2023 tăng áp lực nội sọ

CẬP NHẬT XỬ TRÍ TĂNG ÁP LỰC NỘI SỌ 2023 PGS TS BS Phùng Nguyễn Thế Nguyên Trưởng Bộ Môn Nhi – ĐHYD TPHCM Trưởng khoa Hồi sức Nhiễm- BV NĐ1 Nội dung Chẩn đoán tăng áp lực nội sọ (ALNS) Mục tiêu điều trị Sử dụng Mannitol NaCL ưu trương Các vấn đề thực tiễn § Chưa tuân thủ nguyên tắc điều trị § Khơng trì CPP mục tiêu § Sử dụng NaCl ưu trương Áp lực nội sọ tăng ALNS Áp lực nội sọ Table Normal intracranial pressure values Age group w Áp lực nội sọ bình thường < 15 n ICP > 20 mmHg n ICP nặng > 40 mmHg Adults Children mmHg Term infants * Normal range (mm Hg) tuổi: 60 mmHg Người lớn: 60-70 mmHg Emergency Neurological Life Support: Intracranial Hypertension and Hernia:on Neurocritical Care Society 2017 TABLE 10 Thresholds for CPP Recommendations Strength of Recommendations: Weak (Continued) Cerebral Perfusion Pressure: Summary of Evidence preterminal data; the rest ofStudy the reports not discuss whether Reference Design 2019 by the Society of Cri2cal Care Medicine and the World Type of Trauma Center n these data are included or excluded Geographic Age (yr) Federa2on of Pediatric Intensive and Cri2cal Care Socie2es Location Outcomes Class Results Taken together, caution should be applied whenData interpretClass series et al ingNarotam the results fromTreatment pediatric TBI CPP studies and apply- Mortality (60) Uncontrolled Mean CPP was 81.52 ± 16.1 mm Hg for survivors vs n the = 16 series 50.33 ± 31.7 mm Hg for nonsurvivors (p < 0.033) Level II trauma Age: mean, 14; strategies range, ing the information to treatment for TBI center GOS 1.5–18 Omaha, NE Mortality, GOS at mo Levels I and II postinjury Evidenceseries There was insufficient evidence to support a level I or II recom- Evaluation Class Stiefel et al of theTreatment (84) Uncontrolled n=6 Quality of the Body of Evidence Studies included for this mendation for this topic series Level I trauma Age: mean, 12; range, 6–16 center discharge topic addressed theMortality, questions about GOS what are the minimum Philadelphia, PA thresholds and target ranges for managing CPP; are ranges Level III To Improve Overall Outcomes III.1 Treatment to maintain a age-specific, and what is the target threshold for infants? MulClass Randomized controlled trial Adelson et al of hypothermia therapyevidence (40)class studies provided tiple low-quality CPP at a minimum of 40 mm Hg is suggested No supporting control for confounders Analysis of average CPP Multicenter: a minimumPA;target of over 40 mm of age-specific III.2 A CPP target between 40 and 50 mm Hg is suggested to Pittsburgh, in CPPranges theHg firstand d use of care analysis (for Sacramento, = 102 (Table 11).FL;AlthoughnAge: onemean classage study provided data supportensure that the minimum value of 40 mm Hg is not breached CA; hypothermia, Miami, in two part this is a class Salt Lake City, study 6.89itand 6.95 yrconsidered ing Hershey, use of age-specific ranges, was not sufficient There may be age-specific thresholds with infants at the lower