[Application of shot-latency cortical somato-sensory evoked potentials for evaluation of swallowing disorders in early period after posterior fossa surgery].

UNLABELLED: Main tasks of early postoperative period in patients after posterior fossa surgery are the timely and safe weaning from mechanical ventilation and extubation. For clinical assessment of the hypopharynx function we use an algorithm developed in the intensive care unit (ICU) of the Burdenko Scientific Research Institute of Neurosurgery. Disadvantages of the clinical test for assessment of patient's readiness for extubation are subjectivity and impossibility to use it in conditions of even superficial sedation. Shot-latency somato-sensory evoked potentials (SSEP) can be applied in conditions of sedation and objectify the brain stem deficit. The goal of the study was to define the changes of cortical SSEP in patients with disorders of swallowing after posterior fossa surgery. To assess the swallowing disorders we used a scale of swallowing disorders in intubated patients with brain stem damage. We compared results of cortical SSEP, test of swallowing disorders in intubated patients and clinical results of extubation. 17 patients with tumors of posterior fossa were included in the study. All patients were divided into two groups depending on duration of mechanical ventilation. Patients of the group-1 were successfully extubated in 4.5 hours. Patients of the group-2 were mechanically ventilated more than 15 hours because of impossibility to pass the test of readiness for extubation. RESULTS: Central conduction time symmetry index after the surgery was lower in the group-1 than in group-2. There was inverse correlation between amplitude of cortical response N20 and time from the patient's admission to the ICU until the moment of extubation. CONCLUSIONS: Asymmetry of central conduction time and decreasing of N20 amplitude can be used as additional predictor of swallowing disorder.

[Citicoline as component of the therapy of postoperative delirium in neurosurgical patients].

Delirium is a clinical sign of acute cerebral dysfunction. It is characterized by consciousness alterations with attention impairment and mentally disorganization. Frequency of delirium is 40-80% in general intensive care and more in patients in neurointensive care unit. We tried to assess citicoline (Ceraxon, Nycomed) safety and efficacy in treatment of postoperative delirium in patients with tumors of chiasm-sellar area of brain. 12 patients were included in citicoline group and 8--in control group. In both group combined type of delirium was common: 83.3% and 75%, accordingly. Citicoline didn't influence on delirium duration. Median of duration of mechanical ventilation was 1.5 and 6 days; mean and standard deviation were 10.5 +/- 15.4 and 17.5 +/- 27.9 days. Median of length of stay in ICU was 7 and 9.5 days; mean and standard deviation were 25.4 +/- 33.1 and 14.9 +/- 15.1 days. These results show that citicoline didn't influence on duration of mechanical ventilation and length of stay in ICU. Outcomes were similar in both groups, but frequency of full functional state recovery in citicoline group was significantly higher: 5 (41.7%) to 2 (25%) in control group (p < 0.05). We consider that citicoline therapy is safe for patients with tumors of chiasm-sellar area and lead to increasing of frequency of full functional state recovery.

[Analysis of thyroid homeostasis disorders in patients with severe traumatic brain injury].

Aim of the study was to investigate the status of thyroid homeostasis and the relationship between severe traumatic brain injury (TBI) and thyroid disorders. The study included 56 patients. Protocol of the study concluded: noninvasive and invasive hemodynamic monitoring, including PICCO, transcranial Doppler ultrasonography, measurement of intracranial pressure (ICP), indirect calorimetry, levels of thyroid stimulating hormone (TSH), T3, T4 and free fractions. Patients were divided into three groups. Group 1--with normal thyroid hormones (n = 20), Group 2--with the low T3 (n = 23) and Group 3 with the low T3 and T4 (n = 13). Correlation between the Glasgow Coma Scale (GCS) and thyroid hormone levels was obtained: the first group between GCS and T4 (r = 0.50), GCS, and free fraction T4 (r = 0.51); between the GCS and TSH (r = 0.51), T3 (r = 0.48) and T4 (r = 0.57) in the second group, and the third--with TSH (r = 0.67). Poor outcomes in the first group compound 15%, in the second group--39.2%, and in the third group--62.5% of patients. Doses of vasopressors were significantly higher in groups 2 and 3 compared with a first group. ICP was significantly higher in the group with the low T3 and T4. Development of intracranial hypertension correlated with the formation of thyroid insufficiency. Deficiency of thyroid hormones, especially the simultaneous reduction and T3, and T4 is associated with poor outcome in patients with severe TBI. Doses of sympathomimetic drugs used to optimize the parameters of systemic hemodynamics in acute severe head injury were higher in patients with deficiency of thyroid hormones.

