Method for prevention of severe complications accompanying surgical management of massive and submassive blood loss with continuous haemorrhages

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely resuscitation and may be used for prevention of severe complications in surgical management of massive and submassive blood loss with continuous haemorrhages. That is ensured by the intraoperative intravenous drop-by-drop introduction of Perftoran 2-4 ml/kg following mechanical arrest of the continuous haemorrhages. With underlying restorable blood volume, higher body oxygenation with eliminated nitrogen oxide inhalation. Rheamberyn is introduced in an average therapeutic dose at the end of the operation and on the first three postoperative days.

EFFECT: invention provides higher effectiveness of infusion-transfusion management, improved clinical course of the operative and postoperative period, reduced percentage of complications and mortality.

2 ex

 

The present invention relates to the field of medicine, resuscitation, and can be used to increase the effectiveness of perioperative infusion-transfusion providing surgical treatment of massive blood loss with ongoing bleeding.

Despite the achievement of surgery, anesthesiology, intensive care Transfusiology, efficient provision of surgical treatment of acute and subacute hemorrhage with ongoing bleeding remains one of the most actual problems of modern medicine.

There are various ways to treat bleeding. So, there is a method of restoring circulating blood through the introduction of a medicinal product. As drug use lectin, which is injected intravenously and intramuscularly (see RF Patent 2066190, 1996, AV 35/55).

The known method transfusion of perftoran during surgery, the infusion was started after the introduction of the patient to the anesthesia and was carried out with a speed of 50-60 drops per minute (see Biryukov DL, Petrova M.V. possibility of optimization of the transport of oxygen by the application of emulsion perftoran in patients with surgical treatment of lung cancer. // Performancesee compounds in biology and medicine: scientific transactions., 2001. - C.116-119).

The disadvantage of this method is the gain does not remain blencogo bleeding and the appearance of increased bleeding tissue, especially in cases of weakening of the hemostatic system, for example due to excessive dilution of the blood with blood substitutes. When the transfusion of perftoran during surgery for General anesthesia using nitrous oxide is necessary to reduce the oxygen content in the inhaled gas mixture of 30% and below.

Closest to the claimed is a method of treatment of bleeding by introducing reamberine patients with gastroduodenal ulcer bleeding. In the course of conservative treatment patients underwent intensive therapy according to the severity of the condition and along with the standard therapy was performed infusion of Reamberine 1.5% in 400 ml 2 times a day during the whole period of stay in the intensive care unit. (Morgunov S. Application of reamberine intensive therapy of gastroduodenal bleeding. // Metod.rekom. - Izhevsk: IHM, 2006 - 10 seconds). However, increased tissue demands for oxygen (reduced shipping) leads to the breakdown of the energy circuits in the tissues and, ultimately, to complications such as weakness of the cardiac activity. Another disadvantage is the danger of using reamberine for correction of hypoxia in the conditions of decreased oxygen delivery to the tissues under such pathological conditions as pulmonary edema, respiratory distress syndrome of adults voznikayushie is as complications of massive blood loss.

The technical result of the proposed method is to increase the efficiency of infusion-transfusion support, improve current surgical and postoperative period, a lower rate of complications and mortality.

New to the achievement of the technical result is that during the operation to impose perftoran 2-4 ml/kg intravenous drip after mechanical stop ongoing bleeding on the background of the restoring circulating blood volume, high oxygenation of the body with the exception of inhalation of nitrous oxide. New is also that Reamberin pour in srednestatisticheskiy dose at the end of surgery and in the first three days after surgery.

The introduction of perftoran before infusion reamberine improves the delivery of oxygen to tissues that activates the metabolic action of reamberine and prevents the buildup of oxygen deficiency in the tissues caused by the activation of metabolic processes. The effects from the use of perftoran fully manifested when pouring the drug in small quantities. Achieved prior to the introduction of perftoran activation of the metabolic actions of reamberine allows you to restore the metabolism in the cells and prevent the development of fatal complications. While doing due to the fact that the period m is xymalos efficiency of perftoran is observed within 1 hour after infusion. The joint introduction of perftoran and reamberine will vzaimopoleznoe positive effects of drugs: antihypoxic, anti-oxidant, rheology, microcirculation, diuretic, detoxifying, repeatedly accelerating oxigenada and deoxyribose processes of the hemoglobin of red blood cells depending on the partial pressure of oxygen in the environment, activating the enzymatic processes of the Krebs cycle, improving respiration and detoxifying function of the liver, restoring the energy potential of the cells. The authors found that the inclusion of infusion of perftoran and reamberine in the program of infusion-transfusion ensure emergency operations during bleeding with massive blood loss and the carrying out of these infusions on the basis of the established principles improves the course of operative and post-operative periods and reduces the amount and intensity of needed treatment.

