RU2122415C1 - Method of intensive therapy of patients with traumatic shock - Google Patents

Abstract

FIELD: medicine, in particular, anesthesiology and reanimatology; applicable in treatment of patients with traumatic shock at early hospital stage. SUBSTANCE: method includes anesthesia, infusion therapy, compensation of blood losses, artificial pulmonary ventilation, medicamentous correction of metabolism disturbances. Intravenous bolus injection of dalargin in a dose of 1 mg is made for stabilization of hemodynamics depending on functional state of blood vascular system with presence of hyperdynamic type of central hemodynamics (cardiac index > 4.2 l (min.sq.m)^-1 and peripheral resistance is less than 1200 din.s.^-5). In case of presence of hypodynamic type of central hemodynamics (cardiac index is less than 2.2 l (min.sq.m)^-1 and peripheral resistance is above 2500 din.s.cm^-5) actovegin in a dose of 2000 mg in 0.9-% solution of sodium chloride of 5-% glucose is injected intravenously at the rate of 20-40 ml/min. EFFECT: higher efficiency. 2 tbl

Description

 The invention relates to medicine, namely to anesthesiology and intensive care, and can be used to treat patients with traumatic shock at an early hospital stage.

 In terms of the absolute value of deaths, injuries come second after cardiovascular diseases, and among young, most able-bodied people, first; 2.5% of all herbs are accompanied by shock and every fourth of this group of victims dies (Seleznev S. A., Khudayberenov G. S. Traumatic disease. Actual aspects of the problem. - Ashkhabad: Ylym, 1984). Of course, with severe traumatic injuries, traumatic shock develops (Kochetygov N.I., Pozdnyakov P.K., Vinogradova L.M., Kulikov A.M. // Hematol. And transfusion. - 1983, No. 3, p. 39- 42).

 Circulatory disorders are one of the most important elements of the body's response to severe trauma and determine the course of traumatic shock (Shtykhno Yu.M., Udovichenko V.I., Donskikh E.A. // Pat. Physiol. - 1986, N 6, p. 28 -31). There are two types of circulatory disorders in the development of traumatic shock, one of which is characterized by hypocirculation (low cardiac output), and the other by hypercirculation (Seleznev SA, Khudayberenov GS Traumatic disease. Actual aspects of the problem. - Ashgabat: Ylym, 1984) .

 The development of hypoxia, one of the most important factors in the pathogenesis of shock, is most closely associated with circulatory disorders in shock. The pathophysiological essence of shock is a violation of microcirculation (V.K. Kulagin. Pathological physiology of trauma and shock. - L .: 1978) and, only by eliminating this main link in the pathogenesis of shock, you can be sure of its favorable outcome.

A known method of intensive care for traumatic shock, including anesthesia, infusion therapy, replenishment of blood loss, mechanical ventilation, drug correction of metabolic disorders (Traumatic shock / Ed. By I.P. Petrov. - Medgiz, Leningrad. Department., 1962; Shuteu Yu. Et al. Shock. - Bucharest, Military Publishing House, 1991; Features of the pathology of the lesion, diagnosis and emergency medical care for the population during natural disasters and other disasters / Edited by G. A. Ryabov. - M.: 1993), allowing maintain arterial e pressure at a level higher than critical due to volumetric velocity and high-quality composition of infusion therapy. Nevertheless, this method is not without serious drawbacks:
- the existing intensive care regimen does not sufficiently take into account the individual approach in its appointment, because the generalized average values of the volume and dosages of infusion-transfusion therapy are only an approximate guideline for the appointment of a specific patient with traumatic shock;
- hemodynamic disorders in shock are quite diverse, so transfusions alone do not always give a positive therapeutic effect (Traumatic shock: Pathogenesis. Clinic. Treatment / Edited by V.I. Nigulyanu. - Chisinau, Shtiintsa, 1988); providing the task of quantitative correction of hypovolemia, differentiated therapy of central hemodynamic disorders is impossible depending on its functional state, which largely determines the final result of treatment;
- focusing on an integral indicator of the state of the cardiovascular system, which is blood pressure, and not taking into account the type of hemodynamic disorder in a patient with traumatic shock at an early hospital stage, it is impossible to stabilize systemic and peripheral hemodynamics as soon as possible and prepare the patient for emergency surgical treatment.

