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Орипнальш дозддження
Original Researches
МЕДИЦИНА
НЕВ1ДКЛАДНИХ СТАН1В
UDC 616.381-083.98-036.2-092 DOI: 10.22141/2224-0586.4.99.2019.173933
O.V. Kravets
State Institution "Dnipropetrovsk Medical Academy of the Ministry of Health of Ukraine", Dnipro, Ukraine
Evaluation of baseline pathophysiological changes in patients with emergency abdominal pathology
Abstract. Background. Acute surgical pathology is associated with high rates ofpostoperative complications and mortality. The aim is to determine baseline pathophysiological changes in patients with acute abdominal pathology and their dependence on the grade of surgical risk. Materials and methods. We examined 200 patients with urgency laparotomy. We have divided the patients into two groups (according to the surgical risk score — P-POSSUM), namely moderate (n = 100) and high (n = 100) surgical risk. We measured routine clinical laboratory characteristics, central hemodynamic state and fluid compartments of the body by the noninvasive bioelectric integral evaluation of the body structure with the Diamant monitor complex. Results. We found significant decrease of extracellular volume due to reduction ofplasma volume (83 % of the norm (p < 0.05) in the 1st group, 86 % of the norm (p < 0.05) in the 2nd group); and dehydration was not defined. All patients had adaptive hemodynamic response. The 1st group was found to have decline in stroke volume by 10 % (p < 0.05) due to hypovolemia. We fixed a decrease of stroke volume index by 122 % of the norm (p < 0.05), which was compensated with moderate tachycardia and formed relative hyperdynamia (cardiac output was 107 % of the norm (p < 0.05)) for the 1st group. As a result, tissue perfusion complied with the standard rate. The relative hypodynamia was determined in the 2nd group (cardiac output was 84.6 % of the norm (p < 0.05)) despite tachycardia (heart rate was 45% over the norm (p < 0.05)) and vasospasm (systemic vascular resistance was 184 % of the norm (p < 0.05)) while tissue perfusion decreased (peripheral perfusion index accounted for 81.3 % of the norm (p < 0.05)). Conclusions. Acute surgery pathology under II rate of dehydration forms the moderate volume depletion/hypovolemia, causes redistribution of extracellular fluid volume. Hypovolemia also deals with loss ofplasma volume and causes development of hemodynamic disorder and water redistribution between body sectors. Severity of pathophysiological abnormality depends on the patient's surgical risk degree. Compensatory raise of heart rate forms relative hyperdynamia and preserves tissue perfusion in patient of moderate surgical risk. Pathognomic development of tachycardia and vasospasm forms relative hypodynamic and tissue perfusion decrease, which is relevant for patient of high surgical risk. Keywords: emergency abdominal pathology; surgical risk; fluid compartments; central hemodynamics; hypovolemia
Introduction
Acute surgical pathology is a condition including a large number of diseases [1—8]. The basic treatment method for it is emergency laparotomy. Emergency laparotomy is associated with a disproportionately high rates of postoperative complications and mortality in all age categories of patients [2, 4]. This could be explained by the limited time of diagnosis, human factor and patho-
physiological changes in patients. Hypovolemia is the most dangerous pathogenic cause of a patient's condition [3]. Hypovolemia is formed by pathological losses. Untimely and inadequate intensive therapy of hypovolemia goes with tissue perfusion and leads to the formation of multiple organ dysfunction/failure and seriously worsens the prognosis of life in patients with acute abdominal pathology [5, 6].
© «Медицина невщкладних сташв» / «Медицина неотложных состояний» / «Emergency Medicine» («Medicina neotloznyh sostoanij»), 2019 © Видавець Заславський О.Ю. / Издатель Заславский А.Ю. / Publisher Zaslavsky O.Yu., 2019
Для корреспонденции: Кравец Ольга Викторовна, кандидат медицинских наук, доцент кафедры анестезиологии, интенсивной терапии и медицины неотложных состояний ФПО, ГУ «Днепропетровская медицинская академия МЗ Украины», ул. Вернадского, 9, г. Днепр, 49044, Украина; e-mail: [email protected]
For correspondence: O. Kravets, PhD, Associate Professor at the Department of Anesthesiology, Intensive Care and Emergency Medicine of Faculty of Postgraduate Education, State Institution "Dnipropetrovsk Medical Academy of the Ministry of Health of Ukraine", Vernadsky str., 9, Dnipro, 49044, Ukraine; e-mail: [email protected]
The purpose is to specify baseline pathophysiological changes in patients with acute abdominal pathology and their dependence on the grade of surgical risk and hypovolemia.
