RU2238071C2 - Method for treating patients with craniocerebral trauma in early post-traumatic period - Google Patents

Abstract

FIELD: medicine, neurotraumatology, neuroresuscitation.

SUBSTANCE: the method deals with carrying out conventional intensive therapy and hyperbaric oxygenation (HBO). Moreover, since the 1^st d of craniocerebral trauma (CCT) one should supplement clonidine hydrochloride at daily dosage of 2 mcg/kg patient's body weight into therapy course for 6-10 d. Moreover, daily dosage of clonidine hydrochloride should be distributed by equal portions for three intakes to be introduced per os with food in equal time spaces. Since the 2^nd d after CCT patient should undergo 6-10 HBO seances at seance duration being about 30-40 min and pressure in pressure chamber being 1.1-1.6 atm. The method enables to increase efficiency of therapy due to avoiding destruction of neurons and keeping the degree of their survival in early post-traumatic period, it, also, restricts additional; activation of free radical oxidation associated with further application of HBO.

EFFECT: higher efficiency of therapy.

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Description

The invention relates to medicine, namely to neurotraumatology and neuroreanimatology, and can be used to treat victims with traumatic brain injury in the early post-traumatic period.

The number of victims of traumatic brain damage is increasing every year. The extent of the prevalence of the pathology under consideration can be quite clearly represented by providing the following information: traumatic brain injury (TBI) accounts for half of all fatal injuries (Konovalov A.E. Likhterman LB, Potapova AA Clinical guide to cranial brain injury. - M .: Antidor, 1998, p. 55; Willenberg E., Wisiel I., Credo J., Liczkowski B. Haufigkcif und Problematic des Shaddelhirn traumas unter Alkoholeinfluss // Zibl. Chir. - 1982. - Bd. 107, No. 176. - S.1106) and in a third of cases it is the cause of disability (Moguchaya O.V. Epidemiology of traumatic brain injury among the adult population, in asks prevention and scientific substantiation of the organization of therapeutic and preventive care in a large city (on the model of St. Petersburg): Abstract of diss ... MD St. Petersburg, 1993, p.4).. In the contingent of young people, TBI is currently taking the first place among the causes of mortality (Likhterman L.B., Potapov A.A., Belov V.P., Lebedev A.N. Craniocerebral trauma // Small Medical Encyclopedia at 6 these volumes under the editorship of Pokrovsky V.I., M .: Medicine, 1996, volume 6, p.268), and the overall mortality rate in TBI reaches 80% (Moguchaya O.V. Epidemiology of traumatic brain injury among adults, prevention issues and the scientific rationale for the organization of medical and preventive care in a large city (on the model of St. Petersburg): Author's abstract diss. candidate of medical sciences St. Petersburg, 1993. - p. 5), and in terms of age, victims aged 20 to 50 years prevail (Asenssio MJ, Pelaer J., Yoe S. et al. Mortality in closed head injury . (Pap. Soc. Crit. Care med. 26th Educ. And Sci. Symp., San-Diego, Calif, 1997.) Crit. Care Med. - 1997. - v.25. - No. 1. - Suppl . - p.75). Opinions are even expressed about a peculiar traumatic epidemic (in relation to the head injury) that swept the civilized world (Yartsev V.V., Nepomnyashchy V.P., Akshulanov S.K. The main epidemiological indicators of acute head injury among urban residents // Neurosurgery Issues - 1995. - No. 1, p. 37; Annoni JM, Beer S., Kesselring J. Severe traumatic brain injury epidemiology and outcome after 3 years. // Disability & Rehabilitation. - 1992. - v.14. - No. 1, p .23).

Traumatic brain injury is accompanied by a number of pathological changes both in the brain that has been injured and in the body as a whole - endotoxemia, stimulation of lipid peroxidation (LP) processes, and depletion of the patient's antioxidant system (AOS). The main trigger and supporting factor for these changes is hypoxia, which has a different genesis and is represented by all its known species (Zilber A.P. Clinical physiology in anesthesiology and intensive care. - M .: Medicine, 1984, p. 89). Therefore, recently, the use of hyperbaric oxygenation (HBO) has played a large role in the treatment of TBI. The mechanism of the positive effect of HBO is due to the very essence of HBO, which consists in the ability of hyperbaric oxygen to not only eliminate tissue hypoxia (Barret K., Hareh P., Masel B. et al. Cognitive and cerebral blood flow improvements in chronic stable traumatic brain injury induced // Undersea Hyper. Med. -1998. - No. 25, p.2), but also create more favorable conditions for the flow of oxidative processes in tissues and organs by directly activating them, increasing tissue energy supply at the mitochondrial level (Kazantseva N.V., Gusev E .I., Makarova LD and others. Barotherapy in neurology // Hyperbaric phys. Biology and Medicine - 2000. - No. 1, p. 18).

