How early therapy of gastrointestinal bleeding

 

(57) Abstract:

The invention relates to medicine, anesthesiology and intensive care and surgery and it can be used for early treatment of gastrointestinal bleeding. Administered drugs, such as Mildronate, dalargin, dicine and other 0.9% and 7.5% solution of sodium chloride, and drugs injected into the Central and peripheral vein in a certain sequence. This invention allows you to quickly restore blood volume (CBV) and to spend adequate etiopathogenetic treatment of gastrointestinal bleeding in the early stages.

The invention relates to medicine, namely to provide emergency medical care, anesthesiology and intensive care and surgery, can be used for early treatment of gastrointestinal bleeding.

Known early therapy of gastrointestinal bleeding prehospital (M. C. A., Miroshnichenko, A., a Guide for physicians ambulance. SPb.: Nevsky Dialect, 2001. - S. 281-284). The essence of therapy is the use of simple stretcher mode, the appointment of antacids and tromboticeskih tools inside, cold on the stomach; severe crooping therapy plazmozameschayuschie solutions first jet, and with the rise of systolic blood pressure above 80 mm RT. senior - drip, intravenous injection of 4 ml of 3% solution vikasola or 2 ml of dicynone (with profuse bleeding the contents of the first vial of dicynone injected slowly and simultaneously in 20 ml of isotonic sodium chloride solution, the second vial is added into the vial with plazmozameschayuschim solution to a drip) with the addition of inhibitors of fibrinogen (50-60 ml of 5% solution of aminocaproic acid inside).

According to some authors (Drapkin O. M., Gatsolaeva D. C., Goryacheva M. C. and others Ulcer duodenal ulcer complicated by perforation, bleeding // Russian journal of gastroenterology, Hepatology, Coloproctology. - 2000. No. 1. - S. 76-80) number of patients with peptic ulcer disease complicated by bleeding, for the last year increased by 3-4 times, and the existing standard therapy of gastrointestinal bleeding prehospital not always lead to a positive effect, because it does not account for disorders of microcirculation, and the volume of infusion therapy is focused on indices of Central hemodynamics. This can not affect the further course of pathological change is e, tactical and technical errors in the structure of mortality in acute surgical diseases of abdominal cavity organs: Information letter. - SPb., 2001. - 24 S.).

The task of the invention is to increase the effectiveness of early treatment of gastrointestinal bleeding.

The task reach due to the fact that the patient is additionally administered a 7.5% solution of sodium chloride, dalargin or Mildronate, contrical (gordox), heparin, ascorbic acid, vitamin B6, Riboxin, first in the Central veins of 7.5% sodium chloride 200-300 ml, dalargin 0,001-0,003 g or systolic blood pressure below 90 mm RT. senior - Mildronate 10%-5-6 ml, then under the control of the Central venous pressure injected with 0.9% sodium chloride 400-800 ml dicinorum 4-8 ml 5% glucose solution 400-800 ml insulin 6-12 UNITS and potassium chloride 4% solution - 20-30 ml, calcium chloride 10% solution of 8-10 ml magnesium sulfate 25% solution of 4-6 ml of 0.9% sodium chloride 400-800 ml contrical (gordochom) 20-40 thousand UNITS, infocol 500-800 ml, odnogroupna plasma 600-800 ml, heparin 3000-4000 IU intravenous bolus of 0.9% solution of sodium chloride (20 ml, and then injected into a peripheral vein ascorbic acid 5% - 4-6 ml in the Yes 10 ml, vitamin B61-2 ml intravenous bolus of 20 ml of 0.9% solution of sodium chloride, simultaneously intramuscularly injected vikasol 1% solution of 4-6 ml, in a Central vein continue the introduction of a 20% glucose solution 300-400 ml insulin 20-26 UNITS that are single-group blood transfusion of erythrocyte mass 400-600 ml, with unstable hemodynamics continue intravenous 0.9% sodium chloride solution with infusion of dopamine 5-10 mg/kg/min, and after stabilization of hemodynamic parameters, correction of volume of circulating blood dalargin administered intramuscularly in a dose of 0.001-0.003 to 2 times a day, or the patient Mildronate 5-6 ml of 10% solution intravenously to 15 ml of 0.9% sodium chloride 1 times a day for 10-14 days and pentamin 5% solution of 0.3-0.5 ml intramuscularly 3 times a day for 3-5 days.

The method is as follows.

