RU2362482C1 - Method of hyperbaric oxygenation therapy mode selection in treatment of patients with lower limbs ischemia - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: before initiation and after the third session of HOT, visually evoked potentials (VEPs) are recorded. The HOT mode is considered to be optimal, if latency of all components of primary VEP complex is increased with lowering their amplitude, while latency of late response components after the third session. ^ EFFECT: extended range of HOT mode-selection facilities in treatment of patients with lower limb ischemia. ^ 3 dwg, 2 ex

Description

The invention relates to medicine, namely to the treatment of chronic obliterating diseases of the arteries of the lower extremities using hyperbaric oxygenation (HBO), and will be widely used to assess the individual reaction of the body to hyperoxia.

The widespread prevalence of diseases caused by occlusive lesions of the arteries of the lower extremities, a steadily progressing course, early disability, a significant proportion in the structure of mortality dictate the urgent need to improve treatment methods for patients with this pathology (Savelyev B.C., Koshkin V.M., 1997).

Currently, two main forms of chronic lesions of peripheral arteries are distinguished - obliterating endarteritis and obliterating atherosclerosis. Such a separation is necessary for the implementation of differential prevention and drug treatment.

One of the most important components of the complex treatment of patients with chronic ischemic diseases of the arteries of the lower extremities is the HBO method. However, from the point of view of a specialist in HBO, it is important not only to distinguish one form of the disease from another, but to assess the degree of blood flow disturbance in the limb (Lyskin G.I., Lukich V.L., 1986).

Subjective and objective tests are used to select the HBO mode. Subjective tests are the patient’s condition at certain levels of compression, the dynamics of pain, the nature of skin color changes in the limbs at the height of compression, psychosomatic status, etc. Most objective authors include a complex of biochemical and electrophysiological studies, such as heart rate monitoring, ECG, polarograms, RVG, thermometry, capillaroscopy, blood saturation, KHS and other studies (Rafikov A.M. et al., 1995; Kazantsova N.V., 1996; Selivra A.I., 1996; Vorobyev K.P., 2000).

Very important is the first, so-called trial HBO session, which provides tactical information on clinical parameters and serves as a prognostic test regarding the success of the treatment undertaken (Efuni S.N. Guide to hyperbaric oxygenation (theory and practice of clinical use). - M .: Medicine , 1986.- 416 p.). The disadvantages of this method include low accuracy. The duration of hyperbaric oxygenation is determined solely by the effectiveness of this treatment method.

HBO specialists are constantly solving the problem of oxygen regulation based on the results of a clinical assessment of the effects of HBO. However, the information obtained in this case is not always sufficiently correct, and its assessment is often subjective in nature and largely depends on the experience of medical personnel, and therefore oxygen rationing in HBO remains generally empirical. The question of choosing the HBO regimen for various diseases is still open, and this is due to the imperfection of methods to objectively and timely control the therapeutic and toxic effects of hyperbaric oxygen.

Thus, at the current level of understanding the mechanism of the physiological and toxic effects of increased oxygen pressure, in addition to clinical observations, the development of objective neurophysiological criteria of a non-invasive nature for the purposes of practical medicine should be recognized as necessary and promising.

Many authors note that the main task of HBO tactics is to determine the optimal individual dose of HBO during the session and the course of oxygen therapy. The objective functional characteristics of the reactivity to hyperoxia during HBO allow us to determine the favorable and precursors of the pathogenic effects of hyperbaric oxygen. A standardized technology for determining the precursors of impaired adaptation to hyperoxia based on heart rate variability data was developed and tested (Vorobyov KP Strategy and tactics of HBO in extreme conditions // Beale, Ambition and Intensive Therapy. - 2001. - No. 1. - P.58- 69).

There are a number of ways to determine individual sensitivity to hyperbaric oxygen and to diagnose oxygen intoxication.

