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Functional computer monitoring system in the diagnosis of conditions that "threaten" the development of a systemic inflammatory response syndrome

Successful treatment of the systemic inflammatory response syndrome and sepsis as one of its forms should be based, first of all, on early diagnosis. As a rule, the treatment of advanced conditions that manifested themselves in the full clinical picture, unfortunately, is ineffective and leads mainly to adverse results. This position has long been well known to practical doctors, but the methods of early diagnosis of “threatening” conditions and their prevention still have no practical embodiment. The strategy and tactics of early preventive therapy, that is, to which patients, which drugs, in what dose and during which period should be prescribed, is decided differently in each medical institution, and most often every more or less experienced doctor. Thus, the identification of early, rather threatening, signs of complications is a very important task in practical terms.

Using the criteria of a functional computer monitoring system allows us to highlight a number of points in the dynamics of the clinical course, which may become crucial in determining the main trends in the development of events in the post-traumatic period. As was already emphasized in the fourth chapter, during the pathophysiological characteristics of the selected clusters, it was possible to isolate a cluster of “metabolic imbalance”, in which there is still no visible decompensation of vital functions, however, apparently, all the prerequisites are created for this.

The main one is the progression of the anaerobic nature of energy synthesis in the body, which is extremely unfavorable energetically (compared with aerobic) and leads to the accumulation of unoxidized products. At the heart of this phenomenon, as already noted, there are several mechanisms. The most probable is the blocking (by endotoxins 0) of the intracellular mechanisms of oxygen-dependent energy synthesis - the tricarboxylic acid cycle. The use of a functional monitoring system allows you to diagnose the signs of this pathophysiological profile in the earliest possible time.

A study using the criteria of functional computer monitoring of observations with a developed systemic inflammatory response syndrome and sepsis made it possible to determine that out of 53 observations with SSIR in 43 (which corresponds to 81%), they were located in the zone of the “metabolic imbalance” profile - cluster B (that is, the distance from the center of a specific observation to the center of cluster B was minimal at that moment). Thus. zone. in which the distance to cluster B will be minimal. even in the absence of clinical signs of SSVR can be considered a kind of “risk zone” for the development of this syndrome. Can. it is likely to believe that the development of a clinical sign of a systemic inflammatory response syndrome occurs against the background of metabolic disorders characteristic of the pathophysiological profile of “metabolic imbalance”. The condition of patients, as shown by clinical analysis, is characterized by instability of the main pathophysiological criteria, accompanied by the rapid dynamics of the studied parameters.

In such a situation, a functional computer monitoring system becomes especially necessary. The effectiveness of its use is clearly demonstrated using the following clinical example.

Injured S., 17 years old, March 23, 1991 entered the admission department of the clinic of military field surgery 1 hour after receiving several gunshot wounds. Along the way, the ambulance team introduced intravenously: polyglucin - 400 ml. disol - 400 ml. atropine sulfate - 0.7 ml, prednisone 90 mg. calypsol - 100 mg.

A preliminary examination revealed a penetrating wound with damage to the abdominal organs, continuing intra-abdominal bleeding. During an emergency laparotomy, up to 500 ml of blood with a large amount of fecal contents was found in the abdominal cavity, intestinal loops are hyperemic. During the audit of the abdominal cavity organs, a penetrating wound of the sigmoid colon, transverse colon, multiple penetrating injuries of the jejunum (five wounds in the 10 cm area), a penetrating wound of the antrum, a through wound of the right lobe of the liver, a through wound of the gallbladder and aperture domes.

Made suturing wounds of the transverse colon, stomach. resection of the jejunum section with an anastomosis of the end-to-end type, performed cholecystostomy. suturing wounds of the liver and the dome of the diaphragm. A section of the sigmoid colon with bullet holes is removed in the left ileal region in the form of a double-barreled unnatural anus. For decompression of the transverse colon, a cecostomy is applied. Intubation of the small intestine with a nasogastrointestinal probe was performed.

