Effect of prophylaxis of thromboembolic complications on postoperative period in geriatric patients with polytrauma

It is known that about 75% of patients of older age groups in the postoperative period have disorders of coagulation-anti-convolving blood systems of various degrees, and their nature is determined by the volume of blood loss, the extent of tissue damage and the type of treatment performed. Ignoring the factors that provoke the formation of thrombosis, or simply not observing the algorithms of its prevention, are often the cause of the fatal course of the postoperative period, especially in gerontological patients, which is due to their age-related anatomical and physiological changes. It was found that the frequency of thromboembolic complications correlates with the severity of the condition assessed by the APACHE II scale. In this case, the probability and timing of the onset of thrombosis directly depend on the methods of treatment of the existing lesions. The most common hemocoagulation disorder in gerontological patients in the postoperative period is hypercoagulability, which is observed, as a rule, with the prevalence of endogenous toxicosis and is a condition in which as a result of certain pathological changes there is an inadequate accumulation of platelets or fibrin, which eventually can lead to thrombosis vessels. This is exacerbated by such unfavorable factors as forced hypodynamia, lack of sucking effect of the chest during ventilation with the introduction of muscle relaxants, non-physiological position (excessive rotation) of the limb in the state of muscle relaxation.

In recent years in clinical practice, low molecular weight heparins (LMWH) are preferred, which have a pronounced antithrombotic and weak anticoagulant effect and the safety of which has been confirmed by numerous studies. However, the search for pathogenetically determined methods of prevention and treatment of hemocoagulation complications in elderly patients, which is aimed at the possibility of stepwise monotherapy, is necessary, which is necessary in the presence of concomitant somatic pathology, aggravating the course of the postoperative period. That is why, with a differentiated approach to the prevention of thromboembolic complications, the pharmacological profile of the drugs included in our comparative analysis was taken into account.

In turn, pentosan polysulphate SP 54, which we also consider as a variant of a prophylactic anticoagulant in gerontological patients, inhibits the formation of factor Xa in the endogenous clotting system, preventing the formation of excess thrombin. The main difference from LMWH and UFH is its AT-III-independent mechanism of action on the X factor. This allows the use of pentosan polysulfate for the prevention of thromboembolic complications for a longer period (up to 25 days in the injectable form), in contrast to unfractionated heparin and LMWH. Presence of ampouled and tabletted forms of release allows to translate into enteral form according to the principle of stepwise prevention of possible occurrence of thromboembolic complications. The drug activates endogenous fibrinolysis by releasing the tissue plasminogen activator from the endothelium into the blood. In addition, pentosan polysulfate activates kallikrein and XII coagulation factor, which is another way of activating fibrinolysis; inhibits the activation of the plasma VIII factor, preventing its transition to an active form and participation in the activation of the plasma X factor; reduces plasma factor V activity by more than 50%; inhibits intravascular aggregation of erythrocytes, thus preventing the stasis of erythrocytes; Helps reduce blood viscosity and improves microcirculation. Pentosan polysulphate reduces collagen-induced platelet aggregation, but is weaker than unfractionated heparin, which causes less bleeding from the wound surface. It reduces the aggregation of erythrocytes in terminal vessels by improving the elasticity of their membranes.

We conducted a study whose goal was to study the effectiveness of specific prevention of thrombotic complications in gerontological patients with polytrauma using differentiated use of drugs with anticoagulant properties.

