INFUSIONAL THERAPY (Latin infusio injection, injection; grech, therapeia treatment) — the type of treatment, to-rogo is the cornerstone intravenous injection of large amounts of various liquids during considerable time (several hours and even days).
And. t. — a component of a complex of the therapeutic events held at the diseases and damages which are followed considerable patol, changes in the main bodies and systems responsible for a homeostasis therefore it is widely used during the rendering the emergency medical care at resuscitation (see) and intensive care (see). Tasks And. t., and consequently also indications, are: 1) maintenance of normal volume and composition of extracellular liquid, including and volume of the circulating blood (VCB); 2) normalization of electrolytic balance of an organism taking into account the natural daily need for electrolytes and them patol, losses; 3) correction of shifts of an acid-base state; 4) normalization of homeostatic and rheological properties of blood; 5) maintenance normal macro - and microcirculation; 6) prevention and treatment of dysfunctions of heart, lungs, a liver, kidneys, went. - kish. path, closed glands; 7) ensuring adequate metabolism, i.e. compensation of a metabolic cost of an organism, and correction of protein, fatty and carbohydrate metabolism.
For And. t. use the liquids possessing both selective, and versatile influence on an organism of the patient. One of them serve preferential for completion of OTsK (whole donor blood, blood preparations — albumine, a protein, etc., krupnomolekulyarny plasma substitutes). Others provide needs of the patient for water and electrolytes: simple solutions (0,9% solution of sodium chloride, 0,3 — 0,6% solution of potassium chloride, 1,9% solution of sodium lactate, 0,9% solution of ammonium chloride, 4,5 — 8,4% solution of sodium bicarbonate), the combined solutions (Ringer's solution — Locke, Gartmann's solution, Butler's solution, Darrou's solution, etc.). The third deliver plastic materials — replaceable and irreplaceable amino acids. These are, as a rule, protein hydrolyzates: Amincrovinum, Aminopeptidum, protein hydrolyzate of TsOLIPK casein, aminoevils; synthetic amino-acid mixes: moriamin, friamin, aminofuzin, etc. The fourth are a source of completion of a metabolic cost: fatty emulsions (intralipid, lipofundinum of S), sugar (5 — 40% solution of glucose and its laevoisomer — levulose), alcohol, sorbitol.
Also the drugs administered for the purpose of desintoxication are used: Haemodesum, Neocompensanum, periston. Success And. t. substantially is defined by individual selection of infusional liquids on the basis of accurate knowledge of their structure, physical. - chemical properties, their pharmacodynamics and pharmacokinetics taking into account an etiology and a pathogeny a zabolevniya, age and weight of a condition of the patient, associated diseases and extent of dysfunction of the main bodies and systems.
Administration of infusional solutions is carried out by catheterization of the main veins — - subclavial, jugular, femoral, umbilical (see. Catheterization of veins puncture ) or venipunctures and venosektion of peripheral veins of top and bottom extremities (see. Venipuncture , Venosektion ).
In a wedge, practice during the determination of quantity and composition of the entered liquids proceed from need of the healthy person for water, proteins, fats, carbohydrates, and also for the necessary number of calories (tab. 1), for electrolytes and vitamins (see. Vitamins , Vitamin deficiency , Water salt metabolism ), strictly considering the quantity them lost by the patient with then, urine at defecation, vomiting, on drainages from a stomach, belly and pleural cavities, through outside fistulas, etc. Besides, it is necessary to use the data obtained during the calculation of deficit of extracellular water and electrolytes by means of the level of a hematocrit (Ht), amount of hemoglobin (Hb) and content of sodium in plasma. Calculation of deficit of extracellular water:
1. By means of a hematocrit (it is normal of 45%): deficit oxen in l = [(Ht ist Ht dolzhn ) / Ht dolzhn ] * (the weight of the patient in kg / 5).
In tab. 2 the data obtained by means of this formula at various body weight of the patient, level of a hematocrit in a venous blood are summed up (both the formula, and data of tables cannot be used at blood loss or anemia of other etiology).
2. By means of average molecular concentration of hemoglobin — mHbK of Hb/100 of ml of erythrocytes = ([of Hb/100] / Ht about %)* 100 (it is normal of mHbK = 33-34 g of Hb/100 of ml of erythrocytes): deficit of water in l = [(mHBK ist — mHBK dolzhn ) / mHBK dolzhn ] * 100 * (the weight of the patient in kg / 5).
3. By means of the content of sodium in plasma (is normal 140 — 145 mekv/l): deficit of water in l = [(Na ist - Na dolzh ) / Na dolzh ] * (the weight of the patient in kg / 5).
In all these formulas the indicator (the weight of the patient in kg / 5) designates the volume of extracellular space: Ht ist , mHBK ist , Na ist - — contents at the patient, and HT dolzhn , mHBK dolzhn , Na dolzhn — contents is normal.
Calculation of deficit of extracellular electrolytes (E) can be made by means of definition of their concentration in plasma: deficit of E mekv/l = (E dolzhn - E ist ) * (the weight of the patient in kg / 5) * (mHBK dolzhn / mHBK ist ) (designations as well as in the previous formulas).
