RU2306843C1 - Method for detecting anesthesiological means and surgical access depending upon the severity of patient's state in case of inner hemorrhage - Google Patents

Abstract

FIELD: medicine, anesthesiology, resuscitation.

SUBSTANCE: on the moment of patient's entering a hospital it is necessary to detect the state of consciousness, the rate of respiratory movements, the test for capillary fullness, the availability of the symptoms of peritoneal irritation, average arterial pressure, Algover's index, supposed blood loss volume in % against the volume of circulating blood. Each parameter should be evaluated in points, ranged 0-2 to sum them up at in case of the quantity of points ranged 0-3 the degree of disease severity should be evaluated as "satisfactory", one should apply regional anesthesia or in case of standard contraindications general anesthesia, laparoscopic surgical access, at 4-6 points - as "average severity", one should apply regional anesthesia or at availability of standard contraindications - general anesthesia, laparoscopic access, at 7-9 points - "severe degree", one should apply general anesthesia, laparotomic surgical access; 10 and more points - "extremely severe degree", one should apply general anesthesia, laparotomic surgical access. The innovation enables to evaluate the degree of patient's state severity more quickly and accurately and choose adequate technique of anesthesia before operation.

EFFECT: higher accuracy and efficiency of detection.

4 ex

Description

The present invention relates to medicine, namely to anesthesiology-resuscitation and surgery.

Adequate selection of anesthetic benefits in urgent abdominal surgery, taking into account an individual assessment of the severity of the patient's condition, is the most important task of critical state medicine. The objective objective separation of patients according to the severity of the pathological condition in the preoperative period remains relevant, despite the creation of a number of special scales (TISS, SOFA, SAPS, Trauma Score, APACHE, CITO I and II, Shotov I and II, etc.) using the same criteria (Svetukhin AM, Zvyagin A.A., Slepnev S.Yu. Systems for an objective assessment of the severity of the condition of patients. Parts I and II. // Surgery. - 2002. - No. 9. - P.51-57; Surgery. - 2002. - No. 10. - S.60-69; Gumanenko E.K., Boyarintsev V.V., Suprun T.Yu. Objective assessment of the severity of injuries.Clin.med. and pathophysiol., 1996, No. 1, p.24- 27; Abakumov M.M., Lebedev N.V., Malyarchuk V.I. Objective assessment of the severity of injury in patients with combined injuries.Vestnik of Surgery, 2001, vol. 160, No. 6, p. 42-45; Isaev A.F., Alimov A.N., Safronov EP, Otlygin Yu.V., Useinov EB, Muradov IU Assessment of the severity of the condition in patients with combined and isolated injuries of the abdomen with rupture of the spleen, Surgery, 2005, No. 9, pp. 31-35 ; Shevchenko Yu.M., Tonkonogov D.A., Dubovskoy A.V. Assessment of the severity of the condition of patients at the prehospital and hospital resuscitation stages of the provision of resuscitation and counseling in the conditions of medical institutions of the Astrakhan region. // Materials of a scientific and practical conference dedicated to the 25th anniversary of the course of anesthesiology and intensive care of the ASMA, September, 2000. "Regional problems of anesthesiology, resuscitation and intensive care. " - Astrakhan Medical Academy, 2000. NPK Ecological Medicine, 2000. CPI Fakel, 2000. - P.70-73, Cullen D., Civetta J., Briggs B. et al. Therapeutic Intervention Scoring System: A method for quantitative comparison of patient care // Crit Care Med. - 1974. - No. 2. - P.57-62; Knaus W., Zimmerman J., Wagner D., et al. APACHE - acute physiology and chronic health evaluation: A physiologically based classification system // Crit. Care Med. - 1981. - Vol. 9. - P.951-955; Knaus W, Drapper E., Wagner D., et al. APACHE II: A severity of disease classification system // Crit Care Med. - 1985. - Vol.13. - P.818-826; Knaus W., Douglas P., Wagner D., et al. The APACHE III Prognostic System: Risk Prediction of Hospital Mortality for Critically 111 Hospitalized Adults // Chest. - 1991. - Vol. 100. - P.1619-1636; Le Gall J., Loirat P., Alperovich A., et al. A simplified acute physiology score (SAPS) for ICU patients // Crit Care Med. - 1984. - No. 12. - P.975-979; Wong D., Barrow Ph., Gomez M., McGuire G. A comparison of the Acute Physiology and Chronic Health Evaluation (APACHE) II score and the Trauma-Injury Severity Score (TRISS) for outcome assessment in intensive care unit trauma patients / / Crit Care Med. - 1996. - Vol.24, No. 10. - P.1642-1648). Nevertheless, most authors, considering blood loss as a variant of multiple organ dysfunction syndrome, admit that the most informative and accessible criteria for assessing the severity of patients' condition today remain: pulse more than 110 beats per minute, respiratory rate more than 24 per minute, average arterial pressure less than 71 mm Hg, hematocrit less than 21%, Glasgow coma score less than 11 points (Kostyuchenko K.V., Rybachkov V.V. Principles for determining surgical tactics for treating common ne Etonitis Surgery, 2005, No. 4, pp. 9-13; Sergeev A.P., Latypov A.S., Galeev F.S., Bakirov N.K. Expert assessment of predictors in tubal pregnancy - Materials of the first All-Russian Scientific Forum "Innovative technologies of medicine of the XXI century. Medical computer technologies." - Moscow. - 2005. - P.461-463). Today, the APACHE-II score for patients is recognized as the “gold standard” for intensive care units worldwide. However, the specifics of the nosology of individual laboratory studies (biochemical and anesthesiological parameters) and the complexity of mathematical calculations require additional time and a certain material base, which is unjustified with ongoing intraperitoneal bleeding.

