RU2549531C1 - Method of estimating severity degree and prediction of lethal outcome in patients with combined trauma and continued bleeding - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: registration of the age, average arterial pressure (APav), hematocrit (Ht) value and saturation with oxygen of venous blood samples from the central vein (SvO2) is carried out. Each parameter is given points. Age ≤32 years - 1 point, 33-56 - 2 points, age ≥57 years - 7 points. Ht value >24.5% - 1 point, 12-24.5% - 5 points, Ht<12% - 16 points. APav value ≤70 mm Hg - 3 points, APav>70 mm Hg - 1 point. Value SvO2≥63% - 1 point, 32-62% - 4 points, SvO2<32% - 10 points. If the sum of the points is ≤6, the state is evaluated as of moderately severe with a low risk of lethal outcome. If the sum of the points is 7-13, the state is evaluated as severe with a medium risk of lethal outcome. When the sum of the points is ≥14, the state of the injured people is evaluated as extremely severe with a high risk of lethal outcome.

EFFECT: method makes it possible to evaluate the patient's state in the preoperative period with high prognostic accuracy and predict probability of lethal outcome due to the application of a minimal set of parameters, which do not require carrying out the analyses, requiring long time.

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Description

The invention relates to medicine and can be used to assess the severity of the condition of victims and the prognosis of death from injuries in the departments of anesthesiology and intensive care, surgical departments.

In modern anesthesiology, scales and classifications for assessing the physical condition and risk of anesthesia are widely used (ASA classification, ASA modification by Peter and Lutz, MNOAR classification). These classifications do not imply a detailed quantitative assessment of physiological and pathological changes in a particular patient. The physiological state is described in general terms (for example, “a patient with a severe systemic uncompensated disease”), and partly the assessment is based on the personal experience of the doctor and cannot be detailed and quantified. The classification of ASA and its modifications, the classification of MNOAR are not intended for an individual assessment of the risk of surgical treatment and do not allow the patients to be identified in the operating room with a high risk of death in the postoperative period.

The closest technical solution adopted for the prototype is the APACHE III scale, which is recognized as the standard for the integral assessment of the severity of patients in critical condition. APACHE III is intended for the quantitative determination of the severity of a condition, the prognosis of a fatal outcome in a hospital, and the evaluation of the duration of follow-up in the intensive care unit (Abdominal injury: a manual for doctors / Edited by A.S. Ermolov, M.Sh. Khubutiya, M.M. Abakumov. - Moscow: Vidar Publishing House. - M., 2010. - 504 p .; Gain Yu.M., Hulup G.Ya., Zavada N.V. et al. Objective assessment of the severity of the patient's condition and prognosis in surgery. - Minsk : BelMAPO. - Minsk, 2005. - 299 p .; Marino P. Intensive care. - Moscow, GEOTAR. - 2010. - 770 p .; Gelfand B.R., Yaro Getsky A.I., Protsenko D.N., Romanovsky Yu.Ya. Integral systems for assessing the severity of patients with polytrauma // Bulletin of intensive care. - 2004. - No. 1. - p. 58; Yaroshetsky A.I., Protsenko D.N., Ignatenko O.V., Gelfand B.R. Prediction of fatal outcome in severe trauma // Anesthesiology and Intensive Care. - 2006. - No. 6. - P. 58-65; Knaus W., Zimmerman J., Wagner D. et al. APACHE - acute physiology and chronic health evaluation: A physiologically based classification system // Crit. Care Med. - 1981. - Vol. 9. - P.951-955; Knaus W.A., Wagner D.P., Draper E.A. et al. The APACHE III prognostic system. Risk prediction of hospital mortality for critically ill hospitalized adults // Chest. - 1991. - Vol. 100. - N6. - P.1619-1636; Leme-show S., Le Gall J.-R. Modeling the severity of illness of ICU patients. A systemic update // JAMA. - 1994 .-- Vol.272. - N13. - P.1049-1055; Jones H.J.S., de Cossart L. Risk scoring in surgical patients // British Journal of Surgery. - 1999. - Vol. 86. - P.149-157; Beck D.H., Smith G. B., Pappachan J. V., Millar B. External validation of the SAPS II, APACHE II and APACHE III prognostic models in South England: a multicentre study // Intensive Care Medicine. - 2003 .-- Vol.29. - P.249-256; Sakr Y., Krauss C, Amaral A.C.K.B. et al. Comparison of the perfomance of SAPS II, SAPS 3, APACHE II, and their customized prognostic models in a surgical intensive care unit // British Journal of Anaesthesia. - 2008 .-- Vol. 101. - N6. - P.798-803).

