RU2352943C1 - Method of estimation of inflammatory process course in postoperative period - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention concerns medicine, namely, clinical biochemistry, surgery and can be used for estimation of a current of inflammatory process in the postoperative period. Content of proinflammatory interleukins TNFα, IL-1α, proteins of the antiprotease system α₁-antitrypsin, α₂-macroglobulin are determined at patients. Integrated indicators of proinflammatory interleukins (P₁, P₂), and proteins of the antiprotease system (P₃, P₄) are calculated under the relation of their content at the patient to average value at healthy persons. Prognostic factor (K) is calculated by multiplication of relations of integrated indicators proinflammatory interleukins (P₁×P₂), to indicators of proteins of the antiprotease system (P₃×P₄) and at value (K) peer and less than 2.7, favourable outcome of inflammatory process is prognosticated; and at the value, above 2.7, intensifying of inflammatory process, with the subsequent development of proinflammatory complications in the postoperative period is prognosticated.

EFFECT: rising of accuracy of an estimation of a current of inflammatory process at the expense of the account of functioning in the conditions of regulating influence of the antiprotease system.

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Description

The invention relates to medicine, namely to clinical biochemistry and surgery, can be used to assess the course of the inflammatory process in the postoperative period.

It is proved that almost any surgical operation has an adverse effect on the immune system and causes the development of immunodeficiency, the main manifestation of which is infectious postoperative complications. Therefore, determining the degree of immunodeficiency, as well as factors and mechanisms leading to the development of local and systemic inflammatory complications, is important in choosing the right therapeutic tactics for the patient [1, 2].

Inflammatory and immune reactions are the result of the interaction of a large number of different body systems. Immune cells secrete numerous soluble mediators (cytokines), some of which are highly specific. Outside of the inflammatory response and immune response, cytokines in the blood are contained in extremely small quantities. Enhanced synthesis of cytokines begins in response to the penetration of microorganisms into the body or tissue damage.

The body has regulatory systems that inactivate already released cytokines. These include an antiprotease system that controls the distribution, activity and destruction of a series of cytokines (TNFα, IL-1α and β, IL-2, IL-6, IFN, CSF).

In this regard, it may be promising to create a method for assessing the nature of the inflammatory process in the postoperative period, based on the effect of blood antiproteinases (α ₁ -antitripsin and α ₂ -macroglobulin) on the physiological mechanisms of nonspecific modulation and activation of cytokines. Activation of α ₁ -antitrypsin and α ₂ -macroglobulin with the transition to the “fast” form, interacting with cytokines and their receptors, reduces the severity of local and systemic effector reactions due to the system of pro-inflammatory cytokines (IL-1α and β, IL-2, IL -6, TNFα) [3].

A known method for diagnosing the development of complications and determining indications and contraindications for surgical interventions in case of combined trauma of the lower extremities and skull [4]. The severity of the condition and the possible generalization of infection are judged by the increase in the content of the initial products of lipid peroxidation (LPO) and a decrease in antioxidant activity (AOS) in the blood serum of patients. The method is carried out by determining in blood serum in dynamics (1, 3, 7, 14 days) the content of primary (diene conjugates - DC) and intermediate (malondialdehyde - MDA) LPO products. To assess the state of AOS, the concentration of lipid antioxidant alpha-tocopherol (TF) and the extracellular protein ceruloplasmin (CP), which has an antioxidant effect, were determined. To assess the imbalance in the POL-AOS system, we used the integral indicator (K), which is normally 1.12, while strengthening the LPO processes, the integral indicator increases above 1.12, which indicates the development of infectious complications.

However, this method has a number of disadvantages: firstly, the study of only the parameters of the POL-antioxidants system is not sufficiently informative, since an imbalance in this system can be registered under various pathological conditions, since lipid peroxidation is a non-specific process; secondly, the assessment of multicomponent antioxidant protection by studying the content of alpha-tocopherol and ceruloplasmin alone is not entirely objective, since antioxidant protection is provided by a large number of compounds of both enzymatic and non-enzymatic nature.

