Method for diagnosing disseminated intravascular blood coagulation in the cases of burn disease

FIELD: medicine.

SUBSTANCE: method involves analyzing symptoms manifesting initial disseminated intravascular blood coagulation syndrome danger like burn area, availability of upper air passages burn, shock with its severity degree taken into consideration, sepsis development; clinical manifestations of disseminated intravascular blood coagulation syndrome like lung, kidney, liver function insufficiency, cerebral dysfunction, local and multiple hemorrhages, thrombosis, infarction; homeostasis system laboratory analysis data, hyper- and hypocoagulation based on chronometry test data, number of blood platelets, fibrin-monomer complexes, D-dimers, activity of antithrombin III, C and S proteins, XIIa-dependent fibrinolysis plasminogen content, availability of injured erythrocytes, combinations of laboratory tests for recognizing disseminated intravascular blood coagulation syndrome. Each sign under consideration receives a number of points corresponding to its diagnostic significance and integral value is calculated DIBCSIV=(X1+X2+…+Xn)/n, where n is the number of signs taken into consideration. DIBCSIV value equal to 1.0-1.5 units shows physiological norm. The value being between 1.6 and 2.5 units, light disseminated intravascular blood coagulation syndrome is diagnosed. The value being between 2.6 and 3.5 units, disseminated intravascular blood coagulation syndrome of medium severity is diagnosed; 3.6-4.5 points to one heavy severity degree; 4.6 and greater indicates highly severe case of disseminated intravascular blood coagulation syndrome.

EFFECT: high accuracy and objectiveness in differentiating syndrome severity degrees.

1 tbl

 

The invention relates to medicine, more specifically, to methods of diagnosis of the most life-threatening patient complications of burn disease - DIC (disseminated intravascular coagulation), and can be used by medical combustiologists, and medical technicians for timely detection of disorders of hemostasis in patients with thermal injury.

In practice, clinicians diagnosis of disseminated intravascular coagulation put on the analysis of clinical manifestations of this complication, as well as evaluating the overall results of laboratory tests of different parts of the system gemokoagulyatsii, endogenous anticoagulants and fibrinolysis. However, the conclusions of the medical clinicians on the results of considered characteristics largely subjective, depending on the level of professional knowledge and medical experience. As a result of the conclusion of the treating physicians combustiologists, consultants to the bedside, as well as specialists-clinical departments of the medical institution (medical technicians) are not standardized, and often diametrically opposed due to ambiguous understanding of the diagnostic value of certain characteristics of the syndrome of internal combustion engines, which are subjected to analysis. One of the main clause is icin this situation - no integral indicator, which allows you to combine all the analyzed characteristics and to Express the state of the system gemokoagulyatsii in the form of one single value.

Closest to the proposed technical solution is a method of diagnosis of DIC developed Weglikowy (Liceu VG Diagnosis and treatment of disseminated intravascular coagulation. - 2nd ed., Rev. - N.Novgorod, (in GMD, 1998. - 191 C.). According to the method prototype for assessing the status of the system gemokoagulyatsii take into account the signs (evidence) class a (initial clinical situation - starting factors for initiation and progression of the syndrome of internal combustion engines or so-called basic pathology), class b (clinical manifestations of DIC) and class C (data from laboratory tests of hemostasis). Each of the qualifying characteristics are assigned to "confidence", reflecting the degree of specificity of one or another symptom for the syndrome of ice. A set of confidence building measures (accounting certificates class a, b and C) are calculated according to equation Shortliffe. POI achieving aggregate measures of trust to 0.95 and more diagnosis of DIC. If a set of confidence building measures less than 0.95 diagnosis of DIC syndrome is rejected.

However, according to this method analyzes only the probability that the patient DIC. The more owls is the synergy of confidence building measures, the higher it is. The severity (form) DIC is not taken into account. Regardless of the value of aggregate measures of trust more than 0,95 Clinician using this method, this information is not received. It is not clear that the patient has latent, subacute or acute DIC, how the shape of the syndrome of ice time. It is impossible to determine when the latent DIC becomes subacute, and further in acute and Vice versa. It is not possible to quantify the dynamics of the pathological process (DIC) when the progression of burn disease or, on the contrary, when the recovery of the patient, and depending on the adequacy or inadequacy of medical treatment. In addition, the procedure of calculation of aggregate measures of trust various characteristics of class a, b and C using the equation of Shortliffe is rather time-consuming if it is not automated.

The present invention is to eliminate the existing shortcomings - the creation of an integrated indicator based on the information about the initial clinical situation (availability of factors of inductors initiation and progression of DIC), clinical manifestations of DIC syndrome and the results of laboratory tests of hemostasis system to evaluate and improve the accuracy of diagnosis of DIC based on gravity (form, and simplify this process.

