RU2639096C1 - Method for prediction of postoperative period in adult patients with acute heart failure after open heart surgery that receive treatment by extracorporal membrane oxygenation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: in adults with acute heart failure after open-heart surgery treated with extracorporeal membrane oxygenation, the amount of total protein and albumin, concentration of highly sensitive troponin T and procalcitonin are determined daily in the serum, then the integral index is calculated by the formula: AI= (K1+K2)/(K3+K4)×100, where AI is the integral index; K1 is the ratio of the total protein value in the patient to the total protein value, which is an indication for protein metabolism correction, - 50 g/l; K2 is the ratio of the albumin value in the patient to the albumin value, which is an indication for protein metabolism correction, - 30 g/l; K3 is the ratio of highly sensitive troponin T in a patient to the maximum value of highly sensitive troponin T in surviving patients receiving treatment with extracorporeal membrane oxygenation - 4330 ng/l; K4 is the ratio of procalcitonin value in the patient to the procalcitonin value, which indicates the development of an infectious-inflammatory process, - 2 ng/l. If the integral index is below 97.56, unfavourable postoperative period is predicted in adult patients with acute heart failure after open heart surgery receiving extracorporeal membrane oxygenation.

EFFECT: improved assessment of the postoperative period course prediction; allows at any time to assess the course of the postoperative period; gives an assessment of the therapy effectiveness and, if necessary, to carry out its correction, the outcome of surgical treatment.

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Description

The invention relates to medicine, namely cardiac surgery and cardioreanimatology, and can be used to assess the prognosis of the postoperative period in adult patients with acute heart failure after open heart surgery receiving treatment with extracorporeal membrane oxygenation.

The development of cardiovascular surgery has significantly expanded the boundaries of the surgical treatment of coronary heart disease and chronic rheumatic heart disease.

However, despite the use of the latest technologies for myocardial protection in open heart surgery, acute heart failure remains a formidable complication, the frequency of development of which is 3.6-15.4% of cases, and in 40-80% of cases, acute heart failure leads to fatal the outcome [S.V. Gauthier, V.N. Poptsov, E.A. Spirin. Extracorporeal membrane oxygenation in cardiac surgery and transplantology. - M .: - Tver: LLC Triada. 2013 - 272 p.].

The cause of acute heart failure after open heart surgery is:

- mechanical injury of the myocardium,

myocardial overload

- damage to the conductive system,

- acute myocardial hypoxia,

- initial myocardial failure.

For the treatment of acute heart failure in patients after open heart surgery, the method of extracorporeal membrane oxygenation is used.

Extracorporeal membrane oxygenation, a method of mechanical support of blood circulation, improves hemodynamics and gas composition of the blood, which reduces the incidence of systemic and organ disorders and improves the clinical condition of patients with acute heart failure after open heart surgery.

When using the method of extracorporeal membrane oxygenation in patients with acute heart failure after open heart surgery, there is a high risk of complications that can lead to an increase in patient days in the intensive care unit and increase the economic costs of intensive care for patients with this pathology and, with an unfavorable outcome to the death of the patient.

The most common complications in patients with acute heart failure after open heart surgery using the extracorporeal membrane oxygenation treatment method are:

1) the development of renal hepatic failure,

2) the development of infectious and inflammatory diseases (sepsis),

3) the development of disorders from the coagulation and anticoagulation system of hemostasis,

4) intravascular hemolysis.

In this connection, the development or determination of criteria for assessing the prognosis of the course of the postoperative period in patients with acute heart failure after open heart surgery receiving treatment with extracorporeal membrane oxygenation is relevant today.

A known method for predicting the course of the postoperative period in children with congenital heart defects after open heart surgery receiving treatment with extracorporeal membrane oxygenation, based on the study of the following laboratory parameters - blood concentrations of creatinine and urea, transaminases, free hemoglobin, lactate. With a creatinine concentration of more than 107 mmol / l; urea concentration of more than 15 mmol / l; concentrations of AsAT more than 200 PIECES / l; AlAT concentrations of more than 31 U / l; free hemoglobin concentrations of more than 35 mg / dl; lactate concentrations of more than 3.85 mmol / l during the postoperative period are unfavorable when using the method (method) of venoarterial extracorporeal membrane oxygenation in children with congenital heart defects after open heart surgery [L. Boqueria, K. Shatalov, A. Brodsky. G. et al. The method of extracorporeal membrane oxygenation in the treatment of heart failure in young children in a heart surgery clinic // Children's heart and vascular diseases. 2012. - No. 1. - S. 19-25].

