Infusion therapy in anesthesiology. Rules for the technique of infusion therapy

Infusion therapy is a drip injection or infusion intravenously or under the skin of drugs and biological fluids in order to normalize the water-electrolyte, acid-base balance of the body, as well as for forced diuresis (in combination with diuretics).

Indications for infusion therapy: all types of shock, blood loss, hypovolemia, loss of fluid, electrolytes and proteins as a result of indomitable vomiting, intense diarrhea, refusal to take fluids, burns, kidney disease; violations of the content of basic ions (sodium, potassium, chlorine, etc.), acidosis, alkalosis and poisoning.

The main signs of dehydration of the body: retraction of the eyeballs into the orbits, dull cornea, dry, inelastic skin, characteristic palpitations, oliguria, urine becomes concentrated and dark yellow, the general condition is depressed. Contraindications to infusion therapy are acute cardiovascular failure, pulmonary edema and anuria.

Crystalloid solutions are able to compensate for the deficiency of water and electrolytes. Apply 0.85% sodium chloride solution, Ringer and Ringer-Locke solutions, 5% sodium chloride solution, 5-40% glucose solutions and other solutions. They are administered intravenously and subcutaneously, by stream (with severe dehydration) and drip, in a volume of 10–50 ml/kg or more. These solutions do not cause complications, except for overdose.

The goals of infusion therapy are: restoration of BCC, elimination of hypovolemia, ensuring adequate cardiac output, maintaining and restoring normal plasma osmolarity, ensuring adequate microcirculation, preventing aggregation of blood cells, normalizing the oxygen-transport function of blood.

Colloidal solutions are solutions of macromolecular substances. They contribute to the retention of fluid in the vascular bed. Hemodez, polyglucin, reopoliglyukin, reogluman are used. With their introduction, complications are possible, which manifest themselves in the form of an allergic or pyrogenic reaction. Routes of administration - intravenously, less often subcutaneously and drip. The daily dose does not exceed 30–40 ml/kg. They have a detoxifying quality. As a source of parenteral nutrition, they are used in case of prolonged refusal to eat or inability to feed by mouth.

Blood and casein hydrolysins are used (alvezin-neo, polyamine, lipofundin, etc.). They contain amino acids, lipids and glucose. Sometimes there is an allergic reaction to the introduction.

Rate and volume of infusion. All infusions in terms of volumetric infusion rate can be divided into two categories: requiring and not requiring rapid correction of the BCC deficiency. The main problem may be patients who need rapid elimination of hypovolemia. i.e., the rate of infusion and its volume must ensure the performance of the heart in order to properly supply regional perfusion of organs and tissues without significant centralization of blood circulation.

In patients with an initially healthy heart, three clinical landmarks are most informative: mean BP > 60 mm Hg. Art.; central venous pressure - CVP > 2 cm of water. Art.; diuresis 50 ml/h. In doubtful cases, a test with a load in volume is carried out: 400–500 ml of a crystalloid solution is poured over 15–20 minutes and the dynamics of CVP and diuresis are observed. A significant rise in CVP without an increase in diuresis may indicate heart failure, which suggests the need for more complex and informative methods for assessing hemodynamics. Keeping both readings low suggests hypovolemia, then maintain a high infusion rate with repeated step-by-step assessment. An increase in diuresis indicates prerenal oliguria (hypoperfusion of the kidneys of hypovolemic origin). Infusion therapy in patients with circulatory insufficiency requires a clear knowledge of hemodynamics, large and special monitoring monitoring.

Dextrans are colloidal plasma substitutes, which makes them highly effective in the rapid recovery of BCC. Dextrans have specific protective properties against ischemic diseases and reperfusion, the risk of which is always present during major surgical interventions.

The negative aspects of dextrans include the risk of bleeding due to platelet disaggregation (especially characteristic of rheopolyglucin), when it becomes necessary to use significant doses of the drug (> 20 ml / kg), and a temporary change in the antigenic properties of the blood. Dextrans are dangerous because of their ability to cause a "burn" of the epithelium of the tubules of the kidneys and therefore are contraindicated in renal ischemia and renal failure. They often cause anaphylactic reactions, which can be quite severe.

Of particular interest is a solution of human albumin, as it is a natural colloid of a plasma substitute. In many critical conditions accompanied by damage to the endothelium (primarily in all types of systemic inflammatory diseases), albumin is able to pass into the intercellular space of the extravascular bed, attracting water and worsening interstitial tissue edema, primarily the lungs.

Fresh frozen plasma is a product taken from a single donor. FFP is separated from whole blood and frozen immediately within 6 hours of blood collection. Stored at 30°C in plastic bags for 1 year. Given the lability of clotting factors, FFP should be infused within the first 2 hours after rapid thawing at 37°C. Transfusion of fresh frozen plasma (FFP) gives a high risk of contracting dangerous infections, such as HIV, hepatitis B and C, etc. The frequency of anaphylactic and pyrogenic reactions during transfusion of FFP is very high, so compatibility according to the ABO system should be taken into account. And for young women, Rh-compatibility must be considered.