The problem is solved due to the fact that in patients with burns analyze and take into account information about the original clinical DIC dangerous situation (the presence of the etiological factors in the initiation and progression of the syndrome DIC) - certificate class And clinical manifestations of disseminated intravascular coagulation (evidence grade b), and the results of laboratory tests of hemostasis (evidence grade C). Each indicator is assigned a score, the magnitude of which increases with increasing diagnostic significance (informative) one or another of the analyzed characteristic for the diagnosis of DIC (table). The integral indicator for the diagnosis of DIC syndrome (IPDS) calculated by the formula:

IPDS = (X1+X2+Xi)/n

where (X1+X2+Xi- the set of points of any number of attributes, n is the number of considered features, and when is IPDUS in the range of 1.0 to 1.5 units of the state system gemokoagulyatsii assessed as being within the physiological norm, in the range of 1.6 to 2.5% diagnose latent (light) DIC, 2,6-3,5% - subacute (moderate), 3,6-4,5%- acute (severe), and 4.6% and more acute (extremely heavy) syndrome disseminated is vertuani blood. IPDS expressed in conditional units.

The maximum number of considered features, especially when combined characteristics of all classes, will allow the most accurate and objective diagnosis of DIC, to define its shape (weight), or reject such, as some inaccuracies in the magnitude of the score of one or another of the analyzed characteristic offset by the aggregate of many other more accurate indication when calculating EPDS.

The method is as follows. The patient with thermal injuries analyze signs (evidence) class a, b and C, are presented in the table. Note the characteristics of the class: the burn area, the presence of burns of the upper respiratory tract, shock, given its severity, the development of the patient's severe complications of burn disease is sepsis. These symptoms reflect the degree of internal combustion engine-a dangerous situation. In the second phase, analyze the clinical manifestations of DIC syndrome (evidence grade C) - 14-24 (table). To detect signs of multiple organ failure (failure of function of lungs, kidneys, liver, brain dysfunction), local and multiple manifestations of disorders of blood clotting (bleeding, including gastrointestinal bleeding, thrombosis, heart attack). In the third step calculates the amount of points reflecting the measure of deviations (or lack thereof) in various parts of the system gemokoagulyatsii, endogenous anticoagulants and fibrinolysis - A.25-40 (table). Analyze the results of timing tests, counting the number of platelets, the study of structural indicators, activity of anti-thrombin III, etc. and also gives a measure of diagnostic value in points different variations of the results of laboratory tests for the detection of DIC (paragraph 41-50), which, as the data of literature and practice, have the greatest information with respect to the value for the diagnosis of disseminated intravascular coagulation. Summarize all the points, count the number of considered parameters (table) and calculate IPDS by the formula:

IPDS = (X1+X2+Xi)/n

where (X1+X2+Xi- the set of points of any number of attributes, n is the number of considered features, and when is IPDUS in the range of 1.0 to 1.5 units of the state system gemokoagulyatsii assessed as being within the physiological norm, in the range of 1.6 to 2.5% diagnose latent (light) DIC, 2,6-3,5% - subacute (moderate), 3,6-4,5% - acute (severe), and 4.6% and more acute (extremely heavy) syndrome disseminated intravascular swerty the project for blood.

Below are a few examples illustrating the application of the integral indicator for the diagnosis of DIC in burn disease (the results of the retrospective analysis of case histories of patients who were treated in the Russian burn center on the basis of the Nizhny Novgorod research Institute of traumatology and orthopedics).

Example 1.

Patient B-John S., 41 (East. b-nor No. 195571), entered the Russian burn center on the basis of the Nizhny Novgorod research Institute of traumatology and orthopedics about burn the flame of the head, trunk, upper and lower extremities AB-IV century in the area of 40% of the body surface. Burns of the upper respiratory tract. Index severity index (Frank) - 140 units report on the state of hemostasis on the totality of symptoms - acute DIC, (severe). Dynamics of IPDS: a day after thermal injury - 3,86% after 2 days - 4,22% after 5 days - 5,95% (acute DIC, extremely severe). On the 7th day the patient died.

Example 2.

Patient C-VA M.A., 45 East. b-nor N 191489), was admitted to the Department of thermal injury NIETO in connection with scald I-IIA tbsp. face, neck, trunk and upper extremities in the area of 40% of the body surface (an index of the severity of the defeat - 40%). In the interval from the first to 12th day after thermal injury, EPDS ranged from 2.0 to 2.33% Diagnosed latent DIC-si is drôme (mild), does not require special treatment for the correction of system gemokoagulyatsii. A day after thermal injury, IPDS - 2,1%, on the 6th day - 2,0%, on the 7th of 2.33%, 12th - 2,1% Starting from 14 days after burn (IPDS - 1,4 units) indicator not prevail of 1.5%, indicating full recovery of coagulation and anticoagulation systems of the body. The patient was discharged from hospital in satisfactory condition on the 19 th day from the date of the burn.

Example 3.

This example illustrates the wave-like change in the severity of the syndrome of the internal combustion engine when the latter moves from one form to another as the flow of burn disease.

