RU2602957C1 - Method of prediction of development of pleuropulmonary complications in patients with posttraumatic curtailed hemothorax, without continuous bleeding, receiving treatment by methods of minor surgery, video-assisted thoracoscopional and open surgery - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to surgery, traumatology, and can be used for selection of the method of treating patients with a minimum risk of pleuropulmonary complications in patients with posttraumatic curtailed hemothorax without continuous bleeding. Before treatment at patients is determined age, heart rate, temperature, haemoglobin value, erythrocyte sedimentation rate, value of urine specific gravity, value of chlorine, creatinine, albumin, aspartate aminotransferase, glucose. For each method of treatment calculate the risk of pleuropulmonary complications (RPPC): for small surgery (RPPC₁), for video-assisted thoracoscopinal interventions (RPPC₂), for open surgery (RPPC₃) by formulas. Method of treatment is chosen that, which gained the highest value of RPPC as a method with minimal risk of development of pleuropulmonary complications.

EFFECT: method allows the accurate and simple to carry out the choice of a method of treatment, and also to reduce the risk of development of pleuropulmonary complications at the expense of a complex assessment of the most significant parameters.

1 cl, 2 tbl, 2 ex

Description

The invention relates to medicine, namely to diagnostic methods in surgery, thoracic surgery, cardiovascular surgery, traumatology.

A multicenter European study (analogue) is known where the choice of a method of treatment for hemothorax is based on an assessment of the volume of hemothorax, the likelihood of a diaphragm injury and antibiotic prophylaxis (DuBose J., K. Inaba, Demetriades D. et al. Management of post-traumatic retained hemothorax: a prospective, observational, multicenter AAST study. Trauma Acute Care Surg. 2012; 72: 1: p. 11-22). So, if the volume of hemothorax is less than 900 ml, there is no diaphragm injury and antibiotic prophylaxis is carried out, then video thoracoscopy can be used. If there is a diaphragm injury, the volume of hemothorax is more than 900 ml, then most likely the patient should apply thoracotomy. The disadvantage of this technique is its complexity, the inability to use in health facilities with low diagnostic potential, which include almost all central district hospitals.

There is a method of choosing a method for treating patients with coagulated hemothorax, which was developed as part of a dissertation (analogue) (Dergunova S.A. Optimization of surgical tactics for various types of hemothorax: abstract of thesis ... candidate of medical sciences / S.A. Dergunova. - Samara, 2005 .-- 22 p.). It is proposed to use the puncture of the pleural cavity with a small amount of hemothorax with the duration of the disease no more than 2 days. It is proposed to use the drainage of the pleural cavity with medium and large hemothorax, with the duration of the disease not more than 3-5 days. Indication for the use of videothoracoscopy is coagulated hemothorax with a prescription of the disease of not more than two weeks. Thoracotomy is performed in case of inefficiency of video thoracoscopy. The disadvantage of this research method is the small amount of objective data used to select a treatment method.

The closest analogue to the proposed solution (prototype) is a method for the diagnosis and treatment of coagulated hemothorax according to A. Ya. Malchikov (RF patent for the invention No. 2368333 dated 09/27/2009). The essence of the method consists in a daily analysis of the patient’s health status, conducting an X-ray examination of the breast with increasing symptoms of general and local inflammation, puncturing the pleural cavity from several points when a massive x-ray shadow is detected in the damaged half of the chest with a shift to the healthy side, installing drains, removing contents through them with determination of its volume and color, repeated x-ray examination, issuing an opinion on the presence of coagulated hemothorax according to the evaluation results volume and color of content. In this case, before piercing the tissue of the chest, anesthetize, before the puncture, establish the upper drainage with the exhaust valve. The puncture is carried out under ultrasonic control of the accuracy of administration with a pre-injection of 0.9% sodium chloride solution in a volume of 1-1.5 ml before the end of the needle is inserted into the blood clot. Replace the needle along the conductor with an elastic catheter, and then change the patient’s body position in space, achieving the adoption of the selected department of the lowest position in the pleural cavity. Then, an equal volume diluting solution containing 5% sodium bicarbonate and 1.5% hydrogen peroxide is introduced into the selected dimming area, heated to 37 ° C. After 10 minutes, the patient’s thoracic region is placed in an upright position, fixed, the lowest point of the pleural cavity is determined, the end of the lower drainage tube is inserted into it and the liquid contents are removed from the pleural cavity with it. Repeated x-ray examination. The conclusion about the presence of coagulated hemothorax is issued with a decrease in the dimming of the pulmonary field and the removal of an increased volume of red foamy fluid from the cavity. The treatment is carried out by means of the next similar injections of a diluting solution in the remaining darkening areas until the last of them is removed and all the diluted blood is removed through the lower drainage. Then, with the help of drains, the pleural cavity is washed with a solution of 0.9% sodium chloride heated to 37 ° C to "pure water". This method does not allow to predict the possibility of development of pleuropulmonary complications.

