RU2407009C1 - Method of diagnosing infectious-septic processes in patients with thermal trauma - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: method of diagnosing infectious-septic processes in patients with thermal trauma lies in the following: blood is analysed and presence of damaged erythrocytes is detected, number of platelets in plasma is determined, activity of antithrombin III is analysed, in blood sample serum, concentration of urea, sodium creatinine, albumin, general cholesterol and aspartat-aminotranspherase activity are determined. Integral index of infectious-septic process (II) is determined and if II is 15.2 units and higher infectious-septic process is diagnosed. ^ EFFECT: increase of accuracy of infectious-septic process diagnostics. ^ 3 ex, 1 tbl

Description

The present invention relates to medicine, in particular to methods for diagnosing infectious-septic processes (pneumonia, sepsis) in patients with burns.

A known method for the diagnosis of infectious-septic complications in patients with thermal injury, including the determination of 8 indicators, based on an analysis of the results of which diagnose the presence or absence of these complications in patients (increased heart rate, increased patient’s body temperature, increased white blood cell count, registration of stab a shift in the leukocyte formula, the detection of lymphopenia, hypoproteinemia, hypoalbuminemia, an increase in the level of fibrinogen in the blood) and at the same time an increase in the number of positive values of these tests from 4 to 8 makes a judgment about the increased likelihood of a patient developing purulent-septic complications (Usov V.V., Obidennikova T.N., Gorsheev A.I. et al. Prediction and prevention of purulent-infectious complications in patients with thermal injury. Emergency medical care. - 2006. - No. 3. - P.94).

However, this method is implemented by performing and analyzing the results of comprehensive tests that are not combined into an integral indicator that would be convenient for clinicians in terms of the possibility of monitoring one parameter in the dynamics of the pathological process, operative assessment of the effectiveness of therapeutic measures, taking emergency measures with a sharp change in the magnitude of the observed indicator.

Closest to the proposed technical solution is a method for the diagnosis of sepsis, based on the determination of one indicator of the hemostatic system - the activity of XIIa-dependent fibrinolysis (RF patent No. 2185624, 2002).

However, the known method is adapted to detect only generalized infections (sepsis) and does not allow to diagnose other (focal) purulent-infectious complications (for example, pneumonia).

The task of the invention is to expand the diagnostic capabilities of the method.

The problem is solved due to the fact that, in addition to determining the activity of XII-dependent fibrinolysis, in addition to determining the activity of XIIa-dependent fibrinolysis, indicators used in the diagnosis of disseminated intravascular coagulation in such patients are also analyzed (RF patent No. 2257574). Blood is taken from patients with burns and antithrombin III (ATIII) activity, XIIa-dependent fibrinolysis (XIIa-ZF) activity, soluble fibrin-monomer complexes (RFMC), platelet count, presence of a lightened red blood cell fraction in the blood sample are determined using known methods (test for damaged red blood cells), as well as an integral indicator of renal-hepatic insufficiency (STI). At the same time, the severity of each indicator is assigned a score, the value of which increases as the disorders of a particular link in the analyzed system deepen (table). The integral indicator of the infectious-septic process (IP) is calculated by the formula:

PI = BI + BII + BIII + BIV + BV + BVI,

where BI is the number of points of activity of ATIII from 1 to 5,

BII - activity XIIa-ZF from 1 to 5,

BIII - content RFMK from 1 to 5,

BIV - platelet counts from 1 to 5,

BV - red blood cell damage test from 0 to 3,

BVI - integral indicator of renal hepatic insufficiency (STI) from 1 to 5,

and with an IP value of 15.2 units. and above diagnose an infectious-septic process. With a value of 15.1 units. and lower the probability of an infectious-septic process is rejected.