With regard to anesthetic management for emergency abdominal surgical interventions, including the elimination of internal bleeding, the literature discusses the reasonable choice of anesthesia method. According to MSArbous, the frequency of erroneous choices in the structure of mortality associated with anesthesia is 15%, of which half are due to compromised cardiovascular disease (Arbous MS, Grobbee DE van Kleef JW et al. Mortality associated with anesthesia: a qualitative analysis to identify risk factors // Anesthesia, - 2001. - Vol. 56. - P.1141-1153).

The main requirements for anesthesia are: simplicity and accessibility of its implementation; security; economic expediency; adequate nociceptive protection (guaranteeing the prevention of microcirculation disorders and intestinal motor function after surgery); providing sufficient relaxation; reduced toxicity of drugs used; the possibility of verbal monitoring of the patient's condition during surgery; prevention of hyperglycemic and neurovegetative reactions in the postoperative period; the possibility of prolonging anesthesia in the postoperative period, excluding the use of narcotic analgesics. Regional (spinal and epidural) anesthesia fully complies with these requirements, which pushes classical general (endotracheal) anesthesia into the background (Mayorov ON The use of spinal anesthesia in emergency surgery. Collection of scientific papers dedicated to the 85th anniversary of Samara State Medical University and the 20th anniversary of the Department of Surgical Diseases No. 2 "Urgent and reconstructive surgery. Samara - 2004. - P.146-148).

Possible complications associated with the use of regional anesthesia are most often caused by technical errors during manipulations and severe systemic vasodilation.

A preliminary assessment of the functional state of hemodynamics is known by conducting a sublingual test with 500 mg of nitroglycerin to predict the development of severe arterial hypotension during regional anesthesia. This test is simple, safe, informative, non-invasive and possible in the operating room immediately prior to surgery. An unfavorable prognostic criterion is a decrease in the left ventricular power index (equal to the product of the mean arterial pressure and cardiac output by a factor of 0.0022, W-m ² ) and a decrease in systolic blood pressure of more than 25% compared to the initial one. With a positive prognosis, regional anesthesia is used, with a negative one, classical general anesthesia (Shevkulenko D.A., Lebedinsky K.M. Assessment of the functional state of hemodynamics in relation to the choice of anesthesia. Collection of scientific papers dedicated to the 85th anniversary of Samara State Medical University and the 20th anniversary Department of Surgical Diseases №2 "Urgent and reconstructive surgery". Samara. - 2004. - S.231-234.).

