RU2731606C1 - Method for preventing transient hyperlactatemia in extensive hepatectomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine and can be used as a method for preventing transient hyperlactatemia in extensive hepatectomy. Method for preventing transient hyperlactatemia in extensive hepatectomy by using drug preparations, consists in the fact that the drug preparations are infusions of short insulin with rate of 1–6 units/hour and solution of 10 % gluconate and calcium chloride with infusion rate of 1–8 ml/h.

EFFECT: invention provides higher accuracy of hyperlactatemia correction ensured by a biochemical mechanism of stimulating gluconeogenesis and Krebs cycle in hepatocytes.

1 cl, 3 ex

Description

The invention relates to medicine and can be used as a method for the prevention of transient hyperlactatemia in extensive liver resections.

A known method for the prevention of transient hyperlactatemia, including the infusion of substrate antihypoxants, followed by prolonged veno-venous hemofiltration (PVVHF) against the background of PVVHF, which made it possible to halve the amount of lactate released into the filtrate and achieve a statistically significant reduction in hyperlactatemia in group 6 of patients. [1 - Yakovlev A.Yu., Zaitsev P.P., Abramov A.V., Chistyakov S.I. Extracorporeal correction of lactatemia in sepsis. Scientific and educational conference. Topical issues and innovative technologies in anesthesiology and resuscitation. April 4-5, 2019. Sat. abstracts. Saint Petersburg 2019, p. 92-93]. This method is taken as an analogue.

A known method for the prevention of transient hyperlactatemia during operations on the aorta with ischemic colitis. This method is taken as a prototype [2- Trekova N.A., Akselrod B.A., Yudichev I.I., Gus'kov D.A., Markin A.V., Popov A.M. Clinical aspects of the blood lactate dynamics during operations on the heart and the aorta in conditions of cardiopulmonary bypass. Anesteziologiya i reanimatologiya (Russian journal of Anaesthesiology and Reanimatology) 2016; 61 (5): 324-329. (In Russ.). DOI: http://dx.doi.org/10.18821/0201-7563-2016-61-5-324-3291. Introductory anesthesia included the balanced use of midazolam 2.5-5 mg, fentanyl up to 4 μg / kg, propofol up to 1 mg / kg, in some patients with ketamine in a sub-drug dose. Pipecuronium bromide 0.09-1 mg / kg was administered for tracheal intubation. Sevoflurane, propofol, fentanyl, and pipecuronium bromide were used to maintain anesthesia. Transfusion tactics included limiting the transfusion of donor blood by introducing all methods to reduce blood loss and save the patient's blood. However, the proposed method for correcting hyperlactatemia is not based on the biochemical mechanism of stimulating gluconeogenesis and the Krebs cycle in hepatocytes.

The goal is to improve the accuracy of hyperlactatemia correction due to the biochemical mechanism of stimulation of gluconeogenesis and the Krebs cycle in hepatocytes.

The technical result is achieved by infusion of short insulin at a rate of 1-6 U / hour and a solution of 10% calcium gluconate or 10% calcium chloride. with an infusion rate of 8-1 Ml / hour.

The method is carried out as follows.

Long-term lactatemia is a predictor of death in many critical conditions, accompanied by impaired oxygen transport and extraction. Unfortunately, it should be stated that recommendations for the correction of respiratory failure and anemia, hemodynamic support, do not lead to a proper increase in oxygen extraction. Hyperlactatemia is evidence of this in sepsis and septic shock. Therefore, the search for new directions for its correction by reducing the production of lactate in reversible mitochondrial insufficiency, gluconeogenesis processes, and finally, the elimination of excess lactate with diuresis or using methods of extracorporeal detoxification can be considered promising. Continuous intravenous intraoperative infusion of short insulin at a rate of 1-6 U / hour.

In combination with intravenous infusion of calcium gluconate 10% or calcium chloride 10%. with an infusion rate of 8-1 Ml / hour provides strict control of glycemia and activation of mitochondrial dehydrogenases in hepatocytes, which helps to accelerate the metabolism of lactate and use it as an additional source of energy, which is especially important in extended liver resections.

Patients come with complaints of yellowness of the skin and dull pain in the right hypochondrium.

From the anamnesis it is known that obstructive jaundice was observed during the last 2-3 months. In the City Clinical Hospital - ERCP, stenting of the common bile duct with plastic stents of the direct type was performed. In the postoperative period, acute pancreatitis occurred. Against the background of treatment, the phenomena of jaundice, acute pancreatitis were arrested. CT scan of the abdominal cavity - biliary hypertension in the confluence area is determined by a tumor formation measuring 2.0-4.0 cm with the spread of infiltration to the left and right lobar ducts - portal cholangiocarcinoma.

Then endoscopic removal of stents of the bile duct, antegrade percutaneous transhepatic drainage of the bile ducts under ultrasound, RTV control is performed. Then, percutaneous transhepatic cholangiostomy of the ducts of the liver lobe is performed, followed by percutaneous transhepatic modified drainage of the ducts of the liver lobe through the disconnected ducts of the 4th segment. Then the right pleural cavity is drained.

