目標(biāo)化鎮(zhèn)靜和體溫管理與腦保護

1、目標(biāo)化鎮(zhèn)靜和體溫管理與腦保護,關(guān)于地震和海嘯的聯(lián)想,原發(fā)損傷,繼發(fā)損傷,灌注障礙,利用障礙,讓時間凝固，將整個城市催眠,Pharmacology & Therapeutics 105 (2005) 23–56,,,腦損傷的原發(fā)和繼發(fā)機制,Primary Injury & Neurosurgery,,腦復(fù)蘇Cerebral resuscitation,CHINA International Neuroscience In

2、stitute ICU,治療原發(fā)疾病：包括中樞神經(jīng)系統(tǒng)血管??；創(chuàng)傷和腫瘤等。Situations where primary brain insult occurs.防治繼發(fā)腦損傷：實質(zhì)上是防治減少細胞灌注的各種因素，包括：低氧血癥；低血壓，腦水腫，細胞內(nèi)改變，代謝，還有保護腦血管自動調(diào)節(jié)功能，血腦屏障等。Management directed towards prevention of secondary brain insult

3、multiple insults all end up in reduced cellular perfusion：hypoxia，hypotension，cerebral oedema，intracellular changes，metabolic,如何防治繼發(fā)腦損傷?,繼發(fā)腦損傷形成的機制僅僅是“缺血缺氧性腦病”嗎？,CHINA International Neuroscience Institute ICU,,原發(fā)損傷：物理損

4、傷：外傷，血腫，腦疝，手術(shù)創(chuàng)傷等。繼發(fā)損傷：缺乏足夠的血供：動脈低血壓，血管梗阻，高CVP或ICP或組織壓，微循環(huán)障礙等。血供質(zhì)量差：低氧血癥（充血），高血糖，低血糖，內(nèi)環(huán)境紊亂，不良代謝產(chǎn)物等。腦組織充血和再灌注損傷：過高的腦灌注壓（不僅僅是高血壓腦?。绕涫悄X血管自動調(diào)節(jié)功能受損時。代謝需求過高（相對于血供）：高熱，癲癇，興奮性神經(jīng)遞質(zhì)增加等。,繼發(fā)腦損傷形成的過程 就是不同程度的腦灌注與腦代謝失衡的過程,繼發(fā)腦

5、損傷防治的過程 就是不斷尋找腦灌注與腦代謝平衡點的過程。,繼發(fā)腦損傷的防治,CHINA International Neuroscience Institute ICU,,如何尋找腦灌注與代謝的平衡點？如何達到腦灌注與代謝的平衡點？如何維持腦灌注和代謝的平衡？,繼發(fā)腦損傷的防治,CHINA International Neuroscience Institute ICU,,如何尋找腦灌注與代謝的平衡點？如何達到腦灌注與代謝的平

6、衡點？如何維持腦灌注和代謝的平衡？,CHINA International Neuroscience Institute ICU,腦 自身如何實現(xiàn)灌注與代謝匹配？,腦血管自動調(diào)節(jié)功能（CA）:腦自我保護功能血腦屏障(BBB)：腦自我保護功能腦血流量：占心輸出量（CO）的15-20%；供能；散熱。腦代謝：體重的2%，消耗 20%氧；60%ATP ；循環(huán)停止10秒就出現(xiàn)意識障礙，5-6分鐘神經(jīng)損傷不可逆?；緹o儲備。,大腦是需求最苛

7、刻的器官嗎？,CHINA International Neuroscience Institute ICU,腦的自我保護功能：腦血管自主調(diào)節(jié)功能（CA）本質(zhì)是：腦根據(jù)代謝需求調(diào)節(jié)腦血管舒縮調(diào)節(jié)腦血流量。,腦血管自主調(diào)節(jié)功能的各個機制是相互獨立的。CA對于保證顱腔內(nèi)容積穩(wěn)定至關(guān)重要。,理解CA：CA 與 Bp,注意CA是肌源性的。通過調(diào)節(jié)血管直徑改變腦血管阻力。,尋找適當(dāng)?shù)哪X灌注：滴定治療,,,,腦血管自主調(diào)節(jié)功能受損或喪失的情況下，

