RU2586243C1 - Method of treating secondary immune deficiency in sepsis and septic shock in urology - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: extra corporal blood indirect electrochemical oxidation is carried out with 0.06 % sodium hypochlorite. At that, patient's blood for treatment of sodium hypochlorite is taken from subclavian vein for creating of venous extracorporeal circuit. Indirect electrochemical oxidation is performed on 3 litres of blood using 0.06 % sodium hypochlorite solution in dose of 2.0 mg/kg, with blood flow velocity in circuit of 80-100 ml/min, rate of sodium hypochlorite introduction added in extracorporeal circuit of 5-8 ml/min. Indirect electrochemical blood oxidation is carried out daily 1 time a day in amount of 2 procedures.

EFFECT: method enables providing patients with positive increase in absolute lymphocyte count in 6 hours after first session of procedure, normalising indices of blood formula and leukocytic intoxication index on 3rd day of treatment.

1 cl, 7 tbl, 3 ex

Description

The invention relates to medicine, namely to urology, and can be used in clinical practice for the treatment of patients with infectious and inflammatory diseases of the urinary system, complicated by sepsis and septic shock with the development of secondary immune deficiency, general immunosuppression, the objective sign of which is absolute lymphopenia, and endotoxemia 2-3 degrees.

A known method of treating immunosuppression in sepsis in humans (Tsibin Yu.N., Gromov M.I., Pivovarova L.P. and others. Patent for invention RU No. 21115428 C1, 07.20.1998; Kozlov V.K. Sepsis: etiology, immunopathogenesis, the concept of modern immunotherapy. - Kiev: ANNA-T, 2007. P. 214-235), in which it is proposed to use human yeast recombinant interleukin-2, which differs from endogenous cytokine by the absence of a polysaccharide fragment, as a means for correcting immunosuppression. The main indication for cytokinotherapy with human yeast recombinant interleukin-2 is surgical sepsis of any etiology, accompanied by a state of general immunosuppression, which is combined or follows the development of a systemic inflammatory response syndrome. Human yeast recombinant interleukin-2 causes the activation and proliferation of T-lymphocytes. In this case, the number of blood lymphocytes increases and their activity increases. However, the introduction of a yeast recombinant human interleukin-2 preparation may be accompanied by side effects: a threatening decrease in blood pressure, severe allergic reactions, anaphylactic shock, diarrhea. Recombinant human interleukin-2 yeast preparation contains ballast yeast cells, it cannot be administered to patients with toxic toxic shock, administration of the drug can deplete the immune system reserves and be accompanied by lymphopenia.

A known method of treating secondary immunodeficiency in patients with advanced purulent peritonitis (Cherdantsev D.V., Pervova O.V., Vinnik Yu.S. Patent for invention RU No. 2312664 C1, 04/06/2006), characterized in that in intensive care of the patient with the syndrome of a systemic inflammatory reaction and multiple organ failure, intramuscular administration of the drug galavit in a dose of 100 and 200 mg is additionally included. The immunomodulator Galavit is a 5-amino-1,2,3,4-tetrahydrophthalazine-1,4-dione sodium salt. Galavit regulates the synthesis of cytokines by macrophages (IL-1, TNF, etc.) and lymphocytes (IL-2), as well as the proliferative activity of natural killers (NK cells) by reversibly inhibiting the synthesis of hyperactive macrophages of pro-inflammatory cytokines for 6-8 hours or stimulating them with initial failure. Galavit stimulates the functional activity of T-lymphocytes, modulates the immunoglobulin-producing ability of B-lymphocytes, and stimulates the synthesis of interferons by all leukocytes. The disadvantage of this method is its low efficiency: the relative and absolute number of blood lymphocytes when using the drug galavit was restored only on the 14th day. Galavit is not used in septic shock.

