RU2341796C1 - Method of prediction of autointoxication severity associated with suppurative inflammatory diseases of uterine appendages - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention can be used for prediction of autointoxication (AI) severity associated with suppurative inflammatory diseases of uterine appendages. Method of prediction implies testing of blood serum for erythrocyte sorption property (ESP) and soluble fibrin-monomeric complexes (SFMC). Autointoxication ratio is calculated by formula R_AI=ESP/SFMC. If values R_AI=2.48±0.10, severe autointoxication is predicted. Values R_AI=3.29±0.29 indicate medium autointoxication, while R_AI=4.60±0.08 indicates slight autointoxication associated with suppurative inflammatory diseases of uterine appendages.

EFFECT: higher information value and accuracy of prediction, reduced time of prediction.

3 ex, 2 tbl

Description

The invention relates to the field of medicine - gynecology and can be used in predicting the severity of endogenous intoxication (EI) in purulent inflammatory diseases of the uterus (GVZPM).

HCVM are the most common cause of hospitalization of patients in a surgical hospital, the frequency of complications and relapses ranges from 13 to 35%, and mortality reaches 2-4% [1, 2]. Significant inflammatory changes in the fallopian tubes and ovaries are characteristic of limited peritonitis on the background of HMVR. Common peritonitis is characterized by the involvement in the inflammatory process of other anatomical areas of the abdominal cavity and the penetration of pathological exudate into the slightly drained spaces of the upper floor. In the mechanisms of general pathophysiological reactions with purulent peritonitis, the main role is played by intoxication. Active surgical intervention in the early stages of acute inflammation in the abdominal cavity and removal of the focus of infection prevents the development of EI [3]. With advanced forms of the inflammatory process, the removal of the purulent focus and its active rehabilitation only contributes to the elimination of individual components of EI at the level of cellular degeneration and decay of microbial pathogens. At this time, products of intermediate metabolism settle in the vascular bed and parenchymal organs, the accumulation of which leads to autolysis and the predominance of catabolic processes over anabolic and the development of EI and multiple organ dysfunction [3, 4]. The nature of coagulopathic disorders in HHVPM directly depends on the stage of the inflammatory process and reliably reflects the degree of destructive disorders in the purulent focus. DIC-syndrome, even in the case of a favorable course of the process, can persist for a long time in the form of hypercoagulation [1, 2, 5]. In the practical work of the surgeon, it is important to assess the severity of the patient’s condition, the degree of toxicosis and the presence of multiple organ failure to conduct complex intensive care in the pre- and postoperative period [3].

Known methods for predicting the severity of endogenous intoxication with HMVD are to determine the most significant clinical and laboratory criteria: severe pain in the abdomen; pallor of the skin, dry mucous membranes, plaque on the tongue; bowel paresis phenomena; febrile or hyperpyretic fever, tachycardia; leukocytosis (over 12.0 G / l); accelerated ESR (over 25 mm / h), increased circulating immune complexes (CEC, conv. units), leukocyte intoxication index (LII, conv. units) [1, 2, 3, 4].

Known methods for predicting the severity of endogenous intoxication in cases of GVZPM are as follows: determining the binding function of serum albumin [6] leukocyte intoxication index (LII) according to J. Ya. Kalf-Kalif [7]; in calculating the intoxication index according to the formula, the total concentration of albumin, the content of low and medium molecular weight substances (VNSSM) in blood plasma and in erythrocytes and LII are determined [8].

However, these methods of forecasting are not accurate enough and objective, and each individually or in aggregate, does not always reflect with sufficient completeness the severity of EI in HMRS, which leads to a delay in pathogenetic therapy. In addition, the implementation of the laboratory stage of diagnosis requires the presence of technically sophisticated equipment and a significant investment of time. So, the production time of the blood formula, ESR, LII is 1 hour - 1 hour 20 minutes, immunological studies - 5 days.

Closest to the proposed one is a method for predicting the severity of endogenous intoxication by determining the permeability of erythrocyte membranes - TEM by the degree of urea hemolysis of erythrocytes and the sorption ability of erythrocytes - SSE by the intensity of sorption of the membrane of erythrocyte methylene blue [9]. However, the SSE data do not always correspond to the severity of malignant intoxication, even in critical conditions.

