RU2249432C2 - Method for determining quantitative estimation of state severity degree of patients and victims having injuries and evaluating effectiveness of applied therapy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves determining linear blood circulation speed above and below diaphragm using dopplerography approach. State severity class is determined as healthy, recovering and heavy from measured linear velocities ratio. Applied therapy effectiveness is determined on the measured linear velocities ratio exiting beyond the scope of severity class range, when analyzing patient state dynamics.

EFFECT: high accuracy in estimating patient health state.

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Description

The invention relates to medicine and can be used in departments of various profiles and at the outpatient stage of medical rehabilitation to determine a quantitative assessment of the severity of the condition of patients with various diseases and injured with injuries. The invention can be used to dynamically monitor the condition of patients and injured in departments of various profiles, to assess the effectiveness of the therapy.

Known methods for determining the quantitative assessment of the severity of the condition, the change of which is a measure of the effectiveness of treatment in patients with injuries and in patients with various pathologies. For example, at present, the ARACNE scale is used most often in Russia and other countries to determine the quantitative assessment of the severity of a condition (10). The ARACNE-2 scale is recognized in America as the “gold standard”, since it determines the reliability of other methods for determining the severity of the condition (2).

The high reliability of the predicted and real outcome was proved, depending on the assessment of the severity of the condition on the ARACNE-2 scale (1). One of the advantages of the ARACNE-2 scale is the inclusion of the Glasgow coma scale in its composition (2.10).

However, with all the advantages and high reliability of the ARACNE-2 scale, it has the following disadvantages.

- Many parameters included in this scale remain unchanged during the day, despite ongoing intensive rehabilitation measures, which makes it impossible to determine the effectiveness of the therapy and the dynamics of the rehabilitation process. For example, for a day or more they may remain unchanged - a Glasgow coma score, white blood cell count, hematocrit, and other indicators.

- Parameters of PaO ₂ , pH, Na, K, creatinine, hematocrit, leukocyte count suggest invasive laboratory research methods, which is not always justified after transferring the injured and patients from intensive care units to specialized departments and to the outpatient treatment stage.

- It is doubtful to use this scale for an individual forecast, since its accuracy does not exceed 74% (2).

- It is problematic to assess the severity of the condition and the effectiveness of rehabilitation measures with a score of 10 points or lower on the ARACNE-2 scale, since many indicators of the scale, although they do not reach the norm, are already in the 0 point rating range.

Known methods for determining blood flow velocity using a dopplerograph in the lower vena cava (IVC) section below the diaphragm (3.6).

However, the known methods do not make it possible to determine changes in blood flow velocity in the LEL sections depending on changes in the pressure gradient in the HUB (8) and on changes in the severity of the condition of the injured and patients. The literature does not describe methods for determining the difference in blood flow velocities in the LEL section above and below the diaphragm, their dependence on the pressure gradient in this section (8), therefore, there is also no way to assess the severity of the condition and the effectiveness of the therapy in patients and patients using these indicators.

The aim of the invention is the creation of a reliable non-invasive method for determining changes in the quantitative assessment of the severity of the condition of patients and injured victims in departments of various profiles and at the outpatient stage of medical care.

This goal is achieved by the fact that the method of determining the quantitative assessment of the severity of the condition and the effectiveness of the therapy in patients and patients by determining the blood flow velocity in the inferior vena cava by Doppler ultrasonography (3, 6, 8) is that to assess the effectiveness of the therapy in Doppler In this mode, the linear blood flow velocity of the LSC is first determined above (V ₁ ) and then below (V ₂ ) the diaphragm according to the generally accepted technique (3, 6). To numerically evaluate the ratio of speeds at the time of the study, the results of this study are compared among themselves in terms of the fraction, in the numerator of which - the blood flow velocity in the IVC above the diaphragm (V ₁ ), and in the denominator - the blood flow velocity in the IVC below the diaphragm (V ₂ ). The obtained ratio of the linear velocity ratio is denoted by POL. POLS = V ₁ / V ₂ . According to the indicator, which is a quantitative assessment of the severity of the condition of patients and injured with injuries at a given time, determine the appropriate severity class, which is indicated in the table. A change in the index of POLS in dynamics and its going beyond the range of the severity class indicates an improvement or worsening of the condition of patients, the effectiveness or inefficiency of the therapy.

Description of the invention.

In studies on the possibility of an objective quantitative assessment of the severity of the condition, all researchers of this problem came to the conclusion that the scales for determining the severity of the condition should include integral indicators of impaired body functions (1, 2, 4, 5, 10). It is known that centralization of blood circulation, impaired peripheral circulation and a violation of the function of external respiration are the main signs of the severity of the condition (1, 4, 5, 8, 9).

