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Hirndruckmonitoring beim Polytraumatisierten mit Schädel-Hirn-Trauma

Intracranial pressure monitoring in polytrauma patients with traumatic brain injury

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Zusammenfassung

Hintergrund

Die Messung des intrakraniellen Drucks stellt einen Grundpfeiler bei der Intensivtherapie Schädel-Hirn-Verletzter dar. Mehrere Systeme werden zur Messung angeboten. Als ultima ratio kann bei konservativ nicht beherrschbarer Drucksteigerung die dekomprimierende Kraniektomie erwogen werden.

Fragestellung

Pathophysiologie des intrazerebralen Drucks, Polytraumamanagement und Schädel-Hirn-Trauma (SHT), Vergleich der Messsysteme und ihrer Komplikationen; Indikation zur Entlastungskraniektomie bei malignem Hirnödem.

Material und Methode

Retrospektive Auswertung des eigenen Krankenbestandes in den Jahren 2010 bis 2016. Diskussion relevanter Publikationen, insbesondere der Indikation zur Überwachung des „intracranial pressure“ (ICP) und dessen Einfluss auf das Polytraumamanagement.

Ergebnisse

Von 2010 bis 2016 wurden bei 106 Patienten mit einem Durchschnittsalter von 65,9 Jahren bei geschlossenem SHT insgesamt 120 Hirndrucksonden implantiert. Es handelte sich überwiegend um Parenchymsonden (111/120), gefolgt von Ventrikelsonden (8/120) und einer Kombinationssonde (1/120). 29/106 Patienten (27,4 %) wiesen ein Polytrauma auf und 35/106 (33,0 %) nahmen gerinnungsaktive Substanzen ein. Die Liegedauer der Sonden betrug im Durchschnitt 8,51 Tage, der Intensivaufenthalt 20 Tage. Bei 74/106 Patienten (69,8 %) erfolgte die Sondenimplantation nicht isoliert, sondern im Rahmen einer Trepanation. Bei 7/106 (6,6 %) Patienten traten sondenspezifische Komplikationen auf, wobei Fehlfunktionen am häufigsten zu finden waren. Die Liegedauer der Sonden war signifikant mit dem Vorliegen eines Polytraumas (p = <0,001) und zum Alter (>60; p = 0,03) korreliert. Die Intensivdauer war ebenfalls signifikant korreliert zum Vorliegen eines Polytraumas (p = 0,02) wie auch zu Sondenkomplikationen (p ≤ 0,001). Die Mortalität war zur Einnahme gerinnungsaktiver Medikamente (p = 0,01) und zum Alter (>60; p = 0,03) korreliert.

Schlussfolgerungen

Die Messung des ICP ist eines der wichtigsten Mittel in der Behandlung von SHT. Für den Verlauf spielen v. a. das Vorliegen eines Polytraumas, das Alter und die Einnahme gerinnungsaktiver Substanzen eine Rolle.

Abstract

Background

The monitoring of intracranial pressure (ICP) represents a cornerstone in the intensive care of patients with traumatic brain injury (TBI) and the industry provides various technical solutions to this end. Decompressive craniectomy can be an option if conservative measures fail to reduce excessive ICP.

Objective

To examine the pathophysiology of ICP in trauma, the management of polytrauma involving TBI, and the indications for decompressive craniectomy; and to compare the different monitoring systems and their complications.

Material and methods

A retrospective analysis of TBI patients between 2010 and 2016 was performed. Relevant publications are discussed, particularly those relating to the indications for monitoring and its influence on polytrauma management.

Results

Between 2010 and 2016, 106 patients with closed TBI and a mean age of 65.9 years received a total of 120 ICP monitors, most of which were parenchyma devices (111/120), followed by intraventricular catheters (8/120), and one combined system (1/120). Of these patients, 27.4% had sustained polytrauma, whilst 33% regularly used anticoagulants. ICP monitors were removed after 8.5 days on an average and the mean ICU stay was 20 days. Probe insertion was combined with craniectomy in 69.8% patients. Probe-related complications, most commonly involving malfunction, were seen in 6.6%. The duration of monitoring was significantly related to polytrauma (p ≤ 0.001) and age <60 (p = 0.03). ICU stay was also significantly related to polytrauma (p = 0.02) and monitoring complications (p ≤ 0.001). Mortality was related to anticoagulant medication (p = 0.01) and age <60 (p = 0.03).

Conclusions

ICP monitoring is one of the most important tools in TBI treatment. The course and outcome of these severe injuries is affected by polytrauma, age, and the use of anticoagulants.

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  1. Unfallchirurgische Abteilung, Landesklinikum Horn, Spitalgasse 10, 3580, Horn, Österreich

    T. Neubauer, W. Buchinger, E. Höflinger & J. Brand

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Correspondence to T. Neubauer.

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T. Neubauer, W. Buchinger, E. Höflinger und J. Brand geben an, dass kein Interessenkonflikt besteht.

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Neubauer, T., Buchinger, W., Höflinger, E. et al. Hirndruckmonitoring beim Polytraumatisierten mit Schädel-Hirn-Trauma. Unfallchirurg 120, 745–752 (2017). https://doi.org/10.1007/s00113-017-0355-9

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