【作者】 刘伟；

【导师】 孙明莉；

【作者基本信息】 吉林大学 ， 临床医学硕士（专业学位）， 2025， 硕士

【摘要】 背景:昏迷预后不良可引发多系统并发症、神经损伤、身心创伤及家庭经济危机,加剧社会资源消耗,治疗与功能恢复是重症医学领域的核心挑战,中枢神经系统虽具备一定可塑性,但传统促醒手段(如药物、感觉刺激)疗效有限、有侵入性操作风险高等问题。高压氧治疗通过增强脑氧代谢、减轻继发性损伤;脑电仿生电刺激通过改善脑血流及神经可塑性进行治疗。二者联合应用可能形成协同效应。然而,现有研究对联合治疗的干预时机、疗程与疗效的关系缺乏系统性探讨,尤其对重度昏迷患者的循证依据不足。两者联合治疗对昏迷患者的疗效、预后具有重要意义。目的:本研究旨在评估不同治疗时机及疗程下高压氧联合脑电仿生电刺激治疗对重度昏迷患者的促醒效果,探讨影响预后的危险因素,为建立最适治疗方案提供科学依据。方法:本研究为回顾性研究,纳入2022年10月至2024年10月吉林大学第一医院高压氧科重症监护病房的143例重度昏迷患者(GCS≤8分)。根据发病到启动治疗时间分为四组:A组(0-10天开始治疗)、B组(11-20天开始治疗)、C组(21-30天开始治疗)、D组(≥31天后开始治疗);按照疗程分为三组:1个疗程治疗组、2个疗程治疗组、3个疗程治疗组。所有患者接受高压氧联合脑电仿生电刺激治疗,同步进行常规药物治疗(神经保护、抗炎等)。主要疗效指标为格拉斯哥昏迷量表评分(glasgow coma scale,GCS)与振幅整合脑电图评分(amplitude egrationel electroencephalo gram,a EEG)的变化,次要指标为出院后28天格拉斯哥预后量表(glasgow outcome scale-extended,GOS)评分。采用重复测量方差分析评估组内与组间差异,Logistic回归筛选预后危险因素,ROC曲线分析联合预测效能。结果:1、治疗时机与疗效:早期干预组(≤30天开始干预)治疗后GCS评分显著高于延迟组(≥31天后开始干预),a EEG评分改善显著。延迟治疗(≥31天)是预后不良的独立危险因素,其患者预后不良比例达85.7%,显著高于早期组预后不良比例64.4%。2、疗程累积效应:3疗程组治疗的患者GCS评分较治疗前提升41.6%,a EEG评分在3个疗程后提升8.5%,改善幅度显著高于1疗程组与2疗程组,而2疗程组改善幅度又优于1疗程组。3、预后预测:治疗前GCS评分与发病到开始治疗时间联合预测预后的ROC曲线下面积(Area Under Curve,AUC)面积为0.733,优于单一指标(治疗前GCS评分AUC=0.660,距发病到启动治疗时间AUC=0.609)。结论:1、高压氧联合脑电仿生电刺激治疗昏迷患者在3个疗程内,随着治疗疗程的增加,疗效越来越显著。2、在30天内启动高压氧联合脑电仿生电刺激治疗疗效最佳,并可改善患者预后。3、治疗前GCS评分、发病到开始治疗时间,可预测昏迷患者预后,二者联合预测效果更好。4、高压氧联合脑电仿生电刺激治疗昏迷患者的最适方案:在发病30天内启动治疗并完成至少3个疗程效果最佳。更多还原

