RU2475234C2 - Method for prevention of severe complications accompanying surgical management of massive and submassive blood loss with continuous haemorrhages - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely resuscitation and may be used for prevention of severe complications in surgical management of massive and submassive blood loss with continuous haemorrhages. That is ensured by the intraoperative intravenous drop-by-drop introduction of Perftoran 2-4 ml/kg following mechanical arrest of the continuous haemorrhages. With underlying restorable blood volume, higher body oxygenation with eliminated nitrogen oxide inhalation. Rheamberyn is introduced in an average therapeutic dose at the end of the operation and on the first three postoperative days.

EFFECT: invention provides higher effectiveness of infusion-transfusion management, improved clinical course of the operative and postoperative period, reduced percentage of complications and mortality.

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Description

The present invention relates to medicine, to intensive care, and can be used to increase the efficiency of perioperative infusion-transfusion support for the surgical treatment of massive blood loss with ongoing bleeding.

Despite the achievements of surgery, anesthesiology, intensive care of transfusiology, the effective provision of surgical treatment of acute and subacute hemorrhage with ongoing bleeding remains one of the most urgent problems of modern medicine.

Various methods for treating bleeding are known. Thus, a known method of restoring circulating blood by introducing a drug. As a drug, lactin is used, which is administered intravenously and intramuscularly (see RF Patent 2066190, 1996, A61B 35/55).

A known method of transfusion of perftoran during surgery, while infusion was started after the patient was anesthetized and carried out at a rate of 50-60 drops per minute (see Biryukov D.L., Petrova M.V. Possibility of optimizing oxygen transport using perftoran emulsion in patients with surgical treatment of lung cancer. // Organofluorine compounds in biology and medicine: Sb.nauch.tr., 2001. - C.116-119).

The disadvantage of this method is the increase in unstoppable bleeding and the appearance of increased bleeding of tissues, especially in cases of weakening of the hemostatic system, for example, as a result of excessive dilution of blood with blood substitutes. Also, during transfusion of perftoran during surgery, for the conduct of general anesthesia using nitrous oxide, it is necessary to reduce the oxygen content in the inhaled gas mixture to 30% or lower.

Closest to the claimed is a method of treating bleeding by administering reamberin to patients with gastroduodenal ulcer bleeding. During conservative treatment, patients underwent intensive therapy according to the severity of the condition and, along with standard therapy, infused Reamberin 1.5% with 400 ml 2 times a day for the entire period of stay in the intensive care unit. (Morgunov S. S. The use of reamberin in intensive therapy of gastroduodenal bleeding. // Method.recom. - Izhevsk: IGMA, 2006 - 10 p.). However, an increase in tissue oxygen demand (with reduced delivery) leads to disruption of the energy chains in the tissues and, ultimately, to complications, such as weak heart activity. Another disadvantage is the danger of using reamberin to correct hypoxia in conditions of reduced oxygen delivery to tissues in pathological conditions such as pulmonary edema, adult respiratory distress syndrome, which arise as complications of massive blood loss.

The technical result of the proposed method is to increase the efficiency of infusion-transfusion support, improving the course of the surgical and postoperative period, reducing the percentage of complications and mortality.

New in achieving the set technical result is that during the operation, 2-4 ml / kg of perfluorane is administered intravenously after a mechanical stop of ongoing bleeding against the background of the restored volume of circulating blood, high oxygenation of the body with the exception of nitrous oxide inhalation. Also new is the fact that reamberin is poured in a medium therapeutic dose at the end of the operation and in the first three days after surgery.

The introduction of perftoran before the start of reamberin infusion improves oxygen delivery to tissues, which activates the metabolic effect of reamberin and prevents the growth of oxygen deficiency in tissues caused by activation of metabolic processes. The effects of the use of perftoran are fully manifested when the drug is transfused in small volumes. The activation of the metabolic action of reamberin, achieved by the preliminary administration of perfotoran, allows you to restore metabolism in the tissues and prevent the development of fatal complications. The lead time is due to the fact that the period of the maximum effectiveness of perftoran is observed 1 hour after its infusion. The combined administration of perftoran and reamberin mutually potentiates the positive effects of the drugs: antihypoxic, antioxidant, rheological, microcirculatory, diuretic, detoxification, repeatedly accelerating the oxygenating and deoxygenating processes of erythrocyte hemoglobin depending on the partial pressure of oxygen in the environment, activating the enzymatic and tissue processes, improving the tissue cycle K detoxifying liver function, restoring the energy potential of cells. The authors found that the inclusion of perftoran and reamberin infusion in the program of infusion-transfusion support of emergency operations for bleeding with massive blood loss and the implementation of these infusions on the basis of the developed principles improves the course of the surgical and postoperative periods and reduces the volume and intensity of the necessary treatment.

