#91
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Kondor, âðà÷è - íå óáèéöû, îíè âñå íàåìíûå ðàáî÷èå - èñïîëíèòåëè è ðàáîòàþò â ðåàëüíûõ óñëîâèÿõ, ñîçäàííûõ óïðàâëåíèÿìè çäðàâîîõðàíåíèÿ. Ýòî íå ñòðàøíî, ýòî ðåàëüíî. Ñ 1992 ãîäà ÿ çàíèìàþñü â îñíîâíîì òîëüêî èíñóëüòàìè â ñòàöèîíàðå, âèæó åæåäíåâíî ðåàëüíîå îòíîøåíèå îáùåñòâà ê èíñóëüòíûì áîëüíûì, êîòîðîå â ýòîì ôîðóìå íå îïèñàòü. Èíâàëèäíîñòü óñòàíàâëèâàåòñÿ ïî ñòðîãèì êðèòåðèÿì ôóíêöèîíàëüíûõ íàðóøåíèé è îãðàíè÷åíèé æèçíåäåÿòåëüíîñòè, êòî â ñîñòîÿíèå ïðîéòè êàáèíåòû ïî îôîðìëåíèþ ïîñûëüíîãî ëèñòà, à ýòî äëÿ ïîñòèíñóëüòíîãî áîëüíîãî êîëîññàëüíàÿ íàãðóçêà, òîò ïîëó÷èò ãðóïïó.
Ïî äàííûì Ãîñêîìñòàòà â òå÷åíèå 2- 3 ïîñëåäíèõ ëåò îòìå÷àåòñÿ ñíèæåíèå êîëè÷åñòâà èíâàëèäîâ, ýòî ïîòîìó- ÷òî ïåðåñòàëè ïðèíèìàòü ïîñûëüíûå ëèñòû îò ïåíñèîíåðîâ. À êîëè÷åñòâî áîëüíûõ ñ èíñóëüòàìè íå óìåíüøàåòñÿ, à óâåëè÷èâàåòñÿ è îí ìîëîäååò. Àíàëèç ïðè÷èí íåñòàöèîíàðíîé ëåòàëüíîñòè è ñìåðòíîñòè â ïîæèëîì âîçðàñòå â ïîëèêëèíèêàõ âåäåòñÿ, â îñíîâíîì âñåõ " õîðîíÿò" îò èíñóëüòîâ, ò.ê. îñòàëüíîå ïèñàòü íåëüçÿ - óïðàâëÿåìàÿ ïàòîëîãèÿ. Ó íàñ î÷åíü ìíîãî çàïðåòîâ è íîðìàòèâíûõ èíñòðóêöèé, êîòîðûå íàäî âûïîëíÿòü. |
#92
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Âûâåñèâ íàø àíåñòåçèîëîãè÷åñêèé ïðîòîêîë âåäåíèÿ äàííûõ ïàöèåíòîâ, ïîïûòàëàñü âñïîìíèòü, êîãäà æå ñàìà â ïîñëåäíèé ðàç ó÷àñòâîâàëà â ïðîöåäóðå è íè÷åãî íå ïðèïîìíèëà çà ïîñëåäíèé ãîä: íàøè íåéðîðàäèîëîãè/íåéðîõèðóðãè â îñíîâíîé ìàññå ñòàëè ïðîâîäèòü ýòè ïðîöåäóðû ïîä ìåñòíîé àíåñòåçèåé ñ íåáîëüøîé ñåäàöèåé (ó íèõ íàêîïèëèñü äàííûå, ÷òî ïðè âûïîëíåíèè òðîìáîëèçèñà ó ïàöèåíòîâ ñ èíñóëüòîì ïîä îáùåé àíåñòåçèåé (ìû òàê íà÷èíàëè íåñêîëüêî ëåò íàçàä) ðåçóëüòàòû õóæå, ÷åì ïðîñòî ñ ìèíèìàëüíîé ñåäàöèåé ñèëàìè ñàìîé íåéðîõèðóðãè÷åñêîé áðèãàäû - âîçìîæíî, ÷òî ïàäåíèå äàâëåíèÿ ïðè èíäóêöèè âëèÿåò ía ðåçóëüòàò), ñàìè æå è êîíòðîëèðóþò äàâëåíèå (íî â òåõ æå ïðåäåëàõ). Ïî ïîâîäó ÊÒ: ìèíèìàëüíî, ÷òî îíè äåëàþò (èëè ïîëó÷àþò ñ ïàöèåíòîì ïðè ïåðåâîäå èç äðóãîãî ãîñïèòàëÿ) - ýòî áåñêîíòðàñòíûé ÊÒ, òàê æå äåëàþò ÊÒ - àíãèî, ÊÒ - ïåðôóçèþ, íî íå âñåì (êàê ãîâîðÿò - "çàâèñèò îò ïàöèåíòà"), ñàìîå îñíîâíîå - îíè ñìîòðÿò, åñëè èíñóëüò óæå çàâåðø¸ííûé (òóò óæ, êîíå÷íî, ðàäèîëîãàì âèäíåå, êàê îíè ýòî îïðåäåëÿþò, äëÿ òàêèõ æå "÷àéíèêîâ" êàê ÿ îíè ïðîñòî îáúÿñíÿþò, ÷òî åñëè âñÿ îáëàñòü èíñóëüòà "ò¸ìíàÿ" íà ÊÒ - òî "ëîâèòü" óæå íå÷åãî, êðîìå ïîâûøåííîãî ðèñêà èíòðàöåðåáðàëüíîãî êðîâîòå÷åíèÿ).
