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Functional computer monitoring system for uncomplicated early post-shock period

A functional computer monitoring system was developed with the aim of early recognition and prevention of complications arising in patients with mechanical damage, especially the systemic inflammatory response syndrome. In this regard, a comparison was made of clinical and laboratory parameters with the parameters of the PCM system in patients who suffered severe mechanical trauma with uncomplicated early post-shock period. The main distinguishing feature of this group of victims, from the standpoint of a functional computer monitoring system, is a pronounced hyperdynamic reaction during almost the entire observation time, which indicates a normal compensatory stress response [3. 8. 9 |.

A good example of such a course of the post-traumatic period is the following clinical observation.

Affected M 16 years. and about. No. 17444 was delivered to the clinic one hour after she got into a car accident. In the route entered: polyglucin - 400 ml, reopoliglukin - 200 ml, relanium - 20 mg, calypsol - 50 mg, prednisolone - 90 mg. Upon admission to the clinic, the condition of the victim is regarded as serious. During the examination, a closed abdominal trauma and an extraperitoneal rupture of the bladder were diagnosed. An emergency laparotomy, revision of the abdominal cavity organs, suturing of mesenteric ruptures of the small and large intestine were performed. An epicystostomy and drainage of paravesical fiber were performed. The final diagnosis was formulated: “A severe combined trauma to the head, abdomen, pelvis, and both lower extremities. Closed head injury. Brain contusion of moderate severity, subarachnoid hemorrhage. Closed abdominal injury with rupture of the mesentery of the colon and small intestine, contusion of the wall of the ascending intestine. Closed fractures of both the pubic and sciatic bones, the wings of the right ilium with a mixture of fragments. Extraperitoneal rupture of the bladder. Open fractures of both bones of both legs. Torn-bruised soft tissue wounds of the left popliteal region, parieto-occipital region, chin region. 3 degree traumatic shock. ”

Stopping bleeding during the operation, as well as resuscitation measures, including replenishment of blood loss (1000 ml of erythromass and 2500 ml of plasma-mixed solutions), artificial ventilation of the lungs, the use of anticoagulants, antiplatelet agents and ganglion blockers led to stabilization of the condition six hours after being transferred to the intensive care unit therapy and resuscitation. Blood pressure is 120 and 80 mm Hg, heart rate is 78 per minute, body temperature is 36.2 ° C. The trajectory of the dynamics of the state of this victim during the entire period of stay in the intensive care unit is shown in Fig. 5.1.



Fig. 5.1

The trajectory of the dynamics of the state of patient M. in the system of functional computer monitoring

.

In accordance with the results of studies in the functional computer monitoring system, it can be noted that within a few hours after the operation, the pathophysiological profile of the victim was at a minimum distance from the profile of the “hyperdynamic stress response”. These data obtained in the PCM system are confirmed by the results of general laboratory blood tests and clinical examination of the victim.

Despite the significant amount of blood loss (over 2 liters), the degree of its replenishment was quite adequate, which is confirmed by analyzes: hematocrit - 0.36 l / l. hemoglobin - 126 g / l, red blood cells - 4.1 • 1012 c / l. The number of leukocytes is moderately increased - 9.2-U9 to / l. with a slight shift to the left of stab neutrophils - 10%. The total number of lymphocytes is slightly reduced - 0.920x109 c / l. and the segmental lymphocytic index (6.4) is doubled. which is characteristic of a normal stress response [3]. During this period, an increase in the activity of transaminases is noted: alanine aminotransferase - up to 4.48 mmol / l per hour, aspartate aminotransferase - up to 2.65 mmol / l per hour. Serum glucose was increased to 11 mmol / L.

Such changes, obviously, are directly caused by severe mechanical injury (the severity of the injury according to the 1SS criterion corresponds to 45 points), complicated by massive blood loss. The severity of the condition, assessed by the criterion APACNE II. amounted to 14 points at the time of the study. It should be emphasized that in connection with such a severe injury, in addition to adequate replenishment of blood loss with erythromass, the patient received a full range of symptomatic therapy. Including to reduce the activity of autoimmune processes, stabilize cell membranes, corticosteroids were administered at a dose of 60 mg of prednisolone 4 times a day intravenously.