The postoperative diagnosis was formulated as follows: “Multiple combined bullet blind wounds of the pelvis. the abdomen. chest, left upper limb. Through bullet wound of the left forearm, blind thoracoabdominal bullet wound with damage to the liver, gall bladder, stomach, skinny, transverse colon and sigmoid colon, dome of the diaphragm. Continuing abdominal bleeding, diffuse fecal peritonitis, reactive phase. Alcohol intoxication. Traumatic shock of 1 degree. ”

Already after completion of the operation, which lasted six hours, in connection with the unstable condition of the victim during surgery, esophagoscopy, thoracoscopy and pericardiocentesis were performed. The bullet is removed from the pericardial cavity. In total, the patient was under anesthesia for 12 hours. In order to prevent wound infection, the wounded man was injected with a 100 ml solution of metrajil 2 times a day, ampicillin sodium salt of 1 million units. 4 times a day intravenously. Given such a severe injury - ISS = 36. artificial lung ventilation was performed with the Phase-5 apparatus; intensive therapy continued, including infusion, blood transfusion, symptomatic, cardiac glycosides. camphor preparations, corticosteroids.

25.03.91 g a day after being transferred to the intensive care unit, the patient underwent studies of the SPSK criteria, which were subsequently met daily until the end of the acute period. The trajectory of the patient's condition in the system of functional computer monitoring for the noted period is presented in Fig. 5.5. The numbers indicate the sequence of studies, and in parentheses are those clusters to which the distance at the time of the study was minimal. At three points - 3. 4, 5 - affixed days of research and time.

An analysis of the presented trajectory indicates that at the time of the first study, the wounded man was in a state as close as possible to the profile of the control values. - distance to R = 3.95.

Fig. 5.5.

The trajectory of the dynamics of the state of wounded S. in the system of functional computer monitoring


Assessment of hemodynamic parameters: stable blood pressure in the range of 120/60 - 120/80 mm Hg, pulse rate was 114 beats / min, respiration rate - 25-30 in 1 min. General clinical blood test: Hb - 130 g / l. erythrocytes - 4.7 - 1012 c / l. hematocrit - 0.46 l / l. white blood cells - 7.2-104 k / l. stab - 30%. leukocyte intoxication index - 7.3. body temperature for the entire time of observation remained within 36.2–36.7 ° C.

By the way, in accordance with the decisions of the “conciliation conference”, in this situation it was possible to diagnose a systemic inflammatory reaction, but we believe that in cases of combined trauma, a combination of all four criteria is necessary for such a diagnosis. This approach is due to the fact that in the case of severe injuries, a systemic inflammatory reaction is necessarily present as a component of the normal reaction of the body. However, with the appearance of her entire expanded picture, this process probably goes from physiological to pathological.

Analysis of biochemical parameters indicated that practically all indicators remained within the normal range (the activity of alanine aminotransferase and aspartate aminotransferase was slightly increased). The total infusion was 4.320 ml. Daily diuresis - 2.2 l without the use of diuretics. From the first day after the injury, in order to prevent the development of disseminated intravascular coagulation syndrome, the patient began to receive anticoagulant therapy - heparin and trental. To treat peritonitis and prevent its progression, the lymphatic duct was drained in the first interdigital space on the back of the foot and antegrade endolymphatic therapy was started, which included heparin, metrogil, ampicillin.

The minimum distance to the profile R (profile of normal values) during this period can be interpreted as the result of the combined efforts of surgeons and resuscitators to stabilize the condition of this wounded man, which did not allow the development of the pathological processes that appeared at the time of the injury — peritonitis, acute respiratory and cardiac failure. At the same time, it is apparently early to consider that all the difficulties of the post-traumatic period are behind us. as evidenced by the high score ARACNE II - 10.

