PLASMAPHERESIS IN ACUTE INTRAVASCULAR HEMOLYSIS

Transcription

1 IN SURGERY 3 1 IN ACUTE INTRAVASCULAR HEMOLYSIS The development of acute intravascular hemolysis, as a rule, is connected with immune and non-immune hemotransfusional complications, complications (mechanical, chemical, termal etc) of hardware-controlled extracorporeal hemoperfusion, Wilson-Konovalov s disease and so on. This condition may be identified as acute endotoxicosis, characterized by accumulation of different products of disintegration of erythrocytes in plasma: ions of potassium, biologically active substances, procoagulants, free hemoglobin, stroma of destroyed cells and others. Endotoxicosis is characterized by alteration of rheological properties of blood and microcirculation, hypercoagulation and aggregation of forming elements, accumulation of proteolytic ferments and vasoactive substancesl, as well as by quick development of polyorgan, first of all renal, failure. It is recommended to begin PA procedures when the initial content of the free hemoglobin in plasma is of 200 mg%, sometimes less, but with a steady trend to growing PA procedures should be started as soon as possible, at the first signs of appearance of free hemoglobin in plasma and urine Absolute: Agonal condition of the patient Relative: Hemotransfusion shock Instable hemodynamics Plasmapheresis session should be finished in case of a complete disappearance of signs of hemolysis in plasma and urine Possible complications of a high-volume plasmapheresis: hemodynamic disorders, pulmonary edema, citrate intoxication, allergic ones. Prevention: plasma substitution adequate in composition and time, intravenous administration of calcium prteparations. In case of unstable hemodynamics is possible a cardiotonic support. Quick-frozen donor plasma is transfused by way of using leucofilters after having carried out an obligatory bioassay

2 IN SURGERY 3 2 IN ISCHEMIA-REPERFUSION SYNDROME By the term ischemia- reperfusion syndrome are meant the conditions developing on the background of the restitution of the main blood flow in an organ or a segment of a limb, which has for a long time been subject to ischemia or traumatic amputation. Thus, the ischemia-reperfusion syndrome may be encountered in transplantology (transplantation of kidney, liver, heart, of a complex of organs), in vascular surgery, in replantation of large fragments of limbs with using of microsurgical technology. Biochemical disorders corresponding to the ischemiareperfusion syndrome are connected with a temporary transition of the affected organ or zone of a limb to anaerobic metabolism. The postischemic period is characterized by a massive inflow into the central blood flow of products of anaerobic metabolism, of free myoglobin, of stroma of the destroyed myofibrillas and blood cells, biologically active substances, mediators of systemic inflammatory response etc, with development of the syndrome of polyetiological endogenic intoxication. Consequence of the reperfusion syndrome is a development of polyorgan intoxication. Starting of a central blood flow in the limb which has been subject of critical ischemia or traumatic intoxication Unstable hemodynamics Surgery bleeding Plasmapheresis should be finished after recovering a normal hour-to-hour diuresis and colouration of the urine. As objective indicators of PA efficiency serve the normal indicators of the functions of the liver (bilirubin, transaminase, LDG, GGT and others) and kidneys (electrolytes, urea, creatinine) registered 8-12 hours after completing the PA procedure

3 IN SURGERY 3 3 AFTER KIDNEY TRANSPLANTATION Transplantation of donor kidney is inevitably associated with development of a posttransplantation ischemia reperfusion syndrome, which, in turn, determines the early and the delayed functions of the transplant, its actuary survivalability. What constitutes the cause of the present syndrome is heat and cold ischemia of the donor s organ in the process of its taking, transportation and preparation for transplantation. PA procedure may be recommended to all recipients in case of allotransplantation of kidneys There are no absolute contraindications for performing PA procedures in patients of this category, being possible to refer to relative ones unstable hemodynamics The efficiency of the procedure shall be assessed by the restitution of the urinary excretion function of the transplant in the postoperative period, by the terms of subnormalization of the level of creatinine, and by the number of postoperative hemodyalisis procedures. Regrettably, there are no unambiguous markers of the ischemia-reperfusion syndrome registered in organs transplantation.

