Purpose: evaluation of the clinical significance of parametric monitoring of the effectiveness of intensive care and rehabilitation based on the analysis of the functional state of the autonomous nervous system in patients with brain damage of different genesis.Materials and methods. The study included 66 patients on day 20—50 after the traumatic brain injury; anoxic damage; and stroke consequences. The isolation of clinical groups and subsequent analysis of clinical status is based on the analysis of the functional state of the autonomic nervous system based on the dynamics of the heart rate variability (HRV) parameters. Findings obtained in studies of 500 patients in the postoperative period with a 5-minute HRV were tested as normal and abnormal ANS parameters [1]. Parasympathetic hyperactivity was measured within the limits for SDNN (standard deviation of all normal-to-normal R-R intervals) > 41.5 ms; for rMSSD (root-meansquare of the successive normal sinus R-R interval difference) > 42.4 ms; for pNN50% (the percentage of interval differences in successive NN intervals greater than 50 ms (NN50) / total number of NN intervals) > 8.1%; for SI (Baevsky stress index, in normalized units) < 80 n. u.; for TP (total power of variance of all NN intervals) > 2000 ms2. Sympathetic hyperactivity was determined within the limits for following parameters: SDNN, < 4.54 ms; rMSSD, < 2.25 ms; pNN50%, < 0.109%; SI, > 900 n. u.; TP < 200 ms2. Normal HRV parameters were selected within the limits of the values for: SDNN [13.31-41.4ms]; rMSSD [5.78—42.3 ms]; pNN50% [0.110—8.1%]; SI [80—900 nu]; for TP [200—2000 ms2]. To verify the parasympathetic or sympathetic hyperactivity within these limits, 3 of 5 parameters were chosen [1].Results. Based on the dynamics of the HRV parameters before the intensive care and on days 30—60 of the intensive therapy and rehabilitation of patients with traumatic and non-traumatic brain injuries, 5 main clinical groups of patients were identified. Group 1 (n=27) consisted of patients with normal parameters of the ANS functional activity (both at the time of admission to the hospital and on the 30—60th day of the intensive therapy and rehabilitation). Group 2 (n=9) included patients with the baseline sympathetic hyperactivity of the ANS at admission to the intensive care unit and normal functional activity of the ANS on the 30—60th day of the intensive care and rehabilitation. Group 3 (n=8) included patients with baseline normal functional state of the ANS and the signs of sympathetic hyperactivity of the ANS on the 30—60th day of the intensive care and rehabilitation. Group 4 (n=15) consisted of patients with signs of sympathetic hyperactivity of the ANS both initially and on the 30—60th day of the intensive care and rehabilitation. Group 5 (n=7) included patients with signs of parasympathetic hyperactivity of the ANS (according to the parameters of HRV) both at baseline, at admission to the intensive care unit, and on the 30—60th day of the intensive care and rehabilitation.Conclusion: The normalization of HRV parameters is accompanied by patients’ recovery from the vegetative state and coma to minimal consciousness or normal consciousness; the index of disability rate decreases, the social reintegration grows, according to the DRS scale (M. Rappaport, 1982); dependence on mechanical ventilation reduces, and the muscle tone normalizes.
The aim of the study was to develop an informative method for assessing chemoreflex sensitivity and to evaluate its prognostic capacity for restoring spontaneous breathing in patients with brain damage of various etiologies. The study included 16 healthy volunteers and 38 patients on prolonged mechanical ventilation (VE) after a traumatic brain injury, anoxic brain damage, and cerebrovascular events. The external respiration variables were assessed from the initial level to the development of the first episode of desaturation with spO 2 in the range of 90-80% against the background of normobaric hypoxia as indicators reflecting the development of adaptive ventilatory response and characterizing the state of peripheral chemoreflex sensitivity (PCS). The peripheral chemoreflex sensitivity index (PCSI) was calculated using the equation: PCSI = [RR(e) : RR(i)] × [Vt(e) : Vt(i)] × [VE(e) : VE(i)] × Vt(e) × VE(e), where PCSI is the peripheral chemoreflex sensitivity index in L 2 /min; RR(i) and RR(e); Vt(i) and Vt(e); VE(i) and VE(e) are the respiratory rate, tidal volume, minute ventilation initially (i), before a functional stress test, and during a functional test of normobaric hypoxia with spO 2 in the range of 90-80% (e). With the PCSI values ≥15.6 L 2 /min, successful weaning from ventilators and recovery of spontaneous breathing are predicted. The sensitivity and specificity of PCSI were 78.57 [95% CI: 49.2-95.26] and 83.3% [95% CI: 62.6-95.26], respectively. The sensitivity and specificity of the traditional indicator of the success rate of weaning from ventilators and recovery of spontaneous breathing, Rapid Shallow Breathing Index (RSBI), in this cohort of patients was 69.23 [95% CI: 38.6-90.9] and 28.0% [95% CI: 12.03-49.3], respectively. A predictor of the patient's weaning from mechanical ventilation is the assessment of peripheral chemoreflex sensitivity, which can be measured by a simple non-invasive bedside test based on measuring the difference in external ventilation parameters before and during a functional normobaric hypoxic trial.
