RU2235332C1 - Method for prognosis in development of post-traumatic meningitidis in reanimation patient with severe craniocerebral trauma - Google Patents

Abstract

FIELD: medicine, traumatology, reanimation.

SUBSTANCE: method involves assay of liquor transferrin in reanimation patients on, 1, 3, 5, 7 and 9 day after severe craniocerebral trauma. High probability in development of post-traumatic meninigitidis is prognosticated in patients with severe craniocerebral trauma at transferrin value above 170 ng/ml. Method allows carrying out the detection of high risk degree in development of post-traumatic meningitides in patients with severe craniocerebral trauma before appearance of clinical and laboratory features and to take optimal therapy method opportunely based on obtained data.

EFFECT: improved, enhanced and valuable method for prognosis.

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Description

The invention relates to medicine, in particular to anesthesiology and intensive care.

Post-traumatic meningitis occurs in 5-8% of patients with severe traumatic brain injury (BMI). Infection, as a rule, develops in a day or more after an injury. Post-traumatic meningitis significantly worsens the outcome of the disease, is a powerful factor in secondary brain damage, and causes the development of intracranial hypertension due to impaired cerebrospinal fluid and cerebrospinal fluid resorption. Thus, the identification of patients with a high risk of developing post-traumatic meningitis is very important and will lead to a decrease in the frequency of such a formidable complication.

A known method for predicting the development of local infectious complications of cerebral wounds when using the tidal system by examining the condition and composition of phagocytes of the wound canal dialysate, the activity of neutrophil peroxidase. In the group with developing local infectious complications, a decrease in the activity of neutrophil peroxidase on the 1st and 2nd day of the postoperative period and a subsequent increase in this indicator on the 3rd day by 1.5 times against the background of high values of the lysosomal cationic neutrophil test. The course of the wound process is predicted by the percentage of macrophages in the dialysate on the second or third day after the operation (Gizatulin MI “Features of the reactivity of the phagocytic system in the acute period of isolated brain damage.” Abstract of dissertation for the degree of candidate of medical science. Leningrad, 1990).

The disadvantage of this method is the low prevalence of the use of the tidal system of brain wounds, the inefficiency of the method in the development of isolated meningitis.

There is a method of assessing local immunity during the first 14 days in patients with HST in a comatose or soporous state, for which it is recommended to study the concentration of transferrin, alpha-2 macroglobulin, ceruloplasmin and prealbumin in cerebrospinal fluid, which, according to the authors, are prognostic immunobiochemical criteria for death (Okutov V.M. Clinical and diagnostic value of changes in indicators in the acute period with isolated brain injuries. Abstract of dissertation the degree of candidate of Medical Science, St. Petersburg, 1997).

The disadvantage of this method is the possibility of developing a fatal outcome not only after meningitis, but also due to edema and dislocation of the brain, which is manifested by a change in the concentration of the above indicators.

The closest method to early diagnosis we propose is a method for diagnosing meningitis according to liquor examination, which, in addition to analyzing the qualitative and quantitative cellular composition, protein content and measuring cerebrospinal fluid pressure, also included the study of enzyme activity (Alt, ACT, LDH) and the level of medium molecules . The authors proved an increase in the activity of these enzymes, especially lactate dehydrogenase, 1-2 days before the appearance of pronounced pleocytosis in the cerebrospinal fluid (Gorbunov V.I. Progressional course of traumatic brain injury. Abstract of dissertation for the degree of candidate of medical sciences, Moscow, 1990).

The disadvantage of this method is the possibility of increasing the activity of enzymes in the cerebrospinal fluid (Alt, ACT, LDH) and the level of medium molecules in patients with PMI against the background of foci of crushing of brain tissue substance and the absence of meningitis.

The objective of this invention is to improve the accuracy and earlier diagnosis (at the stage before the appearance of clinical and laboratory signs) of the development of post-traumatic meningitis in patients with PMI by determining lactoferrin (LF) in the cerebrospinal fluid on days 1, 3, 5, 7, 9 after the injury. Based on this, the optimal method of therapy is selected, aimed at the correction of antibacterial therapy, immune status and antioxidant defense of the body.

The task is achieved by the fact that in the cerebrospinal fluid of patients with PMI, the LF content is determined on the 1st, 3rd, 5th, 7th, 9th day after the injury. With an increase in the LF level of more than 170 ng / ml and maintaining the indicator at a high level in the dynamics of the study, the development of post-traumatic meningitis is predicted.

The novelty of the method.

1. Monitoring the content of LF in the cerebrospinal fluid is carried out in dynamics on 1, 3, 5, 7 and 9 days after the injury.

