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МЕДИЦИНА И ЗДОРОВЬЕ
UDK 616-099:615.246.2:616.15]-06-084-085
Akentiev S. O., candidate of medical science
Associate professor of the department of Anesthesiology and Resuscitation
Berezova M.S., candidate of medical science Assistant of the department of Internal Medicine of Higher State Educational Institution of Ukraine «Bukovinian State Medical University»
Ukraine, Chernivtsi
EFFERENT THERAPY IN COMPLEX TREATMENT OF JAUNDICE OF
DIFFERENT GENESIS UNDER CONDITIONS OF INTENSIVE
THERAPY
Аннотация. Проведен анализ влияния плазмосорбции (ПС) в группе больных с синдромом печеночной (острой и хронической) недостаточности (12 больных, 21 сеанс). Контрольная группа из 10 больных с подобными нозологиями, которым проведен плазмаферез. Белоксохраняющий и диуретический эффекты, исключение плазмозамещения и повреждения эритроцитов в процессе проведения процедуры ПС делают ее оптимальным методом детоксикации при желтухах различного генеза.
Ключевые слова: эфферентная терапия, плазмосорбция, плазмаферез, элиминация метаболитов, билирубин, фракции билирубина.
Abstract. The influence of plasma sorption (PS) in the group of patients with hepatic (acute and chronic) failure syndrome (12 patients, 21 sessions) was analyzed. The control group involved 10 patients with similar nosologies, who underwent plasmapheresis. Protein-preservation and diuretic effects, the exclusion of plasma replacement and erythrocyte damage during the PS procedure make it an optimal detoxification method at jaundices of different genesis.
Key words: efferent therapy, plasma sorption, plasmapheresis, elimination of metabolites, bilirubin, fractions of bilirubin.
Complex treatment of severe forms of jaundice of various genesis, often due to the increase of endotoxicosis rate (bilirubinemia, enzymopathy, hypoproteinaemia, ammonemia), requires intensification of therapeutic measures with the involvement of efferent therapy (plasmapheresis, hemosorption, plasma sorption, etc.) [1, 2]. The extracorporeal detoxification procedures under conditions of hepatic (acute or chronic) failure syndrome may be problematic as there appear disorders in the system of coagulation.
The study aims at optimizing the complex treatment of severe forms of jaundice of different genesis using the method of plasma sorption (PS).
Materials and methods. PS (21 sessions) was performed in 12 patients: 5
men, 7 women. By age, the patients were divided as follows: up to 30 years old -2 patients, up to 40 years old - 3 patients, up to 50 years old - 5 patients, up to 60 years old - 1 patient and over 60 years old - also 1 patient. The PS method was tested at parenchymatous cytolytic and cytolytic-cholestatic jaundice (A.F. Bluger, 1968), which were caused by the development of liver cirrhosis, viral hepatitis, toxic hepatitis, purulent cholangitis, and hepatosis. PS method was applied to 3 more patients with mechanical (subhepatic) jaundice caused by cancer of the head of the pancreas (1 patient), indurative pancreatitis (1 patient) and acute calculous cholecystitis (1 patient). PS was performed during the first 1-2 days of admission of patients to the intensive care department (Chernivtsi, Regional Clinical Hospital, Chief Doctor Ushakov V.I., Head of the Department of Anesthesiology with beds of intensive care Rusnak A.D.). In those patients who underwent surgical intervention, the PS was performed in the postoperative period after 2-3 days. PS sessions were conducted in a routine intermittent (fractional) way. The process of the PS included the following steps: a) the preparation of the system with hemosorbent ("SCN-4M"); b) preparation of the patient for detoxification (puncture of both subclavian veins); c) blood draw of the first dose into the plastic containers of the type "Hemakon - 500/300" or glass bottles of 500 ml (stabilizer of the type "Glugicir"); d) centrifugation of blood (centrifuge "PC-06", mode of operation - 2 thousand revolutions per minute, centrifugation time - 15 minutes); e) separation of plasma from the formed elements with the help of the plasma extractor "PE-01"; f) the return of the formed elements and purification of the patient's plasma; g) repeated cycles of blood draw, purification and return of biological liquids to the patient; h) completion of the PS session. During one session blood was drawn in the amount of 2000 ml, the total amount of purified plasma returned to the organism was up to 1200 ml. On average one patient received 2 sessions of the PS. Inclusion criteria: presence of clinically and laboratory-isolated severe hepatic failure. Exclusion criteria: a combination of hepatic failure with the renal one, fulminant forms of disease, terminal states, shock liver. A comparison group involved 10 patients with similar nosologies, who underwent plasmapheresis (PPh). Criteria for using repeated PS sessions: ineffectiveness of one session of the PS - preservation of the patient's previous condition and the metabolites rate in the blood. Criteria for termination of PS sessions: improvement of the general condition of the patient, reduction of jaundice, itching of the skin, absence of a pronounced "drainage" effect due to the metabolites rate (total bilirubin and its fractions), gradual decrease of their level in blood. Basic therapy: infusion therapy (glucose, albumin, etc.), diuretics, antibiotics, vitamins, hepatoprotectors, antioxidants.