On the second day after the injury, a sharp increase in cardiac activity is determined, with an increase in one-time (SRLZH_I = 98.85 g / m2) and minute (SI = b.15 d / (min-m2)) performance, which is so characteristic of the pattern of hyperdynamic stress response. Based on these data, it can be stated that on the second day, the development of the very stressful reaction that should accompany the injury occurred. According to the results of the analyzes, there is a slight decrease in the severity of the shift of the leukocyte formula to the left - the number of stab leukocytes decreased to 209g. the level of leukocyte intoxication index decreased to 5.2. a decrease in the integral indicator for assessing the severity of the condition is noted - on the ARACNE II scale it is 1 point. The volume of infusion therapy was planned in the amount of 2800 ml. However, at 15 hours, against the background of the ongoing infusion therapy, a rise in body temperature to 38.8 ° C was recorded. in this connection (hyperthermia was regarded as a reaction to the transfusion of the infusion medium), it was decided to refuse further therapy. During an X-ray examination on March 26, 1991, the patient was diagnosed with “the presence of fluid in the left pleural cavity”. Against this background, from 7 a.m. on March 27, v the patient had a rise in blood pressure from 130 to 160 mm Hg. An assessment of the results of laboratory control at 10 am showed that the position of the pathophysiological profile (in the system of FCM criteria) of the wounded at this point in time shifted relative to 10.00 on March 26, 91 due to a sharp increase in metabolic disturbances in the area closest to the profile of “metabolic imbalance” (Fig. 5.6.). From the presented pathophysiological pattern it follows that during this period the wounded patient decreased cardiac output and carbon dioxide tension in the venous blood. decreased arteriovenous oxygen gradient.

Distance R = 9.2; A = 17.2; B-2.3; C = 15.0; D = 9.5; C / B-6.47; D / A = 0.55

Fig. 5.6.

The pathophysiological profile of the wounded S. 03/27/91, 10 hours.

Distances to typical clusters are indicated. Legend, as in fig. 4.13.

Given the corresponding puncture data of the pleural cavity - about 100 ml of serous fluid, 1.0 ml of claforan was introduced into the pleural cavity. Infusion therapy was resumed in full. Corticosteroids were again prescribed, canceled before that - March 26. At 15 hours, studies were repeated in the FCM system (Fig. 5.7). It is clearly seen that oxygen consumption increased - the arteriovenous gradient increased, the work of the left ventricle of the heart increased, and the cardiac index increased accordingly. At the same time, all the signs characteristic of the metabolic imbalance profile were preserved - a moderate shift in the acidity of the venous blood towards an increase in pH to 7.48, with a significant decrease in the partial pressure of carbon dioxide in the venous blood, which can be regarded as a compensatory mechanism for increasing the level of lactate and the increase in acidosis .
An analysis of the criteria for SFCM shows persisting signs of the pathophysiological profile of the “metabolic imbalance”, despite the absence of signs of a systemic inflammatory response syndrome.

Distance R = 4.7; A = 10.2; B = 1.5; C = 14.3; D = 5.4; C / B = 9.7; D / A = 0.5

Fig. 5.7.

Pathophysiological profile of the wounded S. 03/27/91. 15 hours

Distances to typical clusters are indicated. Legend, as in fig. 4.13.

Thus, a rise in temperature on March 26, 91, can be regarded either as a reaction to a transfusion of an infusion medium, or as the first manifestations of a developing inflammatory process in the pleural cavity. The metabolic disturbances that arose probably as a result of “cytokine aggression” led to a corresponding reaction of the central hemodynamic system. as was noted in the results of the study at 10 a.m. Conducted therapeutic measures eliminated the cause of metabolic disorders. However, the time elapsed from the start of targeted therapy to sampling was insufficient to compensate for the disturbances that occurred, on the one hand, and, on the other hand, the inertness of metabolic disorders was apparently large enough to respond to therapeutic measures in such a short time full size. Therefore, on the presented pathophysiological profile of the condition for 15 hours, we see that the C / B ratio increased to 9.65 (compared with 6.47 at 10 hours). However, this increase did not lead to any changes in the D / A ratio, which, although indirectly, suggests the absence of a significant increase in metabolic disturbances. Obviously, only a control study is able to assess the adequacy of the therapy. The data of the study performed the next day are shown in Fig. 5.8.

