#1
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Èíôóçèîííàÿ òåðàïèÿ ïðè ýïèñòàòóñå
Âîïðîñû:
1) íóæíî ëè îãðàíè÷èâàòü ïîëó÷åíèå æèäêîñòè ïðè óãðîçå îò¸êà ìîçãà? 2) îòäàòü ëè ïðåäïî÷òåíèå ïðè ýòîì ïåðîðàëüíîìó ââåäåíèþ æèäêîñòè? |
#2
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Ïðè ýïèëåïòè÷åñêîì ñòàòóñå êàê ïðàâèëî íåîáõîäèì â/â äîñòóï, ïîýòîìó ìåäëåííîå ââåäåíèå èçîòîíè÷. ðàñòâîðà êàê ïåðâàÿ ìåðà ðåêîìåíäîâàíà (åñëè ïîäîçðåâàåòñÿ ãèïîãëèêåìèÿ: +60 ìë 40% ãëþêîçû + 100 ìã òèàìèíà):
Obtaining intravenous access is the next step, and blood should be sent to the laboratory for measurement of serum electrolyte, blood urea nitrogen, glucose, and antiepileptic drug levels, as well as a toxic drug screen and complete blood cell count. Isotonic saline infusion should be initiated. Because hypoglycemia may precipitate status epilepticus and is quickly reversible, 50 mL of 50 percent glucose should be given immediately if hypoglycemia is suspected. If the physician cannot check for hypoglycemia or there is any doubt, glucose should be administered empirically. Thiamine (100 mg) should be given along with the glucose, because glucose infusion increases the risk of Wernicke's encephalopathy in susceptible patients. Management of Status Epilepticus [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] Ïðè ñóïåð-ðåôðàêòåðíûõ ýïèñòàòóñàõ ìîæåò áûòü íàçíà÷åíà â/â ìàãíåçèÿ (+ïèðèäîêñèí ó äåòåé), ïîäðîáíåå: The treatment of super-refractory status epilepticus: a critical review of available therapies and a clinical treatment protocol [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#3
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Êîíå÷íî æå, ó ðåá¸íêà åñòü â/â äîñòóï. Ïàöèåíò íà ïîñòîÿííîì òèîïåíòàëîâîì íàðêîçå 100ìã/÷àñ (âåñ 70êã).  îòäåëåíèè âîçíèêëà ñïîðíàÿ ñèòóàöèÿ - ïðè ãåìàòîêðèòå 0,49 ââîäèòü ëè ïðåïàðàòû â âåíó ïðè ñêîìïðîìåíòèðîâàííîì ìîçãå èëè ââåñòè åé ôèçïîòðåáíîñòü (2400ìë) ÷åðåç çîíä. Èëè âåñòè â îãðàíè÷èòåëüíîì ïî æèäêîñòè ðåæèìå.  êà÷åñòâå ïðîôèëàêòèêè îò¸êà ìîçãà ïîëó÷àåò ìàãíåçèþ 10ìë íà ôèçðàñòâîðå, êàïåëüíî, ëèçèí.
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#4
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#5