In the APACHE III scale, the analysis of the patient's condition and prognosis is based on several groups of indicators, which include:

- physiological parameters (pulse, respiratory rate, body temperature),

- indicators of homeostasis and gas exchange (pH, pO2 and pCO2 of arterial blood, oxygenation index when the oxygen fraction in the inhaled air is more than 50%),

- biochemical and functional tests (hematocrit, white blood cell count, creatinine and blood urea, blood bilirubin, sodium, proteinemia, glycemia, diuresis per day);

- assessment of neurological status (based on the Glasgow com scale);

- age of the patient and related diseases.

Each analyzed characteristic is assigned a specific score. If the value of the indicator is unknown, then it is considered appropriate. Additionally, a correction index is set depending on the reason for hospitalization in the intensive care unit (therapeutic disease, a specific type of surgical disease and surgical intervention). Then determine the index of the APACHE III scale (directly characterizes the severity of the patient's condition) and the risk of death in the hospital.

Despite the high accuracy of the evaluation in intensive care, for objective reasons, the APACHE III scale cannot be used in emergency anesthesiology and surgery due to a number of disadvantages:

1) information about concomitant diseases is not always available;

2) the necessary data of a biochemical blood test (creatinine, urea, bilirubin, total protein) and a clinical blood test (white blood cell count) are missing;

3) the study of the acid-base state and arterial blood gases may also be unavailable due to centralization of blood circulation and severe spasm of the arteries;

4) observation data for the day (diuresis) upon admission to the operating room are not available.

Thus, out of 20 indicators of the APACHE III scale, in case of emergency admission to the operating room, only 9 characteristics are available for analysis.

Based on the foregoing, at present, the assessment of the physiological status of victims entering the operating room is rather vague and subjective, and the APACHE III scale recognized as optimal cannot be used due to lack of data. This does not allow a quantitative description of the severity of the condition of the victims and the identification of individuals with a high risk of an adverse outcome of injuries requiring special treatment methods.

The objective of the invention is to develop a new method for quantitative preoperative assessment of the physiological status of victims with combined trauma and ongoing intra-abdominal bleeding.

The technical result consists in increasing the speed of obtaining forecast results while simplifying the method of forecasting (by reducing the number of analyzed parameters, reducing the number of studies and reducing the time to monitor physiological functions (diuresis)) and maintaining high predictive accuracy.

The problem is solved in that a method for quantitative preoperative assessment of the physiological status of victims with combined trauma and ongoing bleeding involves recording the following indicators - age, mean arterial pressure (BP), hematocrit (Ht) and saturation of oxygen taken from the central vein (SvO2) ), assignment to each indicator of points with their subsequent summation and determination of the individual risk of death as a reflection of the physiological status and assessment Ki severity of the condition according to interval scoring;

while the indicators are assigned the following points:

if the age is ≤32 years, - 1 point, is in the range of 33-56 years - 2 points, age ≥57 years - 7 points;

if the value of Ht> 24.5%, - 1 point, is in the range of 12-24.5% - 5 points, Ht <12% - 16 points;

if the value of blood pressure ≤70 mm Hg, - 3 points, blood pressure> 70 mm Hg - 1 point;

if the value of SvO2≥63%, - 1 point, is in the range 32-62% - 4 points, SvO2 <32% - 10 points,

with a score of ≤6, the condition is assessed as moderate with a low risk of death; with a score of 7-13, the condition is assessed as severe with an average risk of death; with a score of ≥14 points, the condition of the victims is assessed as extremely severe with a high risk of death.

The invention is illustrated by drawings, where figure 1 shows a graph of the survival rate in the hospital and the total score in points at admission (n = 285).

The method is as follows.

