Chronic neurological diseases can manifest as either a permanent neurological defect or a progressive increase in symptoms. In mild, non-progressive cases, with the help of orthopedic devices, rehabilitation measures, etc., the patient can be provided with a full-fledged existence. In severe cases, they strive to make the most of the remaining functionality.
With progressive diseases, treatment depends on the rate of increase and severity of symptoms. For example, amyotrophic lateral sclerosis and malignant tumors quickly lead to death, but in these cases, clarification of prognosis and supportive measures can be of great benefit to the patient and his family. Here are recommendations for the care of neurological patients and the treatment of their most common somatic complications. These recommendations, with some individual adjustments, can be applied to any neurological disease.
1. Dysphagia is a complication caused by flaccid or spastic paresis of the muscles of the pharynx and tongue. Aspiration of saliva or food can cause this complication to be fatal.
A. Shows early imposition of gastrostomy, cervical esophagostomy or jejunostomy. Temporarily, a nasogastric tube can also be used for feeding, but it is less convenient, can lead to necrosis of the nasal passages and does not completely prevent aspiration. The nasogastric tube should be as small as possible. Soft rubber probes for children are quite suitable (including for adults). In walking patients, cervical esophagostomy is more appropriate, since they can independently insert the tube when eating, and the rest of the time, cover the hole with a bandage and clothes. In severe paralysis, gastrostomy is indicated, since independent food intake is impossible. At the same time, cervical esophagostomy is safer.
B. Care of the gastrostomy is simple: within 10-14 days after inserting the tube, a fistulous passage is formed and the tube can be easily changed. A Foley catheter (caliber 22-24 F) or a special gastrostomy tube is used to introduce food.
B. For nutrition, use ready-made mixtures (for example, sustakol or sustagen) in an amount corresponding to the patient’s energy consumption.
1. In active patients, energy consumption is 1200-2400 kcal / day. 1 ml of standard liquid nutritional mixture usually contains 1 kcal, but if diarrhea occurs after administration, the mixture is diluted. To prevent clogging, the tube is rinsed with water after each feed.
2. To avoid diarrhea and malabsorption, a diluted mixture containing only half of the required calories is first introduced, and then its concentration is gradually increased. Before feeding, you need to make sure that the previously introduced mixture is absorbed, for this, the stomach contents are aspirated through the tube. In the beginning, they feed often (every 1-2 hours) and in small portions. The maximum single volume is approximately 200 ml (150 ml of the nutrient mixture, then 50 ml of water).
3. Introducing large quantities of the mixture may cause vomiting and aspiration. At the same time, people with a large physique require more volume. If necessary, small amounts of liquid are injected between feedings. To induce a feeling of fullness in the stomach and relieve the patient of hunger, dry food mixtures diluted with milk or water can be administered through the gastrostomy tube. Sometimes continuous feeding is carried out (50-70 ml / h).
D. If there is a danger of aspiration of saliva or mucus, an endotracheal tube with a cuff is inserted. To reduce salivation, M-anticholinergics or tricyclic antidepressants are used; when there is little saliva, patients can swallow it on their own. However, sometimes, with the constant threat of aspiration, it is necessary to resort to tracheostomy and ligation of the trachea above the tracheostomy.
E. The decision on palliative operations (gastrostomy, tracheostomy, etc.) is made taking into account the general condition. For example, in the late stages of fatal progressive diseases, tracheostomy is usually not performed, but at the same time it is often indicated for non-progressive lesions of the trunk or spinal cord.
II. Dysfunctions of the bladder most often develop as a result of a spinal cord injury, less often with other lesions – multiple sclerosis, tumors, discogenic myelopathy, and tabes dorsalis. The areflex type of URTI can occur with peripheral neuropathies (for example, diabetes mellitus or shingles). UDMPs are also found in lesions of the overlying centers, in particular in Parkinson’s disease, tumors of the frontal lobes, and vascular diseases of the brain. To clarify the type of UDM and exclude organic lesions of the urinary tract, cystometry and consultation of a urologist are indicated.
A. Physiology of the bladder. Normally, urination is carried out only voluntarily.
1. Most of the detrusor is innervated by parasympathetic fibers (S2-S4), and the zone of the cystic triangle is innervated by sympathetic fibers (Th 1-L2). Sensory innervation is provided by somatic, parasympathetic and sympathetic fibers.
and. Both somatic and parasympathetic sensory fibers go from the bladder to S2-S4 segments, and sympathetic sensory fibers to Th9-L2 segments. Information enters the overlying centers through the lateral spinothalamic tract and Gaul’s bundle.
b. Voluntary regulation of urination is provided by the corticospinal tracts that control the urethral sphincter and pelvic floor muscles. The primitive urinary reflex closes at the S2-S4 level and is realized through the parasympathetic motor fibers.
2. Retention of urine. Urine accumulates in the bladder when the intravesical pressure is insufficient to overcome the tone of the retaining muscles – the smooth muscles of the bladder neck and urethra and the striated muscles of the perineum (in particular, the deep transverse perineal muscle, which forms an arbitrarily adjustable urethral sphincter). In turn, intravesical pressure is determined by the volume of urine in the bladder and the tone of the smooth muscles of its walls, which forms the muscle that expels urine, or the detrusor. Thus, urinary retention depends on the relationship between detrusor and retaining muscle tone. In neurological diseases, this ratio can be disturbed, which leads to urinary retention or incontinence. So, with flaccid paresis of the retaining muscles, urinary incontinence occurs even with low intravesical pressure. With spastic paresis, emptying of the bladder is possible only at very high intravesical pressure, and therefore the volume of residual urine may increase and vesicoureteral reflux may occur.
