Two objectives as follows: Description of clinical, subclinical characteristics and some factors related to mechanical ventilation of patients with acute cerebral infarction above the cerebellar tent. Identify some of prognostic factors of patients with acute cerebral infarction above the cerebellum tent requiring mechanical ventilation.
Trang 1108 INSTI TUTE O F CLINICAL MEDICAL AND
PHARMACEUTICAL SCIENCES
TRAN THI OANH
STUDYI NG CLINICAL, SUBCLINICAL CHARACTERISTICS
AND SO ME R ELAVANT FACTORS OF PATI ENTS WITH ACUTE
CEREBRAL INFARCTIONABOVETHE CEREBELLUM TENT
REQUIRI NGMECHANICAL V ENTI LATION
Speciality: Neurology Code: 62720147
SUMMARY OF MEDICAL DOCTORAL THESIS
HA NOI – 2019
MEDICAL AND PHARMACEUTICAL SCIENCES
Scientific instructors:
1 Prof PhD Nguyen Van Thong
2 PhD Nguyen Hong Quan
Reviewer 1:
Reviewer 2:
Reviewer 2:
This thesis will be presented at Institute Council at:
Day Month Year
The thesis can be found at:
1 National library
2 Library of 108 Institute of clinical medical pharmacological sciences
Trang 2INTRODUCTION
Stroke is one of the leading c auses of death and disability in adults, with
about 80-85% of cerebral infarction Patients with severe cerebral
infarction often have consciousness disorders, loss of ability to protect the
airway, sputum congestion, causing respiratory failure Intubation and
mechanical ventilation for these patients is needed to support breathing to
protect the airway and ensure adequate oxygen supply to brain cells
Although the proportion of patients with right ventilated cerebral infarction
is not high (10-16%), the prognosis is very poor All patients have severe
clinical circumstances, complex evolutions, need many pos itive treatments
but high mortality The death rate in the hospital is 35-75% The patients
who survived are mostly w ith severe neurological sequelae and dependent
There have been many studies in the world and in the country about
patients with cerebral infarction in general but there have not been many
studies on patients with mechanical ventilation with cerebral infarction
about factors related to ventilation indications and prognostic factors in
these patients
Therefore, we conducted the subject: "Studying clinical, subclinical
characteristicand some relevant factors of patients with acute cerebral
infarction above the cerebellum tent requiring mechanical ventilation"
with two objectives as follows:
1 Description of clinical, subclinical characteristics and some factors
related to mechanical ventilation of patients with acute cerebral
infarction above the cerebellar tent
2 Identify some of prognostic factors of patients with acute cerebral
infarction above the cerebellum tent requiring mechanical ventilation
THE NEWCONTRIBUTIONOF THE THESIS
1 The thesis topic has scientif ic, practical and topical significance to contribute to show some clinical, subclinical and imagingcharacteristics of patients with acute cerebral infarction above the cerebellum tent requiring mechanical ventilation
2 Determining a number of factors related to mechanicalventilation of patients with acute cerebral infarction above thecerebellum tent, some prognostic factors of mortality and prognosis ofgood functional state m RS 0-3 at the time of 1 year This will helpclinicians predict and prescribe timely treatment intervention
THE S TRUCTURE OF THE THESIS
The thesisconsists of130pages: 2pagesof introduction, 36pages of overview, 13pages of subjects and methods, 33pages ofresearchresults, 43pages of discussion, 2pages of conclusionsand 1 page of suggestion, 40 tables,13 charts, 9 images, 1 figures and 148 references
Chapter 1 - OVERVIEW
1.1 Physiology of cerebral infarction
A c erebral infarction occurs when the amount of brain blood falls below 18–20 ml / 100g brain / m inute, the c entre of the infarction is the n ecrotic area with a blood f low of 10-15ml/100g brain/minute, around this area (Penumbra area) has a blood flow of 20-25ml/100g brain / minute, although brain c ells are still a live but inactive The area cells die over a few hours and are different for every patient This is the window time for reperfusion treatment interventions Treatment measures to save this area
