Рандомизированное контролируемое исследование эффективности электрофизиологического мониторинга дексмедетомидина у пациентов с повреждением головного мозга различного генеза

Background.At the same time, the main effect of the use of this drug is the elimination of the autonomic nervous system dysfunction and sympatholysis. It seems important to search for a method of indications and selection of a dose of dexmedetomidine in intensive care.Aims to improve the clinical effectiveness of the electrophysiological navigation of the prolonged use of dexmedetomidine in patients with brain pathology of various origins.Methods.The study included 83 patients 2050 days after the traumatic brain injury, anoxic damage; consequences of acute disorders of cerebral. 37 patients comprised the 1st intervention group with a clinical course of dexmedetomidine (male 28; female 9; average age 49.62.3 years) and 46 patients comprised the 2nd control group without pharmacological correction with dexmedetomidine (male 23; female 23, average age 512.5 years). Criteria for the inclusion of prolonged infusion of the drug dexmedetomidine (Orion Pharma, Finland) are based on heart rate variability (HRV) indicators characteristic of sympathetic hyperactivity, the target task of titration of doses of dexmedetomidine served as the parameters for achieving normal HRV indicators, the appearance of parasympathetic hyperactivity served as the basis for reducing the dosage of the drug or stopping it of application. HRV parameters were recorded before dexmetomedine infusion-initially, on 13; 45; 910; 1520 days of drug administration.Results.The starting dose of dexmedetomidine with sympathetic hyperactivity in patients was 0.12 to 0.24 g.kg1.hr1(average dose 0.160.01; total 200 mg/day). According to digital data from HRV, the effective dose of dexmedetomidine ED50 was 0.260.03 g.kg1.hr1(total daily 353.835.1 g) and was achieved on day 910 using dexmedetomidine.Conclusions.The protective role of dexmedetomidine with correction of sympathetic hyperactivity based on electrophysiological navigation according to the HRV is reliable in the following indicators: The improvement of consciousness; a significant decrease in the incidence of distress lung syndrome; septic shock; mortality.Обоснование. Дексмедетомидин используетсяприпроцедурной седациииликвидации симптомов симпатической гиперактивности (ажиотация, тахикардия, гипертензияит.п.). Основной эффект применения данного препарата устранение дисфункции автономной нервной системыисимпатолизис. Представляются важными поиск метода объективизации показанийиподбор дозы дексмедетомидинавинтенсивной терапии.Цель исследования улучшить возможности мониторингаиклиническую эффективность примененияидозирования дексмедетомидинаспомощью электрофизиологической навигацииупациентовспатологией головного мозга различного генеза.Методы.Висследование включено 83 пациента (51 мужчина, 32 женщины; средний возраст 50,381,7 года)впериод более 20днейспоследствиями: черепно-мозговой травмы (ЧМТ) (n=24; 28,9%); острого нарушения мозгового кровообращения (ОНМК) (n=17; 20,5%); аноксического повреждения головного мозга (n=16; 19,3%); субарахноидального кровоизлияния (n=23; 27,7%); нейрохирургических операцийнаголовном мозге (n=3; 3,6%). 37 пациентов (28 мужчин, 9 женщин; средний возраст 49,62,3 года) составили первую группу вмешательстваcкурсом клинического применения дексмедетомидинаи46 пациентов (23 мужчины, 23 женщины; средний возраст 512,5 года) вторую (контрольную) группубезфармакологической коррекции дексмедетомидином. Критерии начала пролонгированной инфузии препарата дексмедетомидина (фирмаOrionPharma, Финляндия) основанынапоказателях вариабельности ритма сердца (ВРС), характерныхдлясимпатической гиперреактивности; таргетированной задачей титрования дозы дексмедетомидина служили параметры достижения нормы показателей ВРС; появление парасимпатической гиперактивности служило основанием уменьшения дозировки препаратаилипрекращения его применения (использовались 5-минутные записи кардиоинтервалов (прибор Полиспектр-8 ЕХ фирмы Нейрософт, Россия)). Регистрировали следующие показатели ВРС: SI стресс-индекс Баевского (индекс напряжения регуляторных систем индекс напряжения)внормализованных единицах (н.е.); SDNN среднеквадратичное отклонение RR-кардиоинтерваловвмс; rMSSD среднеквадратичное отклонение разности двух смежных отсчетов RR-кардиоинтерваловвмс; pNN50% доля RR-кардиоинтерваловвпроцентах, отличающихсяотпредыдущего более чемна50 мс;TP общая мощность спектра частотвмсек2. Параметры ВРС регистрировалидоинфузии дексметомидина исходно,на13-и, 45-е, 910-е, 1520-е сут применения лекарственного препарата.Результаты.Стартовая доза дексмедетомидинапри симпатической гиперактивности составилаупациентовот0,12до0,24 мкг/кг/ч (средняя доза 0,160,01; суммарно 200 мкг/сут).Поцифровым данным ВРС эффективная доза дексмедетомидина ЭД50составила 0,260,03 мкг/кг/ч (суммарнозасутки 353,835,1 мкг)ибыла достигнутана910- й день применения дексмедетомидина.Заключение.Коррекция симпатической гиперактивностиприприменении дексмедетомидина вызывает повышение уровня сознания, снижает частоту возникновения септического шока, дистресс синдрома легких, летальность

