Diagnosis and treatment of patients with recurrent gastroduodenal hemorrhage - Shaprynskyi V.O. 2009

General principles of management of recurrent gastroduodenal bleeding
Infusion and transfusion therapy, characteristics of the main preparations

Hemorrhagic Shock is caused by significant Blood loss over a short period of time. The Clinical presentation largely depends on the volume of blood lost, The rate of bleeding, and the body's ability to employ compensatory mechanisms.

Currently, several blood replacement regimens are used to manage blood loss of varying severity. For this purpose, transfusion-infusion therapy is employed, which is a method of correcting homeostatic disturbances and managing bodily Functions by targeted influence on the properties, composition, and volume of circulating blood.

The MAIN OBJECTIVES OF infusion-Transfusion Therapy:

✵ elimination of intravascular and extravascular fluid deficits; stabilization of micro- and macrohemodynamics, improvement of blood rheological properties and its gas transport functions;

✵ reduction of the body's catabolic response, restoration of Energy Expenditure, and support of plastic processes.

Among modern approaches to infusion-transfusion therapy in acute blood loss, two main strategies are distinguished:

1. Pre-transfusion administration of crystalloid solutions in a volume exceeding the blood loss, aimed at short-term maintenance of systemic hemodynamics (the American doctrine).

2. Infusion of colloid solutions prior to blood transfusion, which have a longer duration of action (the European doctrine).

Infusion-transfusion therapy (ITT) is an essential and critical component of the management of hemorrhagic shock. Mortality in acute Hemorrhage is highest within the first few hours; therefore, initial fluid resuscitation must be highly effective. Based on the fundamental pathophysiological mechanisms of hemorrhagic shock, the clinician's primary goal is to maintain tissue oxygen consumption to support cellular METABOLISM. The first challenges a physician encounters in managing acute blood loss are hypovolemia and low Cardiac Output, followed by anemia. The choice of infusion-transfusion media for the initial management of hemorrhagic shock is based on its ability to increase cardiac output. Colloid solutions have proven more effective at enhancing blood flow, whereas red blood Cell transfusion has shown less success in this regard. It has been established that tissue oxygen consumption increases following an increase in cardiac output, but does not rise when hematocrit increases As a result of blood transfusion. This is because blood transfusion can reduce cardiac output, thereby neutralizing the beneficial effect of increased blood Hemoglobin levels. Therefore, blood transfusion for the correction of anemia does not guarantee improved tissue oxygenation, and blood hemoglobin levels may be an inaccurate criterion for initiating blood transfusion.

Hemodynamic plasma expanders are primarily used to treat shock and hypovolemia resulting from massive hemorrhage. Plasma expanders in this group restore circulating fluid volume, normalize blood pressure, increase blood colloid osmotic pressure, and significantly improve baseline circulatory parameters. They are also effectively used for hemodilution and normalization of microcirculation.

An ideal hemodynamic (anti-shock) plasma expander should: rapidly restore lost circulating blood volume; restore hemodynamic balance; have a sufficiently long intravascular retention time; improve the rheology of circulating blood; enhance the delivery of oxygen and other components; be easily metabolized, not accumulate in Tissues, be easily excreted, and be well tolerated.

Currently, natural and artificial colloids (gelatinol, dextrans, and hydroxyethyl starches), as well as crystalloids, are used as anti-shock agents.

Class="center">Colloid solutions

The severity of hemorrhagic shock depends on the reduction in left ventricular filling (low PCWP - pulmonary capillary wedge pressure), which leads to a decrease in CO (cardiac output), in turn causing vasoconstriction and an increase in SVR (systemic vascular resistance).

In general, when performing infusion-transfusion therapy for acute blood loss, the physician should adhere to the following principles:

1. All solutions must be infused warm (around 37°C);

2. Initiate infusion-transfusion therapy in acute hemorrhage with the administration of saline solutions at a rate of up to 100 mL/min until blood pressure rises and stabilizes at a level of at least 60-80 mmHg. Preference is given to balanced crystalloid solutions, which can replenish electrolyte deficits and compensate for metabolic acidosis.

