We have repeatedly said that congestive pneumonia or, as people say, pneumonia can be considered the most frequent and rather dangerous complication that occurs after a stroke.

According to various authors of the medical literature, congestive or hypostatic pneumonia can accompany from 35% to 50% of all cases of apoplexy. Moreover, in about 15% of stroke patients, this complication is the main cause of death.

The main risk factors for the occurrence of this dangerous complication of primary apoplexy physicians include:

• Deeply elderly or even senile age of patients, when the victims of a brain stroke crossed the 65-year mark.
• Overweight patient.
• History of chronic lung or heart disease.
• The development during stroke pathology of too sharp depression of consciousness (we are talking about conditions when the indicators on the Glazko coma scale are below nine points).
• Too long artificial ventilation of the lungs, usually more than a week.
• Excessively long hospitalization, with being in a static position and with weakness.
• Long-term use of certain drugs (say, such as H2 blockers).

Why does pneumonia occur in post-stroke patients?

The main pathophysiological reasons why pneumonia can develop in patients who are hospitalized after a stroke are:

1. Prolonged depression of the patient's consciousness.
2. Central disorders of respiratory function.
3. These or other hypodynamic changes in the physiologically normal blood flow going through the pulmonary circulation, which is responsible for the blood supply to the lungs.

It is important to understand that after a stroke, the victims experience massive damage to certain parts of the brain, which ultimately leads to varying degrees of damage to the mechanisms of full self-regulation, as well as self-defense of the human body.

As a result, in such patients, the drainage function of the pulmonary system may be impaired, the cough reflex (allowing to get rid of sputum) may decrease or be completely absent, the healthy microflora may be deformed, which is simply replaced by highly virulent strains of a particular nosocomial infection. Naturally, all this can contribute to a fairly rapid development and progress of the disease.

In addition, long-term artificial ventilation of the lungs, necessary for resuscitation, aspiration, can also be direct reasons why pathogenic flora can penetrate into the respiratory tract, due to the growth of which pneumonia develops.

Most often, neurotrophic pneumonia has the ability to develop in the most acute period after a severe form of stroke, when there is a pathological effect of the focus directly on the hypothalamus or brain stem. The prognosis for the course of the disease, in this case, is the least favorable.

Further, in the acute period, after the primary manifestations of a stroke, pneumonia occurs in almost 25% of all patients, with a moderate degree of apoplexy, and in almost 85% of patients with a severe degree of cerebral stroke. The so-called second wave of pneumonia usually falls on the third or maximum fifth week of the recovery period (this is a late form of pulmonary pathology).

As we have already noted, doctors distinguish two forms of pneumonia in patients after a stroke, these are:

• Early.
• And, accordingly, late pneumonia, which initially differ in their development mechanism.

So, in the pathogenesis of early inflammation of the lungs lie dysregulation of the entire central nervous system, and the rate of development of pulmonary complications depends on where exactly the focus of ischemia or hemorrhage is located.

And, here, at a later date, the development of pneumonia is due to pathological inflammatory changes directly in the lungs, which are provoked by hypostatic processes.

Symptoms and treatment of post-stroke pneumonia

Unfortunately, today, the diagnosis of inflammation of the lungs that occurs after a stroke remains a huge unresolved problem. Often, untimely diagnosis of a pulmonary problem contributes to the development of a number of complications that can lead to death.

The clinical picture of early post-stroke pneumonia is non-specific and can often be veiled by manifestations of the primary pathology:

• Moderate increase in body temperature.
• Breathing disorders - the same shortness of breath, pathological Cheyne-Stokes or Kussmaul breathing.
• Absence of cough due to violations of the cough reflex, etc.

At the same time, late pneumonia is much easier to diagnose. The main clinical and laboratory indicators of the development of post-stroke pneumonia can be considered:

• The development of fever with body temperature above 38 ° C.
• Pronounced leukocytosis.
• The presence of purulent discharge from the trachea (sputum).
• Focal pathological changes in the lungs on x-rays, etc.

With this pathology, therapeutic measures are always reduced to the most rapid relief of hypoxia, to the prevention of pulmonary edema, to the suppression of the infectious agent. As a rule, in addition to drugs for the treatment of the underlying disease, antibiotics are prescribed, and in fairly large doses, oxygen therapy, the appointment of diuretics, cardiotonic and expectorant (mucolytic) agents may be required.

Sometimes, such patients may be prescribed various methods of exercise therapy, massage or physiotherapy. It is important to understand that in some cases, after two or three days of treatment, it may be necessary to adjust the choice of antibiotic, depending on:

• Pathogens identified during research.
• The real sensitivity of a particular strain to the selected chemotherapy drugs.
• The resulting reaction of the body.

Pneumonia in patients with severe stroke

Piradov M.A. Ryabinkina Yu.V. Gnedovskaya E.V.

Pneumonia is the most common and dangerous infectious complication severe stroke. It occurs in half sick and in 14% of cases is the main cause of death.

High frequency of development pneumonia at heavy forms stroke due to deep depression of consciousness appearing almost from the first day, central disorders of breathing, swallowing and hemodynamic changes in blood flow in the lungs. In the vast majority of patients with heavy forms stroke. who are in the intensive care unit (ICU), there is a "hospital", or the so-called nosocomial pneumonia. This term denotes pneumonia. developed 48 hours or more after admission sick to the hospital with the exclusion of infectious diseases with lung damage, which could be at the time of hospitalization in the incubation period.

Highly virulent flora with rapidly increasing resistance to traditional antibacterial drugs leads to the development heavy forms pneumonia with high mortality rates. An additional factor is the need for prolonged mechanical ventilation, while the frequency of development pneumonia increases by 6-20 times. The risk of ventilator-associated pneumonia, the so-called ventilator-associated pneumonia (VAP), increases significantly with increasing ventilator time. The onset of pneumonia severe stroke increases length of stay sick in neuro intensive care units for an average of 10 days.

Etiology and pathogenesis

The main cause of pneumonia in severe stroke- a bacterial infection, the causative agents of which are characterized by severe pneumotropism. The main pathogens are Pseudomonas aeruginosa, Enterobacter, Klebsiella, Escherichia coli, Proteus. Often there are also Staphylococcus aureus, streptococcus pneumoniae, less often anaerobic flora.

According to our data, up to 20% of pneumonias that develop in sick with a severe stroke almost immediately after hospitalization (early pneumonia), are caused by gram-negative flora. Pneumonia that occurs after 3 days in the ICU - late pneumonia - more than 50% sick also caused by gram-negative strains.

