顱內(nèi)高壓患者血壓多少合適

1、顱內(nèi)高壓患者血壓多少合適,,主題——ICU常見的顱內(nèi)高壓癥,{,{,腦外傷（TBI）,顱高壓癥,中風,腦出血（ICH）腦梗塞（ischemic ）自發(fā)蛛網(wǎng)膜下腔出血（SAH）,共同的特點：多存在高血壓繼發(fā)性損害：出血加重和腦水腫,概述,腦灌注壓（CPP）與腦血流（CBF）的關(guān)系（實驗）,概述,,,,腦血流的自主調(diào)節(jié)功能（Cerebral Autoregulation),CPP、MAB與腦血流的關(guān)系,CPP:60—130mmHg

2、,,,,概述,繼發(fā)性損傷問題（Secondary brain damage）,CBV↑,CPP ↑,ICP ?,Hypertension,Brain edema,,Edema and hematoma,Primary injury,CBF ↑,Lower BP,CPP = MAP – ICP,hematoma ↑,Ischemia,?,?,?,概述,繼發(fā)性損傷問題（Secondary brain damage）,如何降低ICP的基礎(chǔ)

3、上，保持合適的CCP和血壓，以減少繼發(fā)性損傷？,Hypertension,Lower BP,CPP = MAP – ICP,CPP,Hypotension,,,,概述,ICP與TBI預(yù)后,Balestreri, etal. Neurocrit. Care 2006;04:8–13,,,重癥腦外傷,CPP與TBI預(yù)后,Balestreri, etal. Neurocrit. Care 2006;04:8–13,,,,,,重癥腦外傷,恰當?shù)?/p>

4、CPP,重癥腦外傷,Steiner,etal. CCM.2002,血壓控制現(xiàn)在觀點：,重癥腦外傷,腦灌注壓閾值：CPP ≥60mmHg(2001-2005)Lund:>50mmHg（2003）但避免：CPP<50mmHg維持 ICP < 20 mm Hg,MAP = CPP + ICP （20/50）70mmHg≤MAP≤120mmHg,Brain Trauma Foundation. J Neurotraum

5、a 2007；24（5）：S59,腦出血（ICH）急性期血壓控制,目的：減少24h內(nèi)繼續(xù)出血降低血腫周圍72h的水腫(perihematomal edema)什么時候降壓、血壓控制到多少合適？爭論最大，而持續(xù)！,Broderick et al: Guidelines for the management of spontaneous intracerebral hemorrhage: A statement for healthc

6、are professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 1999; 30:905–915Robinson TG, Potter JF. Blood pressure after stroke.Age Ageing 2004; 33: 6–12.,腦出血,ICH指南演變,Stroke.

7、 1999;30:905-915，Stroke. 2007;38:2001-2023， Stroke. 2010;41:2108-2129,腦出血,腦出血,結(jié)論：ICH患者快速降低MBP顯著增加死亡率。提出MBP在150mmHg以下，并非必須積極降壓.,105例ICH患者24小時降壓回顧性風險分析：（平均 MBP:140mmHg） 死亡組：MAP降幅 64.8/2.7mmHg; 生存組：MAP降幅28.8/1.2 mm H

8、g。,Qureshi AI, etal. Rate of 24-hour blood pressure decline and mortality after spontaneous intracerebral hemorrhage: a retrospective analysis with a random effects regression model. Crit Care Med. 1999;27:480,平均動脈壓的演變,,

9、,,,SBP和DBP的演變,Qureshi AI, etal. A prospective multicenter study to evaluate the feasibility and safety of aggressive antihypertensive treatment in patients with acute intracerebral hemorrhage. J Intensive Care Med. 2005

10、;20:34–42.,target ：160/90 mm Hg,,24小時內(nèi)使維持BP在160/90mmHg,可減少7%的繼發(fā)出血量和9%的腦水腫。該研究奠定了目標血壓控制在160/90mmHg.,腦出血,強化控壓對ICH的預(yù)后評估,腦出血,2008Craig等發(fā)表強化降壓治療（即在發(fā)作6小時內(nèi)控制SBP ≤ 140 mmHg）安全研究。,目的：評估ICH患者早期6h不同降壓水平對出血量和預(yù)后的影響：分