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17 ëåò, 70êã. Ïîñòóïèëà ñ ïîâòîðíûìè ýïèçîäàìè òîíèêî-êëîíè÷åñêèõ ñóäîðîã, êóïèðóþùèõñÿ ñèáàçîíîì. Íà ñëåäóþùèé äåíü ãåíåðàëèçîâàííûå òîíèêî-êëîíè÷åñêèå ñóäîðîãè, ïîòîðÿþùèåñÿ êàæäûå 15-30 ìèí ïðè ââåäåíèè ñèáàçîíà â/â. Ïåðåâåäåíà íà ÈÂË, òèîïåíòàëîâûé íàðêîç. Ñóäîðîãè íå ïîâòîðÿëèñü. ×åðåç 15 ÷àñîâ ÈÂË òèîïåíòàë îòìåí¸í, ýêñòóáèðîâàíà. Áåç àïïàðàòà 11 ÷àñîâ, ïîñëå âîçíèêëè ýïèçîäû àïíîý äî 5-10ñ ñ ïîñëåäóþùåé ãèïåðâåíòèëÿöèåé, íåðåãóëÿðíîå äûõàíèå. Äî ýòîãî ïðè ãåìàòîêðèòå 0,49 ââåäåíî 600 ìë ãëþêîçû 5% + ôèçðàñòâîðà. Ïîâòîðíî ïåðåâåäåíà íà ÈÂË. Ñîñòîÿíèå ðàñöåíåíî êàê
1) âîçíèêíîâåíèå îò¸êà ìîçãà íà ôîíå ìàññèâíîé èíôóçèè? 2) ðàííÿÿ ýêñòóáàöèÿ? Ïðèíÿòî ðåøåíèå âåñòè íà îãðàíè÷èòåëüíîì ïî æèäêîñòè ðåæèìå - ôèçïîòðåáíîñòü (2400ìë/ñóò) õ 0,7 = 1800ìë/ñóò. Âñå äíè äèóðåç ñî ñòèìóëÿöèåé ôóðîñåìèäîì. Âåä¸òñÿ â íóëåâîì áàëàíñå. Êîðìëåíèå çîíäîâîå, ñìåñüþ. Íà ÈÂË 36 ÷àñîâ, ýêñòóáèðîâàíà ñåãîäíÿ óòðîì.  14-30 4 ýïèçîäà ñíà÷àëà òîíè÷åñêèõ, à ïîòîì òîíèêî-êëîíè÷åñêèõ ñóäîðîã, íà êàæäûé ýïèçîä ââîäèëñÿ ñèáàçîí 2,0 â/â.  èòîãå ñíîâà ïåðåâåäåíà íà ÈÂË, ëå÷åáíûé íàðêîç òèîïåíòàëîì 300ìã/÷àñ ñ ïîñòåïåííûì ñíèæåíèåì äîçû äî 50ìã/÷àñ, âñëåäñòâèå ÷åãî ýïèçîä òîíè÷åñêèõ ñóäîðîã ñ àóðîé â âèäå ãîëîâîêðóæåíèÿ, ãîëîâíîé áîëè, ðàñøèðåíèÿ çðà÷êîâ. Äîçà óâåëè÷åíà äî 100ìã/÷àñ, ââåä¸í ñèáàçîí. Ãåìàòîêðèò 0,48. ÖÂÄ 60ñì H2O. |
#6
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Ïðè âåäåíèè ýïèñòàòóñà, ïðîòèâîýïèëåïòè÷åñêèå ïðåïàðàòû (áàçîâûå), íàçíà÷àþòñÿ ïàðàëëåëüíî íåîòëîæíûì ìåðîïðèÿòèÿì (÷èòàé: òèîïåíòàëîâîìó íàðêîçó). Âåðñèÿ ñ îòåêîì ìîçãà çàìàí÷èâà, íî åñëè ñóäîðîæíàÿ àêòèâíîñòü (ïî ÝÝÃ, à íå ïî âèäèìûì ñóäîðîãàì) áûëà ïîäàâëåíà, à òàêæå íå áûëî äðóãèõ ïðè÷èí äëÿ âòîðè÷íîãî ïîâðåæäåíèÿ ìîçãà (ãèïîêñèÿ, ãèïîòîíèÿ íà ýòàïå ïîñëå ïåðâîé ýêñòóáàöèè), òî îíà ìàëîâåðîÿòíà. Âûïîëíåíèå ÝÝÃ, íåéðîâèçóàëèçàöèÿ, â ïîèñêàõ ïðè÷èíû ýïèñèíäðîìà (÷òî ëå÷èì?) íå óêàçàíû. Ïðèìåíåíèå èçîòîíè÷åñêîãî ðàñòâîðà ãëþêîçû áåç äîñòàòî÷íûõ íà òî ïîêàçàíèé (åäèíñòâåííîå - "ãèïåðòîíè÷åñêàÿ äåãèäðàòàöèÿ", ïî îäíîé èç äðåâíèõ êëàññèôèêàöèé) íå îïðàâäàíî íè÷åì, èáî ñóòü åñòü âîäà äèñòèëëèðîâàííàÿ. Ñîîòâåòñòâåííî äåãèäðàòèðîâàòü ïàöèåíòà ïî ïîäîçðåíèþ íà "îòåê ìîçãà" íå åñòü õîðîøî. Åùå è àêòèâíî ôóðîñåìèäîì. ×òî òàì ñ íàòðèåì? Äîçà òèîïåíòàëà äà, íà÷èíàåòñÿ ñ 3-5 ìã/êã/÷àñ, ïîäáèðàåòñÿ ïî ïîäàâëåíèþ ñóäîðîæíîé àêòèâíîñòè íà ÝÝÃ, íî ïîñëå 48 ÷àñîâ èíôóçèè ñíèæàåòñÿ, òàê êàê ïðåïàðàò àêòèâíî íàêàïëèâàåòñÿ â æèðîâîé òêàíè.
