Does ICP monitoring make a difference in neurocritical care?

O L Cremer
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引用次数: 28

Abstract

Raised intracranial pressure and low cerebral perfusion pressure are associated with ischaemia and poor outcome after brain injury. Therefore, many management protocols target these variables. However, there are no randomized controlled trials that have demonstrated the effectiveness of intracranial pressure-guided care in severely head-injured patients. Observational studies of such therapy have yielded inconsistent results, ranging from decreased mortality to no effect or increased morbidity or mortality. A recent cohort study supports the notion that the possible benefits of intracranial pressure monitoring after traumatic brain injury are small - if present - and would exceed a number needed for the treatment of 16. Furthermore, intracranial pressure monitoring and aggressive management of intracranial pressure and cerebral perfusion pressure have been associated with increased lengths of stay in the neurocritical care unit, conceivable costs and possibly an increased rate of complications. Against this background, there is sufficient clinical equipoise to warrant an adequately powered randomized controlled trial to compare intracranial pressure-guided care with supportive critical care without intracranial pressure monitoring in patients with severe traumatic brain injury. However, the realization of such a trial is likely to be problematic for a number of reasons, not least of which the firmly held biases of many clinicians.

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颅内压监测对神经危重症护理有影响吗?
颅内压升高和脑灌注压降低与脑损伤后缺血和预后不良有关。因此,许多管理协议都以这些变量为目标。然而,尚无随机对照试验证明颅内压引导护理对严重颅脑损伤患者的有效性。这种疗法的观察性研究产生了不一致的结果,从降低死亡率到没有效果或增加发病率或死亡率。最近的一项队列研究支持这样一种观点,即外伤性脑损伤后颅内压监测可能带来的好处很小——如果存在的话——而且会超过治疗16人所需的数字。此外,颅内压监测和积极的颅内压和脑灌注压管理与神经重症监护病房的住院时间增加、可想象的费用和可能增加的并发症发生率有关。在此背景下,有足够的临床平衡来保证一项足够有力的随机对照试验来比较颅内压引导护理与无颅内压监测的重症监护对严重创伤性脑损伤患者的影响。然而,由于许多原因,实现这样的试验可能会出现问题,尤其是许多临床医生的坚定偏见。
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