RU2267320C1 - Method for medicinal prophylaxis of hemodynamic complications - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: the present innovation deals with preventing hemodynamic complications at restoring circulation in a prolongly ischemized limb, or due to premeditated tourniquet application during operative interference. For this purpose, 5-12 min before the onset of circulatory restoration it is necessary to start intravenous injection of antihistamine and glucocorticosteroid preparations, followed by drop-by-drop infusion of inhibitors of proteolytic enzymes which should be continued after tourniquet removal, as well. The method provides tourniquet shock and tourniquet shock-associated complications along with developing the chance for increasing the duration period of operation.

EFFECT: higher efficiency of prophylaxis.

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Description

The present invention relates to anesthesiology and resuscitation, in particular to the prevention of the development of hemodynamic complications arising from the restoration of blood flow.

When applying the tourniquet, a number of serious complications can be observed, the most dangerous is the turnstile shock, which develops after removing the tourniquet. It is characterized by significant inhibition of the main systems (respiratory, cardiovascular, excretory, nervous) due to the development of toxemia by metabolic products from a temporarily bloodless area (V.N. Gorbachev, N.S. Zuev, S.B.Syryatyeva: “Bleeding”; Tyumen State Academy, Tyumen, 2003, p.6-7).

It is known that a prolonged blockade of blood circulation causes a deep oxygen deficiency in liquid media, an almost complete disappearance of glycogen stores, and excessive accumulation of decay products and water in tissues. This occurs as a result of inhibition of activity in the cells of the enzyme systems of aerobic and anaerobic metabolism, inhibition of synthetic processes, pronounced deficiency of ATP, ADP and excess AMP in tissues, activation of proteolytic, lipolytic processes in them, which leads to an increase in the ionic permeability of membranes. The accumulation of Na and especially Ca in the cytosol activates endogenous phospholipases. In this case, the splitting of the phospholipid membranes leads to the appearance in the microcirculatory disturbance zone of a large number of non-viable cells with signs of acute damage, from which an excessive amount of toxic products of lipid peroxidation, ischemic protein toxins, unoxidized products, lysosomal enzymes, biologically active substances are released into the extracellular medium (histamine, kinins) and water (Mikhailov VV "Fundamentals of pathological physiology": a Guide for doctors, M .: Medicine, 2001, .104).

The closest way to the claimed one is the method of correction of hypotension that occurs after removal of the turnstile, described by the authors: Juelsgaard P, Larsen UT, Sorensen JV. "Hypotensive epidural anesthesia in total knee replacement without tourniquet: reduced blood loss and transfusion." In: Reg Anesth Pain Med (2001 Mar-Apr) 26 (2): 105-10 ISSN: 1098-7339, which consists in the use of vasopressors for the onset of clinical manifestations of shock in order to correct them.

The aim of the invention is the prevention of hemodynamic complications arising from the restoration of blood flow in a long-term ischemic limb, in particular, by intentionally applying a tourniquet during surgical intervention on it.

This goal is achieved by the fact that 5-12 minutes before blood flow restoration, intravenous bolus administration of antihistamines, glucocorticosteroid drugs is performed, drip infusion of proteolytic enzyme inhibitors is started, which continues even after removal of the tourniquet taking into account average therapeutic calculated doses of drugs of all three groups.

The essence of the claimed method is illustrated by the following specific examples of its implementation.

Example 1

Patient Sadovsky V.N., 70 years old, medical history No. 1881. The main clinical diagnosis: "Deforming osteoarthrosis of the right knee joint." Concomitant pathology - ischemic heart disease: atrial fibrillation, constant normosystolic form, angina pectoris II functional class, moderate arterial hypertension, obesity 2 degrees. General condition is satisfactory.

On April 6, 2004, total knee replacement was performed under spinal anesthesia under conditions of mild sedation while maintaining spontaneous breathing.

At 9 h 25 min, spinal anesthesia was performed at the level of L ₃ -L ₄ without technical difficulties with the introduction of 4 ml of a 0.5% solution of marcaine into the subarachnoid space. HELL - 140/90, heart rate - 82 beats. per minute. The effect of anesthesia is satisfactory.