Particular attention was paid to improving the rheological properties of blood by administering reopoliglukin and a direct anticoagulant heparin at a dose of 1000 sp. intravenously every hour. combining with the introduction of trental 5 ml three times a day. Cardiac glycosides were introduced - corglycon 1.0 ml twice a day and solucamfocaine - 2.0 ml three times a day. Holding this one. It is likely that the therapy that is adequate to the damage received made it possible, when studying the criteria of a functional computer monitoring system, to obtain the ratio C / B = 0.74 as an integral estimate. D / A = 1.71. The pathophysiological (functional) profile of this victim at 9 a.m. on December 5, 91 is displayed in Fig. 5.2. From the graph it is clear that he presented a rather complicated picture for analysis. Significantly increased both single and minute cardiac output, at the same time, the arteriovenous oxygen gradient was sharply increased, the partial pressure of oxygen was reduced, and the partial pressure of carbon dioxide in the venous blood was increased. The interpretation of such changes in the usual analysis of each of the indicators, of course. extremely difficult. This example can serve as a clear illustration of the effectiveness of computer assessment.

The intensive therapy and an adequate assessment of the victim's condition made it possible to perform surgical intervention on 6.12.91: the primary surgical treatment and osteosynthesis of the right and left lower leg fractures were performed by extrafocal fixation using the rod devices developed at the Department of Military Field Surgery, closed reposition and fixation of fractures pelvic bones using the same core devices.

As is known, the fixation of fractures of long tubular bones in case of combined trauma is considered an operation of choice in the very early stages after the trauma. There are opinions [2. 4. 6. 7. 10, 11] on the feasibility of performing these surgical interventions immediately upon admission of the victim to the clinic, during the period of stabilization of the main hemodynamic parameters. On the other hand, in this case, apparently, the tactics of early surgical interventions, performed after compensation for vital disorders, is preferable. The presented clinical observation can serve as evidence of the effectiveness of such surgical tactics.



Distance R-22.6; A-13.2; B-25.8; C = 19.1; D = 22.5; C / B-0.74; D / A = 1.71

Fig. 5.2.

The pathophysiological profile of the injured M. 5.12.91, 10 hours.



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



Adequately selected therapy during and after surgery made it possible to maintain the functioning of the body at the level of “normal stress response” (JHSiegel et al.) (16). This is evidenced by the remaining stable number of red blood cells, hemoglobin, hematocrit.
When studying the leukocyte blood count, there is a decrease in the number of stab neutrophils, an increase in the number of lymphocytes. This led to the fact that the segmental-lymphocytic index, which is a characteristic of the stress response, decreased to 3.9. leukocyte intoxication index - up to 4.3. A study of the performance of a functional computer monitoring system also confirms these data. When assessing the integral criteria of this system, the C / B ratio is 1.29. a D / A - 1.9 (that is, the ratio of the distance from the patient’s pathophysiological profile at a particular moment to typical profile C to the corresponding distance to typical profile B. D / A is calculated in the same way). The pathophysiological profile at the time of the study is shown in Fig. 5.3.

Distance R = 10.6; A = 9.6g; B = 14.1; C = 18.2; D = 18.3; C / B = 1.29; D / A = 1.9

Fig. 5.3.

The pathophysiological profile of the affected M. 7.12.91, 10 hours.



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

The dynamics are clearly visible in comparison with the data from 5.12.91. Within the normal range, the cardiac index became, despite the increased work of the left ventricle of the heart. The partial pressure of carbon dioxide decreased and the partial pressure of oxygen in the venous blood increased slightly while maintaining a high arteriovenous oxygen gradient. This can be interpreted as a decrease in violations of the ventilation-perfusion relationship that existed on December 5, 91, which contributed to an increase in oxygen delivery and the removal of carbon dioxide. At the same time, an increase in the C / B ratio indicates a certain (rather minimal) increase in the anaerobic mechanisms of metabolism, which is quite explainable by the intensification of reparative processes in this period.