3. Both reflex and voluntary mechanisms are involved in the regulation of urination. As the bladder fills, the intravesical pressure increases slightly; this is due to both the plasticity of the bladder and the reflex decrease in detrusor tone. When the pressure reaches 30-40 cm of water. Art., the tone of the retaining muscles reflexively decreases, the detrusor contracts and urination begins. The minimum volume that induces the urge to urinate is 100-200 ml. At the same time, a healthy person can hold up to 400-450 ml of urine due to voluntary control of the sphincter of the urethra. The larger the bladder volume, the shorter the latency period between the voluntary command to urinate and the onset of urine expulsion.
B. The main objectives of treatment for UDM
1. To reduce the volume of residual urine and to reduce vesicoureteral reflux in order to prevent hydronephrosis and urinary infection.
2. Reduce urinary incontinence.
3. To increase the functional capacity of the bladder so that the emptying of the bladder occurs no more than 4-6 times a day.
B. The hyperreflex type of UDM (lesion above the S2-S4 level) is characterized by frequent uninhibited contractions of the detrusor with a small intravesical volume, a decrease in the functional capacity of the bladder, involuntary urination, and a strong stream of urine. With chronic lesions of the spinal cord above S2-S4, the sensation of filling the bladder disappears, and as a result, emptying occurs reflexively, as soon as the intravesical volume reaches a threshold level. In such cases, urination can be induced, for example, by introducing ice water into the bladder. If the function of the retaining muscles is normal, then the bladder is completely emptied. With an increased tone of the retaining muscles, vesicoureteral reflux occurs, with a decreased tone, urinary incontinence. When the higher centers of urination regulation (cerebral cortex, posterior hypothalamus, midbrain, anterior pons) are affected, urgency and frequent urination without other disorders of urinary retention or urination are noted. Hyperreflexia of the bladder can also be observed in the absence of neurological diseases: with cystitis (due to irritation of nerve endings) or with obstructive diseases of the urethra.
1. In case of incontinence resulting from hyperreflex UDM (for example, in the stage of hyperreflexia of spinal shock), treatment begins with periodic catheterization of the bladder. It should be performed by experienced personnel in the early stages to avoid infection.
and. Drinking regime. A large volume of fluid is given to reduce the risk of infection and stone formation. The fluid is given by mouth, nasogastric tube, or IV. Bladder catheterization is performed every 2-4 hours.
b. Simultaneously, they conduct training in controlled urination (see clause II.B.2). As soon as the patient learns to urinate independently (usually using reflex stimuli), catheterization is performed less often, and then (if the volume of residual urine does not exceed 100 ml) is stopped. In most cases, with complete transverse lesion of the spinal cord, spontaneous urination can be restored within 90 days. However, in 10-20% of patients, improvement does not occur due to excessively high excitability of the detrusor or because of the small capacity of the bladder. If intermittent catheterization is ineffective, an indwelling catheter must be inserted or other measures must be taken.
in. With incomplete transverse damage to the spinal cord, reflex urination is restored faster and more completely. However, in some cases, when it does not provide sufficient emptying, it is necessary to use intermittent catheterization of the bladder for a long time.
2. Teaching controlled urination allows you to prevent sclerosis of the bladder, teach the patient to reflexively empty it and determine the degree of its filling.
and. It is necessary to persist in trying to develop reflex urination in the patient. With a complete loss of sensitivity of the lower half of the body, various methods can be used for this: squeezing the glans of the penis, stimulating the scrotum, pulling on the pubic hairs, tapping on the bladder area; deep palpation of the rectum is most effective.
b. Drinking plenty of fluids prevents infection and stone formation. However, after learning to urinate under control, fluid is restricted so that urination is not too frequent.
in. It is necessary to monitor the water balance by measuring the flow of fluid and urine output.
d. External pressure on the bladder increases the amount of urine emitted. thereby reducing the volume of residual urine.
e. Changing body position during urination also increases the volume of urine emitted.
3. Drug therapy. Long-term use of drugs is limited by their toxicity.
and. Betanechol is an M-cholinergic stimulant that stimulates detrusor function and enhances its reflex activity. Dosage: 10-50 mg orally or 5-10 mg s / c every 4-6 hours.
b. Methacholine chloride (M-cholinostimulant) is prescribed 200-400 mg orally or 10-20 mg s / c every 4-6 hours.It is used to reduce the threshold of the urinary reflex, when it does not provide sufficient emptying of the bladder, and in the early period spinal cord injury – to stimulate reflex activity. in. If reflex urination starts already with a small amount of urine in the bladder, then the urinary reflex threshold is increased to increase the interval between urination. For this purpose, apply:
1) Methantelinium bromide and propantheline bromide M-anticholinergics, inhibiting the reflex activity of the detrusor. They are prescribed orally at 50 mg (methantelinium bromide) or 15 mg (propantheline) 4 times a day. These and other M-anticholinergics are most effective for urgent urge or frequent urination in cases of incomplete interruption of the spinal cord or lesions of higher centers. At the same time, M-anticholinergics increase the volume of residual urine and sometimes lead to a paradoxical increase in urinary frequency (due to a decrease in the functional capacity of the bladder). An increase in residual urine volume increases the risk of infection with the development of chronic cystitis and even pyelonephritis. Therefore, if the volume of residual urine exceeds 15% of the volume of excreted urine, these drugs are canceled.
