Method for predicting disseminated intravascular clotting (dic)at burn disease

FIELD: medicine, diagnostics.

SUBSTANCE: one should study blood components to detect anticoagulant-fibrinolytic activity. Moreover, patient's blood should be sampled: in whole blood one should detect the presence of affected erythrocytes and evaluate the quantity of thrombocytes, in plasma it is necessary to study the activity of antithrombin III, XIIa-dependent fibrinolysis, the content of soluble fibrin-monomeric complexes, in blood serum of the sample taken one should detect the concentration of urea, creatinine, sodium, albumin, total cholesterol and the activity of aspartate aminotransferase, moreover, one should calculate integral value of renal-hepatic deficiency, to put corresponding point for the degree of parameters under testing, then one should calculate integral value of disseminated intravascular clotting (IVDIC) and at its value being 6.3 U and more DIC-syndrome should be diagnosed, moreover, at IVDIC value ranged 6.3-10.1 U it is possible to diagnose latent DIC-syndrome, at 10.2-14.6 - subacute DIC-syndrome and at 14.7 and higher - acute DIC-syndrome should be concluded.

EFFECT: higher accuracy and efficiency of diagnostics.

4 ex, 2 tbl

 

The invention relates to medicine, more specifically, to methods of diagnosing disseminated intravascular coagulation (DIC) and can be used by medical combustiologists and medical technicians for the early detection of this complication in patients with thermal injury.

The diagnosis of DIC assess the totality of the results of various laboratory methods of analysis, and then make a judgment about the depth hemostatic disorders (encyclopedia of clinical laboratory tests / edited Nautica. TRANS. with ang. edited Riv. M: Labelform, 1997. - 960 C.). The result of this overall assessment of disparate results based on the data from laboratory tests largely subjective and depends largely on the knowledge and experience of the Clinician.

Closest to the proposed technical solution is a method of diagnosis of DIC is based on the results of a study of blood components and determine its anticoagulant-fibrinolytic activity, which are described in the monograph Tshwaragano and Appamada (Basis of diagnosis of disorders of hemostasis. - M.: Novamed, 1999. - 224 S.). However, in this case the results are not merged into the index, making it difficult to objectively diagnose DIC, it is not possible if the natural enemy can Express the depth of hemostatic disorders with complication (to determine the severity of the syndrome DIC), to monitor its dynamics during treatment of the patient, promptly appoint an adequate therapeutic measures.

The present invention is to eliminate the existing shortcomings - the creation of an integrated indicator based on laboratory analysis of blood for objectification and rapid diagnosis of disseminated intravascular coagulation.

The problem is solved due to the fact that in patients with burns away the blood and using the known methods in whole blood to determine the presence of damaged erythrocytes, estimate the number of platelets, plasma investigate the activity of anti-thrombin III (AT III), XIIa-dependent fibrinolysis (XIIa-PD), the content of soluble fibrin-monomer complexes (; fibrin monomer complex), in the serum sample to determine the concentration of urea, creatinine, sodium, albumin, total cholesterol and the activity of aspartate aminotransferase, calculate the integral indicator of renal-hepatic insufficiency, the severity of identified parameters is assigned a corresponding score (table 1)calculate the integral indicator of disseminated intravascular coagulation (IPDS) by the formula:

IPDS=ABOVE+COMMITMENT+B+IV+V+VI, where

ABOVE is the number of points activity of anti-thrombin III from 1 to 5,

COMMITMENT - XIIa activity-dependent febrina is for from 1 to 5,

B content of soluble fibrin-monomer complexes from 1 to 5,

IV - platelet count from 1 to 5,

V - test damage of erythrocytes from 0 to 3,

VI - integral indicator of renal-hepatic insufficiency from 1 to 5,

and when is IPDUS of 6.3% and above diagnosed with DIC, and when is IPDUS in the range from 6.3 to 10.1% diagnose latent DIC, from 10.2 to 14.6 - subacute DIC, and from 14.7 and above with acute disseminated intravascular coagulation. When the rate of 6.2% and lower the probability of the presence of DIC is rejected.