A known method of intracorporal indirect electrochemical oxidation (NEHO) of blood in patients with septic complications and a level of endotoxemia of 2-3 degrees (classification Gostischeva V.K. Fedorovsky N.M., 1993), which is used to detoxify the body (Fedorovsky N.M. ., Gostishchev V.K., Dolina O.A. Indirect intravenous electrochemical detoxification technique in the complex treatment of endotoxicity syndrome // Intensive Care Bulletin. - 1993. - No. 1. - P. 31-33; Sergienko V.I., Lopukhin Yu.M. et al. Methodological manual for doctors. // Efferentn I therapy -. 1996. - Volume 2. - №4 -. pp 25-32). In this method, a 0.06% solution of sodium hypochlorite (GN) is injected into one of the central veins at a speed of 40-60 drops per minute in a volume of not more than 1/10 of the volume of circulating blood (Russian Drug Register. Radar Drug Encyclopedia. 14 vol. / Ch. ed.G.L. Vyshkovsky. - M .: RLS, 2006.S. 553-554). Patients with a developed venous system may inject a 0.03% GN solution into large cubital veins for the purpose of immunostimulation. Intravenous administration of a 0.03% GN solution, as well as 0.02-0.01% GN solutions, in peripheral veins is almost always accompanied by inflammation of the latter and obliteration. The use of the method in septic patients with signs of bacterial toxic shock in urology was successful in those patients who did not have signs of secondary immunodeficiency, general immunosuppression, lymphopenia. For the purpose of detoxification, patients of this group had a 3-4th blood NEHO session with a 0.06% GN solution daily or after 1 day at a dose of 2.0-4.0 mg / kg / day intracorporeally through a catheter in one of the central veins. The average total volume of intravenously administered 0.06% GN solution per course of treatment was 964 ± 280 ml. In a group of 4 patients with severe general immunosuppression, lymphopenia, and manifestation of signs of septic shock, a 100% fatal outcome was observed. In this group, patients underwent 4-5 sessions of NEHO blood with a GN solution daily at a dose of 2.0-4.0 mg / kg / day, the average volume per treatment course of a 0.06% GN solution injected into the central vein was 1.5 liter (Danilkov A.P., Ivashchenko V.V. et al. Sodium hypochlorite in the treatment of toxic toxic vascular shock // Urology. - 2000. - No. 6. - S. 16-18). The method of intracorporeal NECHO blood with a 0.06% solution of GN in a dose of 2.0-4.0 mg / kg / day with daily use and the total volume for the entire course of treatment of 1500 ml is not effective in the treatment of secondary immune deficiency and lymphopenia with sepsis and septic shock in severe patients with urological diseases.

Closest to the claimed method (prototype) is the method of extracorporeal NEHO blood 0.06% solution of GN in patients with infectious and inflammatory diseases of the urinary system and the level of endotoxemia of the 1st degree (Apolikhin O.I., Ivaschenko V.V. and others Patent for the invention RU No. 2522221 C1, 07/10/2014). The method is characterized in that the patient’s blood in the volume of 2 liters is oxidized with a 0.06% GN solution at a dose of 0.75 mg / kg at a rate of 2-2.5 ml per minute in the venous extracorporeal circuit at a blood flow rate of 50 ml per minute. Extracorporeal NEHO blood in patients with infectious and inflammatory diseases of the urinary system does not violate the basic biochemical homeostatic constants, increases the concentration of IgG in the blood, causes a minimal immunosuppressive effect, which is accompanied by a pronounced immunostimulation on the 3-4th day, characterized by an increase in the absolute number of T- and B lymphocytes. When conducting extracorporeal blood oxidation with a 0.06% GN solution at a dose above 0.75 mg / kg and treating a blood volume of more than 2.0 liters in patients with infectious and inflammatory complications in urology and grade 1 endotoxemia, side effects may occur in the form of a short-term decrease blood pressure, redness of the skin with hyperemia of the face. Pallor of the skin and cooling of the hands, weakness after the end of the procedure are possible.

The method is designed to increase the effectiveness of treatment of patients with infectious and inflammatory diseases of the urinary system and the level of endotoxemia of the 1st degree, causes a short-term immunosuppressive effect, and the absolute number of lymphocytes, compared with the initial value, increases by 3-4 and 7-10 days after the first session of extracorporeal NEHO blood. The method was developed for the treatment of patients on an outpatient basis. The use of the described method of treatment in patients with urological diseases complicated by sepsis and septic shock is impossible due to centralization of blood circulation in this category of patients, reduction of venous blood flow in peripheral veins, which does not allow the creation of an extracorporeal venous circuit. Moreover, the weak immunostimulating effect of the method on the 3-7th day after the 1st session of extracorporeal NEHO blood of 0.06% GN solution at a dose of 0.75 mg / kg is accompanied by an unfavorable prognosis of survival of this category of patients, which indicates the inadequacy of care, which get sick.

The aim of the invention is to increase the effectiveness of the treatment of secondary immune deficiency, manifested by general immunosuppression, lymphopenia in patients with urological diseases complicated by sepsis and septic shock.

