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5УДК: 616-001-617.55-07-089 CHOICE OF TREATMENT METHODS FOR SEVERE CONCOMITANT
ABDOMINAL TRAUMA Mustafakulov Ishnazar Boynazarovich1
Head of the Department of Surgical Diseases No. 2, Candidate of Medical Sciences; Mamaradjabov Sobirjon Ergashevich2 Head of the Department of Surgical Surgery and Topographic Anatomy, Dean of the Faculty of
International Education, d.m.n Norov Mirvokhid Chariyevich3
Surgeon of the Republican Scientific and Practical Center for Medical Emergencies,
Kashkadarin Branch; Juraeva Zilola Aramovna4 Lecturer of the Department of Endocrinology; Boynazarov Mekhrojmirzo Eshnazarovich 5 student of Thermiz branch of the TTA;
Samarkand State Medical University, Republic of Uzbekistan, Samarkand https://doi. org/10.5281/zenodo. 7419260
Abstract: Prospective analysis of the studied factors of unfavorable outcome in combined abdominal traumas in 70 victims has been carried out. Estimation of severity of condition during the first 24 hours according to APACHE II and SAPS II scales was made and working characterizing curves (WCC) and evaluation of areas under the curves (AUROC) were built. To reveal intensity and character of connection of APACHE II and SAPS II methods and also to reveal the character of interdependence, correlative and regressive analyses were performed. Strong correlative connection between APACHE II and SAPS II was revealed (rate=0,851). To develop surgical tactics on admission, wide spread clinic laboratory parameters were tested: hemoglobin, hemotacrit, rate of heartbeats (RHB), AP and also Algover Index (AI). Prognosis of the outcome and development of complications in severe combined trauma is possible on the basis of evaluation of the severity of victims' condition according to APACHE II, SAPS II scales.
Key words: closed abdominal trauma, liver injury,
ВЫБОРА МЕТОДЫ ЛЕЧЕНИЯ ТЯЖЕЛОЙ СОЧЕТАННОЙ ТРАВМЫ ЖИВОТА
Аннотация: Проведен проспективный анализ исследований факторов неблагоприятного исхода при сочетанных повреждениях живота у 70 пострадавших. Провели оценку тяжести состояния в первые сутки по шкале АРАСНЕ II и SAPSII и построили рабочие характеристические кривые (ROC) и оценки площади под кривыми (AUROC). Для выявления силы и характера связи метод шкалами APACHE II и SAPS II, а также выяснения характера взаимозависимости провели корреляционный и регрессионный анализы. Выявлена прямая сильная корреляционная связь между шкалами APACHE II и SAPS II (ч=0,851). Для разработки хирургической тактики при поступлении тестировали широко распространенные клинико-лабораторные параметры: гемоглобин, гематокрит, лейкоциты, ЧСС, АД, а также индекс Алговера (ИА). Прогнозирование исхода и развития осложнений при тяжелой сочетанной травме возможно на основе оценки тяжести состояния пострадавших по школам APACHE II, SAPS II.
Ключевые слова: закрытая травма живота, повреждение печени
ЦОРИН БУШЛИГИНИНГ ОГИР ЦУШМА ШИКАСТЛАНИШЛАРИНИ ДАВОЛАШ УСУЛЛАРИНИ ТАНЛАШ
Аннотация; Корининг цушма шикастланишлари билан 70 нафар беморларда нохуш - салбий оцибат омиллари тадцщотларининг проспектив тащили утказилди.Биринчи кеча-кундузда беморлар а^волининг огирлигини бауолаш АРАСНЕII ва SAPS II шкалалари буйича утказилди ва узига хос хусусиятли ишчи эгри графиклари (ROC) ва эгри график эгаллаган майдон ба^оси (AUROC) ишлаб чицилди. Алоцалар кучини ва хусусиятини аницлаш учун АРАСНЕ II ва SAPS II шкала усулларидан фойдаланилди, бир-бирига боглицлик хусусиятини аницлаш учун корреляцион ва регрессион тахлиллар утказилди. АРАСНЕ II ва SAPS II шкалалар уртасида тугридан - тугри кучли корреляцион алоцалар борлиги аницланди (ч=0,851). Жарро^лик тактикасини ишлаб чициш учун, шикастланганларни цабул цилиш вацтида, кенг тарцалган клиник - лаборатор курсаткичлар: гемоглобин, гематокрит, лейкоцитлар, ЮКС, АБ, Алговер индекслари (АИ) орцали синов утказилди. Огир цушма жароуатларда шикастланганларнинг ауволи огирлиги оцибатини ва асоратлар ривожланишини АРАСНЕ II ва SAPS II шкалаларини ба^олаш асосида олдиндан айтиш имконияти бор деб щсоблаймиз.
Калит сузлар: цушма шикастланиши., цорин бушлиги шикастланишлари.
