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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 TECHNOLOGICAL FEATURES OF PLASMOSORPTION OPTIONS
UNDER INTENSIVE CARE
Аннотация
На основе практического опыта лечения тяжелых эндотоксикозов в условиях интенсивной терапии очерчены основные технологические особенности, преимущества и недостатки вариантов плазмосорбции.
Ключевые слова: детоксикация, плазмосорбция, гемосорбент, плазмафильтр, внешний контур.
Abstract
We have outlined the basic technological features, advantages and disadvantages of plasmosorption options on the basis of practical experience in the treatment of severe endotoxicosis under intensive care,.
Key words: detoxication, plasmosorption, hemosorbent, plasma filter, external circuit.
It is universally recognized that application of efferent therapy for detoxication in treating a number of diseases, including those under intensive therapy, plays a significant supporting role [1]. However, when the conventional therapy is not effective, their use often becomes crucial. Even a slight "artificial" removal of excess metabolites and toxins from the body helps to restore its own system of detoxification and accelerates the final sanogenesis. A group of known sorption methods of extracorporeal detoxification (hemosorption, lymphosorption, plasmosorption etc.), which are based on the phenomenon of adsorption and absorption, are highly efficient with respect to the removal of various metabolites, xenobiotics, average weight molecules and circulating immune complexes etc. out of the body [2]. In plasmosorbtion (PS) blood plasma is,in fact, an object for clearance, and it is separated from the blood corpuscles. This separation of blood into plasma and globular portion can be made using different technological methods based on the skills of a doctor-efferentologist who performs an active surgical detoxification, as well as on technical equipment of medical institutions. The authors, in their prior research [3; 4; 5] studied the possibility of using PS in various diseases and conditions under intensive care and resuscitation. PS, as well as other methods of extracorporeal detoxification is a direct interference in the
internal environment of the body. Therefore, during the procedure of detoxification the patient's safety and their tolerability to procedures based on their functional reserves must be a priority. Easy carrying out the procedure of PS due to the creation of additional external circuit including detoxifying systems (sorbent column, plasma filter) is equally important. PS was used at the department of anesthesiology and intensive care of regional hospital in Chernivtsi while treating 75 patients (110 sessions) with severe endotoxemia. Characteristics of the patients by gender: 48 men and 27women. Age distribution was as follows: 18 patients were under30, 45 of them - under 50 and 12 patients were over 50 years old.
Fractional (discrete) version of PS was used in 23 patients (37 sessions) with following nosology forms: severe sepsis, leptospirosis, cirrhosis, viral type B and C hepatitis, diffuse fibrinous-purulent peritonitis, acute glomerulonephritis with acute renal failure, chronic glomerulonephritis with nephrotic syndrome. Despite the fact that the method is routine, we singled out the following stages: a) preparation of the system with hemosorbent (using carbon brands "SKN-4M", "SKN-1K," HSHD "); b) preparing the patient for the procedure (a puncture of two subclavian veins, previous water stress with 200-500 ml, if necessary); c) sampling the first portion of blood in plastic containers such as "Hemakon 500/300" or in 500 ml glass bottles; d) centrifuging blood (centrifuge "PC-06" operation mode settings: 2000 rpm for 15 min); d) separating plasma from the globular part (plasmoextractor "FC-01" or a specially prepared system for sampling plasma out of glass bottles); e) reinfusion of the treated plasma and globular part to the patient (aseptic and temperature conditions); g) repeated samplings of new amounts of blood; g) end of PS session. During the session 9001200 ml of plasma was purified in the sorbent column. The advantages of this gravisurgical technique are: 1) easy implementation; 2) the availability of the technique; 3) no need for expensive equipment; 4) avoiding common heparinization. However, there are some disadvantages too: 1) extended time for performance (4-5 hours); 2) the likelihood of blood and its components supercooling during the procedure; 3) there is a risk of microbial contamination of blood components.
