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МЕДИЦИНА И ЗДОРОВЬЕ
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 PROSPECTS OF THE PLASMA SORPTION TECHNOLOGY UNDER
THE INTENSIVE CARE
Аннотация
По результатам раннее проведенного исследования намечены перспективные пути усовершенствования метода плазмосорбции в условиях интенсивной терапии.
Ключевые слова: новые технологии, плазмосорбция, плазмадиализ, ультрафильтрация.
Abstract
We have singled out promising ways to improve the method plasma sorption in terms of the intensive care based on the previous study.
Key words: high technology,plasma sorption, plasma dialysis, ultrafiltration
In the prior studies [1, 2], where the purpose was to explore the possibilities of applying plasma sorption (PS) under the intensive care, provided the fractional (discrete) option was going to be used. Patients with syndrome of endogenous intoxication against the background of multiple organ failure were involved in the study. The patients often had anemia, hypoproteinemia, hypotension, hypoxia. The severity of the underlying disease, the presence of these complications precluded the possibility of traditional methods of detoxification: hemodialysis, plasmapheresis or hemosorption.
The above mentioned variant of plasma sorption allowed treating small quantities of plasma (300-500 ml) through some sorbent, creating comfortable conditions for the patients during the procedure without significant pathological complications in the course of the disease. A session of PS meant multiple blood sampling for the plasma department while monitoring the patient's condition, which insured some smoothness in the procedure, minimal complications and the detoxication which was very important.
Nevertheless, a number of critical states required more intensive detoxication with the clearance of 1200-1500 ml of plasma. Such a volume of plasma could be provided by the above mentioned variant of PS. In this case the procedure of PS took 5-6 and more hours, which did not always insure the stability of the adaptive span of the patients.
To improve the intensity of detoxication and the effectiveness of PS we carried out some preparatory work in order to implement a continuous variant of PS
[3]. The whole complex of preparation included: installation of the apparatus for plasmapheresis "n0-05" (Lviv, Ukraine) and settings for rotor sterilization to reuse them for gravitational separation of blood into plasma and blood corpuscles. A particular attention was paid to the formation of the outer contour, which ensures continuity of blood flow, separation of blood, returning blood corpuscles to the body, further purification through a sorbent and returning purified plasma back into the patient's body.We worked out options to avoid contamination of biological fluids, strict aseptic and antiseptic treatment, thermal stabilization of liquid media outside the body in a closed circuit.
This version of PS makes it possible to clean, if necessary, 1.5-2 circulating plasma volumes. The time of the procedure is reduced by 2-3 times compared to the fractional option. However, the need arose for a total or regional heparinization. In addition, the option suggested the formation of additional external circulation range of biological fluids that requires greater vigilance during the procedure because of the potential number of reactions and complications in the patient.
The unit "n0-05" allows getting the flow of plasma, which becomes a proper medium for further cleaning from toxic elements: in the closed circuit on the way of plasma various detoxifying systems can be included. This can be: a column of hemo or plasma sorbent (sorption technology) hemodialyzer (to ensure plasma dialysis or ultrafiltration through a vacuum filtration), donor spleen of pigs (splenoplasmosorption). The cellular part of blood, with a separate route, avoids the effect of detoxifying systems, which in fact, is one of the significant advantages of the PS method.
The authors understand that the use of special devices that do not carry the required functions but are adapted to perform functionality not provided procedures is in itself primitive and does not provide complete safety to the patient. Therefore, the fields of efferent therapy are terra incognita for engineers.
The undeniable fact is that the combination of different detoxification technologies leads to greater resulting effect because different methods simulate a particular phase of detoxification, and when the detoxification system fails several stages of detoxification often suffer.
According to the authors, the prospects of the PS using is its combination with lymphosorption (LS) in severe cases of intoxication on the background of hepatic and hepatorenal syndromes. Such an approach ensures the implementation of several tasks: cleaning both lymph and blood plasma of toxins. The resultant effect of the detoxification is a reliable protection of the body from toxic effects. It is appropriate in the septic abdominal complications, as an addition, to have a recanalized umbilical vein through which it becomes possible to clean plasma of the portal system, avoiding exposure of the liver to toxins.
I will be also appropriate to use the sessions of PS for preoperative preparation of certain groups of patients. In patients with hepatic syndromes (jaundice), and renal (prostate cancer) failure PS with the clearance of small doses of plasma (300-500 ml) will contribute to a more tolerant postoperative period in these groups of patients.