Distance R = 19.3; A = 12.5; B = 18.8; C = 26.7; D = 24.3 C / B = 1.42; D / A = 1.94

Fig. 5.8.

The pathophysiological profile of the wounded S. 03/28/91, 10 hours.

Distances to typical clusters are indicated. Conventional notation, as in Fig. 4.13.

According to the trajectory of the dynamics of the state of this wounded man (see Fig. 5.5.), It can be noted that quite significant changes occurred from 15:00 on March 27 to 10:00 on March 28.

From the perspective of a functional computer monitoring system, a decrease in the C / B ratio from 9.65 to 1.42 and an increase in the D / A ratio from 0.52 to 1.94 can be noted. The minimum distance at this moment is noted to the profile of the "hyperdynamic reaction". Such dynamics of integral indicators is clearly illustrated by the pathophysiological pattern (see Fig. 5.8). In the analysis of its components, a sharp increase in both single and minute cardiac output, an increase in oxygen consumption amid a decrease in the partial pressure of carbon dioxide in the venous blood, and also a decrease in the partial pressure of oxygen in the venous blood can be noted. Thus, an adequate type of metabolic reactions is restored after their short-term disturbance. Blood tests during this period are characterized by an increase in the stab shift from 10% 27.03 to 16% 28.03. a decrease in hemoglobin from 124 to 114 g / l. marked reduction in hematocrit - during the entire period after surgery, he was in the range 0.43-046. 03/27 - 0.46. and 28.03 - 0.30 l / l. Biochemical parameters remained within normal values, with a slight increase in the activity of transaminases and alkaline phosphatase.

It should be noted that we did not diagnose the development of a systemic inflammatory reaction syndrome during the post-shock period in this wounded person due to the absence of all four of his symptoms (there was no hyperthermia). At the time of diagnosis of the minimum distance to the profile of “metabolic disturbance”, only three signs were positive.

Given the general stable situation, the normal indicators of analysis, the patient was transferred to the general surgical department for further treatment. Patients transferred to the general surgical department, as a rule, no longer need intensive therapy, so he was prescribed a reduced amount of therapy, including reogluman and subcutaneous heparin. Since the nasogastrointestinal probe was removed on March 28, enteral nutrition of the wounded began on March 29.

In order to monitor dynamically on April 1, 1991, a study was carried out on the performance of a functional computer monitoring system, which showed rather interesting results. In the trajectory of the dynamics of the state of this wounded man (see Fig. 5.5), a further decrease in the C / B ratio from 1.42 March 28 to 0.74 can be noted. and the D / A ratio after rising to 1.94 decreased again to 0.2. The minimum distance from the pathophysiological process4) while walking this wounded man was to the profile of “hypovolemic disorders” (profile D). The developed hemodynamic and metabolic disorders are clearly visible on the graph, reflecting the pathophysiological profile of this wounded man at the time of the study on April 1, 1991 (Fig. 5.9).

It is likely that the decrease in the volume and severity of infusion therapy was somewhat premature, which could affect the development of the pathophysiological profile characteristic of hypovolemic disorders. One can clearly see a decrease in the one-time productivity of the heart, while the minute productivity remaining in the normal range. Наиболее характерный признак профиля “гиповолемических нарушений” — снижение производительности сердца на фоне значительного усиления экстракции кислорода тканями — проявляется в данный момент особенно отчетливо.

