RU1796193C - Method for treatment acute hepatic-renal insufficiency - Google Patents

Abstract

The invention relates to medicine, in particular intensive care and resuscitation, and can be used to treat acute hepatic-renal failure. The purpose of the invention is to reduce mortality. The goal is achieved by additionally irradiating with UV rays 200-300 ml of exfused blood for 10-12 minutes at a rate of 20-25 ml / min, followed by reinfusion to the patient. The method reduces mortality from 80 to 36%.

Description

The invention relates to medicine, in particular to intensive care and resuscitation, and can be used to treat acute hepatic-renal failure (ARF).

It is known that the development of OPPN is accompanied by the accumulation of ammonia in the blood (1, 2, 3, 4) as a result of a violation of its inclusion in the urea cycle in a pathologically altered liver, a violation of its excretion from the body in the form of ammonium salts through the kidneys, and also as a result increased ammonia formation due to the accumulation of protein breakdown products in the intestinal lumen. The toxicity of ammonia is well understood. First of all, ammonia is considered cerebral g due to its intrusion into the energy metabolism of the brain: ammonia disrupts the normal path of the Krebs cycle, which leads to severe defects in energy metabolism. This is a decrease in the level of synthesis of energy phosphates (ATP), accompanied by a decrease in oxygen consumption by the tissue (ATP), and a decrease in the consumption of

oxygen by brain tissue, as well as a decrease in cerebral blood flow and a decrease in glucose consumption. Clinically, this is the development of severe toxic (metabolic) encephalopathy: confusion, stupor, coma, inadequate behavior, and sleep inversion. In addition, increased levels of ammonia in the blood are a harbinger of coma. Some authors believe that the depth of coma correlates with the concentration of ammonia in the blood (1, 2, 3, 4). Therefore, in the treatment of this pathology, it is extremely important to remove ammonia from the blood.

A known method of reducing the concentration of ammonia in the blood by intravenous or intraportal administration of glutamic acid, alpha arginine, L-block acid. Ammonia binds to one of the carboxyl groups of glutamic and aspartic acids to form non-toxic glutamine and asparagine.

However, this method has disadvantages. The administration of glutamic acid and other ammonia-binding drugs is a symptomatic treatment, so

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as a binding of ammonia in the blood, these drugs are not able to prevent the formation of ammonia in pathologically altered liver and kidneys. Therefore, the introduction of glutamic acid, alpha-arginine, L-block acid causes a temporary and insignificant decrease in ammonia in the blood. Moreover, the rate of ammonia binding is very small, which necessitates the long-term administration of these drugs and their large amount: for example, 1% glutamic acid. For 7-10 days at a dose of 4-5 mg / kg, in addition, the introduction of glutamic acid may cause side effects such as nausea, dizziness, vomiting, redness of the face, sweating, chills, itching of the skin, decreased pressure.

These deficiencies have been partially eliminated in the method of treating OPNP by extracorporeal hemosorption (ECGS), which we adopted as a prototype. According to the prototype method, central venous vessels, for example, femoral or subclavian veins, are punctured with patients with OPPN, 400-500 units of heparin are administered. SCCO KAU, SKN-2K, SKN-4M .. During ECGS, the concentration of ammonia in the blood decreases as a result of sorption of ammonia molecules on the sorbent.

The disadvantages of the prototype method are, first of all, the presence of complications during ECG in critically ill patients. This is due to the fact that OPPN in critical conditions is accompanied by severe hemodynamic disorders: decreased stroke volume (UO), cardiac output (MOS), decreased stroke index (UI), cardiac index (SI), and high peripheral resistance (OD .C), as well as decreasing central venous pressure (CVP). Moreover, the connection of the third - extracorporal circle of blood circulation can lead to collapse and even to the development of uncontrolled hypotension. Along with this, the course of AKI is accompanied by tissue hyperhydration and, in particular, cerebral edema. Therefore, hemodilution accompanying ECGS can lead to increased cerebral edema and impaired vital functions. In addition, heparinization, necessary for ECG, can increase bleeding that accompanies acute liver failure, and manifests in nose, stomach, intestinal, and uterine bleeding, which are difficult to treat. Therefore, ECG in patients with acute renal failure is dangerous and not always feasible due to the severity of the condition.

sick. In addition, hemosorption treatment is very expensive, since one ECGS session costs approximately 50 rubles, and 5 rubles per day are allocated for treatment of one patient in the intensive care unit.