Stage 1. Data logging. Upon admission to the operating room, the victim is recorded age and connected to a monitoring monitoring system. After that, blood pressure is measured in a non-invasive way and the average blood pressure is recorded. Then, under sterile conditions, a central vein (internal jugular, subclavian, femoral) is catheterized, from which a venous blood sample is taken into a preheparinized syringe. Not later than 10-15 minutes after blood sampling, the acid-base state and gases of the venous blood sample are analyzed, which includes the saturation of hemoglobin of venous blood with oxygen, the hemoglobin content and hematocrit in the presented sample. For further analysis, the hematocrit values (in percent) and the saturation of hemoglobin of venous blood with oxygen (in percent) are recorded.

2 stage. Score indicators. The values of each indicator (age, mean arterial pressure, hematocrit, saturation of hemoglobin of venous blood with oxygen) are assigned a corresponding score (Table 1), which depends on the risk of death.

Table 1 Evaluation of indicators in points upon admission to the operating room Indicator Value Intervals Scoring Age ≤32 years one 33-56 years old 2 ≥57 years 7 Ht,% > 24.5% one 12-24.5% 5 <12% 16 ADsred, mmHg ≤70 mmHg 3 > 70 mmHg one SvO2,% ≥63% one 32-62% four <32% 10 Maximum points = 36

3 stage. Individual assessment of the physiological status of the victim. The scores obtained are summarized and the individual risk of death within 28 days after surgery (Table 2) and, accordingly, changes in the physiological status of the injured are determined by the results obtained.

4th stage. Assessment of the severity of the condition of the victim. With a score of ≤6, the probability of death does not exceed 8.6%, the condition is assessed as moderate with a low risk of death. With a score of 7–13, the probability of a fatal outcome increases to 10.7–34.4%; the condition is assessed as serious with an average risk of a fatal outcome. With a score of ≥14 points, the risk of death is maximum and exceeds 40.2%, the condition of the victims is extremely serious with a high risk of death. The survival of the victims, depending on the severity of the condition and the risk of death on the proposed scale are presented in figure 1.

table 2 Individual assessment of the risk of death in those entering the operating room Total points Chance of death Total points Chance of death Total points Chance of death four 5,4 fifteen 46.2 26 92.3 5 6.8 16 52,4 27 94.3 6 8.6 17 58.4 28 95.2 7 10.7 eighteen 63.3 29th 96.3 8 13.3 19 69.7 thirty 97.2 9 16,4 twenty 74.6 31 97.8 10 twenty 21 79 32 98.1 eleven 24.3 22 82.8 33 98.5 12 29.1 23 86 34 98.8 13 34.3 24 88.7 35 99.1 fourteen 40,2 25 90.5 36 99.3

The method was developed using the method of mathematical statistics based on a retrospective analysis of the course of anesthesia and the results of surgical treatment of 285 patients with combined injuries and ongoing bleeding. All victims were operated on an emergency basis to stop the bleeding. The sensitivity of the prognostic model is 88.4%, the specificity is 82.9%.

Example 1. Zhukova OM, 69 years old, was admitted to the operating room for a severe combined injury (fracture of 4-10 ribs on the left scapular line with damage to the rib pleura, right-sided hemothorax, rupture of the spleen, serous and muscle layers of the stomach, hemoperitoneum 4300 ml , closed fracture of the neck of the right thigh, diaphysis of the right thigh, abrasion and hemorrhage of soft tissues). There are no concomitant diseases listed on the APACHE III scale. Sick in consciousness (15 points on the Glasgow com scale). Heart rate 113 in min, BP 120/60 mm Hg (average blood pressure 80 mm Hg), NPV 22 per minute, independent breathing. Temperature 36.7 ° C. Ht 22.8%. CBS of arterial blood was not determined (it is impossible to puncture an artery). Blood sodium 135.3 mmol / L, glycemia 6 mmol / L, venous blood pH 7.195, venous blood pCO2 34.1 mmHg, SvO2 63.4% (venous blood from the subclavian vein catheter). The APACHE III severity score was 39 points and was significantly underestimated, since a number of laboratory blood parameters (arterial blood gases, white blood cells, creatinine, bilirubin, urea, total protein) and daily diuresis were not available. The risk of death on the APACHE III scale is 7.39%. Assessment of severity on the proposed scale was 14 points (extremely serious condition, extremely high probability of death within 28 days - 40.2%). The outcome of the injury - the victim died on the 27th day of postoperative observation due to complications.

