RU2362591C1 - Way of treatment of burn disease at children with serious thermal trauma - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention concerns medicine, namely to combustiology, intensive and efferent therapy and can be used for treatment of children with a serious thermal trauma. For this purpose anticoagulant therapy is performed to patients for maintenance of hypocoagulation and level of molecules of average mass (AMM) at a wavelength of 254 nanometres are defined in a blood plasma. Treatment is performed at its value from 0.31 to 0.39 standard units, provided that accumulation of AMM prevails in plasma and on erythrocytes, or, at AMM level more than 0.39 standard units, and at AMM accumulation on erythrocytes, in plasma and urine. Infusion of crystalloid solutions in volume of coming hemoexfusion is preliminary performed. Then procedure of discrete centrifugal plasma depletion by unitary hemoexfusion in volume of 10-12% of volume of circulating blood, its gravitational separation and plasma excision is performed. After that 2 ml of the 1% ATP solution and an antibiotic from a number of cephalosporins of III generation in the higher single dose for children in are consistently entered into the received autocell mass.

EFFECT: working out of a way which allows preventing possible complications at treatment of children with the given pathology at the expense of a cryoplasm transfusion exception and other albuminous preparations and also to lower level of an endogenous intoxication, to simplify procedure of extracorporal haemocorrection at conservation of high degree of effect of detoxicating.

2 tbl, 2 ex

Description

The invention relates to medicine and can be used to treat children with severe thermal injury.

Known methods of extracorporeal hemocorrection are aimed at reducing the level of endogenous intoxication and are not always available to children with severe thermal injury. This is due to the fact that 20-25% of children with thermal injuries can receive qualified medical care in a specialized hospital with the appropriate equipment (burn department, burn center) [1]. According to our data, the average age of children with burn disease is 4.01 ± 0.3 9 years and limits the possibility of carrying out methods such as membrane-free plasma plasmapheresis, hemosorption, plasma absorption, and lymph detoxification. Extensive thermal damage does not allow the use of methods with the need for an arteriovenous shunt, access to two or more main vessels, and drainage of the thoracic lymphatic duct [2]. Dialysis-filtration methods include the availability of expensive equipment, inaccessible in a general surgical hospital, and are often accompanied by hemostasiological and technical complications [2]. The implementation of the method of traditional plasmapheresis is associated with the replacement of protein losses, which is fraught with the risk of infection of the patient (viral hepatitis, syphilis, malaria, human immunodeficiency virus, cytomegalovirus), the development of anaphylactic and pyrogenic reactions during transfusion of freshly frozen plasma (cryoplasma) and other protein preparations [ 3]. Plasma exchange in a volume exceeding 150% of the circulating plasma volume (CCP) is not cost-effective; it threatens the development of citrate intoxication [4]. The closest prototype to the proposed method is a discrete centrifugal plasmapheresis.

This invention allows to solve a new technical problem:

- decrease in the level of endogenous intoxication;

- simplification of the method of extracorporeal hemocorrection while maintaining a high degree of detoxification effect;

- the exclusion of transfusions of cryoplasm and other protein preparations with a replacement purpose;

- prevention of the development of purulent-septic complications of a burn disease, such as pneumonia, sepsis;

- reduction in the area of operative autodermoplasty.

To solve the problem in a method of treating a burn disease in children with severe thermal injury by performing discrete centrifugal plasmapheresis, including a single blood sampling, gravity separation, plasma removal, incubation of the antibiotic in the autocellular mass and its subsequent reinfusion to the patient, additionally conduct anticoagulant therapy with the creation of conditions hypocoagulation, determine in the blood plasma the level of medium-weight molecules (MSM) at a wavelength of 254 nm and with its value of 0.31 to 0.39 conventional units, at provided that the accumulation of MSM prevails in plasma and on red blood cells, or at a level of more than 0.39 conventional units, with the accumulation of MSM on red blood cells, in plasma and urine, a treatment procedure is performed, for which crystalloid solutions are pre-infused in the volume of hemexfusion, then hemexfusion of blood is carried out in an amount of 10-12% of the circulating blood volume (BCC), then 2 ml of a 1% ATP solution and an antibiotic from a number of third generation cephalosporins in a single dose for d are incubated into the autocellular mass for Tei.