【Abstract】 Background:Poor prognosis in comatose patients can lead to multisystem complications,neurological damage,psychological trauma,and family financial crises,exacerbating the consumption of social resources.Treatment and functional recovery represent core challenges in critical care medicine.Although the central nervous system possesses a certain degree of plasticity,traditional awakening methods(such as pharmacological interventions and sensory stimulation)have limited efficacy and carry risks associated with invasive procedures.Hyperbaric oxygen therapy(HBOT)enhances cerebral oxygen metabolism and mitigates secondary injury,while electroencephalographic bioelectric stimulation improves cerebral blood flow and neural plasticity.The combined application of these two modalities may yield synergistic effects.However,existing research lacks systematic exploration of the relationship between the timing,duration,and efficacy of combined therapy,particularly in terms of evidence-based support for patients with severe coma.The combined treatment of HBOT and electroencephalographic bioelectric stimulation holds significant implications for the efficacy and prognosis of comatose patients.Objective:This study aims to evaluate the awakening efficacy of hyperbaric oxygen therapy(HBOT)combined with electroencephalographic bioelectric stimulation in patients with severe coma under different treatment timings and durations.It also seeks to explore the risk factors influencing prognosis,thereby providing a scientific basis for establishing the optimal treatment protocol.Methods:This study is a retrospective analysis involving 143 patients with severe coma(GCS≤8)admitted to the Hyperbaric Oxygen Department and Intensive Care Unit of the First Hospital of Jilin University between October 2022 and October 2024.Based on the time from onset to initiation of treatment,patients were divided into four groups:Group A(treatment initiated within 0-10 days),Group B(11-20 days),Group C(21-30 days),and Group D(≥31 days).According to the treatment duration,patients were categorized into three groups:those receiving one course of treatment,two courses,and three courses.All patients underwent combined hyperbaric oxygen therapy(HBOT)and electroencephalographic bioelectric stimulation,alongside conventional pharmacological treatments(e.g.,neuroprotection,anti-inflammatory therapy).The primary efficacy measures were changes in the Glasgow Coma Scale(GCS)score and amplitude-integrated electroencephalography(a EEG)score.The secondary outcome was the Glasgow Outcome Scale(GOS)score at 28 days post-discharge.Repeated measures analysis of variance(ANOVA)was used to assess within-group and between-group differences,logistic regression was employed to identify prognostic risk factors,and receiver operating characteristic(ROC)curve analysis was conducted to evaluate the combined predictive efficacy.Results:1.Timing of Treatment and Efficacy:The early intervention group(treatment initiated≤30 days post-onset)showed significantly higher post-treatment Glasgow Coma Scale(GCS)scores and greater improvements in amplitude-integrated electroencephalography(a EEG)scores compared to the delayed intervention group(treatment initiated≥31 days post-onset).Delayed treatment(≥31 days)was identified as an independent risk factor for poor prognosis,with 85.7%of patients in this group experiencing unfavorable outcomes,significantly higher than the 64.4%observed in the early intervention group.2.Cumulative Effect of Treatment Courses:Patients in the three-course treatment group demonstrated a 41.6%improvement in GCS scores and an 8.5% increase in a EEG scores after three courses of treatment,significantly greater than the improvements observed in the one-course and two-course groups.Furthermore,the two-course group showed better outcomes than the one-course group.3.Prognostic Prediction:The combined predictive efficacy of pre-treatment GCS scores and the time from onset to treatment initiation,as evaluated by the area under the receiver operating characteristic(ROC)curve(AUC),was 0.733.This was superior to the predictive performance of either indicator alone(AUC for pre-treatment GCS scores=0.660;AUC for time from onset to treatment initiation=0.609).Conclusions:1.The efficacy of hyperbaric oxygen therapy(HBOT)combined with electroencephalographic bioelectric stimulation in the treatment of comatose patients increases progressively with the number of treatment courses,up to three courses.2.Initiating HBOT combined with electroencephalographic bioelectric stimulation within 30 days post-onset yields the best therapeutic outcomes and significantly improves patient prognosis.3.Pre-treatment Glasgow Coma Scale(GCS)scores and the time from onset to treatment initiation can predict the prognosis of comatose patients,with the combination of these two factors providing superior predictive accuracy.4.The optimal treatment protocol for comatose patients involves initiating HBOT combined with electroencephalographic bioelectric stimulation within 30 days post-onset and completing at least three treatment courses for the best outcomes.更多还原