содержание .. 2 3 4 5 ..
РАССЕЯННЫЙ СКЛЕРОЗ У ВЗРОСЛЫХ И ДЕТЕЙ, (код по МКБ-10: G35). КЛИНИЧЕСКИЕ РЕКОМЕНДАЦИИ (2020 год) - часть 4
информационных технологий и систем поддержки принятия решений, которые
могут собирать, обрабатывать и фиксировать данные, полученные от пациента
и передавать их лечащему врачу в соответствии с действующим
законодательством.
75
7. Дополнительная информация (в том числе факторы, влияющие на
исход заболевания или состояния)
При постановке диагноза рассеянного склероза должны быть исключены все другие
заболевания нервной системы, в том числе поражения при инфекционных, токсических,
сосудистых и неопластических заболеваниях, а также системные аутоиммунные
заболевания с васкулитами и наследственно-дегенеративные заболевания.
При начале и проведении ПИТРС необходимо учитывать соматическое состояние
пациента и возможные побочные реакции. Особое внимание нужно уделить следующим
состояниям на фоне терапии ПИТРС:
−
Интерфероны-бета
- возможно усиление депрессии, усиление
спастического повышения тонуса, повышение риска припадков при наличии эпилепсии в
анамнезе;
−
Терифлуномид
- у женщин детородного возраста
- тщательная
контрацепция, патология поджелудочной железы;
−
Диметилфумарат
- гастроинтестинальные проблемы, симпатические
реакции («жжение и горение» и др.), лимфопения и риск ПМЛ;
−
Митоксантрон
- существенное повышение риска развития лейкозов,
повышение риска развития патологии сердца;
−
Натализумаб - острые инфузионные аллергические реакции на введение,
риск ПМЛ в зависимости от наличия JC-инфекции и титра антител к этому вирусу, а
также от предшествующей иммуносупрессии и длительности курса терапии препаратом,
при отмене препарата -IRIS и обострения РС, нельзя сочетать с другими ПИТРС;
−
Финголимод - брадикардия и нарушения ритма сердца, нельзя назначать
при наличии сердечно-сосудистых заболеваний, особенно с брадикардией, при
применении препаратов, замедляющих сердечный ритм, отек макулы (в малой степени),
лимфопения и риск ПМЛ и других инфекций, высокий риск развития обострения при
отмене препарата;
−
Алемтузумаб - острые инфузионные аллергические реакции на введение,
риск оппортунистических инфекций (в том числе листериоза), патология щитовидной
железы, иммунная тромбоцитопения (ИТП) и другие вторичные аутоиммунные реакции;
−
Окрелизумаб - острые инфузионные аллергические реакции на введение,
риск оппортунистических инфекций.
76
Критерии оценки качества медицинской помощи
Уровень
Уровень
№
Критерии качества
убедительности
достоверности
рекомендаций
доказательств
Этап постановки диагноза
1.
Выполнена консультация врача-невролога
5
C
Проведено сопоставление результатов
2.
неврологического осмотра с последними5
C
актуальными критериями диагноза
Выполнена
магнитно-резонансная
томография
головного
мозга
с
3.
1
А
контрастированием, согласно протоколу
исследования
Выполнено структурированное описание
4.
результатов
магнитно-резонансной5
C
томографии, согласно протоколу
Проведено сопоставление результатов
5.
МРТ с последними актуальными1
А
критериями диагноза
Проведена дифференциальная диагностика
с
основными
заболеваниями,
6.
5
C
вызывающими многоочаговое поражение
ЦНС
Проведена своевременная госпитализация
7.
при обострении
(в зависимости от1
А
медицинских показаний)
Проведена пульс-терапия для лечения
обострения
(в
зависимости
от
8.
1
А
медицинских показаний и при отсутствии
противопоказаний)
Выполнено другое лечение обострения
9.
при наличии противопоказаний к пульс-2
В
терапии
77
Уровень
Уровень
№
Критерии качества
убедительности
достоверности
рекомендаций
доказательств
Выполнен лабораторный
минимум,
включающий в себя: Клинический анализ
крови
развернутый;
Биохимический
анализ крови (маркеры функции печени и
10
5
C
почек, воспаления, уровень кальция,
глюкозы); Анализ крови на уровень ТТГ,
свободный
Т4,
антитела
к
тиреопероксидазе и тиреоглобулину.
Установлен и сформулирован диагноз с
11
5
C
учетом, формы и типа течения болезни
Определен балл EDSS на момент
12
5
C
постановки диагноза
Выполнено парное иммунологическое
исследование ЦСЖ и сыворотки крови на
13
олигоклональный IgG для определения2
C
типа синтеза
(в
зависимости от
медицинских показаний)
Этап
лечение
(диспансерное наблюдение)
14
Определен тип течения болезни
5
C
Выполнена оценка уровня EDSS на
15
5
C
момент осмотра
Выполнена оценка прогрессирования
16
5
C
инвалидизации
Выполнена оценка усиления
17
5
C
инвалидизации
Назначен препарат из группы ПИТРС (с
18
1
А
учетом показаний и противопоказаний)
Определен балл EDSS на момент начала
19
5
C
терапии ПИТРС
20
Выполнен план обследования перед
5
C
78
Уровень
Уровень
№
Критерии качества
убедительности
достоверности
рекомендаций
доказательств
назначением ПИТРС
Выполнен план наблюдения
(план
21
управления рисками) за состоянием5
C
пациента во время лечения ПИТРС
Проведена
оценка
эффективности
22
3
В
проводимой терапии ПИТРС
Этап реабилитация
Установлен реабилитационный диагноз
при поступлении и при выписке в доменах
23
5
C
Международной
классификации
функционирования
Установлены и документированы цели
24
реабилитации: долгосрочная, этапная и5
С
краткосрочные
Выполнена оценка степени тяжести
неврологических
нарушений
с
25
использованием
Шкалы5
C
Реабилитационной
Маршрутизации
(ШРМ) при поступлении и при выписке
Выполнена оценка уровня EDSS при
26
4
В
поступлении и при выписке
Выполнен
осмотр
специалистов
мультидисциплинарной реабилитационной
27
бригады, сформированной в соответствии5
C
с
требованиями,
установленными
действующим законодательством
28 Проведена физическая реабилитация
1
А
При наличии показаний, проведены
29
2
В
занятия по эрготерапии
При наличии показаний, проведена
30
1
А
когнитивная реабилитация
79
Уровень
Уровень
№
Критерии качества
убедительности
достоверности
рекомендаций
доказательств
При наличии показаний, проведены
31
2
В
занятия с медицинским психологом
При наличии показаний, оказано
32
2
В
логопедическое пособие
Проведена оценка риска образования
33
пролежней, в истории болезни отражены5
С
противопролежневые мероприятия
В выписном эпикризе указана информация
о
достижении/не
достижении
34
поставленных целей реабилитации, в5
C
случае не достижения целей указана
причина
80
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