Head Injury Managament at MMC 急性颅脑损伤在MMC管理课件.ppt

Survival Outcome Wade et al in 1997 performed a metanalysis of TBI shocked subgroups received HTS/dextran (n=223) ? improved survival odds ration 2.12 (P=0.048). Cooper et al in 2004 RCT HTS /NS with an out of hospital GCS 8 SBP 100mmhg (n=229) ? mortality higher than 50% in the treatment group and no difference in GOSE at 6 months ? ICP was monitored in only 27.5% of patients Some patients died before receiving ICP monitor Maybe a longer course of hypertonic osmotherapy is required to show an effect Dilutional effect of crystaloid ICP was placed according to physician after randomization. Thus the initial resuscitation could have improved the patient and hence hindered its insertion ICP inserted after admission to ICU hence the effect on ICP was not detected Trend towards greater nosocomial infection in the treatment group !! Complications : Neurological Osmotic demyelination syndrome due to a rapid rise of Na affecting deep white matter , with pons being most susceptible Human trials did not report rapid increase in Na When Na reached 187 in certain cases no osmotic demyelination was seen in MRI Subdural and intracerebral haemorrhage in children and cats have been reported with rapid rise in Na Complications : Renal Insuffeciency Burn patients had more renal failure when resuscitated with HTS compared to RL May not apply to TBI Complications Dilutional coagulopathy . However smaller volumes should over come this effect No fluid overload have been reported in SAH when received HTS Hypokalaemia Hyperchloraemic metabolic acidosis that can be easily treated with solutions with 50/50 Cl/acetate Rebound increased in ICP after 24 hrs : this could be due to intrinsic half life of HTS Conclusion A number of level 2 evidence confirm its equivalent effect to mannitol in reducing ICP , and improving CPP No clear cut evidence regarding mortality with prolonged consitent osmotherapy More studies are required to identify clNo Strong Solid level one evidence available