Methods and methods
We examined 200 patients with acute abdominal pathology and obtained the informed consents within local Ethics Committee approval. A prospective, observational study was performed in the period from January 2016 to December 2018. All patients undergoing emergency laparotomy (emergency laparotomy is an immediate lifesaving operation, which involves exploration of the abdomen usually within 2 hours), have potentially life-threatening conditions that require prompt intervention. Acute cases of emergency laparotomy were: acute intestinal obstruction (n = 65), perforated gastric and duodenal ulcer (n = 51), strangulated hernia (n = 84). We examined 106 (53 %) men and 94 (47 %) women of mean age 61.1 ± 11.5 [45 : 75] years.
Inclusion criteria: the patient's age is more than 45 years and less than 75 years; emergency laparotomy, predicted intraoperative blood loss less than 500 ml; ASA Ill E, diabetes mellitus at the stage of compensation, moderate dehydration (according to II grade by P. Shelestyuk [9]); surgical risk of patient >10 % (according to the surgical risk score P-POSSUM [8]).
Exclusion criteria: the patient's age is less than 45 years and more than 75 years; gastrointestinal bleeding; ASA I—II—IV, diabetes mellitus at the stage of decompensation; pregnancy and lactation; allergic reactions to any component of drug therapy; mild/severe dehydration (according to I or III grades by P. Shelestyuk); surgical risk of patient < 10 % (according to the score P-POSSUM); patient's refusal to participate in the study.
We examined all patients according to the protocol of the Ministry of Health of Ukraine No 297 (02.04.2010) [9]. Concomitant pathology was identified as: excessive body weight (obesity I—II stage) (n = 12), ischemic heart disease (n = 112), arterial hypertension (n = 89), atrial fibrillation (n = 52), chronic obstructive bronchitis in remission (n = 34), diffuse diabetes mellitus type II in remission (n = 22). All patients who were divided in two groups according to the surgical risk score P-POSSUM were treated in ICU before having surgery. Portsmouth Physiological and Operative Severity Score for the enUmeration of mortality and Morbidity (P-POSSUM) is risk-adjusted score that predicts a patient outcome. P-POSSUM score calculation is based on usage of 12 physiological and 6 operative variables of a patient, which are graded as 1, 2, 4 or 8 relying on their magnitude then summed to form a physiological score and operative severity score. The physiological score and operative severity score predict the risk of mortality and morbidity [8, 10].
The first group (n = 100) included patients of moderate surgical risk (1—5 %), the patients of high surgical risk (> 5 %) were in the second group (n = 100). The baseline characteristics of the patients by sex, age, con-
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comitant and acute surgical pathology in the 1st group were 63 (63 %) men and 37 (37 %) women of mean age 49 [Me 45 : 60] years with excessive body weight (obesity I—II stage) (n = 9), ischemic heart disease (n = 32), arterial hypertension (n = 24), atrial fibrillation (n = 12), chronic obstructive bronchitis in remission (n = 24), diffuse diabetes mellitus type II in remission (n = 8). Surgical diagnoses were: acute intestinal obstruction (n = 15), perforated gastric and duodenal ulcer (n = 41), and strangulated hernia (n = 44).
The 2nd group (n = 100) involved 51 (51 %) men and 49 (49 %) women of mean age 71 [Me 60 : 75], excessive body weight (obesity I—II stage) (n = 3), ischemic heart disease (n = 80), arterial hypertension (n = 65), atrial fibrillation (n = 40), chronic obstructive bronchitis in remission (n = 10), and diffuse diabetes mellitus type II in remission (n = 14). Surgical diagnoses were: acute intestinal obstruction (n = 50), perforated gastric and duodenal ulcer (n = 10), strangulated hernia (n = 40).