8、CPP與CBF，CBV和ICP呈正比。此種狀況下，適當(dāng)?shù)哪X灌注壓選擇變得異常重要；不適當(dāng)?shù)墓嘧簳斐刹贿m當(dāng)?shù)哪X灌注，意味著腦缺血或充血。灌注壓過高或過低對患者都會造成損害。[7],7. J. H. van Blankenstein, et al. Effect of arterial blood pressure and ventilation gases on cardiac depression induced by corona

9、ry air embolism. J Appl Physiol,1994; 77: 1896 - 1902.,CHINA International Neuroscience Institute ICU,腦的自我保護功能：血腦屏障（BBB）,本質(zhì)是為了保持中樞神經(jīng)系統(tǒng)內(nèi)環(huán)境的穩(wěn)定。,繼發(fā)腦損傷的防治,CHINA International Neuroscience Institute ICU,,如何尋找腦灌注與代謝的平衡點？找不到的！

10、要保護腦，先保護血管！保護和恢復(fù)腦血管自動調(diào)節(jié)功能保護和恢復(fù)血腦屏障功能保持內(nèi)環(huán)境良好且穩(wěn)定動態(tài)連續(xù)評估腦代謝狀況和底物供應(yīng)狀況,繼發(fā)腦損傷的防治,CHINA International Neuroscience Institute ICU,,如何尋找腦灌注與代謝的平衡點？如何達到腦灌注與代謝的平衡點？如何維持腦灌注和代謝的平衡？,腦保護和腦復(fù)蘇,先保護、再復(fù)蘇：保護腦血管自動調(diào)節(jié)功能保護血腦屏障功能保護腦組織增加

11、灌注并且降低代謝,腦保護和腦復(fù)蘇,先保護、再復(fù)蘇：保護腦血管自動調(diào)節(jié)功能保護血腦屏障功能保護腦組織增加灌注并且降低代謝,腦保護和腦復(fù)蘇,腦保護策略：避免損害腦血管自動調(diào)節(jié)功能的因素：穩(wěn)定血壓，降低灌注壓力、穩(wěn)定內(nèi)環(huán)境（PCO2等）避免損傷血腦屏障的因素：如甘露醇保護腦組織，降低腦水腫還有嗎？,低溫與腦保護：降低腦代謝，降低氧耗穩(wěn)定細胞膜保護血腦屏障減少細胞內(nèi)酸中毒減少腦充血、減少腦水腫,腦保護和腦復(fù)蘇,先保護、

12、再復(fù)蘇：保護腦血管自動調(diào)節(jié)功能保護血腦屏障功能保護腦組織增加灌注并且降低代謝,腦保護和腦復(fù)蘇,增加灌注：控制顱內(nèi)高壓提高灌注壓,顱內(nèi)壓增高的根本原因是什么？：顱腔內(nèi)容物增多顱內(nèi)壓增高的本質(zhì)風(fēng)險是什么？：原發(fā)損傷：腦組織移位，腦疝造成腦組織直接損傷：繼發(fā)損傷：最終導(dǎo)致腦灌注下降甚至停止，缺血缺養(yǎng)性腦病。包括早期充血再灌注導(dǎo)致細胞水腫和微循環(huán)障礙。所以，防治早期充血也應(yīng)包括在治療方案內(nèi)。,關(guān)于顱內(nèi)壓增高的幾個問題Thi

13、nk Different,Think Different ！,顱內(nèi)高壓 ? Yes! CBF？,顱內(nèi)壓增高意味著腦代償?shù)牡竭_極限，繼發(fā)腦損傷將隨之到來?。?！,CHINA International Neuroscience Institute ICU,缺血還是充血？,TCD告訴你!,,腦脊液引流,CPP,PEEP,過度通氣；體位；頸位；靜脈竇支架…LUND therapy,滲透壓治療,鎮(zhèn)靜，低溫,外科手術(shù)減壓,顱內(nèi)

14、高壓的形成和針對性治療方案,隆德概念（Lund concept）,基本概念：腦血管自動調(diào)節(jié)功能（CA）血腦屏障(BBB)腦代謝重點關(guān)注：減少顱腔內(nèi)容體積，哪怕5ml也好！不用甘露醇控制顱內(nèi)壓！,Midazolam 5-20 mg/h+Low-dose thiopental 0.5-3 mg?kg-1?h-1 + Fentanyl 2-5 ?g?kg-1?h-1 + ?1-anta

