Intraoperative infusion therapy. Infusion therapy Department of anesthesiology and resuscitation FPKV lower Presentation on the topic of the department of anesthesiology and resuscitation

Gizatullin R.Kh.

Anesthesiology and resuscitation - section
clinical medicine, studying problems
pain relief, management of vital
bodily functions before, during and after
operations, as well as in critical conditions.
Anesthesiology and resuscitation - a single
speciality
1995 - the Department of Anesthesiology and
resuscitation BSMU
2

Efrem Osipovich Mukhin 1766 - 1850

Efrem Osipovich Mukhin
published the first
monograph on problems
revival of "Discourses on
means and methods
revive the dead
strangled and suffocated"
3

Fyodor Ivanovich Inozemtsev 1802 - 1869

1847, February 7 Fedor
Ivanovich Inozemtsev
for the first time in Russian
Empires put to sleep
ether sick and
removed the cancer
mammary gland with
metastases in
axillary region
4

Nikolai Ivanovich Pirogov 1810 -1881

1847, February 14 Nikolai
Ivanovich Pirogov began
operate under ethereal
anesthesia
1847, May - published
the world's first monograph,
dedicated to ether anesthesia,
"Recherches pratiqes et
phsiologiqus sur l'ethrisation",
owned by N.I.
Pirogov
5

Vladimir Alexandrovich Negovsky 1909 - 2003

1936 - organized "Laboratory
experimental physiology on
revitalization of the body"
the leadership of V.A. Negovsky.
1943 - monograph published
V.A.Negovsky "Restoration
vital functions of the body
in a state of agony
or period of clinical death
1961 - V.A.Negovsky proposed
name the science of revival
"resuscitation".
6

2. History of domestic anesthesiology and resuscitation

1847, July - the first book in Russian "On
the use of vapors in operational medicine
sulfuric ether” was written by the doctor N.V. Maklakov.
1879 - V.K. Anrep discovered a local anesthetic
action of cocaine.
1881 - S.K. Klikovich used nitrous oxide.
1885 - A.I. Lukashevich first described
conductive anesthesia.
1899 - I.Ya.Meerovich in Ekaterinodar for the first time
performed spinal anesthesia.
1902 - N.P. Kravkov performed intravenous anesthesia
hedonal.
7

3. History of domestic anesthesiology and resuscitation

1904 - S.N. Delitsin published a monograph
"General and Local Anesthesia".
1912 - S.F. Deryuzhinsky announced the first
successful resuscitation
.
8

4. History of domestic anesthesiology and resuscitation

1946 - the first in the USSR endotracheal anesthesia with artificial
lung ventilation (Leningrad Military Medical Academy,
clinic of P.A. Kupriyanov)
1950 - synthesis of the muscle relaxant "ditilin" at the All-Union Scientific Research Chemical-Pharmaceutical Institute named after.
Ordzhonikidze.
1956 - in the Leningrad Military Medical Academy open cycle
specialization of physicians in anesthesiology.
1959 - The Ministry of Health of the USSR published
"Regulations on the anesthesiologist"
1961 - the first issue of the journal "Experimental Surgery and
anesthesiology", which since 1977 became known as "Anesthesiology and
resuscitation".
1966 - the All-Union Scientific Society of Anesthesiologists and Resuscitators was created (dissolved in 1991).
9

1. History of anesthesiology

William T.G. Morton became famous after October 16, 1846, when
in Boston demonstrated to the whole world that ether can
exert an anesthetic effect.
March 30, 1842 Crawford W. Long used ether to remove
two small neck tumors. Until 1849, Long did not disclose his
ether results.
Joseph Priestley was the first to get nitrous oxide.
Pristley is also famous for discovering clean gas, now
known as oxygen.
Humphy Davy coined the name "laughing gas" for nitrous
nitrogen. He reported that N2O could be used in
surgical operations.
Horace Wells, a dentist in Hartford, Connecticut, was the first
who assessed the potential value of N2O in tooth extraction.
Public demonstration in January 1845 at Harvard
medical school failed, Wells was booed by the audience.
10

General anesthesia

temporary artificially induced
a condition in which there are no or
reduced response to surgery
intervention and others
nociceptive stimuli.
11

Components of anesthesia

1. Inhibition of mental perception - elimination of emotions and
unpleasant experiences (hypnotics)
2. Analgesia - elimination of the reaction to pain irritation
(analgesics)
3. Neurovegetative blockade - warning
neuroendocrine and autonomic reactions to the complex
stress factors (neuroleptics)
4. Muscle relaxation - elimination of muscle activity
(muscle relaxants)
5. Maintaining adequate gas exchange - mechanical ventilation, maintaining
airway patency
6. Maintaining adequate circulation - maintaining
BCC, IOC, total peripheral resistance
(infusion therapy, adremimetics)
7. Regulation metabolic processes, metabolism - acid-base balance, water-electrolyte balance, correction of protein and carbohydrate
exchange (nutritive support-perioperative period).
12

1. Stages of anesthesia (on the example of ethereal) Guedel's classification was modified by I.S. Zhorov

I. Analgesia 3-8 minutes, disorientation, speech
loose, facial skin hyperimated, pupils
react to light, respiratory rate, heart rate, tactile,
temperature sensitivity and reflexes
saved
II. Excitations 1-5 minutes - speech and motor
excitation. The skin is hyperemic,
eyelids closed, pupils dilated, reaction to light
preserved, lacrimation, trismus, cough and
gag reflexes increased RR, HR, possibly
respiratory depression.
13

2. Stages of anesthesia (on the example of ethereal) Guedel's classification was modified by I.S. Zhorov

III. Surgical 12-20 min - loss of all kinds
sensitivity, muscle relaxation, inhibition of reflexes,
respiratory depression, heart rate decreases.
III1 - muscle tone is preserved, laryngo-pharyngeal
reflexes. Breathing is even, blood pressure at baseline, mucous membranes
wet, skin pink
III2 - eyeballs fixed, corneal reflex
disappears, pupils are constricted, laryngeal and pharyngeal reflexes
missing. Breathing is even, pulse and blood pressure are at the initial level
III3 - The level of pupil dilation - paralysis of the smooth
muscles of the iris, tachypnea, pulse accelerates,
BP at baseline or decreased.
III4 - level of diaphragmatic breathing - unacceptable!!!
Overdose.
IV - awakening
14

Stages of general anesthesia

Preoperative preparation
patient and equipment
Premedication
Induction (induction anesthesia)
Maintenance of anesthesia
Withdrawal from anesthesia
Postoperative management
15

1. Studying the anamnesis

Studying the anamnesis
1. family history of congenital conditions,
associated with anesthesia
problems (malignant
hyperpyrexia, hemophilia, etc.)
2. Diseases of CVS and DS
3. Pregnancy? Early dates teratogenic
effect, late - the risk of regurgitation and
acid aspiration syndrome.
4. Indications of previous anesthesia
5. History of HIV infection, viral hepatitis
16

2. Studying the anamnesis

Studying the anamnesis
Smoking is a disease of the brain and
coronary blood flow, cancer, chronic bronchitis.
Stop smoking at least 12 hours before
surgery, optimally 6 weeks.
The action of nicotine on the sympathetic nervous
system - tachycardia, hypertension, increased
coronary vascular resistance.
Cessation - relieves angina
Decreased hemoglobin available for oxygen
25%
17

3. Studying the anamnesis

Alcohol - regular consumption
alcohol leads to induction
liver enzymes and tolerance
to anesthetics. Abuse
alcohol damages
liver and heart. In alcoholics in
postoperative period
recovery can be seen
delirium tremens as a result of cancellation
drug.
18

4. Studying the anamnesis

Medical history - many
drugs interact with agents
used for anesthesia (adrenaline,
antibiotics, anticonvulsants). Some
drugs are canceled before surgery.
Monoamine oxidase inhibitors are canceled for
2-3 weeks Before the operation. – consultation
psychiatrist. Oral contraceptives
should be canceled 6 weeks before the scheduled
surgery - the risk of venous thrombosis.
19

Objective examination

All organs and systems are examined! Strictly
document all findings.
Assessment of the proposed tracheal
intubation. Examine teeth: identification
caries, the presence of crowns, the absence of teeth,
the presence of protruding teeth. Degree
mouth opening is evaluated along with
degree of cervical flexion
spine and extension
atlantooccipital joint.
20

Special Studies

1. Urinalysis
2. Complete blood count
3. ecg
4. Blood for HIV infection, viral hepatitis
5. Plasma urea and electrolyte concentrations
6. Liver function tests
7. Radiography chest, other radiographs
8. Blood glucose concentration
9. Pulmonary function tests
10. Blood gas analysis
11.Coagulation tests
21

Risk assessment

Mortality due to surgery
0,6%
Mortality due to anesthesia 1 in 10,000)
In many large scale studies
lethality are common factors that
regarded as conducive
anesthetic mortality include
inadequate assessment of patients in
preoperative period, insufficient
supervision and control during the operation and
inadequate follow-up and management after
operations.
22

1.ASA scale

The ASA scoring system was originally introduced
as a simple description of the physical state
patient. Despite its apparent simplicity, this
remains one of the few perspective descriptions
patient, which correlate with the risk of anesthesia and
operations. However, the assessment does not reflect all aspects
anesthetic risk, since it is not
takes into account many criteria such as age or
difficulty in intubation. However, she is extremely
useful and should be done in all patients
before surgery
23