We evaluated the clinical parameters of systemic he-modynamics: blood pressure, mean arterial pressure (MAP), heart rate (HR), central venous pressure, and routine clinical laboratory tests (general blood and urine analysis, coagulogram, biochemical blood test, acid-base status, plasma blood electrolytes, and lactate). We measured plasma, urine osmolarity and mean cell volume by calculation method [11]. The central and peripheral he-modynamic parameters were determined by the method of integral rheography with the apparatus Diamant: cardiac index (CI), stroke volume (SV), stroke volume index (SVI), systemic vascular resistance (SVR). Such indicators of the body fluid compartments as the extracellular fluid volume (ECF), intracellular fluid volume (ICF), the total volume of fluid, the plasma volume (PV), total volume of blood (TVB) were measured by the method of noninvasive bioelectric integral evaluation of the body structure with the Diamant monitor complex. We evaluated tissue perfusion by peripheral perfusion index (PI) with the apparatus +Biomed [12].
Scoring scales ASA and P-POSSUM were used for stratification of surgical risk.
Statistical analysis of the results was carried out with MS Excel 2007, Statistica 6 software package. The data are given in the form M ± m. Statistically significant values were p < 0.05.
Results
According to the preset principle, the patients of both groups were assigned as moderate grade of dehydration (according to II grade by P. Shelestyuk), which is associated with intravascular volume depletion/moderate hypovolemia. Indeed, our results suggest that baseline pathophysiological changes in acute abdominal pathology are associated with hypovolemia, dehydration and central hemodynamic changes. In fact, our results revealed the redistribution of fluid between all of the fluid compartments (Table 1). There were no differences in absolute values of ECF and ICF. So, the ECF decreased consequently due to the volume of circulating
blood, namely by reducing the plasma volume (85.1 % of the norm (p < 0.05)) in the patients with moderate surgical risk. We did not identify intracellular dehydration (95.5 % of the norm (p > 0.05)), but decrease in circulating blood volume due to plasma volume reduction in the patients with high surgical risk, too. However, the absence of statistically significant difference in TVB and PV reduction in both groups did not cause the development of significant dehydration. No electrolyte abnormalities were observed in both groups of patients. Levels of sodium, potassium and chlorine were normal. Plasma osmolality coincided to reference range of 280 mmol/kg.
Baseline volume status is a statistically significant variable of systemic hemodynamic parameters due to the initial volume depletion (Table 2). Moreover, clinical sign of groups seemed different. We determined decrease of SV (87 % of the norm; p < 0.05) and SVI (58 % of the norm (p < 0.05)) in the group of high surgical risk. It is associated with tachycardia (HR 145 % of the norm (p < 0.05)) and vasospasm (SVR 184 % of the norm; p < 0.05). Wherein MAP were above normal and formed relative hypodynamia (CI 84 % of the norm; p < 0.05). However, these mechanisms did not satisfy the adequate tissue perfusion — PI was significantly reduced (81.3 % of the norm; p < 0.05). The same hypovolemia associated with relative hyperdynamia (CI 107 % of the norm; p < 0.05) and statistically nonsignificantly increased SVR (105 % of the norm; p < 0.05) and tachycardia (HR 122 % of the norm; p < 0.05) in patients of moderate surgical risk maintained satisfactory tissue perfusion. Nevertheless, level of lactate was within norm.
Discussion
It is known that acute surgical pathology is associated with hypovolemia and dehydration. We have determined moderate volume depletion/hypovolemia and its compliance to the II grade of dehydration (P. She-lestyuk) in surgical patient with acute pathology [4—6]. We have also found redistribution of fluid in all the fluid compartments almost to the same extent in both groups. To the best of our knowledge, this prospective, observational study is the largest reported to investigate the hemodynamic response. So, hypovolemia is associated with relative hyperdynamia and statistically significant tachycardia in patients of moderate surgical risk. These compensatory reactions maintained satisfactory tissue perfusion. Another hemodynamic response was established in patients of high surgical risk. Relative hypo-dynamia is associated with tachycardia and vasospasm. The result of this investigation demonstrated over-normal MAP that disguises the clinical signs of patients' condition severity and gives impression of imaginary healthy living. However, these mechanisms did not satisfy the adequate tissue perfusion.
