#1
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Õèðóðãè÷åñêîå ëå÷åíèå ïðè ñîïóòñòâóþùèõ íåâðîëîãè÷åñêèõ çàáîëåâàíèÿõ
Óâàæàåìûå êîëëåãè! Ðàáîòàþ íåâðîëîãîì â ïîëèêëèíèêå, êî ìíå íà ïðèåì íåñêîëüêî ðàç ïðèñûëàëè ïàöèåíòîâ ñ íåâðîëîãè÷åñêîé ïàòîëîãèåé âðà÷è äðóãèõ ñïåöèàëüíîñòåé (õèðóðãè÷åñêèõ), òðåáóÿ îò ìåíÿ ðàçðåøåíèÿ íà ïðîâåäåíèå èì õèðóðãè÷åñêèõ îïåðàöèé. Áîëåå êîíêðåòíî, íàïðèìåð, ìîæíî ëè ïðîâîäèòü æåíùèíå, ïåðåíåñøåé ÎÍÌÊ ãîä íàçàä (íåâðîëîãè÷åñêèé äåôèöèò òîëüêî â âèäå óìåðåííîé äèçàðòðèè), îïåðàöèþ ïî ïîâîäó êèñòû ÿè÷íèêà. Õîòåë áû óçíàòü, ÷åì ðóêîâîäñòâîâàòüñÿ â ýòîì ñëó÷àå è âî âñåõ ïîäîáíûõ ñèòóàöèÿõ? È âîîáùå èìåþò ëè ïðàâî íåâðîëîãè äàâàòü òàêèå ðàçðåøåíèÿ? îòäåëüíûé âîïðîñ ïî ýòîé òåìå - êàê ïðîãíîçèðîâàòü ïåðåíîñèìîñòü íàøèìè ïàöèåíòàìè àíåñòåçèè?
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#2
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ïî ïîñëåäíåìó âîïðîñó âîò òàêîå:
Wait as Long as Possible for Noncardiac Surgery After Stroke Compared with patients who never experienced strokes, those who had prior strokes had higher risk for major adverse cardiovascular events (MACE: a composite of nonfatal myocardial infarction, nonfatal ischemic stroke, and cardiovascular-related death): Stroke within 3 months before surgery: odds ratio, 14.2 Stroke between 3 and 6 months prior: OR, 4.9 Stroke between 6 and 12 months prior: OR, 3.0 Stroke ≥12 months prior: OR, 2.5 A similar pattern in risk was seen for 30-day mortality. Risk for MACE and all-cause mortality leveled off at 9 months.
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#3
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Çäðàâûì ñìûñëîì âêóïå ñ ìåäèöèíñêèìè ïîçíàíèÿìè. Åñëè ïàöèåíòà ñ íåâðîë. çàáîëåâàíèåì íóæíî îïåðèðîâàòü, åãî îïåðèðóþò, íå ñïðàøèâàÿ íåâðîëîãà. Êàêîå çíà÷åíèå äëÿ îïåðàöèè íà ÿè÷íèêå èìååò òîò ôàêò, ÷òî ïàöèåíò ïåðåíåñ îíìê? Ðàçâå ÷òî â ïëàíå âòîðè÷íîé ïðîôèëàêòèêè, íî òóò óæ ñàì õèðóðã äîëæåí çíàòü, áóäåò ëè îí îïåðèðîâàòü ïîä òåì æå àíòèàããðåãàíòîì èëè íåò, è êîãäà ïîñëå îïåðàöèè àñïèðèí îïÿòü ìîæíî íàçíà÷àòü áåç ðèñêà êðîâîòå÷åíèÿ.
Òàê æå è ñ íîàê. Ïî÷åìó ïðîãíîçèðîâàòü ïåðåíîñèìîñòü àíàñòåçèè äîëæåí íåâðîëîã? |
#4
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Âàäèì Âàëåðüåâè÷, ññûëêà òðåáóåò çàëîãèíèòüñÿ èëè ïëàòèòü.