Currently, the only absolute indication for the use of FFP is the prevention and treatment of coagulopathic bleeding. FFP performs two important functions at once - hemostatic and maintaining oncotic pressure. FFP is also transfused with hypocoagulation, with an overdose of indirect anticoagulants, with therapeutic plasmapheresis, with acute DIC, and with hereditary diseases associated with a deficiency of blood coagulation factors.

Indicators of adequate therapy are a clear consciousness of the patient, warm skin, stable hemodynamics, the absence of severe tachycardia and shortness of breath, sufficient diuresis - within 30-40 ml / h.

Complications of blood transfusion: post-transfusion disorders of the blood coagulation system, severe pyrogenic reactions with the presence of hyperthermic syndrome and cardiovascular decompensation, anaphylactic reactions, erythrocyte hemolysis, acute renal failure, etc.

The basis of most complications is the reaction of rejection by the body of foreign tissue. There are no indications for transfusion of canned whole blood, because the risk of post-transfusion reactions and complications is significant, but the most dangerous is the high risk of infection of the recipient. In case of acute blood loss during surgical intervention and adequate replenishment of the BCC deficiency, even a sharp decrease in hemoglobin and hematocrit does not threaten the life of the patient, since oxygen consumption under anesthesia is significantly reduced, additional oxygenation is acceptable, hemodilution helps prevent the occurrence of microthrombosis and mobilization of erythrocytes from the depot, increase blood flow velocity and etc. The “reserves” of erythrocytes that a person has by nature significantly exceed the real needs, especially in a state of rest, in which the patient is at this time.

1. Transfusion of erythrocyte mass is carried out after the restoration of the BCC.

2. In the presence of severe concomitant pathology, which can lead to death (for example, severe anemia is poorly tolerated in severe coronary heart disease).

3. In the presence of the following indicators of the patient's red blood: 70-80 g / l for hemoglobin and 25% for hematocrit, and the number of red blood cells is 2.5 million.

Indications for blood transfusion are: bleeding and correction of hemostasis.

Types of erythrocytes: whole blood, erythrocyte mass, EMOLT (erythrocyte mass separated from leukocytes, platelets with saline). Blood is administered intravenously by drip, using a disposable system at a rate of 60–100 drops per minute, in a volume of 30–50 ml/kg. Before blood transfusion, it is necessary to determine the blood group and Rh factor of the recipient and donor, conduct a test for their compatibility, and a biological test for compatibility is performed at the patient's bedside. When an anaphylactic reaction occurs, the transfusion is stopped and measures to eliminate shock begin.

The standard platelet concentrate is a suspension of double-centrifuged platelets. The minimum platelet count is 0.5? 1012 per liter, leukocytes - 0.2? 109 per litre.

Hemostatic characteristics and survival are most pronounced in the next 12-24 hours of preparation, but the drug can be used within 3-5 days from the moment of blood sampling.

Platelet concentrate is used for thrombocytopenia (leukemia, bone marrow aplasia), thrombopathy with hemorrhagic syndrome.

In severe diseases accompanied by severe disturbances of homeostasis, it is necessary to provide the body with energy and plastic material. Therefore, when nutrition through the mouth is impaired or completely impossible for some reason, it is necessary to transfer the patient to parenteral nutrition.

In critical conditions of various etiologies, the most significant changes occur in protein metabolism - intensive proteolysis is observed, especially in striated muscles.

Depending on the severity of the ongoing process, body proteins are catabolized in the amount of 75-150 g per day (daily protein losses are shown in Table 11). This leads to a deficiency of essential amino acids, which are used as an energy source in the process of gluconeogenesis, resulting in a negative nitrogen balance.

Table 11

Daily protein loss in critical conditions

The loss of nitrogen leads to a decrease in body weight, since: 1 g of nitrogen \u003d 6.25 g of protein (amino acids) \u003d 25 g of muscle tissue. Within a day from the onset of a critical condition, without adequate therapy with the introduction of a sufficient amount of essential nutrients, its own reserves of carbohydrates are exhausted, and the body receives energy from proteins and fats. In this regard, not only quantitative, but also qualitative changes in metabolic processes are carried out.

The main indications for parenteral nutrition are:

1) anomalies in the development of the gastrointestinal tract (esophageal atresia, pyloric stenosis, and others, pre- and postoperative period);

2) burns and injuries of the oral cavity and pharynx;

3) extensive body burns;

4) peritonitis;

5) paralytic ileus;

6) high intestinal fistulas;

7) indomitable vomiting;

8) coma;

9) severe diseases accompanied by an increase in catabolic processes and decompensated metabolic disorders (sepsis, severe forms of pneumonia); 10) atrophy and dystrophy;

11) anorexia due to neuroses.

Parenteral nutrition should be carried out in conditions of compensation for volemic, water-electrolyte disorders, elimination of microcirculation disorders, hypoxemia, and metabolic acidosis.

The basic principle of parenteral nutrition is to provide the body with an adequate amount of energy and protein.

For the purpose of parenteral nutrition, the following solutions are used.

