Method for homeostatic disorder correction in children with hepatic hemangiomas

FIELD: medicine.

SUBSTANCE: invention relates to medicine, particularly to paediatrics, X-ray surgery, paediatric surgery, and concerns the hemostatic disorder correction in the children with hepatic hemangiomas. For this purpose, three days before the endovascular embolisation of the hepatic hemangioma, Protromplex 600 - a preparation of plasma factors II, VII, IX, X is administered intravenously in a dose of 20 IU/kg at max. 2 ml/min; on the first postoperative day, Protromplex is administered in the same dose, and further Fraxiparine is administered subcutaneously in a dose of 158 IU/kg of body weight for 3 days.

EFFECT: presented dose schedule of the preparations provides the effective and safe correction of hemostatic disorders in the children with hepatic hemangiomas due to normalising the internal and external mechanisms of blood coagulation and fibrinolysis.

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The invention relates to medicine, specifically to x-ray surgery, pediatric surgery, and can be used for the correction of disorders of hemostasis in endovascular operations for hemangiomas of the liver in children.

Liver disease lead to complex disorders of the hemostatic system while maintaining the fragile balance between coagulation and anticoagulation systems blood (Minov A.F., Zajko A.M., Rummo OO Violation of hemostasis in liver diseases. Journal of Transplantology and artificial organs. Volume XII, No. 2, 2010. S). Disorders of hemostasis, developing for hemangiomas of the liver, affect all its parts, including the system of fibrinolysis. There are four groups of disorders of hemostasis in liver pathology: decreased synthesis of coagulation factors; a decrease in the concentration factors at the expense of spending as a result of consumption coagulopathy; abnormal synthesis of clotting factors; quantitative and qualitative changes of platelets; reduction in the number of antiplasmin.

In recent years, endovascular surgery serves as an alternative to resection for the treatment of hemangiomas of the liver.

There is a method of rapid assessment of the functional state of the hemostatic system. The essence of the method lies in the fact that they measure electraprobe the ability of the blood by passing through it an alternating current with a frequency of 200 Hz, write electrocoagulator and determined by her timing and amplitude characteristics And the amplitude reduction of the functional curve, mV; T - time reduction of the amplitude functional curve to the minimum value in minutes. With a decrease or increase the value of the indicator A/T relative norms judge violations in the hemostatic system: when values of A/T, equal 3-5, assess the condition of hemostasis as the norm, when values of A/T less than 3 determine the hypocoagulation, and when values of A/T over 5 - hypercoagulation. (Patent RF №2413954).

The known correction method indicators of hemostasis through the use of ozonated physiological solution in which to obtain hypocoagulation effect use of ozone-oxygen gas mixture containing 800-2000 mg/l ozone. It is passed through a container with 200 ml of 0.9%sodium chloride solution for 10 min at a gas flow rate of 0.5-1 l/min is Administered intravenously, at a rate of 5-10 treatments. To accelerate the blood coagulation for local hemostasis using saline, treated with ozone-oxygen gas mixture with ozone 3500-5000 µg/L. Way, you can affect the performance of the hemostatic system. This increases the efficiency and safety of correction of the hemostatic system (Patent RF №2166949). The disadvantage is about the absence of any data on the system of hemostasis in patients with hemangiomas of the liver and its effective correction in pre - and postoperative period.

There is a method of correction of disorders of hemostasis with extensive operations on the organs typical for hepatic-pancreaticoduodenal area, including subcutaneous administration of fraxiparina dose of 0.3-0.6 ml, while the correction of disorders of hemostasis performed intraoperatively, and Fraxiparine enter through the 40-80 min from the start of operations in conjunction with intravenous drip of Mexidol, which is injected at a dose of 5-6 mg/kg of patient's weight, dissolved in 400 ml of 0.9%NaCl solution at 60 drops per minute (RF Patent No. 2279853).

The disadvantages of this method are the contraindications of Mexidol in the liver and kidneys. For hemangiomas of the liver develops reduced levels of prothrombin complex, platelet deficiency of inhibitors of coagulation and impaired fibrinolysis system, the proposed method has a very low degree of efficiency of correction of disorders of hemostasis, as it has, in fact, only antithrombotic effect in combination with the improvement of rheological properties of blood.