Results and their discussion. The combined PS detoxification method is one of the effective eliminating methods of extracorporal hemocorrection based on the sorption technology after the separation of blood into the globular and cellular components, in particular by means of gravity forces or the filtration method. The elimination of toxins results from the processing of plasma, separated from the
formed elements. The latter, avoiding the negative effects of a column with a hemosorbent, return to the body undamaged.
The data below demonstrate the effects of PS on some essential indices of the biochemical composition of the blood under conditions of functional liver hyperactivity. Everyone knows the role of the total protein concentration as an important factor in plasma detoxification, binding and transport of free bilirubin in the liver. At the stage of plasma separation from the formed elements some protein remains with erythrocytes (20%). Prior to the procedure the total protein in the blood before PS was 69.1±4.3 g/l, and the protein in plasma proper immediately before sorption was 55.2±6.3 g/l. After the sorption the protein concentration decreased and became 39.5±4.6 g/l (p<0.05). Percentage of absorption capacity was 28%. Despite this, protein reduction, both on the first day and the next two days on end, did not occur. Thus, on the third day after the procedure the total protein was 69.8±4.6 g/l. This is stipulated by the fact that standard therapy was conducted in full, in addition, small amounts of plasma were subjected to purification. At PPh: before the procedure the protein was 74.8±6.7 g/l, on the first day it was 65.6±4.3 g/l, during the next two days 68.3±2.4 g/l and 65.5±4.5 g/l. This situation required an adequate plasma replacement.
Investigations of individual bilirubin exchange units showed an increase in both general bilirubin and its fractions (direct and indirect bilirubin) in patients. The data below denote the dynamics of total bilirubin fractions under the influence of PS and PPh. The given data demonstrate that there is a more pronounced "drainage" effect at PPh as compared to PS, especially this concerns the toxic fraction of bilirubin - free, indirect bilirubin. This phenomenon arises, in our opinion, due to the fact that after the PS optimal conditions are maintained for the binding and transportation of this fraction of bilirubin to the liver.
Table 1
Direct blood bilirubin dynamics at PS and PPh (n=9, Mx±o) in ^mol/l
Detoxification method Direct bilirubin dynamics
Before the operation 1st day 2nd day 3rd day
PS 108.8±21,1 114,6±22,4 120,4±30,2 80,7±20,7
PPh 164,4±14,0 115,5±36,8 150,7±25,9 145,3±42,0
Table 2
Indirect blood bilirubin dynamics at PS and PPh _(n=9, Mx±o) in p.mol/l_
Detoxification method Indirect bilirubin dynamics
Before the operation 1st day 2nd day 3rd day
PS 89.1±19,2 67,4±11,0 88,6±30,2 54,7±17,7
PPh 89,3±27,2 99,8±35,9 123,8±49,6 127,3±45,0
Liver parenchyma failure, its functional hyperactivity under conditions of jaundice of different genesis is explained by the depth of cytolytic processes, which is characterized by an increase in the level of indicator enzymes: alanine aminotransferase (ALT), aspartate aminotransferase (AST) and alkaline phosphatase (ALP). Thus, the rate of ALT in the blood prior to the session of the PS was 93.6±23.8 ^mol/l, and in plasma after separation from the formed elements it was 81.3±23.4 ^mol/l, after the passage of plasma through the sorbent, its activity is likely to decrease to 53.6±19.0 ^mol/l. On the first day after sorption, this index was 55.3±21.5 ^mol/l, during the following days there was a tendency to its decrease. A similar situation is observed concerning AST. In the case of ALP: up to the sorption this index was 568.7±68.5 ^mol/l in the blood, in the plasma after its separation from the formed elements it was equal to 459.0±36.1 ^mol/l, after the sorption - 253.3±23, 1 ^mol/l. Thus, a decrease in the rate of these enzymes contributed to the functional rest of the liver.