There are some differences in the pathogenesis of early and late pneumonia. In the development of early pneumonia, violations of corticovisceral regulation are of decisive importance. The rapid development of early pneumonia in stroke, its predominant occurrence in patients with localization of the focus in the area of ​​​​the location of higher vegetative centers or with a secondary effect on the hypothalamus and stem structures, the presence in the lungs of patients with signs of circulatory disorders in the form of plethora, hemorrhages and edema confirm the role of central disorders in the origin of this complication. In the development of late pneumonia, the hypostasis factor plays a decisive role.

With the development of VAP in terms of less than 7 days from the start of mechanical ventilation, the causative agents of pneumonia are pneumococci, Haemophilus influenzae, Staphylococcus aureus and anaerobic bacteria. With the development of VAP at a later date after the start of mechanical ventilation, drug-resistant strains of enterobacteria, Pseudomonas aeruginosa, Acinetobacner spp. and methicillin-resistant strains of Staphylococcus aureus (MRSA). Sudden outbreaks of pneumonia caused by Legionella pn. primarily associated with infection of humidifiers, inhalers, tracheostomy tubes, tap water, and air conditioners. In patients receiving long-term antibiotics or glucocorticoids, pneumonia may be due to fungi (eg, Aspergillius spp.).

Risk factors for the development of pneumonia in severe stroke are: the level of consciousness on the Glasgow Coma Scale less than 9 points, dysphagia, tracheal intubation, mechanical ventilation for more than 7 days, prolonged hospitalization, age over 65 years, the presence of chronic pulmonary and heart diseases, the use of H2-histamine blockers receptors, smoking, obesity, hyperglycemia, unbalanced diet, uremia.

The main route of entry of microorganisms into the respiratory tract in patients with severe stroke is the bronchogenic route. It is associated with microaspiration of the contents of the nasopharynx and stomach due to bulbar disorders, inhibition of the cough reflex and the reflex that provides reflex spasm of the glottis.

Extensive brain damage (more than any other critical condition) is accompanied by damage to the body's nonspecific defense mechanisms, including local cellular and humoral immunity, which also facilitates the bronchogenic penetration of microorganisms into the respiratory sections of the lungs. A change in the composition of the normal microflora of the upper respiratory tract to a highly virulent and very often resistant to traditional antibiotics microflora contributes to the rapid infection of the lungs.

Of great importance is the violation of the drainage function of the respiratory tract: a decrease in the rate of mucociliary transport, which develops from the first hours of a stroke, which is often accompanied by increased production of tracheobronchial secretions. In addition, infection through ventilators and during the necessary invasive procedures (sanitation of the tracheobronchial tree, fibrobronchoscopy), infection of the tracheostomy wound (or wound infection of the tracheostomy) increase the risk of invasion of microorganisms. It should be remembered that in each specific case, the features of the pathogenesis and clinical course are determined by the properties of the pathogen, the initial state of the patient and various body systems involved in inflammation, and the body's response to infection.

Clinic and diagnostics

Clinical diagnosis of pneumonia in severe stroke is still a challenge and continues to be developed. Difficulties in establishing a diagnosis are associated with both overdiagnosis and underdiagnosis, and late diagnosis is one of the reasons for the development of complications and death.

In patients with severe stroke, the clinical signs of pneumonia are masked by symptoms of the underlying disease. Diagnosis of early pneumonia is especially difficult, since its clinical manifestations are hidden behind the severity of cerebral and focal neurological symptoms. Diagnosis of late pneumonia against the background of an improving neurological condition of the patient is less difficult. Complicates the examination process and the severity of the underlying disease, as well as the need for prolonged use of mechanical ventilation.

The clinical picture of pneumonia consists of signs of local pulmonary inflammation, extrapulmonary manifestations of pneumonia, laboratory and radiological changes. Diagnosis of pneumonia is usually based on the following clinical and laboratory signs (Table 1). It should be remembered that in conditions of severe stroke, each of these criteria is non-specific.

Diagnosis of pneumonia is made only in the presence of 4 of the listed criteria, and the presence of 3 of them makes the diagnosis of pneumonia likely.

Comprehensive treatment of pneumonia should be aimed at suppressing the infection, restoring pulmonary and general resistance, improving the drainage function of the bronchi, and eliminating the complications of the disease.

Antibacterial drugs are the mainstay of treatment for pneumonia. The choice of the most effective one depends on many factors, including:

Accurate pathogen identification

Determination of its sensitivity to antibiotics

Early initiation of adequate antibiotic therapy

Nevertheless, even with a well-equipped microbiological laboratory, the etiology of pneumonia can only be established in 50-60% of cases. Moreover, it takes at least 24-48 hours to obtain the results of microbiological analysis, while antibiotic therapy should be prescribed as soon as the diagnosis of pneumonia is established.

The diversity of the etiology of nosocomial pneumonia, the simultaneous detection of several pathogens in one patient, and the lack of methods for express diagnostics of the sensitivity of microorganisms to antibacterial drugs make it difficult to plan therapy. Under these conditions, there is a need for the use of empirical antibiotic therapy, which ensures the study of drugs with the widest possible spectrum of activity. The choice of a drug is based on an analysis of the specific clinical and epidemiological situation in which the patient developed pneumonia, and taking into account factors that increase the risk of infection with a particular pathogen.

For nosocomial pneumonia in severe forms of stroke, the weight of gram-negative microflora, staphylococcus and anaerobic bacteria is the highest. Therefore, cephalosporins of the I-III generation (in combination with aminoglycosides) or fluoroquinolones are most often used as initial therapy.

The following combinations and monotherapy regimens may be effective:

Combination of ceftazidime with "respiratory" fluoroquinolones

Combination of “protected” antipseudomonal ureidopenicillins (ticarcillin/clavulanic acid, piperacillin/tazobactam) with amikacin

Monotherapy with IV generation cephalosporin (cefepime)

Monotherapy with carbapenems (imipenem, meropenem)

Combination of ceftazidime or cefepime or meropenem or imopenem with second-generation fluoroquinolones (ciprofloxacin) and modern macrolides

The course of the pneumonia resolution process is assessed using clinical or microbiological studies. Clinical indicators are: a decrease in the amount of purulent sputum, a decrease in leukocytosis, a decrease in body temperature, signs of resolution of the inflammatory process in the lungs according to radiography or computed tomography. It is believed that during the first 72-2 hours of empiric therapy, the selected treatment regimen should not be changed.