The aim of our proposed method is to simplify and improve the forecast for the development of pleuropulmonary complications in patients with post-traumatic coagulated hemothorax, without ongoing bleeding, treated with minor surgery methods, videothoracoscopic (VTS, VATS) and open surgical interventions based on multivariate statistical modeling for the objective selection of a number of physical and laboratory data, namely: data on age (VZR), heart rate (HR), body temperature (TT, оС), hemoglobin values (heme, gram / liter), erythrocyte sedimentation rate (ESR millimeters / hour) in the general analysis of blood, urine specific gravity (UVM) in the general analysis of urine, chlorine values (Chl, mmol / liter), creatinine (Cr, μmol / liter), albumin (Al, gram / liter), aspartate aminotransferase (AcAT, microcatal / L), glucose (H, mmol / L) in a biochemical blood test.

This goal is achieved by calculating the risk of pleuropulmonary complications (RVPLO), as the classification value of the discrimination equation according to the formula: RVPLO = VZR × ZnP1 + HR × ZnP2 + TT × ZnP3 + Gem × ZnP4 + ESR × ZnP5 + UVM × Zn P6 + Cr × ZnP7 + Chl × ZnP8 + Al × ZnP9 + AsAT × ZnP10 + Gl × ZnP11 + Ki, where ZNP ₁ ... ₂ is the observed value for the corresponding sample variable, Ki is a constant for this population.

Solving this equation three times, for each treatment method, receive the corresponding classification value. And if the classification value is algebraically maximum, then the risk of developing pleuropulmonary complications is minimal.

The novelty of the proposed solution lies in the fact that for the first time in patients with post-traumatic coagulated hemothorax, without ongoing bleeding, receiving treatment with minor surgery, video-assisted thoracoscopic surgery and open surgical interventions, they predict the formation of pleuropulmonary complications by calculating the classification value of the discrimination equation and calculating posterior probabilities.

Technical solutions having features that match the distinguishing features of the proposed method are not identified, which allows us to conclude that the proposed method meets the criterion of "inventive step".

In the process of developing the method, a survey was conducted of 106 patients with coagulated post-traumatic hemothorax, without ongoing bleeding, receiving treatment with minor surgery, and video-assisted thoracoscopic surgery. The examination included obtaining anamnestic, physical, instrumental and laboratory data of the patient. Accounting was carried out according to some physical and laboratory data.

The data were processed using the statistical software package STATISTICA (Data analysis software system, StatSoft, Inc. 2008) version 10.0. A discriminant analysis was used. It was possible to determine the most significant parameters for assessing the state, which discriminated the sample into groups and made it possible to identify the presence or absence of a risk for the development of pleuropulmonary complications in patients with coagulated hemothorax receiving treatment with the help of minor surgery methods, video thoracoscopic and open surgical interventions. The discriminant analysis data for significant physical and laboratory data are shown in table 1.

Table 1

To predict the possible risk of pleuropulmonary complications in the patient treatment groups, a classification procedure was performed. The result of the classification is a matrix of classification functions (Table 2) containing the number of samples correctly classified (on the diagonal of the matrix).

table 2

Based on the mathematical processing, a set of optimal signs was obtained and a method was developed for predicting the risk of pleuropulmonary complications in patients with post-traumatic coagulated hemothorax, without ongoing bleeding, undergoing treatment with minor surgery, and video-assisted thoracoscopic surgery, which consists in determining the classification value using the formula. It is necessary to solve the corresponding formula three times - according to the number of groups of patient treatment methods. Given the classification values obtained, the formulas that need to be used for patients who are treated with minor surgery methods (RVPLO ₁ ), video-thoracoscopic (RVPLO ₂ ) and using open surgery (RVPLO ₃ ), look as follows:

The proposed method is as follows: each hospitalized patient records data on age, heart rate, body temperature, hemoglobin, ESR in a general blood test, urine specific gravity in a general urinalysis, chlorine, creatinine, albumin, aspartate aminotransferase, glucose in a biochemical blood test. Using the obtained values, three types of equations are solved:

Solving these equations three times, for each treatment method, receive the corresponding classification value. And if the classification value is algebraically maximum, then the risk of developing pleuropulmonary complications is minimal.

