The way to prevent thrombogenic complications after prolonged abdominal operations

 

(57) Abstract:

The invention relates to medicine, namely to surgery. A method for prevention of thrombogenic complications in post-operative patients, including the introduction of anticoagulant, wherein the patient from the first day after surgery lasting more than 3 hours to enter therapy under the control of electrocochleography when the amplitude of the retraction and fibrinolysis less than 0.9.E., lifetime dense clot more than 2.1 min and the blood clotting time less than 6 minutes Method eliminates the risk of thrombogenic complications and reduce mortality in the early postoperative period. 1 C.p. f-crystals, 2 ill., table 1.

The invention relates to medicine and can be used in the rehabilitation of post-operative patients

The problem of postoperative phlebothrombosis in elderly patients with often neoplastic lesions of the gastrointestinal tract and pancreatobiliary system, with a number of concomitant diseases, propensity active hemostasis to hypercoagulability, undoubtedly relevant.

The phlebothrombosis and pulmonary embolism complicating the early postoperative period is 2-3 times more often than is commonly believed. Pulmonary embolism (PE) are defined in General the th involve the use of indirect anticoagulant.

All indirect anticoagulants are derivatives of coumarin (dikumarina, neodikumarin, acenocoumarol or singular).

Anticoagulants of indirect action are antagonists of vitamin K, necessary for the formation in the liver of prothrombin. The mechanism of action is inhibition of VII, IX, X clotting factors.

Unlike heparin, these drugs do not give effect immediately, are slowly and continuously, have cumulative properties.

Anticoagulants of indirect action are not widely used in patients in the early postoperative period.

These drugs have been successfully used as supportive therapy in cases of heparin in acute myocardial infarction, rheumatic heart disease, pulmonary embolism. (C. I. Metelitsa. Reference cardiologist for clinical pharmacology./ Ed. by E. I. Chazov, 2nd ed., reprocessing. and extra - M.: Medicine, 1987., 368 C.)

There are also known ways to prevent thrombogenic complications with medications aimed rheological actions, that is acetylsalicylic acid. (Diagnosis, prognosis, and prevention of postoperative venous, thromboembolization has a weak anticoagulant activity and has a marked inhibitory effect on spontaneous and induced platelet aggregation. Aspirin is administered to the patient within 1 hour before surgery the rate of 7 mg/kg of body weight. After surgery the patient is in the same dose gets this drug every 8 hours.

The disadvantages of the method include the fact that such a dose aspirin may be used in patients with low and moderate risk thrombogenic complications in the early postoperative period, and after a short, low-volume operations.

For the prototype we have adopted a method of preventing thrombogenic complications by patient heparin (Diagnosis, prognosis, and prevention of postoperative venous thromboembolic complications. Moscow, 1993, guidelines. Author D. M. N. Nozdrachev Y. N.).

In patients with high risk of thrombogenic complications in the immediate postoperative period prescribed heparin, 50 units/kg 2 hours before surgery, followed by the introduction of the drug every 8 hours in the same dose within 1 day, with 2 on the 9th day of the postoperative period, the dose is increased up to 70 units/kg with the same interval, then gradually reduce and cancel.

In nefrackzionirovannam drugs, called "heparin", dominated by high molecular weight fraction chap who priori calculations, because hypocoagulation effect it individually varies within very wide limits. It depends on four main factors:

- the plasma of the patient of anti-thrombin III, without which heparin has no anticoagulant actions, and this resistance cannot be overcome by increasing the dose of the medication;

- blood levels of acute phase proteins that bind and inactivate heparin;

the degree of fixation of complex antithrombin III - heparin on vascular endothelium;

- the heterogeneity of heparin because of the different content of high - and low-molecular components;

When intermittent injections of heparin, every four hours, there are major differences in the gemokoagulyatsii from full neverthemore blood to its normal performance, or even hypercoagulable before each new introduction (pologize heparin in circulation is 70 - 100 minutes, so by the end of 3-4 hours in the blood is almost there).

Hemorrhagic thrombotic complications such intermittent introduction 7 times more often than with long-term infusion of the drug. (Liceu Century, Diagnosis and treatment of disseminated intravascular coagulation. M, Medicine, 1993, is LNA fibrotic transformation of the hemostatic clot ends within 24 hours after injury of the vascular wall. (Hemodynamics surgical bleeding Francoise Clinquart, Nicola d' Attellis, Jean-Francois Baron, France, 1999)

The degree of risk of thrombogenic complications increases with long-term (over 3 hours) operations, when the source of hypercoagulation, especially in the elderly on the background of the tumor process.