3. In the absence of hemodynamic stabilization, another vein (preferably central) should be cannulated to establish a second venous access, and the infusion of colloid plasma expanders and FFP should be initiated;

4. When using colloid plasma expanders, the following should be considered:

- they must not affect hemostasis or blood typing results;

- they must have concentrations that are iso-osmotic to Blood Plasma;

- they should constitute no more than 50% of the total volume of plasma expanders administered to the patient;

- the viscosity of the plasma expander must be sufficiently low to avoid placing an additional workload on The Heart;

(Polyoxydin, gelofusine, infukol HES 6% and 10%).

5. Until the central venous pressure reaches 8-12 cm H2O and the hourly urine output exceeds 30 ml, the patient requires infusion therapy at a sufficiently high infusion rate (up to 100 ml/min); once these parameters are achieved, the infusion rate is reduced (to 20-40 ml/min); the criteria for adequate fluid resuscitation are the normalization of central venous pressure and hourly urine output;

6. Indications for packed red blood cell transfusion include a confirmed deficit of oxygen carriers, provided there is adequate oxygen delivery. A safe level of hemodilution is a hematocrit of 0.30 l/l and hemoglobin of 65-70 g/l. The borderline acceptable hematocrit level is below 0.25-0.28 l/l (blood loss exceeding 30-40% of the CBV), at which point the physician should consider the possible, though not mandatory, use of red blood cell products. Unjustified administration of packed red Blood Cells can, in some cases, lead to clinical deterioration and even death. For instance, in the Development of Respiratory distress syndrome, where erythrocyte stasis occurs in the alveolar capillaries of the Lungs, donor red blood cell transfusion will only promote the progression of pathochemical and pathophysiological Changes in the patient's body;

7. The volume ratio of FFP and albumin to packed red blood cells in acute blood loss should be 3:1;

8. Transfusion of FFP and albumin should be performed before administering red blood cells at a dose of 15-20 ml/kg of body weight. It is the transfusion of FFP that allows for the rapid and effective replenishment of plasma coagulation factors consumed and depleted from the Circulation, restoring the rheological properties of blood and the balance of fibrinolytic factors. Transfusion of donor red blood cells before the dissolution of disseminated microthrombi only further slows blood flow and deepens erythrocyte stasis in the circulation. A "vicious cycle" arises, where red blood cell transfusion triggers a new wave of bleeding, which can ultimately prove fatal for the patient;

9. Situations often arise where a single transfusion of FFP, even in an adequate volume (up to 1-2 l), may not be sufficient. This occurs primarily because the transfused coagulation factors are rapidly consumed, and bleeding may recur. In such cases, repeated FFP transfusions become necessary, with volumes guided by the dynamics of coagulation profile parameters and the stability of hemostasis;

10. If the patient had a pre-existing deficit of circulating red blood cells, plasma, platelets, or plasma coagulation factors prior to The Development of massive blood loss, their replenishment must begin concurrently with the infusion of saline solutions, while monitoring the degree of hemodilution;

11. The intensity of transfusion therapy can be reduced by ensuring adequate oxygen delivery and maintaining systolic blood pressure above 90 mmHg, provided that the circulating blood volume is compensated, hypothermia is absent, and active bleeding has ceased;

12. When transfusing packed red blood cells or FFP at a rate exceeding 1 unit (200-300 ml) per 5 min, the administration of 5-10 ml of 10% calcium chloride solution is indicated for every 2 units of packed red blood cells or FFP to prevent citrate toxicity and hypocalcemia;

13. For transfusion, packed red blood cells with a short shelf life (up to 3-5 days) are preferred. Prior to transfusion, a crystalloid solution, such as 0.9% sodium chloride, should be introduced into the container with packed red blood cells in an amount equal to the volume of the red cells to improve the rheological Properties of the blood component;

14. A key feature of managing acute blood loss is the time factor, making the correction of critical hypovolemia a measure of "utmost urgency." Replenishment of the lost fluid volume must begin as quickly as possible. The rate of volume restoration must exceed the rate of bleeding. If the initiation of infusion therapy is delayed, the required volume of solutions and their composition change. With a delay of more than 60 minutes, the infusion volume increases by 15-20% for each hour of delay;

15. When performing ITT, the risk of developing acute Heart Failure and pulmonary edema due to overload of the Pulmonary Circulation must be considered. For this reason, plasma expanders with a high volume expansion effect must be used with extreme caution.