The method is as follows. In patients with burns from the ulnar vein, blood is taken and placed in 3 tubes: for preparing plasma (1st tube), a sample for counting platelet count (2nd tube) and serum (3rd tube). In the obtained samples, using known methods, indicators are determined that characterize the state of the hemostatic system (1st tube) - ATIII activity (a decrease in the activity of ATIII, the main endogenous anticoagulant, indicates the depletion of this link in the hemostatic system regulation mechanism, and the continued decrease in the indicator indicates the progression of DIC syndrome); activity of XIIa-dependent fibrinolysis (XIIa-ZF) (the value of XIIa-ZF reflects the state of the main plasma proteolytic systems; an increase in the lysis time of the euglobulin clot indicates a slowdown in this process; an increase in the DIC syndrome is accompanied by an increase in this indicator); the content of soluble fibrin-monomer complexes (RFMC) using the orthophenanthroline test (an increase in RFMC indicates an increase in blood of non-polymerizable "blocked" fibrin-monomer complexes, which are a marker of DIC). The platelet count is examined in vitro 2. Thrombocytopenia in DIC is a consequence of their consumption (platelet aggregation into microtubules). A sharp increase in thrombocytopenia indicates the progression of DIC. Whole blood to detect a lighter fraction of red blood cells (test for damaged red blood cells) is taken from tube 1 until the plasma is separated from the red blood cells. Isolation of the light fraction of red blood cells is carried out in a capillary on a solution of verographin of a given specific density (RF patent No. 2134421, 2225002). A positive red blood cell damage test characterizes the activation of intravascular coagulation. Damage (fragmentation) of red blood cells occurs when they pass through microvessels blocked by filaments of fibrin formed from fibrinogen under the influence of the proteolytic enzyme thrombin. Then determine the concentration of urea, creatinine, sodium, albumin, total cholesterol and the activity of aspartate aminotransferase (test tube 3) to calculate the integral indicator of renal-hepatic insufficiency - IPPN, which reflects the depth of multiple organ disorders that occurred during the development of DIC due to microtrombosis of vessels of parenchymal organs, disorders microcirculation, hypoxia and subsequent failure of their function (RF patent No. 2223496), according to the formula:

IPPN = (K ₁ + K ₂ + K ₃ + K ₄ ) / (K ₅ + K ₆ ),

where K ₁ - the ratio of the concentration of urea in the blood serum of the patient to the arithmetic mean of the analyte content of healthy people;

To ₂ - the ratio of the concentration of creatinine in the blood serum of the patient to the arithmetic mean of the analyte content of healthy people;

K ₃ - the ratio of the concentration of sodium in the blood serum of the patient to the arithmetic mean of the analyte content of healthy people;

K ₄ - the ratio of the activity of aspartate aminotransferase in the blood serum of the patient to the arithmetic mean activity of the analyte of healthy people;

To ₅ - the ratio of serum albumin in the patient to the arithmetic mean of the analyte content of healthy people;

To ₆ - the ratio of total cholesterol in the blood serum of the patient to the arithmetic mean of the analyte content of healthy people.

The obtained results of each test are ranked, that is, a certain score is assigned to a certain value of the analyzed indicator, guided by the data in the table. Calculate the integral indicator (PI) for the diagnosis of infectious-septic process according to the formula:

PI = BI + BII + BIII + BIV + BV + BVI,

where BI is the number of points of activity of ATIII from 1 to 5,

BII - activity XIIa-f from 1 to 5,

BIII - content RFMK from 1 to 5,

BIV - platelet counts from 1 to 5,

BV - red blood cell damage test from 0 to 3,

BVI - an integral indicator of renal hepatic insufficiency from 1 to 5, and with an IP value of 15.2 units. and above diagnose an infectious-septic process. With a value of 15.1 units. and lower the probability of an infectious-septic process is rejected.

Ranks of values of indicators of the state of the hemostatic system and the depth of renal hepatic failure in patients with burns No. p / p Name of test and ranking ranges of research results Points one. Antithrombin III Activity (%) 1.1. 80-115 one 1.2. 70-79 2 1.3. 60-69 3 1.4. 50-59 four 1.5. 49 and below 5 2. The activity of XIIa-dependent fibrinolysis (min) 2.1. 4-10 one 2.2. 11-50 2 2.3. 51-100 3 2.4. 101-120 four 2.5. 121 and more 5 3. Soluble fibrin-monomer complexes - RFMC (mg / l) 3.1. 0-40 one 3.2. 41-100 2 3.3. 101-150 3 3.4. 151-200 four 3.4. 201 and more 5 four. Platelet count (thousand / μl) 4.1. 141-420 one 4.2. 101-140 2 4.3. 75-100 3 4.4. 50-74 four 4.5. 49 and below 5 5. Erythrocyte damage test 5.1. Negative 0 5.2. Weak positive one 5.3. Positive 2 5.4. Sharply positive 3 6. The integral indicator of renal hepatic insufficiency (conventional unit) 6.1. up to 3.54 one 6.2. 3,55-4,24 2 6.3. 4.25-4.94 3 6.4. 4.95-5.64 four 6.5. 5.65 and above 5

The basis for determining the IP value of the infectious-septic process, above which it is possible to judge the development of infectious-septic complications in patients, was the results of a study of this indicator in patients who suffered thermal injury and were being treated at the Russian Burn Center at the Nizhny Novgorod Research Institute of Traumatology and Orthopedics .