1.ASA physical status scale

Grade Score
I
healthy patients
Patients with systemic diseases of the middle
II
III
IV
V
E
gravity
Patients with severe systemic
uncompensated disease
Patients with uncompensated systemic
a disease that poses a constant threat
life
Dying patients who are not expected to
survival within 24 hours (with or without surgery)
her)
Added as a suffix for emergency operations
24

Mortality after anesthesia and surgery for each ASA physical status (emergency and elective)

ASA class
I
II
III
IV
V
Mortality, %
0,1
0,2
1,8
7,8
9,4
25

premedication

Premedication means psychological
and pharmacological training
patients before surgery. IN
Ideally, all patients
must enter preoperative
period without anxiety, sedated,
but easily accessible to contact and
ready to cooperate with
doctor.
26

Drugs used for premedication

Benzodiazepines
Opioid analgesics
Butyrophenones (Neuroleptics)
Anticholinergic agents (atropine,
hyoscine)
Premedication option: 30 minutes before
operations i/m seduxen 10 mg + atropine
1 mg.
27

Plan of conversation with the patient during the preoperative examination

Medical history discussion
Accompanying illnesses
Regularly taken drugs
Anesthesia history
Description of the anesthetic technique and associated
risk
Discussion of planned premedication and start time
operations
A story about what to expect when applying to
operating room
Message about the estimated duration of the operation
Description of methods for eliminating postoperative pain
28

Goals of pharmacological premedication

Eliminate anxiety
Sedation
Amnesia
analgesia
Suppression of secretion in respiratory tract
Prevention of reactions of the autonomic nervous system
Decreased volume and increased pH of gastric contents
Antiemetic action
Reduced need for anesthetics
Facilitate the introduction of anesthesia
Prevention of allergic diseases
29

Introductory anesthesia

Induction anesthesia - the beginning of anesthesia,
usually begins with an introduction
mind-numbing drugs
intravenously (propofol, thiopental Na)
or inhaled (halothane, nitrous
nitrogen, sevoran)
30

Maintenance of anesthesia

Most often carried out
a combination of drugs can
administered intravenously or
inhalation.
31

Withdrawal from anesthesia

This period is due to
anesthesia method and used
drugs
32

1. Complications and difficulties

Complications
obstruction of the upper
respiratory tract
laryngospasm
Solutions
Correct
positioning
patient, IVL
Termination
throat stimulation,
deepening
anesthesia, 100% O2,
muscle relaxants,
tracheal intubation,
IVL.
33

opens with negative pressure
36

It should be noted that this form of obstruction is not anatomical in origin, but physiological.

Final prototypes Nunn used in his research*

* Brodrick PM, Webster NR, Nunn JF. The Laryngeal Mask Airway
- A study of 100 Patients During Spontaneous Breathing.
Anaesth 1989; 44:238‑241
38

Level
anatomical
obstruction–
PROTECTED
Level
physiologically
th obstruction
PROTECTED
39

Classification of sealing strategies using supraglottic ducts:

Majority
epiglottic
air ducts
to LM
COPA type
Combitube type
Laryngeal tube type
LMA type
40

2. Complications and difficulties

Bronchospasm
Malignant
hyperthermia
ICP increase
The same as at
laryngospasm
dendralene,
termination
surgery and anesthesia.
Adequate
ventilation
patient,
maintaining
adequate
hemodynamics
41

3. Complications and difficulties

Pollution
atmosphere
Usage
cleansing
equipment.
maintenance
patency
respiratory tract
is one of
critical tasks
anesthesiologist.
Inhalation agents
may be submitted through
face mask or
tracheal tube.
42

1.Monitoring during anesthesia

Monitoring is a process
during which the anesthetist recognizes and
evaluates potential physiological
problems and predictive trends in
real time mode. Effective
monitoring helps to recognize
violations before they lead to
serious or irreversible damage,
which reduces the risk of complications.
Monitors increase accuracy and
specificity of the clinical evaluation.
43

2.Monitoring during anesthesia

Anesthesia chart management
(Medications used and
dosage, blood pressure, heart rate, ventilation, respiratory rate, FiO2,
ventilation data, volume
blood loss, any problems or
difficulties, instructions for
postoperative management of the patient)
44

3.Monitoring during anesthesia

ECG - monitoring
Circulation monitoring (peripheral pulse,
peripheral oxygen saturation,
peripheral circulation, diuresis, blood pressure
Clinical control of ventilation
Airway pressure measurement
Measurement of inspiratory and expiratory volumes
Monitoring of delivery and removal of gases
Delivery of anesthetic vapors
Laboratory evaluation of blood parameters
45

Postoperative management

Transfer of the patient from the operating room to the ward
awakening, specialized department,
intensive care unit
Patient positioning
Monitoring of hemodynamics and respiration
Adequate postoperative
anesthesia
Treatment of the underlying disease, nutritional
support

Infusion therapy is a method of treatment based on the introduction of various drugs intravenously or under the skin. medicinal solutions and drugs, in order to normalize the water-electrolyte, acid-base balance of the body and correct pathological losses of the body or prevent them.

Every anesthesiologist-resuscitator needs to know the rules of infusion therapy in the department of anesthesiology and resuscitation, since the principles of infusion therapy for intensive care patients not only differ from infusion in other departments, but also make it one of the main methods of treatment in severe conditions.

What is infusion therapy

The concept of fluid therapy in intensive care includes not just parenteral administration medicines for the treatment of a certain pathology, but a whole system of general effects on the body.

Infusion therapy is intravenous parenteral administration of medicinal solutions and preparations. Infusion volumes in intensive care patients can reach several liters per day and depend on the purpose of its appointment.

In addition to infusion therapy, there is also the concept of infusion-transfusion therapy - this is a method of controlling body functions by correcting the volume and composition of blood, intercellular and intracellular fluid.

The infusion is often given around the clock, so continuous intravenous access is required. For this, patients undergo central vein catheterization or venesection. In addition, critically ill patients always have the possibility of developing complications that require urgent resuscitation, so reliable, constant access is essential.

Goals, tasks

Infusion therapy can be carried out in shock, acute pancreatitis, burns, alcohol intoxication- The reasons are different. But what is the purpose of infusion therapy? Its main goals in intensive care are:

There are other tasks that she sets for herself. This determines what is included in infusion therapy, which solutions are used in each individual case.

Indications and contraindications

Indications for infusion therapy include:

• all types of shock (allergic, infectious-toxic, hypovolemic);
• body fluid loss (bleeding, dehydration, burns);
• loss of mineral elements and proteins (uncontrollable vomiting, diarrhea);
• violation of the acid-base balance of the blood (diseases of the kidneys, liver);
• poisoning (drugs, alcohol, drugs and other substances).

There are no contraindications to infusion-transfusion therapy.

Prevention of complications of infusion therapy includes:

How is it carried out

The algorithm for conducting infusion therapy is as follows:

• examination and determination of the main vital signs of the patient, if necessary - cardiopulmonary resuscitation;
• catheterization of the central vein, it is better to immediately do catheterization Bladder to monitor the excretion of fluid from the body, as well as put a gastric tube (rule of three catheters);
• determination of the quantitative and qualitative composition and initiation of infusion;
• additional studies and analyzes, they are already done against the background of ongoing treatment; the results affect its qualitative and quantitative composition.

Volume and preparations

For introduction use medications and means for infusion therapy, classification of solutions for intravenous administration, shows the purpose of their assignment:

• crystalloid saline solutions for infusion therapy; help to fill the deficiency of salts and water, these include saline, Ringer-Locke solution, hypertonic sodium chloride solution, glucose solution and others;
• colloidal solutions; These are high and low molecular weight substances. Their introduction is indicated for decentralization of blood circulation (Polyglukin, Reogluman), in violation of tissue microcirculation (Reopoliglyukin), in case of poisoning (Hemodez, Neocompensan);
• blood products (plasma, erythrocyte mass); indicated for blood loss, DIC syndrome;
• solutions that regulate the acid-base balance of the body (sodium bicarbonate solution);
• osmotic diuretics (Mannitol); used to prevent cerebral edema in stroke, traumatic brain injury. The introduction is carried out against the background of forced diuresis;
• solutions for parenteral nutrition.

Infusion therapy in resuscitation is the main method of treatment of resuscitation patients, its full-fledged implementation. Allows you to bring the patient out of a serious condition, after which he can continue further treatment and rehabilitation in other departments.

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Lecture No. 16. Infusion therapy

Infusion therapy is drip introduction 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 eyeballs in 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.

Goals of infusion therapy: restoration of BCC, elimination of hypovolemia, ensuring adequate cardiac output, maintaining and restoring normal plasma osmolarity, ensuring adequate microcirculation, preventing aggregation shaped elements blood, normalization of the oxygen-transport function of the 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. 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 values ​​low suggests hypovolemia, then a high infusion rate is maintained 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.

TO negative sides dextrans should 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 ischemia of the kidneys and kidney 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 to itself and worsening the 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) poses a high risk of infection 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 reading to 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 indirect anticoagulants, during therapeutic plasmapheresis, with acute DIC and with hereditary diseases associated with deficiency of clotting 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.

| |

Kharitonova T. V. (St. Petersburg, Mariinsky Hospital)
Mamontov S.E. (St. Petersburg, Medical Unit No. 18)

Infusion therapy is a serious tool for an anesthesiologist-resuscitator, and can give an optimal therapeutic effect only if two indispensable conditions are met. The doctor must clearly know the purpose of the drug and be aware of its mechanism of action.

Rational infusion therapy is the most important aspect of maintaining hemodynamic function during surgery. While it is certainly necessary to maintain acid-base and electrolyte balance, oxygen transport, and normal blood clotting during surgery, normal intravascular volume is the primary life-support parameter.

