As a manuscript

GINKO VLADIMIR EVGENIEVICH

BLOOD ULTRAFILTRATION IN COMPLEX

ANESTHETIC SERVICE

FOR CARDIAC SURGERY IN CHILDREN

(clinical study)

14.00.37 - anesthesiology and resuscitation;

14.00.44 - cardiovascular surgery

Novosibirsk - 2008 3

The work was performed in the Department of Resuscitation and Intensive Care of the State Institution "Research Institute of Cardiology of the Tomsk Scientific Center of the Siberian Branch of the Russian Academy of Medical Sciences"

scientific adviser:

doctor of medical sciences, professor Shipulin Vladimir Mitrofanovich

Official Opponents:

Doctor of Medical Sciences, Professor Vitaly Evgenyevich Shipakov (Department of Anesthesiology, Resuscitation and Intensive Care of the State Educational Institution of Higher Professional Education "Siberian State Medical University") Doctor of Medical Sciences Yury Semenovich Sinelnikov (Laboratory of Congenital Heart Diseases of the Center for Pediatric Cardiac Surgery and Neonatal Surgery of the Federal State Institution "Novosibirsk Research Institute of Circulatory Pathology named after Academician E.N. Meshalkin")

Lead organization:

State Institution "Research and Production Problematic Laboratory of Reconstructive Surgery of the Heart and Vessels with the Clinic of the Siberian Branch of the Russian Academy of Medical Sciences"

(650002, Kemerovo, Sosnovy Boulevard, 6)

The defense will take place on September 10, 2008 at 2 pm at a meeting of the Dissertation Council D 208.063.01 at the Federal State Institution “Novosibirsk Research Institute of Circulatory Pathology named after academician E.N. Meshalkin. Address: Novosibirsk-55, st. Rechkunovskaya, 15; www.meshalkin.ru

The dissertation can be found in the library of the Federal State Institution “NNIIPK named after academician E.N. Meshalkin” The abstract was sent out on August 5, 2008

Scientific secretary of the council for the defense of doctoral and master's theses, doctor of medical sciences, professor Lenko E.V.

LIST ABBREVIATIONS

BP - arterial pressure AIK - heart-lung machine BEI - bioelectrical impedance ZSLZh - posterior wall of the left ventricle ALV - artificial lung ventilation EC - artificial circulation EDV - end diastolic volume EDV - end diastolic size CODE - colloid osmotic pressure ESV - end systolic volume ESV - final systolic size LA - pulmonary artery LA - left atrium IVS - interventricular septum MLW - left ventricular myocardial mass IVO - minute blood volume perfusion BCC - circulating blood volume RV - right ventricle PO - primary oxygenator filling volume LPO - lipid peroxidation PP - right atrium Rpeak - peak inspiratory pressure Pavg. - average airway pressure C - lung compliance or pulmonary compliance with SI - cardiac index SV - stroke volume UV - ultrafiltration CVP - central venous pressure ECG - electrocardiogram ECC - extracorporeal circuit Rvp. - airway resistance SaO2 - blood oxygen saturation Relevance research topics. The number of operations performed annually for CHD all over the world and in Russia in particular is steadily increasing. At the same time, the number of surgical interventions in children with complex CHD, performed during the neonatal period, is increasing. Improving the results of surgical treatment of children with congenital heart defects is largely due to the improvement of the methods of anesthetic support for operations, the expansion of the possibilities of artificial circulation and the prevention of complications associated with the use of this method [Menshugin I.N. 1998, Stark I. 1997, Gaynor J.W. 2001, Boodhwani M. 2006, Williams G.D. 2006].

The anesthesiologist and perfusionist who provides cardiopulmonary bypass in a child, first of all, faces the problem of hemohydrobalance disturbance and its correction. The reasons for the violations are as follows: a significant discrepancy between the primary volume of filling the circuit of the heart-lung machine and the volume of the child's circulating blood, the forced need to use transfusion media, the physiological hydrophilicity of the tissues of the child's body, imperfect kidney function, the use of hemodilution and hypothermia, the lack of complete biocompatibility of the materials of the extracorporeal circuit and the patient's blood . All this leads to the activation of enzymatic cascades, the development of a syndrome of increased “capillary sweating” and tissue hyperhydration [Menshugin I.N. 1998, Dittrich S. 2004, Elliott M.G.

1993, Journois D. 1995, Michelle S.C. 2004, Naik S.K. 1993].

Of the existing methods for correcting the syndrome of hyperhydration, the most effective, according to a number of authors, is blood ultrafiltration. [Osipov V.P. 1992, Yarustovsky M.B. 1998, Elliott 1993, Gaynor J.W. 2001, Journois D. 1994, Naik S.K. 1994 Williams G.D. 2006].

Currently, the effectiveness of the impact of MUF on the children's body is widely studied. Many works have been published showing the high efficiency of this procedure in terms of reducing tissue edema [Pak 1999, Ad Gaynor J.W. 2001]. Such positive effects of MUF as an increase in blood pressure, hemoconcentration, an increase in plasma oncotic pressure have been noted, the dynamics of some biochemical parameters, the level of inflammatory mediators, and myocardiodepressive factors have been studied [Yarustovsky 98, Blanchard N 2000, Dittrich S. 2004, Gaynor J.W. 2001]. Recent studies in this area are devoted to comparative evaluations of various ultrafiltration techniques, assessment of cerebral blood flow during the procedure, and the effect of the technique on mortality after cardiac surgery. Published review articles prove that the use of ultrafiltration in both pediatric and adult cardiac surgery significantly reduces the need for the use of transfusion media.

It seemed interesting to us to improve the MUF technique and evaluate its effectiveness in the complex of anesthetic support for pediatric cardiac surgery, thereby supplementing the available data on the effects that MUF has on the child's body and the course of anesthesia.

Purpose of the study To improve the method of modified blood ultrafiltration as a component of cardiopulmonary bypass during cardiac surgery in children and to evaluate its effect on the course of anesthesia, homeostasis and clinical parameters.

1. Compare the proposed method of blood FMU (patent for invention No. 2190428 dated October 10, 2002) with the method of Elliott M. J.

2. To study the effect of a new method of modified blood ultrafiltration on perioperative central hemodynamics and respiratory biomechanics.

3. To study the pharmacokinetics of fentanyl during modified blood ultrafiltration according to our method and, based on the data obtained, optimize the tactics of anesthesia.

4. To evaluate the effect of the developed method of modified blood ultrafiltration on biochemical and clinical parameters in the postperfusion period.

Scientific novelty 1. A new method of modified blood ultrafiltration has been developed as a component of cardiopulmonary bypass in pediatric cardiac surgery.

2. The effect of our method of modified blood ultrafiltration on intraoperative central hemodynamics and the morphofunctional state of the myocardium was studied.

3. The effect of the proposed method of modified blood ultrafiltration on the parameters of respiratory biomechanics and blood gas composition was studied in 4 patients. For the first time, the effect of the method of modified blood ultrafiltration on the intraoperative pharmacokinetics of fentanyl was studied.

5. The influence of the developed method of modified blood ultrafiltration on the indicators of the acid-base state of the body and hemostasis was studied.

The difference between the obtained new scientific results and these results obtained by other authors In contrast to the method of modified blood ultrafiltration proposed by Naik S.R. end Elliott M.J. in 1991, our proposed technique does not require additional cannulation of the right atrium. Fluid removal can be carried out during the entire perfusion, and the duration of the procedure after cardiopulmonary bypass is shorter in time by 45.4%. Patent for invention No. 2190428 dated 10/10/2002.

The fact of an increase in blood pressure by the end of the modified ultrafiltration was mentioned in the works of Elliott 1994, Yarustovsky 1998. Davies 1998 and Blanchard 2000, evaluating the echocardiographic picture, noted an improvement in the systolic function of the left ventricular myocardium. In contrast to these data, in a comprehensive study of hemodynamics, we for the first time established a positive effect of the proposed method of modified ultrafiltration on total pulmonary and peripheral resistance, diastolic myocardial function. There was a decrease in the mass of the left ventricular myocardium and normalization of the morphological picture after the procedure.