Comparative analysis of the prototype shows that the inventive method is characterized by the fact that during the operation to impose perftoran 2-4 ml/kg intravenous drip after mechanical stop ongoing bleeding on the background of the restoring circulating blood volume, high oxygenation of the body with the exception of inhalation of nitrous nitrogen, and Reamberin pour in srednestatisticheskiy dose at the end of operation is in the first three days after surgery, that meets the criterion of "novelty."

A new set of features improves the efficiency of infusion-transfusion support, improve current surgical and postoperative period, a lower rate of complications and mortality, reduction in the duration of hospital stay after surgery, reduce the dose of the drugs used, celebrated early postoperative activation of patients that meets the criterion of "industrial applicability".

The method is as follows.

After reaching the surgical hemostasis conduct replenishment of circulating blood volume, further correction of anemia, acute metabolic changes in the blood, the stabilization of the oncotic pressure of plasma, which provides the necessary oxygen transport to the tissues and transcapillary exchange. The main means of infusion-transfusion therapy are isotonic solution of sodium chloride and colloidal solutions (gelofusine, 6% solutions gidroksietilirovannogo starch - infocol BSE, reportan, voluven, dextrans) in the ratio 3:1. Part of transfused environments include inkjet-drip transfusion 2-3 doses melted fresh frozen plasma. To replenish the lost red blood cells are used donor erythrocytapheresis environment in the quantity required is ω for maintaining a chosen level of hemodilution (hematocrit in the range of 25-30%, hemoglobin 80-90 g/l). In case of hemodynamic inefficiency obamamobile therapy connect cardiotonic and vazopressornye intravenous therapy (dopamin, dopamine, adrenaline and others) in doses that provide the necessary stabilization of hemodynamics. In severe injuries using a single administration of large doses of glucocorticoids.

After creating giperwolemicescoy hemodilution, after a stop ongoing bleeding mechanically, with careful surgical hemostasis during surgery impose perftoran in a dose of 2-4 ml/kg intravenous infusion at a rate of 30 drops per minute after first running the tests for tolerance (reactogenicity) drug. Transfusion of perftoran during surgery and in the first day after the transfusion the patient provide high oxygenation, as is the ability of perftoran to carry oxygen is in direct linear dependence on the partial pressure of oxygen in the environment. It reaches enrichment in the inhaled oxygen to 70-85%for respiratory support by means of artificial ventilation of the lungs or through the nasal catheters. Transfusion of perftoran during surgery for General anesthesia do not use nitrous oxide, as its application is necessary to reduce retained the s of oxygen in the inhaled gas mixture of 30% and below. Maintaining adequate anesthesia intravenous reach fractional administration of fentanyl (4-5 µg/kg/h), calypsol (2 mg/kg/h), ardoin (0,02-0,04 mg/kg/h), diazepam (5-10 mg before induction of anaesthesia and at the final stage of the operation). Not later than one hour after infusion of perftoran poured Reamberin in the medium therapeutic dose of 400 ml with a speed of 4.0 to 4.5 ml/min on the background keep hypervolemia, stable hemodynamics and high oxygenation of the body. After surgery, daily for 3 days, poured in 400 ml of reamberine on the background of high oxygenation of the body.

The proposed method is illustrated by the following clinical examples.

