Реализация «бесшовной» модели оказания специализированной медицинской помощи пациентам с сердечной недостаточностью

Heart failure (HF) is a widespread disease and tends to increase. Despite the possibilities of modern therapy, the prognosis of patients with HF remains unfavorable. Foreign experience shows that the creation of specialized heart failure clinics improves the quality of care for patients with HF, reduces the frequency of repeated hospitalizations and death of patients. The Russian Federation has gained experience in creating such clinics, in particular, in Nizhny Novgorod, Ufa, St. Petersburg and a number of other cities. The article describes the organization of the work of the Center for HF on the basis of a multidisciplinary hospital in Moscow in period 01.11.2020-01.12.2022. The database included 2,400 patients hospitalized due to acute decompensation of chronic HF (ADCHF). The leading triggers of ADCHF in the studied patient population were an episode of atrial fibrillation/flutter (37 %), low adherence to treatment (25 %) and uncontrolled hypertension (17 %), exacerbation of concomitant diseases (11 %), infection (4 %). In 6 % of patients, the leading trigger could not be identified. The hospital stage included 950 (39.5 %) patients who, in the first 24 hours from the moment of hospitalization, underwent standard physical, laboratory and instrumental examination, including lung ultrasound, NT-proBNP, liver fibroelastometry, VEXUS protocol study, bioimpedance analysis of body composition, of which 496 (20.5 %) people passed the same studies at discharge. In the structure of patients hospitalized with ADCHF who were included in the hospital follow-up stage (n=950), patients with preserved (HFpEF) 42.5 % (n=404) and reduced ejection fraction (HFrEF) prevailed 36 % (n=342), patients with a mildly reduced (HFmrEF) ejection fraction were found in 21.5 %. 1,552 (64.5 %) patients refused additional studies and visits to the CH center, but agreed to outpatient follow-up in the form of telephone contacts. In 370 (15.4 %) patients, contact was lost after discharge. 240 (10 %) patients actively visit the HF center with a comprehensive assessment of congestion and correction of therapy at each visit. Conclusion. There are two stages in the treatment of patients with chronic HF. The first stage is hospital, the second one is outpatient. It is important not to make omissions in the prescribed drug therapy, which can lead to a fatal outcome. To this end, it is necessary to introduce a “seamless” model of medical care for patients with chronic HF, when the patient comes under the supervision of a multidisciplinary team that carries out timely monitoring.Сердечная недостаточность (СН) является широко распространенным заболеванием и имеет тенденцию к увеличению. Несмотря на возможности современной терапии прогноз пациентов с СН остается неблагоприятным. Зарубежный опыт показывает, что создание специализированных клиник сердечной недостаточности улучшает качество оказания помощи больным с СН, снижает частоту повторных госпитализаций и смерти больных. В Российской Федерации появился опыт создания таких клиник, в частности в Нижнем Новгороде, Уфе, Санкт-Петербурге и ряде других городов. В статье описана организация работы Центра по СН на базе многопрофильного стационара в г. Москва с 01.11.2020 по 01.12.2022 гг. В базу данных было включено 2400 пациентов, госпитализированных в связи с острой декомпенсацией хронической СН (ОДХСН). Показано, что ведущими триггерами ОДХСН в исследуемой популяции пациентов являлись эпизод фибрилляции/трепетания предсердий (37 %), низкая приверженность к лечению (25 %) и неконтролируемая артериальная гипертония (17 %), обострение сопутствующих заболеваний (11 %), инфекция (4 %). У 6 % пациентов ведущий триггер выделить не удалось. В госпитальный этап были включены 950 (39,5 %) пациентов, которым в первые 24 часа от момента госпитализации, проводили стандартное физическое, лабораторное и инструментальное обследование, включая УЗИ легких, NT - proBNP, фиброэластометрию печени, исследование по протоколу VEXUS, биоимпедансный анализ состава тела. Из 950 пациентов 496 (20,5 %) человек прошли те же исследования при выписке. В структуре пациентов, госпитализированных с ОДХСН, которые были включены в госпитальный этап наблюдения (n = 950), преобладали пациенты с сохранной 42,5 % (n = 404) и низкой фракцией выброса 36 % (n=342), пациенты с умеренно низкой фракцией выброса встречались в 21,5 %. 1552 (64,5 %) пациента отказались от дополнительных исследований и визитов в центр СН после выписки, однако дали согласие на амбулаторное наблюдение в виде телефонных контактов. У 370 (15,4 %) пациентов после выписки контакт был утерян. 240 (10 %) пациентов активно посещают центр СН с проведением комплексной оценки застоя и коррекции терапии на каждом визите. Выводы. При терапии пациентов с хронической СН выделяют два этапа. Первый этап - госпитальный, второй - амбулаторный. Важно не допускать пропусков в назначенной медикаментозной терапии, что может привести к летальному исходу. С этой целью необходимо внедрить «бесшовную» модель оказания медицинской помощи больным с хронической СН, когда пациент поступает под наблюдение многопрофильной бригады, осуществляющей своевременное наблюдение