Regarding the biomechanics of respiration in the literature, we came across the works of Nikolaenko 1996 and Kozlov 1997, in which the authors note that artificial circulation in adults worsens pulmonary compliance, increases airway resistance, leads to the formation of dys- and atelectasis, worsens pulmonary ventilation and gas exchange. We have conducted such studies for the first time in children operated on the open heart, showing the positive effect of the proposed method of modified ultrafiltration on the parameters of respiratory biomechanics and gas exchange.

In the literature, we found a single report by Hodges et al.

1994, who investigated the plasma concentrations of fentanyl in neonates operated under cardiopulmonary bypass. Unlike us, they used significantly higher doses of fentanyl for anesthesia and removed smaller volumes of ultrafiltrate. Therefore, they did not receive a significant decrease in plasma concentrations of this drug after modified ultrafiltration. In our study, we showed that 28% of the plasma concentration of fentanyl undergoes filtration, the drug is determined in the ultrafiltrate, and its concentration in the blood decreases significantly after ultrafiltration in our category of patients.

In our study, we showed that in the course of modified ultrafiltration, bicarbonate buffer is eliminated from the blood, which leads to an increase in compensated metabolic acidosis and requires appropriate correction. We have not been able to find information in the available literature on the study of the acid-base state in children operated on under conditions of cardiopulmonary bypass and modified ultrafiltration.

Practical significance The expediency of improving the technique of modified blood ultrafiltration as a component of anesthesia and perfusion during open-heart cardiac surgery in children is theoretically substantiated. The clinical efficacy of the proposed method of modified blood ultrafiltration, its beneficial effect on intraoperative hemodynamics, external respiration, homeostasis, and the clinical outcome of the operation were confirmed. The tactics of anesthesia and perfusion adapted to the new method of modified blood ultrafiltration during open-heart cardiac surgery in children have been developed.

Reliability of conclusions and recommendations Conclusions and recommendations are based on the results processed by modern statistical programs. The analysis of the data of 69 patients was carried out, 44 of which underwent the procedure of modified blood ultrafiltration, which is evidence of the reliability of the conclusions and recommendations formulated in the thesis. All conclusions and recommendations were published in peer-reviewed publications and received no criticism.

Brief description of the clinical material (object of study) and scientific methods of research In our work, in order to solve the set tasks, we studied the course of the intraoperative period in 69 children with congenital septal defects operated under EC conditions in the Department of Cardiovascular Surgery of the State Research Institute of Cardiology, TNTs SO RAMS during the period from 1998 to 2004.

All operated children were divided into 2 groups. The criterion for dividing into groups was the modified ultrafiltration procedure. In the control group (n=25), surgery did not include ultrafiltration. Patients of the main group (n=44) were divided into 2 subgroups. In subgroup 1 (n=15), at the initial stage of the study, modified ultrafiltration was carried out according to the scheme proposed by Elliott M.J (Fig. 1). In subgroup 2 (n=29) the scheme developed by us was used (Fig. 2).

Rice. 1. Scheme of modified ultrafiltration according to Nike and Elliott (1991). Fig. 2. Scheme of modified blood ultrafiltration developed at the OSSH Research Institute of Cardiology (Author's certificate No. 2190428 dated October 10, 2002). The age of operated children in the main group was 2.7 (2.0; 3.9) years, body weight 11 (10 .5; 14.0) kg. Male patients - 15 children, female - 19 children. In the control group, the age was 2.5 (2.0;4.0) years, body weight was 12 (11.1;13.3) kg. Male patients - 10 children, female - 15 children. The patients were comparable in terms of the nature and severity of the defect, the time of cardiopulmonary bypass, and had a standard protocol for anesthesia and perfusion.

The material obtained during the study was processed using the integrated system of statistical analysis and processing of results STATISTICA® 5.0. Stat Soft® Inc., USA, 1984-95. Distribution normality was assessed using the Shapiro-Wilk W-statistic at n50. Statistical significance was assessed using T test Wilcoxon, U test Mann-Whitney, criterion 2. Results are presented as Me (25;75).

Used equipment, equipment and apparatus In the course of work in the intraoperative period, the parameters of central hemodynamics were studied using SIEMENS SC 9000 XL monitor complexes (Germany). Minute blood volume and structural and functional parameters of the myocardium were determined using transesophageal echocardiography on an Aloka SSD-2200 Vario View ultrasound system (Japan) using a multiplane transesophageal transducer with a frequency of 5 MHz. Breathing biomechanics indicators were studied using a Puritan Bennett 7200 microprocessor ventilator. The study of the concentration of fentanyl in the blood and ultrafiltrate was carried out on an IBM-compatible automatic auto-analyzer TA manufactured by Technoanalyt at Tomsk Polytechnic University. Biochemical homeostasis was assessed using a Stat profile 5 gas-electrolyte analyzer from NOVA Biomedical (USA). Biochemical methods for studying blood and its coagulation system were also used.

Personal contribution of the author in obtaining new scientific results of this study. The author was directly involved in the conduct of anesthesia or cardiopulmonary bypass in the vast majority of patients included in the study material. The applicant independently conducted a study of indicators of central hemodynamics, biomechanics of respiration, acid-base state, assessed the clinical course of the postperfusion period. The obtained data were statistically processed and analyzed by him.

I would like to express my special thanks and appreciation to Valery Olegovich Kiselev, Doctor of Medical Sciences, for his consultative assistance in the preparation and execution of the dissertation work.

Approbation of work and publications on the topic of the dissertation Basic provisions, conclusions and practical recommendations were reported at the Second Annual Scientific Session Bakulev with the All-Russian Conference of Young Scientists (Moscow, 1998), the Fourth All-Russian Congress of Cardiovascular Surgeons (Moscow, 1998), the Tenth All-Russian Congress of Cardiovascular Surgeons (Moscow, 2004), the Anniversary Conference dedicated to the memory of Academician of the Russian Academy of Medical Sciences E.N. Meshalkin (Novosibirsk, 2006), the Twelfth All-Russian Congress of Cardiovascular Surgeons (Moscow, 2006) and published in the central scientific and medical literature.

The proposed method of modified blood ultrafiltration after cardiopulmonary bypass in patients with congenital heart defects was introduced in the cardiosurgical department of the Primorsky Regional Clinical Hospital No. 1 (Vladivostok) (act of implementation No. 43 dated 16.01.2007) and in the Department of Cardiovascular Surgery of the Republican Hospital No. 1-NTsM of the Ministry of Health of the Republic of Sakha (Yakutia), Yakutsk (act of implementation No. 2 dated 10.01.2007).

Structure and scope dissertations The dissertation work is framed in the form of a specially prepared manuscript, set out on 139 pages. The text is designed in accordance with the requirements for works sent to print. The work consists of an introduction, 6 chapters, conclusions, practical recommendations, a list of references, contains 26 tables, 15 figures. The bibliography lists 222 sources (of which 139 are foreign).

Basic provisions for defense 1. Carrying out the blood MUF procedure according to the developed method in children operated under EC conditions reduces myocardial edema, normalizes its morphofunctional state, and has a positive effect on central and peripheral hemodynamics. At the same time, the dynamics of respiratory biomechanics and blood gas parameters associated with fluid accumulation and interstitial pulmonary edema significantly improves.

2. During the MUF procedure according to our method, fentanyl undergoes ultrafiltration, but this does not adversely affect the course of anesthesia and central hemodynamics. At the same time, the change in the acid-base state of the blood towards compensated metabolic acidosis requires appropriate correction.

3. The use of the MUF procedure according to the presented method improves the clinical course of the intraoperative period in children operated under EC conditions.

MAIN RESULTS OF THE RESEARCH

In our study, a new method of connecting a filtration column to a perfusion system was tested. This arrangement of the ultrafilter makes it possible not only to carry out blood MUF without additional surgical procedures, but also to control the degree of hemodilution by carrying out hemoconcentration during EC. To assess the benefits of our scheme, patients were divided into two subgroups. In subgroup 1, MUF was performed according to the Elliott method (n=15), in subgroup 2, according to the proposed method (n=29). At the stages of the study, the level of hematocrit, protein concentration, and the time of the procedure were assessed (Table 1).