Example 1. Patient I., 36 years old, weight 72 kg, entered the x/o Bachurski CRH 10.01.2008, 02.15 with a diagnosis of a Knife penetrating wound of the abdomen with damage to internal organs. Intra-abdominal bleeding, hemorrhagic shock II Art. From the anamnesis it is known that knife wound received about 4 hours ago in the village Harlan (60 km from CRH), examined by a nurse, after first aid car SMP delivered in CDH, during transport was carried out small-volume infusion therapy (R-R ringer - 400, sodium chloride 0,9% - 400). Heredity without features, comorbidities, no. At admission the patient's condition is extremely serious. Lethargic, drowsy. Leather is s integument pale, cold. The symptom of "white spots" more than 3 seconds In the epigastric region two wounds linear shape with a length up to 3 cm, from wounds scarce hemorrhagic discharge. In the lungs vesicular breathing, weak in the lower divisions, the number of 20 breaths per minute heart sounds muffled, rhythmic. Blood pressure is 80/40 mm Hg, pulse 120 beats per minute, on peripheral arteries is not defined. Abdomen, painful on palpation, the symptoms of peritoneal irritation positive. Produced catheterization upper Vena cava to the right, CVP - negative, continues infusion therapy. When catheterization of the bladder received a small amount of urine is straw-yellow color.

The General analysis of blood: Hb - 52 g/l, Ht - 17%, erythrocytes - 1,95·1012/l, leucocytes - 12,6·109/l, platelets - 112·109/l, total protein - to 54.4 g/l, AST - 63 u/l, ALT - 22 e/l In the study of hemostasis - prothrombin index 81%, fibrinogen - 2.5 g/l, coagulation time by Burker - 5 min 30 s, the rate of bleeding by Duque - 2 min 05 C.

"Shock index" - 1.5 (deficit BCC - 40%), which corresponds to the condition is extremely severe, the estimated blood volume by the method of F. Moore was 5040 ml (deficit BCC - 60%).

The patient urgently taken to the operating room. Under the General multicomponent anesthesia and artificial ventilation air produced verkhnesadinsky l is paroemia, revision of the abdominal cavity, suturing wounds of the right lobe of the liver and small intestine, sanitation and drainage of the abdominal cavity. During the operation of the abdomen removed 2.5 liters of blood, contaminated small bowel contents, clots up to 0.2 liters

Hemodynamics during surgery unstable, there was a decrease in a/D to 20/0, heart rate was not determined, was conducted inotropic support with dopamine at a dose of 5 ml/kg/min

After surgical hemostasis (suturing wounds of the liver) infusion-transfusion therapy was performed in the regime of moderate giperwolemicescoy hemodilution (sodium chloride 0.9% reportan 6%), against this background, transferred perftoran in the amount of 2.8 ml/kg, which helped stabilize the hemodynamics after 15 min from the start of the infusion (a/D - 125/80 mm Hg). At the final stage of the operation transferred to 400 ml of reamberine. Only during the operation transferred: erythrocyte mass - 550 ml, AW - 940 ml, reportan 6% - 1250 ml sodium chloride 0.9 per cent 1200 ml ringer's solution - 1000 ml, Global - 400 ml, Reamberin 1,5% - 400 ml, perftoran - 200 ml

Postoperative diagnosis: combined Penetrating stab wound of the abdomen, the wound in the right lobe of the liver, the loops of the small intestine. The ongoing massive intra-abdominal bleeding. Hemorrhagic shock III degree.

After surgery the patient within 8 hours was on prolongedopen the th AV. In the early postoperative period in a serious condition, stable hemodynamics And/D - 130/80 mm Hg, pulse 96 / min, good content.

Complete blood count: Hb - 72 g/l, Ht - 23%, erythrocytes - 2,15·1012/l, leucocytes - 10,6·109/l, platelets - 154·109/l, LII (Calf-Khalifa) - 2,1; GPI - 1,8 Wed; bilirubin - 10.6 µmol/l; AST - 48,4 u/l; ALT - 19.2 e/l; total protein decreased to 46.6 g/l; cholesterol - 3.1 mmol/l; urea - 4.9 mmol/l; creatinine - 59 µmol/l urine Output adequate to 70 ml/h without stimulation.

During the following days, the state with the positive dynamics, complications were noted, were conducted infusion-correcting therapy (in which shimmered Reamberin), symptomatic, antibacterial.