15、gonist metoprolol 0.2-0.3 mg?kg-1?24h-1 iv.+ ?2-agonist clonidine 0.4-0.8 ?g?kg-1?h-1 ?4-6 iv. + 維持正常血容量，適度液體負平衡：速尿1-3mg/hr + 維持

16、膠體滲透壓和攜氧能力：ALB≥40g/L ;Hb ≥12.5 g%,,隆德概念的 BUNDLE,鎮(zhèn)靜,控制應(yīng)激反應(yīng),腦灌注的質(zhì)和量的管理,鎮(zhèn)痛,輸血加鎮(zhèn)靜：提高灌注質(zhì)量+減低代謝,,腦代謝的指標(biāo)：Microdialysis,顱內(nèi)壓增高的控制思路Think Different,腦脊液引流,CPP,PEEP,過度通氣；體位；頸位；靜脈竇支架…LUND therapy,滲透壓治療,鎮(zhèn)靜，低溫。,外科手術(shù)減壓,腦水腫治療：揚湯止沸還是釜底抽

17、薪？,ICP異常增高！為什么？,看上去很安靜？,強化鎮(zhèn)靜試試？5mg 咪唑安定靜推！,寒戰(zhàn)、鎮(zhèn)靜與ICP控制,降低腦代謝的手段：鎮(zhèn)靜和麻醉依賴或不依賴于腦血流變化,,Think DifferentDHCA腦保護帶來的啟示,體溫與腦血流量和腦氧代謝率的關(guān)系,鎮(zhèn)靜低溫就是循環(huán)支持,腦保護和腦復(fù)蘇,先保護、再復(fù)蘇：保護腦血管自動調(diào)節(jié)功能保護血腦屏障功能保護腦組織增加灌注并且降低代謝,調(diào)整策略，主動出擊、釜底抽薪：降低腦代謝--

18、--鎮(zhèn)靜和低溫,,僅僅關(guān)于鎮(zhèn)靜的問題:拿什么指標(biāo)作鎮(zhèn)靜的尺子？用什么藥物鎮(zhèn)靜？用什么藥物鎮(zhèn)痛？多早？多深？多久？蓄積？如何減藥？停藥？,目標(biāo)化鎮(zhèn)靜管理的目標(biāo)制定,僅僅關(guān)于鎮(zhèn)靜的問題:拿什么指標(biāo)作鎮(zhèn)靜的尺子？用什么藥物鎮(zhèn)靜？用什么藥物鎮(zhèn)痛？多早？多深？多久？蓄積？如何減藥？停藥？,目標(biāo)化鎮(zhèn)靜管理的目標(biāo)制定,目標(biāo)化鎮(zhèn)靜的質(zhì)控：Bis和EEG,NCSE,僅僅關(guān)于鎮(zhèn)靜的問題:拿什么指標(biāo)作鎮(zhèn)靜的尺子？用什么藥物

19、鎮(zhèn)靜？用什么藥物鎮(zhèn)痛？多早？多深？多久？蓄積？如何減藥？停藥？,目標(biāo)化鎮(zhèn)靜管理的目標(biāo)制定,關(guān)于中長期鎮(zhèn)靜藥物的問題:冬眠合劑：氯丙嗪50mg、異丙嗪50mg、哌替定100mg，iv 持續(xù)泵入，每日2-3 個全量。咪達唑侖：5-20mg/h iv 持續(xù)泵入輔助：異丙酚、右美托嘧啶。不使用肌松劑！不間斷喚醒！,目標(biāo)化鎮(zhèn)靜管理的目標(biāo)制定,僅僅關(guān)于鎮(zhèn)靜的問題:拿什么指標(biāo)作鎮(zhèn)靜的尺子？用什么藥物鎮(zhèn)靜？用什么藥物鎮(zhèn)痛

20、？多早？多深？多久？蓄積？如何減藥？停藥？,目標(biāo)化鎮(zhèn)靜管理的目標(biāo)制定,關(guān)于鎮(zhèn)靜藥物減藥、蓄積和停藥的問題:長期應(yīng)用存在蓄積可能，需要注意。但長程“冷靜”治療后更多見耐藥！根據(jù)腦代謝灌注平衡情況及病理生理過程逐漸減藥停藥。,目標(biāo)化鎮(zhèn)靜管理的目標(biāo)制定,僅僅關(guān)于鎮(zhèn)靜的問題:拿什么指標(biāo)作鎮(zhèn)靜的尺子？用什么藥物鎮(zhèn)靜？用什么藥物鎮(zhèn)痛？多早？多深？多久？蓄積？如何減藥？停藥？同溫度控制策略,目標(biāo)化鎮(zhèn)靜管理的目標(biāo)制定

