RU2192847C2 - Method for treating acute pancreatitis - Google Patents

Abstract

FIELD: medicine, gastroenterology. SUBSTANCE: additionally to traditional therapy it is suggested to apply sodium oxybutyrate at 4.0-8.0 daily dose to obtain normal values of urinary diastase. The method enables to achieve improved results due to earlier and more complete restoration of pancreatic function. EFFECT: higher efficiency of therapy. 1 cl, 1 ex

Description

 The invention relates to medicine, namely to intensive care, and can be used for emergency medical care for patients with acute pancreatitis.

 Since 1950, protease inhibitors have been widely used to treat acute pancreatitis: trasilol, tsalol, contracal, etc.

 “Since the 80s, the vast majority of surgeons have preferred the conservative treatment of acute pancreatitis” (Dr. Surgery, 1994, 6, p. 38) using high doses of protease inhibitors.

 It is known that to relieve pain, as a defining symptom in the diagnosis of acute pancreatitis, in most cases a subcutaneous or intravenous 2% solution of promedol is used (MM Boger. Pancreatitis. Novosibirsk, 1984, p. 103). Due to the severe pain syndrome in acute pancreatitis, antihistamines are prescribed to enhance the effect of promedol, but despite 4-6-fold injections of these drugs, the pain syndrome does not completely stop, often causing respiratory failure with the subsequent development of multiple organ failure leading to death. Therefore, to eliminate the pain syndrome, a search is underway for the use of new drugs, cocktails or blockades (Zh. Surgery, 1994, 6, p. 38). "We must not forget that at present many cases of" promedalism "are described similarly to morphinism" (B.E. Votchal. Essays on Clinical Pharmacology. Publishing House "Medicine", 1965, p. 405).

 The prototype of the invention is a method for the treatment of acute pancreatitis by the intravenous administration of protease inhibitors, in which "trasilol is administered intravenously in a 5% - 40 ml glucose solution at a dose of 100 thousand to 1 million units per day. In recent years, the use of higher doses "(MM Boger. Pancreatitis. Novosibirsk. 1984, p. 109).

 The surgical treatment method is indicated for patients in whom intensive therapy is ineffective, and the operation itself is a “despair operation”, because despite the constant expansion of the arsenal of intensive care methods and means, the mortality rate among the operated remains high -50-85%, and with fulminant form 98-100% (J. Surgery, 1994, p. 38).

 "In recent years, there have been reports of insufficient effectiveness of protease inhibitors in severe forms of destructive pancreatitis" (MM Boger. Pancreatitis. Novosibirsk, 1984, p. 109). "... on the effectiveness of protease inhibitors in acute pancreatitis, there is evidence of their dubious effectiveness or complete lack of effect in the treatment of pancreatitis." "According to several authors, the use of protease inhibitors in the treatment of acute pancreatitis does more harm than good, therefore it is advisable to completely abandon them" (J. Surgery, 1994, p. 39).

 The technical result is an increase in the effectiveness of treatment due to the earlier and more complete restoration of pancreatic function, prevention of its infection and transition to the phase of pancreatic necrosis, reduction of indications for surgical intervention, reduction of the mortality rate and reduction of the patient’s hospital stay.

The inclusion in the intensive care program of acute sodium pancreatitis of oxybutyrate is dictated by its multifaceted pharmacological activity, which affects many links of pathogenesis, namely:
- suppresses pain
- reduces the secretory activity of the pancreas,
- reduces the production of enzymes,
- reduces intra-flow pressure,
- removes the emotional component,
- helps relieve spasm and improve the drainage function of the ducts,
- has antihypoxant and antioxidant effects,
- limits the destruction of cell membranes,
- protects the pancreas from necrobiotic processes.

A method of treating acute pancreatitis is as follows:
the patient at the time of admission to the hospital when filling out a medical history is diagnosed with the severity of the condition, treatment plan and examination plan. The survey plan includes indicators of urine diastases. The resuscitator, according to the severity of the pathological condition, hospitalizes the patient in the intensive care unit and determines the volume of infusion therapy, which additionally includes sodium oxybutyrate:
glucose 5% - 200.0 ml
novocaine 0.25% - 100.0 ml
platifillin 0.2% - 2.0 ml
diphenhydramine 1% - 1.0 ml
sodium oxybutyrate (GHB) 20% - 10.0 ml (2.0 g)
potassium chloride 7.5% - 30.0 ml
MDS. Intravenously, drip 2-3 times a day. The daily dose of sodium oxybutyrate is prescribed depending on the body weight and severity of the patient - 4.0 g - 8.0 g.