The treatment of head injury is currently of great importance, since the timely implementation of the necessary therapeutic measures makes it possible to reduce the negative consequences of this pathology.

Treatment of TBI is multi-stage and consists of conducting at the first, and perhaps the most critical stage - in the early post-traumatic period - medical and resuscitation measures, the essence of which is to remove the victim from an unconscious state - coma - and to prevent the serious consequences of TBI to various complications and even deaths. However, the variety of treatment methods for TBI indicates that it is currently not determined at what stages of development of the pathology under consideration, in which cases, at what time and in which regimes, from the point of view of the optimal treatment of TBI, certain medical measures are most effective, in t .h. and the use of HBO, and that there are no optimal options for dealing with the consequences of TBI. All this compels us to study and develop new, more advanced and more effective methods of treating this pathological condition.

Conducted research on the medical-scientific and patent literature revealed various methods of treatment of head injury.

So, in the work of Usenko L.V., Kligunenko E.N. Principles of intensive care for severe brain contusion (guidelines). - Dnepropetrovsk. - 1992, 18 p. A method is described for treating patients with head injury by carrying out HBO on the background of "standard" intensive care starting from the 10th day of the injury.

The disadvantage of this method is the lack of treatment effectiveness in terms of restoring the functional activity of brain cells suffering from hypoxia in the early post-traumatic period - the most critical period of their struggle for survival. Treatment for a long time, as a rule, allows you to restore the function of only completely preserved brain structures, a large number of complications and deaths.

USSR copyright certificate No. 1560203 (A 61 G 10/04) published in B.I. No. 16, 1990, defended the "Method for the treatment of residual neurological manifestations after brain injuries" by inclusion in the comprehensive treatment of HBO.

The disadvantage of this method is its low efficiency in terms of restoring the functional activity of brain cells in the early post-traumatic period. The method itself is traumatic, the treatment is long, a large number of complications.

The closest in technical essence and selected as a prototype is a method for the treatment of traumatic brain injury in the early post-traumatic period (Belitskaya T.S. Optimization of intensive care for severe traumatic brain injury / Abstract of diss. Ph.D. - Rostov-on-Don, 2000, p.13), including the implementation of generally accepted intensive care and, starting from 5 days after the head injury, 5-7 sessions of HBO under a working pressure of 1.2-1.5 ata .

Analysis of the case histories received from a traumatic brain injury in the Department of Anesthesiology and Resuscitation BSMP-2 of Rostov-on-Don 30 victims whose treatment in the early post-traumatic period was carried out according to the prototype, namely, included the implementation of generally accepted intensive care and, starting from 5 days after TBI, conducting 5-7 sessions of HBO under a working pressure of 1.2-1.5 ata, showed that:

1) the exit of patients from coma occurred on average on day 12;

2) the number of complications was observed in 20 (66.7%) patients;

3) a fatal outcome occurred in 9 (30%) victims;

4) the treatment of patients in the intensive care unit and anesthesiology on average was 18 days.

The use of HBO only from the 5th day after the injury did not contribute to the successful prevention of the development of negative processes in the brain and made it impossible at the early stage of the development of pathology to ensure the viability of the injured areas of the brain suffering from hypoxia, and especially those located in " border "state between life and death and, if an oxidizing agent is delivered to them in a timely manner, they can maintain viability and restore their functions.

Thus, the disadvantage of the prototype is that the efficiency of restoring the functional activity of brain cells - the exit of patients from a coma - has not yet reached the desired level, the treatment of victims in the intensive care unit and anesthesiology is quite long, and the percentage of complications and deaths is still large. All this indicates the lack of effectiveness in the treatment of victims of head injury in the early post-traumatic period according to the prototype and requires new approaches in conducting medical and resuscitation measures.

