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The number of victims with difficult defects of the skull bones, which should restore the integrity of the skull is growing annually, both in connection with the increase in severe traumatic brain injury (TBI), and in connection with the expansion of indications for decompressive craniotomy not only in traumatic brain injury, but also vascular disease, neuro-Oncology for the relief of hypertension-dislocation syndrome. Cranioplasty at the stage of early rehabilitation of patients after decopressive craniotomy is an important condition for effective rehabilitation measures. Currently, titanium, polyether ethyl ketone (PEEK), polymethyl methacrylate (PMMA) and hydroxyapatite are actively used as the material for the implant. Unfortunately, none of the synthetic materials used meet the conditions of the perfect implant by 100%. CAD/CAM 3D printing technologies are used to achieve absolute accuracy of the implant that replicates the missing part of the patients skull bone, which is especially important in the presence of extensive and complex defects. The use of this technology at the preoperative stage directly in the medical institution where the cranioplasty will be performed avoids additional logistics, reduces the time from the patients admission to the hospital before the operation and reduces the cost of manufacturing implants, making them more accessible to healthcare institutions. also, the absence of the need for intraoperative implant adjustment significantly reduces the operation time, reduces the risk of infectious complications and complications associated with prolonged general anesthesia. The favorable course of the postoperative period allows you to resume rehabilitation activities on the third or fourth day after cranioplasty.

Prophylaxis, diagnostics and correction of nutritional status disturbances is considered as one of the main treatment methods of patients with COVID-19 infection-directed to resolve systemic inflammatory response and correction of metabolic response to a viral infection. Systemic Inflammatory Reaction (SIR) manisfestation as a result of viral infection leads to pronounced metabolic processes disturbances. The main metabolic manifestations of SIR is reflected as hypermetabolic-hypercatabolic syndrome with complex disturbances of protein, lipids and carbohydrates metabolism, increased consumption of carbohydrate-lipid reserves and breakdown of tissue proteins. Thus, adequate correction of metabolic disorders and a wholesome nutritional support, taking into account the clinical picture, severity of the disease, ongoing respiratory and intensive care therapy is an integral component in treating patients with COVID-19 infection which determines the efficiency of its treatment and reduction in mortality. Given the relevance of the problem, the authors decided that it was important to increase the COVID-19 treatment efficacy by producing guidelines based on the most fundamental provisions of the modern approach to nutritional support in critical patients with community acquired pneumonia, acute respiratory failure, ARDS, sepsis, multiple organ failure.

Background: Thanks to advances in emergency medical and surgical care, the number of patients experiencing acute critical illnesses is increasing. However, a group of patients in the so-called chronic critical illness (CCI) was formed. In this category of patients, the problem of treating decubital ulcers is relevant, since they are characterized by a combination of prolonged immobilization, severe protein catabolism, neuroendocrine and metabolic disorders, protein-energy malnutrition (PEN) and tissue trophic disorders. Aims: Analyze the correlation of the degree of regeneration of decubital ulcers according to the Bates-Jenson scale in the modification S.Y.R. in relation to indicators of the nutritional status of patients in the CCI after brain damage. Materials and methods: The study included 26 patients with pressure ulcers II, III, IV stage with PEN. To evaluate decubital ulcers, the adapted Bates-Jensen scale in the S.Y.R. modification was used. (with graphic model). The severity of PEN was evaluated by a complex of anthropometric (BMI, shoulder circumference, thickness of the skin-fat fold, circumference of the shoulder muscles) and laboratory (transferrin, absolute lymphocyte count) indicators. The dynamics of anthropometric indicators and the results of laboratory studies were separately considered. Results: As a result, it was found that the change in anthropometric data correlated with laboratory parameters and the healing rate of decubital ulcers in only 26.9% of cases. Moreover, this correlation between the dynamics of transferrin and the absolute number of lymphocytes with the regeneration of decubital ulcers was observed in all patients. The obtained results demonstrated a direct correlation between the dynamics of healing of pressure ulcers and changes in laboratory indicators of nutritional status (as opposed to anthropometry data) in patients who are in a CCI after brain damage. Conclusions: These findings provide an opportunity to review the weight of indicators in assessing the severity of protein-energy malnutrition, as well as introducing the rate of regeneration of a decubital ulcer in the presence of a patient into the assessment of the nutritional status.