Comparative analysis with the prototype shows that the inventive method is characterized in that during the operation, 2-4 ml / kg perftoran is administered intravenously after a mechanical stop of continued bleeding against the background of the restored volume of circulating blood, high oxygenation of the body with the exception of nitrous oxide inhalation, and reamberin poured in a medium therapeutic dose at the end of the operation and in the first three days after surgery, which meets the criterion of "novelty."

A new set of features provides an increase in the efficiency of infusion-transfusion support, an improvement in the course of the operational and postoperative period, a decrease in the percentage of complications and mortality, a reduction in the length of hospital stay after surgery, a reduction in the dose of drugs used, early postoperative activation of patients is noted, which meets the criterion of “industrial applicability” ".

The method is as follows.

After surgical hemostasis is achieved, replenishment of the volume of circulating blood, further correction of anemia, acute metabolic changes in the blood, stabilization of plasma oncotic pressure is carried out, which ensures the necessary transportation of oxygen to tissues and transcapillary exchange. The main means of infusion-transfusion therapy are isotonic sodium chloride solution and colloidal solutions (gelofusin, 6% hydroxyethylated starch solutions - infucol HES, refortan, voluven, dextrans) in a 3: 1 ratio. The composition of the transfused media includes jet-drop transfusions of 2-3 doses of thawed freshly frozen plasma. To replenish lost red blood cells, donor erythrocyte-containing media are used in the amount necessary to maintain a selected level of hemodilution (hematocrit within 25-30%, blood hemoglobin 80-90 g / l). In the case of hemodynamic inefficiency of volumetric therapy, cardiotonic and vasopressor intravenous therapy (dopmin, dopamine, adrenaline, etc.) is connected in doses that provide the necessary stabilization of hemodynamics. In severe injuries, single doses of large doses of glucocorticoids are used.

After the creation of hypervolemic hemodilution, after stopping the ongoing bleeding mechanically, with careful surgical hemostasis during the operation, perftoran is administered at a dose of 2-4 ml / kg intravenously at a rate of 30 drops per minute after the preliminary test for tolerability (reactogenicity) of the drug. During transfusion of perftoran during the operation and on the first day after its transfusion, the patient is provided with high oxygenation, since the ability of perftoran to transport oxygen is in direct linear dependence on the partial pressure of oxygen in the environment. This is achieved by enrichment of the inhaled air with oxygen up to 70-85%, with respiratory support through mechanical ventilation or through nasal catheters. When transfusion of perftoran during the operation, nitrous oxide is not used for general anesthesia, since when it is used, the oxygen content in the inhaled gas mixture has to be reduced to 30% or lower. Maintenance of adequate anesthesia is achieved by intravenous fractional administration of fentanyl (4-5 μg / kg / h), calypsol (2 mg / kg / h), arduan (0.02-0.04 mg / kg / h), diazepam (5- 10 mg before induction of anesthesia and at the final stage of the operation). Not later than an hour after the infusion of perftoran, reamberin is poured in an average therapeutic dose of 400 ml at a rate of 4.0-4.5 ml / min against the background of maintaining hypervolemia, stable hemodynamics and high oxygenation of the body. After the operation, 400 ml of reamberin are poured daily for 3 days against the background of high oxygenation of the body.

The proposed method is illustrated by the following clinical examples.