According to V.A. Barsukov et al. (Barsukov V.A., Barsukov M.V., Leonov A.N. Unified method of dosing hyperoxia // Bull. Hyperbaric, biol. And medicine. - Voronezh, 1999. - No. 1-4. - P.28-30 ) the existing method for assessing the dose of the pharmacological action of hyperoxia by PO ₂ in the respiratory medium and exposure does not take into account the chemical and saturation components of increased oxygenation. The author offers a method for selecting individual parameters of hyperoxic effects (RF patent No. 2080104, 1997.05.27), which was developed taking into account the redox potential of oxygen dissolved in arterial blood. The method is based on two dependencies that determine the individual dose of hyperoxia and its toxicity, expressed in the form of an adaptive load on the lungs or brain:

D = 2.056- (logPaO ₂ -logPaO ₂ °) t;

L = 2,056 · ₍₂ lgRaO -lgRaO ₂ °) -t / k;

where D is the individual dose of hyperoxia;

L - selective adaptive load of hyperoxia on the lungs or brain;

PaO ₂ - partial pressure of oxygen in arterial blood during hyperoxia (mmHg)

PaO ₂ ° - partial pressure of O ₂ in arterial blood before hyperoxia (mm RT. Art.);

t is the duration of hyperoxia (h);

PaO ₂ - the threshold of the adaptive load of the partial pressure of oxygen in arterial blood on the lungs or brain;

K is the constant of resistance of the lungs or brain to adaptive load. It can be noted that such a technique is complex in view of the multifactorial nature of the studied quantities.

KP Vorobyov (Vorobyev KP Standard for monitoring the patient’s functional state during HBO // Bull. Hyperbar. Biol. And medicine. - Voronezh, 1999. - No. 1-4. - P.3-5) considers that the standard for monitoring the patient’s functional state during HBO must include a mathematical, computer analysis of the heart rhythm with the calculation of the PMBaevsky index. As the control stages of the HBO session, it is proposed to use 14 time intervals: before and after the HBO, 2 stages each during compression and decompression and 8 in the isopression mode. To determine the group variability of resistance to hyperoxia, it is proposed to use a cluster analysis of derivatives of the mathematical analysis of heart rhythm within the same nosology.

Currently, in practical public health, the diagnosis of oxygen intoxication is most often carried out on the basis of data from changes in EEG, REG, ECG, biochemical analyzes (KHS, POL and coagulograms). Thus, the known methods can detect already developed oxygen deficiency, often with its clinical manifestations (Koziro V.I. et al., 1999; Kazantseva N.V. et al., 1999; Baibarodov B.D., 2000; Kisen S .O., Lebedev M.A., 2002; Markaryan E.G., 2003).

There is a method of determining individual sensitivity to HBO (RF patent No. 2146050, 2000.02.27), the essence of which is that saliva is collected from patients before and immediately after the first session of HBO therapy and, on average, an increase in the intensity of the benzidine oxidation reaction is collected 1.4-6.2 times with the initial indicators determine the sensitivity to HBO, and in the absence of differences or a decrease to an average of 7 times - stability.

There is a method of determining indications for hyperbaric oxygenation in the treatment of patients with acute limb ischemia (RF patent No. 2282401, 2006.08.27) after fractures of long bones, including determining the partial pressure of gas in the tissues of the damaged limb before a HBO session, and the partial pressure of carbon dioxide is determined by non-invasive method distal to the level of damage before and 3 hours after the trial session of HBO, compare their values and in the presence of an increase in the partial pressure of carbon dioxide in the tissues, the relative but the values before the HBO session at 30 mm RT. Art. and more consider it appropriate to conduct a course of treatment of HBO.

In recent years, in order to achieve an individual dose of hyperbaric oxygen, few studies have been conducted on animals to study the dynamics of evoked potentials in the visual cortex of the cerebral hemispheres. This method today is one of the most sensitive to the toxic effect of hyperbaric oxygen in animals and humans. As a result of the experiments, it was found that the initial (physiological) effect of hyperoxia is characterized by an increase in the positive fluctuation of the primary response and an increase in the amplitude of the slow surface-negative wave of the secondary response (Selivra A.I. Strategy for monitoring the functional state of the body during hyperoxia // Bul. Hyperbaric biol. and medicine. - 1998. - No. 3-4. - C.3-12).

We have not come across other studies on the dynamics of evoked potentials in the visual cortex of the cerebral hemispheres of the brain in order to select an individual dose regimen for hyperbaric oxygen in clinical patients.

The objective of the invention is to increase the accuracy of the selection of individual maximum permissible parameters of hyperoxia and reduce trauma due to a unified assessment of the therapeutic, side and adaptive effect.