In this regard, an increase or decrease in this parameter is not an objective enough criterion for assessing the generalization of a surgical infection. In addition, this method does not reflect the main pathogenetic link of purulent-inflammatory complications, namely cytokine-dependent immunodeficiencies. This makes it difficult to objectify the stage of the inflammatory process and, as a result, the choice of adequate treatment tactics.

A known method for predicting the course of purulent-inflammatory postoperative complications in the clinic of abdominal surgery by determining the parameters of the immune system of patients immediately before surgery and on the second day of the postoperative period by setting the reaction of the formation of lymphocytes of the patient after incubation with autoplasma and without it [5]. An index is calculated equal to the ratio of the number of incubated cells to the number of active T-lymphocytes. With a value of the indicator greater than 1.1, a favorable course of the postoperative period is predicted, and with a value of 1.0 or less, the occurrence of purulent-inflammatory complications.

However, the method for determining rosette-forming cells using autoplasma is not specific enough, because, firstly, the patient’s autoplasma necessarily carries many factors that not only accelerate, but also inhibit the formation of outlets. These factors can be of either serum or leukocyte origin, which can affect the diurnal dynamics of the coefficient, respectively diurnal and circadian rhythms, misleading the doctor. Secondly, changes in the coefficient parameters in a rather narrow range of numbers reduces the accuracy and reproducibility of the results.

The prototype for this invention is a method for predicting the course of the wound process [6], which is based on the determination in the blood serum of patients of the level of pro-inflammatory (TNFα, IL-1α) and anti-inflammatory cytokines IL-4, IL-10. The integral indicators of pro-inflammatory interleukins (P ₁ , P ₂ ) and anti-inflammatory interleukins (P ₃ , P ₄ ) are calculated according to the ratio of their content in the patient to the average value of healthy individuals, the prognostic index of inflammation (PIV) is calculated in relation to the integrated indicators of pro-inflammatory interleukins (P ₁ × P ₂₎ to that of anti-inflammatory interleukins (R ₃ × R ₄₎ and at a value of TID equal to 1.4 and above, predict the development of inflammatory complications, and a value of less than 1.4, predict favorable for wound th process.

The disadvantages of the method include the fact that in this method only activators and inhibitors of the inflammatory process are considered, i.e. forecasting in the above index is carried out within the framework of one system, which reduces the reliability of the forecast. In addition, the features of the functioning of cytokines under the regulatory influence of a number of systems, in particular the anteprotease system, which controls the distribution, activity and destruction of a series of cytokines (TNFα, IL-1β, IL-2, IL-6, IFN, CSF, are not taken into account )

To improve the accuracy of assessing the nature of the inflammatory process in the blood serum of patients on the second day of the postoperative period, the content of pro-inflammatory interleukins IL-1α, TNFα, the content of transport proteins of the antiprotease blood system α ₁ -antitrypsin, α ₂ -macroglobulin are determined and then the following indicators are calculated: 1 ) the relative content of pro-inflammatory interleukin TNFα, P ₁ according to the formula

2) the relative content of pro-inflammatory interleukin IL-1α, P ₂ according to the formula

3) the relative content of α ₁ -antitrypsin P ₃ according to the formula

4) the relative content of α ₂ -macroglobulin P ₄ according to the formula

where i is the protein content of the antiprotease system, interleukins in patients;

n is the average value of the proteins of the antiprotease system, interleukins in healthy individuals.

After that, the integral coefficient (K) is calculated by the ratio of the products of the relative content of pro-inflammatory interleukins (P ₁ × P ₂ ) to the product of the relative content of α ₁ -antitripsin and α ₂ -macroglobulin (P ₃ × P ₄ ) according to the formula

The method is as follows.

On the 2nd day of the postoperative period, 10 ml of blood is taken from a cubital vein into a test tube.

определяют белки антепротеазной системы крови α₁-антитрипсин и α₂-макроглобулин и рассчитывают интегральные показатели по формуле

The concentration of interleukins (TNFα, IL-1α) is determined by enzyme-linked immunosorbent assay using double antibodies and the integral indicators of pro-inflammatory interleukins TNFα, IL-1α are calculated by the formula

determine the proteins of the anteprotease blood system α ₁ -antitrypsin and α ₂ -macroglobulin and calculate the integral indicators according to the formula

As a control, we used the average indicators of the regional content of pro-inflammatory interleukins and proteins of the anteprotease system of healthy people (7):

TNFα = 25 ± 3 pg / ml; IL-1α = 36 ± 5 pg / ml;

α ₁ -antitrypsin = 2384 ± 22 μg / ml; α ₂ -macroglobulin = 1742 ± 15 μg / ml.