UT; study) Range: 0–13 PA; Seattle, WA Dichotomized GOS (79) at mo to make a level II recommendation Evidence from two end and adolescents at or above the upper end of this range (level I pediatric postinjury trauma center) Changes From Prior Edition There are no content changes small class studies was insufficient to make a recommendafrom Second Edition to the máu recommendations w theÁp lực tưới não:Of the 15 tion specific to infants (73, 80) (Table 9) Class Treatment series et Twelve of the 15 studies were published since included studies (30, 40, 44, 52, 60, 61, 73, 74, 79–85), four are Chambers alApplicability (30) Uncontrolled n = 84 median, yr; range, CPP ĐẠT 50new class Neurosurgical 2000 (30, 40, 44, 60,Age: 61,mo73, 74, 79,1081, 83–85).3 The series body of evinew to thisn edition One CẦN new class (79) and three Centre at to 16 yr GOS dichotomized dence included multisite studies and atuse6 mo of registry data from retrospective observational studies were added to the evidence Newcastle – 60 mmHg General Hospital postinjury All survivors had good outcome Mortality in died Mean daily CPP in survivors was 75.63 ± 11.73 mm Hg GOS of 6: of 6: of 6: GOS Average CPP was 69.19 ± 11.96 mm Hg for favorable vs 56.37 ± 20.82 mm Hg for unfavorable (p = 0.0004) outcome groups Percent time with CPP > 50 mm Hg was 94.2% ± 16.9% for favorable vs 87.3% ± 29.5% for unfavorable (p = 0.0001) Mean CPP on day was higher in the hypothermia group (70.75 mm Hg) than the normothermia group (64.84 mm Hg), p = 0.037 No significant differences between groups on days 2–5, and GOS was not assessed in relation to differences in CPP on day GOS Poor outcome in all eight cases with CPP < 40 mm Hg; more patients had good outcome than poor outcome when mean CPP was > 40 mm Hg MAP target? w A systolic blood pressure < 90 mmHg must be corrected immediately w The American Association of Neurological Surgeons and the Congress of Neurological Surgeons Guidelines MAP at 85 to 90 mm Hg first seven days Muzevich, 2009 Levi, 1993; Licina, 2005 w 50-90% of adults with cervical SCI require fluid resuscitation and vasoactive infusions to achieve the adult parameters recommended w (MAP 85-90 mm Hg for days) Tối ưu hóa tưới máu dịch vận mạch trẻ không sốc??????????? MAP:70-80 mmHg Muzevich, 2009 Levi, 1993; Licina, 2005 Corrected chi-square test Fisher exact test c Composite poor outcome defined as severe neurodisability or death All data are presented as number of patients with the specified outcome/total nu Neurodisability grading: Mild neurodisability (Pediatric Cerebral Performance Ca level, but grade perhaps not appropriate for age due to possibility of mild neurolo cerebral function for age-appropriate independent activities of daily life, school-a and severe neurodisability (PCPC score 4: conscious, dependent on others for a b CPP hay ICP w 110 Bệnh nhi (55 nhóm) w nhóm mục tiêu CPP > 60 mmHg, dùng dopamine (10-20) hay noradrenalin (0,05-0,5) w nhóm ICP < 20 mmHg, dùng Mannitol 20% hay NaCL