Dynamics of hematocrit and protein in subgroups at study stages Before IC 35.4 (33.1;37.2) 64.2 (61.3;68.7) 35.1 (32.8;36.9) 65.1 (61.9;68.6) Start of IC 24.2 (23;24.9) 52.6 (50.3;55.7) 24.4 (22.9;25) 53.2 (50.9 ;56.6) After cardioplegia End of IC 21.1 (20;22.4) 46.1 (44.1;49.8) 26.3 (24.2;27.1)* 54.1 (51. 2;58.3)* After UV 33.8 (32.1;35.2) 59.3 (56.8;62.5) 34.2 (33.1;36.3) 60.2 (57 .4; 63.9) End of operation UV time (min.) 502;706) ml versus 534 (492;657) ml). During EC in subgroup 2, the level of Ht and protein concentration remained stable and exceeded similar indicators of the comparison subgroup by 11.5% (p0.05) and 13.1% (p0.05), respectively.

At the same time, due to the volume of fluid removed during perfusion, the volume removed after the end of EC also decreased. This significantly shortened the time of the FFM procedure itself. In our case, the duration of the MUF in subgroup 2 was 8.1 (6.5; 10.9) minutes, which is 45.4% (p0.05) less compared to the Elliott method.

An analysis of the clinical course of the intraoperative period clearly demonstrated the effect of blood MUF on the main hemodynamic parameters (Fig. 3).

Note: *Р0.05 in comparison with the data obtained after EC. The obtained data showed that after the MUF according to our method, there was a significant change in a number of integral hemodynamic parameters, which were not observed in the control group, where this procedure was not performed. Thus, the increase in the mean blood pressure was 18% (p0.05), while the calculated OPS was within the physiological range and tended to increase slightly. After the MUF, the pressure in the LA in the main group decreased by 15% (p0.05), and the OLS by 24.4% (p0.05), while in the control group there was no significant change in the pressure in the LA and the OLS.

The decrease in heart rate after MUF reached 6% of the values ​​obtained immediately after the restoration of independent hemodynamics. At the same time, the minute blood volume increased in the main group by 11.5% and significantly differed from the median values ​​of the comparison group (p0.05). The positive dynamics of the hemodynamic parameters presented above led to an increase in SI by 11.7% (p0.05).

We evaluated the data obtained in conjunction with the dynamics of structural and functional parameters of the left ventricular myocardium. Functional assessment of the dynamics of the state of the myocardium during the MUF according to our method was carried out using intraoperative transesophageal echocardiography.

The data are presented in table. 2 and 3.

Dynamics of dimensional and volume parameters of the left ventricle at the stages of the study (Me (25; 75)). Main gr. (n=29), control group. (n=25) CDR (mm) CDO (ml) Main. 30.5 (24.6;33.6) 32.7 (28.3;37.4)* 32.7 (28.4;37.5)* CSR (ml) Main. 10.2 (9.4;13.3) 9.3 (8.7;12.8)* 9.2 (8.8;12.7)* SV (ml) EF (%) Note:* - p0.05 compared with the stage after CPB and between groups. Dynamics of thickness of the IVS, RLSV and MMLV at the stages of the study (Me (25; 75)). Main group (n=29), control group (n=25) 45.6 (38.7;52.3) 43.2 (36.4;50.4)* 43.1 (36.5;50)* between groups The study showed that after the end of the MUF procedure in the main group, the thickness of the LVL decreased by 6.6% (p0.05), and the IVS by 5.7% (p0.05). At the same time, there was an increase in CDR by 3.6% (p0.05) and a decrease in CFR by 5.6% (p0.05). Accordingly, LV volume parameters changed. RR increased by 7.2% (p0.05), while CSR decreased by 9.9% (p0.05). These changes led to an increase in EF by 4.8% (p0.05), and SV by 20% (p0.05). Clear evidence of a decrease in myocardial edema was a decrease in LVML by 5.5% after MUF (p0.05).

Similar positive dynamics was noted in the study of the morphological structure of the myocardium. A study was made of segments of the RA myocardium, which were taken before CPB, after CPB, and after MUF (Fig. 4,5,6).

Rice. Fig. 4. Myocardium of the auricle of the right pre-Fig. 5. Myocardium of the right atrial appendage before connecting the IR. Staining of the heart after IR. Pronounced total hematoxylin-eosin. SW. x 100 edema of cardiomyocytes and interstitium.

Rice. 6. Myocardium of the right atrial appendage after MUF.

Decreased interstitial edema after MUF. Hematoxylin-eosin stain. Magnification x The obtained data made it possible to reveal the reliable dynamics of the morphological pattern. Changes caused by the presence of congenital heart disease transformed into reliable histological signs of myocardial edema:

cardiomyocytes lost their transverse striation, small vessels became empty, swelling of collagen fibers occurred. The specific volume of edema reached 0.196 (0.168; 0.221) mm3/mm3. After the MUF was performed according to our method, the edema of the interstitial tissue of the myocardium decreased almost to the initial state.

At the same time, the specific volume of edema was 0.10 (0.08; 0.182) mm3/mm3, and transverse striation was restored in cardiomyocytes.

Assessing the pulmonary blood flow, we could not help touching on the issue of the impact of the presented method of MUF on the dynamics of the biomechanical properties of the lung tissue and blood gas composition. The studied parameters were studied at the following stages of surgery: stage 1 - the beginning of the operation; 2nd - before IR; 3rd - restoration of independent hemodynamics after EC; 4th after MUF (for the main group) and 15 minutes after CI (for the control group); 5th - the end of the operation (Table 4).

Dynamics of respiratory biomechanics parameters in comparison groups (Me (25; 75)). Main group (n=29), control group (n=25) Stage (16.5;21 (15.5;21) (3.8;5.6) (3.8;5.6) (28; 32) (27;32.5) (29.2;33) (31;34) (14;19) (14;19.5) (3.6;5.2) (4.3;5.1 ) (27;30) (26.5;30) (30;34) (31;34.6) (19;23) (19;24) (4.7;6) (4.9;5.8 ) (34;36) (32.7;37) (34;37.2) (34.1;38) (15;21) (21;24) (3.6;5.7) (5.0 ;5,6) (28;32) (33;38) (32;36) (35;39)

* - p0.05 compared with stage 1;

** - p0.05 compared with stage 1 and 2;

*** - p0.05 compared with stage 3 and between groups;

# - p0.05 compared to step 1 and between groups.

Assessment of the parameters of the biomechanics of respiration at the stages of the study showed that EC worsens the biomechanical properties of the lungs in children during cardiac surgery. After the MUF procedure according to our method, the main group showed positive dynamics in terms of respiratory biomechanics. There is a decrease in Rpeak. by 10%, Rav. by 5.3%, Rdp. by 3.6%, and the extensibility of the lung tissue increases by 17.4%. Accordingly, the oxygen tension in the arterial blood after MUF increases by 21.7% (Fig. 7). In the control group, the negative changes in the biomechanics of respiration and blood gas composition that occurred after the end of EC did not significantly change by the end of the operation.

Note: * - P0.05 compared with stage 1 and # - P0.05 compared with stage 1 and between groups at stage Fig. 7. PO2 of arterial blood at the stages of the study In previous studies, some authors note that the MUF procedure leads to an increase in blood pressure [Yarustovsky M.B. 1998; Naik S.K. 1994; Blanchard N. 2000; Michelle S. Chew 2004].

Our study of hemodynamics confirms these data. To explore the possible reasons for this phenomenon, it was hypothesized that the removal of a significant amount of fentanyl from the bloodstream during filtration may cause pain and, as a consequence, an increase in blood pressure. Based on this, we assessed the dynamics of the concentration of fentanyl in blood plasma in patients who did not undergo MUF and in patients who underwent blood MUF according to our method (Fig. 8).

