Полиорганная недостаточность у пациентов с сочетанной травмой груди: диагностика и лечение

Актуальность. Современные методы диагностики и лечения пострадавших с тяжёлой сочетанной травмой, выполнение условий «золотого часа» не решают проблему благоприятного исхода, сепсис и полиорганная недостаточность (ПОН) остаются основной причиной смерти.

Цель исследования: продемонстрировать возможности комплексной диагностики и лечения с использованием комбинированных методов экстракорпоральной гемокоррекции у пациентов с ПОН после тяжёлой сочетанной травмы груди.

Объект и методы. Проанализированы результаты диагностики и лечения 20 пострадавших с сочетанной травмой груди. Критерии включения в исследование были следующие: возраст старше 18 лет; тяжёлая сочетанная закрытая травма груди: AIS > 2 на фоне сочетанных повреждений, ISS 28–34 балла, тяжесть состояния по шкале АPACHE II свыше 20 баллов, применение методов экстракорпоральной гемокоррекции (МЭГ).

Результаты исследования. У пациентов на фоне тяжёлой сочетанной травмой груди показана тяжесть течения полиорганной недостаточности и определена эффективность комбинированных методов экстракорпоральной гемокоррекции (МЭГ), особенности проявлений ПОН и динамика изменений показателей на фоне проводимого комплексного лечения. Основным методом диагностики ПОН являлась клинико-лабораторная картина с учётом коагулогических, биохимических нарушений, биомаркеров воспаления и инструментальная оценка КТ лёгких и УЗДГ картина состояния паренхиматозных органов груди и живота.

Выводы. Комплексный подход к ведению пострадавших с ПОН, включающий раннее проведение МЭГ, способствует снижению интоксикации, стабилизации состояния и увеличивает продолжительность жизни.

1. Wafaisade A, Lefering R, Bouillon B, Sakka SG, Thamm OC, Paffrath T, et al.; Trauma Registry of the German Society for Trauma Surgery. Epidemiology and factors of sepsis after multiple trauma: an analysis of 29, 829 patients from the Trauma Registry of German Society for Trauma Surgery. Crit Care Med. 2011;39(4):621-628. PMID: 21242798 https://doi.org/10.1097/CCM.0b013e318206d3df

2. AlRawahi AN, AlHinai FA, Doig CJ, Ball CG, Dixon E, Xiao Z, et al. The prognostic value of serum procalcitonin measurements in critically injured patients: a systematic review. Crit Care. 2019;23(1):390. PMID: 31796098 https://doi.org/10.1186/s13054-019-2669-1

3. Honore PM, David C, Attou R, Redant S, Gallerani A, De Bels D. Procalcitonin to allow early detection of sepsis and multiple organ failure in severe multiple trauma: beware of some confounders. Crit Care. 2020;24(1):9. PMID: 31910884 https://doi.org/10.1186/s13054-020-2729-6

4. Honoré PM, Jacobs R, De Waele E, Van Gorp V, Spapen HD. Evaluating sepsis during continuous dialysis: are biomarkers still valid? Blood Purif. 2014;38(2):104–105. PMID: 25342547 https://doi.org/10.1159/000363497

5. van Wessem KJP, Leenen LPH. Reduction in mortality rates of postinjury multiple organ dysfunction syndrome: a shifting paradigm? a prospective population-based cohort study. Shock. 2018;49(1):33–38. PMID: 28682941 https://doi.org/10.1097/SHK.0000000000000938

6. Булава Г.В. Патогенетические механизмы органной дисфункции при тяжелой сочетанной травме. Журнал им. Н.В. Склифосовского «Неотложная медицинская помощь». 2023;12(1):92-98. https://doi.org/10.23934/2223-9022-2023-12-1-92-98

7. Lush CW, Kvietys PR. Miccrovascular dysfunction in sepsis. Microcirculation. 2000;7(2):83-101. PMID: 10802851 https://doi.org/10.1038/sj.mn.7300096

8. Mira JC, Brakenridge SC, Moldawer LL, Moore FA. Persistent inflammation, immunosuppression and catabolism syndrome. Crit Care Clin. 2017;33(2):245–258. PMID: 28284293 https://doi.org/10.1016/j.ccc.2016.12.001

9. Saïd-Sadier N, Ojcius DM. Alarmins, inflammasomes and immunity. Biomed J. 2012;35(6):437-449. PMID: 23442356 https://doi.org/10.4103/2319-4170.104408

10. Minutoli L, Puzzolo D, Rinaldi M, Irrera N, Marini H, Arcoraci V, et al. ROS-mediated NLRP3 inflammasome activation in brain, heart, kidney, and testis ischemia/reperfusion injury. Oxid Med Cell Longev. 2016;2016:2183026. PMID: 27127546 https://doi.org/10.1155/2016/2183026

11. McKee CA, Lukens JR. Emerging roles for the immune system in traumatic brain injury. Front Immunol. 2016;7:556. PMID: 27994591 https://doi.org/10.3389/fimmu.2016.00556. eCollection 2016.