Clinical outcome and risk assessment in hospitalized COVID-19 patients with elevated transaminases and acute kidney injury: A single center study

Objectives:Initial reports indicate a high incidence of abnormal aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels in patients with COVID-19 and possible association with acute kidney injury (AKI). We aimed to investigate clinical features of elevated transaminases on admission, its association with AKI, and outcomes in patients with COVID-19. Methods:A retrospective analysis of the registered data of hospitalized patients with laboratory-confirmed COVID-19 and assessment of the AST and ALT was performed. Multinomial logistic regression was used to determine factors associated with community-acquired AKI (CA-AKI) and hospital-acquired AKI (HA-AKI). Results:The subjects comprised 828 patients (mean age = 65.0±16.0 years; 51.4% male). Hypertension was present in 70.3% of patients, diabetes mellitus in 26.0%, and chronic kidney disease in 8.5%. In-hospital mortality was 21.0%. At admission, only 41.5% of patients had hypertransaminasemia. Patients with elevated transaminases at admission were younger, had higher levels of inflammatory markers and D-dimer, and poorer outcomes. The AKI incidence in the study population was 27.1%. Patients with hypertransaminasemia were more likely to develop AKI (33.5% vs. 23.3%, p = 0.003). Patients with predominantly elevated AST (compared to elevated ALT) were more likely to have adverse outcomes. Multinomial logistic regression found that hypertension, chronic kidney disease, elevated AST, and hematuria were associated with CA-AKI. Meanwhile, age \u3e 65 years, hypertension, malignancy, elevated AST, and hematuria were predictors of HA-AKI. Conclusions:Elevated transaminases on admission were associated with AKI and poor outcomes. Patients with elevated AST were more likely to have adverse outcomes. Elevated AST on admission was associated with CA-AKI and was a predictor of HA-AKI

Диагностика и профилактика осложнений cпортивной черепно-мозговой травмы

Sports-related traumatic brain injuries (TBI) accounts for up to 20 % of all injuries that are obtained by athletes and its incidence rises annually due to rise in population involving in sports, growing popularity of extreme sports and high level of motivation to achieve record results among young sportsmen. The aim of the review is to present the potential benefits of using microwave radiothermometry and craniocerebral hypothermia technologies in sports-related TBI. The review considers most common form of traumatic brain injury in athletes - mild TBI, which in turn can provoke a wide range of complications and negative consequences in near and delayed periods after the injury. The main shortcomings of programs for complication prevention in treatment and rehabilitation of athletes after TBI are considered, which do not take into account the peculiarities of injury mechanisms, its significant differences from household, road or criminal injuries with brain damage. Lack of objective methods of instrumental diagnosis for injury severity is also described. In addition, pathophysiological component characteristics of sports TBI is accentuated: frequency of repetition, increasement of brain and body temperature, peripheral redistribution of blood flow and hypocapnia, which significantly affects cerebral blood flow. Based on the analysis of the available scientific literature, it is elicited that TBI is an independent cause of cerebral hyperthermia development, which significantly aggravates the consequences of the injury. Conclusions. The authors propose an innovative way to use microwave radiothermometry method as a diagnostic tool for sports-related TBI. In addition, the review highlights the main recommendations for complications prevention by using craniocerebral hypothermia technology, which reduces overall physical and cerebral hyperthermia, and augments the resistance of cerebral cortex neurons to hypoxia and trauma. However, the authors believe that the described approaches in sports medicine are not used purposefully due to lack of awareness of sports team doctors and coaches.На долю спортивных черепно-мозговых травм (ЧМТ) приходится до 20 % всех спортивных повреждений, а встречаемость первых возрастает ежегодно за счет прироста числа людей, занимающихся спортом, растущей популярности экстремальных и контактных видов спорта, а также высокого уровня мотивации на достижение рекордных результатов среди молодых спортсменов. Основная цель данного обзора - представить возможности применения методики микроволновой радиотермометрии и технологии краниоцеребральной гипотермии в контексте спортивной ЧМТ. В обзоре рассмотренна наиболее часто встречающаяся форма ЧМТ у спортсменов - легкая ЧМТ, которая в свою очередь может спровоцировать развитие очень широкого спектра осложнений и негативных последствий как в ближайшем, так и отсроченном периоде после полученной травмы. Рассмотрены основные недостатки программ по профилактике осложнений при лечении и реабилитации спортсменов после ЧМТ, которые недостаточно учитывают особенности механизмов развития самой травмы, ее значимые отличия от бытовых, дорожных или криминальных травм с повреждением головного мозга. Авторами описана актуальная проблематика отсутствия объективных методов инструментальной диагностики тяжести травмы. Детализована патофизиологическая составляющая, характерная для спортивных ЧМТ: периодичность повторения, повышение температуры тела и мозга пострадавшего, периферическое перераспределение кровотока и гипокапния, которые значимо влияют на мозговой кровоток. На основании проведенного анализа имеющейся отечественной и зарубежной научной литературы можно сделать вывод, что черепно-мозговая травма является независимой причиной развития церебральной гипертермии, которая существенно усугубляет последствия полученной травмы. Выводы. Авторами предложен новаторский способ использования метода микроволновой радиотермометрии в качестве диагностического инструмента спортивных ЧМТ. Кроме того, в обзоре выделяются основные рекомедации для профилактики осложнений с использованием технологии краниоцеребральной гипотермии, которая позволяет снизить общую физическую и церебральную гипертермию, а также способствует повышению устойчивости нейронов коры головного мозга к гипоксии и травме. Однако авторы считают, что описываемые подходы в спортивной медицине используются нецеленаправленно и связано это с недостаточной осведомленностью тренеров и врачей спортивных команд