The patient with gastrointestinal bleeding into the Central vein injected with 7.5% sodium chloride 200-300 ml, dalargin 0,001-0,003 g or systolic blood pressure below 90 mm RT. senior - Mildronate 10% - 5-6 ml, then under the control of the Central venous pressure injected with 0.9% sodium chloride 400 - 800 ml dicinorum 4-8 ml 5% glucose solution 400-800 ml insulin 6-12 UNITS and chlorite is sodium chloride 400-800 ml contrical (gordochom) 20-40 thousand UNITS, infocol 500-800 ml, single-group plasma 600-800 ml, heparin 3000-4000 IU intravenous bolus of 0.9% sodium chloride 20 ml, and then injected into a peripheral vein ascorbic acid 5% - 4-6 ml intravenous bolus of 40% glucose solution 15 ml, Riboxin 8-10 ml intravenous bolus of 0.9% sodium chloride 10 ml, vitamin B61-2 ml intravenous bolus of 20 ml of 0.9% solution of sodium chloride, simultaneously intramuscularly injected vikasol 1% solution of 4-6 ml, in a Central vein continue the introduction of a 20% glucose solution 300-400 ml insulin 20-26 UNITS that are single-group blood transfusion of erythrocyte mass 400-600 ml, with unstable hemodynamics continue intravenous 0.9% sodium chloride solution with infusion of dopamine 5-10 mg/kg/min, and after stabilization of hemodynamic parameters, correction of volume of circulating blood dalargin administered intramuscularly in a dose of 0.001-0.003 to 2 times a day, or the patient Mildronate 5-6 ml of 10% solution intravenously to 15 ml of 0.9% sodium chloride 1 times a day for 10-14 days and pentamin 5% solution in 3-5 days.

The use of a 7.5% solution of sodium chloride allows faster to compensate for the loss of extracellular fluid, thus the smaller infusion likvidirovat is of dalargin allows to normalize microcirculation and lymph flow in the damage zone, reduces the secretion of hydrochloric acid, prevents the development of degenerative and atrophic changes in the mucosa of the gastrointestinal tract, accelerates the regeneration, induces sedative and analgesic effect.

Introduction mildronata improves metabolic processes, due to the stimulation charitynavigator of fatty acid metabolism and activation of glucose metabolism, regulation of cellular immunity. Mildronate corrects organ disorders in ischemic conditions and adrenergic effects, has a cardioprotective effect.

Contrical (gordox) allows to reduce the activity of proteolytic enzymes, the increase which occurs when many critical States

Blood loss in the first hours there is an increase in coagulation properties of blood, heparin, introduced in this period, allows to normalize the coagulation system also has an immunosuppressive effect and improves coronary blood flow.

The use of ascorbic acid allows you to adjust the oxidation-vostanovlenie processes, carbohydrate metabolism, clotting of the blood, promotes tissue regeneration, normalization of permeability is oxen, as a precursor to adenosine triphosphate, regulates carbohydrate metabolism, stimulates the synthesis of nucleotides, has antihypoxic effect, increases the energy balance of a myocardium, improves coronary blood flow.

The use of blood loss as infusion therapy crystalloid solutions allows you to quickly compensate for the loss of interstitial fluid, in combination with blood transfusions has a good effect in this pathology (Malyshev Century of Intensive therapy. Reanimation. First aid. - M.: Medicine, 2000. - S. 197-198), avoids many of the complications caused by the introduction of a large volume of colloidal solutions (Likhachev E. A., yanchyn Y. M. Treatment of traumatic and hemorrhagic shock in the prehospital hypertonic solution of sodium chloride // Actual problems of emergency medical care for urgent conditions and prospects of their development. Collection of scientific papers. I part. - Novokuznetsk, 1994. - S. 68-72).

Pentamin improves peripheral circulation, oxygenation of tissues, improves metabolic processes in tissues by influencing the trophic function of the nervous system, in small doses does not cause hypotension, oblad is ARSC, 1999. - S. 38-56).