2) Tricyclic antidepressants (for example, amitriptyline, 150 mg at night), which also have anticholinergic activity, increase the functional capacity of the bladder.
d. Phenoxybenzamine blocks (alpha-adrenergic receptors of the smooth muscles of the bladder neck, which leads to relaxation of these muscles and, accordingly, to facilitate urination and reduce the volume of residual urine. It is prescribed 10-30 mg 3 times a day. With good effect (alpha -adrenergic blockers eliminates the need for resection of the bladder neck.
e. Propranolol increases the tone of the smooth muscles of the bladder neck and urethra. It is used when urinary incontinence is caused by uninhibited detrusor contractions against the background of paresis of the retaining muscles. Usually appoint 20-40 mg 4 times a day or more.
e. Drugs that reduce the spasticity of the muscles of the perineum, contribute to a more complete emptying of the bladder. The effectiveness of dantrolene has been little studied, while baclofen, according to some reports, reduces the volume of residual urine; This tool is used in the learning process for controlled urination.
4. Surgical treatment
and. Surgical intervention is indicated when conservative treatment is ineffective, when either it is not possible to develop controlled reflex urination, or high intravesical pressure persists and vesicoureteral reflux occurs, which can lead to hydronephrosis. Usually, resection of the bladder neck or dissection of the urethral sphincter is performed to reduce both urodynamic resistance and intravesical pressure. Sometimes for controlled urination it is necessary to eliminate the obstruction of the urethra by an enlarged prostate gland or congenital valves.
b. Other methods can increase the pressure of urine expulsion, decrease or increase the capacity of the bladder, and carry out urine diversion. In each case, a consultation with a urologist is necessary. in. In case of severe hyperreflexia of the bladder, leading to a sharp decrease in its functional capacity, alcoholization of the cauda equina or anterior and posterior rhizotomy at the Thl2-S3 level is performed. However, these interventions are permissible only with paraplegia. A common complication is impotence. The main indication is the risk of developing hydronephrosis.
D. Areflex type UDMP is characterized by very low intravesical pressure, absence of detrusor contractions, large bladder capacity, large residual urine volume, and weak urine stream. There is no or decreased feeling of full bladder. The reason is damage to the S2-S4 segments, cauda equina, spinal roots or peripheral nerves. Temporary urinary retention sometimes occurs after LA or, more often, after myelography. The risk of urinary retention is especially high with concomitant prostate adenoma. In these cases, bladder catheterization is performed every 4-6 hours, sometimes additionally 10-25 mg bethanechol is prescribed orally every 6-8 hours. Usually, with temporary urinary retention, urination is restored spontaneously within 24-48 hours.
1. If the need for periodic catheterization of the bladder persists for a long time, it can be performed by the patient himself. Catheterization is done at specific times to ensure regular bladder emptying. If necessary, a non-sterile catheter can also be used because the risk of infection is low. The patient should always have a catheter with him. However, self-catheterization is not always possible, especially in patients with severe ataxia, paresis of the arms, spasticity of the adductor muscles of the thigh, and dementia.
2. External pressure on the bladder in combination with the tension of the abdominal muscles allows the volume of residual urine to be reduced to an acceptable level (less than 15% of the volume of excreted urine). Since there is often no sensation of filling the bladder, the bladder should be emptied at a specific time. With weakness of the abdominal muscles, a lumbosacral corset is used to increase intra-abdominal pressure.
3. Drug therapy
and. To enhance the reflex activity of the bladder with partial injuries of the spinal cord, bethanechol is used (10-25 mg orally every 8 hours. If ineffective, they switch to subcutaneous administration.
b. Phenoxybenzamine (20-40 mg 3 times a day) reduces the smooth muscle tone of the bladder neck and urethra and provides more complete emptying.
4. Surgical treatment
and. Bladder neck resection relieves the spasm that obstructs the flow of urine and promotes more complete emptying of the bladder.
b. Residual urine volume sometimes decreases after prostatectomy or removal of congenital urethral valves.
D. Urinary incontinence. With the areflex type of UDM, paradoxical ischuria is observed, and with the hyperreflex type, periodic reflex urination with the release of a large volume of urine. The easiest way to combat urinary incontinence is to periodically empty your bladder. They should be produced as often as necessary to avoid a large accumulation of urine (usually every hour). As a rule, the bladder is emptied more often at first, and then the interval is selected individually.
1. It is especially difficult to treat incontinence in women with a hyperreflex type of UDMP, when a large volume of urine is excreted at the same time. Sometimes there is a need for an indwelling urinary catheter. If the volume of excreted urine is small, then periodic catheterizations are advisable (if the patient is able to carry them out on their own), and in the intervals use pads.
2. A number of devices are used for incontinence in men.
and. A condom bag is used both temporarily and permanently. It is attached to the body of the penis using adhesive plaster or special glue and left in this position for no more than 12 hours. The urine bag can be attached to the thigh and hidden by clothing. Many men with pelvic dysfunctions use a urine collection bag only when they appear in public. With frequent condom changes (every 6-8 hours) and treatment of the skin of the penis, the risk of complications is low. If ulceration or maceration of the skin of the penis still occurs, the condom is removed, the damaged area is dried and treated with an emollient ointment. In the hospital, for faster healing, the urine bag is replaced with diapers. In bedridden patients, a drainage bag increases the risk of urinary infection, especially if the tube becomes clogged and urine accumulates in the condom.
b. The Cunningham clamp compresses the penis and thereby creates mechanical obstacles to the flow of urine. However, to avoid necrosis of the penis or urethra, it must be removed frequently. This device is not used if the tactile sensitivity of the penis is impaired.
