Clincial Research of Early Hyperbaric Oxygen Treatment on the patients after Craniortomy with Severe Traumatic Brain Injury
|School||Southern Medical University,|
|Keywords||Severe traumatic brain injury After craniotomy Hyperbaric Oxygen Therapy GCS GOS Tracheotomy|
[Background] brain injury (traumatic brain injury, TBI) is known as the silent epidemic in the United States. TBI is still a major cause of death and disability of patients worldwide. In severe traumatic brain injury (severe traumatic brain injury, STBI) accounts for about 20% of TBI, mortality statistics in 1988-1993 to 43 percent in 1993-1996 to 36.8% in 1997-2004 to 29.75 %. Mortality after after many efforts TBI hospitalized patients in the United States dropped from 50% in the 1970s to 17% in 2003. However, the overall mortality is still high, a serious burden to the society and the family. The STBI clinical prognosis depends largely on secondary brain damage in molecular biology and cytology changes, which alter the pathophysiology of brain injury. TBI divided into primary and secondary injury. Primary injury can cause brain tissue damage of the cerebral cortex contusion and bleeding, but do not have a wide range of neurons and other brain cells, the degradation of axons. Progress of secondary injury after injury, the patient's survival, mortality decisive role. Secondary brain injury include two aspects of reaction ① molecular biology brain injury: the release of excitatory amino acids and free radicals, the formation of nitrogen oxides, and the interaction of the three. Cause calcium into cells, impaired the protease, affecting mitochondrial function, causing apoptosis and adenosine triphosphate (adenosine triphosphate, ATP) generated obstacles, while induced super oxide, oxygen free radicals, nitrogen oxide formation, affect cell metabolism and proliferation, and ultimately lead to cell death, the structure and function of the insufficiency. ② changes in physiological parameters of brain damage: Brain Injury ischemia; brain parenchyma and subarachnoid hemorrhage lead to vascular endothelium and the blood-brain barrier (blood brain barrier, BBB) destruction; BBB integrity after damage to the brain damage caused by the brain unstable environment, loss of automatic adjustment function; brain injury after hemorrhage, edema, swelling or mass effect lead to elevated intracranial pressure (intracranial pressure, ICP); cerebral edema can cause brain damage, including interstitial edema (vascular source resistance) and intracellular edema (cytotoxicity). In the domestic the STBI the treatment except primary brain stem injury and diffuse axonal injury mostly need surgical treatment, supplemented by a variety of drugs and rehabilitation after surgery treatment. Standard large trauma craniotomy has become a the STBI major surgical procedure. Postoperative dehydration, corticosteroids, calcium antagonists, endogenous brain protection factor, such as drug application; hypothermia treatment; nutrition therapy; rehabilitation and drugs snooze. Combination therapy. Foreign intervention to reduce mortality and morbidity for a mechanism of secondary injury after TBI, multi-center clinical trial results for a variety of drugs and hypothermia treatment, suggesting no significant neurological outcomes and survival rates improve TBI patients role. However, in recent years, in the field of oxygen therapy, hyperbaric oxygen therapy (hyperbaric oxygen treatment, HBOT), animal and clinical trials have shown that treatment prospects STBI, the instrument technical level with the animal experiments and clinical studies improve , the study found that the HBOT mechanisms embodied in the mitochondrial level, can improve the Brain Injury aerobic metabolic. Clinical hyperbaric oxygen (hyperbaricoxygen, HBO) can reduce mortality and improve neurological outcomes of TBI patients. HBOT has 200 years of history, according to the Plateau Medical Association in 1999 under the sea for (undersea and hyperbaric medical society UHMS) recommendation has been widely used in clinical as: carbon monoxide poisoning, gas gangrene, decompression sickness; With HBOT increasingly common and promotion in 2000 UHMS increase new indications, such as: acute cerebrovascular disease, cerebral edema, brain trauma. In STBI the applications development rapidly, and a large number of domestic and international study found that the mechanism of HBO TBI pathophysiology corresponding to the change, the more complicated. Domestic and foreign research HBOT mechanism: 1, cerebral vasoconstriction, thereby reducing CBF, ICP, reduce cerebral edema, and at the same time improve the bioavailability of oxygen at the cellular level, increase brain oxygen for reducing cerebral ischemia. 2, HBOT can improve ICP, and can still continue to function after treatment. 3, can have a stabilizing effect on the BBB. 4, improve glucose metabolism and aerobic metabolism of patients with severe brain damage, HBOT mitochondrial level to promote oxygen metabolism and improve oxygen utilization. 