[Protein malnutrition in patient in the early postoperative period after uncomplicated removal of the brain tumors].

Malnutrition leads to adverse effects and may worsen clinical outcome. Surgery as a stress factor activates pathological reactions changing metabolism structure. The aim of this study was to evaluate changes of protein metabolism in patients after elective neurosurgical operation. 24 patients were prepared for elective surgery and were enrolled in this study. Evaluation of each patient included: measurement of anthropometric indices--height, weight, arm circumference and the triceps skinfold thickness, the definition of protein loss by determining the loss of nitrogen in the urine, assessment of protein catabolism, determining the violations of nutritional status upon the base of laboratory parameters. During the course of the conducted investigation significant (p < 0.05) decrease in the indices of total protein, albumin, transferrin and the absolute numbers of lymphocytes in the postoperative period was revealed. All the patients developed severe protein catabolism. It became clear that uncomplicated elective surgical intervention, together with the adopted scheme of the nutritional therapy leads to severe protein catabolism in all patients.

[First experience of using adaptive support ventilation (ASV) mode in patients with severe traumatic brain injury].

Capabilities and limitations of ASV mode in TBI patients are studied. 12 patients with severe TBI were enrolled in the study. ICP, MAP, CPP were monitored in all the patients. Cerebral regional blood flow was monitored by thermal diffusion in four patients. Hamilton G5 ventilator was used for mechanical ventilation and respiratory monitoring in all cases. Starting mode of mechanical ventilation was ASV with 100% mechanical substitution. The patient was regarded as ASV-nonresponder and switched to another mode when normoventilation was not possible with any percent of respiratory substitution. ASV mode provided normoventilation during all period of mechanical ventilation in 88 ou of 12 patients. In 4 out of 12 patients ASV mode led to hyperventilation with EtC02 decrease, cerebral regional blood flow slowing and P0,1 index increase. In three patients hyperventilation was induced by high rate of spontaneous breaths caused by brainstem irritation. Switching these patients to SIMV-VC led to normoventilation, normalization of etC02 and cerebral regional blood flow, and P0,1 index decrease. In one patient hyperventilation was caused by lung mechanics disorder when ventilator tried to achieve target minute volume by low tidal volume and high respiratory rate. ASV mode provides adequate lung ventilation during respiratory support period in most patients with severe TBI. It can prove ineffective for some patients with brainstem irritation or lung mechanics disorders.

[Using ASV mode for respiratory support withdrawal in patients after posterior fossa surgery].

The study gives data on how to improve the way from mechanical to spontaneous breathing in patients with weakened respiratory drive after posterior fossa tumor removal. We compared the effectiveness of two methods of weaning from mechanical ventilation in these patients. The main group consisted of 6 patients weaned from ventilator with ASV mode. The control group was made up of 10 patients weaned from ventilator with SIMV or PS modes. The duration of weaning from ventilator using ASV mode was significantly shorter than with SIMV or PS modes. During ASV ventilation spontaneous breath rate gradually increased. In all patients the level of P0,1 index representing respiratory center activity was initially lower than normal. While spontaneous breath activity increased the level of P0,1 index also gradually normalized. Plmax index (respiratory effort index) measured once a day increased as well. Weakened respiratory drive is accompanied by P0,1 and Plmax indexes' decrease in patients after posterior fossa tumor removal. ASV mode in these patients allows quicker weaning from mechanical ventilation.

[First experience of using CoolGard system in intensive care patients after neurosurgical interventions: series of 10 observations].

