (5 vs 3, p < 0.23). Saline lavage usage was significantly higher in the open suction group (18% vs 40%). Open suction demonstrated a greater reduction in SpO₂ and nearly three times the incidence of increases in HR and MAP compared to closed suction. Reductions in MAP or HR were comparable across the two methods.ConclusionsIn conclusion, CS could be performed with less staffing time and number of nurses, less physiological disturbances to our patients and no significant increases in adverse events.     

The standard of suction for patients undergoing endotracheal intubation.

The purpose of this study was to determine whether using a standard method of endotracheal suctioning, to ensure consistent use of available knowledge, had any impact on patient care. Using experimental study design, the results of two different methods of suctioning in a cardiovascular surgery intensive care unit were compared. One method was the suctioning procedure applied by the nurses working in the intensive care unit. The other one, standard suctioning procedure, was developed based on the related literature and applied to the patients assigned to the experimental group by the researcher herself. Mean arterial blood pressure (MAP), heart rate (HR), and arterial blood gases (ABGs) were measured before the procedure, immediately after, 5 and 15 minutes after the procedures for both control and experimental group. The majority of the nurses suctioning the control group did not evaluate the ABGs after endotracheal suctioning, none of these patients was given oxygen both before and after the suctioning, and suctioning took longer time than recommended. To compare the results of the two different methods, the values of MAP, HR, PO2 (arterial oxygenation), PCO2 (arterial carbondioxide), and HCO3- (hydrogen carbonate) 15 minutes after the procedure were used, and the differences between the two methods were statistically significant (P < 0.05).     

不同呼气末正压水平对肺复张患者脑灌注压及血流动力学的影响

目的 观察肺复张(RM)对颅内压(ICP)、脑灌注压(CPP)及平均动脉压(MAP)的影响.方法 选择因严重颅脑疾患伴肺损伤需要进行机械通气的6例患者,在进行RM的同时进行持续ICP、MAP、中心静脉压(CVP)、脉搏血氧饱和度(SpO2)等监测.RM采用压力控制通气模式,逐步提升呼气末正压(PEEP)的方法.结果 6例患者共进行22例次RM,2例次分别在3 cm H2O(1 cm H2O=0.098 kPa)和6 cm H2O PEEP水平出现MAP、CPP显著降低而终止.其余20例次RM中不同PEEP水平相应的MAP、CVP、ICP、CPP平均值与基础值相比差异均无统计学意义(P均>0.05);MAP与CPP呈高度相关性(r=0.706,P=0.000).20例次RM中,单次RM内参数间呈高度相关性的比例:MAP与CPP占85%(17/20);PEEP与CVP占75%(15/20);PEEP与ICP占75%(15/20);PEEP与CPP占40%(8/20).22例次RM中MAP随PEEP变化有6种趋势:8例次相对稳定;6例次随PEEP增加而降低,然后随PEEP降低而逐渐回升;2例次随PEEP增加而升高,随PEEP降低逐渐回到基础值;2例次随PEEP增加而降低,PEEP降低后MAP不能相应升高;2例次随PEEP增加而增加,在PEEP降到基础值后MAP仍维持在高水平;2例次随PEEP增加MAP急剧降低而终止RM.11例次RM中ICP随PEEP升高而升高,随PEEP降低而降低;6例次在RM过程中无明显变化;3例次RM后ICP处于高值末回到基线.12例次RM中CPP随PEEP升高而降低,随PEEP降低而增加,并随PEEP回到基线时恢复到基础值;6例次无明显变化;2例次CPP维持在低值,分别在PEEP回到基线后10 min、20 min恢复到基础值.结论 RM对MAP、ICP、CPP的影响存在明显的个体差异.ICP监测有助于保障脑部疾患合并肺损伤患者RM实施的安全性.     

不同吸痰负压对重型颅脑损伤气管切开术后病人的效果研究

目的:探讨不同吸引负压对重型颅脑损伤病人气管切开术后的影响。方法:选择神经外科监护病房65例重型颅脑损伤并行气管切开术后病人为研究对象,随机分为A、B、C三组,分别采取90～120 mmHg、121～150 mmHg、151～180 mmHg压力进行气管内吸痰,分析3组病人吸痰前后ICP数值变化、吸痰频率、吸痰间隔、吸痰彻底评分以及7 d内气道黏膜损伤的发生率。结果:A组ICP的影响最小,达到的峰值最低,恢复至基线的时间最短,24 h吸痰频率最高,吸痰间隔最短,但吸痰效果最不理想。B组在吸痰后ICP升高,但平均ICP峰值较A组升高,并在2min左右恢复基线,24 h吸痰频率较低,吸痰间隔较长,吸痰效果较理想。C组对ICP的影响最大,达到的峰值最高,恢复至基线的时间最长,24 h吸痰频率最低,吸痰间隔最长,但吸痰效果最理想。3组吸痰负压7 d内气道黏膜损伤的发生率的比较有统计学意义(P<0.05)。结论:重型颅脑损伤病人气管切开术后宜采用121～150 mmHg负压进行气管内吸痰,较为安全有效。