重型颅脑损伤患者甘露醇、速尿和白蛋白降颅压作用的临床观察

目的观察甘露醇、速尿和白蛋白在不同使用方法和剂量上的降颅压效果,探讨临床合理的药物降颅压方法。方法124例重型颅脑损伤患者随机分为5组,全部进行持续颅内压(ICP)监测,连续观察静脉使用甘露醇、速尿和白蛋白后的ICP、血钾、血钠和血尿素氮(BUN)的变化。结果甘露醇和速尿降ICP作用明显(P<0.05);半量甘露醇加速尿或白蛋白降ICP作用显著(P<0.05)且持续时间长(P<0.05);降ICP的过程中可能出现电解质、肾功能的异常和ICP的反跳现象。结论半量甘露醇+速尿降ICP的方法值得临床提倡;半量甘露醇联合使用中、大剂量白蛋白在有条件的情况下也是适宜的降ICP方法。     

甘露醇治疗颅内高压的临床研究

本课题旨在通过观察不同剂量甘露醇及配伍速尿降颅内压效果及对血浆渗透压、肾功能、水电解质的影响,揭示其利弊,指导临床合理用药。     

速尿和甘露醇引起的颅内压、血清渗透压和电解质的变化

神经外科病人注射甘露醇使脑体积缩小常伴有一些副作用,例如颅压反跳,脑和循环血量一过性增多,凝血和血粘稠度变化,血清渗透压增高和电解质减少等。磺胺类利尿药—速尿主要抑制远端肾小管的再吸收,可用以降低脑含水量,因副作用较少可以取代甘露醇。作者分别测定甘露醇和速尿对颅内压,血清渗透压和电解质的影响并加以比较。本组共20例患脑动脉瘤、动静脉畸形或脑瘤的病人择期施行开颅术。术前均无高颅压体征。一律选用氟烷—笑气—氧麻醉,控制呼吸使PaCO_2保持在25～30托。一组一次注入甘露醇1克/公斤;另一组一次静注速尿1毫克/公斤,并在手术前,麻醉诱导,利尿开始、药效最高与利尿结束以及术后分别测定颅内压,血细胞压     

不同浓度高渗盐水和甘露醇降颅压效果及不良反应的比较

目的比较3%、7.5%高渗盐水(HS)和20%甘露醇降颅压有效性、安全性。方法 24例重型颅脑损伤患者接受不同浓度高渗盐水及20%甘露醇治疗,用药后6h内测定颅内压(ICP)、平均动脉压(MAP)、中心静脉压(CVP)、血Na+、K+、Cl-、血浆渗透压、脑灌注量(CPP)、血清S100B浓度。结果用药后,三者均可有效降低颅内压,3%高渗盐水组可较好保持中心静脉压处于正常水平,7.5%高渗盐水降压较为平稳,3%、7.5%高渗盐水较20%甘露醇组,作用持续时间更长,提升平均动脉压、脑灌注量更有效,差异有统计学意义(P0.05)。三者血清SIOOB浓度均升高,高渗盐水组上升幅度均较甘露醇组小。3%、7.5%高渗盐水组低钠血症发生率明显低于20%甘露醇组。结论高渗盐水降颅压作用持续时间长,有助于减轻伤后血脑屏障继发性损伤,并发症少,不良反应小,可作为降低颅内压的一线治疗药物。     

不同剂量的甘露醇对血浆渗透压的影响

目的 观察不同剂量甘露醇对血浆渗透压的影响，以指导临床合理用药。方法 33例颅内压增高的病人随机分成二组，第1组17例，给予20％甘露醇0．5g/kg；第2组16例，给予20％甘露醇1．0g/kg，两组均6-8h输注一次。监测两组病人每日首剂甘露醇前、后的血浆渗透压数值。结果 两组病人甘露醇使用前、后血浆渗透压差值比较有统计学意义（P〈0．01）。连续多日反复使用甘露醇后，可引起血浆渗透压基础值逐渐增高，且使用时间越长，血浆渗透压基础值越高。结论 对于甘露醇，切莫盲目使用大剂量。从安全的角度考虑，提倡使用小剂量的甘露醇，有条件者应在用药期间监测血浆渗透压。     