According to the bile crops, a multi-resistant flora presented by Klebs was revealed. Pneumoniae, Pseudomonas aeruginosa, and vancomycin-resistant Enterococcus fecalis. Against the background of conservative antibacterial therapy (Linezolid, Imipenem, Polymyxin, Fluconazole), the clinical and laboratory phenomena of cholangitis were stopped, with control inoculations the microbial concentration of Klebsiella decreased from 10 ^∧ 7 to 10 ^∧ 5, Pseudomonas aeruginosa from 10 ^∧ 7 to 10 ^∧ 3, growth of enterococcus not marked.

CT: in the confluence area there is a solid area of 20 × 40 mm, the adjacent tissue in the area of the liver hilum is infiltrated, this infiltration involves the left and right branch of the portal vein, circular left or right hepatic artery, the tissue at the level of the liver hilum is compacted with the presence of lymph nodes up to 6 mm, lymph nodes along the hepatoduodenal ligament up to 8-9 mm, multiple; common bile duct in the supraduodenal and intrapancreatic section with a diameter of 2-3 mm, can be traced to the OBD; the structure of the arteries of the CMB is typical.

Cancer council: diagnosis of cancer of the proximal extrahepatic bile ducts cT3NxM0 (Klatskin's tumor type 3B according to Bismutch-Corlette). Considering the prevalence of the oncological process, recurrent cholangitis, positive dynamics during therapy, at the first stage, radical surgical treatment in the volume of laparotomy, extended left-sided hemihepatectomy (extended with the intraoperative need to remove the anterior sector - the volume of the posterior sector is 50% by scintigraphy, V right lobe 97 %, IPD 2.6), resection of extrahepatic bile ducts, formation of BDA. Solving the issue of specific therapy after receiving the results of a planned histological examination of the operating material.

Concomitant pathology does not require surgical and therapeutic correction. There are no contraindications to surgical treatment.

Diagnosis:

Main C24.0 Cancer of proximal extrahepatic bile ducts cT3NxM0 (Klatskin's tumor type 3B according to Bismutch-Corlette), Ia class. Group.

Complications K83.1 Tumor stricture of extrahepatic bile ducts. ERCP, stenting of the common bile duct. Chronic recurrent reflux cholangitis. Endoscopic removal of stents of the bile duct, antegrade bisectoral percutaneous transhepatic cholangiostomy of the ducts of the right lobe of the liver under ultrasound, PTV control. External CChS of the ducts of the left lobe of the liver. Modified CChS of the ducts of the left lobe of the liver through the ducts of the 4th liver segment. Concomitant diseases E03.9 Hypothyroidism, drug-compensated. Mild anemia of mixed genesis.

Operation: laparotomy, unilateral hemihepatectomy, marginal resection of the portal vein trunk with autograft plasty, resection of extrahepatic bile ducts, formation of BDA.

Operation time 500-530 min.

Intraoperatively:

KShchS # 1 11.00

1.pH 7.391

2.pCO2 - Parts. CO2 pressure 42.4 mm Hg

3.pO2 - Parts. O2 pressure 193.0 mm Hg

4.ctHB - Hemoglobin 93.0 g / l

5.sO2 - O2 saturation 100.4%

6. FO2HB - Oxyhemoglobin 97.1%

7. FCOHB - Carboxyhemoglobin 2.2%

8.FHHB - Deoxyhemoglobin -0.4%

9. FmetHB - Methemoglobin 1.1%

10.Hct - Hematocrit 28.7%

11.cK + - Potassium 3.8 mmol / l

12.cNa + - Sodium 137 mmol / l

13. cCa2 + - Calcium ion. 1.01 mmol / L

14.cCl- - Chlorine 103 mmol / l

15.cGlu - Glucose 6.6 mmol / l

16.cLac - Lactate 0.8 mmol / l

17. Total bilirubin 22.0 μmol / l

18.mOsm - Osmolality 280.6 mmol / kg

19. НСО3- (P, st) - Standard bicarbonate 25.1 mmol / l

A short insulin was introduced at a rate of 1 U / hour and a solution of calcium chloride 10% - 8 ml / hour

After operation:

KShchS # 1 19.00

1.pH 7.397

2.pCO2 - Parts. CO2 pressure 47.2 mm Hg

3.pO2 - Parts. O2 pressure 47.1 mm Hg

4.ctHB - Hemoglobin 88.0 g / l

5.sO2 - O2 saturation 84.6%

6. FO2HB - Oxyhemoglobin 80.5%

7. FCOHB - Carboxyhemoglobin 3,1 FHHB - Deoxyhemoglobin 14,7%

8. FmetHB - Methemoglobin 1.70%

9.Hct - Hematocrit 27.2%

10.cK + - Potassium 4.2 mmol / l

11.cNa + - Sodium 137 mmol / l

12. cCa2 + - Calcium ion. 1.24 mmol / L

13. cCl- - Chlorine 101 mmol / l

14.cGlu - Glucose 5.6 mmol / l

15.clac - Lactate 1.2 mmol / l

16. Total bilirubin 32.0 μmol / l

17.mOsm - Osmolality 279.0 mmol / kg

18.HCO3- (P, st) -Bicarbonate standard 27.4 24.0-28.0 mmol / l

KShchS # 2 21.30

1.pH / blood gases

2.pH 7.425

3.pCO2 - Part. CO2 pressure 41.8 mm Hg

4.pO2 - Parts. O2 pressure 91.5 mm Hg

5. Oximetry - - -

6.ctHB - Hemoglobin 77.0 g / l

7.sO2 - O2 saturation 99.3%

8. FO2HB - Oxyhemoglobin 95.3%

9.FCOHB - Carboxyhemoglobin 2.6%

10.FHHB - Deoxyhemoglobin 0.7%

11. FmetHB - Methemoglobin 1.4%

12. Hct - Hematocrit 24.1%

13. Electrolytes

14.cK + - Potassium 4.6 mmol / l

15. cCa2 + - Calcium ion. 1.21 mmol / L

16.cCl- - Chlorine 100 mmol / l

17.cGlu - Glucose 10.0 mmol / l

18.clac - Lactate 1.2 mmol / l

19. Total bilirubin 24.0 μmol / l

20. НСО3- (P, st) - Standard bicarbonate 27.0 mmol / l

21. cBase (Ecf, oh) - Standard excess of bases At 100% sat. O2 2.8 mmol / L

For the prevention of transient hyperlactatemia, medications are used - infusion of short insulin at a rate of 1-6 U / hour and a solution of 10% calcium gluconate or calcium chloride at an infusion rate of 1-8 ml / hour, until a lactate level of 0.5-1.2 mmol is reached \ l.

Intraoperative glycemic control is performed every 30 minutes. Monitoring the level of ionized calcium every 60 minutes. Infusion of calcium preparations must be started no later than 30 minutes after the onset of surgical liver damage.

The method is confirmed by the following examples

Example 1. Patient M., 42 years old, was admitted at the end of August 2019 and was prepared for a planned operation.

From the anamnesis it is known that obstructive jaundice since the beginning of August 2019. Yudin underwent endoscopic retrograde cholangiopancreatography and stenting of the common bile duct with two straight plastic stents. In the postoperative period, she suffered acute pancreatitis. Against the background of treatment, the phenomena of jaundice, acute pancreatitis were arrested. CT scan of the abdominal cavity shows biliary hypertension from the level of confluence; in the confluence area, a tumor formation measuring 4.0 cm with the spread of infiltration to the left lobar duct - portal cholangiocarcinoma is determined.

At the end of August 2019, endoscopic removal of bile duct stents, antegrade percutaneous transhepatic drainage of the bile ducts under ultrasound, RTV control.

In early September 2019, a percutaneous transhepatic cholangiostomy of the ducts of the left lobe of the liver was performed, a week later - percutaneous transhepatic modified drainage of the ducts of the left lobe of the liver through the disconnected ducts of the 4th segment.

At the end of September 2019, the right pleural cavity was drained.

According to the bile culture data, the multi-resistant flora presented by Klebs. Pneumoniae, Pseudomonas aeruginosa, and vancomycin-resistant Enterococcus fecalis. Against the background of conservative antibiotic therapy (Linezolid, Imipenem, Polymyxin, Fluconazole), clinical and laboratory phenomena of cholangitis were stopped, with control cultures the microbial concentration of Klebsiella decreased from 10 ^∧ 7 to 10 ^∧ 5, Pseudomonas aeruginosa from 10 ^∧ 7 to 10 ^∧ 3, growth of enterococcus not marked.

Sowing

from 09/23/19: Klebs. Pneumoniae 1 * 10 ^∧ 5, imipenem and polymyxin were used. Pseudomonas aeruginosa 1 * 10 ^∧ 3, polymyxin, zerbaksa were used.

from 17.09.19 in the posterior sector of enterococcus fecalis (posterior sector) 1 * 10 ^∧ 2 linezolid was applied.

CT 09/18/19: In the confluence area there is a solid area up to 12 × 18 mm, the adjacent tissue in the area of the liver hilum is infiltrated, this infiltration involves the left branch of the portal vein (the vein itself is not defined), the circular left hepatic artery, the tissue at the level of the liver hilum is compacted with the presence of LN up to 6 mm, LN along the hepatoduodenal ligament up to 8-9 mm, multiple; common bile duct in the supraduodenal and intrapancreatic regions up to 3 mm in diameter, can be traced to OBD; the structure of the arteries of the CMB is typical.

CANCER CONSILIUM 09/25/2019: cancer of the proximal extrahepatic bile ducts cT3NxM0 (Klatskin's tumor type 3B according to Bismutch-Corlette). Considering the prevalence of the oncological process, recurrent cholangitis, positive dynamics during therapy, at the first stage, radical surgical treatment in the volume of laparotomy, extended left-sided hemihepatectomy (extended with the intraoperative need to remove the anterior sector - the volume of the posterior sector is 50% by scintigraphy, V right lobe 97 %, IPD 2.6), resection of extrahepatic bile ducts, formation of BDA. Solving the issue of specific therapy after receiving the results of a planned histological examination of the operating material.

1000 ml of erythrocytes and 1500 ml of fresh frozen plasma were ordered for the operation.

Concomitant pathology does not require surgical and therapeutic correction. There are no contraindications to surgical treatment.

The patient is informed about the expected volume of the operation, the likelihood of its change in accordance with the intraoperative situation. The patient agrees to the operation. She was warned about possible intraoperative changes in the volume of the operation.

Diagnosis:

Main C24.0 Cancer of proximal extrahepatic bile ducts cT3NxM0 (Klatskin's tumor type 3B according to Bismutch-Corlette), Ia class. Group.