After that, the prognostic coefficient (K) is calculated - the ratio of the number of obtained populations of pro-inflammatory interleukins IL-1α, TNFα to the proteins of the antiprotease system α ₁ -antitrypsin and α ₂ -macroglobulin according to the formula

The parameters of the prognostic coefficient are interpreted as follows. If the coefficient is equal to or less than 2.7, a favorable outcome of the inflammatory process is predicted. If the coefficient is more than 2.7, an increase in the inflammatory process is predicted with the subsequent development of purulent-inflammatory complications in the postoperative period.

A method for predicting the course of the wound healing process is illustrated by the following examples.

Example 1. Patient K., 34 years old, operated on for a closed fracture of the right thigh, performed intramedullary osteosynthesis with a metal pin. On the second day of the postoperative period, the patient determines the content of interleukins and transport proteins of the antiprotease system α ₁ -antitrypsin, α ₂ -macroglobulin in blood serum.

Interleukins: TNFα (PCG / ml) 100, IL-1α (PCG / ml) 164, α ₁ -antitrypsin 4872 μg / ml, α ₂ -macroglobulin 3660 μg / ml.

We calculate the integral indicators of the ratio of the content of pro-inflammatory interleukins and proteins of the antiprotease system in the test sample to the same indicators in the control in healthy people:

An adverse course of the postoperative period was suggested: subsequently, on the 3rd day after the operation, edema and hyperemia appeared around the sutures, with palpation in the middle third of the right thigh - a dense painful infiltrate measuring 12.5 × 6.0 cm with fluctuation in the center, from the postoperative drainage wounds - serous-purulent discharge. The sutures were removed, the sowing of the wound discharge gave rise to staphylococcus in association with Pseudomonas aeruginosa. The contamination of the wound by microorganisms per 1 g of tissue was 10 ⁸ .

Subsequently, for 8 days, local treatment of a purulent wound was performed by washing the wound with a hypertonic sodium chloride solution, dioxidine, dressings with Levomekol ointment were used,

On day 9, a second study of interleukins was conducted. Interleukins: IL-1α (PCG / ml) 59, TNFα (PCG / ml) 59, α ₁ -antitripsin 3347 μg / ml, α ₂ macroglobulin 1929 μg / ml

By this time, the wound measuring 9.0 × 3.0 cm was made of a fine-grained, bright red granulation tissue, and edge epithelization was noted.

Early secondary sutures were imposed. Complete healing.

Example 2. Patient M., 19 years old, was admitted to the hospital with a diagnosis of open comminuted fracture (type II B) of the left femur in the middle third with displacement of fragments. On examination, the wound is 7.0 × 2.5 cm in the middle third of the left thigh, along the outer lateral surface, the ends of the bone fragments of the femur will stand in the wound. After 1.5 hours from the moment of receipt, the primary surgical treatment of the wound was made, primary sutures were applied to the wound, the fracture was fixed by Ilizarov’s apparatus. On the second day, a study was made of the concentration of interleukins.

Interleukins: TNFα (PCG / ml) 56; IL-1α (PCG / ml) 64, α ₁ -antitrypsin 3447 μg / ml, α ₂ -macroglobulin 1929 μg / ml

P ₁ = 56/25 = 2.24; P ₂ = 64/36 = 1.77; P ₃ = 3447/2384 = 1.44;

P ₄ = 1929/1742 = 1.10. K = 2.57.

A favorable course of the wound process is predicted, without complications. Postoperative therapy was carried out according to generally accepted methods. The postoperative period was uneventful, the wound healed by primary intention. The patient in satisfactory condition was discharged 12 days after surgery.

The proposed method for assessing the course of the wound process was carried out in 52 patients (see table). Compared with the prototype, the accuracy and sensitivity of the forecast increases by 50-55%.