A new technical task is to increase the information content and accuracy of forecasting, reducing the time it takes to complete the method.

To solve the problem in a method for predicting the severity of endogenous intoxication with purulent inflammatory diseases of the uterine appendages by determining the sorption capacity of blood erythrocytes - SSEs, the level of soluble fibrin-monomer complexes - RFMCs in blood plasma is additionally determined, the index of the degree of endogenous intoxication is calculated by the formula I _ei = SSE / RFMC and with I _ei = 2.48 ± 0.10 predict a high degree, with I _ei = 3.29 ± 0.29 predict a moderate degree and with I _ei = 4.60 ± 0.08 predict a low degree of severity e ndogenic intoxication.

The method is as follows. Venous blood is sampled and, according to the well-known methodology, “Diagnosis of endogenous intoxication” [10], the sorption capacity of red blood cells is determined using a FKF-3 photoelectric photometer (Zagorsk Optical and Mechanical Plant JSC) TU 3-3.2164-89.

The level of soluble fibrin-monomer complexes in blood plasma is determined by taking blood from the cubital vein and performing a paracoagulation orthophenanthroline test (FT) (Kit and reagents for hemostasis studies manufactured by Technologiya Standart. License of the Ministry of Health of the Russian Federation No. 42 / 97-466-0406 ) [eleven].

The methodology for determining the sorption ability of red blood cells. 4 ml of blood are drawn from a vein into a test tube containing 1 ml of a 3.8% sodium citrate solution; erythrocytes are mixed and separated by centrifugation for 10 minutes at 3000 rpm. Plasma is removed. Transfer 1 ml of erythrocyte mass into a test tube containing 3 ml of a vital dye solution (methylene blue 0.025%) prepared in physiological saline. Stirred and incubated for 10-12 minutes at room temperature. The packed liquid is transferred to a KFK-3 photoelectric photometer, after being centrifuged for 10 minutes at 3000 rpm. The optical density of the initial solution and packed liquid in extinction units is determined by the colorimetric method with respect to physiological saline at a spectrophotometer wavelength of 630 nm. The amount of absorbed dye is calculated by the following formula: A% = 100- (C × 100 / B), where A is the amount of absorbed dye (in%), B is the optical density of the solution (in units of extinction), C is the optical density of the dye solution after incubation with the patient erythrocytes (in units of extinction) [10].

Methodology for determining RFMK. From the ulnar vein, 4 ml of blood is taken on an empty stomach with a silicone needle with a wide clearance without a syringe (by gravity). Blood is mixed with a 3.8% solution of sodium citrate in a ratio of 9: 1. Immediately after filling the tubes with blood to the required volume, close with a piece of plastic film and turn it over 2-3 times (without shaking). At room temperature, 0.78% -0.1 ml of an aqueous solution of o-phenanthroline hypochloride (Chemapol, Czech Republic) prepared immediately before the study was immediately added to 0.1 ml of the test plasma, and a stopwatch was immediately started. With continuous shaking of the tube in transmitted light (illuminator for a microscope, type OI-19), the time from the moment the reagent is added to the appearance of the first fibrin flakes (grains) is recorded. Accounting is carried out only for 150 seconds. A test is considered positive if flakes or grains of a paracoagulant are clearly visible in the transmitted light in the first 150 seconds. The time of occurrence of paracoagulant grains in seconds is noted and the amount of RFMC in blood plasma is determined from the table constructed on the basis of the calibration graph [11].

The index of the degree of endogenous intoxication is calculated by the formula: And _ei = SSE / RFMC and when the values of And _ei = 2.48 ± 0.10, a high degree is predicted, with the values of And _ei = 3.29 ± 0.29, the average degree is predicted and with the values of And _ei = 4.60 ± 0.08 predict a low severity of endogenous intoxication with purulent inflammatory diseases of the uterine appendages.

