Method of therapeutic plasmapheresis

FIELD: medicine.

SUBSTANCE: treatment of the patients with chronic heart disease and obliterating atherosclerosis of lower limb is ensured by a course of plasmapheresis consisting of 5-6 sessions every 3-5 days. Each session starts with introduction of 50-60 ml of physiologic saline and removal of 300 ml to 900-1200 ml of plasma prepared by centrifugation in a cold centrifuge at rotary speed 1500-1800 rpm and temperature +4 - + 6C within 15-20 minutes. Plasma is compensated with physiologic saline at the ratio 1:1. The course involves gradual increase of the volume of removed plasma starting with the minimal amount in the first session to the maximal amount to the middle and following decrease of this volume to minimum by the end. Total amount of removed plasma is 1-1.5 volumes of circulating plasma.

EFFECT: method allows administering out-patient continuous treatment of said group of the patients, including in case of resistance to drug therapy.

4 tbl, 2 ex

 

The invention relates to medicine, transfusion medicine, angiology and cardiovascular surgery and can be used for treatment plasmapheresis with coronary heart disease (CHD) and obliterating atherosclerosis of the lower extremities (OANC).

There is a method of therapeutic plasmapheresis, in which eksponirovannoi from the patient's blood is centrifuged in a system of plastic containers at t=22-23 for 18-20 minutes at a speed of 2000 rpm, thus obtained erythrochlamys diluted saline solution in a 2:1 ratio and injected intravenously inkjet and received during the last procedure erythrochlamys additionally irradiated with ultraviolet rays at a dose of 520-560 j/m2[EN 2220746 C2, 01.10.2004]. This method adopted by the authors for the prototype.

The disadvantage of the prototype is a high temperature selected for centrifugation, which can lead to hemolysis plasma and erythrocytes, as well as bolus injection of large volumes of data for plasmodesmata, from the point of view of the authors, the calculation of plasmodesmata 2:1 is for outpatient chronic patients excessive, may cause hypervolemia and lead to congestion in the small circle of blood circulation. Breeding received erythrocyte mass saline solution is unjustified, as may also the damage to the red blood cells and at too rapid introduction of saline solution into the package may cause hemolysis, and also once again disrupted the integrity of the container with the red blood cells, which increases the risk of infectious complications. The implementation of the method requires inpatient treatment. The method does not allow for the treatment of patients with a history of CHD and OINK, resistant to drug therapy, and are not designed for prolonged use in 5-10 years in outpatient treatment.

The technical result of the invention is to increase the efficiency of therapeutic plasmapheresis in patients with ischemic heart disease and OINK, resistant to drug therapy, and the possibility of its long-term use in outpatient treatment with a minimum of medication therapy.

This technical result is achieved by the fact that patients with CHD and OINK remove 1-1 .5 volume of circulating plasma (CGO) for the course of treatment consisting of 5-6 sessions with an interval of 3-5 days, while at the beginning of each session, the patient is injected 50-60 ml of physiological solution; remove session from 300 to 900-1200 ml plasma, gradually increasing the amount of plasma from a minimum at the first session to the maximum by the middle of the course with the subsequent reduction of this volume to the minimum by the end of the course; the plasma is obtained by centrifugation on a refrigerated centrifuge at a speed of 1500 -1800 rpm at a temperature of +4to+6C for 15-20 min, wasmes the tion produce a physiological solution at a ratio of 1:1.

Based on many years of experience in the management of chronic patients with CHD and OANK with the use of therapeutic plasma exchange in the proposed method revealed that these patients for a long period of time can be treated as outpatients by using this method, running courses at intervals of 4-12 months depending on the patient's condition.