Ó íàñ íåò ðåêîìåíäàöèé íå îïåðèðîâàòü â íå-îñòðîé ôàçå ïîñëå èíñóëüòîâ. Ãëàâíûé ôàêòîð: åñòü ïîêàçàíèÿ äëÿ îïåðàöèè èëè íåò. Ýëåêòèâíûå âåùè â îñòðîì ïåðèîäå, åñòåñòâåííî, äåëàòü íå ñòàíóò, ýòî ëîãè÷íî. |
#5
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Ó ìåíÿ ïî÷åìó-òî îòêðûâàåòñÿ, ïîýòîìó ïîäóìàë, ÷òî òàê ó âñåõ
Risk for postoperative adverse cardiovascular events was especially high during the first 9 months after stroke. Stroke is a known risk factor for adverse perioperative outcomes in patients undergoing noncardiac surgery. Whether this relation is time dependent is unclear. Researchers in Denmark examined a nationwide cohort of adult patients who underwent elective noncardiac surgery between 2005 and 2011. Of the almost half a million patients who underwent noncardiac surgery, 1.5% had histories of stroke (those with prior transient ischemic attacks or hemorrhagic stroke were excluded). Compared with patients who never experienced strokes, those who had prior strokes had higher risk for major adverse cardiovascular events (MACE: a composite of nonfatal myocardial infarction, nonfatal ischemic stroke, and cardiovascular-related death): Stroke within 3 months before surgery: odds ratio, 14.2 Stroke between 3 and 6 months prior: OR, 4.9 Stroke between 6 and 12 months prior: OR, 3.0 Stroke ≥12 months prior: OR, 2.5 A similar pattern in risk was seen for 30-day mortality. Risk for MACE and all-cause mortality leveled off at 9 months. COMMENT This study suggests that, similar to patients who suffer acute myocardial infarctions, patients with acute ischemic stroke are at excess risk for complications immediately following noncardiac surgery. Risk drops significantly at 6 months and stabilizes (although at a level still higher than baseline) at 9 months. Although we await further confirmation of these observational findings, we probably should wait at least 9 months before scheduling stroke patients for elective noncardiac surgery. çäåñü åùå îäíà ïóáëèêàöèÿ â âêëþ÷åíèåì ðåêîìåíäàöèé îò Society for Neuroscience in Anesthesiology and Critical Care [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] òàì â òàáëèöå äâà òîæå Candidate Modifiable Risk Factor -> Possible Risk Reduction Strategy Recent stroke -> Delay elective surgery ≥9 months after stroke "îñòðûé ïåðèîä" - ïîíÿòèå ðàñòÿæèìîå, õèðóðãàì ïîðîé íóæíî çíàòü åãî â êîëè÷åñòâå äíåé/ìåñÿöåâ
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#6
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Ñïàñèáî áîëüøîå çà îòâåòû!
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#7
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ß ïðîøó òàêîå çàêëþ÷åíèå îò òåðàïåâòîâ ïî ïîâîäó îïåðàöèé ïîä ïðîâîäíèêîâîé èëè ìåñòíîé àíåñòåçèåé ó áîëüíûõ âîçðàñòîì ïîñëå 60 ëåò è ñ ñîïóòñòâóþùåé ïàòîëîãèåé. Ìíîãèå òåðàïåâòû è ñåìåéíûå âðà÷è îòêàçûâàþòñÿ ïèñàòü çàêëþ÷åíèå, ÷òî ïðîòèâîïîêàçàíèé ê ïðîâåäåíèþ îïåðàöèè íåò. Ó êîãî íåò òàêîãî çàêëþ÷åíèÿ, òåõ íå îïåðèðóþ. Êòî ïðàâ?
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#8
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ÈÌÕÎ. Ýòî ñòðàõîâêà ðèñêîâ, íå èìåþùàÿ þðèäè÷åñêîãî îáîñíîâàíèÿ è çíà÷åíèÿ. Ýäàêîå ðàçäåëåíèå îòâåòñòâåííîñòè.
Ïî ñóòè çíà÷èìû äâà ôàêòîðà: 1. Èìååò âðà÷ êîìïåòåíöèþ ïðîèçâîäèòü êîíêðåòíûå äåéñòâèÿ? 2. Ïàöèåíò îñâåäîìëåí î âñåõ âîçìîæíûõ ïîñëåäñòâèÿõ è ïîäïèñàë ñîãëàñèå?
