Application of Cryoplasma-Anti-Enzyme Complex in the Treatment of Patients with Severe Combined Trauma

The study is dedicated to the development and evaluation of the effectiveness of a cryoplasma-anti-enzyme complex in the comprehensive treatment of patients with severe combined trauma complicated by disseminated intravascular coagulation syndrome. The work analyzes data from 263 polytrauma patients hospitalized between 2002 and 2006. The research demonstrates that the use of fresh-frozen plasma, heparin, and protease inhibitors, depending on the severity of the injury and the nature of disturbances in the hemostasis and fibrinolysis systems, allows for more effective suppression of the DIC syndrome, reduction of hospitalization duration, and decrease in the number of purulent-septic complications and mortality.

Relevance

In the second half of the 20th century and at the beginning of the 21st century, in connection with the development of industry, transportation, and high-rise construction, there was a significant increase in the number and severity of polytraumas. Cases of mass trauma resulting from accidents and natural disasters pose new tasks for Russian healthcare regarding the improvement of methods of emergency traumatological care and treatment of victims.

The term "polytrauma" refers to the presence of two or more zones of damage in one or several anatomical areas, when one of the injuries or their combination poses a danger to the life and health of the victim, which necessitates the provision of emergency qualified or specialized medical care [138].

In polytraumas, several organs and systems are simultaneously involved in the pathological process, among which injuries of the thoracic cage and its cavities account for 12-15% [111, 139], organs of the abdominal cavity and retroperitoneal space - 3.6-18%, of which splenic rupture - 24-24.3%, liver and gallbladder - 9.3-27.6%, mesentery and omentum - 9.9%, large intestine - 4.5-16.6%, small intestine - 4.1-11.1%, pancreas - 3.7-8%, kidneys - 4-5.8%), urinary bladder - 3.7-8%, diaphragm - 4.5% [3, 68, 74, 152], craniocerebral trauma - 55-72%), musculoskeletal apparatus - more than 70% of victims [72, 116, 119].

As early as 1964, S. A. Seleznev first expressed the idea of the advisability of a comprehensive consideration of all processes arising during severe mechanical injuries (in their dynamics and interrelationships) from onset to final outcome, denoting the entire complex by the single concept of traumatic disease.

In 1987, in the monograph "Traumatic Disease" by Deriabin I.I. and Nasonkin O.S. [47], substantial factual data characterizing the clinical picture of traumatic disease, especially the disturbance of metabolic processes in it, were presented.

Thus, severe combined trauma - polytrauma - requires not only the documentation of injuries and syndromic therapy, but also the forecasting of pathological and adaptive reactions of the body, from its onset to outcome [111].

One of the important pathogenic links in severe combined injuries is the activation of humoral proteolytic systems of blood plasma, primarily the coagulation, fibrinolytic, kallikrein-kinin, and complement systems.

At the moment of injury, in addition to mechanical damage to bones and violation of skin integrity, injuries of internal organs of the thoracic and abdominal cavities affect large muscle masses of the extremities and trunk, resulting in the release into the vascular bed of tissue coagulation factors and activators of platelet function. The release of tissue thromboplastin (Factor III, apoprotein III), contact activation of collagen of the subendothelium of both platelets and blood coagulation (activation of Factor XII).

This initiates the disturbance of microcirculation, due to changes in the coagulation system, the development of a prethrombotic state, and then disseminated intravascular coagulation syndrome (DIC).

The development of DIC syndrome significantly aggravates the severity of the disease course, contributing to the progression of ischemia in damaged organs and tissues, in wound surfaces, and impeding the penetration of protease inhibitors and antibiotics into the focus of damage in sufficient doses; the disturbance of microcirculation in the intestinal wall leads to the release into the vascular bed of pathogenic microflora and generalization of infection [143].

Goal of the work.

The goal of the work was to increase the effectiveness of complex treatment of patients with severe combined trauma by weakening the manifestations of disseminated intravascular coagulation syndrome.

To achieve the stated goal, it was necessary to solve the following tasks:

Research tasks:

1. To study the features of disturbances in the coagulation and fibrinolysis systems in patients with severe combined trauma.

2. To determine rational approaches to correcting the identified disturbances in the coagulation and fibrinolysis systems in patients with severe combined trauma (SCT), depending on the severity and nature of the injuries.

3. To evaluate the treatment outcomes in patients with SCT with differentiated correction of the identified disturbances in the coagulation and fibrinolysis systems and in patients who received basic therapy.

Material and methods of research:

The data of 263 victims (192 males and 71 females) with polytraumas hospitalized in the department of severe combined trauma of MUZ "City Hospital No. 1" for the period from 2002 to 2006 were analyzed.

The age of patients ranged from 16 to 79 years.

In the structure of traumatism, road traffic accidents, criminal and domestic injuries predominated, less frequently industrial injuries and falls from height were noted.

In most cases, damage to the skeletal system or craniocerebral trauma was combined with severe chest injury, damage to abdominal cavity organs and retroperitoneal space.