Clinical example 1. Patient B., aged 40, was examined by the emergency room physician to resolve further tactics. At the time of inspection of patient contact, adequate. Clear consciousness. Pale skin, a symptom of pale spots = 1 C. vesicular Breathing, wheezing no, NPV - 20 per minute. Heart tones are clear, rhythmic, pulse, sufficient filling. Heart rate is 110 beats/min, BP - 100/60 mm RT. Art., SaO2- 94%, shock index (SHI) is 1.1. The patient complains of nausea, repeated vomiting mixed with dark blood, weakness, dizziness. Peptic ulcer disease is not noted. Prehospital patient was introduced to 200.0 ml of a 7.5% solution of sodium chloride, dalargin 0,001 intravenous bolus of 20 ml of 0.9% solution of sodium chloride. After injection the patient noted improvement. Objectively: the skin is pink, normal humidity. Symptom pale spots <1 C. heart rate of 98 beats/min, BP is 140/80 mm RT. Art., SaO2- 99%, CHI - 0,7, NPV - 18 per minute. Repeated vomiting was not observed. In hospital at endoscopic examination found 2 linear gap in the field of cardia of stomach bleeding Forrest 2B. At the hospital stage the patient received fluid resuscitation with 0.9% solution of sodium is the PR of calcium chloride 8 ml, 25% solution of magnesium sulfate 4 ml of 0.9% solution of sodium chloride (400 ml contrical 20 thousand UNITS. Intravenous bolus the patient was administered ascorbic acid 5% 4 ml 20 ml 40% glucose solution, Riboxin 9 ml intravenous bolus of 10 ml of 0.9% solution of sodium chloride, vitamin b61 ml intravenous bolus of 20 ml of 0.9% solution of sodium chloride, was intramuscularly injected vikasol 1% solution of 4.0 ml Within 10 days the patient received dalargin 0.001 g intramuscularly 2 times a day, pentamin 0.5 ml of 5% solution intramuscularly 3 times a day for 3 days. When observed in the dynamics of re-bleeding was not observed, the patient was operated after the stabilization, correction posthemorrhagic anemia. The postoperative period was uneventful, the patient was discharged from hospital in satisfactory condition for 12 hours.

Clinical example 2. Patient C., 53 years old, when viewed from the emergency doctor complained of repeated vomiting dark blood, severe weakness, dizziness. During the inspection: a serious condition, consciousness - stun 1-2 degrees, the skin pale, cool, acrocyanosis, wet. Symptom pale spots = 2 C. vesicular Breathing, wheezing no. NPV - 22 min. Heart tones are the od Art. The abdomen is soft, sensitive in the epigastric region. At the stage of ambulance patient entered into the Central vein of 250 ml of 7.5% sodium chloride/drip, 5 ml of 10% solution mildronata/jet 15 ml of 0.9% solution of sodium chloride. Then therapy was continued with the introduction of 0.9% solution of sodium chloride (400 ml) and 5% glucose solution 200 ml After administration of a hypertonic solution of sodium chloride and mildronata the patient noted improvement objectively: the skin is pink, moist, symptom pale spots = 1 C. AD - 110/60 mm RT. Art., heart rate 100 beats/min, SaO2- 98%, CHI - 0,9, CVP 30 mm of water. Art., NPV - 20 per minute. At the stationary phase at endoscopic examination detected gap mucosa of the gastric cardia, stopped the bleeding Forrest 2B. Therapy continued for introduction into the Central vein 200 ml of 0.9% solution of sodium chloride with dicinorum 5.0 ml, 600 ml of 5% glucose solution with 9 UNITS of insulin, 25 ml of 4% solution of potassium chloride, 9 ml of 10% solution of calcium chloride, 5 ml of 25% solution of magnesium sulfate, 600 ml of 0.9% solution of sodium chloride with contrical 30 thousand UNITS, infocol 500 ml, single-group plasma 600 ml heparin 3000 IU intravenous bolus of 0.9% sodium chloride 20 ml, then in a peripheral vein was injected ascorbic who e sodium chloride solution, 10 ml, vitamin B61.5 ml intravenous bolus of 20 ml of 0.9% solution of sodium chloride, intramuscularly injected vikasol 1% solution of 4 ml, in a Central vein continued the introduction of a 20% glucose solution 300 ml insulin, 20 UNITS were single-group blood transfusion of erythrocyte mass 400 ml.

After stabilization of hemodynamic parameters, correction BCC patient received Mildronate 5 ml of 10% solution intravenously to 15 ml of 0.9% sodium chloride 1 time a day for 10 days and pentamin 5% solution of 0.4 ml for 4 days.

Repeated episodes of bleeding were observed, after 11 days the patient was discharged in satisfactory condition.