Fibrinogen is a plasma globular glycoprotein that belongs to the "acute phase" proteins and determines to a large extent the viscosity of blood and plasma. Therefore, hyperfibrinogenemia, which is a marker of a clear or latent current inflammatory process, is itself a factor of high thrombogenic risk and needs to be eliminated. The final phase of blood coagulation, as is known, is characterized by the transformation of fibrinogen dissolved in plasma into fibrin fibers, which form the main frame of the blood clot. Under the influence of thrombin, fibrinogen peptides A and B are split off from fibrinogen molecules, fibrin monomers and their oligomers are formed, which are designated as soluble fibrin-monomer complexes (RFMCs) [5]. The determination of the level of soluble fibrin-monomer complexes is investigated by a known method using a quantitative version of the phenanthroline test [11].

The test is based on an estimate of the time of appearance of fibrin flakes (grains) in the studied platelet-poor citrate plasma after adding phenanthroline to it and is called the phenanthroline test (TF). This time is shorter, the higher the plasma concentration of RFMC. Test run time is 3 minutes. Normally, the content of RFMC in plasma is 3.0-4.0 mg / 100 ml.

As clinical examples, confirming the advantages of the proposed method, the medical history of patients with various clinical forms of HHVPM is given.

Example 1. The medical history No. 10153. Patient B., 35 years old, was urgently admitted to the admission department of the Tomsk Regional Clinical Hospital (OKB) on May 23, 2005 at 13:00. 40 min Clinical diagnosis: Tubo-ovarian abscesses on both sides of the IUD (10 years). Parametritis. Purulent omentitis. Common peritonitis. Septic shock. Anemia 1 tbsp. Oligophrenia.

The duration of the disease is 7 days. Upon receipt of a complaint of nausea and vomiting, pain in the lower abdomen, temperature 39 ° C. Found: pulse 100 beats / min., BH 24 per minute, blood pressure 85/60 mm Hg, skin is pale; tongue is covered with white coating, dry; the stomach is painful, tense; symptom of peritoneal irritation (+++), CEC 125 conv. units; white blood cells 16.5 g / l, ESR 30 mm / h, SSE 54.56%, RFMC 22 mg%, LII 14.3; SAPS scale 4 points.

All clinical and laboratory studies revealed significant changes corresponding to septic shock. The obtained data on the proposed method And _ei = 2.48 allowed us to predict a high probability of developing severe EI.

In the first 2 hours from the moment I / O intensive therapy was started: detoxification, antibacterial (cefasin 2.0), disaggregants (trental at a dose of 5.0, diluted in physiological saline 400.0); symptomatic therapy. In an emergency, radical surgical treatment was performed under endotracheal anesthesia: laparotomy, removal of the uterine appendages from both sides, omentum resection, decompression of the small intestine, rehabilitation and drainage of the abdominal cavity. Blood loss 150.0. MPI 28 points.

In the postoperative period, the patient against the background of respiratory support (prolonged mechanical ventilation, 2 hours) underwent complex drug therapy: 3 multidirectional antibacterial drugs (cefasin, amikacin, metronidazole), infusion, desensitizing, symptomatic and stage-by-stage extracorporeal detoxification; incubation of the cell mass of blood with thienam. The length of hospital stay was 21 days. The patient was discharged with recovery.

In this case, predicting the high likelihood of developing severe EI predetermined active tactics with intensive detoxification therapy before surgery, intraoperatively and in the postoperative period, using 4 antibacterial drugs with sequential extracorporeal detoxification in combination with extracorporeal pharmacotherapy in the drug treatment complex.

Example 2. The medical history No. 8806. Patient P., 30 years old, was urgently admitted to the admission department of the OKB on 05/01/2005 at 12 o’clock. 35 minutes Clinical diagnosis: Tubo-ovarian abscess on the right. Limited peritonitis. Adhesive process of the pelvis. History: childbirth 2, abortion 4, IUD, hepatitis, left tubectomy (for peritonitis) and cholecystectomy.