2. The LF level is more than 170 ng / ml and maintaining at this level indicates a pronounced inflammatory process, which requires additional therapy: strengthening the antibacterial component, the use of immunomodulators, and an increase in general resistance.

The essence of the method is as follows: the cerebrospinal fluid is sampled to study the LF content in dynamics on the 1st, 3rd, 5th, 7th and 9th days of the course of a traumatic brain disease after PMI. To determine the content of lactoferrin, cerebrospinal fluid is used, which is immediately centrifuged immediately after exfusion in a volume of 1 ml. Subsequently, an enzyme-linked immunosorbent assay of cerebrospinal fluid for lactoferrin content was performed. Lactoferrin belongs to the group of proteins containing metal ions of variable valency, which, by binding metal ions, reduces the likelihood of OH-generated reactions, such as the Fenton reaction, has antibacterial and antioxidant properties. Monitoring the level of lactoferrin is due to the fact that the LF content in the cerebrospinal fluid allows us to judge the activity of the inflammatory process. Early diagnosis of inflammation activity is important for the appointment of adequate therapy. Our choice of iron-containing LF protein allows us to reliably and early diagnose the development of intracranial inflammatory complications - meningitis and to prescribe an adequate and enhanced antibiotic therapy in a timely manner. The sensitivity of this test is 65%, and the specificity is 78%, which characterizes the study of lactoferrin as an effective prognostic test of the study of the possibility of developing intracranial infectious complications.

The LF level is more than 170 ng / ml and maintaining the indicator at this level indicates a high risk of developing meningitis, which requires additional therapy: strengthening the antibacterial component, immunomodulating therapy.

A level of LF less than 170 ng / ml indicates a low risk of developing meningitis and does not require correction of antibiotic therapy.

Example 1

Patient L., 58 years old, medical history No. 947, was hospitalized in the Department of Neurosurgery of the City Clinical Hospital No. 29 of Novokuznetsk on 02.07.2001. with a diagnosis of severe closed head injury. A brain contusion with compression of the subacute intracerebral hematoma of the right temporal lobe and subdural hygroma on the right. Subarachnoid hemorrhage. Bruises of the soft tissues of the head. Dislocation of the brain in the phase of gross clinical decompensation. The diagnosis was made on the basis of clinical, neurological and physiological studies, data of angiography and computed tomography of the brain. An emergency operation was performed under endotracheal anesthesia: osteoplastic trepanation of the skull in the left frontoparietal-temporal region. Removal of intracerebral hematoma of the right temporal lobe and subdural hygroma on the right. Temporal decompression. He was transferred to the resuscitation department for extended artificial lung ventilation and further therapy. Complex therapy was carried out in the intensive care unit (respiratory, antibacterial, brain protection, infusion-transfusion, antioxidant, antihypoxant, nootropic, nutritional support).

Along with general clinical, biochemical, and liquorological studies, the patient began dynamic studies of the LF content in the cerebrospinal fluid on the first 1, 3, 5, 7, and 9 days (Table 1).

The patient’s level of lactoferrin was increased from 1 day and remained elevated throughout the study day.

According to generally accepted methods, only on the 3rd day were high CSF cytosis (c-2080; n-100%) and on the basis of the presence of meningeal syndrome, inflammatory reaction of the blood (increase in leukocyte intoxication index more than 6), data of cerebrospinal fluid examination (cytosis according to clinical analysis) was diagnosed with meningitis (Table 2).

Correction and strengthening of the antibacterial component of the treatment was carried out (cephalosporins of the third generation were added to the treatment, hormone therapy was carried out, dioxidine was administered endolumbally, intracarotid infusion of antibiotics was carried out), but despite intensive therapy, the condition worsened, the patient died from post-traumatic meningitis, which is confirmed by the results of .

The diagnosis of post-traumatic meningitis could be assumed on the basis of changes in the immunobiochemical analysis of the level of LF in the cerebrospinal fluid, the increase of which occurred already on the first day of the study. Clinical diagnosis of post-traumatic meningitis was made on the third day after surgery and treatment correction was ineffective. This clinical example illustrates that according to the content of LF in the cerebrospinal fluid, it was possible to assume the development of meningitis from the first day of admission to the intensive care unit. But since, at the time of treatment of the patient, prognostically significant concentrations of LF were not established, the diagnosis of meningitis was made from the third day and treatment was started. In our opinion, the late start of treatment could be one of the causes of death.

