Correction of blood loss in surgery

The blood loss in surgery is an inevitable aspect of surgical intervention. At the same time, it is important to not only localize the surgical intervention, but also the volume, diagnosis, the presence of concomitant pathology, the initial state of the blood indicators. Therefore, it is necessary to predict the volume of putative blood loss, risk of bleeding, compensatory possibilities of the organism. All of the above affects the prognosis and outcome of the disease for this patient. Hence the high importance of the strategy of timely and accurate correction of the blood state in the perioperative period.

A number of areas of surgery characterized by increased blood loss. In particular, this is neurosurgery, cardiosurgery, oncology, urology, obstetrics, traumatology. Therefore, there are certain aspects that need to be considered when compensating and correcting the homeostasis of blood during surgical interventions.

Successful solution of this task is determined by the need to focus on a number of key positions, in this situation it is timely compensation of blood loss with the physiological correlation of plasma and shaped cellular blood composition in order to maintain oncotic balance between vascular and extraovascular bed volume, prevention of vascular wall damage, prevention and treatment coagulation disorders. Each nosological unit has its own features and mechanisms of damage, requiring consideration when choosing the tactic of the transfusiologist.

One of the most accessible and common procedures is the use of frozen autogenous red blood cells. The possibility of long-term storage of cryopreserved autogenous erythrocytes can improve the results of planned surgical interventions in patients with high demands on the quality of transfused media. The component principle of transfusion therapy is quite applicable to autologous transfusions. Fractionation of harvested autoblood to obtain autogenous erythrocytic mass (auto EM) and freshly frozen autoplasm (auto FFP) significantly enhances the therapeutic effect of their use when replenishing operating blood loss. The preparation in the blood transfusion department (or office) of the medical institution of fresh frozen autoplasma by the plasmapheresis method allows to accumulate it in the necessary quantities and to use it both for compensation of the intravascular volume and for replenishment of the deficiency of plasma clotting factors. Presence of 1-3 doses of autogenous fresh frozen plasma provides additional correction possibilities for acute coagulation disorders with massive intraoperative blood loss and / or intraoperative return of erythrocytes. Thawed and washed erythrocytes are areactogenic, devoid of plasma proteins, leukocytes and platelets, therefore their transfusions are especially shown by the reactive, alloimmunized patient.

ESMO recommendations for the transfusion of erythromass: a reduction in hemoglobin of less than 80 g / L, ASCO (American Society for Clinical Oncology) - the presence of clinical cardiac signs of anemia (tachycardia), with adaptation to low hemoglobin (80 g / l ) tachycardia can not be, here are estimated not established reference values, but the state of patients.

The clinical use of erythropoietin marked the onset of a new era of transfusion medicine with the inclusion of pharmacological agents in the strategy of blood saving. Recombinant human erythropoietin can play a significant role in routine operations with significant blood loss, including complex revision and bilateral total arthroplasty. Preoperative use of erythropoietin (Epoetin alfa) increases the possibility of pre-operative harvesting of autologous blood and perioperative mass of erythrocytes.

Clinical recommendations for the work with erythropoietins indicate the benefits of using them at a hemoglobin level of 90 to 110 g / l, with lower indications, a preliminary transfusion of erythromass followed by the introduction of erythropoietins, since erythrocytes introduced by serythromass are destroyed and the patient returns to anemia. There is a tactic of early intervention, that is, the sooner (with hemoglobin 90-110 g / l) the introduction of erythropoietins is started, the better, without waiting for the decrease in the hemoglobin index to 80-90 g / l, especially in cardiovascular pathology, or in the presence cardiac symptoms of anemia (tachycardia). Intravenous administration of erythropoietins not only increases the effectiveness in the treatment of anemia, but also reduces the incidence of thrombosis. There is a relationship between thromboses and anemia. Hypoxia of the organs increases the frequency of thrombosis. However, treatment with only erythropoietins is a factor in the development of thromboses. It is necessary to connect intravenous iron on the 7-10th day of treatment with erythropoietins. Iron does not have time to leave the depot into the blood, and own iron in the blood has already been consumed, thus there is a functional deficiency of iron. A plateau forms - hemoglobin seems to freeze, which is regarded as ineffectiveness of treatment with erythropoietins, and therapy is discontinued. The main purpose of erythropoietins is not to restore the level of hemoglobin, but to eliminate other possible causes of anemia. If the indicator of the level of endogenous erythropoietin reaches 1 IU, then the introduction of it from outside the problem does not solve, with its lack this is an absolute indication for its introduction. The problem of anemia is not only the problem of reducing hemoglobin, but also the survival of red blood cells. This is especially true for oncological patients. The possible fear that erythropoietins are pro-oncogenes is unreasonable, due to the lack of erythropoietins for this substrate and expressive receptors.

Thus, three apologists are justified in the therapy of perioperative blood loss: erythromass, erythropoietins and intravenous iron.