In the course of the study, an analysis of the complex laboratory-instrumental examination and intensive care of 62 gerontological patients with polytrauma, who were on inpatient treatment in the department of anesthesiology and intensive care of polytrauma of the Kharkov City Clinical Hospital of Emergency and Emergency Medical Care, was carried out. Prof. A. I. Meshchaninov in the period of 2006-2011. All patients aged 65.19 ± 4.74 years were stratified according to the nature and severity of the lesions (APACHE II 17.5 ± 3.2 points) and the anticoagulant used. Surgical correction was performed within 12 hours from the moment of admission to the hospital. Evaluation of risk factors for thromboembolic complications by Tibiana Duprarc (1961) and the risk of postoperative venous thromboembolic complications in S. Samama and M. Samama in a modification (1999) showed that all patients were at high risk. In accordance with the preparation, the patients were divided into 4 groups. In the first group (n = 18), enoxaparin was used to prevent thromboembolic complications, in the second group (n = 14) - dalteparin, in the third group (n = 16) - supraparin, in the fourth group (n = 14) - pentosan polysulfate. According to the scheme, prophylactic administration of direct anticoagulants was started 4 hours after surgery at dosages: enoxaparin-40 mg, dalteparin-5000 IU, supraparin-0.6 ml, pentosan polysulphate - at a dose of 100 mg once / 5 days after the operation, then from the 5th to the 10th day, 100 mg once a day with the transition to taking the tablet form of pentosan polysulphate 50 mg of the drug 2 times a day for 20 days, then switching to 50 mg 1 time per day. Along with general clinical and biochemical studies, a hemostatic system was studied with determination of the number of platelets and their aggregation properties, activated partial thromboplastin time, prothrombin index. The studies were carried out on the 1st, 3rd, 5th, 7th and 10th days from the time of injury. Statistical calculations were performed using the Statistica 6.O software package. An assessment of the reliability of the differences between the groups was carried out using the parametric t-test of Student with the Bonferroni correction for multiple comparisons.

In the course of the study, it was revealed that the greatest number of thrombotic complications in the form of proximal thrombosis of the veins of the lower extremities (according to ultrasound) was determined in the group using nadroparin, 9 (19.6%). And only in this group of 3 (6.5%) patients in the early postoperative period, thromboembolism of small branches of the pulmonary artery was diagnosed. In groups where enoxaparin was used, dalteparin and pentosan polysulphate, thrombotic complications were detected in 5 (17.2%), 6 (17.2%) and 2 (6.7%) cases, respectively.

Analysis of the number of hemorrhagic complications, which manifested bleeding of the postoperative wound, showed that in the I group it was the maximum - 10.3% (3 cases). In the II, III and IV groups, it was 5.7% (2 cases), 6.5% (3 cases) and 4% (1 case), respectively.

Thus, based on clinical observations, it can be said that the greatest antithrombotic properties in the prevention of thromboembolic complications in gerontological patients with polytrauma were detected in pentosan polysulfate. At the same time, against the background of its use, the number of hemorrhagic complications did not differ significantly. Dynamics of blood coagulation properties in the use of LMWH reflected a moderate increase in activated partial thromboplastin time and a decrease in the prothrombin index, which were more pronounced in the enoxaparin group, but were not statistically significant.

The results obtained in our studies once again confirmed the opinion of other authors that due to the insignificant effect on the coagulogram indices, the use of LMWH does not require constant laboratory monitoring. In turn, the analysis of the indices of vascular-platelet hemostasis showed that LMWH in gerontological patients with acute surgical pathology can cause moderately expressed transient thrombocytopenia, accompanied by a decrease in aggregation capacity of platelets (differences in platelet count and aggregation properties between groups are unreliable).

Summarizing the results of specific prevention of thrombotic complications in gerontological patients with acute surgical pathology, we can draw the following conclusions.

Postoperative period in gerontological patients with polytrauma is characterized by a high risk of thromboembolic complications, which can be fatal. This is due not only to the volume of surgical intervention and concomitant pathology, but also to the syndrome of hypercoagulability.

Given the difference in the antithrombotic spectrum of direct anticoagulants and the potential probability of hemorrhagic complications, the use of low molecular weight heparins in patients with combined trauma requires a differentiated approach and a laboratory control of all links of hemostasis.

In gerontological patients with polytrauma pathogenetically justified is the use of the injective form of pentosan sodium sulfate polysulphate for the prevention of thromboembolic complications in the postoperative period with the subsequent transition to the tablet form.

Pentosan polysulphate is the only direct anticoagulant, a preparation for the prevention of thromboembolic complications, which has two forms of release, which determines the most effective stepwise long-term therapy of postoperative complications associated with disorders of the rheological properties of the blood.

According to the generally accepted standards for the prevention of thromboembolic complications, a group of direct anticoagulants is mandatory for appointment in the postoperative period of management of the patient. The appearance in the arsenal of the doctor of new injectable and tablet preparations for the prevention of thromboembolic complications makes it possible to expand the possibilities of conducting the necessary therapy.

 Assoc. Yu. V. Volkova. Influence of prophylaxis of thromboembolic complications on postoperative period in gerontological patients with polytrauma // International Medical Journal - №4 - 2012

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