 This therapy is used from the first hour of the patient’s admission to the hospital and in the following days until the normalization of urine diastases. For example, urine diastasis decreased from 2048 units to 16-64 units.

 Urine diastasis is examined twice a day daily at its high rates.

 Example.

 Patient R., 34 years old, was admitted on December 16, 1999 (case history 16330) at 02:30 in an emergency with a diagnosis of Acute pancreatitis.

 Complaints of acute intense pain in the upper abdomen, pain of a constant nature, girdle, with radiation in the back.

 He became acutely ill at about 01:00 on 12.16.99 after eating fatty foods. Due to severe pain, the patient was taken by ambulance to the 18th clinical hospital in Ufa.

 The patient's condition is severe: excited, rushing about from pain. Consciousness is clear. The skin is pale, clean, dry.

 Heart - tones are muffled, rhythmic. HELL 160/90 mm RT. Art. Pulse 100 beats per minute, rhythmic, satisfactory filling.

 In the lungs vesicular breathing, no wheezing. The symptom of striking on both sides is negative.

 St. Localis. The tongue is dry with a white coating. The abdomen is round, swollen. In the midline of the abdomen from the xiphoid process to the navel is a keloid scar. In the right hypochondrium there is a star scar. The patient was operated on at City Clinical Hospital 021 in 1997. about acute pancreatic necrosis. Palpation in the epigastrium and left hypochondrium is sharply painful. The symptom of Ortner is sharply positive. Symptom Shchetkina - negative.

 Diagnosis: Acute pancreatitis.

Survey Plan:
1. Urine diastasis
2. White blood cells
3. ECG
4. Therapist consultation
5. Consultation by an anesthetist
6. Observation in dynamics
Treatment plan:
1.Infusion-detoxification therapy
2. Antispasmodics
3. Local hypothermia
4. Analgesics
Upon receipt 02 ⁴⁵
Diastasis of urine - 1024 units according to Voyachek (normal 16-64 units)
Glucose - 6.98 mmol / L
ALT - 15.2 u / l
Total protein - 61.2 g / l
Urea 2.68 mmol / L
Total bilirubin - 10.0 mmol / l
PTI 100%
Red blood cells 4.8 • 10 ¹² / l
HB - 152 g / l
White blood cells 10.6 • 10 ⁹ / l
E-1%, P-4%, C - 71%, L - 20%, m - 2% ESR - 5 mm / h
02 ³⁰ Examination by a general practitioner. The diagnosis is the same - Acute pancreatitis.

02 ⁴⁵ Examination by an anesthetist - assesses the severity of the condition as severe.

 The diagnosis is the same - Acute pancreatitis.

Recommended by:
1. Infusion therapy in the amount of 2 liters
Glucose 5% - 200.0
Novocaine 0.25% - 100.0
Platifillin 0.2% - 2.0
Diphenhydramine 1% - 1.0
Sodium hydroxybutyrate (GHB) 20% - 10.0 (2.0 g)
KCl 7.5% - 30.0
Prednisone 30 mg. Intravenously, drip.

2. Adequate pain relief
3. The control of urine diastases in dynamics
4. Hunger
5. Local hypothermia
Ultrasound and fibrogastroscopic studies were performed to clarify the diagnosis. The diagnosis of acute pancreatitis was confirmed.

 After 30 minutes from admission and 2 hours from the onset of the disease, infusion therapy with sodium oxybutyrate was carried out intravenously.

 No protease inhibitors were prescribed in this patient.

 12/16/99. Adequate pain relief was carried out with sodium hydroxybutyrate 2.0 g intravenously (twice a day) and promedolum (three times) intramuscularly.

List of medical appointments in the intensive care unit 12/16/99
1. Glucose 10% - 400.0
KCl 7.5% - 30.0
MgSO ₄ 25% - 10.0 2 times / day
Insulin 8 units
2. Ringer's solution - 400.0 2 times / day
Eufillin 2.4% - 10.0
3. Glucose 10% - 200.0
Novocaine 0.25% - 200.0
Sodium oxybutyrate (GHB) 20% - 10.0 (2.0 g) 2 times / day
Prednisone 30 mg
Diphenhydramine 1% - 1.0
Platifillin 0.2% - 1.0
4. Sodium chloride 0.9% - 400.0
Agapurin 5.0
5. Promedol 2% - 1.0 v / m 3 times
6. Vitamins B ₁ 3.0 iv, B ₆ 3.0 iv
7. Cold on the epigastric region
8. Cleansing enema
Blood pressure, heart rate, heart rate, urine output, body t were monitored. There was vomiting once. Inspection by the surgeon 16.12. Conservative treatment recommended.