This example 586 patients proved that within 5-10 years, such patients may be at a minimum of maintenance therapy. Thus, the dose used to stabilize the lipid metabolism of Liprimar was reduced twice, lipid profile in these patients remained within the normal range, no protein loss was not required compensation of donor plasma, was not required to conduct sedation before plasmapheresis. During the 5-year observation period no complications when using this method of plasmapheresis. During the observation the majority of patients, approximately 70%, was not required re-admission to hospital, and if patients received plasma exchange after previous reconstructive surgery was not required repeated surgical treatment, in patients with increased distance walk without pain (decreased intensity intermittent claudication), decreased shortness of breath, decreased casota occurrence of arrhythmic episodes, less frequent is the occurrence of angina.

It should be noted that for treatment using the proposed method have been selected patients resistant to medicamentous therapy, with initially high values of total cholesterol and its fractions, often with inherited hypercholesterolemia, as well as patients who have had previous surgery, to avoid re-operation. Some of the patients needed plasmapheresis due to intolerance of drugs for diseases of the liver and various polyallelic States.

The results of this research with clinical examples below confirm the achievement of the technical result of the invention in the implementation of all essential attributes.

Studies have shown that deleting therapeutic plasmapheresis less than 1 CGO (Patient F. 62 years of age with CHD and OANC) had no positive clinical effect was not reliable data about the improvement of microcirculation, has not been significant reduction in total cholesterol and low density lipoprotein (LDL). Deleting a course more than 1.5 CGO (Patient W. 40 years with CHD and OANC) was revealed hypoproteinemia, which required three plasmodesmata with donor plasma. It was also marked by a very rapid increase in total cholesterol and LDL from session to session, the e was obtained reliable data about the improvement of microcirculation during treatment.

Positive results were achieved with the removal of 1-1,5 CGO from course to course: there are surveillance up to 10 years. For example, in a patient So 49 years with CHD and OINK lipid levels remained stable, close to normal, and clinical condition of the patient did not require repeated surgical intervention.

When conducting predisposing training in more than 60 ml, namely 250 ml of saline, the patient A. 61 years with ischemic heart disease, previous heart attack in history and OINK had an unpleasant sensation in the chest, tachycardia, headache.

Research confirms that the introduction at the beginning of each session low doses of saline, namely 50-60 ml is optimal, well tolerated and is an essential characteristic of the proposed method.

When plasmodesmata 1:1.5 to the patient P. 56 years with coronary heart disease, myocardial infarction in anamnesis, OINK caused swelling of the lungs, which had to be cut short by the introduction of cardiac glycosides and diuretics. The patient's condition was unstable and had to be hospitalized in the hospital, while the remaining patients well tolerated the procedures are usually performed in outpatient their plasmodesmata 1:1.

Research has helped to identify the most optimal fence plasma from session to session. Essential for the study of pain who's turned out to be the volume of the collected plasma in the first procedure, namely, no more than 300 ml. So, the patient M 65 years with coronary heart disease and OINK when the first procedure took 450 ml of plasma, which resulted in a drop in blood pressure, grazianos, tachycardia, I had to stop jet physiological solution and solution Haemohes. For subsequent sessions of plasmapheresis in patients with such unpleasant hemodynamic phenomena did not occur. Further change in the amount of exfuze from session to session made gradually to avoid sudden changes in hemodynamics, which is very important for patients with ischemic heart disease.

Clinical researches have allowed to identify the optimal intervals between sessions of plasmapheresis. When the interval between sessions 2 days in a patient, 54 years of age with CHD and AANC has arisen phenomena gipoproteinemii that demanded compensation for expensive donor plasma, which is also undesirable due to the possibility of intrusion by various types of hepatitis and other infections transmitted by blood.

When the interval between sessions over 5 days 6-7 days a patient J. 42 years with CHD and OANK not there was a steady decrease in cholesterol and LDL, and no apparent improvement of microcirculation in peripheral tissues (toes), there was no pronounced positive effect of plasmapheresis procedures that have questioned their effectiveness.