Fever is a proven factor in secondary brain damage and worsens outcome in neuro intensive care patients. However, large randomized studies have shown neuroprotective effects of induced hypothermia only in patients with cardiac arrest and in neonates with perinatal hypoxic-ischemic brain damage. Nevertheless, now there is an active search for alternative modes of temperature correction, which would have been effective in other groups of patients with brain damage. Moreover, new management techniques of body temperature are being created. In this paper we presented a series of 10 observations when the used cooling system was CoolGard/CoolLine. 5 patients underwent hypothermia, 5 patients normothermia . Hypothermia was used for cerebroprotection in 1 case and for the correction of resistance to the therapy of intracranial hypertension in 4 cases. Normothermia was used for correction of resistance to pharmacological treatment of fever. In all cases the target temperature was achieved, and only for 1 patient to achieve hypothermia additional external cooling was used. Patients with normothermia did not need sedation, because they have not developed discomfort and muscle tremor. 2 patients died, in one case was due to intracranial hypertension and hemotamponade of brain ventricular system. Cause of second death was pulmonary embolism. Thus, the CoolGard system effectively lowers the body temperature to the target values for neuro intensive care patients. Application of this system is relatively safe. However, the most dangerous are the thromboembolic complications, thus the daily ultrasound scanning of lower limb veins and the possible early use of low molecular weight heparins is crucial.

[Plasma catecholamines in consciousness recovery in patients with severe traumatic brain injury].

Changes in plasma noradrenalin (NA) and dopamine (DA) levels were evaluated in the stages of consciousness recovery in patients with severe traumatic brain injury with and without deep brain structure damage. Forty-eight patients (36 men and 12 women), aged from 12 to 56 (31,9±10,9) yeas, were enrolled in the study. Two variants of catecholamine (CA) changes were found: 1) a CA-dissociation that was oppositely directed to NA and DA changes was observed in unconsciousness; 2) a CA-dissociation (unidirectional NA and DA changes) that was observed after the restoration of consciousness. In patients with the damage of two frontal lobes and deep brain structures, CA-association periods were seen in the stage of mental confusion with psychomotor agitation or when the brain stem was damaged. The duration of CA-association was negatively correlated with the velocity, quality of consciousness recovery and outcomes evaluated by the Glasgow scale.

[A respiratory failure rating scale in neurosurgical patients].

A respiratory failure (RF) rating scale has been developed to objectify indications for artificial ventilation (AV). The scale consists of three blocks gauging the level of consciousness, the degree of swallowing problems, cough, airway patency, and lung parenchymatous injury. The scale was tested in the period December 2009 to March 2010. Selection of patients in accordance with the chosen study inclusion and exclusion criteria allowed 15 patients to be enrolled in the study. Of them there were 8 (53%) women and 7 (47%) men. The patients' age was 25 to 68 years; median age was 42 years. There were cerebrovascular aneurysms and brain tumors of various locations and histology in 7 and 8 cases, respectively. Three groups of patients were identified. The first two groups included patients with successful extubation, but Group 2 patients were further reintubated because of neurological deterioration. In Group 3 patients, extubation was unsuccessful, i.e. these required reintubation within 48 hours after extubation. Groups 2 and 3 patients developed inflammatory complications, such as nosocomial pneumonia and sepsis; there were worse outcomes. If the tactics of AV initiation were determined from scale scores, it should not differ in Groups 1 and 2. Based on the scale scores, AV should be regained much more early than was practised. The developed scale allows one to optimize the time of AV initiation. Single patient assessment can ascertain a direct cause of respiratory failure (RF) while dynamic assessment can determine the sequence of changes in the magnitude of individual determinants of RF. In patients with unsuccessful tracheal intubation, the scale will optimize the time of reintubation, thereby reducing the incidence of nosocomial and aspiration pneumonia.

[Continuous mechanical ventilation in a neurosurgical intensive care unit (one-year analysis of results)].

This was a retrospective study. Its inclusion criterion was mechanical ventilation (MV) for more than 48 hours. One hundred and eighty-four case records of 184 neurosurgical intensive care unit patients were analyzed. Ventilation modes, upper airway cares and prosthetic replacement were chosen by the protocol accepted at the Institute. Great differences were found in the structure of indications for MV and in the duration of respiratory support in relation to the neurosurgical nosological entity and the site of a major process. The upper airway care protocols accepted at the Institute were shown to reduce the incidence of ventilator-associated pneumonia. Some risk factors for ventilator-associated pneumonia were identified.