The disadvantages of this method are:

1. The child’s body is different from the adult, therefore, it is not possible to use the values of laboratory indicators of renal hepatic insufficiency (creatinine, urea, transaminases), intravascular hemolysis (free hemoglobin) and tissue hypoxia (lactate) given in children. In adult patients with acute heart failure after open heart surgery, the values of these indicators are higher (15-20 times) than in children.

2. In the known method, the assessment of the prognosis after the operational period is based on the determination of markers of renal hepatic insufficiency (creatinine, urea, transaminases), intravascular hemolysis (free hemoglobin) and tissue hypoxia (lactate). These indicators against the background of ongoing therapy change in dynamics very slowly: changes are observed on 3-4 days against the background of ongoing therapy. For a daily laboratory assessment of the prognosis of the course of the postoperative period in patients with acute heart failure after open heart surgery receiving treatment with extracorporeal membrane oxygenation, the use of these indicators is not possible. Patients on extracorporeal membrane oxygenation due to acute heart failure after open heart surgery need to make a laboratory assessment of the prognosis of the postoperative period daily, and not once every 3-4 days.

3. As a rule, renal-hepatic insufficiency, intravascular hemolysis and tissue hypoxia are secondary manifestations of a systemic inflammatory response and indicate the development of complications amid acute heart failure. Myocardial damage primarily occurs, which leads to the development of acute heart failure, later on, against the background of already existing acute heart failure, other complications develop. The authors in the known method do not use a specific marker of myocardial damage (troponin T), although the main reason for the development of acute heart failure after open heart surgery is myocardial damage of various nature and degree.

4. In addition, the authors did not take into account the development of the most formidable complication in the treatment with extracorporeal membrane oxygenation, which most often leads to the death of the patient, the development of the infectious and inflammatory process - sepsis.

The invention is aimed at improving prediction of the course of the postoperative period in adult patients with acute heart failure after open heart surgery receiving extracorporeal membrane oxygenation treatment, based on the determination of protein metabolism (the amount of total protein and albumin in the blood serum), a specific marker of myocardial damage ( the concentration in the blood serum of highly sensitive troponin T) and a marker of the infectious inflammatory process (concentration serum procalcitonin in the blood).

The technical result is achieved in that in adult patients with acute heart failure after open heart surgery receiving treatment with extracorporeal membrane oxygenation, the amount of total protein and albumin, the concentration of highly sensitive troponin T and procalcitonin are determined in blood serum daily, and then the integral index is calculated by the formula :

AI = (K1 + K2) / (K3 + K4) × 100,

where AI is the integral index;

K1 - the ratio of the amount of total protein in the patient to the value of total protein, which is an indication for the correction of protein metabolism, - 50 g / l;

K2 - the ratio of the amount of albumin in the patient to the value of albumin, which is an indication for the correction of protein metabolism, - 30 g / l;

K3 - the ratio of highly sensitive troponin T in a patient to the maximum value of highly sensitive troponin T in surviving patients receiving extracorporeal membrane oxygenation treatment - 4330 ng / l;

K4 - the ratio of procalcitonin in the patient to the value of procalcitonin, which indicates the development of an infectious and inflammatory process, - 2 ng / l,

and with an integral index value below 97.56, an adverse postoperative period is predicted in adult patients with acute heart failure after open heart surgery receiving extracorporeal membrane oxygenation treatment.

Any operations, regardless of the method of support, are accompanied by changes in all types of metabolism, the ultimate goal of which is the adaptation of the body to surgical trauma. Changes are primarily observed in protein metabolism. After surgery, there is a decrease in the amount of total protein in the blood.

The reasons for the decrease in total protein in the blood after surgery are:

- blood loss, which leads to the loss of not only the formed elements of the blood, but also the protein component;

- changes in the system of “anabolism - catabolism” in response to extensive surgical trauma, characterized by the breakdown of tissue proteins (activation of catabolism processes) to compensate for the energy and plastic needs of the body in the postoperative period.

A common protein is a collective concept, includes more than 200 blood proteins that differ in structure, function, and physicochemical properties.

Blood proteins perform many functions in the human body: transport, hormonal, respiratory, enzymatic, protective, are involved in maintaining colloid-osmotic pressure, blood buffer capacity, blood coagulation. Therefore, a decrease in the amount of total protein in the blood can lead to a violation of the above functions in the human body. The determination of the amount of total protein in serum has a prognostic value.