The method is as follows: conduct discrete plasmapheresis on a domestic apparatus for centrifuge fractionation of the type "PC-6" or "OS-6-M". The system of highways includes disposable blood transfusion systems PK 21-01- “synthesis” GOST 25047-87. Vascular access in children upon admission to a hospital with severe thermal damage is provided by catheterization of the subclavian vein according to the Seldinger method. Anticoagulant therapy is carried out for the burned patient with the creation of hypocoagulation conditions controlled by chronometric indicators of the coagulogram: activated partial thromboplastin time (APTT) and thrombin time (TB), and aggregatograms: coagulation constant r + k [5]. The anticoagulant is administered micro-jet, intravenously and continuously throughout the day, the dose is calculated upon receipt by the value of the coagulation constant r + k, which characterizes the state of the initial phases of blood coagulation and the intensity of activation of the hemostasis system [5]. The chosen tactics of anticoagulant therapy allows to minimize the initial disorders in the hemostatic system, to avoid fluctuations in hemostatic potential, to prevent the development of disseminated intravascular coagulation, aggravating the state of endogenous intoxication. Before the start of the plasmapheresis procedure, the patient is given an intravenous infusion of crystalloid preparations, for example, “Disol” or “Quintasol”, in an amount corresponding to the volume of forthcoming hemexfusion, that is, 10-12% of the circulating blood volume (BCC). The process of the procedure consists in a single hemexfusion using a roller pump at a speed in the range of 20-40 ml per minute [3] from the subclavian catheter along the vascular line to a sterile graduated vessel with a glugicir as a blood preservative, the amount of which corresponds to the volume of blood taken in a ratio of 1: four. Then, the blood sampled in the vessel is subjected to gravitational separation at a rotor speed of 1800 rpm ^-1 for 20 minutes, after which the plasma is removed under sterile conditions and 2 ml of a 1% solution of adenosine triphosphoric acid (ATP) and antibiotic are successively incubated. from the group of third generation cephalosporins, namely cefotaxime, or ceftazidime, or cefoperazone, or ceftriaxone, in the highest single dose for children, respectively, body weight. The resulting mixture was incubated for 25 minutes at an ambient temperature of 20-25 ° C and then reinfused to the patient.

An indication for the use of the new method is the criterion for assessing endogenous intoxication - the level of medium-weight molecules (MSM ₂₅₄ ), determined at a wavelength of 254 nm, where the quantitative determination of medium-molecular peptides objectively characterizes the degree of intoxication in burn disease [6]:

1. The value of MSM ₂₅₄ in plasma in the range from 0.31 to 0.39 conventional units, while the level of medium molecular peptides prevails on red blood cells and in plasma.

2. The value of MSM ₂₅₄ in plasma exceeds 0.39 conventional units, i.e. at any level of medium molecular peptides on red blood cells, plasma and urine.

It is known that the efficiency of the plasmapheresis method is greatest at the beginning of the procedure [3], therefore, its implementation can be limited in the amount of a single hemexfusion in the range of 10-12% of the bcc of the child, which refers to the variant of low-volume plasmapheresis [4]. The proposed volume of blood sampling in children is optimal - it does not lead to the occurrence of critical hypoxia and hemorrhagic shock [3], does not require replenishment of the removed plasma with donor cryoplasma and protein preparations, and excludes the development of hemodynamic disorders during the procedure and the risk of patient infection. It is known that the method of extracorporeal pharmacotherapy consists in the use of autologous cells in order to change their properties during joint incubation of an ATP solution and an antibacterial drug in an autogenous cell mass, directed transport of the antibiotic into the area covered by the pathological process, which allows achieving 4-6 long (up to 2 days) a multiple increase in the concentration of the drug in the focus of inflammation [4, 7]. The drug of choice for antibiotic therapy in the proposed method for burn injury are third-generation cephalosporins [8].

The applicants analyzed the clinical material of the course of burn disease in children with severe thermal injury during periods of burn shock and acute burn toxemia. The main group (n = 40) consisted of patients whose injury severity index (ITP) averaged 103.48 ± 7.4 units, and underwent anticoagulant therapy and a new method of extracorporeal hemocorrection according to indications. The comparison group (n = 30) consisted of patients whose ITP averaged 105.1 ± 10.16 units and underwent anticoagulant therapy without taking into account initial disorders in the hemostatic system and extracorporeal hemocorrection, including the traditional plasmapheresis method or the ultraviolet irradiation method. The groups were comparable by age and severity index (p> 0.05). The dynamics of endogenous intoxication by the level of MSM in the plasma of patients at a wavelength of 254 nm is shown in Table 1 “Dynamics of the level of average-weight molecules in children with burn disease,” according to which during the period of burn shock, the growth of endogenous intoxication occurred in both groups and had a similar course (p > 0.05). In patients of the main group, on the 5-7th and 10-12th days, there was a persistent decrease in the level of endogenous intoxication, significantly different from that in the comparison group (p <0.05), which indicated the effectiveness of the new method.

