话题性:为多发性创伤患者提供帮助,在酒精中毒的状态下,复杂的酒精谵妄,在提供麻醉护理时是一个严重的问题,特别是,选择镇静药物。考虑到机械损坏的严重性,与酒精中毒和身体严重生化紊乱相关的并发症,即碳水化合物,脂质代谢,电解质变化,所有系统的活动都依赖于此,有必要研究对这些过程的影响,这取决于他们的药物矫正的选择。
目的:工作的目的是选择一种镇静方法,以改善多发性创伤和酒精戒断患者的治疗结果,基于碳水化合物代谢指标变化的研究。
方法:本文分析了80例多发性创伤和慢性酒精中毒患者的酒精戒断状态的研究结果,复杂的酒精谵妄,他在12张病床的麻醉科接受了强化治疗,并为KNP“哈尔科夫市急诊临床医院”合并创伤的患者接受了强化治疗。O.I.Meschaninov“KhMR。所有患者均被诊断为多发性创伤(胸部和/或腹部创伤:肋骨骨折,血液-,气胸,肝或脾血肿,腰部的骨头骨折,和/或上肢和/或下肢,骨盆骨折)。在研究过程中,为了实现目标,确定了碳水化合物代谢的主要指标,通过关键代谢物的含量来评估:葡萄糖,丙酮酸,乳酸。这项研究是在1日进行的,患者住院的第3天和第7天。
结论:在所有使用右美托咪定进行镇静的酒精戒断综合征和酒精性谵妄的创伤患者(第1组)和用作镇静剂的患者中,地西泮和氟哌啶醇(第2组),在血液中观察到这些参数的变化,与对照组的健康人相比。至于第1组患者血液中的葡萄糖含量,第一天,在健康人群中,持续性高血糖的发生率比这一指标高1.7倍.接下来,在住院后第3天和第7天测定患者的血糖水平.与第一天测定的水平相比,第3天的葡萄糖含量降低了9.4%。第七天,血液中的葡萄糖含量下降到正常值,与第一天血液中的葡萄糖含量相比降低了26.5%。在第二组患者中,第一天使用地西泮和氟哌啶醇,也观察到高血糖-在健康个体的对照组中高于该指标1.9倍.第三天,血液中的葡萄糖水平下降了6%。在第七天,下降了20.5%。因此,在酒精戒断综合征患者的血液中观察到高血糖,住院期间并发谵妄,在住院的第3天(第一组和第二组)和第二组患者的第7天,这表明违反了碳水化合物的代谢和缺氧的发展,肝脏和胰腺功能受损。根据研究的目的和目标,血糖代谢的主要代谢产物——丙酮酸和乳酸——在入院时和治疗后一周也进行了血液含量研究,这使得有可能全面评估可能的碳水化合物代谢紊乱和表征身体的能量供应的特点,在多创伤和戒断酒精的组合,复杂的酒精谵妄。根据研究结果,与健康人相比,在慢性酒精中毒的背景下,多发性创伤患者的乳酸和丙酮酸含量增加。在分析多发性创伤和酒精戒断综合征患者血液中的乳酸含量时,入住重症监护病房时并发酒精中毒性谵妄,该指标显着增加了97.1%和113.0%,分别,在第一组和第二组的患者中。强化治疗后一周,第1组患者血液中的乳酸含量显着降低-与入院时的该指标含量相比,降低了13%(÷<0.0001)。在第二组患者的血液中,第七天,乳酸含量保持不变,106.3%超过了对照组血液中的这一生化指标。也观察到高丙酮酸血症-当第二组患者进入医院时,含量比健康人高55.4%,治疗一周后仍然升高-30.1%,并且没有返回到正常值。在第一组患者中,入院后,血液中丙酮酸含量比对照组高53.0%,在第7天,它显著下降了18.9%,但未达到对照组的值(保持在24,比对照组高1%)。患者高丙酮酸血症和高乳酸血症的原因也可能是他们酶促转化为衰变产物的侵犯。乳酸是葡萄糖厌氧氧化的最终产物,它是由于丙酮酸的转化而形成的,在缺氧条件下乳酸脱氢酶的作用条件下。碳水化合物代谢状态的重要指标,即体内厌氧和有氧过程的平衡,是乳酸/丙酮酸比率,对照组为14.33[13.82;14.49]。在第一组患者中,观察到这一比率的增加-在进入重症监护病房和治疗后一周,分别为18.46[18.3;20.59]和19.81[18.96;21,17],分别。实际上,在第二组患者中观察到该比率的相同值-19.65[18.97;22.3]和22.73[21.3223.91],分别,根据强化治疗的时间。最新数字表明,在重症监护室住院期间,身体组织的能量供应发生了重组。
结论:因此,在多发性创伤和酒精戒断综合征患者中,复杂的酒精谵妄,无氧糖酵解的过程加剧,丙酮酸含量的增加证明了这一点,乳酸,乳酸/丙酮酸比率,并伴有缺氧状态。在比较重症监护室的住院条件时,已确定,与苯并二氮卓类药物相比,使用右美托咪定治疗酒精性谵妄可将重症监护时间缩短34小时.因此,在第2组中,强化治疗酒精性谵妄的持续时间为89[82-96.2]小时,而在第1组中,它降低到55[52.2-59.8](p=0.020427)。此外,发现患者对药物的消耗不同。在第一天,第1组为20[20-30]mg,第2组为40[40-50]mg.在强化治疗期间,两组在药物的总剂量方面也存在显着差异,因此,在第1组患者中,总消耗量为30[30-40]mg,在第2组中-80[80-90]mg(p=0.033011)。