In addition, a decrease in the amount of total protein is noted with renal-hepatic pathology. Unlike creatinine, urea, transaminases, the amount of total protein in the blood in cardiac patients varies daily, and based on the daily change in the amount of total protein in the blood, one can assess the severity of the patient's condition, the course of the postoperative period, the effectiveness of the therapy and the outcome of surgical treatment.

Albumin accounts for 55-60% of the total protein. The main function of albumin is to maintain colloid osmotic pressure. With a decrease in the amount of albumin in the blood, colloid osmotic pressure changes, hemodynamics and water-electrolyte balance are disturbed.

In addition, albumin performs a transport function. Carries out the transport of bilirubin, metals, drugs.

With a decrease in the amount of albumin in the blood, the bioavailability of drugs is disrupted. Albumin binds toxins and inactivates them. With a decrease in the amount of albumin in the blood, detoxification function is impaired.

Albumin is a negative protein of the acute phase of inflammation. The decrease in the amount of albumin in the blood in the postoperative period occurs due to increased synthesis of proteins of the acute phase of inflammation (C-reactive protein).

The determination of the concentration of C-reactive protein in the blood today is widely used to assess the course of the postoperative period in surgical patients, the risk of developing infectious and inflammatory processes, and the prognosis of treatment. High concentrations of C-reactive protein indicate an unfavorable course of the postoperative period in surgical patients. Therefore, the higher the level of C - reactive protein, the lower the value of albumin. Thus, the determination of the amount of albumin in cardiac surgical patients is of prognostic value.

To date, to determine and assess the degree of myocardial damage in cardiac surgery, a specific marker of myocardial damage is used - troponin T. Troponin T is involved in the formation of a troponin complex with tropomyosin. Troponin T is a regulatory globular protein, is involved in the process of muscle contraction. The molecular weight of troponin T is 37 kDa.

Distinguish between the cytosolic and structural pool of troponin T.

The cytosolic pool of troponin T is a highly sensitive troponin T. When the cytosol of cardiomyocytes is damaged, the release of the cytosolic (free, not connected with myofibrils) pool of troponin T.

The structural pool of troponin T is the “normal” troponin T. When the structures of cardiomyocytes are damaged, the release of the structural (associated with myofibrils) pool of troponin T. The structural pool of troponin T is the “usual” troponin T.

To date, in clinical practice, diagnostic systems (test systems) are used that allow the determination of “normal” troponin T and highly sensitive troponin T in the blood.

The highly sensitive troponin T has a number of advantages over the “usual” troponin T:

- the concentration of highly sensitive troponin T in the blood can be determined from 0 ng / l and higher, and the "usual" troponin T from 100 ng / l;

- The highly sensitive troponin T is a cytosolic pool. In case of damage to cardiomyocytes (myocardium), the highly sensitive troponin T is first found in the blood, which is important for early determination of myocardial damage. An early determination of the increase in the concentration of highly sensitive troponin T in the blood reduces the time to start activities, reduces the time spent by patients in the intensive care unit and the economic costs associated with this;

- the dynamics of the levels of highly sensitive troponin T, which allows us to differentiate acute myocardial damage (cardiomyocytes) from chronic;

- a short period of ischemia, not associated with a clear myocardial infarction, leads to the release of a small amount of highly sensitive troponin T into the blood;

- high levels of highly sensitive troponin T in patients with stable diseases of the coronary arteries indicate a high risk of heart failure, but not the risk of developing myocardial infarction;

- the levels of highly sensitive troponin T allow us to evaluate the course of the postoperative period, the effectiveness of the therapy and the prognosis of the course of the postoperative period;

- The highly sensitive troponin T is a predictor of adverse outcomes.

Procalcitonin - a protein that is a precursor of calcitonin, is synthesized in the thyroid gland. The concentration of procalcitonin in serum is the gold standard in the diagnosis, evaluation of the effectiveness of therapy and the course of the infectious and inflammatory process - sepsis. An increase in the concentration of procalcitonin in blood serum above 2 ng / l indicates the development of an infectious and inflammatory process - sepsis. The concentration of procalcitonin rises above 2 ng / l with the development of infection caused by gram-negative and gram-positive microflora. In infections caused by fungi or viruses, the concentration of procalcitonin does not exceed 1 ng / L. The level of increase in the concentration of procalcitonin is used for the differential diagnosis of the pathogen of the infectious and inflammatory process. With the development of an infectious-inflammatory process, an increase in the concentration of procalcitonin in the blood serum during therapy indicates an incorrect treatment strategy for the patient and an unfavorable outcome, and, conversely, a decrease in the concentration of procalcitonin in the blood serum during therapy indicates the correct treatment tactics of the patient and a favorable outcome treatment [Belkov V.V. Procalcitonin and C-reactive protein in the laboratory diagnosis of inflammatory processes. Laboratory. - Number 3. - 2008. - S. 15-19].