However, to date, there have been no studies on the quantitative characteristics of centralization of blood circulation, the main component of which is the deposition of blood in the NPS pool and impaired venous return (7, 8, 9).

To study the quantitative characteristics of centralization of blood circulation in injured and sick people in dynamics with a decrease in the severity of the condition at various stages of medical care, 307 people of various sexes aged 18 to 70 years were examined. To obtain the norm indicators, healthy volunteers were studied - men and women aged 18 to 70 years - 54 people (17.6% of all studied).

There were 253 patients with combined trauma and various volumes of lesions, patients with cardiac pathology, pneumonia, paralysis of various etiologies (multiple sclerosis, cerebral palsy, spinal cord and spinal cord injury).

The studies were carried out at 3 stages of rehabilitation: in the intensive care unit, in specialized hospital departments and at the outpatient stage. 139 (54.9%) of the injured and sick were examined in the intensive care unit. 49 (19.4%) of the injured and sick were examined in specialized departments. 65 (25.7%) of the injured and patients underwent outpatient treatment.

All injured and sick were divided into 7 groups.

Groups 1-5 were in the intensive care unit, group 6 was in specialized hospital departments, and group 7 was in the outpatient treatment phase (Table 1).

1 group. 15 (5.9%) people were in a coma. These were the victims with severe combined injuries who underwent anti-shock measures on the 1st day after admission to the hospital, victims with severe head injury (injuries and damage to brain matter), and victims with injuries incompatible with life, as well as patients with heart and pulmonary pathology (heart attacks, severe pleuropneumonia).

Reflexes in the subjects were not determined. The pupils did not react to light. The assessment by ARACNE-2 in the 1st group was from 30 to 35 points and above, the mortality forecast from 60% to 75% and above.

All subjects underwent mechanical ventilation, massive infusion therapy, antibacterial therapy, and vasopressors were prescribed.

2 group. 7 (2.8%) of the injured and patients were also in a coma on mechanical ventilation, but they had reflexes to severe pain stimuli, as well as a reaction of the pupils to light stimuli. These were injured and sick after anti-shock measures, after emergency surgery (2-3 days). He underwent transfusion therapy, continued antibacterial therapy, and vasopressors for these victims were prescribed according to indications. Evaluation by ARACNE-2 in these subjects was from 25 to 30 points, the prognosis of mortality from 50% to 60%.

3rd group. 9 (3.5%) of the subjects were in a stupor or their consciousness was confused. He performed mechanical ventilation. Their reflex activity was reduced, there was a good reaction of the pupils to the light.

Transfusion therapy was carried out by this investigator, but its volumes were much smaller than that of the subjects in a coma. No vasopressors were prescribed for these patients. Evaluation by ARACNE-2 in these patients was from 23 to 28 points, the prognosis of mortality to 50%.

4 group. 17 (6.7%) of the subjects who were on mechanical ventilation in the support mode were prescribed inhalations with oxygen. The volumes of infusion therapy were reduced, and antibiotics were prescribed taking into account the sensitivity of microflora. Assessment by ARACNE-2 in this group was from 20 to 25 points, the mortality forecast from 30 to 50%.

After the doctor’s repeated commands, they reacted weakly and could follow the simplest instructions (“shake hands”), but they couldn’t change their position on the bed, and therefore the help of the medical staff was required for their coups.

5th group. 91 (36.0%) people were conscious. Their breathing was independent. Their cough reflex was reduced, but at the command of a doctor they could cough. Their infusion therapy was minimal. Antibiotic therapy was carried out taking into account the sensitivity of microflora. These victims could follow the doctor’s instructions. Their blood pressure was within the lower limit of normal. The ARACNE-2 score for these victims was 10-19 points, and the risk of mortality did not exceed 30%.

6th group. 49 (19.4%) of the subjects were in specialized departments. For the purpose of prevention and treatment, they were prescribed antibiotic therapy, symptomatic therapy and special therapy, depending on the diagnosis. Their ARACNE-2 score was much lower than 10 points, and the mortality forecast was minimal.

7th group. 65 (25.7%) of the injured and patients underwent outpatient treatment. These were people with disabilities with paralysis after a trauma to the spine and spinal cord, lower paraplegia that developed as a result of multiple sclerosis, and patients with cerebral palsy. This group included patients with diseases of the lungs and cardiovascular system who did not need hospitalization.

