RU2013092C1 - Method of treatment of brain edema at tuberculosis meningoencephalitics - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: heparin is injected into cerebrospinal canal, its dose being 100 units per 1 kg of body mass. Usually within 24 h after injection significant clinic effect takes place. At different stages of the disease 1-4 endolumbar injections are to be carried out. Once a day subdermal injection of heparin is also carried out, its dose being as mentioned above. EFFECT: improves efficiency of treatment, decreases residual effects and lethality. 1 tbl

Description

 The invention relates to medicine, namely to phthisiology.

 A number of known methods of dehydration therapy for tuberculous meningoencephalitis. In these methods, the most commonly used drugs are considered to relieve cerebral edema and swelling (OHM). In severe forms of meningoencephalitis, the most commonly used hypertonic solutions of urea, mannitol, glycerol give only a short-term effect, followed by a new rise in intracranial pressure. It was noted that osmotic diuretics, including furasemide (lasix), reducing intracranial pressure, dehydrates intact rather than edematous brain tissue, mannitol with ONM in 54% of cases has no effect. In severe meningoencephalitis with an elevated level of protein in the cerebrospinal fluid, it is recommended that prednisone be administered endolumbally at 0.025-0.06 g 2-3 times a week. For patients with impaired consciousness and other disorders that preclude oral administration, prednisone or hydrocortisone is administered intramuscularly or intravenously in the same doses. The above method of dehydration using corticosteroids is taken as a prototype. However, it was noted that in the last decade only 37% of patients with meningoencephalitis experienced a clinical recovery, and 45.7% of patients showed residual changes leading to disability, and 2.9% of them died.

 The aim of the invention is the accelerated and persistent removal of edema and swelling of the brain and meninges as a cause often leading to fatal disability in severe forms of tuberculous meningoencephalitis.

 The goal is achieved by the prototype method in the treatment complex by the introduction of prednisolone by the endolumbar route, and by the proposed method by the endolumbar route by introducing heparin in a dose of 100 units per 1 kg of weight until a clinical effect is achieved (from 1 to 4 injections) and 100 units. per kg of subcutaneous mass 1 time per day between endolumbar punctures.

 The essence of the invention lies in the endolumbar administration of heparin as a form of pathogenetic therapy, in achieving accelerated stable dihydration of edematous brain tissue, eliminating cerebrovascular disorders and eliminating metabolic changes. Studies of a number of authors of microcirculation in the extracellular space of the brain showed that the transport of substances from the cerebrospinal fluid into this space is carried out by diffusion.

 The question of the usefulness of anticoagulants for swelling and swelling of the brain and meninges, meningoencephalitis is left open.

 Along with the hypocoagulation properties, heparin, concentrating 100 times more in endothelial cells than in blood plasma, prevents platelet adhesion. Heparin improves transcapillary metabolism and indicators of central hemodynamics, the functional ability of capillaries. Heparin has an antialdosterone effect, with which a dysuretic effect is associated; antihistamine, antihyaluronidase effect, which is due to the anti-inflammatory effect on the anti-inflammatory effect of heparin, carried out by the activity of hyaluronidase, regulating tissue permeability. The dehydration effect of heparin by increasing urinary excretion of sodium, chlorine and water is also known.

A method of using heparin for meningoencephalitis is that patients receive endolumbar punctures in the supine position, the legs bend strongly to the stomach, and the head to the chest. Between the spinous processes III and IV of the lumbar vertebrae at an angle ^of 70-80 produced puncture the spinal canal. After extracting the mandrel, the pressure and the rate of cerebrospinal fluid expiration are measured, and after taking the cerebrospinal fluid for analysis on the same needle, heparin is introduced at the rate of 100 units. per 1 kg of patient weight. A pronounced clinical effect is usually observed within 24 hours after administration. Depending on the severity of the disease, 1 to endolumbal heparin is required for a good clinical effect. To maintain the effect obtained, heparin is administered subcutaneously 1 time daily in the days between the punctures in the same dosages as in the spinal canal.

 Examples of clinical efficacy of endolumbar administration of heparin are given below.

