床旁经颅多普勒超声评估儿童神经危重症患者颅内压的临床价值

张涛; 刘春峰

doi:10.7499/j.issn.1008-8830.2203081

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中国当代儿科杂志 ›› 2022, Vol. 24 ›› Issue (9) : 973-978. DOI: 10.7499/j.issn.1008-8830.2203081

论著·临床研究

床旁经颅多普勒超声评估儿童神经危重症患者颅内压的临床价值

张涛, 刘春峰

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Clinical value of bedside transcranial doppler ultrasound in assessing intracranial pressure in critically ill pediatric patients with nervous system disease

ZHANG Tao, LIU Chun-Feng

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摘要

目的研究床旁经颅多普勒超声（transcranial doppler，TCD）在评估儿童重症监护病房（pediatric intensive care unit，PICU）神经危重症患儿颅内压（intracranial pressure，ICP）水平中的应用价值。方法前瞻性纳入2020年11月至2021年11月入住中国医科大学附属盛京医院PICU的神经危重症患儿进行研究。纳入病例行床旁TCD检查，计算搏动指数（pulsatility index，PI）；之后行床旁腰椎穿刺术，测量ICP。采用Pearson相关分析法行PI值与ICP值的相关性分析。采用受试者工作特征（receiver operating characteristic，ROC）曲线评价PI诊断ICP增高（≥20 mm Hg）的价值。结果 56例儿童神经危重症患儿纳入研究。颅内感染（24例，43%）、颅脑创伤（11例，20%）及脑血管疾病（5例，9%）的占比居原发病前3位。Pearson相关分析显示，PI和ICP呈显著正相关（r=0.536，P<0.001）。按原发病分组研究，显示颅脑创伤组PI与ICP呈显著正相关（r=0.655，P=0.029），而颅内感染组PI与ICP无显著相关性（r=0.324，P=0.122）。ROC曲线分析显示，PI预测神经危重症患儿ICP是否≥20 mm Hg的曲线下面积为0.828（95%CI：0.677~0.979）；PI=1.255为最佳临界值，预测ICP≥20 mm Hg的灵敏度为83.3%，特异度为79.5%。结论 TCD监测ICP技术可以用来预测神经危重症患儿ICP变化情况，以指导临床治疗和预后评估。［中国当代儿科杂志，2022，24（9）：973-978］

Abstract

Objective To study the value of bedside transcranial doppler (TCD) in evaluating the level of intracranial pressure (ICP) in critically ill pediatric patients with nervous system disease in the pediatric intensive care unit (PICU). Methods A prospective analysis was performed on the critically ill pediatric patients with nervous system disease who were admitted to the PICU of Shengjing Hospital, China Medical University, from November 2020 to November 2021. Bedside TCD was performed on all patients, and pulsatility index (PI) was calculated. Bedside lumbar puncture was performed to measure ICP. A Pearson correlation analysis was used to assess the correlation between PI and ICP. The receiver operating characteristic (ROC) curve was used to assess the value of PI in the diagnosis of elevated ICP (≥20 mm Hg). Results A total of 56 children were included in the study. The top three primary diseases were intracranial infection (24 children, 43%), traumatic brain injury (TBI) (11 children, 20%), and cerebrovascular disease (5 children, 9%). The Pearson correlation analysis showed that PI was positively correlated with ICP (r=0.536, P<0.001). The subgroup analysis based on primary disease showed that in the TBI group, PI was positively correlated with ICP (r=0.655, P=0.029), while no significant correlation between PI and ICP was observed in the intracranial infection group (r=0.324, P=0.122). The ROC curve analysis showed that PI had an area under the curve of 0.828 (95%CI: 0.677-0.979) in predicting ICP≥20 mm Hg, with a sensitivity of 83.3% and a specificity of 79.5% at the optimal cut-off value of 1.255. Conclusions TCD technology for ICP monitoring can predict the change in ICP in critically ill pediatric patients with nervous system disease, suggesting it is useful for treatment options and prognosis evaluation. Citation:Chinese Journal of Contemporary Pediatrics, 2022, 24(9): 973-978

导出引用

张涛, 刘春峰. 床旁经颅多普勒超声评估儿童神经危重症患者颅内压的临床价值[J]. 中国当代儿科杂志. 2022, 24(9): 973-978 https://doi.org/10.7499/j.issn.1008-8830.2203081

ZHANG Tao, LIU Chun-Feng. Clinical value of bedside transcranial doppler ultrasound in assessing intracranial pressure in critically ill pediatric patients with nervous system disease[J]. Chinese Journal of Contemporary Pediatrics. 2022, 24(9): 973-978 https://doi.org/10.7499/j.issn.1008-8830.2203081

