RU2328315C1 - Method of autoblood preoperative preparation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: 2 blood samples are taken with interval 3 days against complex medicinal supplement under the following scheme. Therapy of the first exfusion day is characterized with single introduction of phetabolyl 0.4 mg/kg intramuscularly, 5% vitamin B1 - 50 mg intravenously, vitamin B12 - 500γ st. units intramuscularly, 5%vitamin C - 150 mg intravenously and 10 % aminoplasmal E - 250 ml intravenously drop-by-drop. The same day and the next two days imply intramuscular injection of ferrum lek 100 mg once, sorbypher 325 mg twice a day, folic acid - 5 mg 3 times a day. For the second day exfusion is accompanying with single subcutaneous introduction of epocryne in dosage 4 thausand UNITS. Then for the third day control inspection is carried out. The second day of exfusion implies single introduction of 5% vitamin B6 - 50 mg intravenously, 5% vitamin C - 150 mg intravenously, vitamin B12 - 500γ st.units intramuscularly and 10% aminoplasmal E - 250 ml intravenously drop-by-drop. This day and in the subsequent two - three days imply intramuscular introduction of ferrum lek 100 mg once, sorbypher 325 mg twice a day, folic acid - 5 mg 3 times a day. For the second day exfusion is accompanying with single subcutaneous introduction of epocryne in dosage 4 thausand UNITS. Then for the third day control inspection is carried out again. Since the first exfusion and before autoblood preparation nutritive supplement is carried out using module protein added to mix "Berlamine Modular" 50 g twice a day daily. After exfusion autoblood is divided on erythrocyte mass and fresh frozen plasma.

EFFECT: prevention of dangerous erythropoiesis and metabolic disorders.

1 ex, 3 cl

Description

The invention relates to medicine, namely to transfusiology and anesthesiology, and can be used to optimize the preparation of a patient for surgical treatment of scoliosis in the conditions of preoperative autologous harvesting.

Known methods for preoperative harvesting of autologous blood (M.M. Petrov et al. Application of autohemotransfusion in a multidisciplinary hospital // Materials of the international scientific-practical conference "Bloodless Surgery on the Threshold of the 21st Century." Moscow. 2000. P.85-87; Björn Lysander. Comparative evaluation of various methods of blood preservation in surgery // in "Alternatives to blood transfusion in surgery", annex to the journal "Anesthesiol. And resuscitation." M., 1999. P.81-93; Aria Chander. Anesthetic management and pharmacological agents for period restrictions irrational blood loss // in "Alternatives to blood transfusion in surgery", annex to the journal "Anesthesiol. and resuscitation." M., 1999. P.68-80; Jean-Francois Baron "Pharmacological methods of stimulation of erythropoiesis - erythropoietin in combination with methods blood savings "// in" Alternatives to blood transfusion in surgery ", annex to the journal" Anesthesiol. and resuscitation. "M., 1999. S. 68-80).

These methods involve a long period of blood procurement, which leads to a delay in surgical intervention and a significant increase in the length of hospital stay. In addition, long-term storage of blood components is accompanied by the development of degenerative changes in canned blood, which entails a violation of the oxygen-transport function of the blood, as well as the formation of cellular microaggregates, which can cause damage to the microcirculation system, especially in the lungs. This fact is absolutely unacceptable in patients with scoliosis with initial cardio-respiratory disorders, due to the high risk of complications from the cardiovascular and respiratory system.

Closest to the claimed is a method of preoperative harvesting of autologous blood in children for orthopedic surgeries: blood is taken before surgery at 7-day intervals. The last blood supply - a week before the operation. The amount of blood taken corresponds to the weight of the child and the level of hematocrit (minimum hematocrit 0.34 l / l). On average, 2.29 doses of blood are harvested. All patients are prescribed iron therapy (Silvergleid A.J. Safety and effectiveness of preposit autologus transfusion in preterm and adolescent children // JAMA. 1987. N.257. P.3403-3404).

This method of preoperative blood preparation provides the necessary amount of autologous blood for the upcoming surgical treatment. However, the method does not take into account the fact that the process of autodonation with exfusion of the patient’s blood in the amount of up to 10-15% of the BCC is accompanied by a stressful reaction of the body with the possible development of a systemic neuroendocrine response, due to:

1. fluctuations in the volume of circulating blood (bcc);

2. painful and emotional influences (especially in patients of childhood and adolescence);

3. the development of a metabolic response to stress (activation of the adrenal system, vasoconstriction, direct protein loss, increased catabolism, increased oxygen consumption).