4 IN SURGERY 3 4 IN LONG-TIME SQUEEZING SYNDROME AND POSITIONAL SQUEEZING SYNDROME The crush-syndrome and the positional squeezing syndrome are forms of polyendotoxicosis which development is due to a long period of critical ischemia of tissues with the following restitution of the main blood flow. The character of biochemical disturbances corresponds to those registered in postischemic disorders, presenting hypercoagulation, alteration of rheological properties of blood and microcirculation disorders. Elimination of the squeezing factor, hospitalization of the patient into the intensive therapy unit As a laboratory criterion by the beginning of the exchange plasmapheresis procedure shall serve the content of free myoglobin of 30 mg% and above (renal threshold) Unstable hemodynamics Surgery bleeding The plasmapheresis session shall be finished after disappearance of free myoglobin from the plasma. As criteria of efficiency of a plasmapheresis procedure can serve a normal level of the indicators of liver and kidneys functions registered 8-12 hours after the procedure Both conditions are characterized by a quick development of polyorgan failure.

5 IN SURGERY 3 5 AFTER COMPLICATED CARDIOSURGICAL INTERVENTIONS Operations performed with artificial or auxiliary blood circulation quite often (in 3-5% of the cases) are accompanied by complications: perioperative bleedings, myocardial infarction, DVS-syndrome, acute intravascular hemolysis, anaphylactic reactions and others. Consequences of these serious perioperative complications are breaches of blood rheology and microcirculation in myocardium and parenchymatous organs, development of endotoxicosis and early polyorgan failure. Plasmapheresis may be recommended If the cardiosurgical intervention has been accompanied by long (for 3 hours and more) or repeated artificial or auxiliary blood circulation, massive blood loss, massive blood substitution, acute intravascular hemolysis, allergic or anaphylactic reactions, development of a DVS-syndrome, perioperative myocardial infarction or others There are no absolute contraindications for performing PA procedures Relative: Unstable hemodynamics and presence of surgery bleeding. Hemodynamics is usually regulated by means of cardiotonic support The efficiency of an early postoperative plasmapheresis procedure is estimated by the readings of a number of metabolic parameters indicative of the state of the liver and kidneys functions 8 to 12 hours after finishing the operation Normal levels of bilirubin, transaminases, LDG, GGT, urea, and creatinin are indicative of the efficiency of the PA. procedure performed

6 IN SURGERY 3 6 IN THE TREATMENT OF POLYORGAN FAILURE Polyorgan failure is due to polyetiological endotoxicosis. Different variants of EC hemocorrection are used depending on the prevalence of the failure of one or another organ in the clinical picture. In the event of prevailing in the clinical picture of hepatic failure an accumulation is registered of circulating macromolecular (of 90,000 Dalton and more) liposoluble metabolites, products of disintegration of hepatocytes (hepatic ferments, bilirubin and others.). Prevalence of hepatic or hepatic-renal insufficiency in the picture of polyorgan failure There are no absolute contraindications for performing PA, and the relative ones are unstable hemodynamics, presence of a source of surgery bleeding, presence of a non-treated suppurative focus. Normalization of the modified biochemical parameters Accordingly, the possibilities of difusion or filtration EC methods herewith are reduced. PA can be used as independent method or in combination with methods of substitutive renal therapy.

7 IN SURGERY 3 7 IN ANGIOPATHIES OF DIFFERENT GENESIS Angiopathies of different genesis (aterosclerotic, diabetic, Raynaud s syndrome and disease, chronic venous insufficiency, obliterating endarteritis, obliterating thrombangiitis, non-specific aortoarteritis and others) are invariably accompanied by breaches of coagulation, viscosity of blood and microcirculation. Most of these diseases are characterized by distal forms of vascular affections and badly yield to surgical treatment. Occlusional affections of the vessels of the lower limbs (Fauntain II - IV) Inefficacy of conservative therapy Impossibility of surgical treatment There are no absolute contraindications, and the relative ones are fresh cankers and erosions of GIT, severe cardiovascular insufficiency. The efficiency of the applied therapy is valued by the general condition of the patient, the State of the struck limbs (the limbs), by the change of expent of the distance, passable for a patient without pain syndrome (intermittent lameness), as well as by the factor of the State of bones, rheology, microcirculation and coagulogram For normalization of broken parameters of the metabolism can be applied different methods of rheoapheresis, as well as plasmapheresis (PA), which allows to eliminate macromolecular compounds.