The method is as follows. In patients with burns from the cubital vein to take blood and put in 3 test tubes for preparation of plasma (1 test tube), the sample for counting the number of platelets (2nd tube) and serum (3 tube). In the obtained samples using known methods to determine the parameters characterizing the state of hemostasis (1 tube) - the activity of AT III (fall activity AT III - main endogenous anticoagulant indicates a depletion of the link mechanism of the regulation of hemostasis, and the continuing decline - progression DIC); activity Ha PD (value Ha PD reflects the state of the main loft is built of proteolytic systems; the increase in time of lysis euglobulin clot indicates a slowdown of this process; the deepening of DIC is accompanied by an increase in this figure); contents; fibrin monomer complex with orthophenanthroline test (increase; fibrin monomer complex is an indication of increasing blood depolymerizes "locked" fibrin-monomer complexes, which is a marker of DIC).

The number of platelets examined in vitro 2. Thrombocytopenia when DIC is a consequence of their consumption (platelet aggregation in the microthrombi). Sharply increasing thrombocytopenia indicates the progression of the syndrome of ice.

Whole blood for the detection of damaged erythrocytes (test for damaged red blood cells) taken from the tube 1 until the separation of plasma from red blood cells. The allocation of damaged red blood cells is carried out in the capillary on the solution urografin a given density. A positive test for damaged erythrocytes characterized by the activation of intravascular coagulation. Damage (fragmentation) of erythrocytes by passing them through microvessels, blocked threads of fibrin is formed from fibrinogen under the influence of proteolytic enzyme thrombin.

Determine the concentration of urea, creatinine, sodium, albumin, total cholesterol and aktivnosti aspartate aminotransferase (tube 3). The integral indicator of renal-hepatic insufficiency (IPPN), reflecting the depth of multiorgan disorders arising in the process of development of DIC due to macrothrombocytopenia vessels parenchymatous organs, disorders of microcirculation, hypoxia and subsequent failure of their function, calculated by the formula

IPPN=(C1+C2+C3+C4)/(K5+C6), where

K1- the ratio of the concentration of urea in the serum of the patient to the average content of the analyte healthy people;

K2- the ratio of the concentration of creatinine in the serum of the patient to the average content of the analyte healthy people;

To3- the ratio of the concentration of sodium in the serum of the patient to the average content of the analyte healthy people;

To4- the ratio of aspartate aminotransferase activity in serum of the patient to the average activity of the analyte healthy people;

K5the content of albumin in the serum of the patient to the average content of the analyte healthy people;

To6- the ratio of the content of total cholesterol in the serum of the patient to the average content of the analyte healthy people.

The results of each test rankings the Ute, that is, a specific value of the analyzed indicator is assigned a corresponding score, the magnitude of which increases as the deepening of disorders of one or another element of the analyzed system, guided by the data in table 1. Calculate the integral indicator (IPDS) for the diagnosis of DIC by the formula

IPDS=ABOVE+COMMITMENT+B+IV+V+VI,

where ABOVE - the number of points activity of ATIII from 1 to 5,

COMMITMENT - activity Ha-f from 1 to 5,

B content; fibrin monomer complex from 1 to 5,

IV - platelet count from 1 to 5,

V - test damage of erythrocytes from 0 to 3,

VI - integral indicator of renal-hepatic insufficiency from 1 to 5,

and when is IPDUS of 6.3% and above diagnose DIC. IPDS in the range from 6.3 to 10.1% indicates the development of the patient latent (mild) form of DIC, from 10.2 to 14.6 - subacute (moderate) syndrome internal combustion engine, and when the value of the index from 14.7 and above - acute (severe) disseminated intravascular coagulation. The value of 6.2% and below allows you to reject the diagnosis of DIC.

The basis for determining the value of IPDS, above which it is possible judgment about the development of the patient DIC, was the results of a study of relevant indicators in patients receiving thermal injury and were treated in Rossick the m burn center on the basis of the Nizhny Novgorod research Institute of traumatology and orthopedics. Lesions of the skin at the affected light burns did not exceed 20% of the body surface. Patients who received burns moderate, severe and very severe, had lesions of the skin over 20% of the body surface. Depth of burn was varied within II-AB-IV.