The method of induction and maintenance of anesthesia using the central analgesic fentanyl was identical in the comparison groups. By the end of EC, the dose of administered fentanyl was comparable in the groups and was within 32 µg/kg by median values. At the same time, the concentration of the drug in the blood of patients in the control group was 6.45 (4.8; 11.82) ng/ml. In the analysis taken after 10 minutes, it was 6.03 (4.61; 11.02) ng/ml. Thus, the natural elimination of the drug during this time period was 6.5%.

Note: * - P0.05 between groups at the study stage 8. Dynamics of fentanyl concentration in blood and filtrate A different picture was observed in the main group. The concentration of fentanyl at the end of EC was within 6.69 (5.85; 12.39) ng/ml. At the 3rd minute of filtration, the drug concentration decreased to 4.58 (4.03; 8.51) ng/ml. At the same time, fentanyl was determined in the filtrate at a concentration of 1.28 (1.12; 2.38) ng/ml. At the 6th minute of filtration, the concentration of fentanyl in the blood was 3.15 (2.88; 5.94) ng/ml, and in the filtrate 0.88 (0.77; 1.66) ng/ml. After the end of the MUF, the concentration of the drug in the blood was 2.18 (2.01; 4.09) ng / ml, and in the final portion of the filtrate 0.61 (0.53; 1.1) ng / ml. Comparing the blood and filtrate concentrations of fentanyl at each stage of the study, we found that the average fentanyl filtration rate was 28% when performing the FFM according to our method.

In addition, there is a natural elimination of the anesthetic. In this regard, during ultrafiltration every 3 minutes there was a total decrease in the concentration of fentanyl in the blood plasma by an average of 31-32%. In total, during the period of MUF after stopping the EC, the concentration of the narcotic analgesic decreased by an average of 67.4%.

Thus, the concentration of the drug in the blood serum during anesthesia and MUF according to our method was not lower than 2 ng/ml, the minimum level that, according to some authors, is necessary to maintain and maintain anesthesia at the end of the operation.

In the final chapter of our study, we evaluated some of the clinical effects of MUF with our method and also examined the effect of this procedure on biochemical homeostasis. First of all, we assessed the level of water load in children operated without the use of MUF (control group) and children who underwent ultrafiltration during and after CPB (main group). The water load included the fluid transfused before and after CPB, the volume of filling of the extracorporeal circuit, cardioplegia, additions to the oxygenator.

It should be noted that the filling volume of the extracorporeal circuit for the control group was 450 ml, and for the main 520 ml, because. included the filling volume of the ultrafilter system. Fluid loss in addition to the physiological need was blood loss, diuresis, discharge of the gastric tube and the volume of the removed filtrate (for the main group). As a result of the comparison, we noted that using our FMU scheme, during and after the end of perfusion, we were able to remove up to 567 ml of fluid according to median values. In addition, attention was drawn to the fact that in the main group diuresis was less by 55%, separation by gastric tube by 51.4%, and surgical blood loss was lower by 23.5%. In the control group, the amount of fluid transfused after CPB was 63% more than in the main group. Summing up the calculation of the water balance by the end of the operation, we received a significant plus in patients in the control group (up to 300 ml according to median values). The corresponding indicator of the main group was 45 ml according to the median values ​​and was 85% less than in the comparison group. As a result, Ht in patients who received MUF was higher by the end of the operation by 29%, and the protein concentration by 19.5%.

Interpreting the obtained data, we believe that lower diuresis, significantly lower gastric secretion, lower blood loss in patients of the main group are the direct result of timely removal of fluid with the help of MUF. This also contributes to the higher level of Ht and protein concentration in these patients. In children of the control group, despite a pronounced positive water balance, the volume of fluid transfused after CPB was more than 2.5 times greater than in the main group. We explain this by active diuresis, which often requires stimulation, the need to maintain BCC and increase hemoglobin.

When studying the effect of MUF on the dynamics of electrolytes, we found that the electrolyte composition of the ultrafiltrate was similar to the electrolyte composition of the blood and included sodium at a concentration of 138.4 (135.2; 141.7) mmol/l, potassium at a concentration of 4.3 ( 3.9;4.8) mmol/l, calcium at a concentration of 1.1 (0.9;1.2) mmol/l and magnesium at a concentration of 0.56 (0.47;0.69) mol/l. In addition, glucose was determined in it at a concentration of 6.2 (5.1; 6.7) mmol/l and urea at a concentration of 3.1; 4.4) mmol/l. Unlike blood, proteins and bilirubin were not detected in the ultrafiltrate. Despite the fact that electrolytes are removed with the ultrafiltrate during the MUF process, the electrolyte composition of the blood remains unchanged. We explain this by the fact that electrolytes are removed proportionally with water, and the fluid of the third space entering the blood is isoelectrolyte.

Assessing the dynamics of the acid-base state, we noted that MUF is accompanied by the removal of bicarbonates from the blood. As a result, there is a shift in the acid-base state of the body in this group of patients towards compensated metabolic acidosis (Table 5).

The effect of MUF on the dynamics of the acid-base state (Me (25; 75)) nat (mmol/l) (23.4; 24.9) (26.6; 27.8) (19.4; 21.9) ( 26.7;27.7) (mmol/l) (20.7;22.4) (23.9;26.1) (17.7;19.6) (23.7;26) bases (mmol /l) (0.4;1.7) (3.8;5.2) (3.8;5.1) (3.7;5.4) Note: *-P0.05 compared with the initial stage By expressing the pH values ​​in absolute (nmol/l), and not in logarithmic values, we obtained a decrease in this indicator during the MUF by 23.7%. At the same time, we noted a decrease in standard bicarbonate by 14.4%, and true bicarbonate by 16.4%. The resulting base deficit was -4 mmol/L median. Based on the average body weight (11 kg) and the volume of the removed ultrafiltrate (560 ml on average), we found that in this category of patients, up to 10-11 mmol of bicarbonates are lost during the MUF. We found an explanation for the results obtained in the work of Clar A. 2000. In their study, they studied the filtration coefficients of various ingredients and found that for sodium bicarbonate it is equal to 1. This means that the concentration of bicarbonate in the ultrafiltrate is equal to its concentration in the blood. Thus, it must be borne in mind that the concentration of a substance, whether it be sodium bicarbonate, urea, an anesthetic, an antiarrhythmic, or even an ion such as calcium, can be reduced below the physiological or therapeutic level as a result of a long period of hemofiltration.

Our study of hemostasis showed that the most sensitive to the operation with EC in children is the platelet link.

Analysis of the obtained results allows us to say that in the comparison groups after the end of the IC, there is a pronounced decrease in the number of platelets. By the end of the operation, their content is up to 45% of the original values.

At the same time, there is an increase in the aggregation ability in groups by approximately 15%. There was no significant effect of MUF on these parameters, and an unreliably lower platelet count in the main group by the end of the operation, apparently due to the presence of an additional ultrafilter membrane in the circulation circuit.

Conducting EC also affects the coagulation component of the coagulation system. The data obtained are consistent with previous studies, both in adult and pediatric cardiac surgery [Svirko Yu.S.

2000, 2001; Leyh 2001]. So, by the end of perfusion, the prothrombin time increases by 2.3 times, and the thrombin time by 2 times compared with the initial values. Carrying out ultrafiltration in patients of the main group has a positive effect on the dynamics of these indicators. Thus, prothrombin time decreases by the end of the operation by 25% compared with postperfusion values, and thrombin time by 44.6%. Similar changes are noted with the concentration of fibrinogen in the blood. After CPB, the content of this coagulation factor decreases in groups by an average of 32.3% and is within the lower limit of normal. After the MUF in the main group, the content of fibrinogen increases by 40.9% and approaches the initial values. The data obtained allow us to speak about an increase in coagulation potential after hemoconcentration.

The study of the anticoagulant system suggests that it is also influenced by the negative aspects associated with operational stress and EC. After perfusion and at the end of the operation, there is an increase in fibrinolytic activity by 15% compared with the outcome. Conducting the MUF did not have a significant impact on this indicator.

