6.9. Анестезия у пострадавших с последствиями чмт

В целом анестезиологическое обеспечение у постра­давших с последствиями ЧМТ соответствует всем основным принципам современной нейроанесте-зиологии [43]. Однако, этим больным присущи определенные особенности на которых следует ос­тановиться.

Больные с посттравматической гидроцефалией представляют собой обычно достаточно тяжелый контингент нейрохирургических больных. Они на­ходятся, в зависимости от сроков развития гидро­цефалии, в отсроченном или даже резидуальном периодах ЧМТ. У них часто наблюдаются глубокие нарушения высших корковых функций (апаличес-кий синдром, loced-in синдром и др.), а оператив-

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ное вмешательство часто предпринимается как от­чаянная попытка вывести больного из этого со­стояния. Эти больные, как правило, находятся в различной степени истощения. Им присуши хрони­ческий дефицит ОЦК (результат длительного вынуж­денного постельного режима), нарушения водно-электролитного и белкового обмена, которые могут быть скрыты гиповолемией, различная легочная па­тология, параличи и парезы. Проведение индук­ции анестезии и интубации трахеи у этих больных может представлять определенную опасность. У них следует крайне осторожно использовать обычные индукционные агенты, применяемые обычно у нейрохирургических больных (например барбитура­ты). По нашему опыту оптимальной у таких больных для индукции и поддержания анестезии является методика атаралгезии (комбинация бензодиазепи-нов и наркотического анальгетика). От примене­ния сукцинилхолина у таких больных лучше отка­заться вообще или же применять его только после обязательной прекураризации (риск гиперкалиемии и остановки сердца). Скрытая и явная легочная патология в условиях анестезии может проявится легочным шунтом и низкими цифрами перифери­ческой сатурации (менее 90%) несмотря на высо­кие значения FiO₂.

Оперативные вмешательства по поводу посттрав­матической назальной ликвореи требуют широко-то доступа к основанию передней черепной ямки с неизбежной тракцией лобных долей мозга. Эф­фективным методом уменьшения объема мозта в этой ситуации является люмбалъный дренаж, ко­торый все равно необходим этим больным в бли­жайшем послеоперационном периоде.

Больные которым проводится пластическое зак­рытие костных дефектов черепа являются относи­тельно благополучными и анестезиологическое обеспечение при этих вмешательствах редко пред­ставляет проблему. Единственно о чем следует по­мнить, так как эти операции являются по сути косметическими, их проведение должно быть мак­симально отсрочено до полного восстановления больного после перенесенной травмы.

6.10. Заключение

Черепно-мозговая травма является одной из наи­более серьезных медико-социальных проблем на­шего времени, актуальность которой продолжает возрастать. С позиции анестезиолога, пострадавший с ЧМТ представляет собой «трудный контингент». Значение имеют с одной стороны ургентность ней-

рохирургического вмешательства, с другой — прин­ципиальное отличие пострадавших с ЧМТ от дру­гих нейрохирургических больных с опухолевой и сосудистой патологией. Главным условием прове­дения адекватного анестезиологического обеспече­ния у пострадавшего с ЧМТ нам представляется наличие у анестезиолога достаточных знаний по па­тофизиологии как интракраниальной системы, так и других органов и систем организма в условиях травматической болезни. Это позволяет анестезио­логу правильно оценить тяжесть больного, выбрать адекватную схему индукции и поддержания анес­тезии, инфузионно-трансфузионной терапии, про­гнозировать, быстро диагностировать и эффек­тивно корригировать развивающиеся осложнения.

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