Такая трактовка полученных в ходе анализа результатов исследования показателей в системе функционального компьютерного мониторинга находит свое подтверждение и при изучении общелабораторных данных. So. количество гемоглобина на 1.04 составило 104 г/л. снизившись с 128 г/л 27.03 и 114 г/л 28.03. Количество эритроцитов снизилось с 4.25- 1012 к/л до 3.55- 1012 к/л. Лейкоцитарный индекс интоксикации вырос до 11.5 (с 4.2 28.03).

Дистанция R=10.7; A=9.8; B=8.7; C=6.5; D=2.0 C/B=0.74; D/A=0.2

Fig. 5.9.

Патофизиологический профиль раненого С. 1.04.91. 10 час.

Указаны дистанции до типичных кластеров. Условные, обозначения, как на рис. 4.13.

Симптоматическая терапия, проводимая этому раненому наряду с восстановлением пассажа по желудочно-кишечному тракту, большие резервные компенсаторные возможности, молодой возраст способствовали восстановлению нормальных взаимоотношений в структуре метаболизма и между производительностью сердца и симпатическим тонусом периферической сосудистой системы.

По траектории динамики состояния этого раненого (см. рис. 5.5) последняя точка, в которой производились исследования в системе ФКМ. № 7 от 4.04.1991 г. Патофизиологический профиль этого раненого на 10 часов 4.04.1991 г. представлен на рис. 5.10. Отношение С/В осталось на прежнем уровне, а отношение D/A даже несколько увеличилось. Однако минимальное расстояние отмечено в этот момент на графике до профиля “контрольной” (нормальной) группы. Данные общеклинического обследования также подтверждают тенденцию к нормализации состояния — повышенный аппетит, нарастание гемоглобина до 118 г/л. увеличение содержания эритроцитов до 4.4 х 1012 к/л. снижение лейкоцитарного индекса интоксикации до 3.31.

Дистанция R=2.0; А=6.1; В=6.6; С=4.4; D=3.4; С/В=0.67; D/A-=0.56

Fig. 5.10.

Патофизиологический профиль раненого С. 4.04.91. 10 час.

Указаны дистанции до типичных кластеров. Условные, обозначения, как на рис. 4.13.

Как видно, за исключением несколько увеличенного градиента артериовенозного содержания кислорода, все остальные показатели находятся в пределах нормальных значений.

Приведенный клинический пример позволяет провести некоторые клинико-патогенетические параллели в ходе раннего постшокового периода у этого раненого. Быстрая доставка раненого в специализированную клинику бригадой скорой помощи позволила начать оказание хирургической помощи в возможно ранний срок. Соответствующая интенсивная терапия в ходе оперативных вмешательств и относительно небольшая кровопотеря (около одного литра) привели к стабилизации состояния, которое по критериям СФКМ было отнесено к профилю нормальных значений. В последующем развилась адекватная стрессовая реакция на полученные повреждения, что проявилось и в критериях СФКМ — минимальное расстояние в этот период (вторые сутки) было отмечено до патофизиологического профиля “гипердинамической стрессовой реакции”. Это подтверждается снижением количества лимфоцитов, а также значительным усилением сердечного выброса, увеличением экстракции кислорода тканями.

Появление на фоне инфузионной терапии гиперпиретической реакции, возможно, обусловленной и развивавшейся в этот период левосторонней эмпиемой плевры, привели к общему ухудшению состояния раненого, которое выразилось в тошноте, усилении одышки, некоторой эйфории. Вполне возможно, что эти процессы были спровоцированы находящимся в желудочно-кишечном тракте назогастро-интестинальным зондом. Следует отметить, что на следующий день после появления этих симптомов при исследовании патофизиологического профиля было отмечено, что минимальное расстояние в этот момент было до профиля “метаболических нарушений”.

Проведенные лечебные мероприятия — удаление зонда, пункция и удаление экссудата из плевральной полости, интенсивная инфузионная терапия под “прикрытием” кортикостероидов способствовали стабилизации состояния. При оценке в системе функционального компьютерного мониторинга было отмечено минимальное расстояние до профиля “гипердинамической стрессовой реакции”.