8 IN SURGERY 3 8 IN ACUTE PANCREATITIS Pancreatitis usually occurs on the background of a severe endotoxicosis due to the sharply increasing level of proteolitic ferments, activation of the processes of peroxide oxidation of lipids with suppression of the system of antioxidant protection, accumulation of toxic substances of the mediummolecular mass. But also after operative treatment the level of endotoxicosis quite often continues to grow, being one of the main causes of poor outcomes. Right after admission of a patient into the hospital for controlling so far edematous phase of pancreatitis In case of development of pancreonecrosis In case of generalization of the inflammation with development of peritonitis and polyorgan failure Irreversible affection of vitally important organs Non-stopped bleeding Reduction of the level of endotoxicosis Normalization of the level of amilase and transaminase, medium molecules, creatinin in blood, of the coagulogram Normalization of the indicators of hemodynamics In such cases, plasmapheresis (PA) is used for ensuring detoxication, preventing destructive processes in pancreas and development of polyorgan failure. Before operations PA procedures are performed for detoxication and preventing operative complications. After operations and extended bandagings PA is performed till liquidation of endotoxicosis and inflammatory destructive processes in the gland.

9 IN SURGERY 3 9 IN ACUTE CHOLECISTITIS Intoxication syndrome in acute cholecistitis presents a combination of mediators of inflammation, bilirubinеmia and transferasemia, increase of the amount of other biologically active substances, stimulated by decrease in detoxication function of the liver. Plasmapheresis (PA) is applied for: providing detoxication liquidating aftereffects of mechanical jaundice preventing When preparing for operations on the background of long mechanical jaundice 1-2 days after operations on the background of long jaundice or acute destructive cholecistitis for preventing and treating acute purulent cholangitis, peritonitis and polyorgan failure Irreversible affection of vitally important organs Non-stopped bleeding Liquidation of phenomena of endotoxicosis Normalization of clinicallaboratory indicators treating purulent cholangitis, bilious peritonitis

10 IN SURGERY 3 10 IN BURN DISEASE Two waves of endotoxicosis are observed in case of extensive burns. Right after the burn occurs an intensive absorption of the products of acute tissular destruction from the zones of thermal affections, increases the content of free hemoglobin because of destruction of erythrocytes in the vessels adjacent to to these zones. Alteration of the barrier function of the skin with open gates for infection and immunity depression create conditions for suppuration of the affected zones and sepsis with advent of a second wave of endotoxicosis. In the first hours after severe burns a PA procedure is performed for removing the toxic products entering in the blood flow from the zones of thermal affections and the products of disintegration of necrotic tissues In case of development of severe burn endotoxicosis, in order to provide detoxication and normalization of the factors of homeostasis Common for efferent therapy Elimination of endotoxicosis Normalization of hemodynamic disorders, reduction of edemas Normalization of the level of total protein and albumin in the plasma of the blood Normalization of the coagulation system of blood and immune status At later stages, in case of development of secondary inflammatory processes, in order to provide detoxication and immunostimulation

11 IN SURGERY 3 11 IN PERITONITIS Peritonitis is usually accompanied by the most severe endotoxicosis, due not only to endotoxins and exotoxins of the colon bacillus and of other gramnegative flora, to the high absorptive ability and the big area of the peritoneum, but also to the absorption of endotoxins from the lumen of the bowels as a result of activation of putrefacting fermentation under its paresis with increase of permeability of the bowel wall for such toxins. In the early postoperative period, in case of high risk of development of peritonitis In case of development of signs of peritonitis Irreversible damage of vitally important organs Non-stopped haemorrhaging Reduction of the level of endotoxicosis Normalization of the LII, of the level of amilasa and transaminases, medium molecules, creatinin in the blood, of the coagulogram Normalization of the indicators of hemodynamics All this is what motivates the indications for performing plasmapheresis (PA) in case of peritonitis.