RU2151401C1 - Method for diagnosing hemostasis system disorder in circulatory shock patients - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves determining response period, spontaneous blood platelets aggregation intensity, prothrombin constant, maximum amplitude, clot fibrin-blood-platelet structure formation time, general retraction and spontaneous clot lysis index. Response period being found to be within 5-7 min, spontaneous blood platelets aggregation intensity being from -2 to -6 relative units, prothrombin constant being equal to 4-6 min, maximum amplitude being within the limits of 500-700 relative units, clot fibrin-blood- platelet structure formation time being within the limits of 40-60 min, general retraction and spontaneous clot lysis index being equal to 10- 20%, no shock case is to be diagnosed. Spontaneous blood platelets aggregation intensity being from -8 to -14 relative units and no changes in the other values being observed, compensated shock stage is to be diagnosed. Response period being found to be less than 4 min, spontaneous blood platelets aggregation intensity being from -8 to -14 relative units, prothrombin constant being less than 3 min, maximum amplitude being greater than 750 relative units, clot fibrin-blood-platelet structure formation time being less than 40 min, general retraction and spontaneous clot lysis index being equal to 10-20%, decompensated reversible shock stage is to be diagnosed. Response period being found to be greater than 10 min, spontaneous blood platelets aggregation intensity being equal to -4 relative units, prothrombin constant being greater than 9 min, maximum amplitude being less than 400 relative units, clot fibrin-blood-platelet structure formation time being greater than 70 min, general retraction and spontaneous clot lysis index being greater than 20% or less than 5%, decompensated irreversible shock stage is to be diagnosed. EFFECT: enhanced accuracy of the method; accelerated method. 1 dwg

Description

 The invention relates to medicine, specifically to methods for diagnosing damage to the hemostatic system in patients with circulatory shock.

 Known methods for diagnosing such disorders in shock patients include determining blood clotting time, determining platelet counts, evaluating platelet aggregation ability, determining prothrombin time and index, and conducting paracoagulation tests - ethanol and protamine sulfate, in recording thromboelastograms [1, 2]. However, these methods of diagnosing damage to the hemostasis system in shock patients are not objective enough, since they provide information mainly on the individual links of the hemostasis system, which makes it difficult to distinguish the developing DIC from shock from other forms of coagulopathy; recognition of ICE in the early preclinical and low-symptomatic stages of its development; recognition of DIC in those situations when it develops a second time, superimposed on other disorders of hemostasis; determination of the prevailing mechanisms of the development of DIC / hemocoagulation, platelet hyperaggregation, depression of physiological anticoagulants and fibrinolysis /; assessment of the degree of dysfunction of individual parts of the hemostatic system. In addition, for the implementation of most methods of diagnosing disorders of the hemostatic system, a laboratory, appropriate reagents and specially trained personnel are required.

 Closest to the proposed is a method for assessing the functional state of the hemostatic system and fibrinolysis, which consists in recording and evaluating the viscous characteristics of coagulating blood using a low-frequency piezoelectric vibration viscosity sensor. The methodology is based on the registration of the most insignificant changes in the state of aggregation of blood, which reflect the internal processes that occur in the blood during coagulation and lysis of the clot [3,4].

 However, this diagnostic method was practically not used in urgent situations, such as circulatory shock, in which a detailed assessment of the functional state of the parts of the hemostatic system allows not only laboratory confirmation of the clinical symptoms of shock, but also to determine the degree of decompensation of this pathological process.

 The problem solved by this invention is to increase the accuracy and reduce the time of the study of the hemostatic system in patients with circulatory shock in order to obtain additional laboratory confirmation of the presence of a shock condition and determine the degree of decompensation.

 The problem is solved by using a new method for diagnosing damage to the hemostasis system in patients with circulatory shock, which consists in recording and assessing the viscous characteristics of coagulating blood of the reaction period g, the intensity of spontaneous aggregation of platelets Ar, the thrombin constant k, the maximum amplitude of MA, the time of formation of the fibrin-platelet structure of the clot T, the total rate of retraction and spontaneous lysis of the FA clot, and with g values in the range of 5-7 minutes, Ar is from-2 to -6 rel. units, to within 4-6 minutes, MA within 500-700 rel. units, T within 40-60 min, FA equal to 10-20%, determine the absence of shock, with Ar from -8 to -14 Rel. units and the absence of changes in other indicators, the compensated shock stage is determined, with r less than 4 min, Ar equal to -8 to -14 rel. units , to less than 3 min, MA more than 750 rel. units, T less than 40 min, FA equal to 10-20%, determine the decompensated reversible stage of shock, with r more than 10 min, Ar equal to -4 rel. units and higher, to more than 9 min, MA less than 400 rel. units, T more than 70 min, FA more than 20% or less than 5% determine the decompensated irreversible stage of shock.