The problem is solved by studying the dynamics of evoked potentials in the visual cortex of the cerebral hemispheres. In this case, the study of visual evoked potentials is carried out before the start of hyperbaric oxygenation sessions and after the third hyperbaric oxygenation session. If, after the third session, an increase in latency and a decrease in the amplitude of all components of the primary VIZ complex are recorded, as well as an increase in the latency of the late responses, this regimen of hyperbaric oxygenation is considered optimal for the patient. The appearance of secondary responses with a large amplitude of the peak-wave and wave-peak type with a reduced latency of the late components indicates early intoxication with hyperbaric oxygen. The appearance of high-amplitude slow waves of early and late responses of the peak-wave and wave-peak type is a sign of toxic hyperoxia.

The technical result in the practical use of this method is to improve the results of treatment of patients with chronic lower limb ischemia of the III-IV degree, due to the simplification of the individual prognosis of hypoxic therapy, which expands the scope of its application in clinical practice and will lead to a decrease in the frequency of amputations in this category of patients. This method allows non-invasively in the monitoring mode to capture the first signs of the toxic effect of hyperbaric oxygen.

The prerequisites for the development of this method were our extensive clinical studies. The basis for the development of ischemia is, first of all, a decrease in delivery to the organ, a limb of oxygen, and a violation of the secretion of cellular metabolic products. With ischemia, there is a complex series of processes affecting each organelle and subcellular system as a result of a decrease in the efficiency of ATP formation. This leads to a change in the transport of ions through the plasma membrane, a disruption in the synthesis of proteins and nucleic acids, a cessation of the oxidation of fatty acids, and a change in the rate of glucogenesis. Ultimately, activation of autolytic processes associated with various types of hydrolases located in various cellular structures arises (Savelyev BC, Koshkin V.M., 1997; Buttke TM, Sandstrom PA, 1994; Shen HM et al., 2001; Hancock JT et al., 2001).

With ischemia, there is a phase of reversible damage, when the cell can recover against the background of improved blood circulation and oxygenation. If the “point of irreversible damage” is overcome, the changes become irreversible even when blood flow is restored.

An important place in the prevention of the development of the reversible phase of ischemia is a complex treatment that includes both surgical methods and conservative methods using hyperbaric oxygen.

The question of choosing the HBO regimen for various diseases is still open and this is due to the imperfection of objectively and timely control of the therapeutic and toxic effects of hyperbaric oxygen. It is generally accepted that compensated hypoxia is when PO ₂ in some parts of the body’s oxygen cascade does not lead to a rise in PO ₂ in the cell, subcompensated when, despite the increase in cellular PO ₂ , the antioxidant system of the cell is sufficient to neutralize the active forms that are formed O _2, and asthma, as a result of depletion of the antioxidant system cells are no longer able to catch and neutralize the resulting high velocity oxygen free radicals, leading to the development of oxygen deficiency syndrome (Efuni SN, 1986; A. Leonov, 2002). To control the body’s oxygen regime, it is necessary to take into account the peculiarities of the influence of both excess and lack of oxygen on its functional systems, therefore, the targeted use of hyperbaric oxygen is impossible without knowledge of the biological, biochemical, physiological, and pathological role of oxygen in living systems (Ambrosimova N.P. Belovsky, Yu.Yu., 1999; McDowall DG, 1978).

The first 3-7 sessions can serve as a certain boundary that allows to predict the need to continue the course of HBO and the result of therapy. By the end of this short course, the positive effect of treatment or a clear lack of result becomes apparent. In patients with chronic diseases of the lower extremities, the first sessions show, for example, the dynamics of the trophic ulcer: with a favorable treatment result, first there is an increase in wound discharge, then cleansing of the wound from necrotic masses and fibrin, the appearance of islets of granulation tissue and a decrease in local pain (Lukich V. L., 1975; Sidell BD et al., 1998).

The first signs of intolerance to hyperbaric oxygen are difficulty breathing, dizziness, nausea, excessive sweating, increased blood pressure and increased heart rate. HBO treatment in these cases is stopped or, if necessary, reduced HBO regimes, focusing on the subjective sensations of the patient.

According to different authors, the results of therapy are rated as good in 77% for obliterating endarteritis and in 69% for obliterating atherosclerosis, satisfactory in 14% and 25% of cases, respectively, and without effect, in 9% and 6%, respectively (Efuni S.N. ., 1986). According to S.G. Petrova et al. (1997) an improvement was noted in 62% of cases and unchanged in 38%.

