RU2411046C2 - Method of detoxification in peritonitis patients - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely, to efferent methods in surgery, and can be used in treating peritonitis patients. That is ensured by prolonged venovenous hemofiltration. In 2 hours after the procedure started, through a catheter inserted in a subclavian vein or a abdominal aorta with using a peristaltic pump for 15 minutes 250 ml of HyperHAES solution is introduced.

EFFECT: method allows higher effectiveness of detoxification ensured by an effect of endotoxin redistribution in a vascular bed from an interstitial space owing to introducing the hydroxyethyl starch solution followed by endotoxin elimination from the vascular bed by hemofiltration.

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Description

The method relates to medicine, namely to efferent methods of detoxification.

Impaired renal and liver function complicating the course of peritonitis cause a rapid increase in endotoxemia with subsequent decompensation of multiple organ failure syndrome (SPON) and require the use of extracorporeal detoxification methods [1, 2]. Recent studies have shown the high efficiency of substitution therapy in patients with peritonitis due to the removal of proinflammatory mediators and other biologically active substances responsible for the development of sepsis and SPON from the bloodstream. The highest proven effectiveness is given by the timely use of extended veno-venous hemofiltration, which ensures the maximum removal of endotoxins with low and medium molecular weight [1, 3].

Known is the traditionally used method of extended veno-venous hemofiltration (GF) with the removal of intravascular fluid in a volume of 30 ml / kg / h and constant replacement with special polyionic balanced solutions [3], taken as a prototype.

A limitation of the effectiveness of the procedure for prolonged veno-venous hemofiltration is a reduced inflow of endotoxins into the vascular bed from the interstitial space, which is associated with impaired microcirculation and transmembrane metabolism [3].

The aim of the invention is to increase the effectiveness of the detoxifying effect of prolonged veno-venous hemofiltration by increasing the influx of endotoxins into the vascular bed with the help of Hyperhaes hypertonic isooncotic solution.

The goal is achieved by infusion of the Hyperhaes solution through a catheter installed in the central vein or in the aorta above the celiac stem. Hyperhaes, containing 6% hydroxyethyl starch and 7.2% sodium chloride solution, is administered in an amount of 250 ml within 15 minutes 2 hours after the start of prolonged venous-venous hemofiltration.

The proposed amount of Hyperhaes solution administered corresponds to its dosage for correction of circulating blood volume deficiency in severe hypovolemic shock, the duration of administration is increased from 2-5 minutes to 15 minutes due to the absence of severe hypovolemia and the prevention of the expected side effects of hyperosmotic solutions on blood cells , central hemodynamics and water-electrolyte balance.

This method is safe for the intima of the central veins and aorta, which is confirmed by morphological studies in deceased patients.

The method is implemented as follows. 2 hours after the start of prolonged veno-venous hemofiltration using a peristaltic pump for 250 minutes through a catheter installed in the subclavian vein or abdominal aorta, 250 ml of Hyperhaes solution is injected.

Hyperhaes solution infusion is carried out during each session of prolonged veno-venous hemofiltration in patients with peritonitis 2 hours after its onset. The time of the start of administration of the Hyperhaes solution is due to the beginning of the decrease in endotoxins circulating in the vascular bed and the highest filtration efficiency of hemofilters in relation to the removed endotoxins in the first 8-12 hours of hemofiltration. The average duration of veno-venous hemofiltration is 24 hours. The total duration of efferent replacement therapy depends on the relief of multiple organ failure, assessed on the SOFA organ dysfunction scale.

To monitor the effectiveness and safety of the infusion of the Hyperhaes solution during prolonged veno-venous hemofiltration, indicators of central hemodynamics, endotoxemia, water-electrolyte balance, and acid-base state are used.

Clinical example

Patient M., 48 years old. Diagnosis: acute destructive pancreatitis, enzymatic peritonitis, retroperitoneal phlegmon. Sepsis. Acute respiratory distress syndrome, acute renal failure. Operation: laparotomy, retroperitonestomy, cholecystostomy, drainage and plugging of the omental bursa, abdominal cavity.

The early postoperative period was complicated by the development of multiple organ failure syndrome, among which the clinical and laboratory manifestations of acute renal failure prevailed. In this regard, the patient began an extended veno-venous hemofiltration using the Multifiltrate device (Fresenius, Germany), an FS 600 hemofilter. The filtration rate was 2500 ml / h, ultrafiltration - 100 ml / h. The table shows the indicators of two procedures for prolonged veno-venous hemofiltration in this patient, which differ from each other only in one way - the use of the Hyperhaes solution.

The results of using the Hyperhaes solution, shown in the table, show an increase in the elimination of endotoxins in the substitute after administration of the Hyperhaes solution. The effect of administration of the Hyperhaes solution lasts 2 hours, while the initial values of the electrolyte balance of blood plasma are restored to their original level within two hours after administration of the drug. Increased elimination of sodium in the filtrate does not lead to pronounced and prolonged violations of the water-electrolyte balance, which allows the safe use of Hyperhaes solution during prolonged veno-venous hemofiltration in patients with clinical and laboratory signs of renal dysfunction.