Complications K83.1 Tumor stricture of the extrahepatic bile ducts. Endoscopic retrograde cholangiopancreatography, stenting of the common bile duct 08.2019. Chronic recurrent reflux cholangitis. Endoscopic removal of stents of the bile duct, antegrade bisectoral percutaneous transhepatic cholangiostomy of the ducts of the right lobe of the liver under ultrasound, RTV control 08/29/19. External CChS of the ducts of the left lobe of the liver 03.09.19 Modified CChS of the ducts of the left lobe of the liver through the ducts of the 4th liver segment 03.09.19. Drainage of the right pleural cavity 09/20/19.

Concomitant diseases E03.9 Hypothyroidism, drug-compensated. Mild anemia of mixed genesis.

Operation: laparotomy, left-sided hemihepatectomy, marginal resection of the portal vein trunk with autograft plasty, resection of extrahepatic bile ducts, formation of BDA.

Operation time 515 min.

Intraoperatively:

KShchS No. 111.00

1.pH 7.391

2.pCO2 - Parts. CO2 pressure 42.4 mm Hg

3.pO2 - Parts. O2 pressure 193.0 mm Hg

4.ctHB - Hemoglobin 93.0 g / l

5.sO2-O2 saturation 100.4%

6. FO2HB - Oxyhemoglobin 97.1%

7. FCOHB - Carboxyhemoglobin 2.2%

8.FHHB - Deoxyhemoglobin - 0.4%

9. FmetHB - Methemoglobin 1.1%

10.Hct - Hematocrit 28.7%

11.cK + - Potassium 3.8 mmol / l

12.cNa + - Sodium 137 mmol / l

13. cCa2 + - Calcium ion. 1.22 mmol / L

14.cCl- - Chlorine 103 mmol / l

15.cGlu - Glucose 19.0 mmol / l

16.cLac - Lactate 0.8 mmol / l

17. Total bilirubin 22.0 μmol / l

18.mOsm - Osmolality 280.6 mmol / kg

19. НСО3- (P, st) - Standard bicarbonate 25.1 mmol / l

A short insulin was introduced at a rate of 6 U / hour and a solution of calcium gluconate 10% - 3 ml / hour

KShchS No. 2 15.00

1.pH 7.392

2.pCO2 - Parts. CO2 pressure 40.9 mm Hg

3.pO2 - Parts. O2 pressure 144.0 mm Hg

4.ctHB - Hemoglobin 96.0 g / l

5.sO2-O2 saturation 100.2%

6. FO2HB - Oxyhemoglobin 96.6%

7. FCOHB - Carboxyhemoglobin 2.6%

8.FHHB - Deoxyhemoglobin - 0.2%

9. FmetHB - Methemoglobin 1.0%

10.Hct - Hematocrit 29.7%

11.cK + - Potassium 4.2 mmol / l

12.cNa + - Sodium 137 mmol / l

13. cCa2 + - Calcium ion. 1.24 1.15-1.29 mmol / l

14.cCl- - Chlorine 102 mmol / l

15.cGlu - Glucose 4.7 mmol / l

16.cLac - Lactate 0.5 mmol / l

17. Total bilirubin 29.0 μmol / l

18.mOsm - Osmolality 277.7 mmol / kg

19.HCO3- (P, st) - Standard bicarbonate 24.4 21.8-26.2 mmol / l

20.cBase (Ecf, oh) - Standard excess of bases. At 100% us. O2 0.0 - 1.5-3.0 mmol / L

After operation:

KShchS # 1 19.00

19.pH 7.397

20.pCO2 - Parts. CO2 pressure 47.2 mm Hg

21. pO2 - Parts. O2 pressure 47.1 mm Hg

22. ctHB - Hemoglobin 88.0 g / l

23.sO2 - O2 saturation 84.6%

24. FO2HB - Oxyhemoglobin 80.5%

25. FCOHB - Carboxyhemoglobin 3.1 FHHB - Deoxyhemoglobin 14.7%

26. FmetHB - Methemoglobin 1.70%

27. Hct - Hematocrit 27.2%

28.cK + - Potassium 4.2 mmol / l

29. cNa + - Sodium 137 mmol / l

30. cCa2 + - Calcium ion. 1.12 mmol / L

31. cCl- - Chlorine 101 mmol / l

32.cGlu - Glucose 6.5 mmol / l

33. cLac - Lactate 0.7 mmol / l

34. Total bilirubin 32.0 μmol / l

35.mOsm - Osmolality 279.0 mmol / kg

36. НСО3- (P, st) - Standard bicarbonate 27.4 24.0-28.0 mmol / l

KShchS No. 2 21.30

22.pH / blood gases

23. pH 7.425

24. pCO2 - Part. CO2 pressure 41.8 mm Hg

25.pO2 - Parts. O2 pressure 91.5 mm Hg

26. Oximetry - - -

27. ctHB - Hemoglobin 77.0 g / l

28.sO2 - O2 saturation 99.3%

29. FO2HB - Oxyhemoglobin 95.3%

30. FCOHB - Carboxyhemoglobin 2.6%

31. FHHB - Deoxyhemoglobin 0.7%

32. FmetHB - Methemoglobin 1.4%

33. Hct - Hematocrit 24.1%

34. Electrolytes

35.cK + - Potassium 4.6 mmol / l

36. cCa2 + - Calcium ion. 1.19 mmol / L

37. cCl- - Chlorine 100 mmol / l

38.cGlu - Glucose 5.4 mmol / l

39.cLac - Lactate 1.3 mmol / l

40. Total bilirubin 24.0 μmol / l

41. НСО3- (P, st) - Standard bicarbonate 27.0 mmol / l

42. cBase (Ecf, oh) - Standard excess of bases. At 100% us. O2 2.8 mmol / L.

