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Abstract：
Acute treatment of cerebral edema and elevated intracranial pressure is a common issue in patients with neurological injury. Practical recommendations regarding selection and monitoring of therapies for initial management of cerebral edema for optimal efficacy and safety are generally lacking. This guideline evaluates the role of hyperosmolar agents (mannitol, HTS), corticosteroids, and selected non-pharmacologic therapies in the acute treatment of cerebral edema. Clinicians must be able to select appropriate therapies for initial cerebral edema management based on available evidence while balancing efficacy and safety.
The Neurocritical Care Society recruited experts in neurocritical care, nursing, and pharmacy to create a panel in 2017. The group generated 16 clinical questions related to initial management of cerebral edema in various neurological insults using the PICO format. A research librarian executed a comprehensive literature search through July 2018. The panel screened the identified articles for inclusion related to each specific PICO question and abstracted necessary information for pertinent publications. The panel used GRADE methodology to categorize the quality of evidence as high, moderate, low, or very low based on their confidence that the findings of each publication approximate the true effect of the therapy.
The panel generated recommendations regarding initial management of cerebral edema in neurocritical care patients with subarachnoid hemorrhage, traumatic brain injury, acute ischemic stroke, intracerebral hemorrhage, bacterial meningitis, and hepatic encephalopathy.
The available evidence suggests hyperosmolar therapy may be helpful in reducing ICP elevations or cerebral edema in patients with SAH, TBI, AIS, ICH, and HE, although neurological outcomes do not appear to be affected. Corticosteroids appear to be helpful in reducing cerebral edema in patients with bacterial meningitis, but not ICH. Differences in therapeutic response and safety may exist between HTS and mannitol. The use of these agents in these critical clinical situations merits close monitoring for adverse effects. There is a dire need for high-quality research to better inform clinicians of the best options for individualized care of patients with cerebral edema.
The Neurocritical Care Society recruited experts in neurocritical care, nursing, and pharmacy to create a panel in 2017. The group generated 16 clinical questions related to initial management of cerebral edema in various neurological insults using the PICO format. A research librarian executed a comprehensive literature search through July 2018. The panel screened the identified articles for inclusion related to each specific PICO question and abstracted necessary information for pertinent publications. The panel used GRADE methodology to categorize the quality of evidence as high, moderate, low, or very low based on their confidence that the findings of each publication approximate the true effect of the therapy.
The panel generated recommendations regarding initial management of cerebral edema in neurocritical care patients with subarachnoid hemorrhage, traumatic brain injury, acute ischemic stroke, intracerebral hemorrhage, bacterial meningitis, and hepatic encephalopathy.
The available evidence suggests hyperosmolar therapy may be helpful in reducing ICP elevations or cerebral edema in patients with SAH, TBI, AIS, ICH, and HE, although neurological outcomes do not appear to be affected. Corticosteroids appear to be helpful in reducing cerebral edema in patients with bacterial meningitis, but not ICH. Differences in therapeutic response and safety may exist between HTS and mannitol. The use of these agents in these critical clinical situations merits close monitoring for adverse effects. There is a dire need for high-quality research to better inform clinicians of the best options for individualized care of patients with cerebral edema.
摘要：
脑水肿和颅内压升高的急性治疗是神经损伤患者的常见问题。通常缺乏有关选择和监测用于脑水肿的初始治疗以获得最佳疗效和安全性的疗法的实用建议。本指南评估了高渗剂（甘露醇，HTS),皮质类固醇,和选择的非药物治疗急性脑水肿。临床医生必须能够根据现有证据选择适当的治疗方法进行初始脑水肿治疗，同时平衡疗效和安全性。
神经危重症护理协会招募了神经危重症护理专家，护理,和药房在2017年创建一个小组。该小组使用PICO格式生成了16个与各种神经系统损伤中脑水肿的初始管理有关的临床问题。一名研究馆员在2018年7月之前进行了全面的文献检索。小组筛选了与每个特定的PICO问题相关的已识别文章，并为相关出版物提取了必要的信息。小组使用分级方法将证据质量分类为高，中度,低,或非常低，基于他们的信心，每个出版物的发现接近治疗的真正效果。
小组提出了有关蛛网膜下腔出血的神经重症监护患者脑水肿的初始处理的建议，创伤性脑损伤,急性缺血性卒中,脑出血，细菌性脑膜炎,和肝性脑病.
现有证据表明，高渗性治疗可能有助于降低SAH患者的ICP升高或脑水肿，TBI,AIS,ICH,而他,虽然神经系统的结果似乎没有受到影响。皮质类固醇似乎有助于减少细菌性脑膜炎患者的脑水肿，但不是ICH。HTS和甘露醇之间可能存在治疗反应和安全性的差异。在这些关键的临床情况下使用这些药物值得密切监测不良反应。迫切需要高质量的研究，以更好地告知临床医生对脑水肿患者进行个性化护理的最佳选择。
神经危重症护理协会招募了神经危重症护理专家，护理,和药房在2017年创建一个小组。该小组使用PICO格式生成了16个与各种神经系统损伤中脑水肿的初始管理有关的临床问题。一名研究馆员在2018年7月之前进行了全面的文献检索。小组筛选了与每个特定的PICO问题相关的已识别文章，并为相关出版物提取了必要的信息。小组使用分级方法将证据质量分类为高，中度,低,或非常低，基于他们的信心，每个出版物的发现接近治疗的真正效果。
小组提出了有关蛛网膜下腔出血的神经重症监护患者脑水肿的初始处理的建议，创伤性脑损伤,急性缺血性卒中,脑出血，细菌性脑膜炎,和肝性脑病.
现有证据表明，高渗性治疗可能有助于降低SAH患者的ICP升高或脑水肿，TBI,AIS,ICH,而他,虽然神经系统的结果似乎没有受到影响。皮质类固醇似乎有助于减少细菌性脑膜炎患者的脑水肿，但不是ICH。HTS和甘露醇之间可能存在治疗反应和安全性的差异。在这些关键的临床情况下使用这些药物值得密切监测不良反应。迫切需要高质量的研究，以更好地告知临床医生对脑水肿患者进行个性化护理的最佳选择。