 The method is carried out using a blood rheology analyzer of the portable ARP-01 Mednord, designed to study the rheological characteristics of the patient’s blood, monitor the most minor changes in its state of aggregation during coagulation, calculate the amplitude and chronometric constants characterizing the main stages of hemocoagulation and fibrinolysis, identify pathological deviations of these characteristics for the purpose of early diagnosis of various diseases. The device allows you to get a record of one sample, which requires exactly 2 ml of blood.

The device allows work with unstabilized blood, which is taken for examination from a large vein with a dry / better silicone / large diameter needle / at least 1 mm /. Blood sampling should be carried out in the immediate vicinity of the device. Before taking blood, it must be prepared for work. The device turns on by setting the toggle switch to the “ON” position. When the “NETWORK” LED lights up, it indicates that the device is energized. At the same time, the “THERMOSTAT” LED lights up, signaling that the thermostat is on. The tuning fork needle should be in a free state and not have foreign objects on its surface. The time between blood sampling and the beginning of the recording process should not exceed 1 min. A tourniquet must be applied immediately before taking blood, which is removed immediately after the first drop of blood has been received. After the needle is inserted into the vein, the first drops are allowed to drain, after which the removable glass heated to 37 ^° C is filled with blood / 2 ml /. The removable glass is installed in the working socket of the thermostat radiator, after which the thermostat radiator rises. When the thermostat is heated to the set temperature, the “THERMOSTAT” LED goes out. The message "MAIN MENU" on the indicator board indicates the readiness of the device for operation. The registration of hemocoagulation, retraction and spontaneous lysis of a blood clot is carried out for 90 minutes, which are counted on the screen. If desired, you can find out the value of the current and already defined parameter, without waiting for the entire measurement cycle. At the same time, the corresponding indicator in the given units of measurement is displayed on the screen of the device. An audio device signals the end of the process registration, after which a graphic image of the entire recorded process can be obtained. Information is stored in the device’s memory until it is turned off from the mains, which allows you to get an unlimited number of copies on the printer. The graph of the measurement of the state of aggregation of blood obtained as a result of studies is shown in FIG. 1.

 Example 1

 As an example of using a new method for diagnosing damage to the hemostasis system in a patient with a compensated stage of circulatory shock, the case history of Oleg Anatolyevich Safronov, 29 years old, who was treated at the Toxicology Department of the OKB from December 23 to 26, 1993, case history No. 15382. receipt from the anamnesis revealed that during the last week the patient was systematically alcoholized. December 22, did not drink, but felt ill, nausea, vomiting, pain in the stomach, palpitations were noted. On December 23, dizziness appeared, general weakness caused by the ambulance crew, a decrease in blood pressure was noted, delivered to the toxicological department of the OKB. At the time of admission, the patient’s condition of moderate severity, in consciousness, is adequate, well accessible to contact. Complaints of nausea, weakness, dizziness. The skin is moderately pale, breathing independent, adequate, vesicular, BH 20 / min. Heart sounds are muffled, sinus tachycardia, heart rate 108 / min, blood pressure 90/70 mm RT. Art., CVP = 0. The abdomen on palpation is soft, pronounced soreness is not observed. Urination, according to the patient, is limited. Data from laboratory research methods: general blood and urine tests within normal limits, biochemical parameters without pronounced pathological deviations. A laboratory study of the hemostatic system was very limited and also gave normal results: PV -19 s, PI - 107%, PST - neg., ET - neg. A blood test for alcohol is negative. Given the instability of hemodynamics - tachycardia, a tendency to hypotension, low CVP, it was suggested that the patient had hypovolemic shock in the stage of decompensation. An urgent study was conducted on the indicators of the rheological properties of blood on the device APR-01 "Mednord". The data obtained: Ar = -9 rel. units, g = 6.6 min, k = 6 min, MA = 570 rel.ed., T = 60 min, FA = 15% allowed us to conclude that the patient has only increased aggregation activity of shaped elements, which according to our data may be noted in the compensated stage of circulatory shock. Further analysis of the course of the disease showed that the conclusion about the presence of compensated shock in the patient, made on the basis of a study of blood rheological properties, is more correct. Conducted infusion therapy aimed at correcting hypovolemia quite quickly (within 2 hours) led to the stabilization of hemodynamics. In the future, the patient showed no signs of impaired function of vital organs and systems. On the 4th day in satisfactory condition he was discharged from the hospital.