Continuous massive PS (current version) was included in the comprehensive treatment of 36 patients (53 sessions) with the following nosologies: leptospirosis, viral type C hepatitis, diffuse fibrinous-purulent peritonitis, necrotizing pancreatitis, acute renal insufficiency of different genesis, crash syndrome. The current version of PS, unlike the fractional one ensures a constant flow of plasma through a column of sorbent in extracorporal mode. Gravitational blood separation into the plasma and globular part was carried out by means of a domestic fractionator "PF-05" (Lviv). Parameters of the operation: the overall performance of the machine was 40-50 ml / min; the speed of the centrifuge rotor was 2000 rpm. The rate of passage of packed red blood cells and plasma through the system of the external circuit was determined corresponding to
the hematocrit rate. The rate of plasma flow was 15-25 ml / min. Thus, during a session of PS 0.5-1.5 circulating plasma volumes were purified. The authors worked out options for preanesthetic medication and regional heparinization, medication, for temperature conditions of the external circuit. The following advantages of this option for PS may be mentioned: 1) continuous operation of the external circuit; 2) reduced time of the procedure; 3) greater volume of plasma is purified for a shorter period; 4) avoiding the possibility of microbial contamination of blood components. The disadvantages are: 1) relative complexity of the procedure; 2) the need for special equipment (fractionators) and for the standard wired systems; 3) there is a risk of supercooling biological fluids in the external circuit.
Prolonged membrane PS was used in 16 patients (20 sessions) with multiple organ failure caused by infectious-toxic shock of various etiologies (peritonitis, bilateral pneumonia with abscess formation, leptospirosis, pancreatic necrosis). In the first stage we performed a membrane plasmapheresis using a standard needle system, containing plasma filter "ПФМ-800" (JSC "Nevskaya optics", St. Petersburg, Russia) [6]. On average we received 500 ml of plasma per hour. In the second stage we carried out the PS itself, through the sorbent in recirculation mode at a speed of 40-50 ml / min (duration 20-30 minutes), followed by the return of treated plasma to the patient. The prolonged membrane PS session lasted 6-7 hours. During this time we received and double purified up to 2.0-2.5 liters of plasma. The advantages of this method are: 1) a minimum of trauma in globular part of blood; 2) partially closed application circuit. The disadvantages of the technique are: 1) too long procedure; 2) obtaining less plasma for cleaning (50%).
The criterion for repeated sessions of PS was the presence of clinical and laboratory signs of intoxication. Repeated sessions are usually conducted every other day under control of the dynamics of the main markers of endogenous intoxication (total protein, albumin, creatinine, urea, "average" molecules, total bilirubin, leukocyte index of intoxication, etc.). With all the options we were ready to take necessary measures to stabilize hemodynamics and general condition of the patient. Practical experience has shown that all variants of PS can be used in conditions of intensive care. The authors understand that conventionalism and some primitive techniques are anachronic today. However, new technologies are inaccessible in remoted hospitals. Therefore, a balance between the need for active detoxication and available technical equipment in medical institutions, specialized training of physicians for efferent therapy and their sacrifice is the key to successful treatment of patients with endotoxemia in hospitals of various levels.
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4. Коновчук В.Н., Калугин В.А., Акентьев С.А., Кокалко Н.Н. Плазмосорбция при лечении больных с эндотоксикозами в условиях интенсивной терапии//Эфферентная терапия. 2003. №1. С.138.
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6. Воинов В.А. Эфферентная терапия. Мембранный плазмаферез. Москва, 2009. С.18.
Тихонов В.Э., к.мед.н. врач - ортодонт
БСП «Рязанский государственный медицинский университет» им.
академика И.П. Павлова Минздрава России
Россия, г. Рязань Григорян А.А. стоматолог
ГБУЗ Стоматологическая поликлиника г. Конаково
Россия, г. Конаково Полковникова Л.Б. врач высшей категории, стоматолог - хирург ГБУ Рязанской области «Городская стоматологическая поликлиника № 3»
Гришин М.И. интерн
кафедра ортопедической стоматологии и ортодонтии ГБОУ ВПО «Рязанский государственный медицинский университет» им. академика И.П. Павлова Минздрава России
Россия, г. Рязань ЭСТЕТИКА В ЗУБОПРОТЕЗИРОВАНИИ Аннотация: Красивая улыбка в современных условиях является не только показателем здоровья, но и залогом и показателем уверенности в себе, свободного общения и успешности. Значимое и достойное место в эстетической ортопедической стоматологии занимает художественная реставрация зубов, которая предполагает восстановление анатомической формы зуба, натурального цвета, а также восстановления зубной дуги и
