Method of predicting massive intraoperative blood loss in operations on account of non-organ retroperitoneal tumours

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgery, anesthesiology and intensive therapy, oncology, and can be applied in operations on account of non-organ retroperitoneal tumours. For this purpose prognostic criteria are determined on the basis of clinical and anamnestic parameters: Long stands for longitudinal dimension of tumour, in cm; Transv stands for transverse dimension of tumour, in cm; Rad stands for radical character of operation: 1 point means presence of radical intervention; 0 points means absence, palliative surgery, exploratory laparotomy; AddRes means carrying out additional resection of organs: 1 point means presence of organ resection; 0 points means operation only on tumour ablation; PorS stands for surgery on main vessels: 1 point stands for vascular plasty of arteries, resection of fragments of inferior vena cava, aorta; DifG stands for diffusion growth of tumour without capsulation: 1 point means presence; 0 points means absence. After that, coefficient of regression Z is calculated: Z=-0.581+0.038×Long+0.02×Transv+0.073×Rad+0.166×AddRes+0.133×PorS+0.102×DifG and substituted into formula: P 1 = 1 1 + e ( 1,2 4,18 × Z ) where e is base of natural logarithm with value e=2.72. If P1 constitutes from 0.87 to 0.26, massive intraoperative blood loss, requiring increased dose of colloids, but not more than 40 ml/kg/day in carrying out infusion therapy, is predicted.

EFFECT: method makes it possible to select optimal tactics of compensation of intravascular volume of colloids in operations in said category of patients due to more accurate calculation of blood loss volume.

1 ex

 

The invention relates to medicine, namely to surgical treatment in Oncology and can be used in combined-extended associated with large operating trauma operations retroperitoneal recurrence non-organ tumors (the site, located between), massive cytolysis due to perform extensive lampadistis, massive intraoperative blood loss.

It is known that the specificity of the operations regarding recurrence non-organ retroperitoneal tumors, primarily combined-extended, connected with a large operating trauma, massive cytolysis due to perform extensive impedisce, massive intraoperative bleeding (Gorobets Y.S., S. p. Sviridov Problem of massive blood loss in surgery /Anesthesiology and critical care medicine 2001 No. 5. P.44-47).

At the same time, massive intraoperative blood loss can lead to such consequences as hypovolemic shock, acute DIC, hemodilutional coagulopathy syndrome systemic inflammatory response, acute respiratory distress syndrome, multiple organ failure.

In the situation when the amount of blood loss during the surgical treatment of the site, located between reaches 100% BCC and more, the threat of ice development and RDS-syndrome, multiple organ failure increases dramatically, a favorable outcome in such situations is largely determined by the adequacy and its what remainsto realamateurandtheirbulges events. Intraoperative complications of surgical intervention in patients with the site, located between, can be associated with injury to major vessels, bleeding from the venous plexus, injury hollow or solid organs.

It is known that to replenish intravascular volume when performing extensive surgical interventions use of synthetic colloids (lextran, gelatin, gidroxiatilkrahmal) or crystalloids (saline solutions, for example, a solution of ringer-lactate (Petrova M.V., Balikova N.A. Modern principles of bloodless surgery at planned apreciar in Oncology. Literature review / journal RNCR health Ministry. - 2010 No. 10).

During treatment of patients with modified gelatin us were not used due to their dose-dependent action on platelet hemostasis and existing recommendations to use modified gelatin only in the absence of abnormal hemostasis. Derivatives, dextrans have the most serious change in hemostasis, which does not allow them to recommend in large quantities.

In this regard, we used gidroxiatilkrahmal (BSE) (the average molecular mass of 130 kDa, degree of substitution of 0.4). Intraoperatively (after induction of anesthesia) and within 24 hours after surgery in the intensive care unit, patients received a 6% solution of the BSE and the solution of ringer-lactate for compensation for the Oia intravascular volume.

This was supported by Central venous pressure 8-12 mm Hg on average, patients received as a colloid 2910±360 ml of HES 130/0,4 and crystalloid - 2030±440 ml of ringer-lactate (250 ml/hour).