Example 1. Patient I., 36 years old, weight 72 kg, was admitted to the Bichur Central District Hospital on 10.01.2008 at 02.15 with the diagnosis: Penetrating wound of the abdominal cavity with damage to internal organs. Intraperitoneal bleeding, hemorrhagic shock, II tbsp. From the anamnesis it is known that he was stabbed about 4 hours ago in the village of Harlun (60 km from the central district hospital), examined by a paramedic, after first aid was delivered by ambulance to the central district hospital, small-volume infusion therapy was carried out during transportation (Ringer 400 , sodium chloride 0.9% - 400). Heredity without features, no concomitant diseases. Upon admission, the patient's condition is extremely serious. Inhibited, drowsy. The skin is pale, cold. Symptom of a "white spot" more than 3 s. In the epigastric region there are two linear wounds up to 3 cm long, from the wounds there is scanty hemorrhagic discharge. In the lungs, vesicular breathing, weakened in the lower parts, the number of breaths of 20 per min. Heart sounds are deaf, rhythmic. Blood pressure - 80/40 mm Hg, pulse - 120 beats. in min, on peripheral arteries is not determined. Abdominal painful on palpation, symptoms of peritoneal irritation are positive. Catheterization of the superior vena cava was performed on the right, CVP - negative, infusion therapy continues. During catheterization of the bladder, a small amount of straw-yellow urine was obtained.

Complete blood count :: Hb - 52 g / l, Ht - 17%, erythrocytes - 1.95 · 10 ¹² / l, white blood cells - 12.6 · 10 ⁹ / l, platelets - 112 · 10 ⁹ / l, total protein - 54.4 g / l, AST - 63 e / l, ALT - 22 e / l. In the study of the hemostatic system - prothrombin index 81%, fibrinogen - 2.5 g / l, the clotting time according to Bürker - 5 min 30 s, the bleeding rate according to Duke - 2 min 05 s.

“Shock index” - 1.5 (bcc deficit - 40%), which corresponds to an extremely severe degree, the estimated volume of circulating blood according to the F. Moore method was 5040 ml (bcc deficiency - 60%).

The patient was urgently taken to the operating room. Under general multicomponent anesthesia with artificial ventilation, an upper middle laparotomy, revision of the abdominal cavity organs, suturing of wounds of the right lobe of the liver and small intestine, rehabilitation and drainage of the abdominal cavity were performed. During the operation, 2.5 liters of blood contaminated with small intestine contents were removed from the abdominal cavity in clots up to 0.2 liters.

Hemodynamics during the operation are unstable, there was a decrease in A / D to 20/0, the pulse was not determined, inotropic dopamine support was carried out at a dose of 5 ml / kg / min.

After surgical hemostasis (suturing wounds of the liver), the infusion-transfusion therapy was carried out in the mode of moderate hypervolemic hemodilution (sodium chloride solution 0.9% Reftan 6%), against this background perfluorane was transfused in the amount of 2.8 ml / kg, which allowed to stabilize hemodynamics through 15 min from the start of the infusion (A / D - 125/80 mm Hg). At the final stage of the operation, 400 ml of reamberin solution was transfused. In total, the operation was transfused: erythrocyte mass - 550 ml, SZP - 940 ml, reftan 6% - 1250 ml, sodium chloride solution 0.9% - 1200 ml, Ringer's solution - 1000 ml, Chlosol - 400 ml, reamberin 1.5 % - 400 ml, perfluoran - 200 ml.

Postoperative diagnosis: Penetrating combined stab wound of the abdominal cavity, wound of the right lobe of the liver, loop of the small intestine. Continuous massive intra-abdominal bleeding. Hemorrhagic shock of the III degree.

After surgery, the patient was on prolonged mechanical ventilation for 8 hours. In the early postoperative period, the condition is serious, stable hemodynamics A / D - 130/80 mm Hg, pulse - 96 rpm, good filling.

Complete blood count: Hb - 72 g / l, Ht - 23%, red blood cells - 2.15 · 10 ¹² / l, white blood cells - 10.6 · 10 ⁹ / l, platelets - 154 · 10 ⁹ / l, LII (Kalf -Caliph) - 2.1; GPI - 1.8 units; bilirubin - 10.6 μmol / l; AST - 48.4 e / l; ALT - 19.2 e / l; total protein reduced to 46.6 g / l; cholesterol - 3.1 mmol / l; urea - 4.9 mmol / l; creatinine - 59 μmol / l. Adequate diuresis - 70 ml / h without stimulation.

Over the next days, a state with positive dynamics, no complications were noted, infusion-correcting therapy was carried out (which included reamberin), symptomatic, antibacterial.

On the fourth day after surgery, the patient with improvement was transferred to the surgery department. Discharged on the 14th day after the operation in satisfactory condition.