Conclusions
Acute surgical pathology in patients with moderate volume depletion/hypovolemia causes redistribution of extracellular fluid volume and hemodynamic response depending on surgical risk grade.
Moderate surgical risk is associated with:
— plasma deficit;
— hyperdynamia, supported by chronotropic effect and retaining the tissue perfusion.
Table 1. Impact of acute surgical pathology on fluid distribution (L)
Parameter Regional norm (n = 40) Moderate surgical risk (n = 100) High surgical risk (n = 100)
Extracellular fluid volume 14.1 11.5 ± 0.4+ 11.4 ± 0.2+
Intracellular fluid volume 24.9 23.8 ± 0.8 23.7 ± 0.7
Total volume of fluid 39 35.3 ±1.1 + 35.1 ± 0.9+
Plasma volume 2.7 2.3 ± 0.1 + 2.3 ± 0.1 +
Total volume of blood 4.9 4.1 ± 0.4+ 4.0 ± 0.2+
Parameter Regional norm (n = 40) 1st group, moderate surgical risk (n = 100) 2nd group, high surgical risk (n = 100)
Heart rate (bpm) 74 91.0 ± 2.8* + 108.0 ± 2.8* +
Stroke volume (mL/min) 80 84.0 ± 8.1* + 70.3 ± 7.9* +
Stroke volume index (mL/m2) 52 46.1 ± 3.1* + 30.5 ± 4.1* +
Cardiac index (L/min/m2) 3.9 4.2 ± 0.3* 3.3 ± 0.1* +
Mean arterial pressure (mmHg) 80 85.0 ± 2.8* 108.0 ± 2.0* +
Systemic vascular resistance (dynes • sec/cm5) 1279 1394.0 ± 103.4* 2357.0 ± 340.4* +
Central venous pressure (mmHg) 4.4 0.51 ± 0.01* + 1.80 ± 0.03* +
Peripheral perfusion index 1.6 1.5 ± 0.1* 1.30 ± 0.03* +
Notes: * — p < 0.05 between the groups;f — p < 0.05 compared to the norm.
Note:f — p < 0.05 compared to the norm.
Table 2. Hemodynamics and tissue perfusion in patients of different surgical risk
Dangerous condition in patients of high surgical risk is related to:
— plasma deficit;
— relative hypodynamia compensated by tachycardia and vasospasm, but not providing adequate tissue perfusion.
Conflict of interest. The author reports on obtaining financial assistance for the purchase of some reagents from State Institution "Dnipropetrovsk Medical Academy of the Ministry of Health of Ukraine".
References
1. Emergency Surgery: Standards for Unscheduled Surgical Care, Guidance for Providers, Commissioners and Service Planners / Richard Collins [et al.]; The Royal College of Surgeons, Southampton, UK. Produced by the Publications Department, the Royal College of Surgeons of England. Printed by Hobbs the Printers, Southampton, London, 2011. 54 p. Dep. 14.09.11, № 212808.
2. Update to the high-risk patient released by RCS England. NELA Project Team. Fourth Patient Report of the National Emergency Laparotomy Audit RCoA / Iain Anderson [et al.]; Healthcare Quality Improvement Partnership as part of the National Clinical Audit Programme on behalf of NHS England and the Welsh Government, UK. Produced by the Publications Department Royal College of Anaesthetists, London, 2018. 135p. Dep. 23.08.18, № WC1R 4SG.
3. Murray D. Improving outcomes following emergency laparotomy. Anaesthesia. 2014. Vol. 69. P. 300-305.
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4. Oliver C.M. Risk assessment tools validated for patients undergoing emergency laparotomy: a systematic review. BJA: British Journal of Anaesthesia. 2015. Vol. 115(6). Р. 849-860.
5. Barrow E, Anderson I., Varley S. et al. Current UK practice in emergency laparotomy. Annals of The Royal College of Surgeons of England. 2013. 95(8). Р. 599-603.
6. Chana P., Joy M, Casey N. et al. Cohort analysis of outcomes in 69 490 emergency general surgical admissions across an international benchmarking collaborative. BMJ. 2017. 78(7). Р. 49-60.