From the data obtained it follows that to achieve success with oxygen treatment, a necessary condition is the doctor’s ability to select an individual dose of hyperbaric oxygen. Oxygenobarotherapists are constantly solving the problem of oxygen regulation based on the results of a clinical assessment of the effects of HBO. However, the information obtained in this case is not always sufficiently correct, and its assessment is often subjective in nature and largely depends on the experience of medical personnel. The normalization of oxygen carried out on the basis of this information during HBO remains generally empirical (Selivra A.I., 1998). Obviously, at the current level of understanding the nature of the physiological (pre-toxic) and toxic effects on the body, it is necessary to recognize the need for and introduction into practice, in addition to clinical observations, of more objective and reliable methods of monitoring the functional state of the body to obtain the best treatment effect with HBO.

The method of assessing visual evoked potentials when using HBO is a highly efficient, highly sensitive, objective and non-invasive way of dosing hyperbaric oxygen in order to prevent the development of the toxic phase of hyperoxia.

An analysis of the indicators we obtained characterizing the state of hemodynamics, the central and autonomic nervous system, as well as LPO, AOS, and the status of the kallikrein-kinin system showed that small and moderate compression modes of HBO do not cause adaptation processes in patients with chronic obstructive pulmonary disease in the treatment of hyperbaric oxygen, and have an optimal antihypoxic, physiological therapeutic effect on the patient’s body. This method made it possible to ensure the efficiency, safety, and individual sensitivity of the body to oxygen, which can vary widely even in the same patient with repeated HBO sessions, i.e. to support the physiological (pre-toxic) stage of hyperoxia during treatment.

In the subgroup of patients treated with compression modes of 1.3-1.5 ata, after the seventh HBO session, stabilization of all indicators of the LPO and AOS systems was observed, similar to the same modes after the third session.

All this indicated, on the one hand, that according to the compression regimes of 1.3-1.5 ata of the third session, HBO sessions of the entire course of treatment can be predicted, on the other hand, it can be argued that moderate and small compression modes of hyperbaric oxygen do not cause toxic phases of hyperoxia, and have an optimal, physiological therapeutic effect on the body of patients with chronic occlusive diseases of the arteries of the lower extremities.

We made an attempt to develop individual compression modes of HBO therapy in the treatment of patients with chronic obliterating diseases of the lower extremities based on the studies. To do this, a correlation analysis was carried out between the indicators of systemic hemodynamics, autonomic nervous system, lipid peroxidation, AOS and the status of the kallikrein-kinin system, on the one hand, and, on the other hand, with changes in the parameters of the primary and secondary components of the visual evoked potentials in 123 patients suffering from COPD with various modes of conducting HBO sessions in the postoperative period.

In the process of treating patients with the HBO method, the adaptation processes improved, as evidenced by the indicators of the kallikrein-kinin system and, first of all, the coefficient ratio K = PKK / KK, which ranged from 10.1-11.1 units. at the rate of healthy donors 10.0 units

The first signs of oxygen intoxication, signs of the optimal regimen of HBO, as well as signs of CNS intoxication and criteria for reducing intoxication were determined by changing the latency and amplitude of the VIZ.

In the initial state, VIZ included the early components of the primary complex and the secondary response. So, the latency of the component P ₀ averaged 78.1 ± 1.2 ms, N ₁ - 94.1 ± 2.1 ms, P ₁ - 126.1 ± 3.3 ms, N ₂ - 215.4 ± 2 , 9 ms, P ₂ - 286.5 ± 4.7 ms, N ₃ - 315.9 ± 5.5 ms, P ₃ - 389.5 ± 6.7 ms and N ₄ - 421.6 ± 5.4 ms The amplitude of these same components ranged in the following ranges: P ₀ - 0.1 μV, N ₁ - 6.8 ± 0.35 μV, P ₁ - 10.8 ± 0.31 μV, N ₂ - 8.9 ± 0, 12 μV, P ₂ - 5.9 ± 0.11 μV, N ₃ - 5.2 ± 0.13 μV, P ₃ - 3.8 ± 0.11 μV and N ₄ - 4.2 ± 0.12 μV .