Surveyed 137 patients (297 definitions of IPDS during the observation period, patients with 1's on the 12th day after burn). Similar figures for calculation IPDS defined in healthy people (16 men, the control group). The results are shown in table 2.

Table 2

The integral indicator value for the diagnosis of DIC (IPDS) in patients with burns, depending on the severity of thermal injury (c.u; M±m)
Healthy people (control)Patients with burns (lesions of the skin less than 21%)Patients with burns (lesions of the skin more than 21%)
123
5,4±0,18 (16*)7,9±0,36 (21)

p1<0,001
14,8±0,26 (276)

p2<0,001

p3<0,001
Notes: * in parentheses are number of definitions of IPDS; p - significance of differences of the analyzed parameters in column 1 and 2, p2in 1 and 3, p3in gr and 3.

Is IPDS control was 5.4±0,19% (M±m, where M is the arithmetic mean, m is the average error of the arithmetic). This index varies in the range of 4.7 to 6.2% (M±δwhere δ - error arithmetic mean - Sigma). In patients with thermal injury averaged integral indicator for the diagnosis of DIC in patients with mild burns was 7,9±0,37% and in the group of patients who received burns moderate, severe and very severe - 14,8±0,26% Indicators varied in the range of 6.2 to 10.1 and 10.5-19.1% respectively (M±δ). With the aim of obtaining the highest accuracy and information content of the method of boundary IPDS, within which it is possible to adequately diagnose DIC and its shape (weight), were determined at different values of the coefficients of the mean-square deviation (M±0,67δ, 1δ, 1,5δ 2δ). Optimal for the correct diagnosis of DIC (or reject this diagnosis) was the scale of the analyzed parameters within M±δ in the group of healthy people and those suffering from thermal injury.

Since the upper bound of the range of IPDS in patients with mild burns ends at the value of 10.1%, the patients with more severe thermal injury to the lower boundary of the analyzed indicator starts with 10.5 units, this limit should be lowered to 10.2% While the overall scale of values IPDS not interrupted.

It seems reasonable plot scale EPDS in the range of 10.2-19,1% should be divided equally. It should be assumed that patients with this index in the range from 10.2 to 14.6%, the severity of DIC is less pronounced than in patients with IPDS whose value varies from 14,7 to 19.1% and above. In this regard, DIC parameters of EPDS within 10,2-14,6% more should be classified as subacute (or moderate) DIC-syndrome, while when the metric value of 14.7% and more - mainly to acute (or heavy) the DIC syndrome. When identifying IPDS in the range of 6.3 to 10.1% diagnose latent (or easy) DIC, do not require special or emergency treatment, but implying adequate therapy of the underlying disease, however, disturbing the doctor in terms of careful observation of the hemostatic system of the patient in order to prevent the transition of latent forms of DIC in subacute.

Retrospective analysis of case histories of patients with thermal injury has allowed to test the proposed test is an integral index for the diagnosis of DIC. In the group of patients with burns over 20% of the body surface (117 people) latent DIC was diagnosed in 12 post is Adamchik, subacute - 20, sharp - 50. Form of DIC in 34 patients has varied in the dynamics of metric observation from latent to subacute and acute, as well as from acute to subacute, that adequately reflect the peculiarities of the course of burn disease, deepening disorders, or, on the contrary, the system state restore hemostasis. One patient had IPDS within normal limits. In the group fired with mild thermal injury (burns less than 20% of body surface) of the 20 surveyed at 14 detected light DIC, 2 - subacute, and 4-x - norm.

Below are some examples to illustrate the proposed integrated indicator for the diagnosis of DIC (data retrospective analysis of case histories).

Example 1.

Patient f s A.I. 46 years (the East. b-nor 194632) arrived in Nizhny Novgorod research Institute of traumatology and orthopedics 19.11.2000, with scald I-II-AB extent on the area of 20% of the body surface. IPDS on the 1st day since thermal injury - 8 units, 2 days - 12%, 5th - 10 points, 8-e - 8 unit, 10-e - 9 unit According to IPDS - subacute DIC. The patient was discharged in satisfactory condition at 53-and the day after burn.

Example 2.