At 9 hours and 50 minutes at the level of the upper third of the right thigh, a tight wide tourniquet (tourniquet) was applied, the surgical field was treated with an antiseptic, and at 9 hours and 55 minutes a skin incision was made and the operation was started.

The course of anesthesia and surgery is stable. The patient is in a state of mild sedation by intravenous administration of 10 mg of seduxen, breathing is even, the number of breaths is 16 per minute, blood pressure is 120/70, heart rate is 76 beats. per minute. The joint was opened, the patella was retracted, the femur and tibia were removed to the wound. Measured limb length, the distance between the condyles. Then, for 45 minutes, staged resections of the femur and tibia were carried out with a comparison of their surfaces under the joint template. After numerous measurements in three planes with subsequent grinding of the articular surfaces at 10 h 50 min, an artificial joint was installed. The joint capsule was sutured, tendon attachments restored.

At 11 hours 05 minutes, the anesthetist was warned by the operating surgeon-trauma surgeon that after 10 minutes the tourniquet would be removed. At the same time, 2 ml of a 1% solution of suprastin diluted in 10 ml with a 0.9% sodium chloride solution was injected intravenously with a syringe by an anesthetist and the patient was immediately injected intravenously with 100 mg of prednisolone. At 11 hours 05 minutes, an intravenous drip infusion of ingitril was started - 150 units of the drug, diluted in 200 ml of 5% glucose solution at a rate of 10 ml of solution per minute.

At 11 hours and 15 minutes the tourniquet was removed, blood flow to the limbs was restored. The infusion of the ingitril solution continued. The application time of the tourniquet was 1 hour 25 minutes. The hemodynamic profile has not changed - blood pressure - 120/75, heart rate - 76. The patient is conscious, did not show complaints, the number of breaths - 18 per minute.

At 11 hours 35 minutes - stitches on the skin. The patient was transferred to the postoperative ward. The postoperative period is smooth.

Example 2

Patient Lambrianidi G.A. 60 l., Medical history No. 1993. 04/08/2004 total endoprosthetics of the right knee joint was performed for deforming osteoarthrosis of the right knee joint under spinal anesthesia with mild sedation while maintaining spontaneous breathing.

At 9.00 at the level of L ₃ -L ₄ spinal anesthesia was performed without technical difficulties with the introduction of 4 ml of a 0.5% solution of marcaine into the subarachnoid space. HELL - 120/75, heart rate - 72 beats. per minute. The effect of anesthesia is satisfactory.

At 9 a.m. 20 min a turnstile was placed at the level of the upper third of the right thigh, the surgical field was treated with an antiseptic and a skin incision was made at 9.30 a.m., the operation was started.

The stages of the operation are described in detail in Example 1. It should only be noted that the staged resection of the articular surfaces, due to some technical difficulties, took longer than in the previous example and the time during which the turnstile was applied was 1 hour 40 minutes, that is, at 11 hours removed the tourniquet. 10 minutes before removal of the tourniquet - at 10 hours and 50 minutes, the patient was injected with an intravenous syringe 2 ml of a 1% solution of suprastin diluted in 10 ml with 0.9% sodium chloride solution and immediately followed by intravenous injection of 100 mg of prednisolone. At the same time, intravenous drip infusion of ingitril was started - 150 units of the drug diluted in 200 ml of 5% glucose solution at a rate of 10 ml of solution per minute and lasted up to 11 hours 10 minutes.

During surgery and anesthesia, the hemodynamic picture was characterized as stable. After removing the harness AD - 115-130 / 70, heart rate - 68-76 beats. per minute.

At 11.30 - stitches on the skin and the patient was transferred to the postoperative ward. The postoperative period was uneventful.

Example 3

Patient Smirnova V.M., 64 years old, medical history No. 2227 On April 20, 2004, the left knee joint replacement operation was performed for deforming osteoarthrosis of the left knee joint under spinal anesthesia with sedation and preservation of independent breathing.

At 9.30 at the level of L ₃ -L ₄ spinal anesthesia was performed without technical difficulties with the introduction of 4 ml of a 0.5% solution of marcaine into the subarachnoid space. HELL - 140/85, heart rate - 76 beats. per minute. The effect of anesthesia is satisfactory.