Relevance. Abdominal injuries in concomitant trauma are one of the most difficult problems in emergency surgery [1, 4, 6, 10, 14, 16, 21]. According to world statistics, combined abdominal trauma as a cause of death among patients under 50 years of age ranks first [6,10,26,29] . With multiple and combined injuries, from 60 to 70% of the victims are admitted to medical institutions with symptoms of traumatic shock, and therefore, a third of those admitted die for the first day of treatment [1,5,8,11] .
The complexity of the problem of diagnosis and treatment of severe concomitant injuries can not be solved by the imperativeness of the surgeon and his virtuoso technique [2,4,7,9,12] . Therefore, with the modern method of objective assessment of the severity of the condition is the use of integrated systems [14,18,27,32,34] .
In most of the existing integral systems for assessing the severity of the condition, they do not reflect the effectiveness of treatment, therefore they cannot differentiate the prognosis in the above situation. Integral systems for daily assessment of the severity of the condition can largely overcome these problems [3,17,25,28,35].
Questions of qualitative prediction of the outcome of severe concomitant abdominal trauma remain unresolved; therapeutic tactics, the choice of the optimal volume of surgical intervention in the first hours after injury, depending on an objective assessment of the severity of the condition and prognosis, as well as the pathogenesis of post-infusion complications with increasing degrees of normovolemic hemodilution against the background of massive blood loss, still remain unexplored [19, 22,24,30,31,37] .
The purpose of the study. To develop a qualitative prognosis of the outcome on the first day (upon admission) depending on the severity of the condition of the victims with abdominal injuries in case of combined trauma to determine the treatment tactics.
Scope and methods of research. The prospective phase of the study involved a comprehensive study of risk factors for adverse outcomes in combined abdominal injuries in 70 patients. The study took into account the age and sex of the victims, the time from injury to hospitalization, hemodynamic indicators of the severity of the condition, the volume and duration of the operation, the amount of blood loss.
We studied outcomes in affected people of different age groups. The average age of survivors was 32.15±7.45 years, the average age of deceased victims was 35.35±17.45 years (p=0.251 - differences are not significant).
The overall mortality rate among 70 patients with closed combined abdominal trauma was 61.4% (out of 70 patients, 43 victims died), and in the control subgroup of the most prognostically unfavorable victims - 87%.
Identification of significant differences among the groups of surviving and deceased patients by a number of factors (gender, age, assessment on integral scales) makes it possible to predict the outcome using regression analysis. We performed such an analysis according to the data of the first day from the moment of injury and according to the dynamics of the severity of the condition in 70 victims.
At the same time, no regular dynamics of an increase in mortality with increasing age was noted, which is probably associated with a small number of victims in groups. Thus, mortality in the group of victims under 20 years old was 83.33% (5 out of 6 died), in the group of victims aged 20-29 years 46.0% (12 out of 26 died), and in the group 30-39 years old 53.3% ( 8 out of 15 died), in the group of victims 40-49 years old 46.6% (7 out of 15 died), and in the group over 50 years old - 87.5% (7 out of 8 died).
As is known, the severity of the condition upon admission of the victims makes a significant contribution to the frequency of lethal outcomes. We assessed the severity of the condition on the first day using the APACHE scale II in patients with abdominal injuries in concomitant trauma.
Mathematical expectation (arithmetic mean) on the APACHE scale II for surviving victims was 6.47 points, and the standard deviation was 2.54 points; for the deceased victims, the figures were not statistically different: the mathematical expectation was 8.55 points, the standard deviation was 4.31 points. The information is presented in Table.
Table
APACHEII score at admission in surviving and deceased victims
Number observations APACHE II Expectation Standard deviation
Survived 46 6.47 2.54
Died 24 8.55 4.31
Simple, widely used, affordable and reliable instruments are needed for rapid assessment and selection of surgical tactics upon admission of a patient with a severe closed abdominal injury. Unfortunately, widely used in the practice of intensive care units of the APACHE scale II and SAPS II cannot be used for surgical risk stratification, not only because of their bulkiness and the need to assess a large number of clinical and laboratory parameters, but also for quite objective reasons - they do not correlate with the probability of a lethal outcome in case of a closed abdominal injury on admission (p = 0.20 and p=0.756, respectively), which does not allow using them to develop surgical tactics.
To identify the strength and nature of the relationship between the APACHE scales II and SAPS II, as well as elucidating the nature of interdependence, we conducted correlation and regression analyzes. A direct strong correlation was found between the APACHE scales II and SAPS II (r=0.851).
Formula describing scale dependence in severely traumatized patients: APACHE II (points) = 2.216 + 0.381 x SAPS II (points).
To assess the resolution of the APACHE scales II and SAPS II and for the prediction of lethal outcome, we built operating characteristic curves (ROC - receiveroperatorcurves) and estimated areas under the curves (AUROC).
