颅内高压患者血压多少合适

颅内高压患者血压多少合适,主题ICU常见的颅内高压症,脑外伤（TBI）,颅高压症,中风,脑出血（ICH）脑梗塞（ischemic ）自发蛛网膜下腔出血（SAH）,共同的特点：多存在高血压继发性损害：出血加重和脑水肿,概述,脑灌注压（CPP）与脑血流（CBF）的关系（实验）,概述,脑血流的自主调节功能（Cerebral Autoregulation),CPP、MAB与脑血流的关系,CPP:60130mmHg,概述,继发性损伤问题（Secondary brain damage）,CBV,CPP ,ICP ,Hypertension,Brain edema,Edema and hematoma,Primary injury,CBF ,Lower BP,CPP = MAP ICP,hematoma ,Ischemia,概述,继发性损伤问题（Secondary brain damage）,如何降低ICP的基础上，保持合适的CCP和血压，以减少继发性损伤？,Hypertension,Lower BP,CPP = MAP ICP,CPP,Hypotension,概述,ICP与TBI预后,Balestreri, etal. Neurocrit. Care 2006;04:813,重症脑外伤,CPP与TBI预后,Balestreri, etal. Neurocrit. Care 2006;04:813,重症脑外伤,恰当的CPP,重症脑外伤,Steiner,etal. CCM.2002,血压控制现在观点：,重症脑外伤,脑灌注压阈值：CPP 60mmHg(2001-2005)Lund:50mmHg（2003）但避免：CPP50mmHg维持 ICP 20 mm Hg,MAP = CPP + ICP （20/50）70mmHgMAP120mmHg,Brain Trauma Foundation. J Neurotrauma 2007；24（5）：S59,脑出血（ICH）急性期血压控制,目的：减少24h内继续出血降低血肿周围72h的水肿(perihematomal edema)什么时候降压、血压控制到多少合适？争论最大，而持续！,Broderick et al: Guidelines for the management of spontaneous intracerebral hemorrhage: A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 1999; 30:905915Robinson TG, Potter JF. Blood pressure after stroke.Age Ageing 2004; 33: 612.,脑出血,ICH指南演变,Stroke. 1999;30:905-915，Stroke. 2007;38:2001-2023， Stroke. 2010;41:2108-2129,脑出血,脑出血,结论：ICH患者快速降低MBP显著增加死亡率。提出MBP在150mmHg以下，并非必须积极降压.,105例ICH患者24小时降压回顾性风险分析：（平均 MBP:140mmHg） 死亡组：MAP降幅 64.8/2.7mmHg; 生存组：MAP降幅28.8/1.2 mm Hg。,Qureshi AI, etal. Rate of 24-hour blood pressure decline and mortality after spontaneous intracerebral hemorrhage: a retrospective analysis with a random effects regression model. Crit Care Med. 1999;27:480,平均动脉压的演变,SBP和DBP的演变,Qureshi AI, etal. A prospective multicenter study to evaluate the feasibility and safety of aggressive antihypertensive treatment in patients with acute intracerebral hemorrhage. J Intensive Care Med. 2005;20:3442.,target ：160/90 mm Hg,24小时内使维持BP在160/90mmHg,可减少7%的继发出血量和9%的脑水肿。该研究奠定了目标血压控制在160/90mmHg.,脑出血,强化控压对ICH的预后评估,脑出血,2008Craig等发表强化降压治疗（即在发作6小时内控制SBP 140 mmHg）安全研究。,目的：评估ICH患者早期6h不同降压水平对出血量和预后的影响：分组：强化组（n=203）：目标SBP 140 mmHg 指南组（n=201）：目标SBP 180 mmHg),强化控压对ICH的预后评估,结论：早期强化降压视乎是安全可行的，但对预后无影响,Anderson CS, etal. the INTERACT investigators. Intensive Blood Pressure Reduction In Acute Cerebral Haemorrhage Trial (INTERACT): a randomised pilottrial. Lancet Neurol. 2008;7:391,脑出血,不同降压水平ICH的定量影响,再评价出血和水肿强化组（n=151）指南组（n=145）,早期强化降压能够减少24h和72h （P=0.02）的出血量，但对血肿周围水肿均无影响。,Craig S.etal.Effects of Early Intensive Blood Pressure-Lowering Treatment on the Growth of Hematoma and Perihematomal Edema in Acute Intracerebral Hemorrhage The Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT). Stroke. 2010;41:307-312,脑出血,分层降压对ICH预后的影响：,Antihypertensive treatment of acute cerebral hemorrhage.Crit Care Med 2010:38(2);637,脑出血,分层降压对ICH预后的影响：,结论：分层控制SBP在神经损害和严重事件方面较预期（140mmHg)）的损害要低，三个月死亡率也比预期的低。,Antihypertensive treatment of acute cerebral hemorrhage.Crit Care Med 2010:38(2);637,脑出血,最新研究报告,Stroke.,Yuki Sakamoto, etal. Systolic Blood Pressure After Intravenous Antihypertensive Treatment and Clinical Outcomes in Hyperacute Intracerebral Hemorrhage.Stroke. 2013; 44: 1846-1851,脑出血,血压控制现在观点：,近年的研究提示强化血压控制能够减少脑继发出血，但不能减少或加重脑水肿，因此2010AHA/ASA指南仍沿用2007年控压意见！既目标血压160/90mmHg.,脑出血,缺血性中风的血压控制,脑梗塞,缺血性脑中风血压与预后,Leonardi, etal. Blood pressure and clinical outcomes in the international stroke trial. .Stroke 2002;33(5):1315,脑梗塞,缺血性脑中风血压与预后,早期脑水肿程度,残疾程度,Castillo,etal. Blood Pressure Decrease During the Acute Phase of Ischemic Stroke Is Associated WithBrain Injury and Poor Stroke Outcome . Stroke. 2004;35:520-526,脑梗塞,缺血性脑中风血压与预后,Castillo,etal. Blood Pressure Decrease During the Acute Phase of Ischemic Stroke Is Associated WithBrain Injury and Poor Stroke Outcome . Stroke. 2004;35:520-526,死亡率,脑容积率,脑梗塞,缺血性脑中风血压与预后,CPP与TBI预后： 许多研究证明在脑缺血性中风患者，急性期血压水平与预后呈U型相关性。,George,etal. Blood pressure treatment in acute ischemic stroke: a review of studies and recommendations. Current Opinion in Neurology 2010, 23:4652,脑梗塞,血压控制现在观点：,George,etal. Blood pressure treatment in acute ischemic stroke: a review of studies and recommendations. Current Opinion in Neurology 2010, 23:4652,对缺血性中风应谨慎降压，推 荐当 血压高于220/120mmHg时考虑降压，目标血压140-180/90-100mmHg。需要溶栓的患者目标血压应控制在185/100mmHg以下AHA/ASA和ESO建议,脑梗塞,原发性蛛网膜下腔出血（SAH）,爆发性CPP增高,而ICP升高有限,SAH,SAH出血特点,早期控制血压是必须的！,SAH,血压控制现在