RU2371122C2 - Method for treating acute limb ischemia - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to vascular surgery and intensive therapy, and can be used in treating the patients with acute limb ischemia. It is ensured by preoperative intravenous introduction of Perftoran during 12 hours in a dose 5 ml/kg of body weight combined with inhalation of 40-50% oxygen-enriched air mix in combination with introduction of preparations improving tissue microcirculation. It is followed with operative intervention that depending on the involvement level involves surgical approach to arteries wherein oxygenic Perftoran is introduced in amount 50 ml. Then arteries are clamped with main arteries and collaterals being excluded from blood circulation, and blood flow is restored. After the operation, during 12 h the patient takes inhalations of the oxygen-enriched air mix.

EFFECT: method allows improving clinical effectiveness of such patients, and also preventing development of postischemic syndrome due to joint introduction of oxygenic Perftoran and the oxygen-enriched air mix.

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Description

The invention relates to medicine and can be used to treat patients with acute arterial obstruction of the extremities in complex treatment before surgery.

With all operations on the arteries, at their technical stage, the arteries are clamped, which leads to the shutdown of both the main and collateral pathways of blood supply to limb tissues. Subsequently, during the start of blood flow, this leads to the occurrence of postischemic syndrome. In operations on the arteries of the limbs, local, regional anesthesia is used. To protect tissues from ischemia and improve microcirculation in ischemic limbs, the synthetic neuropeptide Dalargin is used, it is administered bolus every 60 minutes during the entire operation at the rate of 3.7 ± 6.6 μg / (kg · h). In addition, Kreatinolphosphate (Neoton) is used in dosages - iv in a jet 2-4 grams before surgery and subsequent infusion of 8-10 grams in a 5% glucose solution during the operation and reperfusion period.

Heparin (2500-5000 PIECES) is administered at the time of clamping the arteries in order to prevent microthrombosis, improve the rheological properties of the blood, and reduce its viscosity.

The known method is used in all patients with operations on the arteries of the limbs.

The disadvantages of this method:

- When performing the known method, the blood circulation of the tissues of the limbs is reduced, and therefore, the flow of oxygen is reduced, which leads to tissue ischemia.

- The anti-ischemic effect of dalargin, creatine phosphate is mediated through an improvement in metabolism in ischemic tissues. They do not have an oxygen-carrying function.

Currently, the treatment program for acute limb ischemia includes a combination of rheological solutions (reopoliglukin, rheomacrodex) with disaggregants (chimes, trental). The course of treatment lasts 7-10 days. Given the frequent concomitant cardiac pathology, the volume of infusion is 200-250 ml, with slow intravenous administration of solutions, followed by switching to tableted preparations - pentoxifylline (Vazonit, Trental), Curantil.

This method is used in all patients with acute arterial obstruction before surgery.

The disadvantages of this method:

- Reopoliglyukin significantly increases the volume of circulating blood, is excreted by the kidneys and is contraindicated in chronic kidney diseases, heart failure.

- Preparations containing pentoxifylline have a vasodilating effect, can cause "stealing syndrome", exacerbating local tissue ischemia.

- The anti-ischemic effect of rheopolyglucin and trental is mediated through the improvement of the rheological properties of blood and the expansion of the vascular bed. They do not have an oxygen-carrying function.

The most effective is the intravenous administration of prostaglandin E1 analogues - alprostadil. The drug is administered at a dose of 60 mg / day in 200 ml of physiological saline, the infusion lasts at least 2-3 hours. The course of treatment lasts 10 days.

The disadvantages of this method:

- The anti-ischemic effect of alprostadil is mediated through an improvement in the rheological properties of blood, an improvement in microcirculation, and expansion of the peripheral vascular bed. It does not have an oxygen-carrying function.

- Treatment with alprostadil is expensive, an average of 40-43 thousand rubles.

The purpose of the invention is the improvement of oxygen supply to the extremities in acute ischemia.