Intraoperative fluid therapy should be based on an assessment of physiological fluid requirements, comorbidities, effects of drugs used for anesthesia, anesthesia technique, and fluid loss during surgery.

The main goal of ongoing infusion therapy in critical situations is to maintain adequate cardiac output to ensure tissue perfusion at the lowest possible hydrostatic pressure in the capillary lumen. This is necessary in order to prevent leakage of fluid into the interstitium.

Figure 1. Frank-Starling curves under different conditions (lower - hypokinesia, middle - normal, top - hyperkinesia).

Hemodynamics

Maintaining optimal intravascular volume (IVV) and ventricular preload is essential for normal heart function. The principles expressed by E. G. Starling and O. Frank at the beginning of the twentieth century still form our understanding of the physiology of blood circulation, pathophysiological mechanisms and ways to correct them (Fig. 1).

The state of myocardial contractility under various conditions, such as hypokinesia - circulatory failure in hemorrhagic shock, or hyperkinesia - the early phase of septic shock, are examples of situations in which Starling forces operate relatively flawlessly.

However, there are many situations that cast doubt on the universality of the Frank-Starling law for all critical conditions.

Maintaining preload (it is characterized by the end-diastolic volume of the ventricle - EDV) is the basis for correcting unstable hemodynamics. There are many factors that affect preload. Understanding that EDV is a determinant of preload is key to understanding the pathophysiology of hypovolemia and acute insufficiency blood circulation, since pressure in the ventricular cavity in critical conditions is not always a reliable indicator of preload.

Figure 2. Comparison of changes in CVP and DZLK depending on the dynamics of preload.

The ratio of EDV to end-diastolic pressure for both ventricles, depending on the degree of their stretching, that is, preload, always tends to favor volume.

At present, monitoring is often limited to central venous pressure (CVP) alone, although measurements of right ventricular end-diastolic pressure or pulmonary capillary wedge pressure (PCWP) are sometimes used to assess preload. Comparison of CVP, end-diastolic pressure and preload can help to understand how disparate monitoring parameters these are (Fig. 2).

It is very important to understand why such monitoring is imperfect. But it is equally important to know how to correctly interpret its results in order to ensure that adequate hemodynamic function is maintained.

The level of CVP is traditionally judged on the magnitude of venous return and the volume of intravascular fluid. However, with the development of many critical conditions, desynchronization of the work of the left and right hearts is observed (biventricular phenomenon). This phenomenon cannot be detected in a banal study of the CVP. However, echocardiography or other invasive methods can accurately assess myocardial contractility and determine further tactics of infusion and drug support. If, nevertheless, a biventricular phenomenon has already been identified, then it should be regarded as a sign that does not give great hopes for success. A fine balancing act between fluid therapy, inotropic agents, and vasodilators will be required to achieve a positive outcome.

When right ventricular failure develops following left ventricular myocardial insufficiency (for example, with mitral defects), then CVP will reflect the conditions of the left half of the heart. In most other situations ( septic shock, aspiration syndrome, cardiogenic shock etc.), focusing on the CVP figures, we are always late both with the diagnosis and with intensive therapy.

Arterial hypotension as a result of reduced venous return is a convenient framework for explaining the clinical physiology of shock, but in many ways these ideas are mechanistic.

The English physiologist Ernest Henry Starling formulated his ideas on these issues in a famous report of 1918. In this report, he refers to the work of Otto Frank (1895) and some data from his own research on a cardiopulmonary preparation. For the first time, the law formulated and proclaimed stated that "the length of the muscle fiber determines the work of the muscle."

O. Frank's research was carried out on an isolated frog muscle using a kymograph that had just appeared in physiological laboratories. The Frank-Starling addiction got its name "the law of the heart" with the light hand of Y. Henderson, a very talented and inventive experimenter, who at that time focused all his attention on the intravital study of cardiac activity in humans.

It should be noted that the Frank-Starling law ignores the difference between the length of the fibers and the volume of the heart muscle. It has been argued that the law should measure the relationship between ventricular filling pressure and ventricular work.

One gets the impression that everyone seemed to be just waiting for the appearance of such a "convenient" law, since over the next decades of the beginning of the last century, a flurry of various clinical and physiological explanations of all changes in circulatory pathology from the standpoint of the "law of the heart" followed.

Thus, the Frank-Starling law reflects the state of the heart pump and capacitance vessels as a single whole system, but does not reflect the state of the myocardium.

The usual indicators of adequate intravascular volume and perfusion, such as CVP, can be successfully used in monitoring patients without significant vascular pathology and volemic disorders who are undergoing elective surgical interventions. However, in more complex cases, for example, in patients with concomitant cardiac pathology, severe types of shock, careful monitoring is necessary - pulmonary artery catheterization, as well as transesophageal echocardiography. In critical situations, only these monitoring methods can help to adequately assess preload, afterload, and myocardial contractility.

Oxygen transport

Delivery of oxygen to the tissues is determined by the value of cardiac output and the value of the volumetric oxygen content of arterial blood.

The oxygen content in arterial blood depends on the amount of hemoglobin, its saturation with oxygen and, to a small extent, on the amount of oxygen dissolved in the plasma. Thus, an adequate number of erythrocytes is an indispensable condition for maintaining a normal oxygen content in arterial blood, and, accordingly, for its delivery. At the same time, in almost all cases of blood loss, oxygen starvation of tissues occurs not due to hemic hypoxia, but due to circulatory. Thus, the doctor is faced with the task, first of all, to increase the volume of circulating blood and normalize microcirculation, and then restore blood functions (transport, immune, etc.). Possible alternatives to erythrocytes are modified hemoglobin preparations and perftorans.

The volume of water sectors of the body
Wednesday	volume, ml/kg of body weight
women	men
General water
intracellular fluid
extracellular fluid
intravascular water
blood plasma
red blood cells
Whole blood
Volume of circulating blood

Although donor screening has significantly reduced the risk of transfusion transmission of hepatitis and human immunodeficiency virus, numerous transfusion complications and expiration dates remain. As alternatives to blood transfusion, one can consider increasing cardiac output, increasing tissue oxygen utilization, and maintaining a high level of arterial hemoglobin oxygen saturation. However, we must not forget that after surgery, oxygen consumption rises sharply - the so-called postoperative hypermetabolic state.

Electrolyte balance and acid-base status

Despite great importance in the management of the patient to assess and correct the concentrations of calcium, magnesium and phosphates, the main electrolytes of the intraoperative period are sodium, potassium and chlorides. Their concentration is most affected by the infusion of crystalloid solutions.

Saline solutions (physiological sodium chloride solution and Ringer's lactate) affect the concentration of sodium chloride outside the cell and the acid-base state. During surgery and in the postoperative period, the concentration of aldosterone in the blood increases sharply, which leads to an increase in sodium reabsorption in the tubules of the kidneys. This requires an equilibrium reabsorption of the negative anion (i.e. chloride) or secretion of a hydrogen or potassium ion to keep the renal tubules electrically neutral. When using saline sodium chloride solution, the secretion of potassium and hydrogen ions sharply decreases, as a result of which hyperchloremic metabolic acidosis may develop.

The short lumen residence time and relatively low sodium content are arguments against the use of saline sodium chloride solution for the treatment of operative blood loss. The most commonly used in practice are saline sodium chloride solution and balanced salt solutions, for example, Ringer's lactate solution. The very best of saline solutions contain potassium, but they should be used with caution in patients with hyperkalemia, especially in renal failure. You also need to keep in mind that Ringer's lactate solution contains calcium. Therefore, Ringer's lactate solution should not be used in cases where a citrated blood infusion is planned.

The use of Ringer-lactate solution is more physiological, since the sodium / chloride ratio is maintained and acidosis does not develop. Infusion of Ringer's lactate solution in large quantities in the postoperative period can lead to alkalosis, since bicarbonate is formed as a result of lactate metabolism. In this situation, it may be advisable to add potassium and calcium to these standard solutions.

Glucose

The inclusion of glucose in the intraoperative program of infusion therapy has been discussed for a long time. Traditionally, glucose has been administered during surgery to prevent hypoglycemia and to limit protein catabolism. Prevention of hypo- and hyperglycemia is especially important in patients with diabetes mellitus and liver disease. In the absence of diseases that strongly affect carbohydrate metabolism, glucose solutions can be dispensed with.

Hyperglycemia, accompanied by hyperosmolarity, osmotic diuresis and acidosis of brain tissues are the consequences of excessive consumption of glucose solutions. Since the brain functions only on glucose, anaerobic glucose metabolism begins under conditions of hypoxia, and acidosis develops. The longer the duration of acidosis, the more likely the death or irreversible damage to nerve cells. In these situations, glucose solutions are absolutely contraindicated. The only indication for intraoperative use of glucose solutions is the prevention and treatment of hypoglycemia.

clotting factors

Coagulation factor deficiency can lead to bleeding and is therefore an indication for blood products, including fresh frozen plasma, platelets, or cryoprecipitate. The causes of coagulation factor deficiency can be: hemodilution, disseminated intravascular coagulation, hematopoiesis suppression, hypersplenism, and deficiency in the synthesis of coagulation factors. In addition, there may be a violation of platelet function, both endogenous (for example, with uremia) and exogenous (taking salicylates and non-steroidal anti-inflammatory drugs) in nature. Regardless of the cause, before transfusion of blood components, it is strictly necessary to determine and confirm clotting disorders.