The study of the clinical effects of blood MUF according to our method in this category of patients also revealed a number of positive aspects. Thus, the use of our methodology allows us to reduce the use of initial doses of inotropic support by more than 16%, medium doses by 12-15%, and not to use high doses of inotropic drugs at all. At the same time, the need for any inotropic therapy in patients of the main group is 46.4% less than in the comparison group (Table 6).

The need and level of inotropic support in the comparison groups Inotropic therapy Dopmin 10 µg/kg/min + epinephrine 0.05 µg/kg/min Dopmin 10 µg/kg/min + epinephrine 0.1 µg/kg/min Note: *- P0, 05 between groups When studying the nature of heart rhythm recovery, we noted that MUF according to our method can significantly reduce the number of episodes of ventricular fibrillation after removing the clamp from the aorta (Table 7), leads to the normalization of atrioventricular conduction. In the main group, stable sinus rhythm was observed by the end of the operation in more than 88% of cases, and the frequency of using temporary pacing decreased by 21.2% (Table 8). We associate these positive aspects with a decrease in myocardial edema as a result of MUF using our method.

The nature of the recovery of cardiac activity in the comparison groups The nature of the recovery of the heart Control group The main group Note: * - P0.05 between groups The nature of the heart rate by the end of the operation in the comparison groups The nature of the heart rate Note: * - P0.05 between the groups Thus, improvement of the course intra- and postoperative period in children with CHD (prevention of heart failure, prevention of pulmonary complications, treatment of hyperhydration syndrome and control of postoperative bleeding) can be attributed to the most problematic tasks of modern cardiac surgery. Due to the advantages offered and tested by us, the MUF scheme will facilitate the work of both surgeons and perfusionists. The complex effect of IR on the child's body during surgery and subsequent pathological changes in homeostasis should be eliminated as much as possible by various therapeutic methods. We believe that one of these methods is the scheme of blood MUF proposed by us, which has a favorable effect on many negative aspects associated with the use of CI. We are confident that the use of the MUF procedure according to our methodology should take a strong place in pediatric cardiac surgery, especially in operations on the smallest patients.

CONCLUSIONS

1. The developed method of modified blood ultrafiltration during heart surgery in children under cardiopulmonary bypass has a complex positive effect on hemodynamics, respiratory function and perioperative hemohydrobalance indicators, which is achieved by effective and safe correction of the hemodilution level during extracorporeal perfusion and at its completion.

2. The advantages of the developed method of modified blood ultrafiltration during heart surgery in children compared to the classical method Elliott M.J. are the absence of the need for additional surgical procedures and a reduction in the duration of the procedure by 45.4% (p0.01).

3. Conducting modified blood ultrafiltration has a positive effect on the myocardium and hemodynamic parameters, causing a decrease in the specific volume of myocardial edema to the initial value, the mass of the left ventricular myocardium by 5.5% (p0.05), the thickness of the posterior wall of the left ventricle by 6.6 % (p0.05), an increase in mean arterial pressure by 18% (p0.05), a cardiac index by 11.7% (p0.05), a decrease in total pulmonary resistance by 24.4% (p0.05).

4. The proposed method of modified blood ultrafiltration leads to a significant improvement in the biomechanical properties of the lungs: extensibility increases by 17.4% (p0.05), airway resistance decreases by 36% (p0.05), oxygen tension in arterial blood increases by 21, 7% (p0.05).

5. When performing modified blood ultrafiltration, the concentration of fentanyl decreases by 67% (p0.05), however, the achieved average concentration of the drug in the blood of 2.18 ng/ml is sufficient to maintain and provide anesthesia in this category of children at the final stage of the operation.

6. Carrying out modified blood ultrafiltration according to our method allows to reduce the intraoperative water load by 85% (p0.01), normalizes atrioventricular conduction in 50% (p0.05) of cases, reduces the dose of inotropic drugs in 15-16% of operated children, and in 46.4% (p0.05) of cases it allows refusing to prescribe sympathomimetics in the early postoperative period.

1. The method of modified blood ultrafiltration developed by us, which is proposed for use during cardiac surgery in children weighing up to 20 kg during cardiopulmonary bypass, is safe and has no contraindications.

2. When performing modified blood ultrafiltration, it is recommended to timely extract the additional fluid entering the heart-lung machine to achieve a hematocrit level of 35-36% and a protein concentration of 60 g/l by the end of the operation.

3. Induction of anesthesia with fentanyl at a dose of 25 µg/kg and a maintenance dose of 5 µg/kg/h provides adequate anesthesia and does not require an increase in the dose of anesthetics when performing modified blood ultrafiltration according to our method during the correction of septal congenital heart defects 4. Performing modified blood ultrafiltration according to the proposed method, it is accompanied by the removal of bicarbonates from the blood. Therefore, after the end of filtration, it is necessary to carry out compensation at the rate of 20 mmol of sodium bicarbonate per liter of removed ultrafiltrate.

LIST OF WORKS PUBLISHED ON THE THEME OF THE THEsis

1. Merunko A.A. Optimal scheme of modified blood ultrafiltration in children operated under cardiopulmonary bypass / A.A.

Merunko, V.E. Ginko, V.M. Shipulin, V.A. Pak // Proceedings of the Second Annual Scientific Session of the NTSSSH them. A.N. Bakulev with the All-Russian Conference of Young Scientists. - M.: [b.i.], 1998. - S. 80.

2. Dzyuman A.N. Influence of modified blood ultrafiltration on the morphofunctional state of the myocardium / A.N. Dzyuman, V.E. Ginko, A.A. Merunko, V.M. Shipulin // Proceedings of the Second Annual Session of the NTSSSH them. A.N. Bakulev. - M. : [b.i.], 1998. - S. 151.

3. Merunko A.A. Tactics of anesthetic management of operations with cardiopulmonary bypass in children of early age / A.A. Merunko, V.E. Ginko, V.A. Pak // Proceedings of the 6th All-Russian Congress of Anesthesiologists and Resuscitators. - M. : [b.i.], 1998. - S. 171.

4. Pak V.A. Mechanisms for the development of positive effects of modified blood ultrafiltration in children / V.A. Pak, A.A. Merunko, V.E. Ginko // Proceedings of the Fourth All-Russian Congress of Cardiovascular Surgeons. - M. : [b.i.], 1998. - S. 188.

5. Merunko A.A. The use of modified blood ultrafiltration in infants operated on by cardiopulmonary bypass / A.A. Merunko, V.M. Shipulin, V.E. Ginko, V.A. Pak // Proceedings of the Fourth All-Russian Congress of Cardiovascular Surgeons. - M. : [b.i.], 1998. - S. 188.

6. Ginko V.E. Influence of modified blood ultrafiltration on the acid-base state and electrolyte composition of the blood in children operated under cardiopulmonary bypass / V.E. Ginko, A.A. Merunko, V.A. Pak // Proceedings of the Fourth All-Russian Congress of Cardiovascular Surgeons. - M. : [b.i.], 1998. - S. 185.

7. Ginko V.E. Influence of cardiopulmonary bypass and modified blood ultrafiltration on indicators of respiratory biomechanics in children operated on an open heart / V.E. Ginko // Abstracts of the 5th annual seminar of young scientists "Topical issues of pharmacotherapy and surgical treatment of diseases of the cardiovascular system". – Tomsk, 2004.

8. Ginko V.E. Influence of modified blood ultrafiltration on central hemodynamic parameters in children operated on the open heart / V.E. Ginko, A.N. Nikolishin, V.Kh. Vaizov // Proceedings of the Tenth All-Russian Congress of Cardiovascular Surgeons. - M.: [b.i.], 2004. - S. 218.

9. Influence of modified ultrafiltration on myocardial ultrastructure in children with cardiac surgical pathology / V.M. Shipulin, O.V. Saprygina, A.N. Dzyuman, A.A. Miller, V.E. Ginko, I.V. Sukhodolo // Circulatory pathology and cardiac surgery. - 2005. - No. 4. - S. 46-50.