Randomized Controlled Trial Comparing Kaplan-Meier curve showing probability of survival upto day 90 Cerebral Perfusion Pressure–Targeted TherapyFigure Versus Intracranial Pressure–Targeted Therapy for Raised after discharge from PICU in the two study groups (adjusted hazard ratio, Intracranial Pressure due to Acute CNS Infections in Children, Crit Care Med 2014; 42:1775–1787 10 2.25; 95% CI, 1.06–4.79; p = 0.035) CPP = cerebral perfusion pressure, Natri ưu trương 23.4% 2019 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies Tăng ICP trơ với điều trị w Piper & Harrigan: 23.4% natri ưu trương 32 trẻ TBI nặng w Trơ: ICP > 20mm Hg > phút khơng đáp ứng với an thần, giảm đau, thơng khí giữ CPP dãn w 23.4% salin: 0.5mL/kg/ 10 phút, tối đa 30 mL giảm ICP trung bình: 10mm Hg w Nồng độ Na cao 161 mmol/L w 74% trẻ Glasgow cải thiện > điểm 39 Nghiên cứu 2020 so sánh NaCl3% Mannitol tăng ALNS trẻ em nhiễm trùng TKTƯ Tác dụng Tăng thể tích tuần hồn Ảnh hưởng Na máu ảnh hưởng K máu Tác dụng lợi tiểu Tác dụng huyết áp Hội chứng thoái hoá myelin Tác dụng kháng viêm Cách cho Mannitol Natri ưu trương Tăng osmol máu Tăng osmol máu, có tác dụng điều hồ đáp ứng viêm - + Tăng Na máu Tăng Na máu giảm K máu Giảm K máu Có Khơng (nên khơng làm giảm HA) Giảm Tăng Khơng Có Khơng Có 0,25-1 g/kg 4-6 2-6 ml/kg Nacl 3% Thời gian tác dung 1,5-6 Cho qua đường trung tâm 41 Pediatric Risk of Mortality III score, median (IQR) 21 (18–26) 21 (18–25) 22 (17–26) 0.94d Seizure, n (%) 51 (89.5) 25 (86) 26 (93) 0.67c 10 (34) 14 (50) 0.24b w 29 BN NaCl 3% 28 BN Mannitol 20% 24 (42.1) Status epilepticus, n (%) Modified Glasgow Coma Scale score, median (IQR) n (4—6) (5—6) (4—6) 0.79d NaCl 3% 10 ml/kg/20 phút, 0,5-1 ml/kg/giờ, 0,1 ICP không 45 (79) tăng 25 (86)ml/kg/giờ 20 (71)nếu0.17 Meningeal signs, n (%) giảm >Papilledema, 25% n (%) 52 (91.2) 26 (90) 26 (93) 0.67 b b 45 (79) Tonic posturing, n (%) n Mannitol 20% 0,5 ml/giờ/20 phút, có thể48 lặp (84.2) lại Cerebral edema on CT scan, n (%) Cerebral edema on CT scan but opening ICP < 20 mm Hg, n (%) w 68±37 &Normal 60±44 (tháng) CT scan but ICP ≥ 20 mm Hg, n (%) 10 / 48 (20.8) / 48 (10.4) 23 (79) 22 (79) 0.95b 24 (82.8) 24 (85.7) 0.76b / 24 (25) / 24 (16.7) 0.72c / 24 (12.5) / 24 (8.3) 1.00c 0.69b Diagnosis, n (%) w Viêm não Viral vàencephalitis màng não Acute meningitis Etiology, n (%) Neurocritical Care 44 (77.2) 23/29 (79.3) 21/28 (75) 13 (22.8) 6/29 (20.7) 7/28 (25) 51 (89.5) 28 (96.6) 23 (82.1) Japanese encephalitis 21 (41.2) 14/28 (50) 7/23 (30.4) 0.16b Herpes simplex virus 15 (29.4) 7/28 (25) 8/23 (34.8) 0.45b Enterovirus (6) 1/28 (3.5) 2/23 (8.7) 0.58c Pneumococcus (6) 1/28 (3.5) 2/23 (8.7) 0.58c Hemophilus influenzae type b (4) 1/28 (3.5) 1/23 (4.3) 1.00c Scrub typhus (13.4) 4/28 (14.5) 3/23 (13) 1.00c 79 ± 11 78 ± 11 79 ± 13 0.73a 27 ± 13 28 ± 13 27 ± 13 0.82a 48 ± 14 50 ± 12 52 ± 16 0.62a Randomized Clinical Trial of 20% Opening mean arterial blood pressure, mm Mannitol Hg, mean ± SD Versus 3% Hypertonic Saline in Children With Raised