Clinical example 3. Patient G., 66, at the time of inspection by the emergency physician in contact almost does not enter. Near the bed of a sick dark vomit. A serious condition, consciousness is disturbed by type spoor. Pale skin, cyanosis, dry, cold, symptom pale spots >3 C. In the lungs, the breath is held, all fields, hard, no wheezing. NPV 22 per minute. Heart tones are deaf, single extrasystoles, pulse on peripheral arteries is not defined. HELL 60/30 mm RT. senior HR 122 BPM, SaO2- 88%, CHI - 2,03. CVP negative. Phase ambulance ATA/jet 15 ml of 0.9% solution of sodium chloride. Then the treatment was continued by the introduction of crystalloid solutions were placed in 0.9% sodium chloride solution, 400 ml of 5% glucose solution 400 ml connectivity inotropic stimulation in a dose dopamine 5 mcg/kg/min At the time of admission of the patient to the hospital objectively: the skin is pale pink, the symptom pale spots = 1, BP - 90/60 mm RT. Art., heart rate 110 beats/min, SaO2- 97%, CHI - 1,2, NPV - 20 per minute, CVP 10 mm RT. Art. In the hospital during endoscopic examination revealed 2 stomach ulcers, bleeding Forrest 2A. Therapy was continued by introduction into the Central vein under the control of the CVP 0.9% solution of sodium chloride (400 ml dicinorum 6,0 ml 5% glucose solution (800 ml) with insulin 12 UNITS and potassium chloride 4% solution 30 ml, calcium chloride 10% solution - 10 ml magnesium sulfate 25% solution of 6 ml of 0.9% solution of sodium chloride (800 ml) with contrical 40 thousand UNITS, infocol 800 ml, odnogroupna plasma 800 ml heparin 4000 IU intravenous bolus of 0.9% sodium chloride 20 ml, then in a peripheral vein was injected ascorbic acid 5% - 6 ml intravenous bolus of 40% glucose solution 15 ml, vitamin62 ml intravenous bolus of 20 ml of 0.9% solution of sodium chloride, was intramuscularly injected vikasol 1% solution 5 ml, in a Central vein continued introduction of 20% Rastoke stabilize hemodynamic parameters, correction BCC patient received Mildronate 6 ml of 10% solution intravenously to 15 ml of 0.9% sodium chloride 1 time a day for 14 days and pentamin 5% solution of 0.3 ml for 5 days.

After the stabilization, after 2 days the patient was operated. The postoperative course was uneventful. Episodes of re-bleeding was not observed. After 18 days the patient was discharged in satisfactory condition.

Creating a schema of early therapy of gastrointestinal bleeding can improve the effectiveness of treatment in these patients and prevent further complications.

How early therapy of gastrointestinal bleeding by introducing a 0.9% solution of sodium chloride, 5% glucose with insulin, potassium chloride, calcium chloride, magnesium sulfate, dicynone, infacol, plasma, erythrocyte mass odnogroupna blood, vikasola, 20% glucose solution with insulin, holding inotropic stimulation, wherein the patient is additionally administered a 7.5% solution of sodium chloride, dalargin or Mildronate, contrical (gordox), heparin, ascorbic acid, vitamin b6, Riboxin, pentamin, and infusion therapy about sodium chloride 200-300 ml, dalargin 0,001-0,003 g or systolic blood pressure below 90 mm RT.article - Mildronate 10% 5-6 ml, then under the control of the Central venous pressure injected with 0.9% solution of sodium chloride 400-800 ml dicinorum 4-8 ml 5% glucose solution 400-800 ml insulin 10-12 UNITS and potassium chloride 4% aqueous solution of 20-30 ml, calcium chloride 10% solution of 8-10 ml magnesium sulfate 25% aqueous solution of 4-6 ml of 0.9% solution of sodium chloride 400-800 ml contrical (gordochom) 20-40 thousand UNITS, infocol 500-800 ml, odnogroupna plasma 600-800 ml, heparin 3000-4000 IU intravenous bolus of 0.9% sodium chloride solution 20 ml, and then injected into a peripheral vein ascorbic acid 5% 4-6 ml intravenous bolus of 40% glucose solution, Riboxin 8-10 ml intravenous bolus of 0.9% sodium chloride 10 ml, vitamin b61-2 ml intravenous bolus of 20 ml of 0.9% solution of sodium chloride, simultaneously intramuscularly injected vikasol 1% solution of 4-6 ml, in a Central vein continue the introduction of a 20% glucose solution 300-400 ml insulin 20-26 UNITS, carry out a blood transfusion odnogroupna erythrocyte mass 400-600 ml, with unstable hemodynamics continue intravenous administration of 0.9% sodium chloride solution with infusion of dopamine 5-10 mg/kg/min, and nutramigen 0,001-0,003 2 times a day, either the patient Mildronate 5-6 ml of 10% solution intravenously to 15 ml of 0.9% sodium chloride 1 times a day for 10-14 days and pentamin 5% solution of 0.3-0.5 ml intramuscularly 3 times a day for 3-5 days.

 

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