Reduction in the rate of bilirubinemia and cytolytic enzymes at PS is correlated with toxicological data. Thus, the analysis of LII demonstrated its decrease during the first two days after the session in different patients from 8.212.8 to 4.5-7.8 units. There was a decrease in the rate of "average" molecules at a wavelength of 282 nm on average by 52%, and at a wavelength of 253 nm - by 36%. Moreover, the general condition of the overwhelming majority of patients (80%) improved, bilirubinemia stopped developing, there appeared a tendency to its decrease, jaundice, skin itching decreased, appetite grew better, weakness declined. A significant point in the endotoxicosis treatment at jaundices is a probable increase in daily diuresis, especially in patients after PS. Thus, before PS it was on average 673.0±252.0 ml, on the first day after the procedure -1650.0±275.0 ml, and on the third day this index was 2075.0±102.0 ml.
Conclusions. Protein-preservation and diuretic effects, the exclusion of plasma replacement and damage to erythrocytes during the PS procedure make it an optimal detoxification method at jaundices of different genesis.
References:
1. Николаев В.Г. Краткое наставление по современной тактике применения гемосорбционного метода в клинической практике/ В.Г.Николаев. - Киев: ПИИ ООО «Киулонг». - 2011. - С.16.
2. Иоффе И.В. Плазмаферез в комплексном лечении механических желтух,
обусловленных холедохолитиазом/ И.В.Иоффе, В.П.Потеряхин. -Украшський журнал екстремально! медицини iMem Г.О.Можаева. - 2009. -Том 10, №1. -= С.122-125.
UDK 616-083.98-08:615.382
Akentiev S. O., candidate of medical science
Associate professor of the department of Anesthesiology and Resuscitation
Berezova M.S., candidate of medical science Assistant of the department of Internal Medicine of Higher State Educational Institution of Ukraine «Bukovinian State Medical University»
Ukraine, Chernivtsi APPLICATION OF PLASMOSORPTION IN SYNDROME OF KIDNEY FAILURE UNDER THE CONDITIONS OF INTENSIVE THERAPY
Аннотация
Проведен анализ влияния плазмосорбции (ПС) в группе больных с синдромом почечной (острой и хронической) недостаточности (20 больных, 37 сеансов). Контрольная группа с 5 больных с подобными нозологиями, которым проведен плазмаферез. Детоксикационный и диуретический эффекты ПС, преимущества ее методики способствуют регрессу синдрома почечной недостаточности и восстановлению собственных детоксикационных механизмов организма.
Ключевые слова: эфферентная терапия, плазмосорбция, плазмаферез, элиминация метаболитов, мочевина, креатинин, мочевая кислота.
Abstract
The analysis of the influence ofplasma sorption (PS) in a group ofpatients with a syndrome of the renal (acute and chronic) failure (20 patients, 37 sessions) was conducted. The control group included 5 patients with similar nosologies, who had undergone plasmapheresis. The detoxification and diuretic effects of PS, the advantages of its methods contribute to regression of the syndrome of kidney failure and restoration of its own detoxification mechanisms of the organism.
Key words: efferent therapy, plasma sorption, plasmapheresis, elimination of metabolites, urea, creatinine, uric acid.
The problem of intensive treatment of endotoxicosis in acute and chronic kidney diseases remains relevant today. It is already traditional, that the methods of extracorporeal detoxification: hemodialysis, hemosorption, and others are used for detoxification in this pathology. [1]. The authors have some experience in using the method of plasma sorption (PS) for this syndrome, caused by a number of nosological forms of kidney disease, with different etiology, pathogenesis, clinic, morphology and prognosis [2]. PS is an effective method of detoxification based on the sorption technology after the separation of blood into globular and cellular components.
Objective. To assess the effectiveness of the use of PS in the complex