This goal is achieved by the fact that in the complex of intensive care of patients with sepsis and infectious toxic shock, the method of extracorporeal NEHO 3 liters of blood is included with a 0.06% solution of GN in the veno-venous extracorporeal circuit at a dose of 2.0 mg / kg. For extracorporeal blood oxidation with a 0.06% GN solution, central vein catheterization is required, since in conditions of unstable hemodynamics and centralization of blood circulation, the peripheral venous system cannot provide the necessary blood flow velocity in the venous-venous extracorporeal circuit. During extracorporeal NEHO 3 liters of blood with a 0.06% solution of GN at a dose of 2.0 mg / kg, the central hemodynamics are supported by parenteral administration of dopmin at a dose of 2-5 μg / kg / min.

The method of extracorporeal NECHO blood with a 0.06% solution of GN in patients with infectious and inflammatory diseases of the urinary system has advantages over the method of intracorporeal injection of a 0.06% solution of GN directly into the central vein, since: 1) it has a more pronounced immunostimulating effect in relation to the absolute the number of almost all subpopulations of lymphocytes; 2) significantly increases the concentration of blood IgG on the 7-10th day after the first session (Ivashchenko V.V., Kirpatovsky V.I. et al. Extracorporeal indirect electrochemical blood oxidation in urology. / Experimental and clinical urology. - 2013. - No. 4. - S. 104-109).

To achieve a therapeutic effect in the treatment of secondary immune deficiency in patients with sepsis and septic shock with urological diseases, a volume of 0.06% GN solution equal to 150-300 ml (2.0 mg / kg) is used. Processing is subjected to 3 liters of blood of the patient. Indication for the administration of extracorporeal NEHO 3 liters of blood with a 0.06% solution of GN is secondary immune deficiency, general immunosuppression, lymphopenia with an absolute number of lymphocytes in the clinical analysis of blood less than 1.2 × 10 ⁹ / l, with a degree of endotoxemia of 2-3 degrees (classification of Gostischev V.K., Fedorovsky N.M., 1993) or severe and extremely severe severity of endotoxemia (Kozlov V.K. Sepsis: etiology, immunopathogenesis, concept of modern immunotherapy. - Kiev: "ANNA-T", 2007 P. 219).

The method is as follows. The sodium hypochlorite solution for intravenous infusion is prepared on the DEO-01-MEDEK apparatus based on a sterile isotonic sodium chloride solution according to the guidelines for the use of sodium hypochlorite and the provisions of the technical documentation (Fedorovsky N.M. Indirect electrochemical detoxification: A manual for postgraduate training of doctors. - M .: "Medicine", 2004. 144 p.). The concentration of the prepared sodium hypochlorite solution is determined by the method of oxidometric titration.

Elimination of water-electrolyte and colloid-osmotic disorders, normalization of circulating blood volume, preliminary hemodilution are necessary measures for preparing the patient for extracorporeal blood oxidation with 0.06% GN solution, which avoid damage to blood cells and reduce the risk of lowering blood pressure when creating extracorporeal venous circuit.

The dose of a 0.06% GN solution per session of extracorporeal blood oxidation is 2.0 mg / kg. It was determined as a result of practical activities, given that a dose of 0.75 mg / kg was not effective enough in septic patients in urology.

During extracorporeal NEHO 3 liters of blood with a 0.06% GN solution at a dose of 2.0 mg / kg in patients with sepsis and septic shock in urology and 2-3 degrees of endotoxemia, there were no complications associated with the procedure.

To calculate the volume of a 0.06% GN solution during a session of extracorporeal indirect oxidation of 3 liters of blood at a dose of 2.0 mg / kg, the following formula is developed:

V = (20 × M) / 6, where

V is the volume of a 0.06% solution of GN in milliliters (ml);

M is the patient's weight in kilograms (kg).

So, for a patient of 70 kg with sepsis and septic shock with urological diseases, with the development of secondary immune deficiency and lymphopenia, 233 ml of a 0.06% GN solution will be required for the oxidation of 3 liters of blood. You can also use the formula:

V = 3.3 × M, where

V is the volume of a 0.06% solution of GN in ml;

M is the mass of the patient in kg;

3.3 - coefficient.

To create a veno-venous extracorporeal circuit, it is advisable to use the Hemofenix apparatus in connection with its special technical characteristics: a single-needle system, a small amount of filling of the blood supply lines, a convenient port for the introduction of infusion solutions for hemodilution and a 0.06% solution of GN, anticoagulant; electronic interface that allows you to control the volume of processed blood in real time.