Weaning from mechanical ventilation in intensive care units across 50 countries (WEAN SAFE): a multicentre, prospective, observational cohort study

Background Current management practices and outcomes in weaning from invasive mechanical ventilation are poorly understood. We aimed to describe the epidemiology, management, timings, risk for failure, and outcomes of weaning in patients requiring at least 2 days of invasive mechanical ventilation. Methods WEAN SAFE was an international, multicentre, prospective, observational cohort study done in 481 intensive care units in 50 countries. Eligible participants were older than 16 years, admitted to a participating intensive care unit, and receiving mechanical ventilation for 2 calendar days or longer. We defined weaning initiation as the first attempt to separate a patient from the ventilator, successful weaning as no reintubation or death within 7 days of extubation, and weaning eligibility criteria based on positive end-expiratory pressure, fractional concentration of oxygen in inspired air, and vasopressors. The primary outcome was the proportion of patients successfully weaned at 90 days. Key secondary outcomes included weaning duration, timing of weaning events, factors associated with weaning delay and weaning failure, and hospital outcomes. This study is registered with ClinicalTrials.gov, NCT03255109. Findings Between Oct 4, 2017, and June 25, 2018, 10 232 patients were screened for eligibility, of whom 5869 were enrolled. 4523 (77·1%) patients underwent at least one separation attempt and 3817 (65·0%) patients were successfully weaned from ventilation at day 90. 237 (4·0%) patients were transferred before any separation attempt, 153 (2·6%) were transferred after at least one separation attempt and not successfully weaned, and 1662 (28·3%) died while invasively ventilated. The median time from fulfilling weaning eligibility criteria to first separation attempt was 1 day (IQR 0–4), and 1013 (22·4%) patients had a delay in initiating first separation of 5 or more days. Of the 4523 (77·1%) patients with separation attempts, 2927 (64·7%) had a short wean (≤1 day), 457 (10·1%) had intermediate weaning (2–6 days), 433 (9·6%) required prolonged weaning (≥7 days), and 706 (15·6%) had weaning failure. Higher sedation scores were independently associated with delayed initiation of weaning. Delayed initiation of weaning and higher sedation scores were independently associated with weaning failure. 1742 (31·8%) of 5479 patients died in the intensive care unit and 2095 (38·3%) of 5465 patients died in hospital. Interpretation In critically ill patients receiving at least 2 days of invasive mechanical ventilation, only 65% were weaned at 90 days. A better understanding of factors that delay the weaning process, such as delays in weaning initiation or excessive sedation levels, might improve weaning success rates

Weaning from mechanical ventilation in intensive care units across 50 countries (WEAN SAFE): a multicentre, prospective, observational cohort study