This goal is achieved by the fact that in the method of treatment of acute limb ischemia, surgical methods are used; drugs that improve tissue microcirculation are introduced. According to the invention, a patient is treated with perftoran at a dose of 5 ml / kg body weight before surgical treatment and inhalation of an air mixture enriched with oxygen by 40-50% for 12 hours. During surgery, in addition to the arteries of the limbs, 50 ml of oxygenated perftoran are injected, after the operation, the patient is inhaled with an oxygen-enriched air mixture for 12 hours.

The method is as follows. From the moment a patient arrives at the clinic, after a clinical examination and a biological test, as a preoperative preparation, the patient is administered intravenously 5 mg / kg body weight perftoran and the air mixture is inhaled by 40-50% oxygen enriched. Before surgery, anesthetics are performed, then surgical access to the arteries of the limbs. Arteries are punctured and 50 ml oxygenated perfluorane is introduced. Then the arteries are pinched and manipulated on them. After surgery, the patient is inhaled for 12 hours with an oxygen-enriched air mixture.

Perftoran, dissolving in the membrane of red blood cells, makes them more flexible and easily deformable, which reduces the viscosity of the blood. An increase in the elasticity and deformability of the erythrocyte membrane improves their passage through the capillaries and, consequently, the delivery of oxygen to tissues. Perftoran increases blood capacity and gas exchange dynamics. The effect of the use of perftoran is maximal if during and after the infusion during the day the patient breathes an air mixture enriched with oxygen of 40-50% (Perftoran is a blood substitute with gas transport function. Instructions for doctors at clinics of St. Petersburg State Medical University named after academician I.P. Pavlov, St. -Petersburg, publishing house of St. Petersburg State Medical University. 2001, p.6).

The method is used in the treatment of acute limb ischemia

An example of a specific application of the method:

1. Patient V., 55 years old, was admitted to the Department of Vascular Surgery, COCO with a diagnosis of Atherosclerosis. Thrombosis (embolism?) Of the superfemoral artery on the left. Stenosis of the tibial arteries on both sides. Acute ischemia of 2 degrees on the left.

Concomitant diagnosis: Atrial fibrillation, FC 2, CHF II, FC 2.

Arterial hypertension II Art., Risk 4 (very high), FC 2

Ultrasound Dopplerometry and Duplex Scanning: Signs of stenosing atherosclerosis. Thrombosis (embolism?) Of the superfemoral artery on the left.

The transcutaneous oxygen tension (tcRO2) in the supine position is 11 mmHg, while in the sitting position it is 31 mmHg.

In connection with the revealed volume and degree of damage to the patient, an operation was performed - thromboembolectomy from the superficial femoral artery on the left.

In the complex treatment, the patient was given intravenous perfluorane at the rate of 5 ml / kg of the patient’s body weight before the operation and inhaled the air mixture enriched with oxygen by 40-50%. During surgery, oxygenated perfluorane was additionally injected in PBA - 50 ml; after the operation, the patient was inhaled with an oxygen-enriched air mixture for 12 hours.

The transcutaneous oxygen tension (on the second day) was 28 mm Hg. in horizontal position, 48 mm Hg in vertical.

On the first day, the patient was transferred to the vascular surgery department for bed rest. On the second day, drainage was removed, the patient was transferred to general mode.

On the seventh day, after removing the stitches, the patient was discharged for outpatient monitoring by a surgeon at the place of residence. The inventive method allows you to:

- For a long time to work on pinched arteries;

- quick relief of acute ischemia clinic;

- reduce the patient’s hospital stay;

- is economically viable.

Claims (1)

A method of treating acute limb ischemia, in which, depending on the level of the lesion, they provide surgical access to the arteries, squeeze them and turn off the main arteries and collaterals from the blood circulation, perform an intervention on the arteries, and then restore blood flow through the arteries, characterized in that the patient before surgery in combination with the introduction of drugs that improve tissue microcirculation, perftoran is administered intravenously at a dose of 5 ml / kg body weight for 12 hours and the air mixture is inhaled, both aschennoy oxygen at 40-50%, during surgery arteries additionally introduced into 50 ml of oxygenated perfluorane after surgery the patient within 12 hours is carried inhalation air mixture enriched with oxygen.