高渗盐水与甘露醇联合治疗重型颅脑损伤后 颅内压增高的疗效

目的 探讨3%高渗盐水和20%甘露醇联合治疗重型颅脑损伤后颅内压增高的疗效。方法 2016年2月至2017年2月收治30例重型颅脑损伤后出现颅内压增高事件,交替采用160 ml 3%高渗盐水与150 ml 20%甘露醇进行降低颅内压治疗;连续监测用药前、用药后30 min及1、2、3、4 h 颅内压、平均动脉压、脑灌注压及中心静脉压;用药前及用药后1、3 h 血钠水平及血浆渗透压。结果 3%高渗盐水和20%甘露醇均可显著降低颅内压（P<0.01）,两者降低颅内压作用持续时间及颅内压降幅差异均无统计学意义（P>0.05）。用药后脑灌注压均明显上升（P<0.01）;平均动脉压和中心静脉压均无明显变化（P>0.05）。20%甘露醇治疗后血钠明显下降（P<0.05）,3%高渗盐水治疗后血钠明显上升（P<0.05）。20%甘露醇及3%高渗盐水治疗后血浆渗透压均先上升后下降（P<0.01）。结论 3%高渗盐水与20%甘露醇交替使用能有效降低重型颅脑损伤后颅内压增高。     

高渗盐水在神经科疾病中的应用进展

正目前,高渗盐水和甘露醇均被《ASA/AHA2007自发性脑出血治疗指南》明确作为推荐的一线降颅内压药物(I1a类,证据水平C)。甘露醇脱水作用强,可显著提高血浆渗透压,临床应用广泛。但长期、大量应用甘露醇严重影响肾功能,也可导致水钠代谢平衡紊乱。高渗盐水在治疗颅内压(intracranial pressure,ICP)增高方面比甘露醇更有优势,效果更好,作用更持久,也无颅内压"反弹现象",     

甘露醇与尼莫通联合应用对大鼠脑缺血再灌注损伤保护机制的研究

目的探讨甘露醇与尼莫通联合应用对大鼠局灶性脑缺血再灌注损伤的保护机制。方法SD大鼠72只随机等分成假手术组(A组)、局灶性脑缺血再灌注组(B组)、小剂量甘露醇组(C组)、大剂量甘露醇组(D组)、尼莫通组(E组)及甘露醇与尼莫通合用组(F组)6组。采用硝酸还原酶法及末端标记(TUNEL)法分别检测各组大鼠脑组织一氧化氮(NO)含量及神经细胞凋亡数目。结果大鼠脑组织NO含量及神经细胞凋亡数:(1)B组明显高于A、C、D、E及F组(P<0.05～0.01);(2)C组与D组比较差异无显著性(P>0.05);(3)F组明显低于C、D、E组(均P<0.05)。结论不同剂量的甘露醇、尼莫通及两药合用均可通过下调缺血再灌注后脑组织NO含量和减少神经细胞凋亡而发挥脑保护作用,其中两药合用效果最佳。     

半量与全量甘露醇对留置针安全留置时间及无菌性静脉炎发生率的影响

目的探讨半量与全量甘露醇对颅脑肿瘤术后留置针安全留置时间及无菌性静脉炎发生率的影响。方法根据甘露醇使用方法,将222例颅脑肿瘤术后患者按住院号单双号分为全量组和半量组,各111例。全量组使用20%甘露醇250 ml静脉滴注,3次/d,连用10 d;半两组使用20%甘露醇125 ml,3次/d,连用10 d;两组滴注速度均为500 ml/h。比较两组患者的静脉留置时间及无菌性静脉炎发生率。结果半量组留置针安全留置时间≤4 d比例明显低于全量组(P0.05),而≥4 d比例明显高于全量组(P0.05)。半量组Ⅰ、Ⅱ、Ⅲ度静脉炎发生率均明显低于全量组(P0.05)。结论大剂量输注甘露醇时,特别是输液时间长、处于昏迷或昏睡状态以及老年患者,建议缩短静脉针留置时间,加强4 d内皮肤血管护理,预防药物引起的静脉炎的发生。     

甘露醇对局灶性脑缺血再灌注大鼠脑组织NO及神经细胞凋亡的影响

目的探讨甘露醇对大鼠局灶性脑缺血再灌注损伤脑组织NO及神经细胞凋亡的影响.方法SD大鼠48只,随机等分成4组,每组12只.A组:假手术组;B组:模型组,即局灶性脑缺血再灌注组;C组:小剂量甘露醇组;D组:大剂量甘露醇组.采用硝酸还原酶法及TUNEL法分别检测各组大鼠脑组织NO含量及神经细胞凋亡数目.结果 B组脑组织NO含量及神经细胞凋亡数目均明显多于A组(P＜0.01);C组、D组脑组织NO含量及神经细胞凋亡数目均较B组减少(P＜0.05);C组与D组脑组织NO含量及神经细胞凋亡数目比较,无显著差异(P＞0.05).结论甘露醇的脑保护作用不完全与脱水降颅压有关,还可能与下调缺血再灌注后脑组织NO含量、抑制神经细胞凋亡有关.     