Background: Current management practices and outcomes in weaning from invasive mechanical ventilation are poorly understood. We aimed to describe the epidemiology, management, timings, risk for failure, and outcomes of weaning in patients requiring at least 2 days of invasive mechanical ventilation. Methods: WEAN SAFE was an international, multicentre, prospective, observational cohort study done in 481 intensive care units in 50 countries. Eligible participants were older than 16 years, admitted to a participating intensive care unit, and receiving mechanical ventilation for 2 calendar days or longer. We defined weaning initiation as the first attempt to separate a patient from the ventilator, successful weaning as no reintubation or death within 7 days of extubation, and weaning eligibility criteria based on positive end-expiratory pressure, fractional concentration of oxygen in inspired air, and vasopressors. The primary outcome was the proportion of patients successfully weaned at 90 days. Key secondary outcomes included weaning duration, timing of weaning events, factors associated with weaning delay and weaning failure, and hospital outcomes. This study is registered with ClinicalTrials.gov, NCT03255109. Findings: Between Oct 4, 2017, and June 25, 2018, 10 232 patients were screened for eligibility, of whom 5869 were enrolled. 4523 (77·1%) patients underwent at least one separation attempt and 3817 (65·0%) patients were successfully weaned from ventilation at day 90. 237 (4·0%) patients were transferred before any separation attempt, 153 (2·6%) were transferred after at least one separation attempt and not successfully weaned, and 1662 (28·3%) died while invasively ventilated. The median time from fulfilling weaning eligibility criteria to first separation attempt was 1 day (IQR 0-4), and 1013 (22·4%) patients had a delay in initiating first separation of 5 or more days. Of the 4523 (77·1%) patients with separation attempts, 2927 (64·7%) had a short wean (≤1 day), 457 (10·1%) had intermediate weaning (2-6 days), 433 (9·6%) required prolonged weaning (≥7 days), and 706 (15·6%) had weaning failure. Higher sedation scores were independently associated with delayed initiation of weaning. Delayed initiation of weaning and higher sedation scores were independently associated with weaning failure. 1742 (31·8%) of 5479 patients died in the intensive care unit and 2095 (38·3%) of 5465 patients died in hospital. Interpretation: In critically ill patients receiving at least 2 days of invasive mechanical ventilation, only 65% were weaned at 90 days. A better understanding of factors that delay the weaning process, such as delays in weaning initiation or excessive sedation levels, might improve weaning success rates. Funding: European Society of Intensive Care Medicine, European Respiratory Society

Weaning from mechanical ventilation in intensive care units across 50 countries (WEAN SAFE): a multicentre, prospective, observational cohort study

International audienceBackground: Current management practices and outcomes in weaning from invasive mechanical ventilation are poorly understood. We aimed to describe the epidemiology, management, timings, risk for failure, and outcomes of weaning in patients requiring at least 2 days of invasive mechanical ventilation. Methods: WEAN SAFE was an international, multicentre, prospective, observational cohort study done in 481 intensive care units in 50 countries. Eligible participants were older than 16 years, admitted to a participating intensive care unit, and receiving mechanical ventilation for 2 calendar days or longer. We defined weaning initiation as the first attempt to separate a patient from the ventilator, successful weaning as no reintubation or death within 7 days of extubation, and weaning eligibility criteria based on positive end-expiratory pressure, fractional concentration of oxygen in inspired air, and vasopressors. The primary outcome was the proportion of patients successfully weaned at 90 days. Key secondary outcomes included weaning duration, timing of weaning events, factors associated with weaning delay and weaning failure, and hospital outcomes. This study is registered with ClinicalTrials.gov, NCT03255109. Findings: Between Oct 4, 2017, and June 25, 2018, 10 232 patients were screened for eligibility, of whom 5869 were enrolled. 4523 (77·1%) patients underwent at least one separation attempt and 3817 (65·0%) patients were successfully weaned from ventilation at day 90. 237 (4·0%) patients were transferred before any separation attempt, 153 (2·6%) were transferred after at least one separation attempt and not successfully weaned, and 1662 (28·3%) died while invasively ventilated. The median time from fulfilling weaning eligibility criteria to first separation attempt was 1 day (IQR 0–4), and 1013 (22·4%) patients had a delay in initiating first separation of 5 or more days. Of the 4523 (77·1%) patients with separation attempts, 2927 (64·7%) had a short wean (≤1 day), 457 (10·1%) had intermediate weaning (2–6 days), 433 (9·6%) required prolonged weaning (≥7 days), and 706 (15·6%) had weaning failure. Higher sedation scores were independently associated with delayed initiation of weaning. Delayed initiation of weaning and higher sedation scores were independently associated with weaning failure. 1742 (31·8%) of 5479 patients died in the intensive care unit and 2095 (38·3%) of 5465 patients died in hospital. Interpretation: In critically ill patients receiving at least 2 days of invasive mechanical ventilation, only 65% were weaned at 90 days. A better understanding of factors that delay the weaning process, such as delays in weaning initiation or excessive sedation levels, might improve weaning success rates. Funding: European Society of Intensive Care Medicine, European Respiratory Society