Magomedov P., 45 years old. East. disease N 553/47, was admitted to the clinic of TB in 04.10.88, with a diagnosis of tuberculous meningoencephalitis BK-. Contact with a sick TB relative. A patient from April 23 to September 12, 88, was treated in a tuberculosis hospital in Buinaksk due to meningoencephalitis. After improvement (headaches, vomiting, improvement of general health), the patient categorically refused further treatment and left the hospital without permission. The treatment recommended by the local TB doctor was not taken. 04.10.88 g the patient's condition deteriorated sharply, in connection with which he was taken to the phthisiotric clinic. Complaints of severe headaches, periodically with loss of consciousness, cramps, poor sleep, sweating. The condition of the patient is moderate. The skin is pale, moist. There are no catarrhal phenomena in the lungs. Heart - pure tones, pulse 82 beats. in minutes, blood pressure 100/60 mm RT. Art. The edge of the liver at the costal arch, Pasternatsky’s symptom is negative on both sides. Examination by a neurologist, pupils D =. the response to light is satisfactory, slight asymmetry of the nasolabial folds, the tip of the tongue in the midline. Tendon reflexes of medium vivacity, D =, no pathological signs, abdominal reflexes negative. Meningeal signs: stiff neck 2: 5 cm, a weak symptom of Kernig and Brudzinski, more pronounced on the right. Blood from 10.10.88: hemoglobin 124 g / l, ESR - 37 mm / h, white blood cells - 7.2 ˙ ^{10 9} . In sputum at luminescent microscopy and crops (repeated) VK were not found. On radiographs from 1.10.88 g, the pulmonary fields are transparent, the roots are structural, the sinuses are free. The heart and aorta are normal. 10.10.88 endolumbar puncture was performed: the fluid was clear, flowed out jet, when analyzing cerebrospinal fluid - sugar 1.7 mmol / l, chlorides 63 mmol / l, cytosis 295/3, Pandi +++, a coarse web film fell out. Treatment was started with four tuberculostatic drugs with a dosage by weight (tubazide, rifadin, streptomycin, ethionamide), dehydration therapy (lasix, magnesia sulfate - intramuscularly, albudins, subsequently prednisolone according to the scheme), lumbar punctures, vitamin minotherapy, sedatives, cerebrospinal fluid. However, no noticeable clinical effect of the therapy was observed, since 5.10. on 30.10.1088, the patient periodically had attacks of severe headaches accompanied by vomiting, convulsions, severe agitation, slight twitching of the facial muscles of the face, and loss of consciousness. 10/31/08, another lumbar puncture was performed, the fluid was clear, 80 drops per minute flowed out. In the spinal canal introduced 5000 units. heparin, 1.11. the patient’s condition has improved markedly, the sleep is satisfactory, there are no phenomena of right-sided hemiparesis, there is no regression of the occipital muscles, there is no vomiting, headaches are not disturbed. 6.11.88 g repeated lumbar puncture with the introduction of 5000 heparin. Subsequently, the patient categorically refused spinal cord punctures, citing the fact that after the first endolumbal administration of heparin, headaches, vomiting stopped, stiffness passed and she feels quite healthy. The patient's condition allows you to sit on a bed and knit. The patient continues to receive tuberculostatic, dehydration and vitamin therapy.

 Shakhbanova Zaire, 1 year 7 months. , ist. disease N 419, was admitted to the clinic of phthisiology 23. III. 88 g with a diagnosis of tuberculosis of the intrathoracic lymph nodes in the infiltration phase, complicated by meningoencephalitis. Severe form.

 A child from the 4th pregnancy, was born with a mass of 4900 g. BCG scar is 7 mm, the Mantoux test with 2 TE is negative. Grew and developed according to age. Contact with a sick TB relative.

22. II. 88 g started an attack of convulsions, temperature rise to 39 ° ^C. The appeal to the children's department of the village hospital settlement. Komsomol Kalmyk ASSR, the parents refused the proposed hospitalization and left. Until 12. III. 88 g the child was at home, not treated. Pain reappeared, pronounced and prolonged convulsions against the background of hyperthermia, and the child was hospitalized in a district hospital, where he was unconscious for 4-5 days. 21. III. 88 g the condition of the child improved slightly and after consultation with a TB doctor was transferred to a TB clinic.