Topicality: Providing assistance to patients with polytrauma, in a state of alcohol intoxication, complicated by alcoholic delirium, is a serious problem when providing anesthesia care and, in particular, choosing drugs for sedation. Considering the severity of mechanical damage, complications associated with alcohol intoxication and serious biochemical disorders of the body, namely carbohydrate, lipid metabolism, electrolyte changes, on which the activity of all systems depends, it is necessary to study the influence on the course of these processes, depending on the choice of their medicinal corrections.
OBJECTIVE: The purpose of the work is to choose a sedation method to improve the results of treatment of patients with polytrauma and alcohol withdrawal, based on the study of changes in carbohydrate metabolism indicator.
METHODS: The paper analyzes the results of a study of 80 patients with polytrauma and chronic alcohol intoxication with a state of alcohol withdrawal, complicated by alcoholic delirium, who received intensive therapy in the 12-bed department of anesthesiology and intensive therapy for patients with combined trauma of the KNP «Kharkiv City Clinical Hospital of Emergency Medical Care» named after Prof. O. I. Meschaninov» KhMR. All patients were diagnosed with polytrauma (thoracic and/or abdominal trauma: rib fractures, hemo-, pneumothorax, hematomas of the liver or spleen, fracture of the bones of the waist, and/or upper and/or lower limbs, fracture of the pelvis). In the course of the research, to achieve the goal, the main indicators of carbohydrate metabolism were determined, which were evaluated by the content of key metabolites: glucose, pyruvic acid, lactate. The study was conducted on the 1st, 3rd and 7th day of hospitalization of the patients.