Against the background of the third HBO session with compression of 1.7 atm, a decrease in the latency and amplitude of the primary VIZ components and the appearance of secondary responses with large amplitudes of the peak-wave and wave-peak types with a reduced latency of the later components were noted. So, the latency of component N ₁ decreased compared to the previous stage by 17.4%, N ₂ - by 11.2%, P ₂ - by 12.9%, N ₃ - by 9.3%, P ₃ - by 24 , 4% and N ₄ - by 16.8% (p <0.05). There was a tendency to a decrease in the amplitude of early responses, such as N ₁ - by 13.8%, P ₁ - by 25.6% and a significant increase in secondary responses, and above all, N ₃ - by 79.2%, P ₃ - by 176 , 5% and N ₄ - by 115.6%.

The data obtained indicated early intoxication with hyperbaric oxygen.

Thus, the developed individual treatment regimes using the HBO method, based on electrophysiological methods (VEP, ECG, monitoring of the tone of the autonomic nervous system) and, first of all, on assessing the function of the central nervous system, prevent violations of the adaptive and metabolic processes and further development of oxidative stress. Using the developed, objective criterion for dosing hyperbaric oxygen will avoid the side effects of hyperbaric oxygen, toxic hyperoxia and thereby improve the quality of treatment of patients with chronic obstructive diseases of the lower extremities.

The method is as follows.

Prior to the start of treatment, the patient undergoes an X-ray examination of the lungs in the pressure chamber, provided for by the patient's safety rules in the pressure chamber. If the patient has an ENT pathology in the anamnesis and in the present, the otolaryngologist is examined. The ECG was recorded in all patients receiving HBO. Clearly take into account the concomitant pathology, which may require changes to the HBO regime.

Before treatment and during the use of HBO, patients undergo a mandatory basic initial examination, including a clinical study, a general blood test, blood group and Rh factor, a general urinalysis, blood coagulation, PTI, coagulation, blood glucose, chest X-ray, RW or OPC , ECG and therapist's consultation, as well as additional studies: radiopaque arteriography, radioisotope examination of tissue blood flow, computed tomography, magnetic resonance imaging, echocardiography, whether idogrammu and immunogram, according to testimony.

Before treatment, patients are explained in an accessible form the essence of the method, as well as instructing patients on safety rules (oil and fat dressings, static electricity, some techniques that prevent ear injury). Each patient is questioned before HBO about other medical procedures that are carried out in parallel with him (massage, ultrasound), since such procedures involve the use of substances prepared on an oil basis.

Hyperbaric oxygenation is carried out with medical oxygen GOST 5583-50 in a single chamber BLKS-301.

Individual HBO modes are selected using the method of computer assessment of the components of visual evoked potentials, using the developed criteria - signs of toxic hyperoxia.

In order to obtain operational information about the nature and orientation of the body's reactions to hyperoxia, to objectively evaluate the therapeutic effect of HBO, the state of the central nervous system is monitored by visual evoked potentials on a flash of light.

Light stimulation is carried out through a special device with a short flash of light from an LED matrix supplied binocularly to the subject's closed eyes with parameters: duration - 2 ms, frequency - 0.2-1.7 Hz, intensity - 0-2500 mcd, wavelength 594 nm. The device is placed on glass BLKS-301 (distance 30-40 cm from the visual analyzer). The location of the electrodes on the patient’s head, the conditions of stimulation, registration of VEP and treatment are standard, approved by the International 10-20% scheme (V.V. Gnezditsky "Evoked brain potentials in clinical practice. Moscow, 2007). Electrode location: active - 01, 02, 0 _Z , T ₅ , T ₆ ; reference - F _Z ; grounding - C _Z or A ₁ (M ₁ ) or A ₂ (M ₂ ).

Stimulation conditions.

A short flash of light from the LED matrix, delivered binocularly to the subject’s closed eyes,

duration - 1; 2; four; 8 ms;

frequencies - 0.2-1.7 Hz (1.1 Hz);

wavelength - 594 nm.

Registration terms.

Bandwidth: LF - 0.1-3 Hz (1 Hz).

HF - 50-200 Hz (100 Hz).

The retention of the artifact in amplitude is 50-100 μV (70 μV).

Analysis Age - 500 ms.

The number of averagings is 20-500 (100).

Sensitivity: initial signals - 20 μV / D;

after averaging, 5 μV / D.

Repeatability - Repeated averaging is recommended to evaluate the reproducibility of the selected components.

Identification and labeling of components.

Visual evoked potential includes the "early" components (usually in the first 100 ms): P ₀ , N ₁ , P ₁ , N ₂ , P ₂ ; and "late" components with latencies of more than 100 ms: N ₃ , P ₃ , N ₄ (Fig. 1).