Standard ITT protocols for acute blood loss

1. Blood loss up to 10% of CBV rarely requires infusion therapy, provided the patient's physiological state prior to blood loss was normal and there are no concomitant complicating disorders;

2. Blood loss up to 20% of CBV - the total volume of infusion media is 130% of the volume of blood loss (30 ml/kg). Crystalloid and colloid plasma expanders are infused in equal proportions (10-15 ml/kg);

3. Blood loss up to 30% of CBV - the total volume of infusion-transfusion media is approximately 150% of the volume of blood loss (up to 40 ml/kg). The Use of the following media is indicated:

- crystalloid and colloid plasma expanders - 60-70% of the ITT volume;

- albumin 5% - 10-20% of the ITT volume;

- packed red blood cells - 10-20% of the ITT volume (10 ml/kg).

4. Blood loss up to 40% of CBV - the total volume of infusion-transfusion media is approximately 160% of the volume of blood loss (50 ml/kg).

The use of the following media is indicated:

- crystalloid and colloid plasma expanders - 40-50% of the ITT volume;

- albumin 5% - 20% of the ITT volume;

- fresh frozen plasma - 20-30% of the ITT volume;

- packed red blood cells - 20% of the ITT volume.

5. Blood loss greater than 40% of CBV - the total volume of infusion-transfusion media is 180% of the volume of blood loss (> 60 ml/kg).

The use of the following fluids is indicated:

- crystalloid and colloid blood substitutes - 30-40% of the ITT volume (15-20 ml/kg);

- fresh frozen plasma - 30-40% of the ITT volume (1520 ml/kg);

- albumin 5% - 20% of the ITT volume (5-10 ml/kg);

- packed red blood cells - 20% of the ITT volume (20 mg/kg).

Thus, timely and rational infusion-transfusion therapy for acute blood loss, combined with other interventions (reliable surgical hemostasis, pain relief), significantly improves Treatment outcomes in patients with blood loss and helps avoid severe, life-threatening bodily dysfunctions.

Transfusion scheme for blood loss replacement (after P.G. Bryusov, 1998)

I. Artificial colloids

I. Hydroxyethyl starch solutions. HES solutions have been in use since the early 1960s. In 1963, W.L. Thompson and R.F. Walton proposed HES as an alternative to albumin. HES is widely used in the treatment of patients with hemorrhagic, traumatic, septic, and burn shocks, as well as in emergency situations involving CBV deficit, decreased cardiac output, and impaired Oxygen transport.

The most widely used are HES solutions with a Molecular Weight of 200,000 Da and a degree of substitution of 0.5 (half-life of less than 10 hours), which, due to shorter circulation time in the vascular bed, have a less pronounced effect on the hemostasis system.

Classification of hydroxyethyl starches

The use of HES preparations ensures the restoration of impaired hemodynamics, increases cardiac efficiency, and improves tissue oxygen delivery and consumption.

Their administration for the Prevention and treatment of shock prevents the development of multiple organ failure and significantly improves treatment outcomes in surgical interventions and various critical conditions.

HES prevents the development of capillary leak syndrome and reduces the level of circulating adhesion molecules.

Refortan is a 6% hydroxyethyl starch solution with a molecular weight of 200,000 Da and a substitution degree of 0.5 (200/0.5) in isotonic sodium chloride solution. Osmolarity is 300 mOsm/l, COP is 28 mmHg, pH is 4.0-7.0. It contains sodium ions (154 mmol/l) and chloride ions (154 mmol/l). The volemic effect is 100%, with a duration of 3-4 hours.

The daily dose and rate of intravenous infusion of Refortan depend on the volume of blood loss and the hematocrit value. The average daily dose is 20 ml/kg of body weight. The infusion rate is 500 ml of the drug over at least 30 minutes. During the first 20-30 minutes, the drug should be administered slowly while closely monitoring the patient, given that anaphylactoid reactions cannot be completely ruled out.