Intracranial Pressure Due to Acute Opening intracranial pressure, mm Hg, mean ± SD CN S Infections* Opening cerebral perfusion pressure, mm Hg, mean ± SD Ramachandran Rameshkumar, MD, DNB, DM; Arun Bansal, MD; Sunit Singhi, MD; Pediatr Crit Care Med 2020; 21:1071–1080 42 Đặc điểm BN trước can thiệp Co giật Phù gai thị Phù não CT Phù não CT/ ICP < 20 mmHg Bình thường CT/ICP > 20 mmHg ICP CPP MAP NaCl 3% (n= 29) 25 (86) Mannitol 20% (n=28) 26 (93) 0.67 26 (90) 26 (93) 0.67 24 (82.8) 24 (85.7) 0,76 (25) (16.7) 0.72 (12.5) (8.3) 28 ± 13 50±12 78±11 p 27 ± 13 0.82 52±16 0.62 79±13 0,13 Pediatr Crit Care Med 2020; 21:1071–1080 43 Neurocritical Care Figure The trend of mean arterial blood pressure (MABP) during the first 72 hr of the study period in the two study groups A, Mean (± SE) MABP in the mannitol group was 80 ± 1.6 mm Hg and in hypertonic saline group 79 ± 1.6 mm Hg (p = 0.749) B MABP in percentile stat = statistic HTS administration is associated with favorable cerebrohe- edema due to mixed etiology (28) They found that the duw BNeffect dùng vận mạch (69)and&mortality Mannitol 20% 24 (85.7) modynamic profilethuốc due to intravascular volumeNaCl expan- 3% ration20 of coma was lower in patients who resion, increase in the global cerebral perfusion, improvement in ceived 3%-HTS-group A systematic review on the role of w by Điểm mạch: 33.7curve, ± increase 6.9 & 35.2 ± 6.3 oxygen the rightsố shiftvận of oxygen dissociation osmotherapy in children with acute encephalopathies found in cerebral compliance, and decrease in ICP due to decrease that HTS as a continuous infusion was associated with of cerebral edema (27) HTS is less permeable than mannitol a more significant reduction in ICP, sustained effect for a 44 TABLE Outcome in the two study groups Hypertonic Saline Group (n = 29) Mannitol Group (n = 28) Relative Risk (95% CI) p Trend of mean ICP, mm Hg (baseline to 72 hr), mean ± SE 14 ± 22 ± — 0.009a Trend of mean CPP, mm Hg (baseline to 72 hr), mean ± SE 65 ± 2.2 58 ± 2.2 — 0.032a Change in-ICP (delta-ICP), mm Hg (baseline to 72 hr), mean ± SE –14.3 ± 1.7 –5.4 ± 1.7 — < 0.001a Change in-CPP (delta-CPP), mm Hg (baseline to 72 hr), mean ± SE 15.4 ± 2.4 ± 2.4 — 0.007a Number of patients with target average ICP (< 20 mm Hg), n (%) 23 (79.3) 15 (53.6) Outcomes Variables Primary outcome Secondary outcome 1.48 (1.01—2.19) 0.039b adjusted hazard ratio 2.63 (1.23—5.61) Pediatr Crit Care Med 2020; 21:1071–1080 45 Severe Composite poor outcome, n (%) At the time of PICU discharge 7/23 (31) 11/18 (61) 0.50 (0.24–1.02) 0.049b 13/29 (45) 21/28 (75) 0.55 (0.33–0.91) 0.020b 20 (69) 24 (85.7) 0.66 (0.40–1.10) 0.21e Other outcome variables Number of patients requiring short-term hyperventilation, n (%) Number of ICP spikes per patient requiring hyperventilation, median (IQR) First 72 hr (1–8) 14 (4–28) — 0.003c Over total stay (2–10) 18 (5–52) — 0.009c First 72 hr (2–8) 13 (5–36) — 0.002c Over total stay (2–10) 24 (6–68) — 0.005c (18) 14 (50) 0.42 (0.19—0.92) 0.009b