The study of visual evoked potentials is carried out before the start of hyperbaric oxygenation sessions, and after the third hyperbaric oxygenation session, and if after the third session an increase in latency and a decrease in the amplitude of all components of the primary VIZ complex are recorded, as well as an increase in the latency of late responses, this hyperbaric oxygenation regimen is considered optimal for patient, the appearance of secondary responses with a large amplitude of the type of "peak-wave" and "wave-peak" with reduced latency pos these components indicates early hyperbaric oxygen intoxication, the appearance of high-amplitude slow waves early and late responses of the type "peak-wave" and "wave peak" is a sign of toxic hyperoxia.

Clinical example 1

Patient Sh., 60 years old (source.ball. No. 810/51), was admitted to the clinic of surgical diseases No. 1 of Rostov State Medical University on January 31, 2007 with the diagnosis: Atherosclerosis, left ileo-femoral artery occlusion, HOSANK III art. In the preoperative period, a comprehensive examination of the patient was carried out, including general clinical studies (general analysis of blood, urine, MHO, APTT, blood type and Rh factor, ECG, ELISA), as well as ultrasound dopplerography, rheovasography, radiopaque angiography, plasma lipid spectrum, KHS, blood viscosity, lipid peroxidation, AOS activity, and the state of the kallikrein-kinin system. During the examination, the main diagnosis at admission was confirmed: “Atherosclerosis, ileo-femoral artery occlusion on the left, HOZANK IIIA Art.” Concomitant diagnosis: "Hypertension of the III century, erosive esophagitis, chronic gastroduodenitis."

02/12/07, under spinal anesthesia, marcaine snicked in the supine position, with access to n / 3 and in / 3 of the left thigh, iliac-femoral occlusion was exposed and the operation was performed: femoral-popliteal prosthesis with reversed autogenous left.

In the early postoperative period, the operated limb is somewhat cool to the touch, the pulsation on a.dorsalis pedis is determined. Movement and sensitivity saved. The dressing is dry, there are no signs of acute bleeding. Нb - 120 g / l, total protein - 60 g / l, glucose - 6.0 mmol / l, APTT> 2 '. Planned rheological and analgesic therapy is carried out aimed at improving microcirculation, suppressing the overproduction of cytokines and free radicals, increasing antioxidant activity, stimulating the development of collaterals and normalizing lipid metabolism.

02/13/07, the condition of the patient of moderate severity. I feel satisfactory. Complaints of moderate pain in the postoperative wound and in the left lower limb.

Objectively. In the lungs, harsh breathing, no wheezing. NPV - 17 in 1 minute. Heart sounds are rhythmic, heart rate - 92 in 1 ^' , blood pressure - 140/80 mm RT. Art. On the ECG from 02.13.07, sinus tachycardia, the electrical axis is deflected to the left. Violation of the processes of repolarization in the lower lateral wall of the left ventricle. Ripple in the reconstruction zone and PBBA is determined, the foot is cool.

On February 15, 07, a treatment course was started with the HBO method in an individual compression mode, established by the method of computer assessment of various components of visual evoked potentials by the present method. Compression modes in the first three sessions ranged from 1.4-1.5 ata, and in the subsequent 1.6 ata. Signs of an optimal treatment regimen using HBO was an increase in latency and a decrease in the amplitude of all components of the primary complex of VEP, as well as an increase in the latency of the secondary responses after the third session of HBO compared with the initial values (figure 2). In total, nine sessions were conducted with the duration of the therapeutic effect of hyperbaric oxygen in one session of 50-60 minutes. During the complex treatment of the patient after the seventh HBO session, a significant improvement in the general condition of the patient was noted, as well as a complete relief of the pain syndrome at rest and an increase in painless walking in the operated limb.

The dynamics of changes in regional arterial and venous pressure in the affected limb on the background of the treatment indicated an improvement in regional blood flow by 2–3 times, with normalization of the acid-base ratio and blood gas composition in the systemic circulation. There was also an improvement in the system of lipid peroxidation, AOS and kallikrein-kinin status. MDA values ranged from 18.2 ± 0.33-20.6 ± 0.51 nmol / ml, erythrocyte SOD - 2.96 ± 0.12-3.1 ± 0.13 u.mg / Hb, plasma catalase - at the level of 13.7 ± 1.4-15.4 ± 1.2 nmol H ₂ O ₂ / ml / min, and the coefficient of PKK / KK was 9.6-9.8 units. at a rate of 10.9 units, which indicated the normalization of adaptive-metabolic processes in the body of this patient and in the damaged left lower limb. 02/26/07, patient Sh., 60 years old, was discharged from the clinic of surgical diseases No. 1 of Rostov State Medical University in satisfactory condition with recommendations for outpatient treatment.

