Complicated injury of the cervical spine is accompanied by a violation of blood circulation. This condition requires maintaining adequate perfusion pressure in order to prevent secondary damage to the spinal cord and multiple organ failure. The authors did not evaluate the effect of the urgency of spinal decompression on the severity and duration of systemic hypotension in this category of patients previously, as well as the presence of a connection between systemic hypotension and the outcome of the injury. Objective. To determine the effect of early decompression of the spinal cord on the duration and characteristics of adrenomimetics use in the bundle of intensive care measures in the acute period of complicated injury to the cervical spine. Material and Methods. A retrospective analysis of the treatment outcomes in 27 patients with complicated ASIA A cervical spine injury was conducted. Two groups were identified: Group I included 13 patients operated on within the first eight hours from the moment of injury; and Group II - 14 patients operated on within the period from eight to 72 hours. The analyzed parameters were: age, hemodynamic parameters, severity of organ dysfunction, duration of hemodynamic support, neurological status, time spent in intensive care unit, and length of hospital stay. Central hemodynamic parameters were registered using the impedance cardiography technique. To assess organ dysfunction, the SOFA score was used. Results. Complicated injury of the cervical spine is accompanied by a decrease in systemic vascular resistance and cardiac index. Hemodynamic parameters and duration of hemodynamic support in groups were not statistically different. Statistically significant differences in the SOFA score between groups were obtained on the third and 10<sup>th</sup> day of the follow-up. Neurogenic shock was recorded in 70.4 % of cases. Positive dynamics of neurological deficit was observed only in two (15.4 %) patients of Group I. Conclusion. The urgency of spinal decompression does not affect the duration of hemodynamic support, but reduces the severity of organ dysfunction and increases the risk of neurological disorder regression.
Purpose: to study the efficacy and safety of levobupivacaine as the main component of infiltration anesthesia after knee arthroplasty. Patients and methods. Open randomized study included 284 patients (20 - 81 years) after total knee arthroplasty. Patients were divided into 2 groups, 142 patients in each group, depending on the anesthetic used (levobupivacaine or ropivacaine). The severity of pain syndrome within the first 48 hours after the operation by VAS, the need for the use of narcotic analgesics, presence of side effects was evaluated. Results. The mean time of acute pain occurrence was 255±83 min in ropivacaine group and 238±87 min in levobupiavacaine group (p=108). In 4 hours after surgical intervention 30 and 43% of patients from ropivacaine and levobupiavacainegroups required narcotic analgetics, respectively. Neither serious side effects nor complications directly related to infiltration anesthesia were recorded. Conclusion. Infiltration anesthesia with both levobupivacaine and ropivacaine is simple, safe and effective method for pain arrest after surgical interventuions of the knee joint.
Introduction. Cerebral salt-wasting syndrome and diabetes insipidus are serious complications of craniocerebral injury and spinal cord injuries. Each of the syndromes in some cases causes a life-threatening condition. This determines the importance of timely diagnosis and emergency intensive care measures. In the literature, there are only single descriptions of combinations of these symptoms in one patient.Clinical case report. A victim with craniocerebral injury and cervical spinal cord injury underwent, according to emergency indications, emptying and drainage of a tense subgaleal hematoma of the fronto-parieto-occipital region, spinal cord decompression, and stabilization of the spine. Postoperative follow-up and intensive care: on the 1st day the rate of diuresis was 2.5 mL/kg/h, blood glucose level – 14.18 mmol/L, and sodium level – 148–158 mmol/L. The patient was diagnosed with diabetes insipidus, and a therapy with desmopressin at a dose of 0.6 mg/day, restoration of fluid volume with hypotonic solutions, and correction of hyperglycemia was started. On the 4th day blood sodium level was 133 mmol/L, and blood glucose level – 8.67 mmol/L. On the 5th day, hyponatremia of 126–115 mmol/L was noted with a diuresis rate of 4 mL/kg/h and glicemya level of 7.86 mmol/L. The development of cerebral salt-wasting syndrome was diagnosed, and the infusion of hydrocortisone 400 mg/day and of 10% NaCl solution was started. On the 6th day glucose level returned to normal. On the 9th day of follow-up, an increase in the volume of diuresis was again observed, and desmopressin therapy was continued. Stable normalization of water-electrolyte balance, urine output, and glucose levels were observed on the 16th day of follow-up.Conclusion. Monitoring of fluid balance and electrolyte composition of blood serum, and adequate replacement therapy were the conditions for successful treatment of a rare combination of diabetes insipidus and cerebral salt-wasting syndrome in patients with concomitant craniocerebral and spinal cord injuries.