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#93
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Òàøà, ÿ êàê-òî íå î÷åíü ïîíèìàþ äëÿ ÷åãî íóæíà ñåäàöèÿ íà òðîìáîëèçèñ. Ïî ñîáñòâåííîìó ñêðîìíîìó îïûòó, ïàöèåíòû îáû÷íî íå èñïûòûâàëè íèêàêèõ íåïðèÿòíûõ îùóùåíèé âî âðåìÿ ïðîöåäóðû ðàçâå ÷òî íåçíà÷èòåëüíóþ ãîëîâíóþ áîëü.  ïðèíöèïå, ïðîöåäóðó ìîãëè áû ïðîâîäèòü ñàìè íåâðîëîãè åñëè áû çàõîòåëè, ìû áûëè áû òîëüêî ðàäû. Ïðîñòî òàê îðãàíèçàöèîííî ñëîæèëîñü, ÷òî ó íàñ ýòî ñäåëàòü ïðîùå è áûñòðåå è âèçóàëèçàöèÿ äîñòóïíà êðóãëîñóòî÷íî.
Íàñ÷åò öåëåâîãî äàâëåíèÿ âî âðåìÿ ïðîöåäóðû, õîòåë çàìåòèòü, ÷òî ìû ÷àñòî äåëàëè òðàíñêðàíèàëüíûé äîïïëåð âî âðåìÿ ïðîöåäóðû è îòìå÷àëè, ÷òî ÷àñòî âîññòàíîâëåíèå ñèììåòðè÷íîñòè êðîâîòîêà íàáëþäàåòñÿ óæå â ïåðâûå ìèíóòû ïîñëå ââåäåíèÿ ïåðâîãî áîëþñà àëüòåïëàçû. Ïîýòîìó ëè÷íî ÿ ïðåäïî÷èòàþ áîëåå íèçêèå öåëåâûå öèôðû àðòåðèàëüíîãî äàâëåíèÿ âî âðåìÿ ïðîöåäóðû. ÷åì â âàøåì ïðîòîêîëå. |
#94
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#95
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Öèòàòà:
È ïðîñüáà ê Âàì, íåëüçÿ ëè äîêóìåíòû (â ÷àñòíîñòè, àíåñòåçèîëîãè÷åñêèé ïðîòîêîë) äàâàòü â ïåðåâîäå, åñëè íå òðóäíî? Óâû, íå ïîáîþñü ïðèëþäíî ñêàçàòü, ÷òî íå âëàäåþ àíãëèéñêèì â äîñòàòî÷íîé ñòåïåíè, ÷òîáû ÷èòàòü áåãëî). È, åñëè ïîçâîëèòå, ïðîñüáà. Î÷åíü êîðîòêî, ïðèíöèï âåäåíèÿ èíñóëüòîâ â Øòàòàõ, â äàííîì ñëó÷àå, ÷òîáû ïî òåìå, èøåìè÷åñêèõ. ß èìåþ â âèäó òå ñëó÷àå, êîãäà íå ïðèáåãàåòå ê òðîìáîëèçèñó. Ñïàñèáî. Ñ óâàæåíèåì, ß. |
#96
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#97
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Öèòàòà:
Ðàä, ÷òî Âàì ýòî ÷óâñòâî íåâåäîìî, ïîýòîìó ñ íåïîääåëüíûì èíòåðåñîì ÷èòàþ Âàøè ñîîáðàæåíèÿ, ïðî "íå òîò ïóòü", ""íåêðîç ñ èñõîäîì â èíôàðêò" è ò.ä. |
#98