Background. Nutritional support is an important part of the treatment of critically ill patients. However, there are no specific recommendations for patients in a long unconscious state after brain damage to determine their energy needs. Aim. To determine the role of indirect calorimetry in assessing the energy expenditure of patients in prolonged unconsciousness after brain damage. Methods. Prospective cohort study included 81 patients with brain damage who were treated in the intensive care unit. All patients with prolonged unconsciousness had stayed in the intensive care unit for more than 30 days. Mean age of patients was 48.4 16.3 years. Men were predominant (58%). Almost all patients had normal body mass index (BMI) (mean 22.8 6.2 kg/m2). The main cause of brain damage was severe traumatic injury (42%). There were also patients with consequences of subarachnoid hemorrhage (35%), stroke (19%) and hypoxic damage (4%). Results. According to indirect calorimetry, mean energy requirements in patients in prolonged unconsciousness was 25.12 8.8 kcal/kg/day (1595.3 560 kcal/day). Variability of this value was high in this sample (10.661.6 kcal/kg/day, 6733514 kcal/day). According to urine nitrogen loss, mean protein requirement was 0.83 0.46 g/kg/day that was lower than the recommended values for critically ill patients. Variability of data obtained by indirect calorimetry was higher than that of the calculated values despite statistically similar energy requirements of patients. Variability of data obtained by Harris-Benedict equation ranged from 15.4 kcal/kg/day (1023 kcal/day) to 37.3 kcal/kg/day (2065 kcal/day). There was no relationship between energy expenditure and causes of brain damage. Moreover, significant correlation between metabolic rate, urine nitrogen loss and outcomes of disease was also absent. Conclusion. Indirect calorimetry alone is not enough to prescribe optimal nutritional support in patients with prolonged unconsciousness if function of the gastrointestinal tract and other factors affecting energy expenditure are not considered.

Justification. One of the forms of systemic angioreticulomatosis is the combination of a tumor (angioreticuloma) of the cerebellum with retinal angioma (the so-called Hippel-Lindau disease). With this hereditary disease, the general condition of patients and the prognosis depend on concomitant tumor diseases. Including for a comprehensive diagnosis of this syndrome, radiation research methods are used. Description of the clinical case. A young patient with Hippel-Lindau disease and a number of neurological disorders was enrolled in a course of treatment and rehabilitation measures at the Federal Center for Pharmacy of the Republic of Poland. At the hospitalization stage in the previous hospital, she underwent microsurgical removal of an intracerebral tumor. During the examination, possible long-term postoperative complications were excluded, however, kidney and pancreas lesions were detected. As a result of the adjusted course of rehabilitation, the patient showed positive dynamics (in particular, an increase in functional and somatic status). Conclusion. In Hippel-Lindau disease, as one of the forms of multiple angioreticulomatosis, cerebellar angioreticuloma and retinal angioma can be combined with lesions of other internal organs. Therefore, a comprehensive diagnosis of this category of patients is necessary. Timely identification of foci of Hippel-Lindau disease, complications after previous treatment allows you to choose the necessary amount of therapeutic and rehabilitation measures, which in the future can improve the patient’s quality of life and prognosis.

Background. Analysis of the effectiveness of ULTRASOUND navigation in case of percutaneous endoscopic gastrostomy to improve the security method of ensuring the delivery of enteral nutrition. Materials and methods. Percutaneous endoscopic gastrostomy with the technique «pull», supplemented by ULTRASOUND navigation, was performed in 115 patients with the consequences of severe craniocerebral trauma and cerebral strokes, who are in a chronic critical condition and have persistent dysphagia during their rehabilitation. Results. All patients underwent surgery satisfactorily and in a day could receive enteral nutrition. In two patients (1.7%) there was a complication in the form of pneumoperitoneum, which required additional antibacterial therapy and was successfully resolved after 7–10 days, without additional surgical interventions. Adding to the ultrasound technique the area defined by diaphanoscope, proved to be effective in 15 cases (13,0%) of them with a frequency of 73,0% in particular for puncturing points of the detected liver edge, and a rate of 27,0% revealed transverse colon. Conclusion. 1. Percutaneous endoscopic gastrostomy with the technique «pull», supplemented by ULTRASOUND navigation, is an adequate way to ensure the path of enteral nutrition in patients in long-term (chronic) critical condition. 2. Carrying out the ULTRASOUND navigation of the area determined by diafanoscopy immediately before the puncture of the stomach, especially in patients with hepatomegaly, overweight and in patients with a history of surgical interventions in the abdominal cavity, allowed to avoid postoperative severe complications in 13% of cases, which proves the feasibility of the study, as part of percutaneous endoscopic gastrostomy. 3. Performing the percutaneous endoscopic gastrostomy under the ULTRASOUND navigation, it was possible to reduce the number of complications.