 The closest way to the claimed is a method of intensive care in patients with massive blood loss through the combined use of the inotropic cardiotonic dopamine and sodium nitroprusside vasodilator (Gereg V.V., Gidirim G.P., Chikala E.T. et al. // IV All-Union Congress anesthesiologists and resuscitators. Odessa, Dec. 13-16, 1989: Abstracts under the editorship of Prof. T. M. Darbinyan. - M .: 1989, pp. 337-338). According to the authors, the combined continuous infusion of dopamine and nitroprusside contributes to a faster and more efficient process of decentralization and stabilization of systemic, organ and peripheral blood circulation.

However, this method is not without serious drawbacks:
- apply this method to correct hemodynamics in patients with traumatic shock is possible only after replenishing the volume of circulating blood, which requires a sufficient amount of time and is not always achievable in the early hospital phase;
- the authors used a combined continuous infusion of dopamine and sodium nitroprusside in patients with a hypodynamic type of central hemodynamics, characterized by a low cardiac index against a background of high values of total peripheral vascular resistance; using this method of intensive care in patients with traumatic shock in the presence of a hyperdynamic type of central hemodynamics, it is impossible to reduce the hyperactivity of the sympathoadrenal system, prevent the depletion of energy resources of the body and ultimately stabilize hemodynamics;
- the use of these drugs can lead to undesirable and extremely dangerous effects in patients with traumatic shock: the possibility of an overdose, the development of tachyphylaxis, the occurrence of adverse reactions in the form of uncontrolled hypotension.

 The objective of the present invention is to reduce mortality in patients with severe trauma, accompanied by shock, by correcting hemodynamics at an early hospital stage.

The objective is achieved by the fact that at the early hospital stage in the intensive care unit for patients with traumatic shock, with the aim of early correction of hemodynamics, depending on the functional state of the circulatory system, the following are introduced: in the presence of a hyperdynamic type of central hemodynamics, the cardiac index> = 4.2 l • (min • m ² ) ^-1 ; total peripheral vascular resistance <= 1200 dyn • s • cm ^-5 - dalargin at a dose of 1 mg is intravenously bolus, and in the presence of a hypodynamic type of central hemodynamics - cardiac index <= 2.2 l • (min • m ² ) ^-1 ; total peripheral vascular resistance> 2500 dyn • sec • cm ^-5 - Actovegin at a dose of 2000 mg in a solution of 0.9% sodium chloride or 5% glucose by intravenous infusion at a rate of 20-40 ml / min.

The cardiac index (SI) is the main integral indicator of the state of the cardiovascular system (Traumatic disease / Under the editorship of II Deryabin and OS Nasonkin - L .: Medicine, 1987), the general peripheral vascular resistance (OPSS) is important hemodynamic parameter, significantly affecting the contractility of the heart and blood pressure due to changes in preload and venous flow to the heart. Normally, SI ranges from 2.8 - 4.2 L • min • m ² ) ^-1 , OPSS - 1200 - 2500 dyne • s • cm ^-5 (Zhizhevsky Y. A. Fundamentals of infusion therapy: Ref. - Pract. allowance .-- Minsk, Higher school, 1994).

In the early stages of the shock course, the majority of victims, due to excessive activation of the sympathoadrenal system and massive release of catecholamines into the blood, develop a hyperdynamic type of blood circulation (SI (cardiac index)> = 4.2 L • (min • m ² ) ^-1 ; OPSS (total peripheral vascular resistance) <= 1200 dyn • sec • cm ^-5 , which, with inadequate treatment, becomes hypodynamic (SI ≤2.2 l • min • m ² ) ^-1 ; OPSS 2500 dyn • s • cm ^-5 ),
practically not amenable to pharmacological correction, which is due to a decrease in myocardial energy.