 Example 2

 An example of the use of a new method for diagnosing damage to the hemostasis system in patients with decompensated reversible stage of circulatory shock can be the case history of a patient, Sergei Yegorovich Sadov, 35 years old, who was treated at the Department of Toxicology OKB from February 8 to 16, 1994, case history No. 1871. Upon receipt of the anamnesis revealed that the patient about 15 days systematically alcoholized. Over the past 4 days, frequent vomiting, pains in the epigastric region, general weakness appeared. The patient's condition progressively worsened, shortness of breath, palpitations, elements of inadequacy in behavior appeared, there was a short-term attack of seizures. The ambulance team was delivered to the toxicological department of OKB. At the time of admission, the patient's condition is closer to severe. In consciousness, contact is available, but not quite adequate, motor excitement is periodically noted. The skin is pale, moderate acrocyanosis. Breathing independent, vesicular, shortness of breath up to 30 / min. Heart sounds are muffled, sinus rhythm, tachycardia up to 130 beats / min, blood pressure 125/90 mm RT. Art., CVP - negative. The abdomen on palpation is soft, painful in the epigastric region, no peritoneal symptoms are noted. Urination, according to the patient, is limited. Data from laboratory research methods: general blood and urine tests within the permissible norm, according to biochemical blood parameters - an increase in the level of amylase - 64 units, urea - 12 mmol / l. The study of the hemostasis system, conducted in the laboratory, was limited and was reduced to the determination of: PV - 15 s, PI - 130%, PST - neg., ET - neg. Considering that the patient has not been alcoholized for the last 2 days, the blood test for alcohol content is negative, it was suggested that the severity of the condition is caused not by alcohol poisoning, as such, but by the development of toxic gastritis, pancreatitis, leading to vomiting, dehydration, endotoxemia complicated by systemic circulatory disorder in the form of circulatory shock. Since, according to modern concepts, shock, disseminated intravascular coagulation and multiple organ failure syndrome are, in fact, links of a single pathological process and intravascular coagulation in the microvasculature is the morphological equivalent of decompensated forms of shock, the patient was urgently examined for rheological state of blood on the device ARP-01 Mednord. The results obtained: r = 3.8 min, Ar = -10 rel. units , k = 3.9 min, MA = 780 rel. units, T = 38 min, FA = 19%, allowed us to conclude that there is a high aggregation activity of blood cells and the activation of the coagulation component of hemostasis, which corresponds to the first hypercoagulation stage of DIC. The study was conducted for 55 minutes by the attending physician without the involvement of forces and means of the laboratory service. This allowed, in spite of the not quite typical clinical picture of shock (relatively normal BP indicators), to make this diagnosis and to start active antishock therapy in time, supplemented by the use of drugs that actively affect the functional state of the hemostatic system units / antiplatelet agents and anticoagulants /. The treatment during the first day led to the stabilization of the patient's condition. Available signs of impaired blood flow in vital organs / inadequate behavior, shortness of breath, inhibition of urination / stopped.