The proposed method is clearly illustrated by the following examples of its clinical use.

Example 1

Patient K., 26 years old, resident of the Yaroslavl region, unemployed, was hospitalized 7 days after an accident in an accident with a diagnosis of closed chest injury, chest injury, curled hemothorax on the right (late patient treatment). On a panoramic x-ray of the chest organs in a direct and right lateral projection, intense homogeneous dimming of the lower parts of the pulmonary field to the right is determined, starting from the anterior segment of the 4th rib. The dome of the diaphragm does not differentiate. The upper parts of the right lung - without focal and infiltrative changes. The mediastinum is not displaced, on the left without pathology. Upon receipt, a moderate condition. Temperature 36.3 ° C. Complaints of moderate pain in the right side of the chest. Objectively: the skin and visible mucous membranes of normal color and humidity. The chest is symmetrical, vesicular breathing in the lungs, no wheezing, sharply weakened on the right in the posterior and lateral parts, NPV 16 per minute. Heart sounds are clear, rhythmic, heart rate of 74 per minute, blood pressure 120/80 mm Hg For other organs and systems without features. On the ECG, the sinus rhythm, heart rate of 81 per minute, the normal position of the electrical axis of the heart. General clinical blood test at admission: red blood cells 3.17 × 10 ¹² / l, HB 122 g / l, white blood cells 12.7 × 10 ⁹ / l, ESR 34 mm / hour. Urinalysis: color light yellow, specific gravity 1015, protein, sugar, no acetone, polymorphic cells 0-01-2 in the field of view, white blood cells 0-1-3 in the field of view, a moderate amount of mucus, a little oxalate. Biochemical blood test: bilirubin 33 μmol / L, direct 10 μmol / L, total protein 67 g / L, AcAT 44 U / L, AlAT 47 U / L, creatinine 70 μmol / L, urea 4.0 mmol / L, glucose blood 4.6 mmol / L. Performed drainage of the right pleural cavity in the 8 intercostal space along the scapular line with the evacuation of 1300 ml of hemorrhagic exudate. On the control x-ray of the chest organs, intense almost uniform dimming of the lower hemitrax is determined with a clear, even oblique upper border along the posterior part of the 8th rib, convex upward. Bone pleura thickened. According to generally accepted clinical recommendations, the patient was shown surgical treatment by video thoracoscopy. Three discriminant equations are solved:

As a result of solving the three equations, the maximum value was obtained in the first equation, which indicates the need for treatment of the patient with minor surgery methods to reduce the risk of pleuropulmonary complications. Thus, when choosing other methods of treatment, the risk of developing pleuropulmonary complications increases. What was clinically confirmed, namely, when repeated drainage of the right pleural cavity was performed in the 6th intercostal space along the scapular line, 350 ml of hemorrhagic exudate with clots was evacuated. On the control x-ray of the chest organs in dynamics, the patient showed a complete disappearance of fluid, the lung is completely straightened, the sinuses are free. Discharged in satisfactory condition.

