RU2620016C1 - Method for pneumoustic pneumonia prevention in heart recipients in early postoperative period after heart transplantation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: recipients are isolated who have been exposed to extracorporal membrane oxygenation technology for at least 24 hours and/or at least two of the following conditions have been identified: gram negative bacteremia after surgery, intraoperative blood loss of more than 500 ml, mechanical ventilation duration of more than 12 hours in the postoperative period. Such patients receive drug or drugs having a bactericidal or bacteriostatic activity against Pneumocystis jiroveci starting from 2-3 days after the operation, for 5-6 days intravenously at a therapeutic dose.

EFFECT: reduced toxic effect of multicomponent drug therapy as a result of a differentiated approach to administration of toxic and active agents against pneumocystis.

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Description

The invention relates to medicine, namely to transplantology, can be used in the management of patients in the early postoperative period after heart transplantation.

To date, heart transplantation is a popular operation in various regions of the world, regardless of the country's economic development. The main reason for this is the high productivity and quality of life, including the social activity of recipients of orthotopic heart transplantation (OTTS).

It is known that the outcomes of high-tech cardiac surgery operations, the category of which include heart transplantation, are largely determined by the technology of drug and non-drug management of the early hospital period. There are various options for schemes and protocols approved for use in transplant clinics in order to optimize the postoperative period and improve the quality of life of recipients.

In connection with the ongoing immunosuppressive therapy, which is mandatory for all recipients of vital organs, the possibility of developing bacterial and viral infections is a major risk factor for the development of postoperative complications.

The tendency to develop and the severity of infectious complications is determined by the fact that one of the essential components of technological schemes is the use of drugs that prevent the development of infectious complications of a bacterial and viral nature.

It is important to note that in well-known published schemes or protocols for postoperative management of OTTC recipients, in addition to wide-spectrum antibiotics that prevent the development of bacterial infection, it is mandatory to use immunoglobulins containing antibodies to cytomegalovirus and herpes viruses, as well as antifungal drugs.

It is known that patients undergoing immunosuppressive therapy are prone to the development of opportunistic infections (OIF). Among UIFs, pneumocystosis is essential for the development of pathological processes, the development of which can lead to serious, almost poorly curated conditions.

A known method for the prevention of pneumocystic pneumonia in recipients in the postoperative period after heart transplantation (Martin SI, MD MHS JA Fishman, AST Infections Diseases Community of Practice. Pneumocystis pneumonia in solid organ transplantation. Am J Transplant. 2013 Mar; 13 Suppl 4: 272-9 .doi: 10.1111 / ajt.12119. USA).

The essence of the method lies in the fact that for the prophylaxis of Co-trimaxosole, patients are selected who have constant clinical and laboratory monitoring and antigens and antibodies to pneumocysts are determined.

The disadvantage of this method is as follows.

This method does not involve early use of the drug. In addition, for economic reasons, the widespread use of clinical and laboratory monitoring seems inappropriate. At the same time, the expectation of clinical and laboratory results delays the start of preventive therapy.

As a prototype, a well-known method for the prevention of pneumocystic pneumonia in heart recipients in the early postoperative period after heart transplantation was selected (Barbara DA, MD MHS JA Fishman, MD Section Editor KA Marr, MD Deputy Editor AR Thorner. Profilaxis of infections in solid organ transplantations. Http: //www.uptodate.com, 2015, USA).

The essence of this method is the appointment of Co-trimaxosole as a universal prevention to all recipients of solid organs.

The disadvantages of this method are that Co-trimaxosole has many side effects: nausea, vomiting, hypersensitivity to the components of the drug, hypersensitivity to sulfonamides, an allergic reaction (itching, urticaria, fever), which makes it impossible to use it for everyone who needs prevention and treatment of patients. This situation increases the risk of developing an infection.

We set the task - to develop a method for early postoperative prophylaxis of pneumocystic pneumonia in heart recipients by identifying risk groups.

The technical result achieved by the implementation of the proposed method is to reduce the toxic effects of multicomponent drug therapy in some recipients of the heart as a result of a differentiated approach to the appointment of drugs active against pneumocystis.

The general use after the operation of drugs that are active against pneumocysts for the prevention of pneumocystis pneumonia is not indifferent to recipients of the heart, because the drugs are toxic enough, and patients receive powerful multicomponent drug therapy before and from the first day after the operation.

The invention consists in the following.