1.2 Edema in cerebral infarction
Trang 3Cerebral edema in a large cerebral infarction causes increased
intracranial pressure, which can lead to a brain hernia, aggravate
neurological deficiencies and high mortality if left untreated The clinical
development of c erebral edema in p atients with massive cerebral infarction
can be divided into 3 levels: fu lminant (within 24-36 hours), slowly (over
several days), or initial acute course then descending (about a week)
Cytotoxic Edema: Once clogged, there is a stop of oxygen exchange in the
damaged area which leads to the cell losing energy, losing the function of
the transport membrane, the ion pump stops working, Na + from outside
spills into the cell, dragging w ater causes the c ell to swell c ausing c ytotoxic
edema This type of edema does not respond to anti-edematous drugs
according to the osmotic mechanism
Vasogenic Edema: Occurs 4 to 12 hours after embolization, due to a
profound change in the endothelial lining of the capillaries, stagnation of
glycogen in stellar cells, causing bulging star cells, breaking the tight bonds
between intracellular cells tissue and between endothelial cells and stellar
cells leads to blood barrier brain ( BBB), the f luid from the lumen of the
artery is released causing brain ed ema Brain edema b ecomes the strongest
on the third to fifth day and is reduced after one to two weeks This type of
edema responds to anti-edematous drugs according to the osmotic
mechanism
As recommended by the American Heart Association/American Stroke
Association in 2014, the signs predict malignant cerebral edema and poor
prognosis on c ranial CT include increased mid-cerebral artery photon, dot
sign on film within 6 hours, infarction of one-third or more of the
mid-cerebral artery blood supply region, or midline shift push of 5 mm or more
on the cranial CT scan in the f irst 2 days is a lso associated with increased
nerve damage and death early in the acute phase The American Heart
Association/American Stroke Association (2014) recommends serial CT
scans during the first 48 hours of stroke to assess the risk of malignant
brain edema
1.3 Indications and role of mechanical ventilation in patients with cerebral stroke
The most common causes of hypoxemia in brain stroke patients may be due to partial obstruction of the airways due to sputum stagnation, respiratory depression and hypoventilation, choking pneumonia and collapse In these cases, mechanical ventilation helps improve blood oxygenation, maintain oxygenation to the brain and reduce intracranial pressure, but excessive ventilation should be avoided SpO2 target> 94% and pCO2 35 - 40 mmHg In patients stroke with impaired consciousness,
or signs of brain stem dysfunction, decreased oropharyngeal motion and airway reflex loss are at high risk of choking pneumonia Intubation for this patient is necessary to protect the airway and prevent c hoke complications Some patients have coma, disorders of breathing, have apnea, intubation and mechanical ventilation to ensure respiration, ensure oxygen to the brain and body to prevent brain edema progression
The Amer ican Heart Association/Stroke Association 2014recommends for mechanical ventilation in the treatment of acute cerebral infarction: Intubation may be considered for patients with decreased levels of consciousness resulting in poor oxygenation or impaired control of secretions
1.4 Hyperventilation and role of pCO2 in treatment intracranial pressure
Reducing pCO2 is known as a cerebral artery contraction that reduces cerebral blood flow leading to a reduction in intracranial pressure, mainly due to changes in pH around the blood vessels The effect of reducing cerebral blood flow is temporary, after 4 hours brain blood flow has been restored 90% In addition, a rapid increase in pCO2 causes a decrease in the
pH around the blood vessels, causing vasodilation to increase brain blood volume and increase intracranial pressure ("rebound hyperemia") Use hyperventilation should only be used short in cases of life-threatening increase in intracranial pressure, pending surgical intervention pCO2
should be normalized as soon as possible.