Cumulative duration of hyperventilation, minutes; median (IQR) Number of patients with rebound raised ICP, n (%) ICP = intracranial pressure, IQR = interquartile range, m-GCS = modified Glasgow Coma Scale Pediatr Crit Care Med 2020; 21:1071–1080 a Repeated measures analysis of variance 46 Các điểm w CPP đạt > 60 mmHg (50) w MAP 80 (70) mmHg w Thuốc vận mạch (noradrenalin hay adrenalin dung để trì MAP) w NaCl 3% ưu Mannitol n 10 ml/kg/20 phút n 0,5-1 ml/kg/giờ, tăng 0,1 ml/kg/giờ không đạt n Na < 160 Meq/L Pediatr Crit Care Med 2020; 21:1071–1080 47 Điều trị co giật ngừa co giật w Co giật: n Tích cực điều trị n Midazolam, propofol, phenobarbital, valproate w Ngừa co giật n Phenobarbital l Ngừa co giật l Giảm chuyển hoá não, giảm nhu cầu oxy 48 Co giật n n n n Thông đường thở Oxy Lập đường truyền Dextrostix Hạ đường huyết Dextrose 10% 2-5 ml/kg Diazepam/ Midazolam 0,2-0,3 mg/kg x lần, cách phút Tìm & điều trị nguyên nhân Điều trị phù não Phenobarbital 20 mg/kg 15-30 phút, lặp lại lần co giật Midazolam 0,2-1 mg/kg/giờ Propofol 49 Điều chỉnh khác w Điều trị rối loạn điện giải tăng giảm Na máu w Điều trị tăng hạ đường huyết: Duy trì đường huyết 80-120 mg% không để tăng giảm đường huyết w Duy trì nhiệt độ bình thường, điều trị tích cực sốt hạ thân nhiệt w Duy trì Hb 10 g/dl thiếu máu làm tăng lưu lượng máu tăng áp lực nội sọ 50 Kết luận Luôn nghỉ đến BN có tăng ALNS? Siêm âm đường kính dây thần kinh sọ Duy trì MAP 70-80 mmHg NaCl ưu trương truyền liên tục 51 52 Biến chứng NaCL ưu trương w Na< 160 mEq/L Gonda et al Summary of the Associated Complications of Children Treated With Continuous Hypertonic Saline TABLE Sustained Peak Serum Sodium Level (mEq/L) Complication Neutropenia, n (%) < 170 (n = 58) ≥ 170 (n = 30) p (5.2) 11 (36.7) < 0.001 27 (90) < 0.001 (10.3) Thrombocytopenia, n (%) RBC Transfusion, n (%) 20 (34.5) 28 (93.3) < 0.001 Fresh frozen plasma transfusion, n (%) 13 (22.4) 20 (66.7) < 0.001 Renal failure, n (%) (3.4) 16 (53.3) < 0.001 Dialysis, n (%) (1.7) (20) Acute respiratory distress syndrome, n (%) (1.7) 10 (33.3) < 0.001 10 (17.2) 14 (46.7) 0.005 Glasgow Outcome Score < 3, n (%) p 0.006 p Complica2ons Associated With Prolonged Hypertonic Saline Therapy in Children With Elevated equal to 170 mEq/L was the variable most associated with each Pressure, p < 0.001) (Table The prevalence of thrombocytopenia was Intracranial Pediatr Crit2) Care Med 2013; 14: 610–620 53 ... Khơng trì CPP mục tiêu § Sử dụng NaCl ưu trương Áp lực nội sọ tăng ALNS Áp lực nội sọ Table Normal intracranial pressure values Age group w Áp lực nội sọ bình thường < 15 n ICP > 20 mmHg n ICP nặng... nhiệt w Duy trì Hb 10 g/dl thiếu máu làm tăng lưu lượng máu tăng áp lực nội sọ 50 Kết luận Ln nghỉ đến BN có tăng ALNS? Siêm âm đường kính dây thần kinh sọ Duy trì MAP 70-80 mmHg NaCl ưu trương... Mannitol Natri ưu trương Tăng osmol máu Tăng osmol máu, có tác dụng điều hồ ? ?áp ứng viêm - + Tăng Na máu Tăng Na máu giảm K máu Giảm K máu Có Khơng (nên khơng làm giảm HA) Giảm Tăng Khơng Có Khơng