The use of blood transfusion and blood replacement solutions

When removing women from critical conditions associated with blood loss, trauma and infection of the genitals, a wide variety of infusion means that have a directed effect on the disturbed mechanisms of blood circulation and tissue metabolism is used. To use them with maximum effect, a practical physician should have an idea about the qualitative characteristics of the most important infusion media, the necessary amount of their infusion in different situations and the rational ratio of the drugs administered.

Characteristics of the main infusion media.

Conserved donor blood is not currently considered to be the only or primary means of treating critical conditions in gynecological practice, however both the blood itself and its components occupy a certain place in the complex of infusion therapy of extreme conditions. Blood transfusion not only contributes to replenishment of BCC, but also leads to the restoration of the number of erythrocytes, which are the only means of transport of oxygen. The problem of creating blood substitutes that perform the function of transferring to oxygen tissues and removing carbon dioxide has not yet gone beyond the scope of laboratories. Intensive developments are carried out in three directions: the creation of compounds containing metals (cobalt, iron, etc.), the preparation of polymer modifications of the molecule of hemoglobin and emulsions of organofluorine compounds. However, at present the practical doctor still has the only environment that performs the gas transport function - donor blood or its components (erythrocyte mass).

Donor blood is also the only medium containing high-grade plasma proteins.

Hemotransfusion is an extremely important operation that must be carried out under strict indications and with observance of all rules and regulations, because conservation and especially long storage periods of donor blood lead to the fact that it loses some positive properties and acquires undesirable qualities. Already in the first days of storage, vitamins and hormones are destroyed. Due to the destruction of procoagulants and increased fibrinolytic activity, the coagulation ability of blood decreases. Due to the loss of organophosphorus compounds, which leads to an increase in the affinity of hemoglobin for oxygen and a difficulty in its recoil, the ability of erythrocytes to carry oxygen decreases.

As the stored blood is stored, the pH drops (by the 10th day to 6.0) and the potassium content increases (by the 10th day to 8 mmol / l). The need to preserve blood at a temperature of + 4 ° C requires it to be warmed before transfusion to 37 ° C. Otherwise, the recipient organism is forced to expend very tangible energy resources. Transfusion of large amounts of cold blood can lead to a hypothermic hazard for the myocardium.

With blood transfusion, the risk of contracting infectious diseases, including serum hepatitis, syphilis, malaria, and AIDS, remains relevant.

Despite the compatibility of donor and recipient blood in ABO and Rh-Hr systems, the possibility of developing blood transfusion reactions for other factors of erythrocytes, as well as leukocytes and platelets, is not ruled out.

If large amounts of blood are transfused (over 2500-3000 ml per day), complications described in the literature as a syndrome of homologous blood presenting a great danger to the life of the patient may develop. These complications are caused by negative properties of the method of preservation and storage of blood, as well as immunobiological factors. Influence of low temperature of canned blood, poured in large quantities; lowering the pH; hyperkalemia; hypocalcemia due to citrate intoxication; aggregation of uniform elements, microthrombosis and blood sequestration associated with immunological incompatibility of donors and recipient and leading to hypovolemia, cause the development of persistent arterial hypotension, arrhythmia, tachycardia, ventricular fibrillation and cardiac arrest. In addition to violations of the cardiovascular system, the symptom complex of the massive blood transfusion syndrome consists of manifestations of hepatic, renal, pulmonary insufficiency and disorders of coagulating and anticoagulating blood systems.

All of this makes difficult and makes blood transfusions, especially those produced in large quantities, not safe. The effect of negative blood properties should be minimized by observing the following rules:

1. To transfuse blood, one-grouped according to the ABO and Rh-factor systems.
2. To remove women from a critical condition, use blood or its components no later than the 3rd day of storage.
3. Strive to warm up the blood to 37 ° С.
4. For each 500 ml of donor blood, 10 ml of 10% calcium chloride solution, 25 ml of 4% sodium bicarbonate solution, 2 ml of 1% solution of vicasol, 5 ml of 5% solution of ascorbic acid, 100 ml of 20% glucose solution and 5 units of insulin are injected.
5. Blood transfusion is combined with the infusion of blood substitutes in a controlled hemodilution regime that does not exceed 30% of the BCC.