With a progressive increase in inflammatory infiltration, it is necessary to adjust antibiotic therapy. It is recommended, if possible, to identify the microorganism and prescribe targeted (etiotropic) antimicrobial therapy. The subsequent change of antibiotic therapy should be carried out according to the results of only a microbiological examination of sputum.

Considering the type of causative agent of pneumonia, the proposed pathogenetic mechanism for the development of pneumonia and the time of its development from the onset of a stroke, the recommendations given in Table 2 can be followed.

The average duration of antibiotic therapy in patients with pneumonia is presented in Table 3. In most cases, with an adequate choice of antibiotics, 7-10 days of its use is sufficient. With atypical pneumonia, staphylococcal infection, the duration of treatment increases. Treatment of pneumonia caused by gram-negative enterobacteria or Pseudomonas aeruginosa should be at least 21-42 days.

One of the most important conditions for the successful treatment of pneumonia is to improve the drainage function of the bronchi. For this purpose, expectorant, mucolytic and mucoregulatory agents are used, chest massage (percussion, vibration, vacuum), breathing exercises are used. Bronchodilators are prescribed for severe pneumonia and in persons prone to bronchospastic syndrome. In the ICU, it is preferable to prescribe intravenous infusions of a 2.4% solution of aminophylline, less often inhaled forms of b2-adrenergic stimulators, M-anticholinergics.

In severe forms of pneumonia, infusions of native and / or fresh frozen plasma are carried out. Currently, the issue of the need for immunocorrective and immunoreplacement therapy with immunoglobulins and hyperimmune plasma is being considered. Patients with severe forms of pneumonia also undergo detoxification therapy, taking into account cerebral edema and concomitant pathology of the heart and heart failure.

Prevention

Prevention of pneumonia in severe stroke is based on three main approaches.

1. Elevated position of the upper half of the patient's body at an angle of 450, frequent sanitation of the nasopharynx and physiotherapy of the chest. These simple methods reduce the flow of secretions from the upper respiratory tract into the trachea and bronchi, i.e. microaspiration.

2. Personal hygiene of personnel (elementary frequent washing of hands with a disinfectant solution), careful observance of aseptic and antiseptic rules, strict adherence to the protocols for changing and cleaning tracheostomy tubes, humidifier reservoirs and inhalers reduces the growth rate and the addition of additional microflora.

3. The use of a certain type of tracheostomy tube (with supracuff aspiration) and its correct location, timely aspiration of secretions accumulating above the cuff, orotracheal intubation, insertion of a tube for enteral nutrition through the oral cavity reduce the risk of infection of the lower respiratory tract with nasopharyngeal flora. In addition, it helps to reduce the risk of developing sinusitis.

Until now, a unified view on the prophylactic prescription of antibiotics has not been formed all over the world. In our opinion, this approach definitely does not solve the problem of preventing pneumonia in stroke, especially VAP. It must be remembered that pneumonia is a process characterized by certain features of the course associated with the initial state of the patient and his reaction to the infection, and the role of antibiotics is limited only to the suppression of the infectious agent. In addition, with the prophylactic administration of antibiotics, the development of superinfection caused by antibiotic-resistant strains of microorganisms is possible.

Conclusion

Our data and analysis of the literature suggest that the occurrence of pneumonia in patients with severe stroke worsens the condition of patients. In patients who have survived a period of neurological complications, pneumonia often causes death. Preventive measures should be started already from the first hours of a stroke, and rational therapy of pneumonia should be started immediately after its diagnosis.

Literature

1. Vilensky B.S. Somatic complications of stroke // Neurological journal. - No. 3. - 2003. - pp. 4-10.

2. Koltover A.N. Lyudkovskaya I.G. Vavilova T.I. Viktorova N.D. Gulevskaya T.S. Levina G.Ya. Lozhnikova S.M. Morgunov V.A. Chaikovskaya R.P. The role of the pathology of internal organs in the pathogenesis, course and outcome of strokes. // Materials of the Plenum of the Board of the Society of Neurologists and Psychiatrists "Disorders of the nervous system and mental activity in somatic diseases." - Naberezhnye Chelny. - 1979. - S.198-201.

3. Krylov V.V. Tsarenko S.V. Petrikov S.S. Diagnosis, prevention and treatment of nosocomial pneumonia in critically ill patients with intracranial hemorrhages. // Neurosurgery. - 2003. - No. 4. - S. 45-48.

4. Martynov Yu.S. Kevdina O.N. Shuvakhina N.A. Sokolov E.L. Medvedeva M.S. Borisova N.F. Pneumonia in stroke. // Neurological journal. - 1998. - No. 3. - S. 18-21.

5. Addington W.R. Stephens R.E. Gilliland K.A. Assessing the laryngeal cough reflex and the risk of developing pneumonia after stroke: an interhospital comparison. // Stroke. - 1999. - 30. - 6. - R.1203-1207.

6 Chastre J. and J.-Y. Fagon Ventilator-associated pneumonia .//Am. J. Respir. Crit. Care Med. April 1.-2002. - 165(7). - R.867 - 903.

7. Collard H. R. S. Saint, and M. A. Matthay Prevention of Ventilator-Associated Pneumonia: An Evidence-Based Systematic Review Ann Intern Med. //March 18. - 2003. - 138(6). - R.494 - 501.

Treatment of stroke complications

In ischemic stroke, the fight against complications comes to the fore, since neurological symptoms are not very severe. In the case of hemorrhagic stroke, neurological disorders are so severe that they affect the prognosis of the disease.

cerebral edema

Cerebral edema is a reaction of brain tissue to a decrease or cessation of blood circulation. The more severe the damage to the brain, the greater its swelling.

Cerebral edema develops on days 1-2 after the development of a stroke and has a maximum severity on days 3-5, gradually decreasing on days 7-8.

Therapeutic measures taken to reduce cerebral edema:

• decrease in body temperature;
• elevated position of the head;
• relief of pain;
• in extreme cases, they resort to surgical intervention - the removal of a part of the cranial bone that compresses the nervous tissue.

Pneumonia

There are two main causes of pneumonia (pneumonia) in stroke patients:

1. As a result of impaired swallowing, food or stomach contents enter the respiratory tract. This complication is called aspiration, and pneumonia is aspiration.
2. Prolonged immobility may result in hypostatic pneumonia.

In case of violation of swallowing, feeding through a tube inserted into the stomach is used. In this case, it is necessary to carefully monitor the condition of the oral cavity - remove mucus and sputum from the oropharynx. Be sure to brush your teeth after every meal with a soft toothbrush.