In the available medical, scientific and patent literature, the authors did not find indications of the relationship between the severity of the patient's condition and the choice of anesthesia method.

Progressive intra-abdominal bleeding sharply limits the time for evaluating the clinical situation, determining the severity of the patient's condition and, accordingly, choosing the appropriate method of pain relief before emergency abdominal surgery.

Separate references are known that reflect the choice of surgical access for one or another pathology, but the severity of the patient's condition, which determines this choice, is not specifically specified. If there is a suspicion of intra-abdominal bleeding against the background of an erased clinical course of the disease, it is recommended that diagnostic laparoscopy be performed on the first day from the moment of suspicion (Panitkova O.V. Efficiency of standardized diagnosis of acute gynecological diseases. - Abstract for the degree of candidate of medical sciences. - Moscow, 2001 ) Moreover, according to Gasparov A.S. together with stable hemodynamic parameters, laparoscopy makes it possible to carry out organ-preserving and reconstructive operations in 83% of cases, which is not observed during laparotomy (16%) (Gasparov A.S., Volkov N.I., Nazarenko T.A. Endoscopy in the preservation and restoration of reproductive function. - Journal of Obstetrics and Women's Diseases. - 2001. - Issue 3. - T.50. - P.90-95). According to Shtyrov S.V. most contraindications for emergency laparoscopy (obesity, previously undergone abdominal surgery, difficult visualization of the abdominal cavity and small pelvis due to adhesions or the presence of blood) are relative and do not create difficulties for a highly qualified specialist. Moreover, the author focuses on the only absolute contraindication to laparoscopy - hemorrhagic shock (Shtyrov S.V. Laparoscopic surgery for "acute abdomen" in gynecological patients. - Questions of obstetrics and perinatology. - 2002. - T.1. - No. 2. - P.86-89), the mortality rate at which reaches 50-90% (Golubtsov VV Prediction of the severity of hemorrhagic shock. - Bulletin of intensive care. - 2003. - No. 5. - P.62-64). Hemodynamic disturbances (decreased cardiac output and systemic blood pressure, tachycardia, increased peripheral vascular resistance with decreased tissue perfusion), according to studies by F. Galeev et al. - aggravated by laparoscopic procedures, which is not observed with laparotomy. That is, with severe hemodynamic disturbances that sharply increase the risk of surgery, mini- or laparotomy is preferable (Galeev F.S., Bogdanov PP, Plaks I.A., Bazykina H.N. with various types of laparoscopic interventions. - Bulletin of intensive care. - 2002. - Appendix to No. 5. - C.6).

EFFECT: obtaining criteria for choosing anesthetic aid and surgical access, depending on the severity of the condition of patients with intra-abdominal bleeding.

The proposed method is as follows. The patient is examined according to standard methods. Additionally, a test of the filling of capillaries is carried out by pressing the finger nail, forehead skin, earlobe and determining the recovery time of the original color. The doctor clamps the nail phalanx of any of the patient’s fingers between the thumb and forefinger of his hand, applying pressure on the patient’s nail with his thumb for 1 second. After 1 second, the pressure on the patient’s nail phalanx is stopped and the rate of return of the color of the tissue of the nail bed to its original state (in seconds) is estimated. The results of the examination are indicated on a separate sheet, namely: state of consciousness and recovery time of capillary perfusion (capillary filling test), respiratory rate, symptoms of peritoneal irritation, Algover index, mean blood pressure, determine the estimated volume of blood loss as a percentage of the circulating blood volume based on the result of a laboratory rapid test of peripheral blood (hematocrit or hemoglobin).