Example 2. Patient P., 42 years old, weight 68 kg, was admitted to the surgical department of the Bichur Central District Hospital on 02.15.2010 at 13.15 with a clinic of gastrointestinal bleeding (vomiting "coffee grounds", black stool, dizziness, weakness, twice in the morning collapse was noted). There is no ulcerative anamnesis, considers himself ill since 02/12/2010. There are no comorbidities.

Upon admission, the condition is serious, inhibited, severe pallor with acrocyanosis, dizziness, weakness. The skin is pale, cold, moist. In the lungs, vesicular breathing, the number of breaths - 24 per min. Heart sounds are deaf, pulse 120 per minute, rhythmic, weak filling, blood pressure 60/40 mm Hg Blood tests: Hb - 46 g / l, Ht - 11.9%, red blood cells - 1.48 · 10 ¹² / l, leukocytes - 19.2 · 10 ⁹ / l, platelets - 225 · 10 ⁹ / l, total protein - 45.4 g / l, AST - 43 e / l, ALT - 25 e / l. When studying the hemostasis system, the prothrombin index is 95%, fibrinogen is 1.9 g / l, the clotting time according to Bürker is 5 min 00 s, and the bleeding rate according to Duke is 2 min 15 s. “Shock index” - 2 (bcc deficit is more than 40%), which corresponds to an extremely severe degree, the estimated volume of circulating blood according to the F. Moore method was 4420 ml (bcc deficit is 70%). Against the background of respiratory support with oxygen with FiO ₂ - 0.3 (via nasal catheters), preoperative preparation was carried out (6% - 500 ml reftan, 600 ml Ringer's solution, 600% sodium chloride solution 0.9%). The patient was urgently operated on. On the operation: chronic ulcer of the anterior wall of the body of the stomach with a transition to lesser curvature in the infiltrate, with penetration into the right lobe of the liver; blood in the lumen of the stomach, small and large intestine. After separation of the infiltrate, a defect 2 cm in diameter formed with a profuse bleeding vessel from the wall in the stomach wall. Performed a resection of the stomach. Hemodynamics during the operation are unstable, up to the disappearance of the pulse and A / D, inotropic support with dopamine at a dose of 8 μg / kg / min. After ligation of the left gastric artery, infusion of perftoran was carried out - 200 ml (2.9 ml / kg), after 20 minutes from the start of the infusion, A / D stabilization occurred at 120/90 mm Hg, pulse - 108 beats per minute. At the final stage of the operation, 400 ml of reamberin solution was transfused. During the operation, it was transfused: erythrocyte mass - 500 ml, FFP - 840 ml, Infucol 6% - 500 ml, Ringer's solution - 600 ml, 0.9% sodium chloride solution - 1000 ml, perfluoran - 200 ml, reamberin - 400 ml.

After surgery, the patient was on a prolonged mechanical ventilation for 2 hours. In the early postoperative period, the condition is serious, stable hemodynamics A / D - 130/80 mm Hg, pulse - 94 per min, good filling. Complete blood count: Hb - 79 g / l, Ht - 25%, red blood cells - 2.87 · 10 ¹² / l, white blood cells - 14.6 · 10 ⁹ / l, platelets - 121 · 10 ⁹ / l, LII (Kalf -Caliph) - 2.8; GPI - 2.1 units; bilirubin - 7.4 μmol / l; AST - 36.4 e / l; ALT - 24.1 e / l; total protein reduced to 48.6 g / l; cholesterol - 2.1 mmol / l; urea - 5.6 mmol / l; creatinine - 48 μmol / l. Adequate diuresis - 70 ml / h without stimulation.

Over the next days, the state with positive dynamics, was carried out infusion-correcting therapy, which included daily dose of 400 ml reamberin, symptomatic, antibacterial therapy.

On the fourth day after surgery, the patient with improvement was transferred to the surgery department. Discharged 12 days after surgery in satisfactory condition.

Claims (1)

A method for the prevention of severe complications in the surgical treatment of massive and submassive hemorrhage with continued bleeding by the introduction of reamberin, characterized in that during the operation, 2-4 ml / kg perftoran is administered intravenously after a mechanical stop of continued bleeding against the background of the restored volume of circulating blood, high oxygenation organism with the exclusion of nitrous oxide inhalation, and reamberin is administered in a medium therapeutic dose at the end of the operation and in the first three days after surgery th intervention.