RU2523555C2 - Method for intraoperative and early postoperative infusion therapy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine and aims at intraoperative and early postoperative infusion therapy. A method involves administering a crystalloid balanced solution of sterofundin iso and a balanced colloidal solution of tetraspan. In the intraoperative period, sterofundin is administered with tetraspan in the volume ratio 3:1. In the early postoperative period, for the first day, sterofundin and tetraspan are administered in the volume ratio 6:1.

EFFECT: method is simple, safe, enables effectively correcting aqueous electrolyte disorders, stabilising systemic hemodynamic parameters, causing no negative effect on haemostasis and electrolyte composition of the blood serum.

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Description

The invention relates to medicine, in particular to anesthesiology and resuscitation, and can be used for intraoperative and early postoperative infusion therapy in planned and emergency patients in obstetrics and gynecology, surgery, traumatology and orthopedics.

Known electrolyte 0.9% sodium chloride solution, the so-called "physiological" solution (table). This solution contains only two ions - sodium (Na ⁺ ) and chlorine (Cl ^- ) in amounts significantly exceeding physiological values.

Table The composition of electrolyte isotonic solutions in relation to blood plasma Blood plasma Isotonic Sterofundin Solution Ringer's solution The solution of 0.9% sodium chloride Na ⁺ (mmol / L) - 135-145 140.0 140.0 154.0 Cl ^- (mmol / L) - 90-110 127.0 150.0 154.0 K ⁺ (mmol / L) - 3.3-5.5 4.0 4.0 - Mg ²⁺ (mmol / L) - 0.8-1.1 1,0 - - Ca ²⁺ (mmol / L) - 2.1-2.6 2,5 6.0 - NSO ^- ₃ - 24 ± 2 malate (carrier of reserve alkalinity) - 5.0 - - BE (mmol / L): -3 + 2.5 0 -24.0 -24.0 Osmolarity (mosmol / l) - 285 ± 5 304.0 300,0 308.0 Acetate (mmol / L) - 0 24.0 - - pH (venous blood) - 7.34-7.36 4.6-5.4 6.0 6.0

Therefore, when large quantities of 0.9% sodium chloride solution are introduced into the vascular bed of the patient, hypernatremia and hyperchloremia develop. The consequence of this electrolyte imbalance, and especially hyperchloremia, is the occurrence of hyperchloremic metabolic acidosis. The probability of its development in a patient is directly proportional to the amount of sodium chloride solution introduced.

Known Ringer's solution, which also contains a significant amount of chlorine (table). An increase in the concentration of chlorine in the extracellular space causes renal angiospasm and a decrease in glomerular filtration and urine output. An increase in plasma chlorine concentration by 12 mmol / L above normal (up to 122 mmol / L) leads to an increase in renal vascular resistance by 35%, a decrease in glomerular filtration rate by 20% and a drop in blood pressure as a result of acute and chronic decrease in plasma renin activity .

A well-known polyionic balanced solution of sterofundin isotonic, which is as close as possible in its electrolyte composition to blood plasma (table), has a balanced potential excess of bases (BE = 0 mmol / l), and also contains carriers of reserve alkalinity acetate and malate, which are completely metabolized to equivalent the amount of bicarbonate for a short period of time (60-90 minutes), while spending 2 times less oxygen compared to lactate metabolism (Base Excess und Laktatkonzentration von I nfusionslosungen und Blutprodukten. / R. Zander // Anasthesiol Intensivmed Notfallmed Schmerzther. 2002. - Vol. 37. - P.359-363).

Balanced solutions prevent the development of dilutional acidosis. There is no risk of extracellular space hyperchloremia and renal angiospasm during infusion of sterofundin isotonic, which results in decreased diuresis and excessive hydration of the body (Standi Th: Forderungen und Erwartungen an einen optimalen Volumenersatz. / R. Zander., HAAdams, J. Boldt [et all.] // Anasthesiol. Intensivmed Notfallmed Schmerzther. 2005. - Vol. 40. - Druck. - P.68).

Known balanced colloidal solution - tetraspan - colloidal solution of 6% hydroxyethyl starch 130/42, the solvent of which is a balanced electrolyte solution of isotonic sterofundin. Compared with other colloidal solutions of hydroxyethyl starch, tetraspan is the most physiological and safe drug, since all known solutions of hydroxyethyl starch (Reftan, Stabizol, Infukol, Venofundin, Voluven, etc.) contain a solution of 0.9% sodium chloride. This means that with high-volume infusion of colloids, as well as with infusion of isotonic sodium chloride, the development of hyperchloremic acidosis is potentially possible. Tetraspan is deprived of these negative properties due to its balanced composition (Volume replacement with a new balanced hydroxyethylstarch preparation (HES 130 / 0.42) in patiens undergoing abdominal surgery / J.Boldt, T. Schollhorn., G. Schulte, M. Pabsdorf / / European Joirnal of Anaesthesiology. - 2006. - Vol.4. - P.1-9).