21、,Fever Management in SAH V. Scaravilli ? G. Tinchero ? G. Citerio ?The Participants in the International Multi-disciplinary ConsensusConference on the Critical Care Management of Subarachnoid Hemorrhage.2011,僅僅關(guān)于溫度的問題:

22、拿什么溫度作尺子？多早？多低？多久？用什么控溫？復(fù)溫？,目標(biāo)化體溫管理的目標(biāo)制定,Fever Management in SAH V. Scaravilli ? G. Tinchero ? G. Citerio ?The Participants in the International Multi-disciplinary ConsensusConference on the Critical Care Manage

23、ment of Subarachnoid Hemorrhage.2011,僅僅關(guān)于溫度的問題:拿什么溫度作尺子？多早？多低？多久？用什么控溫？復(fù)溫？,目標(biāo)化體溫管理的目標(biāo)制定,Fever Management in SAH V. Scaravilli ? G. Tinchero ? G. Citerio ?The Participants in the International Multi-disciplinary C

24、onsensusConference on the Critical Care Management of Subarachnoid Hemorrhage.2011,僅僅關(guān)于溫度的問題:拿什么溫度作指標(biāo)：皮膚溫度？腋溫？鼻咽溫？肛溫？膀胱溫？血溫？腦溫？,目標(biāo)化體溫管理的目標(biāo)制定,,Pediatric Anesthesia 21 (2011) 347–358 ª 2011 Blackwell Publishing Ltd,

25、SummaryNeurological insults are a leading cause of morbidity and mortality, both in adults and especially in children. Among possible therapeutic strategies to limit clinical cerebral damage and improve outcomes, hypoth

26、ermia remains a promising and bene?cial approach. However, its advantages are still debated after decades of use. Studies in adults have generated con?icting results, whereas in children recent data even suggest that hyp

27、othermia may be detrimental. Is it because brain temperature physiology is not well understood and/or not applied properly, that hypothermia fails to convince clinicians of its potential bene?ts? Or is it because hypothe

28、rmia is not, as believed, the optimal strategy to improve outcome in patients affected with an acute neurological insult? This review article should help to explain the fundamental physiological principles of brain heat

29、production, distribution and elimination under normal conditions and discuss why hypothermia cannot yet be recommended routinely in the management of children affected with various neurological insults.低溫治療：拿什么作尺子？體溫？核心

30、溫度？腦溫！腦溫與腦代謝程度和局部血流灌注情況密切相關(guān)；不同部位，不同病理生理狀態(tài)下均有不同。,膀胱溫與腦溫的差異：ΔT即可作為腦損傷嚴重程度和微循環(huán)障礙的評估，也可作為治療的目標(biāo)點,Fever Management in SAH V. Scaravilli ? G. Tinchero ? G. Citerio ?The Participants in the International Multi-disciplinary

31、ConsensusConference on the Critical Care Management of Subarachnoid Hemorrhage.2011,僅僅關(guān)于溫度的問題:拿什么溫度作尺子？：腦溫！多早？多低？多久？用什么控溫？復(fù)溫？,目標(biāo)化體溫管理的目標(biāo)制定,Fever Management in SAH V. Scaravilli ? G. Tinchero ? G. Citerio ?The Pa

32、rticipants in the International Multi-disciplinary ConsensusConference on the Critical Care Management of Subarachnoid Hemorrhage.2011,僅僅關(guān)于溫度的問題:拿什么溫度作尺子？：腦溫！多早？多低？多久？用什么控溫？溫度的質(zhì)控！復(fù)溫？,目標(biāo)化體溫管理的目標(biāo)制定,低溫方法的選擇決定了目標(biāo)化體溫管

33、理的質(zhì)控從一個病理生理狀態(tài)到另一個,最適合你的方法就是最好的方法：無創(chuàng)，智能，精確，高效，穩(wěn)定，方便，便宜,,CHINA International Neuroscience Institute ICU,Fever Management in SAH V. Scaravilli ? G. Tinchero ? G. Citerio ?The Participants in the International Multi-disci

