Detoxification therapy

Desintoxication therapy, in fact, includes the whole complex of therapeutic measures aimed at combating the disease, but above all it is the excretion of toxic substances from the body. This type of treatment can be carried out using internal resources of the body - intracorporeal detoxification therapy (ID), removal of contents with subsequent cleansing of the gastrointestinal cavity, or by purification of blood outside the body - extracorporeal detoxification therapy (ED).

Intoxication is a nonspecific reaction of the body to the action of various toxins of origin, differing in relative dynamic equilibrium and a certain stability in time. This reaction is represented by a complex of protective-adaptive reactions of the body, aimed at eliminating the toxin from the body.

Toxicosis is a nonspecific, perverse reaction of the body to the action of microbial toxins and viruses. In the genesis of toxicosis, an important role is played by self-damaging of the organism due to the rapid transition of adaptive reactions to pathological ones.

To specific detoxification therapy is etiotropic antitoxic treatment (immunotherapy, use of antidotes). Nonspecific methods of ID are IT, stimulation of the activity of enzyme systems that ensure the binding and metabolism of toxic substances within the body, and the restoration of the function of its own organs and systems of detoxification (liver, kidney, lung, intestine, reticuloendothelial system).

If the damage to organs and systems is so great that the body can not cope with the increasing toxemia, resort to methods of extracorporeal detoxification therapy. 

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

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

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

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

Etiotropic treatment

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

In bacterial infections, antibiotics are used.

To etiotropic treatment with toxic syndrome should be attributed the use of hyperimmune components. In addition to the widely known anti-staphylococcal plasma and immunoglobulins, antidiphtheria serum, plasma is now successfully used: antimeningococcal, antiprotein, anti-escherichiosis, and others, titrated with donor injections of anatoxins. Also effective are special antitoxic serums - antidiphtheria, tetanus, anti-botulinum, anti-gangrene, which are the basis for treating patients with exotoxic infections.

[7]

Pathogenetic detoxification therapy

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

Blood dilution (hemodilution) reduces the concentration of toxins in the blood and in the extracellular space. The increase in the cerebral circulation increases the irritation of the baroreceptors of the vascular wall and the right atrium, and stimulates urination.

Restoration of effective blood circulation is provided by the introduction of electrolytes or colloidal drugs of vollemic action - plasma substitutes.

At the first degree of deficiency, a liquid (plasma substitutes) is introduced at the rate of 7 ml / kg, at grade II - 8-15 ml / kg, with III - 15-20 ml / kg or more during the first 1-2 hours of treatment, a mild degree of deficiency of the cerebral palsy, the entire volume can be administered orally, with the medium-heavy and severe-partially intravenous drip or jet. The improvement of peripheral circulation is facilitated by the introduction of rheoprotectors (reopolyglucin), preparations of the disaggregating action and antispasmodics (trental, komplamin, euphyllin with nicotinic acid, etc.), disaggregants (quarantil at a dose of 1-2 mg / kg, aspirin at a dose of 5 mg / kg per day ), thrombin inhibitors (heparin, antithrombin III-AT III).

In the subsequent maintenance of hemodynamics is ensured by the constant introduction of fluid inside and (or) intravenously, taking into account the continuing loss and volume of food (see Section 2.4 for calculating the volumes), and the water balance by infusion over 1 day or more of the base solution or by enteral administration liquid. In the first days of treatment in infants, infants who are unconscious, fluid and food can be injected through the nasogastric tube in batches (fractional) or continuously drip.

Elimination of all types of hypoxia by oxygenation at an oxygen concentration in the inspired air in the range of 30-40 vol. %. Oxygen therapy is carried out in oxygen tents, under an awning, through the nasopharyngeal probe, nasal cannulae, oxygen mask, its duration is determined by pulse oximetry, gas detection. With toxicosis, IVL is prescribed, in case of severe anemia, an erythrocyte mass is administered. The saturation of hemoglobin with oxygen and the restoration of the affinity of hemoglobin to oxygen is indicated by the normalization of the parameters of CBS, the decrease in body temperature.

Hyperbaric (HBO) and membrane (MO) oxygenation are effective additional methods for treating the effects of hypoxic damage, but can also be used during a critical period that develops 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); only 5-10 sessions daily or (more often) every other day.

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

A simple and objective indicator of effective detoxification is the volume of daily or hourly urine output, since up to 95% of hydrophobic toxins are excreted in the urine, and the clearance of these substances corresponds to the rate of glomerular filtration (most toxins are not reabsorbed in the renal tubules). Normally, daily diuresis is from 20 ml / kg in children older than 50 ml / kg - in infancy, 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 with intoxication of special severity and the absence of OPN is it possible to increase it to 1.5 FP. In the first day in children of the first months of life, with the presence of hypotrophy, heart defects, patients with pneumonia, a total of not more than 80% of the fluids are injected, 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 use drugs that improve microcirculation in the kidneys: eufillin (2-3 mg / kg), nicotinic acid (0 , 02 mg / kg), trental (up to 5 mg / kg per day), dopamine in doses - 1-2 μg / kg-min), etc.

