Way to replenish blood loss

 

(57) Abstract:

The invention relates to medicine, surgery and intensive care, to a method of replacement of massive blood loss of any Genesis. Compensate for blood loss by the introduction of infusion solutions taking into account volemic coefficients of these solutions: erythrocyte mass with volemic factor of 0.8, fresh frozen plasma is 0.86, albumin - 1,47, glucose - 0.3, and at the same time supporting the difference between the absolute values of the colloid oncotic and srednekamennogo pressure of more than 0, the Central pressure at the level not more than 60 mm aq. Art. and the concentration of total protein at the level of 56 g/l and above; when the blood loss of more than 1 l of conduct artificial ventilation for at least 16 hours This invention contributes to the adequate replacement of blood loss by ensuring effective transcapillary exchange and restore oxygen transport function of erythrocytes. 1 C.p. f-crystals.

The invention relates to medicine, namely to resuscitation and surgery, and can be used to compensate for acute massive blood loss of any Genesis.

There is a method of filling acute massive blood loss, including the initial inspection is trality solutions used in high doses in excess of the estimated blood loss by 2-3 times, it is possible for a short time to restore the BCC. Colloidal blood substitutes (poliglyukin, reopoliglyukin, relational and others) is more effective in comparison with saline solutions, as more long-term circulating in the blood stream, restoring the BCC, Central venous pressure, stroke volume heart and blood pressure. In cases of hypovolemia concentrated (20-25%) albumin solution is contraindicated as it can cause interstitial and cellular dehydration, and in high doses may cause fluid overloading the cardiovascular system. You must comply with the best value solutions to meet the condition of the patient (control colloid oncotic pressure, the content of serum albumin is not less than 2.5 g %; no clinical signs of fluid overload) [1].

Closest to the present invention is a method of filling acute blood loss, which take into account the following parameters:

The ratio of heart rate and systolic blood pressure and index ratios determine the volume of circulating blood.

The duration and depth Anh CLASS="ptx2">

- Partial pressure of oxygen in artery in Vienna, arteriovenous difference in oxygen.

Control colloid oncotic pressure and jamming pressure in the pulmonary artery, and the difference between them should be not less than 4 mm RT. Art.

- Transfuziologiia tactics depending on the volume of blood loss.

- The adequacy of transfused fresh frozen plasma - achieving hemostasis or normalization of coagulation.

Filling acute massive blood loss consists of three phases:

Phase I - rehabilitation and maintenance of the BCC,

Phase II - restoration of the mass of circulating red blood cells to a level sufficient to provide the necessary oxygen consumption,

III phase - supplementation of coagulation factors (platelets, plasma factors).

The sequence of filling acute massive blood loss by known techniques:

1. Poured at a rate of 100 ml/min for 15-20 minutes 1.0 to 1.5 l of a solution of crystalloids to stabilize HELL.

2. Transfused erythrocytes universal donor (0(1) RH negative) or single-group. In another vein infusion of albumin and fresh frozen plasma (FFP) in the ratio of doses of erythrocytes begin the transfusion of donor platelets at a rate of 1:1, that is, each subsequent dose of RBCs transfused 1 unit of platelet concentrate.

4. For every 2 doses of RBCs and FFP at the speed of 1 dose within 10 minutes introduce 10 ml of 10% solution of calcium chloride (slowly).

When the diagnosis of metabolic acidosis transfusions of 4.2%, or 8.4% solution of sodium bicarbonate 300 - 150 ml, respectively.

In case of detection of oligouria on the background filled BCC prescribe small doses of dopamine 2 µg/kg of body weight per minute. Then pour eagleman containing mannitol. In the absence of diuresis shown plasmapheresis with exusia at least 1 l of plasma and filled NWS (up to hemodialysis) [2].

However, the known methods of filling acute massive blood loss have significant shortcomings, namely:

1. Do not define the full change of the colloid oncotic pressure of the blood, which leads to disruption of transcapillary exchange.

2. Do not evaluate the condition of transcapillary exchange, which does not allow to estimate the movement of fluid across sectors (the bloodstream, interstitial space).

3. Do not take into account volemic coefficients infusion-transfusion environments that can be CLASS="ptx2">

4. Do not take into account the violation of the processes of phosphorylation and timing recovery 2,3-diphosphoglycerate donor erythrocytes.