10. Ginko V.E. Influence of cardiopulmonary bypass and modified blood ultrafiltration on indicators of respiratory biomechanics in children operated on an open heart / V.E. Ginko, E.V. Krivoshchekov, V.M. Shipulin, V.O. Kiselev // Proceedings of the Anniversary Conference and the First Congress of Cardiac Surgeons of the Siberian Federal District, dedicated to the memory of Academician of the Russian Academy of Medical Sciences E.N. Meshalkin. - Novosibirsk, 2006. - S. 214.

11. Ginko V.E. Influence of modified blood ultrafiltration on the pharmacokinetics of fentanyl in children operated on an open heart / V.E.

Ginko, E.V. Krivoshchekov, S.M. Dzhaffarov, V.O. Kiselev // Proceedings of the Twelfth All-Russian Congress of Cardiovascular Surgeons. - M.: [b.i.], 2006. - S. 196.

12. RU 2190428 C2 7 A 61 M 1/34. The method of modified blood ultrafiltration under cardiopulmonary bypass: RF Patent No. 2190428 dated 11/27/1998 / A.A. Merunko, V.M. Shipulin, Yu.K. Podoksenov, V.A. Pak, V.E. Ginko, A.A. Korbut // Inventions (Applications and patents). 2002. Bull. No. 28.

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If only water is removed through a semi-permeable membrane, it is called ultrafiltration . It is used in acute renal and hepatic insufficiency with severe symptoms of hyperhydration.

At hemofiltration dialysate is not used, the liquid part of the blood is filtered through the dialyzer membrane. In this way, molecules of average mass are removed.

The combination of these two methods is called hemodiafiltration and is used for poisoning with FOS, chlorinated hydrocarbons and other poisons of small and medium weight.

Peritoneal dialysis

This method is used when it is impossible to carry out hemodialysis (presence of contraindications, lack of technology). The essence of the method is to wash the abdominal cavity with dialysis solution. There are 2 methods of peritoneal dialysis: continuous dialysis and discrete dialysis . In the first case, 2 catheters are inserted into the abdominal cavity, through which a continuous flow of dialysis solution is carried out. In the second case, 1 catheter is inserted into the abdominal cavity, through which 2 liters of solution are poured, which is removed after a certain period of time (about 20 minutes). The method is based on the fact that the peritoneum is a natural semi-permeable membrane with a surface area of ​​2 m 2 .

Hypertonic (350…850 mosmol/l) dialysis solution also provides ultrafiltration, which increases the clearance of poisons. Histological studies have shown that such solutions do not cause pathological changes in the peritoneum. To increase the clearance of poisons with an acidic reaction (barbiturates, etc.), the hypertonic dialysis solution is alkalized to pH 7.5 ... 8.4. If the poison has the properties of weak bases, the pH of the dialysis solution is reduced to 7.1 ... 7.25.

In case of poisoning with poisons with a high coefficient of protein binding, the addition of albumin to the dialysis solution is effective. The introduction of oil solutions into the abdominal cavity accelerates the excretion of fat-soluble poisons.

Before use, dialysis solutions are heated to 3737.5°C, in case of hypothermia - up to 3940°C.

A contraindication to peritoneal dialysis is a pronounced adhesive process in the abdominal cavity and late pregnancy. In cases of poisoning accompanied by shock, when other extracorporeal methods of detoxification and forced diuresis are inapplicable, peritoneal dialysis is practically the only method of actively removing the poison from the body. Peritoneal dialysis may be accompanied by peritonism and hypokalemia, which requires appropriate monitoring and management, which usually does not present serious difficulties.

Peritoneal dialysis is most effective in case of poisoning with psychotropic drugs (barbiturates, phenothiazines, benzodiazepines, etc.), chlorinated hydrocarbons, heavy metal compounds, alcohol surrogates, etc.

7.2.2. Sorption methods

The method is based on the adsorption of foreign substances circulating in the blood on the surface of a carbon or other sorbent (SKN, SKT-6a, KAU, SUGS, FAS). The operation is carried out using a special mobile device with a roller-type perfusion pump. Before the operation, two veins are catheterized (most often subclavian or femoral in any combination) or an arteriovenous shunt is applied. Blood is taken from an artery or vein (with the veno-venous route) using a pump, the speed of which can be adjusted (usually within 25 ... 250 ml / min). Then the blood enters the column with the sorbent, where the adsorption process actually takes place, and from the column it returns to the patient's vascular bed. In one operation, 1...2 bcc is perfused through the column.

Effect hemosorption associated with at least two things. Firstly, during hemosorption, the circulating blood is released from the etiological factor, that is, the poison. Secondly, the blood is cleansed of endogenous toxins (including "medium molecules") that are formed in any critical condition.

Hemosorption is shown in the toxicogenic phase of poisoning with psychotropic (barbiturates, benzodiazepines, phenothiazines, amitriptyline, atropine), cardiotropic poisons (cardiac glycosides), FOS, alcohol and its surrogates.

Complications and side effects Hemosorption is most often iatrogenic in nature - a violation of the operation technique, incorrect accounting of indications and contraindications, insufficient preoperative preparation of the patient and the sorbent. The following complications may occur:

1) column thrombosis associated with hypercoagulability; often observed with hypovolemia and insufficient heparinization;

2) acute hypovolemic circulatory failure associated with the diversion of part of the BCC into the detoxification circuit; if the technique of the operation is observed, it is rarely noted;

3) acute circulatory insufficiency associated with the sorption of endogenous vasoactive substances;

4) chills associated with the action of the sorbent itself, blood cooling and infusion therapy;

5) immunosuppression associated with the sorption of immune factors.

To reduce the likelihood of these complications, the following preventive measures are applied accordingly:

1) heparinization of the patient (20,000 units) and the sorbent (treatment in the recirculation mode with a solution containing 15–20 thousand units of heparin);

2) blood sampling is carried out in a circuit pre-filled with saline;

3) treatment of the sorbent in the recirculation mode with glucocorticosteroids and catecholamines (prednisolone, norepinephrine);

4) washing the sorbent with physiological saline in a volume of up to 1200 ml; warming infusion media;

5) carrying out EUFOK.

Hemosorption is contraindicated in acute circulatory failure of any nature, in shock, hemorrhagic syndrome, cerebrovascular accident and in a terminal state.

ultrafiltration- a method for correcting water homeostasis with excess water in the body by removing protein-free fluid from the blood through natural or artificial membranes that play the role of an ultrafilter. Most often, the peritoneum, artificial dialysis and hemofiltration membranes are used as an ultrafilter. The source of ultrafiltrate formation is mainly extracellular fluid entering the bloodstream under the action of oncotic pressure of plasma proteins. Unlike diuretics, ultrafiltration allows for dosed dehydration with little effect on the electrolyte composition and acid-base state of the blood. With the simultaneous removal of a large amount of fluid (several liters), a tendency to hyperkalemia, metabolic acidosis, an increase in hematocrit and blood viscosity, and an accelerated increase in azotemia develops.

Ultrafiltration of fluid in the blood is achieved by creating a pressure difference on both sides of the filtration membrane: osmotic or hydrostatic. Accordingly, osmotic and hydrostatic W are distinguished.

Osmotic U. is usually carried out during peritoneal dialysis. To obtain the effects, it is necessary that the osmotic pressure of the dialysis solution be higher than the osmotic pressure of the blood. Glucose is mainly used as an osmotically active substance, adding it to 1 l isotonic salt solution in the amount of 15, 25 or 42.5 g/l, that, when the solution is injected into the abdominal cavity, it makes it possible to obtain, respectively, 200, 400 or 800 ml ultrafiltrate. After 4-6 h when the difference between the osmotic pressure of the blood and the solution disappears, all fluid from the abdominal cavity is removed. Selecting dialysis solutions with a certain concentration of glucose, regulate the water content in the patient's body.