Carbohydrates: The most acceptable drug used at any age is glucose. The ratio of carbohydrates in the daily diet should be at least 50-60%. For complete utilization, it is necessary to maintain the rate of administration, glucose should be supplied with ingredients - insulin 1 unit per 4 g, potassium, coenzymes involved in energy utilization: pyridoxal phosphate, cocarboxylase, lipoic acid, and ATP - 0.5-1 mg / kg per day intravenously.

When properly administered, highly concentrated glucose does not cause osmotic diuresis and a significant increase in blood sugar levels. For nitrogen nutrition, either high-quality protein hydrolysates (aminosol, aminone) or solutions of crystalline amino acids are used. These drugs successfully combine essential and non-essential amino acids, they are low toxic and rarely cause an allergic reaction.

Doses of administered protein preparations depend on the degree of violation of protein metabolism. With compensated disorders, the dose of administered protein is 1 g/kg of body weight per day. Decompensation of protein metabolism, manifested by hypoproteinemia, a decrease in the albumin-globulin ratio, an increase in urea in daily urine, requires the introduction of increased doses of protein (3–4 g/kg per day) and anti-catabolic therapy. This includes anabolic hormones (retabolil, nerabolil - 25 mg intramuscularly 1 time in 5-7 days), the construction of a parenteral nutrition program in the hyperalimentation mode (140-150 kcal / kg body weight per day), protease inhibitors (kontrykal, trasylol 1000 U / kg per day for 5-7 days). For adequate assimilation of plastic material, each gram of introduced nitrogen must be provided with 200–220 kcal. Amino acid solutions should not be administered with concentrated glucose solutions, as they form toxic mixtures.

Relative contraindications to the introduction of amino acids: renal and hepatic failure, shock and hypoxia.

Fat emulsions containing polyunsaturated fatty acids are used to correct fat metabolism and increase the caloric content of parenteral nutrition.

Fat is the most high-calorie product, however, for its utilization, it is necessary to maintain optimal doses and the rate of administration. Fat emulsions should not be administered together with concentrated polyionic glucose solutions, as well as before and after them.

Contraindications for the introduction of fat emulsions: liver failure, lipemia, hypoxemia, shock conditions, thrombohemorrhagic syndrome, microcirculation disorders, cerebral edema, hemorrhagic diathesis. The required data of the main ingredients for parenteral nutrition are given in Table 12 and Table 13.

Table 12

Doses, rates, calorie content of the main ingredients for parenteral nutrition

When prescribing parenteral nutrition, it is necessary to introduce optimal doses of vitamins that are involved in many metabolic processes, being coenzymes in energy utilization reactions.

Table 13

Doses of vitamins (in mg per 100 kcal) required during parenteral nutrition

The program of parenteral nutrition, carried out in any mode, should be drawn up in terms of a balanced ratio of ingredients. The optimal ratio of proteins, fats, carbohydrates is 1: 1.8: 5.6. For the breakdown and inclusion of proteins, fats and carbohydrates in the process of synthesis, a certain amount of water is necessary.

The ratio between the need for water and the calorie content of food is 1 ml H 2 O - 1 kcal (1: 1).

Calculation of the need for resting energy consumption (RCE) according to Harris-Benedict:

Men - EZP = 66.5 + 13.7? mass, kg + 5? height, cm - 6.8? age (years).

Women - EZP \u003d 66.5 + 9.6? mass, kg + 1.8? height, cm - 4.7? age (years).

The EZP value, determined by the Harris-Benedict formula, averages 25 kcal/kg per day. After the calculation, the patient's physical activity factor (PFA), the metabolic activity factor (FMA) based on the clinical status, and the temperature factor (TF) are selected, with the help of which the energy need (E) of a particular patient will be determined. The coefficient for calculating FFA, FMA and TF are shown in Table 14.

Table 14

Coefficient for calculating FFA, FMA and TF

To determine the daily PE, the EZP value is multiplied by FFA, FMA and TF.

In severe intoxication, active detoxification therapy is necessary, aimed at binding and removing toxins from the body. For this purpose, solutions of polyvinylpyrrolidone (neocompensan, gemodez) and gelatinol are most often used, adsorbing and neutralizing toxins, which are then excreted by the kidneys. These solutions are administered dropwise in an amount of 5-10 ml/kg of the patient's weight, adding vitamin C and potassium chloride solution to them in a minimum amount of 1 mmol/kg of body weight. Mafusol, which is an effective antihypoxant and antioxidant, also has a pronounced detoxifying property. In addition, it improves microcirculation and rheological properties of blood, which also contributes to the detoxification effect. With various poisonings, one of the most effective methods of detoxification is forced diuresis.

Intravenous fluids for the purpose of forced diuresis are prescribed for severe degrees of poisoning and for milder ones, when the patient refuses to drink.

Contraindications to forced diuresis are: acute cardiovascular failure and acute renal failure (anuria).