On the fourth day after surgery the patient is improving transferred to the Department of surgery. Discharged 14 days after surgery in satisfactory condition.

Example 2. Patient P., 42, weight 68 kg, was admitted to the surgical Department Bachurski CRH 15.02.2010, 13.15 clinic with gastrointestinal bleeding (vomiting coffee grounds, black stools, dizziness, weakness, morning, twice mentioned the collapse). Ulcer history is missing, considers himself ill with 12.02.2010, comorbidities not.

When you receive a state of heavy, lethargic, severe pallor with acrocyanosis, dizziness, weakness. Skin is arrowy pale, cold, wet. In the lungs vesicular breathing, number of breaths - 24 in minutes heart sounds deaf, pulse 120 per minute, rhythmic, weak filling, HELL 60/40 mm Hg blood: Hb - 46 g/l, Ht - 11.9%, erythrocytes is 1.48·1012/l, leucocytes - 19,2·109/l, platelets - 225·109/l, total protein of 45.4 g/l, AST - 43 u/l, ALT - 25 u/L. In the study of hemostasis - prothrombin index 95%, fibrinogen - 1,9 g/l, coagulation time by Burker - 5 min 00 sec, the rate of bleeding by Duque - 2 min 15 sec. "Shock index" - 2 (CBV deficit - more than 40%), which corresponds to the condition is extremely severe, the estimated blood volume by the method of F. Moore was 4420 ml (deficit BCC - 70%). On the background of respiratory support oxygen with FiO2- 0.3 to (via nasal catheter) conducted preoperative preparation (reportan 6% - 500 ml ringer's solution and 600 ml sodium chloride 0.9 per cent 600 ml). The patient was urgently operated. Operations: chronic ulcer of the anterior wall of the gastric body with the transition to the small curvature in the infiltrate, with penetration into the right lobe of the liver; blood in the lumen of the stomach, small and large intestines. After separation of the infiltrate in the gastric wall formed defect with a diameter of 2 cm with profuse bleeding vessel from the wall. Performed resection of the stomach. Hemodynamics during surgery unstable, until the pulse disappears and a/D, intr PNA support - dopamine at a dose of 8 µg/kg/min After ligation of the left gastric artery conducted infusion of perftoran - 200 ml (2,9 ml/kg)over 20 minutes from the start of infusion occurred stabilization of the a/D level 120/90 mm Hg, pulse rate was 108 beats per minute. At the final stage of the operation transferred to 400 ml of reamberine. During the operation transferred: red blood cells - 500 ml, AW - 840 ml, infocal 6% - 500 ml ringer's solution and 600 ml sodium chloride 0.9 per cent 1000 ml, perftoran - 200 ml, Reamberin - 400 ml.

After surgery the patient within 2 hours were on prolonged mechanical ventilation. In the early postoperative period in a serious condition, stable hemodynamics And/D - 130/80 mm Hg, pulse - 94 min, good filling. Complete blood count: Hb - 79 g/l, Ht - 25%, erythrocytes - 2,87·1012/l, leucocytes - 14,6·109/l, platelets - 121·109/l, LII (Calf-Khalifa) - 2,8; GPI - 2,1 u.ed; bilirubin - 7.4 µmol/l; AST - 36,4 u/l; ALT - 24,1 u/l; total protein decreased to 48.6 g/l; cholesterol - 2.1 mmol/l; urea - 5.6 mmol/l; creatinine - 48 µmol/l urine Output adequate to 70 ml/h without stimulation.

During the following days, the state with the positive dynamics was conducted infusion-correcting therapy, which included daily Reamberin in a dose of 400 ml, symptomatic, antibacterial therapy.

On the fourth day after surgery the patient is improving transferred to the Department of surgery. yesan for 12 hours after surgery in satisfactory condition.

The way to prevent serious complications in the surgical treatment of massive and submassive blood loss from continuing bleeding by introducing reamberine, characterized in that during the operation to impose perftoran 2-4 ml/kg intravenous drip after mechanical stop ongoing bleeding on the background of the restoring circulating blood volume, high oxygenation of the body with the exception of inhalation of nitrous oxide, and Reamberin injected into srednestatisticheskiy dose at the end of surgery and in the first three days after surgery.



 

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