Detoxification therapy

Detoxification therapy, in essence, includes a whole range of therapeutic measures aimed at combating the disease, but first of all, it is the removal of toxic substances from the body. This type of treatment can be carried out using the body's internal resources - intracorporeal detoxification therapy (ID), removal of contents followed by cleansing of the gastrointestinal tract, or by cleansing the blood outside the body - extracorporeal detoxification therapy (ED).

Intoxication is a non-specific reaction of the organism to the action of toxins of various origins, characterized by relative dynamic equilibrium and a certain stability over time. This reaction is represented by a complex of protective and adaptive reactions of the organism aimed at eliminating the toxin from the organism.

Toxicosis is a non-specific, perverted reaction of the body to the action of microbial toxins and viruses. In the genesis of toxicosis, self-damage of the body plays a major role due to the rapid transition of adaptive reactions into pathological ones.

Specific detoxification therapy includes etiotropic antitoxic treatment (immunotherapy, use of antidotes). Non-specific ID methods include IT, stimulation of the activity of enzyme systems that ensure the binding and metabolism of toxic substances within the body, and restoration of the function of the body's own organs and detoxification systems (liver, kidneys, lungs, intestines, reticuloendothelial system).

If the damage to organs and systems is so significant that the body cannot cope with the increasing toxemia, they resort to methods of extracorporeal detoxification therapy.

These include dialysis, filtration, apheresis, sorption and electrochemical effects on blood.

The symptom complex of intoxication includes changes in the functions of the central nervous system (impaired psychomotor activity, consciousness), skin color (various manifestations of deterioration of peripheral circulation), disorders of the cardiovascular system (brady- and tachycardia, blood pressure level) and gastrointestinal function (intestinal paresis).

Since the intoxication syndrome is caused by exogenous and endogenous factors, its correction includes two interrelated components - etiotropic and pathogenetic treatment.

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Etiotropic treatment

In the complex treatment of patients with severe viral infections, antiviral agents are used, in particular immunoglobulins - sandoglobin, cytotect, domestic immunoglobulin for intravenous administration, as well as other drugs (virolex, acyclovir, ribavirin, reaferon, intron-A, etc.).

Antibiotics are used for bacterial infections.

The etiotropic treatment of toxic syndrome should include the use of hyperimmune components. In addition to the widely known antistaphylococcal plasma and immunoglobulins, antidiphtheria serum, currently successfully used plasma - antimeningococcal, antiproteus, antiescherichia, etc., titrated by administering anatoxins to donors. Also effective are special antitoxic serums - antidiphtheria, antitetanus, antibotulinum, antigangrenous, which are the basis for the treatment of patients with exotoxic infections.

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Pathogenetic detoxification therapy

• blood dilution (hemodilution),
• restoration of effective blood circulation,
• elimination of hypoxia,
• restoration and support of the function of one's own detoxification organs.

Blood dilution (hemodilution) reduces the concentration of toxins in the blood and in the extracellular space. An increase in the VCP stimulates the baroreceptors of the vascular wall and the right atrium, and stimulates urination.

Restoration of effective blood circulation is ensured by the introduction of electrolytes or colloidal preparations of volemic action - plasma substitutes.

At the first degree of VCP deficiency, fluid (plasma substitutes) is administered at the rate of 7 ml/kg, at the second degree - 8-15 ml/kg, at the third degree - 15-20 ml/kg or more during the first 1-2 hours of treatment, and at the mild degree of VCP deficiency, the entire volume can be administered orally, at the moderate and severe - partially intravenously by drip or jet. The peripheral circulation is improved by the administration of rheoprotectors (rheopolyglucin), drugs with antiaggregating action and antispasmodics (trental, complamin, euphyllin with nicotinic acid, etc.), disaggregants (curantil at the dose of 1-2 mg/kg, aspirin at the dose of 5 mg/kg per day), thrombin inhibitors (heparin, antithrombin III - AT III).

