| Abstract | Studija je provedena u Jedinici intenzivnog liječenja Klinike za anesteziologiju, reanimatologiju i intenzivno liječenje KBC Split od kolovoza 2008. god. do travnja 2010. god. Transkranijskim doplerom praćene su hemodinamske promjene koje nastaju nakon primjene različitih doza manitola (0,3, 0,6, 1 g/kg/tm) u traumatskoj ozljedi mozga. Svaka je skupina imala po 20 bolesnika. U studiju su bili uključeni bolesnici (GCS ≤ 8) kojima je MSCT-om dokazana difuzna traumatska ozljeda mozga III. i IV. stupnja po Marshallovoj klasifikaciji, te bolesnici kojima su TKD-om izmjerene vrijednosti IP > 1,4 i FV-min < 20 cm/sek. Od hemodinamskih parametara praćeni su i analizirani IP, FV-min, FV-mean, FV-max. Iz dobivenih TKD vrijednosti, iz formule nCPP=Mean AP x (FV-min / FV-mean) + 14 mmHg računao se moždani perfuzijski tlak. Izravno mjerenje intrakranijskog tlaka nije uvijek moguće, a naročito je problematično razdoblje ranog zbrinjavanja bolesnika s ozljedom mozga. U tom je razdoblju rizik smanjenja moždanoga perfuzijskog tlaka najveći. U ovakvim je situacijama transkranijski dopler predložen kao zamjenski neurološki monitoring. Transkranijski je dopler neinvazivna i lako dostupna metoda praćenja moždane hemodinamike. U traumatskoj ozljedi mozga rano dijagnosticiranje stanja poremećene moždane hemodinamike transkranijskim doplerom dovodi do primjene rane ciljane terapije. Osmoterapija manitolom jedna je od najprimjenjivanijih metoda liječenja edema mozga. Transkranijskim doplerom može se pratiti učinak različitih doza manitola na moždanu hemodinamiku i trajanje djelovanja pojedine doze. Na temelju dobivenih rezultata može se odrediti razamak među pojedinim dozama. Doza manitola od 0,3 g/kg/tm djeluje sporije od većih doza, maksimalno se djelovanje vidi jedan sat nakon primjene, dužina djelovanja iznosi oko dva sata, a dostignute su vrijednosti niže od vrijednosti 0,6 i 1 g/kg/tm. Doza 0,3 gr/kg/tm zadovoljava potrebe umjerene, sporije osmoterapije koja se može češće primjenjivati (svakih 4 - 6 sati). Doza 0,6 g/kg/tm manitola svoje učinke izaziva brzo, maksimalni se učinak vidi neposredno nakon primjene, dostignute su vrijednosti veće nego kod doze 0,3 g/kg/tm, a manje nego kod doze 1 g/kg/tm. Djelovanje ove doze održava se i tri sata nakon primjene. Zbog mogućnosti veće dehidracije i mogućih osmotskih poremećaja razmak među pojedinim dozama ne smije biti manji od 8 sati uz stalni nadzor osmolarnosti u krvi. Primjenu treba usmjeriti prema pacijentima koji imaju značajno poremećenu moždanu hemodinamiku (P I > 1,4, FV-min < 20 cm/sek, a FV-mean < 30 cm/sek). Doza manitola od 1 g/kg/tm djeluje brzo, maksimalno se djelovanje vidi neposredno nakon primjene, a dostignute su vrijednosti veće nego u skupinama 0,3 i 0,6 g/kg/tm. FV-mean je povećana samo do jedan sat od primjene, a FV-min dva sata. IP je smanjen dva sata. Ovu je dozu opravdano primijeniti za potrebe brzog i snažnog djelovanja na teški edem mozga, prijeteću hernijaciju mozga i kraće čekanje na operacijski zahvat. Doza je manitola od 0,6 g/kg/tm najučinkovitija. Nastup je djelovanja brz, maksimalni se učinak vidi neposredno nakon primjene. Popravlja sve pokazatelje poremećene moždane hemodinamike (smanjuje IP, povećava FV-min i FV-mean). Smanjenje FV-min najosjetljiviji je pokazatelj porasta otpora cirkulaciji. Ova doza manitola značajno povećava FV-min u trajanju od oko tri sata. Transkranijskim doplerom može se utvrditi stanje sniženoga moždanoga perfuzijskog tlaka. Mogu se uočiti promjene moždanoga perfuzijskog tlaka nakon primjene različitih doza manitola. Doza 0,6 g/kg/tm manitola pokazuje najduži povoljan učinak na nCPP. Primjenu transkranijskog doplera treba popularizirati i uvoditi u sve širu rutinsku primjenu. |
