Use of hemotransfusion and blood substitute solutions

When bringing women out of critical conditions associated with blood loss, trauma and infectious lesions of the genitals, a wide variety of infusion agents are used, which have a targeted effect on the impaired mechanisms of blood circulation and tissue metabolism. In order to use them with maximum effect, a practicing physician must have an idea of the qualitative characteristics of the most important infusion media, the required amount of their infusion in various situations and the rational ratio of the administered drugs.

Characteristics of the main infusion media.

Preserved donor blood is currently not considered the only or main means of treating critical conditions in gynecological practice, but both the blood itself and its components occupy a certain place in the complex of infusion therapy of extreme conditions. Hemotransfusion not only helps to replenish the BCC, but also leads to the restoration of the number of erythrocytes, which are currently the only means of oxygen transport. The problem of creating blood substitutes that carry oxygen to tissues and remove carbon dioxide has not yet gone beyond the laboratories. Intensive developments are being carried out in three directions: the creation of compounds containing metals (cobalt, iron, etc.), the production of polymer modifications of the hemoglobin molecule and emulsions of organofluorine compounds. However, at present, a practicing physician still has at his disposal the only medium that performs the gas transport function - donor blood or its components (erythrocyte mass).

Donor blood is also the only medium containing complete plasma proteins.

Hemotransfusion is an extremely important operation that must be carried out according to strict indications and in compliance with all rules and instructions, because preservation and especially long periods of storage 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 an increase in fibrinolytic activity, the coagulation capacity of the blood decreases. Due to the loss of organophosphorus compounds, leading to an increase in the affinity of hemoglobin for oxygen and difficulty in its release, the ability of erythrocytes to carry oxygen decreases.

As the preserved blood is stored, the pH decreases (by the 10th day to 6.0) and the potassium content increases (by the 10th day to 8 mmol/l). The need to preserve the blood at a temperature of +4 °C requires warming it up to 37 °C before transfusion. Otherwise, the recipient's body is forced to expend significant energy resources. Transfusion of large quantities of cold blood can lead to hypothermia, which is dangerous for the myocardium.

During 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 according to the ABO and Rh-Hr systems, the possibility of developing hemotransfusion reactions according to other factors of erythrocytes, as well as leukocytes and platelets, is not excluded.

When transfusing large amounts of blood (over 2500-3000 ml per day), complications may develop, described in the literature as homologous blood syndrome, which poses a great danger to the life of the patient. These complications are due to the negative properties of the method of blood conservation and storage, as well as immunobiological factors. The effect of low temperature of preserved blood transfused in large quantities; decreased pH; hyperkalemia; hypocalcemia due to citrate intoxication; aggregation of formed elements, microthrombosis and blood sequestration associated with immunological incompatibility of donors and recipients and leading to hypovolemia, cause the development of persistent arterial hypotension, arrhythmia, tachycardia, ventricular fibrillation and cardiac arrest. In addition to disorders of the cardiovascular system, the symptom complex of massive blood transfusion syndrome consists of manifestations of liver, kidney, and pulmonary failure and disorders of the blood coagulation and anticoagulation systems.

All of the above makes blood transfusions difficult and unsafe, especially those performed in large quantities. The effect of the negative properties of blood must be minimized by following the following rules:

1. Transfuse blood of the same ABO and Rh factor group.
2. To bring women out of a critical condition, use blood or its components no later than the 3rd day of storage.
3. Aim to warm the blood to 37°C.
4. For every 500 ml of donor blood, administer 10 ml of 10% calcium chloride solution, 25 ml of 4% sodium bicarbonate solution, 2 ml of 1% vicasol solution, 5 ml of 5% ascorbic acid solution, 100 ml of 20% glucose solution and 5 U of insulin.
5. Blood transfusion should be combined with the infusion of blood substitutes in a controlled hemodilution mode not exceeding 30% of the circulating blood volume.

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

Blood components and preparations. Red blood cell mass is the main component of whole blood that remains after plasma separation. Compared to ordinary preserved blood, it contains 1.5-2 times more red blood cells; the hematocrit index of red blood cell mass is 0.6-0.7. Transfusion of red blood cell mass is preferable to whole donor blood, since it reduces the number of complications caused by immunological reasons. When bringing a patient out of a critical condition, it is recommended to dilute the red blood cell mass with rheologically active plasma substitutes (for example, rheopolyglucin) in a ratio of 1:2 or 1-3. 86

Erythrocyte suspension is a mass of erythrocytes, completely freed from plasma and suspended in gelatin, rheopolyglucin or glucose with sodium citrate. Erythrocyte suspension is effective in the treatment of hemorrhagic shock, and provides a significant reduction in post-transfusion complications.