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#7
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Òóðåöêèå ïåäèàòðû óêàçûâàþò íà âîçìîæíîñòü ðàçâèòèÿ ñèíäðîìà öåðåáðàëüíîé ïîòåðè ñîëåé "Cerebral salt wasting" íà ôîíå ýïè-ñòàòóñà, êîòîðûé ìîæåò ñîïðîâîæäàòüñÿ ïîâûøåíèåì ãåìàòîêðèòà (à òàêæå äð. ëàá. îòêëîíåíèÿìè):
Cerebral salt wasting in status epilepticus: two cases and review of the literature [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] î ñàìîì ñèíäðîìå: Cerebral Salt Wasting: Pathophysiology, Diagnosis, and Treatment [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#8
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Àïíîý- ìîæåò ïåðåäîçèðîâêà ñèáàçîíà, êàê îäíà èç ïðè÷èí?
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#9
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 òîò äåíü ñèáàçîí íå ââîäèëñÿ.
Áàçîâî áûë íàçíà÷åí âàëüïðîêîì 20ìã/êã (1,5ã/ñóò) â ïåðâûå ñóòêè, 30ìã/êã â ïîñëåäóþùèå. Ïîëó÷àëà îíà åãî ÷åðåç çîíä 3 ðàçà â äåíü. ÝÝà íå ïðîâîäèëàñü - ó íàñ íåò ïîðòàòèâíîãî àïïàðàòà, à âåçòè å¸ êóäà-òî â äðóãîå çäàíèå íà ÈÂË áûëî ïðîáëåìàòè÷íî. ÊÒ íå ïðîâîäèëàñü. Ìåíèíãåàëüíûå, î÷àãîâûå îòðèöàòåëüíûå. Ðàñöåíèâàëè êàê ýïèëåïñèþ. Öèòàòà:
Óðîâåíü íàòðèÿ íîðìàëüíûé. Âîïðîñ îñòà¸òñÿ ïðåæíèì, íå êàñàÿñü êîíêðåòíîãî áîëüíîãî, åñëè åñòü îò¸ê ìîçãà, âåñòè ëè áîëüíîãî â îãðàíè÷èòåëüíîì ðåæèìå ïî æèäêîñòè èëè ïî ôèçïîòðåáíîñòè? |
#10
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Öèòàòà:
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#11
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Âû òàê óâåðåííî ãîâîðèòå î îò¸êå ìîçãà, íî ÿ òàê è íå ïîíÿë ñäåëàëè âû õîòü ÊÒ?
Áàçîâûé ïðèíöèï ëå÷åíèÿ íåéðî ïàöèåíòîâ - íîðìîâîëåìèÿ, îò ýòîãî è îòòàëêèâàéòåñü, ôèç ïîòðåáíîñòü ( ëó÷øå åäîé è ïèòüåì, ÷åðåç çîíä, åñëè â ñåäàöèè). Îòåê ìîçãà ãèïîâîëåìèåé íå ëå÷èòñÿ, âû òîëüêî íàâðåäèòå. Åñëè óæ âû òàê ðàñïåðåæèâàëèñü îá îò¸êå çà÷åì ââîäèòü ðàñòâîð ãëþêîçû ( îí ãèïîîñìîëÿðåí!!!!), îíè ïðîòèâîïîêàçàíû íåéðî ïàöèåíòàì, êðîìå êàê êóïèðîâàíèå ãèïîãëèêåìèè 40% ðàñòâîðîì. Êàê ëå÷èòü îòåê ìîçãà ïî÷èòàéòå â ïðîòîêîëå ëå÷åíèÿ ×ÌÒ îò 2007 ãîäà, áàçîâûå ïðèíöèïû îäèíàêîâûå. ×òî áû ÿ ñäåëàë â âàøèõ îãðàíè÷åííûõ óñëîâèÿõ: 1- ïðî÷èòàë òîò ïðîòîêîë 2 - ÊÒ, áåç íåãî ýòî íå ëå÷åíèå à ãàäàíèå îá îò¸êå êàêîì-òî 2 íîðìî âåíòèëÿöèÿ, îêñèÿ, âîëåìèÿ, ãåìîäèíàìèêà. 3 ïîäáîð ýôôåêòèâíûõ ïðîòèâîñóäîðîæíûõ äëÿ ïëàíîâîé òåðàïèè, à íå òèîïåíòàë. 4. Êîíòðîëü ãëèêåìèè êðîâè è ýëåêòðîëèòîâ, ñìîòðèì íàòðèé è êàëèé, ïðèêèäûâàåì îñìîëÿðíîñòü êðîâè. ÏÑ, î êàêîì ñîëüòåðÿþùåì ñèíäðîìå ìîæíî ðàññóæäàòü, åñëè îíè ëå÷àò ôóðîñåìèäîì! |