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BACKGROUND: The resolution of intestinal insufficiency syndrome remains one of the urgent problems of nutritional support for patients with traumatic brain injury (TBI) and chronic critical illness. AIM: To determine the effectiveness of intestinal lavage in restoring the basic functions of the gastrointestinal tract and microbiocenosis in patients with chronic critical illness. MATERIALS AND METHODS: This prospective, randomized, single-center study analyzed 56 men with TBI of various etiologies and chronic critical illness. At the beginning of treatment and on day 10, the effectiveness of gastrointestinal lavage was evaluated as a complex intensive treatment of intestinal insufficiency syndrome. RESULTS: Patients were randomized into two groups depending on the conduct of intestinal lavage. In group 1 (n=27), enteral tube feeding was performed according to the standard method. In group 2 (n=29), intestinal lavage was also performed and an enterosorbent was added to the saline enterosorbent solution, three procedures with an interval of 3 days. A significant positive dynamics of carbohydrate and protein metabolism, restoration by day 10 of the barrier function of the intestine, motility of the gastrointestinal tract, and microbiocenosis were observed in group 2 (main group) compared with those in group 1 (control). CONCLUSION: The inclusion of gastrointestinal lavage in the complex intensive therapy for SCI in patients with a chronic critical illness for a short period helps resolve the main pathogenetic links of SCI restoration of the barrier function of the intestine, digestive transport, motor evacuation processes in the gastrointestinal tract, normalization of microbiocenosis, and metabolic parameters and nutritional status.

In the intensive care unit, along with other methods of intensive care, such as maintaining blood pressure, antibiotic therapy, mechanical ventilation, and vasopressors, clinical nutrition should always be present. Clinical nutrition is an integral part of the treatment process in the intensive care unit. A large number of publications concerning the prevention and treatment of intensive care outcome syndrome exist. One of the most important and low-cost strategies to prevent this condition is nutritional support for critically ill patients at all stages of curation, from the moment of admission to the intensive care unit to the end of the rehabilitation course. With the correct appointment of nutritional support, taking into account the indications and contraindications for various nosological forms, the advantages are obvious in the form of improved treatment outcomes. Proper organization of nutritional support in the hospital is the main key to success in early rehabilitation. From the understanding of nutritional support, its effectiveness will depend on its organization and mutual understanding between all links. Based on the experience of creating a laboratory for clinical nutrition and metabolism, it can be concluded that the creation of such a laboratory and the organization of clinical nutrition in a hospital can improve the results of treatment of even the most severe category of patients.

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.

One of the important features of patients in chronic critical illness is their need for prosthetics of vital functions. The provision of specialized medical care to all patients in need is impossible without resolving the issues of transportation to a specialized medical center. Inter-hospital transportation of resuscitated patients is one of the tasks of the Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology. The greatest difficulty is the transportation of patients with unstable hemodynamics. The transportation service created in the Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology is engaged in the development of issues of safe transport, including this category of patients by attracting organizational resources, forming a specialized team and equipping it. Medical and diagnostic, additional assessment of the patients condition on the spot. This approach makes it possible to increase the efficiency of intensive care during transportation and to eliminate mortality in this category of patients during transportation. Our experience of inter- and intra-hospital transportation of resuscitation patients was widely discussed at conferences, congresses and today is used in the work of mobile resuscitation teams.

Состояние вопроса. У 100 % пациентов, поступивших в реанимационные отделения Федерального научно-клинического центра реаниматологии и реабилитологии (ФНКЦ РР) в хроническом критическом состоянии (ХКС), обусловленном различными поражениями головного мозга, наблюдается полиморбидность, которая обуславливает наслоение и мозаичность симптоматики. При этом своевременная диагностика и терапия всех сопутствующих заболеваний является одним из важнейших аспектов ранней нейрореабилитации в условиях отделения анестезиологии и реанимации, а отсутствие патогномоничной и четко-дифференцированной симптоматики определяет необходимость использования четких диагностических алгоритмов и диктует необходимость повышенной настороженности у персонала. Материалы и методы. В работе описан случай стронгилоидоза на фоне тяжелой редицивирующей полисегментарной пневмонии и колита неясной этиологии у пациента в ХКС. Описан процесс дифференциальной диагностики клинической картины колита, а также проведенные после выявления глистной инвазии противоэпидемические мероприятия. Результаты. В ФНКЦ РР обследование на наличие глистных инвазий проводится каждому пациенту с учетом общего состояния, связанного с ХКС и иммуносупрессией. Учитывая очень низкий процент выявления любой глистной инвазии при однократном обследовании, также предложен алгоритм диагностики глистных инвазий у пациентов в ХКС: трехкратное проведение лабораторного исследования на глистные инвазии (при поступлении в стационар, при появлении клинических симптомов и через десять дней после начала клиники). Заключение. Такой подход позволяет исключить гиподиагностику глистной инвазии, в том числе начать своевременно лечение при выявлении, а также принять своевременные меры направленные на недопущение распространения инвазии в условиях лечебного стационара.

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.

Background. Along with the measures to restore the basic body functions and prevent secondary brain injury, one of the key areas of modern rehabilitation is nutritional and metabolic support. Aims: to improve the results of the treatment of the patients by optimizing the system of nutritional and metabolic rehabilitation using enteral, parenteral, combined parenteral-enteral nutrition methods, who are undergoing rehabilitation after recovering from Coma resulting from injuries and diseases of the central nervous system. Methods. In a prospective cohort study, the results of the study and complex treatment of 113 patients after recovering from Coma as a result of brain injury of various etiologies who were undergoing rehabilitation in the period from 2017 to 2019 in the FNRC RR were analyzed. Results. Indirect calorimetry has proven to be the most accurate method for creating an effective and adequate program of nutritional and metabolic support in patients in chronic critical conditions who recovers from the coma. In patients who recovers from the coma, due to the excessive process of hypercatabolism, increasing protein requirements: the average protein requirements for a patient who recovers from the coma are 1.261.5 g of protein per kg/weight. Conducting optimal nutritional support for patients recovering from Coma involves determining the functional state of the gastrointestinal tract. To build an effective and adequate program of nutritional and metabolic support where accurate determination of energy needs is of great importance. Conclusions. The indirect calorimetry method is a valuable tool for assessing energy needs, although without taking into account the functionality of the gastrointestinal tract and other factors affecting body compositions, it may not be sufficient to prescribe optimal nutritional support in patients after recovering from Comatose.

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.