The disease is 3 days old. Upon receipt of a complaint of pain in the lower abdomen on the right, chills, temperature 38 degrees. Found: BH 18 per minute, pulse 82 beats / min., BP 110/60 mm Hg, dry tongue, painful stomach, moderately tense, symptom of peritoneal irritation expressed (+++); the number of leukocytes 15.1 G / l, ESR 49 mm / h, SSE 35.2%. RFMC 10 mg%, LII 1.13; CEC 126 conv. units, SAPS scale 1 point.

Studies have shown that the patient had a vivid clinical picture of the inflammatory process, confirmed by laboratory results (pronounced leukocytosis and accelerated ESR). LII was not changed.

The calculated index of the degree of endogenous intoxication And _ei = 3.29 made it possible to predict the moderate severity of EI and to administer drug therapy in the first 2 hours to reduce intoxication and improve the rheological properties of blood (reopoliglyukin, trental): antibiotic (cefasin 2 , 0), trental - 5.0, diluted in physiological saline (400.0); vitamin C - 5% - 5.0 in a glucose solution of 5% (400.0), ringer-lock solution (400.0). Surgical treatment was carried out urgently under intubation anesthesia: laparotomy, removal of the uterine appendages on the right, separation of adhesions, debridement and drainage of the abdominal cavity. Blood loss 200.0. MPI 15 points.

In the postoperative period, the patient received complex drug therapy: antibacterial (cefasin, gentamicin, metronidazole), infusion, desensitizing, symptomatic and 2 sessions of HBO. The length of stay in the hospital was 22 days. The patient was discharged with recovery.

In this example, with a predicted moderate severity of EI against the background of a purulent process, it was advisable to carry out preoperative preparation and radical surgery, and in the postoperative period, intensive drug therapy and give preference to the efferent method - hyperbaric oxygenation.

Example 3. The medical history No. 5091. Patient S., 20 years old, was urgently admitted to the admission department of the OKB on 13.05.05. at 21 o’clock. 30 minutes. Clinical diagnosis: Bilateral purulent salpingitis. Pelvioperitonitis. Trichomoniasis History: childbirth 0, miscarriage 1.

The disease is 3 days old. Upon receipt of a complaint of pain in the lower abdomen, rapid urination, a temperature of 40 degrees, purulent discharge from the genital tract. Found: BH 18 per minute, pulse 100 beats / min., BP 120/80 mm Hg, tongue dry, stomach painful, moderately tense, symptom of peritoneal irritation expressed moderately (++), CEC 92 srvc. units, leukocytes 9.0 G / l, ESR 16 mm / h, SSE 25.3%, RFMC 5.5 mg%, LII 0.24; SAPS scale 3 points.

The conducted studies reflected a vivid clinical picture of the disease against the background of normal ESR, LII and minor leukocytosis. The calculated index of endogenous intoxication by the proposed method IEI = 4.60 allowed us to predict a low degree of likelihood of developing severe EI.

Within 48 hours, drug treatment was carried out (infusion therapy, antibiotics). Against the background of persisting pain, an operation was performed under intubation anesthesia in an emergency: laparotomy, debridement and drainage of the abdominal cavity. Blood loss 100.0. MPI 15 points.

In the postoperative period, the patient received antibacterial (cefasin, amikacin, metronidazole), infusion, desensitizing, symptomatic therapy, physiotherapy, and UFD of blood No. 4. The length of hospital stay was 15 days. The patient was discharged with recovery.

Thus, in the above example, predicting a low degree of likelihood of EI severity made it possible to conduct preoperative preparation and sanitizing surgery with preservation of the fallopian tubes and ovaries within 2 days. In the postoperative period, drug therapy with 3 antibacterial drugs was carried out, enhanced by extracorporeal detoxification.

The criteria proposed for predicting the severity of EI were selected based on the interpretation of the results of clinical trials in 65 women with HRVM who were urgently admitted to the admission department and operated on at the gynecological department of the OKB.

The age of the patients was from 16 to 45 years. The average age of patients was 31.8 ± 5.8 years. Upon admission, all patients complained of: weakness, fever (above 37.5 °), pain in the lower abdomen of a cramping nature of different intensity, purulent discharge from the genital tract. A gynecological examination determined tubo-ovarian complexes on one (15) or both sides (25), without clear contours (25), painful (65), with a pronounced peritoneal reaction throughout the abdomen (45) or over the womb (20). Ultrasound examination confirmed the presence of a tubo-ovarian complex of various sizes in the uterus in 52 patients. Surgical treatment was carried out under endotracheal anesthesia with laparotomy access after 2-48 hours from the time of admission.

