| [Background]Acute traumatic brain injury(TBI) is a common clinical disease and emergency of neurosurgery. It is one kind of trauma with high mortality and disability. Acute severe brain injury often leads to high ICP that despite the maximal medical management. Some cases only part of the initial injury, but a few hours to several days it will causes secondary damage that leading to brain tissue ischemia and hypoxia, and Will eventually lead to intracranial pressure, brain herniation. It is a common cause of death。Therefore, how to real-time monitoring the hypoxic of brain tissue, and how to improve the situation that when found the hypoxic of brain tissue, is the key of clinical treatment to acute severe head injury patients.PbtO2 is a technology that developed to monitor the mature brain tissue partial oxygen through the micro-electrode placed into the brain in recent years, and it can sustainable monitor partial pressure of brain tissue oxygen and temperature. Integrated a number of studies suggest that PbtO2 and inspired oxygen concentration, cerebral perfusion pressure, cerebral blood flow and hemoglobin was positively correlated, and cerebral oxygen extraction ratio was negatively correlated.PbtO2 PbtO2 is the direct measurement of brain tissue oxygen supply situation of the method, and cerebral oxygen metabolism monitoring is reflected in the most accurate method to cerebral oxygen metabolism, and some scholars believe it was to evaluate the effectiveness of the gold standard treatment. Recent studies suggest that PbtO2 not only reflects the local cerebral blood flow is more a reflection of cerebral blood flow and also reflects the cerebral arteriovenous oxygen difference in the results in patients with traumatic brain injury.In the next place, severe head injury patients are mainly used in the treatment of surgical and conservative treatment. To the patients in conservative treatment, if the observation process occurred in the treatment of intracranial deterioration (such as the increase in intracranial hemorrhage, difficult to control brain swelling, etc.) and circumstances beyond the control of drugs also requires surgical treatment. Domestic used standard large decompressive Craniectomy of treatment of patients with severe brain injury and improved treatment success rates.But for standard large decompressive craniectomy with PbtO2 precise relationship between the present study was not entirely clear, and there are still a part of the clinical use of standard large decompressive craniectomy patients of poor prognosis.In this study, we used sophisticated tools to monitor brain tissue oxygen partial pressure in recent years, to do continuous monitoring of observation to emergency surgical treatment of the severe head injury patients before and after surgery. The purpose is to analyse PbtO2 in the standard large decompressive craniectomy of the various steps in the process of change and perioperative continuoused monitoring of changes in PbtO2, and to research the relationship between PbtO2 and the prognosis of surgical patients by tracking. [Objective]To evaluate the clinical significance of continuous monitoring of partial pressure of brain tissue oxygen (PbtO2) in patients with acute severe brain injury by decompressive craniectomy.[Methods]1,The object of study.Two patients of severe head injury within 24 hours after injury are admitted (GCS:3～8, mean GCS:5.6,15 males,7 females, aged 18-65 years, mean age: 32.1 years.) All patients underwent cranial CT on admission a definite diagnosis and fulfilled the indications for emergency surgery. All patients no significant organ damage or failure, no hypotension, no coagulation disorders, no cerebral ischemia, no tumor, no hydrocephalus surgery did not correct, no intracranial infections, no heart disease, no severe arrhythmia or cardiac disease, no pneumonia, no lung bullae, no pulmonary ventilation dysfunction or significant affect the oxygen content of the disease, no chronic active hepatitis, no chronic severe hepatitis, no kidney stones or episodes of urinary tract symptoms of nephritis, and no other important organs of major diseases. Injury Type:epidural hematoma in 9 cases,11 cases of subdural hematoma, subdural hematoma+intracranial hematoma in 2 cases.2,Brain tissue oxygen partial pressure monitoring.We used the brain tissue oxygen partial pressure monitoring system monitor (German GMC Licox-Ⅱtype). All patients in this group after admission were immediately monitored before surgery. Before insertion, head CT as the preoperative selection of normal brain. Generally the amount of fortune in the left after 2～3cm, middle next to the open 2～3cm. We use hand skull drill drilled skull diameter of about 5mm and punctured dural, probe fixed in skull, then builted into the PbtO2 probe in depth of 34±2mm (distance from the meninges to the probe top). After fixed, we start to monitor the data after stable (about 30 minutes). Computer automatically recorded every 15s 1 PbtO2 measurements. Routine head CT scan after surgery review, it was not found in the monitoring period that the secondary hemorrhage affected the monitoring results.3,Treatment.All the patients were emergency intubation in anesthesia and underwent the hypertensive intracerebral hemorrhage+decompressive craniectomy. Routine preoperative blood tests, blood biochemistry, blood gas analysis and routine examination before operation and Signature.4,Monitoring methods.PbtO2 value is in the process of continuous monitoring of operation in the process of 1. After the removal of bone flap(Including the removal of epidural hematoma); 2. After the dural matter was opened (including the removal of subdural hematoma); 3.After sutured scalp. The monitoring time of PbtO2 was decided to the patients condition, those who marked improvement or even of consciousness or death were stopped monitoring for 2 to 5 days. Monitoring time is 2 to 5 days.5,Other monitoring and treatmentWe used multi-parameter vital signs monitor to continuou monitoring of BP,P,R,SpO2,PCaO2,and PaO2. Blood biochemistry and electrolyte be measured every 6-12 hours. All patients continued to send ICU ward care, routine use of dehydrating agents, hormones, hemostatic agents, and prevention of infection, prevention of stress ulcer, nutrition nerve. The patients those estimated can not fully awake of the short period of time after the treatment used surgery of tracheotomy.6,All patients evaluated results by GOS after conventional treatment for 3 months later.7,Statistical analysis. Measurement data is expressed byⅩ±s. We used Fisher exact test to analysis the result of the prognosis of patients with acute severe traumatic brain injury, and used variance of repeated measurement to analysis other data. P<0.05 was significant difference.[Results]1,No complication was associated with the monitoring probe.2,After the osseous flap was removed, PbtO2 in 9 patients with acute epidural hematoma increased from (13.6±3.5) mmHg to (28.4±2.5) mmHg, (P<0.001) After the dura matter was opened, PbtO2 in the same patients increased from (28.4±2.5) mmHg to (30.3±3.0) mmHg, (P<0.005). After the scalp was sutured, PbtO2 in the same patients have no significant increased. The results of the cases suggest that osseous-removed is the crucial step to increase adequate PbtO23,After the osseous flap was removed, PbtO2 in 13 patients with extradural haematoma (include extradural haematoma+intracranial hematoma) increased from (9.8±4.4) mmHg to (13.5±5.2) mmHg, (P<0.001). After the dura matter was opened, PbtO2 in the same patients increased from (13.5±5.2) mmHg to (20.9±6.7) mmHg, (P<0.001). After the scalp was sutured, PbtO2 in the same patients have no significant increased. The results of the cases suggest that dura enlargement is the crucial step to increase adequate PbtO2.4,All patients after traumatic brain injury were observed in low PbtO2 before surgery,15 cases were 10mmHg |
PDF Full Text Request