Царёв, А.А. (2017) Предупреждение интраоперационной непреднамеренной гипотермии у пациентов с политравмой. Медицина неотложных состояний, № 8 (87). pp. 120-124. ISSN 2224-0586 (print), 2307-1230 (online)
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Abstract
Актуальность. Непреднамеренная гипотермия развивается спонтанно как следствие травмы, хирургического вмешательства и наркоза в результате нарушения соответствия теплопродукции теплопотерям и подавления компенсаторного терморегуляционного ответа. Цель: изучить эффективность способа коррекции интраоперационной непреднамеренной гипотермии с использованием системы конвекционного обогрева у пациентов с политравмой. Материалы и методы. Обследовано 20 пациентов с политравмой, которым проводились ургентные оперативные вмешательства. Пациенты были разделены на 2 группы: I — основная группа (n = 10), в которой интраоперационно проводилось активное согревание системой конвекционного обогрева WarmAir 135 (CSZ) с использованием одеял для согревания в условиях операционной; II — контрольная группа (n = 10) без использования конвекционного согревания. Изучалась температура ядра тела (Тсо): исходно, через 30, 60 минут и в конце операции. Рас- считывались следующие показатели: минимальная (Тмин.) и максимальная (Tмакс.) температура, средняя температура (Тср.), температурный диапазон (Тдиап. = Tмакс. – Тмин.). Результаты. У всех пациентов с политравмой и проведением ургентных хирургических вмешательств отмечается развитие клинически значимой непреднамеренной гипотермии. На этапе 60 минут интраоперационного периода Тсо была достоверно выше в I группе (35,38 ± 0,28 °С), чем во II (34,70 ± 0,39 °С) (p < 0,05). Выявлен достоверно более высокий уровень средней Тсо в I группе (35,53 ± 0,66 °С) по сравнению со II группой (34,67 ± 1,74 °С) пациентов (p < 0,05). Диапазон температур, который представляет собой разность максимальной и минимальной Тсо, был достоверно ниже в I группе пациентов (1,36 ± 0,74 °С) по сравнению со II группой (4,55 ± 1,11 °С) (p < 0,05). Выводы. Использование в комплексе интенсивной терапии конвекционной системы согревания хотя и не позволяет достичь исходных значений Тсо, но предупреждает прогрессирование гипотермии, эффективно обеспечивая поддержание температурного гомеостаза у критических пациентов с политравмой. Background. Intraoperative hypothermia develops spontaneously due to trauma, surgical intervention and anesthesia as a result of a violation of the conformity of heat production to heat loss and suppression of the compensatory thermoregulatory response. Intensive care for polytrauma should be aimed at the triad of death: hypothermia, acidosis and coa gulopathy, the main links in the pathoge nesis of polytrauma. Deterioration of microcirculation due to hypovolemia, direct injury, traumatic coagulopathy, intravascular sludge and endothelial damage disrupts tissue perfusion. Tissue hypoxia, in turn, switches the metabolism to glycolysis and leads to the development of lactic acidosis. Development of hypothermia with polytrauma causes cardiac rhythm disturbance, cardiac output decrease, coagul opathy and displacement of the oxyhemoglobin dissociation curve to the left, which aggravates the severity of acidosis, and, as a result, increases the severity of the state and the level of mortality of such patients. Temperature is one of the most important factors determining the coagulation cascade, and since temperature-sensitive plasma esterase reactions, like the functional activity of platelets, are inhibited by hypothermia, it is not surprising that coagulopathy is the final part of triad of death. It should be emphasized that this occurs in conditions of blood loss, i.e. the initial loss of coagu- lation factors and the additional development of dilutional coagulopathy associated with infusion therapy to correct hypovolemia causing a pooling of coagulation factors initially at a low level. The purpose of the work was to study the effectiveness of the method for correcting intraoperative hypothermia by means of forced-air warming device in patients with polytrauma. Materials and methods. Twenty patients with polytrauma who underwent urgent surgical interventions were examined. They were divided into 2 groups: group I (n = 10) persons who were actively heated by the WarmAir 135 (CSZ) system with the use of blankets for warming in the operating room — the FilteredFlo 248; group II — control group (n = 10), convection warming wasn’t used. The temperature of the core of the body (Tco) was studied: initially, after 30, 60 minutes and at the end of the operation. The following indices were calculated: minimum (Tmin) and maximum (Tmax) temperature, average temperature (Ta), temperature range (Tr = Tmax – Tmin). Results. When analyzing the initial level of core body temperature at the time of admission to the operating room, there were no significant differences between the groups of patients (P = 0.420). In group I, hypothermia with Tco < 36 °С was detected in 20 % of patients, and in group II — in 10 %. In all patients with polytrauma and urgent surgical interventions, there was a clinically significant intraoperative hypothermia. At the stage of 60 minutes of the intraoperative period, Tco was significantly higher in group I (35.38 ± 0.28 °С) compared with group II (34.70 ± 0.39 °С) (p < 0.05). A significantly higher level of mean Tco in group I (35.53 ± 0.66 °С) was revealed in comparison with group II (34.67 ± 1.74 °С) (p < 0.05). The temperature range, which is the difference between the ma ximum and minimum Tco, was significantly lower in group I of patients (1.36 ± 0.74 °С) versus group II (4.55 ± 1.11 °С) (p < 0.05). When calculating the maximum decrease in body core temperature in group I with convection heating, this indicator was 13.6 °С, compared with 42.1 °С in group II of patients, which indicated the development of clinically significant intraoperative hypothermia in patients with polytrauma without convection heating. It should also be noted that in both study groups, the maximum increase in Tco was equal to zero, since the value of minimal Tco corresponded to Tco at the end of the surgical intervention. Thus, in patients with severe polytrauma who need urgent surgical interventions, clinically significant hypothermia devel oped in the intraope rative period influen cing the links of homeostasis on the basis of the vicious circle of the polytrauma pathogenesis — the triad of death (acidosis, coagulopathy and hypothermia). It should be emphasized that unintentional hypothermia leads to the development of many complications that arise directly during hypothermia, and no less serious during the recovery of normal thermoregulation. Conclusions. Using forced-air warming device in the intensive care does not allow to reach the initial values of Tco, effectively preventing the progression of hypothermia aggravation and ensuring the maintenance of temperature homeostasis in critically ill patients with polytrauma.
| Item Type: | Article |
|---|---|
| Additional Information: | DOI: 10.22141/2224-0586.8.87.2017.121336 |
| Uncontrolled Keywords: | периоперационная гипотермия; конвекционная система обогрева; политравма; анестезиология; интенсивная терапия. perioperative hypothermia; forced-air warming device; polytrauma; anesthesiology; intensive care. |
| Subjects: | Anesthesiology and Intensive care Polytrauma |
| Divisions: | Departments > Department of Anaesthesiology and Intensive Care |
| Depositing User: | Анастасия Жигар |
| Date Deposited: | 21 Sep 2018 11:43 |
| Last Modified: | 21 Sep 2018 11:43 |
| URI: | http://repo.dma.dp.ua/id/eprint/3221 |
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