Trang 4Chapter 2 - SUBJECTS AND METHODS
2.1 Studying subjects
Severe cerebral infarction patients above the cerebellum tent were
treated at Strokecenter-Central MilitaryHospital108from 9/2013 – 6/2017
2.1.1 Criteria for selecting a patient
The patients was diagnosed as stroke according to the World Health
Organization (1989) stroke definition, arriving at the hospital 72 hours
prior to the onset of c erebral infarction Images of hemispherical infarction
on CT/MRI/ Severe nerve damage with NIHSS≥15 score (if the patient was
hospitalized prematurely, the damage on the first CT was unknown, the
patient would be d iagnosed for a second time on CT Patients were divided
into 2 groups: mechanical ventilation group and non mechanical vent ilation
group
2.1.2 Exclusion criteria
History of stroke with mRS score> 2 points, patients with severe
medical conditions such as liver failure, severe kidney failure, cancer,
COPD,…
2.2 Research methods:
2.2.1 Study design: Progressive, description, follow-up study
2.2.2.Sample size:
Sample size is determined by formula:
p (1-p) n = Sample size to study
n = Z2(1-α/2 ) - Z2(1-α/2): At the probability level 95% (Z =1,96)
d2 d: The desired accuracy (d = 0,05)
p: Estimated ratio, the rate ofcerebral infarctionpatients requiring mechanical ventilationin previous studies, p= 0,11
→ Based on the above formula, the estimated patient sample sizeis 150
In the period of taking data from 9/2013 – 6/2017, we collected 166
patients including 84 ventilated severe cerebral infarction patients and 82
severe cerebral infarction patients without mechanical ventilation
2.2.3 Research variables
Clinical variables : gender, age, medical history, time of admission, pulse, blood pressure, temperature, level of consciousness at admission on Glasgow scale, NIHSS score, degree of paralysis, language disorder, sensory disorders, urinaryincontinence, pupil abnormalities, light reflexes, head-eye deviation, progression of symptoms, related mechanical ventilation c omplications
Subclinical variables: hematology, biochemistry, coagulation, arterial blood gases
Imaging variables: CT, CTA, DSA: parenchymal, artery damage, midline shift Variables of treatment outcome: death, live, mRS at discharge, 1 year
2.2.4 Research contents
Patients were divided into 2 groups: MVgroup and non MVgroup The patients w ere divided into two groups, the MVgroup and the non MV group MVis indicated when at least one of the following criteria: Glasgow ≤ 8, loss
of reflexes protects airway causing mucus congestion, patients with consciousness disorders, stimulation must use safety drugs strong spirit causes respiratory depression, patients with respiratory failure, circulatory failure Describe the clinical and paraclinical features with analysis and comparison between two groups of MV and non MV group to highlight c linical and subclinical c haracteristics of patients requiring MV
Identify factors related to MV, factors related to prognosis of death at hospital discharge and mRS 0-3 at 1 year The supposedly relevant variables are included in univariate analysis and logistic multivariate regressions to find meaningful prognostic factors
2.3 Data analysis
Data processing using SPSS 16.0 software
Description of c linical, subclinical, imaging features: neurological signs
on onset, on admission and during hospitalization, intubation designation, subclinical characteristics, imaging, complications during MV, treatments and outcome
Trang 5Analys is of related factors: Chi-square test of qualitative or quantitative
variables with clustering Statistically signif icant variables in Chi-square
test were included in univariate regression analys is Variables related to
MVand mortality in univariate analysis with signif icance level p <0,05
were included in multivariate regression analysis to identify independent
prognostic variables
2.4 Diagramresearch
Chapter 3 – RESULTS
3.1 Clinical, subclinical characteristics and some factors related to MV in
patients with acute cerebral infarction above the cerebellar tent
3.1.1 Clinical symptoms
Neurological symptoms onset
ISC HEMIC
STROKE wi thout MV
(n = 82patients)
AC UTE ISCHEMIC STRO KE
- Images of HI on CT/MRI
- NIHSS≥15if the damage on the first CT is
unknown, will be diagnosed for 2nd on CT
(n = 166 patients)
ISC HEMIC STROKE wi th MV
