Practical
recommendations.
The
lethality from cerebrovascular diseases is the third after cardiac and
oncologic ones and approximates 12 - 15%. 23 - 27% of insults are of people
younger 50 years; this process goes on. Invalidity after that approaches 40 -
73,4%. Cerebral ishemia can be caused by thrombosis, stenosis, embolus;
cerebral vascular deficiency, thromboembolus and artery-arterial embolus,
after damaging of aneurysms of cerebral vessels (the main reason for ishemia
is the prolonged arterial spasm.
In
sharp period the complications can arrive (pneumonia; secondary transgressions
of cerebral circulation; trophic transgressions; decompensation of
cardio-vascular activity. They significantly improve the lethality. Thereby
treating and preventing of complications of peak period of transgression of
cerebral circulation is of significant importance.
Already
the first period of development of cerebral ishemia the external respiration
is being transgressed; pathology of Chain-Stocks arrives; gaseous composition
and the acid-alcaline balance change with the development of hypohemia;
respiration alkalosis; metabolic acidosis; the changes of central hemodynamics
and peripheral circulation appear. As the hypoxia accompanies all of that, HBO
is of use..
HBO
restores practically any type of oxygental deficiency: prolongs the effective
penetration of oxygen into tissue; guarantees metabolism while the volume
speed of circulation lessens; reserves some add of oxygen in body.
Indications
and contraindications for HBO in top period of transgressions of cerebral
circulation.
1.
HBO is indicated in top period of insult. HBO can be prescript with first-time
and recidives of transgressions. HBO can be combined with surgeonal methods
(trombitimectopy of thrombosis of internal artery, extraintracranial
anastozomes, miocerebrepexy) and conservative therapy.
HBO
was also used for sicks with transforming transgressions of cerebral
circulation.
2.
HBO is indicated for sicks with damaged aneurysms of cerebral vessels when
hematoma is aborted and aneurysm is excluded from stream.
The
main device for HBO were baro-chambers "Oka-MT" and
"BL-3"; thereby the main task was to protect adequate respiration
and stable hemodynamics.
Tracheostoma
or intubational tube couldn't be contraindications for HBO.
Hypertension
(180/110) or hypotension (90/60) also couldn't be contraindications for HBO,
if hypertension crisis is absent; hypotensive therapy is delighted.
For
sicks with damaged aneurysms of cerebral vessels convulsions can appear (with
no epilepsy before), HBO for them can be applied only after deletion of
in-cerebral hematoma and investigation of convulsion activity of cerebrum with
electrocardiogram.
Special
care is needed for sicks with bradicardia: it in known that pulse is lessening
by 8 - 13% after HBO; thus if the beginning figure for it is less than 55, HBO
can be dangerous.
General
contraindications are as usual: caverns in lung; claustrophobia; epilepsy;
otorhinolaryngologic diseases; besides sharp infarct of myocard with
ishemiac insult.
Practical
use and regimes of HBO.
HBO
would be included in complex therapy as soon as possible (1 - 2 day after
insult); because the inflation is lessening. But it is also of use later on.
The
optimal figures for HBO are: 2AT; exposition - 40 minutes; 6 - 10 procedures
in course with 1 - 2 ones a day. The improving of pressure has practically
more advantageous healing effect comparatively with ordinary figure of 1,6AT;
but if the sick suffers (because of age; complications; individual properties
of body) from that, the pressure would be changed to more tender one. For
example: if pneumonia is developed, the procedures would be persued with 1,6AT
and permanent roentgen control on displays of pneumonia; after they diminish
the pressure would be changed to 2AT.
If
HBO is included in therapy before 3 days after insult, the percent of healed
sicks without complications is 1,7 times larger than of those without.
Ordinary
course includes 6 - 10 procedures; if the disease is hard or complications
appear; the course can be prolonged to 15 ones and a repetitive course can be
held in 1,5 - 2 weeks.
Before
the first procedure lung would be investigated on absence of caverns; just
before the procedure oil would be removed from skin; synthetic dress and metal
accessories.