Refortan Plus is a 10% hydroxyethyl starch solution (200/0.5) in isotonic sodium chloride solution. Osmolarity is 300 mOsm/l, COP is 65 mmHg, pH is 4.0-7.0. It contains sodium ions (154 mmol/l) and chloride ions (154 mmol/l). The volemic effect is 130-140%, with a duration of 5-6 hours.

The daily dose and rate of intravenous administration depend on the volume of blood loss and the hematocrit value. The average daily dose for volume replacement is usually 250-1000 ml, and the maximum daily dose is 20 ml/kg of body weight.

Stabizol is a 6% hydroxyethyl starch solution with a molecular weight of 450,000 Da and a substitution degree of 0.7 (450/0.7) in isotonic sodium chloride solution. Osmolarity is 300 mOsm/l, COP is 18 mmHg, pH is 4.0-7.0. It contains sodium ions (154 mmol/l) and chloride ions (154 mmol/l). The volemic effect is 100%; however, HES of this group remains in the vascular bed longer than pentastarches.

A biological test is mandatory before transfusion. Stabizol is administered by intravenous drip. The daily dose and rate of intravenous administration depend on the volume of blood loss or the hematocrit value. The duration and volume of treatment are determined based on the duration and severity of hypovolemia.

The average daily dose is 500-1000 ml, the maximum daily dose is 20 ml/kg, and the infusion rate is 500 ml of the drug over at least 30 minutes.

During the intraoperative period in elective and especially in emergency surgeries, their administration promotes the rapid restoration and maintenance of hemodynamic parameters at a stable level, prevents complications, improves the postoperative course, and prevents the development of multiple organ dysfunction syndrome.

Thus, these data indicate that HES preparations are currently finding increasingly widespread use in clinical practice due to their ability to:

✵ rapidly replace circulating blood volume deficit;

✵ restore hemodynamic equilibrium;

✵ circulate in the vascular bed for a prolonged period;

✵ improve the rheological properties of blood;

✵ improve oxygen delivery to Organs and tissues;

✵ be easily metabolized;

✵ not accumulate in tissues;

✵ not affect The Immune System.

2. Dextran solutions

For a long time, they were considered the primary plasma expanders in hypovolemic states. Dextran is a polysaccharide composed of glucose residues, obtained from cultures of producing Bacteria. The primary increase in plasma volume is achieved due to the high Water-binding capacity of dextrans—approximately 20-25 ml/g.

In clinical practice, dextrans with a medium molecular weight of 60,000-70,000 D and a low molecular weight of 40,000 D are used. The former primarily normalize macrocirculation, while the latter affect microcirculation.

Polyglucin is a 6% dextran solution with a medium molecular weight of 50,000-70,000 D in isotonic sodium chloride solution. Polyglucin has a pronounced hemodynamic effect. Its higher molecular weight and high COP ensure its retention in the vessels and an increase in CBV. The dosage and rate of administration depend on the patient's condition, averaging 400-1200 ml for adults.

Rheopolyglucin is a 10% colloidal dextran solution with a molecular weight of 30,000-40,000 D in isotonic sodium chloride solution. The drug has a pronounced volume-expanding effect. Its water-binding capacity exceeds the physiological binding capacity of blood Proteins, leading to the shift of fluid from the interstitial space into the vascular bed (1 g of rheopolyglucin binds 20-25 ml of water). The increase in plasma volume is particularly pronounced in the first 90 minutes after administration. After 6 hours, its blood concentration decreases by approximately half, and about 80% is excreted in the urine by the end of the day.

Dextrans improve oxidative processes, resulting in increased oxygen uptake by peripheral tissues. Significant deposition in the Cells of the reticuloendothelial system or negative effects of dextrans on the immune system have not been established.

However, dextrans rank first among synthetic colloids in terms of their negative effect on the Blood Coagulation SYSTEM, and this effect is directly proportional to the molecular weight and dose of the administered dextran. It reduces The activity of factors II, V, and VIII.