Optimization of the tactics of detoxification therapy and the choice of indications for the use of a new method of treating a burn disease made it possible to reduce the development of a systemic inflammatory response syndrome (CVD), multiple organ failure and early sepsis, and to exclude complications such as pneumonia and gastrointestinal bleeding. The treatment had a positive effect on the volume of operative activity, so the area of operative autodermoplasty decreased from 17.98 ± 3.31 to 2.84 ± 0.95% of AKI. In the main group, mortality was prevented in children with thermal trauma in acute periods of burn disease, while in the comparison group it was 20%. The total duration of hospitalization of patients with burn disease decreased from 44.61 ± 4.70 to 28.13 ± 2.83 days. The data presented are reflected in table 2 "The results of the treatment of acute periods of burn disease in children with severe thermal injury."

Example 1

An example is the following case history No. 3673 of a patient, Kolimov Klim Evgenievich, 1 year 6 months, who was treated at the Department of Anesthesiology and Reanimation of Children's City Hospital No. 4 of Tomsk from July 6 to August 4, 2004. From the anamnesis it was revealed that the child received a thermal injury by boiling water of the trunk, face, limbs with a depth of II-III degree, on an area of 60% (50% of the III st.). The severity index of the lesion was 170 units, which refers to extremely severe burn shock. At the time of admission, after 30 minutes from the moment of injury, the patient's condition is very serious, anxiety, chills, consciousness corresponds to stupor, shock symptoms were clinically determined. The mucous membranes are pale, dry, clean. The skin outside the burn wound is cold, cyanotic. The nail beds are pale cyanotic, bloodless. White Spot Symptom> 3 seconds. Breathing is independent, puerile, uniform in all departments, with a hard tint. Heart sounds 140 / min, deaf, rhythmic. HELL 150/80 mm Hg, central venous pressure (CVP) after catheterization of the subclavian vein is negative. The patient's body weight was 12 kg. Based on the data from studies of the hemostasis system, the intensive care regimen from the moment of admission included anticoagulant therapy with the creation of a hypocoagulation condition, where in the dynamics of APTT it corresponded to 60-100 seconds, TV - 23-30 seconds, r + k - 15.8-21 , 1 minutes, that is, by lengthening the values of the indicators by 1.5-2.5 times. The introduction of the anticoagulant was carried out continuously, micro-jet, with a syringe infuser. The values of the MSM level in a day from the moment of receipt was 0.3 conventional units (cu). After 3 days, the MSM value increased to 0.33 cu, where the level of average molecular peptides exceeded in plasma and on red blood cells, and not in urine. Accordingly, these data were treated according to the proposed method: hemexfusion in the amount of 12% of the BCC, gravity separation, sequential incubation in the autocellular mass of 2 ml of 1% ATP solution and the antibiotic ceftazidime 400 mg (100 mg × 12 kg: 3) at ambient temperature 23 ° C for 25 minutes, followed by reinfusion. The condition remained stable during the procedure; donor cryoplasma or other protein preparations were not transfused for the purpose of compensation. Monitoring the level of endogenous intoxication after 5 days showed a further increase in the value of MSM - 0.42 cu Secondly performed the proposed method of treatment in the same volume. After 7 days, the MSM value decreased to 0.32 cu, but the level of medium molecular peptides prevailed in the patient's plasma. The extracorporeal hemocorrection procedure was repeated in the same volume. After 10 days, the value of endogenous intoxication was 0.27 cu, with a predominant level of medium-molecular peptides in the patient's urine, which indicated their active removal from the body. The burn disease in the child proceeded favorably, there were no complications, the replacement of damaged skin was performed by autodermoplasty on an area of 1%. The child was discharged from the hospital after 29 days. In this case, a differentiated approach in the context of anticoagulant therapy allowed targeted detoxification therapy in the general treatment regimen leading to recovery.

