Для острого периода церебральной недостаточности (ОЦН) анализ показателя энергопотребности покоя (REE) с помощью метода непрямой калориметрии является эффективным при оценке уровня гиперметаболизма и подборе оптимальной нутритивной поддержки. У пациентов с хроническими нарушениями сознания (ХНС) показана целесообразность такого подхода, но у этой категории пациентов не учитывается влияние реабилитационных мероприятий на потребность в энергии. Вертикализация является сегодня рутинным методом профилактики и лечения иммобилизационного синдрома у пациентов с ОЦН и ее последствиями. ЦЕль ИССлЕдОВАнИя Определить влияние процедуры вертикализации на поворотном столе на динамику показателя REE у пациентов с синдромом безответного бодрствования (СББ). МАтЕРИАл И МЕтОды Проспективное сравнительное нерандомизированное исследование было проведено у 136 пациентов отделения нейрореанимации Клиники Института Мозга. Определение показателя REE проводили с помощью метода непрямой калориметрии без нагрузки и в процессе вертикализации у 75 пациентов с СББ и у 51 пациента отделения реанимации и интенсивной терапии, которые также перенесли ОЦН, но находились в ясном сознании. РЕЗУльтАты У пациентов в ясном сознании при вертикализации происходило увеличение REE в среднем на 300 ккал (20%) от исходных значений. Энергетическая цена вертикализации составила около 5 ккал/кг. Напротив, в группе пациентов с СББ процедура вертикализации практически не увеличивала расход энергии, а энергетическая цена вертикализации немногим превышала 1 ккал/кг. ЗАК лючЕнИЕ Пациенты с синдромом безответного бодрствования имеют особый метаболический статус, вероятно, обусловленный снижением функциональной активности мозга. Это может быть подтверждено с помощью метода непрямой калориметрии. ВыВОды Принята к печати 06.03.2020

Introduction. Evaluation of ICU patients on specialized scales, such as the modified Rankin scale (mRS) and the rehabilitation routing scale (RRS), allows you to determine the degree of dependence on outside help in connection with the development of PICS syndrome, to decide on the level of complexity of the upcoming rehabilitation, and to route the patient to the appropriate rehabilitation center or palliative care department. Aims: Analysis of the experience of application RRS in the system of routing patients in intensive care units for rehabilitation treatment. Methods. As a result of the application of the routing algorithm based on the application of both scales, 224 patients with the level of dependence of RRS 56 (mRS 5) were selected for the examination of the rehabilitation potential and the re-habilitation attempt during 2019. Results. At the end of the rehabilitation course, 60 patients showed a decrease in the level of dependence to 34 points for both mRS and RRS. In 164 patients, the rating on the Rankin scale did not change (mRS 5), while the score on the RRS score of dependence in 135 decreased to 5 points. By the time of discharge, 29 patients with CNS continued to meet the criteria of RRS 6. All of them were verticalized to the level of landing in the chair and included in the remote tele patronage. During the quarterly visits, 9 patients showed signs of realizing their positive prognosis, underwent repeated rehabilitation courses during 20202021, and reduced the level of dependence to RRS 45. In practical terms, a decrease in the grade of SRM to 5 indicated that the patient was ready to stay at home, while patients with SRM 6 remained in need of highly qualified care, requiring at least a referral to the palliative care unit. From the point of view of the mRS scale, both described patient categories corresponded to 5 points, i. e., based on the assessment of the patients condition according to mRS, it was not possible to draw conclusions about further patient management tactics. Conclusions. Thus, the experience of using the RRS scale demonstrated its effectiveness in routing patients with acute cerebral injury and showed greater sensitivity and specificity in comparison with mRS.

The detection of signs of consciousness in patients with chronic disorders of consciousness is a complex clinical task. In recent decades, instrumental methods have been used to improve the accuracy of diagnostics. The phenomenon of covert cognition and cognitive-motor dissociation have been demonstrated in a small proportion of patients in studies using instrumental methods in combination with different paradigms. This article describes the main features of the diagnostic paradigms used for such purposes. Currently, the development of its own complex of paradigms is held at the Research Center of Neurology collaboratively with group of neuropsychologists from Lomonosov Moscow State University. The general characteristics of this complex of paradigms are indicated. The practical significance of detecting the phenomenon of covert cognition and cognitive-motor dissociation in patients with chronic disorders of consciousness is discussed.

Chronic disorders of consciousness include several conditions that differ significantly in both clinical and neurophysiological features. As medical technology continues to develop, the differential diagnosis of disorders of consciousness extends beyond purely clinical work. Nevertheless, all types of consciousness disorders are united by varying degrees of dissociation between wakefulness, cognitive and motor activity. The external similarity and minimal differences in clinical symptoms in unresponsive patients may hide different morphofunctional variants of this condition. In particular, use of electroencephalography and functional magnetic re- sonance imaging techniques allows us to detect covert consciousness in some clinically unresponsive patients. Based on various estimates, this phenomenon occurs in 515% of all cases. A special instance of covert consciousness is cognitive motor dissociation (CMD), defined as activation of cortical motor centers, recorded using neurophysiological techniques, in response to a corresponding instruction to perform a movement without its visible performance. Some researchers believe that detection of CMD indicates a more favourable prognosis for the subsequent restoration of consciousness, rather than its absence. The aim of this review is to examine CMD and its potential significance for outcomes in patients with chronic disorders of consciousness.