Example 2

Patient V., 64 years old, was hospitalized in the Department of Thoracic Surgery of the Clinical Hospital after 6 days from the moment of injury in everyday life. EKS is implanted in the patient, CRPS suffers: combined mitral-aortic heart disease with a predominance of AK stenosis, a constant form of atrial fibrillation, is on a constant intake of warfarin. On a panoramic x-ray of the chest organs, total dimming of the right hemithorax. Performed drainage of the right pleural cavity in the 7th intercostal space along the posterior axillary line with the evacuation of 2 liters of hemorrhagic exudate. On the control x-ray of the OGK, hydrothorax was maintained up to 5 ribs along the posterior segments. There was no drainage exudation. The condition was regarded as coagulated hemothorax. Temperature 36.6 ° C degrees. Complaints of moderate pain in the right side of the chest, discomfort in the drainage position. Objectively: the skin and visible mucous membranes of normal color and humidity. The chest is symmetrical, vesicular breathing in the lungs, no wheezing, weakened on the right in the posterior lower and lateral parts, NPV 18 per minute. Heart sounds are muffled, arrhythmic, heart rate 74-78 per minute, blood pressure 130/80 mm Hg Other organs and systems without features. On the ECG, atrial flutter, flutter, horizontal EOS. General clinical blood test at admission: erythrocytes 3.75 × 10 ¹² / l, HB 116 g / l, white blood cells 8.9 × 10 ⁹ / l, ESR 21 mm / hour. General analysis of urine: color - light yellow, acid reaction, specific gravity 1015, no protein, no sugar, leukocytes 1-3 in the field of view, red blood cells 0-1-2. Biochemical blood test: bilirubin 33.4 μmol / L, direct 10 μmol / L, total protein 55.3 g / L, AsAT 0.46 μkat / L, AlAT 0.2 μkat / L, creatinine 99.9 μmol / L urea 7.3 mmol / L, blood glucose 5.5 mmol / L, potassium 4.97 mmol / L, sodium 134 mmol / L, chlorine 101.2 mmol / L. According to most authors, the treatment of the patient had to be continued by video thoracoscopy. An assessment of the risk of pleuropulmonary complications by solving the discriminant equations:

As a result of solving the three equations, the maximum value was obtained in the first equation, which indicates the need for treatment of the patient with minor surgery methods to reduce the risk of pleuropulmonary complications. Thus, when choosing other methods of treatment, the risk of developing pleuropulmonary complications increases. What was clinically confirmed, namely by performing video thoracoscopy on the right, sanitation of hemothorax, drainage of the pleural cavity. Two 10 mm thoracoports were placed along the posterior and anterior axillary lines. In the pleural cavity in the lower lateral and posterior sections up to 800 ml of hemorrhagic exudate without clots, moderate fibrinous deposits on the parietal and visceral pleura. No other pathology was found. Remediation of hemothorax, drainage with two polyvinyl chloride drains. The intraoperative finding illustrates well the efficiency of the method: it was enough for the patient to drain the right pleural cavity at another point. In this case, for the treatment of the patient, despite the smooth course of the postoperative period and a good clinical and radiological result of treatment, an extra material and technical resource was used.

The proposed method was used in the Department of Thoracic Surgery, GBUZ YAO "Regional Clinical Hospital" and GBUZ YAO "Territorial Center for Disaster Medicine" to predict the risk of pleuropulmonary complications in patients with post-traumatic coagulated hemothorax, without ongoing bleeding, treated with minor surgery, video thoracoscopic and open surgical interventions.

Claims (1)

A method for choosing a method of treating patients with the lowest risk of developing pleuropulmonary complications in patients with post-traumatic coagulated hemothorax, without ongoing bleeding, characterized in that the patients are determined before treatment (age, age, years), heart rate (HR), body temperature (TT, ° C), hemoglobin value (Haem, g / l), erythrocyte sedimentation rate (ESR, ml / h), urine specific gravity (UVM), chlorine value (Chl, mmol / liter), creatinine (Cr, mmol / liter) ), albumin (Al, g / l), aspartate aminotransferase (Ac T mikrokatal / l), glucose (Gl, mmol / l), calculated risk pleuropulmonary complications (RVPLO) as a classification value discrimination equation for each treatment, namely for minor surgery (RVPLO ₁₎ for VATS interventions (RVPLO ₂ ), for open surgical interventions (RVPLO ₃ ), according to the formulas:
RVPLO ₁ = (VZR × 260) + (HR × 158) + (TT × 2592) + (Gem × 34) + (ESR × 5) + (UVM × 122) + (Chl × 415) + (Cr × -98 ) + (Al × 570) + (AcAT × 2448) + (Gl × -418) - 150590;
RVPLO ₂ = (VZR × 263) + (HR × 160) + (TT × 2620) + (Gem × 34) + (ESR × 5) + (UVM × 123) + (Chl × 419) + (Cr × -99 ) + (Al × 577) + (AcAT × 2474) + (Gl × -422) - 153762;
RVPLO ₃ = (VZR × 265) + (HR × 162) + (TT × 2647) + (Gem × 35) + (ESR × 5) + (UVM × 124) + (Chl × 423) + (Cr × -100 ) + (Al × 582) + (AcAT × 2500) + (Gl × -427) - 156896;
and choose the method of treatment that gained the highest value of RVPLO, as the method with the least risk of developing pleuropulmonary complications.