Pneumocystis pneumonia is prevented in the early postoperative period after heart transplantation to heart recipients who have been using extracorporeal membrane oxygenation technology and / or have been diagnosed with at least two of the following conditions: intraoperative blood loss of more than 500 ml, duration of mechanical ventilation lungs in the postoperative period over 12 hours, gram-negative bacteremia. For this, starting from 2-3 days after the operation, for 5-6 days, a drug or drugs with bactericidal or bacteriostatic activity against Pneumocystis jiroveci is administered intravenously daily at a therapeutic dose.

In a particular case, Biseptol 480 is used as a drug.

The method is as follows.

To determine the indications for the administration of a drug or preparations with bactericidal or bacteriostatic activity against Pneumocystis jiroveci in the early postoperative period after heart transplantation, the presence of intraoperative blood loss of more than 500 ml, prolonged mechanical ventilation in the postoperative period (over 12 hours), and gram-negative bacteremia after surgery are determined , the use of extracorporeal membrane oxygenation (ECMO) technology for at least a day.

To determine bacteremia (the presence of bacteria in the blood), blood is taken (mainly venous) in specialized Bactec and Bact / Alert bottles. Blood vials are placed in Bactec 8050 and Bact / Alert devices. In the presence of blood growth, the device gives a signal, the vial with the grown blood is withdrawn. Make a smear (stained by Gram) and look under a microscope. Gram-negative bacteria turn red. Then they do the seeding on the dies and install in a Siemens device to identify the culture and determine the sensitivity to antibiotics.

Various methods can be used to assess blood loss, for example, gravimetric (weighing during the operation all surgical wipes soaked in blood).

When assessing blood loss by blood pressure and the clinical signs of traumatic shock, it is important to remember the action of blood loss compensation mechanisms that can keep blood pressure at normal or near normal levels with significant bleeding (up to 20% bcc, or about 1000 ml). A further increase in blood loss is already accompanied by a significant decrease in blood pressure and the development of a shock clinic. In general, there is a close correlation between the volume of blood lost and the level of blood pressure, which allows an approximate estimate of the magnitude of acute blood loss.

Extracorporeal membrane oxygenation (ECMO) is a procedure for prolonged extracorporeal circulation. Used in patients with acute and potentially reversible respiratory, cardiac or cardiorespiratory failure who do not respond to standard therapy.

There is a veno-venous connection ECMO and veno-arterial. ECMO is established through catheterization of the main vessels of the vascular bed. The place of connection of catheters is determined by the condition of the patient. The purpose of ECMO is to give time for your own recovery of heart function. The procedure can be used before, during and after surgery. Indications for this procedure are heart failure (after cardiac surgery there is no way to turn off cardiopulmonary bypass), after heart transplantation, myocarditis, myocardiopathy, as an addition to cardiopulmonary resuscitation. In special situations, ECMO is connected to a biventricular bypass.

When performing mechanical ventilation use a ventilator. The doctor can accurately determine the frequency and depth of breaths on this unit. In addition, the ventilator has an alarm system that instantly alerts you to each violation of the ventilation process. If the patient is ventilated with a gas mixture, the ventilator sets and monitors its composition. The respiratory mixture enters through a hose connected to an endotracheal tube placed in the patient's trachea. If the patient needs long-term ventilation, the endotracheal tube is inserted through the hole made in the front wall of the trachea, i.e. a tracheostomy is done. The main indication is complex, lengthy operations.

As a drug having bactericidal or bacteriostatic activity against Pneumocystis jiroveci, for example, biseptol can be used.

The therapeutic dose of Biseptolum is 480 by 480 ml 2 times a day intravenously.

Cardiac recipients who have used extracorporeal membrane oxygenation technology for at least 24 hours and / or have identified at least two of the following conditions: gram-negative bacteremia after surgery, intraoperative blood loss of more than 500 ml, the duration of mechanical ventilation in the postoperative period above 12 hours, starting from 2-3 days after the operation, for 5-6 days daily, a drug or preparations having a bactericidal or bacteriostatic a is administered intravenously in a therapeutic dose activity against Pneumocystis jiroveci.

To prove the possibility of realizing the claimed purpose and achieving the specified technical result, we provide the following data.

Clinical example 1.

Patient A., 31 years old.

Diagnosis: Congestive heart failure. Ischemic cardiomyopathy.

Received with complaints of shortness of breath with minor physical exertion, aggravated in the supine position, swelling of the lower extremities, pain in the chest area.

