CC BY
13MEDICAL SCIENCES
HEMOSTASIS INDICATOR DYNAMICS FOR PATIENTS WITH CONCOMITANT ISCHEMIC HEART DISEASE DURING MULTIMODAL ANAESTHESIA
Lysenko V.
Trofimovich E.
Karpenko E.
Maloshtan V.
Elena Trofimovich, graduate student of the Department ofAnaesthesiology and Intensive Care, Kharkiv
Medical Academy of Postgraduate Education.
Abstract
Patients with coronary artery disease are at increased risk of thrombotic complications [1,2,3]. The implementation of traditional measures to prevent thrombosis for them is mandatory, at the same time, there are additional opportunities to influence the hemostatic system in the perioperative period [4]. This primarily concerns drugs that specifically affect on platelet-vascular hemostasis, which is an initiating link in the development of hemorheological disorders.
Keywords: hemostasis, perioperative period, ische
Many works have been devoted to the issues of anesthetic management of noncardiac syrgery in patients with concomitant ischemic heart disease (IHD), which indicates the relevance of this problem [5,6]. Restriction in the drugs use which is achieved by using various schemes of multimodal anesthesia one of the important areas of modern general anesthesia [7,8]. Regional anesthesia methods, non-narcotic analgesics and adjuvants are used for this purpose [9,10]. Some of these drugs effects on the hemostatic system, which must be considered when choosing a method of analgesia.
Purpose of the study. Examine the dynamics of hemostasis indicators in patients with concomitant is-chemic heart disease during multimodal anesthesia.
Materials and Methods. We examined 92 patients who underwent major abdominal surgery under combined general anesthesia with mechanical ventilation. The average age of the patients was 61 ± 12 years, ASA scale - II-III, the assessment of risk factors for thrombosis by Caprini scale was 6.5 ± 0.1, RCRI was 1-3. All patients underwent standard hemodynamic monitoring, capnography, ECG, etc.
The functional state of platelets was assessed using an AP 2110 SOLAR platelet aggregation analyzer by the turbidimetric method and an ADP aggregation inducer at a concentration of 2.5 ^m. The
ic heart disease, multimodal anaesthesia. state of plasma hemostasis was assessed by determining the blood coagulation time, prothrombin index, fibrinogen, plasma heparin tolerance, and APTT. The studies were carried out before, during and one day after the surgery.
For control hemostasis indicators, a group of volunteers of 15 healthy young and middle-aged people (34 ± 9 years) who did not suffer from coronary artery disease and pathology of the blood coagulation system were examined, theirs platelet aggregation indicators were: Me [Q1; Q3]: degree of aggregation,% - 65.2 [60.2; 70.5], aggregation time, min. - 7.1 [6.4; 7.8], the rate of aggregation,% / min - 34.4 [30.8; 41,], platelets thous / ^l - 257.8 [216.4; 314.4].
Results. When studying the features of platelet-vascular hemostasis in patients with concomitant is-chemic heart disease, significant deviations in platelet aggregation indicators were revealed in a significant part of patients. This was the reason for dividing patients into groups. The 1st group included 22 patients (24% of the total number), who had platelet hypoaggregation; Group 2 (38 patients; 41% of the total) consisted of those who had normal platelet aggregation indicators; group 3 - 32 patients (35% of the total) with platelet hyperaggregation.
The quantitative characteristics of platelet aggregation indicators are presented in table 1.
* - differences with the control group (p <0.05)
During the examination before the operation it was to hypercoagulation was noted according to the results found that practically in all patients the state of plasma of the coagulogram (Table 2). hemostasis was within normocoagulation or a tendency
Table 2.
Table 1.