When preparing the apparatus for operation, the arterial and venous ends of the arteries are connected in an air trap using a tip from the system for transfusion of infusion solutions and the plasma exhaust manifold of the Novoplast-M KMAP-01 set. After filling the extracorporeal circuit with physiological saline and connecting the device to the patient, a 0.06% GN solution is supplied to the pump segment at a speed of 10-13 drops per pump cycle, i.e. approximately 5-8 ml per 1 minute. Depending on the volumetric speed of venous blood in the extracorporeal circuit, the duration of the extracorporeal NEHO 3-liter blood procedure with a 0.06% GN solution is about 40-60 minutes. The speed of blood flow in the venous circuit should correspond to 80-100 ml per minute. In order to prevent blood thrombosis of the patient in the extracorporeal circuits, it is advisable to turn on the supply of a 2.4% solution of sodium citrate, which is injected to the pump segment at a rate of 3-4 drops per pump cycle or 1.0-2.0 ml / min.

The course of treatment of urological patients with sepsis and septic shock, which developed in the early postoperative period, with the phenomena of secondary immunodeficiency, general immunosuppression and lymphopenia, endotoxemia of the 2nd to 3rd degree, consists of 2 daily sessions of extracorporeal NECHO blood with a 0.06% GN solution in a dose of 2.0 mg / kg and processing of 3 liters of blood in one session.

Criteria for canceling extracorporeal NEHO blood sessions with a 0.06% solution of GN are: stable normalization of the absolute number of blood lymphocytes in a septic patient more than 1.2 × 10 ⁹ / l, a decrease in the leukocyte intoxication index of less than 3 units, a decrease in the value of the procalcitonin test to less than 2 ng / ml, an increase in the number of eosinophils in the blood formula is more than 0%.

Contraindications to the appointment of extracorporeal NEHO sessions of 3 liters of blood with a 0.06% GN solution at a dose of 2.0 mg / kg in patients with sepsis and septic shock in urological diseases are: conditions requiring resuscitation, active bleeding.

The effectiveness of the treatment method is demonstrated by clinical examples.

Example 1. For a comparative assessment of the claimed method of treatment and the prototype method, a clinical study was conducted.

The claimed method of treatment is characterized in that patients with sepsis and septic shock with urological diseases in order to treat secondary immune deficiency were treated with extracorporeal NEHO (ENEHO) of 3 liters of blood with a 0.06% GN solution at a dose of 2.0 mg / kg with a feed rate GN solution in the extracorporeal circuit of 5-8 ml per minute at a speed of venous blood flow in the extracorporeal circuit of 80-100 ml per minute. An extracorporeal contour was formed after catheterization of one of the central veins. The prototype method is characterized by the treatment of secondary immunodeficiency in septic patients with urological diseases with extracorporeal NEHO of 2 liters of blood of 0.06% GN solution at a dose of 0.75 mg / kg with a flow rate of GN solution in the extracorporeal circuit of 2-2.5 ml per minute at a speed of venous blood flow in the extracorporeal circuit of 40-50 ml per minute.

We studied 12 patients with urolithiasis, prostate adenoma, an abnormality of the development of the urinary system, post-traumatic obliteration of the membranous-bulbous part of the urethra, who developed sepsis in the early postoperative period, with septic shock with signs of secondary immunodeficiency, general immunosuppression, and lymphopenia.

All patients were treated in the intensive care unit, received antibacterial and infusion therapy. All patients underwent sanitation of the source of infection, restoration of the passage of urine through the urinary tract. The condition of patients was complicated by the development of a systemic inflammatory response syndrome (CERD), the progression of renal failure, the development of endotoxemia of the 2nd to 3rd degree. In all patients, the procalcitonin test was greater than 10 ng / ml.

Statistical data processing was performed on a personal computer using the "Statistics 6" program, with reliability calculated using the non-parametric Mann-Whitney U-test.

Group No. 1 consisted of 6 men aged 19 to 79 years with sepsis and septic shock, in whom secondary immune deficiency, general immune dysfunction, and lymphopenia were determined in a laboratory in the early postoperative period. In order to treat immune dysfunction, a session of extracorporeal NEHO of 2 liters of blood with a 0.06% GN solution at a dose of 0.75 mg / kg daily was prescribed in a complex of conservative therapy, for a total of 2 sessions. A clinical blood test was monitored in patients, the blood count, leukocyte intoxication index (LII) were calculated. We fixed the time for normalization of blood count indicators, the presence of signs of CVD, level of procalcitonin test. The dynamics of the indicators of the clinical analysis of blood and LII in patients of the 1st group are presented in table 1.