5, HBOT after hypoxia can promote cognitive recovery, increased brain ATP levels to reduce the loss of hippocampal neurons in a mouse model of research. Used in TBI research at home and abroad HBOT more achieved certain results, a single treatment of experimental and clinical studies suggest that effective. Evidence-based medical centers abroad but do Meta-analysis of the effect of HBOT applied to TBI:'' HBOT for TBI patients valid or not is still a lack of sufficient evidence \few studies of German researchers, 11 patients craniotomy, after ICP and brain tissue oxygen partial pressure by measuring showed that craniotomy decompressive craniectomy surgery of diffuse brain edema and cerebral accounted to improve the bit intraoperative and postoperative brain tissue oxygen supply and ICP multicenter prospective clinical study table Ming, craniotomy after decompressive craniectomy, brain tissue bulging to the vacuum side of the bone window, on behalf of subordinated the cranial cavity inner volume lifted a placeholder oppression brainstem, effective protection of the brain function the cranial contents craniotomy plot the change makes the pressure on the brain tissue of the restoration of the structure, blood supply and oxygen supply to improve ultimately improve patient outcomes. HBOT applied to STBI effect not craniotomy brain contusion, brain stem injury and diffuse axonal injury in patients enrolled patients contain the one hand, cerebral contusion with cerebral edema patients underwent conservative therapy, brain tissue partial placeholder Without good improvements affect local blood oxygen supply leads to cerebral edema and cerebral ischemia occurred the other hand, pure brain stem injury with diffuse axonal injury patients with long duration of coma, the prognosis of patients with different periods of the overall assessment of the interference. craniotomy skull defects ICP prone to fluctuations, particularly in patients with postural changes, such as cough, fever case the above factors and open the cranial postoperative patients together to evaluate HBOT effect may have serious interference. response to this situation, this research is mainly focused on in STBI craniotomy patients, Glasgow Coma Scale (Glasgou coma scale GCS) change and Glasgow prognostic classification (Glasgou outcome scale, GOS) to improve the situation, evaluated HBO improve the patient's state of consciousness and prognosis; HBO restore the role of the patient's airway to evaluate this indicator only lung infection for the past scholars, this study introduces a tracheotomy patient's tracheal tube unplug rate, comprehensive assessment restore the benefit of the patient's airway. [Objective] observed early hyperbaric oxygen therapy for severe traumatic brain injury after craniotomy patients state of consciousness (GCS improvement prognosis (GOS classification) score). completion of the assessment of patients with hyperbaric oxygen treatment (5 weeks of hospitalization) admission March 3. assessment of hyperbaric oxygen therapy for severe traumatic brain injury after craniotomy and tracheotomy to restore the patient's airway (tracheostomy tube the unplug rate) impact. objects and methods]. cohort study, selected Huadu District People's Hospital of Neurosurgery January 1, 2009 ---- 2010 6l November 25 hospitalized patients with severe traumatic brain injury patients, all patients admitted to hospital after emergency craniotomy decompressive craniectomy surgery, patients enrolled in time for about seven days after the craniotomy. enrolled in the clinical study of 61 patients inclusion criteria: (1) between the ages of 18-60 years old; ② severe traumatic brain injury patients, admission GCS score (GCSO) 3-8; decompressive craniectomy surgery ③ 24 hours after admission experts craniotomy patients; ④ hospitalized after l weeks with stable vital signs, and can withstand high-pressure oxygen therapy; ⑤ all enrolled patients treatment informed consent \patients with severe special events in the process. 3. program based on randomized clinical trials (random number table), the final 61 patients enrolled, patients enrolled in the hyperbaric oxygen treatment group, 30 patients in the control group (non-hyperbaric oxygen therapy group) 31 cases (1) hyperbaric oxygen therapy patients, 24 males and 6 females cases; median age of 35 years (range 18-60 years); average weight (60.57 ± 8.61Kg); Average height (165.97 ± 8.09CM) admission; admission GCS average score (6.10 ± 1.42 points); hyperbaric oxygen therapy GCS average score (7.47 ± 1.61 points); tracheotomy patients for 21 cases, not tracheotomy 9 cases; brain herniation 22 patients non-herniation 8 patients; preoperative diagnosis of patients with traumatic brain injury injury form: 25 cases of car accidents, blunt, falling three cases;: are severe traumatic brain injury, post-operative diagnosis: the cerebral contusion three cases of intracerebral hematoma, brain contusion and subdural hematoma in 14 cases of cerebral contusion and epidural hematoma, epidural hematoma l cases, eight cases. composite hematoma (2) of the control group patients, 24 males and and 7 females; median age: 36 years old (19-60 years old); average weight (61.16. ± 8.59Kg); Average height (166.61 ± 6.99CM); the admission GCS Average rating (6.23 ± 1.52 points) ; before hyperbaric oxygen (observation time over the same period) GCS score (7.87 ± 1.31 min); the tracheostomy patients 2l, not tracheotomy in 10 cases; the admission brain herniation 22 patients, non-herniation patients 9 cases; patients with traumatic brain injury hurt constituted: 27 cases of car accidents, blunt 2 cases, to fall 2 cases; preoperative diagnosis: one cases were severe traumatic brain injury, post-operative diagnosis constitutes brain contusion and intracerebral hematoma, brain setback laceration and 14 cases of subdural hematoma, brain contusion and epidural hematoma, subdural hematoma, epidural hematoma in 2 cases, five cases of composite hematoma. 