An to the question about the role of parenterally feed in therapy of intraoperacionnoy massive krovopoteri
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Professor a.E. Shestopalov, professor A.V. Butrov Main combat clinical hospital the name of N.N. Burdenko Russian university of friendship of people, Moscow Nosotropic role of gipovolemii in development of heavy violations of homoeostasis predetermines influence of timely and adequate correction of volemicheskikh violations on the end of operative interferences. In this connection, infuzionno-transfuzionnoy a leading role belongs to therapy in renewal and holding for some the time of adequate haemodynamic to the queries of volume of circulatory blood (OSK), normalization gemoreologii and water-electrolyte balance. At the same time, efficiency of infuzionno-transfuzionnoy therapy in a great deal depends on purposeful grounds its program, descriptions of infuzionnykh environments, their pharmacological properties and pharmakokineticss. Gipovolemiya results in diminishing of return of blood to the heart, decline of minute volume circulation of blood and expressed hypotension. As a result of it develop scray reactions, related to activating of simpatikoadrenalovoy and gipotalamogipofizarnonadpochechnikovoy systems of organism. The first is neurogenic, that by the most rapid, regulator mechanism, second gumoral`nym, included a few later, but operating longer at times. In difficult pathogeny disorders, developing after krovopoteri, an important place is taken to violations of the oxygen mode of organism with forming of cirkulyatornoy and gemicheskoy gipoksii. So, at massive krovopotere falling is inevitable system transport of oxygen which can as compared to an initial level to diminish in 35 times, that is conditioned mainly falling of minute volume circulations of blood. The enhanceable consumption of oxygen results in an increase arteriovenoznoy differences and to growth of koefficenta utilization him in fabrics. Tissue dizoksiya serves as a base for forming of anomalous mechanism of extraction oxygen by peripheral fabrics. There is it due to insufficient desaturacii entering capillaries haemoglobin. System troop landing of citokinov, catecholamins, angiotensin II, prostaglandinov is instrumental in forming tissue shunt with an underperfusion. The cages of blood (neytrofily, basophilies and other) and endotheliocytes are translated by factors aggressions, regardless of their character, in the state of oxygen explosion. In result there is the powerful troop landing by these cages in a blood stream enormous amounts neurohumors of poliorgannoy insufficiency (citokiny, eykosanoidy, oxide nitrogen, fibronectin, oxygen radicals, products of perekisnogo oxidization of lipidov, enzymes and other) of universal basis of critical conditions. Activating of komplementa, cascades kalikreinkininovoy systems, the troop landing of neurohumors is initiated development heterospecific, characteristic for the critical condition of any etiology, reactions hypermetabolism with complex violation of exchange of albumens, carbonhydratess, lipidov, increased by the expense of uglevodnolipidnykh backlogs and disintegration of tissue albumens. In accordance with the folded conception of narusheniya of carbohydrate exchange accompanied a spontaneous hyperglycaemia and increase of oxidization of glucose in fabrics. At it in spite of increase of making of glucose in a liver register gluconeogenesis, steady to introduction of exogenous glucose, combination active gluconeogenesis with tolerance of peripheral fabrics (muscles) to glucose. Disorders of albuminous obmena are characterized speed-up disintegration proteins, by mobilization of amino acid from the myocytes of skeletal musculature for active hepatic gluconeogenesis and synthesis of ostrofaznykh albumens. However synthesis squirrel does not compensate increasing katabolizm of myshechnykh and visceral`nykh albumens, that results in negative nitrous balance. The losses of albumens can arrive at more 20 gramme in days and accompanied the making progress loss of mass of body. Lipidy behave to the most expended energy sources. Process metabolism lipidov accompanied the increase of oxidization of fats, activating lipoliza, by the decline of activity of lipoproteinlipazy. Fatty fabric disintegrates on fat acids, gettings in a system blood stream and liver. Enhanceable receipt in the system blood stream of citokinov instrumental in the decline of utilization fabrics of fat acids and trigliceridov due to suppression of activity of lipoproteinlipazy. narusheniya hormonal obmena show up a noticeable increase in to blood