Given the importance of the above laboratory parameters in assessing the prognosis of the postoperative period, we used these laboratory indicators to develop a method for predicting the course of the postoperative period in adult patients with acute heart failure after open heart surgery receiving treatment with extracorporeal membrane oxygenation.

The method is as follows.

A detailed description of the method and examples of its practical implementation.

In patients with acute heart failure after open heart surgery receiving extracorporeal membrane oxygenation, blood was taken daily to evaluate the prognosis of the postoperative period, and the amount of total protein and albumin, the concentration of highly sensitive troponin T and procalcitonin were determined in blood serum.

Venous blood was used as biological material. Blood sampling was performed from a peripheral vein into the S-monovetta blood sampling system with a blood coagulation activator. To obtain serum, the blood was centrifuged for 10 min at 2500 rpm.

At the prehospital stage, patients were selected for cardiac surgery. At the time of admission to the hospital, the severity of the patients' condition was due to the degree of heart failure and circulatory disorders.

In patients at the preoperative stage, the amount of total protein in the blood serum was within the reference values of 64-83 g / l and averaged 71.74 ± 0.55 g / l, the amount of albumin in the blood serum was within the reference values of 35-52 g / l and averaged 40.5 ± 1.02 g / l, the concentration of highly sensitive troponin T was within the reference values of 0-14 ng / l and averaged 11.8 ± 0.056 ng / l, the concentration of procalcitonin was lower 0.05 ng / L and averaged 0.033 ± 0.001 ng / L. The values of the above laboratory parameters indicated the absence of disorders in the protein metabolism in patients at the preoperative stage, the absence of myocardial damage and the infectious-inflammatory process.

The proposed method has been tested on 28 patients (of which 21 men and 7 women), 26 patients with a diagnosis of coronary heart disease, 2 patients with a diagnosis of chronic rheumatic heart disease. The average age of the patients was 56.5 ± 1.9 years.

Patients diagnosed with chronic rheumatic heart disease underwent valve correction surgery under cardiopulmonary bypass and normothermia.

Patients diagnosed with coronary heart disease underwent coronary artery bypass grafting under cardiopulmonary bypass and normothermia.

Observation (research) was carried out in the period from 2009 to 2015. In the observed patients, the postoperative period was complicated by acute heart failure.

Patients according to the outcome of the postoperative period (acute heart failure) were divided into 2 groups:

1 group of patients - patients with a favorable course of the postoperative period, surviving patients (n = 11 people). In patients of the 1st group, extracorporeal membrane oxygenation was performed on average 4.4 ± 0.5 days, patients in the intensive care unit were on average 14.5 ± 2.5 days, on average, 24.5 ± 2.63 days the patients were discharged from the hospital in satisfactory condition;

2 group of patients - patients with an unfavorable course of the postoperative period, deceased patients (n = 17 people). In patients of the 2nd group, extracorporeal membrane oxygenation was performed on average 8.33 ± 1.63 days, patients in the intensive care unit were on average 8.33 ± 1.63 days, patients died on average 8.33 ± 1.63 days .

The amount of total protein (biuret method, g / l) and albumin (bromine-ash method, g / l) in blood serum was determined on a Cobas 311 c automatic biochemical analyzer (Roche Diagnostic), Germany); the concentration of highly sensitive troponin T (ng / l) and procalcitonin (ng / l) was determined using the electrochemiluminescent method on a Cobas 411 е automatic immunochemical analyzer (Roche Diagnostic, Germany).

The reference interval of the total protein in the blood serum is 64-83 g / l. Reducing the amount of total protein in the blood serum leads to a violation of hormonal, enzymatic, respiratory, protective functions. If the amount of total protein in the blood serum decreases below 50 g / l, correction with the help of drugs is necessary (according to the instructions of the Ministry of Health of the Russian Federation, instructions for the use of the drug for medical use of albumin). The amount of total protein is expressed as a K1 coefficient. Coefficient K1 is the ratio of the amount of total protein in a patient to the value of total protein, which is an indication for the correction of protein metabolism - 50 g / l. With a decrease in the amount of total protein to 50 g / l, the coefficient K1 = 50/50 = 1.