Based on the existing level of technology replenish acute massive blood loss and eliminate their disadvantages was raised issue: to improve the adequacy of replacement of blood loss by ensuring effective transcapillary exchange and restore oxygen transport function of erythrocytes.

The set task is solved using the following methods.

Fill in acute massive blood loss by measuring hemodynamic parameters, blood coagulation and Central venous pressure. New in the solution of the problem is that further define the transcapillary exchange and the introduction of infusion solutions retain the difference between the absolute values of the colloid oncotic and srednekamennogo pressure of more than 0, Central venous pressure at the level not more than 60 mm of water column. In addition, to determine the amount of insertion of infusion solutions take into account volemic coefficients of these solutions, using RBC mass, with volemic factor of 0.8, fresh frozen plasma is 0.86, alletra do artificial respiration for at least 16 hours.

Explain any significant distinguishing features of the proposed method.

Maintaining the difference of the absolute values of the colloid oncotic and srednekamennogo pressure of more than 0 is necessary to ensure the predominance of the processes of reabsorption (venous end of capillary) above the filtration processes (at the arterial end of capillary).

Additional definition of transcapillary exchange in the replacement of blood loss allows us to estimate the movement of fluid across sectors: vascular bed - interstitial space.

Maintain Central venous pressure at 60 mm of a water column provides adequate venous return to the heart and eliminates its preload.

Accounting volemic coefficients of fluids, in particular: erythrocyte mass 0,8; fresh frozen plasma 0,86; albumin 1,47; glucose 0,3, allows you to count and take into account the amount of liquid remaining in the bloodstream after infusion.

Maintaining the concentration of total protein at the level of 56 g/l and above provides normal transcapillary exchange and distribution of liquid across sectors: vascular bed - interstitial space.

the mandatory as the use of donor erythromyci accompanied by the introduction of microshadow in the microcirculation of the lungs and is accompanied by arteriovenous shunting of blood telecardiology in the lungs [3]. The red blood cells of donor blood has a decreased oxygen capacity at the expense of infringement processes phosphorylation, enzyme 2,3-diphosphoglycerate affects the process of dissociation of oxyhemoglobin, reducing the affinity of hemoglobin to oxygen and facilitating the release of the last in the tissues. The processes of phosphorylation in the donor erythrocytes recovered for 16-18 hours. Therefore, mechanical ventilation for at least 16 hours is required auxiliary measure to provide oxygen until there is a restoration of 2,3-diphosphoglycerate and lysis of microshadow in the microcirculation system.

Conducted patent research subclass a 61 M 5/00, and analysis of scientific and medical information that reflects the existing level of technology replenish blood loss did not reveal identical ways. Thus, the proposed method replenish blood loss is new.

The relationship and interaction of the essential techniques of the proposed method achieve the blood loss by ensuring effective transcapillary exchange and restore oxygen transport function of erythrocytes.

The proposed method replenish blood loss can be widely applied in medical practice, as it requires exceptional tools to use.

The essence of the proposed method replenish blood loss is as follows.

Initially assess the initial state of the patient based on the measurement of blood pressure, heart rate and heart rate, Central venous pressure and biochemical parameters of blood. Then calculate the colloid oncotic and srednekamennogo pressure and the difference between them is more than 0 evaluate the transcapillary exchange as effective. Infusion therapy, beginning with the introduction of 5-20% glucose solution with volemic ratio of 0.3. The adequacy of the replacement control measurement of blood pressure, heart rate, Central venous pressure and urine output. Amount of blood loss calculated by the index Alovera is the ratio of heart rate to systolic blood pressure.

1. If the index to 0.8, which corresponds to the loss of 15 percent of the blood volume (750 ml), using glucose solutions having volemic ratio of 0.3 in the amount of 60% of the volume of lost blood and fresh is 1, which corresponds to the loss of 30 percent of the circulating blood volume (1500 ml), the patient is administered a glucose solution having volemic ratio of 0.3 in the volume of 12-24% of the volume of blood loss, use of fresh frozen plasma, volemic coefficient of 0.86 in the number of 60-75% of the volume of blood loss, red blood cell mass, with volemic factor of 0.8, the number 30-26% of the volume of blood loss, 10% albumin, volemic ratio of 1.47 and prednisolone 10 mg/kg Infusion therapy is carried out in the same vein. Additionally, the patient carry out artificial ventilation for at least 16 hours.