34、plinary ConsensusConference on the Critical Care Management of Subarachnoid Hemorrhage.2011,僅僅關(guān)于鎮(zhèn)靜和溫度的問題:拿什么溫度作尺子？腦溫！多早？多低？多久？用什么控溫？溫度的質(zhì)控！復(fù)溫？,目標(biāo)化鎮(zhèn)靜和體溫管理的目標(biāo)制定,Time is Brain,For every minute’s delay, the brain lose

35、s:1.9 million neurons; 190萬神經(jīng)元14 billion synapses; 140億突觸7.5 miles of myelinated fibers. 7.5英里有髓鞘的神經(jīng)纖維If a stroke runs its full course – an estimated 10 hours on average – the brain loses:1.2 billion neurons;

36、12億神經(jīng)元8.3 trillion synapses; 830萬兆突觸4,470 miles of myelinated fibers. 4470英里神經(jīng)纖維,Stroke 2006;37:263-266,在永久性損傷發(fā)生前鎖定問題！確保適當(dāng)?shù)哪X灌注！,Think Different,Discussion We found no signi?cant di?erence in outcome in patients t

37、reated with hypothermia compared with those treated with normothermia; however, patients in the hypothermia group did have a signi?cantly higher number of episodes of increased intracranial pressure than those in the n

38、ormothermia group.,Lancet Neurol 2011; 10: 131–39,Methods The National Acute Brain Injury Study: Hypothermia II (NABIS: H II) was a randomised, multicentre clinical trial of patients with severe brain injury who were e

39、nrolled within 2·5 h of injury at six sites in the USA and Canada. Patients with non-penetrating brain injury who were 16–45 years old and were not responsive to instructions were randomly assigned (1:1) by a random

40、 number generator to hypothermia or normothermia. Patients randomly assigned to hypothermia were cooled to 35°C until their trauma assessment was completed. Patients who had none of a second set of exclusion criteri

41、a were either cooled to 33°C for 48 h and then gradually rewarmed or treated at normothermia, depending upon their initial treatment assignment. Investigators who assessed the outcome measures were masked to treatme

42、nt allocation. The primary outcome was the Glasgow outcome scale score at 6 months. Analysis was by modi?ed intention to treat. This trial is registered with ClinicalTrials.gov, NCT00178711.,Lancet Neurol 2011; 10: 131–3

43、9,Think Different,,Lancet Neurol 2011; 10: 131–39,Think Different,Fever Management in SAH V. Scaravilli ? G. Tinchero ? G. Citerio ?The Participants in the International Multi-disciplinary ConsensusConference on the Cr

44、itical Care Management of Subarachnoid Hemorrhage.2011,僅僅關(guān)于鎮(zhèn)靜和溫度的問題:拿什么溫度作尺子？腦溫！多早？盡早！盡快！多低？多久？用什么控溫？溫度的質(zhì)控！復(fù)溫？,目標(biāo)化鎮(zhèn)靜和體溫管理的目標(biāo)制定,long-term hypothermia therapy,Clinical Articles Effect of long-term mild hypothermia t

45、herapy in patients with severe traumatic brain injury: 1-year follow-up review of 87 casesObject. The goal of this study was to investigate the protective effects of long-term (3–14 days) mild hypothermia therapy (33–35

46、°C) on outcome in 87 patients with severe traumatic brain injury (TBI) (Glasgow Coma Scale score ≤ 8).Methods. In 43 patients assigned to a mild hypothermia group, body temperatures were cooled to 33 to 35°C a

47、 mean of 15 hours after injury and kept at 33 to 35°C for 3 to 14 days. Rewarming commenced when the individual patient's intracranial pressure (ICP) returned to the normal level. Body temperatures in 44 patient

48、s assigned to a normothermia group were maintained at 37 to 38°C. Each patient's outcome was evaluated 1 year later by using the Glasgow Outcome Scale. One year after TBI, the mortality rate was 25.58% (11 of 43

49、 patients) and the rate of favorable outcome (good recovery or moderate disability) was 46.51% (20 of 43 patients) in the mild hypothermia group. In the normothermia group, the mortality rate was 45.45% (20 of 44 patient