The reference interval of serum albumin is 35-52 g / l. A decrease in the amount of albumin in the blood serum leads to a violation of the transport, colloidal osmotic function. If the amount of albumin in the blood serum decreases below 30 g / l, correction with the help of drugs is necessary (according to the instructions of the Ministry of Health of the Russian Federation, instructions for the use of the drug for medical use of albumin). The amount of albumin in serum is expressed as a K2 coefficient. Coefficient K2 is the ratio of the amount of albumin in a patient to the value of albumin, which is an indication for the correction of protein metabolism - 30 g / l. With a decrease in the amount of albumin in serum to 30 g / l, the coefficient K2 = 30/30 = 1.

The reference interval of highly sensitive troponin T in blood serum is 0-14 ng / ml.

Patients during the postoperative period were divided into 2 groups:

1 group of patients - patients with a favorable course of the postoperative period, surviving patients (n = 11 people). In patients of the 1st group, extracorporeal membrane oxygenation and inotropic therapy were performed on average 4.4 ± 0.5 days, patients in the intensive care unit were on average 14.5 ± 2.5 days, on average, 24.5 ± 2.63 day patients were discharged from the hospital in satisfactory condition;

2 group of patients - patients with an unfavorable course of the postoperative period, deceased patients (n = 17 people). In patients of the 2nd group, extracorporeal membrane oxygenation and inotropic therapy were performed on average 8.33 ± 1.63 days, patients in the intensive care unit were on average 8.33 ± 1.63 days, patients died on average 8.33 ± 1 , 63 days.

In patients of the 1st group, the concentration of highly sensitive troponin T in the blood serum was in the range from 635 ng / l to 4330 ng / l (median was 1610 ng / l, standard deviation was 1360 ng / l). After open heart surgery, an increase in the concentration of highly sensitive troponin T to 4330 ng / L was noted, and then, against the background of extracorporeal membrane oxygenation and drug therapy, a decrease in the concentration of highly sensitive troponin T to 365 ng / L was observed. An increase in the concentration of highly sensitive troponin T in the blood serum of patients of the 1st group on the first day after surgery indicated myocardial damage. Against the background of the therapy, the concentration of highly sensitive troponin T in the blood serum of patients of the 1st group decreased in the next day, which indicated the reversibility of myocardial damage and a favorable course of the postoperative period.

In patients of the 2nd group, the concentration of highly sensitive troponin T in the blood serum was in the range from 4331 ng / l and higher. After open heart surgery, high concentrations of highly sensitive troponin T from 4331 ng / L and higher were observed, indicating myocardial damage. Against the background of extracorporeal membrane oxygenation and drug therapy, a further increase in the concentration of highly sensitive troponin T was observed, which indicated the irreversibility of myocardial damage and the lack of effect from extracorporeal membrane oxygenation and drug therapy, an unfavorable course of the postoperative period.

The concentration of highly sensitive troponin T in blood serum is expressed as a K3 coefficient. K3 - the ratio of highly sensitive troponin T in a patient to the maximum value of highly sensitive troponin T in surviving patients receiving extracorporeal membrane oxygenation treatment - 4330 ng / l. With an increase in the concentration of highly sensitive troponin T in blood serum to 4331 g / l, the coefficient K3 = 4330/4330 = 1.0.

An increase in the concentration of procalcitonin above 2 ng / l indicates the development of an infectious and inflammatory process - sepsis. The value of the concentration of procalcitonin in blood serum is expressed as - coefficient K4. The coefficient K4 is the ratio of procalcitonin in the patient to the value of procalcitonin, which indicates the development of an infectious-inflammatory process, - 2 ng / l. With an increase in the concentration of procalcitonin in the blood serum to 2.1 g / l, the coefficient K4 = 2.1 / 2 = 1.05.

The integral index (II) is calculated as the ratio of the sum of K1 and K2 to the sum of K3 and K4 and the result is multiplied by 100, and with an AI value below 97.56, an adverse course of the postoperative period is predicted in adult patients with acute heart failure after open heart surgery, receiving treatment with extracorporeal membrane oxygenation.

The following are test results:

Clinical example 1

Patient I., born in 1957, diagnosis - IHD. Stenosing atherosclerosis of the coronary arteries Angina of exertion III FC. Postinfarction cardiosclerosis (Q-IM from 01/10/2014). Arterial hypertension of the III stage, risk 4. Mitral valve insufficiency 3 degrees. Pulmonary hypertension 2 degrees. CHF IIa degree.

Before surgery, the concentration of highly sensitive troponin T in the blood serum was 12.2 ng / ml. On admission, the severity of the condition is due to heart failure, circulatory failure.

The operation was performed - mammary coronary artery bypass grafting of the right descending artery, coronary artery bypass grafting of 2 coronary arteries, annuloplasty of the mitral valve by the support ring in the conditions of cardiopulmonary bypass and cardioplegia.