All this requires complex interventions to individualize the ability to prevent thrombogenic complications after surgery.

The goal is to ensure reliable prevention of thrombogenic complications in postoperative patients.

Tasks.

1. Ensuring the manageability of the process of formation of fibrin clot under the control of electrocochleography.

2. The elimination of the blocking effect of anticoagulant on fibrinolysis.

3. The lengthening of the period of validity of the drug

4. Reducing the risk of developing thrombocytopenia.

The invention consists in that the patient with the first day after surgery, lasting more than 3 hours, under the control of electrocochleography - (rapid diagnosis, prevention and treatment of acute and chronic coagulopathy, Methodological recommendations for physicians, clinicians and laboratory doctors. Auto is S="ptx2">

For the record electrocochleography specically, only the peripheral venous blood.

The reproducibility of the method is not in doubt, since you used certain equipment and is available for the medical staff process.

The method is as follows.

Based on the existing classification of the degree of risk of thrombogenic complications in the early postoperative period (Diagnosis, prognosis, and prevention of postoperative venous thromboembolic complications. Moscow, 1993 , guidelines. Author D. M. N. Nozdrachev Y. N.) the studied patients were administered 4 hours after surgery therapy (20 to 40 mg) and then every 12 hours after the first injection.

The basis for assigning Clexan immediately after surgery is a specific type of graphic recording electrocochleography at which the amplitude of the retraction and fibrinolysis less than 0.9 conventional units, the existence of a dense clot more than 2.1 min and the blood clotting time less than 6 minutes (Appendix I,II).

The formation of friable clot, according to electrocochleography, is a criterion of adequacy of the selected dose of Clexan (see table).

Predelay, Krasnodar.

The entire group of patients was provided reliable prevention of thrombogenic complications in the early postoperative period.

Example: History N 115. Patient L., 42 years old, was admitted to the hospital with a diagnosis of stomach Cancer. T4N2M1. The main complication: Subphrenic abscess on the left.

Under General anesthesia the patient had an operation combined gastrectomy, splenectomy, resection of the body and tail of pancreas, left nephrectomy, resection of the small and large intestine. Total lymphadenectomy, drainage of the abdominal cavity. The operation is performed under General anesthesia, lasted about 19 hours.

The nature of the underlying disease, the extent of surgical intervention, duration of surgery, patient age, initial hypercoagulation, significantly increased the risk of thrombogenic complications.

Prevention thrombogenic complications in the early postoperative period the patient received 20 mg of Clexan, subcutaneously, the region of the navel, over 12 hours after the first injection, any violations in the hemostatic system during this period have been identified.

Given the continuing threat of thrombosis TCB=5,7 min, IC=87,5%, KA=15,3 srvc. eating informative. A day after the surgery, the dose of Clexan increased to 40 mg twice a day.

After increasing the dose of Clexan up to 80 mg per day increased clotting time (TCB= 7,3 min), almost 20% decrease in coagulation (IC= 66,6%), a decrease of 1.5 times the coagulating activity of the blood (KA=9,13 srvc. units ), increasing the hemostatic potential of 3.6 times (SE= 6,14 srvc. units ), reducing the extent of fibrinolysis (SF) to 3,13% and fibrinolytic potential of AF to 0.3 s.ed.

After a month of observation TCB= 10 min and 20 sec, IC=84,3%, KA= 8,03 srvc.ed., SF= 4,65%, SE=3.63 services.ed., FP= 0.44 services.ed.

The results of monitoring the condition of hemostasis method electrocochleography allowed to make a conclusion about the formation of a loose clot in a patient during the whole time of observation.

When used, the method allows for reliable prevention of thrombogenic complications in the early postoperative period in patients with high risk of thrombosis (age over 40 years, the original hypercoagulation, long and extended surgery) and completely eliminate the mortality in these patients in the early postoperative period from thrombogenic complications.

Spooky thrombogenic complications in postoperative patients including the introduction of anticoagulant, wherein the patient from the first day after surgery lasting more than 3 hours to enter therapy under the control of electrocochleography when the amplitude of the retraction and fibrinolysis less than 0.9. that is , the lifetime of a dense clot more than 2.1 min and the blood clotting time less than 6 minutes

2. The method according to p. 1, characterized in that therapy is administered subcutaneously.

 

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