The most common coagulopathy during surgery is dilutional thrombocytopenia, which often occurs with massive transfusions of red blood cells, colloid and crystalloid solutions.

Coagulation factor deficiency in the absence of liver dysfunction is rare, but it must be remembered that only 20-30% of the labile coagulation factors (factor VII and VIII) are retained in banked blood. The indication for platelet transfusion in a surgical patient is severe thrombocytopenia (50,000 to 75,000). A 2–4-fold increase in standard clotting time is an indication for infusion of fresh frozen plasma, and a fibrinogen level of less than 1 g/l in the presence of bleeding indicates the need for cryoprecipitate.

Infusion therapy

Quantitative aspects

The volume of infusion therapy during surgery is influenced by many different factors (Table 1). In no case should you ignore the results of assessing the state of the intravascular volume (IVV) of the fluid before surgery.

Hypovolemia is often combined with chronic arterial hypertension, causing an increase in total vascular resistance. The volume of the vascular bed is also affected by various drugs that the patient took for a long time before surgery or that were used as preoperative preparation.

If the patient has disorders such as nausea, vomiting, hyperosmolarity, polyuria, bleeding, burns, or malnutrition, then preoperative hypovolemia should be expected. Often it remains unrecognized due to the redistribution of the VSO fluid, chronic blood loss, as well as unchanged, and sometimes even growing body weight. Causes of volemic disorders in this situation can be: bowel dysfunction, sepsis, acute lung injury syndrome, ascites, pleural effusion, and release of hormonal mediators. All these processes are often accompanied by an increase in capillary permeability, resulting in a loss of intravascular volume of fluid into the interstitial and other spaces.

Correction of preoperative fluid deficiency is a cornerstone in the prevention of severe arterial hypotension and hypoperfusion syndrome during induction of anesthesia.

When compensating for a deficiency, it should be remembered that in the absence of hypovolemic shock, the maximum allowable rate of fluid administration is 20 ml / kg / hour (or in terms of body surface area 600 ml / m 2 / hour). Hemodynamic stabilization required to start anesthesia and surgery is characterized by the following indicators:

BP is not lower than 100 mm Hg. Art.

CVP within 8 - 12 cm of water. Art.

diuresis 0.7 - 1 ml/kg/hour

Despite all precautions, induction is in any case accompanied by a decrease in venous return. Intravenous anesthetics used for induction of anesthesia, including sodium thiopental and propofol, significantly reduce total vascular resistance and can also reduce myocardial contractility. Other drugs are also used to maintain anesthesia - for example, etomidate, brietal, dormicum or opiates in high doses can also provoke arterial hypotension due to inhibition of the sympathetic-adrenal system. Muscle relaxants can lead to the release of histamine (curare and atracurium) and reduce total vascular resistance, or increase the volume of venous depots due to pronounced muscle relaxation. All inhalation anesthetics reduce vascular resistance and inhibit myocardial contractility.

Table. Factors affecting the volume of intraoperative infusion therapy

Artificial lung ventilation (ALV), started immediately after induction of anesthesia, is especially dangerous for a patient with hypovolemia, since positive inspiratory pressure sharply reduces preload. The use of regional methods of anesthesia, for example, epidural and spinal anesthesia, can be a real alternative to general anesthesia if there are conditions and time to compensate for fluid deficiency. However, all these methods are accompanied by a sympathetic blockade extending two to four segments above the sensory block, and this can be detrimental to a patient with hypovolemia due to the deposition of blood in the lower extremities.

In practice, two preventive measures are used that have proven themselves well for the prevention of arterial hypotension during epidural and spinal anesthesia: tight bandaging of the lower extremities with elastic bandages and preinfusion of a 6% solution of hydroxyethyl starch (Refortan).

Apart from the effects of anesthesia, the effects of the surgery itself cannot be discounted. Bleeding, removal of ascitic or pleural effusion, the use of a large amount of fluid to wash the surgical wound (especially in cases where massive absorption of this fluid is possible, as, for example, during resection of prostate adenoma) - all this affects the volume of intravascular fluid.

The position of the patient, the technique itself, and changes in temperature have a significant impact on venous return and vascular tone. Many general anesthetics are vasodilators and their use increases heat loss through the skin by about 5%. Anesthesia also reduces heat production by about 20-30%. All these factors contribute to an increase in hypovolemia. The redistribution of fluid and its evaporation from the surgical field should also be taken into account (regardless of what kind of operation it is).

Over the past 40 years, a huge number of points of view on infusion therapy during abdominal and thoracic operations have been published. Before it appeared modern theory on the redistribution of the volume of intravascular fluid, it was believed that the retention of salt and water during the operation dictates the requirements for limiting the injected fluid in order to avoid volume overload. This point of view was based on the registration of elevated concentrations of aldosterone and antidiuretic hormone during surgery. The fact that the release of aldosterone is a response to operational stress has long been and unconditionally proven fact. Moreover, mechanical ventilation in continuous positive pressure mode further contributes to oliguria.

More recently, there has been evidence of fluid loss into the "third space" and most clinicians have agreed that there is a volume deficit of both extracellular and intravascular fluid during surgery.

For many years, especially before the advent of invasive methods for monitoring preload and cardiac output, clinicians were only able to make empirical calculations of fluid therapy based on the location of surgery and its duration. In this case, for abdominal interventions, the infusion rate is about 10 to 15 ml/kg/h of crystalloid solutions, plus the solutions required to compensate for blood loss and drug administration.

For thoracic interventions, the infusion rate is 5 to 7.5 ml/kg/h. Although such strict limits are no longer adhered to, it must be said that such infusion rates provide some confidence in the adequacy of replenishing the deficit of extracellular fluid. With the introduction of modern hemodynamic monitoring and new methods of surgical interventions into clinical practice, doctors no longer use schemes, but provide an individual approach to each patient based on knowledge of the pathophysiology of a particular disease, the method of surgical intervention and the pharmacological properties of the anesthetics used.

During the operation, the volume of infusion therapy is added to the volume of fluid necessary to replenish blood loss and administer drugs. Blood loss is always accompanied by fluid redistribution and loss of extracellular and intracellular fluid volume. It should be remembered that the main threat to the patient is not the loss of red blood cells, but hemodynamic disorders, therefore the main task of infusion therapy is to compensate for the bcc. Blood loss is replenished so that the volume of fluid injected is greater than the volume of blood lost. canned blood is not the optimal transfusion medium for this purpose: it is acidotic, has a low oxygen capacity, up to 30% of its erythrocytes are in the form of aggregates that block the capillaries of the lungs. When compensating for blood loss with crystalloid solutions, three times more crystalloid solutions are required to maintain an adequate volume of intravascular fluid than was lost blood.

Liquid losses must also be taken into account. abdominal operations, but such losses can be very difficult to estimate. Previously, it was believed that after major interventions on abdominal cavity Restriction of fluid intake is required to prevent the development of pulmonary edema and congestive heart failure. This can indeed happen, since in the postoperative period there may be a shift of fluid towards the interstitial space. It should be assumed that this redistribution is based on a change in vascular permeability. The reason for this change in permeability may be the release of pro-inflammatory cytokines, including interleukins 6 and 8, as well as tumor necrosis factor (TNFa) as a result of a stress response to surgery. Although there are few reproducible studies on this, a possible source of endotoxemia is ischemic or traumatized mucosa.

Despite all these mechanisms, over the course of 25 years, a stable point of view has been formed that adequate fluid therapy is necessary during surgery to maintain preload and cardiac output. In cases of deterioration in myocardial contractility, infusion therapy is carried out in such a volume as to maintain a minimum coccoid-diastolic pressure (that is, DZLK should be in the range from 12 to 15 mm Hg), which allows the use of drugs for inotropic support against this background. The need for fluid restriction in the postoperative period and diuresis control is dictated by the pathophysiology of the underlying disease.

Table 3. Criteria for choosing solutions for infusion therapy in the intraoperative period

• Endothelial permeability
• Oxygen transport
• Clotting factors
• Colloidal oncotic pressure
• Tissue edema Electrolyte balance
• Acid-base state
• Glucose metabolism
• Brain disorders

Qualitative aspects

The main arguments in favor of choosing one or another solution should be based on the correct interpretation of various indicators characterizing a given clinical situation, and the comparability of the physicochemical properties of the drug with it (see Appendix).

Colloidal solutions have a high oncotic pressure, as a result of which they are distributed mainly in the intravascular sector and move water from their interstitial space there. The larger the solute molecule, the stronger the oncotic effect and the lower its ability to leave the vascular bed by entering the interstitium or filtering in the glomeruli of the kidneys. At the same time, a valuable quality of medium molecular weight colloids is their ability to improve the rheological properties of blood, which leads to a decrease in afterload and an increase in tissue blood flow. The antiplatelet properties of dextrans allow the use of these drugs to "unblock" the capillary bed (however, at a dose of more than 20 ml / kg / day, the risk of developing coagulopathy is real).

Crystalloid solutions are distributed in an approximate proportion: 25% - in the intravascular, 75% - in the interstitial space.

Separately, there are glucose solutions: volume distribution - 12% in the intravascular sector, 33% - in the interstitium, 55% - in the intracellular sector.

Below we present (Table 3) the effect of various solutions on the CCP, the volume of interstitial fluid and the volume of extracellular fluid per 250 ml of the injected solution.