On the first day of her stay in the department, the patient was transferred to the operating room, where she underwent ECMO and performed orthotopic transplantation of a cadaveric heart (intraoperative blood loss amounted to more than 500 ml). Transferred to the intensive care unit. The patient's condition corresponded to the volume, duration and severity of the surgery and the severity of the initial condition. The pulmonary failure clinic required mechanical ventilation for 40 hours. The following therapy was carried out: Meronem 1 g intravenously 3 times a day, Zivox 600 mg intravenously 2 times a day. ECMO removal was performed on day 17. Medication continued. The patient's condition is moderate, the increase in body temperature to 37.5 ° C. A specialized examination revealed the presence of pneumocystis pneumonia. Prevention of pneumocystis pneumonia by the proposed method was not carried out.

Clinical example 2.

Patient S., 42 years old.

Diagnosis: Coronary heart disease. Angina pectoris.

He was admitted with complaints of shortness of breath with minor physical exertion, aggravated in the supine position, swelling of the lower extremities, pain in the heart.

On the first day of his stay in the department, the patient was transferred to the operating room, where he underwent ECMO and performed orthotopic transplantation of cadaveric heart. Transferred to the intensive care unit. The pulmonary failure clinic required mechanical ventilation for 48 hours. When taking blood for bacteriological examination, gram-negative bacteremia was detected. In the postoperative period, pneumocystic extravmonia was prevented in accordance with the proposed method: biseptol 480 ml 2 times a day. ECMO removal was performed on day 10. The patient's condition is satisfactory, no complaints. During a specialized examination, pneumocystis pneumonia was not detected.

Clinical example 3.

Patient I., 24 years old.

Diagnosis: dilated cardiomyopathy.

Received complaints of pain in the heart, swelling of the lower extremities.

On the first day of his stay in the department, the patient was transferred to the operating room, where he underwent ECMO and performed orthotopic transplantation of a cadaveric heart (intraoperative blood loss amounted to more than 500 ml). Transferred to the intensive care unit. The pulmonary insufficiency clinic required mechanical ventilation for 20 hours. In the postoperative period, pneumocystic extravmonia was prevented in accordance with the proposed method: biseptol 480 ml 2 times a day. ECMO removal was performed on day 2. The patient's condition is satisfactory, no complaints. During a specialized examination, pneumocystis pneumonia was not detected.

Clinical example 4.

Patient D., 36 years old.

Diagnosis: dilated cardiomyopathy.

Received complaints of pain in the heart, swelling of the lower extremities.

On the first day of his stay in the department, the patient was transferred to the operating room, where he underwent orthotopic transplantation of a cadaveric heart (intraoperative blood loss amounted to more than 500 ml). Transferred to the intensive care unit. When taking blood for bacteriological examination, gram-negative bacteremia was detected. In the postoperative period, pneumocystic extravmonia was prevented in accordance with the proposed method: biseptol 480 ml 2 times a day. The patient's condition is satisfactory, no complaints. During a specialized examination, pneumocystis pneumonia was not detected.

Pneumocystis pneumonia prophylaxis according to the proposed method was carried out for 18 recipients of the heart, of which only 2 were confirmed by serological examination of pneumocystis pneumonia.

The total number of pneumocystis infected among heart recipients who did not receive prophylaxis with drugs that have bactericidal or bacteriostatic activity against Pneumocystis jiroveci was 43.3%, the number of pneumocystis infected among heart recipients who were prevented in accordance with the proposed method was 11, one%.

Thus, with the inclusion of biseptol (Co-trimmaxosole) for the prevention of pneumocystic pneumonia in OTTS recipients, a sharp decrease in the incidence of pneumocystic pneumonia was noted.

Claims (2)

1. A method for the prevention of pneumocystic pneumonia in cardiac recipients in the early postoperative period after heart transplantation, characterized in that for recipients who have used extracorporeal membrane oxygenation technology and / or at least two of the following conditions have been identified: gram-negative bacteremia after surgery, intraoperative blood loss of more than 500 ml, the duration of mechanical ventilation in the postoperative period of more than 12 hours, starting from 2-3 days after surgery and for 5-6 days daily intravenous dose is administered in a therapeutic drug or drugs with bactericidal or bacteriostatic activity against Pneumocystis jiroveci. 2. The method according to p. 1, characterized in that as a drug use Biseptol 480.