With prolonged lying, the respiratory sacs in the patient's lungs collapse and this area of ​​\u200b\u200bthe lung tissue stops working, i.e. it does not participate in the exchange of carbon dioxide and oxygen, as a result, an inflammatory process develops. To prevent the collapse of the respiratory sacs, inflation of balloons is prescribed. When the balloon is inflated, residual positive pressure is formed, which pushes the walls of the collapsed breathing sac, it straightens out and begins to work.

Pneumonia is usually treated with antibiotics.

Inflammation of the urinary tract

With urinary incontinence, or urinary retention, a bladder catheterization is done, which causes inflammation of the urinary tract.

To avoid inflammation of the urinary tract, it is recommended:

• strict adherence to asepsis rules when placing a catheter;
• washing 3-4 times a day of the bladder with a catheter;
• in men, the catheter is attached to the abdomen so that it does not bend over and form a bedsore in the urethra;
• frequent bacteriological examination of urine.

This type of inflammation is treated with antibiotics.

Pulmonary embolism

Pulmonary embolism is a blockage of blood vessels supplying the lungs with blood clots (thrombi). It occurs most often in aged patients, with atrial fibrillation, thrombophlebitis of the lower extremities, prolonged immobility, inflammatory diseases of the pelvic organs, diabetes mellitus, active rheumatism.

This serious complication, which occurs between 2 and 4 weeks after a stroke, causes death in 25% of patients.

bedsores

In places where the bones are close to the surface of the skin (the area of ​​the neck, shoulder blades, elbows, sacrum, knees, heels, buttocks), as a result of circulatory disorders, bedsores (necrosis of integumentary tissues) may occur. Theoretically, bedsores can occur in any place where the integumentary tissues are subjected to strong pressure.

The main danger of bedsores is that necrosis penetrates deep, reaching the bones and cartilage. Such wounds become infected and become a source of infection for the entire body.

Prevention of bedsores:

1. Regular change in body position (left, right side, back) at least once every 2 hours is the most effective measure to combat pressure sores:
   • When turning the patient on a healthy side, it is necessary to put pillows behind the back and under the head, evenly distribute the center of gravity, and achieve a stable position. Extend the healthy leg, slightly bend the affected leg and lay it on the pillow. Straighten the paralyzed arm and lay it on the pillow, slightly bending at the elbow, fingers should be evenly placed on the pillow.
   • If the position on the sore side does not cause discomfort to the patient, then it must also be turned to the affected side. The lower leg should be straight, the upper leg bent and on the pillow. The affected arm should lie in front, palm up.
   • The position on the back is the least preferred, but not without it. Pillow your shoulders, head, and neck so that your face is facing up and your head is tilted slightly forward. The position must be stable. The shoulder joint of the affected upper limb should lie on the pillow, the shoulder blade should not rest on the pillow, the arm should be turned palm up. A roller is placed under the knee of the paralyzed leg so that there is support and the leg does not roll down. The spine should be straight, under the head of the pillow of the right size.

Leather processing. It is necessary to monitor the condition of the skin in the perineum, armpits, skin folds (in obese women - folds under the breasts). Wipe every 8 hours with special solutions (for example, warm camphor alcohol).

Particular attention should be paid to the surface on which the patient lies. The sheet should be dry, clean, free of debris and wrinkles. If necessary, you can put an oilcloth under the sheet or put a diaper on the patient. In the area of ​​​​bone protrusions (sacrum, heels, back of the head), special pads made of pure sheepskin, a rubber circle or millet mattresses can be placed.

A daily examination of the skin surfaces is required for the timely detection of bedsores.

Light massage.

Keep away from hot or cold objects.

The patient must have adequate nutrition.

When bedsores form, they must be treated with saline or hydrogen peroxide, followed by careful removal of dead tissue. After this, it is necessary to apply a special wet-drying bandage or a special ointment.

Limited movement in the joints

With prolonged immobility, contracture (stiffness) occurs in the joints. To combat this phenomenon, it is necessary to properly position the limbs when changing the position of the body, to conduct passive therapeutic exercises for paralyzed limbs in combination with massage. These measures must be agreed with the attending physician.

Colon dysfunction

Violation of the large intestine is usually manifested by constipation (lack of stool for more than 2 days). To avoid constipation, you must:

• observe a diet - eat at the same time, meals should be fractional (4-5 times a day), the last meal should be at least 4 hours before bedtime;
• the diet should be balanced and rich in fiber (beets, carrots, cabbage, prunes, honey), dairy products;
• you need to take a lot of fluids (2 liters per day);
• exclude white bread, sweets, rice, raw milk from the diet;
• if diets do not help, it is necessary to resort to enemas or laxatives (after consulting a doctor).

In addition to constipation, there may be other disorders. In this case, consultation with a gastroenterologist is necessary.

A stroke in itself is a serious disease that can easily make a bed invalid out of a person. What can I say, when after one "hit" on health follows a second, no less serious - pneumonia. The congestive variant of this disease most often develops, which is a complication of a previous stroke.

According to statistics, the incidence of pneumonia after a stroke is from 35 to 50%. Approximately 15% of cases of complications of pneumonia is the cause of death. It would seem that a person survived after one illness, but could not cope with the second. Any pneumonia with a stroke has its own causes, it makes sense to deal with them in more detail.

Any disease, including pneumonia after a stroke, has its own causes and risk factors. Such knowledge will help prevent complication and prevent its occurrence in principle.

Often with inflammation of the lungs after a stroke, elderly and senile people experience. Their normal drainage function of the lungs is disturbed, and after a stroke, sputum separation is practically absent, especially if the disease is severe. The risk of pneumonia increases significantly after a person is 65 years old.

Excess weight itself is a predisposing factor for the development of stroke. In the case of a complication in the form of pneumonia, the chances are much higher. Pneumonia can occur in people who had chronic forms of heart and lung disease before the stroke.

After a stroke, a person can often be in a coma, which contributes to the development of a congestive process in the lungs. The cause of this condition is a violation or complete absence of outflow of sputum. A similar condition occurs with prolonged artificial ventilation of the lungs, which is carried out in the absence of spontaneous breathing. Often a week is enough for pneumonia to develop. Sometimes, even in the mind, the patient is on bed rest, which contributes to stagnant processes in the pulmonary system.

Development mechanism

It is no secret that the prognosis after a stroke is often sad. There are some reasons that trigger the pathological mechanism of the development of the disease. They consist:

• in an oppressed mind for a certain time;
• central respiratory dysfunction;
• lack of active movements;
• violation of the blood supply to the lungs.

