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临床时讯 > 临床研究


全文备索静脉推注高渗性液体不显著改善严重脑创伤患者预后


  一项多国研究显示,对非低血容量性休克的严重创伤性脑损伤(TBI)患者,予高渗性液体不显著改善6个月时神经系统预后或生存率。研究发表于《美国医学会杂志》(JAMA)。

  研究纳入2006年5月至2009年5月未达低血容量性休克标准的钝性外伤患者(年龄≥15岁,院前格拉斯哥昏迷量表评分≤8)1087例,分别予250ml7.5%盐水/6%右旋糖酐70(高渗性盐水/右旋糖酐)、7.5%盐水(高渗性盐水)或0.9%盐水(生理盐水)推注,据6个月时扩展格拉斯哥预后量表(GOSE,>4或≤4)评估患者神经系统转归。

  结果为,各组严重TBI患者6个月时神经系统转归无差异(GOSE≤4),在予高渗性盐水/右旋糖酐、高渗性盐水及生理盐水静脉推注后,各组患者的病情改善率分别为53.7%、54.3%和51.5%(P=0.67);治疗28天时各组生存率分别为74.3%、75.7%和75.1%(P=0.88)。

JAMA. 2010 Oct 6;304(13):1455-64.

Out-of-hospital hypertonic resuscitation following severe traumatic brain injury: a randomized controlled trial.

Bulger EM, May S, Brasel KJ, Schreiber M, Kerby JD, Tisherman SA, Newgard C, Slutsky A, Coimbra R, Emerson S, Minei JP, Bardarson B, Kudenchuk P, Baker A, Christenson J, Idris A, Davis D, Fabian TC, Aufderheide TP, Callaway C, Williams C, Banek J, Vaillancourt C, van Heest R, Sopko G, Hata JS, Hoyt DB; ROC Investigators.

Collaborators (388): Kerby JD, George RL, Wang HE, Stephens SW, Williams CR, Acker JE, Minor ML, MacLennan PA, Caldwell S, Lai KR, Idris AH, Benitez F, Fowler R, Lemecha D, Minei J, Pepe P, Ramsay M, Simonson R, Wigginton J, Gandhi R, Smithson J, Griswell J, Climer D, Moffat M, Newman K, Owens P, Bennett A, Black R, Cason D, Craft B, Detamble L, Dykes R, Harvey T, Hewitt S, Isaacs M, Kay J, Kayea T, LaChance R, Lehman T, Mayer P, Metzger J, Miller D, Navarro K, Parker S, Pickard K, Porter W, Starling TJ, Tine T, Vinson C, Roach K, Abebefe D, Arze S, Black S, Bush M, Forman M, Goodloe J, Kelly R, Lachar G, Mangram A, Morales M, Thornton E, Wiebe R, Novonty P, Haynes L, Kerber R, Hata S, Atkins D, Rost C, Drum A, Fabian T, Croce M, Zarzaur B, Magnotti L, Schroeppel T, Maish G, Bee T, Wilson S, Panzer-Baggett S, Waddle-Smith L, Aufderheide TP, Pirrallo RG, Brasel KJ, Winthrop AL, Klein JP, Brandt J, Bialkowski W, Noldin J, Kitscha DJ, Burja BJ, Bertelson H, von Briesen C, Sparks CW, Walsh P, Chianelli J, Forster R, Milbrath M, Pukansky L, Sternig K, Chin E, Frieberg N, Krueger K, Szewczuga D, Duerr T, Funk R, Jacobsen G, Spitzer J, Demien R, Martins J, Cohn J, Spahn RR, Jankowski M, James T, Wentlandt WE Jr, Berousek D, Satula BM, Behling JB, Redman DK, Hook S, Neargarder A, Singer J, Reminga T, Shepherd D, Holzhauer P, Rubin J, Skold C, Alvarez O, Harkins H, Barthell E, Haselow W, Yee A, Whitcomb J, Castro EE, Motarjeme S, Coogan P, Rader K, Glaspy J, Gerschke G, Croft H, Brin M, Wilson C, Johnson A, Kumprey W, Hoyt DB, Shaver J, Nastanski F, Donato B, Stratton S, Miller K, Grubb R, Herrera J, Grihalva L, Barrios C, Lekawa M, Cinat M, Malinoski D, Dolich M, Sauri H, Stiell I, Christenson J, Osmond M, Hameed M, Evans D, van Heest R, Vaillancourt C, Lefaivre P, Da Ponti MA, Banek J, Watpool I, McArdle T, Foxall J, Lewis MJ, Boychuk B, Pennington S, Dreyer J, Munkley D, Maloney J, Colella P, Affleck A, Waldbillig D, Bradford P, Reid A, Boyle K, Luinstra-Toohey L, Trickett J, Sykes N, Graham E, Ballah K, Hedges C, Andrusiek D, Bishop D, Straight R, Twaites B, Donn S, Callaway C, Tisherman S, Rittenberger J, Hostler D, Condle J, Kampmeyer M, Markham T, Morgan M, Sabol P, Sicchitano G, Sherry S, Shrader A, Stull G, Torres M, Groft W, McCaughan R, Rohrer R, Cole J, Fuchs D, Guyette F, Jenkins W, Roth R, Walker H, Corcos A, Doshi A, Ong A, Peitzman A, Schmidt T, Hedges JR, Schreiber MA, Newgard CD, Daya MR, Lowe RA, Griffiths DE, Zive DM, Monnig AW, Yekrang A, Brett J, Jui J, Sahni R, Warden CR, Freedman S, Muhr MD, Stouffer JA, Gorman K, Rosteck P, Newton C, Beeler T, Horn K, Koenig K, Lee J, Barnes R, Tucker H, Allen B, Bishop TJ, Hollingsworth M, Schult E, Sullivan S, Williams R, Dehart S, Stevens M, Hawks R, Glaser A, Rowan R, Chin J, Dargan S, Zoutendijk G, Koppenhafer C, Depuy C, Anderson J, Ramzy AI, Gubler KD, Wittwer LK, Karmy-Jones R, Hoskins G, Underwood S, Haun-Taylor D, Bryant E, Miller J, Barone B, Patterson K, Davis D, Coimbra R, Vilke G, Dunford J, Aker DK, McCallum-Brown L, Haynes B, Schwartz B, Sise M, Kennedy F, Simon F, Tominaga G, Steele J, Kudenchuk PJ, Bulger E, Copass M, Eisenberg MS, Rea TD, Klotz P, Larsen J, Helbock M, Slutsky A, Morrison LJ, Dorian P, Craig A, Baker A, Hutchison J, Rotstein O, Verbeek PR, MacDonald R, Black S, Rizoli S, Cheskes S, Brooks S, Zhan C, Simitciu M, Slater M, D'Souza P, Chung S, Perreira T, Cameron B, Austin D, Burse G, Frank J, Shield J, Locke J, Grant K, Welsford M, Moran P, Burgess R, Suthons R, MacDonald R, Darling S, Dewar S, Tyukodi S, Dodd T, Jones V, Arcand A, O'Connor C, Letovsky E, Dwosh H, Spence J, Choong K, Sne N, Segal S, Bojilov B, Wenkstern C, Watson J, Cicero L, Santos M, Geiteiro R, Farrell R, Rodgerson S, Li Y, Weisfeldt M, Hoyt DB, Holcomb JB, Sopko G, Egan D, Lathrop D, Mascette A, Nickens PD, Wu C, Mitchell P, Hoke T, van Belle G, Emerson S, Nichol G, May S, Bulger E, Powell J, Bardarson B, Gest A, Cook A, Meier E, Crouch L, Devlin S, Schroeder D, Sitlani C, Koprowicz K, Everson-Stewart S, Thomas L, Gabriel E, Wu K, Schmicker R, Ledingham RB, Moore R, Bergsten-Buret B, Shen C, Kirdpoo W, Berhorst J, Leonen A, Wang Y, Hallstrom A.

