RU2489974C2 - Method of topical treatment of hyperfibrinolytic hemorrhages in cardiosurgery - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine and is intended for treatment of hyperfibrinolytic hemorrhages in cardio surgery. Method includes irrigation of pericardium cavity and/or pleural cavity with solution of antifibrinolytic. Solution is introduced during hemorrhage against the background of hyperfibrinolysis after suturing postoperative wound.

EFFECT: method application makes it possible to reduce postoperative hemorrhage, need of transfusion of blood components and necessity of additional surgical hemostasis, ensures maximal concentration of active substance in area of maximal activity of fibrinolysis and in immediate proximity from source of hemorrhage, excluding risk of thrombosis.

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Description

The invention relates to medicine, namely to cardiovascular surgery, and can be used to reduce postoperative blood loss and the need for blood transfusions, reduce the need for additional surgical hemostasis.

Known methods for the treatment of hyperfibrinolytic bleeding in cardiac surgery (II Dementieva I. Hemostasis system for operations on the heart and major vessels. Violations, prevention, correction / II Dementieva, MA Charnaya, Yu.A. Morozov - M .: GEOTAR-Media, 2009 .-- 432 p .; Varela Crespo CA Effect of tranexamic acid on postoperative bleeding in pediatric heart surgery / CA Varela, P. Sanabria, MA Palomero Rodriguez et al // Rev. Esp. Anestesiol. Reanim. - 2007 . - Vol. 54. - P.155-161 .; McCIure PO The use of epsilon-aminocaproic acid to reduce bleeding during cardiac bypass in children with congenital heart disease / PD McCIure, 1 Izsak // Ancsthcsiology. - 1974. - Vol. .40. - P.604-608.), Involving the systemic use of antifreeze rinolitikov such as ε-aminocaproic acid and tranexamic acid.

The disadvantage of these methods is that they do not provide the optimal concentration of the active substance in the region of the highest fibrinolysis activity, that is, in the postoperative wound, in which the fibrinolysis activity exceeds that in the systemic blood. The use of higher doses of these drugs threatens the development of thrombosis of various localizations. In fact, the systemic use of antifibrinolytics inhibits systemic fibrinolysis, the activation of which is often small, but does not have a decisive effect on the local, dominant in the clinic, which determines both the process of lysis of clots in the wound and the persistence of bleeding.

A known method for the topical use of antifibrinolytics in cardiac surgery (De Bonis M. Topical use of tranexamic acid in coronary artery bypass operations: a double-blind, prospective, randomized, placebocontrolled study / M. De Bonis, F. Cavaliere, F. Alessandrini // J Thorac. Cardiovasc. Surg. - 2000. - Vol.119. - P.575-580), including irrigation of the pericardial cavity with a solution of 1 g of tranexamic acid in 100 ml of isotonic sodium chloride solution before suturing the postoperative wound with subsequent removal of the solution through drainage tubes and in the presence of postoperative bleeding, therapy using hemostatic preparations mouth and blood transfusion.

The disadvantage of this method is that it does not have a prolonged effect and does not exclude the risk of postoperative bleeding against the background of activation of systemic or local fibrinolysis. It is known that the activity of fibrinolysis after surgery has been increasing for some time and the preventive use of antifibrinolytics is not able to influence it, which limits the effectiveness of this method and does not exclude the possibility of conducting therapy using hemostatic drugs and blood transfusion.

The technical result of the claimed method is to enhance the action of antifibrinolytic in the region of the highest fibrinolysis activity.

The method is as follows. In case of postoperative blood loss exceeding 3 ml / kg / h, and with normal laboratory parameters of the blood coagulation system (indication of bleeding due to activation of local fibrinolysis), or if the rate of bleeding through the drainage tube persists after normalization of the parameters, or if it is possible to find a source of bleeding in the pleural cavities, the pleural cavities are irrigated with a solution of antifibrinolytic followed by removal of the solution through the drainage tubes. The volume of the solution is calculated based on anthropometric characteristics. In the case of intact pleural cavities, it should not exceed 5 ml / kg. Before administration, the antifibrinolytic solution is heated to body temperature. In order to prevent cardiac tamponade, irrigation is performed under continuous monitoring of heart rate, arterial and central venous pressure.