The severity of injury according to the G. I. Nazarenko scale [96] in most cases ranged from 17 to 37 points, which corresponded to 16-52 points on the ISS scale.

Primary diagnosis, provision of emergency specialized medical care, and examination were carried out simultaneously by all leading specialists in operating room conditions: anesthesiologist-resuscitologist, traumatologist, surgeon, neurosurgeon. When necessary, thoracic surgeon, endoscopist, gynecologist, cardiologist, radiologist, transfusion specialist, functionalist, and other specialists were called in and involved in providing assistance. The leading role in providing assistance and determining the sequence of therapeutic and diagnostic measures was played by the anesthesiologist-resuscitologist.

The examination volume included: clinical (inspection, palpation, percussion, load tests for injuries of the musculoskeletal apparatus, auscultation), complete blood count, blood group and Rh factor, general urine analysis, overview radiography of the skull, thoracic cage organs, pelvic bones, extremities, and, when indicated, puncture and drainage of pleural cavities, laparocentesis using the "striking catheter" method, and in doubtful cases - laparoscopy, thoracoscopy, echoencephalography, ultrasound examination of thoracic and abdominal cavity organs, and, when necessary, pathological soft-tissue cavities caused by the traumatic agent (subcutaneous and intermuscular hematomas).

To study the hemostasis status in patients with severe combined injuries, a comprehensive investigation of the blood coagulation system was conducted. It included the determination of vascular-platelet hemostasis indicators (platelet count, spontaneous platelet aggregation); general coagulation tests and methods characterizing the formation of prothrombinase and thrombin (activated partial thromboplastin time (APTT), autoagglutination test (AAT), and roentgenothrombin time (PRT)); the final stage of coagulation and the determination of paracoagulation products (thrombin clotting time, fibrinogen, ortho-phenanthroline and ethanol tests); physiological anticoagulants and fibrinolysis (antithrombin III (AT-III), high-molecular-weight kallikrein-dependent fibrinolysis, plasminogen reserve index (PRI), fibrinogen degradation products (FDP) by the staphylococci aggregation test (SAT)).

Upon admission of patients to the clinic, along with emergency and urgent surgical interventions aimed at stopping bleeding, catheterization of large vessels for massive infusion therapy, evacuation of intracranial hematomas threatening life due to compression of vital centers of the brain, stabilization of fragments of damaged segments of extremities and pelvis, restoration of skin integrity, drainage of cavities (both anatomical and caused by the traumatic factor: separating hematomas, zones of open fractures, wound surfaces of large area and depth of the wound channel, as well as contusional foci accompanied by tissue crushing and presumed zones of contusion - gunshot wounds), comprehensive treatment was carried out, including infusion anti-shock therapy (including transfusions of blood components and blood substitutes), tetanus prophylaxis, antibiotic therapy according to microbial flora sensitivity, elimination of volumetric disturbances, detoxification therapy, correction of functional disorders of the cardiovascular system, kidneys, liver, and brain, normalization of acid-base balance, direct and indirect anticoagulants, anti-inflammatory agents, desensitization therapy, anabolic hormones, vitamin therapy, physiotherapy, therapeutic physical culture, and massage.

Scientific novelty.

As a result of the conducted research, data were obtained on the features of the development of disseminated intravascular coagulation syndrome in severe combined trauma, contributing to the progression of ischemia of damaged organs and tissues, the attachment and generalization of infection, the reduction of antibiotic therapy effectiveness, and the inhibition of proteolysis in the focus of damage.

A new principle of treatment of traumatic shock and traumatic disease in severe combined trauma was developed - the use of rational dosages of transfused fresh-frozen plasma, heparin, and protease inhibitors depending on the features of the clinical course of the disease and the nature of disturbances in the hemostasis and fibrinolysis system indicators.

Practical significance.

The use of fresh-frozen plasma, heparin, and protease inhibitors in the complex treatment of patients with severe combined trauma contributes to more effective suppression of the DIC syndrome, which made it possible to shorten the duration of hospitalization, substantially improve disease outcomes, and reduce the number of purulent-septic complications and mortality.

Main provisions to be defended:

1. In patients with severe combined trauma, disseminated intravascular coagulation syndrome develops with thrombinemia, a decrease in antithrombin III level, and depression of fibrinolysis.

2. As the severity of the disease increases, the depression of fibrinolysis intensifies and the antithrombin III level decreases.

3. The use of a cryoplasma-anti-enzyme complex in complex treatment contributes to the weakening of the manifestations of disseminated intravascular coagulation syndrome and the improvement of disease outcomes.

4. The amount of transfused fresh-frozen plasma, doses of heparin, and anti-enzyme preparations depend on the severity of the injury and the extent of damage, the features of the clinical course of traumatic disease, and the nature of disturbances in different links of the coagulation and fibrinolysis system.

Thus, despite the development of anesthesiology, resuscitation, and intensive therapy, the improvement of methods of general and local therapy, surgical techniques, the relentless growth in the number and severity of polytraumas, and unsatisfactory treatment results require the investigation of key links in the pathogenesis of traumatic disease and the development of new approaches and methods of treatment.