The victim E-VA S.A., 67 (East. b-nor No. 194684), was admitted to the hospital burn Nizhny Novgorod research Institute of traumatology and orthopedics in connection with the flame burn of face, neck and both upper limbs, the back, the front surface of the chest on the area of 32% of the body surface (30% of severe burns IIIB-IV century). Burns of the upper respiratory tract. Index severity index (Frank) - 122 units a day after the burn, IPDS - 2,64% (subacute DIC or DIC moderate). After 2 days after injury recorded deepening of disturbances in the system gemokoagulyatsii: IPDS was 3,68% are Diagnosed with acute DIC (severe). On the 5th day the state of the system gemokoagulyatsii the creature is but has not improved (IPDS - 3,50% - subacute DIC). In subsequent periods of observation of the patient, the patient's condition continued to deteriorate, despite ongoing intensive treatment. On the 6th day after injury, IPDS was 4,60% (acute DIC, extremely severe), on the 7th day - 4,19 unit (acute DIC, severe), on the 8th day - 3,59 unit, on the 9th day condition continued to deteriorate (IPDS was 4.42%). The patient died on the 10th day after thermal injury.

Example 4.

The following example also demonstrates the wave for the severity of DIC syndrome in a patient who suffered from thermal injury, but with a favorable outcome of the pathological process.

Patient B s VA 41 years (East. b-nor No. 180123), was admitted to the hospital thermal lesions Russian burn center with burns the flame of the right shoulder, the back right side of the torso to the right on the square H. The degree of burn - II-IIIAB-IV. Index severity index (Frank) - 87% a day after the burn, IPDS - 2,43% (light DIC). On the 5th day from the date of injury of the analyzed indicator increased to 3.79% Diagnosed with latent transition in acute DIC (severe). A course of therapy for the correction of the hemostatic system. Starting from the 10th through the 17th day after injury, IPDS were in the range of 2.50% (latent DIC), then re-recorded arowana deterioration of hemostasis: on the 24th day after burn IRDS amounted to 2.64% (subacute DIC moderate). Treatment of disorder of the system gemokoagulyatsii again intensified. In subsequent follow-up period of IPDS declined after 32 days from the moment of thermal injury he amounted to 1.87% (latent DIC). The patient's condition continued to improve. 73-day system gemokoagulyatsii normalized (IPDS of 1.50%). 75 days the patient was discharged in good condition.

It is seen that the proposed method for the diagnosis of DIC in patients with thermal injury adequately reflects the state of the system gimotea, allows not only to diagnose the syndrome of DIC (or reject this diagnosis), but also to quantify the depth of disorders system gemokoagulyatsii to diagnose latent DIC (mild), subacute (moderate), acute (severe form) and acute (extremely severe) of DIC syndrome. This gives the opportunity to observe the development of the pathological process in the dynamics, to quickly identify the transition complications from less severe to more severe form, promptly appoint an adequate therapy, correcting the hemostatic system, to monitor the recovery and restoration of coagulation and anticoagulation mechanisms of blood. Use to calculate EPDS evidence of different classes is key to the most accurate is nd and correct assessment system gemokoagulyatsii, as this takes into account many factors associated with the development of disseminated intravascular coagulation. The ability to assess the state of the system gemokoagulyatsii with one integral quantities allows you to easily use the data not only in practical combustology, but in experimental medicine, in particular for statistical studies, especially in scientific work in assessing the effectiveness of new drugs and other therapeutic procedures that are developed and implemented in practice for the treatment of disseminated intravascular coagulation syndrome in burn disease.

Method for the diagnosis of disseminated intravascular coagulation (DIC) with burn disease, which takes into account the information about the original clinical DIC dangerous situation, the clinical manifestations of DIC syndrome and the results of laboratory tests of hemostasis system, characterized in that analyze the following characteristics of the source engine is a dangerous situation - the burn area, the presence of burns of the upper respiratory tract, shock, given its severity, development of sepsis, the clinical manifestations of DIC-syndrome - failure of the lungs, kidney, liver, brain dysfunction, local and multiple bleeding, gastrointestinal bleeding, thrombosis, heart attack; result is you laboratory studies of homeostasis - Hyper - and hypocoagulation according to timing tests, the number of platelets, fibrin-monomer complexes, D-dimer, the activity of anti-thrombin III, protein C and S, XIIa - dependent fibrinolysis, the content of plasminogen, the presence of damaged red blood cells, the combination of the results of laboratory tests for the detection of DIC, each carried signs assigned a score corresponding to its diagnostic value, and calculate the integral indicator for the diagnosis of disseminated intravascular coagulation (IPDS) by the formula

IPDS = (X1+X2+...+Xn)/n

where (X1+X2+...+Xn- the set of points carried signs;

n is the number of considered features,

and when is IPDUS in the range of 1.0 to 1.5 units of the state system gemokoagulyatsii assessed as being within the physiological norm, in the range of 1.6 to 2.5% diagnose latent (light) DIC, 2,6-3,5% - subacute (moderate), 3,6-4,5% - acute (severe), 4,6 and more acute (extremely heavy) disseminated intravascular coagulation.



 

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