RU2612264C1 - Method of treating patients in vegetative state and minimally conscious state - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: in case of appearance of EEG curve desynchronisation signs, growth of slow activity or appearance of signs of epileptic activity medication is not administered to patient. If at the background of preparation introduction initial EEG pattern changes with appearance of activity of alpha- and beta- range, after 15 minutes introduction of 2 ml of instenon is repeated and registration of EEG is continued. Dose of medication, at which growth of alpha- and beta-range is maximally expressed on EEG and changes of initial EEG pattern are not accompanied by signs of vegetative instability. Depending on obtained EEG alternations, medication is administered in optimal dose 2 or 4 ml per day for 5-10 days.

EFFECT: method increases treatment efficiency, which is achieved due to individual selection of dose of medication introduction by means of EEG registration.

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Description

The invention relates to medicine, namely to resuscitation, neurosurgery and neurology, and can be used to treat patients with severe brain damage in a vegetative state (VS) and a state of small consciousness.

A known method of treating patients in a vegetative state (RF patent No. 2464976, publ. 27.10.2012). The microcatheter is installed in the carotid pool to the level of the cavernous region of the most affected hemisphere of the brain or in the vertebral-basilar pool to the V4 segment. A continuous infusion of drugs is carried out through the microcatheter for seven days: neoton is administered sequentially 14-20 mg / kg / day, nimotope 0.1-0.2 mg / kg / day, ceraxone 85-100 mg / kg / day, and the daily dose divided into two introductions. In parallel, heparin is infused with 10,000-12,000 units. per day.

The method provides effective treatment by creating a high concentration of drugs in the field of brain damage in patients with various etiologies of the vegetative state. However, this method can only be carried out in a hospital providing high-tech medical care, requires the use of expensive supplies, monitoring the patient in the intensive care unit. Contraindications are: the presence of intracranial hypertension, abnormalities of cerebral vessels (AVM, arterial aneurysms, stenosis, etc.). All this significantly limits the capabilities of the method.

Closest to the claimed is a method of treating patients in a vegetative state and a state of small consciousness (RF patent No. 2217143, publ. 11/27/2003). Choline alfoscerate is administered intravenously at a dose of 8-10 g / day, and at the same time, clonidine is administered at a dose of 0.4-0.6 μg / kg / h in the same or another vein.

The disadvantages of the prototype:

- choline alfoscerate is a single drug containing one of the mediators acting on the ascending activating formation. Choline alfoscerate can cause autonomic instability, which requires administration of clonidine to stop it. Selection of an adequate dose of clonidine often takes time (24-48 hours);

- there are no developed instrumental methods for monitoring the effectiveness of drug exposure.

The invention is aimed at creating a method of treating patients in a vegetative state and in a state of small consciousness, providing a comprehensive effect on an activating ascending reticular formation, under the control of the effectiveness of the drug with the subsequent decision on the appropriateness of its use in this patient.

The specified technical result in the implementation of the invention is achieved by the fact that in the known method of treating patients in a vegetative state and a state of small consciousness, including intravenous administration of a drug that acts on the ascending activating reticular formation, the peculiarity is that before, during and after the introduction of 2 ml instenon is recorded by EEG, with the appearance of signs of desynchronization of the EEG curve, an increase in slow activity or signs of epileptic activity, the drug e is prescribed if, against the background of drug administration, the initial EEG pattern changes with the appearance of alpha and beta range activity, after 15 minutes 2 ml of instenon is re-introduced, continuing EEG registration, the dose of the drug at which alpha and beta wave growth is optimal is considered maximally expressed on the EEG, and changes in the initial EEG pattern are not accompanied by signs of autonomic instability, depending on the obtained rearrangements, the drug is prescribed in the optimal dose of 2 or 4 ml per day for 5-10 days.

Instenon has a complex effect. Ethamivan stimulates the respiratory and vasomotor center, has a pronounced activating effect on the limbic system and the reticular formation of the brain stem, which leads to the adequate functioning of neural complexes of the cortex and subcortical-stem structures. Hexobendin stabilizes the mechanisms of autoregulation of cerebral and cardiac blood flow, moderately dilates coronary and cerebral vessels, increases the transport and utilization of glucose and oxygen by brain cells, stimulates neuronal metabolism, activates anaerobic glycolysis and the pentose cycle, facilitates the synthesis and metabolism of neurotransmitters, and restores synaptic transmission. Etophylline increases cardiac output, which contributes to an increase in perfusion pressure in the vessels of the marginal zone of ischemia, stimulates subcortical formations of the midbrain.