3. Implantable sphincter devices are used for both areflex and hyperreflex types of UDMP.
4. In the case of the areflex type of UDMP, electrostimulation of the S2-S4 segments is used, which causes the detrusor to contract.
5. Indwelling catheterization should be avoided.
and. When installing a catheter, you must strictly follow the rules of asepsis.
1) Less salt deposits on Teflon catheters, so they can be changed less often.
2) Conventional rubber catheters are changed every 7-10 days.
3) Balloon Foley catheter is less suitable for continuous use, as the balloon irritates and compresses the bladder wall. However, it has to be used in women, as it is difficult for them to fix a conventional catheter. In men, the catheter can be attached to the penis, so it is not necessary to use a balloon catheter.
b. The drainage bag must not be lifted above the level of the bladder (otherwise gallbladder reflux is possible). Sometimes a disinfectant is added to the bag.
in. Bladder lavage is performed 3-4 times a day using a double-lumen catheter; the volume of fluid for flushing is equal to the functional capacity of the bladder. Any sterile solution can be used. The citric acid solution prevents the deposition of calcium salts on the catheter; solutions of acetic acid or neomycin are also used.
d. Catheter size. It is advisable to use a catheter of caliber up to 16 F. Large-diameter catheters cause urethra abscesses in men, and in women – its expansion. When using a Foley catheter, it is enough to inject 5 ml of fluid into the balloon. In men, the catheter is attached to the abdomen, otherwise it can bend over at the junction of the penis and scrotum and cause a pressure ulcer.
e. Urine flow can be improved by:
1) Early activation of the patient (walking or moving with the help of a wheelchair).
2) Frequent changes in body position.
3) Raising the head of the bed.
e. Drinking plenty of fluids reduces the risk of urinary infection and stone formation. In the absence of contraindications, all patients with an indwelling catheter should drink 3-4 liters per day.
E. Prevention of stone formation
1. Patients who are bedridden for a long time have a high risk of kidney stones. To avoid this, you need good nutrition and plenty of drink. With hypercalciuria, dietary calcium intake is limited.
2. Acidification of urine prevents its infection and precipitation of salts. This measure is especially necessary in the presence of an indwelling catheter.
and. Cranberry juice (250 ml 3 times a day) is not always effective, so other substances are usually used.
b. Ascorbic acid (250 mg orally 4 times a day) and methenamine mandelate (1 g orally 4 times a day) effectively reduce urine pH in the absence of infection. With a urinary infection, they are prescribed simultaneously. Methenamine mandelate also has a bactericidal effect.
G. Urinary tract infections
1. As long as an indwelling catheter is in place, active management of asymptomatic chronic urinary tract infection is not necessary. In order to avoid severe bacteriuria, it is enough to maintain an acidic urine reaction and prescribe methenamine mandelate (1 g 4 times a day), methenamine hippurate (1 g 2 times a day) or sulfisoxazole (1 g 4 times a day). The key to preventing upper urinary tract infections is to prevent vesicoureteral reflux.
2. In acute infection or only when fever appears, antibiotic therapy is prescribed. Instead of intermittent catheterization, a permanent Teflon catheter is used, which is removed only after the infection has been suppressed. If an indwelling catheter was inserted before the infection develops, it is replaced and antibiotics are given. At the same time, it is sometimes advisable to change catheters frequently (with strict adherence to the rules of asepsis).
The goal of therapy is to kill bacteria in the upper urinary tract. Complete sterilization of bladder urine is often not achieved.
III. Colon dysfunction
A. Fecal impaction can develop with various diseases, but especially often it occurs when the nervous system is damaged. In stubborn cases, it is necessary to exclude obstructive intestinal obstruction.
Predisposition. Fecal impaction occurs more often:
and. In bedridden patients.
6. In elderly patients, especially if there is a history of constipation or fecal impaction.
in. With weakness of the muscles of the abdominal wall (due to neuromuscular diseases, neuropathy, spinal cord injury or other reasons).
d. When taking narcotic analgesics and other drugs that inhibit intestinal motility (for example, M-anticholinergics), as well as aluminum hydroxide preparations.
e. When dehydrated, for example due to the use of glycerin or mannitol.
and. Inability to defecate despite the urge.
b. Frequent loose stools.
in. Cramping abdominal pain.
d. X-ray of the abdominal cavity shows an obstruction of the large intestine with fluid levels.
e. Palpation of the abdominal cavity or digital examination of the rectum reveals easily displaced dense formations.
and. Drinking plenty of fluids softens stool and prevents stool blockage.
b. Natural laxatives (such as bran or prunes) soften stool.
in. Some laxatives (such as sodium docusate) increase the water content of the stool and soften it.
d. Often it is necessary to resort to digital or sigmoidoscopic removal of the blockage.
The elimination of the blockage is sometimes facilitated by the intake of vaseline oil (30 ml 1-2 times a day for several days).
B. Constipation and fecal incontinence
1. In paralyzed patients, neurogenic constipation or fecal incontinence often does not occur even with severe UDMP.
2. Often the cause of fecal incontinence is diarrhea, and after
elimination of fecal incontinence stops.