Known "Method of intensive therapy the site, located between patients who underwent surgery, acute massive blood loss" (Klimenkov A.A., Gubina GI recurrence non-organ retroperitoneal tumors: basic principles of diagnosis and surgical approach // Practical Oncology. - 2004 - V.5. No. 4 - S.285-290). In this category of patients included elderly patients with severe comorbidity. This method is chosen as a prototype. The method allows to define the General principles for the management of early paleodrainage period.

The complexity of the construction of infusion-transfusion therapy (ITT) is not only necessary to compensate for a deficiency of BCC, but in the quest to maintain adequate body fluid balance to avoid dangerous, especially for the early postoperative period, overhydration, contributing to the development of ARDS, heart failure, deepening hemodilutional coagulopathies until the development of DIC.

Still not perfect tactics replenish intravascular volume with extensive radical combined oncological operations. A separate task our the work was to develop a rational policy of refund of intravascular volume when you delete the site, located between patients.

The aim of the invention is the definition of massive blood loss and reimbursement of intravascular volume of the colloids in the operations at the site, located between patients. This objective is achieved in that the operated patients, where

Prod - longitudinal tumor size, cm;

Popper is the transverse size of tumor, cm;

Rad - radical nature of the operation;

1 point - the presence of radical intervention;

0 points - the lack of a palliative nature of the operation, trial laparotomy;

Depres - additional resection bodies;

1 point - the presence of resection bodies;

0 points - the operation to remove the tumor;

As a student of the intervention on the main vessels;

1 point - vascular plastic arteries resection of fragments of the inferior Vena cava, aorta;

Dir - diffuse tumor growth without encapsulation;

1 point is available;

0 points - no;

when predicting massive blood loss in patients with retroperitoneal recurrence non-organ tumors, calculate the regression coefficient Z:

Z=-0,581+0,038×Cont+0,02×Poper+0,073×Glad+0,166×Depres+Of 0.133×as a student+Is 0.102×Difr

substitute it into the formula:P1=11+e-(1,2-4,18×Z) ;

where e is the base of natural logarithm, has the value e=2,72;

when R1from 0,87 to 0.26 predict massive intraoperative blood loss, require when performing infusion therapy increased doses of colloids, but not more than 40 ml/kg/day.

The invention of "a Method for predicting a massive intraoperative blood loss during operations regarding recurrence non-organ retroperitoneal tumors is new, because it is unknown in the field of combined-extended operations delete the site, located between massive cytolysis due to perform extensive impedisce, massive intraoperative blood loss.

The novelty of the invention lies in the fact that during surgery and the first postoperative day the patients to fill BCC when conducting ITT instead of the standard volume infusion perform infusion of increasing doses of the colloids, but not more than 40 ml/kg/day.

The developed method allows to calculate the probability of heavy blood loss during surgery, which varies from 0 to 1. In excess of 0.6 (or 60%) predicted a high risk of blood loss that requires an increase in the infusion of colloids.

The claimed invention is industrially applicable as there may be many times repeated and used in the prediction of massive blood loss during operations about And What About and reproduced in various medical and scientific medical institutions.

A method for predicting a massive intraoperative blood loss during operations regarding recurrence non-organ retroperitoneal tumors is as follows:

To replenish intravascular volume when performing extensive surgical interventions use of synthetic colloids (dextrans, gelatin, gidroxiatilkrahmal) or crystalloids (saline solutions, for example, a solution of ringer-lactate) (Petrova M.V. et al., 2010). During treatment of patients with modified gelatin us were not used.

Using the methods of logistic regression and step-by-step selection, calculate the area under the curve sensitivity - specificity" by ROC-analysis of many factors were selected those that most effectively predicted the development of massive blood loss in patients with the site, located between operations. This step-by-step through the selection was added in one variable, evaluated the change prognostic significance of the entire model and factor weights of individual variables.

Factors in the model was the size of the tumor (longitudinal and transverse), the radical nature of the surgery, the need for additional resection of organs, intervention on the great vessels (inferior Vena cava, aorta, iliac vessels), diffuse tumor growth without limitation capsule.

A model is developed to define the probability of massive blood loss during surgery in patients with the site, located between (in percentage units) and introduction to replenish intravascular volume colloids not more than 40 ml/kg/day is as follows:

P1=11+e-(1,2-4,18×Z)

where e is the base of natural logarithm, has the value e=2,72; Z - factor regression.