50、s) and the rate of favorable outcome was 27.27% (12 of 44 patients) (p < 0.05). Induced mild hypothermia also markedly reduced ICP (p < 0.01) and inhibited hyperglycemia (p < 0.05). The rates of complication wer

51、e not significantly different between the two groups.Conclusions. The data produced by this study demonstrate that long-term mild hypothermia therapy significantly improves outcomes in patients with severe TBI.Journal

52、 of Neurosurgery October 2000 / Vol. 93 / No. 4 / Pages 546-549 Ji-Yao Jiang, M.D., Ph.D., Ming-Kun Yu, M.D., Ph.D., and Cheng Zhu, M.D,Think Different，Make Difference,Fever Management in SAH V. Scaravilli ? G. Tinchero

53、 ? G. Citerio ?The Participants in the International Multi-disciplinary ConsensusConference on the Critical Care Management of Subarachnoid Hemorrhage.2011,僅僅關(guān)于鎮(zhèn)靜和溫度的問題:拿什么溫度作尺子？腦溫！多早？盡早！何時都有意義！多低？多久？病理生理過程；ICP？用

54、什么控溫？溫度的質(zhì)控！復(fù)溫？,目標(biāo)化鎮(zhèn)靜和體溫管理的目標(biāo)制定,臨床決策多樣性：Think Different,CHINA International Neuroscience Institute ICU,,h,不同的疾病不同的病理生理過程和階段不同的代謝狀態(tài),不同的個體不同的器官不同的角度不同的反應(yīng)性,理解病理生理過程需要“過程”！,沒那么簡單！Think Different!,理解病理生理過程需要“過程”：不同的疾病的自

55、然病程腦血管自動調(diào)節(jié)功能狀態(tài)的動態(tài)評估TCD？ICP?腦電生理？腦代謝指標(biāo)？血生化：CK?,TCD動態(tài)評估：腦灌注和腦血管自動調(diào)節(jié)功能評估治療反應(yīng)和病理生理狀態(tài)和階段,,Fever Management in SAH V. Scaravilli ? G. Tinchero ? G. Citerio ?The Participants in the International Multi-disciplinary Cons

56、ensusConference on the Critical Care Management of Subarachnoid Hemorrhage.2011,僅僅關(guān)于鎮(zhèn)靜和溫度的問題:拿什么溫度作尺子？：腦溫！多點！多早？盡早！何時都有意義！溫度多低？鎮(zhèn)靜多深？多久？病理生理過程；ICP？用什么控溫？溫度的質(zhì)控！復(fù)溫？,目標(biāo)化鎮(zhèn)靜和體溫管理的目標(biāo)制定,降低腦代謝的手段：鎮(zhèn)靜和麻醉,,Fever Management i

57、n SAH V. Scaravilli ? G. Tinchero ? G. Citerio ?The Participants in the International Multi-disciplinary ConsensusConference on the Critical Care Management of Subarachnoid Hemorrhage.2011,僅僅關(guān)于鎮(zhèn)靜和溫度的問題:拿什么溫度作尺子？：腦溫！多

58、點！多早？盡早！何時都有意義！鎮(zhèn)靜多深？以代謝狀態(tài)以及腦代謝灌注失衡程度定，Bis 30-40？多久？病理生理過程；ICP？用什么控溫？溫度的質(zhì)控！復(fù)溫？,目標(biāo)化鎮(zhèn)靜和體溫管理的目標(biāo)制定,Fever Management in SAH V. Scaravilli ? G. Tinchero ? G. Citerio ?The Participants in the International Multi-disciplina

59、ry ConsensusConference on the Critical Care Management of Subarachnoid Hemorrhage.2011,僅僅關(guān)于鎮(zhèn)靜和溫度的問題:拿什么溫度作尺子？：腦溫！多點！多早？盡早！何時都有意義！溫度多低？多久？病理生理過程；ICP？用什么控溫？溫度的質(zhì)控！復(fù)溫？,目標(biāo)化鎮(zhèn)靜和體溫管理的目標(biāo)制定,,,低溫治療的利與弊評估、權(quán)衡和妥協(xié),神經(jīng)重癥體溫升高是影響

60、預(yù)后和LOS的獨立危險因素,Diringer MN, Reaven NL, Funk SE, Uman GC. Elevated body temperature independently contributes to increased length of stay in neurologic intensive care unit patients. Crit Care Med. 2004;32:1489–95.,,Think D