In transfusiology, in addition to canned blood, freshly citrated and unstabilized "warm" blood of the donor is used. Such blood retains all the basic biological properties of blood, so transfusion of freshly citrated blood is indispensable for coagulopathic and septic conditions. The wider use of such blood is limited because of the increased risk of transmission of infection from the donor to the recipient, as well as the organizational difficulties associated with the need to keep a large number of donors at the ready.

Components and preparations of blood. Erythrocytic mass is the main component of whole blood, which remains after the separation of plasma. In comparison with the usual canned blood, it contains 1.5-2 times more red blood cells; the hematocrit index of erythrocyte mass is 0.6-0.7. Transfusion of erythrocyte mass is preferable to whole blood donation, as this reduces the number of complications due to immunological reasons. When removing the patient from a critical state, the erythrocyte mass is recommended to dilute with rheologically active plasma substitutes (for example, rheopolyglucin) in a ratio of 1: 2 or 1-3. 86

The erythrocyte suspension is an erythrocyte mass completely freed from plasma and suspended in gelatin, rheopolyglucose or glucose with sodium citrate. Erythrocyte suspension is effective in the treatment of hemorrhagic shock, gives a significant reduction in posttransfusion complications.

It seems promising to use frozen erythrocytes in urgent gynecology. Cryopreservation preserves the physiological properties of erythrocytes. Transfusion of even large amounts of frozen erythrocytes does not lead to the development of a syndrome of homologous blood or massive blood transfusions. Significantly reduces the risk of infection with viral hepatitis B.

Plasma - the second component of blood, it includes: water - 90%, proteins - 8%, organic and inorganic substances - 2 %, as well as biologically active substances. Native plasma is used in conditions accompanied by hypo- and disproteinemia, intoxication, hypovolemia, coagulopathies. The daily dose of 250-750 ml. Dry lyophilized plasma possesses all the properties of native plasma. Concentrated solutions of dry plasma contain a significant amount of procoagulants, so they can be used for acute disorders of blood clotting. Enter from 250 to 750 ml.

Platelet mass - the third component of blood - is a suspension of platelets in the plasma. It is used to stop bleeding associated with thrombocytopenia.

Drugs made from donor blood include albumin, protein and eryhemem.

The albumin solution has a high colloid-osmotic activity, which facilitates the movement of fluid from the interstitial to the intravascular space. Albumin is retained for a long time in the bloodstream and is a valuable energy reserve for the body. These positive properties of albumin made it one of the most common infusion media. 5%, 10% and 20% albumin solutions in the amount of 200-400 ml are used to eliminate acute and chronic hypovolemia, to correct hypo- and disproteinemia, for detoxification purposes.

Protein is a 4.3-4.8% solution of proteins of the donor blood, of which albumin accounts for 80-85%, alpha and beta globulin is 15-20%. Protein in its colloid osmotic activity is close to native plasma and is used to eliminate hypovolemia. The approximate dose is 250-500 ml.

Erigem - 3% hemoglobin solution in 5% glucose solution; it is prepared from hemolyzed erythrocytes. Erygem refers to the plasma substitutes for hemodynamic action, therefore it finds its application in cases of hemorrhage. The average dose is 250-500 ml.

At the disposal of the practical physician is a large arsenal of blood substitutes, which are divided into colloidal and crystalloid solutions.

Colloidal solutions include dextran derivatives. Domestic preparations of this series are low molecular weight reopolyglucin and medium molecular polyglucin . These drugs are valuable substitutes for plasma, rapidly increasing the BCC. Improve rheological properties of blood, eliminate stasis and aggregation of blood elements, improve peripheral blood flow and lead to redeposition of blood. In addition, polyglucinum has detoxification properties. The average dose of polyglucin and reopolyglucin is 500-1000 ml.

Dextran derivatives also include rondex, rheopoliglyukin with glucose, reogluman, polyfer.

Rondex - 6% solution of medium-molecular dextran in isotonic sodium chloride solution. Well restores bcc. Indications for use are the same as in polyglucin.