Thus, the method of assessing visual evoked potentials allows you to objectively select the optimal treatment regimen for patients with chronic diseases of the lower extremities using hyperbaric oxygen. The therapeutic effect of HBO in physiological doses has a normalizing effect on the hemodynamics and tone of the autonomic nervous system.

Clinical example 2

Patient M., 70 years old (source of illness No. 6123/289), was admitted to the clinic of surgical diseases No. 1 of Rostov State Medical University on August 29, 2006 with the diagnosis: Atherosclerosis. Occlusion of the arteries of the left lower leg, HOZANK III A station, Occlusion of the lower leg arteries, HOUSANK II Art. "

A comprehensive examination of the patient was carried out and, above all, a duplex scan of the vessels of the lower extremities, which allowed us to make the following conclusion: on the left: BOTH, GBA, PBA, PKA passable, no stenosis. Shin arteries: ZBA - occlusion, PBA - multiple stenoses up to 80%. On the right, the leg arteries are passable, stenosis is in the range of 50-60%. Echocardiographic study No. 703 showed that the cardiac cavities were not dilated. Concentric hypertrophy and an increase in left ventricular myocardial mass. The global contractility of the left ventricle is not changed. Degenerative calcification with severe aortic valve stenosis and moderate insufficiency, calcification of the left fibrous ring with mitral valve insufficiency 2 tbsp. Clinically, the left lower limb is warm, slightly swollen on the foot. On I and II fingers of the left n / limb, ulcerative defects, painful on palpation. Superficial sensitivity is reduced, deep - saved. Ripple on the foot of the left n / limb is not determined. According to the ECG and the conclusion of the cardiologist: "Arterial hypertension, grade 2, stage III, risk III. Calcification of the arterial valve, severe stenosis and moderate valve insufficiency."

On September 6, 2006, an endarterectomy from PCA was performed, an autovenous patch on the popliteal artery. Resection of the fingers of the right foot. Necrectomy of the left foot under spinal anesthesia with marcaine snicale - 4 ml. In the early postoperative period, the patient's condition is regarded as serious. Complaints of moderate soreness in the area of postoperative wounds. The skin of the operated lower limb is warm to the touch, not swollen. Movement and sensitivity are kept in sufficient volume. Ripple on the popliteal artery is determined. The bandage on the lower leg was moderately wet with serous-hemorrhagic discharge. The stump is cold, slightly swollen, pale. Wet dressing serous-hemorrhagic discharge. Heart rate - 78 in 1 ', blood pressure - 160 / 90-150 / 80 mmHg. Art.

In the postoperative period, conservative therapy with thrombolytics, antiplatelet agents, anticoagulants, and antibiotic therapy was carried out. The HBO course was carried out on October 9, 2006 using standard compression modes, which ranged from 1.5 ata to 2 ata, and the session duration was 50-60 minutes. A total of 10 sessions. However, on the left foot, there was a progression of the phenomena of ischemia, increased pain and hyperthermia persisted up to 38 ° C. Given the ineffectiveness of conservative therapy, the progression of ischemia of the patient was performed 23.10.06, the second operation: "Amputation at the level of the upper third of the left leg." Subsequently, in the postoperative period, a comprehensive IT was conducted with a dosed compression regimen of hyperbaric oxygen by the method of visual evoked potentials according to the developed criteria for selecting individual doses of hyperoxia for each HBO session (Fig. 3). The postoperative wound on the cult of the left lower limb healed by primary intention. Sutures were removed on the 9th day. The patient was discharged under the supervision of a surgeon at the place of residence. By the time the patient was discharged from the hospital, normalization in the LPO system, AOS, and kallikrein-kinin status occurred, which indicated a relative normalization of adaptive and adaptive processes in the patient's body.

Thus, it can be stated that the results of the HBO course with standard compression modes do not always allow achieving positive treatment results, while the selection of individual compression modes of hyperbaric oxygen is effective.