The regression coefficient Z is calculated by the formula:

Z=-0,581+0,038×Pre+0,02×Poper+0,073×Glad+0,166×Depres+Of 0.133×as a student+Is 0.102×Difr

where Prod - longitudinal tumor size, defined in cm;

- Popper - the transverse size of the tumor, defined in cm;

- Glad - radical nature of the operation: 1 point - the presence of radical intervention, 0 points absence of a palliative nature of the operation, trial laparotomy);

- Dapres - additional resection of organs: 1 point - available 0 points - only operation to remove the tumor;

- As a student - intervention on the great vessels: 1 point - vascular plastic arteries resection of fragments of the inferior Vena cava, aorta;

- Dir - diffuse tumor growth without encapsulation: 1 point - available 0 points - no.

When predicting massive blood loss in patients with the site, located between rank above characteristics included in the model, calculate the z factor Then put it in the model and determine the probability of massive blood loss requiring p and organization ITT higher doses, colloids, but not more than 40 ml/kg/day.

For example, the patient M, 61, was diagnosed with primary leiomyosarcoma. Longitudinal tumor size was 25 cm, the transverse - 20 see When conducting a radical of the combined intervention were removed in addition to tumors of the kidney on the right, held atypical liver resection, bilateral ovarectomy. Tumor growth is diffuse without capsules.

First, let's calculate the ratio Z:

Z=-0,581+0,038*25+0,02*20+0,073*1+0,166*1+0,133*0+0,102*1=0,741

Then we substitute it into the formula

P1=11+e-(1,2-4,18×Z)

P1=0,87

Therefore, the probability of massive blood loss, requiring additional measures when conducting ITT high and equal to 0.87.

Another clinical example.

Patient K., 28 years old, was diagnosed with primary angiosarcoma. Longitudinal tumor size was 8 cm, transverse -7 see When conducting a radical intervention was removed except for the tumor of the right kidney. The growth of the tumor diffusely invasive with germination per capsule.

Calculate the coefficient

Z=-0,581+0,038*8+0,02*7+0,073*1+0,166*1+0,133*0+0,102*1=0,04

Then we substitute it into the formulaP/mi> 1=11+e-(1,2-4,18×Z)

P1=0,26

Therefore, the probability of massive blood loss low, equal 0,26, and only requires a standard ITT.

Technical and economic efficiency of the Method for predicting a massive intraoperative blood loss during operations regarding recurrence non-organ retroperitoneal tumors is that the ITT contributes to the fact that among patients with the site, located between was not observed phenomena of acute DIC, hypovolemic shock.

Extended ITT is an effective therapeutic measure to replace the volume of blood plasma during operations at the site, located between patients. Gidroxiatilkrahmal 130/0,4 at a dose close to the maximum, had little effect on hemostasis, which is an advantage in a situation of massive effects on the blood clotting system.

The developed model can be used to select patients who need advanced mode ITT.

A method for predicting a massive intraoperative blood loss during operations regarding recurrence non-organ retroperitoneal tumors, including identification of prognostic criteria based on clinical and historical figures, great for the decomposing those what have operated patients, where
- Prod - longitudinal tumor size, cm;
- Popper - the transverse size of tumor, cm;
- Glad - radical nature of the surgery:
1 point - the presence of radical intervention;
0 points - the lack of a palliative nature of the operation, trial laparotomy;
- Dapres - additional resection of agencies:
1 point - the presence of resected organs;
0 points - the operation to remove the tumor;
- As a student - intervention on the great vessels:
1 point - vascular plastic arteries resection of fragments of the inferior Vena cava, aorta;
- Dir - diffuse tumor growth without encapsulation:
1 point is available;
0 points - no;
when predicting massive blood loss in patients with retroperitoneal recurrence non-organ tumors, calculate the regression coefficient Z:
Z=-0,581+0,038·Cont+0,02·Poper+0,073·Rad+0,166·Depres+Of 0.133·as a student of+Is 0.102·Dir
substitute it into the formula:
P1=11+e-(1,2-4,18Z),
where e is the base of natural logarithm, has the value e=2,72;
P1from 0,87 to 0.26 predict massive intraoperative blood loss, require when performing infusion therapeuvery dose of colloids, but not more than 40 ml/kg/day.



 

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