| Abstract (english) | This study was conducted at the Intensive Care Unit of Department of Anesthesia and Intensive Care in University Hospital Split, from August 2008 to April 2010. Transcranial Doppler ultrasonography was used to monitor hemodynamic effects of different mannitol doses (0.3, 0.6 and 1 g/kg) in traumatic brain injury. Each group counted 20 patients. The study included patients with Glasgow Coma Score GCS ≤ 8, who were diagnosed diffused traumatic brain injury of III and IV grade according to Marshall classification, using multislice computed tomography (MSCT) as well as patients with pathological TCD ultrasonography values ( IP > 1.4 and FV-min < 20 cm/sec). PI, FV-min, FV-mean and FV-max were monitored and analyzed. Based on TCD ultrasonography values, using formula nCPP = Mean AP x (FV-min / FV-mean) + 14 mmHg, cerebral perfusion pressure was determined. Direct measurement of ICP is not always possible, and early patient management is particularly problematic. During this period, the risk of decreasing CPP is extremely high. Regarding these circumstances, TCD ultrasonography is suggested as an alternative to neurological monitoring. TCD ultrasonography is a non-invasive and easily available method for cerebral monitoring. In TBI, timely diagnosed states of cerebral hemodynamic disorders by TCD ultrasonography lead to early targeted therapy. Mannitol osmotic therapy represents one of the most applicable methods for brain edema treatment. TCD ultrasonography can be used to monitor the effects of various doses of mannitol on brain hemodynamic and duration of the action of a single dose. On the basis of the obtained results, next dosage administration can be determined. Mannitol dose of 0.3 g/kg induces slow activity in relation to higher doses, its maximal effect is evident one hour after administration, the duration of the action of mannitol lasts approximately two hours and the attained values are lower in relation to mannitol doses of 0.6 and 1 g/kg. Mannitol dose of 0.3 g/kg fulfill needs for moderate and slow infusion, which can be more frequently used (every 4-6 hours). The action of mannitol dose of 0.6 g/kg is rapid, its maximal effect is evident immediately after administration, the attained values are higher in relation to doses of 0.3 and lower than 1 g/kg. The effect of 0.6 g/kg mannitol dose maintains for even three hours after administration. Due to potential significant dehydration and osmotic disorders, the dosage should not be administered at intervals less than 8 hours, with constant monitoring of patient blood osmolarity. Patients with significant disorders of cerebral hemodynamic (PI > 1.4, FV-min < 20 cm/sec, and FV-mean < 30 cm/sec) should be treated with the abovementioned dose of mannitol. The action of mannitol dose of 1 g/kg is rapid, its maximal effect is evident immediately after administration, and the attained values are higher in relation to doses of 0.3 and 0.6 g/kg. FV-mean is increased only one hour after mannitol administration, while FV-min is increased for two hours. IP is decreased for two hours. It is reasonable to administer this mannitol dose with the aim of rapid and powerful treatment of severe intracranial hematoma, threatening brain herniation and short waiting time for surgery. Mannitol dose of 0.6 g/kg shows the most powerful effects. Rapid onset of maximum mannitol effect is evident immediately after administration. All parameters of the abnormal cerebral hemodynamic (decreasing IP, increasing FV-min and FV-mean) are improved. The decreased FV-min is the most sensitive indicator of the increased resistance to cerebral circulation. This mannitol dosage significantly increases FV-min during approximately three hours. TCD ultrasonography can determine the state of decreased noninvasive-CPP. Furthermore, after administration of different mannitol doses variations of noninvasive-CPP can be noted. Mannitol dose of 0.6 g/kg shows long-lasting preferable impact on noninvasive-CPP. The use of TCD method should be popularized and implemented into routine procedures. |