Table 3. Changes in the volume of liquid sectors with the introduction of 250 ml of solutions

		L Interstitial	D Intracellular
(ml)	volume (ml)	volume(ml)
5% solution of glucose
Ripger lactate
5% albumin
25% albumin

Compensation for the lack of oxygen transport and the coagulation system requires transfusion of blood components. The choice still remains with crystalloid solutions if the main disturbances concern the electrolyte balance or acid-base state. The use of glucose solutions, especially in cerebrovascular accidents and surgical interventions, is currently not recommended, as they exacerbate acidosis in the brain tissues.

The greatest number of disputes over the past 30 years has arisen among supporters of colloids and crystalloids as a means of compensating for surgical blood loss. Ernest Henry Starling (1866-1927) - founder of the theory of the influence of colloidal forces on the transport of fluid through membranes. The principles that formed the basis of the famous Starling equation back in 1896 remain relevant today. The balance of forces included in the well-known Starling equation is the most convenient model for not only explaining most of the troubles observed in conditions of impaired vascular endothelial permeability, but also predicting the effects that occur when prescribing various infusion drugs (Fig. 3).

Figure 3 Starling force balance at the level of the pulmonary capillaries

It is known that approximately 90% of the total plasma colloid-oncotic pressure (COP) is created by albumin. Moreover, this is the main force that is able to keep the liquid inside the capillary. The controversy began when studies appeared that declared that with a decrease in COPD, water begins to accumulate in the lungs. Opponents of these authors wrote that an increase in capillary permeability allows colloidal particles to freely pass through the membranes, which levels out shifts in colloidal oncotic pressure. It has also been shown that colloids can bring a lot of trouble - their large particles "clog" the lymphatic capillaries, thereby attracting water to the pulmonary interstitium (this argument regarding colloids of low and medium molecular weight remains completely valid today).

Of interest are data from a meta-analysis of eight randomized clinical trials comparing intravenous therapy with colloids or crystalloids. The difference in mortality in trauma patients was 2.3% (more in the group where colloidal solutions were used), and 7.8% (more in the group where crystalloids were used) in patients without injuries. It was concluded that in patients with obviously increased capillary permeability, the appointment of colloids can be dangerous, in all other cases it is effective. On a large number of experimental models and in clinical research a clear relationship was not obtained between colloid-oncotic pressure, the type of solution administered, and the amount of extravascular water in the lungs.

Table 4. Advantages and disadvantages of colloids and crystalloids

A drug	Advantages	Flaws
Colloids	Less volume of infusions	Big cost
Long-term increase in VCP	Coagulopathy (dextrans > HES)
Smaller peripheral edema	Pulmonary edema
Higher systemic oxygen delivery	Decreased Ca++ ( albumin) Decreased CF Osmotic diuresis (low molecular weight dextrans)
Crystalloids	lower cost	Temporary improvement in hemodynamics
	Greater diuresis	Peripheral edema
Replacement of sequestered interstitial fluid	Pulmonary edema

Thus, in the intraoperative period, the infusion therapy program should be based on a rational combination of two types of solutions. Another question is what solutions to use in critical conditions accompanied by a syndrome of multisystem dysfunction, and therefore occurring against the background of generalized damage to the endothelium.

Commercial colloid preparations currently available are dextrans, gelatin solutions, plasma, albumin, and hydroxyethyl starch solutions.

Dextran is a low molecular weight colloidal solution used to improve peripheral blood flow and replenish the volume of circulating plasma.

Dextran solutions are colloids that consist of polymers of glucose with an average molecular weight of 40,000 and 70,000 D. The first colloid used in the clinic for BCC replacement was a mixed polysaccharide derived from acacia. This happened during the First World War. After him, gelatin solutions, dextrans, and synthetic polypeptides were introduced into clinical practice. However, all of them gave a fairly high frequency of anaphylactoid reactions, as well as a negative effect on the hemocoagulation system. The disadvantages of dextrans, which make their use dangerous in patients with multisystem failure and generalized damage to the endothelium, include, first of all, their ability to provoke and enhance fibrinolysis, change the activity of factor VIII. In addition, dextran solutions can provoke dextran syndrome (damage to the lungs, kidneys and hypocoagulation) (Fig. 4.).

Gelatin solutions in critically ill patients should also be used with extreme caution. Gelatin causes an increase in the release of interleukin-1b, which stimulates inflammatory changes in the endothelium. Under conditions of a general inflammatory reaction and generalized damage to the endothelium, this danger increases dramatically. Infusion of gelatin preparations leads to a decrease in the concentration of fibronectin, which can further increase the permeability of the endothelium. The introduction of these drugs contributes to an increase in the release of histamine, with well-known unfortunate consequences. There are opinions that gelatin preparations can increase bleeding time, worsen clot formation and platelet aggregation, which is due to high content in solutions of calcium ions.

A special situation regarding the safety of the use of gelatin solutions has developed in connection with the threat of the spread of the pathogen of transmissible spongioform encephalopathy of cattle ("mad cows"), which is not inactivated by conventional sterilization regimens. In this regard, there is information about the danger of infection through gelatin preparations [I].

Uncomplicated hemorrhagic shock can be treated with both colloids and crystalloids. In the absence of endothelial injury, there is little to no significant difference in lung function either after colloid administration or after crystalloid administration. Similar contradictions also exist regarding the ability of isotonic solutions of crystalloids and colloids to increase intracranial pressure.

The brain, unlike peripheral tissues, is separated from the lumen of the vessels by the blood-brain barrier, which consists of endothelial cells that effectively prevent the passage of not only plasma proteins, but also low molecular weight ions, such as sodium, potassium and chlorides. Sodium that does not pass freely through the blood-brain barrier creates an osmotic gradient along this barrier. Decreasing the plasma sodium concentration will drastically reduce the plasma osmolality and thereby increase the water content in the brain tissue. Conversely, a sharp increase in sodium concentration in the blood will increase the plasma osmolality and cause water to move from the brain tissue into the lumen of the vessels. Because the blood-brain barrier is virtually impermeable to proteins, colloids are traditionally thought to increase intracranial pressure less than crystalloids.

allergic reactions when using medium and large molecular weight dextrans, they develop quite often. They arise due to the fact that in the body of almost all people there are antibodies to bacterial polysaccharides. These antibodies interact with the injected dextrans and activate the complement system, which in turn leads to the release of vasoactive mediators.

Plasma

Fresh frozen plasma (FFP) is a mixture of three main proteins: albumin, globulin and fibrinogen. The concentration of albumin in plasma is 2 times the concentration of globulin and 15 times the concentration of fibrinogen. Oncotic pressure is determined to a greater extent by the number of colloid molecules than by their size. This is confirmed by the fact that more than 75% of the COD forms albumin. The remainder of the plasma oncotic pressure is determined by the globulin fraction. Fibrinogen plays a minor role in this process.

Although all plasma undergoes rigorous screening procedures, there is a certain risk of infection transmission: for example, hepatitis C - 1 case in 3300 transfused doses, hepatitis B - 1 case in 200,000, and HIV infection - 1 case in 225,000 doses.

Transfusion pulmonary edema is an extremely dangerous complication, which, fortunately, occurs infrequently (1 in 5000 transfusions), but nevertheless can seriously overshadow the process of intensive care. And even if complications of plasma transfusion in the form of alveolar pulmonary edema do not occur, the chance to significantly worsen the condition of the respiratory system and prolong mechanical ventilation is very high. The cause of this complication is the reaction of leukoagglutination of antibodies coming with the donor's plasma. FFP contains donor leukocytes. In a single dose, they can be present in an amount from 0.1 to I x 10 ". Foreign leukocytes, just like their own, in critically ill patients are a powerful factor in the development of a systemic inflammatory response with subsequent generalized damage to the endothelium. The process can be induced by the activation of neutrophils, their adhesion to the vascular endothelium (primarily the vessels of the pulmonary circulation).All subsequent events are associated with the release of biologically active substances that damage cell membranes and change the sensitivity of the vascular endothelium to vasopressors and activate blood coagulation factors (Fig. 5 ).

In this regard, FFP should be used according to the most stringent indications. These indications should be limited only by the need to restore clotting factors.

Hydroxyethylated starch is a synthetic derivative of amylopectin derived from corn or sorghum starch. It consists of D-glucose units connected in a branched structure. The reaction between ethylene oxide and amylonectin in the presence of an alkaline catalyst adds hydroxyethyl to the chains of glucose molecules. These hydroxyethyl groups prevent the hydrolysis of the formed substance by amylase, thereby lengthening the time it remains in the bloodstream. The degree of substitution (expressed as a number from 0 to 1) reflects the number of glucose chains occupied by hydroxyethyl molecules. The degree of substitution can be controlled by changing the reaction time, and the size of the resulting molecules is controlled by acid hydrolysis of the starting product.

Solutions of hydroxyethylated starch are polydisperse and contain molecules of various masses. The higher the molecular weight, for example 200,000-450,000, and the degree of substitution (from 0.5 to 0.7), the longer the drug will remain in the lumen of the vessel. Preparations with an average molecular weight of 200,000 D and a degree of substitution of 0.5 were classified as pharmacological group"Pentastarch", and preparations with a high molecular weight of 450,000 D and a degree of substitution of 0.7 belong to the pharmacological group "Hetastarch".

The weight average molecular weight (Mw) is calculated from the weight fraction of individual molecular species and their molecular weights.

The lower the molecular weight and the more low molecular weight fractions in the polydisperse preparation, the higher the colloid-oncotic pressure (COP).

Thus, at effective COD values, these solutions have a high molecular weight, which predetermines the advantages of their use over albumin, plasma, and dextrans in conditions of increased endothelial permeability.

Solutions of hydroxyethylated starch are able to "seal" the pores in the endothelium that appear in various forms of its damage.