The study of RFMC and SSE was carried out before the start of surgery according to the proposed method.

In patients of group 1 (20) with a prognosis of a high degree of severity of EI, with RFMC 17.65 ± 2.35 mg%, SSE 43.65 ± 4.22 and I _ei = 2.48 ± 0.10, a generalized form really took place inflammatory process: widespread peritonitis complicated by sepsis, in 4 (20%). The volume of surgical intervention in 75% of patients was radical with drainage of the abdominal cavity and total decompression of the small intestine - in 5 (25%). The duration of treatment is 21.18 ± 4.31 c / d.

In patients of group 2 (22) with a prognosis of moderate severity of EI with RFMC 11.45 ± 1.25 mg%, SSE 37.37 ± 1.43%, And _ei = 3.29 ± 0.29, the course of the disease corresponded to an average degree severity with a characteristic formation for such a process of purulent tubo-ovarian formations. So, pyosalpinx was in 10 patients; a tubo-ovarian abscess - in 10, a pioaur - in 2. During the operation, every second patient managed to save the ovary or part of it, in 5 (22.73%) the fallopian tube was preserved. The duration of treatment was 20.41 ± 2.8 f / d.

In group 3 (23), a low degree of EI severity was predicted with RFMC 5.25 ± 0.25 mg%, SSE 24.15 ± 1.12%, and _eu = 4.6 ± 0.08, which was confirmed by a lighter during pelvic peritonitis against a background of purulent salpingitis. In this group, sanitation operations without removal of the reproductive organs were performed in 10 (43.48%) patients, radical operations with removal of the fallopian tube on both sides were performed in 5 (21.74%). The duration of treatment was 14.56 ± 2.21 c / d.

In the postoperative period, depending on the predicted severity of EI in each group of patients, along with an individual complex of drug therapy, extracorporeal detoxification was differentially performed. It was more intense in group 1, for example, in 10 (50%) patients, the cell mass of blood was incubated with a 4th generation cephalosporin antibiotic (2-3 plasmapheresis sessions), barotherapy (100%), ultraviolet blood irradiation (50%), indirect electrochemical blood oxidation (20%). Active detoxification therapy was also carried out in patients of the 2nd group: blood ultraviolet radiation (100%), barotherapy (82%), plasmapheresis (54.547%). In group 3, indications for extracorporeal detoxification were determined in 52.17% of patients (barotherapy and blood ultraviolet radiation).

The correctness of the comparison and the reliability of the obtained data were due to the fact that all patients had the same severity of condition (less than 6 points) upon admission, which was determined by a ranking scale for an objective assessment of the severity of the state of SAPS, i.e. did not differ in 14 basic physiological parameters. The Mannheim Peritoneal Index (MPI) for assessing the severity of purulent peritonitis and the prognosis of mortality (index <20 points corresponds to I degree of severity, index from 20 to 30 points - II degree of severity, index> 30 points - III degree of severity) determined management tactics in the postoperative period and a complex of therapeutic measures [3].

The control group consisted of 15 healthy women (table No. 1).

Upon admission, all patients underwent a study of RFMC and SSE with subsequent evaluation and interpretation of the results. As follows from table No. 2, each indicator corresponds to a certain severity of EI, which corresponds to the clinical picture and the severity of the course of peritonitis on the background of GVZPM.

To assess the prognostic value of the proposed method, the four-table tables method was used - the frequency of coincidence of the prognosis with the actual presence or absence of the studied disease was analyzed. The sensitivity of the proposed method was 78.47% compared with SSE - 69.82% (prototype).

Thus, the application of the proposed method allows practicing surgeons with a high degree of certainty in urgent patients in a short period of time to assess the severity of EI, which contributes to an adequate approach to preoperative preparation; the choice of surgical access, the volume of the operation, its radicalism, the option to complete the operation and the differentiated use of extracorporeal methods of detoxification in the postoperative period with peritonitis against the background of purulent inflammatory diseases of the uterus.