In cases of limited diuresis, the rapid renal excretion of low-molecular-weight dextrans causes a significant increase in urine viscosity, resulting in a sharp drop in Glomerular Filtration, up to anuria. Rheopolyglucin contains more low-molecular-weight dextran fractions. Therefore, in grade III and IV shock, patients are stabilized from their critical condition using polyglucin or other plasma expanders with a similar effect, and rheopolyglucin is prescribed only after the systolic pressure rises above 80-90 mmHg.

Dextrans are highly effective anti-shock infusion media; however, they have A number of side effects, the most severe of which are a high probability of allergic reactions and a pronounced effect on the blood coagulation system.

3. Gelatin solutions

Gelatinol is a polypeptide, an 8% solution of partially hydrolyzed gelatin, usually obtained from bovine Collagen. The average molecular weight is about 35,000 daltons. A significant portion of the drug's Structure is represented by a low-molecular-weight fraction, which is poorly retained in the vascular compartment. It contains a number of Amino Acids: Glycine, Proline, Methionine, etc. Gelatinol is non-toxic and pyrogen-free. The total infusion dose is up to 2 L. The majority of the gelatin is excreted by the Kidneys, with a small portion excreted through the intestines. The duration of its volume-expanding effect is 1-2 hours. During this time, there is no significant effect on either the cells of the reticuloendothelial system or the overall level of Immunity, but on the 2nd-3rd day after the administration of the gelatin solution, a decrease in plasma Fibronectin concentration (serum opsonin) is recorded. Gelatin solutions are known to delay thrombus formation and inhibit platelet aggregation. The administration of gelatin leads to increased diuresis, but even with repeated infusions, it does not impair renal function.

A poor plasma-expanding effect combined with relatively frequent anaphylactic reactions reduces the appeal of this drug for anti-shock therapy. Its use also carries a risk of hemorrhagic complications. Gelatinol is not an ideal plasma expander and should not be chosen for anti-shock therapy.

Gelofusine is a succinylated gelatin preparation (modified liquid gelatin), a colloidal plasma-expanding solution. In cases of massive blood loss, if necessary, up to 10-15 liters of the drug can be infused per day. For patients with coagulation disorders, renal impairment, or chronic Liver diseases, it is recommended to adjust the dose According to the specific clinical situation, taking laboratory parameters into account. Patients receiving Gelofusine must be monitored due to the potential for allergic reactions.

II. Natural colloids.

Among blood products, albumin, protein, and cryoprecipitate are most commonly used in medical practice. The Physiological Role of albumin is determined by two mechanisms: ensuring the required volume of circulating fluid by maintaining intravascular colloid osmotic pressure (COP) through the attraction and retention of tissue fluid in the vascular bed; and providing transport for nutrients, BIOLOGICALLY ACTIVE SUBSTANCES, Enzymes, metabolic products, Trace Elements, and drugs.

Albumin is a human plasma protein that maintains osmotic pressure in the circulating blood and serves as a source of Nutrition for tissues and organs. The drug is available as 5%, 10%, and 20% solutions. A 5% albumin solution is isooncotic to normal plasma, meaning it has an equal oncotic pressure. The administration of this drug reduces the viscosity of circulating blood, which consequently improves microcirculation. A 10% albumin solution is a mildly hyperoncotic protein solution that Supports blood oncotic pressure. When used, fluid is drawn from the interstitial space and retained within the vascular bed, which increases and stabilizes blood pressure. A 20% albumin solution is a hyperoncotic injection solution. Since albumin has high oncotic activity, the administration of 1 gram of the drug binds 18 ml of water. Upon administration of 100 ml of 20% albumin, the plasma volume increases by 360 ml within 30-60 min. This occurs because 260 ml of interstitial fluid is bound by albumin, and 100 ml is the infused volume. If there is an extravascular fluid deficit, administering albumin without prior crystalloid infusion will lead to even greater extracellular dehydration. It should be noted that shock-induced changes in capillary permeability lead to an accelerated and increased transcapillary escape of albumin, reducing its ability to maintain plasma volume, and resulting in an increased albumin content in the interstitial space, along with an increase in interstitial fluid volume. This is associated with the detrimental effect of albumin on pulmonary function in patients (development of interstitial edema, increased stiffness, and decreased diffusing capacity).