Department of Surgery, University of Washington, Seattle, USA.


Abstract

CONTEXT: Hypertonic fluids restore cerebral perfusion with reduced cerebral edema and modulate inflammatory response to reduce subsequent neuronal injury and thus have potential benefit in resuscitation of patients with traumatic brain injury (TBI).

OBJECTIVE: To determine whether out-of-hospital administration of hypertonic fluids improves neurologic outcome following severe TBI.

DESIGN, SETTING, AND PARTICIPANTS: Multicenter, double-blind, randomized, placebo-controlled clinical trial involving 114 North American emergency medical services agencies within the Resuscitation Outcomes Consortium, conducted between May 2006 and May 2009 among patients 15 years or older with blunt trauma and a prehospital Glasgow Coma Scale score of 8 or less who did not meet criteria for hypovolemic shock. Planned enrollment was 2122 patients.

INTERVENTION: A single 250-mL bolus of 7.5% saline/6% dextran 70 (hypertonic saline/dextran), 7.5% saline (hypertonic saline), or 0.9% saline (normal saline) initiated in the out-of-hospital setting.

MAIN OUTCOME MEASURE: Six-month neurologic outcome based on the Extended Glasgow Outcome Scale (GOSE) (dichotomized as >4 or ≤4).

RESULTS: The study was terminated by the data and safety monitoring board after randomization of 1331 patients, having met prespecified futility criteria. Among the 1282 patients enrolled, 6-month outcomes data were available for 1087 (85%). Baseline characteristics of the groups were equivalent. There was no difference in 6-month neurologic outcome among groups with regard to proportions of patients with severe TBI (GOSE ≤4) (hypertonic saline/dextran vs normal saline: 53.7% vs 51.5%; difference, 2.2% [95% CI, -4.5% to 9.0%]; hypertonic saline vs normal saline: 54.3% vs 51.5%; difference, 2.9% [95% CI, -4.0% to 9.7%]; P = .67). There were no statistically significant differences in distribution of GOSE category or Disability Rating Score by treatment group. Survival at 28 days was 74.3% with hypertonic saline/dextran, 75.7% with hypertonic saline, and 75.1% with normal saline (P = .88).

CONCLUSION: Among patients with severe TBI not in hypovolemic shock, initial resuscitation with either hypertonic saline or hypertonic saline/dextran, compared with normal saline, did not result in superior 6-month neurologic outcome or survival.

TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00316004.

PMID: 20924011

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