On admission temperature of 38 ^{° C,} the child's condition is extremely serious, inhibited, moans, weight 10 kg, clean skin, pale. Peripheral lymph nodes are not enlarged. The pharynx is clean, the tongue is wet, pink. The chest is cylindrical in shape, both halves are involved in the act of breathing. Percussion-shortening of pulmonary sound in all fields on both sides. Auscultation in all fields of wet rales of various sizes, NPV - 24 in 1 min. Heart - rhythmic tones, heart rate 120 in 1 min. The abdomen is soft, the edge of the liver protrudes from the hypochondrium by 2 cm, b / painful. Neurological status - stiff neck 4 cm, right hemiparesis. Consultation with an optometrist - subatrophy of the optic nerves in both eyes. Chlorioretinitis of both eyes of tuberculous etiology. Consultation of an otolaryngologist - a child has a severe form of meningoencephalitis. Does not respond to sound, does not speak. Deafness came from high intracranial pressure.

 On radiographs from 21. III. 88 g of the roots of the lungs are expanded, infiltrated. In all fields of both lungs, foci of dissemination are 2–2.5 cm in size, of medium intensity. In cerebrospinal fluid from 23. III. 88 g protein 0.41 g / l, cytosis 73/3 (lymphocytes predominate). Blood from 24. III. 88 g: HB - 108 g / l, ESR - 23 mm / hour, white blood cells - 6.6. Sputum from 23. III. 88 g. No luminescent bacteria were found during luminescence microscopy and inoculation. The child was treated with three anti-TB drugs, dosing according to the weight, age and severity of the disease (tubazide, rifadin, streptomycin), dihydration therapy (albumin, lasix, magnesia sulfate intramuscularly with the subsequent inclusion of prednisolone according to the scheme), lumbar puncture and vitamin therapy. However, from the therapy for 15 days, in addition to lowering the temperature to subfebrile figures, no noticeable clinical effect was noted: right-sided hemiparesis and data from the side of hearing and vision without changes, stiff neck 3 cm. It was decided to add endolumbar heparin administration to the therapy 100 units / kg. Every day, when no lumbar puncture was performed with heparin, the child received 1000 units of heparin subcutaneously.

 11.04.88 g lumbar puncture - in the lateral position between the spinous processes of the 3rd and 4th vertebrae after anesthesia with a 0.5% novocaine solution, a spinal canal was punctured. Upon extraction of the mandrin, a clear-colored liquid flowed jet, 10 ml was sent for analysis. 1000 units were injected into the spinal canal. heparin. The puncture site is treated with alcohol and sealed with adhesive tape. 04/12/08, the child’s condition improved markedly, movements in the right limbs fully recovered, there is a slight hypertonicity in the right lower limb, and began to respond to noise and colloquial speech.

 04/18/88 g repeated lumbar puncture with the introduction of 100 units. heparin. 04/19/88 g child began to notice moving objects. 04/23/88 g after the third lumbar puncture with the introduction of 1000 units. heparin in a child 04/14/88 g marked restoration of vision.

 Spinal fluid analysis data are presented in the table.

 Parents categorically refused further lumbar punctures because they were practically healthy.

 01.01.89 g oculist consultation - the anterior segment has not been changed. The optical system is transparent. Fundus: D N - pink, clear borders, blood vessels not changed. On radiographs from 15. XII. 88 complete resorption in the lungs and significant resorption and compaction of infiltration in the roots of the lungs. After completion of tuberculostatic therapy, the patient prepares for discharge for spa treatment.

Claims (1)

 METHOD FOR TREATING CEREBRAL Edema WITH TUBERCULOSIS Meningoencephalitis by endolumbar administration of drugs, characterized in that heparin is administered in a dose of 100 units. per 1 kg of body weight, in the intervals between punctures once a day is administered subcutaneously in the same dosage, the course of treatment includes 1 to 4 endolumbal injections of the drug.

Images