[Comatose state caused by seizure-free status epilepticus in postoperative period].

We present a rare clinical observation of progressive development of neurological symptoms up to comatose state in a child with extra-intraventricular craniopharyngioma in delayed postoperative period due to seizure-free status epilepticus which was diagnosed only by EEG-monitoring. Concerning this case report, we discuss genesis of seizure-free status epilepticus and its possible role in development of severe condition in patients with different kinds of neurosurgical pathology in postoperative period.

[Choice of optimal respiratory therapy in patients operated for tumors of the posterior cranial fossa].

The results of two different approaches to respiratory support after surgical intervention into the structures of the posterior cranial fossa (PCF) are analyzed in 74 neurosurgical patients, including 41 patients having synchronized pressure support ventilation and 50-80% spontaneous intermittent mandatory ventilation (SIMV + PSV) (Group 1) and 33 patients receiving continuous positive end-expiratory airway pressure (CPAP + PSV) (Group 2). Respiratory therapy has been ascertained to provide at least 50-80% of the minute ventilation volume in neurosurgical patients after interventions into PCF when respiratory failure develops in the postoperative period. Diminished respiratory support may be performed only after neurological stabilization and within 24 hours. Early transition to spontaneous respiration increases the duration of artificial ventilation and worsens neurological symptoms.

[Effective therapy of acute cardiovascular and respiratory failure developed after removal of cervical spinal cord tumor in a child].

Development of hemodynamic and respiratory disturbances in cervical spinal cord injury is a known phenomenon. Its degree depends on severity of injury. Hemodynamic impairments include bradycardia and other arrhythmias, arterial hypotension due to decreased vascular tone and cardiac output and they may result in shock and asystolia. Pathogenesis of respiratory insufficiency is explained by decrease of vital and residual pulmonary volume, dysregulation of respiratory function, development of athelectases, changes in permeability of pulmonary capillaries, pneumonia. This leads to respiratory failure due to acute damage to lungs.

[A rating scale and therapeutic strategy in dysphagia in patients with brain stem damage].

Dysphagia appears in 15-17% of cases after removal of tumors of the posterior cranial fossa (PCF), which is one of the most life-threatening postoperative complications due to a risk of acute airway patency impairment, possible aspiration, bronchopulmonary infectious complications. This makes prognosis workse and complicates a patient's rehabilitation. Based on the results of fibrolaryngotracheoscopic study and treatment of 1653 patients operated on for PCF tumors, the authors have developed a scale for rating the severity of bulbar disorders. The proposed scale promotes decision making on the expediency of performing tracheostomy and on the necessity of evaluating the efficiency of performed therapy (trends in bulbar disorders) and predicting the course of a postoperative period.

[Prediction of respiratory complications after radical surgeries for non-small cell carcinoma of the lung].

A predictive role of volume-velocity (VV) indices of ventilation in prognosis of respiratory complications after radical surgeries for non-small cell carcinoma of the lung was evaluated. It is demonstrated that decreased VV indices of ventilation before surgery directly correlate with a respiratory complication rate after surgery. New methods of diagnosis of ventilation disorders and of monitoring are regarded as promising.

[Short-term results of radical surgeries for non-small cell cancer of the lung].

The results of radical surgical treatment of 358 patients with NSCCL were analyzed. Majority of patients were men (84.6%) and persons older 60 years -- 239 (66.8%) patients. Central cancer was diagnosed in 164 (45,8%) patients, peripheral -- in 194 (54.2%). There were 137 (38.3%) pneumonectomies, 184 (51.4%) lobectomies; 149 (41.6%) surgeries were combined. Complications after radical surgeries were seen in 92 (25.7%) of 358 patients, including 18 (5.0%) patients with <> complications and 74 (21%) patients with <> ones. Complications were seen more often in patients over 60 years and occurred less frequently after segmentectomy (7 patients). Lethality was 5.0% (18 patients). Respiratory complications (7 cases) and pulmonary embolism (5 patients) were the main causes of lethal outcome.