Group 2 consisted of 6 patients, 4 men and 2 women aged 16 to 76 years, with sepsis and septic shock, which developed in the early postoperative period. In patients, secondary immune deficiency, general immune dysfunction, and lymphopenia were determined. The severity of the condition corresponded to the severity of the condition of patients of the 1st group. Patients underwent a similar laboratory and clinical control. In order to treat secondary immune deficiency, sessions of extracorporeal NEHO of 3 liters of blood were prescribed in a complex of conservative therapy with a 0.06% GN solution at a dose of 2.0 mg / kg daily, for a total of 2 sessions. The dynamics of the indicators of the clinical analysis of blood and LII in patients of the 2nd group are presented in table 2.

For patients of the 1st and 2nd groups, blood was oxidized in the venous extracorporeal circuit using a catheter in the subclavian vein.

The results of the study. The 1st and 2nd groups of patients were characterized by signs of severe immune dysfunction, an increase in the absolute number of neutrophils and monocytes, the development of secondary immunodeficiency, the obvious sign of which was lymphopenia 0.7 ± 0.3 and 0.5 ± 0.2 (× 10 ⁹ / l) respectively. The groups of patients were homogeneous and did not have significant differences in the parameters of the clinical analysis of blood and LII at the same time of control except for the absolute number of blood monocytes on the 3rd day after the start of the extracorporeal NEHO blood sessions with a 0.06% GN solution. In group No. 2, the absolute number of monocytes significantly exceeded the same indicator in group No. 1.

The most noticeable changes in the dynamics of the absolute number of lymphocytes in groups No. 1 and No. 2 occurred within 6 hours after the first session of extracorporeal NECHO blood with a 0.06% GN solution. The average rate of increase in the number of lymphocytes in one hour within six hours after the first session of extracorporeal NEHO blood with a 0.06% GN solution in group No. 2 was 4 times higher than that in group No. 1, and the difference in average speed was significant (table 3) .

A significant difference in the average rate of increase in the absolute number of blood lymphocytes within six hours after the first session of NEHO blood in groups No. 1 and No. 2 proves the higher efficiency of extracorporeal NEHO 3 liters of blood with a 0.06% GN solution at a dose of 2, 0 mg / kg compared with extracorporeal NEHO 2 liters of blood with a 0.06% GN solution at a dose of 0.75 mg / kg in the treatment of secondary immune deficiency in patients with sepsis and septic shock in urological diseases.

The number of stab neutrophils significantly decreased on the 3rd day after the first session of extracorporeal NEHO blood 0.06% solution of GN in group No. 1 and group No. 2. Thus, a dose of 0.06% GN solution of 0.75 mg / kg when processing 2 liters of blood and a dose of 0.06% GN solution of 2.0 mg / kg when processing 3 liters of blood are equally effective in inhibiting activity congenital nonspecific immunity to the level of normal values in urological patients with sepsis and septic shock. The dose of a 0.06% GN solution of 2.0 mg / kg when treating 3 liters of blood is more effective than the dose of a 0.06% GN solution of 0.75 mg / kg when treating 2 liters of blood, in relation to the treatment of secondary immunodeficiency in patients with sepsis and septic shock in urological diseases, since it significantly normalizes the state of acquired adaptive immunity, which largely determines the favorable outcome of sepsis and septic shock in patients with urological diseases.

The average values of LII in groups No. 1 and No. 2 at the same time of control did not significantly differ. In group No. 2, the value of LII was normalized by the 3rd day of control, and in group No. 1, the value of LII remained elevated by the 7th day after the first session of extracorporeal NEHO of 2 liters of blood using a 0.06% solution of GN in dose of 0.75 mg / kg.

In groups No. 1 and No. 2, they predicted the outcome of septic complications of infectious and inflammatory diseases according to the patent for invention RU No. 2517110 C1, 09/05/2012 (Apolikhin O.I., Ivaschenko V.V. et al.), Tables 4 and 5. The objective forecasting method used the values of the absolute number of eosinophils and lymphocytes in the peripheral blood of patients, calculated discriminant functions for a group of patients with a favorable outcome of infectious and inflammatory diseases of the urinary system (F1, F3) and a group of patients with a high probability of cial disease outcome (F2, F4). The patient belonged to the group for which the classification value was maximum.