The method is as follows. Initially, an EEG is recorded. Then, one ampoule containing 2 ml of instenon is diluted in 20 ml of physiological saline and injected slowly intravenously for 3 minutes. EEG, heart rate, blood pressure, and BH are monitored. If there are signs of desynchronization of the EEG curve, an increase in slow activity or the appearance of signs of epileptic activity in the future, a repeated dose of the drug is not administered. The described changes in the EEG pattern indicate instability of the diencephalic sections of the trunk, insufficiency of compensatory-adaptive reactions in this patient. In the future, the drug is not prescribed to the patient. If, against the background of drug administration, the initial EEG pattern changes with the appearance of alpha and beta range activity, which indicates the preservation of corticothalamic bonds, sufficient stability of the diencephalic structures, then to select the optimal dose, re-introduction of instenon in the same dose, 2 ml is carried out after 15 minutes ( a total of 4 ml, continuing to monitor the EEG). The dose of the drug (2 or 4 ml) is considered the most effective, at which the increase in alpha and beta waves is most pronounced on the EEG, and changes in the initial EEG pattern are not accompanied by signs of autonomic instability (there is no increase in heart rate, BH, the appearance of hyperhidrosis, increased spasticity) . In the future, the drug is prescribed daily at a dose of 2 or 4 ml per day intravenously slowly for at least 2 hours in a dilution of 200 ml of physiological solution of sodium chloride for 5-10 days.

A method of treating patients in the Armed Forces and state of low consciousness was developed and passed clinical trials in the Department of Anesthesiology and Resuscitation of the Russian National Pedagogical Institute named after prof. A.L. Polenova in the treatment of 26 patients. In 12 of the 26 studied patients, there was a restructuring of the EEG pattern with the appearance of faster activity, which was not accompanied by signs of autonomic instability. In other patients, the drug was not used due to its negative effect on the original EEG pattern. In 12 patients receiving instenon, the period of wakefulness during the period of drug administration was clearly increased, which made it possible to more effectively implement the rehabilitation program.

We give examples - extracts from the medical history

Example 1. Patient Z., 19 years old.

Diagnosis: open TBI, severe brain contusion with the formation of a subdural hematoma on the left, the condition after osteoplastic trepanation of the skull, removal of contusion foci and subdural hematoma of the left cerebral hemisphere.

The patient was admitted to the Department of Anesthesiology and Intensive Care RNHI on the 37th day after a head injury in a vegetative state. According to the claimed method, the EEG was recorded, disorganized low-amplitude activity with the absence of the α-range, moderate interhemispheric asymmetry with emphasis on the theta index in the leads from the right temporal region were recorded (Fig. 1a). Introduced 2 ml of instenon with simultaneous registration of EEG. 2 minutes after administration, it was noted: EEG desynchronization with the appearance of EMG potentials (Fig. 1b), the appearance of signs of autonomic instability: increased heart rate, increased blood pressure, hyperhidrosis. The drug was not re-administered.

Example 2. Patient T., 20 years old.

Suddenly lost consciousness, entered the intensive care unit in a coma 1 state, leaving the coma in a vegetative state.

Received at the Russian National Research Chemical Institute. A.L. Polenova on the 42nd day in a vegetative state. According to the applicant, a standard EEG was recorded - a pattern of polymorphic disorganized activity, without signs of alpha activity (Fig. 2a) - followed by slow intravenous administration of 2 ml of instenon. EEG recording continued during the administration of the drug and 10 minutes after the administration, the alpha range activity appeared, without the correct zonal distribution (Fig. 2b). After 15 minutes, 2 ml of instenon was re-introduced. Significant changes in the electroencephalogram compared with the previous one - with the introduction of 2 ml of instenon was not detected. The optimal dose is 2 ml. Against the background of the introduction of the drug, the patient became more active - awake. The patient received instenon at a dose of 2 ml for 10 days. A positive effect was noted - exit to a small consciousness.

Claims (1)

A method of treating patients in a vegetative state and a state of small consciousness, including intravenous administration of a drug acting on the ascending activating reticular formation, characterized in that before, during and after the administration of 2 ml of instenon, EEG is recorded, when signs of desynchronization of the EEG curve appear, slow activity increases or the appearance of signs of epileptic activity, the drug is not prescribed to the patient if, against the background of the drug administration, the initial EEG pattern changes with the appearance of alpha and beta activity a-band, after 15 minutes re-injected 2 ml of instenon, continuing the registration of the EEG, the dose of the drug is considered optimal, at which the growth of the alpha and beta waves is maximally expressed on the EEG, and changes in the initial EEG pattern are not accompanied by signs of autonomic instability, depending from the obtained rearrangements, the drug is prescribed in the optimal dose of 2 or 4 ml per day for 5-10 days.

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