7. Vester-Andersen M., Lundstrom L.H., Moller M.H. et al. Mortality and postoperative care pathways after emergency gastrointestinal surgery in 2904 patients: a population-based cohort study. BJA. 2014.112(5). Р. 860-870.
8. Copeland G. POSSUM: a scoring system for surgical audit. Br. J. Surg. 1991. Vol. 78. Р. 7-12355-360.
9. Стандарти оргашзаци та професшно opieHmoeaHi протоколи надання HeeidKAadHoi допомоги хворим з хiрургiч-ною пaтoлoгieю оргашв живота (eiдомча тструкщя). Под. ред. Я.С. Березницького. Днтро:Днтро-VAL, 2008. 256с.
10. Carlisle J.B. Risk prediction models for major surgery: composing a new tune. Anaesthesia. 2019. Vol. 74. Р. 7-12.
11. Кишкун А.А. Руководство по лабораторным методам диагностики. М.: ГЭОТАР-Медиа, 2009. 800с.
12. Klijn E, Marit H.N., Lima A. et al. Tissue perfusion and oxygenation to monitor fluid responsiveness in critically ill, septic patients after initial resuscitation: a prospective observational study. Anaesthesia. 2015. 29. Р. 707-712.
Received 20.02.2019 ■
Кравец О.В.
ГУ «Днепропетровская медицинская академия МЗ Украины», г. Днепр, Украина
Оценка исходных патофизиологических изменений у пациентов с неотложной абдоминальной патологией
Резюме. Актуальность. Острая хирургическая патология характеризуется высоким риском возникновения послеоперационных осложнений и смертности. Цель исследования — определить исходные патофизиологические изменения у больных с неотложной патологией органов брюшной полости и их зависимость от степени хирургического риска пациентов. Материалы и методы. Обследовано 200 больных, оперированных ургентно в объеме лапаротомии. В зависимости от степени операционного риска, определяемого по шкале Р-POSSUM, больные были разделены на 2 группы — среднего (п = 100) и высокого (п = 100) хирургического риска. Изучали рутинные клинико-лабораторные показатели, состояние центральной гемодинамики и водных секторов организма методом неинвазивной биоэлектрической интегральной оценки состава тела с помощью аппаратного комплекса «Диамант». Результаты. У всех пациентов среднего хирургического риска наблюдалось уменьшение внеклеточного объема за счет снижения объема плазмы (83 % от нормы в 1-й группе (р < 0,05), 86 % от нормы (р < 0,05) во 2-й группе). Статистически достоверных изменений внутриклеточного объема не отмечалось у пациентов обеих групп. Гемодинамический ответ у всех больных имел приспособительный характер. Так, увеличение ударного
объема на 105 % от нормы (р < 0,05) при снижении ударного индекса на 122 % от нормы (р < 0,05) и компенсации умеренной тахикардией приводило к формированию относительно гипердинамического типа кровообращения (значения сердечного индекса составили 107 % нормы (р < 0,05)) в 1-й группе пациентов. Это позволяло сохранять тканевую перфузию (периферический перфузион-ный индекс соответствовал 93,7 % от нормы; р > 0,05). У пациентов 2-й группы отмечался относительно гипо-динамический тип кровообращения (показатели сердечного индекса соответствовали 84,6 % от нормы; р < 0,05) при высоком напряжении сердечно-сосудистой системы (показатели ЧСС превышали норму на 45 %; р < 0,05, общего периферического сопротивления сосудов — на 84 % (р < 0,05)) и снижении тканевой перфузии (периферический перфузионный индекс соответствовал 81,3 % от нормы; р < 0,05). Выводы. Острая хирургическая патология, ассоциированная со II степенью дегидратации, приводит к умеренному истощению сосудистого объема/ гиповолемии при общем сокращении внеклеточного объема жидкости. Гиповолемия обусловлена потерей плазменного объема и вызывает развитие гемодинамиче-ских нарушений, перераспределение жидкости в водных секторах организма. Тяжесть патофизиологических на-
рушений зависит от степени хирургического риска пациента. У пациентов среднего хирургического риска компенсаторное повышение частоты сердечных сокращений приводит к формированию относительно гипердинамического типа кровообращения и сохранению тканевой перфузии. Для больных высокого хирургического риска
патогномонично снижение тканевой перфузии на фоне тахикардии и вазоспазма, поддерживающих относительно гиподинамический тип кровообращения. Ключевые слова: неотложная абдоминальная патология; хирургический риск; водные секторы; центральная гемодинамика; гиповолемия
Кравець О.В.