Albumin solutions can, at least theoretically, act as an ideal oncotically active agent, since albumin is a natural colloid that, at physiological concentration, maintains up to 60-80% of the colloid osmotic pressure.

Albumin possesses anticoagulant properties due to the inhibition of platelet aggregation and Hageman factor by antithrombin III, as well as free radical scavenging properties. Despite these unique properties, the use of albumin in clinical practice for patients with hemorrhagic shock remains rather problematic.

The efficacy of plasma volume expansion with albumin is determined by its dynamic redistribution between the intravascular and extravascular albumin pools. Due to rapid exchange with the extravascular pool (more than 50% of albumin is located outside the vascular bed), the increase in plasma volume achieved by a 5% albumin solution is very minor, and its intravascular circulation time is approximately 1.5-4 hours.

Impaired renal salt excretion caused by albumin infusion has an extremely negative impact on cardiovascular function, reducing left ventricular contractility.

Highly concentrated human albumin solutions are relatively frequently used in cases of a severe drop in total plasma protein or albumin levels, as well as in patients with low colloid osmotic pressure.

Plasma. Plasma maintains intravascular volume for only 1.5-2 hours after transfusion, which is significantly shorter than other plasma expanders. The vasoactive substances it contains affect vascular tone and capillary permeability in recipients. Moreover, plasma infusion can increase the likelihood of developing multiple organ failure due to the activation of cascade systems by increasing The amount of endogenous Complement. Obviously, for these reasons, plasma cannot be considered an optimal colloid in the shock therapy regimen for patients with hypovolemic shock.

It should be remembered that plasma does not correct Protein deficiency. The main indications for its use are DIC syndrome and coagulopathy, as well as blood loss of 30-40% of the circulating blood volume.

Fresh frozen plasma is a transfusion component prepared from whole blood or plasma collected by plasmapheresis, frozen within a timeframe and to a Temperature that can adequately maintain labile coagulation factors in a functional state.

III. Crystalloid solutions.

Crystalloid solutions, as agents for restoring circulating fluid volume, are widely used in daily practice (isotonic sodium chloride solution, Ringer's solutions, Trisol, "Disol", etc.). Their advantages include low cost, availability, and the absence of allergic reactions. Shock therapy using these solutions helps restore cardiac output. However, due to their rapid shift from the bloodstream into tissues (within just a few minutes, they are evenly distributed between the vascular bed and the interstitial space), it is impossible to maintain CBV and adequate hemodynamics for a long time after the infusion ends. To maintain adequate intravascular volume, 1 L of crystalloids must be infused for every 0.15-0.20 L of blood loss. In other words, to compensate for the CBV deficit and achieve normovolemia, the volume of crystalloids infused must be 4-5 times the volume of blood loss. Since 75-80% of the infused volume enters the extravascular compartment, it is obvious that shock therapy with crystalloids always leads to tissue edema. The "excess" fluid primarily accumulates in tissues such as Skin and Connective Tissue. However, some portion can accumulate in the lungs, increasing their extravascular water content and raising the likelihood of interstitial pulmonary edema. Thus, shock therapy with crystalloids carries an increased risk of pulmonary dysfunction.

Generalized edema associated with crystalloid shock therapy (due to excessive infusion) can impair blood flow by compressing capillaries, thereby disrupting the delivery of oxygen and nutrients to various tissues. This is accompanied by prolonged respiratory support requirements, impaired wound healing, body weight gain, and a longer stay in the intensive care unit. Furthermore, the administration of large volumes of crystalloids can lead to hyperchloremic acidosis and increased potassium excretion from the body.

Therefore, the anti-shock effect of crystalloids is very low. It is advisable to use crystalloids only as an adjunct to colloid solutions in a 1:1 ratio, as well as to replenish the interstitial fluid deficit that occurs when fluid shifts into the bloodstream during blood loss and colloid administration.

Hypertonic sodium chloride solutions.