Example 2

The following example was the case history No. 5374 of a patient of 1 year of Nikitina Karina Alekseevna, who was undergoing treatment at the Department of Anesthesiology and Reanimation of Children's City Hospital No. 4 of Tomsk from October 2 to October 27, 2004. From the anamnesis it was revealed that the child received a thermal injury by boiling water in the area of the anterior abdominal wall, buttocks, perineum, right upper and lower extremities with a depth of II-III degree, on an area of 40% degree (30% of III degree). The severity index of the lesion was 110 units, which refers to extremely severe burn shock. At the time of admission, after 180 minutes from the moment of injury, the patient's condition is very serious, anxiety, chills, clear consciousness, symptoms of shock were clinically determined. The mucous membranes are pale pink, dry, clean. The skin outside the burn wound is cool, acrocyanosis. The nail beds are pale pink, of sufficient filling. White Spot Symptom> 3 seconds. Breathing is independent, puerile, uniform in all departments, with a hard tint. Heart sounds 170 / min, moderately deaf, rhythmic. HELL 110/70 mm Hg, central venous pressure (CVP) after catheterization of the subclavian vein is negative. The patient's body weight was 10.5 kg. From the moment of admission, based on the data from a study of the hemostasis system, anticoagulant therapy with the creation of a hypocoagulation condition is included in the intensive care regimen, where in the dynamics the APTT value corresponds to 56-90 seconds, TV - 22-31 seconds, r + k - 18.2- 23.6 minutes, that is, lengthening the values of the indicators by 1.5-2.5 times. The introduction of the anticoagulant was carried out continuously, micro-jet, with a syringe infuser. The value of MSM in a day from the moment of receipt was 0.32 cu, where the level of average molecular peptides exceeded in the urine, which indicated their active excretion from the body. After 3 days, the MSM value increased to 0.37 cu, while the level of average molecular peptides exceeded in plasma and on red blood cells, and not in urine. Accordingly, these data were treated according to the proposed method: hemexfusion in the amount of 10% of the BCC, gravity separation, sequential incubation in the autocellular mass of 2 ml of 1% ATP solution and cefotaxime antibiotic 350 mg (100 mg × 10.5 kg: 3) at a temperature environment 23 ° C for 25 minutes, subsequent reinfusion. The condition remained stable during the procedure; donor cryoplasma or other protein preparations were not transfused for the purpose of compensation. Monitoring of the level of endogenous intoxication after 5 days showed the preservation of a high MSM value - 0.38 cu The extracorporeal hemocorrection procedure was performed a second time in the same volume. After 7 days, the value of endogenous intoxication decreased to 0.35 cu, but the level of medium molecular peptides prevailed in the patient's plasma. The extracorporeal hemocorrection procedure was repeated in the same volume. After 10 days, the value of endogenous intoxication was 0.23 cu, where the level of medium-molecular peptides exceeded the patient's urine, which indicated their active removal from the body. The child’s burn disease proceeded favorably, there were no complications, and against the background of detoxification, active epithelization of damaged skin occurred over the entire area. The child was discharged from the hospital after 25 days. In this case, a differentiated approach to the method of extracorporeal hemocorrection, under the conditions of anticoagulant therapy, allowed for targeted detoxification therapy in the general treatment regimen that led to recovery.

Thus, the application of the proposed method allows to reduce the level of endogenous intoxication, to simplify the procedure of extracorporeal hemocorrection while maintaining a high degree of detoxification effect, to exclude transfusion of cryoplasma and other protein preparations with a substitute purpose, to prevent the development of purulent-septic complications of a burn disease such as pneumonia, sepsis, reduce the area of operative autodermoplasty.

Table 1

The dynamics of the level of molecules of average weight in children with burn disease

Duration of observation The main group (n = 40) Comparison Group (n = 30) R After 1 day 0.342 ± 0.014 0.350 ± 0.018 > 0.05 On the 3rd day 0.365 + 0.014 0.401 ± 0.026 > 0.05 On the 5-7th day 0.335 ± 0.009 0.410 ± 0.018 <0.05 On the 10-12th day 0.271 ± 0.007 0.365 ± 0.021 <0.05 table 2 The results of the treatment of acute periods of burn disease in children with severe thermal injury Indicators The main group (n = 40) Comparison Group (n = 30) SIRS (SIRS),% 75 90 SPON,% 32,5 66.6 Early sepsis,% twenty 46.6 Pneumonia,% 0 16.7 Gastrointestinal bleeding,% 0 13.3 Area of operative plasty,% 2.84 ± 0.95 17.98 ± 3.31 Bed Duration 28.13 ± 2.83 44.61 ± 4.70 Mortality in the acute period,% 0 twenty

Bibliography

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Claims (1)

A method of treating a burn disease in children with severe thermal injury by carrying out a treatment procedure including discrete centrifugal plasmapheresis by a single hemoexfusion, gravity separation, plasma removal, incubation of the antibiotic in the autocellular mass and its subsequent reinfusion to the patient, characterized in that they additionally carry out anticoagulant therapy hypocoagulation, determine in the blood plasma the level of medium-weight molecules (MSM) at a wavelength of 254 nm, and with its value from 0.31 about 0.39 conventional units, and provided that the accumulation of MSM prevails in plasma and on red blood cells, or when the level of MSM is more than 0.39 conventional units, and with the accumulation of MSM on red blood cells, plasma and urine, a treatment procedure is performed, for which crystalloid solutions are preliminarily infused in the amount of upcoming hemoexfusion, hemoexfusion is performed in the amount of 10-12% of the circulating blood volume (BCC), for incubation, 2 ml of a 1% ATP solution and an antibiotic from a series of third generation cephalosporins are sequentially injected into the autologous mass necks single dose for children.