Rheopolyglucin with glucose is a 10% solution of low molecular weight dextran supplemented with glucose. The drug reduces the viscosity of the blood, improves its rheological properties, promotes the recovery of microcirculation, prevents the aggregation of uniform elements. The average dose is 400-800 ml. It should be remembered that 100 ml of blood substitute contain 5 g of glucose, therefore, when administering significant amounts of the drug, it is necessary to add adequate doses of insulin.

Reogluman - 10 % solution of dextran with the addition of 5% mannitol in isotonic sodium chloride solution. The blood substitute has a polyfunctional property: it reduces viscosity. It contributes to the restoration of microcirculation, prevents and eliminates the aggregation of blood cells, detoxification, diuretic and hemodynamic properties. The drug should not be administered with excessive hemodilution (hematocrit index is below 0.25), with thrombocytopenia, with a violation of the filtration function of the kidneys. Reogluman injected a drop: the average dose - 400 ml, the maximum - 800 ml.

Polifer - blood substitute for polyfunctional action: when it is introduced, along with an increase in bcc, stimulation of hemopoiesis occurs. The average single dose is 400 ml, the daily dose is 1200 ml. The polyferrin is excreted from the body mainly through the kidneys.

Synthetic colloidal plasma substitutes are also derivatives of polyvinylpyrrolidone. In the USSR, a highly effective drug of this kind is produced - haemodesis. The drug has a low molecular weight, is easily and quickly excreted by the kidneys, has good rheological and detoxification properties, helps to eliminate metabolic acidosis. These qualities of haemodesis are used in the treatment of purulent inflammatory processes of the genital organs, peritonitis, sepsis. At a time, 300-450 ml of solution can be administered, after 12 hours the infusion can be repeated.

Finds its place in the therapy of critical conditions in gynecological practice of polydesis - a 3% solution of polyvinyl low molecular weight alcohol in isotonic sodium chloride solution. Has a pronounced detoxification property. Enter intravenously drip. Single dose - up to 400 ml.

Gelatine (gelatin derivative) has a short-term effect of hemodilution, reduces the viscosity of the blood, is easily eliminated by the kidneys and has a detoxification effect. It is widely used in urgent gynecology for the treatment of all types of shock and in the complex therapy of pelvic peritonitis and peritonitis of gynecological origin. The average dose is 500-1000 ml.

From crystalloid solutions clinical application is isotonic solution of sodium chloride, Ringer's solution, Ringer-Locke, lactated Ringer's solution (ringer-lactate), lactasol, gelvisol. Crystalloid solutions are an essential component in the therapy of hemorrhagic shock. Only they can eliminate the deficiency of extracellular fluid, caused by its movement due to both pathophysiological processes in the development of shock, and the therapeutic use of osmotically and oncotically active agents. Crystalloid solutions are capable of mixing with blood in any amount, thereby reducing the viscosity of the blood and contributing to increased blood flow velocity. In addition, ringer-lactate and lactasol allow to correct metabolic acidosis. Crystalloid solutions are successfully used in combination with colloidal media and canned blood.

A wide range of infusion media, knowledge of their characteristics make it possible to individualize the application and to implement a rational combination of drugs in each specific case. In practical gynecology, corrective infusion-transfusion therapy helps:

• to restore the volume of circulating plasma (any colloidal and crystalloid solutions);
• to restore the volume of circulating erythrocytes (canned blood, erythrocyte mass, erythrocyte suspension);
• restore the volume of the interstitial fluid (crystalloid solutions);
• improve the rheological properties of blood (rheopolyglucin, polyglucin, gelatin, hemodez, crystalloid solutions);
• restore the water-electrolyte composition of blood (polyionic crystalloid solutions, glucose solution with potassium chloride);
• promote the normalization of blood COS (lactasol, ringer-lactate, hemodez, sodium bicarbonate);
• eliminate hypo- and disproteinemia (dry and native plasma, albumin, protein);
• optimize kidney function (mannitol, sorbitol, haemodez, reopolyglucin, gelatin);
• increase energy resources of the organism (albumin, protein, glucose solution, fat emulsions);
• promote detoxification of the body (haemodes, plasma, albumin, polyglucin, gelatin);
• to restore violations of hemocoagulation (freshly canned blood, antihemophilic plasma, dry plasma, albumin).