Rebound phenomenon of mannitol and glycerol: clinical studies

A rebound phenomenon after infusion of hypertonic solution of mannitol and glycerol on raised intracranial pressure was studied by epidural pressure recordings for 65 patients. The mean age of the patients was 50 years with a range of 29 to 73 years. The diagnoses of above patients were as follows; 29 were cerebral aneurysms, 19 were brain tumors, 10 were hypertensive intracerebral hemorrhages, 4 were cerebral contusions, 2 were arteriovenous malformations, and one was cerebral abscess. Four methods of infusion were performed. In group A, 0.5 g/kg of mannitol was infused within 15, 30 or 60 minutes. In group B, 1.0 g/kg of mannitol was infused within 30, 60 or 90 minutes. In group C, 0.5 g/kg of glycerol in 5% fructose was infused within 30, 60 or 90 minutes. In group D, 1.0 g/kg of glycerol in 5% fructose was infused within 60, 120 or 180 minutes. The following observations were examined in all patients. (1) The occurrence of the rebound phenomenon. (2) The rate of the raised intracranial pressure (ICP) compared to the ICP before infusion of these hypertonic solutions. (3) The duration of the rebound phenomenon. Results: A rebound phenomenon was found 23% in all patients, and 12% in the mannitol groups and 34% in the glycerol groups. The dose and the rate of mannitol infusion did not influence the occurrence of the rebound phenomenon. In contrast, in the glycerol groups, the infusion method did influence the occurrence of the rebound phenomenon.(ABSTRACT TRUNCATED AT 250 WORDS)     

Effect of NIK-242 inj. (20% erythritol) on intracranial pressure in dogs with acute obstructive hydrocephalus

The effects of NIK-242 inj. (20% erythritol) on intracranial pressure (ICP) and serum osmotic pressure (Osm. P) were investigated in dogs with acute obstructive hydrocephalus, and they were compared with those of 20% mannitol or 10% glycerol in 5% fructose and 0.9% saline. Animals were divided into 5 groups (n = 6 in each group) and treated with either NIK-242 inj. (0.5 g/kg, 1.0 g/kg, 2.0 g/kg), mannitol (1.0 g/kg) or glycerol (0.5 g/kg). These drugs were administrated intravenously for 10 min. NIK-242 inj. rapidly reduced ICP and increased Osm. P. There was correlation between changes of ICP and Osm. P. The regression equation was Y = -6.489 X + 726.206 (n = 104, p less than 0.00001, R = -0.655). The effects were dose-dependent, but there were no significant differences between the effects of NIK-242 inj. 1.0 g/kg infusion and 2.0 g/kg infusion. The most appropriate dose of NIK-242 inj. was 1.0 g/kg, in which group ICP was significantly lower than the initial pressure until 120 minutes after administration (p less than 0.05). The maximum reduction rate of ICP [(initial ICP-minimum ICP)/initial ICP X 100] was 83.6 +/- 10.6% at 22.7 +/- 3.0 min. after administration. It was 61.6 +/- 6.9% at 19.3 +/- 1.6 min. in mannitol group and 77.1 +/- 7.4% at 15.0 +/- 0.8 min. in glycerol group. There was no rebound phenomenon on ICP during 150 min., but there was one in mannitol group and five in glycerol group. NIK-242 inj.(ABSTRACT TRUNCATED AT 250 WORDS)     

顺式阿曲库铵对颅内肿瘤切除术病人运动诱发电位的影响

目的 探讨顺式阿曲库铵对颅内肿瘤切除术病人运动诱发电位（MEP）的影响。方法 选取2016年1月至2018年9月择期行MEP监测下手术治疗的120例颅内肿瘤为研究对象，根据顺式阿曲库铵使用方法分为A、B、C三组，各40例。麻醉诱导期时均给予咪达唑仑（0.07 mg/kg）+丙泊酚（2 mg/kg）+舒芬太尼（0.4 μg/kg）+顺式阿曲库铵（0.15 mg/kg）。麻醉维持期:A组给予顺式阿曲库铵，剂量为0.5 μg/（kg·min）；B组给予顺式阿曲库铵，剂量为0.7 μg/（kg·min）；C组不给予肌松药。结果 与C组比较，A组和B组病灶切除时、手术结束时心率和平均动脉压均明显增高（P<0.05），术中丙泊酚用量明显减少（P<0.05），低血压和体动反应发生率明显降低（P<0.05），自主呼吸恢复时间、苏醒时间和拔管时间明显延长（P<0.05）；A组和B组均无统计学差异（P>0.05）。与C组比较，A组和B组在切开硬脑膜后即刻、切开硬脑膜后1 h、病灶切除后即刻MEP波幅明显降低（P<0.05），并且B组明显低于A组（P<0.05）；B组在切开硬脑膜后即刻、切开硬脑膜后1 h、病灶切除后即刻MEP潜伏期明显缩短（P<0.05），但是A、C组之间以及A、B组之间均无统计学差异（P>0.05）。结论 颅内肿瘤切除术病人麻醉诱导期给予0.15 mg/kg顺式阿曲库铵，随后用0.5 μg/（kg·min）维持，对MEP影响较小，并且可维持血流动力学稳定，减少术中体动反应     

