SciELO - Scientific Electronic Library Online

 
vol.53 issue1Spinal subdural empyemaTies and Gilles de la Tourette syndrome author indexsubject indexarticles search
Home Pagealphabetic serial listing  

Arquivos de Neuro-Psiquiatria

Print version ISSN 0004-282X

Arq. Neuro-Psiquiatr. vol.53 no.1 São Paulo Mar. 1995

http://dx.doi.org/10.1590/S0004-282X1995000100021 

Relevância da otimização ventilatória em hipertensão intracraniana aguda: uma abordagem clínica-fisiológica-terapêutica

 

Relevance of ventilatory optimization in acute intracranial hypertension: a clinico-physiologic-therapeutic approach

 

 

Julio Cruz

Professor Assistente da Disciplina de Neurocirurgia e Coordenador do Centro de Traumatismos Cerebrais da Universidade da Pennsylvania

 

 


RESUMO

Ventilação mecânica em coma agudo traumático é abordada de forma abrangente, através revisão comparativa da literatura pertinente. Aspectos multivariáveis clínico-fisiológico-terapêuticos são apresentados e discutidos, e uma proposição é apresentada para que se otimize ventilação mecânica em circunstâncias nas quais haja evidência de sofrimento cerebral agudo predominantemente difuso. Uma nova técnica é introduzida para que se possam quantificar, à beira do leito e de forma prática, ajustamentos ventilatórios que permitam, simultaneamente, otimização da pressão intracraniana e da extração cerebral global de oxigênio. A última representa adequação terapêutica do fluxo sanguíneo cerebral ao metabolismo cerebral de oxigênio, em âmbito global.

Palavras-chave: hemometabolismo cerebral, hipertensão intracraniana aguda, otimização ventilatória, terapêutica fisiológica multivariável.


SUMMARY

Mechanical ventilation in acute traumatic coma is comprehensively approached, by means of comparatively reviewing the pertinent literature. Multivariate clinico-physiologic-therapeutic aspects are presented and discussed, and a proposition is made for ventilatory optimization under circumstances of predominantly diffuse acute brain insults. A novel technique is introduced for practical, bedside quantification of ventilatory adjustments. This technique allows simultaneous optimization of intracranial pressure and global cerebral extraction of oxygen. The latter represents therapeutic coupling between global cerebral blood flow and oxygen metabolism.

Key words:cerebral hemometabolism, acute intracranial hypertension, ventilatory optimization, multivariate physiologic therapy.


 

 

Texto completo disponível apenas em PDF.

Full text available only in PDF format.

 

 

REFERÊNCIAS

1.  Brodersen P, Jorgensen EO. Cerebral blood flow and oxygen uptake, and cerebrospinal fluid biochemistry in severe coma. J Neurol Neurosurg Psychiatry 1974, 37: 384-391.         [ Links ]

2.  Bruce DA, Langfitt TW, Miller JD, Schutz H, Vapalahti MP, Stanek A, Goldberg HI. Regional cerebral blood flow, intracranial pressure, and brain metabolism in comatose patients. J Neurosurg 1973, 38: 131-144.         [ Links ]

3.  Cruz J. Continuous versus serial global cerebral hemometabolic monitoring: applications in acute brain trauma. Acta Neurochir (Suppl) 1988, 42: 3S-39.         [ Links ]

4.  Cruz J, Miner ME, Allen SJ, Alves WM, Gennarelli TA. Continuous monitoring of cerebral oxygenation in acute brain injury: injection of mannitol during hyperventilation. J Neurosurg 1990, 73: 725-730.         [ Links ]

5.  Cruz J, Gennarelli TA, Alves WM. Continuous monitoring of cerebral oxygenation in acute brain injury: multivariate assessment of severe intracranial "plateau" wave: case report. J Trauma 1992, 32: 401-403.         [ Links ]

6.  Cruz J, Gennarelli TA, Alves WM. Continuous monitoring of cerebral hemodynamic reserve in acute brain injury: relationship to changes in brain swelling. J Trauma 1992, 32: 629-63S.         [ Links ]

7.  Cruz J, Gennarelli TA, Hoffstad OJ. Lack of relevance of the Bohr effect in optimally ventilated patients with acute brain trauma. J Trauma 1992, 33: 304-311.         [ Links ]

