Indications and possibility of using membrane plasmapheresis in emergency medical careWith a wide range of natural and man-made or transportation disasters it is possible serious injury with "crush" syndrome and burns when developing heavy endotoxemia. It occurs due to the accumulation in ischemic tissues not oxidized metabolic products, mainly lactic and pyruvic acids. There is developed necrosis of muscle fibers. With burns there are also occur extensive tissue necrosis, destruction of red blood cells (hemolysis) within the vessels adjacent to the burned area, with the release of free hemoglobin.
When blood flow restored in the vascular system is beginning to enter these toxic products. At the same time as free hemoglobin and myoglobin, released from the breakdown of muscle fibers, in the allocation of kidneys at acidic urine are precipitated in the form of hydrochloric acid hematin or myoglobin, completely blocking the renal tubules, which are not able to unlock even hemodialysis.
The same situation can occur with mass poisonings arising from major transport accidents with damage to tanks carrying toxic compounds. Not exclude the appearance of mass poisoning by toxic products, merging into the system intakes from wastewater chemical companies that do not provide them proper treatment.
Can not be excluded in the near future and mass epidemics "bird" or even any kind of flu with the development of severe respiratory distress syndrome, in which plasmapheresis treatment also showed a sufficiently high efficiency.
When developing endointoxication it is released a number of toxic by-products of inflammation and tissue decay, medium weight oligopeptides, histamine, serotonin, lysosomal enzymes, lipid peroxidation products, cytokines and other biologically active substances. As a result of their exposure there is disturbed vascular permeability with the development of toxic pulmonary edema (adult respiratory distress syndrome) with not correctable parenchymal respiratory failure.
There occur also lesions of other vital organs with the development of multiple organ failure. In this case, renal failure contributes to an even greater accumulation of toxic by-products, hepatic failure reduces the detoxification function of the liver, toxic cardio-myopathy worsens disorders of both central and peripheral blood circulation with tissue hypoxia, respiratory failure and for greater hypoxia and toxic encephalopathy also contributes to the defeat of the lung parenchyma.
Thus there are a number of vicious circles and mutually aggravated lesions that neither the body nor any medications, break no longer able to.
Only the timely removal of such products from the bloodstream can prevent irreversible renal damage. In this case, the life of these patients directly depends on the time of providing such specialized care. It is best to conduct such procedures almost immediately after removing people from the rubble. And the best way possible during membrane plasmapheresis using plasma filters "Rosa" on a portable device "Hemofenix" of the Russian company "Trackpore Technology."
In these cases, the membrane plasmapheresis can be carried out even on the background is not completely stopped bleeding (bleeding apart from major vessels) using as anticoagulant sodium citrate solution. Given the small volume filling the extracorporeal circuit (65 ml) may provide assistance also extremely serious patients, even against the background of unstable hemodynamics, when the blood pressure is only supported by the sympathomimetics. There is no alternative to this method of plasmapheresis in the provision of care for children, including infants [Voinov V.A., 2010].
In such cases, it almost is not just about plasmapheresis, but the plasma exchange when removed plasma with all the toxic products is replaced with fresh frozen plasma donation in the amount of 0.5-1.0 of circulating plasma volume.
If you encounter such situations in remote and inaccessible areas, in the absence of any possibility of immediate transportation of such patients in stationary medical institutions on the one hand, and in the presence of emergency indications membrane plasmapheresis can be made directly in an ambulance to be equipped with a special generator. There is the only way to ensure basic sanitation necessary to perform such an invasive procedure such as membrane plasmapheresis.
Some experience gained aero-mobile hospital of the Ministry of Emergency Situations of Russia, which is applied the membrane plasmapheresis directly to locations of earthquakes and other disasters in patients with "crash" syndrome immediately after being removed from the rubble [Popov A.S. et al., 2007, 2011]. The results of this work are summarized in Table. 1.
The results of treatment of patients with the crash syndrome
|Indicators||Without plasmapheresis||With plasmapheresis|
|Number of victims||23||100||38||100|
|Number of operated||21||91,3||24||63,1|
|Number of amputations||18||78,3||9||23,7|
|Acute renal failure||15||65,2||0||0|
|Fatalitieson the stagesof evacuation||19||82,6||1||2,8|
As can be seen from the table, using plasmapheresis rate of amputations was more than 3 times less completely absent signs of acute renal failure, and more than 30 times less than the patients died on the stages of evacuation (2.6% vs. 82.6%).
Any real alternative to the use of the above plasma filters "Rosa" and the "Hemofenix" apparatus of not only foreign but also this Russian devices not, because they are either too expensive or do not allow use at the right at the crash places.