The aim of the invention is to reduce mortality and reduce complications in the treatment of patients with acute renal failure.

The indicated goal is achieved by that. what

200–300 ml of blood lasting 10–12 minutes at a rate of 20–25 ml / min is performed for patients with acute renal failure.

Blood speed is regulated

pump within 20-25 ml / min according to the instructions for the apparatus for ultraviolet ultraviolet blood of Isolde (6). The highest speed is usually used when taking blood from a patient, otherwise there is a danger of thrombosis of the needle, the lowest - when returning blood to a vein, when this danger is significantly reduced.

The duration of the blood ultraviolet is 10-12 minutes. Such a duration is also established by the Instructions for the Isold apparatus: the duration of the working cycle is not more than 5 minutes, i.e. it takes 5-6 minutes for blood collection and the first passage through the cuvette, another 5-6 minutes for blood return,

those. it takes 10-12 minutes.

Patients are treated according to the claimed method as follows: a central or peripheral venous vessel is punctured. Then the blood is forcibly taken using a peristaltic pump (200-300 ml), passed through a flat quartz cuvette of the Isold apparatus (5), where blood is irradiated. Next, blood is collected in

ampoule. After the accumulation of the required blood volume in the ampoule, the pump is switched to reverse movement. Blood upon return is irradiated a second time. Blood ultraviolet is carried out for 10-12 minutes, the speed of movement

blood regulate the pump in the range of 20-25 ml / min. Before UFO, the level of ammonia in the venous blood is monitored. After blood ultraviolet, blood ammonia levels are also monitored.

Indication for the treatment of the claimed method is acute hepatic-renal failure with subtotal and total damage to liver function, acute renal failure in the stage of oligoanuria. In addition, the treatment according to the claimed method is indicated for patients who are unable to perform ECGS due to the severity of the condition: low blood pressure, central venous pressure, severe hemorrhagic syndrome.

Example 1. Patient P., IS No. 7729, was taken by ambulance aircraft from a maternity hospital in the city of Slav nske to the revival department of the OKB im. Kalinina with a diagnosis of P.'s pregnancy, nephropathy of the 1st century, premature detachment of a normally located placenta, extirpation of the uterus without appendages, acute hepatic-renal failure.

Upon admission, the patient's condition is extremely serious. Consciousness is confused. The skin is pale, acrocyanosis. Sclera is icteric. Independent breathing, shortness of breath - 36 breaths in 1 min. During acculturation in the lungs, hard breathing is heard throughout. Heart sounds are rhythmic, sonorous. Tachycardi, heart rate 136 in 1 minute. HELL 110/30 mm Hg The tongue is dry, coated with a brown coating. The abdomen is swollen, peristalsis in la. On palpation of the abdomen, the patient notes pain along the postoperative wound. The liver protrudes from under the costal arch by 2-3 cm, its palpation is painful. By catheter from the bladder, 100 ml of urine of the color of meat slurry was released.

In the department, the patient was examined. The following biochemical blood test data were obtained: ammonia - 500 μg / l, urea - 19.3 mmol / l, creatinine - 0.25 mmol / l, total bilirubin - 11.28 mmol / l, direct - O, ACT - 1.08 mmol / L / h, ALT - 1.72 mmol / L / h. When studying the indicators of central hemodynamics in a patient, a hypodynamic type of blood circulation was established: UO - 21.29 ml (, 95 ± 2.48), .873 l / min (N 4.46 ± 0.15),, 89 ml / m2 (. 02 ± 2.32),, 48 l / min m2 (, 31 ± 0.42),, 72 dyn.cm-5 (, 46 ± 22.71).