In group No. 1 on the 3rd day after the start of extracorporeal NEHO sessions of 2 liters of blood with a 0.06% GN solution at a dose of 0.75 mg / kg in 4 cases out of 6 (66%) was determined the outcome of septic complications (preliminary forecasting), and the amount of medical care provided was considered inadequate to the severity of the patient's condition. On the 7th day of control in group No. 1 in all patients, the prognosis of the outcome of septic complications was favorable (final prognosis).

In group No. 2, on the 3rd day after the start of extracorporeal NEHO sessions of 3 liters of blood with a 0.06% GN solution at a dose of 2.0 mg / kg, a favorable prognosis of the outcome of septic complication was determined in 100% of cases (preliminary forecasting), and the volume of medical care was adequate to the severity of the condition of the patients. On the 7th day of control in group No. 2, all patients also had a favorable prognosis of the outcome of septic complications (final prognosis).

Thus, in vitro indirect electrochemical oxidation of 3 liters of blood with a 0.06% solution of sodium hypochlorite at a dose of 2.0 mg / kg, carried out daily for 2 days, is an adequate treatment for secondary immune deficiency in sepsis and bacterial toxic shock in patients with urological diseases and significantly improves the prognosis of a favorable outcome of septic complications. The method of extracorporeal indirect electrochemical oxidation of 2 liters of blood with a 0.06% sodium hypochlorite solution at a dose of 0.75 mg / kg is inadequate to the severity of the condition of patients with urosepsis in the treatment of secondary immune deficiency and is characterized by an unfavorable prognosis of the outcome of septic complications in 66% of cases by 3 and the day of treatment.

Example 2. A 34-year-old man entered the Federal State Budget Scientific Research Institute of Urology of the Ministry of Health of Russia with complaints of paroxysmal pain in the lumbar region on the right with irradiation down the abdomen, frequent painful urination, dry mouth, nausea, and weakness.

From the anamnesis it was possible to find out that for nine years the patient suffers from urolithiasis (ICD). In 2007, he underwent nephrolithotomy on the left.

The skin is of normal color. In the lungs, vesicular breathing, no wheezing. Heart sounds are clear, the rhythm of cardiac activity is correct. Blood pressure 110/70 mm Hg, heart rate - 72 beats per 1 min. The abdomen is soft, painless on palpation. Symptom Pasternatsky - slightly positive on the right; the kidneys are painless on palpation. The prostate gland is not enlarged, painless, with a dense-elastic consistency.

Multispiral X-ray computed tomography.

Dimensions of the right kidney: 13.5 × 9.1 × 7.8 cm. Doubling of the pyelocaliceal system and rotation of the lower part anteriorly and laterally according to the type of S-shaped kidney are determined. The lower part of the pelvis is filled with a coral calculus with dimensions of 5.0 × 4.2 × 2.9 cm. The pelvis and ureter are not enlarged. Dimensions of the left kidney: 12.5 × 7.1 × 5.2 cm. No calculi were found in the left kidney. The pyelocaliceal system and ureter are not enlarged.

Laboratory data. Blood clinical 30.07.2012 g .: hemoglobin - 143.0 g / l, leukocytes - 8,06 × 10 ⁹ / L, p / I neutrophils - 2%, s / I neutrophils - 60%, eosinophils - 0% basophils - 3%, lymphocytes - 30%, monocytes - 5%, ESR - 12 mm / hour. Biochemical analysis of blood: urea - 5.7 mmol / L, creatinine - 76 μmol / L, potassium - 4.1 mmol / L, sodium - 139 mmol / L, calcium 2.47 mmol / L. Coagulogram: PTV - 11.9 seconds. MHO - 0.99. PTI - 99%. APTT - 36.4 sec. Fibrinogen 3.4 g / l. TV - 19.9 seconds

Based on patient complaints, medical history, objective examination data, laboratory and instrumental research methods, the diagnosis was made: ICD. Coral stone of the S-shaped right kidney. Chronic pyelonephritis, latent course.

In order to restore an adequate passage of urine from the right kidney, rid the patient of calculus, August 1, 2012, the patient was attempted percutaneous nephrolitholapaxia on the right. Due to bleeding, the operation was discontinued. A nephrostomy on the right is established.

The early postoperative period was complicated by chills, headache, fever up to 39 ° C, hypotension up to 60/40 mm Hg. The patient was transferred to the intensive care unit for further treatment. Procalcitonin test: more than 10 ng / ml.