Thus, the general clinical picture of the injured and sick was distinguished by great variability of clinical symptoms, volumes of lesions, complications, and various severity of the condition.

In accordance with the clinical characteristics, the number of points according to ARACNE-2 and the risk of mortality of the subjects were distributed according to the classes of severity of the condition.

When classifying, they were guided by the following principles. For doctors of any specialty, the prediction of mortality is primarily important. It is clear that the probabilistic forecast “fifty / fifty” - 50% / 50% - is not clear as to mortality, but at the same time it is most important when sorting the victims, mobilizes doctors and directs their actions to take the necessary measures to improve the condition the victim, reducing the quantitative score, and hence improving the probabilistic forecast.

It is known that the probability of an unsuccessful outcome increases sharply with an increase of every 3-5 points in the range starting from 20 points and above (1, 2, 4, 10).

As follows from Table 1, the uncertain forecast “fifty / fifty” - 50% / 50% is maintained in the range of assessing the severity of the condition 20 to 30 points according to ARACNE-2, which coincides with the opinion of other researchers (1, 4, 10). Such a forecast is typical for 2-4 groups.

When assessing more than 30 points according to ARACNE-2 (group 1), the prognosis of mortality becomes extremely unfavorable, reaching 75% and higher.

When assessed in the range from 19 to 15 points, the prognosis of mortality sharply decreases and does not exceed 20%, and in the range from 15 to 10 points it becomes even less, the injured and patients are preparing to transfer from intensive care to specialized departments (group 5).

Group 6 - patients and victims of specialized departments, on the ARACNE-2 scale can be rated at 10 points or less, their risk of mortality is minimal.

Of course, the injured and patients at the outpatient stage of rehabilitation differ in many physiological indicators from healthy people, so they were assigned to group 7.

Guided by the above principles and for the convenience of further research, all victims were distributed according to the predicted risk of mortality on the ARACNE-2 scale, into 4 classes of severity of the condition (Table 2).

Grade 0 was composed of healthy volunteers.

Grade 1 comprised outpatients and victims (group 7).

Grade 2 comprised the injured and patients with an ARACNE-2 score of 10-19 points with a mortality risk significantly lower than 50% (group 5-6).

Grade 3 consisted of injured and patients with an ARACNE-2 score of 20 to 30 points with a dubious prognosis of mortality of 50% / 50% (groups 2-4).

Grade 4 comprised victims with an APACNE-2 score> 30 points, the mortality prognosis of which was estimated to be significantly higher than 50% (group 1).

LSC in the NIP was studied in 117 injured and patients of different sex and age, with different lesions, various diseases, located in different classes of severity and at different stages of medical rehabilitation.

To obtain the values of BFV in the NPS in healthy individuals, as a criterion for comparison with the injured and sick, preliminary studies were conducted in 29 healthy volunteers of different sexes aged 18 to 70 years. To obtain correct results, all injured and healthy volunteers were examined at least 10 minutes after a quiet stay in the supine position.

Dopplerographic study of LSC in the LEL above and below the diaphragm was performed on a HEWLETT-PACKARD apparatus. First, the LSC was studied in the LEL section above the diaphragm - V ₁ , and then the LSC was studied in the LEL section below the diaphragm V ₂ according to the generally accepted method (3, 6). The ratio of linear velocities was indicated by POL. POLS = V ₁ / V ₂ .

The obtained BFV values were highly variable, independent of age, gender, and lesion volumes.

In healthy volunteers in grade 0, the LSF ranges in the LEL above the diaphragm were recorded in the range from 70 cm / sec to 97 cm / sec, and under the diaphragm, in the range from 63 cm / sec to 87 cm / sec.

In the 0th grade, the PEFC was always greater than 1 and averaged 1.125 ± 0.03.

In the 4th grade of severity of the condition with an ARACNE-2 score of more than 35 points and a mortality risk of more than 75%, the obtained BFV values in the LEL above the diaphragm were recorded in the range from 43.2 to 63.3 cm / s, and from 86 under the diaphragm 5 to 140.8 cm / sec. POCL was less than 1 and ranged from 0.87 to 0.32. The lowest HEMF - from 0.56 to 0.32 was in patients with combined injuries incompatible with life, in patients with extensive myocardial infarction. POLICE in these subjects during subsequent measurements tended to decrease, despite the ongoing intensive care.

In 13 injured and grade 4 patients with an assessment of 30-32 points and a mortality risk of more than 50%, the CAP was less than 1, but against the background of intensive therapy, after a day it increased and became more than 1, and the ARACNE-2 score decreased to 25-27 points.