In this case, the degree and duration of metabolic disorders directly depends on the adequacy of the treatment during the preoperative harvest of autologous blood and the type of pathology.

Objective: to ensure the safety of preoperative harvesting of autologous blood, to reduce harvesting time, preventing the occurrence of a stressful reaction of the body.

In solving this problem, there is a positive therapeutic effect, which consists in the fact that through the use of a complex of drug preparation (epocrine, ferrum lek, sorbifer, B vitamins, ascorbic acid, folic acid, retabolil), parenteral administration of amino acids (aminoplasmal 10% E ) and conducting nutritional support using the protein module for the Berlamin Modular mixture, it is possible to achieve a high degree of restoration of erythropoiesis and protein metabolism, which allows for a short time (6 days) tovit 4 doses of autologous blood components - 2 doses packed RBCs and 2 FFP dose without compromising the patient's health. The method can significantly reduce the patient’s hospital stay, prevent the development of severe complications associated with the transfusion of homologous blood preparations both during surgery and in the postoperative period, the development of which requires significant additional costs, and therefore, when using the method, there is an economic effect.

The technical result is achieved due to the comprehensive drug protection of the body from a stress reaction. Blood exfusion is considered a safe procedure for most patients. However, it is important to note that possible reactions in the process of blood sampling may be: hypotension, vasovagal symptoms, ischemic manifestations in the brain and cardiac arrhythmias. Therefore, it is mandatory to compensate for the exfused blood volume with an equivalent volume of plasma-replacing solutions (crystalloids) and to carry out mandatory monitoring of blood pressure, ECG, and pulse oximetry.

The amount of blood that can be exfused from an autodonor depends on the mass of circulating red blood cells and on the ability to quickly restore the volume of removed red blood cells. In turn, the ability to quickly restore the mass of red blood cells can be limited by the production of endogenous erythropoietin (EPO). Epocrine - recombinant human erythropoietin is indistinguishable from natural glycoprotein hormone - human erythropoietin, both in biological activity and immunologically. His appointment during the period of blood collection is aimed at reducing or preventing the development of anemia. The effect of EPO therapy is very often limited by the depletion of iron reserves, therefore, the appointment of iron preparations (ferrum lek, sorbifer) leads to a more adequate and faster supply of iron to erythron cells, which gives an increased erythropoietic reaction.

B vitamins, folic acid are stimulators of protein biosynthesis. Ascorbic acid has a pronounced antioxidant effect.

Any stressful situation causes metabolic shifts towards increased catabolism, which, in turn, is accompanied by impaired protein-amino acid, carbohydrate, fat metabolism, electrolyte-electrolyte balance, metabolism of biologically active endogenous regulators of homeostasis, which is especially dangerous in patients with body weight deficiency , which constitute a risk group in terms of the occurrence of intra- and postoperative complications. Of course, preoperative stress, harvesting of autologous blood determine the increase in the body's needs for energy substrates. There is no doubt that in this situation, the provision of metabolic protection and compensation for increased basic metabolism should be carried out with the help of medical nutrition, which prevents the violation of immunity, the synthesis of enzymes and hormones, biochemically active substances. The restoration of protein balance is impossible without amino acids, the use of which makes it possible to carry out not only substitution nutritional therapy, but also influence biosynthetic processes in the body 1-2 hours after their use. The advantages of the Aminoplasmal 10% E solution include: content of 20 amino acids, per 100 g of which 41% are essential, which is necessary for facilitated protein synthesis in the patient's body; preservation of amino acid homeostasis, complete assimilation by the body, good tolerance to patients.

The introduction of a 10% glucose solution has a protein-saving effect in the face of increasing glucose requirements of the body.

In order to prolong the anabolic action and promote the synthesis of proteins, retabolil is prescribed.

In addition to the clinical nutrition that the patient receives in the hospital, it is necessary to use nutrietics, namely the protein module for the Berlamin modular mixture (Berlin Chemi) registered in the Ministry of Health of the Russian Federation, which contains high-quality genetically unmodified soy protein (50 g of the mixture contains 43, 6 g of protein), a balanced amino acid composition (18 amino acids, including essential amino acids), allows you to increase the amount of protein introduced without a significant increase in the amount of enteral nutrition.