A randomized controlled study of the effectiveness of electrophysiological monitoring of dexmedetomidine in patients with brain damage of various origins [Рандомизированное контролируемое исследование эффективности электрофизиологического мониторинга дексмедетомидина у пациентов с повреждением головного мозга различного генеза]

Background. At the same time, the main effect of the use of this drug is the elimination of the autonomic nervous system dysfunction and sympatholysis. It seems important to search for a method of indications and selection of a dose of dexmedetomidine in intensive care. Aims - to improve the clinical effectiveness of the electrophysiological navigation of the prolonged use of dexmedetomidine in patients with brain pathology of various origins. Methods. The study included 83 patients 20-50 days after the traumatic brain injury, anoxic damage; consequences of acute disorders of cerebral. 37 patients comprised the 1st intervention group with a clinical course of dexmedetomidine (male - 28; female - 9; average age 49.6 ± 2.3 years) and 46 patients comprised the 2nd control group without pharmacological correction with dexmedetomidine (male - 23; female - 23, average age 51 ± 2.5 years). Criteria for the inclusion of prolonged infusion of the drug dexmedetomidine (Orion Pharma, Finland) are based on heart rate variability (HRV) indicators characteristic of sympathetic hyperactivity, the target task of titration of doses of dexmedetomidine served as the parameters for achieving normal HRV indicators, the appearance of parasympathetic hyperactivity served as the basis for reducing the dosage of the drug or stopping it of application. HRV parameters were recorded before dexmetomedine infusion-initially, on 1-3; 4-5; 9-10; 15-20 days of drug administration. Results. The starting dose of dexmedetomidine with sympathetic hyperactivity in patients was 0.12 to 0.24 μg.kg-1.hr-1 (average dose 0.16 ± 0.01; total 200 mg/day). According to digital data from HRV, the effective dose of dexmedetomidine ED50 was 0.26 ± 0.03 μg.kg-1.hr-1 (total daily 353.8 ± 35.1 μg) and was achieved on day 9-10 using dexmedetomidine. Conclusions. The protective role of dexmedetomidine with correction of sympathetic hyperactivity based on electrophysiological navigation according to the HRV is reliable in the following indicators: The improvement of consciousness; a significant decrease in the incidence of distress lung syndrome; septic shock; mortality. © 2020 Izdatel'stvo Meditsina. All rights reserved

Monitoring of the effectiveness of intensive care and rehabilitation by evaluating the functional activity of the autonomic nervous system in patients with brain damage