8.  Cruz J. Hemometabolismo cerebral: de medidas isoladas a medidas de monitorização e terapêutica. Arq Neuropsiquiatr 1993, 51: 1-7.         [ Links ]

9.  Cruz J. On-line monitoring of global cerebral hypoxia in acute brain injury: relationship to intracranial hypertension. J Neurosurg 1993, 79: 228-233.         [ Links ]

10.  Cruz J, Jaggi JL, Hoffstad OJ. Cerebral blood flow and oxygen consumption in acute brain injury with acute anemia: an alternative for the cerebral metabolic rate of oxygen consumption? Crit Care Med 1993, 21: 1218-1224.         [ Links ]

11.  Cruz J. Combined continuous monitoring of systemic and cerebral oxygenation in acute brain injury: preliminary observations. Crit Care Med 1993, 21: 1225-1232.         [ Links ]

12.  Cruz J. Continuous monitoring of cerebral oxygenation in acute brain injury: assessment of cerebral hemometabolic regulation. Minerva Anestesiol 1993, 59: 555-562.         [ Links ]

13.  Cruz J. Hemodinâmica e metabolismo cerebrais em coma traumático: relevância da resistência vascular cerebral e da hipocapnia otimizada. Tese. São Paulo, 1994.         [ Links ]

14.  Cruz J. An additional therapeutic effect of adequate hyperventilation in severe acute brain trauma: normalization of cerebral glucose uptake. J Neurosurg 1995 (In press).         [ Links ]

15.  Gibbs EL, Lennox WG, Nims LF, Gibbs FA. Arterial and cerebral venous blood: arterial-venous differences in man. J Biol Chem 1942, 144: 325-332.         [ Links ]

16.  Gordon E, Rossanda M. Further studies on cerebrospinal fluid acid-base status in patients with brain lesions. Acta Anaesthesiol Scand 1970, 14: 97-109.         [ Links ]

17.  Jaggi JL, Obrist WD, Gennarelli TA, Langfitt TW. Relationship of early cerebral blood flow and metabolism to outcome in acute head injury. J Neurosurg 1990, 72: 176-182.         [ Links ]

18.  Miller JD, Sweet RC, Narayan R, Becker DP. Early insults to the injured brain. JAMA 1978,240:439-442.         [ Links ]

19.  Muizelaar JP, Marmarou AM, Ward JD, Kontos HA, Choi SC, Becker DP, Gruemer H, Young HF. Adverse effects of prolonged hyperventilation in patients with severe head injury: a randomized clinical trial. J Neurosurg 1991, 75: 731-739.         [ Links ]

20.  Nordstrom C-H, Messeter K, Sundbarg G, Schalen W, Werner M, Ryding E. Cerebral blood flow, vasoreactivity, and oxygen consumption during barbiturate therapy in severe traumatic brain lesions. J Neurosurg 1988. 68: 424-431.         [ Links ]

21.  Obrist WD, Langfitt TW, Jaggi JL, Cruz J, Gennarelli TA. Cerebral blood flow and metabolism in comatose patients with acute head injury: relationship to intracranial hypertension. J Neurosurg 1984, 61: 241-253.         [ Links ]

22.  Rappapoft ZH, Ransohoff J, Hass WK. Cerebral metabolism in head trauma. Prog Neurol Surg 1981,10:1-13.         [ Links ]

23.  Reivich M. Arterial PC02 and cerebral hemodynamics. Am J Physiol 1964, 206: 25-35.         [ Links ]

24.  Shalit MN, Beller AJ, Feinsod M. Clinical equivalents of cerebral oxygen consumption in coma. Neurology 1972, 22: 155-160.         [ Links ]

25.  Tabaddor K, Bhushan C, Pevsner PH, Walker AE. Prognostic value of cerebral blood flow (CBF) and cerebral metabolic rate of oxygen (CMRO.) in acute head trauma. J Trauma 1972, 12: 1053-1055.         [ Links ]

 

 

Aceite: 23-julho-1994.

 

 

Julio Cruz,M.D.,Ph.D. - Division of Neurosurgery, Hospital of the University of Pennsylvania - 3400 Spruce Street - Philadelphia, PA 19104, USA.