The effectiveness of hepatosplanchnic ischemia treatment monitored with intramucosae pH in polytrauma

Authors

  • L.O. Malseva State Institution “Dnipropetrovsk Medical Academy of the Ministry of Health of Ukraine”, Dnipro, Ukraine
  • S.A. Aleksyuk State Institution “Dnipropetrovsk Medical Academy of the Ministry of Health of Ukraine”, Dnipro, Ukraine
  • I.A. Malsev State Institution “Dnipropetrovsk Medical Academy of the Ministry of Health of Ukraine”, Dnipro, Ukraine
  • N.A. Kazimirova State Institution “Dnipropetrovsk Medical Academy of the Ministry of Health of Ukraine”, Dnipro, Ukraine

DOI:

https://doi.org/10.22141/2224-0586.16.7-8.2020.223702

Keywords:

polytrauma, hepatosplanchnic ischemia, empirical re-oxygenation, intramucosal pH

Abstract

The study aimed to substantiate and introduce the empirical oxygenation of general and local action into intensive care for heptosplanchnic ischemia during polytrauma. The study included 85 patients with polytrauma with the brain injury of mild to moderate severity according to the modern clinical classification. The conditions for inclusion in the study were as follow: Injury Severity Score (ISS) more than 32 points, Acute Physio­logy and Chronic Health Evaluation (APACHE II) — 25 points or more. Clinical and biochemical studies were carried out at the following stages: upon admission (stage 1), 12–24 hours after the start of intensive care (stage 2), in 3, 5, 7 days (stages 3, 5, 7, respectively). The clinical observation was carried out up to 32 days from the time of the injury. The manifestations showed certain differences depending on the outcome of the disease. Victims with a subsequent fatal outcome had higher blood loss (by 27.65 %, p < 0.05), blood volume deficiency (by 33.42 %, p < 0.05), more severe hypotension, tachycardia; increased arterial hypoxemia; the indicator of venous blood shunting in the lungs significantly exceeded the normal values and those of the group of survivors. With sigmoidal gas tonometry in survivors, the intramucosal pH ranged 6.88–7.0; pCO2 from 85.6 to 118.38 mmHg. In the dead, the intramucosal pH ranged from 6.79 to 6.9 units; pCO2 from 95.61 to 121.71 mmHg. In 85 % of cases of endoscopic visuali­zation, erosive-ulcerative changes in the mucous membrane of the antrum were determined. Gastrointestinal insufficiency in patients with subsequent fatal outcome clinically corresponded to II–III stages; according to the manifestations of histological changes in the mucous membrane of the antrum of the stomach to the III–IV stages. The described features are based on the prevalence of 11.77 % ISS scales in deceased victims, APACHE II by 20.78 %, and SOFA by 71.52 %, which determines the severity of the damage, the condition of the victims, and the severity of organ damage. Starting from the 1st day of intensive care, the differences between the studied parameters in survivors and deceased victims continued to worsen. In surviving patients, oxygenation of arterial blood was restored from the first day to the physiological values due to the elimination of venous bypass blood in the lungs, and the transition to normodynamic blood circulation. Then on the 3rd day, the intramucosal pH was 99.59 % of the norm. In the dead, the restoration of the oxygenation index on the 1st day was combined with a decrease in tissue oxygen extraction, hypovolemic shock, refractory to vasopressor therapy from the 3rd day of the study. The pH values exceeded 7.35 only by the 5th day, while clinically the digestive function did not recover on the 7th day of the study. The data of the clinical evaluation of gastroenteric insufficiency were confirmed in the endoscopic picture, the data of histological and histochemical studies of the mucous membrane of the antrum. High, positive, reliable correlations between intramucosal pH and the outcome of the disease have been established. The actual mortality rate at the intermediate points was 20 %: 3 victims died on the 3rd day, 2 victims — on the 5th day. Before the 28th day of clinical observation, the actual mortality rate was 44 % (the rest 6 victims died from the 7th day to the 28th day). After 28 days to 32 days, death was not registered.

References

Marshall Y.C., Meacins Y.L. The gastrointestinal tract — the andrained of multiple organ failure. Ann. Surg. 1993. № 218. Р. 111-119.

Мальцева Л.А., Усенко Л.В., Мосенцев Н.Ф. и др. Гастроинтестинальная недостаточность, пути диагностики и коррекции. Д.: Нова iдеологiя, 2006. 130 с.

Published

2021-04-05

Issue

Section

Original Researches