Purpose: evaluation of the clinical significance of parametric monitoring of the effectiveness of intensive care and rehabilitation based on the analysis of the functional state of the autonomous nervous system in patients with brain damage of different genesis. Materials and methods. The study included 66 patients on day 20—50 after the traumatic brain injury; anoxic damage; and stroke consequences. The isolation of clinical groups and subsequent analysis of clinical status is based on the analysis of the functional state of the autonomic nervous system based on the dynamics of the heart rate variability (HRV) parameters. Findings obtained in studies of 500 patients in the postoperative period with a 5-minute HRV were tested as normal and abnormal ANS parameters [1]. Parasympathetic hyperactivity was measured within the limits for SDNN (standard deviation of all normal-to-normal R-R intervals) > 41.5 ms; for rMSSD (root-mean-square of the successive normal sinus R-R interval difference) > 42.4 ms; for pNN50% (the percentage of interval differences in successive NN intervals greater than 50 ms (NN50) / total number of NN intervals) > 8.1%; for SI (Baevsky stress index, in normalized units) < 80 n. u.; for TP (total power of variance of all NN intervals) > 2000 ms2. Sympathetic hyperactivity was determined within the limits for following parameters: SDNN, < 4.54 ms; rMSSD, < 2.25 ms; pNN50%, < 0.109%; SI, > 900 n. u.; TP < 200 ms2. Normal HRV parameters were selected within the limits of the values for: SDNN [13.31-41.4ms]; rMSSD [5.78—42.3 ms]; pNN50% [0.110—8.1%]; SI [80—900 nu]; for TP [200—2000 ms2]. To verify the parasympathetic or sympathetic hyperactivity within these limits, 3 of 5 parameters were chosen [1]. Results. Based on the dynamics of the HRV parameters before the intensive care and on days 30—60 of the intensive therapy and rehabilitation of patients with traumatic and non-traumatic brain injuries, 5 main clinical groups of patients were identified. Group 1 (n=27) consisted of patients with normal parameters of the ANS functional activity (both at the time of admission to the hospital and on the 30—60th day of the intensive therapy and rehabilita-tion). Group 2 (n=9) included patients with the baseline sympathetic hyperactivity of the ANS at admission to the intensive care unit and normal functional activity of the ANS on the 30—60th day of the intensive care and rehabilitation. Group 3 (n=8) included patients with baseline normal functional state of the ANS and the signs of sympathetic hyperactivity of the ANS on the 30—60th day of the intensive care and rehabilitation. Group 4 (n=15) consisted of patients with signs of sympathetic hyperactivity of the ANS both initially and on the 30—60th day of the intensive care and rehabilitation. Group 5 (n=7) included patients with signs of parasympathetic hyperactivity of the ANS (according to the parameters of HRV) both at baseline, at admission to the intensive care unit, and on the 30—60th day of the intensive care and rehabilitation. Conclusion: The normalization of HRV parameters is accompanied by patients’ recovery from the vegetative state and coma to minimal consciousness or normal consciousness; the index of disability rate decreases, the social reintegration grows, according to the DRS scale (M. Rappaport, 1982); dependence on mechanical ventilation reduces, and the muscle tone normalizes. © 2018, V.A. Negovsky Research Institute of General Reanimatology. All rights reserved

Functional activity of the autonomous nervous system at different levels of consciousness in patients with a brain damage