The method allows to provide the preparation of the required number of components of autologous blood for the surgical treatment of scoliosis in the absence of dangerous disorders of erythropoiesis, metabolic and metabolic disorders at the stage of autologous blood preparation and thus avoid the development of severe complications of the surgical period associated with the use of donor blood components and with the preoperative preparation process autologous blood, the treatment of which requires significant additional costs.

The problem is solved due to the fact that 2 autologous blood samples are taken with an interval of 3 days against the background of comprehensive drug support according to the scheme: on the day of the first exfusion, retabolil 0.4 mg / kg is administered intramuscularly, vitamin B1 5% - 50 mg intravenously, vitamin B12 500γ intramuscularly, vitamin C 5% - 150 mg intravenously and aminoplasmal 10% E 250 ml intravenously, on the day of the first exfusion and on the next two days - ferrum Lek 100 mg 1 time intramuscularly, sorbifer 325 mg 2 times a day, folic acid 5 mg 3 times a day, on the second day after exfusion once but enter epocrine in a dose of 4 tons. UNITS subcutaneously; on the day of the second exfusion, vitamin B6 5% is administered once - 50 mg intravenously, vitamin C 5% - 150 mg intravenously, vitamin B12 500γ intramuscularly and aminoplasmal 10% E 250 ml intravenously, on the day of the second exfusion and on the next two or three days - ferrum lek 100 mg 1 time intramuscularly, sorbifer 325 mg 2 times a day, folic acid 5 mg 3 times a day; on the second day after exfusion, epocrine is administered in a dose of 4 tons. ED 1 time subcutaneously; on the day of the first exfusion and until the autologous blood is harvested, nutritive support is carried out using the protein module for the Berlamin Modular mixture 50 g 2 times a day daily. On the third day after exfusion, a control examination is performed. After exfusion, blood components are prepared from autologous blood - erythrocyte mass and freshly frozen plasma.

The method is as follows.

Before the planned autodonation, all patients undergo a full clinical and paraclinical examination: anthropometry, biochemical analysis of blood serum (concentration of bilirubin, total protein, urea, glucose and electrolytes), analysis of the hemostasis system (IPT, fibrinogen concentration, blood coagulation time, bleeding duration, platelet count ), a general blood test, a general urinalysis.

Of the functional tests required are: ECG, chest x-ray. Additional examinations include ultrasound examination of the heart, kidneys, liver, and spirography.

There are the following absolute contraindications to preoperative autologous blood production in children and adolescents:

1. Severe cardiovascular disease.

2. Blood diseases accompanied by anemia.

3. Acute infections.

4. Hypoproteinemia of any etiology.

Relative contraindications include:

1. Deficiency of body weight.

2. Age up to 10 years.

3. Poor venous access.

4. Positive reactions to HвsAg.

After examination, in the absence of contraindications for patients, an individual autodonation program is drawn up:

1. The first exfusion of autologous blood is carried out from a cubital vein in a volume of 10 ml / kg (10-13% of BCC) into a plastic bag with a preservative. Next, the blood is divided into fractions - erythrocyte mass and FFP. Harvested blood components are stored in accordance with order No. 363 of the Ministry of Health of the Russian Federation of 2000, which regulates the operation of blood transfusion stations using hemacons from TURUMO.

2. Compensation of the volume of exfused blood is carried out with an equivalent volume of plasma-replacing drugs: crystalloids in a volume of 6 ml / kg, 10% glucose solution 10 ml / kg.

3. On the day of exfusion, retabolil 0.4 mg / kg is administered once intramuscularly, vitamin B1 5% - 50 mg intravenously, vitamin B12 500γ intramuscularly, vitamin C 5% - 150 mg intravenously and aminoplasmal 10% E 250 ml intravenously, per day exfusion and in the next 2-3 days - ferrum lek 100 mg 1 time intramuscularly, sorbifer 325 mg 2 times a day, folic acid 5 mg 3 times a day; on the second day after exfusion, epocrine is prescribed in a dose of 4 tons. UNITS 1 time subcutaneously.

4. Patients are assigned nutritional support using a protein module to the mixture of “Berlamin Modular” 50 g 2 times a day daily.

5. On the 3rd day after the first exfusion of blood, laboratory monitoring is carried out according to the scheme: biochemical analysis of blood serum (concentration of total protein, urea, glucose and electrolytes), analysis of the hemostasis system (IPT, concentration of fibrinogen, platelet count), general blood test, general urine analysis. The minimum allowable hemoglobin level before the second blood exfusion is - 120 g / l; color indicator - 0.9; hematocrit - 36.