61、ifferent ： 我們是否曾經(jīng)片面強調(diào)追求灌注而忽略了體溫的控制？！,Fever Management in SAH V. Scaravilli ? G. Tinchero ? G. Citerio ?The Participants in the International Multi-disciplinary ConsensusConference on the Critical Care Management of Sub

62、arachnoid Hemorrhage.2011,NORMOTHERMIA:蛛網(wǎng)膜下腔出血的發(fā)熱控制1、發(fā)熱（體溫＞38.3℃，72%SAH患者）與SAH后的不良預(yù)后及住院日延長相關(guān)，是獨立于血管痙攣的有害因素。但發(fā)熱如何影響預(yù)后仍不明確，發(fā)熱可能促進繼發(fā)性神經(jīng)損傷，也可能發(fā)熱本身即是某些不良事件的標(biāo)志。2、獨立于出血嚴重程度和感染，發(fā)熱可能與癥狀性腦血管痙攣有關(guān)，兩者中均有炎癥激活。3、發(fā)熱發(fā)生發(fā)展的危險因素：疾病嚴重程度、蛛

63、網(wǎng)膜下腔出血量及腦室內(nèi)出血；加重缺血性損傷及腦水腫，升高顱內(nèi)壓，影響意識狀態(tài)。SAH后即使是一過性發(fā)熱，與預(yù)后不良有關(guān)，在級別較低的SAH患者中亦然。4、非感染性發(fā)熱通常比感染性發(fā)熱早，多發(fā)生在SAH后3天內(nèi)；感染性發(fā)熱也不少見，需要立即應(yīng)用抗生素治療。累計性發(fā)熱負荷（SAH后13天體溫＞38℃的累計）與患者預(yù)后不良及延遲康復(fù)有關(guān)。5、發(fā)熱的控制包括應(yīng)用退熱劑、體表降溫及血管內(nèi)降溫。降溫的益處可能由寒戰(zhàn)帶來的不良反應(yīng)抵消。寒戰(zhàn)的防治

64、包括應(yīng)用丁螺環(huán)酮、糾正低血鎂、使用杜冷丁，及鎮(zhèn)靜。,發(fā)熱負荷管理和目標(biāo)化體溫管理,Fever Management in SAH V. Scaravilli ? G. Tinchero ? G. Citerio ?The Participants in the International Multi-disciplinary ConsensusConference on the Critical Care Management of

65、 Subarachnoid Hemorrhage.2011,關(guān)于NORMOTHERMIA的問題:Fever Burden 發(fā)熱負荷的監(jiān)測和管理有所謂的正常體溫嗎？正常人有，那病人呢？,發(fā)熱負荷管理和目標(biāo)化體溫管理,體溫也是個相對概念：腦灌注和代謝的平衡！,腦灌注代謝平衡匹配的評估Think Different,ICP 18CPP70BIS 50Tb 38,ICP16CPP90BIS 40Tb37,ICP 14CPP

66、100BIS 35Tb 33,ICP22CPP100BIS 30Tb 32,CHINA International Neuroscience Institute ICU,腦代謝的指標(biāo)：Microdialysis,輸血加鎮(zhèn)靜,,腦代謝的指標(biāo)：Microdialysis,CHINA International Neuroscience Institute ICU,Think Different：沒有所謂金指標(biāo)不同的方法、不同的參

67、數(shù)、不同的角度,不同的結(jié)果、能相互替代嗎？,平衡、匹配和妥協(xié),繼發(fā)腦損傷的防治,CHINA International Neuroscience Institute ICU,,如何尋找腦灌注與代謝的平衡點？如何達到腦灌注與代謝的平衡點？如何維持腦灌注和代謝的平衡？,Targeted Sedation and Temperature Management Protocol For a SAH,Monitoring : CA , T

68、CD ,ICP, MAP , VS ,生化：PAB,CRP、CKICP 150 mmHg （FiO2 50%）；PCO2 ：30-35mmHgPH 7.40T brain 30-35 ℃ （匹配）BIS 30-50 EEG？NCSE?CI:3-5;視 CBF 定EVLW : 10G/L;HCT 30-35%I / O : 避免大出大入器官保護：早期放置鼻腸管，低流量EN，必要時加PN，低熱卡護理：