A retrospective study of the infectious-septic IP was performed by analyzing an array of case histories of patients with burns on the area of skin lesions of more than 20% of the body surface with a burn depth of II-IIIAB-IV degree (moderate burns, severe and extremely severe burns) in the period from 3 to 9 days after thermal injury. Patients (98 people) were divided into 2 groups: those who had DIC (disseminated intravascular coagulation) in combination with the infectious-septic process (pneumonia, sepsis) - group I (59 people), and patients who developed DIC without infectious-septic process - group II (39 people). At the same time, group I includes patients with a verified diagnosis of the infectious-septic process according to clinical, special laboratory and hardware-instrumental methods of research, as well as the results of the autopsy of deceased patients. The arithmetic mean of the integral index (IP) in group I was 18.0 ± 0.36 units. (M ± m, where M is the arithmetic mean, m is the error of the arithmetic mean). In this group, the IP ranged from 14.3 to 21.8 units. (M ± σ, where σ is the standard deviation - sigma). In group II, the arithmetic average of the indicator was 13.5 ± 0.33 units. (M ± m). Moreover, the IP ranged from 11.0-16.0 units. (M ± σ). The difference in arithmetic mean values was statistically significant with a high degree of reliability (p <0.001).

Since the upper limit of the IP range in patients with DIC, who do not have a concomitant complication in the form of an infectious-septic process, is 16.0 units, and the lower limit of this indicator in the group of patients suffering from DIC is combined with an infectious-septic process - 14.3 units, then establish a dividing line for both variants of the course of the DIC syndrome (with and without the accompanying septic infection process) between them - 15.15 units. ([16.0 + 14.3] / 2). Therefore, with a value of IP of 15.2 units. and above they diagnose an infectious-septic process (in combination with DIC), while when the value of the analyzed indicator is 15.1 units. and below the diagnosis of an infectious-septic process is rejected.

The adequacy of the proposed method for the diagnosis of infectious-septic processes in patients with thermal injury is illustrated by the following clinical examples.

Example 1

Patient Fs A.S., 30 years old (source B-ni No. 228093), entered the Russian Burn Center on the basis of the Nizhny Novgorod Research Institute of Traumatology and Orthopedics (NNIIITO) on March 19, 2007 with a flame burn of degree P-IIIAB on the square 35% of the body surface, burn of the upper respiratory tract, burn of the mucous membranes of the eyes (index of severity of the lesion - 73 units). PI one day after the burn amounted to 8 units, 3 days - 9 units, 5 days - 9 units, 8 days - 12 units, 11 days - 10 units. Diagnosed with a violation of the blood coagulation system by the type of latent form of DIC. No data were found for the infectious-septic process. The state of the blood coagulation system was corrected, and the skin was restored. The patient was discharged in satisfactory condition 38 days after the burn.

Example 2

Patient K-ev M.Yu., 28 years old (source B-ni No. 226026), was admitted to the NNIIIT on November 7, 2006 about a degree IIIAB flame burn on an area of 20% of the body surface, upper respiratory tract burn. The severity index of the lesion is 78 units. 3 days after the thermal injury, pneumonia was suspected on the basis of clinical signs, after 6 days the pneumonia was confirmed by fibrobronchoscopy, after 7 days by the results of an X-ray examination, and after 8 days, the localization and nature of pneumonia was clarified by computed tomography. PI a day after a burn - 17 units, 2 days - 15 units, 6 days - 19 units, 8 days - 20 units, 10 days - 13 units. Thus, the patient is diagnosed with a focal purulent-inflammatory process - pneumonia, which is combined with a simultaneously developed violation of the blood coagulation system as an acute syndrome of DIC. After active treatment of the patient with antibiotics, adequate correction of the hemostatic system, as well as restoration of the skin, the patient was discharged in satisfactory condition on the 84th day after thermal injury.