Table 1
Laboratory and immunological blood counts in healthy women * Indicators, M ± m White blood cells, g / l 6.03 ± 1.15 LII 1.71 ± 0.61 SSE (sorption capacity of red blood cells),% 19.24 ± 1.26 ESR, mm / hour 7.10 ± 1.20 CEC, conv. units 80.10 ± 2.22 RFMK, mg% 3.25 ± 0.25 Note: * number of healthy women n = 15

table 2
The likelihood of developing the severity of EI depending on the level of RFMC in plasma and the sorption ability of red blood cells in various forms of GVZPM Clinical forms of GVZPM Indicators RFMK, M ± m SSE indicators, M ± m Endogenous intoxication index And _ee = SSE / RFMK mg% % Common peritonitis 17.65 ± 2.35 43.65 ± 4.22 2.48 ± 0.10 Purulent tubo-ovarian formations 11.45 ± 1.25 37.37 ± 1.43 3.29 ± 0.29 Pelvioperitonitis with purulent salpingitis 5.25 ± 0.25 24.15 ± 1.12 4.60 ± 0.08

Literature

1. Podzolkova N.M., Nikitina T.I. Severe bacterial infections in obstetrics. Infek. and antimicrobial. ter. 2004, 3; 89-93.

2. Krasnopolsky V.I., Buyanova S.N., Schukina N.A. Purulent gynecology. M .: "MED-Pressinform." 2006; 295.

3. Gostishchev V.K., Sazhin V.P., Avdovenko A.L. Peritonitis. M: GEOTAR-MED, 2002; 238.

4. Vasiliev IT. The mechanism of development of endotoxemia with purulent diseases of the abdominal organs. Surgery them. N.I. Pirogova, 1995, 2.54-58.

5. Barkagan Z.S., Momot A.P. The basics of the diagnosis of hemostatic disorders. M: "Newdiamed-AO." 1999, 213.

6. Gavrilov V. B., Bidula M. M., Furmanchuk D. A., Konev SV., Aleinikova O. V. Assessment of body intoxication by imbalance between the accumulation and binding of toxins in blood plasma. Wedge. lab. the diagnosis 1999, 2.13-17.

7. Kostyuchek D.F. Organization of the process of diagnosis and treatment of patients with purulent-septic infection in gynecological practice // Methodical recommendations of the Ministry of Health of the Russian Federation. Leningrad. - 1989.38.

8. Stepanov I.P., Dmitrieva L.M., Patyukov A.G., Vysokogorsky V.E., Atavina O.V. A method for assessing the endotoxemia of the body. PH 20031322548/15. 2003.07.18.

9. Mikhailovich V.A., Marusanov V.E., Bichun A.B. and others. Permeability of erythrocyte membranes and sorption ability of erythrocytes are optimal criteria for the severity of endogenous intoxication. Anesthesiology and resuscitation. 1993, 5: pp. 66-69.

10. Togaybaev A.A., Kurguzkin A.V., Rikun I.V., Karibzhanova P.M. A method for the diagnosis of endogenous intoxication. Lab case, 1988; 9: 22-24.

11. Momot A.P., Elykomov V.A., Barkagan Z.S. Methodology and clinical significance of the paracoagulation phenanthroline test. Wedge. laboratory diagnostics. 1996, 4: 17-20.

Claims (1)

A method for predicting the severity of endogenous intoxication in purulent inflammatory diseases of the uterine appendages by determining the sorption capacity of erythrocytes - SSE, characterized in that they additionally determine the level of soluble fibrin-monomer complexes - RFMC in blood plasma, calculate the degree of endogenous intoxication according to the formula I _ei = SSE / RFMC and with the values of And _ei = 2.48 ± 0.10 predict a high degree, with the values of And _ei = 3.29 ± 0.29 predict the average degree and with the values of And _ei = 4.60 ± 0.08 predict a low degree the severity of endogenous intoxication with purulent inflammatory diseases of the uterus.