At 9 a.m. 50 min a turnstile was placed at the level of the upper third of the left thigh, the surgical field was treated with an antiseptic and a skin incision was made at 10 a.m., the operation was started.

The course of anesthesia and surgery is stable. The patient is in a state of superficial sedation by intravenous administration of 10 mg of seduxen, smooth breathing, number of breaths - 16 per minute, blood pressure - 130/70, heart rate - 68 beats. per minute. The course of the operation as described above without features.

At 11.15 a.m., the anesthetist was warned by the operating trauma surgeon that the tourniquet would be removed in 10 minutes. At the same time, 2 ml of a 1% solution of suprastin diluted in 10 ml with a 0.9% sodium chloride solution was injected intravenously with a syringe by an anesthetist and the patient was immediately injected intravenously with 100 mg of prednisolone. At 11 hours and 15 minutes, an intravenous drip infusion of ingitril was started - 150 units of the drug, diluted in 200 ml of 5% glucose solution at a rate of 10 ml of solution per minute.

At 11 hours 25 minutes the tourniquet was removed, blood flow to the limbs was restored. The infusion of the ingitril solution continued. The application time of the tourniquet was 1 hour 35 minutes. The hemodynamic profile has not changed - AD-120/75, heart rate - 72. The patient was conscious, had no complaints, the number of breaths was 18 per minute.

At 11 hours 55 minutes - stitches on the skin. The patient was transferred to the postoperative ward. The postoperative period is smooth.

In total, our clinic performed 134 knee joint replacement operations, the complexity of which was so significant that it required the coordinated work of two teams of specialists - surgeons and anesthetists and careful monitoring of the turnstile time.

Despite the apparent simplicity, the claimed invention is not obvious to specialists working in this field.

It is completely unobvious for specialists that the proposed method allows to increase the duration of reconstructive operations on the knee joint, which, in particular, is extremely important in some cases, preventing the disability of patients.

The fact of the possibility of drug prophylaxis of turnstile shock for specialists in anaesthesiologists and resuscitators is completely unobvious. Despite the popularity of the drugs used, it was previously believed that all of them should be administered in case of development of hemodynamic complications. The need, quantity and ratio of injected drugs was determined by the clinical picture of the complications that arise.

We first introduced, in principle, known and proven drugs not to eliminate the developed hemodynamic complications, but to prevent in all cases and in the absence of any clinical manifestations 5-12 minutes before the restoration of blood flow.

Of course, specialists are widely aware of the effect of the drugs used, but before our studies it was believed that it was necessary to deal with the emerging complications and to use these drugs in accordance with them.

We were the first to propose the use of bolus injections of drugs to eliminate hemodynamic complications, but not to treat them, but in advance of their development, in particular 5-12 minutes before removing the tourniquet during long-term operations, in particular, with prosthetics of the knee joint (before restoration of blood flow )

The turnstile shock is known, there are strict time limits for applying the tourniquet, which are strictly observed by all specialists. However, we carried out for the first time the introduction of drugs for the treatment of hemodynamic complications even before removing the tourniquet, moreover in a bolus and for prophylactic purpose.

The proposed method is the method of choice in exceptional cases, namely when, due to the complexity or the abundance of traumatic injuries, the time for applying the tourniquet to the limb approaches two hours, and at least temporary weakening of the tourniquet is impossible due to the obvious impossibility of stopping the surgery, in particular, when the work of an entire team of orthopedic trauma surgeons seeking to complete the restoration of fragmented limb fragments in the hope of full restoration of its function.

It is completely unobvious for specialists and we first revealed the fact of preventing seemingly inevitable hemodynamic disturbances before removing the tourniquet. A previously unknown opportunity has opened up to replace the fight against turnstile shock and life-threatening complications with their prevention.

Claims (1)

A method for the medical prevention of hemodynamic complications arising from the restoration of blood flow in a long-term ischemic limb, in particular, by intentionally applying a tourniquet during surgical intervention on it, characterized in that 5-12 minutes before the restoration of blood flow, intravenous administration of antihistamines and glucocorticosteroid drugs is started, they begin to drip infusion of proteolytic enzyme inhibitors, which continues even after removal of the tourniquet, taking into account the average therapeutic calculated oz drugs of all three groups.