 Dalargin is a synthetic analogue of leu-enkephalin, synthesized in the laboratory of peptide synthesis of the All-Russian Scientific Center of Medical Sciences of the USSR as a drug for the treatment of peptic ulcer of the stomach and duodenum.

 Dalargin manifests its properties in conjunction through several systems: antioxidant, stress-limiting and energy supply systems (Slepushkin V.D., Zolooev G.K., Vinogradov V.A., Titov M.I. Neuropeptides. Their role in physiology and pathology. - Publishing house of Tomsk University, Tomsk, 1988).

 Actovegin (HAFSLUND MYCOMED PHARMA AG, Austria) - deproteinized derivative of blood plasma obtained by ultrafiltration. Thanks to this method of obtaining the finished product is free from proteins, antibodies and is pyrogen-free. Serum contains many active substances that have a regulatory effect on the growth and function of tissue cells.

 The ability of Actovegin to activate metabolism at the cellular level is noted (Jaeger KH // Die Forderung, der Zellatmung durch einen Blutextrak. Arzmeim. - Forsch. 15. - 1965. - 750; Pichotka J. Wirkungeines Blutextrakt auf den Stoffwechsel einfachersysteme. Arzneims. . 15. - 1965. - 754). The main mechanism of action of actovegin is aimed at increasing the penetration of oxygen and glucose into cells and is manifested mainly in pathological conditions of hypoxia. Actovegin acts directly on cell metabolism by increasing the accumulation of oxygen and glucose. This inorganotropic effect ultimately leads to the optimization of the energy state of cells, due to which the metabolic state improves, especially in conditions of its insufficiency.

 Dosages of dalargin for hyperdynamic type of central hemodynamics - 1 mg intravenously bolus, and Actovegin for hypodynamic - 2000 mg in 400.0 ml of 0.9% sodium chloride solution or 5% glucose intravenously infusion at a rate of 20-40 ml / min, tested in clinical trials and are optimal in patients with traumatic shock at an early hospital stage.

The method is as follows:
When a patient with a traumatic shock enters the admission department, one of the two central veins is catheterized, if it was not performed at the prehospital stage, infusion therapy is started and central hemodynamics is studied simultaneously with generally accepted clinical and laboratory examinations. If a hyperkinetic type of blood circulation is diagnosed (cardiac index> = 4.2 L • (min • m ² ) ^-1 ; total peripheral vascular resistance <= 1200 dyn • s • cm ^-5 ), then after introducing a minimum volume of fluid into the bloodstream ( high molecular weight dextrans or a 7.5% solution of sodium chloride) is administered intravenously bolus 1 mg of dalargin; Actovegin is administered in the presence of a hypokinetic type of central hemodynamics (cardiac index <= 2.2 L • (min • m ² ) ^-1 , total peripheral vascular resistance> 2500 dyn • sec • cm ^-5 ) according to the same scheme at a dose of 2000 mg in 400 ml of a solution of 0.9% sodium chloride or 5% glucose intravenously infusion at a rate of 20-40 ml / min.

 Further intensive therapy is carried out according to the generally accepted standard technique, taking into account the BCC deficiency, the degree of impairment of oxygen transport function, metabolic needs for fluids and electrolytes.

Example 1
Patient P., 28 years old, medical history N 577, was taken to the emergency room by an ambulance from the scene of a road accident 10 minutes after the injury. Diagnosis at admission: Road injury. An open fracture of the bones of the left tibia in the middle third. Closed pelvic fracture. Closed fracture of the right thigh in the middle third. Traumatic shock of the II degree (16 points on the scale of severity of damage to the St. Petersburg Research Institute of Emergency Care named after II Dzhanelidze).