Thus, the use of balanced isotonic crystalloid and colloidal solutions in the program of infusion therapy in patients at the stage of surgical treatment and the early postoperative period subsequently significantly reduces the risk of electrolyte and acid-base balance disturbances and is characterized by the absence of negative effects, unlike unbalanced crystalloid solutions , indicators of electrolyte and acid-base balance.

OBJECT OF THE INVENTION - improving the method of intraoperative and early postoperative infusion therapy.

The problem is solved in that patients during surgical treatment are given balanced infusion therapy (balanced crystalloid sterofundin isotonic solution + balanced tetraspan colloidal solution), which is continued in the early postoperative period. The volume of infusion therapy depends on the severity of the condition of the patients, the severity of water-electrolyte disturbances and anthropometric indicators.

The method is as follows. During surgical intervention, patients receive intraoperative balanced (crystalloid-colloidal) infusion therapy, the effectiveness of which is assessed using data from systolic, diastolic and mean blood pressure (BP) and heart rate (HR). Upon patient admission, after surgical treatment, in the intensive care unit or specialized surgical department, the intraoperatively balanced infusion therapy is continued, the volume and speed of which depend on the duration and severity of the operation, the severity of the general condition of the patients, the patient's reaction to the therapy and the severity of water-electrolyte disturbances. In the intraoperative period, sterofundin is administered with tetraspan in a volume ratio of 3: 1, and in the early postoperative period, during the first day, sterofundin and tetraspan are introduced in a volume ratio of 6: 1.

The effectiveness of infusion therapy is evaluated by increasing the volume of circulating plasma, the parameters of central hemodynamics, systolic, diastolic and mean blood pressure, heart rate and central venous pressure.

EXAMPLE

Patient S., 26 years old, March 13, 2011 was in the MUZ RD №2 about pregnancy. After examining the obstetrician-gynecologist, the patient decided to have an operative delivery (cesarean section) in connection with a scar on the uterus after conservative myomectomy and the presence of a large fetus. On March 14, 2011, the patient was taken to the operating room, where a successful delivery was performed under spinal anesthesia. The condition corresponds to the severity of the operation. In the mind, adequate. The skin is normal and warm. The tongue is wet. The vesicular breathing is evenly carried out in all departments of the lungs. NPV = 14 min ^-1 . Heart sounds are muffled, the rhythm is correct. HELL = 100/70 mm Hg Pulse 74 min ^-1 . Dressings on the wound are dry. Blood loss during surgery 500 ml. Infusion therapy (isotonic sterofundin (1500 ml) and tetraspan (500 ml)) in a volume of 2000 ml. Upon admission to the intensive care unit, the following tests were recorded: hemoglobin - 126 g / l, red blood cells - 4.1 * 10 ¹² , white blood cells - 5.5 * 10 ⁹ , bilirubin - 17.2 μmol / l, AlAt - 25.5, AcAt - 34.3, blood glucose - 4.9 mmol / L, total protein - 75 g / L, platelets - 264, potassium - 4.2 mmol / L, sodium - 141 mmol / L, chlorine - 99 mmol / L, The pH of venous blood is 7.36. According to the ECG, the sinus rhythm is 112 min ^-1 . In the early postoperative period, infusion-transfusion therapy was continued (sterofundin isotonic in a volume of 1500 ml and tetraspan in a volume of 250 ml), antibiotic therapy and analgesia were prescribed. The above hematological and biochemical parameters are the same.

The technical result - in the proposed method of intraoperative and postoperative infusion therapy, the use of a balanced (crystalloid-colloid) infusion therapy option allows you to effectively correct electrolyte-electrolyte disturbances, stabilize the parameters of systemic hemodynamics, and not have a negative effect on hemostasis and electrolyte composition of blood serum. Moreover, our proposed method is easy to use, effective, safe, does not require high material costs, which allows you to obtain a significant economic effect, as well as devoid of the disadvantages that are found in other methods of infusion therapy that we studied.

Claims (1)

The method of intraoperative and early postoperative infusion therapy, including the introduction of a crystalloid balanced solution of sterofundin isotonic and balanced colloidal tetraspan solution, characterized in that in the intraoperative period, sterofundin is administered with tetraspan in a volume ratio of 3: 1, and in the early postoperative period, during the first day, sterofundin and tetraspan are introduced in a volume ratio of 6: 1.