12/16. Resuscitator
24 ^{00 The} condition is serious. In the mind. Complaints of pain in the epigastrium, bloating.

t-36.6 ^o C
The skin is clean, normal color. The vesicular breathing, no wheezing. HELL 120/70 mm Hg Pulse 84 in 1 min, rhythmic.

 The tongue is moist, the stomach is soft, swollen.

 Peristaltic noises are not heard.

 Cleansing enema without effect.

 Diuresis is sufficient.

 12/17/99 Resuscitator.

 The condition is serious. The pain syndrome has decreased.

 The skin is clean, normal color.

 Breathing and hemodynamics are satisfactory.

 HELL 120/70 mm RT. Art. Pulse 84 in 1 min.

 The tongue is moist, the stomach is soft, moderately swollen.

 Diuresis is sufficient.

 Diastasis of urine 256 units.

 12/17/99.

 Inspection of the head. surgical department.

 The condition is stable. Consciousness is clear, calm.

 Pain in the upper abdomen. There is no jaundice. Tongue dry, coated. Pulse 90 in 1 min, satisfactory filling and voltage.

 The abdomen is not swollen, symmetrical, with palpation soreness in the epigastric region. There are no peritoneal signs. Intestinal motility is active. Diastase 128 units. Conservative therapy to continue.

17 ³⁰ State of moderate severity. Subjectively, the patient feels better. The pain stopped.

 The skin is of normal color.

 The tongue is dry.

 In the lungs vesicular breathing, no wheezing.

 Heart tones are muffled, the rhythm is correct.

 HELL 130/90 mm Hg Pulse 96 in 1 min.

 The abdomen is moderately swollen, peristaltic noises are heard.

 Diuresis is adequate.

 Urine diastasis is reduced.

 12/17/99.

24 ^{00 The} patient was transferred to the surgical department with positive dynamics. Reduced infusion therapy.

In the department, treatment continued:
1. Glucose 5% - 400.0 ml 1p / day - 4
4 insulin
GHB 20% - 10.0 ml
Novocaine 0.25% - 100.0 ml 2
NaCl 0.9% - 200.0 ml 1p / day - 4
Analgin 50% - 2.0 ml
Diphenhydramine 1% - 1.0
MgSO ₄ 25% - 10.0
3. Atropine 0.1% - 1.0 subcutaneously 2p / day
4. Control of blood pressure, R, BH, urine diastases
12/18/99.

10 ^{00 The} surgeon on duty.

 The patient's condition is satisfactory. Subjectively notes improvement. The skin is of normal color. Pulse 74 in 1 min. The abdomen is soft, painless, not swollen. The dynamics are positive. Conservative therapy to continue.

 12/19/99.

12 ⁴⁵ Diastasis of urine 256 units
After the treatment, the patient's condition is satisfactory. Discharged 12/28/99. Spent only 12 k / days (in intensive care unit 1 k / day).

Diagnosis at discharge: Acute pancreatitis, edematous form. Concomitant: Erosive gastritis. Analyzes from 12.23.99. Diastasis of urine - 64 units
Blood tests: white blood cells 8.5 • 10 ⁹ / l, red blood cells - 4.8 • 10 ¹² / l, HB - 152 g / l.

Blood biochemistry:
Glucose - 6.1 mmol / L
Bilirubin - 10 mmol / L
Total protein - 61 g / l
Urea - 2.4 mmol / L
Urinalysis: protein (-), white blood cells - 3 in the s / s, the epithelium is hyaline unified. in p / 3r.

 It is discharged in satisfactory condition under the supervision of a local gastroenterologist.

 The proposed method of using sodium oxybutyrate in the conservative treatment of acute edematous pancreatitis has reduced the hospital bed in intensive care (1.8 k / day) and in the hospital 12 k / day (MES - 14 k / day), after surgery for acute destructive pancreatitis - in intensive care unit 4.4 k / day, in the hospital 25.6 w / day (MES - 45), without surgery - in intensive care unit - 3.7 w / day.

 Mortality decreased with destructive forms of acute pancreatitis: after surgery - 20.6%, with conservative treatment - 12.2%, with edematous form of acute pancreatitis, mortality - 0.

 Given the simplicity, accessibility and high efficiency of the proposed method for the treatment of acute pancreatitis, it can be recommended for active implementation for the intensive treatment of acute pancreatitis in practical health care.

Claims (1)

 A method of treating acute pancreatitis, including symptomatic and infusion-detoxification therapy, characterized in that sodium oxybutyrate is additionally administered in a daily dose of 4-8 g until normal urine diastase values are normalized.