The aim of the present invention is to increase the effectiveness of intensive care, reducing the number of complications, deaths and treatment time for victims of head injury in the early post-traumatic period.

This goal is achieved by the fact that the victim is given generally accepted intensive care. Starting from the first day of TBI, clonidine hydrochloride (the brand name of the drug is clonidine / clonidine /) in a daily dose of 2 μg / kg of the patient’s body weight is included in the course of treatment for 6-10 days. The daily dose of clonidine hydrochloride is distributed in equal parts into three doses and is administered to the patient per os with food at regular intervals. Starting from the second day after the injury, 6-10 HBO sessions are carried out daily for the victim with a session duration of 30-40 minutes and a pressure in the pressure chamber of 1.1-1.6 ata.

The method is as follows.

After a preliminary examination of the victim who arrived at the hospital, the necessary clinical and laboratory tests are started, treatment is started.

According to the results of the studies, the patient is prescribed generally accepted intensive therapy, the main sections of which include respiratory support, tracheobronchial tree sanitation, hemostasis, fight against brain edema, desensitization, antihypoxic and traditional antioxidant therapy, the use of membrane protectors, neurotransmitters and drugs that improve myocirculation, detoxification therapy, antibacterial drugs, metabolism and nootropics, craniocerebral hypothermia and probe nutrition, and, n Finally, specific care measures aimed at the prevention of pressure sores and septic complications, the prevention of congestion in the lungs and pneumonia.

Starting from the first day of TBI, the patient is additionally treated with clonidine hydrochloride in a daily dose of 2 μg / kg of the patient’s body weight for 6-10 days. So, for example, for a patient weighing 75 kg, the daily dose of clonidine hydrochloride is 150 μg, i.e. one tablet of clonidine (clonidine), which contains 150 micrograms of clonidine hydrochloride. The daily dose of clonidine hydrochloride is distributed in equal parts into three doses and is administered to the patient per o s with food at regular intervals.

Clonidine hydrochloride, having an antioxidant, membrane-protective effect, prevents the development of nitrosating and oxidative stresses, which makes it possible to inhibit the cascade of pathological reactions that develop during head injury in the early post-traumatic period (Lebedeva M.N., Bykova E.V., Ageenko A.M., Novikov VV Use of the clonidine stress protector in surgical vertebrology // VIII All-Russian Congress of Anesthesiologists and Resuscitators (thesis. Dokl., Omsk, 2002, p. 146) helps to prevent damage to neurons or maintain the degree of survival impermeability of the latter and thus increases the efficiency of the treatment of traumatic brain injury in the early post-traumatic period.

Starting from the second day after the injury, 6-10 HBO sessions are carried out daily for the victim with a session duration of 30-40 minutes and a pressure in the pressure chamber of 1.1-1.6 ata. HBO sessions are conducted in a single medical pressure chamber, for example, of the OKA-MT type (TU1-01-0889-89), which is part of the OKA-MT-S hyperbaric system (TU1-01-0677-81), manufactured by the Kiev Aviation Production Association. When carrying out HBO, medical oxygen is used in accordance with GOST 5583-78.

After the patient comes out of a coma, the administration of clonidine hydrochloride and HBO are stopped, appropriate tests are performed if necessary, and the patient is transferred from the intensive care unit to the specialized department.

The practical application of the proposed method is illustrated by examples from clinical practice.

Example 1

Patient O., 46 years old, case history No. 35121, was admitted to the anesthesiology and intensive care unit of BSMP-2 in Rostov-on-Don due to a closed head injury, severe brain contusion, with compression of the brain by a subdural hematoma and bruised face wounds. Upon admission, the condition is extremely serious, the skin and visible mucous membranes are pale in color, HELL = 145/80 mm Hg, pulse = 92 beats. in min, BH = 22 in min, level of consciousness - coma I, pupils D = S, photoreaction is reduced, horizontal nystagmus, muscle tone is reduced. According to computed tomography of the brain (CT): hemorrhagic contusion of the frontal region on the left, subdural hematoma of the left hemisphere, displacement of the middle structures to the right. An ultrasound (US) examination of the abdominal organs revealed no pathology; free fluid was not determined. The patient was prescribed an intensive care complex, which included hemostatic, dehydration measures, as well as inhalation of moistened oxygen through a nasal catheter, and surgical intervention was performed in the volume: drainage of the subdural hematoma of the left frontal region from the milling holes.