Carrying out forced diuresis requires strict accounting of the volume and quantitative composition of the injected fluid, the timely appointment of diuretics, clear clinical and biochemical control. As the main solution for water load, it is proposed: glucose 14.5 g; sodium chloride 1.2 g; sodium bicarbonate 2.0 g; potassium chloride 2.2 g; distilled water up to 1000 ml. This solution is isotonic, contains the required amount of sodium bicarbonate, the concentration of potassium in it does not exceed the permissible one, and the ratio of the osmotic concentration of glucose and salts is 2: 1.

At the initial stage of forced diuresis, it is also advisable to introduce plasma-substituting and any detoxification solutions: albumin 8-10 ml / kg, hemodez or neocompensan 15-20 ml / kg, mafusol 8-10 ml / kg, refortan or infucol 6-8 ml / kg kg, reopoliglyukin 15–20 ml/kg.

The total amount of injected solutions should approximately exceed the daily requirement by 1.5 times.

INFUSION THERAPY

Correction of homeostasis

Definition of infusion medium

All infusion media can be divided into:

Classification of infusion media according to V. Hartig, V.D. Malyshev

I. VOLUME SUBSTITUTE SOLUTIONS

I. Volume-substituting solutions. I.1. Biocolloids.

I. Volume-substituting solutions. I. 1. Biocolloids.

Volume-substituting solutions I. Biocolloids.

l. Volume replacement solutions

I. Volume replacement solutions I.3. BLOOD PRODUCTS

I. Volume-substituting solutions I.4. PREPARATIONS WITH OXYGEN TRANSFER FUNCTION:

II. BASIC INFUSION MEDIA

II. BASIC INFUSION MEDIA

III. Corrective infusion media (crystalloids)

III. Corrective infusion media

III. Corrective infusion media

IV. DIURETIC SOLUTIONS

IV. Diuretic solutions

V. PARENTERAL NUTRITIONS

TO MEANS FOR PARENTERAL NUTRITION ARE

Modern volume-replacing biocolloids based on hydroxyethyl starch with a molar mass of up to 400,000 Dalton Group I

Modern volume-replacing biocolloids based on hydroxyethyl starch with a molar mass of up to 200,000 Dalton II group

Modern volume-replacing preparations based on hydroxyethyl starch with a molar mass of up to 130,000 Dalton group III

Modern volume-replacing biocolloids based on hydroxyethyl starch with a molar mass of up to 130,000 Dalton Group IV

ROUTES OF INFUSION MEDIA ADMINISTRATION Vascular access

ROUTES OF INTRODUCTION OF INFUSION MEDIA

ALLOWABLE VOLUME OF INFUSION, VOLUME AND RATES OF THEIR INTRODUCTION

CONTROL OF THE ADEQUACY OF INFUSION THERAPY

Complications related to the route and technique of infusion

I. COMPLICATIONS OF PUNCTIONS OF THE MAIN VEIN (SUBCLAVIAN CATHETERIZATION):

II COMPLICATIONS OF THE SUBSEQUENT STAY OF THE CATHETER IN THE VEIN

II COMPLICATIONS OF THE SUBSEQUENT STAY OF THE CATHETER IN THE VEIN

Literature

Literature

Thank you for your attention!

Infusion therapy The emergence of infusion therapy has revolutionized medicine, in other words, through infusion therapy, for the first time, it was possible to temporarily replace one of the very important functions of the body - the function of the gastrointestinal tract. July 10, 1881 should be considered the birthday of infusion therapy. Landerer successfully infused the patient with a “physiological saline solution”, ensuring the immortality of this infusion medium.

Infusion therapy As early as 1830, there were attempts to introduce infusion therapy into the clinic for the treatment of cholera, but they were unsuccessful, because sodium bicarbonate solution was used to correct losses, and at that time no suspected of ASC was suspected.

Infusion-transfusion therapy The next milestone in the development of infusion therapy was the discovery of blood groups and the Rh factor. Since that time, infusion therapy has become known as infusion-transfusion therapy, which implies the transfusion of blood and its components. Blood groups were discovered in 1900, and the Rh factor was discovered only in 1939, these discoveries greatly expanded the possibilities of medicine in the first place - surgery.

The main reasons for the appointment of intravenous infusion: Pre- and intraoperative fluid deficiency and blood loss Dehydration and hypovolemia Disturbances in blood coagulation and its oxygen capacity Disorders of water and electrolyte homeostasis Administration of drugs and nutrients

It is necessary to strive for the following intraoperative indicators: CVP 6 -10 cm of water. st; Heart rate 60 -90 per minute; Mean BP >70 mm. rt. Art. ; The wedge pressure in the pulmonary capillaries is 10-15 mm. rt. st; Cardiac index 2, 5 -4, 5 l / min per 1 m 2; Oxygen saturation >80%

The main components and purpose of intravenous infusion: Crystalloids (saline solutions) - replenishment of extracellular fluid and electrolytes Tools for correcting BBS: sodium bicarbonate Colloidal solutions (artificial and natural) - replenishment of intravascular volume Blood products and fresh frozen plasma - "component" hemotherapy, replenishment of intravascular volume

Artificial colloidal solutions 3 main groups are used: - Dextrans - Hydroxyethyl starch preparations - Gelatin preparations - Polyethylene glycol based preparations

Hydroxyethyl Starch is an artificial glycogen-like polysaccharide derived from corn starch. Tetrastarch (Venofundin 6% solution; Voluven 6% r-; Tetraspan 6 and 10% rry) Hetastarch (Stabizol 6% r-r) Pentastarch (Hemohes 6 and 10% r-r; Infucol HES 6 and 10% r- r; Refortan H 6% solution and plus - 10% solution; HAES-steril 6 and 10% solution

Indications for HES: hypovolemia, prevention and treatment of hypovolemic shock Contraindications: hyperhydration, renal failure, intracranial bleeding, severe hyperkalemia, children under 2 years of age, CHF.