The value of the prognostic coefficient (K) in patients in the postoperative period on the 2nd day in various clinical groups (M ± m). Groups N TNFα pkg / μl IL-1α pkg / μl α ₁ -antitrypsin μg / ml α ₂ -macroglobulin, μg / ml TO Exodus Group I n = 26 105 ± 10 * 124 ± 8 * 5500 ± 42 * 3980 ± 31 * 2.70 ± 0.30 Adverse Group II n = 26 53 ± 2 * / ** 64 ± 3 * / ** 3442 ± 24 * / ** 1928 ± 22 * / ** 2.40 ± 0.28 Favorable Group III n = 25 25 ± 3 36 ± 5 2384 ± 22 1742 ± 15 1.0 ± 0.10 Norm Note: * - the differences are significant compared with the control; ** - differences are significant between the 1st and 2nd groups I - a group of patients with purulent-inflammatory complications; II - a group of patients without purulent-inflammatory complications; III - a group of healthy individuals;

Thus, a dynamic study of the status of the cytokine pro-inflammatory status and antiprotease system allows the patient to determine the nature of the inflammatory process as a whole (in the direction of its strengthening or weakening). The therapeutic tactics chosen in connection with this will be aimed at correcting both local (from the side of surgical intervention) and general manifestations of the inflammatory process.

Information sources

1. Ostrovsky V.K. Leukocyte indices in the diagnosis of purulent and inflammatory diseases and in determining the severity of purulent intoxication / V.K. Ostrovsky, P.P. Alimov, A.V. Mashchenko // Bulletin of Surgery named after I.I. Grekov. - 2003. - T.162, No. 6. - S. 102-104.

2. Postoperative dynamics of the level of cytokines in the blood, depending on the options used for general anesthesia / IZ Katiashvili and others // Cytokines and inflammation. - 2005. - T.4, No. 4. - S. 27-34.

3. Minaev S.V. The value of cytokines in the pathogenesis of acute surgical pathology of the abdominal cavity / S.V. Minaev // Cytokines and inflammation. - 2004. - T.3, No. 2. - S. 41-46.

4. Suvalyan A.G. Surgical tactics for combined trauma to the skull and lower extremities / A.G. Suvalyan, P.P. Golikov, B.V. Davydov, K.I. Rakhimi // Bulletin of Traumatology, Orthopedics named after N.N. Priorova. - 1999. - No. 3. - S.11-16.

5. Patent SU 1629847 A1 RU, G01N 33/53. A method for predicting the course of postoperative purulent-inflammatory complications / J.Sh. Zhumadilov; Semipalatinsk Medical Institute. - No. 4438383/14; Stated 06/08/1988; Publ. 02/23/91. Bull. Number 7.

6. Patent No. 2285924 of the Russian Federation, IPC G01N 33/55. A method for predicting the course of the wound healing process / E.V. Namokonov, A. A. Gerasimov, B. S. Khyshiktuev, S. O. Davydov; Applicant and patent holder E.V. Namokonov. - No. 2004109767; declared 03/30/2004; publ. 10/20/2006, Bull. No. 29.

7. On the prediction of purulent-inflammatory complications in traumatology. Clinical and immunological aspects / E.V. Namokonov and others // Bulletin of the VSNS SB RAMS. - 2006. - No. 4. - S.198-201.

Claims (1)

A method for assessing the course of the inflammatory process in the postoperative period by determining the content of proinflammatory interleukins in the blood serum, characterized in that the content of proinflammatory interleukins TNFα, IL-1α, proteins of the antiprotease system α ₁ -antitrypsin, α ₂ -macroglobulin is determined in patients, integral indicators of pro-inflammatory are calculated interleukins (P ₁ , P ₂ ), and proteins of the antiprotease system (P ₃ , P ₄ ) according to the ratio of their content in the patient to the average value in healthy individuals, calculate the prognostic coefficient (K) by multiplying the ratios of integral indicators of pro-inflammatory interleukins (P ₁ × P ₂ ) to the indicators of proteins of the antiprotease system (P ₃ × P ₄ ) and with a value (K) equal to or less than 2.7, a favorable outcome of the inflammatory process is predicted , and with a value above 2.7 predict the strengthening of the inflammatory process, followed by the development of purulent-inflammatory complications in the postoperative period.