Introduction. Stroke has a high prevalence and mortality rate. Examining the impact of patient treatment on disease outcomes is particularly important for decision making in clinical practice. Obj'ectives. To analyze the treatment of patients with severe stroke requiring respiratory support, and identify predictors of death. Materials and methods. A multicenter observational clinical study “REspiratory Therapy for Acute Stroke” (RETAS) was conducted under the aegis of the “Federation of Anaesthesiologists and Reanimatologists” (FAR). The study involved 14 clinical centers and included 1289 stroke patients with respiratory support. Results. We found that initial hypoxemia in the 28-day period was associated with high mortality (in patients with 20 or more NIH scores) (p = 0.004). Risk factors for lethal outcome: hyperventilation used to relieve intracranial hypertension (in patients with 20 or more NIH scores) (p = 0.0336); volume-controlled ventilation (VC) versus pressure-controlled ventilation (PC) (in patients with 20 or more NIH scores) (p < 0.001); use of clinical methods for monitoring ICP in comparison with instrumental ones (p < 0.001). We found that the use of standard respiratory status monitoring scales (CPIS, LIS, etc.) was associated with a decrease in mortality (p < 0.001). Conclusions. We identified risk factors that increase mortality in patients with acute stroke with respiratory support: initial hypoxemia, lack of instrumental monitoring of ICP and monitoring of respiratory status according to standard scales, the use of hyperventilation, as well as volume-controlled ventilation.
Objective: to determine the prognostic value of the indicators of fluid and electrolyte balance in the acutest period of severe ischemic stroke (IS). Patients and methods. A total of 150 patients with severe IS of various locations and pathogenetic subtypes were examined. The impact of plasma osmolarity or sodium levels on the course and prognosis of IS was studied on day 1 of the disease. Results and discussion. It has been established that in patients with severe IS, the most common type of fluid and electrolyte imbalance is hyperosmolar hypernatremic syndrome that develops at the onset of severe IS, serves as a factor for poor outcome, and is accompanied by high mortality. The rate of fatal outcomes in hypoosmolar syndromes is higher than that in normal plasma osmolarity, but significantly lower than that in hyperosmolar syndromes. Cerebral salt wasting (CSW) is associated with a higher mortality rate than syndrome of inappropriate antidiuretic hormone secretion (SIADH), which confirms a worse prognostic value in hypovolemia than in normo- and hypervolemia. The development of diabetes insipidus at the onset of IS reflects the degree of brainstem structural destruction and, accordingly, is associated with the highest rate of fatal outcomes. The cardioembolic pathogenetic subtype of IS is characterized by a more severe course and a higher probable mortality rate in both hypoosmolar and normosmolar conditions.Conclusion. Impaired fluid and electrolyte homeostasis is of significant prognostic value for the outcome of IS. In this case, the leading role is played by the hyperosmolar hypernatremic syndrome, in which the probability of a fatal outcome is highest and there is a need for continuous patient health monitoring and high-speed decision-making aimed to correct this condition. Therapeutic policy for diabetes insipidus depends on the duration of IS. The risk for fatal outcome in the cardioembolic pathogenetic subtype of IS is higher than that in atherothrombotic stroke, at any plasma osmolarity and sodium levels.
It has been shown that hyponatremia is not an independent predictor of outcome of IS, but requires a diagnostic search of the causes of this condition with subsequent correction of sodium levels. For hypernatremia therapeutic tactics varies depending on the timing of the beginning of IS. A conservative strategy for the correction of hypernatremia to plasma sodium blood levels of 150 mmol/L on the first day of IS and to 155 mg/dL since the third day can be used. If these values are exceeded, the most rapid correction of hypernatremia is necessary.
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