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Öèòàòà:
 îáùåì-òî ïîäàâëÿþùåìó áîëüøèíñòâó ýòèõ áîëüíûõ â ðåàíèìàöèè äåëàòü íå÷åãî, êðîìå êàê äåëèðèé çàðàáàòûâàòü. Èì íóæåí õîðîøèé óõîä, íåíàâÿç÷èâàÿ òåðàïèÿ è ìîíèòîðèíã, ðàííÿÿ äâèãàòåëüíàÿ ðåàáèëèòàöèÿ è ïðîôèëàêòèêà îñëîæíåíèé. Íà çàïàäå áîëüøèíñòâî ýòèõ áîëüíûõ íàõîäÿòñÿ â ñïåöèàëüíûõ stroke centers âäàëè îò àíåñòåçèîëîãîâ è ñåäàöèè. Õîòÿ ÿ ñåáÿ ñ÷èòàë ñòîðîííèêîì íåàãðåññèâíîãî ïîäõîäà, íî è ó ìåíÿ âûçâàëè íåäîóìåíèå íåêîòîðûå ìîìåíòû, êàñàþùèåñÿ âåäåíèÿ òàêèõ áîëüíûõ. Õî÷ó äàòü ññûëêó íà íåäàâíþþ äèñêóññèþ íà äðóãîì ôîðóìå : http://www.critical.ru/php/agora/vie...82#A1263272879 ×òîáû óâèäåòü âñþ äèñêóññèþ - íàæìèòå "ïîñëåäîâàòåëüíûé ñïèñîê". |
#99
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Öèòàòà:
Íà ïðåäìåò ìîåé îãîâîðêè, ÿ óæå ïîÿñíèë. Åñëè Âû íå ïîíÿëè, Âàøè ïðîáëåìû. Íî, çà÷åì ïåðåæ¸âûâàòü îäíî è òî æå? Âïðî÷åì, ìîæåòå çàáàâëÿòüñÿ. È î÷åíü æàëü, ÷òî êìí (çäåñü ýòî íå èìÿ, à, êàê ïîëàãàþ, Âàøà ñòåïåíü èëè ìå÷òà î íåé) ïîáîÿëñÿ îòâåòèòü íà î÷åíü ïðîñòåíüêèé (ñòóäåí÷åñêèé) âîïðîñ. Íî, â îáùåì, ïðàâèëüíî - êàçàòüñÿ âñåãäà ëåã÷å, ÷åì áûòü. È ïîòîì, ÿ â ïîëíîì íåäîóìåíèè. Âîò Âû ãîâîðèòå: "íå ñòîèò çàìîðà÷èâàòüñÿ.", à ñàìè ÷òî-òî âñ¸ çà ìíîé èùåòå. |
#100
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Ñïàñèáî çà ññûëêó, óâàæàåìûé Àëåêñàíäð Ñåðãååâè÷
Ïðåäñòàâëÿþ, êàê ñåé÷àñ áóäåò ðåçâèòüñÿ ÊÌÍ, íî ñïðîøó - à çà÷åì ïðè ïåðåëîìàõ íàêëàäûâàþò ãèïñ? Âû æå íå ñ÷èòàåòå, ÷òî êàòàñòðîôà â ãîëîâíîì ìîçãå áåçðàçëè÷íà äëÿ áîëüíîãî â ïëàíå îõðàíèòåëüíîãî òîðìîæåíèÿ, êîòîðîå äîëæíî áûòü ïðè ëþáîì, îñîáåííî ïðè ñåðü¸çíîì, çàáîëåâàíèè. Ñ óâàæåíèåì, ß. |
#101
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 îáùåì, ëîãèêà ïîíÿòíà. Íó à êàê æå âû ðåøàåòå, êîãî ñåäàòèðîâàòü, à êîãî íåò ?