Tetrastarch Preparations with an average molecular weight of 130,000 and a degree of substitution of 0. 4. The effect lasts an average of 4 hours. Adults 50 ml/kg; children and adolescents over 10 years old 33 ml/kg; children under 10 years of age and newborns 25 ml / kg. The maximum daily dose of 10% solution is 30 ml/kg.

Getastarch A drug with an average molecular weight of 450,000 and a degree of substitution of 0.6-0. 8. Volemic effect 100% within 4 hours. In they drive 500-1000 ml, maximum on the first day, 20 ml / kg.

Pentastarch A drug with an average molecular weight of 200,000 and a degree of substitution of 0.5 6% isotonic solution, 10% hypertonic solution. Volemic effect 6% - 100%, 10% - 130-140% within 4-6 hours. Enter 10% - 20 ml / kg, 6% 33 ml / kg or 5001000. The total dose is not more than 5 liters for 4 weeks.

Hyper. HAEC Molecular weight 200000, degree of substitution 0.5 with addition of sodium chloride solution up to 7.2%. Hypertonic isotonic solution. Enter once 2-5 minutes, 4 ml/kg (250 ml for a patient 60-70 kg). Better in the central vein.

Dextrans are natural polysaccharides of bacterial origin that have undergone acid hydrolysis. High molecular weight dextrans Polyglucin; Polyfer; Polyglusol; Rondferrin (a stimulant of hemipoiesis after a course of chemotherapy and radiation therapy) Low molecular weight dextrans Reopolidex; Hemostabil Reopoliglyukin; Rheomacrodex Dextran + Mannitol = Rheogluman Prolit

Polyglucin - is a 6% solution of the medium molecular fraction of partially hydrolyzed dextran Polyglucin has an average MW of 60,000 ± 10,000 and is a colorless or slightly yellowish liquid. The drug is sterile, non-toxic, non-pyrogenic. Indication: hypovolemia and massive blood loss. With developed shock or acute blood loss - in / in a jet, 0.4–2 l (5–25 ml / kg). After an increase in blood pressure to 80-90 mm Hg. Art. usually switch to drip at a rate of 3–3.5 ml/min (60–80 drops/min). In case of burn shock: in the first 24 hours, 2-3 liters are administered, in the next 24 hours - 1.5 liters. Children in the first 24 hours - 40-50 ml / kg, in the next day - 30 ml / kg.

Polyfer - is a modification of polyglucin. It contains dextran with MM 60000 and iron in the form of an iron dextran complex. Indications for use: prescribed for traumatic, burn, hemorrhagic, surgical shocks. Contraindications: the drug should not be used in patients with traumatic brain injury, pulmonary edema and circulatory failure. Enter intravenously in a stream from 400 to 1200 ml per day.

Polyglusol is a 6% dextran solution with MM 70,000 ± 10,000 with the addition of ionically balanced salts. Indications for use. Traumatic and burn shock, acute blood loss and various conditions accompanied by hypovolemia, combined with impaired water and electrolyte balance, as well as metabolic acidosis. Dosage: with a positive biological test, the drug is administered in the amount of 400-1200 ml on the first day, on the second day 200-400 ml. Contraindications: pulmonary edema, decompensation of cardiovascular activity, high blood pressure, traumatic brain injury with increased intracranial pressure, etc., individual intolerance.

Reopoliglyukin - 10% solution of low molecular weight dextran with low viscosity and average MM 35000. Indications for use: prescribed for traumatic, surgical and burn shocks. Hypovolemia, violation of the rheological properties of blood, prevention of thrombosis. Contraindications: thrombocytopenia, with chronic kidney disease, as well as patients who are contraindicated in intravenous administration of large amounts of fluid. Individual intolerance. Intravenously, 400-1200 ml / day and not more than 5 days. For children, the total dose should not exceed 15 ml / kg / day. In cardiovascular operations, children under the age of 2-3 years are administered 10 ml / kg 1 time per day (for 60 minutes), up to 8 years - 7-10 ml / kg (1-2 times a day), up to 13 years old - 5-7 ml / kg (1-2 times a day), over 14 years old - a dose for adults. For detoxification, 5–10 ml/kg is administered over 60–90 minutes.