For
prophylaxis of pain in ears during the compression solution of ephedrine or
naphtisin can be used. Sicks with transgressions of consciousness become
aggressive; the pulse improves. For these violations of respiratory are
dangerous after tongue retraction; to avoid this, patient would be put on
side. Tracheostoma can violate respiratory because of transformation of its
phlegm into film during the procedure of HBO.
Patient
would also release urinary bladder to avoid moving activities during the
procedure.
Sedative
medicines are desirable for preventing activity of psychically inadequate
sicks.
An
electrocardiographic control is compulsory; if something is wrong or the
patient is too active, the procedure would be changed to more tender or
interrupted. The majority have no troubles with HBO; only sometimes pain in
ears arrive, or claustrophobia, or ventricular blockade.
Including
of HBO in complex therapy of sharp violations of cerebral circulation is an
effective method of treating.
The
neuralgic displays have positive dynamics from the very beginning of
application of HBO. The degree of unconsciousness for those with it is
lessening; the patients become more active and communicable. The headaches,
dizziness and vomity diminish. These positive changed reduce partly after the
procedure; but the dynamics is positive. For sicks with hard violation the
positive changes are less than others this is probably because the cerebrum
of hard sicks has organic
violation
of its substance besides inflation.
The
efficiency of HBO was investigated on two similar (on age, degree of
violations, clinic criteria) groups of sicks: one of them had HBO included in
complex therapy (main group); other (control one) hadn't. Complex therapy
included: dehidratational, vessel-broadening, hypotensive, antiseptic therapy;
correction of reology of blood and acid-alkaline balance; normalizators of
cerebral metabolism; parental food if needed.
Worthening
for the main group took place 3 times more rare than for control one on 4 - 6
day after insult; that worthening must have been caused by improvement of
inflation and arriving of secondary phenomena.
The
period of being in hard state reduced for main group at three days on average.
A
good result of treating - means dynamics of neuralgic symptoms by 2 points and
absence of complications on the top of disease; a satisfactory one - means
dynamics of neuralgic symptoms by 1 point and absence of complications on the
top of disease for part of patients; the treating is ineffective if the
dynamics of general symptoms is positive, but no regress of local symptoms is.
Table
1. Results of treating of main and control groups.
|
Group |
Result
of treating, % |
||
|
good |
satisfactory |
absence of effect |
|
|
Main |
50 |
25 |
25 |
|
Control |
39 |
34 |
27 |
In
main group good results took place 2 times more often; in control group these
are almost equal. In main group 11% improvement of complete recreation of
moving and speaking activity is observed.
Besides
positive influence of HBO on treating of insult, the number of complications
(pneumonia, trophic transgressions, repetitive violations of cerebral
circulation) also lessens for main group. Amount of complications of sharp
period reduces 4 times; pneumonia 2 times; HBO diminishes recidives of
violation of cerebral circulation on 3 - 4th week after insult. HBO is an
excellent protection from bedsores.
General
lethality is 2,4 times less for the main group; time, spent in clinic - a week
shorter on average.
All
these results are caused by HBO-therapy with working pressure of 2AT and
beginning of course as soon as possible; comparative results of other variants
of application of HBO are represented in Table 2.
Table
2. Comparative results of variants of application of HBO.
|
|
result of treating, % |
|||
|
working
pressure |
beginning of course |
Good |
satisfactory |
absence
of effect |
|
1,6AT |
1 - 3 day |
|
13 |
20 |
|
4th day and later |
67 |
32 |
30 |
|
|
2AT |
1 - 3 day |
38 |
21 |
8 |
|
4th day and later |
71 |
31 |
25 |
|
|
|
44 |
|
||
HBO
reduces the primary recreation after operations on cerebral vessels after
violated aneurysms: lessens meningeal syndrome, headache, temperature
reaction, pussing of wound after operation; 18% - improvement of proper
recreation of functions; prevents psychic's violations (if broval hematoma is
absent).
In
main group the complications are usually appear together with hematoma. For
control group the psychic's violations appear even in absence of hematoma of
any localization - probably because of vascular spasm, ishemia and inflation
of broval segment. Literature data predicts positive influence of HBO on
traumal and sharp exogenous psychoses. HBO probably reduces the cerebral
damage after spasm and inflation; this results in lessening of psychical
changes.