The purpose of the present literature review is a systematization of known evidence on the problem of postoperative delirium as a frequent complication in elderly and senile patients during extensive reconstructive
Цель исследования. Анализ динамики неврологической симптоматики и структуры осложнений при использовании метилпреднизолона, метода поддержания целевых показателей среднего артериального давления при хирургическом лечении пациентов в остром периоде позвоночно-спинномозговой травмы (ПСМТ).Материал и методы. В исследование включены 110 пациентов в остром периоде ПСМТ с компрессией сегментов спинного мозга, доставленных в клинику с января 2012 г. по март 2018 г., которым в первые 2-3 ч после поступления проведены декомпрессивностабилизирующие операции. С целью улучшения кровоснабжения поврежденных сегментов спинного мозга, а также профилактики полиорганной недостаточности главным направлением интенсивной терапии в двух выделенных группах пациентов являлось поддержание целевого артериального давления на уровне 85-90 мм рт. ст. в течение первых 7-10 дней. Группы исследования: MPD (n = 43) -пациенты, получившие в качестве нейропротектора метилпреднизолон в дозе 30 мг/кг болюсно в течение первого часа после поступления с последующей инфузией в дозе 5,4 мг/кг/ч в течение 23 ч; MAP (n = 67) -пациенты, которым метилпреднизолон не вводили. Неинвазивный мониторинг показателей центральной гемодинамики осуществляли на основе данных импедансной кардиографии. Анализировали объективный статус пациентов, данные лучевой диагностики в момент предоперационного осмотра и инструментальных исследований, а также в интервалы времени 3-14 дней и в среднесрочном периоде (до 4-6 мес.) послеоперационного периода.Результаты. В группе MPD 22 пациента имели неврологический дефицит по ASIA тип A, из которых только y 4 (18 %) отмечено увеличение степени ASIA. Пациентов с неполным повреждением в этой же группе было 18, из них 9 (50 %) имели положительную динамику. В группе MAP с неврологическим дефицитом по ASIA A было 38 пациентов, из них с улучшением -11 (29 %), с ASIA B, C или D -28, из которых у 17 (61 %) была положительная динамика неврологической симптоматики. Статистически значимых различий не обнаружено. В группе MPD в 3 раза чаще наблюдалось развитие таких осложнений, как нозокомиальная пневмония и острый эндобронхит, в 4 раза чаще -ТЭЛА и декубитальные язвы мягких тканей, в 2 раза чаще -сепсис, острый респираторный дистресс-синдром, инфекция области хирургического вмешательства. Статистически значимые различия были в частоте нозокомиальных пневмоний и острых эндобронхитов (p = 0,004 и p = 0,002 соответственно).Заключение. Поддержание среднего артериального давления на уровне 85-90 мм рт. ст. в течение первых 7-10 дней после поступления пациента в стационар позволило достичь большего числа случаев улучшения неврологического статуса, в отличие от применения метилпреднизолона. Применение метилпреднизолона при острой ПСМТ в 2,91 раза (p = 0,003) увеличивало шансы возникновения у пациентов нозокомиальных пневмоний или острых эндобронхитов.Ключевые слова: позвоночно-спинномозговая травма, метилпреднизолон, неврологическая симптоматика, поддержание артериального давления.
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