Method for treating pulmonary edema in patients with hyperhydration syndrome
FIELD: medicine, anesthesiology, resuscitation.
SUBSTANCE: one should perform puncturing of epidural space at Th12-L1 level. Through the lumen of puncture needle one should introduce catheter to move it cranially at the depth of 3 cm. After that one should inject 10 ml 05%-marcaine solution to perform repeated injections per 5.0 ml every 4 h during 1-8 d. The effect is achieved due to unloading minor cycle of circulation.
EFFECT: higher efficiency of therapy.
The invention relates to medicine, namely to anesthesiology and intensive care, the treatment of such kind of acute cardiovascular insufficiency, as pulmonary edema.
Treatment of acute pulmonary edema regardless of its origin is a difficult task, because it is not always possible to eliminate the cause.
Today one of the most effective ways of treatment of pulmonary edema syndrome overhydration are in vitro methods: acute hemodialysis and HDF.
The deficit and the price used for these purposes, equipment hinder the wide application of this treatment in clinical practice. It is not always possible to hold an emergency session of acute hemodialysis or ultrafiltration because of the risk of bleeding (extensive trauma, early post-operative period) or due to the load equipment.
As a prototype, the author offers a traditional medical method of treating pulmonary edema with diuretics and vasodilator (Zilber A.P. Respiratory failure. - A guide for physicians. - M.: Medicine, 1989. - 512 S.).
In the pathogenesis of pulmonary edema in patients with overload leading are two syndrome: hypertension and the syndrome hypervolemia. The use of drugs that reduce vascular tone, allows the medium of the expansion of blood vessels to increase the volume of the vascular bed and to Deposit excess amount of blood thereby to reduce the flow of blood into the lungs. The reduction of blood pressure to normal - or moderate hypotension observed with this, leads to the reduction of hydrostatic pressure in the capillary channel and reduce excessive filtration of fluid in the interstitium. For these purposes, the use of drugs of different pharmacological groups: ganglioblokatory (pentamin, arfonad, benzogeksony), the arteriolar vasodilator (nitroprusside sodium), venous vasodilator (nitroglycerin), neuroleptics (droperidol), narcotic analgesics (morphine, promedol). The use of diuretics allows you to remove excess fluid from the body and thus reduce the effects of overhydration.
Traditional medical therapy of pulmonary edema has several disadvantages:
1. The effect of all vasoactive drugs develops quickly “on the needle” and also ends quickly with decreasing speed of the introduction or cessation. Overdose of the drug may lead to severe hypotension or collapse. This circumstance requires precise dosing of vasodilator and “titration” of the input dose by matching the speed of its introduction into the vein.
2. Quickly enough patients developing tahifilaksiya to introduce drugs, and to achieve clinical effect have to increase their dose.
3. Each and is used in the treatment of pulmonary edema of vasodilator has his peculiar side effects: for ganglioblokatorov - this is a violation of the autonomic innervation of all internal organs, sodium nitroprusside - the risk of cyanide toxicity, narcotic analgesics and antipsychotics - respiratory depression.
4. The use of diuretics to remove excess fluid from the body may be ineffective in patients with compromised renal function and phenomena oligoanuria.
The author proposes a method for the treatment of pulmonary edema in patients with the syndrome of fluid overload. Since the main task of pathogenetic therapy of pulmonary edema is the unloading of a small circle of blood circulation by increasing the volume of the vascular bed and depositing the excess blood on the periphery, in the treatment of this syndrome is suggested to use high extended epidural blockade. The development of high sympathetic block to the level of Th5 with epidural blockade leads to severe vasodilation, decrease high blood pressure and depositing the excess volume of blood in the periphery. This goal is achieved by injection into the epidural space through a fixed catheter local anesthetic long-acting marcaine and achieve the level of sensory block to Th7 (sensor unit below sympathetic to 2 segments). Emerging in the area of the blockade-induced sympathectomy vascular causes vasodilation and pick up the and the periphery of the excess blood volume, which leads to the discharge of a small circle of blood circulation and relief of symptoms of pulmonary edema. Blockade of the sympathetic cardiac nerves eliminates tachycardia and thereby normalize heart rhythm. The effect of epidural blockade is extended by periodic introduction of marcaine.