Indices of platelet aggregation in the perioperative period Me [Q1; Q3]
Index Operation Patient group
stages 1 2 3
Degree of 1 47[42; 51,2] * 68,2[59,5; 78,1] 63,6[60; 72,6] *
aggregation 2 68,5[65,9; 76,2] 72,5[55,9; 76,3] 77,5[64,7; 96,8]
(%) 3 97,9[94,2; 103,7] * 79,7[75,3; 94,2] 74,6[59,2; 83,4]
Aggregation 1 3,8[3,5; 5,5] * 3,4[2,8; 4,5] 4,9[4,2;5,2]
time (minutes) 2 6,2[4,7; 7,1] 5,1[3,9; 7,1] 5,0[4,1; 6,6]
3 7,3[5,4; 8,9] 7,6[5,4; 9,2] 5,7[5,1; 6,7]
Aggregation 1 44,7[25,3; 49,8] 64,2[28,6; 68,2] 63,8[27,0; 71,1]
speed 2 33,0[26,4; 45,8] 41,0[32,0; 52,4] 39,6[26,6; 49,5]
(%/minutes) 3 68,0[65,5; 87,4] * 52,8[41,0; 64,4] 47,2[37,8; 71,2]
Рlatelet 1 217,1[153,0; 240,8] 225,2[174,8; 265,7] 209,5[155,6; 239,0]
(mcL) 2 188,3[169,0; 224,3] 187,8[142,1; 252,8] 193,7[146,9; 223,0]
3 196,9[165,8; 242,3] 186,3[136,9; 225,5] 200,4[166,6; 230,3]
Indices of plasma hemostasis in the perioperative period M ± SD
Index Operation Patient group
stages 1 2 3
Рrothrombin index 1 89,2±11,5 93,0±11,5 90,1±4,9
2 90,5±6,6 92,3±8,1 88,6±7,6
3 89,1±14,9 91,3±14,5 89,6±8,3
Activated partial 1 33,3±2,1 31,1±3,0 31,3±2,5
thromboplastin time 2 29,0±2,6 29,8±2,3 30,1±2,2
(Seconds) 3 27,0±7,3 26,7±4,1 28,7±3,3
dotting time (Sec- 1 8,5±1,0 9,0±1,2 9,2±2,3
onds) 2 9,1±0,8 8,7±0,8 8,8±0,7
3 9,1±0,8 9,1±1,1 9,3±1,1
Fibrinogen 1 3,7±1,4 3,9±1,2 4,0±1,0
level (grams / liter) 2 3,6±1,1 3,9±0,9 4,1±1,0
3 3,8±1,2 4,0±1,0 4,0±0,9
Plasma tolerance to 1 12,0±3,5 11,4±1,8 11,1±1,3
heparin (minutes) 2 11,3±1,9 10,8±1,5 11,8±3,2
3 12,1±3,9 12,5±5,1 11,9±1,6
The main differences between the groups of patients were age and duration of ischemic heart disease. Thus, in the 1st group with initial platelet hypoaggre-gation, the age and duration of ischemic heart disease were 64.1 ± 2.6 and 9.4 ± 1.3 years; in the third with platelet hyperagregation - 64.2 ± 1.5 and 7.7 ± 0.9 years, respectively. Indicators of age and duration of ischemic heart disease in patients of the 2nd group (58.0 ± 1.8 and 4.9 ± 0.6 years) significantly differed from the corresponding indicators of the 1st and 3rd groups (p <0.05).
The way of management in the perioperative period and the choice of multimodal anesthesia was carried out depending on the revealed disorders of platelet-vascular hemostasis on the basis of modern recommendations for the management of patients with concomitant cardiac pathology.
In patients of the first group, the following scheme was used:
- complete exclusion of drugs that affect platelet aggregation, such as antiplatelet agents, non-steroidal anti-inflammatory drugs;
- for additional anesthesia, together with narcotic analgesics, non-narcotic analgesics of central action (paracetamol) and sub-narcotic doses of ketamine were used;
- a restrictive regimen of infusion therapy (3 ml / kg hour during surgery and 15-20 ml / kg per day after surgery) with the achievement of "zero" fluid balance;
- perioperative administration of low molecular weight heparins in accordance with current recommendations;
- specific correction of platelet-vascular hemostasis disorders: ethamsylate 12.5%, 4.0 ml before surgery and in the postoperative period, 4.0 ml 3 times a day; ascorbic acid 100-200 mg before surgery and then 100200 mg per day.
In patients of the 2nd group, for multimodal anesthesia, a scheme was used that included narcotic and non-narcotic analgesics, ketamine in sub-narcotic
doses. Low molecular weight heparins were prescribed prophylactically 6-8 hours before surgery with further administration 12 hours after surgery.
In the 3rd group, the following scheme of perioperative management of patients was used:
- for multimodal analgesia, together with narcotic analgesics, non-steroidal anti-inflammatory drugs were prescribed (intravenous infusion of dexketoprofen, 2550 mg), sub-drug doses of ketamine, in patients with arterial hypertension - magnesium sulfate;
- a relatively liberal regimen of infusion therapy (5-10 ml / kg hour during surgery and 20-25 ml / kg per day after surgery) with the desired achievement of "zero" or moderately positive balance;
- perioperative administration of low molecular weight heparins according to current recommendations;
- specific correction of hemorheological disorders was carried out using the drug pentoxifylline, which has angioprotective and antiplatelet properties, 5 ml of 2% solution 2 times a day.