The simplest calculations are used (Allgover M., Burri C. Shock index. Dtsch. Med. Wschr, 1976, v. 92, No. 3, p. 1947-1950; EHKligunenko. Acute blood loss. Liquidity and diagnosis, 2002, No. 3, p.20-28; Kulakov V.I. et al. Anesthesiology and intensive care in obstetrics and gynecology. M., Triada-X, 2000):

где АД - артериальное давление.

where blood pressure is blood pressure.

Moore Formula:

where KP - blood loss (%);

Bcc - the proper volume of circulating blood. For women, it is 60 ml / kg, for men - 70 ml / kg, for pregnant women - 75 ml / kg;

Htd - due hematocrit equal to 45% for men and 42% for women;

Htf - the actual hematocrit of the patient.

In this formula, instead of hematocrit, you can use the hemoglobin index (in women - 120-140 g / l, in men - 140-160 g / l):

Given the need for practical use of this formula in both men and women, we modified it by averaging the main indicators: BCC _D = 65 ml / kg, HTD = 43%, Nvd = 140 g / l. After the mathematical transformation, the final form of the modified Moore formula used has the following form:

A) in the presence of data only on hematocrit:

or

B) if there is data only on hemoglobin:

Thus, the result of the express analysis of peripheral blood determines the estimated volume of blood loss as a percentage of the volume of circulating blood according to one of the above formulas. In the presence of indicators of both hematocrit and hemoglobin, the calculation of the preliminary volume of blood loss is carried out only by the hematocrit index.

Each parameter is evaluated in points, namely:

1) Consciousness - clear, adequate behavior - 0 points,

superficial stunning, lability of consciousness, drowsiness - 1 point,

deep stunning, stupor, coma - 2 points.

2) Test of capillary filling (symptom of a "white spot" - reflects the state of capillary perfusion) up to 3 seconds - 0 points,

3-4 seconds - 1 point,

more than 4 seconds - 2 points.

3) Respiratory rate - 16 - 20 movements per minute - 0 points,

21-24 movements - 1 point,

more than 24 movements - 2 points.

4) Symptoms of peritoneal irritation - absent - 0 points,

doubtful - 1 point,

positive - 2 points.

5)

The calculation result is rounded to the nearest arithmetic number.

80 mmHg and more - 0 points,

71-79 mmHg - 1 point

less than 71 mmHg - 2 points.

, результат округляют до одной десятой:6)

, the result is rounded to one tenth:

Up to 0.8 - 0 points,

0.8-0.9 - 1 point,

1.0 or more - 2 points.

7) The estimated volume of blood loss as a percentage of the volume of circulating blood (according to the Moore formula), the result is rounded to the nearest arithmetic number:

A) For hematocrit = 65-1.5 * hematocrit, or

B) for hemoglobin = 65-0.5 * indicator of hemoglobin.

In the presence of both indicators, the calculation is carried out only for hematocrit:

0-10% - 0 points

10-20% - 1 point,

more than 20% - 2 points.

The points received are summarized.

With a score of 0-3, the severity is assessed as "satisfactory", laparoscopic access is performed under regional or standard contraindications with general anesthesia;

4-6 points - "moderate", conduct laparoscopic access under regional or in the presence of standard contraindications for general anesthesia;

7-9 points - "heavy", laparotomy is performed under general anesthesia

10 or more points - "extremely severe", a laparotomy is performed under general anesthesia.

Example 1

Patient S., 26 years old (history No. 587), was admitted to the hospital urgently after 48 hours from the onset of the disease, with complaints of a cycle disorder, bloody vaginal discharge. From the anamnesis - 1 pregnancy (interruption for social reasons at 24 weeks), vaginitis, chronic gastritis. During the examination: the abdomen on palpation is painless, with a bimanual examination, a slight pastiness and sensitivity in the region of the left appendages is determined. After examination, a preliminary diagnosis is made: Progressive tubal pregnancy on the left.