В этот же период больной был переведен на общехирургическое отделение, что. вероятно, в данном случае было несколько преждевременным. так как повлекло за собой снижение темпа интенсивной терапии. Об этом свидетельствуют нарастание анемии по общелабораторным данным и минимальная дистанция до профиля “гиповолемических нарушений” (D). Однако эта негативная тенденция не привела к какому-либо значимому изменению в течении посттравматического периода, что. вероятно, обусловлено целым комплексом причин. Среди них. видимо, сыграли не последнюю роль молодость и большие компенсаторные возможности организма, восстановившиеся от непосредственною повреждения (прошло уже семь суток после травмы).

Хотелось бы отметить, что контроль и системе функционального компьютерного мониторинга за течением посттравматического периода у этого раненого позволил определить и критический момент и в последующем оценить эффект от проведенных лечебных мероприятии.

Thus. использование критериев системы функционального компьютерного мониторинга в сопоставлении с клиническими и табора горными данными, соотнесенными к определенному моменту времени, позволило нам выделить промежуточный тип состояния между неосложненным течением и развитием синдрома системной воспалительной реакции у пострадавших с механическими повреждениями в посттравматическом периоде. Его можно охарактеризовать как “угрожающий” развитием синдрома системной воспалительной реакции. В этот период патофизиологический профиль пациента становится наиболее близким к типичному патологическому профилю “метаболического дисбаланса”, однако еще нет всех положительных симптомов, необходимых для диагностики синдрома системной воспалительной реакции. К сожалению, диагностика этого типа состояния невозможна без применения СФКМ. В то же время лечебные мероприятия, проводимые в этот период, наиболее эффективны.
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Система функционального компьютерного мониторинга в диагностике состояний, "угрожающих" развитием синдрома системной воспалительной реакции

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    “The physiological response to severe sepsis is the result of a complex interaction between sympathetically determined cardiac, vascular and pulmonary compensatory mechanisms in response to fundamental disturbances in the intermediate metabolism caused by the septic process.” JHSiegel “Physiological and metabolic correlations in human sepsis” Essentially in this chapter
    “Direct confirmation of sepsis. usually late, and decides the outcome of a quick treatment, its early start. A full diagnosis should be made on the basis of indirect signs of sepsis - clinical and laboratory. ” A.P. Kolesov “Hospital infection” The main difference between the modern stage of the study of surgical infection is the formation of in-depth ideas about the mechanisms of interaction
  9. Обоснование избранного подхода к разработке функционального компьютерного мониторинга
    Предложенная JHSiegel и соавт. |33. 35] система функционального компьютерного мониторинга основана на предположении, что применение математической методики кластерного анализа позволяет выделить типовые клинические образы (как их называет сам автор — паттерны [31. 32|). Патогенетической основой для определения таких клинических образов при некоторых критических состояниях (травма, сепсис)
  10. Dynamic monitoring of the functional state of the central nervous system, respiratory system, hemodynamics, homeostasis (2nd principle)
    ICP monitoring is leading in patients with severe OCD and swelling symptoms. The most common invasive monitoring of ICP is used for severe traumatic brain injury, after operations to remove intracerebral hemorrhages, brain tumors. However, with ischemic strokes, hypoxic and ischemic injuries of the central nervous system, an invasive ICP measurement is practically not used. therefore
  11. Понятие о стресс-реакции или адаптационном синдроме. Диагностика и профилактика стрессовых состояний
    Ведущая идея.. Стресс-реакция (стресс) является одним из защитно-приспособительных механизмов организма человека, выработавшихся в процессе эволюции как средство сохранения жизни в постоянно меняющихся условиях обитания. Дозированный физический стресс - это способ достижения резистентности (устойчивости) организма при действии на него повреждающих факторов Учебная цель. Based
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