 Example 3

 An example of the use of a new method for diagnosing damage to the hemostasis system in a patient with a decompensated irreversible stage of circulatory shock can serve as a case history of the patient V. Menshikov. 34 years old, who was treated in the toxicology department of the OKB from January 5 to 7, 1994, the medical history N 171. From the anamnesis it is known that the patient was alcoholized for a long time. On January 5, there was an attack of seizures with loss of consciousness, and the resuscitation team of the ambulance station was called. Upon examination by a doctor, the condition is regarded as serious. Deeply inhibited, difficult to contact, unstable hemodynamics - BP 80/60 mm Hg, Ps 132 beats / min, integuments icteric, acrocyanosis, shortness of breath up to 40 / min. After carrying out infusion therapy and the relative stabilization of hemodynamics - blood pressure 95/70 mm Hg, Ps 124 beats / min, delivered to the toxicological department of OKB. At the time of admission, the patient remained in a serious condition. Consciousness is preserved, but inhibited, lethargic and dynamic. No active complaints, skin integument icteric, dry, significantly pronounced acrocyanosis. Independent breathing, shortness of breath up to 40 / min, in the lungs auscultatory hard breathing, scattered dry rales. Heart sounds are deaf, sinus tachycardia, heart rate 120 / min, blood pressure 100/75 mm Hg, CVP = 0. The abdomen on palpation is soft, painful in the epigastric region, there are no obvious symptoms of peritoneal irritation, swell, intestinal motility in the form of single waves . With the introduction of a catheter into the bladder, up to 30 ml of bloody urine is obtained. According to laboratory research methods: Hb = 174 g / l, Ht = 0.6; which indicates a thickening of the blood against a background of dehydration. In the urine, the presence of red blood cells and hyaline cylinders. Biochemical parameters indicate signs of renal hepatic failure: urea = 26 mmol / L, creatinine = 0.5 mmol / L, total bilirubin = 256 mmol / L, amylase level 64 c.u. According to a study of the hemostatic system: PV = 29 s, PI = 68%, PST = +, ET = ++. The obtained clinical and laboratory data made it possible to suspect the presence of circulatory shock in the patient, complicated by DIC - syndrome and multiple organ failure. An urgent study was conducted on the indicators of the rheological state of the blood on the device APR-01 "Mednord". The data obtained: Ar = -3.5, g = 11 min, k = 10.5 min, MA = 330 rel.ed., T = 75 min, FA = 30% allowed us to conclude that there is a low aggregation activity of blood cells , inhibition of the coagulation component of hemostasis against the background of high fibrinolytic activity, which corresponds to the late phases of the DIC, complicated by multiple organ failure, and is extremely unfavorable in terms of prognosis. The further course of the disease fully confirmed our assumptions. During the first hours of the patient’s stay in the hospital, active anti-shock therapy showed improvement: the hemodynamics of blood pressure was relatively stabilized - 120/90 mm Hg. Art., Ps - 108 / min, normalized CVP = 8 cm aq. Art. However, the condition remained serious, anuria, signs of hepatopathy, shortness of breath, encephalopathy persisted. Subsequently, against the background of the onset of symptoms of improved peripheral circulation, progression of heart weakness was noted. There was a drop in blood pressure, progression of tachycardia, the occurrence of arrhythmias, the development of alveolar pulmonary edema. Despite carrying out intensive care measures - transferring the patient to mechanical ventilation, conducting cardiotonizing therapy, the patient's condition progressively worsened and blood circulation stopped on 7/01-94. Resuscitation measures did not give effect, death was ascertained.

 These criteria for changes in hemocoagulogram parameters characteristic of shock damage to the hemostatic system are selected based on a study of 100 patients with circulatory shock. In 98% of cases, the clinical signs of shock were confirmed by the presence of disorders in the hemostatic system. In addition, the nature of the damage to the hemostatic system, detected using the proposed diagnostic method, allows you to determine the degree of decompensation of this pathological process, which later also received 97% clinical confirmation.

 Thus, the application of the proposed method for diagnosing damage to the hemostatic system in patients with circulatory shock allows the attending physicians directly at the patient’s bedside not only to obtain more accurate laboratory confirmation of the clinical diagnosis, but also to determine the degree of decompensation of this pathological process in a shorter time.

Bibliography
1. V.P. Baluda, 3.S. Barkagan, E.D. Goldberg, B.I. Kuznik, K.M. Lakin Laboratory methods for studying the hemostasis system. - Tomsk. 1980 .-- 309 s.

 2. 3.S. Barkagan Hemorrhagic diseases and syndromes. - M .: Medicine. 1988 .-- 528 p.

 3. Patent for the invention of the Russian Federation N 2063037, BI N 18 from 06/27/96.

 4. I.I. Tyutrin, O.Yu. Pchelintsev, M.N. Shpisman, A.N. Parshin, V.E. Shipakov A new way of integrative assessment of the functional state of the hemostatic system. // Clinical laboratory diagnostics. -M. 1994. - N 6. -C. 26-27.

Claims (1)

 A method for determining the stages of the pathological process in patients with circulatory shock, which consists in recording and evaluating the viscous characteristics of the coagulating blood of the reaction period r, thrombin constant k, the maximum amplitude of MA, the formation time of the fibrin-platelet structure of clot T, the total retraction rate and spontaneous lysis of the FA clot, characterized in that it additionally determines the intensity of spontaneous aggregation of Ar platelets and at r values within 5 - 7 min, Ar from - 2 to - 6 Rel. units, k within 4–6 min, MA within 500–700 relative units, T within 40–60 min, FA equal to 10–20%, determine the absence of shock, with Ar from –8 to –14 rel. and the absence of changes in other indicators, the compensated shock stage is determined, with r less than 4 min, Ar equal to –8 to –14 rel.units, less than 3 min, MA more than 750 rel.units, T less than 40 min, FA, equal to 10 - 20%, determine the decompensated reversible stage of shock, when r more than 10 min, Ar, equal - 4 rel. and above, to more than 9 min, MA less than 400 rel.ed, T more than 70 min, FA more than 20% or less than 5% determine the decompensated irreversible stage of shock.

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