Example # 2. Patient T., 57 years old, was admitted on September 19, 2019. Prepared for planned surgery.

History of the disease: 5 years ago, there were no acute cholecystitis attacks after dietary errors, no jaundice. She was hospitalized in a planned manner in the medical center named after V.M. Buyanov for surgical treatment for gallstones. Chronic calculous cholecystitis. 05/27/19 diagnostic laparoscopy, intraoperative infiltration in the subhepatic space, differential diagnosis between gallbladder cancer or cholelithiasis with a contracted gallbladder and Mirizzi's syndrome.

Examined:

MPT 05/31/19: in the area of the gate of the liver, an irregularly shaped infiltrate 20 × 35 × 40 mm, including the gallbladder, wall 12 sc. at the level of the bulb, protruding into the liver in the area of the gate, the infiltrate accumulates a contrast agent, restricts diffusion. Choledoch 7 mm.

CT 07/15/2019 a picture of diffuse thickening of the walls of the gallbladder in the area of the bottom and body with infiltration of the surrounding parenchyma of the liver S4b-S5, adjacent parts of the stomach and duodenum, surrounding tissue, single gas bubbles in the lumen of the gallbladder, vesico-duodenal fistula, regional lymphadenopathy the revealed changes do not allow to exclude a tumor of the gallbladder, to differentiate with inflammatory changes. Steatosis and enlargement of the liver. Cyst (Bosniak 1) and microlith of the left kidney. Incomplete doubling of the right ureter.

Tumor markers 07/12/2019: CA 19-9 79 U / ml

Ultrasound on 08/26/19: the gallbladder is represented by a conglomerate of irregular shape, with walls thickened to 25-30 mm, with hypoechoic infiltration extending beyond the wall of the gallbladder to the adjacent intestinal loop. In the gallbladder, calculi up to 8 mm with acoustic shadows, as well as hyperechoic inclusions with a reverberation effect, are determined. In the course of the hepatoduodenal ligament, separately located rounded hypoechoic lymph nodes up to 17 mm in size are determined, and conglomerates of lymph nodes with a total size of up to 80 × 90 mm. Hepaticoholedochus in the proximal section is up to 8.6-9.0 mm, in the distal section - up to 4.0-2.0 mm, the walls are thickened up to 1.5 mm throughout.

Rg-stomach with oral contrast: a picture of an unfixed axial cardiofundal hernia of the esophageal opening, diffuse esophagospasm of 1 degree, cardiac insufficiency, gastroptosis of 2 degrees, hypertonicity of the duodenal bulb. Duodenal-cystic fistulous tract was not found.

At control CT from 08/30/19: there is an increase in infiltration of 4% of liver segments, an increase in lymphadenopathy of the hepatoduodenal ligament.

Objective examination data are in satisfactory condition, no hyperthermia. The skin is of normal color. Satisfactory nutrition. Respiratory and hemodynamic disorders are absent. NPV - 16 per min. Heart rate - 67 per minute. BP 125/75 mm Hg The abdomen is soft and painless. Physiological functions are not violated.

Laboratory: Antibodies to HIV 1,2 and HIV1 p24 antigen, HBs antigen, anti-HCV, Treponema pallidum were not detected.

Clinical diagnosis: gallbladder cancer cT3NxM0. Diagnostic laparoscopy 05/27/19.

Oncological consultation: taking into account the anamnesis, additional examination data, the patient has a clinical and instrumental picture of locally advanced gallbladder cancer cT3NxM0. Given the stage of the disease, radical surgical treatment is indicated in the scope of diagnostic laparoscopy, cholecystectomy, urgent histological examination, resection of 4.5 liver segments, resection of the extrahepatic bile ducts. Hospitalized for elective surgery.

Indications for surgical treatment: clinical and instrumental picture of resectable neoplasm of the gallbladder body.

Planned surgery: diagnostic laparoscopy, cholecystectomy, urgent histological examination, resection of 4.5 liver segments, resection of the extrahepatic bile ducts.

Auto-sampling of blood: not performed.

In the blood transfusion room ordered: Fresh frozen plasma - 1500 ml, erythromass - 1000 ml.

Physical status by ECOG 0

The patient is informed about the nature of the disease, the scope of the forthcoming surgical treatment, about alternative methods of treatment and their effectiveness. The patient is informed about the possible complications of the upcoming surgery. The possibility of conversion has been warned. Informed consent for surgical treatment was obtained.

Diagnosis.

Main: C23 Cancer of the gallbladder cT3NxM0, cT3NXM0, non-oral stage, class II. Group

Concomitant diseases: J45.0 Bronchial asthma, remission. Chronic gastritis. Liver steatosis. Cyst (Bosniak 1) of the left kidney. ICD: microlith of the left kidney. Cholelithiasis: chronic calculous cholecystitis.

Operation: Anatomical liver resection (diagnostic laparoscopy, laparotomy, cholecystectomy, resection of 4.5 liver segments, resection of the duodenum, duodenojejunostomy on a disconnected Roux loop).

Operation time 530 min.