Oral disintoxication therapy consists in the appointment of boiled water, a table of mineral water, tea, berry or fruit broth. Infant and neonatal infants may be injected through a nasogastric tube in a fractional or continuous drop.

Infusion detoxification therapy

Infusion detoxification therapy is carried out with the help of glucose-salt solutions (more often in the ratio of 2: 1 or 1: 1). Its volume depends on the degree of intoxication: at level I, half the volume can be administered intravenously drip 2-3 hours, at the second degree this volume together with the plasma compensation fluid is introduced for 4-6 hours (up to 8 hours), and the rest - up to end of 1 day (slowly), at grade III 70-90% of the total volume of fluid is administered intravenously evenly for 1 day, then - depending on the dynamics of clinical manifestations of intoxication with the mandatory addition of diuretics.

In cases of severe intoxication and the absence of a true ARF, a powerful method is a method of forced diuresis with intravenous infusion of glucose-salt solutions in a volume of 1.0-1.5 FP in combination with lasix (single dose 1-2 mg / kg), mannitol (10% solution in a dose of 10 ml / kg) in such a way that the volume of the injected liquid was equal to diuresis. Forced diuresis is used mainly in older children; in the first day they usually do not get food, to improve the effect of the gastric and intestinal lavage.

Forced diuresis is more often performed with the use of intravenous infusions (if the patient's condition allows, oral water load is possible) with an average speed of 8-10 ml / (kg-h). Short-term hemodilutants (Ringer's solution or other official electrolyte mixtures in combination with 5 or 10% glucose solution) are used. To maintain the necessary VCI and provide microcirculation with moderate hemodilution (blood dilution), blood substitutes are shown: rheopolyglucin 10 ml / kg-day) and protein preparations - 5-10% albumin solution at a dose of 10 ml / kg-day. If there is no desired increase in diuresis, diuretics are used (lasix in a daily dose of 1 to 3 mg / kg).

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

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

Detoxification therapy: drugs

To enhance the effect of parenteral detoxification therapy, drugs that have cleansing properties are used: haemodes, reoglumane (reopolyglucin solution containing glucose and mannitol in 5% concentration), albumin is prescribed only with hypoalbuminemia <35 g / l, expressed hypovolemia. A positive effect is given by the appointment of various enterosorbents (smect, enterode, polysorb, entersgel, etc.) into the interior, as well as the timely elimination of the intestinal paresis, against which the penetration of the products of microbial metabolism and the bacteria from the intestine is increasing in the vascular channel. Means that improve the functions of hepatocytes (hepatoprotectors), motor activity of biliary tract and gastrointestinal tract (chole- and enterokinetic, antispasmodics, etc.) are also shown.

The presence of a true deficiency of the organs of detoxification (arthritis, hepatargia, intestinal paresis of grade III) serves as an indication for inclusion in the treatment complex (in the first 1-2 days) of ED methods. Extracorporeal detoxification therapy is suitable for the majority of patients with toxicosis, against or against the threat of renal, hepatic or polyorganic insufficiency.

[8], [9], [10], [11]

Detoxification therapy in children

In urgent medicine, children often use hemosorption (HS), plasmapheresis (PF) or HMF, hemodialysis (HD), less often - ultraviolet (UV) and laser (LOK) irradiation.

Disintoxication therapy (hemosorption) is based on the absorption of foreign substances on the surface of the solid phase of biological (albumin), plant (wood, stone) and artificial (synthetic coals, ion exchange resins) sorbents and allows the elimination of medium- and large-molecule toxic substances, including bacterial toxins and microbes themselves. The effect of HS is much faster (0.5-1 hour) than HD and even PF, which allows this method to be used as an emergency aid to patients.

In the treatment of infants and young children, columns with a capacity of 50-100 ml are used, contours for blood with a capacity of no more than 30 ml. Perfusion rate along the contour is 10-20 ml / min, while at the beginning and at the end of the procedure it should change gradually - within 5 minutes from 0 to the operating value. Columns with a sorbent should be filled with a 5% solution of albumin. For total heparinization, 300 units / kg of heparin is usually required. Detoxification effect of HS 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 cancerous toxicosis, draining pneumonia, sepsis, allergic diseases, viral hepatitis. PF is most convenient in the presence of unstable hemodynamics in children and severe intoxication. It is advisable in children of maternal age to perform plasma substitution only SFP from one donor. In children of the first months of life, due to the difficulty of mobilizing large veins and the danger of destabilization of the systemic circulation when external contour is switched on, preference is given to peritoneal dialysis. As an auxiliary method, intestinal and gastric dialysis (lavage, washing) is still often used, however, low-flux haemofiltration, which requires an appropriate structure for monitoring VEOs and the functions of life support systems, is becoming increasingly important.

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

[12], [13], [14], [15], [16]