The degree of damage depends on the massiveness of the damage to the brain tissue, as well as the place where the hemorrhage or blockage of the vessel occurred. As a result, the function of sputum drainage from the lungs suffers in some patients. Reduces or absent cough reflex or urge to cough, it is he who is protective and promotes sputum discharge. There is a replacement of microorganisms with more aggressive ones that can cause disease. Further, it is just a matter of time and the disease does not take long to wait, the inflammatory process develops rapidly.

Other factors

But not always artificial ventilation of the pulmonary system after a stroke is the cause of the development of the disease. Often an infection joins, which is constantly in the hospital, especially in the intensive care unit. The level of immune protection also decreases, the body is not able to resist infection.

Symptoms of the disease

Diagnosing pneumonia after a stroke, even at the present stage of development of medicine, can be very difficult. The problem remains open for the next generations of doctors. It is difficult diagnosis that is the factor that contributes to human mortality. In general, manifestations can be easily veiled by the primary disease.

Some of the symptoms may turn on:

• the temperature rises moderately;
• breathing is disturbed according to the type of pathological variant of Cheyne-Stokes or Kussmaul;
• as a result of a violation of the cough reflex, there is no sputum separation;
• on auscultation heard wheezing of various calibers.

Features of aspiration pneumonia

This variant develops as a result of food particles entering the respiratory tract. After such a segment of the lung ceases to perform its function normally, and the bacteria that are there are rapidly developing.

With aspiration pneumonia, the manifestations resemble intoxication or poisoning. Initially draws on a cough, which is excruciating. The hilar variant of aspiration pneumonia is difficult to diagnose. A high temperature joins, it becomes painful to cough. A dangerous option is the situation when a large bronchus is blocked by pieces of food.

Late symptoms

Diagnosis of the late version of the disease is much easier. To make a proper diagnosis, a doctor will need certain symptoms. Among them it is worth noting:

• rapidly developing fever, numbers above 38 degrees;
• in a blood test, an increased number of leukocytes is of interest;
• pus is present in sputum or discharge from the trachea;
• pathological changes in the lung tissue are clearly visible on the x-ray.

Final diagnosis

In addition to the symptoms, there are some standards for instrumental diagnosis of the problem. Initially, it is worth listening to the chest with a phonendoscope, if there is a suspicion of pneumonia, then an X-ray examination of the lungs is prescribed. In the picture, in addition to stagnation, the most intense focus of shading will be clearly visible.

The sputum or washings from the bronchi are subject to research. This analysis will determine the type of pathogen, after which its individual sensitivity to antibacterial drugs is carried out. This analysis will later allow the doctor to prescribe an effective treatment.

Treatment

In case of pneumonia, which could complicate a stroke, measures are aimed at eliminating hypoxia as soon as possible. The tissues should receive more oxygen, this is done with the help of artificial ventilation of the lungs or the use of oxygen pillows. It is necessary to pay attention that pulmonary edema often joins, which is why prevention of this condition is carried out.

In parallel, the treatment of the underlying disease is carried out, which is prescribed by a neuropathologist. After establishing the type of pathogen and its sensitivity to antibiotics, appropriate drugs are used. Prior to this analysis, broad-spectrum antibacterial drugs are indicated. The dose of the antibiotic is selected individually, but, as a rule, they are used in large quantities.

Diuretics are mandatory, they help reduce swelling and prevent pulmonary edema. Cardiac preparations and expectorants are indicated. If there are problems with expectoration due to its viscosity, the doctor may prescribe drugs to thin it.

Additionally

After stabilizing the condition for a stroke, physiotherapy is recommended for a person. Excellent helps to remove sputum electrophoresis with potassium iodide. Exercise therapy is also shown under the guidance of an instructor, it is mainly aimed at restoring breathing.

Even in bed, the doctor may recommend breathing exercises to a person. If the patient is able to breathe on his own, then in bed he is recommended to inflate balloons. Special drainage positions are also used to help expel sputum from the lungs. Massage in the acute period is undesirable, but in a mild form it helps to remove sputum and is carried out by a massage therapist.

Prevent pneumonia

When there is an understanding of the mechanism of the development of the disease, it is possible to prevent the development of the disease. Based on this, certain preventive measures were developed, the observance of which will reduce the risk of developing the disease. An approximate list of them can be presented as follows:

1. It is worth reducing the pathogenic factor, because the risk of developing the disease largely depends on medical workers, the quality of their performance of their duties. In the intensive care unit, in addition to processing instruments and surfaces, sanitation of the bronchial tree is mandatory.
2. It is required to carefully observe the rules of hygiene, including personal. Medical workers should adhere to the rules of asepsis and antisepsis.
3. The tube that is used for ventilation of the lungs must be for individual use and after use it is processed and disposed of. The same applies to the rest of the instruments that can come into contact with the human respiratory system.

Prevention

There are some steps you can take to help prevent the development of pneumonia after a person has had a stroke. Some moments will require efforts from the carer and staff, but then they will fully justify themselves.

Initially, it is worth ensuring a constant supply of fresh air. This can be done by ventilating the room, but with certain precautions to prevent hypothermia. A person should be covered with a blanket, and in the cold season with several.

Oral hygiene is mandatory, when a person is unable to cope with it himself, those who care for him help him. To prevent stagnation, the position in bed changes every two hours. In the normal state of the patient, he is given a semi-recumbent position at an angle of 45 degrees.

Additionally, breathing exercises are shown, which is carried out no earlier than one and a half hours after the last meal. It is useful to inflate baby balloons. Additionally, a special massage is performed for about three sessions throughout the day.

As the symptoms of a stroke regress, a person must be activated, first in bed, and then within the ward. This approach will prevent the accumulation of sputum and prevent congestion.

Not really

Leading experts in the field of neurosurgery:

Balyazin Viktor Alexandrovich

Balyazin Viktor Alexandrovich, Professor, Doctor of Medical Sciences, Honored Doctor of the Russian Federation, Excellence in Public Health of the Russian Federation, Neurosurgeon, Head of the Department of Nervous Diseases and Neurosurgery

Moldovanov Vladimir Arkhipovich

Moldovanov Vladimir Arkhipovich, Candidate of Medical Sciences, Doctor of the highest qualification category, 35 clinical experience

Savchenko Alexander Fedorovich

Savchenko Alexander Fedorovich, Candidate of Medical Sciences, Doctor of the highest qualification category, Head of the neurosurgical department of the Emergency Hospital No. 2

A. A. Rastvorova (Moscow)

Pulmonary edema is a kind of formidable syndrome, which is sometimes observed in violation of cerebral circulation. With pulmonary edema, extravasation from the capillaries into the pulmonary alveoli and stroma occurs. In the pathogenesis of pulmonary edema, a violation of the nervous regulation is important, causing an increase in permeability and an increase in pressure in the capillaries.