CONCLUSIONS: In all traumatized patients with alcohol withdrawal syndrome and alcoholic delirium with the use of dexmedetomidine for sedation (group 1) and in patients who were used as sedatives, diazepam and haloperidol (group 2), changes in these parameters were observed in the blood, compared to healthy people of the control group. As for the glucose content in the blood of the patients of the 1st group, on the first day, persistent hyperglycemia was observed in them 1.7 times higher than this indicator in healthy people. Next, patients\' blood glucose levels were determined on the 3rd and 7th day after hospitalization. Glucose content on the 3rd day decreased by 9.4% compared to the level determined on the first day. On the 7th day, the content of glucose in the blood decreased to normal values, which is 26.5% lower compared to the content of glucose in the blood on the first day. In the 2nd group of patients, where diazepam and haloperidol were used on the first day, hyperglycemia was also observed - 1.9 times higher than this indicator in the control group of healthy individuals. On the third day, the level of glucose in the blood decreased by 6%. And on the 7th day, it decreased by 20.5%. Thus, hyperglycemia was observed in the blood of victims with alcohol withdrawal syndrome, complicated by delirium during hospitalization, on the 3rd day of hospitalization (first and second groups) and on the 7th day in patients of the second group, which indicates violation of carbohydrate metabolism and the development of hypoxia, with impaired liver and pancreas function. In accordance with the aim and objectives of the study, the blood content of the main metabolites of glucose metabolism - pyruvate and lactate - was also studied upon admission to the hospital and one week after treatment, which made it possible to comprehensively assess possible carbohydrate metabolism disorders and characterize the features of the body\'s energy supply in the combination of polytrauma and withdrawal alcohol, complicated by alcoholic delirium. According to the results of the research, there is an increase in the content of lactate and pyruvate in patients with polytrauma against the background of chronic alcoholism compared to healthy people. When analyzing the content of lactate in the blood of patients with polytrauma and alcohol withdrawal syndrome, complicated by alcoholic delirium upon admission to the intensive care unit, a significant increase of this indicator was observed by 97.1% and 113.0%, respectively, in patients of the first and second groups. One week after the intensive therapy, the patients of the 1st group had a significant decrease in the lactate content in the blood - by 13% (Р<0.0001) compared to the content of this indicator at the time of admission to the hospital. In the blood of the patients of the 2nd group, on the 7th day, the lactate content remained unchanged, and by 106.3% it exceeded this biochemical indicator in the blood of the control group. Hyperpyruvatemia was also observed - when entering the hospital in patients of the 2nd group, the content was 55.4% higher compared to healthy people, remained elevated after a week of treatment - by 30.1%, and did not return to normal values. In the patients of the first group, upon admission to the hospital, the pyruvate content in the blood was 53.0% higher compared to the control group, and on the 7th day it significantly decreased by 18.9%, but did not reach the values of the control group (remained at 24, 1% higher compared to the control). The cause of hyperpyruvatemia and hyperlactatemia in patients may also be a violation of their enzymatic transformation into decay products. Lactate is the final product of anaerobic oxidation of glucose, it is formed due to the transformation of pyruvate, under the conditions of action of the lactate dehydrogenase enzyme in conditions of hypoxia. An important indicator of the state of carbohydrate metabolism, namely the balance of anaerobic and aerobic processes in the body, is the lactate / pyruvate ratio, which in the control group was 14.33 [13.82; 14.49]. In the patients of the first group, an increase in this ratio was observed - and it was 18.46 [18.3; 20.59] and 19.81 [18.96; 21,17] upon admission to the intensive care unit and one week after treatment, respectively. Practically the same value of this ratio was observed in patients of the second group - 19.65 [18.97; 22.3] and 22.73 [21.32 23.91], respectively, according to the time of intensive therapy. The latest figures indicate the restructuring of the energy supply of body tissues during the stay of patients in the intensive care unit.
CONCLUSIONS: Thus, in patients with polytrauma and alcohol withdrawal syndrome, complicated by alcoholic delirium, there is an intensification of the processes of anaerobic glycolysis, which is evidenced by an increase in the content of pyruvate, lactate, the lactate/pyruvate ratio, and is accompanied by a hypoxic state. When comparing the terms of stay in the intensive care unit, it was determined that the use of dexmedetomidine for the treatment of alcoholic delirium compared to benzodiazepines allows reducing the time of intensive care by 34 hours. Thus, in group 2, the duration of intensive therapy for alcoholic delirium was 89 [82-96.2] hours, while in group 1 it was reduced to 55 [52.2-59.8] (p=0.020427). In addition, it was found that the consumption of drugs by patients was different. During the first day, it was 20 [20-30] mg in group 1, and 40 [40-50] mg in group 2. The groups also differed significantly in terms of the total dose of the drug during intensive therapy, so in patients of group 1, the total consumption was 30 [30-40] mg, in group 2 - 80 [80-90] mg (p=0.033011).