(n = 84patients)
1 Descripti on of cli nical , subcl ini cal chara cteristics and
so me factor related to MV
2 Identi f y some of prognosti c
f actors in pati ents ischem ic stroke with MV
Prognostic factors
of mortality Clinicalcharac
te ristics
Related fact ors of mRS 0-3 at 1 ye ar Subclinical
charac ter istics
Related fact ors
of MV
Table 3.4 Neurological symptoms onset
Non - MV(n=82) p
Lips/ coma does not say 53 63,1 41 50 >0,05 Hemiplegia in the face 83 98,8 82 100 >0,05
Ur inary incontinence 56 66,7 16 19,5 <0,001
Comment: Disturbances of consciousness, vomiting/nausea, and ur inary
incontinence were statistically different with p <0,05
Neurologic symptoms at hospital arrival
Table 3.5 Neurologic symptoms at hospital arrival
Symptoms MV(n=84) Non - MV(n=82) p
Average Glasgow score 10,31 ± 2,02 11,84 ± 1,95 <0,001
Average NI HSS score 22,82 ± 5,39 19,90 ± 3,73 <0,001
Glasgow point at
NIHSS point at admission>20 52 61,9 34 41,5 < 0,01
Head-eye deviation 36 42,9 16 19,5 <0,001
Dilated pupils admission 10 11,9 1 1,2 < 0,01
Ur inary incontinence
Severe paralysis
Average strength of arm 0,32 ± 0,64 0,62 ± 0,94 < 0,05
Average strength of leg 0,45 ± 0,67 0,87 ± 1,05 < 0,01
Trang 6Comment: The Glasgow average score was lower for the MV group than
for the non MV group The average NIHSS score for MV w as higher than
for the non MV group Signs of head-eye deviation met 42,9% in the MV
group, higher than the MV group in 19,5% Severe paralysis ½ people in 2
groups are 92,9% MV group and 78% MV group
Some characteristics related to mechanical ventilation
Table 3.10 Indication for intubation
Nerve
96,4
Respiratory failure, c irculatory failure 3 3,6 3,6
Comment: Only 3,6% indicated intubation due to respiratory failure,
circulatory failure 96,4% indicated intubation related to nerve
Chart 3.7 Time of intubation Table 3.11 Characteristics in mechanical ventilation
Average intubation time from admission (days) 1,64 ± 0,91
Time of tracheostomy
Mean duration fromintubationtotracheostomy (days) 3,74 ± 1,21 Mean duration of MV
Comment: The rate of intubation was mainly in the f irst and second day
after admission The rate of tracheostomy early 38,2% The group with MV time of 4-7 days had the highest rate of 54,8%
Table 3.12 Arterial blood gas averages the points
Factors The first day after MV
(n= 84)
Day 3 after MV (n= 58)
Comment: Blood g as factors at the time of day 1 after MV and day 3 after
MV had reached the goal
Table 3.15 Complications related to MV
Comment: Common complications: pneumonia 35,7%, reflux 25%
Trang 73.1.2 Image characteristics
Table 3.19 Characteristics of images on CT scan first
Image characteristics
MV (n=84)
Non -MV (n=82)
Sum (n=166)
Comment: 64,5% of patients had hypodens ity at the first CT scan on
admission, 30,7% had no damage of images
Table 3.22 Image of edema brain on CT scan
Image of edema brain
MV (n=84)
Non -MV (n=82)
Sum (n=166)
Only blurry brain groove 14 16,7 21 25,6 35 21,1
Blurry brain groove and
ventricular collapse 8 9,5 17 20,7 25 15,1
Comment: Image of edema brain differs between the two groups
Table 3.23 Midline shift classification on CT scan
Midline shift
MV (n=62)
Non - MV (n = 17)
Midline shift
classification
Average m idline shift(mm) 10,04 ± 4,69 5,25 ± 3,43
Comment: Midline shift difference between the 2 groups p<0,001
3.1.3 Some factors related to mechanical ventilation in patients with acute cerebral infarction above the cerebellar tent
Results of univariate analysis including 12 clinical and subclinical variables with statistical significance related to MV were included in the
multivariate regression analysis
Table 3.30 Factors related to mechanical ventilation in multivariate analysis
Vomiting /nausea onset 6,586 1,138 - 38,131 0,035
Ur inary incontinence onset 8,027 2,628 - 24,518 0,000
Glasgow point at admission≤10 0,888 0,298 - 2,639 0,830 NIHSS point at admission> 20 0,790 0,260 - 2,397 0,677
Dilated pupils admission 7,699 0,443 - 133,935 0,161 Temperature admission> 37,50C 5,228 0,929 - 29,416 0,061
Leukocytes > 10G/l 3,212 1,149 - 8,982 0,026 Midline shift > 5mm 13,511 4,392 - 41,560 0,000
Comment:In the multivariate analysis, 5 variables were statistically
significant: onset consciousness consciousness, vomiting/nausea onset , urinary incontinence onset , leukocyte > 10G / l, midline shift > 5mm.