Solutions of hydroxyethyl starch usually affect the volume of intravascular fluid within 24 hours. The main route of elimination is renal excretion. HES polymers with a molecular weight of less than 59 kilodaltons are almost immediately removed from the blood by glomerular filtration. Renal elimination by filtration continues after the hydrolysis of larger fragments into smaller ones.

It is assumed that larger molecules do not enter the interstitial space, while smaller ones, on the contrary, are easily filtered and increase oncotic pressure in the interstitial space. However, the works of R.L. Conheim et al. raise some doubts about this assertion. The authors suggest that the capillaries have both small pores (with a reflectance of 1) and large pores (with a reflectance of 0), and in patients with "capillary leak" syndrome, it is not the size that changes, but the number of pores.

The oncotic pressure created by HES solutions does not affect the current through large pores, but mainly affects the current through small pores, which are the majority in capillaries.

However, V.A. Zikria et al. and other researchers have shown that the molecular weight distribution and degree of substitution of starch HES solutions significantly affect "capillary leakage" and tissue edema. These authors suggested that hydroxyethyl starch molecules of a certain size and three-dimensional configuration physically "seal" the defective capillaries. It's tempting, but how can you test whether such an intriguing model works?

It appears that HES solutions, in contrast to fresh frozen plasma and crystalloid solutions, can reduce "capillary leakage" and tissue edema. Under conditions of ischemia-reperfusion injury, HES solutions reduce the degree of lung damage and internal organs, as well as the release of xanthine oxidase. Moreover, in these studies, animals administered hydroxyethylated starch solutions had a significantly higher gastric mucosal pH than those administered Ringer's lactate solution.

Liver function and mucosal pH in patients with sepsis improve significantly after the use of hydroxyethyl starch, while these functions do not change with albumin infusion.

In hypovolemic shock, infusion therapy using HES solutions reduces the incidence of pulmonary edema compared with the use of albumin and saline sodium chloride solution.

Infusion therapy, which includes solutions of HES, leads to a decrease in the level of circulating adhesion molecules in patients with severe trauma or sepsis. Decreased levels of circulating adhesion molecules may indicate reduced endothelial injury or activation.

In an in vitro experiment, R.E. Collis et al. showed that HES solutions, unlike albumin, inhibit the release of von Willebrand factor from endothelial cells. This suggests that HES is able to inhibit the expression of P-selectin and the activation of endothelial cells. Since interactions between leukocytes and endothelium determine transendothelial output and tissue infiltration by leukocytes, influencing this pathogenetic mechanism can reduce the severity of tissue damage in many critical conditions.

From all these experimental and clinical observations, it follows that hydroxyethylated starch molecules bind to surface receptors and influence the rate of synthesis of adhesion molecules. Apparently, a decrease in the rate of synthesis of adhesion molecules can also occur due to the inactivation of free radicals by hydroxyethyl starch and, possibly, a decrease in the release of cytokines. None of these effects are found when studying the action of solutions of dextrans and albumin.

What else can be said about solutions of hydroxyethyl starch? They have another therapeutic effect: they reduce the concentration of circulating factor VIII and von Willebrand factor. This seems to be more relevant to Refortan, and may play an important role in patients with initially low concentrations of clotting factors, or in patients undergoing such surgical interventions where reliable hemostasis is absolutely necessary.

The effect of HES on the processes of blood coagulation in the microvasculature may be advantageous in patients with sepsis. It is impossible not to mention the use of hydroxyethyl starch in kidney donors (with an established diagnosis of brain death), and the subsequent effect of the drug on kidney function in recipients. Some authors who have studied this problem noted a deterioration in kidney function after the use of the drug. HES can cause damage similar to osmotic nephrosis in the proximal and distal tubules of the donor kidney. The same damage to the tubules is observed with the use of other colloids, the infusion of which is carried out in various critical conditions. The significance of such damage for those donors who take a single kidney (that is, healthy people with normal brain function) remains unclear. However, it seems to us that the state of hemodynamics, and not the appointment of colloidal solutions, plays a much greater role in the occurrence of such damage.

The dose of hydroxyethylated starch solutions should not exceed 20 ml/kg due to possible dysfunction of platelets and the reticuloendothelial system.

Conclusion

Intraoperative infusion therapy is a serious tool for reducing mortality and morbidity. Maintaining adequate hemodynamics in the intraoperative period, especially preload and cardiac output, is absolutely necessary for the prevention of severe cardiovascular complications during both induction and main anesthesia. Knowledge of the pharmacology of anesthetics, the correct position of the patient on the operating table, compliance with the temperature regime, respiratory support, the choice of the method of surgical intervention, the area and duration of the operation, the degree of blood loss and tissue trauma - these are the factors that should be considered when determining the volume of infusion.

Maintaining adequate intravascular fluid volume and preload is important to maintain normal tissue perfusion. Although the amount of fluid administered is certainly the main factor, the qualitative characteristics of the fluid administered must also be taken into account: the ability to increase oxygen delivery, the effect on blood clotting, electrolyte balance and acid-base state. Authoritative and detailed studies have appeared in the domestic literature, which also prove a direct and indirect economic effect when using solutions of hydroxyethyl starch.

In critical conditions, which are accompanied by generalized damage to the endothelium and a decrease in plasma oncotic pressure, the drugs of choice in the infusion therapy program are solutions of hydroxyethylated starch of various concentrations and molecular weights (Refortan, Stabizol and others).

Name	characteristic	testimony	contraindications
polyglucin dose 1.5-2 g/kg/day	Volume-replacing action maximum action 5-7h excreted by the kidneys (on the 1st day 50%)	acute hypovolemia (professional and treatment), hypovolemic shock	carefully - with NK, AMI, GB
	hyperosmotic solution 1)" expander "d-e (1g binds 20-25 ml of liquid) 2) rheological d-e maximum action 90 min excreted by the kidneys, mainly on the 1st day	hypovolemia microcirculation disorders (thromboembolism, shock lung, intoxication)	hemorrhagic diathesis, anuria NC/complication: "dextran" kidney/
gelatinol up to 2 l/day	protein solution; less effective plasma substitute (briefly restores plasma volume) duration of action 4-5 hours rapidly excreted by the kidneys	acute hypovolemia intoxication	acute kidney disease fat embolism
albumen 20% -no more than 100 ml infusion rate 40-60 drops / min	maintains colloid osmotic pressure	hypovolemia, dehydration decreased plasma volume hypoproteinemia long-term suppurative diseases	thrombosis severe hypertension ongoing internal bleeding
250-1000 ml	osmotically active mixture of proteins increases BCC, MOS reduces OPS (improves blood rheology) 290 mOsm/l	hypovolemia detoxification hemostasis	sensitization hypercoagulation
blood		O. blood loss
lactasol 4-8 mg/kg/h, up to 2-4 l/day	isotonic solution close to plasma pH=6.5; Na-136, K-4, Ca-1.5, Mg-1, Cl-115 lactate-30; 287 mosm/l	hypovolemia fluid loss metabolic acidosis
Ringer's solution	isotonic, high in chlorine, low in potassium and water pH 5.5-7.0; Na-138, K-1.3, Ca-0.7 Cl-140 HCO3-1.2; 281 mosm/l	iso/hypotonic dehydration deficiency of sodium, chlorine hypochloremic alkalosis	excess chlorine, sodium iso/hypertonic overhydration metabolic acidosis
rr Ringer-Locke	isotonic, excess chlorine, glucose present, low potassium, free water pH=6.0-7.0; Na-156, K-2.7, Ca-1.8 Cl-160 HCO3-2.4, glucose 5.5; 329 mosm/l	dehydration with electrolyte deficiency hypochloremia + alkalosis	iso/hypertonic overhydration metabolic acidosis
5% glucose solution	isotonic 1 l ® 200 kcal pH 3.0-5.5; 278 mosm/l	hypertensive dehydration free water deficit	hypotonic dyshydria hyperglycemia methanol poisoning
10% glucose solution	hypertonic, too much water 1 l ® 400 kcal pH=3.5-5.5; 555 mosm/l	hypertensive dehydration water scarcity	The same
isotonic solution NaCl ( without taking into account electrolytes causes hyperchloremia, metabolic acidosis)	isotonic, low water, high chlorine pH 5.5-7.0; sodium 154, chlorine 154 308 mosm/l	hypochloremia + metabolic alkalosis hyponatremia oliguria	metabolic acidosis excess sodium, chlorine increased hypokalemia
chlosol	isotonic, a lot of potassium pH 6-7; sodium 124, potassium 23, chlorine 105, acetate 42; 294 mosm/l	electrolyte losses hypovolemia metabolic acidosis (acetate)	hyper/iso-hyperhydration hyperkalemia anuria, oliguria metabolic alkalosis
disol	sodium chloride + sodium acetate (chlorine concentration equivalent to plasma) pH 6-7; sodium 126, chlorine 103, acetate 23 252 mosm/l	hypovolemic shock	metabolic alkalosis
trisol	isotonic (NaCl+KCl+NaHCO3) pH 6-7; sodium 133, potassium 13, chlorine 99, bicarbonate 47; 292 mosm/l	dehydration metabolic acidosis	hyperkalemia hyper/isotonic overhydration metabolic alkalosis
acesol	alkaline pH 6-7; sodium 109, potassium 13, chlorine 99, acetate 23; 244 mosm/l	hypo/isotonic dehydration hypovolemia, shock metabolic acidosis	hypertensive dyshydria hyperkalemia metabolic alkalosis
mannitol	hyperosmolar (10%, 20%) solutions 20% solution - 1372 mosm/l	prevention of acute renal failure treatment of anuria after shock, cerebral edema, toxic edema lungs	O. heart failure hypervolemia be careful with anuria
HES solutions dose up to 1 liter per day (up to 20 ml/kg/24)	high molecular weight: M = 200000 - 450000 colloid osmotic pressure 18 - 28 torr sodium 154, chlorine 154 mmol/l osmolarity 308 mosm/l	hypovolemia all kinds of shock hemodilution	hypersensitivity hypervolemia severe heart failure oliguria, anuria age less than 10 years

Literature

1. Goldina O.A., Gorbachevsky Yu.V. Advantage modern drugs hydroxyethyl starch among plasma-substituting infusion solutions. Bulletin of blood service. - 1998.-№3. - S. 41-45.
2. Zilber A.P., Shifman E.M. Obstetrics through the eyes of an anesthesiologist. "Epodes of Critical Medicine", Z.Z. -Petrozavodsk: PetrGU Publishing House. -1997. - S. 67-68.