The duration of cardiopulmonary bypass was 5 hours 30 minutes.

The postoperative period was complicated by acute heart failure - in the first hours after the operation, circulatory arrest. Diagnosed perioperative myocardial infarction of the anterior-septal, apical region.

The development of acute heart failure required resternotomy, repeated coronary artery bypass grafting, and extracorporeal membrane oxygenation.

On the 1st day after surgery, the patient receives treatment with extracorporeal membrane oxygenation. The patient's condition is serious, the severity is due to heart failure.

The amount of total protein was 48 g / l, the amount of albumin was 24.2 g / l, the concentration of highly sensitive troponin T was 3657 ng / l, and the concentration of procalcitonin was 1.9 ng / l.

Based on the results of a laboratory examination, the patient assessed the prognosis of the course of the postoperative period II = (48/50 + 24.2 / 30) / (3657/4330 + 1.9 / 2) × 100 = 98.88.

AI is 98.88, i.e. above 97.56. Based on the values of AI, despite the serious condition of the patient, the patient has a low probability of an adverse course of the postoperative period.

On the 2nd day after surgery, the patient receives treatment with extracorporeal membrane oxygenation. The patient's condition is serious, the severity is due to heart failure.

The amount of total protein was 50 g / l, the amount of albumin was 26 g / l, the concentration of highly sensitive troponin T was 3543 ng / l, the concentration of procalcitonin was 1.5 ng / l.

Based on the results of a laboratory examination, the patient assessed the prognosis of the course of the postoperative period II = (50/50 + 26/30) / (3543/4330 + 1.5 / 2) × 100 = 119.11.

AI is 119.11, i.e. above 97.56. Despite the severity of the patient's condition, the patient has no risk of developing an unfavorable course of the postoperative period.

On the 3rd day after surgery, the patient receives treatment with extracorporeal membrane oxygenation. The patient's condition is serious, the severity is due to heart failure.

The amount of total protein was 52 g / l, the amount of albumin was 28 g / l, the concentration of highly sensitive troponin T was 2909 ng / l, the concentration of procalcitonin was 0.8 ng / l.

Based on the results of a laboratory examination, the patient assessed the prognosis of the course of the postoperative period II = (52/50 + 28/30) / (2909/4330 + 0.8 / 2) × 100 = 184.11.

AI is 184.11, i.e., above 97.56. Despite the severity of the patient's condition, the patient has no risk of developing an unfavorable course of the postoperative period.

On the 4th day after surgery, the patient receives treatment with extracorporeal membrane oxygenation. The patient's condition is serious, the severity is due to heart failure.

The amount of total protein was 52 g / l, the amount of albumin was 28 g / l, the concentration of highly sensitive troponin T was 2767 ng / l, the concentration of procalcitonin was 0.8 ng / l.

Based on the results of a laboratory examination, the patient assessed the prognosis of the course of the postoperative period II = (55/50 + 30/30) / (2767/4330 + 0.8 / 2) × 100 = 201.92.

AI is 201.92, i.e. above 97.56. Despite the severity of the patient's condition, the patient has no risk of developing an unfavorable course of the postoperative period.

On the 5th day after surgery, the patient receives treatment with extracorporeal membrane oxygenation. The patient's condition is serious, the severity is due to heart failure.

The amount of total protein was 56 g / l, the amount of albumin was 30 g / l, the concentration of highly sensitive troponin T was 2305 ng / l, the concentration of procalcitonin was 0.8 ng / l.

Based on the results of a laboratory examination, the patient assessed the prognosis of the course of the postoperative period II = (56/50 + 30/30) / (2305/4330 + 0.8 / 2) × 100 = 227.96.

AI is 227.96, i.e. above 97.56. Despite the severity of the patient's condition, the patient has no risk of developing an unfavorable course of the postoperative period.

On the 6th day after surgery, the patient receives treatment with extracorporeal membrane oxygenation. The patient's condition is serious, the severity is due to heart failure.

The amount of total protein was 59 g / l, the amount of albumin was 31 g / l, the concentration of highly sensitive troponin T was 1905 ng / l, and the concentration of procalcitonin was 0.5 ng / l.

Based on the results of a laboratory examination of the patient, the prognosis of the course of the postoperative period II = (59/50 + 31/30) / (1905/4330 + 0.5 / 2) × 100 = 320.29 was evaluated.

AI is 320.29, i.e. above 97.56. Despite the severity of the condition to the patient, the patient has no risk of developing an unfavorable course of the postoperative period.