Parameter Result Score Consciousness Clear, adequate 0 Capillary fill test 3 seconds one Respiratory rate 16 per minute 0 Symptoms of peritoneal irritation are absent 0 Arterial pressure 120/65 - Pulse 84 - Algover Index ^* 0.7 0 HELL Average ^** 83 0 Hematocrit 32 - Estimated volume of blood loss ^*** 17% one ^* Algover index = 84/120 = 0.7 ^** Average BP = (65 × 2 + 120) / 3 = 250/3 = 83 ^*** Estimated blood loss = 65-1.5 * 32 = 17%.

The sum of the points = 2 points, which corresponds to the severity level "Satisfactory", the use of regional anesthesia, laparoscopic access is recommended.

During the operation with laparoscopic access, the diagnosis was made: "Progressive tubal pregnancy", the volume of blood loss at the beginning of the operation was 50.0 ml. The postoperative period was uneventful, the patient was discharged in satisfactory condition on day 8 after surgery.

Example 2

Patient M., 69 years old (history no. 14325), was admitted to the hospital urgently 4 hours after the accident, with complaints of abdominal pain. From the anamnesis - chronic gastritis, chronic cholecystopancreatitis, there were no abdominal surgical interventions. During the examination: the abdomen during palpation is slightly painless, the symptoms of peritoneal irritation are doubtful. After examination, a preliminary diagnosis is made: Closed abdominal injury. Hemoperitoneum?

Parameter Result Score Consciousness Clear, adequate 0 Capillary fill test 4 seconds one Respiratory rate 18 per minute 0 Symptoms of peritoneal irritation doubtful one Arterial pressure 125/70 - Pulse 86 - Algover Index ^* 0.7 0 HELL Average ^** 87 0 Hematocrit 34 - Estimated volume of blood loss ^*** fourteen% one ^* Algover index = 86/125 = 0.7 ^** Average BP = (70 × 2 + 120) / 3 = 260/3 = 87 ^*** Estimated blood loss = 65-1.5 * 34 = 14%.

The sum of the points = 3 points, which corresponds to the degree of severity "Satisfactory", the use of regional anesthesia, laparoscopic access is recommended. During the operation with laparoscopic access, the diagnosis was made: "Tear of the parietal peritoneum of the anterior abdominal wall", the volume of blood loss at the beginning of the operation was 400.0 ml. The postoperative period was uneventful, the patient was discharged in satisfactory condition 10 days after surgery.

Example 3

Patient B., 39 years old (history No. 1024), was admitted to the clinic urgently after 72 hours from the onset of the disease, with complaints of pain in the lower abdomen, dizziness, weakness, bloody vaginal discharge. From the anamnesis - 1 birth, 2 medical abortions, ectopia of the cervix, hypertension 1, stage 1, risk 2. During the examination: the abdomen on palpation is painful, the symptoms of peritoneal irritation are positive, with a bimanual examination, pain during movements behind the cervix. After examination, a preliminary diagnosis is made: Ectopic pregnancy, tube rupture.

Parameter Result Score Consciousness Surface stunning one Capillary fill test 5 seconds 2 Frequency Respiratory movements 26 per minute 2 Symptoms of peritoneal irritation positive 2 Arterial pressure 80/50 - Pulse 64 - Algover Index ^* 0.8 one HELL Average ^** 60 2 Hematocrit thirty - Estimated volume of blood loss ^*** twenty% one ^* Algover index = 64/80 = 0.8 ^** Average BP = (50 × 2 + 80) / 3 = 180/3 = 60 Estimated blood loss ^*** = 65-1.5 * 30 = 20%.

The sum of the points = 11 points, which corresponds to the severity of “Extremely severe”, reflects the presence of hemorrhagic shock and is an indication for laparotomy under general anesthesia.

When conducting a laparotomy, the diagnosis was confirmed: "Tubal pregnancy, interrupted by the type of pipe rupture." The volume of blood loss at the beginning of the operation was 1200.0 ml. The postoperative period was uneventful, the patient was discharged in satisfactory condition 10 days after surgery.