Molchanov I.V., Mihslson V.A., Goldina O.A., Gorbachevsky Yu.V. Modern trends in the development and use of colloidal solutions in intensive care // Bulletin of the blood service of Russia. - 1999. -№3. - S. 43-50.

3. Molchanov I.V., Serov V.N., Afonin N.I., Abubakirova A.M., Baranov I.I., Goldina O.A., Gorbachevsky Yu.V. Basic infusion-transfusion therapy. Pharmaco-economic aspects // Bulletin of intensive therapy. - 2000. -№1.-S. 3-13.
4. Shifman E.M. Clinical pharmacology and modern principles of intensive care for acute circulatory failure // Actual problems of critical care medicine. - Petrozavodsk: PetrGU Publishing House. - 1994. - S. 51-63.
5. Shifman E.M. Modern principles and methods of infusion therapy of critical conditions in obstetrics // Actual problems of medicine of critical conditions. -Petrozavodsk. -1997.- S. 30 - 54.
6. Axon R.N., Baird M.S., Lang J.D., el "al. PentaLyte decreases lung injury after aortic occlusion-reperfusion. // Am. J. Respir. Crit.Care.Med.-1998.-V. 157.-P. 1982- 1990.
7. Boldt J., Heesen M., Padberg W., et al. The influence of volume therapy and pentoxifylline infusion on circulating adhesion molecules in trauma patients // Anaesthesia. - 1996. - V. 5 I. - P. 529-535.

Boldt J., Mueller M., Menges T., et al. Influence of different volume therapy regimens on regulators of the circulation in the critically ill // Br. J. Anaesth. - 1996. - V. 77. - P. 480-487.

Cittanova M.L., Leblanc 1., Legendre C., et al. Effect of hydroxyethylstarch in brain-dead kidney donors on renal function in kidney-transplant recipients // Lancet. - 1996. - V. 348. - P. 1620-1622.

Collis R.E., Collins P.W., Gutteridge C.N. The effect of hydroxyethylstarch and other plasma volume substitutes on endot-helial cell activation; An in vitro study // Intensive Care Med. -1994.-V.20.-P. 37-41.

Conhaim R.L., Harms B.A. A simplified two-pore filtration model explains the effects of hypoproteinemia on lung and soft tissue lymph flux in awake sheep // Microvasc. Res. - 1992. - V. 44. -P. 14-26.

8. Dodd R.Y. The risk oftranfusion-transmitted infection // N.Engl.J. Med. - 1992. - V. 327. -P. 419-421.

Ferraboli R., Malheiro P.S., Abdulkader R.C., et al. Anuric acute renal failure caused by dextran 40 administration // Ren. Fail.-1997.-V. 19.-P. 303-306.

Fink M.P., Kaups K.L., Wang H., et al. Maintenance of superior mesenteric arterial perfusion prevents increased intestinal mucosal permeability in endotoxic pigs // Surgery. - 1991. - V. 110. -P. 154-161.

Nielsen V.G., Tan S., Brix A.E., et al. Hextend (hetastarch solution) decreases multiple organ injury and xanthine oxidase release after hepatoenteric ischemia-reperfusion in rabbits // Crit. Care Med.- 1997.-V.25.-P. 1565-1574.

Qureshi A.I., Suarez J.I. Use ofhypertonic saline solutions in treatment of cerebral edema and intracranial hypertension // Crit. Care Med. - 2000.- V. 28. - P. 3301-3314.

9. Rackow E.C., Falk J.L., Fein A., et al. Fluid resuscitation in circulatory shock: A comparison of the cardiorespiratory effects of albumin, hetastarch, and saline infusions in patients with hy-povolemic and septic shock // Crit Care Med. - 1983.- V. 11. - P. 839-848.
10. Rosenthal M.H. Intraoperative Fluid Management-What and How Much? //Chest. -1999.-V.115. -P. 106-112.
11. Velanovich V. Crystalloid versus colloid fluid resuscitation: a meta-analysis of mortality// Surgery.- 1989.-V. 105. - P. 65-71.
12. ZikriaB.A., King T.C., Stanford J. A biophysical approach to capillary permeability // Surgery. - 1989. - V. 105. - P. 625-631.

Please enable JavaScript to view the 2 hour lecture.
Teacher:
Kuranova
Ludmila
Vladimirovna

Plan
Theoretical basis infusion
therapy.
Classification of infusion media.
Permissible volumes, speed and methods of their
introductions
Control of the adequacy of the infusion
therapy.
Complications of infusion therapy.

INFUSION THERAPY

This is a treatment method that
parenteral administration of various
solutions for the purpose of correction
homeostasis disorders.

Correction of homeostasis

-
-
Correction of homeostasis consists in:
elimination of hypovolemia;
water-electrolyte imbalance;
normalization of the acid-base state;
restoration of rheological and
coagulation properties of blood;
regulation of metabolic disorders;
ensuring efficient oxygen transport
detoxification.

Definition of infusion medium

The infusion medium is the volume of liquid,
introduced into the body for the purpose of
volemic effect

Infusion therapy has an effect on
circulatory system in the first place, so
how the drugs administered
direct effect on blood vessels and blood;

The effect of infusion therapy depends on:
- the administered drug;
- volume, speed and routes of administration
- from functional state organism on
the time of the event;

colloids
crystalloids

All infusion media can be divided into:

Colloids:
Poliglukin;
Reopoligyukin;
Gelatinol;
Gelofusin;
Hemohes;
Stabizol;
Venofundin;
Voluven;
Tetraspan
Crystalloids:
Ringer's solution;
Lactasol;
Acessol;
Sterofundin;
Plasma-Lite;
glucose solutions;
Glucosteril;
Dissol;
Quintasol

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

All infusion media can be divided into:
I. Volume-substituting solutions. (Plasma-substituting
solutions):
I.1. Biocolloids. I.2. Solutions of synthetic colloids.
I.3. Blood products. I.4. Blood substitutes with function
oxygen transfer.
II. Basic infusion media. (Solutions of glucose and
electrolytes to maintain normal performance
water-electrolyte exchange)
: for correction
water-electrolyte metabolism (WEO) and acid-base state (ACS)
.
IV. Solutions of diuretics.
V. Infusion media for parenteral nutrition.

I. VOLUME SUBSTITUTE SOLUTIONS

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

1.1. Dextrans
Ingredient: glucose polymer
Representatives: Poliglukin, Macrodex,
Reopoliglyukin, Reogluman, Reomacrodex

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

1.2. Solutions based on gelatin
Ingredients:
- based on oxypolygelatin
Representatives: gelatinol, gemogel,
neofundol
- solutions obtained by succination
polypeptides from gelatin
Representatives: gelofusin, gelofundin,
heloplasm.

Volume-substituting solutions I. Biocolloids.

1.3. Preparations based on hydroxyethyl starch (HES);
Ingredients: hydroxyethyl starches by molar mass:
- large molecular weight (up to 450,000 D)
Representatives: Stabizol
- medium molecular weight (up to 200,000 D)
Representatives: Gemohez, HAES-steril - 6 and 10% solutions,
Refortan; Volekam (170,000 D),
- low molecular weight:
Group 1 - Voluven, Venofundin (130,000 D)
Group 2 - Tetraspan (130,000 D) (refer to the 4th group of HESs,
as it is based on a balanced polyion
solution)

l. Volume replacement solutions

I.2 SYNTHETIC COLLOIDS
-polyoxidin
-polyoxyfumarin

I. Volume replacement solutions I.3. BLOOD PRODUCTS

L
-Albumen
5,10,20% solutions,
-blood plasma,

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

Fluorocarbon emulsions: Hemoglobin solutions:
- perftoran;
- hemolink (hemosol);
- Fluoran-MK,
- somatogen;
- Fluoran-NK;
- gelenpol;
-fluoran-2.5-5;
- hemoxane.
- fluozol;
- oxygen;
- adamantane.

II. BASIC INFUSION MEDIA

II. BASIC INFUSION MEDIA

- glucose solutions (5%, 10%);
- electrolyte solutions:
Ringer's solution
lactasol (Ringer's solution - lactate),
Hartig's solution.

III. Corrective infusion media (crystalloids)

III. Corrective infusion media

0.9% sodium chloride solution;
5.84% sodium chloride solution
8, 4% and 7.5% potassium chloride solution
chlosol, disol, trisol;

III. Corrective infusion media

polyionic solutions: acesol, quadrasol,
quintasol;
8.4% sodium bicarbonate solution;
0.3% solution of TNAM (trisamine).