When using these schemes of perioperative management of patients, positive changes in the studied parameters were noted already during the operation, this tendency persisted in the p / o period (Table 1). In the majority of patients of the 1st and 3rd groups with revealed disorders of primary hemostasis, the indicators of platelet aggregation in the perioperative period were within the normal range. So the degree of platelet aggregation in patients of the 1st group was 68.2% and 63.6% during the operation and every other day, respectively; in group 3 patients, these indicators were slightly higher, but with a clear tendency towards normalization - 79.9% and 74.6%, respectively.
Clinical manifestations of increased bleeding during surgery were identified in 3 patients of the 1st group and one each of the 2nd and 3rd groups. This was manifested by a 1.5-2 times increased volume of postoperative blood loss, difficulties in surgical hemostasis and the need for additional use of hemostatics - tranexamic acid; plasma transfusion was not required for any of the patients.
When studying plasma hemostasis, no significant dynamics was revealed, all indicators were within normal values.
In the early postoperative period and with further follow-up, none of the examined patients had throm-botic complications in the form of pulmonary embolism, myocardial infarction, or acute cerebrovascular accident.
Thus, the modification of the regimen of pain relief and intraoperative fluid therapy, taking into account
the initial state of hemostasis in patients with concomitant coronary artery disease, can help normalize platelet aggregation and reduce the risk of hemorrhagic and thrombotic complications.
REFERENCES:
1. Perioperatsionnoe vedenie bolnyih s narusheniyami sistemyi gemostaza. - V kn.:Perioper-atsionnoe vedenie bolnyih s soputstvuyuschimi zabolevaniyami. Tom 2. - 2-e izd., pererab. i dop. (pod red. Zabolotskih I.B.). (rukovodstvo dlya vrachey). Moskva: Prakticheskaya meditsina, [2016. - 304s.].
2. Zabolotskih I.B., Sinkov S.V., Lebedinskiy K.M., Bulanov A.Yu. Perioperatsionnoe vedenie bolnyih s narusheniyami sistemyi gemostaza// Vestnik intensivnoy terapii. - [2015. - # 1. - S. 65-77].
3. Tromboz i gemostaz. Shkalyi i algoritmyi (posobie pod red. Roytmana E.V. i Levshina N.Yu.). [M:2016. 62 s.].
4. Marcucci C.E., Schoettker P. Perioperative Hemostasis. Springer; [2015. 454 s.].
5. Perioperatsionnoe vedenie bolnyih s soputstvuyuschimi zabolevaniyami / Pod red. I.B. Zabolotskih - M.: Prakticheskaya meditsina, [2011. -240 s.].
6. Glumcher F.S., Anesteziologicheskoe obespechenie u patsientov s soputstvuyuschey patolo-giey serdechno-sosudistoy sistemyi// «Ostryie i neot-lozhnyie sostoyaniya v praktike vracha» [5-6 (13) '2008].
7. Rozenko D.A., Ushakova N.D., Dimitriadi S.N. ANESTEZIOLOGICHESKOE OBESPECHENIE SOCHETANIEM MNOGOKOMPONENTNOY OBSCHEY ANESTEZII I EPIDURALNOY ANALGEZII V ONKOLOGICHESKOY PRAKTIKE // Sovremennyie problemyi nauki i obrazovaniya. -[ 2016. - # 6].
8. Gorobets E.S., Shin A.R., Dzhabieva A.A., Labutin Yu.A. Multimodalnaya anesteziya i analgeziya v hirurgii podzheludochnoy zhelezyi i pecheni // Re-gionarnaya anesteziya i lechenie ostroy boli. [2008. T. 2, # 4. S. 11-20].
9. Brown, E.N., Pavone, K.J. and Naranjo, M. (2018) Multimodal General Anesthesia: Theory and Practice. Anesthesia& Analgesia, [127, 1246-1258]. https://doi.org/10.1213/ANE.0000000000003668
10. Beverly A, Kaye AD, Ljungqvist O, Urman RD. Essential Elements of Multimodal Analgesia in Enhanced Recovery After Surgery (ERAS) Guidelines. Anesthesiol Clin. [2017;35(2):e115-e143]. doi: 10.1016/j.anclin.2017.01.018.