In table 1,2 presents the parameters of microcirculation, confirming the effectiveness of plasma exchange offer by way of immediately after plasmapheresis, and in the remote period after 1 year and 5 years.

Table 1
PeriodThe parameters of microcirculation
Vas, cm/secVam, cm/secVakd, cm/secQam, ml/secRI, usledAVK, usled
before the session2,71330,761,56330,121,440,560,01190,00410,79670,0750,61330,071
after the session2,690,221,56330,191,52670,260,01220,00160,69670,03590.740,022

Table 2
Period The parameters of microcirculation
Vas, cm/secVam, cm/secVakd, cm/secQas, ml/secQam, ml/secRI, usledAVK, usled
1 year2,79540,78631,4260,54061,39690,54110,02190,00850,01160,00450,80,09550,61590,0987
5 years2,68450,82991,55150,33631,5340,46770,02110,00650,01180,00280,78580,09390,60060,0954

From table 1, 2 shows that, immediately after plasmapheresis parameters of microcirculation is improved, and over time (after 1 year through 5 years) practically does not change, which indicates the stabilization of the microcirculation in the treatment process.

Assessment of the microcirculation was produced using ultrasonic microvascular Doppler "minimax-Doppler To".

Estimated detected device blood flow speed characteristics: Vas-max system is aliaska speed along the curve of the average velocity, Vam - average speed along the curve of average speed, Vakd - end-diastolic velocity curve average speed; indicators of volumetric blood flow - Q or the average speed of the blood flow along the curve of average speed (ml/sec) and the peripheral resistance index (the index Pursel, reflecting the state of the resistance to blood flow distal to the measurement RI in conventional units RI=(Vs-Vd)/Vs,

where Vs- maximum systolic velocity curve maximum speed (envelope) in cm/sec;

Vd- end-diastolic velocity curve maximum speed in cm/sec.

As well as the indices of systolic blood pressure at the ankle and forearm determined during Doppler, with subsequent determination of the coefficient of Windsor (K)

AVK=TO=hell on the ankle/HELL on his forearm.

In table 3 presents indicators of atherosclerotic process in the long term.

Table 3
PeriodIndicators of atherosclerotic process
obsol., mmol/lLDL, usledHDL, mmol/l To haemoglobin, usled
1 year7,0518180,86921163,363648,8713021,829090,3675172,9954550,785791
5 years6,010,95159685,154551,8384781,3718180,5042983,9481820,870077

As can be seen from table 3, the levels of total cholesterol over time will degrade somewhat, i.e stabilize its growth, however, due to the progression ateroskleroticheskoe process increases the amount of LDL (low density lipoprotein) and decrease HDL (high density lipoprotein), which is To increase haemoglobin in both groups of patients. However, the growth of the haemoglobin is not as significant as in untreated group of patients,

In table 4 presents the performance of the atherosclerotic process directly after plasmapheresis.

Table 4
PeriodIndicators of atherosclerotic process
obsol., mmol/lLDL, usledTo haemoglobin, usled
Before the session6,8166670,576,256670,761,6366670,493,4366670,43
After the session6,090,5267,776670,851,480,453,0833330,56

As can be seen from table 4, the levels of total cholesterol, LDL, HDL and atherogenic immediately after plasmapheresis reduced.

The method is as follows.

After puncture of the cubital vein carry out short predisposing training in the volume of 50-60 ml of saline intravenous (IV) drip. Then provide exposio 500 ml of blood in plastic containers Gamecon 500/300" and after equilibration containers centrifuged last in the centrifuge RC-3BP at speeds 1500-1800 rpm at a temperature of +4 to +6C for 15-20 minutes. At this time, saline medlenno continues to flow to the patient via the cubital vein. The plasma was transferred to a small container (300 ml) using plasmacytoma PE-01. Remaining in big bags RBC mass injected to the patient/drip. The plasma loss refund at the end of proceduralization the solution at a ratio of 1:1. This is limited to the first session. Volume remote plasma for the first session does not exceed 300 ml During the second or third session, it is possible to re-exfuze blood in the same amount of pre-closing the plasma loss/infusion of saline at a rate of 1:1. The plasmapheresis performed after 3-5 days, at the rate of approximately 5-6 sessions, over the course of treatment it is necessary to remove not more than 1.5 CGO, but not less than 1 recipient.

