2016年 · 第96卷第21期

Severe neurosurgical patients often have different degrees of consciousness disorders, and most of them are accompanied by respiratory dysfunction, spontaneous cough, poor sputum discharge function, poor discharge of secretions in the airway, easy to complicate lung infection, affecting ventilation and ventilation function, and in severe cases, leading to hypoxemia, which will aggravate the function damage of the brain and vital organs in the whole body, seriously affect the prognosis of patients, and even become a fatal factor. Therefore, the Neurosurgery Branch of Chinese Medical Association and the China Neurosurgery Critical Care Management Collaborative Group organized and wrote the Expert Consensus on Airway Management of Critical Neurosurgery Patients in China (2016).

Idiopathic normal pressure hydrocephalus (iNPH), as a group of idiopathic clinical syndromes without obvious triggers, is characterized by the triad of gait disturbance, cognitive impairment and urinary incontinence. In 1965, Hakim and Adams first proposed the concept of normal intracranial pressure hydrocephalus (NPH) syndrome. Its clinical manifestations are not only triad, but also ventricular enlargement and normal cerebrospinal fluid pressure by lumbar puncture^[1]。 In recent years, more and more neuroscientists at home and abroad have paid attention to and studied this disease. Many hospitals in China are also carrying out surgical treatment of iNPH. But there are still many problems to be faced together.

Severe neurosurgical patients (such as severe craniocerebral trauma, brain tumor, severe cerebrovascular disease, intracranial inflammatory lesions, etc.) often have metabolic disorders such as consciousness and swallowing dysfunction, acute stress reaction, hormone secretion and visceral function imbalance, resulting in malnutrition and immune function decline, which in turn increases the risk of infection, organ dysfunction and death, and affects clinical outcome. Severe neurosurgical patients, in addition to the metabolic characteristics of other severe patients, also have the following particularities^[1,2]: (1) Most of them are accompanied by different degrees of consciousness disorder, dysphagia and motor dysfunction: (2) High metabolism and higher nutritional demand; (3) Spontaneous respiratory disorder will prolong the time of mechanical ventilation; (4) There are mostly endocrine dysfunction; (5) some stress gastrointestinal dysfunction; (6) there are special nutrient requirements associated with nerve damage repair; (7) Most of them are complicated with basic diseases such as diabetes and hyperlipidemia. All of the above can lead to a high risk of malnutrition and an adverse clinical outcome.

Airway management is an important part of basic treatment for all critically ill patients, and improper airway management will directly threaten patients' lives. Severe neurosurgical patients often have airway obstruction due to central and non-central reasons, resulting in hypoxia, aggravating the condition and even life-threatening. Based on the understanding of the importance of airway management in critically ill patients, in order to improve the level of airway management in critically ill patients and ensure patient safety, the following expert consensus has been reached on the basis of reviewing a large number of literatures.

Normal pressure hydrocephalus (NPH) refers to the triad of gait disturbance, cognitive impairment and urinary incontinence as clinical manifestations. The patient's condition shows progressive development to varying degrees, with ventricular enlargement on imaging examination and cerebrospinal fluid pressure measured at 70-200 mmH₂O (1 mmH₂O =0.009 8 kPa) A group of clinical syndromes of.

A 38-year-old male came to the Department of Endocrinology of Peking Union Medical College Hospital in February 2014 due to "loss of appetite, weight loss and darkening of skin for more than half a year". The patient was diagnosed with AIDS in August 2013 and received antiviral therapy against human immunodeficiency virus (HIV), oral zidovudine 100 mg/time, twice/day; Critica (each tablet containing lopinavir 200 mg and ritonavir 50 mg) 2 tablets/time, 2 times/day; Lamivudine 100 mg/dose, 1 dose/d. Due to the suspected diagnosis of pulmonary tuberculosis, oral anti-tuberculosis drugs were also taken for 2 to 3 months (details unknown). After that, appetite loss, nausea, fatigue, weight loss and skin pigmentation gradually appeared, which lasted for half a year without relief, and came to our hospital for treatment in February 2014. Physical examination: blood pressure 100/70 mmHg (1 mmHg =0.133 kPa), dark skin all over the body, obvious pigmentation of the lips, no enlargement of the thyroid gland, clear breathing sounds in both lungs, heart rate 70 beats/min, and uniform rhythm. Plasma corticotropic hormone (ACTH)>275 pmol/L (reference value: 0-10 pmol/L) at 8:00 a.m. and serum cortisol 20.97 nmol/L (reference value: 110-607 nmol/L) at 8:00 a.m.; Serum potassium was 4.1 mmol/L, sodium 127 mmol/L, chlorine 94 mmol/L, and creatinine 113 μ mol/L (reference value: 59-104 μ mol/L). Thyroid function was normal, and CT of both adrenals showed that "the medial branch of the left adrenal gland was slender, and the right adrenal gland was almost invisible" (Figure 1)。 Diagnosis: AIDS; Primary adrenocortical insufficiency (AI).