Nevertheless, acute isovolemic hemodilution (IVHD) is one of the most simply realized, cheap and effective methods of blood preservation. The method of isovolemic hemodilution is now widely and successfully used in various areas of surgery, including in neurosurgery, where significant blood loss is predicted on the basis of a complex of clinical and X-ray data - a large tumor volume, proximity to large vessels, a marked accumulation of contrast agent computed tomography, magnetic resonance imaging), the presence of an intrinsic vasculature of the tumor (cerebral angiography), intraventricular tumors, as well as patients with sheath GOVERNMENTAL kranioplasticheskimi reconstructions. This method allows you to significantly reduce the amount of actual operational blood loss and, accordingly, the necessary transfusion burden on the patient.

This problem is especially important in neurosurgical interventions in children - low absolute values of BCC and tolerance to blood loss, rapid development of circulatory decompensation, systemic hemodynamic and metabolic disorders. In children, due to the massive blood loss, a combination of isovolemic hemodilution and the method of hardware reinfusion of autoerithrocytes (Cell Saver Fresenius CATS) was used. This method allows you to significantly reduce the amount of actual operational blood loss and, accordingly, the necessary transfusion burden on the patient.

Hemotransfusion and today remains one of the main methods of treatment of the edge of the blood vessel, as this is the only transfusion medium containing hemoglobin.

Of the four main variants of hemotransfusion (transfer of conserved blood, direct transfer, reinfusion and autohemotransfusion) direct blood circulation at present according to the order of the Ministry of Health of the Russian Federation No. 363 is prohibited. Blood reinfusion reduces the risk of blood transfusion complications, eliminates the risk of transmitting blood transfusion to the patient, and expands the possibilities for extensive surgical interventions. Autohemotransfusion or reverse transplantation of the previously harvested blood in recent years is gaining more and more recognition in the Acupexan practice. At the same time it is treated as a preparation of autoplasm (feces usually begin 1-2 months prior to abdominal podopazresheniya by plasmapheresis), and cryopreservation of erythrocytes by creating an autocraft bank even before pregnancy.

Natural erythematosus of blood gases include erythrocyte mass and erythrocyte suspension: one dose of donor erythrocytes increases hemoglobin by 10 g / l, and hematocrit - by 3-4%. The following values of the hemogram indicate the adequately filled volume of circulating erythrocytes, which provides effective oxygen transport: hematocrit - 27%, hemoglobin - 80 g / l.

At the present time preference is given to eritrovsesvesi, because when using the epitomassum in the treatment of the crookedness to the 2-3th day of storage, the level of 2,3-diphosphoglycerate in it falls sharply; in conditions of a generalized endothelial damage, taking place in decompensated shock, it very quickly turns out to be in an interstitial space; The risk of the occurrence of acute lung injury syndrome (SSSL) when applied in the case of a massive blood vessel in comparison with whole blood will increase 2-3 times.

Plasma and albumin occupy a special place in the replacement of bcc. The merits of plasma include the fact that it is a universal tool for hemocoagulation. Negative point - clogged plasma patient with mikrogosgustkami, aggregates of blood cells and their fragments, increasing the blockade of microcirculation and dysfunction of target organs; an increase in the concentration in the plasma of coagulating active phospholipid matrices that support hypercoagulation even against the background of intensive anticoagulant therapy; as well as an increase in the level of antiplasmin and tissue activator plasminogen.

Albumin has a high oncotic activity, good support for colloid osmotic pressure, which causes a high hemodynamic effect of the drug. The ability of the drug to bind various substances, including bilirubin (in this respect, albumin of increased sorption capacity is particularly effective), determine its transport function and make it indispensable for the elimination of foreign substances and degradation products, and the effect of 100 ml of 20% albumin solution corresponds to the on- effect of about 400 ml of plasma. It should be remembered that the use of albumin in severely disturbed vascular permeability due to a change in the angle of repulsion as a result of pronounced hypoproteinemia can lead to edema of the lungs and aggravation of hypovolemia due to migra- tion of the fluid into the intestines.

Of blood substitutes-oxygen transpeaters, hemoglobin solutions without struma (erigem) and fluorocarbons (perfluorane, perfukol) are of the greatest importance. For the present, their use is constrained by such practical drawbacks as low oxygen capacity, a short time of cir- culation inorganism, and reactogenicity. In the face of all the growing AIDS epidemic, as well as numerous shortcomings of the conserved blood, the future is in transfusiology behind oxygen carriers.

When treating the hypovolemia of colloids or crystalloids, it is advisable to adhere to the following rule: colloid solutions must be at least 25% of the volume infused.

Additional hemodynamic and inotropic support with adrenomimetics dopamine and dopamine provides a positive effect on the renal blood flow and minimizes microcirculatory disorders; it also requires the inclusion of a short course of glucocorticoids, according to indications - inhibitors of fibrinolysis, recombinant coagulation factors (Novoseven).

It is important to take into account the need for a thin individual combination of optimal for the patient methods of treating anemia during surgery, which is the ability to continuously react dynamically. Thus, correction of blood loss in the perioperative period is quite a jewelry score in the skillful hands of a blood transfusion the most frequently being an anesthesiologist-resuscitator, while retaining the constants of classical blood transfusion, which do not interfere but are organically connected with the freedom of creative experimentation.

Doctor of Medical Sciences, Professor Zyatdinov Kamil Shagarovich. Correction of blood loss in surgery // Practical medicine. 8 (64) December 2012 / volume 1

[1], [2], [3], [4], [5], [6], [7], [8]