Intraoperatively:

KShS No. 1.11.30

1.pH 7.386 7.350-7.450 -

2.pCO2 - Parts. CO2 pressure 38.7 35.0-45.0 mm Hg

3.pO2 - Parts. O2 pressure 139.0 83.0-108.0 mm Hg

4.ctHB - Hemoglobin 132.0 120.0-160.0 g / l

5.sO2 - Saturation 02 99.7 95.0-99.0%

6. FO2HB - Oxyhemoglobin 95.7 94.0-98.0%

7. FCOHB - Carboxyhemoglobin 2.4 0.5-1.5%

8.FHHB - Deoxyhemoglobin 0.3%

9.FmetHB - Methemoglobin 1.6 0.0-1.5%

10.Hct - Hematocrit 40.5 36.0-48.0%

11.cK + - Potassium 4.0 3.4-4.5 mmol / l

12.cNa + - Sodium 133 135-146 mmol / l

13. cCa2 + - Calcium ion. 1.13 mmol / L

14.cCl- - Chlorine PO 98-106 mmol / l

15.cGlu - Glucose 16.5 3.9-5.9 mmol / l

16.cLac - Lactate 1.6 mmol / l

17. Total bilirubin 24.0 5.0-21.0 μmol / l

18.mOsm - Osmolality 275.0 280.0-301.0 mmol / kg

19.HCO3- (P, st) - Standard bicarbonate 23.2 21.8-26.2 mmol / l

20.cBase (Ecf, oh) - Base excess, standard At 100% sat. O2 -1.6 -1.5-3.0 mmol / L

Correction of lactatemia was made by the introduction of short insulin 1 U / hour and a solution of calcium gluconate 10% - 8 ml / hour

KShchS No. 2 15.30

1.pH 7.371 7.350-7.450 -

2.pCO2 - Parts. CO2 pressure 43.6 35.0-45.0 mm Hg

3.pO2 - Parts. O2 pressure 162.0 83.0-108.0 mm Hg

4.ctHB - Hemoglobin 115.0 120.0-160.0 g / l

5.sO2 - O2 saturation 100.3 95.0-99.0%

6. FO2HB - Oxyhemoglobin 96.2 94.0-98.0%

7. FCOHB - Carboxyhemoglobin 3.2 0.5-1.5%

8. FHHB - Deoxyhemoglobin -0.3 -%

9.FmetHB - Methemoglobin 0.9 0.0-1.5%

10.Hct - Hematocrit 35.5 36.0-48.0%

11.cK + - Potassium 3.4 3.4-4.5 mmol / l

12.cNa + - Sodium 136 135-146 mmol / l

13. cCa2 + - Calcium ion. 1.39 mmol / L

14.cCl- - Chlorine 111 98-106 mmol / l

15.cGlu - Glucose 7.9 3.9-5.9 mmol / l

16.cLac - Lactate 1.2 mmol / l

17. Total bilirubin 15.0 5.0-21.0 μmol / l

18.mOsm - Osmolality 280.2 280.0-301.0 mmol / kg

19. НСО3- (P, st) - Standard bicarbonate 24.3 mmol / l

20.cBase (Ecf, oh) - Standard excess of bases. At 100% sat. -1.5-3.0 mmol / l

After operation:

KShchS # 1 19.30

1.pH 7.316 7.260-7.360 -

2.pCO2 - Parts. CO2 pressure 44.8 46.0-58.0 mm Hg

3.pO2 - Parts. O2 pressure 45.5 37.0-42.0 mm Hg

4. Oximetry - - -

5.ctHB - Hemoglobin 114.0 120.0-160.0 g / l

6.sO2 - O2 saturation 77.2 70.0-76.0%

7. FO2HB - Oxyhemoglobin 75.4 40.0-70.0%

8.FCOHB - Carboxyhemoglobin 1.7 Non-smokers 0.0-0.5% Smokers 1.5-5.0%%

9.FHHB - Deoxyhemoglobin 22.3 -%

10. FmetHB - Methemoglobin 0.60 0.40-1.50%

11.Hct - Hematocrit 35.1 36.0-48.0%

12. Electrolytes - - -

13.cK + - Potassium 4.3 3.4-4.5 mmol / l

14.cNa + - Sodium 136 135-146 mmol / l

15. cCa2 + - Calcium ion. 1.2 mmol / L

16. cCl- - Chlorine 110 98-106 mmol / l

17. Metabolites - - -

18.cGlu - Glucose 6,3 mmol / l

19.cLac - Lactate 1.1 mmol / l

20. Total bilirubin 10.0 5.0-21.0 μmol / l

21. НСО3- (P, st) - Standard bicarbonate 21.2 24.0-28.0 mmol / l

22. SBE - Surplus founded. std. -3.0 -2.5-2.5 mmol / l

KShchS No. 2 20.40

1.pH 7.327 7.260-7.360 -

2.pCO2 - Parts. CO2 pressure 48.5 46.0-58.0 mm Hg

3.pO2 - Parts. O2 pressure 33.7 37.0-42.0 mm Hg

4.ctHB - Hemoglobin 116.0 120.0-160.0 g / l

5.sO2 - Saturation 02 62.0 70.0-76.0%

6. FO2HB - Oxyhemoglobin 59.1 40.0-70.0%

7. FCOHB - Carboxyhemoglobin 3.3 Non-smokers 0.0-0.5% Smokers 1.5-5.0%%

8.FHHB - Deoxyhemoglobin 36.2 -%

9.FmetHB - Methemoglobin 1.40 0.40-1.50%

10.Hct - Hematocrit 35.7 36.0-48.0%

11.cK + - Potassium 4.1 3.4-4.5 mmol / l

12.cNa + - Sodium 137 135-146 mmol / l

13. cCa2 + - Calcium ion. 1.24 mmol / L

14.cCl- - Chlorine 112 98-106 mmol / l

15.cGlu - Glucose 6.0 mmol / l

16.cLac - Lactate 1.2 mmol / l

17. Total bilirubin 19.0 5.0-21.0 μmol / l

18.mOsm - Osmolality 282.3 280.0-301.0 mmol / kg

19.HCO3- (P, st) - Standard bicarbonate 22.9 24.0-28.0 mmol / l

20.cBase (Ecf, oh) - Standard excess of bases. At 100% us. O2 -0.8 -1.5-3.0 mmol / L.

Example No. 3. Patient M. 66 years old.

On May 13, 2019, the patient underwent right-sided nephrectomy and atypical resection of the 6.7 liver segment for cancer of the right kidney pT4N0M0 with a spread of the 6.7 segment of the liver. After 3 months, with control abdominal MSCT in the 6-7 liver segment, continued tumor growth is visualized.

Chronic and past illnesses: type 2 diabetes, hypertension

Allergic history: No peculiarities

For the last 21 days, he denies contact with patients with measles.

Epidemiological anamnesis: HIV, HCV, RW, HbsAg negative from 08/19/19

Complete blood count from 08/19/19 without pathology

Biochemical blood test from 08/19/19 without pathology.

MSCT OBP: the liver is enlarged, the shape and position are not changed. The contours are smooth, clear. The structure of the parenchyma is heterogeneous due to the visualization of additional education in 6-7 segments of a heterogeneous slightly reduced density in a native study. After intravenous contrasting, a non-uniform sharp accumulation of KB in the arterial phase of the study is noted, dropping KB into the venous and parenchymal phases, measuring 20 × 40 × 30 mm. Surgical treatment in the amount of laparoscopic liver resection S 6.7 is shown.

The risk of PE - PV, prevention - elastic compression of the lower extremities, low molecular weight heparins in prophylactic doses.

The volume of the preoperative examination is sufficient. Concomitant pathology does not require surgical and therapeutic correction. There are no contraindications to surgical treatment. The patient is informed about the expected volume of the operation, the likelihood of its change in accordance with the intraoperative situation. The patient agrees to the operation. I have been warned about the possibility of conversion.

Diagnosis.

Main: C78.7 Cancer of the right kidney pT4N0M0 with germination in S6, 7 liver. Right nephrectomy, atypical resection of the 6.7 segment of the liver from 05/13/2019. The progression of the disease from 08/09/2019 in the form of focal lesion S 6.7 of the liver.

Operation: Atypical resection of the 6.7 liver segment, atypical resection of the 3 liver segment, drainage of the abdominal cavity.

Operation time: 530 min.

Intraoperatively:

KShchS No. 111.10

1.pH 7.364 7.350-7.450 -

2.pCO2 - Parts. CO2 pressure 46.1 35.0-45.0 mm Hg

3.pO2 - Parts. O2 pressure 167.0 83.0-108.0 mm Hg

4.ctHB - Hemoglobin 131.0 120.0-160.0 g / l

5.sO2-Saturation 02 100.0 95.0-99.0%

6. FO2HB - Oxyhemoglobin 96.0 94.0-98.0%

7. FCOHB - Carboxyhemoglobin 2.2 0.5-1.5%

8. FHHB - Deoxyhemoglobin 0.0 -%

9.FmetHB - Methemoglobin 1.8 0.0-1.5%

10.Hct - Hematocrit 40.4 37.0-47.0%

11.sK + - Potassium 4.2 3.4-4.5 mmol / l

12.cNa + - Sodium 132 135-146 mmol / l

13. cCa2 + - Calcium ion. 1.10 mmol / L

14.cCl- - Chlorine 106 98-106 mmol / l

15.cGlu - Glucose 8.3 mmol / l

16.cLac - Lactate 1.2 mmol / l

17. Total bilirubin 27.0 5.0-21.0 μmol / l

18.mOsm - Osmolality 273.1 280.0-301.0 mmol / kg

19.HCO3- (P, st) - Standard bicarbonate 24.8 21.8-26.2 mmol / l

20.cBase (Ecf, oh) - Standard excess of bases. At 100% us. O2 0.8 -1.5-3.0 mmol / L.

Correction of lactatemia was made by the introduction of short insulin 5 U / hour and a solution of calcium gluconate 10% - 6 ml / hour