3. Sometimes it is necessary to take measures to form a defecation regime.
and. Daily enemas or suppositories until regular self-defecation is restored.
b. Regular attempts at defecation using, if necessary, an abdominal corset, which increases intra-abdominal pressure with weakness of the muscles of the abdominal wall; The gastrointestinal reflex can be used to facilitate bowel movements, trying immediately after a meal.
in. Softening feces with the help of abundant casting, the use of prunes, bran, laxatives (sodium docusate, 100 mg 3 times a day).
d. With Guillain-Barré syndrome – regular use of enemas or suppositories, up to the restoration of the function of the abdominal muscles; if the stool is soft, suppositories that release carbon dioxide are effective. This increases the pressure in the intestinal lumen and thus stimulates the defecation reflex.
e. Drugs that cause constipation (eg narcotic analgesics) are contraindicated.
4. Chronic fecal incontinence can occur, for example, with diabetes mellitus.
and. To reduce intestinal motility, use opium tincture (5-10 drops, 2 times a day).
6. Morning enema reduces the risk of involuntary bowel movements during the day, after which it is enough for the patient to wear pads.
in. With the help of biofeedback methods, it is possible in some cases to train the patient to control the external sphincter of the anus and other muscles necessary for the retention of feces.
IV. Management of patients with tracheostomy
A. Imposition of a tracheostomy
1. In acute respiratory disorders, tracheal intubation is primarily indicated. However, if there is no hope for the restoration of respiratory function within the next 7-10 days, then it is advisable to immediately impose a tracheostomy.
2. Indications. In neuromuscular diseases, motor neuron or brainstem lesions, tracheostomy is performed in order to:
and. Ensure airway patency.
6. Avoid aspiration.
in. Suction from the deep parts of the respiratory tract.
d. Reduce dead space and breathing energy.
1. In adults, mortality during tracheostomy is 1.6%, in children – 1.4%. The most common causes of death are bleeding and tube misalignment. In the later period after tracheostomy, deaths are less common – as a rule, due to blockage of the tube or its disconnection from the respirator.
2. Causes of blockage of the tracheostomy tube
and. The tube may become clogged with hardened mucus, especially if the inhaled air is not humid enough or if the tube is not changed for a long time.
6. When using a metal tube, a slipped cuff may close the lumen.
in. If the tracheostomy is located in the lower part of the neck, then the end of the tube may overlap with the keel of the trachea. If the tube is too long, only one bronchus can be intubated; this can be recognized by auscultation or X-ray.
d. Due to extensive tracheal trauma, the tube may become clogged with tissue detritus or granulation tissue.
and. Acute postoperative bleeding can be fatal.
b. Later, the cause of massive bleeding may be erosion of the mucous membrane or erosion of an artery or vein, which leads to aspiration of blood and large blood loss,
4. Subcutaneous and mediastinal emphysema usually does not require treatment, however, in severe emphysema, the position of the tube should be changed and the edges of the tracheostomy should be tightened. Subcutaneous emphysema leads to pneumothorax, so all patients with subcutaneous emphysema or pneumomediastinum are shown a chest x-ray.
and. Wound infection.
b. Chronic tracheitis. Sowing bacteria from secretions in patients with tracheostomy does not yet indicate an infectious disease. A significant number of pathogenic microorganisms are found in most of these patients.
B. Choice of tracheostomy tube
1. Metal tubes are used for permanent tracheostomy. They usually consist of an outer cannula that is permanently located in the trachea and an inner cannula that can be removed and cleaned. The metal tubes do not have a cuff, but it can be attached. Patients should be trained in proper tube care.
2. Patient can speak when using valve tubes. Usually these tubes are also metal. A conventional inner cannula without a valve can be inserted at night.
3. Plastic tubing with an anti-aspiration cuff has recently been used more and more. Their disadvantage is that when secretions accumulate, it is necessary to change the entire tube. For neurological disorders, cuffed tubes are almost always indicated.
D. Rules for the use of cuffed tubes
1. To prevent tracheal necrosis, wide cuffs are used, which are supported by low pressure.
2. The volume of air during inflation of the cuff must be strictly regulated. The required volume is determined by air leakage from under the cuff. During mechanical ventilation, the cuff is first inflated to such an extent that no air passes along its periphery, then several milliliters of air are released until a small leak appears.
3. For the prevention of pressure ulcers, the cuff should be deflated every 1-2 hours for 5-10 minutes, after sucking the trachea contents above the cuff. To prevent aspiration at this point, the patient is placed in the Trendelenburg position or at least on his back. The use of wide, low pressure cuffs reduces the risk of necrosis.
4. Prescribe an abundant drink, and when using plastic tubes to reduce the viscosity of the contents of the trachea, additionally moisturize the respiratory tract with aerosols. The air in the room was humid and warm enough. To supply the patient with warm humidified air, a tracheostomy “mask” is used.
5. Frequent suction of tracheal contents prevents its accumulation in the tube. To reduce the viscosity of the contents of the trachea, 5-10 ml of sterile saline is instilled into the tube.
6. To remove the contents of the bronchi, postural drainage is used.
7. Patients with any tracheostomy tube can speak by deflating the cuff and covering the tube.
8. The tracheostomy closes on its own several days after the tube is removed. With slow healing, you can speed up the process by securing the edges of the wound with adhesive tape or covering the opening with an airtight bandage with petroleum jelly. Sometimes the tracheostomy has to be sutured.
