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"Emergency medicine" 8 (63) 2014

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Diagnostics and correction of multiorgan disorders for critical patients with a hemorrhagic stroke

Authors: K. Serikov, B. Goldovsky, S. Potalov, O. Levkin, E. Sid - State Institute “Zaporizhzhia Medical Academy of Postgraduate Education of Ministry of Health of Ukraine”; A. Svetlicskiy - Zaporizhzhya state medical university (Ukraine)

Categories: Medicine of emergency

Sections: Specialist manual

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Keywords

diagnosis, multiorgan disorders, hemorrhagic stroke, intensive therapy.

Summary. A comprehensive examination and intensive care measures of 25 critical patients with primary intracerebral hemorrhage (ICD-10 code: I61) was made.

The average age of the patients was (62 ± 2) years, 14 men (56.0 %) — the average age (64 ± 3) years; women — 11 (44.0 %) — the average age (63 ± 4) years.

In this case, the recovered was 18 — the average age of (64 ± 2) years, 9 men (50.0 %) — the average age (65 ± 4) years; women — 9 (50.0 %) — the average age (64 ± 3) years.

Deceased patients was 7 — the average age of (60 ± 5) years, 5 men (71.4 %) — the average age (62 ± 3) years; women — 2 (28.6 %) — the average age (55 ± 19) years.

All the patients underwent neurological monitoring the severity of hemorrhagic stroke according to National Institutes of Health Stroke Scale (NIHSS).

The presence of multiorgan damage was determined by the severity of cerebral, respiratory and cardiovascular disorders.

Correction of multiorgan disorders in critically ill patients with hemorrhagic stroke was carried out by taking into account the "Standardized protocol of care and rehabilitation — Hemorrhagic stroke, in 2013."

Correction of functional disorders of the central nervous system.

Cerebral perfusion pressure (CPP) is calculated as the difference between mean arterial pressure (MAP, mmHg) and intracranial pressure (ICP, mmHg)

CPP = MAP — ICP, mmHg, in which:

1 In assessing consciousness Glasgow coma scale (GCS) score at 14-13, ICP is 15 mmHg

2 When the level of consciousness on the GCS score at 12-11, ICP corresponds to 20 mm Hg

3 In assessing consciousness GCS 10-9 score, ICP is 25 mmHg

4 At the level of consciousness on the GCS ≤ 8 points, ICP corresponds to 30 mm Hg

Proceeding from this correction is made the target values of MAP, in order to maintain adequate cerebral blood flow:

SBP = CPP + ICP, mmHg, where:

1 MAP = 70 (the lower limit of normal CPP) + 15 = 85 mmHg — In patients with impaired consciousness by the type of inhibition.

2 MAP = 70 + 20 = 90 mm Hg — Patients in the contact stupor.

3 MAP = 70 + 25 = 95 mm Hg — Patients in a non-stupor.

4 MAP = 70 + 30 mm Hg = 100 mmHg — Patients in a comatose state.

Correction of functional disorders of the respiratory system.

Preventive oxygenation is carried out at the level of oxygen saturation in arterial blood (SaO2) ≤ 94 % — humidified oxygen flow rate of 2-6 liters per minute.

The level of fraction of inspired oxygen (FiO2) during spontaneous breathing depends on the disturbance of consciousness of patients with GCS:

1 At the level of consciousness on the GCS 14-13 points — FiO2 of 0.3 %

2 In assessing consciousness GCS 12-11 points — FiO2 of 0.4 %

3 At the level of consciousness on the GCS score 10-9 — FiO2 of 0.5 %

4 At the level of consciousness on the GCS score of 8 respiratory rate < 30 per minute, oxygen tension in arterial blood (PaO2) > 70 mm Hg, carbon dioxide tension in arterial blood (PaO2) < 45 mm Hg — FiO2 is 0.6 %.

In the case of growth of respiratory distress signs or further impairment of consciousness on the GCS, the question of holding orotracheal intubation and transfer of the patient to an artificial lung ventilation (ALV). In this case, according to the order of the Ministry of Health of Ukraine from 01.03.2004, № 108 "About improvement of the organization of emergency neurosurgical care" for mechanical ventilation only one of the following factors:

- The level of consciousness on the GCS < 8 points

- The frequency of respiratory movements > 30 per minute

- PaO2 < 70 mm Hg

- PaCO2 > 45 mm Hg

Correction of hemodynamic disturbances.

Correction of hypertension:

- Systolic blood pressure (SBP syst.) > 200 or SBP > 150 mmHg without suspicion of ICP increase — long in / infusion hypotensive drug, monitoring of blood pressure every 5 minutes

- AP chem. > 180 or SBP > 130 mmHg in conjunction with a suspected increase in ICP — ICP monitoring, as well as blood pressure reduction to the level of CPP ≥ 70 mmHg

- AP chem. > 180 or SBP > 130 mmHg without suspicion of increased intracranial pressure — lowering blood pressure chem. up to 160 or 110 to SBP mm Hg, every 15 min.

Correction of hypotension:

- Norepinephrine 5 micrg?min-1, increasing the dose to achieve the desired effect:

• 5-10 micrg?min-1 — the predominant β-adrenostimuliruyuschee (cardiotonic) effect

• > 10 micrg?min-1 — the predominant α-adrenostimuliruyuschee (vazotonichesky) effect

• is used for categorical hypotension (BP syst. < 70 mm Hg), after its removal shows the introduction of dopamine or dobutamine [10]

- Dopamine 1 micrg?kg-1?min-1, increasing the dose to achieve the desired effect:

• 1-3 micrg?kg-1?min-1 — dofaminstimulative effect (improved perfusion of the mesenteric vessels, kidneys, and myocardium)

• 4-10 micrg?kg-1?min-1 — the predominant β-adrenostimulative effect

• 11-20 micrg?kg-1?min-1 — sochetannyj α- and β-adrenostimulative effect

• > 20 micrg?kg-1?min-1 — the predominant α-effect adrenostimulative

- Dobutamine 5 micrgram ? kg-1 ? min-1, increasing the dose to achieve the desired effect:

• 5-15 micrg?kg-1?min-1 — increasing β-adrenostimulative effect

• > 15 micrg?kg-1?min-1 — the predominant β-adrenostimulative effect

- Epinephrine 1 micrg?min-1, increasing the dose to achieve the desired effect:

• 1-4 micrg?min-1 — β-adrenostimulative effect

• 5-20 micrg?min-1 — increasing α-effect adrenostimuliruyuschee

• > 20 micrg?min-1 — the predominant α-effect adrenostimuliruyuschee

Thus, the use of NIHSS score to determine the severity of the disease, based on the severity of neurological symptoms, while monitoring multiorgan disorders reflects the vital changes in the body of critical patients with hemorrhagic stroke, which allows timely adjusted intensive therapy aimed at stabilization of vital functions of the body.


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