Based on the positive dynamics in the blood serum of highly sensitive troponin T and the data of electro- and echo-cardiography, the patient is disconnected from the extracorporeal membrane oxygenation apparatus on the 7th day after the operation. The patient's condition is serious, the severity of the condition is due to heart failure.

On the 12th day after the operation, the patient’s condition is of moderate severity, the severity is due to heart failure, for further treatment the patient was transferred from the intensive care unit to the cardiac surgery department.

The amount of total protein was 65 g / l, the amount of albumin was 35 g / l, the concentration of highly sensitive troponin T was 341 ng / l, the concentration of procalcitonin was 0.33 ng / l.

Based on the results of a laboratory examination, the patient assessed the prognosis of the course of the postoperative period II = (65/50 + 35/30) / (341/4330 + 0.33 / 2) × 100 = 1008.16.

AI is 1,008.16, i.e., above 97.56. II was higher than 97.56, therefore, the patient has no risk of developing an unfavorable course of the postoperative period.

On the 21st day after surgery, the patient was discharged from the hospital in satisfactory condition.

The patient received the following treatment: adrenergic agonists (inotropic), infusion therapy to correct the volume of circulating blood, colloid osmotic pressure and acid-base balance, antibiotics (meropenem, ciprofloxacin), anticoagulants, de-aggregates, antiarrhythmic drugs, non-steroidal anti-inflammatory drugs, , insulin, proton pump inhibitors, mucolytics, bronchodilators, neuroprotectors, iron preparations, kinetic and respiratory therapy.

The values and dynamics of the amount of total protein and albumin, the concentration of highly sensitive troponin T and procalcitonin, and the integral index indicate a favorable course of the postoperative period.

Thus, this clinical example demonstrates the possibility of using the integral index in patients with acute heart failure after open heart surgery receiving extracorporeal membrane oxygenation treatment to predict the course of the postoperative period.

Clinical example 2

Patient G., born in 1959, diagnosis - IHD. Stenosing atherosclerosis of the coronary arteries Angina of exertion III FC. Postinfarction cardiosclerosis (Q-IM from 01/10/2014). Arterial hypertension of the III stage, risk 4. Mitral valve insufficiency 3 degrees. Pulmonary hypertension 2 degrees. CHF IIa degree.

Before surgery, the concentration of highly sensitive troponin T in the blood serum was 10.1 ng / ml. On admission, the severity of the condition is due to heart failure, circulatory failure.

An operation was performed - mammary coronary artery bypass grafting of 4 coronary arteries. The duration of cardiopulmonary bypass was 5 hours 30 minutes.

The postoperative period was complicated by acute heart failure - in the first hours after the operation, circulatory arrest was recorded. Diagnosed perioperative myocardial infarction of the anterior-septal, apical region. Against the background of perioperative myocardial infarction, acute heart failure developed, which required a resternotomy, repeated re-coronary artery bypass grafting and the connection of an extracorporeal membrane oxygenation apparatus.

1st day after surgery. The patient for acute heart failure receives treatment with extracorporeal membrane oxygenation. The patient's condition is severe, the severity is due to acute heart failure.

The amount of total protein was 50 g / l, the amount of albumin was 25.4 g / l, the concentration of highly sensitive troponin T was 1527 ng / l, the concentration of procalcitonin was 1.68 ng / l.

Based on the results of a laboratory examination, the patient assessed the prognosis of the course of the postoperative period II = (50/50 + 25.4 / 30) / (1527/4330 + 1.68 / 2) × 100 = 155.46.

AI is 155.46, i.e. above 97.56. Therefore, the patient has no risk of developing an adverse course of the postoperative period.

2nd day after surgery. The patient receives treatment with extracorporeal membrane oxygenation. The patient's condition is severe, the severity is due to acute heart failure.

The amount of total protein was 48 g / l, the amount of albumin was 23 g / l, the concentration of highly sensitive troponin T was 5285 ng / l, and the concentration of procalcitonin was 2.8 ng / l.

Based on the results of a laboratory examination, the patient assessed the prognosis of the course of the postoperative period II = (48/50 + 23/30) / (5285/4330 + 2.8 / 2) × 100 = 66.03.

AI is 66.03, i.e. below 97.56. Therefore, the patient has a risk of developing an unfavorable course of the postoperative period.

Based on the values of AI, the patient undergoes correction of treatment - doses of adrenergic agonists and infusion therapy, acid-base balance, antibiotic therapy.

3rd day after surgery. The patient receives treatment with extracorporeal membrane oxygenation. The patient's condition is extremely serious, the severity is due to acute heart failure.