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#102
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Öèòàòà:
Ñôîðìóëèðóéòå êîíêðåòíî, ÷åì Âû ïðîòèâ ÒËÒ ïðè èíñóëüòå. Åñòåñòâåííî ðå÷ü èäåò î ÷åòêîì âûïîëíåíèè ïðîòîêîëà, îòíîñèòåëüíî âðåìåíè, íåîáõîäèìîãî îáñëåäîâàíèÿ ïåðåä ïðîöåäóðîé è ò.ä. Öèòàòà:
P.S. ÊÌN ýòî èíèöèàëû ìîåé ëþáèìîé ïîêîéíîé ìîðñêîé ñâèíêè. |
#103
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Êõì... Êîëëåãà remember, îòêðîâåííî ÿ òàêæå íå óñïåâàþ çà ñåìèìèëüíûìè øàãàìè Âàøåé êëèíè÷åñêîé ìûñëè. Âû âûñêàçàëè ìíåíèå, ÷òî òðîìáîëèçèñ - "íå òîò ïóòü". Ýòî Âàøå ïðàâî, íî ïðåäëîæèòå æå àëüòåðíàòèâó. Êðîìå òîé, ÷òî èìåëàñü è èìååòñÿ â íàøåé ðîññèéñêîé ïðàêòèêå äî òðîìáîëèòèêîâ. Âû îçíàêîìèëèñü ñ Åâðîïåéñêèìè ðåêîìåíäàöèÿìè, è "íå óâèäåëè òàì íè÷åãî íîâîãî", íî ïðè ýòîì Âû ñïðàøèâàåòå î öåëè îãðàíè÷åíèÿ ñèñòîëè÷åñêîãî ÀÄ ïðè ïðîâåäåíèè ïðîöåäóðû. Íåóæåëè òàì ýòîãî íåò? Âî âñåõ ïîñòàõ Âû íå ïðåäñòàâëÿåòå êàêîé ëèáî èíôîðìàöèè, íà êîòîðóþ ñòÎèò îáðàòèòü âíèìàíèå è îáñóäèòü. Íî âîò îïåðèðîâàíèå îïðåäåëåíèÿìè "îòâåòíàÿ ðåàêöèÿ îðãàíèçìà íà ïíåâìîíèþ è èíñóëüò". ×òî Âû èìååòå ââèäó?  ÷åì íà Âàø âçãëÿä äîëæíà çàêëþ÷àåòñÿ ýòà "îòâåòíàÿ ðåàêöèÿ". Íåò, ìîæíî êîíå÷íî ñåé÷àñ çàëåçòü â íåïðîõîäèìûå äåáðè öèòîêèíîâûõ êàñêàäîâ, àêòèâàöèè ïåðåêèñíîãî îêèñëåíèÿ ëèïèäîâ, àïîïòîçà èëè òåðìîäèíàìè÷åñêîãî ãîìåîñòàçà. È äàæå íàéòè òî÷êè ñîïðèêîñíîâåíèÿ ïðè óêàçàííûõ Âàìè ïàòîëîãèÿõ. Âîïðîñ. ×òî äàëüøå? Ýòè ðàññóæäåíèÿ êàê ïðèìåíèòü íà ïðàêòèêå? Èëè æå èìååòñÿ â âèäó íå÷òî äðóãîå, ïîä ñëîâàìè "îòâåòíàÿ ðåàêöèÿ". À âîò "îõðàíèòåëüíîå òîðìîæåíèå" - ýòî ðåàëüíî ÷òî òàêîå? Óñûïèòü êàæäîãî áîëüíîãî ñ èíñóëüòîì, ÷òîáû ïîòîì ãåðîè÷åñêè áîðîòüñÿ ñ òðîôè÷åñêèìè íàðóøåíèÿìè, áèòüñÿ çà ñòóë è ïîáåæäàòü èíôåêöèþ? Èëè êàê? Ïðîñòèòå, åñëè ÿ âíîâü íåâåðíî èíòåðïðåòèðóþ Âàøè ñëîâà, òàêæå êàê è "íåêðîç ñ èñõîäîì â èíôàðêò", íî ñîãëàñèòåñü, ÷òî "êòî ÿñíî ìûñëèò - ÿñíî èçëàãàåò". È ÷òîáû ïðåäñòàâèòü ñåáÿ íåïðàâîìåðíî ïðåñëåäóåìûì, âñå æå íåîáõîäèìî îáúÿñíèòü ïî÷òåííåéøåé ïóáëèêå ñâîþ òî÷êó çðåíèÿ, à íå îòâå÷àòü âîïðîñîì íà âîïðîñ. È ïîòîì âñòàòü â ïîçó - "âîò âèäèòå, îí ñàì íå çíàåò ÷åãî õî÷åò". Íó ýòî ÈÌÕÎ.