This method is chosen as a prototype.

The objective of the invention is to develop an efficient method for the correction of the hemostatic system in patients with hemangiomas of the liver.

The technical result is to increase the efficiency and safety way to adjust the parameters of the system of hemostasis.

The entity from whom retene is that 3 days before endovascular embolization of liver hemangiomas conduct preoperative correction of hemostasis, which prescribe the drug Protonix 600 at a dose of 20 IU/kg, administered intravenously at a rate not exceeding 2 ml/min on the first day after the operation again prescribed the drug Protonix 600 at a dose of 20 IU/kg, optionally, from the first day of the postoperative period, appoint subcutaneous administration of the drug Fraxiparine, dosage 158 IU/kg body weight for 3 days.

These assignments due to the fact that in the study in the preoperative period of hemostasis in children with hemangiomas of the liver were revealed in all its parts. Was identified chronometric hypocoagulation, due to decreased activity factors of the prothrombin complex. With changes both internal and external mechanism was not accompanied by a violation of the final stage of blood coagulation. In the study of platelet-vascular hemostasis was noted desegregation thrombocytopathies with endotheliosis and oppression inner path of fibrinolysis. All this contributed to the increasing trend to increased thrombosis. After endovascular embolization (occlusion) of hemangiomas of the liver revealed a deficiency of factors of internal and external mechanisms swerty the project for blood, namely-vitaminsvitamin factors (II, VII, IX, X, XII). In the study of platelet-vascular hemostasis was noted increased platelet activity and ADP-aggregation oppression inner path of fibrinolysis high endothelium and lower production of anti-thrombin III. These violations contribute to the emergence of processes macrothrombocytopenia. Thus, for a more predictable course of the disease, as well as favorable postoperative period was timely and appropriate correction of disorders of hemostasis, which was the purpose of the drug Protonix 600 for 3 days prior to endovascular embolization of liver hemangiomas, repeated use of the drug was carried out after endovascular embolization for 1 day postoperative period. In parallel with the first day of the postoperative period, was conducted therapy drug Fraxiparine in 3 days.

Protronix 600 is a complex of blood coagulation factors, which is based on replacing the missing factors (II, VII, IX and X), providing hemostatic and regenerating effect in patients with deficiency of these factors.

The method is as follows.

To increase prothrombin complex, preoperative correction of hemostasis start 3 days before PCI is embolizarii hemangioma of the liver. Preparation of a solution of the drug Protonix 600 carried out according to these instructions. The drug is injected slowly at a rate not exceeding 2 ml/min, at a dose of 20 IU/kg Repeated administration of the drug is carried out after endovascular embolization of liver hemangiomas at 1 day post-operative period in the same dosage.

In parallel, starting from 1 day post-operative period for 3 days, exercise therapy drug Fraxiparine by subcutaneous injection at a dosage 158 IU/kg of body weight. Correction of hemostatic disorders carried out under the control of hemostasis.

Clinical example of the method.

Boy P., 1 year 3 months. Diagnosis: multiple hemangioma of the right lobe of the liver. From the anamnesis it is known that during routine ultrasound of the abdomen revealed multiple lesions of the right lobe of the liver (cavernous hemangioma?) sizes from 10×15 mm to 30×50 mm In the preoperative period was carried out a number of instrumental diagnostic studies, including the study of hemostasis (all values are given relative to the normal indicators of hemostasis): in the coagulation hemostasis revealed reduction of the maximum clotting activity in autocompletion test (MA ACT) by 11%. Was lengthening of activated time the river is ecificatio (ABP) in 6.1 seconds, activated partial thromboplastin time (APTT) of 2.2 seconds. Thrombin and prothrombin time was increased by 1.8 seconds. Moderately decreased the number of fibrinogen to 2.7±0.16 g/l In the study with a snake venom ancistrodon test was extended by 3.4 seconds, compared with the control group and 30.7±0,21". In the study of platelet-vascular hemostasis platelet count compared with the control group was reduced to 231,2±10,15±109. The aggregation function of platelets with ADP increased by 3.0 seconds. In addition, the marked increase in the index of platelet activity to 26.5±0.2% and von Willebrand factor by 17.5%. In the study of fibrinolytic system showed increased XII-dependent fibrinolysis 2.3 minutes. When determining the primary physiological anticoagulants revealed a moderate decrease in activity of AT III to 97.4±1.3 percent. Defining markers of intravascular coagulation revealed an increase of orthophenanthroline test 2.3 times, while negative ethanol test.