For irrigation use official prescriptions of solutions of antifibrinolytics. The volume of injected solution is limited by the volume of the pericardial cavity, and the threat of heart rhythm disturbances and coronary perfusion determines the need for warming the solution.

The technical result is achieved in that in the method for the topical treatment of hyperfibrinolytic bleeding in cardiac surgery, including irrigation of the pericardial cavity with an antifibrinolytic solution, the solution is injected during bleeding against hyperfibrinolysis after suturing the postoperative wound into the pericardial cavity and / or into the pleural cavity.

Irrigation of the pericardial cavity and / or pleural cavity with an antifibrinolytic solution during bleeding against the background of hyperfibrinolysis provides the maximum concentration of the active substance in the region of the highest fibrinolysis activity and in the immediate vicinity of the bleeding source, eliminating the risk of thrombosis due to the lack of systemic effect of the drug.

Example. Patient D., 1 g. 9 months, weight 11.7 kg. Clinical diagnosis: ventricular septal defect. The child underwent plastic surgery of an interventricular septal defect under conditions of artificial hypothermic blood circulation and pharmacological cold cardioplegia. In the early postoperative period, blood flow through the drains with an intensity of 5 ml / kg / h was noted. At the same time, violations of the coagulation phase of blood coagulation, mainly due to an excess of heparin, were noted: MHO (international normalized ratio) - 1.15, APTT (activated partial thromboplastin time) - 150 s, CT _in (coagulation time of thromboelastogram (TEG) upon activation of the internal pathway) - 587 s, CT _ex (TEG coagulation time when the external path is activated) - 61 s, CFT _in (TEG thrombus formation time when the internal path is activated) - 233 s, CFT _ex (TEG thrombus formation time when the external path is activated) - 131 s , with secondary disorders e apa stabilize thrombus: fibrinogen, 2 g / L, platelets 238 × 10 ⁹ / L, α _in 51 °, α _ex 65 °, MCF; n (the maximum clot strength TEG upon activation of the intrinsic pathway) - 44 mm, MCF _ex (max clot strength by TEG upon activation of the external pathway) - 48 mm and normal fibrinolysis activity indicators: D-dimer 314 ng / ml, Lys30 _ex (percentage of clot lysis by TEG after 30 min upon activation of the external pathway) - 0%, Lys30 _in (percentage lysis of the clot by TEG after 30 minutes with activation of the internal pathway) - 9%. The therapy was carried out, including the introduction of protamine sulfate, aprotinin, freshly frozen plasma. During therapy, stabilization of the main parameters of the thromboelastogram was noted (CT _in - 126 s, CT _ex - 66 s, CF0T _in - 78 s, CFT _ex - 93 s, α _in - 75 °, α _ex - 72 °, MCF _in - 53 mm , MCF _ex -55 mm) with an increase in the activity of systemic fibrinolysis (Lys30 _ex - 18%, Lys30 _in - 14%), despite the systemic use of antifibrinolytics. The rate of blood loss decreased, but remained excessive, amounting to 3.6 ml / kg / h. Through a drainage tube, 50 ml of a 5% solution of ε-aminocaproic acid was introduced into the pericardial cavity. Hemodynamic disturbances are not noted. Drainage is pinched. After 10 minutes, the remaining antifibrinolytic solution is aspirated through a drainage tube. The intensity of blood loss decreased to 0.7 ml / kg / h, the potential need for red blood cell transfusion and additional surgical hemostasis was eliminated. The patient was extubated after 10 hours, transferred to the clinical department on the 2nd day. The wound healed by primary intention. The child was discharged from the hospital on the 7th day.

The proposed method provided the cessation of bleeding, reduction of postoperative blood loss, the need for transfusion of blood components and the need for additional surgical hemostasis due to the action of antifibrinolytic - a solution of ε-aminocaproic acid injected through the drainage tube into the pericardial cavity, during bleeding against the background of hyperfibrinolysis, that is, the maximum effect antifibrinolytic in the area of the highest fibrinolysis activity.

Claims (1)

A method for the topical treatment of hyperfibrinolytic bleeding in cardiac surgery, including irrigation of the pericardial cavity with an antifibrinolytic solution, characterized in that the solution is administered during bleeding against hyperfibrinolysis after suturing the postoperative wound into the pericardial cavity and / or pleural cavity.