Цель -оценка уровня сознания у пациентов с повреждением головного мозга на основе электрофизиологического обследования функционального состояния автономной нервной системы путем регистрации параметров вариабельности ритма сердца.Материал и методы исследования. В исследование включили 77 пациентов на 20-50-е сутки после черепно-мозговой травмы, аноксического повреждения, последствий острых нарушений мозгового кровообращения. В качестве критериев нормы и патологии активности автономной нервной системы (АНС) приняли следующие параметры вариабельности ритма сердца (ВРС) для 5-минутной записи: парасимпатическую гиперактивность (гипервагусное состояние) с 95% доверительными интервалами принимали в пределах значений для SDNN (стандартное отклонение от средней длительности всех синусовых R-R интервалов), [41,5-149,3 мс]; для rMSSD (среднеквадратичное отклонение разности двух смежных отсчетов R-R кардиоинтервалов в мс), [42,0 мс]; для pNN50% (доля в % соседних синусовых R-R интервалов, которые различаются более чем на 50 мсек), [8,14-54,66%]; для SI (стресс-индекс напряжения Баевского), [0-80 нормализованных единиц н. е.]; симпатическую гиперактивность принимали в пределах значений для SDNN [4,54-13,30 мс]; для rMSSD [2,25-5,77 мс]; для pNN50% [0-0,109%]; для SI >900 н. е.; Норма параметров ВРС принималась в пределах значений для SDNN [13,31-41,4 мс]; для rMSSD [5,78-42,3 мс]; для pNN50% [0,110-8,1%]; для SI [80-900 н. е.]. Для верификации гипервагусного состояния, симпатической гиперактивности или нормы в указанных пределах принимали 3 из 4-х параметров.Результаты. У 40 (51,9%) пациентов из обследованных 77-и после повреждения головного мозга параметры функциональной активности АНС находились в зоне патологических значений. Симпатическую гиперактивность выявили у 34-х пациентов и в 6-ти случаях зафиксировали гипервагусное состояние. Патологические параметры HRV выявили у 80% пациентов при тяжелых формах нарушения сознания (вегетативное состояние, кома), а при норме сознания -обнаружили лишь у 20% пациентов.Заключение. Компьютерный анализ вариабельности сердечного ритма -необходимый элемент обследования пациентов с различными уровнями сознания после повреждения головного мозга травматического и нетравматического генеза. Частота патологических изменений со стороны функционального состояния автономной нервной системы достоверно нарастает в группах пациентов от нормального уровня сознания к состоянию минимального сознания, вегетативному состоянию и коме. Основным вариантом патологии АНС в группах пациентов находящихся в состоянии минимального сознания, вегетативном состоянии и коме является симпатическая гиперактивность. Ключевые слова: автономная нервная система; вариабельность сердечного ритма; синдром минимального сознания; вегетативное состояниеАдрес для корреспонденции: Юрий КирячковThe purpose of the study -assessment of the level of consciousness in patients with a brain damage on the basis of electrophysiological examination of the functional state of the autonomous nervous system by recording parameters of the hear...
BACKGROUND: Long-term respiratory support is a severe disabling factor and is accompanied by a long stay of patients in intensive care units. AIMS: The analysis of the predictors of the success of disconnection from mechanical ventilation on the basis of clinical and diagnostic criteria in patients with brain damage of various etiologies. METHODS: The study included 53 patients (husband ― 28, women ― 25; cf. age 53.69 2.34) who are in 2019 with the consequences of traumatic brain injury (TBI) (n = 18; 33.9%); consequences of acute cerebrovascular accident (n = 24; 45.3%); the effects of anoxic brain damage (n = 3; 5.7%); consequences of subarachnoid hemorrhage (n = 8; 15.1%). RESULTS: The statistically significant predictor of recovery of spontaneous breathing in the 1st and 2nd groups of patients were preserved chemoreflex sensitivity (IPCS), the sensitivity and specificity of IPCS was 78.57% [95 % DI 49.295.26] and 83.3 % [95 % CI 62.695.26]. The index of peripheral chemoreflex sensitivity (IPCS) was calculated using the formula: IPCS = [RRe / RRi] [Vt(e) / Vt(i)] [VE(e) / VE(i)] [Vt(e) VE(i)], where IPCS is the index of peripheral chemoreflex sensitivity in l/min; RRi and RRe; Vt(i) and Vt(e); VE(e) and VE(i) ― respiratory rate (RR, breaths/min), tidal volume (Vt), minute ventilation (VE), (l/min) of the starting point ― (i) before carrying out a functional stress test and (e) ― during a functional test of normobaric hypoxia with SpO2 in the range of 9080 %. CONCLUSIONS: The most significant clinical parameters statistically reliably hampering the process of successful recovery of spontaneous breathing in addition to chemoreflex sensitivity are the presence of severe heart failure, pneumonia, autonomic dysfunction, level of consciousness, age, higher levels of inspiratory and expiratory pressure mounted on a respirator.
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