3.2 Study some prognostic factors in patients with cerebral infarction
in upper cerebellum tent with mechanical ventilation
3.2.1 Clinical outcome
Trang 8Chart3.12 Functional status upon discharge
Comment: In the MV group, no patients had a level of mRS 1-2 Mortality
(mRS 6) 34,5% In the group with no MV, mRS 4-5 was 68,3%
3.2.2 Some of factors related to prognosis of death in patients with
cerebral infarction in the cerebellum tent with MV
Table 3.32 Some clinical factors related to clinical outcome at discharge in
patients with cerebral infarction abovethe cerebellum tent with MV
Factors Clinical outcome at discharge p
Dead (n=29) Alive (n=55)
Ur inary incontinence onset 25 (86,2) 31 (56,4) 0,006
Average Glasgow score 10,31 ±2,12 10,29 ±2,01 0,967
Glasgow point at admission≤10 18 (62,1) 33 (60) 0,854
Average NI HSS score 22,76 ± 5,65 22,84 ± 5,34 0,951
NIHSS point at admission> 20 13 (44,8) 36 (65,5) 0,356
Decreased Glasgow ≥ 2 at intubation 18 (62,1) 25 (45,5) 0,173
Glasgow point ≤8 at intubation 18 (62,1) 28 (50,9) 0,364
Intubation in the first day 17 (58,6) 32 (58,2) 1,000
Aggravation in the first 48 hours 22 (75,9) 41 (75,4) 1,000
Dilated pupils admission 21 (72,4) 19 (34,5) 0,001
Loss of light reflection 24 (82,8) 10 (18,2) 0,000
Temperature admission>37,50C 11 (37,9) 6 (10,9) 0,003
AverageSBPadmission 142,79±33,55 145,56 ±21,93 0,65 AverageDBPadmission 85,93 ± 15,47 85,58 ± 14,39 0,918 Averagepulesadmission 89,72 ± 22,22 87,58 ± 19,84 0,653
Comment: Factors w ith statistical signif icance: urinary incontinence onset,
dilated pupils admission, loss of light refraction, temperature admission
>37,50C
Table3.33 Some subclinical factors related to clinical outcome at hospital discharge in patients with cerebral infarction in the cerebellum tent with MV
Factors Clinical outcome at discharge p
Dead (n=29) Alive(n=55) Leukocytes > 10G/l 18 (62,1) 39 (70,9) 0,409 Blood g lucose >11,1 mmol/l 5 (17,2) 5 (9,1) 0,303 pCO2 on the first MV < 35mmHg 12 (41,4) 17 (30,9) 0,337
Midline shift >5mm 23 (79,3) 30 (54,5) 0,025
Table 3.34 Some factors are associated with mortality prognosis in
univariate regression analysis
Comment: The factors in the table are all related to statistically significant
mortality outcomes in univariate analys is
Trang 9Table 3.35 Some factors related to mortality prognosis in multivariate
logistic regression analysis
Comment: When analyzing multivariate logistic regression, the factors
associated with mortality outcome were statistically signif icant: urinary
incontinence onset , loss of light reflection
3.2.3.Som e factors related to mRS 0-3 good function at 1 year
- There are 55 patients discharged At 1 year after discharge, there were 7
patients losing follow-up, 11/48 patients died, 20,3% mRS 0-3
Table 3.39 Some prognostic factors of good functional mRS 0-3 at 1 year
in univariate regression analysis
Comment:Factors with a negative predictive effect on good functional mRS
0-3 at 1 year include: ages > 60, pneumonia
Table 3.40 Some prognostic factors of good functional mRS 0-3 at 1 year
in multivariate regression analysis
Significant variables related to the good functional mRS 0-3 at 1 year in
univariate analysis w ere included in the multivariate regression analys is
Comment: When analyzing multivariate logistic regression, the negative
predictive factors giving good results of mRS 0-3 recovery at 1 year of
statistical significance include: ages > 60, pneumonia
Chapter 4 – DISCUSSION
4.1 Clinical, subclinical characteristics and some factors related to MV
in patients with cerebral infarction above the cerebellum tent
4.1.1 Clinical characteristics, imagings
- Conscious disorders onset
The study results showed that 79,8% of patients with MV had consciousness disorder onset compared with 37,8% in the group without MV(p<0,001) Santoli (2001) reported 69% of patients had consciousness disorder onset In Gupta’s study (2014), 60% of stroke patients had onset in
MV group compared with 12% in non-MVgroup (p <0,05) In major cerebral infarction, which causes widespread cerebral infarction, some cases of early cognitive impairment due to the influence of the neural activation n etwork in the lower part of the hypothalamus by damage to the hemisphere
- Vomiting/nausea onset
Vomiting/nausea is an uncommon manifestation of cerebral infarction