In the course of treatment is monitored indicators red blood parameters of coagulation and lipid metabolism.

No heparinization or sedation when performing this procedure is not carried out. At the end of 3 to 6 sessions depending on the condition of the patient at the end of procedures to produce infusion reopoligliukina with answered and subsequent plasmodesmata rate of 1:1) include this amount. Between sessions, patients are at a minimum of maintenance therapy. Courses repeat every 6 months depending on the condition of the patient, sometimes with the deterioration of the earlier 4 months, with regular treatment can increase the interval between courses up to 8-12 months.

Clinical examples illustrating the inventive

Example 1. Patient G., 61 years with CHD and OINK. The course of treatment consisted of 5 sessions and what tervalon 3-4 days. Predictiona preparation before each session was 50-60 ml of physiological solution. For the first session removed 300 ml of plasma per second 600 ml, for the third - 900 ml, for the fourth - 600 ml and for the fifth - 300 ml-reimbursement saline 1:1. Over the entire course of treatment was removed 1 CGO. Plasma was obtained by centrifugation at refrigerated centrifuge at a speed of 1500 rpm and at a temperature of +4C for 20 minutes as a result of treatment decreased the frequency of angina attacks, increased distance walk without pain, normalized processes of microcirculation in the feet, decreased the content of total cholesterol in the blood and decreased haemoglobin rate.

Example 2. Patient O. 57 years with coronary heart disease, acute myocardial infarction in anamnesis and OINK. Treatment with plasmapheresis proposed method. Conducted 6 sessions at intervals of 3-5 days. Predictiona preparation amounted to 50-60 ml of physiological solution. For the first session was removed 300 ml of plasma per second 600 ml, for the third - 900 ml, for the fourth - 1200 ml, for the fifth - 900 ml, for the sixth - 300 ml filling with saline 1:1. During the course of treatment was removed 1,5 CGO. Plasma was obtained by using a centrifuge at a temperature of +6C, the rotation speed of 1800 rpm for 15 minutes as a result of treatment the patient improved ECG data, the patient stopped jalow is sterile on the nightly attacks of chest pain. Decreased intensity intermittent claudication, significantly improved circulation, decreased haemoglobin rate.

Compared with the known solutions, the proposed method can improve the efficacy of therapeutic plasma exchange in ambulatory patients with chronic diseases, has a strong detoxification and improves microcirculation, stabilizing lipid metabolism effect, allows plasmapheresis procedure in an outpatient procedure quite difficult group of patients, prolongs the lifetime without surgical treatment and improves their condition, if necessary, waiting operational berths, no complications with long-term use and with minimal medical therapy. And helps to reduce the cost of the procedure, the simplicity and accessibility of execution.

The method of therapeutic plasmapheresis, including exposio blood, centrifugation and recovery of plasma, characterized in that in patients with ischemic heart disease and atherosclerosis obliterans of the lower limbs removed 1-1 .5 volume of circulating plasma during the course of treatment consisting of 5-6 sessions with an interval of 3-5 days, while at the beginning of each session, the patient is injected 50-60 ml of physiological solution; remove session from 300 ml to 900-1200 ml plasma, the gradual is but increasing the volume of removed plasma from a minimum at the first session to the maximum by the middle of the course with the subsequent reduction of this volume to the minimum by the end of the course; plasma is obtained by centrifugation on a refrigerated centrifuge at a speed of 1500-1800 rpm at a temperature of +4 - +6C for 15-20 min, compensation produce a physiological solution at a ratio of 1:1.



 

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