12. Han S, Mallampalli RK. The acute respiratory distress syndrome: from mechanism to translation. J Immunol. 2015;194(3):855–860. PMID: 25596299 https://doi.org/10.4049/jimmunol.1402513

13. Relja B, Horstmann JP, Kontradowitz K, Jurida K, Schaible A, Neunaber C, et al. Nlrp1 inflammasome is downregulated in trauma patients. J Mol Med. 2015;93(12):1391–1400. PMID: 26232934 https://doi.org/10.1007/s00109-015-1320-0

14. Helling H, Stephan B, Pindur G. Coagulation and complement system in critically ill patients. Clin Hemorheol Microcirc. 2015;61(2):185–193. PMID: 26410872 https://doi.org/10.3233/CH-151993

15. Shankar-Hari M, Phillips GS, Levy ML, Seymour CW, Liu VX, Deutschman CS, et al. Developing a new definition and assessing new clinical criteria for septic shock: for the third international consensusdefinitions for sepsis and septic shock (sepsis-3). JAMA. 2016;315(8):775–787. PMID: 26903336 https://doi.org/10.1001/jama.2016.0289

16. Takala A, Jousela I, Jansson SE, Olkkola KT, Takkunen O, Orpana A, et al. Markers of systemic inflammation predicting organ failure in communityacquired septic shock. Clin Sci (London). 1999;97(5):529-538. PMID: 10545303 https://doi.org/10.1042/cs0970529

17. Takeda K. Evolution and integration of innate immune recognition systems: The Toll-like receptors. J Endotoxin Res. 2005;11(1):51-55. PMID: 15826379 https://doi.org/10.1179/096805105225006687

18. Howard BM, Kornblith LZ, Christie SA, Conroy AS, Nelson MF, Campion EM, et al. Characterizing the gut microbiome in trauma: significant changes in microbial diversity occur early after severe injury. Trauma Surg Acute Care Open. 2017;2(1):e000108. PMID: 29766103 https://doi.org/10.1136/tsaco-2017-000108 eCollection 2017.

19. Karasu E, Nilsson B, Köhl J, Lambris JD, Huber-Lang M. Targeting Complement Pathways in Polytrauma-and Sepsis-Induced Multiple-Organ Dysfunction. Front Immunol. 2019;10:543. PMID: 30949180 https://doi.org/10.3389/fimmu.2019.00543 eCollection 2019.

20. Knaup H, Stahl K, Schmidt BMW, Idowu TO, Busch M, Wiesner O, et al. Early therapeutic plasma exchange in septic shock: a prospective open-label nonrandomized pilot study focusing on safety, hemodynamics, vascular barrier function, and biologic markers. Crit Care. 2018;22(1):285. PMID: 30373638 https://doi.org/10.1186/s13054-018-2220-9

21. Nguyen T, Carcillo J. Bench-to-bedside review: thrombocytopenia-associated multiple organ failure – a newly appreciated syndrome in the critically ill. Crit Care. 2006;10(6):235. PMID: 17096864 https://doi.org/10.1186/cc5064

22. Cruz DN, Antonelli M, Fumagalli R, Foltran F, Brienza N, Donati A, et al. Early use of polymyxin B hemoperfusion in abdominal septic shock: the EUPHAS randomized controlled trial. JAMA. 2009;301(23): 2445-2452. PMID: 19531784 https://doi.org/10.1001/jama.2009.856

23. David S, Bode C, Putensen C, Welte T, Stahl K. Adjuvant therapeutic plasma exchange in septic shock. Intensive Care Med. 2021;47(3):352-354. PMID: 33471132 https://doi.org/10.1007/s00134-020-06339-1

24. Ярустовский М.Б., Абрамян М.В., Кротенко Н.П., Попов Д.А., Плющ М.Г., Гордеев С.Д. и др. Новая концепция сочетанного применения экстракорпоральных методов гемокоррекции в комплексной интенсивной терапии тяжелого сепсиса у пациентов после кардиохирургических операций. Анестезиология и реаниматология. 2015;(5):75-80.]

25. Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-810. PMID: 26903338 https://doi.org/10.1001/jama.2016.0287

26. Kidney Disease: Improving Global Outcomes (KDIGO). Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int Suppl. 2012;2(1):1–126. Available from: https://kdigo.org/wp-content/uploads/2016/10/KDIGO-2012-AKI-Guideline-English.pdf [Accessed May 26, 2023]

27. Ostermann M, Bellomo R, Burdmann EA, Doi K, Endre ZH, Goldstein SL, et al. Controversies in acute kidney injury: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Conference. Kidney Int. 2020;98(2):294–309. PMID: 32709292 https://doi:10.1016/j.kint.2020.04.020

28. Putzu A, Schorer R, Lopez-Delgado JC, Cassina T, Landoni G. Blood Purification and Mortality in Sepsis and Septic Shock a Systematic Review and Metaanalysis of Randomized Trials. Anesthesiology. 2019;131(3):580-593. PMID: 31246600 https://doi.org/10.1097/ALN.0000000000002820

29. Snow TAC, Littlewood S, Corredor C, Singer M, Arulkumaran N. Effect of Extracorporeal Blood Purification on Mortality in Sepsis: a Meta-Analysis and Trial Sequential Analysis. Blood Purif. 2021;50(4-5):462-472. PMID: 33113533 https://doi.org/10.1159/000510982

30. Chen JY, Chen YY, Pan HC, Hsieh CC, Hsu TW, Huang YT, et al. Accelerated versus watchful waiting strategy of kidney replacement therapy for acute kidney injury: a systematic review and meta-analysis of randomized clinical trials. Clin Kidney J. 2022;15(5):974–984. PMID: 35498901 https:/doi.org/10.1093/ckj/sfac011 eCollection 2022 May.

31. Gaudry S, Hajage D, Martin-Lefevre L, Lebbah S, Louis G, Moschietto S, et al. Comparison of two delayed strategies for renal replacement therapy initiation for severe acute kidney injury (AKIKI 2): a multicentre, open-label, randomised, controlled trial. Lancet. 2021;397(10281):1293-1300. PMID: 33812488 https://doi.org/10.1016/S0140-6736(21)00350-0

32. Zarbock A, Nadim MK, Pickkers P, Gomez H, Bell S, Joannidis M, et al. Sepsis-associated acute kidney injury: consensus report of the 28th Acute Disease Quality Initiative workgroup. Nat Rev Nephrol. 2023;19(6):401-417. PMID: 36823168 https://doi.org/10.1038/s41581-023-00683-3

33. Kishikawa T, Fujieda H, Sakaguchi H. Comprehensive analysis of cytokine adsorption properties of polymethyl methacrylate (PMMA) membrane material. J Artif Organs. 2022;25(4):343-349. PMID: 35301606 https://doi.org/10.1007/s10047-022-01323-6

34. Broman ME, Hansson F, Vincent JL, Bodelsson M. Endotoxin and cytokine reducing properties of the oXiris membrane in patients with septic shock: A randomized crossover double-blind study. PLoS One. 2019;14(8):e0220444. PMID: 31369593 https://doi.org/10.1371/journal.pone.0220444 eCollection 2019.

35. Guan M, Wang H, Tang X, Zhao Y, Wang F, Zhang L, et al. Continuous Renal Replacement Therapy with Adsorbing Filter oXiris in Acute Kidney Injury with Septic Shock: A Retrospective Observational Study. Front Med (Lausanne). 2022;9:789623. PMID: 35463014 https://doi.org/10.3389/fmed.2022.789623 eCollection 2022

36. Ferrari F, Husain-Syed F, Milla P, Lorenzin A, Scudeller L, Sartori M, et al. Clinical Assessment of Continuous Hemodialysis with the Medium Cutoff EMiC®2 Membrane in Patients with Septic Shock. Blood Purif. 2022;51(11):912-922. PMID: 35263746 https://doi.org/10.1159/000522321

37. Lumlertgul N, Hall A, Camporota L, Crichton S, Ostermann M. Clearance of inflammatory cytokines in patients with septic acute kidney injury during renal replacement therapy using the EMiC2 filter (Clic-AKI study). Crit Care. 2021;25(1):39. PMID: 33509215 https://doi.org/10.1186/s13054-021-03476-x

38. Payen DM, Guilhot J, Launey Y, Lukaszewicz AC, Kaaki M, Veber B, et al.; ABDOMIX Group. Early use of polymyxin B hemoperfusion in patients with septic shock due to peritonitis: a multicenter randomized control trial. Intensive Care Med. 2015;41(6):975-984. PMID: 25862039 https://doi.org/10.1007/s00134-015-3751-z

39. Dellinger RP, Bagshaw SM, Antonelli M, Foster DM, Klein DJ, Marshall JC, et al.; EUPHRATES Trial Investigators. Effect of Targeted Polymyxin B Hemoperfusion on 28-Day Mortality in Patients with Septic Shock and Elevated Endotoxin Level: The EUPHRATES Randomized Clinical Trial. JAMA. 2018;320(14):1455-1463. PMID: 30304428 https://doi.org/10.1001/jama.2018.14618

40. Klein DJ, Foster D, Schorr CA, Kazempour K, Walker PM, Dellinger RP. The EUPHRATES trial (Evaluating the Use of Polymyxin B Hemoperfusion in a Randomized controlled trial of Adults Treated for Endotoxemia and Septic shock): study protocol for a randomized controlled trial. Trials. 2014;15:218. PMID: 24916483 https://doi.org/10.1186/1745-6215-15-218