In the study, the group with MVhad the rate of vomiting / nausea was 16,7%, different from the group with MVwithout 3,7% (p <0,05) Gupta (2014) showed signs of vomiting in 43,3% of patients with MV and 14,3% with non-MV(p <0,05) Signs of vomiting more likely may be due to studies conducted in both patients with cerebral infarction and cerebral hemorrhage
-Urinary incontinence onset
The study results showed that urinary incontinencein the MVgroup was 66,7% and this sign in the MV group was 17,1% Doan Thi Huyen (2009) studied a group of large brain infarcts with the ratio of urinary incontinence was 66,67% In the study of Nguyen Van Tuyen (2013) also recorded the rate of urinary incontinencein patients with MVwas 97,01% compared to the group without MV2,08% (p <0,05)
Trang 10- Glasgow points at admission
The mean Glasgow score was 10,31 ± 2,02 in the MVgroup and 11,84 ±
1,95 in the non - MVgroup (p <0,001) 20,2% of MVgroup patients had a
score of Glasgow ≤ 8 on admission In both groups, the proportion of
patients with a score of Glasgow 9-12 w as predominant (63,1% in theMV
and 59,8% in the non-MVgroup) The score of Glasgow admission in
Mengi's study (2018) was 11,5 ± 2,78
- The degree of nerve damage conform the NIHSS scale
The NIHSS score is an indicator of the severity of nerve damage The
average NIHSS admission to hospital in the MV group (22,82 ± 5,39) was
higher than that in the non-MV group (19,90 ± 3,73), p <0,001 In Santoli’s
study (2001), the average NIHSS score was 21,12 ± 5
- Head-eye deviation
Head-eye deviationusually appear after a large cerebral infarction in the
tent, either due to les ions around the 8th region of the pre-motor region of
the upper frontal lobe or due to severe brain damage brain edema leading to
brain compression and appearance this sign Head-eye deviation is a
serious prognosis factor in stroke patients Research results showed that
29,4% of patients showed signs of head-eye deviation, and met a higher
rate in the MVgroup was 42,9% compared with 19,5% in the non- MV
group In the Gupta study (2014), head-eye deviation in the MV group was
17,3% and in the non-MV groupwas 10,9%
- Signs of mydriasis
In the MVgroup, 11,9% of patients showed signs of mydriasis, in the
non -MVgroup, this rate was 1,2% (p <0.01) When there was aggravation
of neurological d eficiencies, the rate of mortality was 47,6% of patients in
MVgroup In the Gupta’s study (2014), the group of patients with MVwho
had MVhad the rate of mydrias is abnormalities of 17,3% and the group of
MV with 10,9% (p = 0,25) In the Gujjar’s study(1998), the rate of
mydriasis abnormalities was 16% in mechanicallyventilated cerebral
infarction patients
- Indication of intubation
The study results showed that 96,4% of intubation and MVrelated to nerves (including G lasgow score ≤ 8 was 21,4%, loss of airway protection, risk of sputum congestion was 27,4% and nerve progression was 47,6%) Traditionally, some authors have indicated intubation and MVwhen impaired consciousness with a score of Glasgow ≤8, or consciousness preserved but impaired oropharyngeal function,congestion of phlegm The study results showed that 45,2% of patients with a score of Glasgow 9-10 when intubated had neurologic progression, or loss of airway protective reflexes
According to Nguyen Hong Quan (2012), indication of intubation related to nerves was 85,6% In published studies, intubation indicated was mostly related to nerves: Gujjar’s study (1998) was 82%; Schielke's study (2005)was 71%; Berrouschot’s study (2000) was 90%; Milhaud'sstudy (2004) was 86%
- The time of MV
The average MV time was 4,40 ± 2,28 days, the group of MVpatients
4-7 days accounted for the highest proportion (54,8%) In Berrouschot’s study (2000), averageMV time was 172 ± 182 hours (7,17 ± 7,58 days), Santoli's study (2001), averageMV time was 8,6 ± 8,8 days Popat's study (2018) averageMV time was 6,5 ± 5,9 days In massive cerebral infarction, adverse neurologic events usually occur within the first 48 hours, especially malignant brain edema, requiring MV At the end of the period of severe cerebral edema, the patient has adequate self-breathing, can stop MV, avoid prolonged MV, limiting the complications of MV
- Characteristics of arterial blood gases
The pO2 index on the first day:132,3 ± 54,3 and 112,8 ± 37,15 on day
3 This was appropriate because the patients in the study had good pulmonary ventilation and 96,4%of intubation was related to nerves Arterial b lood gas on the first day after MV pH 7,436 ± 0,057, pCO2 36,8
± 8,9 mmHg, on day 3 MVpH 7,439 ± 0,048, pCO2 37,9 ± 6,75 mmHg