The patient was prescribed traditional infusion therapy, including drugs that improve liver function, lower blood ammonia: glucose solutions, rheopoliglucin, prednisolone, albumin, glutamic acid, hemodes. However, due to the ineffectiveness of traditional treatment, taking into account the high level of ammonia in the blood, which cannot be corrected, it was decided to include active detoxification methods in the treatment plan of the patient. Moreover, hemosorption was unsafe for the patient due to severe hypodynamia of blood circulation and the possibility of developing uncontrolled hypotension in

connecting the extracorporeal circle of blood circulation. Therefore, in order to reduce ammonia intoxication, the patient underwent ultraviolet irradiation of blood.

In the operating room, the patient is punctured by the femoral vein. Then, blood was forcedly taken with a needle using a peristaltic pump in an amount of 200 ml and passed through a flat quartz cuvette of the Isold apparatus, then blood was collected in a sterile ampoule. During the flow of blood through the cuvette, it was irradiated with a lamp. After 200 ml of blood was accumulated in the ampoule, the pump was switched to reverse movement. Blood on return was irradiated a second time. Blood UV was carried out for 10 minutes, blood flow rate was monitored for blood ammonia level. The ammonia concentration decreased from 500 μg / L to 210 μg / L, i.e. the ammonia concentration decreased by 42%, compared with the initial level.

After a course of therapy, including blood ultraviolet radiation, the patient's condition improved markedly. The patient regained consciousness, intoxication symptoms decreased, diuresis recovered, the biochemical parameters of ammonia - 170 μg / l, urea - 6.5 mmol / l, creatinine - 0.074 mmol / l, bilirubin - 5.64 mmol / l, normal - Oh, ACT - th, 48 mmol / l, h, ALT - 0.86 mmol / l / h. The hemodynamic indices also improved: UO - 56.4 ml, MOS - 5.197 l / min, UI - 44.7 ml / m2 SI - 4.12 l / min m2, OPS - 1641.0 dyn.sm.

Taking into account the positive dynamics in the patient’s condition, the pronounced detoxification effect after the blood UV, the hemosorption was not necessary.

Subsequently, the patient was transferred to the gynecological department at the place of residence.

Example 2. Patient G., IB M 11842 was admitted to the intensive care unit OKB them. Kalinin 22. VI.87, diagnosed with a condition after colectomy, sigmotomy 11.VI.87 g, peritonitis, relaparotomy 15.VI.87, acute renal failure.

Upon admission, the patient's condition is extremely serious. Inhibited, inadequate. Low power. Turgor tissue is sharply reduced. The skin is earthy gray. Sclera is subicteric. Breathing is independent, adequate. During auscultation in the lungs, hard vesicular breathing, weakened in the lower-lateral parts, is heard. Heart sounds are rhythmic, gluten. Tachycardi 112 min., HELL 130/80 mm PT, dry tongue. The abdomen is retracted, painful throughout. Stagnant gastric contents are secreted through the nasogastric tube. Intestinal contents are secreted through the ileostomy. 60 ml of concentrated urine are excreted via the catheter from the bladder.

The patient was examined in the department: ammonia 1020 μg / L, urea - 56.7 mmol / L, creatinine - 0.79 mmol / L, total bilirubin - 79.0 μmol / L, direct 67.6 μmol / L, ALT - 1.28 mmol / l.h., ACT - 0.96 mmol / l. When studying the parameters of central hemodynamics, the hyperdynamic type of blood circulation was established: UO 159.70 ml, MOS - 12.776 l / min, UI - 83.61 ml / m2, SI - 6.68 l / min m2, OPS-751, One. with.,

The patient was prescribed traditional infusion therapy aimed at correcting impaired liver and kidney functions, which reduces ammonia intoxication. However, due to the ineffectiveness of traditional treatment, it was decided to include active detoxification methods in the patient's treatment plan. At the same time, hemosorption in the patient threatened with such complications as: pulmonary edema, brain, wedge of the brain stem followed by respiratory arrest and blood circulation. Therefore, with a detoxification goal, the patient received an ultraviolet blood test.