Infusion therapy was aimed at correcting water-electrolyte disturbances, hypovolemia, and stabilizing hemodynamic parameters. From antibacterial drugs, the patient received sulperazone, thienam, amikacin.

On August 2, 2012, a session of extracorporeal NEHO of 2 liters of blood with a 0.06% GN solution was prescribed in the complex of conservative therapy of septic shock with the goal of treating secondary immunodeficiency with lymphopenia. An extracorporeal circuit was created using the Hemofenix apparatus, blood was drawn from a catheter in the subclavian vein, and the apparatus worked on a single-needle system. In the extracorporeal circuit, 2 liters of blood were treated with a 0.06% GN solution at a dose of 0.75 mg / kg (100 ml GN solution). On August 3, 2012, the patient was given a second session of extracorporeal NEHO of 2 liters of blood with a 0.06% solution of GN at a dose of 0.75 mg / kg. The results of laboratory tests are presented in table 6.

Body temperature and hemodynamic parameters returned to normal on 08/05/2012, i.e. on the 3rd day after the first session of extracorporeal NEHO blood 0.06% solution of GN. During the entire observation period, the patient complained of general weakness. On the 3rd day after the first session of extracorporeal NEHO 2 liters of blood with a 0.06% GN solution at a dose of 0.75 mg / kg, the patient determined an unfavorable prognosis of the outcome of septic complications due to persisting general immune dysfunction against the background of secondary immunodeficiency, lymphopenia.

On the 7th day after the first NEHO blood test with a solution of GN at a dose of 0.75 mg / kg, the prognosis of the outcome of the infectious and inflammatory disease in the patient became favorable.

In satisfactory condition with a nephrostomy on the right, the patient was discharged to continue treatment under the supervision of a urologist at a clinic with a recommendation for re-hospitalization after 2 months.

This clinical example shows the low efficiency of extracorporeal NEHO 2 liters of blood with a 0.06% solution of GN at a dose of 0.75 mg / kg in a patient with sepsis and septic shock with a urological disease. Secondary immunodeficiency was eliminated only by the 7th day after the start of extracorporeal NEHO blood sessions. Normalization of the blood formula occurred without a significant increase in the absolute number of blood monocytes, an important component of effective immune phagocytosis of adaptive immunity.

Example 3. A 33-year-old woman was admitted to the FSBI Research Institute of Urology of the Ministry of Health of Russia with a diagnosis of ICD. Coral stone of double left kidney. Hydronephrosis on the left. Chronic pyelonephritis, remission stage.

The patient was repeatedly operated on: 2005 - pyelopyelostomy on the left, 2010 - ureterolithotomy of the upper third on the right.

The skin is of normal color. In the lungs, vesicular breathing, no wheezing. Heart sounds are clear, the rhythm of cardiac activity is correct. Blood pressure 120/80 mm Hg, heart rate - 84 strokes in 1 min. The abdomen is soft, painless on palpation. Pasternatsky’s symptom is negative on both sides.

CT scan. Dimensions of the right kidney: 10.7 × 5.0 × 4.9 cm. The pyelocaliceal system of the kidney is not expanded. Kidney stones were not detected. Dimensions of the left kidney: 12.1 × 7.5 × 5.5 cm. A calculus of 4.8 × 3.0 cm is determined in the pelvis. A calculus of up to 1.4 cm in diameter is determined in the upper cup of the left kidney. Two were found in the middle cups. calculus - 1.5 cm and 0.6 cm. The cups of the upper group are expanded to 3.4 cm.

Dynamic nephroscintigraphy. The secretory function of the right kidney corresponds to the lower limit of the norm. The evacuation of the radiopharmaceutical from the right kidney is slowed down. The secretory function of the left kidney is reduced. Deficiency deficiency is 32%. The evacuation of the radiopharmaceutical from the left kidney is significantly slowed down at the level of the pyelocaliceal system.

In urine culture on October 3, 2014, the growth of a bacterial strain of E. coli in a titer of 10 ⁴ CFU / ml was detected. Gentamicin was treated. The culture of Kl.pneumoniae in the titer of 10 ⁵ CFU / ml was revealed in the sowing dated October 14, 2014.

In order to save the patient from calculus and prevent further death of the renal parenchyma of the patient’s left kidney, an operation was performed on October 15, 2014: percutaneous nephrolithotripsy, laser endopyelotomy, left nephrostomy.