The distinctive features of the 4th class studied (when assessing more than 30 points according to ARACNE-2 and the maximum risk of mortality) were that the absolute values of the LSC in the LEL above the diaphragm were always less than the values of the LSC recorded under the diaphragm, and the FEL was always less 1.

In grade 3 severity, the state of the LSC in the LEL above the diaphragm was recorded in the range from 127 to 145 cm / sec, under the diaphragm - from 104 to 147 cm / sec. With an improvement in condition, a decrease in the scoring from 30 to 25 ± 2 points and a decrease in the risk of mortality, the CAP increased to 1.6-1.7 and averaged 1.65 = 1 = 0.05.

The victims of the 3rd class with a score of 20-30 points according to ARACNE-2 and a dubious prognosis noted the following features: the average values of LSC in the LEL above the diaphragm were greater than the values of LSC under the diaphragm. In this class, the maximum mean POL values were recorded, compared with other groups (p <0.05).

In the studied class 2 severity conditions with an APACNE-2 score of 19 to 10 points and with a tendency of mortality risk to a minimum, LSC in the LEL above the diaphragm were recorded in the range from 87 cm / sec to 160 cm / sec, under the diaphragm - from 70 to 130 cm / sec The average values of the POL were 1.235 ± 0.03.

Distinctive features in the 2nd grade were the following:

- The values of the BFV in the LEL above the diaphragm have always been greater than the values of the BFV under the diaphragm (p <0.05).

- The mean POL in the 2nd grade was less than in the POL in the 3rd grade, but higher than in the 0th group (p <0.05).

In the 1st class of severity, the state of the BFV in the LEL above the diaphragm was recorded in the range from 65.6 cm / sec to 130 cm / sec, and the BFV under the diaphragm was recorded in the range of 42.3 cm / sec to 110 cm / sec.

In the 1st grade, the FIRM was within the limits of (M ± m) 1.19 ± 0.01, the BFV above the diaphragm was also always larger than the BFV under the diaphragm (p <0.05). POLS in this group did not reach the values recorded in healthy individuals.

Thus, the studies showed that the BFV in the NPS among the subjects differed in large ranges of variability, did not depend on gender and age, disease and lesion volumes, but depended on the severity of the condition of the victims. (Table 3).

POLS, in contrast to LSC, is a more accurate criterion for determining the severity of a condition, since its variability within the class is not so significant compared with the variability of LSC.

The data obtained indicate persisting signs of blood deposition, impaired venous return in patients and patients at all stages of medical rehabilitation until recovery.

POLS is a quantitative integral indicator of the violation of the central hemodynamics of CHD, in general, and the violation of venous return, blood deposition, in particular. POLS can be used as an indicator of the effectiveness of ongoing rehabilitation measures.

On the basis of the studies, the ranges of POL for the different classes of severity of the condition, their correlation with the assessment by ARACNE -2, the table of qualitative and quantitative characteristics of the severity of the condition was compiled (Table 4).

In the 4th grade, the COLF is always registered less than 1. When the state improves and the score decreases below 30 points, the COLF tends to jump in growth and becomes much larger than 1 (inverse correlation dependence).

POL in the 1-3 grade of severity is significantly higher than in healthy individuals (p <0.05). With a change in the severity of the condition from grade 3 to grade 1, a decrease in the score for ARACNE-2 and a mortality risk below 50%, there is a tendency to a decrease in POL (direct correlation dependence).

Clinical example.

1. Injured M. 23 was admitted with a diagnosis of Combined injury. TBI. Fracture of the arch and base of the skull. Bruise of the brain. Dumb abdominal injury.

The victim, who was in a coma, on mechanical ventilation, the ARACNE-2 score on admission on the first day was 32 points, the risk of mortality was more than 75%. LSK above the diaphragm - 54 cm / sec. LSK below the diaphragm - 83 cm / sec. POL was equal to 0.65, which corresponded to class 4 severity of the condition. Decompressed craniotomy was performed to the injured person due to increasing intracranial hematoma. After the operation, the condition of the victim stabilized, but remained severe. LSC studies were conducted 2 days after surgery, when the victim was in a coma, on mechanical ventilation. The ARACNE-2 score decreased to 26 points, the mortality risk - up to 50-60% of LFV in the LEL above the diaphragm - 127.5 cm / sec, LFV in the LEL below the diaphragm -75.5 cm / sec, FOL = 1.7. These data corresponded to class 3 severity.