0,4 0,6 0,8
1- Специфичность Rice. 1. Operating characteristic curve of the APACHE II scale. Area under the operating characteristic curve for evaluating the resolution of the APACHE scale II in relation to predicting a lethal outcome was 0.717 (AUROC = 0.717, p < 0.001). However, for good resolution, the area under the curve for the scale should be greater than 0.9 (90%), (H - L 3.45; p=0.840).
SAPS scale has an unsatisfactory resolution for predicting a lethal outcome in patients with severe concomitant injury. II (AUROC - 0.763; p<0.001), ( H - L ; p=0.783).
0,50 0,75 1,00
Rice. 2. Operating characteristic curve of the SAPS II scale.
As can be seen, neither the APACHE scale II nor SAPS scale II do not have a good -resolution for predicting a lethal outcome in patients with severe concomitant injury. To develop a surgical approach on admission, we tested widely used clinical and laboratory parameters: hemoglobin, hematocrit, leukocytes, heart rate, blood pressure, and the Algover index (AI).
The concentration of hemoglobin and the number of leukocytes at admission do not correlate with the probability of death (p=0.68 and p=0.343, respectively). The level of hematocrit at admission has a weak negative correlation with the probability of death (r = -0.234, p = 0.02). The hematocrit level does not allow its use for stratification of patients with closed abdominal trauma due to poor operational performance (AUROC = 0.639, no cutoff point).
Hemocrit
0,2 0,4 0,6 0,8 1,0
1 - Specificity
Rice. 3. Characteristic curve of hematocrit in closed abdominal trauma.
However, the assessment of hematocrit level 3 hours after admission has a high prognostic value (AUROS = 0.729), while a decrease in hematocrit less than 20.4 can predict a lethal outcome with a sensitivity of 71% and a specificity of 68%. However, the need to use this parameter in active bleeding is questionable.
Hematocrit
I
0,2 0,4 0,6 0,8 1,0 1 - Specificity
Rice. Fig. 4. Characteristic curve of hematocrit 3 hours after admission of patients with closed
abdominal trauma
Systolic BP at admission has a negative inverse correlation with the probability of death ( rho = -372, p<0.001). Operational characteristics of the test for systolic blood pressure less than 100 ммHg . - sensitivity 70%, specificity 75%, AUROC = Q .721.
Systolic BP
1,0
1 - Specificity
Rice. 5. Characteristic curve of systolic blood pressure at admission. The heart rate at admission has a correlation of average strength with the probability of a lethal outcome (rho =0.378, p<0.001).
The probability of a lethal outcome increases sharply with an initial heart rate of more than 1000 per minute (AUROC = 0.725, sensitivity 74%, specificity 89%).
This heart rate value can serve as a dividing point for the choice of surgical tactics « damage control ".
Heart rate
1- Specificity
Rice. 6. Characteristic curve of heart rate in closed abdominal trauma
Often mentioned in the medical literature, the Algover index (AI) (heart rate / blood pressure ratio), according to our data, has a correlation of average strength with the probability of a lethal outcome ( rho = : -0.392, p <0.001). AI has a strong inverse correlation with heart rate ( rho =-765, p <0.001).
Based on the assessment of heart rate, it is possible to calculate IA even without assessing the value of blood pressure, the measurement of which in a non-invasive way in shock can lead to significant errors:
Algover index (AI) = 0.014 x HR - 0.467 (p < 0.001)
The probability of a lethal outcome increases sharply with an AI value of more than 1 ( AUROC = 0.733, sensitivity 76%, specificity 76%). This parameter can also serve as a dividing point for the choice of surgical tactics « damage control ".
Algover index
1 - Specificity
Rice. Fig. 7. Characteristic curve of IA in closed abdominal trauma.
One of the simplest predictive tools can be the assessment of the condition of the skin of the extremities according to the visual analogue scale for evaluating the condition of the extremities (1 point - warm, 2 points - cold, 3 points - cold with marbling, 4 points - cyanosis). The scale has a correlation of average strength with the probability of a lethal outcome (r=0.334, p=0.03).
The division point of the scale is 3 points, that is, the appearance of marbling of the skin with the development of severe shock (sensitivity 75%, specificity 75%).
Limb condition
1,0-p
0,0
0,0
0,2
0,4
0,6
0,8
1,0
1 - Specificity
Rice. 8. Characteristic curve of temperature and color of extremities. The data obtained allow us to draw the following conclusions:
1) Predicting the outcome and development of complications in severe concomitant trauma in victims is possible using APACHE integral scales II, SAPS II.
2) The probability of a lethal outcome increases sharply with an AI value of more than 1 (AUROC = 0.733, sensitivity 76%, specificity 76%). This parameter can also serve as a dividing point for the choice of surgical tactics « damage control ".
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