6. The second exfusion of autologous blood is carried out from a cubital vein in a volume of 10 ml / kg (10-13% of bcc). Take blood in a plastic bag with a preservative. Next, the blood is divided into fractions. Harvested blood components are stored in accordance with order No. 363 of the Ministry of Health of the Russian Federation of 2000, which regulates the operation of blood transfusion stations using hemacons from TURUMO.

7. Compensation of the volume of exfused blood is carried out by plasma-substituting solutions: crystalloids in a volume of 6 ml / kg, 10% glucose solution 10 ml / kg.

8. On the day of the second exfusion, vitamin B6 is prescribed once 5% - 50 mg intravenously, vitamin C 5% - 150 mg intravenously, vitamin B12 500γ intramuscularly and aminoplasmal 10% E 250 ml 1 time intravenously, on the day of exfusion and on the next 2- 3 days - ferrum lek 100 mg 1 time intramuscularly, sorbifer 325 mg 2 times a day, folic acid 5 mg 3 times a day; epocrine is prescribed on the second day after exfusion in a dose of 4 tons. UNITS 1 time subcutaneously; continued nutritional support using the protein module to the mixture “Berlamine Modular” 50 g 2 times a day daily.

An example of the clinical use of the method.

Patient S. born in 1990 (15 years old) was admitted to the clinic of the Novosibirsk Research Institute of Traumatology and Orthopedics on 10.21.05. In the clinic, according to the accepted method, a complete clinical laboratory and X-ray examination was performed. Clinical diagnosis: Idiopathic uncomplicated progressive subcompensated mobile left-sided lumbar lordoscoliosis of the IV degree. When studying the function of external respiration, spirometry indicators correspond to the age norm - 2300 ml. An X-ray examination of the chest organs revealed no pathological changes in the lungs and mediastinal organs. ECG data - sinus rhythm with a frequency of 83 per minute, violation of intraventricular conduction along the right leg of the bundle of His. Ultrasound of the heart - mitral valve prolapse of the 1st degree. Ultrasound of internal organs, ultrasound of the kidneys without pathology. The patient's weight is 43 kg. An allergic history is not burdened. General tests of blood, urine, biochemical analyzes within the standard norm: red blood cells 4.0 · 10 ¹² / l, hemoglobin - 134 g / l, color indicator 1.00, platelets 272 · 10 ⁹ / l, hematocrit 42%, ESR 9% mm / h, blood formula without features, bleeding duration 1 min, clotting time 4 min 12 sec, total protein 76 g / l, urea 6.5 mmol / l, total bilirubin 15.9 mmol / l, serum potassium 4.1 mmol / L, serum sodium 143 mmol / L, blood glucose 4.7 mmol / L, prothrombin index 94%, fibrinogen 3.1 g / L. Systolic blood pressure 110 mm Hg, diastolic blood pressure 65 mm Hg, heart rate 80. The patient was examined by a pediatrician, there were no contraindications to surgical treatment and preoperative autologous blood preparation. The estimated volume of intraoperative blood loss is 1000 ml (30% bcc).

On October 24, 2005, the first sampling of autologous blood from a cubital vein was performed in a volume of 400 ml (10 ml / kg, which corresponded to 13% of BCC) in a plastic bag with a preservative. Next, the blood was divided into fractions - erythrocyte mass and FFP. The prepared blood components were stored in accordance with the order No. 363 of the Ministry of Health of the Russian Federation of 2000, which regulates the operation of blood transfusion stations using hemoucons of the TURUMO company. Compensation of the volume of exfused blood was carried out with Acesol 200 ml and 10% glucose 400 ml. Prescribed and administered - retabolil 0.4 mg / kg 1 time intramuscularly, vitamin B1 5% - 50 mg 1 time intravenously, vitamin B12 500γ 1 time intramuscularly, vitamin C 5% - 150 mg 1 time intravenously, aminoplasmal 10% E 250 ml 1 time intravenously, ferrum lek 100 mg 1 time intramuscularly (and then on 10/25/05; 10/26/05), sorbifer 325 mg 2 times a day (and then on 10/25/05; 10/26/05), folic acid 5 mg 3 times a day (and further 10.25.05; 10.26.05); 10/21/2005 appointed epocrine in a dose of 4 tons. UNITS 1 time subcutaneously. Since October 20, 2005, the patient was prescribed nutritional support using a protein module for the mixture of “Berlamin Modular” 50 g 2 times a day daily. During blood sampling and complex drug therapy, the patient's condition did not suffer, the level of blood pressure did not change significantly - systolic blood pressure 110-100 mm Hg, diastolic blood pressure 65-70 mm Hg, heart rate 96 heart rate per minute .