The use of hypertonic sodium chloride solutions assumes that a high osmotic gradient ensures rapid mobilization of fluid from the interstitial space, red blood cells, and endothelium. Thus, the circulating volume quickly compensates for the CBV deficit, increasing blood pressure and cardiac output, improving tissue perfusion, and stabilizing central hemodynamics. Literature sources provide data on the transfusion of 7.5-10% sodium chloride solutions. Given the high probability of hemolysis, a 2.5% sodium chloride solution is recommended for use. The transfusion volume is small (on average 5-8 ml/kg of body weight or 12 ml/kg/day). They are cheap, readily available, and do not cause allergic reactions. However, their duration of action is short (1-2 hours). Combining hypertonic saline with colloids allows for a significantly prolonged effect.

IV. Blood components and preparations

Packed red blood cells (PRBCs) are one of the main blood components obtained from whole preserved blood by centrifugation and subsequent Separation of plasma, leukocytes, and platelets.

The following types of PRBCs are used in clinical practice:

✵ packed red blood cells (hematocrit 0.65-0.8 l/l);

✵ red blood cell suspension;

✵ leukocyte- and platelet-depleted packed red blood cells (washed red blood cells);

✵ thawed and washed packed red blood cells.

Plasma is a transfusion medium representing the liquid portion of blood, which transports nutrients and vital substances to tissues and organs, participates in protective (immune) reactions and coagulation, and assists in The excretion of Metabolic waste products.

Fresh frozen plasma (FFP). Its high therapeutic efficacy is due to the preservation of all protein coagulation factors, including labile ones (fibrinogen, blood coagulation factors II, V, VII, VIII, IX, XI, XIII, and von Willebrand factor), for up to 12 months of storage at -30°C.

Immediately before transfusion, FFP is thawed at t° = +37-38°C. After thawing, the plasma may be stored for no more than 1 hour at t° = +1-6°C before transfusion begins.

The dosage of FFP depends on the clinical situation and the course of the disease, ranging from 250-300 ml to 1000 ml.

Indications for plasma transfusion

✵ DIC syndrome

✵ Correction of circulating blood volume in massive blood loss, external and internal bleeding

Antihemophilic plasma is plasma frozen no later than 2 hours after donor blood collection. It contains clotting factor VIII (antihemophilic globulin) in higher concentrations than FFP frozen at a later stage. In clinical practice, it can be replaced by cryoprecipitate.

With a significant arsenal of plasma expanders and blood components, it is essential to follow a clear program for blood loss compensation. The main theoretical principles of component therapy for blood loss are based on the circulating blood volume (CBV) deficit. According to current principles, with blood loss of up to 10% of CBV, complete volume replacement is achieved using crystalloids, the amount of which is calculated at a 3:1 ratio to the estimated blood loss. If administering large volumes of fluid is undesirable, the volume deficit can be replenished with an isovolemic HES solution—Refortan 500 ml—or a combination of hypertonic saline (2.5% sodium chloride at 4-6 ml/kg) with isotonic crystalloid solutions, the volume of which should exceed the blood loss by 1.5-2 times.

With a CBV deficit of up to 20%, blood loss is replaced by a combination of colloids and crystalloids in a 1:1 ratio, or a combination of colloids, hypertonic crystalloids, and isotonic crystalloid solutions.

With a CBV deficit of 20% to 40%, the administration of fresh frozen plasma and packed red blood cells is indicated, along with the use of hypertonic saline solutions (5 ml/kg of body weight) combined with colloid and crystalloid solutions.

With a CBV deficit of over 40%, the total volume of infusion therapy should exceed the amount of blood lost by 2-2.5 times. In this case, it is recommended to maintain the following ratio of fluids: 35-40% blood, 30% colloids, and 30% crystalloids.

To maintain blood pressure at an adequate level, the vasopressor dopamine is used. Dopamine indirectly activates α- and β-adrenoceptors. The effects of their stimulation depend on the dose range: 1-3 mcg/kg/min—renal vasodilation and stimulation of renal function, causing dilation of cerebral, coronary, and visceral vessels (liver, Pancreas, and gastrointestinal tract); at a dose of 3-7.5 mcg/kg/min, it increases cardiac output; at a dose of > 10 mcg/kg/min, an α- and β-adrenostimulatory effect is observed, leading to vasoconstriction and centralization of circulation. Dosage depends on the level of ARTERIAL BLOOD PRESSURE.