Subsequently, hemodynamics are maintained by continuous oral and/or intravenous fluid administration, taking into account ongoing losses and food volume (see Section 2.4 for principles of volume calculation), and water balance is maintained by infusion over 1 day or more of a basic solution or by enteral fluid administration. In the first days of treatment in infants and unconscious newborns, fluid and food can be administered through a nasogastric tube in portions (fractionally) or continuously by drip.

Elimination of all types of hypoxia using oxygenation at an oxygen concentration in the inhaled air within 30-40 vol.%. Oxygen therapy is carried out in oxygen tents, under an awning, through a nasopharyngeal tube, nasal cannulas, an oxygen mask, its duration is determined using pulse oximetry, gas determination. In case of toxicosis, artificial ventilation is prescribed, in case of severe anemia, red blood cell mass is administered. Normalization of the parameters of the acid-base balance and a decrease in body temperature indicate the saturation of hemoglobin with oxygen and the restoration of the affinity of hemoglobin to oxygen.

Hyperbaric (HBO) and membrane (MO) oxygenation are effective additional methods of treating the consequences of hypoxic damage, but can also be used during a critical condition that has developed against the background of respiratory distress syndrome or multiple organ failure. HBO is usually performed with gradually increasing oxygen pressure to 0.5-1.0 ATI (1.5-2.0 ATA); a total of 5-10 sessions daily or (more often) every other day.

Restoration and maintenance of the body's own detoxification system (primarily the functions of the liver, kidneys and RES), which depends on the quality of central and peripheral hemodynamics, and the provision of the body with fluid (water).

A simple and objective indicator of effective detoxification is the volume of daily or hourly diuresis, since up to 95% of hydrophobic toxins are excreted in the urine, and the clearance of these substances corresponds to the glomerular filtration rate (most toxins are not reabsorbed in the renal tubules). Normally, daily diuresis ranges from 20 ml/kg in older children to 50 ml/kg in infants, hourly - 0.5-1.0 and 2.0-2.5 ml/kg, respectively.

The total volume of fluid with intoxication, as a rule, does not exceed FP; only in case of particularly severe intoxication and absence of acute renal failure is it possible to increase it to 1.5 FP. On the 1st day in children of the first months of life, with the presence of hypotrophy, heart defects, patients with pneumonia, a total of no more than 80% of FP is administered, then - about 1.0 FP.

To stimulate diuresis, you can add lasix (furosemide) at a dose of 0.5-1.0 mg/kg once orally or intravenously, and also use drugs that improve blood microcirculation in the kidneys: euphyllin (2-3 mg/kg), nicotinic acid (0.02 mg/kg), trental (up to 5 mg/kg per day), dopamine at doses of 1-2 mcg/kg-min), etc.

Oral detoxification therapy consists of prescribing boiled water, table mineral water, tea, berry or fruit infusions. For infants and newborns, fluid may be administered through a nasogastric tube in small increments or continuously by drip.

Infusion detoxification therapy

Infusion detoxification therapy is carried out using glucose-salt solutions (usually in a ratio of 2:1 or 1:1). Its volume depends on the degree of intoxication: at degree I, half of the volume can be administered intravenously by drip over 2-3 hours, at degree II, this volume together with plasma replacement fluid is administered over 4-6 hours (up to 8 hours), and the rest - until the end of the first day (slowly), at degree III, 70-90% of the total volume of fluid is administered intravenously evenly over the course of the first day, then - depending on the dynamics of clinical manifestations of intoxication with the obligatory addition of diuretics.

In severe intoxication and the absence of true acute renal failure, a powerful method is forced diuresis using intravenous infusion of glucose-salt solutions in a volume of 1.0-1.5 FP in combination with lasix (single dose of 1-2 mg/kg), mannitol (10% solution at a dose of 10 ml/kg) so that the volume of injected fluid is equal to diuresis. Forced diuresis is used primarily in older children; on the first day, they usually do not receive food, and gastric and intestinal lavage is performed to enhance the effect.