Rheomacrodex is a plasma-substituting agent based on dextran with MM 40000. Indications for use. Microcirculation disorders in shock, burns, fat embolism, pancreatitis, peritonitis, paralytic ileus, traumatic and idiopathic hearing loss; slowing of arterial and venous blood flow with the threat of gangrene, Raynaud's disease, acute stroke; prevention of thrombus formation on grafts (heart valves, vascular grafts). In case of microcirculation disturbance due to shock or other reasons, 500 to 1000 ml (10–20 ml/kg) are administered dropwise; in case of circulatory disorders - intravenously drip from 500 to 1000 ml on the 1st day; the next day and every second day for 2 weeks - 500 ml. thromboembolism, 500-1000 ml, 2-1 days, 500 ml. Reactions and complications. Feeling hot, chills, fever, nausea, skin rash; possible anaphylactic reactions with the development of mipotonia and vascular collapse, oliguria. Contraindications: thrombocytopenia, oligo- and anuria.

Reogluman is a 10% dextran solution with MM 40,000 ± 10,000, with the addition of 5% mannitol and 0.9% sodium chloride. Indication: improvement of capillary blood flow, prevention and treatment of microcirculation disorders. The drug is indicated for traumatic, surgical, burn, cardiogenic shocks, accompanied by a violation of capillary blood flow, in violation of arterial and venous circulation (thrombosis and thrombophlebitis, endarteritis and Raynaud's disease), to improve local circulation in vascular and plastic surgery, with a detoxification purpose for burns, peritonitis and pancreatitis. Method of application and dose. Reogluman is administered intravenously by drip, slowly. Start infusion with 5-10 drops. /min for 10–15 min. After that, a break is made to determine biocompatibility. In the absence of a reaction, the introduction is continued at a rate of 30–40 drops. /min 400 -800 ml. Contraindications Excessive hemodilution (with a hematocrit below 25%), hemorrhagic diathesis, heart or kidney failure, severe dehydration, allergic conditions of unknown etiology.

Gemostabil is a molecular dextran with mm 35000 -45000. Indications: Prevention and treatment of traumatic, surgical and burn shock; violations of arterial and venous circulation, treatment and prevention of thrombosis and thrombophlebitis, endarteritis; for adding to the perfusion fluid during heart operations performed using a heart-lung machine; to improve local circulation in vascular and plastic surgery; for detoxification with burns, peritonitis, pancreatitis. Diseases of the retina and optic nerve, inflammation of the cornea and choroid. Contraindications: Hypersensitivity, thrombocytopenia, kidney disease with anuria, CHF, and other conditions in which it is undesirable to inject large amounts of liquid; deficiency of fructose-1, 6-diphosphatase, pulmonary edema, hyperkalemia. Enter 400-1000 ml per day.

Promit is a preparation based on dextran with MM 1000. Indications for use. Prevention of severe anaphylactic reactions to intravenous administration of dextran solutions. Method of application and dose. Adults are injected intravenously with a stream of 20 ml (for children - at the rate of 0.3 ml / kg of body weight) promit 1–2 minutes before intravenous administration of a dextran solution. If more than 15 minutes have passed, the drug should be re-introduced. Contraindications Use with caution during pregnancy and lactation.

Gelatin preparations are a denatured protein obtained from the collagen of animal tissues. Gelatinol 8% solution Gelofusin 4% solution Modelegel 8% solution - a preparation of deionized gelatin one-time up to 2 l / day.

Gelatinol is an 8% solution of partially hydrolyzed gelatin. It is a transparent liquid of amber color with MM 20000, easily foaming when shaken and containing some amino acids. Indications for use: used for traumatic and burn shock, as well as for the prevention of operational shock. It is used as a means of restoring hemodynamics in case of severe blood loss, as well as for filling the heart-lung machine during open heart surgery. Method of application and dose. Assign intravenously (drip or jet) both once and repeatedly. It can also be administered intra-arterially. The total dose of infusion is up to 2000 ml. Gelatin infusions usually do not cause adverse reactions and complications in the patient. Contraindications The introduction of gelatinol is not indicated for acute kidney disease. Volemic effect 60% within 1-2 hours.

Gelofusin is a solution of modified liquid gelatin for intravenous infusion. Indications for use: in case of hypovolemia to replenish the BCC, to prevent a possible drop in blood pressure during spinal or epidural anesthesia, hemodilution, extracorporeal circulation. Contraindications: hypersensitivity, hypervolemia, hyperhydration, severe heart failure, impaired blood coagulation Volemic effect within 3-4 hours, at a rate of 100% Administer up to 200 ml/kg, up to 2000 ml at a time.

Polyethylene glycol preparations. Polyoxidin - 1.5% solution of polyethylene glycol-20000 in 0.9% isotonic sodium chloride solution. Indications for use. Hypovolemic conditions due to acute blood loss, post-traumatic and surgical shock in adults. Method of application and dose. Enter intravenously (stream or drip). Doses and rate of administration depend on the indications and the patient's condition. In various forms of shock, polyoxidine is administered intravenously in a stream until blood pressure rises to a physiological level, after which they switch to drip administration at a rate of 60–80 drops. /min The dose of the injected solution is 400 - 1200 ml / day (up to 20 ml / kg). During operations, in order to prevent operational shock, the drug is administered intravenously by drip (60–80 drops / min), switching to a jet injection with a sharp decrease in blood pressure. Contraindications Traumatic brain injury, occurring with increased intracranial pressure; diseases in which intravenous administration of large doses of fluid is contraindicated.