After 2 weeks, against the background of intensive therapy, M.'s condition improved. He regained consciousness. Mechanical ventilation with support. The rating on ARACNE-2 became equal to 18 points, the risk of mortality became less than 20%. LSC in the LEL above the diaphragm is 145 cm / s, LSC below the diaphragm is 111 cm / s, POLS = 1.3, which corresponds to Grade 2.

After 2 weeks, when assessing 10 points for ARACNE-2 and POLS = 1.2, the victim was transferred to the neurosurgical department.

The given example shows that, in individual studies in the dynamics of POL, correlates with the assessment of the severity of the condition according to ARACNE-2 with the same pattern that we obtained in statistical group studies in the general population.

2. In victim B. 54, with extensive myocardial infarction in a coma, on mechanical ventilation, the ARACNE-2 score at the time of the study was 32 points. LSK above the diaphragm - 54 cm / sec. LSK below the diaphragm - 83 cm / sec, POL = 0.65, which corresponded to grade 4 severity. A day later, the LEL decreased to 0.51, that is, did not go beyond the range of the 4th class indicated in the table. The patient died after 2 days, despite ongoing intensive care.

This example shows that the method can be used for dynamic monitoring of the patient and assess the effectiveness of therapeutic measures. In this case, all modern methods of intensive care have been found to be ineffective, as evidenced by the decrease in LPS in dynamics.

Table 1.
The main distinguishing features in groups. No. / Group No. Quantity in groups ARACNE-2 score Character
Chronicles of consciousness Breathing features Rehabilitation stage Abs % Points Mortality risk% 1 fifteen 5.9 30-35 60-75 Not Mechanical ventilation Resuscitation and intensive care 2 7 2,8 25-30 50-60 Not Mechanical ventilation 3 nine 3,5 23-28 50-60 Sopor. Mechanical ventilation 4 17 6.7 20-25 30-55 In the mind IVL with support, independent 5 91 36.0 10-19 10-20 In the mind Self 6 49 19,4 <10 → 0 In the mind Self Specialized departments 7 65 25.7 <10 → 0 In the mind Self Outpatient Total 253 100 ~ - - - -

Table 2.
Schematic diagram of the classification of the severity of the condition. Severity rating Grade Grade 0 1 2 3 4 Quality Healthy Recovered
Wow Less heavy Heavy Very heavy Points on ARACNE-2 - <10 10-19 20-30 > 30 ARACNE-2 mortality risk (%) - Risk → 0 <50 50/50 > 50 Qualitative characteristics of the forecast Satisfactory Satisfactory Doubtful Very bad

Table 3
The average values and indicators of the relationship of linear blood flow velocities in the inferior vena cava in the subjects. The investigated parameters The average values of BFV and POL for the subjects (M ± m) Grades of severity 0 1 2 3 4 V ₁ cm / sec 91.5 ± 1.2 131.3 ± 1.2 144.75 ± 1.02 127.18 ± 1.14 56.2 ± 1.07 V ₂ cm / sec 81.5 ± 1.3 110.1 ± 1.1 118.75 ± 1.02 86.9 ± 1.13 132.5 ± 1.05 POLS = V ₁ : V ₂ 1.125 ± 0.03 1.19 ± 0.01 1.235 ± 0.03 1.65 ± 0.05 0.485 ± 0.05

Table 4.
Qualitative and quantitative characteristics of the classes of severity of the condition of victims and patients. Severity rating Severity classes 0 1 2 3 4 Quality Healthy Recovering Less heavy Heavy Very heavy Points on ARACNE-2 - <10 10-19 20-30 > 30 ARACNE-2 mortality risk (%) - Risk → About <50 50/50 > 50 Qualitative characteristics of the forecast - Satisfactory Satisfactory Doubtful Very bad REF 1.05-1.15 1.16-1.25 1.26-1.35 > 1.35 <1

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Claims (1)

A method for determining a quantitative assessment of the severity of the condition of patients and injured with injuries and evaluating the effectiveness of the therapy, including assessing the severity classes, characterized in that the Doppler method determines the linear blood flow velocity first higher (V1) and then lower (V2) of the diaphragm according to the generally accepted method, and the severity class of the condition is determined by the ratio of linear velocities POLS = V1 / V2, while in healthy - 0 class, POLS = 1.05-1.15, the recovery in class 1 severity includes patients and patients with POLS = 1.16 -1.25 for 2 classes - less severe - COLP is 1.26-1.35, for 3 classes - heavy - CAPP> 1.35 and for 4 classes - very severe - CAPP <1, when researching the dynamics of overcocci exceeding the range of the class severity determines the effectiveness of the therapy.