12 декабря 2018г.
In various publications in recent years, there have been reports of increased mortality associated with the use of starch solutions of the last generation with Delta b (130/0,4 -0,42) in patients in critical conditions. Ours country colloidal solutions are used to compensate for acute blood loss in emergency surgery, so the problem of safety of their use is extremely urgent.
Objective: to determine the impact of intraoperative infusion of various types of colloidal drugs on the outcomes of surgical treatment of victims with injuries complicated by blood loss of more than 30% of BCC.
Materials and methods: The intraoperative mortality and lethality during the first postoperative day and the long-term results of mortality within 28 days after surgery were retrospectively studied in 85 patients operated for colorectal cancer in emergency cases. All patients on admission needed an emergency laparotomy due to intra- abdominal bleeding. The severity of the condition was 30 (26; 45) ISS points. On a scale APACHE II 3±2.3 points, on a SOFA scale was 4.1±0.7 points. The volume of blood loss accounted for reached an average of 1400 (2000; 2500) ml. Statistical processing of the material was carried out using the software package Statistics V. 09 Comparison of mean values in groups was performed using student's t-test. The data for quantitative values are presented in the form of median (25%; 75%), average (95% confidence interval), probability of death in the form of 95% confidence interval. The results were considered significant at p<0.05.
Results and their discussion: During the operation, the patient was administered 4975 (4768; 8177) ml of infusion media and blood components. Colloids (K) were not used in 7 (2.5%) patients, who were subsequently excluded from treatment. analysis. Only colloids 130/0, 4(0.42) were used in 26 (48.1%) patients, dextrans were used in 23 (11.6%), modified gelatin in 6 (2%), a combination of colloids 130/0, 4(0.42) with dextrans in 22 %) patients. During the operation was entered 1000 (675; 1300) ml kolloidov, which amounted to 7 (5; 11) ml/(kg×hour). Colloids accounted for 18 (13; 23)% of the total volume of infusion and transfusion media. The total dose of colloid in all cases did not exceed the recommended daily dose. In just 3 weeks of follow-up 9 people were killed (hospital mortality 29±3%), including 2 people on the operating table (intraoperative mortality 9±2%), during the first postoperative day 5 more patients (mortality for the first day 4±1.5%). The leading cause of death was a flagrant violation of homeostasis and gipotalamicheski suffering a severe shock and its effects. It was found that the probability of death increased with increasing doses of colloids (intraoperative mortality χ2=49,17, p<0.001, R2 Nagelkerke 0,292, AUC 0.821 (0.755; 0.886), p<0.001; for lethality during the first day χ2=27.769, p<0.001, R2 of Nigelkirk 0.283, AUC 0.737 (0.666; 0.807), p<0.001; for hospital lethality χ2=55.284, p<0.001, R2 of Nigelkerk 0.257, AUC 0.737 (0.666; 0.807), p<0.001). The choice of a colloid did not affect the mortality during the operation and during the first postoperative day, but changed the probability of death in the hospital (Log Rank=8,468, p=0,037). The worst results were noted in the combination of drugs (hospital mortality 7.2±4.8%; LogRank=6.806, p=0.009). The mortality rate during the infusion of dextran or HES 130/0,4(0,42) differed insignificant (Log Rank=0,6, p=0,438). The type of used colloids did not affect the frequency of development of purulent-septic complications. Creatinine and bilirubin levels during the first three postoperative days also did not differ in different types of colloids used or their combinations. Patient survival depended on the speed of introduction of colloids 130/0,4(0,42) (for intraoperative mortality LogRank=104,286, p<0.001; for mortality during the first days, p=0.001; in-hospital mortality LogRank=41,927, p<0.001). The probability of death in hospital at infusion of colloids 130/0,4(0.42) at doses of 3 and 6 ml/(kg×h) did not actually differ (LogRank=0.989, p=0.320). However, the acceleration of colloid infusion 130/0. 4 (0.42) from 2 to 5 ml/(kg×h) significantly increased the probability of death during surgery (Log Rank=10,962; p=0,001), despite the absence of significant differences in blood loss and severity. It should be noted that the rate of colloid infusion 130/0.4(0.42) correlated with the severity of the condition (ISS in points, R2=0.189,p=0.003) and blood loss (R2=0.206, p=0.002). There was no correlation between the fact of use and/or rate of administration of 130/0,4(0.42) and creatinine levels during three postoperative days (p>0.05 for all parameters), which at first approximation did not confirm the negative effect of colloids 130/0,4(0.42) on renal function in patients. The risk of developing purulent-septic complications in the postoperative period was independent of the rate of colloid administration 130/0.4(0.42) (p>0.05). Therefore, there is currently no conclusive evidence to support the high risk of intraoperative colloids 130/0. 4 (0.42). The rate of infusion of colloidal media, as one of the components of intensive therapy in life-threatening blood loss, possibly reflects the completeness of compliance with intraoperative CCC replenishment in blood loss. This assumption needs further careful analysis.
Summary: With increasing dose and rate of intraoperative colloid infusion significantly increases the likelihood of adverse outcome in patients with blood loss of more than 30% of BCC, due to the volume of blood loss. Especially unfavorable is the combination of colloidal infusion media. A relatively safe dose of colloids 130/0, 4(0.42) is not more than 4 ml/(kg×hour) or 11 ml/kg during surgery. The issue of safety of intraoperative infusion of colloidal drugs in acute blood loss in emergency Coloproctology needs further careful study.