Crystalloid solutions Ionic solution 5% and 10% glucose, potassium, magnesium Sodium chloride Disol Acesol Trisol Quantasol Plasma-Lit, Plasma_Lit with 5% glucose solution Ringer-Locke solution Hartmann solution

Crystalloids with antihypoxic action Mafusol (adults up to 2-3 / day, children 30-35 ml / kg / day; in severe shock adults 1 l / day, children 15 ml / kg / day) Polyoxyfumarin (400-800 ml, max up to 2 L / day, 1-3 days) Reambirin (adults 400-800 ml / day, children 10 ml / kg 1 time per day. Course 2-12 days.)

Principles for calculating the volume of IT V = FP + TPP + D Where FP - physiological needs (1500 mlm 2 or 40 mlkg) TPP - current pathological losses, no matter how large they are, they must be fully compensated D - fluid deficiencies that occurred earlier

Calculation of intraoperative infusion in adults Small operations 3-4 ml/kg*h Medium operations 5-6 ml/kg*h Major operations 7-8 ml/kg*h

Physiological fluid requirements depend on body weight and are calculated as: body weight up to 10 kg - 4 ml / kg / h; 11-20 – 2 ml/kg/h, more than 21 kg – 1 ml/kg/h On an average person weighing 70 kg, the infusion rate is 110/ml/h, and the infusion volume is 2640 ml/day.

Calculation of intraoperative infusion for children Small operations 5 ml/kg*h Medium operation 7-8 ml/kg*h Major operation 10-15 ml/kg*h

Lecture No. 16. Infusion therapy

Infusion therapy is a drip injection or infusion intravenously or under the skin of drugs and biological fluids in order to normalize the water-electrolyte, acid-base balance of the body, as well as for forced diuresis (in combination with diuretics).

Indications for infusion therapy: all types of shock, blood loss, hypovolemia, loss of fluid, electrolytes and proteins as a result of indomitable vomiting, intense diarrhea, refusal to take fluids, burns, kidney disease; violations of the content of basic ions (sodium, potassium, chlorine, etc.), acidosis, alkalosis and poisoning.

The main signs of dehydration of the body: retraction of the eyeballs into the orbits, dull cornea, dry, inelastic skin, characteristic palpitations, oliguria, urine becomes concentrated and dark yellow, the general condition is depressed. Contraindications to infusion therapy are acute cardiovascular failure, pulmonary edema and anuria.

Crystalloid solutions are able to compensate for the deficiency of water and electrolytes. Apply 0.85% sodium chloride solution, Ringer and Ringer-Locke solutions, 5% sodium chloride solution, 5-40% glucose solutions and other solutions. They are administered intravenously and subcutaneously, by stream (with severe dehydration) and drip, in a volume of 10–50 ml/kg or more. These solutions do not cause complications, except for overdose.

The goals of infusion therapy are: restoration of BCC, elimination of hypovolemia, ensuring adequate cardiac output, maintaining and restoring normal plasma osmolarity, ensuring adequate microcirculation, preventing aggregation of blood cells, normalizing the oxygen-transport function of blood.

Colloidal solutions are solutions of macromolecular substances. They contribute to the retention of fluid in the vascular bed. Hemodez, polyglucin, reopoliglyukin, reogluman are used. With their introduction, complications are possible, which manifest themselves in the form of an allergic or pyrogenic reaction. Routes of administration - intravenously, less often subcutaneously and drip. The daily dose does not exceed 30–40 ml/kg. They have a detoxifying quality. As a source of parenteral nutrition, they are used in case of prolonged refusal to eat or inability to feed by mouth.

Blood and casein hydrolysins are used (alvezin-neo, polyamine, lipofundin, etc.). They contain amino acids, lipids and glucose. Sometimes there is an allergic reaction to the introduction.

Rate and volume of infusion. All infusions in terms of volumetric infusion rate can be divided into two categories: requiring and not requiring rapid correction of the BCC deficiency. The main problem may be patients who need rapid elimination of hypovolemia. i.e., the rate of infusion and its volume must ensure the performance of the heart in order to properly supply regional perfusion of organs and tissues without significant centralization of blood circulation.

In patients with an initially healthy heart, three clinical landmarks are most informative: mean BP > 60 mm Hg. Art.; central venous pressure - CVP > 2 cm of water. Art.; diuresis 50 ml/h. In doubtful cases, a test with a load in volume is carried out: 400–500 ml of a crystalloid solution is poured over 15–20 minutes and the dynamics of CVP and diuresis are observed. A significant rise in CVP without an increase in diuresis may indicate heart failure, which suggests the need for more complex and informative methods for assessing hemodynamics. Keeping both readings low suggests hypovolemia, then maintain a high infusion rate with repeated step-by-step assessment. An increase in diuresis indicates prerenal oliguria (hypoperfusion of the kidneys of hypovolemic origin). Infusion therapy in patients with circulatory insufficiency requires a clear knowledge of hemodynamics, large and special monitoring monitoring.