Spyrographic
investigations of external respiration of sicks with insult and recidival
violation of nerve trunk pathologic rhythmes of respiration; alterniral
Chain-Stock's breath; hyperventilation are observed. Volume per minute (VPM)
can achieve 270% in phase of aspnoe; the use of oxygen improves - that
compensates ventilation in phase of aspnoe.
Some
patients have wave-type respiration with improved or normal VPM. Only 20%
perform no changes of external respiration. Changes in respiration can be
non-adequate the degree of disease. Hypoxemia, respiratory alkolosis and
metabolic acidos can appear in blood.
HBO
positively influents the external respiration: pathology of Chain-Stocks, if
any, changes with wave respiration with temporary hyperventilation.
Improvement of venial stream from head prevents from cerebral inflation. The
use of oxygen reduces.
We
have no data on use of HBO for treating the primary truncal violation;
probably this would be useless.
Together
with improvement of VPM and wave typisation of respiration the rhythm and
ventilation are also bettering. VPM from 194% changes to 146%. This is caused
mainly by big figure of VPM from the beginning. With lessening of VPM the
efficiency if respiration also improves.
Before
HBO sicks often have shifts of acid-alkaline balance with the improvement of
metabolic acidos; respiratory alkolosis have 69% of hard sicks. After
operation on cerebral vessels majority of sicks acquire compensated form of
metabolic acidos.
Hypoxemy
usually is observed at decompensated form of metabolic acidos; at respiratory
alkolosis oxygental tension in capillaries is reduced moderately.
In
process of HBO acid-alkaline balance normalizes. Best correction acquire less
evident violations of acid-alkaline balance.
Diminishing
of external load from external respiration displays lessening of hypoxia and
proves the healing activity of HBO.
HBO,
if used in sharp state of ishemiac insult, reduces violations of hemodynamics.
This is very important for the security of sick.
5%
of sicks showed the improvement of systolic pressure by 14mm. on average, but
usually it lessens after HBO. If pressure is small from the beginning, after
HBO it can slightly improve.
HBO
recreates electric ventricular systole, improves activity of myocard, reduces
taxycardia and lessens extrasystolation, according to electrocardiographical
data.
For
sicks with compensational hypodynamics of myocard VPM lessens from 11 to 8,66
liters per minute and this also proves lessening of hypoxia. Unloading of
myocard prevents the damaging of compensation abilities of body and
development of cerebral deficiency. Lessening of stroke volume also protects
from cerebral inflation. 42% of sharp insults are supplied hypodynamic
circulation with lessening of stroke volume. Low stroke volume strengthen the
hypoxia and can cause cerebra-vascular deficiency. This is the mechanism of
developing of recidive of violation of cerebral circulation at 3 - 4 week
after insult.
For
control group hypodynamic circulation has similar probability at 1, 2, 3 weeks
of sharp period. The most significant changes of stroke volume are at the
third week (UOS - 43,61+-3,14ml; VPM - 3,26+-0,27 l/min., SI - 1,86+-0,15
l/min*m2).
Hypodynamic
circulation was rare after HBO - only 9% at third week (comparatively 42% of
control group). Changes of central hemodynamics are less transparent (UOS -
63,00+-4,21ml; VPM - 4,35+-0,77 l/min., SI - 2,48+-0,17 l/min*m2). HBO
improves squeezing of myocard and diminishing of ishemia (according to
electrocardiogram); that causes improvement of VPM.
PEG
has no regular dependence of HBO. For hypodynamic sicks UOS improves
(REG-amplitude remains low) when tonus of cerebral vessels can improve or
lessen.
Thus
HBO can prevent complications after sharp cerebral ishemia (recidive insult,
pneumonia, bedsores), improves external respiration and central hemodynamics,
and sequentially is important in treating of sharp violations of cerebral
circulation.
Doctor
S.Pravdenkova,
Professor
Yu.Isakov,
Doctor
V.Shelkovsky.