 The condition at admission is serious, due to traumatic, hemorrhagic shock. In the mind, excited. The skin is pale. Independent breathing, carried out in all departments, no wheezing, respiratory rate of 28 per minute. Hemoglobin saturation 90%. The partial oxygen tension of capillary blood is 42 mm Hg. Art. Blood pressure 150/70 mm Hg, heart rate 96 beats per minute. The stomach is soft.

An anesthesiologist performed percutaneous catheterization of the right connected vein from the subclavian access using the Seldinger technique in the admission department, and infusion therapy was started - an intravenous 7.5% sodium chloride solution at a rate of 50 drops per minute. Simultaneously with the clinical and radiological examination, a study of central hemodynamics was carried out according to the tetrapolar rheovasography technique: blood pressure 150/70 mm Hg , mean arterial pressure 96 mm Hg, heart rate 96 beats / min, stroke volume of the heart 70.0 ml, cardiac index 4.5 l • (min • m ² ) ^-1 , total peripheral vascular resistance 1087.0 din • s • cm ^-5 . Dalargin in a dose of 1 mg was bolus administered intravenously. After 15 minutes, the central hemodynamics was re-examined by the method of tetrapolar rheovasography: blood pressure 120/80 mm Hg, average blood pressure 86 mm Hg, heart rate 102.0 beats / min, stroke volume 57.0 ml , cardiac index 3.6 l • (min • m ² ) ^-1 , total peripheral vascular resistance 1215.0 dyne • s • cm ^-5 . The partial oxygen tension in capillary blood, measured by the transcutaneous method, was 55 mmHg. By this time, the volume of intravenous infusion was: 400 ml of 7.5% sodium chloride solution, 50 ml of polyglucin. Further intensive therapy was carried out according to the generally accepted technique, including anesthesia, infusion therapy, blood transfusion under the control of central venous pressure. By the end of the fourth hour after the patient’s admission, the total infusion volume was 3200 ml, hourly diuresis 80-90 ml / hour. Indicators of central hemodynamics: blood pressure 120/80 mm Hg, average blood pressure 86 mm Hg, heart rate 78.0 beats / min, stroke volume 75.0 ml, cardiac index 3.4 l • (min • m ² ) ^-1 , total peripheral vascular resistance 1215.0 dyne • s • cm ^-5 . Hemoglobin saturation 100%, partial oxygen tension in capillary blood 71 mmHg

 The patient underwent surgical treatment of open bone fracture of the left leg. Imposed skeletal traction. At the end of the operation, the patient was transferred to the intensive care unit, the immediate postoperative period without complications. Recovery.

Example 2
Patient S., 22 years old, medical history N 2011, delivered 30 minutes after falling from a height of the fourth floor. Diagnosis at admission: Combined catatrauma. Dumb abdominal injury. Intra-abdominal bleeding. Closed fracture of the II, III, IV ribs on the left, hemothorax on the left. Bruises of the soft tissues of the left thigh. Traumatic shock of the II degree (18 points on the severity scale of damage to the St. Petersburg Research Institute of Emergency Care named after II Dzhanelidze).

The condition at admission is serious, due to traumatic, hemorrhagic shock. Inhibited, dynamic. The skin is pale, moist, cool. Respiratory rate 24 per minute, auscultation weakened on the left. The abdomen is tense, painful on palpation. Blood pressure 105/45 mm Hg, average blood pressure 65 mm Hg, heart rate 102.0 beats / min. Central hemodynamics according to tetrapolar rheovasography: stroke volume of the heart 29 ml, cardiac index 1.7 l • (min • m ² ) ^-1 , total peripheral vascular resistance 2500.0 dyn • s • cm ^-5 . Hemoglobin saturation 85%, partial oxygen tension of capillary blood, measured by the transcutaneous method, 16 mm Hg