10/27/2005 laboratory control was carried out: red blood cells 3.9 · 10 ¹² / l, hemoglobin - 128 g / l, color indicator 0.98, platelets 242 · 10 ⁹ / l, hematocrit 37%, ESR 12 mm / h, blood count without features, total protein 66 g / l, urea 8.5 mmol / l, total bilirubin 12.0 mmol / l, serum potassium 4.3 mmol / l, serum sodium 145 mmol / l, blood glucose 5.0 mmol / l, prothrombin index 97%, fibrinogen 3.0 g / l, urinalysis without pathology, ECG data without dynamics, systolic blood pressure 110 mmHg, diastolic blood pressure 70 mmHg, heart rate 84 heart rate per minute .

On October 27, 2005, a second autologous blood exfusion was performed in a volume of 400 ml (10 ml / kg, which corresponded to 13% of the bcc). Blood was collected in a plastic bag with a preservative with the separation of blood into fractions, the prepared blood components were stored in accordance with Order No. 363 of the Ministry of Health of the Russian Federation of 2000. The volume of exfused blood was replaced with Acesol plasma-substituting solutions in a volume of 200 ml and 10% glucose solution 400 ml . 10/27/2005 prescribed and administered: Vitamin B6 5% - 50 mg 1 time intravenously, Vitamin C 5% - 150 mg 1 time intravenously, Vitamin B12 500γ 1 time intramuscularly, aminoplasmal 10% E 250 ml 1 time intravenously, ferrum Lek 100 mg 1 time intramuscularly (and further on 10/28/05; 10/29/05; 10/30/05), sorbifer 325 mg 2 times a day (and then 10/28/05; 10/29/05; 10/30/05), folic acid 5 mg 3 times a day (and further on 10/28/05; 10/29/05; 10/30/05); 10.28.05 appointed epocrine in a dose of 4 tons. UNITS 1 time subcutaneously; continued nutritional support using the protein module to the mixture of “Berlamin Modular” 50 g 2 times a day daily. The second blood exfusion was carried out with stable hemodynamic parameters - systolic blood pressure 115 mm Hg, diastolic blood pressure 70 mm Hg, heart rate 88 heart rate per minute, no complications were recorded. Thus, for the upcoming operation, 2 doses of erythrocyte mass (150 ml and 170 ml) and 2 doses of FFP (250 ml and 270 ml) were prepared. Surgical intervention was performed on 02.11.2005 in full with intraoperative blood loss of 850 ml, without complications.

Claims (3)

1. The method of preoperative autologous blood collection by taking, restoring blood counts, characterized in that 2 blood samples are taken with an interval of 3 days against the background of comprehensive drug support according to the scheme: on the day of the first exfusion, retabolil 0.4 mg / kg is administered once intramuscularly, vitamin B1 5% - 50 mg intravenously, vitamin B12 500γ intramuscularly, vitamin C 5% - 150 mg intravenously and aminoplasmal 10% E 250 ml intravenously, on the day of the first exfusion and on the next two days - ferrum Lek 100 mg 1 time intramuscularly, sorbifer 325 mg 2 times a day, folate acid 5 mg 3 times a day, on the second day after exfusion, epocrine is administered once in a dose of 4 tons. UNITS subcutaneously; on the day of the second exfusion, vitamin B6 5% is administered once - 50 mg intravenously, vitamin C 5% - 150 mg intravenously, vitamin B12 500γ intramuscularly and aminoplasmal 10% E 250 ml intravenously, on the day of the second exfusion and on the next two or three days - ferrum lek 100 mg 1 time intramuscularly, sorbifer 325 mg 2 times a day, folic acid 5 mg 3 times a day; on the second day after exfusion, epocrine is administered in a dose of 4 tons. ED 1 time subcutaneously; on the day of the first exfusion and until the autologous blood is harvested, nutritive support is carried out using a protein module for the mixture of Berlamin Modular 50 g 2 times a day daily. 2. The method according to claim 1, characterized in that on the third day after exfusion, a control examination is carried out. 3. The method according to claim 1, characterized in that after exfusion from the autologous blood components of the blood - erythrocyte mass and freshly frozen plasma are prepared.