The use of frozen erythrocytes in urgent gynecology seems promising. Cryopreservation preserves the physiological properties of erythrocytes. Transfusion of even large quantities of frozen erythrocytes does not lead to the development of homologous blood syndrome or massive blood transfusions. The risk of infection with viral hepatitis B is significantly reduced.

Plasma is 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 dysproteinemia, intoxication, hypovolemia, coagulopathy. The daily dose is 250-750 ml. Dry lyophilized plasma has all the properties of native plasma. Concentrated solutions of dry plasma contain a significant amount of procoagulants, so they can be used in acute blood clotting disorders. From 250 to 750 ml is administered.

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

Products made from donor blood include albumin, protein and erygem.

Albumin solution has high colloid-osmotic activity, due to which it promotes the movement of fluid from the interstitial to the intravascular space. Albumin is retained in the bloodstream for a long time and is a valuable energy reserve for the body. These positive properties of albumin have made it one of the most commonly used 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 dysproteinemia, for detoxification purposes.

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

Erigem is a 3% solution of hemoglobin in 5% glucose solution; it is prepared from hemolyzed erythrocytes. Erigem is a hemodynamic plasma substitute, therefore it is used in cases of blood loss. The average dose is 250-500 ml.

A practicing physician has at his disposal 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 rheopolyglucin and medium-molecular polyglucin . These preparations serve as valuable plasma substitutes, quickly increase the BCC, improve the rheological properties of blood, eliminate stasis and aggregation of formed elements of the blood, improve peripheral blood flow and lead to redeposition of blood. In addition, polyglucin has detoxifying properties. The average dose of polyglucin and rheopolyglucin is 500-1000 ml.

Dextran derivatives also include rondex, rheopolyglucin with glucose, rheogluman, and polyfer.

Rondex is a 6% solution of medium molecular dextran in isotonic sodium chloride solution. It restores the BCC well. The indications for use are the same as for polyglucin.

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

Reogluman is a 10 % dextran solution with the addition of 5% mannitol in an isotonic sodium chloride solution. The blood substitute has a multifunctional property: it reduces blood viscosity, helps restore microcirculation, prevents and eliminates aggregation of formed elements of the blood, has detoxifying, diuretic and hemodynamic properties. The drug should not be administered in case of excessive hemodilution (hematocrit below 0.25), thrombocytopenia, or impaired renal filtration function. Reogluman is administered dropwise: average dose - 400 ml, maximum - 800 ml.

Polifer is a blood substitute with a multifunctional effect: when it is administered, along with an increase in the BCC, hematopoiesis is stimulated. The average single dose is 400 ml, the daily dose is 1200 ml. Polifer is excreted from the body mainly through the kidneys.

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

Polydez, a 3% solution of low-molecular polyvinyl alcohol in isotonic sodium chloride solution, finds its place in the therapy of critical conditions in gynecological practice. It has a pronounced detoxifying property. It is administered intravenously by drip. Single dose - up to 400 ml.

Gelatinol (a gelatin derivative) has a short-term hemodilution effect, reduces blood viscosity, is easily eliminated by the kidneys and has a detoxifying 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.

Of the crystalloid solutions, isotonic sodium chloride solution, Ringer's solution, Ringer-Locke's solution, Ringer's lactate solution (Ringer's lactate), lactasol, and gelvisol are used clinically. Crystalloid solutions are a necessary 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 during the development of shock and the therapeutic use of osmotically and oncotically active agents. Crystalloid solutions can mix with blood in any quantities, thereby reducing blood viscosity and promoting an increase in blood flow velocity. In addition, Ringer's lactate and lactasol help correct metabolic acidosis. Crystalloid solutions are successfully used in combination with colloidal media and preserved blood.

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

• restore the volume of circulating plasma (any colloidal and crystalloid solutions);
• restore the volume of circulating red blood cells (preserved blood, red blood cell mass, red blood cell suspension);
• restore the volume of interstitial fluid (crystalloid solutions);
• improve the rheological properties of blood (rheopolyglucin, polyglucin, gelatinol, hemodez, crystalloid solutions);
• restore the water-electrolyte composition of the blood (polyionic crystalloid solutions, glucose solution with potassium chloride);
• promote normalization of blood acid-base balance (lactasol, ringer-lactate, hemodez, sodium bicarbonate);
• eliminate hypo- and dysproteinemia (dry and native plasma, albumin, protein);
• optimize kidney function (mannitol, sorbitol, hemodez, rheopolyglucin, gelatinol);
• increase the body's energy resources (albumin, protein, glucose solution, fat emulsions);
• promote detoxification of the body (hemodes, plasma, albumin, polyglucin, gelatinol);
• restore blood coagulation disorders (freshly preserved blood, antihemophilic plasma, dry plasma, albumin).