3. When the index of 1.2, which corresponds to the loss of 40% of circulating blood volume (1500 ml), infusion therapy is carried out in two veins parallel with the introduction of erythrocyte mass with volemic 0.8 ratio in the number of 30-35% of the volume of blood loss. The second vein at the same time infusion of glucose with volemic ratio of 0.3, in the amount of 24% of the volume of blood loss and fresh frozen plasma with volemic coefficient of 0.86 in the amount of 75% of the volume of blood loss. Enter patient also prednisolone 15 mg/kg Additional patient hold the art who are by measuring blood pressure, pulse, which is retained within the original normal values, Central venous pressure, the value of which is retained within not more than 60 mm of a water column, the presence of diuresis in the amount not lower than 30 ml per hour and normal body temperature.

The essence of the proposed method is illustrated by a clinical example.

Patient M., age 19, weight 58 kg

Diagnosis: Cancer of the right lobe of the liver.

The scope of the operation - extended right hemihepatectomy (removal of 6 segments). Operation duration 3 hours 40 minutes, the amount of blood loss in the operating room - 2 litres 700 ml. of Diuresis on the operating table 300 ml.

Baseline:

Blood pressure (BP) 120/80 mm RT. Art.

Pulse, heart rate of 78 beats per minute.

Central venous pressure of 60 mm of water column.

Hemoglobin (Hb) 104 g/l

The number of erythrocytes 3,41012,

Hematocrit(NT) 0,38

Total protein 62 g/l

The indices of coagulation in normal clotting time of whole blood 3 min 40 sec

The original design parameters:

The average capillary pressure (ACS) 18.6 mm RT. article.

Colloid oncotic pressure (CODE) 24.0 mm RT. Art.


Fresh frozen plasma (FFP) 1200 ml, volemic factor of 0,86;

Albumin 10% 1000 ml, volemic coeff. 1,47;

The soda solution 4% 100 ml;

Glucose 13% 1200 ml, volemic ratio of 0.3.

The calculation of the required number of infusion media:

Amount of blood loss 2700 ml, Ht 0,38 consists of

cell volume 1026 ml,

the plasma volume 1674 ml.

Daily requirements 56 kg of patient weight was 2800 ml (50 ml x 56).

From 6 a.m. until the end of the operation (1/3 day) natural needs amounted to 930 ml (2800: 3).

Balance amounted 4400 ml, including:

930 ml daily needs to the end time of the operation,

300 ml of diuresis on the operating table,

300 ml of artificial ventilation of the lungs,

2700 ml blood loss during surgery,

200 ml perspirate.

The hemodynamics of the patient is stable, adequate diuresis, indicators of homeostasis during transfer to the ICU following:

Ht = 0,34

AD = 120/80 mm RT. Art.

CVP = 50 mm water Art.

PS - HR = 84 beats per min.

Total protein = 56 g/l

ACS (srednesibirskoe pressure) = 18,8 mm RT. Art.

TO THE

The clotting time of whole blood 3 min 10 sec

In connection acute massive blood loss and transfusion donor erythromyci the patient in the postoperative period, there was a ventilator in mode peep of 16 hours, after which it is translated into spontaneous breathing.

Filling acute massive blood loss this patient carried out adequately.

Thus, the Method of replacement of blood loss based on the principles of normalization of transcapillary exchange and the use of intravenous fluids with regard to their volemic factors can significantly reduce the total volume of infusion therapy, not to exceed the daily needs of the body and abnormal losses, while maintaining effective hemodynamics, adequate hourly diuresis and effective transcapillary exchange.

Sources of information

1. Rumyantsev A. G., Agranenko Century A. Clinical Transfusiology //M: GEOTAR MEDICINE. - 1997. - S. 100-101.

2. Gorodetsky C. M. Tactic of transfusion in acute blood loss. // The Hematology and Transfusiology. - 1994. - So 39. 3. - S. 25-28.

3. Usenko L. C., Shifrin, A. Intensive therapy for blood loss.// Kiev: Health. 1990. C. 8-22.

2. Way to replenish blood loss under item 1, characterized in that the blood loss of more than 1 l of conduct artificial ventilation for at least 16 hours

 

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