The importance of the nervous system in the pathogenesis of pulmonary edema has been confirmed by experimental studies by A. D. Speransky, K. M. Bykov et al., A. V. Tonkikh,

GS Kan et al. Acute pulmonary edema may occur with left ventricular failure. At the same time, the state of increased excitability of the stem and hypothalamic centers of respiration is essential.

A number of authors who have studied clinical and pathological-anatomical changes in the lungs in the acute stage of cerebral stroke pay great attention to the role of nervous regulation disorders in the genesis of pulmonary edema. The frequency of pulmonary edema in cerebral stroke is different according to the authors (15% according to N. K. Bogolepov, 9% according to Luisada).

Pulmonary edema in violation of cerebral circulation occurs acutely. Its occurrence may be associated with the nature of the pathological process (more often with hemorrhagic stroke), the localization of the lesion (ventricular, hemispheric, cerebellar, stem) and the period of cerebral stroke.

From the analysis of 666 cases of cerebral stroke carried out by N. K. Bogolepov and his staff, observed in an ambulance on the first day, pulmonary edema was noted in 18 patients (0.34%). Pulmonary edema in stroke patients is observed in terminal conditions. According to Camezan, of 66 autopsies of those who died from cerebral hemorrhage, 44 had pulmonary edema. N. K. Bogolepov often noted pulmonary edema with hemorrhage in the hemispheres with a breakthrough into the ventricles of the brain, flowing with hormones.

The paper presents data from a “study of 224 patients with cerebral stroke who developed pulmonary edema.

Etiology of stroke: hypertension - 132 patients, atherosclerosis of cerebral vessels - 76 patients, aneurysm of cerebral vessels - 8 patients, rheumatism - 8 patients. There were 11 patients under the age of 30, 27 from 31 to 40 years old. from 41 to 50 years - 28, from 51 to 60 years - 49, from 61 to 70 years - 56, over 71 years - 53 patients.

Pulmonary edema was observed in 148 hypertensive patients with hemorrhagic stroke. Parenchymal hemorrhages were in 145 patients, subarachnoid - in 3 patients. Hemorrhages in the cerebral hemispheres were determined in 126 patients, in the brainstem and cerebellum - in 17 patients, in 2 patients there were combined hemorrhages in the hemispheres and the brainstem. Hemorrhage in the hemispheres with a breakthrough of blood into the ventricles of the brain was in 72 patients. With hemorrhages in hemispheres of the brain, not complicated by ventricular hemorrhage, 34 patients had a latero-capsular localization of the hematoma, 20 patients had a mediocapsular hematoma, with the capture of the subcortical nuclei.

Pulmonary edema in patients with hemorrhagic stroke developed mainly in the soporous-coma state in the terminal period of stroke, more often on the 3rd-6th day of the disease. In the clinical picture of a stroke, the phenomena of cerebral edema with compression of the brain stem were observed. Respiratory disorders of the obstructive type due to coma, loss of reflexes from the mucous membranes of the upper respiratory tract, as well as bulbar or pseudobulbar paralysis were combined with a violation of the central regulation of respiration (changes in the rhythm, frequency and structure of the respiratory cycle). Insufficient blood oxygenation, observed in most patients in the acute period of cerebral stroke, led to a sharp disruption of oxidative processes in tissues and the accumulation of underoxidized metabolic products. Hypoxemia contributed to an increase in cerebral edema and an increase in secondary dislocation phenomena. Thus, in patients with hemorrhagic stroke, pulmonary edema developed against the background of prolonged suppression of stem functions and respiratory disorders.

In ischemic stroke, pulmonary edema was observed in 76 patients. 21 patients had cerebral infarction due to thrombosis of cerebral vessels, 55 had non-thrombotic softening. The localization of softening foci in the cerebral hemispheres prevailed (63). Softening in most cases was extensive, and the white matter of the cerebral hemispheres and subcortical nuclei were affected. In 3 cases, there was a combined softening in the cerebral hemispheres and the brain stem (Table 1).

Among patients with ischemic stroke, two groups could be distinguished. In the first group of patients predisposed

The underlying factors in the development of pulmonary edema were heart diseases: atherosclerotic and post-infarction cardiosclerosis, mitral heart disease with a predominance of stenosis, myocardial infarction. In these patients, cardiac arrhythmias (atrial fibrillation, group extrasystole), as well as impulse conduction disorders (atrioventricular blockade of various degrees) were detected. There were phenomena of circulatory failure with increased pressure in the pulmonary circulation and congestion in the lungs. Some patients in this group had lung diseases: emphysema, pneumosclerosis, pneumonia, and pulmonary heart failure. Consequently, in patients of the first group, a cerebral stroke occurred against the background of a severe somatic disease. Pulmonary edema sometimes occurred in the initial period of a stroke, causing profound hemodynamic disturbances, dyscirculatory and hypoxic disorders, especially when there was a drop in blood pressure, which aggravated cerebrovascular insufficiency.

In the second group of patients with ischemic stroke complicated by pulmonary edema, the development of pulmonary edema was due to cerebral stroke. Cardiopulmonary failure was not observed, but pulmonary edema was preceded by pulmonary complications: pneumonia, atelectasis. Pulmonary edema developed in the terminal period of ischemic stroke, when symptoms of brain stem damage were expressed. In patients who were in a soporous-comatose state, violations of the autonomic and respiratory functions were found.

In patients with hemorrhagic and ischemic stroke, several variants of the clinical course of pulmonary edema were noted. The most common form was acute pulmonary edema lasting several hours. On the first day of a stroke, it occurred in patients with severe cardiopulmonary pathology and circulatory failure. In other patients, this form of pulmonary edema was observed in the terminal period, sometimes against the background of pneumonia. With a protracted form, clinical manifestations of pulmonary edema were observed for more than a day. It occurred equally often in the terminal period of hemorrhagic and ischemic stroke in patients who did not suffer from heart disease in the past.

Rarely observed "lightning" form of pulmonary edema, lasting about an hour. It developed in patients with a rapidly flowing cerebral stroke (ventricular hemorrhage), sometimes in combination with acute cardiopulmonary failure due to myocardial infarction or pulmonary embolism.