Example 3

Sh-s S.A., 57 years old (source b-ni No. 225070), entered the Nizhny Novgorod Research Institute of Traumatology and Orthopedics on September 10, 2006 in connection with a burn with hot steam of IIIAB-IV degree on an area of 50% of the body surface, burn upper respiratory tract (the severity index of the lesion is 110 units). Based on the clinical manifestations of the complication, the results of a bacteriological blood test (Pseudomonas aeruginosa isolated), as well as changes in the indicators of a clinical blood test (drop in the number of leukocytes to 2.8 thousand / μl of blood, shift of the blood count to the “left” - an increase in the number of immature forms of leukocytes) the patient is diagnosed with sepsis only 10 days after thermal injury. However, the IP value already in 2 days after the burn was 19 units, 3 days - 19 units, 5 days - 21 units, 9 days - 22 units, 11 days - 21 units. Despite the treatment, the patient died on the 12th day after the burn. A generalized infection (sepsis) in this patient proceeded in combination with an acute form of DIC. This example illustrates the capabilities of the proposed method. If, using traditional methods for identifying infectious-septic complications, the patient was diagnosed with sepsis only 10 days after the burn, then according to the PI, 2 days after the thermal injury, the patient could be suspected of the so-called fulminant sepsis and a timely set of additional diagnostic procedures , as well as early treatment with effective antibiotics.

A method for the diagnosis of infectious-septic processes in patients with thermal injury has a fairly high specificity. The correct diagnosis of a purulent-inflammatory complication (in combination with DIC) was carried out in 75% of cases (with 82 definitions of the indicator out of 110 performed in the dynamics of the examination of 52 patients). DIC-syndrome without concomitant infectious-septic complications was adequately diagnosed in 92.5% of cases (with 46 definitions of the indicator out of 56 performed in the course of the examination, 39 patients with burns).

An important advantage of the proposed method is that in order to identify a purulent-inflammatory complication in a patient, as well as a generalized process (sepsis), it is not necessary to perform additional laboratory and instrumental studies (for example, systematically perform chest x-ray in a severe patient with burns, having damaged skin on a large surface of the upper half of the body). These complications can be identified based on the ready-made results of the analysis of coagulological and biochemical parameters. Early detection of an integral indicator above 15.1 units. indicates the development in the patient of not only DIC, but also an infectious-septic process, which should alert and oblige the clinician to prescribe a detailed set of additional diagnostic procedures to the patient in order to clarify the nature of the purulent-inflammatory process. In this case, in the early stages of the development of this complication, an adequate and effective antibiotic treatment may be prescribed to the patient until a vivid manifestation of the clinical picture and progression of the infectious-septic process.

The above confirms the adequacy and usefulness of using the proposed method not only for the diagnosis of DIC, but also focal purulent-inflammatory processes (pneumonia), as well as generalized infection. All this is the basis for recommending the use of the developed method both in clinics of thermal lesions, and in clinical diagnostic laboratories.

Claims (1)

A method for the diagnosis of infectious-septic processes in patients with thermal injury, which includes determining the activity of CPA-dependent fibrinolysis in blood plasma, characterized in that the presence of damaged red blood cells is additionally detected in whole blood and platelet counts are assessed, the activity of antithrombin III, the content of soluble fibrinmonomers are examined in plasma complexes, in the blood serum of the sample determine the concentration of urea, creatinine, sodium, albumin, total cholesterol and the activity of aspartate aminotransf times, calculating the integral component renal hepatic failure severity defined parameters are assigned corresponding to the score calculated integral indicator infectious and septic process (SP) by the formula
PI = BI + BII + BIII + BIV + BV + BVI, where
BI - the number of points of activity of antithrombin III from 1 to 5,
BII - activity of CPA-dependent fibrinolysis from 1 to 5,
BIII - the content of soluble fibrinmonomeric complexes from 1 to 5,
BIV - platelet count from 1 to 5,
BV - tests of damage to red blood cells from 0 to 3,
BVI is an integral indicator of renal-hepatic insufficiency from 1 to 5, and with an IP value of 15.2 units. and above diagnose an infectious-septic process.