Forced diuresis is most often performed using intravenous infusions (oral water loading is possible if the patient's condition allows) at an average rate of 8-10 ml/(kg-h). Short-acting hemodilutants are used (Ringer's solution or other officinal electrolyte mixtures in combination with 5 or 10% glucose solution). To maintain the required VCP and ensure microcirculation with moderate hemodilution (blood dilution), blood substitutes are indicated: rheopolyglucin 10 ml/kg-day) and, if indicated, protein preparations - 5-10% albumin solution at a dose of 10 ml/(kg-day). If the desired increase in diuresis does not occur, diuretics are used (lasix at a daily dose of 1-3 mg/kg).

At the end of forced diuresis, the electrolyte content and hematocrit are monitored, followed by compensation for any violations detected.

The forced diuresis method is contraindicated in cases of intoxication complicated by acute and chronic cardiovascular insufficiency, as well as in cases of impaired renal function.

Detoxification therapy: drugs

To enhance the effect of parenteral detoxification therapy, drugs with cleansing properties are used: hemodez, rheogluman (rheopolyglucin solution containing glucose and mannitol in 5% concentration), albumin is prescribed only for hypoalbuminemia < 35 g / l, severe hypovolemia. A positive effect is achieved by the oral administration of various enterosorbents (smecta, enterodez, polysorb, entersgel, etc.), as well as timely elimination of intestinal paresis, against the background of which the penetration of microbial metabolism products and bacteria from the intestine into the vascular bed is enhanced. Also indicated are drugs that improve the function of hepatocytes (hepatoprotectors), motor activity of the biliary tract and gastrointestinal tract (chole- and enterokinetics, antispasmodics, etc.).

The presence of true insufficiency of detoxification organs (acute renal failure, hepatargia, grade III intestinal paresis) serves as an indication for the inclusion of ED methods in the treatment complex (in the first 1-2 days). Extracorporeal detoxification therapy is advisable in most patients with toxicosis, against the background of or at risk of developing renal, hepatic or polyorgan failure.

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Detoxification therapy in children

In emergency medicine for children, hemosorption (HS), plasmapheresis (PP) or OPZ, hemodialysis (HD) are most often used, and less often, ultraviolet (UFO) and laser (LOC) irradiation.

Detoxification therapy (hemosorption) is based on the absorption of foreign substances on the surface of the solid phase of biological (albumin), plant (wood, stone charcoal) and artificial (synthetic carbons, ion-exchange resins) sorbents and allows removing medium- and large-molecular toxic substances from the body, including bacterial toxins and the microbes themselves. The effect of GS occurs much faster (after 0.5-1 hour) than HD and even PF, which allows this method to be used as emergency aid to patients.

When treating infants and young children, columns with a capacity of 50-100 ml and blood circuits with a capacity of no more than 30 ml are used. The perfusion rate along the circuit is 10-20 ml/min, and at the beginning and end of the procedure it should change gradually - within 5 minutes from 0 to the working indicator. Columns with sorbent are best filled with a 5% albumin solution. For total heparinization, 300 units/kg of heparin are usually required. The detoxifying effect of GS is achieved with perfusion of a relatively small amount of blood (1.5-2.0 BCC), the duration of the procedure is 40-60 minutes.

Intermittent (discrete) PF is widely used in children with keel toxicosis, confluent pneumonia, sepsis, allergic diseases, viral hepatitis. PF is most convenient in the presence of unstable hemodynamics in children and severe intoxication. It is advisable to perform plasma substitution in infants only with FFP from one donor. In children of the first months of life, due to the difficulty of mobilizing large veins and the risk of destabilization of the systemic circulation when turning on the external circuit, preference is given to peritoneal dialysis. As an auxiliary method, intestinal and gastric dialysis (lavage, lavage) is still often used, but the method of low-flow hemofiltration is becoming increasingly important, requiring an appropriate structure for monitoring the VEO and the function of the life-support organs.

UFO and LOC are prescribed quite rarely, usually in the presence of a septic process. Irradiation is carried out in courses of 5-10 procedures daily or every other day.

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