4. emergency line open all the patients admitted to hospital cranial craniectomy decompression surgery after two groups of patients given early ECG, blood oxygen monitoring in flow oxygen requiring tracheal pieces thereof within 4 days after tracheal incision, and I suctioning and I dehydration, hemostasis, Huwei, drugs and supportive care to prevent infections, neurological nutrition, energy, rehydration, in stable condition after about a week after I review cranial CT and clear no active bleeding line Huoxue medication. hyperbaric oxygen treated patients in about seven days after admission, the vital signs were stable, into the hyperbaric oxygen hyperbaric oxygen therapy 28 times, the control group was given equivalent treatment except to hyperbaric oxygen. 5. OUTCOME MEASURES: ① The two groups of patients admitted to hospital and 1, 2, 3, 4, 5 weeks after admission GCS score; ② prognosis, the use of hyperbaric oxygen before the start of GOS classification (GOSb), the end of the five weeks after admission or hyperbaric oxygen treatment the GOS classification (GOS5w, when) March after admission GOS classification (GOS3m), observe the GOS classification change, GOS were classified into five: 1, death; 2, plant survival; 3, severe disability; 4, moderate disability; 5, good. ③ observed severe traumatic brain injury craniotomy and tracheotomy patients admitted to hospital five weeks after admission, March tracheal cannula removal of the number of cases. 6. statistical methods: SPSS13.0 statistical analysis software, all patient information After data collection and processing, database entry and corresponding statistical description and test measurement data normally distributed with mean, standard deviation described using two independent samples t-test; does not comply with the normal distribution of the measurement data using mean rank, rank and description using the Wilcoxon rank sum test of two independent samples; count data rate of adoption described using the chi-square (χ2) test P lt; 0.05 considered statistically significant differences. [results] 1. selected two groups of 61 cases of patients (tracheotomy 2l patients in each group) general baseline data for statistical description and examination, age, high-pressure oxygen treatment before GOS the rating (GOSb), gender, tracheotomy, hospitalization brain herniation, injury due to height, weight, admission GCS score, hyperbaric oxygen therapy before (treatment l weeks) GCS score corresponding statistical tests, all P gt; 0.05, two groups of patients with baseline data variables no statistically significant differences in selected patients with baseline information balanced between the two groups of patients after admission GCS score difference of two weeks without significant statistical difference (t = 1.684, P = 0.097) between the two groups of patients admitted to hospital after three weeks GCS score (t = 2.091, P = 0.041); four weeks GCS score (t = 2.240, P = 0.029), five weeks GCS score (t = 2.759, P = 0.008) were statistically significant differences. 3. between the two groups GOS5w with GOSb comparison the patients the number (iGOS5w) improve GOS3m ??with the the comparative increase the number of patients in GOSb (iGOS3m), chi-square (χ2) test results suggest that there is a statistically significant difference in the two groups iGOS5w (χ2 = 4.725 P = 0.030), the two groups iGOS3m ??significant statistical difference (χ2 = 5.19l P = 0.023); two stages of the two groups of patients, the difference of the tracheal cannula unplug rate (after five weeks after admission and admission March), were No significant chi-square test, five weeks after admission prompted tracheal cannula disconnect rate a statistically significant difference (χ2 = 8.005, P = 0.005; Fisher's Exact Test P = 0.011), March Unplug the number of cases of tracheal tube after admission significant difference (χ2 = 3.500, P = 0.061). [Conclusion] 1. early hyperbaric oxygen therapy for patients with severe traumatic brain injury after craniotomy promote awareness to improve the role; 2 with severe traumatic brain injury after craniotomy patients early hyperbaric oxygen therapy can promote improved prognosis; 3. postoperative tracheotomy patients, hyperbaric oxygen therapy can promote the patient's airway to restore craniotomy in severe brain damage and early role more evident than late.