An anesthesiologist performed percutaneous catheterization of the right subclavian vein from the supraclavicular access using the Seldinger technique in the admission department; the central venous pressure was negative. Infusion therapy has begun - 2000 mg of Actovegin in 400 ml of 0.9% sodium chloride solution at a rate of 40 ml per minute, this solution was introduced in 10 minutes. Further preoperative preparation, along with clinical, laboratory and x-ray examination, was carried out according to the generally accepted scheme, including analgesia, infusion therapy, and blood transfusion under the control of central venous pressure. 55 minutes after the patient’s admission, the volume of infusion therapy was 1420 ml (polyglucin 400 ml, 7.5% sodium chloride 400 ml, Ringer-Lock solution 400 ml, single-group donor blood 220 ml), diuresis was 110 ml. Central venous pressure of 50 mm water column Central hemodynamics was studied by the method of tetrapolar rheovasography: blood pressure 120/70 mm Hg, mean blood pressure 86 mm Hg, heart rate 90.0 beats / min, stroke volume 51.0 ml, cardiac index 2, 6 l • (min • m ² ) ^-1 , total peripheral vascular resistance 1528.0 dyne • s • cm ^-5 . Hemoglobin saturation 97%, partial oxygen tension of capillary blood 43 mmHg The patient was served on the operating table, under endotracheal anesthesia, surgical treatment was performed: drainage of the pleural cavity on the left in the 6 intercostal space along the posterior axillary line, local anesthesia of the fracture of the ribs. Laparotomy Revision of the abdominal cavity. Splenectomy. The course of surgery and anesthesia without complications. At the end of the operation, he was transferred to the intensive care unit, the postoperative period without complications. Recovery.

 According to the claimed method, studies were performed on victims of both sexes with a combined injury, accompanied by a shock of the II-III severity level (from 14 to 35 points on the severity scale of injuries of the St. Petersburg Research Institute of Emergency Medicine named after I.I.Dzhanelidze (Algorithms for the diagnosis and treatment of combined shockogenic injuries Methodical recommendations. / Under the editorship of S. Seleznev, Yu. B. Shapot - St. Petersburg, 1994. The average age of patients was 32 years. The group of patients with hyperdynamic type of central hemodynamics, dalargin was prescribed in the treatment regimen eleven 6 patients who were prescribed actovegin - 78 patients. The control was a randomized group of patients treated according to generally accepted schemes of infusion-transfusion therapy, with a hyperdynamic type of central hemodynamics there were 45 people, with a hypodynamic type - 34. Patients with a head injury were excluded from the study.

 The assessment of central and peripheral hemodynamics at the stages of intensive therapy was carried out according to the tetrapolar rheovasography, recorded by the Kubitschek technique in the Pushkar modification with computer processing at the time of the study. The partial oxygen tension in capillary blood was determined by the transcutaneous method using a domestic device "chkR02-01".

 Statistical processing of the results was carried out using the Adan application package developed at the Department of Medical Cybernetics and Computer Science of the Novokuznetsk State University of Economics and Technology using Student's t test on IBM-AT 386.

 The initial data in the control and study groups in patients with hyperdynamic type of central hemodynamics did not statistically differ (Table 1. Appendix 1). 15 minutes after a bolus injection of 1 mg of dalargin in the group of patients with hyperdynamic type of central hemodynamics, a marked decrease in the hyperactivity of the sympathoadrenal system was observed, which was accompanied by a decrease in the cardiac index by an average of 12.5%, an increase in the total peripheral vascular resistance by 37% (p < 0.05), an increase in heart rate by 12.5%, a decrease in stroke volume of the heart by 22% (p <0.05). Tissue oxygen supply was improved, which was confirmed by an average increase of 29% (p <0.05) in the partial oxygen tension of capillary blood and an increase in hemoglobin saturation. By this time, the volume of infusion therapy was no more than 10% of the total 4-hour infusion, we explain the changes in hemodynamics and oxygen-transport function by the use of dalargin. After 4 hours of intensive therapy in the group of patients using dalargin compared with the control group, with statistically different indicators of mean blood pressure and heart rate, an average of 17% higher values of stroke volume of the heart (p <0.05) and 28% higher values of the partial oxygen tension in capillary blood (p <0.01).