IV. DIURETIC SOLUTIONS

IV. Diuretic solutions

- Osmodiuretics (10% and 20% solutions
mannitol);
- 40% sorbitol solution.

V. PARENTERAL NUTRITIONS

TO MEANS FOR PARENTERAL NUTRITION ARE

energy sources:
- carbohydrates (glucose 20% and 40% solutions, glucosteril 20% and 40% solutions)
- fat emulsions ("Lipofundin" MCT / LCT", Lipofundin 10% and 20%, omegaven.
protein sources:
- solutions of amino acids (aminoplasmal "E", aminosol "KE", aminosteril 10%,
vamin-18).
Special Purpose:
- with liver failure (aminoplasmal-hepa; aminosteril-hepa).
- in chronic renal failure (neframin).
Vitamins and trace elements:
- Soluvit - water-soluble vitamins.
- Vitalipid - fat-soluble vitamins.
- Addamel - trace elements.

Biocolloids
Solutions
synthetic
colloids
Dextrans
(glucose polymers)
Polyoxidine
Blood products
Blood and its components
Albumin (solutions 5, 10, 20%)
Gelatin derivatives:
- based
hydroxypolygelatin
- received at
succination
polypeptides from gelatin
Preparations with
transfer function
oxygen
emulsions
fluorocarbons
Perftoran
Ftoran-MK
Fluorane - 2.5; 5
Oxygent
Adamantane
Based
hydroxyethyl starch
Polyoxyfumarin
Solutions
hemoglobin
Hemolink (Hemosol)
Somatogen
Gelenpol (hemoxane)

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

Peripheral vein:
subclavian vein
the introduction is excluded
concentrated
solutions.
limited period of stay
catheter in a vein;
rapid infection;
development of phlebitis;
vein thrombosis.
possible introduction
solutions of any
concentration;
long stay
catheter in a vein;
it is possible to measure CVP;
introduction of endocardial
electrodes;
installation of a SwanGans catheter

ROUTES OF INTRODUCTION OF INFUSION MEDIA

special vascular accesses:
umbilical vein catheterization (intraorganic administration with
liver disease)
intra-aortic infusion (after femoral catheterization)
arteries) are used in this way. for administering medicinal
substances to the abdominal organs, it is also possible
usage femoral artery with massive CP.
extravascular routes (very rarely used):
subcutaneous administration - limited volume (no more than 1.5 l / day) and composition
injected fluids (only isotonic solutions are allowed
salts and glucose);
intraosseous injection.

ALLOWABLE VOLUME OF INFUSION, VOLUME AND RATES OF THEIR INTRODUCTION

Depending on the program of infusion therapy, the introduction of solutions
carried out:
- jet;
- drip;
- using mechanical and (or) electronic systems dosing:
(syringes-perfusors
small
containers,
voluminous
dispensers,
infusion pumps with precise infusion rate adjustment, infusion pumps with
program control)
The rate of infusion depends on:
- CVP values;
- diameter of the catheter;
- qualitative composition of the infusion medium

CONTROL OF THE ADEQUACY OF INFUSION THERAPY

Grade general condition sick;
Monitoring of hemodynamics (HD): pulse, arterial
(BP) and central venous pressure (CVP), pressure
jamming pulmonary artery(DZLA) ;
Assessing Daily Fluid Balance: Careful Accounting
all losses (diuresis, perspiration, drainage losses,
vomiting, defecation, intestinal paresis) and
fluid intake (per os, through a tube, parenteral
introduction) ;
Laboratory indicators: ( general analysis blood
(hematocrit, hemoglobin) and urine (specific gravity); general
protein, albumins, urea, bilirubin, electrolytes,
plasma osmolarity, hemostasis, saturation);

Complications related to the route and technique of infusion

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

1. Accidental puncture of nearby organs and tissues, puncture or
vascular rupture:
- puncture of the subclavian artery
- puncture of the pleura (lung injury; pneumo-, hemothorax)
- damage to the thoracic lymphatic duct with lymphorrhea
- puncture of the trachea with the development of emphysema of the neck, mediastinum
- puncture damage to the thyroid or thymus glands
- damage to nerve trunks and nodes (recurrent; diaphragmatic
nerve; upper stellate node; brachial plexus)
- puncture of the esophagus with subsequent development of mediastinitis
2. External bleeding, hematoma
3. Air embolism when removing the syringe from the needle

1. swelling of surrounding tissues and compression of the subclavian vein;
2. necrosis at the site of paravasal drug administration;
3. catheterization pleural cavity, hydrothorax;
4. escape and migration of the catheter into the vein and heart;
5. Thrombotic complications:
- catheter thrombosis;
- vein thrombosis;
- thrombosis of the superior vena cava with the development of SVC syndrome (manifestations:
shortness of breath, cough, swelling of the face, dilation of the veins of the neck and upper
limbs, CNS disorders up to coma;
- thrombosis of the right parts of the heart;
- TELA;
6.When
intra-arterial
infusions
Maybe
violation
blood supply due to thrombosis or angiospasm;
7. Traumatic damage to the walls of blood vessels and the heart (perforation
end of the catheter of the vein wall, right atrium, right
ventricle; pericardial tamponade; internal bleeding);

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

8. Infectious-septic complications:
- infection of the catheter during prolonged stay in the vessel;
- local inflammatory processes(abscesses, phlegmon, thrombophlebitis);
-mediastinitis;
- catheterization sepsis;
9. Allergic reactions, anaphylactic shock.


- water intoxication with excessive administration of electrolyte-free liquids;
- excessive hemodilution;

11. Specific complications.
- hyperthermia;
- chills;



-overdose, drug incompatibility

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

9. Allergic reactions, anaphylactic shock.
10. Iatrogenic disorders of homeostasis:
- hyperhydration up to pulmonary and cerebral edema;
- water intoxication with excessive administration of electrolyte-free
liquids;
- excessive hemodilution;
- metabolic acidosis or alkalosis according to the acid-base balance;
11. Specific complications.
- hyperthermia;
- chills;
-reaction to the introduction of cold solutions;
- acute volemic load with an increase in the rate of infusion;
-introduction of pyrogens, bacterially contaminated environments;

Literature

1. "Fundamentals of anesthesiology and resuscitation" edited by
O.A. Valley. Textbook for universities. Moscow, GEOTAR-MED, 2002
552str.
2. "Circulatory shock" under the general editorship of E.I.
Vereshchagin. Guide for doctors. Novosibirsk. 2006
80p.
3. "Intensive care in charts and tables". methodical
manual for students and cadets FPC and teaching staff. Arkhangelsk.
2002.70str
4. Anesthesiology and resuscitation"
Textbook for secondary medical schools (under
edited by prof. A.I. Levshankova - St. Petersburg: special. Lit, 2006 - 847
With.
5. "Fundamentals of anesthesiology and resuscitation" edited by
V.N. Kokhno. Tutorial. Novosibirsk. Sibmedizdat.
NSMU. 2007 435pp.

Literature

6. "Actual issues of anesthesiology and resuscitation" under
edited by prof.E. I. Vereshchagin. Lecture course. Novosibirsk.
Sibmedizdat NGMU. 2006 264pp.
7. "Anesthesia and intensive care in geriatrics" under
edited by V.N. Kokhno, L.A. Solovieva. Novosibirsk. OOO
"RIC". 2007 298str
8. "Fundamentals of anesthesiology and resuscitation" edited by
V.N. Kokhno. 2nd edition, revised and enlarged.
Tutorial. Novosibirsk. Sibmedizdat. NSMU. 2010
526pp.
9. Kokhno V. N. “Rational tactics of emergency replenishment
volume of circulating blood. Guidelines.
V. N. Kokhno, A. N. Shmakov. Novosibirsk, 2000 26p.

Thank you for your attention!

Pharmacological properties of synthetic colloids
Blood substitute
Volemic effect
%
HVAC
CODE,
mmHg.
Medium
molecular
mass, D
Duration
hours
Hemostatic effect
Primary
hemostasis
Secondary
hemostasis
Maximum
daily
dose in ml/kg
Dextrans
Poliglukin, Intradex
120
4-6
2,8 – 4,0
58,8
60 000
Reduces
Reduces
20
Reopoliglyukin, Reogluman
140
3-4
4,0 – 5,5
90
40 000
reduces
Reduces
12
20 000
Doesn't change
Will not change
30-40
Doesn't change
Doesn't change
200
Gelatin preparations
Based on hydroxypolygelatin
Gelatinol (Gemogel,
Neofundol)
60
1,5 – 2
2,4 – 3,5
16,2 – 21,4
When succinating polypeptides from gelatin
Gelofusin, Gelofundin
100
3-4
1,9
33,3
30 000
Preparations based on hydroxyethyl starch
Stabizol
100
6-8
3
18
45 000 – 0,7
Significantly reduces
Significantly reduces
20
HAES - sterile 6%
100
3-4
1,4
36
200 000 – 0,5
Reduces
Reduces
33
HAES - sterile 10%
145
3-4
2,5
68
200 000 – 0.5
Reduces
Reduces
20
Gemohes
100
3-4
1,9
25-30
200 000 – 0,5
Reduces
Reduces
20
Refortan 6%
100
3-4
1,4
28
200 000 – 0,5
Reduces
Reduces
20
Refortan Plus 10%
145
3-4
2,5
65
200 000 – 0,5
Reduces
Reduces
20
Volekam 6%
100
3-4
3,0 -3,6
41-54
170 000 – 0,6
Reduces
Reduces
33
Voluven 6%
100
3-4
9
36
130 000 – 0, 4
Reduces in
high doses
Reduces in
high doses