守谷 俊

Background: Intracranial pressure control has long been recognized as an important requirement for patients with severe traumatic brain injury. Hypertonic saline has drawn attention as an alternative to mannitol in this setting. The aim of this study was to assess the effects of hypertonic saline versus mannitol on clinical outcomes in patients with traumatic brain injury in prehospital, emergency department, and intensive care unit settings by systematically reviewing the literature and synthesizing the evidence from randomized controlled trials. Methods: We searched the MEDLINE database, the Cochrane Central Register of Controlled Trials, and the Igaku Chuo Zasshi (ICHUSHI) Web database with no date restrictions. We selected randomized controlled trials in which the clinical outcomes of adult patients with traumatic brain injury were compared between hypertonic saline and mannitol strategies. Two investigators independently screened the search results and conducted the data extraction. The primary outcome was all-cause mortality. The secondary outcomes were 90-day and 180-day mortality, good neurological outcomes, reduction in intracranial pressure, and serum sodium level. Random effects estimators with weights calculated by the inverse variance method were used to determine the pooled risk ratios. Results: A total of 125 patients from four randomized trials were included, and all the studies were conducted in the intensive care unit. Among 105 patients from three trials that evaluated the primary outcome, 50 patients were assigned to the hypertonic saline group and 55 patients were assigned to the mannitol group. During the observation period, death was observed for 16 patients in the hypertonic saline group (32.0%) and 21 patients in the mannitol group (38.2%). The risks were not significant between the two infusion strategies (pooled risk ratio, 0.82; 95% confidence interval, 0.49-1.37). There were also no significant differences between the two groups in the other secondary outcomes. However, the certainty of the evidence was rated very low for all outcomes. Conclusions: Our findings revealed no significant difference in the all-cause mortality rates between patients receiving hypertonic saline or mannitol to control intracranial pressure. Further investigation is warranted because we only included a limited number of studies

Background: The exacerbation of intracranial bleeding is critical in traumatic brain injury (TBI) patients. Tranexamic acid (TXA) has been used to improve outcomes in TBI patient. However, the effectiveness of TXA treatment remains unclear. This study aimed to assess the effect of administration of TXA on clinical outcomes in patients with TBI by systematically reviewing the literature and synthesizing evidence of randomized controlled trials (RCTs). Methods: MEDLINE, the Cochrane Central Register of Controlled Trials, and Igaku Chuo Zasshi (ICHUSHI) Web were searched. Selection criteria included randomized controlled trials with clinical outcomes of adult TBI patients administered TXA or placebo within 24 h after admission. Two investigators independently screened citations and conducted data extraction. The primary "critical"outcome was all-cause mortality. The secondary "important"outcomes were good neurological outcome rates, enlargement of bleeding, incidence of ischemia, and hemorrhagic intracranial complications. Random effect estimators with weights calculated by the inverse variance method were used to report risk ratios (RRs). Results: A total of 640 records were screened. Seven studies were included for quantitative analysis. Of 10,044 patients from seven of the included studies, 5076 were randomly assigned to the TXA treatment group, and 4968 were assigned to placebo. In the TXA treatment group, 914 patients (18.0%) died, while 961 patients (19.3%) died in the placebo group. There was no significant difference between groups (RR, 0.93; 95% confidence interval, 0.86-1.01). No significant differences between the groups in other important outcomes were also observed. Conclusions: TXA treatment demonstrated a tendency to reduce head trauma-related deaths in the TBI population, with no significant incidence of thromboembolic events. TXA treatment may therefore be suggested in the initial TBI care.

成人心拍再開後の集中治療および予後評価における改訂の要点(学会担当分)を示す。心拍再開後の集中治療【呼吸管理】酸素化に関して、低酸素症の回避を推奨し、高酸素症の回避を提案する。また、心拍再開(return of spontaneous circulation、ROSC)後、動脈血酸素飽和度または動脈血酸素分圧が確実に測定されるまでは100%吸入酸素濃度の使用を提案する。PaCO2に関してバンドル治療の一部としてPaCO2を生理的な正常範囲内に維持することを提案する。【循環管理】バンドル治療の一部として循環管理の目標(例:平均血圧、収縮期血圧)設定を考慮することを提案する。【体温管理療法】ROSC後に刺激に反応がない場合は、体温管理療法の施行を推奨/提案し、体温管理療法を行わないことには反対する。体温管理療法は、初期ECG(electrocardiogram)波形が電気ショック適応の院外心停止に対しては推奨し、初期ECG波形が電気ショック非適応の院外心停止および全ての初期ECG波形の院内心停止に対しては提案する。体温管理療法施行時には、32〜36℃の間で目標体温を設定し、その温度で一定に維持することを推奨する。体温管理療法を施行する場合は、維持期間を少なくとも24時間とすることを提案する。ROSC直後、急速な大量冷却輸液による病院前冷却をルーチンには行わないことを推奨する。体温管理療法終了後も昏睡状態が遷延している場合は発熱を防止し治療することを提案する。【てんかん発作の管理】てんかん発作の予防をルーチンには行わないことを提案する。てんかん発作の治療を推奨する。【血糖管理】標準的血糖管理プロトコルを変更せず適応することを提案する。予後評価【低体温による体温管理療法が施行されたROSC後昏睡患者の予後評価】ROSC後72時間以前に臨床所見のみで予後を評価しないよう提案する。鎮静や筋弛緩の残存が疑われる場合は、臨床所見を継続して観察することを提案する。それにより予後評価の偽陽性を最小化することができる。単一の検査または所見のみを信用することなく、多元的な検査(臨床所見、神経生理学的な手法、イメージング、あるいは血液マーカー)を、予後評価のため使用することを提案する。予後不良を評価するには、ROSCから少なくとも72時間以後において、両側対光反射消失、もしくは両側の瞳孔および角膜反射消失を使用することを推奨する。予後不良を評価するためにROSCから少なくとも72時間後に計測された短潜時体性感覚誘発電位(short latency somatosensory evoked potential、SSEP)のN20波の両側消失を使用することを推奨する。予後不良を評価するために、BIS(bispectral index)の使用を避けるように推奨する。【体温管理療法を施行していないROSC後昏睡患者の予後評価】ROSC後72時間以降における対光反射消失を予後不良の評価に用いることを推奨する。ROSC後から72時間以内でのSSEP N20波の両側消失を、予後不良の評価に用いることを推奨する。(著者抄録)