The purpose of the study - assessment of the level of consciousness in patients with a brain damage on the basis of electrophysiological examination of the functional state of the autonomous nervous system by recording parameters of the heart rate variability (HRV). Materials and Methods. The study included 77 patients on Day 20-50 after a traumatic brain injury, anoxic injury, consequences of acute cerebral circulation disorders. The following parameters of the HRV for a 5-minute recording were accepted as criteria of norm and pathology of the autonomous nervous system (ANS) activity: (1) parasympathetic hyperactivity (hypervagal state) values with 95% confidence intervals were recorded within the accepted values for (a) SDNN (standard deviation of normal to normal R-R intervals), [41.5 -149.3 ms]; (b) rMSSD (root-mean-square of the successive normal sinus R-R interval difference in ms), [42.4-175.0 ms];(c) pNN50% (percentage of successive normal sinus RR intervals >50 ms), [8.14-54.66%]; (d) SI (Baevsky stress index), [0-80 normalized units, n. u.]; (2) the sympathetic hyperactivity recordered within the range of values for (a) SDNN [4.54-13.30 ms]; (b) rMSSD [2.25- 5.77 ms]; (c) pNN50% [0-0.109%]; (d) SI >900 n. u.; (3) the normal value of ANS parameters were recordered within the range of values for (a) SDNN [13.31-41.4 ms]; (b) rMSSD [5.78-42.3 ms]; (c) pNN50% [0.110-8.1%]; (d) SI [80-900 n. u.]. For verification of the hypervagal state, sympathetic hyperactivity or normal state, at least 3 of 4 parameters should be within the specified limits. Results. In 40 (51.9%) of 77 patients examined after a brain damage, ANS functional activity parameters were within the range of pathological values. The sympathetic hyperactivity was identified in 34 patients, and in 6 cases the hypervagal state was diagnosed. Pathological parameters of HRV were found in 80% of patients with severe forms of unconsciousness (vegetative state, coma), and only in 20% of patients with normal consciousness. Conclusion. The computer analysis of the HRV is a necessary element of examination of patients with different levels of consciousness after a brain damage of a traumatic and non-traumatic genesis. The frequency of pathological changes in the functional state of the autonomous nervous system increases significantly in groups of patients from the normal level of consciousness to the state of minimal consciousness, vegetative state, and coma. The sympathetic hyperactivity is the main type of ANS pathology in the groups of patients with minimal consciousness, in the vegetative state, and coma. © 2018, V.A. Negovsky Research Institute of General Reanimatology. All rights reserved

Functional activity of the autonomous nervous system at different levels of consciousness in patients with a brain damage

The purpose of the study - assessment of the level of consciousness in patients with a brain damage on the basis of electrophysiological examination of the functional state of the autonomous nervous system by recording parameters of the heart rate variability (HRV). Materials and Methods. The study included 77 patients on Day 20-50 after a traumatic brain injury, anoxic injury, consequences of acute cerebral circulation disorders. The following parameters of the HRV for a 5-minute recording were accepted as criteria of norm and pathology of the autonomous nervous system (ANS) activity: (1) parasympathetic hyperactivity (hypervagal state) values with 95% confidence intervals were recorded within the accepted values for (a) SDNN (standard deviation of normal to normal R-R intervals), [41.5 -149.3 ms]; (b) rMSSD (root-mean-square of the successive normal sinus R-R interval difference in ms), [42.4-175.0 ms];(c) pNN50% (percentage of successive normal sinus RR intervals >50 ms), [8.14-54.66%]; (d) SI (Baevsky stress index), [0-80 normalized units, n. u.]; (2) the sympathetic hyperactivity recordered within the range of values for (a) SDNN [4.54-13.30 ms]; (b) rMSSD [2.25- 5.77 ms]; (c) pNN50% [0-0.109%]; (d) SI >900 n. u.; (3) the normal value of ANS parameters were recordered within the range of values for (a) SDNN [13.31-41.4 ms]; (b) rMSSD [5.78-42.3 ms]; (c) pNN50% [0.110-8.1%]; (d) SI [80-900 n. u.]. For verification of the hypervagal state, sympathetic hyperactivity or normal state, at least 3 of 4 parameters should be within the specified limits. Results. In 40 (51.9%) of 77 patients examined after a brain damage, ANS functional activity parameters were within the range of pathological values. The sympathetic hyperactivity was identified in 34 patients, and in 6 cases the hypervagal state was diagnosed. Pathological parameters of HRV were found in 80% of patients with severe forms of unconsciousness (vegetative state, coma), and only in 20% of patients with normal consciousness. Conclusion. The computer analysis of the HRV is a necessary element of examination of patients with different levels of consciousness after a brain damage of a traumatic and non-traumatic genesis. The frequency of pathological changes in the functional state of the autonomous nervous system increases significantly in groups of patients from the normal level of consciousness to the state of minimal consciousness, vegetative state, and coma. The sympathetic hyperactivity is the main type of ANS pathology in the groups of patients with minimal consciousness, in the vegetative state, and coma. © 2018, V.A. Negovsky Research Institute of General Reanimatology. All rights reserved