level of adrenalin, Noradrenalinum, glyukogena and kortikosteroidov. In counterbalance to the increase of rezistentnosti to insulin his level rises in blood. Sharply utilization of energoistochnikov increases a basic exchange rises on 10100% (depending on expressed of aggressive factor). Change of metabolic processes, developing in postgemorragicheskom period, it is the reflection of general neyroendokrinnykh reactions of organism, directed on maintenance of OCK and functions of the serdechnososudistoy system at level providing to adequate perfuzii of fabrics. In the conditions of developing hypoxia the aerobnyy way of exchange changes on anaerobnyy, which is accompanied by an accumulation metabolitov. One of indexes of anaerobic inversion of metabolism at this is a lactification in place of So2, that contingently less entering of piruvata cycle of Krebsa at a hypoxia and large by a translation him in a lactat. Thus correlation lactat/piruvat and concentration lactat can increase in 45 times. vozrosshaya requirement in energies and narrow-mindedness of supplies of carbonhydratess of vyzyvaet razvitie processes of glyukoneogeneza with the increase of mobilization and katabolizma fats and albumens. As a result of it in blood accumulate intermediate and the finished goods of biochemical reactions, resulting in development metabolic acidoza and system endotoksemii. Thus value of rn blood on late stages can arrive at 7,0 with the proper increase of deficit buffer grounds, and developing respirator indemnification is frequently inadequate. Thus, ostraya krovopoterya is the factor of aggression, capable to lead to organ insufficiency and deep violations of metabolizma, that in default of timely complex and adequate therapy inevitably accompanied by development of hemorragic shock, to poliorgannoy insufficiency with high by probability of fatal outcome. A metabolic answer for stress carries phase kharakter. First phase (ebb phase) first 12-24 ch after aggression characterized the decline of temperature bodies, diminishing of consumption of oxygen, vasoconstriction. In the second phase (flow phase) there are activating of the adrenalovoy system, increase of katabolizma, increase consumptions of oxygen, rapid loss of nitrogen. At the same time on forming negative nitrous balance have influence violation feeds patient (grave condition, coma, intoxication, violations of functions of ZHKT and ò. d.) and direct loss of albumen (krovopoterya, proteinuriya, wounds, necrosises, burns and pr.). Thus weight and duration of display of metabolic violations straight depend on the degree of aggression, type of pathology and adequacy of conducted treatments. For the first phase tension of scray possibilities of organism is characteristic, mobilization power resources in behalf of vital and systems (CNS, breathing and circulation of blood). Reaction on stress extraordinarily power-hungry process. A basic endogenous energy source are myshechnye squirrel and fatty depot. The too late begun and inadequate metabolic treatment conducts an to blowing off scray possibilities of organism, and then there is a direct threat lives patient. Thus, efficiency of parenterally feed depends on to the timeliness his beginnings, to the full value of providing of organism all necessary nutrientami and optimum terms of leadthrough. The last means, that duration of PP is determined the terms of stabilizing of basic parameters metabolism. To date the decision of this task in the first phase is arrived at facilities infuzionnoy to therapy, to directed on the removal of disorders of hemodynamics, violations acid-basic state (SCYTHES), correction of gipovolemii and gas homoeostasis, and also improvement of reologicheskikh and transport functions of blood. Modern tendencies to the decline of volume of gemotransfuzii, exposed limitations for applications of solutions on the basis of dextrane, plasma and albumen of man dictate necessity of further perfection of methods and facilities infuzionnotransfuzionnoy therapies during an operation and in a posleoperacionnom period. Development and production of new colloid infuzionnykh solutions on basis gidroksietilkrakhmala (refortan, stabizol, KHAES, volyuven) and modified gelatin (gelofuzin) became the alternative of colloid plazmozameniteley on basis dextrane. On the second stage with the purpose of decline of catastatic reaction of organism, fillings in power expenses and providing of plastic processes in infuzionnuyu therapy is included by environments for a parenterally feed. Began the leadthroughs of parenterally feed obligatory conditions (PP) and mastering nutritives, entered parenterally, are: |