Dextrans are colloidal plasma substitutes, which makes them highly effective in the rapid recovery of BCC. Dextrans have specific protective properties against ischemic diseases and reperfusion, the risk of which is always present during major surgical interventions.

The negative aspects of dextrans include the risk of bleeding due to platelet disaggregation (especially characteristic of rheopolyglucin), when it becomes necessary to use significant doses of the drug (> 20 ml / kg), and a temporary change in the antigenic properties of the blood. Dextrans are dangerous because of their ability to cause a "burn" of the epithelium of the tubules of the kidneys and therefore are contraindicated in renal ischemia and renal failure. They often cause anaphylactic reactions, which can be quite severe.

Of particular interest is a solution of human albumin, as it is a natural colloid of a plasma substitute. In many critical conditions accompanied by damage to the endothelium (primarily in all types of systemic inflammatory diseases), albumin is able to pass into the intercellular space of the extravascular bed, attracting water and worsening interstitial tissue edema, primarily the lungs.

Fresh frozen plasma is a product taken from a single donor. FFP is separated from whole blood and frozen immediately within 6 hours of blood collection. Stored at 30°C in plastic bags for 1 year. Given the lability of clotting factors, FFP should be infused within the first 2 hours after rapid thawing at 37°C. Transfusion of fresh frozen plasma (FFP) gives a high risk of contracting dangerous infections, such as HIV, hepatitis B and C, etc. The frequency of anaphylactic and pyrogenic reactions during transfusion of FFP is very high, so compatibility according to the ABO system should be taken into account. And for young women, Rh-compatibility must be considered.

Currently, the only absolute indication for the use of FFP is the prevention and treatment of coagulopathic bleeding. FFP performs two important functions at once - hemostatic and maintaining oncotic pressure. FFP is also transfused with hypocoagulation, with an overdose of indirect anticoagulants, with therapeutic plasmapheresis, with acute DIC, and with hereditary diseases associated with a deficiency of blood coagulation factors.

Indicators of adequate therapy are a clear consciousness of the patient, warm skin, stable hemodynamics, the absence of severe tachycardia and shortness of breath, sufficient diuresis - within 30-40 ml / h.

Anesthesiology and resuscitation Marina Alexandrovna Kolesnikova

56. Infusion therapy

56. Infusion therapy

Infusion therapy is a drip injection or infusion intravenously or under the skin of drugs and biological fluids in order to normalize the water-electrolyte, acid-base balance of the body, as well as for forced diuresis (in combination with diuretics).

Indications for infusion therapy: all types of shock, blood loss, hypovolemia, loss of fluid, electrolytes and proteins as a result of indomitable vomiting, intense diarrhea, refusal to take fluids, burns, kidney disease; violations of the content of basic ions (sodium, potassium, chlorine, etc.), acidosis, alkalosis and poisoning.

Crystalloid solutions are able to compensate for the deficiency of water and electrolytes. Apply 0.85% sodium chloride solution, Ringer and Ringer-Locke solutions, 5% sodium chloride solution, 5-40% glucose solutions and other solutions. They are administered intravenously and subcutaneously, by stream (with severe dehydration) and drip, in a volume of 10–50 ml/kg or more.

The goals of infusion therapy are: restoration of BCC, elimination of hypovolemia, ensuring adequate cardiac output, maintaining and restoring normal plasma osmolarity, ensuring adequate microcirculation, preventing aggregation of blood cells, normalizing the oxygen-transport function of blood.

Colloidal solutions are solutions of macromolecular substances. They contribute to the retention of fluid in the vascular bed. Hemodez, polyglucin, reopoliglyukin, reogluman are used. With their introduction, complications are possible, which manifest themselves in the form of an allergic or pyrogenic reaction.

Routes of administration - intravenously, less often subcutaneously and drip. The daily dose does not exceed 30–40 ml/kg. They have a detoxifying quality. As a source of parenteral nutrition, they are used in case of prolonged refusal to eat or inability to feed by mouth.

Dextrans are colloidal plasma substitutes, which makes them highly effective in the rapid recovery of BCC. Dextrans have specific protective properties against ischemic diseases and reperfusion, the risk of which is always present during major surgical interventions.

Fresh frozen plasma is a product taken from a single donor. FFP is separated from whole blood and frozen immediately within 6 hours of blood collection. Stored at 30 C in plastic bags for 1 year. Given the lability of coagulation factors, FFP should be transfused within the first 2 hours after rapid defrosting at 37 C. Fresh frozen plasma (FFP) transfusion poses a high risk of contracting dangerous infections such as HIV, hepatitis B and C, etc. Frequency of anaphylactic and pyrogenic reactions during transfusion of FFP is very high, so compatibility according to the ABO system should be taken into account. And for young women it is necessary to take into account Rh - compatibility.