Hydrostatic U. is usually carried out with the help of a dialyzer, on the membrane of which a positive difference is created between the blood pressure and the hydrostatic pressure of the dialysis solution. The rate of ultrafiltration depends on the value of this difference, called the transmembrane pressure, as well as on the permeability coefficient of the membrane for the ultrafiltrate. The permeability coefficient is expressed by the amount of ultrafiltrate (in ml) passing through the membrane in 1 h for each mmHg st. transmembrane pressure. According to the value of this coefficient, all manufactured dialyzers are small (2-3 ml/mmHg st. in 1 h), medium (4-6 ml/mmHg st. in 1 h) and large (8-12 ml/mmHg st. in 1 h) permeability. The arrangement of the apparatuses makes it possible to set the required mode of ultrasonication according to the selected transmembrane pressure. By subtracting from the latter the blood pressure measured by the direct method in the venous bubble chamber, the pressure of the solution on the outside of the membrane is determined, which is necessary to obtain the required ultrafiltration rate. The pressure of the solution in the apparatus is controlled manually or automatically according to the set transmembrane pressure. There are devices in which the management and control of U. are carried out on the principle of volumemetry or electromagnetic flowmetry. The limiting value of the transmembrane pressure should not reach the bursting pressure (approximately 600 mmHg st.).

Ultrafiltration at speeds from 5 to 35 ml/min eliminates a fairly significant fluid retention for several hours. With some variants of the method, for example, with the help of constant spontaneous (due to blood pressure) arteriovenous U., for 1 day. can be removed from the body if necessary 15-20 l liquids, completely eliminating edema.

In patients with heart failure, U. effectively reduces the central volume and central venous blood pressure, restoring the working capacity of the heart and eliminating ventilation and gas exchange disorders. In patients with uremia, the combination of hemodialysis with large U., which is usually combined with fluid replacement infusion, improves the quality of blood purification (primarily from substances of medium molecular weight) and accelerates the regression of many of the dangerous symptoms of uremia.

Indications for urgent use of U. are pulmonary edema of any etiology, as well as cerebral edema that develops in connection with acute water stress. Along with other methods, U. is used in the complex treatment of patients with anasarca, with edema due to congestive heart failure (especially in the presence of resistance to diuretics and glycosides) or nephrotic syndrome without renal failure, with fluid retention in the body after surgery with cardiopulmonary bypass and hemodilution. In addition, U. is an integral part of the program of hemodialysis treatment of patients with renal insufficiency, in which fluid is retained due to oliguria. Sequential use of U. and hemodialysis in such patients is advisable only in cases where their joint conduct creates a threat of development collapse.

Contraindications to the use of the method are hypovolemia, arterial hypotension, hyperkalemia, metabolic acidosis, intoxication with cardiac glycosides, adrenal insufficiency.

Ultrafiltration is carried out only in a hospital. The procedure is performed in the position of the patient on a functional bed. Before the start of the procedure, the patient is administered heparin at a dose of 15-30 IU per 1 kg body weight to prevent blood clotting at the time of filling the dialyzer; in the process of ultrafiltration, a constant infusion of heparin is carried out at a rate of 10-15 units per 1 kg body weight per hour. Throughout the procedure, the ultrafiltration mode is controlled; if necessary, with the help of special devices, its speed is regulated and the patient's fluid balance is maintained. The effectiveness of the procedure is assessed by the amount of fluid removed, the decrease in the patient's body weight, and the regression of symptoms of overhydration. Particular attention is paid to the dynamics of the filling of the jugular veins, the frequency of pulse and respiration, peripheral edema, ascites, hydrothorax, hydropericardium, liver size, wet rales in the lungs, discoloration of the blood in the extracorporeal system. For an objective characterization of the effectiveness of treatment, in some cases, repeated chest radiography is performed, the dynamics of central venous pressure, volumes of circulating plasma and extracellular fluid are noted. After U., oliguria is almost always observed.

Hypovolemia, cramps in the muscles of the legs and arms, spastic pains in the abdomen and chest, hoarseness, and vomiting can be complications during U.'s conduct. In the case of severe hypovolemia, collapse may develop with loss of consciousness, generalized convulsions and respiratory arrest. It should be borne in mind that severe collapse is rarely the result of an error during U., rather, it can be a manifestation of sudden onset of internal bleeding, cardiac tamponade, myocardial infarction, bacterial shock, adrenal insufficiency. The threat of collapse increases during U. in patients receiving b-adrenergic blockers and antihypertensive drugs. Treatment of emerging complications is carried out immediately. Muscle cramps that occurred before reaching the desired result U. are stopped without interrupting the procedure with infusions of 60-80 ml 40% glucose solution, 20 ml 10% calcium gluconate solution, 20-40 ml 10% sodium chloride solution. First aid for arterial hypotension is to timely lower the head end of the bed below the horizontal level, reduce the speed or stop ultrafiltration, slow down arteriovenous blood perfusion. Then, based on the situation, an infusion of 500 ml 5% glucose solution, prepared on a polyionic basis (easier to perform through the arterial line of the dialysis system using a pump); if necessary, enter 200 ml 20% albumin solution, 30-60 mg prednisolone, return blood from the apparatus.

The hemofiltration procedure is often used in the treatment of diseases of the urinary system. This type of therapy will help the patient reduce the intoxication of the body, which occurs with a number of conditions and diseases.

Hemofiltration

Hemofiltration is a method of purifying blood by filtering it through synthetic highly permeable membranes, while the filtrate removed in the blood is replaced by a special solution. Treatment is carried out using a hemofilter connected to a large vessel, as well as parallel infusion of the necessary solutions.

Like, hemofiltration refers to methods, but has significant differences with it.

Features of hemofiltration are as follows:

• Blood purification is carried out due to the movement of toxic substances from the plasma through the membranes in the same way as it is done in the renal glomeruli - due to transmembrane pressure.
• The procedure is effective for removing both large and small molecules of toxins from the blood, including inflammatory elements, microglobulins, enzymes, bacterial endotoxins.
• Due to the removal of a large volume of water and salts from the blood, they must be replaced with appropriate solutions.

Hemofiltration is a modern type of treatment, close in its effect to the natural activity of the kidneys. Now it is widely used in intensive care units, helping to save the lives of many patients. For the results of the procedure to be high, the volume of plasma filtration should be up to 80% of the person's weight.

What is hemofiltration of blood

Indications

Hemofiltration is a common treatment for acute kidney failure, especially after kidney surgery. The procedure is widely used for various types of multiple organ failure, and in this case it is prescribed continuously.

Other indications for blood filtration are:

1. Chronic renal failure.
2. Acute poisoning, other types of intoxication.
3. Pronounced phenomena of hyperhydration.
4. Acidosis.
5. Coma states.
6. Hyperkalemia.
7. Pulmonary edema.
8. Toxic effect or overdose of drugs, alcohol, drugs.
9. Heavy.
10. Brain damage.
11. Some acute heart diseases.

Despite the use of hemofiltration in various types and forms of diseases, in most cases this procedure is prescribed for patients with nephrological pathologies.

Contraindications

You can not carry out this type of treatment with:

• Uncorrected arterial hypotension;
• Heavy bleeding.

Kinds

There are several types of procedures that apply in different circumstances:

1. Hemofiltration as an adjunct to hemodialysis. It is used in chronic renal failure, especially in those patients who suffer from weight gain due to fluid accumulation. The procedure helps to remove more fluid than with hemodialysis as monotherapy.
2. Continuous hemofiltration (slow continuous ultrafiltration). Recommended for patients with acute renal failure. The process is regulated by means of a screw clamp, which is superimposed on the outflow tube. The filtered substances are collected in the urinal. The method helps to remove large volumes of liquid.
3. Supportive hemofiltration. Just like the first method, it is combined with hemodialysis and is intended to remove nitrogenous toxins from the blood. Intended for the treatment of acute renal failure.

For treatment, special devices are used - hemoprocessors. Some of them are quite simple in operation, others are equipped with a complex process regulation system. There are modern devices that independently prepare high-quality substitution solutions, and the whole process is controlled by a powerful computer. A number of portable models are now being produced that allow for hemodialysis and hemofiltration even at home.

