目的 探讨多模态神经监测（multimodality neuromonitoring，MMM）指导下的阶梯式镇痛镇静护理策略对大面积脑梗死去骨瓣减压术（decompressive craniectomy，DC）后患者颅内压（intracranial pressure，ICP）变化及预后的影响。 方法 采用便利抽样法选取2022年1月—2024年12月在长春市某三级甲等医院神经内科ICU收治的84例大面积脑梗死DC患者，使用区组随机化（区组长度4）分为试验组和对照组。试验组以MMM为导向，采用阶梯式镇痛镇静护理策略，对照组给予常规镇痛镇静，比较两组术后7 d平均ICP、72 h内ICP达标时间占比、机械通气时间、ICU住院时间、术后72 h和出院时日常生活活动能力评分（Barthel指数评分）、术后90 d改良Rankin量表（Modified Rankin Scale，mRS）评分。 结果 试验组在术后7 d平均ICP为（12.76±2.45） mmHg（1 mmHg=0.133 kPa），低于对照组的（14.91±4.56） mmHg，P=0.002；72 h内ICP达标率为52.4%，高于对照组的33.3%，P=0.038；绝对风险差提升19.1%，相当于每治疗5.2例患者可多获得1例达标。试验组住院时间为（21.93±2.51） d，短于对照组的（23.60±3.91） d，P=0.006。两组机械通气时间、术后72 h的Barthel指数评分差异无统计学意义（P=0.104、P=0.714），但试验组出院时Barthel指数评分为（35.83±21.04）分，高于对照组的（24.76±24.69）分，P=0.022；试验组术后90 d mRS≤3分（轻、中度残疾）比例为30.9%，高于对照组（14.8%），mRS≥4分（中重度残疾及死亡）比例为40.5%，低于对照组（52.4%），P=0.036。 结论 基于MMM的阶梯式镇痛镇静护理策略可优化ICP管理、缩短ICU住院时间、改善神经功能预后，为大面积脑梗死DC患者的护理提供了依据。

Objective To explore the impact of a stepwise analgesia and sedation nursing strategy guided by multimodality neuromonitoring（MMM） on intracranial pressure（ICP） changes and prognosis after decompressive craniectomy in patients with large-area cerebral infarction. Methods A total of 84 patients with large-area cerebral infarction who underwent decompressive craniectomy and were admitted to the neurology ICU of a tertiary hospital in Changchun from January 2022 to December 2024 were selected by convenience sampling and randomly divided into a control group and an experimental group using block randomization. The control group received conventional analgesia and sedation，while the experimental group adopted a stepwise analgesia and sedation nursing strategy guided by MMM. The average ICP within 7 days after surgery，the proportion of time within 72 hours that ICP reached the target，mechanical ventilation time，ICU stay，Barthel lndex at 72 hours after surgery and at discharge，and Modified Rankin Scale（mRS） score at 90 days were compared between the two groups. Results The average ICP in the experimental group was lower at 7 days post-operation（12.76±2.45 vs 14.91±4.56 mmHg，P=0.002），and the rate of reaching the ICP target within 72 hours was higher than the control group（52.4% vs 33.3%，P=0.038），with an absolute risk difference increase of 19.1%，which mean that for every 5.2 patients treated，one more patient could reach the target. The hospital stay in the experimental group was shorter than that of control group（21.93±2.51 vs 23.60±3.91 days，P=0.006）. There was no statistically significant difference in mechanical ventilation time and Barthel Index score at 72 hours post-operation（P=0.104，P=0.714），but the Barthel Index score at discharge was higher in the experimental group（35.83±21.04 vs 24.76±24.69，P=0.022）. The proportion of patients with mRS≤3（mild to moderate disability） at 90 days was higher in the experimental group（30.9% vs 14.8%），and the propor-tion of patients with mRS≥4（moderate to severe disability and death） was lower（40.5% vs 52.4%，P=0.036）. Conclusion The stepped analgesia and sedation protocol based on MMM can optimize ICP management，shorten ICU stay，and improve neurological prognosis，which provide a basis for the care of patients undergoing decompressive craniectomy for large-area cerebral infarction.