脑出血2010指南.ppt
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1、2010 ICH 临床指南 Guidelines for the Management of Spontaneous Intracerebral Hemorrhage (自发性脑内出血的治疗指南) 2010年美国卒中协和脑出血临床指南 摘译 孙芸芸 梁志刚,A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association 给予来自美国心脏协会/美国卒中协会的卫生保健专业人员的指南,一、Emergency Diagnosis and Assessment
2、 of ICH and Its Causes Recommendations 关于脑出血的紧急诊断和评估的建议,1. Rapid neuroimaging with CT or MRI is recommended to distinguish ischemic stroke p1 from ICHp2 (Class I; Level of Evidence: A). (Unchanged from the previous guideline) CT或MRI(核磁共振成像)的快速成像便于很好地区分缺血性中风和脑出血(出血性脑中风)。(与先前的指南并无差异),2. CT angiography
3、 and contrast-enhanced CTp3 may be considered to help identify patients at risk for hematoma expansion (Class IIb; Level of Evidence: B), CT血管造影术和强化CT或许可以辅助鉴别有血肿扩散危险的病人 and CT angiography, CT venography, contrast-enhanced CT, contrast-enhanced MRI, magnetic resonance angiography, and magnetic resona
4、nce venography can be useful to evaluate for underlying structural lesions, including vascular malformations and tumors when there is clinical or radiological suspicion (Class IIa;Level of Evidence: B). (New recommendation) 同时,CT血管造影术、CT静脉造影术、加强CT、加强MRI(核磁共振)、磁共振血管造影、磁共振静脉造影,可以检查到潜在的结构损伤,包括临床上或放射学上怀
5、疑的血管畸形和肿瘤。(新推荐),二、Medical Treatment for ICH Recommendations 关于脑出血内科治疗的建议p4,1. Patients with a severe coagulation factor deficiency or severe thrombocytopenia should receive appropriate factor replacement therapy or platelets, respectively (Class I;Level of Evidence: C). (New recommendation) 严重缺乏凝血因子
6、或者说有严重血小板减少症的病人,应该适当地接受外来因子或者血小板来进行治疗。(新推荐),2. Patients with ICH whose INRp5 is elevated due to OACsp6 should have their warfarin withheld, receive therapy to replace vitamin Kdependent factors and correct the INR, and receive intravenous vitamin K (Class I; Level of Evidence: C). 对于那些由口服抗凝剂OACsp7 导
7、致INR(国际标准化比值)升高的脑出血病人,不应该再用华法令,而该接受上述治疗来取代维生素K依赖性因子,同时,该改善INR水平、接受静脉内维生素K治疗。 PCCsp8 血浆凝固剂have not shown improved outcome compared with新鲜冷冻血浆 FFPp9 but may have fewer complications compared with FFP and are reasonable to consider as an alternative to FFP (Class IIa; Level of Evidence: B). 与新鲜血浆相比,血液凝
8、固剂并没有显示出明显改善的治疗成果,但是可能并发症更少,是值得考虑的新鲜血浆替代物。,rFVIIap10 does not replace all clotting factors, and although the INR may be lowered, clotting may not be restored in vivo; therefore, rFVIIa is not routinely recommended as a sole agent for OAC reversal in ICH (Class III; Level of Evidence: C). (Revised fr
9、om the previous guideline). 重组凝血因子VII并不能替代所有的凝结因子;虽然INR可能会被降低,但是体内的血凝块并不能消除。所以,并不推荐把rFvlla作为脑出血病人OAC逆转的唯一药剂。(由先前指南修订),3. Although rFVIIa can limit the extent of hematoma expansion in noncoagulopathic ICH patients, thereis an increase in thromboembolic risk with rFVIIa and no clear clinical benefit i
10、n unselected patients. Thus rFVIIa is not recommended in unselected patients. (Class III; Level of Evidence: A). (New recommendation) Further research to determine whether any selected group of patients may benefitfrom this therapy is needed before any recommendation for its use can be made. 虽然重组凝血因
11、子VII可以限制非凝血异常性脑出血病人血肿扩大,但是应用rFVlla 时发生血栓的危险性却增加了,同时,对于随机选定的患者没有明显的临床利益。(新推荐)在可以得出有关其应用的任何推荐之前,需要做更深层次的研究来验证是否任何被选定的病人群体都可以从这种治疗获益。,4. The usefulness of platelet transfusions in ICH patients with a history of antiplatelet use is unclear and is considered investigational (Class IIb; Level of Evidence:
12、 B). (New recommend) 对于有抗血小板治疗病史的脑出血病人,给予输液血小板治疗的有效性并不清楚、有待于研究。(新推荐) 5. Patients with ICH should have intermittent pneumatic compressionp11 for prevention of venous thromboembolism in addition to elastic stockingsp12 (Class I;Level of Evidence: B). (Unchanged from the previousguideline) 为了预防脑出血病人出现下
13、肢静脉栓塞p13 ,除了下肢要穿弹力袜子、也要进行间歇性的充气压迫治疗(与先前的指南并无差异),6. After documentation of cessation of bleeding, lowdose subcutaneous low-molecular-weight heparin or unfractionated heparin may be considered for prevention of venous thromboembolism in patients with lack of mobility after 1 to 4 days from onset (Clas
14、sIIb; Level of Evidence: B). (Revised from the previousguideline) 在确定病人出血停止后,皮下注射低剂量的低分子量的肝素或者肝素,可能用于防止病人发病后1到4天后发生静脉栓塞。(由先前指南修订),三、Blood Pressure Recommendations(有关血压方面的建议),1. Until ongoing clinical trials of BP intervention for ICH are completed, physicians must manage BP on the basis of the prese
15、nt incomplete efficacy evidence.Current suggested recommendations for target BP in various situations are listed in Table 6 and may be considered (Class IIb; Level of Evidence: C). (Unchangedfrom the previous guideline) 在正在进行的脑出血病人血压干预临床试验完成之前,医师必须依据目前不完善的循证医学证据的基础,来适当控制血压。目前,对于不同情况下所推荐的血压处理方法,请见表6,
16、值得借鉴。(与先前的指南并无差异),2. In patients presenting with a systolic BP of 150 to 220 mm Hg, acute lowering of systolic BP to 140 mm Hg is probably safe (Class IIa; Level of Evidence: B). (New recommendation) 对于收缩压在150到220mmHg之间的病人,收缩压迅速降低到140mmHg或许是安全的。(新推荐),四、Inpatient Managementp14 and Prevention of Secon
17、dary Brain Injury Recommendations 关于住院病人的处理治疗和预防二次脑损伤的建议,1. Initial monitoring and management of ICH patients should take place in an intensive care unit with physician and nursing neuroscience intensive care expertise (Class I; Level of Evidence: B). (Unchanged from the previous guideline) 脑出血病人最初的
18、监测和管理,应该在一个拥有神经科学重专业护理人员和内科医生的加强治疗中心ICU。(与先前的指南并无差异),Management of Glucose(血糖控制) 1. Glucose should be monitored and normoglycemia is recommended (Class I: Level of Evidence: C). (New recommendation) 应该监测血糖,保证血糖的正常。(新推荐),Seizures and Antiepileptic Drugsp15 (控制惊厥及抗癫痫药物) 1. Clinical seizures should be
19、treated with antiepileptic drugs (Class I; Level of Evidence: A). (Revised from the previous guideline) Continuous EEGp16 monitoring is probably indicated in ICH patients with depressed mental status out of proportion to the degree of brain injury (Class IIa; Level of Evidence: B). Patients with a c
20、hange in mental status who are found to have electrographic seizures on EEG should be treated with antiepileptic drugs (Class I; Level of Evidence: C). Prophylactic anticonvulsant medication should not be used (Class III; Level of Evidence:B). (New recommendation)临床的癫痫发作应该给予抗癫痫药物;(一级推荐A级证据)对那些精神状态抑制
21、与脑损伤程度不相符合的脑出血病人,进行持续的脑电图监视可能会有一定的诊断预警作用。p17 那些发现有脑电图痫性异常的精神状态改变的病人,应该用抗癫痫药物(C级证据一级推荐);不建议预防性应用抗痉挛剂。(新推荐),六、Procedures/Surgery Recommendations (关于手术程序的建议),1. Patients with a GCSp18 score of 8, those with clinical evidence of transtentorial herniationp19 , or those with significant IVHp20 or hydrocep
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