Example 2. Soboleva LA, 66 years old, was admitted to the operating room after a suicide attempt (9 penetrating stab wounds of the anterior abdominal wall with damage to the right lobe of the liver, stomach, mesentery root of the small intestine and superior mesenteric artery; non-penetrating stab wounds the front surface of the neck and chest on the left; 9 cut wounds on the front surface of both forearms). The volume of recorded blood loss of 2500 ml. There are no concomitant diseases listed on the APACHE III scale. Sick in consciousness (14 points on the Glasgow com scale). Heart rate 126 per minute, blood pressure 80/50 mm Hg (average blood pressure 60 mm Hg), NPV 24 per minute, independent breathing. Ht 28.8%. The ARC of the arterial blood was not determined (it is impossible to puncture the artery), the pH of the venous blood was 7.233, and the pCO2 of venous blood was 34.8 mm Hg. Art., SvO2 39.9% (venous blood from the subclavian vein catheter). The APACHE III score of 36 points was significantly underestimated (laboratory parameters are not available - arterial blood gases, leukocytes, creatinine, bilirubin, urea, total protein, glycemia, natremia; it is impossible to determine the amount of daily urine output). The risk of death on the APACHE III scale is 6.36%. Assessment of severity upon admission to the operating room was 15 points on the proposed scale (extremely serious condition, extremely high risk of death within 28 days after surgery - 46.2%). The outcome of the injury - the victim died on the 28th day of postoperative observation due to complications.

Example 3. Krasnozorkin AL, 57 years old, was hospitalized with a severe combined trauma to the chest, abdomen and right lower limb (bruising and hemorrhage of soft tissues of the right lateral surface of the chest, fracture of 2-10 ribs on the right along several anatomical lines with lung damage, fracture of the diaphysis of the right clavicle, rupture of tissue of the right kidney in the gate region, retroperitoneal hematoma on the right in the paranephral tissue with spread along the right lateral canal, crushing of soft tissues of the right foot and metatarsal braids s 2-5 fingers). The volume of recorded blood loss is 2900 ml. There are no concomitant diseases listed on the APACHE III scale. The level of consciousness is 14 points on the Glasgow com scale. Heart rate 100 min, blood pressure 60/20 mm Hg (average blood pressure 33 mmHg). NPV 22 per min. The temperature is normal. Ht 11.7%, blood sodium 130 mmol / L, glycemia 22.4 mmol / L, venous blood pH 7.229, venous blood pCO2 44 mmHg, SvO2 22% (venous blood obtained from the subclavian vein catheter). The APACHE III score was 42 points with a probability of fatal outcome of 8.57% (arterial blood gases, white blood cells, creatinine, bilirubin, urea, total protein are not available; daily diuresis cannot be determined). The rating on the proposed scale is maximum - 36 points - with the highest risk of death (99.3%). The victim died on the 12th day of observation due to complications.

Thus, the proposed method for determining the risk of death upon admission to the operating room allows you to more accurately predict the likelihood of death within 28 days of observation with a minimum number of recorded indicators, unlike the APACHE III scale.

Claims (1)

A method for quantitative preoperative assessment of the physiological status of victims with combined trauma and ongoing bleeding, including recording the following indicators: age, mean arterial pressure (BP), hematocrit (Ht) and saturation of venous blood taken from the central vein with oxygen (SvO2), assignment to each indicator points with their subsequent summation and determination of the individual risk of death as a reflection of the physiological status and assessment of the severity of the condition at intervals th scoring;
while the indicators are assigned the following points:
if the age is ≤32 years, - 1 point, is in the range of 33-56 years - 2 points, age ≥57 years - 7 points;
if the value of Ht> 24.5%, - 1 point, is in the range of 12-24.5% - 5 points, Ht <12% - 16 points;
if the value of blood pressure ≤70 mm Hg, - 3 points, blood pressure> 70 mm Hg - 1 point;
if the value of SvO2 ≥63%, - 1 point, is in the range 32-62% - 4 points, SvO2 <32% - 10 points,
with a score of ≤6, the condition is assessed as moderate with a low risk of death; with a score of 7-13, the condition is assessed as severe with an average risk of death; with a score of ≥14 points, the condition of the victims is assessed as extremely severe with a high risk of death.

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