We carried out a correlation analysis between indicators of systemic hemodynamics, autonomic nervous system, lipid peroxidation, AOS and the status of the kallikrein-kinin system, on the one hand, and, on the other hand, with changes in the indicators of primary and secondary components of visual evoked potentials in 123 patients suffering from COPD in various conditions HBO sessions in the postoperative period in the clinic of surgical diseases No. 1 of Rostov State Medical University. The age of the patients ranged from 41-70 years, with 65 people (52.7%) suffering from atherosclerosis obliterans and 58 patients suffering from obliterating endarteritis, i.e. 47.3%. Patients aged 51 to 70 years predominated in the structure of a hozank with obliterating atherosclerosis, and obliterating endarteritis from 46 to 55 years predominated. Patients with obliterating atherosclerosis underwent mainly shunting operations, accompanied by prosthetics of the occlusion sites, and in patients with endarteritis, mainly sympathectomy with shunts.

In all groups of patients, the largest percentage of concomitant diseases was CHD (53%) and hypertension (73% of cases).

All patients were divided into two groups. The first group included patients who underwent comprehensive standard intensive care (IT) with HBO without selecting individual compression modes of hyperbaric oxygen. Compression modes in the first group ranged from 1.3-2 ata with a session duration of 40-60 minutes. The number of sessions per treatment course ranged from 7 to 10. In the second group of patients, a comprehensive IT was performed with HBO, but with individually developed treatment regimens for hyperbaric oxygen by the method of computer assessment of various components of visual evoked potentials. In the course of treatment with the HBO method, a correlation was made between the parameters of the VEP components and the hemodynamic data, the tone of the autonomic nervous system and the biochemical results of the study of lipid peroxidation, AOS and kallikrein-kinin system.

The use of the method of visual evoked potentials as an objective criterion for dosing hyperbaric oxygen showed that in patients of the second group the optimal compression regimes ranged from 1.4-1.6 at. In all patients for whom an individual treatment regimen for HBO was selected, during the seventh session, an increase in latency and a decrease in the amplitude of all components of the primary complex of VEP were noted, as well as an increase in the latency of late responses. An individual treatment regimen using the HBO method provided patients with stable indicators of systemic hemodynamics, the state of the autonomic nervous system, and data on lipid peroxidation, AOS and kallikrein-kinin status.

All electrophysiological studies (ECG, blood pressure, heart rate, cardiointervalography on a Centaur 1A apparatus) were carried out in the monitoring mode at various stages of HBO sessions, including at the stages of biochemical studies.

All biochemical studies were carried out in three stages:

- in the initial state (prior to the HBO session);

- after the third session of hyperbaric oxygenation;

- after the seventh session of HBO, and with various compression modes (1.3 ata; 1.5 ata; 1.7 ata and 2 ata).

Digital material was processed statistically with the definition of Student and Wilcoxon criteria, for which we used a personal computer CRU Pentium III 550/5 12 Se CC2 and the program "Excel-2000".

The method of assessing visual evoked potentials in the application of HBO is a very efficient, objective and non-invasive way of dosing hyperbaric oxygen in order to prevent the development of toxic hyperoxia and can be successfully applied in practical health care. Conducted comprehensive clinical and laboratory studies of the proposed method for selecting the HBO regimen established its high efficiency, safety and economy, the clinical effectiveness of the method, manifested in the normalization of metabolic changes caused by ischemia, significantly exceeds the traditionally applied HBO regimen.

Thus, the proposed method for the selection of individual parameters of hyperoxic effects is less traumatic and allows you to more accurately determine and implement the parameters of hyperoxic effects in comparison with known methods.

All these advantages make the claimed method the most preferred in everyday clinical practice. It will be widely used in medical institutions / in the departments of HBO therapy /, where the method of hyperbaric oxygenation / HBO is used to assess the individual reaction of the body to hyperoxia.

Claims (1)

A method for assessing the hyperbaric oxygenation (HBO) regimen in the treatment of patients with ischemic diseases of the lower extremities, including recording and studying the dynamics of evoked potentials in the visual cortex of the cerebral hemispheres, characterized in that the visual evoked potentials (VEP) are recorded before and after the third session HBO and, if after the third session there is an increase in latency and a decrease in the amplitude of all components of the primary complex of VIZ, as well as an increase in latency of late components of the answer, the HBO mode is rated optimal.

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