Ôåäåðàëüíûé íàó÷íî-êëèíè÷åñêèé öåíòð ñïåöèàëèçèðîâàííûõ âèäîâ ìåäèöèíñêîé ïîìîùè è ìåäèöèíñêèõ òåõíîëîãèé ÔÌÁÀ Ðîññèè, ÌîñêâàПредставлен клинический случай пациента с жалобами на повторяющуюся внезапную одышку в ночное время. В статье приводится алгоритм диагностических и лечебных мероприятий. Продемонстрирована эффективность лечения дыхания Чейн Стокса методом адаптивной сервовентиляции.Ключевые слова: дыхание Чейн Стокса, центральное апноэ сна, адаптивная сервовентиляция, ХСН, ишемическая болезнь сердца CHEYNE STOKES RESPIRATION DURING SLEEP AS THE MASK OF EXACERBATION OF IHD. DIAGNOSIS AND TREATMENT BY ADAPTIVE SERVOVENTILATIONThe case report of the patient with complaints of recurrent sudden breathlessness at night is pre sented. The approach of the diagnosis and therapy is introduced. The effectiveness of the treatment of Cheyne Stokes respiration by adaptive servoventilation has been shown.Key words: Cheyne stokes respiration, central sleep apnea, adaptive servoventilation, CHF, ischemic heart disease Введение Принятие решения о проведении диагнос тических и лечебных мероприятий у пациента в пожилом возрасте всегда вызывает трудности вследствие высокой сочетаемости различных патологий, общим соматическим статусом па циента, неспецифическим характером многих симптомов. Ситуация зачастую усугубляется тем, что врач рассматривает многие симптомы как «возрастные», не придавая им особого зна чения, или неправильно оценивает некоторые клинические ситуации из за недостаточности знаний.Жалобы, возникающие у пациента в ночное время, в основном интерпретируются врачами в свете традиционных представлений о тече нии той или иной патологии. Однако за пос леднее время знания в области сомнологии все активнее внедряются в сознание врачей, рас ширяя их представления о патогенезе различ ных нозологий в рамках их специальности. Это помогает принимать правильные решения при проведении лечебно диагностических меро приятий.Роль нарушений дыхания во время сна (НДС) в течении многих заболеваний в насто ящее время сильно недооценивается, несмотря на то, что они имеют широкую распространен ность и, зачастую, имеют существенное влия ние на прогноз. Распространенность НДС, как обструктивного апноэ сна (ОАС), так и цент рального апноэ сна (ЦСА) у пациентов с диас толической и систолической сердечной недос таточностью достигает 70% и 76%, соответ ственно.Также показано, что ОАС является незави симым фактором риска развития сердечной не достаточности (СН). С увеличением же степе ни тяжести СН увеличивается распространен ность дыхания Чейн Стокса.
An 84‐year‐old man reported several episodes of palpitations over the previous 6 months. He had a history of a prior non‐Q‐wave myocardial infarction (MI) and had received a dual‐chamber pacemaker for control of subsequent sick sinus syndrome. Pacemaker data revealed 8000 premature ventricular beats (PVBs) daily and nonsustained ventricular tachycardia (NSVT). The patient agreed to add omega‐3 fatty acid ethyl ester supplementation (1 g/day) to his treatment regimen. Pacemaker analyses 3 months later demonstrated no NSVT and only 215 PVBs daily. In more than 1 year of follow‐up, the patient has remained well and has had no further ventricular arrhythmias. We conclude that omega‐3 fatty acid ethyl ester supplementation may be beneficial in post‐MI patients with pacemakers who develop ventricular arrhythmias.
In the article the questions of medical rehabilitation at a hospital stage, terminology, indications and contra-indications, staging actions are considered. The general algorithm of rehabilitation in clinic is illustrated.
Background: Most clinical trials of sepsis treatment modalities fail at their primary objective of establishing superiority over placebo when added to background standard of care. While there is no definitive explanation for the high failure rate, it might be stated that our attempts to insert a new therapeutic agent into standard of care encounters severe problems with definition of exactly what stage is ongoing, and what are the criteria for progression or resolution from that time point onwards. Clearly there is need for a means of defining steps in the septic process that would apply to individuals, and to better define the course of sepsis in each patient after they are enrolled in a trial. Methods: For core model development, 30 septic patients were studied for time-related progression in relation to biomarkers, employing a Load Model in a neural net algorithm in MatLab. Causative bacterial infections were linked to primary infection sites. In order to minimize overparameterization, the model was allowed to estimate outputs using the best three input parameters. Bacterial load was tracked from origin using clinical and microbiologic data to provide an estimate at the start of sepsis. The bacterial load as well as clinical and laboratory parameters were model inputs with the output parameter being organ failures and/ or mortality. Results: At onset of sepsis, human bacterial load estimates ranged from between 10 8 and 10 11 CFU, which is consistent with inocula in animal models of sepsis. Sepsis proceeds to organ failures and mortality in a series of steps that are initially linked to bacterial load and inflammatory response, followed by coagulopathy, ischemia, oxygen deprivation in organs and tissues, and culminating in organ failures. The later stages of sepsis are all driven by metabolic parameters, and there seems to be little benefit to blocking inflammation at later stages. Substrate and oxygen deficiencies must be addressed first. Conclusion: Neural net progression models based on biomarkers and physiological markers are able to describe the evolution of sepsis to septic shock, organ failures, and provide some evidence that mortality may be a consequence of the stages of sepsis. Overall, these models appear useful to the task of sorting out organ failure endpoints and mechanisms in individual patients with sepsis progression across sepsis to septic shock. P2Extracellular matrix turnover, angiogenesis and endothelial function in acute lung injury: relationship to pulmonary dysfunction and outcome S Sayed * , N Idriss, H Sayyed Faculty of Medicine, Assuit University, Assuit, Egypt E-mail: 1@bmc.com Critical Care 2012, 16(Suppl 3):P2 Background: Acute lung injury (ALI) is a syndrome with a diagnostic criteria based on hypoxemia and a classical radiological appearance, with acute respiratory distress syndrome at the severe end of the disease. Facts recommended the occurrence of rupture of the basement membranes and interstitial matrix remodeling during ALI. Matrix metalloproteinases (MMPs) participate in...
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