A patient With s N. 41 (East. b-nor 194557) received NIETO 14.11.2000, about burn the flame I-II-AB degree in the area of 40% body surface burn eyes I metro IPDS on the 1st day after injury - 12 unit, 2nd unit 14, 4th of 14 units, the 8th is the 14 units, 10 12 unit According to a study in IPDS - subacute DIC. The patient was discharged in good condition after 43 days after burn.

Example 3.

Patient B in SN. 41 (East. b-nor 195571) entered the Institute 31.01.01, with a burn with flame IIIB-IV degree in the area of 40% body surface burn of the upper respiratory tract and eyes. IPDS 1st day - 14 units, 2 days 21 units, 5th day - 21 units on the 7th day after burn despite aggressive treatment, the patient died. According to IPDS - acute DIC.

Example 4.

Victim X in AV 39 years (East. b-nor 186138). He entered the Russian burn center 07.04.99, with a burn with flame AB-IV degree on the area of 60% of the body surface. IPDS 1st day - 20%, 4th day - 22 units, 5-f - 22 unit On the 6th day the patient died. IPDS shows the development in a patient with acute DIC.

Thus, the proposed test for the diagnosis of DIC in patients with burns, as shown by the results of testing the method on a set of case histories of patients with thermal injury (retrospective analysis)adequately reflects the disorders of hemostasis and allows not only to detect DIC, but also to quantitatively characterize the depth of this pathological process. The latter is particularly important to study the dynamics of development of DIC and monitoring for research n the o drugs for the treatment of internal combustion engine, statistical analysis that allows us to objectify the resulting findings and conclusions. An important advantage of the proposed method is its suitability for the diagnosis of DIC in any phase - Hyper - and gipokoagulyatsii, in the transition phase, as well as various form of its course (acute, subacute, latent). Along with the many tests that are performed during the examination of the patient, the doctor-combustible additionally receives one integral parameter characterizing the state of the hemostatic system that allows you to quickly assess the situation and make timely decisions on the appointment of a patient complex of those or other therapeutic measures aimed at the elimination of DIC syndrome. Use to retrieve the source data for calculation IPDS various modern analytical equipment (biochemical auto analyzer, the analyzer ion of blood, Hematology analyzer, analyzer for koagulologicheskih research) and independent from each other analytical methods, characterizing the link in the complex mechanism of pathogenesis of DIC syndrome, improves the accuracy of diagnosis of this complication and more objectively evaluate the patient's condition. All this, ultimately, allows us to recommend the method developed in clinics thermal lesions, and in which lineco diagnostic laboratories facility.

Method for the diagnosis of disseminated intravascular coagulation in burn disease through research blood components and definitions of anticoagulant-fibrinolytic activity, characterized in that the patient take the blood, whole blood to determine the presence of damaged red blood cells and estimate the number of platelets, plasma investigate the activity of anti-thrombin III, Ha-dependent fibrinolysis, the content of soluble hybridmonolith complexes in the serum sample to determine the concentration of urea, creatinine, sodium, albumin, total cholesterol and the activity of aspartate aminotransferase, calculate the integral indicator of renal-hepatic insufficiency, the severity of identified parameters is assigned a corresponding score, calculate the integral indicator of disseminated intravascular coagulation blood (IPDS) by the formula:

IPDS=ABOVE+COMMITMENT+B+IV+V+VI, where

ABOVE is the number of points activity of anti-thrombin III from 1 to 5,

COMMITMENT - activity Ha-dependent fibrinolysis from 1 to 5,

B - content soluble hybridmonolith complexes from 1 to 5,

IV - platelet count from 1 to 5,

V - test damage of erythrocytes from 0 to 3,

BVI is an integral indicator of renal-hepatic nedostatocno and from 1 to 5,

and when is IPDUS of 6.3% and above diagnosed with DIC, and when is IPDUS in the range from 6.3 to 10.1% diagnose latent DIC, from 10.2 to 14.6 - subacute DIC, and from 14.7 and above with acute disseminated intravascular coagulation.



 

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1 ex, 4 tbl

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3 dwg, 3 ex, 2 tbl

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2 ex, 2 tbl

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5 tbl

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7 cl, 4 dwg, 1 tbl

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