To increase prothrombin complex, preoperative correction of hemostasis was performed with drug Protonix 600 for 3 days prior to endovascular embolization. The contents of the vial immediately before use was dissolved in 20 ml of sterile 0.9% sodium chloride solution. Obtained the solution should be transparent and should not contain suspended particles. If the drug does not require the definition of a group and rhesus toiletries recipient. The introduction of the drug was carried out intravenously, slowly at a rate not exceeding 2 ml/min, at a dose of 20 IU/kg After 3 days the patient was performed endovascular superselective embolization of hemangiomas of the right lobe of the liver PVA spheres and spirals of Gianturco. The patient's condition corresponded to the severity and volume of made of x-ray treatment. Complications were noted. At 1 day post-operative period was repeated introduction of the drug Protonix 600 as described above. On the same day was initiated concurrent therapy drug Fraxiparine. The drug in the dosage 158 IU/kg body weight was injected into the patient lying, subcutaneously, anterolateral or posterolateral surface of the abdomen. The needle was introduced perpendicularly into the pinched fold of skin formed between thumb and forefinger. The fold of skin supported during the entire period of drug administration. The drug Fraxiparine was injected as described above within 3 days of the postoperative period. At the end of therapy Fraxiparina follow-up study of indicators of hemostasis.

In the study of indicators of hemostasis on the 3rd day of polioviral the frame period revealed the following changes: a study of coagulation hemostasis showed a slight decrease of the maximum clotting activity in autocompletion test (MA ACT) by 1.5%. Was lengthening of activated time rekaltsifikatsii (ABP) 1.4 seconds, activated partial thromboplastin time (APTT) in 2.7 seconds. Revealed a slight increase in thrombin time by 0.6 seconds with normal prothrombin time in 16,1±0.4 sec. Moderately decreased the number of fibrinogen to 2.8±0,13 g/l In the study with a snake venom ancistrodon test is lengthened by 1 second compared with the control group and amounted to 28.3±0,52". In the study of platelet-vascular hemostasis platelet count compared with the control group were not significantly changed (271,2±10×109), does not change the index of platelet activity (24,4±0,4%). The aggregation function of platelets with ADP accelerated slightly (21,5±0,3"). However, there is an increase of von Willebrand factor of 13.8%. The study of the fibrinolytic system have revealed increasing XII-dependent fibrinolysis 2.4 minutes. When determining the primary physiological anticoagulants revealed a moderate decrease in activity of AT III to 97.4±1.3 percent. Defining markers of intravascular coagulation revealed increase of orthophenanthroline test at 1.1 times when negative ethanol test. In a satisfactory condition the child was discharged.

Thus, changes in the indicators in the hemostatic system 3 and the ducks postoperative period, after we conducted specific therapy, showed a positive dynamics of all indicators of hemostasis in comparison with the normal values. There had been a slight hypocoagulation while maintaining normal values of total activity of physiological anticoagulants with minor changes in the vascular and platelet-hemostasis.

The method allows to increase the efficiency and safety of correction of hemostasis disorders in children with hemangiomas of the liver.

The correction method of hemostasis disorders in children with hemangiomas of the liver, including subcutaneous administration of the drug antithrombotic activity, such as Fraxiparine, characterized in that 3 days before endovascular embolization of liver hemangiomas intravenously at a rate not exceeding 2 ml/min injected the drug plasma factors (II, VII, IX, X), blood clotting, such as Protronix 600 at a dose of 20 IU/kg on the first day after surgery, re-enter Protronix the same dosage, and advanced subcutaneously injected Fraxiparine in dosage 158 IU/kg body weight for 3 days.



 

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