9. If the tracheostomy was applied for long-term mechanical ventilation, then after the end of mechanical ventilation the tracheostomy is usually closed (unless it is necessary to leave it for prophylactic purposes – for example, in severe myasthenia gravis). In order to assess whether a tracheostomy is needed, it is covered, and the patient breathes through the mouth – first a few minutes, then this period is increased to several hours. If the patient feels comfortable enough without a tracheostomy, then sometimes it can be closed, despite some deviations in the blood gas composition and other indicators.
10. With a permanent tracheostomy, observation by an otolaryngologist is indicated.
D. Changing the tracheostomy tube
1. Plastic tubes are changed every 5-10 days. The metal tubes are cleaned daily and can be changed less frequently.
2. The tracheostomy course is formed within 3-5 days after the operation. The surgeon must change the tube earlier than this.
3. The tube is inserted with a light but firm motion, and a cough reflex usually occurs.
4. The new tube must be the same diameter as the old one. Often, however, increasingly narrow tubes are used because they are easier to insert. As a result, the tracheostomy tract narrows and may require surgical expansion.
1. Pressure ulcers are often observed in patients with paralysis and sensory impairment. The most effective prevention is the regular change in body position, in particular – turning in bed. With tetraplegia, the Stryker frame is useful, with which you can easily turn the patient every 1-2 hours. Thus, the prevention of bedsores is entirely dependent on care.
2. Special protection is required for areas of bony protrusions (heels, ischial tubercles, sacrum). In children with chronic hydrocephalus, measures are taken against scalp pressure sores.
3. Sheepskin pads, water mattresses and other soft materials are used to prevent bedsores. Round pads should not be used, the central convex part of which can cause skin ischemia and contribute to the development of pressure sores.
4. The skin must be dry. This should be especially monitored in patients with urinary incontinence. In the absence of an indwelling catheter, diapers are placed.
5. To prevent maceration, wet or sweating areas of the skin are treated with emollient ointments (for example, petroleum jelly).
6. A necessary condition for maintaining healthy skin is good nutrition.
7. With edema, the skin becomes thinner, and its blood supply deteriorates. To prevent skin cracks, prevention and treatment of edema of paralyzed limbs is necessary.
1. If the compression of the affected skin area continues, then the healing of the pressure ulcer is impossible and, moreover, it may increase. The bedsores are treated with saline or hydrogen peroxide, after which necrotic tissue is carefully removed. Wet-drying dressings are applied to large bedsores until fresh granulations are formed. Ointments with lytic enzymes are also used. These ointments are applied 2-3 times a day after pre-treatment. Enzymes are also used in the form of solutions, applying wet-drying dressings with them. For extensive bedsores, surgical debridement is necessary. After treatment, the wound must remain dry (for this, a gauze or other light bandage is applied to it ).
2. Also use occlusive dressings with petroleum jelly or zinc oxide. From antacid solutions containing gels of aluminum and magnesium hydroxide, you can prepare a paste, for this you need to drain the top layer of liquid from the bottle. When applied to the area of ulceration, this paste hardens to form a surface protective layer. It is usually applied 3 times a day.
3. An important role in the pathogenesis of pressure ulcers is played by microcirculation disorders. Moisturizing and gently massaging the surrounding skin improves blood flow and heals the pressure sore faster.
4. With insufficient nutrition and anemia, bedsores do not heal well.
5. For extensive and deep ulcers with undermined edges, surgical debridement and skin grafting are indicated.
6. Infection is usually not the cause of ulceration, but life-threatening sepsis may develop with severe pressure ulcers. Local use of antibiotics is ineffective in this case.
7. Applying a film of synthetic material that is permeable to water and oxygen on the bedsore appears to accelerate healing. The film is left until moisture appears on it. At first, the film has to be changed often, then (as it heals) less and less and, finally, it is changed once a week. An extremely rare complication is inflammation of the subcutaneous tissue.
Vi. Sexual dysfunction.
Sexual function and sexual satisfaction depend on a complex interplay of psychological, neurological, endocrine, vascular and anatomical factors. Diagnosing and treating sexual dysfunction requires awareness in many areas of medicine.
A. Initial examination
1. Anamnesis. Sexual issues are often reluctant to be discussed by both patients and doctors. First of all, it is necessary to clarify the nature and duration of sexual dysfunction. Decreased sex drive is often observed in any chronic disease, as well as in depression, alcoholism, drug addiction, endocrine disorders, diseases of the genital organs, self-doubt or taking certain medications. An important factor is incompatibility with a sexual partner, and a conversation with him, if possible, should also be carried out.
2. Conduct general, urological (or gynecological) and neurological examination, vascular examination and consultation with a psychologist.
B. Impotence is the inability to have sexual intercourse due to erectile dysfunction.
1. Physiology of erection. An erection is provided by a vegetative reflex, which is closed in the sacral segments of the spinal cord. An erection occurs under the influence of mental stimuli, stimulation of the genitals, interoceptive impulses from the bladder and rectum. Its psychogenic inhibition is possible. The motor link of the reflex is represented by parasympathetic fibers coming from the S2-S4 segments. When these fibers are excited, the flow of arterial blood to the cavernous tissue of the penis increases. The enlarged cavities of the cavernous bodies compress the veins, which leads to a decrease in outflow and an even greater accumulation of blood in the penis. Finally, the inflow and outflow of blood is compared and the penis no longer enlarges, but remains tense.