The study of the relationship between pulmonary edema and cerebral stroke revealed a number of patterns. More often, pulmonary edema occurs with strokes of hemispheric localization and with the involvement of the brain stem in the process. Most often, pulmonary edema occurred at the stage of a stroke, when, with extensive hemorrhage or ischemic softening, the phenomena of diffuse brain damage join. In this case, the leading ones were dysfunctions of the hypothalamic-stem departments due either to their direct damage, or as a result of edema and dislocation of the brain. In these cases, pulmonary edema could not be considered as a manifestation of left ventricular failure: it was due to damage to the centers of autonomic regulation and extreme expression of autonomic disorders. In this regard, it becomes clear that hemorrhagic strokes (65%) among cerebrovascular accidents complicated by pulmonary edema, which, due to the severity and characteristics of their course, cause an increase in intracranial pressure, edema, dislocation and damage to the hypothalamic-stem structures of the brain.

In some cases, especially with the development of pulmonary edema c. the first day of the disease, it was possible to associate its occurrence mainly with cardiopulmonary insufficiency. Heart disease in many cases caused cerebrovascular insufficiency, and pulmonary edema in these patients was a manifestation of cardiac decompensation.

Thus, pulmonary edema in cerebral stroke has a complex pathogenesis and depends on the severity, nature and stage of cerebral stroke, as well as the state of the cardiovascular and pulmonary systems.

It is extremely important to recognize the initial symptoms of pulmonary edema in order to prevent the development of pathological phenomena. Identification of the pathogenesis of pulmonary edema is important for active therapy aimed at. elimination of pulmonary edema, the fight against hypoxia and cardiovascular insufficiency.

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Stroke is a dangerous neurological pathology that entails brain damage and a lot of serious consequences, one of which is congestive pneumonia.

The development of this kind of pathological process, according to various sources, is diagnosed in 30-60% of patients who have had a stroke. The risk of getting pneumonia increases in the elderly and senile, with about 10-12% of such cases becoming fatal. To counter this problem, it is necessary to understand the mechanism of development of "post-stroke pneumonia", the causes, symptoms and methods of treating the pathology.

Strokes - their relationship with congestive pneumonia

A stroke, that is, an acute violation of blood circulation in the brain, leads to severe brain damage, followed by disorders of many vital human functions.

The mechanism of development of ischemic and hemorrhagic stroke

organism. Depending on in which part of the brain the stroke was localized and what was the extent of the lesions, the brain centers responsible for the functioning of the respiratory system may be affected.

If during a stroke the part of the brain in which the respiratory center is located was affected, the supply of nerve impulses to the receptors of muscle fibers in the lungs is disrupted, congestive pneumonia begins.

In clinical practice, there are two main types of strokes, after which congestive pneumonia can begin:

• Ischemic - complete or partial obstruction of a vessel in the brain, due to its blockage. At the same time, blood ceases to flow in the required quantities to certain areas of the brain, causing tissue damage and related complications.
• Hemorrhagic - this type of stroke is less common and at the same time is the most dangerous, since we are talking about a violation of the integrity of the vessel, rupture of its wall, followed by cerebral hemorrhage. The danger lies not only in the fact that blood stops flowing to a certain area of ​​​​the main organ, there is a high risk of complications due to increased intracranial pressure, the appearance of a hematoma, etc.

How and why does pneumonia develop after a stroke?

Pneumonia, also known as pneumonia, is a respiratory disease in which an inflammatory process develops in the lung tissues. In most cases, the disease is infectious.

Congestive pneumonia is a slightly different type of pathology, which is characterized by stagnation of fluid or blood masses in the lungs and bronchi. The fact that, after a stroke, nerve activity and communication with the receptors of the muscle fibers of the respiratory organs is disturbed, increases the likelihood of developing congestive pneumonia.

We are talking about the fact that damage to the part of the brain responsible for the respiratory process leads to a disorder of respiratory functions. A person ceases to control the process of inhalation and exhalation, the cough reflex is dulled, the excretion of sputum stops, fluid begins to accumulate in the lungs. These are the main conditions for the occurrence of congestive pneumonia.

Given these factors, congestive pneumonia in bedridden patients develops much more often and faster, especially if the patient has remained unconscious for a long time and is then bedridden. In itself, the horizontal position, if it persists for an excessively long time, contributes to stagnant processes, filling the lung alveoli with exudate.

Another reason related to the main ones is that during and after a stroke, the chance of involuntary reflux of vomit and gastric juice into the lungs increases, which leads to the rapid development of inflammation of the lung tissues. This process is also more often observed in bedridden patients due to the forced horizontal position of the body.

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Factors in the development of post-stroke pneumonia

Taking into account the complications after a stroke mentioned above and the increased likelihood of developing congestive processes, a number of factors can be identified that contribute to the development of congestive pneumonia:

• The risk zone is headed by the elderly (usually over 60-65 years). The fact is that it is among the elderly that the likelihood of a stroke is highest. In addition, in old age, the body copes much worse with any shocks, and the development of stagnant processes is aggravated, we can say that there is a predisposition to this. For the same reasons, pneumonia after a stroke among the elderly often leads to death;
• At the second stage in the incidence of congestive pneumonia are people who have had any form of pneumonia in the past, as well as those who have chronic diseases associated with the lungs and respiratory system. Those most at risk are asthmatics and patients with tuberculosis;
• Congestive pneumonia is much more likely to occur in people who are obese. The deposition of excess fat masses in itself causes enormous harm to the functioning of organs and the whole organism as a whole. Obesity increases the chance of developing a stroke, and after that it also increases the chances of developing pneumonia and congestive processes;
• As mentioned earlier, in a recumbent patient, congestive pneumonia develops with an increased degree of probability. For this reason, those bedridden patients who are in an unconscious state (coma) are at risk.
• Often after a stroke, pneumonia develops in people with diseases of the cardiovascular system and heart defects;
• Functional disorders provoked by a stroke (failure of cough or swallowing reflexes, pathologies of blood microcirculation in the bronchi or disorders of the drainage system in the same department) entail the development of stagnant processes that lead to pneumonia.

In a bedridden patient after a stroke, congestive pneumonia develops with an increased degree of probability.

This list can be continued for quite a long time, supplementing the replacement of the healthy microflora of the respiratory organs with pathogenic ones, taking H2-blockers, as well as other "heavy" drugs.

About why the temperature rises with stroke, you will learn from

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Subject: Got rid of the pressure

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Signs of congestive pneumonia

Recognizing post-stroke pneumonia in a bedridden patient is not so difficult, but the process of making a diagnosis becomes more complicated at times if the patient is in a coma, because in this case, many symptoms do not make themselves felt.