11、組：強化組（n=203）：目標SBP ≤140 mmHg 指南組（n=201）：目標SBP ≤180 mmHg),強化控壓對ICH的預(yù)后評估,結(jié)論：早期強化降壓視乎是安全可行的，但對預(yù)后無影響,,,Anderson CS, etal. the INTERACT investigators. Intensive Blood Pressure Reduction In Acute Cerebral Haemorrhage Tri

12、al (INTERACT): a randomised pilottrial. Lancet Neurol. 2008;7:391,腦出血,不同降壓水平ICH的定量影響,再評價出血和水腫強化組（n=151）指南組（n=145）,早期強化降壓能夠減少24h和72h （P=0.02）的出血量，但對血腫周圍水腫均無影響。,Craig S.etal.Effects of Early Intensive Blood Pressure-Lowe

13、ring Treatment on the Growth of Hematoma and Perihematomal Edema in Acute Intracerebral Hemorrhage The Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT). Stroke. 2010;41:307-312,,腦出血,分層降壓對

14、ICH預(yù)后的影響：,Antihypertensive treatment of acute cerebral hemorrhage.Crit Care Med 2010:38(2);637,腦出血,分層降壓對ICH預(yù)后的影響：,結(jié)論：分層控制SBP在神經(jīng)損害和嚴重事件方面較預(yù)期（<140mmHg)）的損害要低，三個月死亡率也比預(yù)期的低。,Antihypertensive treatment of acute cerebral he

15、morrhage.Crit Care Med 2010:38(2);637,,,腦出血,最新研究報告,Stroke.,Yuki Sakamoto, etal. Systolic Blood Pressure After Intravenous Antihypertensive Treatment and Clinical Outcomes in Hyperacute Intracerebral Hemorrhage.Stroke. 20

16、13; 44: 1846-1851,,腦出血,血壓控制現(xiàn)在觀點：,近年的研究提示強化血壓控制能夠減少腦繼發(fā)出血，但不能減少或加重腦水腫，因此2010AHA/ASA指南仍沿用2007年控壓意見！——既目標血壓160/90mmHg.,腦出血,缺血性中風的血壓控制,腦梗塞,缺血性腦中風血壓與預(yù)后,Leonardi, etal. Blood pressure and clinical outcomes in the international

17、stroke trial. .Stroke 2002;33(5):1315,腦梗塞,,缺血性腦中風血壓與預(yù)后,早期腦水腫程度,殘疾程度,,,,,Castillo,etal. Blood Pressure Decrease During the Acute Phase of Ischemic Stroke Is Associated WithBrain Injury and Poor Stroke Outcome . Stroke. 20

18、04;35:520-526,腦梗塞,缺血性腦中風血壓與預(yù)后,Castillo,etal. Blood Pressure Decrease During the Acute Phase of Ischemic Stroke Is Associated WithBrain Injury and Poor Stroke Outcome . Stroke. 2004;35:520-526,死亡率,腦容積率,,,,,腦梗塞,缺血性腦中風血壓與預(yù)后

19、,CPP與TBI預(yù)后： 許多研究證明在腦缺血性中風患者，急性期血壓水平與預(yù)后呈U型相關(guān)性。,George,etal. Blood pressure treatment in acute ischemic stroke: a review of studies and recommendations. Current Opinion in Neurology 2010, 23:46–52,腦梗塞,血壓控制現(xiàn)在觀點：,George,e

20、tal. Blood pressure treatment in acute ischemic stroke: a review of studies and recommendations. Current Opinion in Neurology 2010, 23:46–52,對缺血性中風應(yīng)謹慎降壓，推 薦當 血壓高于220/120mmHg時考慮降壓，目標血壓140-180/90-100mmHg。需要溶栓的患者目標血壓應(yīng)控制在

21、185/100mmHg以下AHA/ASA和ESO建議,腦梗塞,原發(fā)性蛛網(wǎng)膜下腔出血（SAH）,爆發(fā)性CPP增高,而ICP升高有限,SAH,SAH出血特點,早期控制血壓是必須的！,SAH,血壓控制現(xiàn)在觀點：,指南推薦： 控制BP150-160/100 mmHg,,SAH,結(jié)束語,顱腦外傷：謹慎降壓，避免CPP200 mmHg, MBP>130考慮 控制血壓. 目標BP: 160