ÇÛ. Íà ÐÌÑ àíãëèéñêèé ÿçûê ïðèíÿò êàê âòîðîé, â ñðåäå ïðîôåññèîíàëüíîãî îáùåíèÿ. È ñîâåðøåííî íîðìàëüíî ïóáëèêîâàòü òåêñòû íà àíãëèéñêîì. Êîìó íóæíî, ñàì ïîëåçåò â ñëîâàðèê è îñèëèò. Ïóñòü è íå "áåãëî". |
#104
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Ó ìåíÿ íà ÊÏÊ áûë êàêîé-òî ãàéä, òàê òàì áûëî âñå ïîìèíóòíî ðàñïèñàíî - â êàêèå ñðîêè ñäåëàòü ÊÒ, íà êàêîé ìèíóòå åãî äîëæåí ïîñìîòðåòü ðàäèîëîã, íà êàêîé - ðåøèòü âîïðîñ è ïð. Òîëüêî âîò ÿ åãî ïîòåðÿë . Òàê èëè èíà÷å,
Recommendations a Thrombolytic treatment with alteplase should only be given provided that: (A) i it is administered within three hours of onset of stroke symptoms (unless as part of a clinical trial) ii haemorrhage has been definitively excluded iii the NINDS criteria have been met iv the patient is in a centre registered with Safe Implementation of Thrombolysis in Stroke Monitoring Study (SITS-MOST) b Patients given alteplase outside the context of a research trial should be notified to the international audit of thrombolysis SITS-MOST (C) c Intra-arterial thrombolysis should only be used in centres with an interventional neuroradiology service (C) Evidence P.S. Âèäèìî, Êàïèòàí Î÷åâèäíîñòü äîëæåí áûë âîðâàòüñÿ ñþäà ñ ýòèì: "Èíôàðêò (ëàò. infarcire - íà÷èíÿòü, íàáèâàòü) — îìåðòâëåíèå (íåêðîç) îðãàíà âñëåäñòâèå íåäîñòàòêà êðîâîñíàáæåíèÿ" |
#105
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Öèòàòà:
Åñëè Âû îáðàòèëè âíèìàíèå, òî ÿ ãîâîðèëà îá èíòðààðòåðèàëüíîì òðîìáîëèçèñå (ÿ äàæå íå óâåðåíà, ÷òî ó íàñ åù¸ äåëàåòñÿ âíóòðèâåííûé, òê åñòü êðóãëîñóòî÷íàÿ âîçìîæíîñòü äåëàòü èíâàçèâíûå ïðîöåäóðû). Ïîýòîìó è íåéðîðàäèîëîãè ïîíà÷àëó ïðåäïî÷èòàëè äåëàòü òðîìáîëèçèñ ïîä îáùèì îáåçáîëèâàíèåì âñåì ïàöèåíòàì (áîÿëèñü ìèíèìàëüíîãî äâèæåíèÿ, êàøëÿ ïàöèåíòîâ âî âðåìÿ ïðîöåäóðû), ÷òî îêàçàëîñü â êîíå÷íîì èòîãå ñîâåðøåííî íå ïðîáëåìîé. Íó à íàñ÷¸ò êîíòðîëÿ àðòåðèàëüíîãî äàâëåíèÿ, òî òàì âåäü äåéñòâèòåëüíî íåò äîñòàòî÷íî ÷¸òêèõ ðåêîìåíäàöèé, äàæå äëÿ ëå÷åíèÿ àðòåðèàëüíîé ãèïåðòåíçèè ó ïàöèåíòîâ ñ èíñóëüòîì. Òàê ÷òî íàøè íåéðîàíåñòåçèîëîãè âûáðàëè äàííûå ïàðàìåòðû. Circulation. 2007 May 22;115(20):e478-534. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. 5. The management of arterial hypertension remains controversial. Data to guide recommendations for treatment are inconclusive or conflicting. Many patients have spontaneous declines in blood pressure during the first 24 hours after onset of stroke. Until more definitive data are available, it is generally agreed that a cautious approach to the treatment of arterial hypertension should be recommended (Class I, Level of Evidence C). Patients who have other medical indications for aggressive treatment of blood pressure should be treated. This recommendation has not changed from previous statements. 6. Patients who have elevated blood pressure and are otherwise eligible for treatment of rtPA may have their blood pressure lowered so that their systolic blood pressure is 185 mm Hg and their diastolic blood pressure is 110 mm Hg (Class I, Level of Evidence B) before lytic therapy is started. This recommendation has not changed from previous statements. If medications are given to lower blood pressure, the clinician should be sure that the blood pressure is stabilized at the lower level before treating with rtPA and maintained below 180/105 mm Hg for at least the first 24 hours after intravenous rtPA treatment. Because the maximum interval from stroke onset until treatment with rtPA is short, many patients with sustained hypertension above recommended levels cannot be treated with intravenous rtPA. 7. Until other data become available, consensus exists that the previously described blood pressure recommendations should be followed in patients undergoing other acute interventions to recanalize occluded vessels, including intra-arterial thrombolysis (Class I, Level of Evidence C). This recommendation has been added since the previous guideline. |