In general, to detect the disease, one should pay attention to the following clinical signs:

• With inflammation of a stagnant nature, subfebrile temperature is observed in 90% of cases, rarely the thermometer readings exceed 38 degrees of mercury;
• Difficulty breathing is present, which is especially noticeable at the moments of inspiration, there is also shortness of breath;
• The previous clinical sign is confirmed by listening to the chest. This symptom is often accompanied by wheezing or whistling sounds on inspiration and expiration;
• Cough is one of the main symptoms of pneumonia. It is initially dry, then becomes moist with copious expectoration. Recognition of this symptom is difficult if the patient has no cough reflex after a stroke or is in a coma;
• Pain in the chest area is noted, they are aggravated by inhalation or with increased physical exertion, for example, climbing stairs;
• Congestive pneumonia is accompanied by a general deterioration, weakness throughout the body, patients complain of systematic fatigue, drowsiness;
• In some cases, excessive sweating appears in the history taking. It is important to understand that sweating increases regardless of physical activity, season or indoor climate.

Diagnostics

Due to the fact that some symptoms may be blurred or indicate any other complications after a stroke, certain diagnostic measures are required to make an accurate diagnosis and start adequate treatment:

• First of all, blood is taken from the patient for general and biochemical analysis, followed by determination of the level of leukocytes, ESR, detection of inflammatory proteins, etc.;
• In addition, it is important to take a sputum sample for analysis in order to conduct a bacteriological study. If congestive pneumonia is diagnosed, the results of this analysis will also help in the selection of drugs;
• The implementation of radiography will allow to detect foci of the inflammatory process in the lung tissues, to establish the localization and extent of the lesion;
• In some cases, bronchoscopy, CT and MRI are also required.

Treatment

Taking into account the fact that congestive pneumonia often develops after a severe stroke, when complications affect not only the lungs, but also other organs and systems, treatment is often very complicated, and the prognosis for recovery is unfavorable.

In such cases, efficiency and an integrated approach to treatment are important:

• Taking antibiotics;
• Anti-inflammatory drugs for stopping the inflammatory process;
• The patient is prescribed a mucolytic drug that helps to eliminate sputum;
• The most important aspect of therapy is the prevention or suppression of cerebral edema;
• Immunotherapy is also carried out, including vitamin complexes to enhance the body's defenses;
• Congestive pneumonia requires improved drainage functions. In cases where the patient is unconscious, artificial aspiration of stagnant contents may be required;
• In addition to the general course of treatment, a special massage, physiotherapy exercises, etc. are prescribed.

Such a dangerous complication after a stroke is stopped only with the participation of a neuropathologist and a pulmonologist, often in a hospital setting. Sometimes even after the stabilization of the patient and the onset of improvement, a long course of rehabilitation may be required.

Drawing conclusions

Strokes are the cause of almost 70% of all deaths in the world. Seven out of ten people die due to blocked arteries in the brain. And the very first and main sign of blockage of blood vessels is a headache!

Blockage of blood vessels results in a disease under the well-known name "hypertension", here are just some of its symptoms:

• Headache
• Increased heart rate
• Black dots before the eyes (flies)
• Apathy, irritability, drowsiness
• blurred vision
• sweating
• Chronic fatigue
• swelling of the face
• Numbness and chills in fingers
• Pressure surges

Attention! If you notice at least 2 symptoms in yourself, this is a serious reason to think!

The only remedy that has given a significant result ...

Pulmonary edema due to inflammation after a stroke

Asks: Marina, Moscow

Gender: Male

Age: 86

Chronic diseases: There was a stomach ulcer, now in remission; polyarthritis.

Hello, this is the situation: my grandfather (86 years old) had a stroke 2 weeks ago, lives in a small town in Ukraine, where there is no CT scan, but they said that it was impossible to transport him to another city for examination. Examined by a local neurologist, said that most likely a hemorrhagic stroke.
At the moment, the clinical picture: the temperature is low, earlier (yesterday) it was 38.6, it rose to 40.0 (before that it was also low), the pressure is 100/60 (a couple of days ago it rose to 200/130).
Speech is practically absent (in the first half of the day he spoke in monosyllables), the left side has hemiparesis (the previous picture), meningeal symptoms are less pronounced than initially.
Cough. The left lung at the bottom in front is not audible. Heart rate - with extrasystoles.
The doctor suggests pulmonary edema due to inflammation.
Prescribed Ceftriaxone 1.0. Tell me, please, is this antibiotic enough?
Thanks in advance for your reply!

3 answers

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No, not enough. Diuretics are needed, but what kind and how much can only be said by a therapist under constant monitoring of blood pressure. Also, in this condition, patient care is important - you need to turn the grandfather at least 5 times a day and do a massage-rub with a mixture of camphor alcohol and water (in equal parts) everything, starting from the fingers, toes to the torso and the whole body the same way. Stroke care is more important than medication.

Marina 2016-04-23 12:42

Hello!
Thank you very much for the answer!
With the lungs, it seems, everything returned to normal, they began to grind more, from antibiotics there was ceftriaxone with the addition of metronidazole. The doctor says that he no longer hears problems (although they did not take a picture). From the positive dynamics: he became more contact, it is difficult to speak, but if necessary, he even explains with gestures of his right hand.
But now in the evenings the temperature rises to 37.8 (it is removed with dipyrone with diphenhydramine), in the mornings there is no temperature. The doctor says about this that there may be different reasons (for example, shallow bedsores appeared - of the 2nd degree, but now they are gradually disappearing, and there is a temperature in the evening). The most alarming thing is the stiffness of the occipital muscles (he still cannot bend his head) and the fact that he strongly reduces the leg on the active side (he complains very much). He also complains that the chewing muscles hurt. The doctor gives midokalm for this (but this is a symptomatic treatment, as I understand it).
From other drugs: L-lysine, thiotriazoline, thiocetam, glucose and ascorbic acid.
From what happened in the last few days, it is important that the doctor prescribed latren (for bedsores, 18 days had passed after the stroke), after which convulsions began and consciousness was less clear (answered only certain questions), dripped for two days , after the cancellation (two days ago), the consciousness returned to the state before, but now the muscles hurt, it feels like the occipital muscles are more rigid (although it feels like the state of the muscles changes during the day).
Tell me, please, are additional studies and appointments needed? And what else can be done with muscle pain (mydocalm works for a limited time after the injection)?

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