FAST-HUG
Give your patient a fast hug (at least) once a day
GHOST CAP
01
G
Glucose 血糖
G: glucose is the neuron's primary source of energy. Hypoglycemia(≤80mg/dL) can impair brain metabolism and hyperglycemia (≥ 180 mg/dL) has also been associated with worse outcomes. In patients with acute brain injury, tight glycemic control may not significantly improve the outcomes and may increase the risk of hypoglycemia. Target levels between 80 and 180 mg/dL may be reasonable (Supplemental Table 1).
为什么神经损伤以后血糖不能那么低呢？因为神经细胞是不能够利用脂肪作为一个能源物质，它只能用糖、乳酸、酮体这三种物质作为它的一个能源物质，在重症的病人，高血糖的一个自然保护的机制，为什么会让血糖增高，其中非常重要的一点就是通过糖原的分解、糖异生、糖的无效循环，减少脂肪和肌肉的这样的一个糖的利用，来提供关键组织的糖的利用。
02
H
Hemoglobin 血红蛋白
H: hemoglobin is an important determinant of oxygen delivery (DO2). Usually, cerebral DO2 is sufficient so that when cerebral blood flow (CBF) is reduced, the brain has enough physiological reserve.
Although CBF can increase to preserve cerebral DO2, low hemoglobin levels may be associated with brain hypoxia, cell energy dysfunction, and worse outcome. No well-designed randomized clinical trial (RCT) has addressed ideal transfusion thresh-olds in patients with acute brain injury, but a 7-9g/dL threshold seems reasonable.
03
O
Oxygen血氧
O: oxygen is another important determinant of DO2.Hypoxemia is harmful to the injured brain, but hyperoxemia can be associated with excitotoxicity and worse outcomes. In a recent RCT, a strategy limiting oxygen exposure (i.e., target SpO2 90-97%)was not associated with worse outcomes than a standard strategy in a subgroup of patients with acute brain injury. Targeting a SpO2 between 94 and 97% seems reasonable.
. We recommend that the optimal target range of PaO2 in patients with ABI who do not have clini-cally significant ICP elevation is 80-120 mmHg(strong recommendation, low-quality evidence).
. We recommend that the optimal target range of PaO2 in patients with ABI who have clinically significant ICP elevation is 80-120 mmHg (strong recommendation, no evidence; good practice statement).
04
S
Sodium 血钠
S: sodium concentration affects brain volume and is often altered in patients with acute brain injury, because of hyperosmolar fluid therapy, diabetes insipidus, inappropriate free water retention,increased natriuresis, and/or AKI. Hyper-and hyponatremia have been reported to be independently associated with worse outcomes in this patient population, and hyponatremia (sodium < 135 mEq/L) can contribute to increased brain volume and intracranial hypertension. Hypernatremia may occur as a result of intracranial pressure (ICP)-directed therapies, and sodium levels up to 155 mEq/L may be tolerated in such conditions.
高钠血症发生原因
05
T
Temperature 体温
T: temperature is strictly regulated to optimize cellular function. Hyperthermia is part of a systemic inflammatory reaction after acute brain injury and not usually associated with infection. Hyperthermia can be associated with increased ICP, cerebral hypoxia, metabolic distress, and worse outcomes in this setting. Whether fever is a prognostic factor or a marker of severity remains unclear, but core temperatures > 38.0C should be avoided, particularly if associated with neurological deterioration or altered cerebral homeostasis.
06
C
Comfort 舒适
C: patient comfort, including control of pain,agitation, anxiety, and shivering, is an important goal, to avoid physical and psychological distress, excessive cerebral stimulation, increased ICP, and secondary tissue hypoxia. The main aim is to keep patients calm, comfortable, and collaborative.Deep sedation may be required in some specific situations, such as elevated ICP, refractory status epilepticus, and severe shivering.
07
A
Arterial pressure
A: arterial blood pressure is the main determinant of CBF. Even mild hypotension can result in brain hypoperfusion, especially in pathological conditions such as impaired cerebral autoregulation, increased ICP, cerebral edema, and/or microvascular disturbances. Achieving an 'optimal' cerebral perfusion pressure (CPP) is crucial, but clinical benefits of monitoring the cerebral circulation/autoregulation need to be assessed in prospective trials. Maintaining a mean arterial pressure (MAP) ≥ 80 mmHg and a CPP≥ 60 mmHg may be reasonable in unconscious patients; in awake patients, MAP targets can be titrated according to repeated neurological examination.
BRAIN TRAUMA FOUNDATION 指南第一版到第三版，推荐SAP>90mmHg，即避免低血压
08
P
PaCO2血二氧化碳分压
P: acute changes in PaCO2 cause proportional changes in CBF (a 4% change in CBF per mmHg change in PaCO2). If intracranial compliance is reduced, any increase in CBF may increase cerebral blood volume, and thereby ICP. On the other hand, excessive hyperventilation can result in cerebral ischemia, and PaCO2 < 35 mmHg should be avoided.
We recommend that the optimal target range of PaCO2, in patients with ABI who do not have clinically significant ICP elevation is 35-45 mmHg(strong recommendation, low-quality evidence).
We recommend short-term hyperventilation as a therapeutic option in patients with ABI who have brain herniation (weak recommendation, no evi-
dence).
We are unable to provide a recommendation regarding the use of short-term hyperventilation as a therapeutic option in patients with ABI who have clinically significant ICP elevation (no recommendation, no evidence).
Summary
小结：GHOST CAP
G:Glucose 血糖：4-10mmol/l(8-10mmol/l)
H:Hemoglobin血蛋白：7-9g/dl(输血阈值)
O:Oxygen氧：SpO2 94-97%, PaO2 80-120mmHg
S:Sodium钠：135-155 mmol/l
T: Temperature体温：避免T>38.0℃
C:Comfort舒适度：镇痛、镇静、抗交感
A: Arterial pressure动脉压 ：MAP ≥80mmHg，SAP >100-110mmHg
P:PaCO2二氧化碳分压：PaCO2 35-45 mmHg
联系客服