Example 4

Patient B., 31 years old (history No. 13200), was admitted to the hospital urgently 1 hour after a traffic accident, with complaints of pain in the lower abdomen, growing weakness. From the anamnesis - appendectomy in 2001. During the examination: the abdomen on palpation is sharply painful, the symptoms of peritoneal irritation are positive. After examination, a preliminary diagnosis is made: Combined injury. Closed abdominal injury.

Parameter Result Score Consciousness Surface stunning one Capillary fill test 6 seconds 2 Respiratory rate 30 per minute 2 Symptoms of peritoneal irritation positive 2 Arterial pressure 85/45 - Pulse 85 - Algover Index ^* 1,0 2 HELL Average ^** 58 2 Hematocrit 28 - Estimated volume of blood loss ^*** 23% 2 ^* Algover index = 85/85 = 1.0 ^** Average BP = (45 × 2 + 85) / 3 = 175/3 = 58 Estimated blood loss ^*** = 65-1.5 * 28 = 23%.

The sum of the points = 13 points, which corresponds to the severity of "Extremely severe", reflects the presence of hemorrhagic shock and is an indication for laparotomy under general anesthesia.

When conducting a laparotomy, the diagnosis was made: "Combined trauma. Closed abdominal trauma with a tear of the root of the mesentery of the small intestine, rectosigmoid division. Retroperitoneal fiber imbalance on the right and left. Rupture of the spleen. Hemoperitoneum.". The volume of blood loss at the beginning of the operation was 1000.0 ml. The postoperative period was uneventful, the patient was discharged in satisfactory condition on the 18th day after the operation.

The application of the proposed method using the Scale for Assessing the Severity of the Condition (Patient) for Abdominal Bleeding (SHOTSAK) allows you to quickly and easily determine the type of anesthetic and surgical access, depending on the severity of the patient's condition with intraperitoneal bleeding without complex mathematical calculations.

This assessment method was used in 120 patients aged 18 to 43 years with intra-abdominal bleeding. The proposed method was equally effective in all cases, which allows us to recommend it for use in emergency conditions in hospitals with a surgical profile.

Claims (1)

A method for determining anesthetic benefit and surgical access in a patient with intra-abdominal bleeding, characterized in that upon admission to the hospital, the state of consciousness, respiratory rate, capillary filling test, symptoms of peritoneal irritation, mean arterial pressure, Algover index, estimated blood loss in percent of the circulating blood volume, each indicator is evaluated in points, namely: consciousness - clear, adequate behavior - 0 points, turns host stunning, lability of consciousness, drowsiness are rated as 1, deep stunning, stupor, coma - as 2 points; respiratory rate - 16-20 movements per minute is estimated as 0 points, 21-24 movements - as 1, more than 24 movements - as 2 points; capillary filling test - up to 3 s is estimated as 0 points, 3-5 s - as 1, more than 5 s - as 2 points; symptoms of peritoneal irritation - none are rated as 0 points, doubtful - as 1, positive - as 2 points; average arterial pressure - 80 mm Hg and more evaluate as 0 points, 71-79 mm Hg - as 1, less than 71 mm Hg - as 2 points; Algover index - less than 0.8 is estimated as 0 points, 0.8-0.9 - as 1, 1.0 and more - as 2 points; the estimated volume of blood loss - 0-10% is estimated as 0 points, 11-20% - as 1, more than 20% - as 2 points; summarize them and, if the number of points is from 0 to 3, the severity of the disease is assessed as “satisfactory”, regional anesthesia is used, or if standard contraindications are used, general anesthesia, laparoscopic surgical access; 4-6 points - as "moderate", use regional anesthesia or, in the presence of standard contraindications, general anesthesia, laparoscopic surgical access; 7-9 points - "heavy", use general anesthesia, laparotomic surgical access; 10 or more points - "extremely difficult", use general anesthesia, laparotomic surgical access.