Abstract

Introduction: Aortic dissection (AD) is a rare, life-threatening condition that usually presents with intense chest pain. The only life-saving treatment is surgical intervention, which should be performed as soon as possible to avoid a fatal outcome. Postoperatively, AD can be accompanied by numerous complications, one of the rarest being paraplegia. This paper aims to present a physiotherapeutic approach to a patient with extensive AD complicated by paraplegia.

Case report: A 64-year-old male patient, recently discharged from Cardiac Surgery where he underwent surgical treatment of an AD type A, which was complicated by paraplegia caused by malperfusion syndrome, and a large stage 4 presacral pressure ulcer, was admitted to the Medical Intensive Care Unit (MICU) with signs of septic shock and multiorgan dysfunction caused by nosocomial bacterial pneumonia. At the beginning of hospitalization the patient was mechanically ventilated and analgosedated, presenting with respiratory and peripheral muscle weakness and hypersecretion. Following the implementation of intensive care measures, including physiotherapy initiated from day one, the patient was successfully weaned from mechanical ventilation after 23 days and continued to breathe spontaneously via an endotracheal cannula, which was removed after one month. At that point, he was able to speak, cough, and swallow. Due to significant respiratory muscle weakness, respiratory physiotherapy was administered daily to promote airway clearance and maintain pulmonary function. After two months of intensive physiotherapy, muscle contractions became evident in the upper limbs and upper trunk, and the patient achieved independent sitting. Following a 108-day stay in our MICU, the patient was discharged home with a prescription for physical therapy, home nursing care, a wheelchair, and an anti-decubitus mattress.

Conclusion: To our knowledge, this is the first case report describing a physiotherapy approach in a patient with Stanford type A AD complicated by paraplegia. This case also highlights the importance of a dedicated, multidisciplinary therapeutic approach in the recovery of chronically critically ill patients.

Key words: aortic dissection, Stanford type A, paraplegia, physiotherapy, rehabilitation

Sažetak

Uvod: Disekcija aorte (DA) predstavlja rijetko, životno ugrožavajuće stanje koje se najčešće prezentira intenzivnom boli u prsima. Jedini način spašavanja života je hitna kirurška intervencija kojoj je potrebno pristupiti u što kraćem roku kako bi se spriječio smrtni ishod. Postoperativno DA može uzrokovati brojne komplikacije, rijetko uključujući i paraplegiju. Cilj ovog rada je prikazati fizioterapijski pristup bolesniku s ekstenzivnom DA kompliciranom paraplegijom.

Prikaz slučaja: Muškarac u dobi od 64 godine nakon otpusta s Odjela za kardijalnu kirurgiju gdje je operiran zbog disekcije aorte tipa A komplicirane malperfuzijom leđne moždine s posljedičnom paraplegijom i razvojem dekubitusa četvrtog stupnja u presakralnom području, hospitaliziran je na Odjelu za intenzivnu medicinu zbog razvoja septičkog šoka i višestrukog zatajenja organa uzrokovanih nozokomijalnom bakterijskom pneumonijom. Početkom hospitalizacije bio je mehanički ventiliran i analgosediran, uz izraženu respiratornu i perifernu mišićnu slabost te hiperprodukciju bronhijalnog sekreta. Uz provođenje mjera intenzivnog liječenja, uključujući i fizioterapiju koja je započela prvog dana, nakon 23 dana bolesnik je uspješno odvojen od mehaničke ventilacije te je nastavio spontano disati putem endotrahealne kanile, koja je uklonjena mjesec dana kasnije čime je omogućen govor, kašalj i gutanje. Zbog izražene slabosti respiracijskih mišića svakodnevno se provodila respiratorna fizioterapija s ciljem eliminacije sekreta i očuvanja plućnog kapaciteta. Nakon dva mjeseca intenzivne fizioterapije mišićne kontrakcije su vidljive u gornjim ekstremitetima i gornjem dijelu trupa te je omogućeno samostalno sjedenje. Nakon 108 dana hospitalizacije, pacijent se otpušta kući uz propisanu fizikalnu terapiju, zdravstvenu njegu, invalidska kolica i antidekubitalni madrac.

Zaključak: Prema našim saznanjima ovo je prvi prikaz slučaja koji opisuje fizioterapijski pristup pacijentu s DA tipa A komplicirane paraplegijom. Ovaj prikaz naglašava važnost multidisciplinarnog terapijskog pristupa u rehabilitaciji kronično kritičnih bolesnika.

Ključne riječi: disekcija aorte, Stanford tip A, paraplegija, fizioterapija, rehabilitacija