A 29-year-old female was admitted to the First Affiliated Hospital of the People's Liberation Army General Hospital on August 8, 2015 due to intermittent rash for 1 month and fever with neck mass for 2 weeks. The patient developed wheal-like rash on both upper limbs without trigger 1 month ago, mild pruritus, which resolved after self-administration of anti-allergic drugs. A similar rash reappeared on both upper limbs and face 2 weeks ago. Then fever and fatigue occurred after working outdoors in the hot sun. The fever was mainly low fever, with the highest body temperature of 38.0℃. The peak body temperature was obvious in the afternoon and night, and it could be reduced to normal the next day after symptomatic treatment. Fever is accompanied by obvious sore throat and oral ulcer, pulsatile headache, intermittent attacks, obvious in the temporal and occipital regions, aggravated when changing body position, no nausea, vomiting, and normal vision. At the beginning of the fever, a mass was found in the left neck, which was progressively enlarged and tender. There was no nasal congestion, runny nose, cough or expectoration during the course of the disease; No abdominal pain, diarrhea, frequent urination, urgency and painful urination, no joint and muscle pain, no weight loss, night sweats, etc. Visited a local hospital and had a peripheral blood white blood cell count of 3.2×10⁹/L, considered as an "infectious disease", given acyclovir tablets, moxifloxacin hydrochloride tablets and acetaminophen tablets and other drugs successively, the headache was relieved, and the body temperature could temporarily drop to 37℃, but it rose again the next day. Three days ago, when the patient's body temperature increased, he again experienced bilateral severe pulsatile pain in the temporal and occipital regions, aggravated symptoms of postural change, accompanied by nausea, and vomited the stomach contents once, which was non-jetting. Physical examination at admission: temperature 36.6 ℃, pulse 72 beats/min, breathing 18 beats/min, blood pressure 92/62 mmHg (1 mmHg =0.133 kPa). Several swollen lymph nodes can be palpable in the left neck, with obvious tenderness, the larger one is about 2.5 cm ×1.0 cm, with medium texture, smooth surface, good mobility, no adhesion to the subcutaneous area, and no swollen lymph nodes are palpable in the remaining area. A 0.4 cm ×0.3 cm ulcer was seen in the right buccal mucosa of the oral cavity, with tenderness. The pharynx is slightly red and the tonsils are not large. No abnormal signs of heart, lung, abdomen and nervous system were observed.

A 23-year-old female was admitted to our hospital on May 12, 2007 due to "recurrence of acinar cell carcinoma of the right parotid gland 1 month after surgery". In April 2007, he underwent parotid mass resection in an external hospital due to right parotid mass. Postoperative pathology showed acinar cell carcinoma, and a mass under the right ear was found again 1 month after operation. Admission physical examination: body temperature 36.5 ℃, heart rate 90 beats/min, breathing 22 beats/min, a mass of 1.2 cm ×1.0 cm ×0.6 cm in size was seen at the lower pole of the parotid gland, with obvious tenderness, adhesion to surrounding tissues, and poor mobility; Re-examination of parotid CT scan showed high-density nodules in the right parotid gland, with uniform density and clear boundaries (Figure 1)。 Laboratory test: white blood cells 7.9×10⁹/L, hemoglobin 116 g/L; There were no abnormalities in liver and kidney function, electrolyte, coagulation function and blood glucose; There were no obvious abnormalities in chest CT and abdominal color Doppler ultrasound. Extended parotidectomy and total parotidectomy were performed under general anesthesia on May 19, 2007. The facial nerve was preserved. Postoperative pathology showed that acinar cell carcinoma (Figure 2)。 The patient refused further treatment after surgery. At the reexamination in February 2008, he developed mild limitation of mouth opening, and complained of occasional symptoms of headache and nausea. CT scans of parotid gland and brain showed intracranial metastases, involving the medial pterygopalatine muscle and pterygopalatine fossa (Figure 3，Figure 4)。

Severe infection is one of the main diseases in the Department of Critical Care Medicine (ICU). 51% of ICU patients have infection, and the incidence increases with the length of admission^[1]。 At least 750,000 patients in the United States develop severe infections and septic shock each year, with a trend of increasing year by year^[2]。 In recent years, immune dysfunction in severely infected patients has received extensive attention. Among them, the "cytokine storm" of severe infection and its secondary immunosuppression are considered to be the main pathophysiological processes. Immunosuppression can reduce the body's reactivity and clearance ability to antigen, and it is easy to occur secondary infection. Many studies have intervened for this process, but there have been few positive results. This is not only related to individual differences, but also to the timing of the intervention. Therefore, dynamic monitoring of the patient's immune function and individualized adjustment of the treatment plan according to the monitoring results may further reduce the mortality rate of patients with severe infection and septic shock.