Patient under operating room conditions, punctured femoral vein rights. Then the blood was forcibly taken with a needle using a peristaltic pump and passed through a quartz cuvette from the Isold apparatus, and then blood was collected in an ampoule. During the flow of blood through the cuvette, it was irradiated with a lamp. After accumulating 300 ml of krbi in an ampoule, the pump was switched to reverse. Blood upon irradiation was irradiated a second time. Ultraviolet irradiation was carried out for 12 minutes, the blood speed was regulated by a pump within 25 ml / min.

After the UFO of the blood, the level of ammonia in the blood decreased from 1020 μg / L to 850 μg / L, i.e. ammonia concentration decreased by 27.5%. In a subsequent patient, another 2 sessions of blood ultraviolet radiation were performed in connection with a high concentration of ammonia (see table). Conducting 3 sessions of UFO blood allowed. significantly reduce intoxication. Against this background, indicators of central hemodynamics improved:, 75 ml, 684 l / min, 84 ml / m2,, 59 l / min s2, OPS - 673.0 dyn.s.This allowed later

give the patient two hemosorb sessions

tion. After treatment, the patient's condition improved significantly. Acute hepatic-renal failure was resolved. Biochemical parameters returned to normal: ammonia - 175 μg / L, urea - 13.2 mmol / L, creatinine - 0.099 mmol / L, total bilirubin - 16.9 μmol / L, direct - O, ACT - 0.76 mmol / l.h., ALT- 1.24 mmol / l.h. When transferred to the surgical department, the patient is conscious, adequate, active.

The most important advantage of the claimed method is the reduction in mortality in patients with acute

5 hepatic-renal insufficiency. 25.25% in comparison with the prototype method.

Inclusion of blood in the treatment plan for patients with acute renal failure, leads to an increase in

0 ammonia elimination by 14-15% in comparison with the prototype method. Adequate and fast elimination of ammonia from the blood leads to an improvement in the condition of patients with acute renal failure, which reduces the number of

5 necessary hemosorption, which is unsafe for acute renal failure due to the possibility of developing complications such as collapse, uncontrolled hypotension, pulmonary edema, cerebral edema, wedge of the brain stem,

0 respiratory arrest and blood circulation. Thus, the use of ultraviolet irradiation of blood in patients with acute renal failure has reduced the number of necessary hemosorption by 3-4 times. Along with this, treatment for

5 of the claimed method makes it possible to refuse to conduct hemosorption, since the ultraviolet ultraviolet is sufficient to lower the level of ammonia in the blood. A decrease in the number of necessary hemosorption allows achieving a pronounced economic effect. Thus, the exclusion of one hemosorption from the patient’s treatment plan reduces the cost of treatment by 40-50 rubles.

The rapid and effective reduction of ammonia in the blood also reduces the amount of medication administered to the patient in order to bind and excrete ammonia.

An important advantage of the claimed

0 of the method is a time factor. So hemosorption takes an average of 2.5-3 hours (150-180 min.), And blood ultraviolet radiation 10-12 minutes. Consequently, UFO blood is carried out 15 times faster, and elimination

5 ammonia with blood ultraviolet radiation is 13-14% higher; this, in order to achieve effective elimination of ammonia in HS, it is necessary to perfuse 8–9 L of blood through a sorbent, and in case of ultraviolet blood the volume of blood obtained is 200–300 ml.

Such exfusion of blood does not lead to hemodynamic disorders in patients with acute renal failure.

Also, blood ultraviolet radiation, having a good detoxification effect, improves central hemodynamics, which subsequently allows hemosorption to be included in the treatment plan for patients.

Clinical trials of the claimed method were carried out on the basis of the Department of Anesthesiology-Reanimatology of the Donetsk Medical Institute in 11 patients.

A clinical trial report and evidence of the benefits of the claimed method are included.

Formulas of the invention

A method for the treatment of acute hepatic-renal failure, including detoxification of the body, characterized in that, in order to reduce mortality,

additionally, ultraviolet rays are irradiated with 200-300 ml of exfuscated blood for 10-12 minutes at a rate of 20-25 ml / min, followed by re-infusion to the patient.