The amount of total protein was 45 g / l, the amount of albumin was 20 g / l, the concentration of highly sensitive troponin T was 18378 ng / l, the concentration of procalcitonin was 4.5 ng / l.

Based on the results of a laboratory examination, the patient assessed the prognosis of the course of the postoperative period II = (45/50 + 20/30) / (18378/4330 + 4.5 / 2) × 100 = 24.19.

AI is 24.19, i.e. below 97.56. Therefore, the patient has a risk of developing an unfavorable course of the postoperative period.

Based on the values of AI, the patient undergoes correction of treatment - doses of adrenergic agonists and infusion therapy, antibiotic therapy.

4th day after surgery. The patient receives treatment with extracorporeal membrane oxygenation. The patient's condition is extremely serious, the severity is due to acute heart failure.

The amount of total protein was 40 g / l, the amount of albumin was 20 g / l, the concentration of highly sensitive troponin T was 22600 ng / l, the concentration of procalcitonin was 6.2 ng / l.

Based on the results of a laboratory examination, the patient assessed the prognosis of the course of the postoperative period II = (40/50 + 20/30) / (22600/4330 + 6.2 / 2) × 100 = 17.67.

AI is 17.67, i.e. below 97.56. Therefore, the patient has a high risk of developing an adverse course of the postoperative period. Based on the values of AI, the patient undergoes correction of treatment - doses of adrenergic agonists and infusion therapy, antibiotic therapy.

Despite the therapy, the patient died on the 5th day after the operation. The cause of death of the patient is acute heart failure, sepsis, multiple organ failure.

The patient received the following treatment: adrenergic agonists (inotropic), infusion therapy to correct the volume of circulating blood and acid-base balance, antibiotics (meropenem, ciprofloxacin), anticoagulants, antiplatelet agents, antiarrhythmic drugs, non-steroidal anti-inflammatory drugs, diuretics, insulin inhibitor, mucolytics, bronchodilators, neuroprotectors, iron preparations, kinetic and respiratory therapy.

The values and dynamics of the amount of total protein and albumin, the concentration of highly sensitive troponin T and procalcitonin, and the integral index indicate an unfavorable course of the postoperative period.

A clinical example demonstrates the possibility of using the integral index in adult patients with acute heart failure after open heart surgery to predict the course of the postoperative period.

The advantages of the proposed method are:

- improved prediction of the course of the postoperative period in adult patients with acute heart failure after open heart surgery receiving treatment with extracorporeal membrane oxygenation;

- allows at any time to evaluate the course of the postoperative period in adult patients with acute heart failure after open heart surgery receiving treatment with extracorporeal membrane oxygenation;

- the values of the integral index allow us to evaluate the effectiveness of the therapy and, if necessary, carry out its correction, the outcome of surgical treatment.

Thus, the claimed method allows to predict the course of the postoperative period in adult patients with acute heart failure after open heart surgery receiving treatment with extracorporeal membrane oxygenation, and use this method to assess the effectiveness of the therapy and the outcome of surgical treatment: based on determining the amount in serum blood total protein and albumin, serum concentrations of highly sensitive troponin T and procalcitonin can be consider the integral index, with which you can predict the course of the postoperative period, evaluate the effectiveness of the therapy, the outcome of surgical treatment.

Claims (8)

A method for predicting the course of the postoperative period in adult patients with acute heart failure after open heart surgery receiving extracorporeal membrane oxygenation treatment, which is that in adult patients with acute heart failure after open heart surgery receiving treatment with extracorporeal membrane oxygenation, daily in the blood serum determine the amount of total protein and albumin, the concentration of highly sensitive troponin T and p rocalcitonin, then calculate the integral index by the formula: AI = (K1 + K2) / (K3 + K4) × 100, where AI is the integral index; K1 - the ratio of the amount of total protein in the patient to the value of total protein, which is an indication for the correction of protein metabolism, - 50 g / l; K2 - the ratio of the amount of albumin in the patient to the value of albumin, which is an indication for the correction of protein metabolism, - 30 g / l; K3 - the ratio of highly sensitive troponin T in a patient to the maximum value of highly sensitive troponin T in surviving patients receiving extracorporeal membrane oxygenation treatment - 4330 ng / l; K4 - the ratio of procalcitonin in the patient to the value of procalcitonin, which indicates the development of an infectious and inflammatory process, - 2 ng / l, and with an integral index value below 97.56, an adverse course of the postoperative period is predicted in adult patients with acute heart failure after open heart surgery receiving extracorporeal membrane oxygenation treatment.