Examples of the latest generation of hemoprocessors are as follows:

1. Nikkiso Aquarius. This is an automated device for renal replacement therapy used in the treatment of adults and children. The device is equipped with an alarm signal that notifies the medical staff of all emerging violations. The hemoprocessor on the screen displays the main indicators - the rate of injection of the solution, its volume, temperature, etc.
2. Infomed. Allows you to perform all types of hemofiltration, as well as hemodialysis in children and adults. All processes performed by this device are fully automated.

Substitution solutions for blood hemofiltration are close in composition to the protein-free part of plasma. In total, there are about 14 types of solutions, the difference between which is the amount of glucose, other substances, as well as osmotic pressure. The solutions are placed in sterile containers of 5 liters in volume.
Video review of the device for hemofiltration:

Execution engine

The hemoprocessors are equipped with a pump for blood perfusion, a pump for removing the filtrate, and devices for infusing replacement solutions. There is also a thermostat in the devices for heating the solution, electronic scales for measuring its amount. The process is controlled by a microprocessor - an automatic device that monitors the course of blood filtration.

The design of the device must necessarily provide protection against:

• Fluid imbalance;
• Leakage of blood into the filtrate;
• Air entering the blood
• Introduction of superheated solution.

Apparatus for hemofiltration

The mechanism of action of the devices is based on the removal of toxins and metabolites circulating in the blood using a filter. The resulting filtrate is similar to normal urine excreted by the kidneys of a healthy person. The blood flow through the filter is provided by the difference in the osmotic pressure of the blood and the replacement solution. The amount of the injected solution is calculated based on individual indicators of the state of the body.

A special bed is used for hemofiltration. The procedure for the procedure is as follows. A double-lumen catheter of large diameter is inserted into the central vein, the blood flow is set to approximately 120-150 milliliters per minute. Heparin preparations are injected into the blood, but this method is undesirable in patients with a risk of bleeding. Also, blood purification and replacement with special solutions can be carried out through an external arteriovenous shunt or arteriovenous fistula, otherwise the procedure for hemofiltration is similar. The duration of the procedure can be from days to several weeks.

Hemofiltration mechanism

Diet

Many patients with acute renal failure are shown parenteral nutrition. If the patient can eat independently, a diet rich in amino acids is recommended. On hemofiltration, a person needs an increased amount of protein, because the nitrogen balance is greatly disturbed. The calorie content of the diet should be sufficient, but the amount of salt in the diet is strictly controlled and calculated individually.

The strictest control of the level of calcium, phosphorus and vitamins is necessarily carried out, and, if necessary, is corrected with the help of drugs.

Complications

Hemofiltration disturbs the osmotic balance to a small extent, so life-threatening complications from the heart, blood vessels, and brain are rare. Possible consequences due to the performance of blood perfusion and the introduction of heparin - bleeding, failure of the hemostasis system, thromboembolism is occasionally observed.

Other possible complications:

• Hyperhydration, dehydration;
• Decreased potassium in the blood;
• hypoglycemia;
• loss of amino acids.

In case of violation of hemofiltration technology, infection with HIV, hepatitis, the occurrence of a feverish state are occasionally observed, in some patients prolonged arterial hypertension develops. To prevent complications, the patient is given heart preparations, Panangin, glucose, amino acids are administered, aseptic rules and hemofiltration techniques are strictly observed.

Patient C, 52 years old, entered the Russian Academy of Medical Sciences March 10, 1989 with a diagnosis of rheumatism, inactive phase. Rheumatic mitral heart disease: stenosis of the left atrioventricular orifice, mitral valve insufficiency. Relative insufficiency of the tricuspid valve. Cardiomegaly. Atrial fibrillation. Circulatory insufficiency of stage IB (classification by V.Kh. Vasilenko and N.D. Strashesko).

Rheumatic mitral heart disease identified in 1979. Since 1986, a constant form of atrial fibrillation. In the summer of 1988, signs of circulatory failure appeared and gradually progressed in both circles. Significant deterioration in the condition since the beginning of 1989. Shortness of breath at rest began to bother, significant swelling of the legs, hepatomegaly appeared.

On admission general condition is severe. The skin is pale, acrocyanosis. Swelling of the legs with trophic skin disorders. The respiratory rate at rest is 22 per minute. In the lungs, breathing is hard, weakened in the posterior lower sections. Blood pressure 140 and 80 mm Hg. Art., heart rate 86, the rhythm is wrong. The abdomen is enlarged due to ascites. The liver has a densely elastic consistency, protrudes from under the edge of the costal arch by 12 cm. Radiologically, in the pulmonary circulation, there are pronounced signs of arterial-capillary stagnation, fluid in the right pleural cavity with its leakage along the interlobar fissures; the heart is significantly enlarged in volume (397% of the norm). On the ECG, atrial fibrillation, signs of hypertrophy of both ventricles of the heart, mainly the right one. According to echocardiography, the size of the hollow ventricle is 3.9 cm systolic, diastolic - 5.3 cm; left atrium - 7.6 cm, right ventricle - 2.4 cm. Radioisotope study of the circulatory system - BCC 78.8 ml/kg, cardiac index - 2.32 lDminhm2), stroke index - 20.3 ml/m2. Biochemical parameters of blood, electrolytes, hemoglobin and hematocrit are within normal limits.

Considering failure of conservative therapy(cardiac glycosides, saluretics, peripheral vasodilators for 10 days, infusion of small doses of dopamine for 2 days), the patient underwent 2 sessions of isolated ultrafiltration. The right femoral and right internal jugular veins were catheterized. Removed 2500 and 3000 ml of ultrafiltrate per procedure. The patient's condition improved: shortness of breath, hepatomegaly decreased (the liver protrudes from under the edge of the costal arch by 1.5 cm), ascites (free fluid in the abdominal cavity is not detected), swelling in the legs disappeared, diuresis increased without the use of diuretics from 400-500 up to 1200-1500 ml per day. In the study of central hemodynamics, a decrease in CVP from 23 to 11 mm Hg was noted. Art., increase in SI from 2.8 to 4.2 l / (min / hm2). Subsequently, the patient was hospitalized twice more in our department due to circulatory decompensation, mainly in a large circle. Repeated IUF sessions were carried out: in May 1989 - three, a total of 9500 ml of ultrafiltrate was removed; in October 1989 - one, 3200 ml of ultrafiltrate was removed. There was a significant improvement in the patient's condition, restoration of sensitivity to previous drug treatment. Significant side effects from the IUF sessions were not noted.

Thus, the received data testify to the high efficiency of IUF in the treatment of congestive heart failure, which is confirmed by other researchers.

The main positive effect of IUV along with a decrease in generalized edema is an increase in cardiac output in patients with decompensated heart failure.

As our research has shown, IUF not for all categories of patients with heart failure is an effective and safe method of treatment.

In cases of terminal stages of heart failure the use of IUF leads to an imbalance between a significantly increasing oxygen consumption and the ability of the cardiorespiratory system to increase oxygen delivery to tissues and further worsen the condition of patients.

We have carried out influence studies dobutamine in doses of 3 to 5 µg/kg per minute on the parameters of central hemodynamics in patients with congestive heart failure during IUF.

Before Appointment dobutamine the studied patients had a syndrome of low cardiac output, caused by myocardial insufficiency, high pre- and afterload of the ventricles of the heart. Dobutamine infusion at doses of 3 to 5 µg/kg per minute resulted in a significant increase in cardiac performance both due to an increase in myocardial inotropism and a decrease (optimization) of pre- and afterload pressures of the heart ventricles at their initially high values. In patients, CVP and TPVR decreased by an average of 14-18%, and CO, CI, UI, LVIR, and LVCV increased by 25-28%. Inotropic myocardial support with dobutamine allowed us to use IUF in patients with a critical decrease in stroke output, both due to impaired myocardial contractile function and volume overload of the heart cavities.

Dobutamine use allowed to achieve a significant increase in SI with a decrease in the filling pressure of the ventricles of the heart, which expanded the indications for IUF in the most severe patients, ensured the hemodynamic stability of the procedure and its clinical effectiveness.

Educational video of indications and contraindications for hemodialysis

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