The victim, in the course of treatment, starting from the first day after a TBI, was additionally included clonidine hydrochloride and a daily dose of 150 μg, which was distributed in equal parts into three doses and was administered to the patient per os with food at regular intervals. Starting from the second day after the TBI, the patient was daily given HBO sessions with a session duration of 40 minutes and a pressure in the pressure chamber of 1.5 ata.

On the 8th day, the patient left the coma, on the 9th day, the administration of clonidine hydrochloride and HBO were canceled, and on the 12th day the patient was transferred from the ARC to the neurosurgery department. During the period of being in the ARC, the patient had no complications.

Example 2

Patient Y., 53 years old, medical history No. 35193, was admitted to the Department of Anesthesiology and Resuscitation of BSMP-2 due to a closed head injury, severe brain contusion, subarachnoid hemorrhage, fracture of the left frontotemporal-parietal region, and intracerebral hematoma of the left frontal region. Upon admission, the condition is extremely serious, the skin and visible mucous membranes are pale in color, HELL = 180/90 mm Hg, pulse = 84 beats. in min, BH = 18 in min, level of consciousness - coma I, pupils D = S, photoreaction is reduced, paresis of the gaze to the right, tendon reflexes are high, Babinsky syndrome is weakly positive on the right. According to a CT scan of the brain: intracerebral hematoma of the left temporal-parietal region with a shift in the middle structures to the right, traces of blood in the subarachnoid fissures. On the radiograph of the skull: a linear fracture of the left parietal region. The patient was prescribed an intensive care complex, which included hemostatic, dehydration measures, as well as inhalation of moistened oxygen through a nasal catheter, and surgical intervention was performed in volume: resection craniotomy in the left temporal-parietal region, removal of intracerebral hematoma.

The victim, in the course of treatment, starting from the first day after a head injury, was additionally included clonidine hydrochloride in a daily dose of 180 μg, which was distributed in equal parts into three doses and was administered to the patient per os with food at regular intervals. Starting from the second day after the TBI, the victim was given daily HBO sessions with a session duration of 30 minutes and a pressure in the pressure chamber of 1.2 ata.

On the 10th day, the patient left the coma, on the 11th day the administration of clonidine hydrochloride and HBO were canceled, and on the 14th day the patient was transferred from the ARC to the neurosurgery department.

The proposed method in the intensive care unit and anesthesiology BSMP - 2, Rostov-on-Don in the early post-traumatic period, medical assistance was provided to 30 victims who were admitted to the department with a head injury. The analysis of the treatment results showed that:

1) the exit of patients from a coma occurred on average on day 9, and compared with the prototype, the exit time from a coma decreased by 25%;

2) the presence of complications was observed in 16 (53.3%) patients and compared with the prototype decreased by 13.4%;

3) a fatal outcome occurred in 4 (13.3%) of the victims and compared with the prototype was reduced by 16.6%.

4) the treatment of patients in the intensive care and anesthesiology department averaged 14 days and decreased by 22.2% compared with the prototype;

Thus, in comparison with the prototype, the proposed technical solution allows to reduce the recovery time of the functional activity of brain cells - the time of the patient’s exit from the coma, reduce the number of complications, reduce the number of deaths and shorten the treatment time for victims of head injury in the early post-traumatic period.

Claims (1)

A method for the treatment of victims of traumatic brain injury (TBI) in the early post-traumatic period, including the implementation of generally accepted intensive care and hyperbaric oxygenation (HBO), characterized in that, starting from the first day of TBI, the patient is treated for an additional 6-10 days include clonidine hydrochloride in a daily dose of 2 μg / kg body weight of the patient, and the daily dose of clonidine hydrochloride is distributed in equal parts into three doses and is administered to the patient per os with food at regular intervals; starting from the second day after the head injury, 6-10 HBO sessions are carried out daily for the victim with a session duration of 30-40 minutes and a pressure in the pressure chamber of 1.1-1.6 ata.