高渗盐复合液治疗大鼠冷冻性脑水肿的实验研究

目的探讨高渗盐复合液(HSH)对大鼠冷冻性脑水肿的治疗作用。方法运用大鼠冷冻性脑水肿动物模型,分别以三种剂量(2ml/kg、4ml/kg、8ml/kg)的HSH、20%甘露醇(MNT,4ml/kg)和0.9%NaCl(4ml/kg)进行治疗,其中0.9%NaCl组为假治疗组,其余为治疗组;监测颅内压,测定脑含水量。结果治疗组给药2h内均有同样的降颅压作用,其中2ml/kgHSH组脱水作用时间明显短于其它三组、降颅压效果弱于其它三组;HSH4ml/kg和8ml/kg组具有相似的降颅压作用,无显著差异。治疗组健侧大脑半球含水量与假治疗组比较明显降低;治疗组伤侧大脑半球含水量与假治疗组对应侧相比稍减少,差异不显著。结论HSH可降低颅内压、减少脑含水量,其降颅压作用与MNT类似,作用呈量效关系,临床推荐的最佳剂量为4ml/kg。     

Intracranial pressure changes with different doses of lignocaine under general anaesthesia.

The effect of intravenous lignocaine on intracranial pressure (ICP) was studied on thirty patients of either sex, aged above 5 years and scheduled for elective ventriculoperitoneal shunt surgery. The patients were randomly divided into 3 groups, which received intravenous lignocaine in the dose of 1 mg, 1.5 mg and 2 mg/kg body weight respectively. Intracranial pressure, heart rate, ECG, arterial pressure and arterial blood gases were monitored at various intervals for a period of 30 minutes. Maximum decrease in ICP was seen at 2 minutes after IV lignocaine in all the three groups (p<0. 001). The fall in ICP was significantly more in group II and group III (35.65% and 37.5% respectively) as compared to group I (17.47%) (p<0.001). This fall in ICP in all the three groups persisted below the basal level, throughout the study period. None of the groups showed any significant change in the heart rate, but a statistically significant fall in arterial pressure was observed in group III (p<0. 05). In conclusion intravenous lignocaine, in a dose of 1.5 mg/kg, causes significant fall in ICP without causing any untoward cardiovascular effects and is recommended for routine clinical use.     

7.5%高渗盐水的不同给药方式对大鼠重型颅脑损伤后颅内压及血压的影响

目的建立大鼠重型颅脑损伤模型,比较7.5%高渗盐水(HS)三种不同给药方式对重型颅脑损伤大鼠颅内压(ICP)及血压(MBP)的影响。方法将50只健康雄性SD大鼠随机分为A组、B组、C组、生理盐水组、空白对照组,每组10只。造模后A组采用快速输注方式、B组采用缓慢输注方式、C组采用先快速后缓慢输注的方式,比较给药前及给药后1-6h内ICP及MAP的变化。结果 (1)7.5%HS三种给药方式ICP均会下降(2)A、B、C三组在ICP最低值、药物起效时间、ICP降至最低用时方面均有统计学差异(P0.001).(3)三组ICP降幅及用药前后MBP无统计学差异(P0.05)(4)生理盐水组输注前后颅内压无明显变化。结论 (1)7.5%HS不同给药方式均会降低颅内高压(2)快速输注组起效时间更快,维持时间最长,降颅内压效果明显。     

An evaluation of the role of 5-HT(2) receptor antagonism during subchronic antipsychotic drug administration in rats