2. Psychogenic impotence. It used to be thought that erectile dysfunction in most cases is due to emotional disorders. Recently, however, it has been established that most often organic disorders underlie impotence, although mental factors often aggravate it.
and. General information. Common causes of impotence are depression, anxiety, obsessive fears, incompatibility with a partner. Although psychological factors can suppress an erection, it is possible in certain circumstances. Sometimes a full erection occurs only with a specific partner, or only in the morning or with masturbation.
b. Diagnosis. The diagnosis of psychogenic impotence is established by exclusion. At night, most men have an erection during REM sleep. There are special devices that measure the circumference of the penis (or its tension) during sleep. The preservation of a nocturnal erection is an important, but not pathognomonic, sign of psychogenic impotence: sometimes a nocturnal erection persists in neurological disorders.
in. Psychotherapy is aimed at identifying and correcting factors that can lead to sexual dysfunction (stress, depression, anxiety, family difficulties). The experience and personality of the therapist is extremely important.
d. Drug therapy. Cancellation of drugs for psychogenic (and organic) impotence is much more useful than prescribing new ones. The use of drugs and alcohol is the cause of at least 25% of cases of impotence.
1) Androgens. With psychogenic impotence, as a rule, there is no reason for the appointment of androgens. Testosterone is probably no more effective than placebo and has many side effects (eg, accelerates the growth of prostate cancer, causes fluid retention and hypercalcemia).
2) Yohimbine – plant alkaloid, alpha2-blocker. The drug relaxes vascular smooth muscle and thus can enhance erection. However, its effectiveness has not been proven. The usual dose is 5.4 mg 3-4 times a day. The side effects are minimal.
3. Impotence in neurological diseases
and. A common cause of impotence is autonomic neuropathy. It is with autonomic neuropathy that impotence in diabetes mellitus is often associated (it is detected in 10-25% of young and 50% of elderly patients with diabetes). There is a strong correlation between UDMP (as measured by cystometry) and impotence. Impotence associated with damage to the autonomic nervous system often develops in diseases such as alcoholic polyneuropathy, primary amyloidosis, Shay-Drager syndrome and familial autonomic dysfunction.
b. Multiple sclerosis. Neurogenic impotence often occurs in patients with multiple sclerosis and does not always correspond to the severity of the disease. In a recent study of 29 patients with multiple sclerosis suffering from impotence, only 3 had it purely psychogenic.
in. Spinal cord injury
1) General information. Sexual dysfunctions in spinal cord injuries are well understood. The severity of violations depends on the level and degree of damage. In most cases, when the spinal cord is transected at the cervical or thoracic level, the ability to erect is restored. In such patients, an erection can occur spontaneously (for example, during flexion spasms), but it is not caused (in the case of a complete interruption of the spinal cord) by psychological stimuli. With damage to the lumbosacral spinal cord and cauda equina, erection in most cases is absent.
2) Treatment under the guidance of a specialist in sexual dysfunction with para- or tetraplegia often helps the patient to resume sexual activity. In men who have suffered severe spinal cord injury, the ability to naturally fertilize is usually impaired, but in these cases, artificial insemination is possible.
Diseases of the brain
1) Impotence can occur with tumors or injuries to the temporal lobe. A decrease in sexual activity is also described in patients with temporal lobe epilepsy, but it is possible that in these cases psychogenic factors are important. At the same time, treatment of temporal lobe seizures often has a positive effect on sexual function.
2) Impotence associated with Parkinson’s disease often resolves with levodopa treatment. Sometimes levodopa and dopamine agonists cause hypersexuality in the elderly.
4. Other causes of impotence
and. Impotence with endocrine diseases, as a rule, is associated with a decrease in sex drive, and not directly with erectile dysfunction. A decrease in libido and potency is noted in Addison’s disease, hypothyroidism, hypopituitarism, Cushing’s syndrome, acromegaly, hypogonadism, Klinefelter’s syndrome, atrophic myotonia. Impotence is often the first symptom of prolactinoma. In general, endocrine disorders are a rare cause of impotence.
b. Vascular diseases. Adequate blood flow to the penis is required to develop and maintain an erection, and therefore atherosclerotic narrowing of the abdominal aorta or iliac arteries can lead to impotence. Such patients often have a murmur over the affected arteries, a decrease in pulse rate, intermittent claudication. The vascular genesis of impotence is indicated by a change in the ratio of systolic pressure in the artery of the penis and in the brachial artery (however, the normal ratio does not exclude vascular impotence). If the vascular lesion is incurable, intracavernous injections or phalloplasty are indicated.
in. A venous fistula of the penis is a rare cause of impotence. Treatment is prompt.
5. Treatment. Even with incurable neurological diseases, patients can be helped to resume sexual activity.
and. Intracavernous injections. Direct injection of vasoactive agents such as papaverine or alprostadil into the corpus cavernosum causes an erection. Due to cross-circulation, even a one-sided injection leads to a bilateral enlargement of the penis. The injections are done with a very fine needle and are almost painless. An erection occurs 5-10 minutes after the procedure and lasts from 30 minutes to 2 hours, slightly decreasing after ejaculation. The dose of papaverine is selected individually. The most serious and urgent side effect is priapism, which is more common after the first injection. Scarring or infection from repeated injections is rare. Alprostadil is often better tolerated than papaverine, but less readily available.