The way extended epidural blockade is as follows.
Carefully processed the skin around the puncture and the hands of the anesthesiologist-resuscitator. Is the puncture of the epidural space of the patient is in sitting position at the level of Th12 - L1. For identification of the epidural space using the loss of resistance. Make sure the correct location of the puncture needle, through its lumen of the catheter. The catheter is pushed into the epidural space in the cranial direction to a depth of 3 see After which the puncture needle is carefully removed and the catheter is fitted along the spine and bring in the subclavian region, locking adhesive tape throughout. After catheterization of the epidural space type “test dose of local anesthetic (lidocaine 2% to 4.0 ml). Within 5 minutes of careful observation of patients to identify signs of spinal block. In the absence of data for the development of spinal anesthesia introduces the basic dose of marcaine. The author offers a 0.5% solution mark the ina as a local anesthetic, with the longest period (Mikhailov IB workbook for the physician in clinical pharmacology. A guide for physicians. - SPb.: Folio, 2001. - 736 C.). The initial dose was 10 ml with the development of epidural blockade in a patient, the normalization of hemodynamic parameters: reduces high blood pressure, disappears tachycardia, normal Central venous pressure (CVP). The effects of pulmonary edema are reduced. Re-introduction of marcaine implemented in 5.0 ml after 4 hours. The volume of injected anesthetic is determined by the parameters of Central hemodynamics (blood pressure drop to normal, eliminating tachycardia) and should be sufficient for the development of sensory blockade were below Th7. Daily dose of 0.5% solution of marcaine 30 ml. During extended epidural anesthesia in a patient are monitored constantly hemodynamic parameters (blood pressure, heart rate, CVP) and the saturation of hemoglobin with oxygen (Sa O2).
The advantages offered by the author of the method of treating pulmonary edema with respect to the prototype are:
1. The treatment is used only one drug marcain.
2. Marcain causes expansion of the vascular bed is not independently and indirectly due to sympathetic blockade over a large area, which is more physiological.
3. There is no need for constant Jn is usii drugs and constant control over the speed of his entry into the body, and therefore, less risk of overdose and the development of severe hypotension.
4. therapeutic effect of the author's proposed method edema pulmonary edema is persistent and continuous epidural block can be maintained at a desired level by periodic introduction of marcaine in a few days.
5. When pulmonary edema in patients with impaired renal function, when use of diuretics are ineffective, prolonged epidural blockade, eliminating the effects of pulmonary edema, allows you to buy time and wait for the physiological fluid losses through the skin and breath (an average of 1,000 ml/day). In addition, against the background of epidural blockade improves microcirculation of the kidney and increases their function.
6. On the background of epidural blockade and kupirovannom of pulmonary edema of a patient can be transported to a specialized medical institution for sessions of extracorporeal removal of fluids from the body.
Suggested by the way the author treated 7 patients with pulmonary edema and symptoms of overhydration. The age of patients ranged from 28 to 48 years.
Clinical example 1.
Sick So 28 years, medical card No. 25908 was admitted to the intensive care Department Bureau of the genus. home 02.11.03 with a diagnosis of post-partum period (birth, 01.11.03), late gestosis, after preeclampsia in childbirth, acute lavorel dachkova failure, pulmonary edema. Oliguria.
When entering a state of heavy, lethargic. Pale skin, acrocyanosis. Swelling of hands, legs. Shortness of breath - 26 min. HELL 170/120 mm Hg heart rate of 126 per minute. Auscultatory - light weight mixed moist rales. Sa O290% on the background of the inhalation of oxygen through a nasal catheter. Diuresis - 450 ml. blood - hypoproteinemia - 52 g/L.
Antihypertensive therapy: magnesium, ACE inhibitors, beta-blockers, the effect is not given. Control blood pressure was possible only with high doses of solution perlinganit. However, on the second day of applying perlinganit its effect began to weaken due to tahiphylacsii. Stimulation of diuresis by saluretics gave a slight effect - increased output of up to 900 ml/ day. Infusion therapy colloidal solutions: BSE, albumin, plasma, was limited by diuresis and the ongoing phenomena of acute left ventricular failure.