It is necessary to consider that at in the fever patients at fervescence on 1 ° exchange increases by 10 — 13%, and thus at a temperature of 40 ° can exceed usual level for 40%. According to it additional correction of structure and volume of infuziruyemy solutions is necessary. All ingredients used for And. t., it is necessary to enter taking into account not only the minimum requirements, but also the maximum tolerance of an organism to them.
If release of water and electrolytes with urine is absent, then to 75% of the entered dose passes into intersticial liquid during 2 hours after infusion. Therefore the minimum quantity of the emitted urine shall be apprx. 600 ml a day, and in the fever patients shall allocate not less than 1 l of urine a day.
And. t., carried out for the purpose of normalization of frustration of a hemodynamics, shall include the means filling the OTsK influencing cordial emission and improving a peripheral blood stream. In case of reduction of OTsK as a result of blood loss transfuse blood or plasma substitutes. The volume of blood, to-ruyu it is necessary to pour at blood loss, it is possible to define in various ways, including and by table 3.
Disorders of microcirculation eliminate with inclusion in composition of infuziruyemy solutions rheological of active means (reopoliglyukin, polyvinyl pyrrol and Don) and heparin. Use also such drugs as an Euphyllinum, komplamin etc.
Need of correction of an acid-base state arises as at development of a metabolic acidosis, and alkalosis. Treatment of acidosis is reached by administration of sodium bicarbonate or Trisaminum (TNAM). During the use of 0,3 M of solution (3,66%) of TNAM quantity mekv the bases = BE X 0,3 X the weight of the patient in kg (or the number of ml of 0,3 M of TNAM solution = BE X weight in kg). However total quantity of TNAM shall not exceed 1,5 g/kg a day. Correction of a metabolic alkalosis is more difficult. At treatment of an alkalosis selection of solutions with low pH is of particular importance. Besides, apply potassium chloride, inhibitors of a karbongidraza (Diacarbum, Fonuritum), ascorbic to - that. In literature there are messages on positive effect at administration of solutions salt to - you, solution of ammonium chloride, calcium chloride.
Essential part I. t. makes parenteral food. At the healthy person with a stable weight with urine, a stake, the same amount of nitrogen is distinguished then, a cut it accepts with food, i.e. there is a zero nitrogenous balance.
For reproduction of proteins the person needs 18 — 20 amino acids among which 8 — irreplaceable. Therefore enter protein hydrolyzates or synthetic amino-acid mixes into composition of infusional solutions, selecting them so that to provide optimum structure of proteinaceous food. Caloric content is provided also with administration of carbohydrates, fats, alcohols. Injection of the concentrated solutions of glucose is most widespread. Addition of insulin allows to enter a large amount of glucose. It is possible to enter alcohol to 190 g a day that at observance of speed of infusion of 8 g/hour corresponds to its oxidation in an organism and delivers at the same time apprx. 1344 kcal. Fatty emulsions along with the fact that deliver a significant amount of calories are a source of phosphatides, sincaline, fat-soluble vitamins and is high - nonlimiting fat to - t.
Complications which can arise in time And. t., happen the general and local character. The general complications are connected with individual intolerance of the patient, allergic and pyrogenic reactions. To complications can conduct: excess transfusion of liquid — a hypervolemia, electrolytes — a hyperpotassemia etc. Local complications in the form of damage of walls of vessels, phlebitis, thrombophlebitises are connected with use of high concentration of the entered substances (glucose, etc.) or with development of an infection at long finding of a catheter in a vein.
Absolute contraindications to And. t. no. With care it should be seen off at a cardiovascular, liver and renal failure when it is necessary to reduce considerably amount of the poured liquid and to carry out more careful control of a condition of the patient.
Table 1. DAILY NEED of the ADULT FOR WATER, PROTEINS, FATS, CARBOHYDRATES AND CALORIES (W. Seifart, 1971)
Table 2. CALCULATION of DEFICIT OR EXCESS of EXTRACELLULAR LIQUID by means of the HEMATOCRIT (W. Seifart, 1971)
Table 3. The VOLUME of WHOLE BLOOD NECESSARY FOR TRANSFUSION AT BLOOD LOSS DEPENDING ON the WEIGHT of the PATIENT, CONCENTRATION of HEMOGLOBIN AND GEMATOKRITNY NUMBER (W. N of Taylor, 1970)
Bibliography Bogolyubov V. M. Pathogeny and clinic of water and electrolytic frustration, L., 1968, bibliogr.; Koshelev N. F. Problems of parenteral food, L., 1975, bibliogr.; A. A baby lion. Water and electrolytic exchange, M., 1972, bibliogr.; Problems of parenteral food, under the editorship of V. A. Kor-zan, etc., Riga, 1969, bibliogr.; Savelyeva G. M. Infusional therapy in obstetrics and gynecology, M., 1976, bibliogr.; Sudzhyan A. V. Parenteral food in an onkokhirurgiya, M., 1973, bibliogr.; At an ilkinsona.a. Water and electrolytic exchange in surgery, the lane with English, M., 1974, bibliogr.; Seifart W. Kurzer Leitfaden der praktischen Infusionstherapie, Stuttgart, 1971; Taylor W. H. Fluid therapy and disorders of electrolyte balance, Philadelphia, 1970.
V. M. Buyanov.