Stable values of metabolic and fermentemic indices against the background of administration of the Hyperhaes solution indirectly indicate the absence of the damaging effect of the drug on body tissues. The constant values of the gram-negative bacteria lipopolysaccharide confirm the safety of the use of Hyperhaes solution in relation to the potentiation of translocation of endogenous flora. Increasing the efficiency of removal of endotoxins due to their redistribution into the vascular bed from the interstitial space is more than 20% for 8 hours of venous-venous hemofiltration with the introduction of Hyperhaes solution and leads to an increase in the level of endotoxicosis compensation.

On the 13th day of intensive care, the patient was transferred to the surgical department and was discharged in satisfactory condition 24 days after the second operation.

Information sources

1. Peritonitis: A Practical Guide / Ed. V.S. Saveliev, B.R. Gelfand, M.I. Filimonova. - M .: Litera, 2006 .-- 208 p. - (Series "Practical Guides").

2. Fedorovsky N.M. Combined efferent detoxification in the complex treatment of peritonitis: Abstract. diss ... doctor of medical sciences - M., 1993 .-- 46 p.

3. Yakovleva I.I. Extracorporeal blood purification in the pathogenetic therapy of sepsis and septic shock: Abstract. diss ... doctor of medical sciences - M., 2002 .-- 48 p.

Table Method of detoxification in patients with peritonitis Indicator Research stages To gf 2 h gf 2 h 30 min GF 3 h gf 4 h gf 8 h gf VNiSMM plasma, cu GF + Hyperhaes 43.22 41.03 43.07 44.95 36.84 32,42 Gf 42.34 40.75 38.94 39.57 37.91 35.64 VNiSMM erythr., Cu GF + Hyperhaes 40.32 39.86 39.72 38.94 36.83 36.19 Gf 41.15 40.18 39.04 38.65 38,20 37.63 VNiSMM urine, cu GF + Hyperhaes 39.18 40.15 43.56 44.29 47.19 45.24 Gf 42.40 41.11 42.40 40.57 42.94 40.96 VNiSMM filtrate, cu GF + Hyperhaes 40.19 40.75 42.03 43.75 35.15 31.26 Gf 39.77 37.13 35.10 35.37 33.18 31.74 VNiSMM in Σ of the filtrate, c.u. GF + Hyperhaes 39.25 Gf 33.03 ISEI, cu GF + Hyperhaes 44.47 40.73 39.27 39.52 28.75 25.93 Gf 41.09 39.82 35.86 37.69 33.72 32,74 Urea, mmol / L GF + Hyperhaes 20,4 19.6 18.7 17.9 17,2 16.1 Gf 21.3 20.9 19.9 19.0 18,4 17.5 Glucose, mmol / L GF + Hyperhaes 11.5 10,4 9.5 8.7 8.1 6.9 Gf 11.2 10.6 10.1 9.3 7.9 7.5 Lactate, mmol / L GF + Hyperhaes 4.8 4.9 4,5 4.6 4,5 4.1 Gf 4,5 4.7 4.9 4.4 4.3 4.6 LDH, ED / L GF + Hyperhaes 856 831 806 834 782 769 Gf 805 824 791 809 816 803 KFK, U / l GF + Hyperhaes 457 431 440 422 439 408 Gf 472 468 427 434 468 451 LPS, pg / l GF + Hyperhaes 128 64 64 64 64 64 Gf 64 64 64 64 64 64 Na +, mmol / l GF + Hyperhaes 134 137 146 144 142 140 Gf 138 135 138 136 139 136 Osmolarity, mosm / l GF + Hyperhaes 309 308 320 316 309 307 Gf 309 311 309 308 306 305 HELL cf., mmHg GF + Hyperhaes 69 71 86 84 75 73 Gf 73 70 74 71 73 70 CVP, mm water column GF + Hyperhaes 40 40 90 70 60 fifty Gf thirty twenty 40 twenty thirty 40 Heart rate GF + Hyperhaes 113 109 114 107 111 105 Gf 109 107 104 110 107 109 Note: GF - hemofiltration, VNiSMM - substances of low and medium molecular weight, ISEI - index of endogenous intoxication syndrome, LDH - lactate dehydrogenase, CPK - creatine phosphokinase, LPS - lipopolysaccharide of gram-negative bacteria, AD cf. - medium blood pressure, CVP - central venous pressure, heart rate - heart rate.

Claims (1)

A method of detoxification in patients with peritonitis, including prolonged veno-venous hemofiltration, characterized in that 2 hours after the start of prolonged veno-venous hemofiltration using a peristaltic pump for 15 min, a 250 ml solution is administered through a catheter installed in the subclavian vein or abdominal aorta Hyperhaes.