The patient is in the sitting position was made puncture and catheterization of the epidural space at the level of L1 - Th12. After the test dose (2% lidocaine 80 mg)in the epidural space is entered 10 ml of 0.5% solution of marcaine. Received touch the level of blockade to Th7 - Th6. After 20 minutes as the development of epidural blockade HELL decreased to 140/95 mm Hg, heart rate of 90 per minute. Rales in the lungs disappeared. The saturation of oxygen in silos up to 95% on the background of inhalation through the nasal catheters. Shortness of breath disappeared.
Epidural blockade increased diuresis, on a background of stimulation he rose to 3500 ml per day.
Due to severe preeclampsia and severe overload epidural blockade was carried out for 6 days until regressed phenomena of preeclampsia. During this time, the phenomenon of left ventricular failure were not recorded, the swelling disappeared, received adequate diuresis. Hemodynamics stabilized: HELL 130/80 mm Hg, heart rate of 80 per minute
Stay in the hospital was 8 days, after which the patient was transferred to the Nephrology Department, where was discharged 2 weeks later.
Clinical example 2.
Patient S., 48 years, medical card No. 9360, transferred from the intensive care unit of the Oncology center in the emergency Department Bureau of Tver with a diagnosis of lymphosarcoma of the stomach. Subtotal gastrectomy. Complications: acute destructive pancreatitis, peritonitis, acute liver, acute renal failure. Toxic encephalopathy, coma 9 points on a scale Glasgow.
Previously held the patient infusion-transfusion therapy: colloidal solutions (plasma, red blood cells, dextrans) in the background suddenly developed ARF led to severe overhydration and edema of the lungs. Hemodynamics (blood pressure 180/110 mm Hg, heart rate of 130 per minute Despite the transfer of a patient on a ventilator in which egime peep and the use of vasodilator, diuretics, pulmonary edema was not cropped. Auscultation: the light weight of the wet rales. The oxygen saturation was 85% at Fi O21,0. To make emergency extracorporeal removal of fluid was not possible due to the utilization equipment to conduct the session acute hemodialysis was possible only after 5 hours).
The patient in position on the side was made puncture and catheterization of the epidural space at the level of L1 - Th12. After the test dose (2% lidocaine 80 mg)in the epidural space is entered 10 ml of 0.5% solution of marcaine. After 20 minutes as the development of epidural blockade HELL decreased to 130/85 mm Hg, pulse rate is 88 / min. Rales in the lungs disappeared. The oxygen saturation increased to 95% at Fi O2to 0.5. After 6 hours the patient was held the first session of acute hemodialysis, which consolidated the results achieved thanks to the extracorporeal removal of 2 litres.
High epidural sympathetic blockade was performed to the patient within 8 days. On the background of sympathetic blockade hemodynamic parameters always remained stable. There was no hypertension and tachycardia. During this time the patient was conducted 4 sessions of hemodialysis. After 5 days the renal function has recovered.
Subsequently the patient underwent 4 rehabilitation operations regarding destructive pancreatitis and PE is iconica. The first 14 days of stay in the intensive care unit was conducted respiratory support apparatus “Crossvent-4”. Conducted infusion-transfusion therapy, antibiotic therapy, parenteral nutrition, detoxification, symptomatic therapy. Stay in the intensive care unit was 32 days, after which the patient was transferred to the Department of purulent surgery. Discharged therefrom with recovery within 18 days.
Treatment of pulmonary edema in patients with the syndrome of fluid overload, including vasodilatation and increased vascular bed, characterized in that patient, who is in a sitting position, handle the skin of the back in the area of the puncture at the level of h12 - L1, produce punctures the epidural space, through the lumen of the puncture needle catheter and advance it in a cranial direction to a depth of 3 cm, the needle is removed and the catheter is fitted along the spine and bring in the subclavian region, locking adhesive tape all over, after catheterization enter 4,0 ml of 2%lidocaine solution, followed by introduction the initial dose of 0.5% marcaine in a volume of 10 ml, and repeated in 5.0 ml after 4 h for 1 to 8 days.
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