Massive blood loss, as determined by the specific gravity of blood (1.046) upon admission to the clinic (which roughly corresponds to 2L blood loss), despite adequate replenishment with blood products, apparently leads to the development of the phenomenon of the so-called “blood sequestration”, which is expressed in the increase in anemia two to three days after the injury. The study of laboratory data on the fifth day after the injury - 12/12/91 confirms this position. The level of red blood cells decreased to 2.56x1012 cell / liter. the same trend is observed for hemoglobin - 82 g / l. although the hematocrit remained at a fairly high level - 0.33 l / l. At the same time, the white blood cell count remains within the normal range. The leukocyte formula retains a tendency to gradual recovery: the number of segmented neutrophils - 75%, stab - 6%, lymphocytes - 18%. The segmental-lymphocytic index characterizing the depth of the stress response almost returned to normal values ​​- 3.9. Normalized biochemistry indicators, including those sensitive to non-specific damage. like transaminase activity. This state fully reflects the pathophysiological profile of the indicators of the functional clinical monitoring system shown in Fig. 5.4.

The body responded to the developed anemia by enhancing the single work of the left ventricle of the heart and increasing the cardiac index, as well as by increasing the extraction of oxygen by tissues (lowering the partial pressure of oxygen in the venous blood and increasing the arteriovenous oxygen gradient). The increase in gas exchange in the lungs is accompanied by a decrease in the partial pressure of carbon dioxide in arterial and venous blood to 23 and 39 mm Hg. respectively.

Thus, the decrease in the efficiency of oxygen transport due to the increase in anemia (a decrease in the amount of hemoglobin. The main transport agent) was not compensated for by the transition to the anaerobic pathway of metabolism, which is most characteristic of the metabolic imbalance profile, but by an increase in heart productivity in order to make better use of the remaining red blood cells and increased oxygen extraction by tissues. This compensatory mechanism, which is a characteristic feature of a normal stress response, is clearly recorded using a functional computer monitoring system.

Conducted infusion and symptomatic therapy contributed to the onset of a favorable treatment outcome. It should be noted. that the number of red blood cells by the seventh day after the injury recovered to 3.25 • 1012 k / l. and hemoglobin increased to 96 g / l without additional blood transfusions. Laboratory tests performed during this period did not reveal differences from normal values. Studies of the criteria of a functional computer monitoring system showed that the minimum distance from the pathophysiological profile of this victim to the studied clusters of typical states during this period is noted to the profile of “control values” (profile R). On this day, therapy was completed in the intensive care unit and intensive care unit and the patient was transferred to the general surgical department.

Distance R = 15.6; A = 5.9; B = 19.8; C = 18.5; D = 16.3 C / B = 0.93; D / A = 2.75

Fig. 5.4.

The pathophysiological profile of the affected M. December 9, 91. 10 hours



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

The use of a functional computer monitoring system in the dynamics of the early post-shock period in injured M. made it possible, first of all, to note the predominance of “hyperdynamic stress response” throughout the observation period, which was confirmed by clinical observation data and general laboratory indicators, the absence of signs of a systemic inflammatory reaction syndrome, any or other complication of inflammatory genesis. Secondly, the use of this system made it possible to identify some pathophysiological features of the course of the uncomplicated post-traumatic period.

In all likelihood, it is advisable to attribute to them the mechanisms of compensating for the deficit in the volume of circulating blood that are characteristic for the profile of the “hyperdynamic stress response”. The decrease in the number of red blood cells due to bleeding and due to an increase in the capacity of the vascular bed (a phenomenon that develops after a period of spasm characteristic of centralization of blood circulation) is compensated by two pathophysiological mechanisms. The single productivity of the heart increases, which is also accompanied by tachycardia, which further contributes to an increase in the minute volume of blood circulation. The second compensating pathophysiological mechanism is the enhancement of tissue oxygen extraction, which is characterized by an increase in the arteriovenous oxygen gradient.

Both of these mechanisms characterize the pathophysiological profile of the hyperdynamic stress response, i.e., A. cluster, which was noted throughout the entire study period in the given clinical example.

It should be noted that, despite the signs of threatening decompensation - an increase in the partial pressure of carbon dioxide in the venous blood, a decrease in the number of red blood cells, the minimum distance is maintained to the profile of “hyperdynamic stress response”. This can serve as further evidence of the effectiveness of the functional computer monitoring technique. to identify the leading trend in the metabolism of the body of the victim.

Thus, maintaining the minimum distance to the pathophysiological profile of the “hyperdynamic stress response” against the background of a decrease in the general severity of the condition according to the ARACNE II scale or any other objective system for assessing the severity of the condition are characteristic signs of the uncomplicated course of the post-shock period.
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Functional computer monitoring system for uncomplicated early post-shock period

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