KShchS No. 2. 14.30

1.pH 7.333 7.350-7.450 -

2.pCO2 - Parts. CO2 pressure 44.5 35.0-45.0 mm Hg

3.pO2 - Parts. O2 pressure 140.0 83.0-108.0 mm Hg

4.ctHB - Hemoglobin 100.0 120.0-160.0 g / l

5.sO2 - Saturation 02 99.2 95.0-99.0%

6. FO2HB - Oxyhemoglobin 97.3 94.0-98.0%

7.FCOHB - Carboxyhemoglobin 1.3 0.5-1.5%

8.FHHB - Deoxyhemoglobin 0.8 -%

9.FmetHB - Methemoglobin 0.6 0.0-1.5%

10.Hct - Hematocrit 31.0 37.0-47.0%

11.cK + - Potassium 4.4 3.4-4.5 mmol / l

12.cNa + - Sodium 141 135-146 mmol / l

13. cCa2 + - Calcium ion. 1.24 mmol / L

14.cCl- - Chlorine 106 98-106 mmol / l

15.cGlu - Glucose 7,1 mmol / l

16.cLac - Lactate 1.7 mmol / l

17. Total bilirubin 4.0 5.0-21.0 μmol / l

18.mOsm - Osmolality 290.3 280.0-301.0 mmol / kg

19.HCO3- (P, st) - Standard bicarbonate 22.5 21.8-26.2 mmol / l

20. SBE - Surplus founded. std. -2.0 -2.5-2.5 mmol / l

After operation:

KShchS # 1 18.30

1.pH 7.345 7.350-7.450 -

2.pCO2 - Parts. CO2 pressure 46.1 35.0-45.0 mm Hg

3.pO2 - Parts. O2 pressure 98.2 83.0-108.0 mm Hg

4.ctHB - Hemoglobin 109.0 120.0-160.0 g / l

5.sO2 - Saturation 02 97.8 95.0-99.0%

6. FO2HB - Oxyhemoglobin 96.2 94.0-98.0%

7. FCOHB - Carboxyhemoglobin 1.1 0.5-1.5%

8. FHHB - Deoxyhemoglobin 2.2 -%

9.FmetHB - Methemoglobin 0.5 0.0-1.5%

10.Hct - Hematocrit 33.6 37.0-47.0%

11. Electrolytes - - -

12.cK + - Potassium 5.0 3.4-4.5 mmol / l

13.cNa + - Sodium 136 135-146 mmol / l

14. cCa2 + - Calcium ion. 1.18 mmol / L

15. cCl- - Chlorine PO 98-106 mmol / l

16.cGlu - Glucose 5.9 mmol / l

17.cLac - Lactate 0.5 mmol / l

18. Total bilirubin 6.0 5.0-21.0 μmol / l

19.mOsm - Osmolality 280.9 280.0-301.0 mmol / kg

20. НСО3- (P, st) - Standard bicarbonate 23.7 21.8-26.2 mmol / l

21. SBE - Surplus founded. std. -0.5 -2.5-2.5 mmol / l

KShchS No. 2. 22.30

1.pH 7.330 7.260-7.360 -

2.pCO2 - Parts. CO2 pressure 50.5 46.0-58.0 mm Hg

3.pO2 - Parts. O2 pressure 40.5 37.0-42.0 mm Hg

4.ctHB - Hemoglobin 111.0 120.0-160.0 g / l

5.sO2 - Saturation 02 76.8 70.0-76.0%

6. FO2HB - Oxyhemoglobin 74.3 40.0-70.0%

7.FCOHB - Carboxyhemoglobin 2.1 Non-smokers 0.0-0.5% Smokers 1.5-5.0%%

8. FHHB - Deoxyhemoglobin 22.4 -%

9.FmetHB - Methemoglobin 1.20 0.40-1.50%

10. Hct - Hematocrit 34.3 -%

11.cK + - Potassium 5.0 3.4-4.5 mmol / l

12.cNa + - Sodium 135 135-146 mmol / l

13. cCa2 + - Calcium ion. 1.12 mmol / L

14. cCl- - Chlorine 104 98-106 mmol / l

15. Metabolites - - -

16.cGlu - Glucose 5.4 mmol / l

17.cLac - Lactate 1.1 mmol / l

18. Total bilirubin 15.0 5.0-21.0 μmol / l

19.mOsm - Osmolality 281.2 280.0-301.0 mmol / kg

20. НСО3- (P, st) - Standard bicarbonate 24.1 24.0-28.0 mmol / l

21.cBase (Ecf, oh) - Excess bases, standard At 100% sat. O2 0.4 -1.5-3.0 mmol / l

Elevated blood lactate levels after extensive liver resections correlate with perioperative mortality. This method of correction allows a timely decrease in the level of lactate in the blood, thereby correcting metabolic acidosis and accelerating the recovery of patients in the postoperative period. The method was reproduced for 16 patients with a positive result

Literature sources

1.1 - Yakovlev A.Yu., Zaitsev P.P., Abramov A.V., Chistyakov S.I. Extracorporeal correction of lactatemia in sepsis. Scientific and educational conference. Topical issues and innovative technologies in anesthesiology and resuscitation. April 4-5, 2019. Sat. abstracts. Saint Petersburg 2019, p. 92-93.

2. 2 - Trekova N.A., Akselrod V.A., Yudichev I.I., Gus'kov D.A., Markin A.V., Popov A.M. Clinical aspects of the blood lactate dynamics during operations on the heart and the aorta in conditions of cardiopulmonary bypass. Anesteziologiya i reanimatologiya (Russian journal of Anaesthesiology and Reanimatology) 2016; 61 (5): 324-329. (In Russ.). DOI: http://dx.doi.org/10.18821/0201-7563-2016-61-5-324-329.

Claims (1)

A method of preventing transient hyperlactatemia with extensive liver resections by using medications, characterized in that short insulin infusions at a rate of 1-6 U / hour and a solution of 10% gluconate and calcium chloride at an infusion rate of 1-8 ml / hour are used as medications ...