 The use of dalargin at an early hospital stage as part of intensive care in patients with traumatic shock and the initial hyperdynamic type of blood circulation helps to reduce the hyperactivity of the sympathoadrenal system, prevents the depletion of the body’s energy resources, allows it to stabilize central hemodynamics and improve tissue oxygen supply, which ultimately the result will reduce mortality in this category of patients.

 The initial data in the control and studied groups of patients with a hypodynamic type of central hemodynamics did not differ statistically (Table 2. Appendix 2). In the group of patients who had an initially hypokinetic type of blood circulation with low SI and UO, 1 hour after the infusion of 2000 mg of Actovegin, an increase in the cardiac index and stroke volume of the heart was observed by an average of 36% and 47.3% (p <0.05), respectively. a decrease in total peripheral vascular resistance by an average of 64% (p <0.05), which was accompanied by a decrease in heart rate by 17.5% and an increase in mean arterial pressure by 31% (p <0.05). Changes in hemodynamics were accompanied by an increase in the partial oxygen tension of capillary blood compared with the initial data by 73.6% (p <0.01) and an increase in hemoglobin saturation.

 Changes in the hemodynamics and oxygen supply of tissues reached their maximum values by the fourth hour of the intensive care: the average blood pressure increased by 38.9% compared with the initial values (p <0.01) and by 28.2% compared with the control group (p <0.01), the cardiac index increased by 36.7% compared with baseline data (p <0.05) and 15.3% compared with the control group. Indicators of total peripheral vascular resistance during the ongoing intensive care remained within the physiological norm and were lower by 38% compared with the control group (p <0.05). The stroke volume of the heart by the end of the 4-hour infusion therapy increased by 80% compared to the initial level and was 25% higher than in the control group (p <0.05). In the group of patients using Actovegin, compared with the control group, the heart rate was lower (p <0.05). In the group of patients with a hypodynamic type of central hemodynamics who did not use Actovegin, oxygen supply to tissues remained low, the partial oxygen tension of capillary blood increased compared to the initial level by only 51% (p <0.01), and when using Actovegin increased by 178% compared with the initial data (p <0,% 1); Hemoglobin saturation indices in both groups did not statistically differ.

 The use of actovegin in the intensive care regimen in patients with traumatic shock and the initial hypodynamic type of central hemodynamics allows, by optimizing intracellular energy processes and improving tissue oxygen supply, to stabilize hemodynamics at an early hospital stage, to prepare the patient for emergency surgical treatment in a short time, and ultimately reduce mortality in this category of patients.

 The use of dalargin and actovegin in intensive care regimens in patients with traumatic shock at an early hospital stage made it possible to reduce the total dose of central analgesics by 3 times without compromising the quality of neuro-vegetative defense.

Claims (1)

A method of intensive therapy of traumatic shock, including anesthesia, infusion therapy, inflammation of blood loss, mechanical ventilation, drug correction of metabolic disorders, characterized in that at an early hospital stage in patients with traumatic shock to stabilize hemodynamics, depending on the functional state of the circulatory system, they are administered: the presence of hyperdynamics - cardiac index> = 4.2 l • (min • m ² ) ^-1 and total peripheral vascular resistance <= 1200 dyn • s • cm ^-5 - dalargin in a dose of 1 m g is intravenously bolus, and in the presence of a hypodynamic type of central hemodynamics - a cardiac index <= 2.2 L • (min • m ² ) ^-1 and a total peripheral vascular resistance> 2500 dyn • s • cm ^-5 - Actovegin at a dose of 2000 mg a solution of 0.9% sodium chloride or 5% glucose by intravenous infusion at a rate of 20 - 400 ml / min.

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