6. Vacuum devices are used to increase blood flow to the penis. After a sufficient erection has developed, the penis is tied tightly at the base.
in. Various prostheses have been proposed that are directly sewn into the corpus cavernosum. Some of them are constantly tough, others inflate and deflate. The patient’s sensations and ejaculation are not disturbed. This method is especially indicated in relatively healthy men suffering from organic impotence that does not respond to other methods of treatment. The effect is noted in 90% of patients.
B. Violations of sexual function caused by drugs. Many common drugs interfere with sexual function in both men and women. This can be manifested by a decrease in sex drive, impotence, anorgasmia. Therefore, in patients with impaired sexual function, all drugs are canceled if possible. Especially often lead to such violations:
1. Antihypertensive drugs, including thiazide diuretics, clonidine, methyldopa, beta-blockers (propranolol, metoprolol, pindolol). Angiotensin-converting enzyme inhibitors (captopril, enalapril) and calcium antagonists (eg verapamil) do not cause sexual dysfunction.
2. H2-blockers (cimetidine, ranitidine, etc.) increase the secretion of prolactin. which can lead to impaired sex drive and impotence. A new drug, famotidine, may not cause these problems.
3. Antipsychotics (haloperidol, chlorpromazine, perphenazine, thiothixene) and tricyclic antidepressants (amitriptyline, imipramine, desipramine, nortriptyline) cause sexual dysfunction due to their antiadrenergic and anticholinergic action. The antidepressant trazodone can cause priapism.
4. MAO inhibitors (eg phenelzine) cause anorgasmia in both men and women.
5. Drugs that depress the central nervous system (sedatives, tranquilizers, marijuana, alcohol, heroin) reduce sex drive, disrupt erection and inhibit ejaculation.
D. Disorders of ejaculation and orgasm
1. Ejaculation is caused by a spinal reflex, which is closed in the thoracic and lumbar segments of the spinal cord. Excitation of sympathetic fibers leads to the release of semen from the seminal vesicles into the posterior part of the urethra, which, in turn, leads to reflex contraction of the periurethral muscles and ejaculation. Suprasegmental centers affect ejaculation, but it can be carried out without their participation.
2. Orgasm is a subjective sensation accompanied by contraction of the striated muscles of the perineum and smooth muscles of the genitals. The subjective component of orgasm is associated with the higher centers of the brain, which is proved by the possibility of orgasmic sensations during epileptic seizures and the existence of “phantom” orgasms in patients with paraplegia.
3. Premature ejaculation
and. Definition. Premature ejaculation is a relative concept: it depends on the ideas and requirements of both sexual partners. So, ejaculation that occurs 5-10 minutes after the onset of sexual intercourse, a man can be regarded as premature or normal, depending on the feelings of the partner. It is generally accepted that if a man complains of too fast, in his opinion, ejaculation, then it should be defined as “premature.”
b. Differential diagnosis. The ability to restrain ejaculation is acquired with experience; in young men who begin their sexual activity, this ability is practically absent. Sometimes a man does not seek to restrain ejaculation, because he believes that the satisfaction of his partner is irrelevant or even impossible. Other psychological causes of premature ejaculation can be ideas about their sexual inferiority, difficulties in relationships between partners or hostility between them. Very rarely, premature ejaculation is based on an organic disorder, in particular a spinal cord injury (multiple sclerosis, tumor) or urological disease.
in. Treatment is often effective. First of all, the patient should be convinced of the possibility of improvement. It is necessary to discuss with the patient the most important psychological problems for him; sometimes it helps in solving them. It should be especially emphasized that during intercourse one should have pleasure, and not strain. Often, such measures as masturbation before intercourse, an attempt to achieve two or more orgasms during one sexual intercourse, the use of a condom, and squeezing of the penis before ejaculation by the patient or his partner are often effective.
4. Lack of ejaculation and anorgasmia
and. General information. The inability to achieve ejaculation and orgasm can be selective (that is, manifest only in certain situations) or complete (ejaculation and orgasm are absent both during masturbation and during intercourse).
6. Differential diagnosis. The complete impossibility of ejaculation and orgasm can be associated with some organic diseases.
1) Violation of the sympathetic innervation of the pelvic organs (for example, after sympathectomy or other surgical procedures). Anorgasmia in women with diabetes mellitus is associated with diabetic autonomic neuropathy.
2) A spinal cord injury can cause ejaculation disorders with an intact erection.
3) Taking drugs that deplete the reserves of sympathetic mediators (guanethidine, MAO inhibitors, methyldopa).
4) As we age, ejaculation becomes progressively slower and eventually does not occur with every intercourse. The pathophysiology of these changes is unclear. The absence of ejaculation only with intravaginal contact or during intercourse with a specific partner indicates the psychogenic nature of the disorder. It can be caused by fear of pregnancy, interpersonal problems, etc.
5. Retrograde ejaculation
and. General information. Retrograde ejaculation occurs when semen is ejected into the urethra if the bladder sphincter is not sufficiently closed. In this case, orgasm occurs without the release of sperm, and only then traces of it are found in the urine.
b. Differential diagnosis. Retrograde ejaculation occurs when the sympathetic innervation or the anatomical integrity of the bladder neck is disturbed. It can be an early sign of diabetic autonomic neuropathy. Sometimes, with autonomic neuropathy, retrograde ejaculation precedes impotence. In addition, retrograde ejaculation may result from sympatholytics (eg, guanethidine), bilateral sympathectomy, transurethral resection of the prostate or bladder neck .