After a series of benchmark tests in the clinic the authors used plasma dialysis in combination with ultrafiltration and PS in patients with severe chronic renal failure. Patient M., 56 years old, was diagnosed with chronic glomerulonephritis, chronic renal failure, laboratory blood parameters: urea - 31.5 mg / dL, creatinine -1394 umol / L, uric acid - 744 mg / dL. For the purpose of detoxifying the patient we received 750 ml of plasma using the sampling analysis, which was passed through hemodializator "^Kn-02-02" (a semipermeable membrane- " Cuprophan" 1 m2) of a working kidney "AHn-140" in a closed mode using a roller pump. "Sample" in the tank with dialysis fluid according to the patient's state. The volume velocity of plasma in a closed circle is 120 ml / min. After 30 minutes of work in this mode, plasma urea is 2.5 mmol / L, creatinine - 56 mmol / L, uric acid - 26 mg / dL. After 60 minutes, the plasma urea - 0.8 mmol / L, creatinine - 15 mmol / L, uric acid - 17 mg / dL. Thus, plasma dialysis opens new opportunities for traditional extracorporeal hemodialysis and can give impetus to its optimization and improvement.
In another case, the patient S., 65, was diagnosed with chronic pyelonephritis, chronic renal failure, laboratory blood parameters: urea - 57.8 mmol / L, uric acid -188 mg / dL. We received 500 mL of plasma from the patient using the descrete option, which was subjected to ultrafiltration through hemodializator "^Hn-02-02" using "dry" dialysis. As a result, we received 250 ml of ultrafiltrate with increased toxicity. In the laboratory we found that the ultrafiltrate contained 17.9 mmol / L of urea and uric acid was absent. The residue of the concentrated plasma subsequently passed the second stage of treatment - PS using fractional method (discretevariant) and returning the plasma to the patient's body. After the sorbent plasma urea was 3.9 mmol / L, uric acid - 88 mg / dL. The feasibility of such a combination of methods is possible, for example, with the excess of fluid in the body.
The current period of efferent therapy is marked with a new, as to the principle of operation, method of detoxification - MAPC system [4, 5], where dialysis technology is basic. The use of albumin- impenetrable highly stream-oriented dialysis membrane and the dialysis solution as 20% albumin enables a continued support of antitoxic liver function. Albumin containing dialysate recovers by dialysis followed by passage through a column of the first carbon sorbent and then through a column of ion exchange resins. Thus, the further development of methods of extracorporeal detoxification should be done by involving high technology.
Development of new variants of combining the efferent therapy methods and the search for new ways and methods of treating biological environments of the body requires further painstaking hard work of enthusiastic doctors and engineers. The effectiveness of intensive care for endotoxemia will rise provided improvement of existing efferent methods of detoxification both in terms of more selective removal of toxins from the body and maximum terms of cleaning liquid medium, which is a carrier of these toxins.
References:
1. ^eTOKCHKamnHa nna3M0C0p6ma y BiggmeHm inreHCHBHO i Tepanii/
B.Ф.Стащук, Ю.М.Полщук, С.О.Акентьев // Актуальш питання невщкладно! допомоги: Мaтерiaли I Украшсько! науково-практично! конференцii з невiдклaдноi допомоги, м.Одеса, 30 червня - 1 липня 1993 р. Одеса, 1993.
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2. Сташук В.Ф., Акентьев С.О. Плазмосорбщя - метод штенсивно! терaпii // Вiсник Сумського державного ушверситету. 1995. №.3. С. 104-107.
3. Массивная беспрерывная плазмосорбция при лечении заболеваний, сопровождающихся почечной недостаточностью, в условиях интенсивной терапии/ Коновчук В.Н., Калугин В.А., Станкевич Л.В., Акентьев С.А. и др. // Нефрологический семинар-98: сб. трудов VI ежегодного Санкт-Петербургского нефрологического семинара, 23-25 июня 1998г. Санкт-Петербург, Россия. СПб.: РЕНКОР, 1998. С.120-121.
4. Альбуминовый диализ в комплексной интенсивной терапии больных после кардиохирургических операций. Первый собственный опыт / Бокерия Л.А., Ярустовский М.Б., Гептнер Р.А. и др. // Анестезиолог. и реаниматол. 2005. №2. С. 78 - 83.
5. Роль и место альбуминового диализа в лечении больных с печеночной недостаточностью / Кутепов Д.Е., Пасечник И.Н., Попов А.В. и др. // Анестезиолог. и реаниматол. 2010. №2.С.53-58.
Попова В.О. студент 4 курса факультет «Лечебного дела и педиатрии» Медицинский институт НИУ БелГУ
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Ключевые слова: гигиена, психогигиена, вредные привычки, курение, алкоголь, наркотики, наркомания, насилие
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