A widely postulated mechanism of action for the atypical profile of many novel antipsychotic drugs (APDs) is their relatively high affinity for 5-HT(2) receptors. The present study investigated motor function and striatal dopamine (DA) efflux and metabolism in rats given 21 daily injections of drugs that differed in 5-HT(2) affinity. These drugs included: risperidone (high 5-HT(2A/2C)/high D(2)), clozapine (high 5-HT(2A/2C)/low D(2)), haloperidol (low 5-HT(2A/2C)/high D(2)), haloperidol+ritanserin (selective 5-HT(2A/2C)), or vehicle. Rats injected with haloperidol (0.5 mg/kg) or haloperidol+ritanserin (0.5 mg/kg and 1.0 mg/kg, respectively) showed extreme catalepsy on day 1, but significantly decreased catalepsy when tested again on days 7 and 21. Acute or subchronic risperidone (0.05 or 0.5 mg/kg), clozapine (20 mg/kg), or vehicle did not induce significant catalepsy. Microdialysis performed 24 h after the last injection demonstrated that rats treated with risperidone, clozapine, or vehicle showed similar increases in DA efflux and metabolism following an acute injection of a selective DA D(2/3) antagonist (raclopride, 0.5 mg/kg). DA efflux showed an attenuated response to raclopride in the haloperidol alone group; this effect was less apparent in the haloperidol+ritanserin group. However, both of these groups showed a similar tolerance effect to the raclopride-induced increase in DA metabolites. These results suggest that the profile seen after subchronic risperidone more closely resembles clozapine than haloperidol. While ritanserin reduced the tolerance-like effects of haloperidol on striatal DA efflux, the overall results demonstrate that potent 5-HT(2) blockade alone may not entirely account for the distinctive profile of novel APDs.     

The mechanism of intracranial pressure-reducing effect of mannitol

The effect of mannitol to decrease the raised ICP is well documented and mannitol is now widely used in clinical practice. However, its mechanism of lowering ICP still remains controversial, especially under the condition of vasogenic edema. The objective of this study is to reexamine and delineate the mechanism of ICP reducing effect of mannitol, using quantitative vasogenic edema model, specific gravimetric technique to measure the brain water content, and the method to estimate the CSF dynamics without disturbing the physiological condition of intracranial compartments in cats. Quantitative increase of water content of the white matter was produced by the infusion of 0.5 ml of normal saline though stereotaxically inserted 25-G needle into the left frontal white matter. In control group, cats were sacrificed and water content of the gray and white matter of each coronary sliced brain was measured by specific gravimetric technique. In the mannitol group, 20% of mannitol (2 g/kg) was administrated via femoral vein within 3 minutes. The maximum reduction of ICP was achieved at the average of 30 minutes. At this time, the cats were sacrificed and the water content of brain was measured in the same way as in the control group. PVI, Ro, If (Marmarou) were calculated before and after mannitol administration. In parameter group, BP, ICP, CVP, serum osmotic pressure and osmolarity were measured without terminating the experiment. The changes of water content of the gray and white matter before and after mannitol administration in the area of infusion edema were 80.7% to 80.8% and 76.8% to 77.1% respectively.(ABSTRACT TRUNCATED AT 250 WORDS)     

快速颅内压监测联合血肿穿刺在严重高血压脑出血患者术前应用的临床研究

目的探讨快速颅内压（ICP）监测联合颅内血肿穿刺在严重高血压脑出血（HICH）患者术前应用的临床意义。 方法选取重庆市急救医疗中心神经外科自2016年1月至2019年6月收治的90例严重HICH患者,按随机数字表法分为YL-1型针快速颅内血肿穿刺+开颅血肿清除及去骨瓣减压组（对照组1）,单纯开颅血肿清除及去骨瓣减压组（对照组2）,ICP探头快速置入ICP监测+YL-1型针快速颅内血肿穿刺+开颅血肿清除及去骨瓣减压组（试验组）,每组病例30例。比较3组患者开颅准备时间,各时间点ICP、GCS评分,神经外科重症监护室（NICU）总住院时间以及6个月后的预后情况。 结果3组患者的开颅准备时间比较,差异无统计学意义（P>0.05）;NICU住院时间比较,试验组病例最短,对照组1次之,对照组2最长,差异有统计学意义（P<0.05）。3组患者术后当天及术后1 d的ICP值比较,差异无统计学意义（P>0.05）;术后3、5 d,试验组<对照组1<对照组2,差异有统计学意义（P<0.05）;3组患者术后1 d的GCS评分比较,差异无统计学意义（P>0.05）,术后1周、1个月,试验组>对照组1>对照组2。术后6个月随访,试验组的GOS评分优于对照组1和对照组2,差异有统计学意义（F=10.361,P=0.001）。 结论快速ICP监测联合颅内血肿穿刺在严重HICH患者术前应用能有效降低患者术后ICP,缩短NICU住院时间,改善患者预后,且不延长开颅准备时间,值得在临床治疗中推广应用。