ДУ «Днпропетровська медична академя МОЗ Украни», м. Днпро, Украна
Оцшка вих^них патофiзiологiчних змш у пащенпв i3 нев^кладною абдомiнальною патологieю
Резюме. Актуальтсть. Гостра хiрургiчна патологiя характеризуеться високим ризиком виникнення тсля-операцiйних ускладнень i смертность Мета до^джен-ня — визначити вихщш патофiзiологiчнi змiни у хворих iз невiдкладною патологiею органiв черевно! порожни-ни i 1х залежшсть вiд ступеня хiрургiчного ризику па-цiентiв. Матерiалu та методы. Обстежено 200 хворих, оперованих в обсязi ургентно! лапаротоми. Залежно вщ ступеня операцшного ризику, що визначався за шкалою P-POSSUM, хворi були розподшеш на 2 групи — серед-нього (п = 100) i високого (п = 100) хiрургiчного ризику. Вивчали рутиннi клiнiко-лабораторнi показники, стан центрально! гемодинамши та водних секторiв органiзму методом неiнвазивноi бюелектрично! iнтегральноi оцш-ки складу тша за допомогою апаратного комплексу <«Ща-мант». Результаты. У всiх пащенпв середнього хiрургiч-ного ризику спостеркалося зменшення позаклiтинного об'ему за рахунок зниження об'ему плазми (83 % вщ норми (р < 0,05) у 1-й груш, 86 % вщ норми (р < 0,05) у 2-й грут). Статистично вiрогiдних змiн внутршньокль тинного об'ему не вщзначалось у пацiентiв двох груп. Гемодинамiчна вiдповiдь в усiх хворих мала пристосу-вальний характер. Так, збшьшення ударного об'ему на 105 % вщ норми (р < 0,05) при зниженш ударного шдексу на 122 % вiд норми (р < 0,05) i компенсаци помiрною та-хiкардiею приводило до формування вiдносно пперди-намiчного типу кровооб^у (значення серцевого iндексу становили 107 % вщ норми (р < 0,05)) у 1-й грут пащен-
TiB. Це дозволяло зберкати тканинну перфузiю (перифе-ричний перфузшний iндекс вiдповiдав 93,7 % вщ норми; p > 0,05). У пащенпв 2-1 групи вiдзначався вщносно ппо-динамiчний тип кровообiгу (показники серцевого шдексу вщповщали 84,6 % вщ норми; p < 0,05) при високому напруженш серцево-судинно1 системи (показники ЧСС перевищували норму на 45 %; p < 0,05), загального пери-феричного опору судин — на 84 % (p < 0,05)) i зниженш тканинно1 перфузи (периферичний перфузiйний шдекс вiдповiдав 81,3 % вiд норми; p < 0,05). Висновки. Гостра хiрургiчна патолог1я, асоцiйована з II ступенем дегщра-таци, приводить до помiрного виснаження судинного об'eму/гiповолемii при загальному зниженш об'ему по-закттинного простору. Гiповолемiя пов'язана з утратою плазмового об'ему i викликае розвиток гемодинамiчних порушень, перерозподiл рiдини у водних секторах орга-нiзму. Тяжшсть патофiзiологiчних порушень залежить вiд ступеня хiрургiчного ризику пацiента. У пащентав середнього хiрургiчного ризику компенсаторне пщви-щення частоти серцевих скорочень приводить до фор-мування вiдносно гiпердинамiчного типу кровооб^у й збереження тканинно1 перфузи. Для хворих високого xi-рургiчного ризику патогномошчне зниження тканинно1 перфузи на rai таxiкардii та вазоспазму, що пщтримують вiдносно гiподинамiчний тип кровообиу. Ключовi слова: невщкладна абдомiнальна патолопя; хь рургiчний ризик; воднi сектори; центральна гемодинамь ка; гiповолемiя