Example 2

Patient Z., 48 years old, medical history No. 280, was hospitalized in the Department of Neurosurgery of the City Clinical Hospital No. 29 of Novokuznetsk 02.25.01. with a diagnosis of severe closed head injury. A brain contusion with compression of an acute subdural hematoma in the left frontotoparietal-temporal region. Bruises of the soft tissues of the head. Dislocation of the brain in the phase of gross clinical decompensation. The diagnosis was made on the basis of clinical, neurological and neurophysiological studies, data of angiography and computed tomography of the brain. In an emergency, an operation was performed under endotracheal anesthesia: resection craniotomy in the left frontoparietal-temporal region. Removal of acute subdural hematoma. He was transferred to the resuscitation department for extended artificial lung ventilation and further therapy. Comprehensive therapy was carried out in the intensive care unit (respiratory, antibacterial, brain protection, infusion-transfusion, antioxidant, antihypoxant, nootropic, nutritional support).

Along with general clinical, biochemical, and liquorological studies, the patient began dynamic studies of the LF content in the cerebrospinal fluid on the first 1, 3, 5, 7, and 9 days (Table 3).

On the basis of the LF indicator, the diagnosis of post-traumatic meningitis was suggested on the first and third days, the symptoms of which (cytosis in the analysis of cerebrospinal fluid and leukocyte intoxication index according to the clinical blood analysis, Table 4) lagged by a day compared to immunobiochemical parameters of cerebrospinal fluid (cerebrospinal fluid was obtained after regression of symptoms of brain dislocation).

Against the background of timely, adequate therapy (strengthening of the antibacterial component, ceftalaborin of the 3rd generation ceftriabol, hormone therapy, detoxification, antioxidant, endolumbal administration of antibiotics, aminoglycoside - amikacin 40 mg), the clinical and laboratory signs of meningitis were stopped, the patient's condition improved.

Example 3

Patient K., 37 years old, medical history No. 2997, was hospitalized in the Department of Neurosurgery of the City Clinical Hospital No. 29 of Novokuznetsk on 10.11.2000 with a diagnosis of severe open head injury. A brain contusion with compression of an acute epidural hematoma in the left fronto-parietal-temporal region. A linear fracture of the temporal bone scales on the left with the extension of the fracture line to the base of the middle cranial fossa on the left. Dislocation of the brain in the phase of gross clinical decompensation. The diagnosis was made on the basis of clinical, neurological and neurophysiological studies, data of angiography and computed tomography of the brain. In an emergency, an operation was performed under endotracheal anesthesia: resection craniotomy in the left frontoparietal-temporal region. Removal of acute epidural hematoma. He was transferred to the resuscitation department for extended artificial lung ventilation and further therapy. Comprehensive therapy was carried out in the intensive care unit (respiratory, antibacterial, brain protection, infusion-transfusion, antioxidant, antihypoxant, nootropic, nutritional support). Along with general clinical, biochemical, and liquorological studies, the patient began dynamic studies of the LF content in the cerebrospinal fluid on the first 1, 3, 5, 7, and 9 days (Table 5).

The post-traumatic period was not complicated by meningitis, despite the open head injury, which, according to the literature and our own data, in a large percentage of cases is complicated by the development of infectious complications. The normal immunobiochemical picture of the LF content in the cerebrospinal fluid was also characteristic, which testified to the preserved reactivity of the cerebrospinal fluid sanogenesis systems, which made it possible to confine ourselves to standard therapy. The further course of the post-traumatic period confirmed our assumption and the correctness of the chosen tactics (Table 6).

After complex treatment, the patient was transferred to the neurosurgical department.

Thus, the use of lactoferrin and the study of its content in the cerebrospinal fluid allows predicting the development of post-traumatic intracranial infectious complications in the early stages (that is, before the appearance of clinical and laboratory data) and correcting the complex therapy of PMTCT in a timely manner. The method expands the possibilities of early diagnosis of the development of post-traumatic meningitis to the appearance of a clinical picture and an increase in cytosis in the cerebrospinal fluid. The inventive forecast method is based on the determination of one objective indicator - LF liquor. This method of early diagnosis of the development of post-traumatic meningitis is used in the neuroresuscitation department of the City Clinical Hospital of 29 Novokuznetsk and was used in 18 patients.

Claims (1)

A method for predicting the development of post-traumatic meningitis in resuscitation patients with severe head injury by studying the immunobiochemical parameters of cerebrospinal fluid, characterized in that in patients with severe head injury, the content of lactoferrin in the cerebrospinal fluid is examined on days 1, 3, 5, 7, and 9 after the injury, and with its values more 170 ng / ml predict a high likelihood of developing post-traumatic meningitis in resuscitation patients with severe traumatic brain injury.