The early postoperative period was complicated by chills, nausea, vomiting, fever up to 39 ° C, hypotension up to 80/40 mm Hg. Procalcitonin test: more than 10 ng / ml. The patient's condition was severe. Urological disease was complicated by bacterial toxic shock. Treatment was continued in the intensive care unit. Dopmin was intravenously infused at a dose of 5 mcg / kg / min. Of the antibacterial drugs, the patient was prescribed an invasion intravenously of 1.0 gram 2 times a day.

On October 16, 2014, in a clinical blood test, signs of secondary immune deficiency, immune dysfunction, and lymphopenia were observed. Clinical blood test 10.16.2014: hemoglobin - 101 g / l, leukocytes - 24 × 10 ⁹ / l, neutrophils - 32%, neutrophils - 56%, eosinophils - 0%, basophils - 0% lymphocytes - 3%, monocytes - 9%, ESR - 20 mm / hour. Biochemical blood test: urea - 4.6 mmol / l, creatinine - 80 μmol / l, potassium - 3.0 mmol / l, sodium - 139 mmol / l. Coagulogram: PTV - 19.8 sec. MHO - 1.76. IPT - 41%. Fibrinogen 1.84 g / l. Procalcitonin test: more than 10 ng / ml.

On October 16, 2014, in order to treat secondary immune deficiency in sepsis, general immunosuppression, and lymphopenia, the patient was prescribed a session of extracorporeal NEHO of 3 liters of blood with a 0.06% GN solution at a dose of 2.0 mg / kg. An extracorporeal circuit was created using the Hemofenix apparatus, blood was drawn from a catheter in the subclavian vein, and the apparatus worked on a single-needle system. In the extracorporeal circuit, 3 liters of blood were treated with a 0.06% GN solution at a dose of 2.0 mg / kg (300 ml of GN solution). On October 17, 2014, a second session of extracorporeal NEHO of 3 liters of blood was performed with a 0.06% GN solution at a dose of 2.0 mg / kg. The results of laboratory tests are presented in table 7.

Secondary immune deficiency, general immunosuppression, lymphopenia were eliminated 6 hours after the first session of extracorporeal NEHO of 3 liters of blood with a 0.06% GN solution at a dose of 2.0 mg / kg. Indices of central hemodynamics returned to normal 1 day after the first session of extracorporeal NEHO blood, intravenous administration of dopmin was canceled on October 17, 2014. Body temperature returned to normal on October 18, 2014 on the 3rd day of the postoperative period. Extensive herpetic eruptions appeared on the lips and nasolabial fold.

In the future, the postoperative period proceeded calmly. Nephrostomy drainage has been removed. In the middle group of calyxes, a residual calculus remained, which was not available for removal during surgery.

This clinical example shows the high efficiency of the extracorporeal NEHO method of 3 liters of blood with a 0.06% GN solution at a dose of 2.0 mg / kg in the treatment of secondary immune deficiency in sepsis and septic shock in patients with urological diseases. Lymphopenia was eliminated 6 hours after the first session of extracorporeal NEHO blood, the number of stab and segmented leukocytes, the amount of LII normalized on the 7th day of control, the peak activity of the immune monocytic macrophage phagocytosis was manifested on the 3rd day of control.

The method of extracorporeal NEHO 3 liters of blood with a 0.06% sodium hypochlorite solution at a dose of 2.0 mg / kg at a rate of 5-8 ml per minute with a venous blood flow velocity in the extracorporeal circuit of 80-100 ml per minute is more effective than others known methods of NECHO blood with a solution of GN in the treatment of secondary immune deficiency in patients with urological sepsis and septic shock and 2-3 degrees of endotoxemia in the early postoperative period; It provides adequate assistance in the intensive care unit and is characterized by a favorable prognosis of the outcome of septic complications in patients with urological diseases in 100% of cases.

Claims (1)

A method for the treatment of secondary immune deficiency in urological patients with sepsis, septic shock or 2-3 degrees of endotoxemia, which involves extracorporeal indirect electrochemical oxidation of blood with a 0.06% sodium hypochlorite solution, characterized in that the patient’s blood is taken from the subclavian vein for treatment creating a venous extracorporeal circuit, while indirect electrochemical oxidation is subjected to 3 liters of blood using a 0.06% sodium hypochlorite solution in a dose of 2.0 mg / k g, with a blood flow rate in the circuit of 80-100 ml / minute, the rate of introduction of sodium hypochlorite added to the extracorporeal circuit is 5-8 ml / minute, while indirect electrochemical blood oxidation is carried out daily 2 times a day in the amount of 2 procedures.