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Êîãäà çíàåøü ïî÷åìó íåëüçÿ, òî óæå ìîæíî (ñ) Ñ óâàæåíèåì, Ãóñåéíîâ Òèìóð Þñóôîâè÷ Ñàéò dr-timur.ru |
#9
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Öèòàòà:
Öèòàòà:
Ïàöèåíò-òî ñîãëàñèå ïîäïèñàë, íî åñëè ÷òî: áÀìàæêè-òî îò òåðàïåâòà íåò! Òåðàïåâòû îáû÷íî ìîòèâèðóþò ñâîé îòêàç òåì, ÷òî àíåñòåçèîëîã âî âñåì ðàçáåðåòñÿ. Íî ÿ æå ïðîâîæó àíåñòåçèþ ñàì, ïîýòîìó, äåéñòâèòåëüíî, îòíîøóñü êî âñåìó ñåðüåçíî è ñòðàõóþñü. Åñòü â ýòîì ëîãèêà? |
#10
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Öèòàòà:
2. Ñ ìîåé òî÷êè çðåíèÿ, ïðè ïðàâèëüíî ïîñòàâëåííîé îðãàíèçàöèè, ïðîâîäíèêîâóþ àíåñòåçèþ äîëæåí äåëàòü àíåñòåçèîëîã. Äàæå åñëè õèðóðã èìååò íà ýòî ïðàâî. Òóò âñå ïðîñòî. Óçêèé ñïåöèàëèñò â ñâîåé îáëàñòè âñåãäà çíàåò áîëüøå. Íàïðèìåð, ñåé÷àñ åñòü ìíîãî äåâàéñîâ ïîâûøàþùèõ óñïåõ è òî÷íîñòü áëîêàäû íåðâà ïðè ìèíèìàëüíîì ðèñêå ïîâðåæäåíèÿ íåðâà.  òî æå âðåìÿ, îáåñïå÷èâàÿ çàäà÷ó îáåçáîëèâàíèÿ, ïðîäîëæåíèåì ïðîâîäíèêîâîé àíåñòåçèè ìîæåò áûòü ðàñøèðåíèå ïîñîáèé, âïëîòü äî íàðêîçà. À ýòî îáåñïå÷èòâàåò àíåñòåçèîëîã. 3. Åñëè õèðóðã èìååò ïðàâî íà ïðîâîäíèêîâóþ àíåñòåçèþ (ÿ íå ñîìíåâàþñü, ÷òî ýòî òàê), õèðóã îáúÿñíèë âîçìîæíûå îñëîæíåíèÿ, à ïàöèåíò ñ ýòèì ñîãëàñèëñÿ, ìíåíèå òåðàïåâòà íå âàæíî. ß òàê ïîíèìàþ, ñìûñë ïðèâëå÷åíèÿ òåðàïåâòà (ýíäîêðèíîëîãà, êàðäèîëãîãà...) îáåñïå÷èòü ïîäãîòîâêó ïî îòäåëüíîìó óçêîìó âîïðîñó. Äðóãîé ðàçãîâîð, ÷òî, âñå ðàâíî, àíåñòåçèîëîã ïðîñòàâëÿåò ðèñê ñâîåãî ïîñîáèÿ è áåðåòñÿ èëè íåò. È,êñòàòè, îïÿòü òàêè ïàöèåíò ñîãëàøàåòñÿ ïîä ïîäïèñü. Èëè íå ñîãëàøàåòñÿ.
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Êîãäà çíàåøü ïî÷åìó íåëüçÿ, òî óæå ìîæíî (ñ) Ñ óâàæåíèåì, Ãóñåéíîâ Òèìóð Þñóôîâè÷ Ñàéò dr-timur.ru |
#11
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Öèòàòà:
Öèòàòà:
Öèòàòà:
Öèòàòà:
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#12
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Äà ïîíÿòíî. Ïîëàãàþ, ÷òî ýòî îñîáåííîñòü ïîñòñîâåòñòêîãî ïðîñòðàíñòâà. Äóìàþ â Ðîññèè, ÷óòîê äàëüøå îò Ìîñêâû è Ïèòåðà, òå æå æèçíåííî-ïðàêòè÷åñêèå ïîäõîäû
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Êîãäà çíàåøü ïî÷åìó íåëüçÿ, òî óæå ìîæíî (ñ) Ñ óâàæåíèåì, Ãóñåéíîâ Òèìóð Þñóôîâè÷ Ñàéò dr-timur.ru |