参考文献

1 Kochanek PM, Tasker RC, Carney N, et al. Guidelines for the management of pediatric severe traumatic brain injury, third edition: update of the brain trauma foundation guidelines, executive summary[J]. Pediatr Crit Care Med, 2019, 20(3): 280-289. PMID: 30830016. DOI: 10.1097/PCC.0000000000001736.
2 中华医学会神经病学分会神经重症协作组, 中国医师协会神经内科医师分会神经重症专业委员会. 难治性颅内压增高的监测与治疗中国专家共识[J]. 中华医学杂志, 2018, 98(45): 3643-3652. DOI: 10.3760/cma.j.issn.0376-2491.2018.45.004.
3 Chesnut R, Aguilera S, Buki A, et al. A management algorithm for adult patients with both brain oxygen and intracranial pressure monitoring: the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC)[J]. Intensive Care Med, 2020, 46(5): 919-929. PMID: 31965267. PMCID: PMC7210240. DOI: 10.1007/s00134-019-05900-x.
4 Marehbian J, Muehlschlegel S, Edlow BL, et al. Medical management of the severe traumatic brain injury patient[J]. Neurocrit Care, 2017, 27(3): 430-446. PMID: 28573388. PMCID: PMC5700862. DOI: 10.1007/s12028-017-0408-5.
5 Millet A, Evain JN, Desrumaux A, et al. Clinical applications of transcranial doppler in non-trauma critically ill children: a scoping review[J]. Childs Nerv Syst, 2021, 37(9): 2759-2768. PMID: 34244843. DOI: 10.1007/s00381-021-05282-w.
6 LaRovere KL, O'Brien NF, Tasker RC. Current opinion and use of transcranial doppler ultrasonography in traumatic brain injury in the pediatric intensive care unit[J]. J Neurotrauma, 2016, 33(23): 2105-2114. PMID: 26983462. DOI: 10.1089/neu.2015.4344.
7 Zeiler FA, Cardim D, Donnelly J, et al. Transcranial doppler systolic flow index and ICP-derived cerebrovascular reactivity indices in traumatic brain injury[J]. J Neurotrauma, 2018, 35(2): 314-322. PMID: 29050524. DOI: 10.1089/neu.2017.5364.
8 Rollet-Cohen V, Sachs P, Léger PL, et al. Transcranial doppler use in non-traumatic critically ill children: a multicentre descriptive study[J]. Front Pediatr, 2021, 9: 609175. PMID: 34277513. PMCID: PMC8282928. DOI: 10.3389/fped.2021.609175.
9 Martí-Fàbregas J, Belvís R, Guardia E, et al. Prognostic value of pulsatility index in acute intracerebral hemorrhage[J]. Neurology, 2003, 61(8): 1051-1056. PMID: 14581663. DOI: 10.1212/01.wnl.0000090520.67254.14.
10 Alkhoury F, Kyriakides TC. Intracranial pressure monitoring in children with severe traumatic brain injury: national trauma data bank-based review of outcomes[J]. JAMA Surg, 2014, 149(6): 544-548. PMID: 24789426. DOI: 10.1001/jamasurg.2013.4329.
11 Ducharme-Crevier L, Mills MG, Mehta PM, et al. Use of transcranial doppler for management of central nervous system infections in critically ill children[J]. Pediatr Neurol, 2016, 65: 52-58.e2. PMID: 27743745. DOI: 10.1016/j.pediatrneurol.2016.08.027.
12 Bennett TD, DeWitt PE, Greene TH, et al. Functional outcome after intracranial pressure monitoring for children with severe traumatic brain injury[J]. JAMA Pediatr, 2017, 171(10): 965-971. PMID: 28846763. PMCID: PMC5710627. DOI: 10.1001/jamapediatrics.2017.2127.
13 国家卫生健康委员会脑损伤质控评价中心. 中国儿童脑死亡判定标准与操作规范[J]. 中华儿科杂志, 2019, 57(5): 331-335. PMID: 31060123. DOI: 10.3760/cma.j.issn.0578-1310.2019.05.003.
14 钱素云, 王荃, 宿英英. 中国儿童脑死亡判定标准与操作规范解读[J]. 中华儿科杂志, 2019, 57(11): 826-829. PMID: 31665835. DOI: 10.3760/cma.j.issn.0578-1310.2019.11.003.
15 O'Brien NF, Maa T, Reuter-Rice K. Noninvasive screening for intracranial hypertension in children with acute, severe traumatic brain injury[J]. J Neurosurg Pediatr, 2015, 16(4): 420-425. PMID: 26140576. DOI: 10.3171/2015.3.PEDS14521.
16 Melo JR, Di Rocco F, Blanot S, et al. Transcranial doppler can predict intracranial hypertension in children with severe traumatic brain injuries[J]. Childs Nerv Syst, 2011, 27(6): 979-984. PMID: 21207041. DOI: 10.1007/s00381-010-1367-8.
17 Budohoski KP, Schmidt B, Smielewski P, et al. Non-invasively estimated ICP pulse amplitude strongly correlates with outcome after TBI[J]. Acta Neurochir Suppl, 2012, 114: 121-125. PMID: 22327676. DOI: 10.1007/978-3-7091-0956-4_22.
18 Cardim D, Robba C, Donnelly J, et al. Prospective study on noninvasive assessment of intracranial pressure in traumatic brain-injured patients: comparison of four methods[J]. J Neurotrauma, 2016, 33(8): 792-802. PMID: 26414916. PMCID: PMC4841086. DOI: 10.1089/neu.2015.4134.
19 Bellner J, Romner B, Reinstrup P, et al. Transcranial doppler sonography pulsatility index (PI) reflects intracranial pressure (ICP)[J]. Surg Neurol, 2004, 62(1): 45-51. PMID: 15226070. DOI: 10.1016/j.surneu.2003.12.007.
20 Fonseca Y, Tshimanga T, Ray S, et al. Transcranial doppler ultrasonographic evaluation of cerebrovascular abnormalities in children with acute bacterial meningitis[J]. Front Neurol, 2020, 11: 558857. PMID: 33643174. PMCID: PMC7907511. DOI: 10.3389/fneur.2020.558857.
21 卢志超, 刘春峰. 经颅超声多普勒在PICU的临床应用[J]. 中国小儿急救医学, 2017, 24(11): 859-863. DOI: 10.3760/cma.j.issn.1673-4912.2017.11.014.