Sources of obtaining whole human blood and its components are not limitless and now can no longer ensure the needs of surgery, especially if you consider the increasing number of operational interventions using artificial blood circulation devices, artificial kidney and others that require large amounts of blood. Obtaining and use of body blood, dutile blood preparations also did not solve this problem completely. Achievements of chemistry, enzymology allow to obtain heterobellated, polysaccharide and synthetic preparations from affordable raw materials.
The bloodstream solutions must meet the following requirements:
be similar physico-chemical properties with plasma blood;fully excreted from the body or metabolized by enzyme systems;
do not cause the body sensitization during repeated administrations;
do not toxic action on organs and fabrics;
withstand sterilization by autoclaving, during long time Keep your physico-chemical and biological properties.
The blood-absorbing solutions are made to divide on colloidal solutions-dextre (polyglyukin, refooliglucin), gelatin preparations (gelatinol), polyvinylpyrrolidone solutions (hemodez); Solutions - isotonic solution sodium chloride, Ringer's solution - Locke, lactosol; buffer solutions - sodium bicarbonate solution, trisamine solution; Sugar solutions and polyhydric alcohols (glucose, sorbitol, fructose); protein preparations (protein hydrolyzates, amino acid solutions); Fat preparations - fat emulsions (lipofundine, intralipide).
Depending on the direction of action, the bloodstream solutions are classified as follows.
Classification of bloodstream solutions:
1. Hemodynamic (anti-shock):low molecular weight dextrans - REOPOLIGLUKIN;
Medium molecular decadnes - polyglyukin;
Gelatin preparations - gelatin.
2. Disinfection:
low molecular weight polyvinylpyrrolidone - hemodhet;
Low molecular weight polyvinyl alcohol - grades.
3. Preparations for parliamentary power:
protein hydrolyzates - casein hydrolyzate, aminoptide, amino-robin, amino (M1, hydrolysin);
Amino acid solutions - polyamine, marijamine, froamine;
Fat emulsions - intralipide, lipofundine;
Sugar and polyhydric alcohols - glucose, sorbitol, fructose.
4. Regulators of the water-salt and acid-base state: saline solutions - isotonic sodium chloride solution, ringer solution, lactosphere, sodium hydrocarbonate solution, trisamine solution.
Anti-deposit blood substitutes:
High molecular weighting blood substitutes are mainly hemodylutants, contribute to the increase in the BCC and thereby restoring blood pressure levels.They are able to circulate to circulate in the bloodstream and attract an intercellular fluid into the vessels.
These properties are used in shock, blood loss. Low molecular weight heroes improve the capillary perfusion, are less circulated in the blood, the kidneys are highlighted faster, carrying out the excess fluid. These properties are used in the treatment of disorders of capillary perfusion, for the dehydration of the body and the control of intoxication due to the removal of toxins through the kidneys.
Polyglyukin - the colloidal solution of polymer glucose dextran bacterial origin containing the medium molecular weight of 60,000 ± 10,000) dextran fraction, the molecular weight of which is approaching such albumin, providing a normal colloid-osmotic pressure of human blood.
The drug is a 6% dextran solution in a sodium chloride isotonic solution; PH of the drug 4.5-6.5. They are produced in sterile form in bottles of 400 ml.
Store at temperatures from -10 to +20 ° C. Shelf life is 5 years. Perhaps freezing of the drug, after thawing medical properties Restore.
The mechanism of therapeutic action of polyglyukin is due to the ability to increase it and support the BCC due to attracting fluid into the vascular bed from the interstitial spaces and hold it due to its colloidal properties. With the introduction of polyglyukin, the volume of blood plasma increases by a large amount than the volume of the administered drug. The drug circulates in the vascular bed of 3-4 days; The half-life of it is 1 day.
In hemodynamic action, polyglyukin exceeds all the well-known blood substitutes, due to its colloid-osmotic properties, it normalizes arterial and venous pressure, improves blood circulation. Polyglukin has up to 20% of low-molecular weight fractions of dextran, capable of increased diuresis and remove toxins from the body. Polyglyukin contributes to the exit of tissue toxins into the vascular bed and then remove their kidneys.
Indications for the use of polyglyukin are as follows:
shock - traumatic, burn, operational;sharp blood loss;
acute circulatory failure with severe intoxication (peritonitis, sepsis, intestinal obstruction and etc.);
Blood transfusion with hemodynamic violations.
The use of the drug is not shown during the injury of the skull and increase intracranial pressure, continuing internal bleeding.
One-time dose of 400-1200 ml, if necessary, it can be increased to 2000 ml.
Polyglyukin is introduced intravenously drip and stove (depending on the state of the patient). In emergency situations, the jet introduction of the drug is beginning, then with increasing arterial pressure Go to drip infusion at a speed of 60-70 drops per minute.
Reopolyiglyukin - This is a 10% solution of low molecular weight (molecular weight of 35,000) dextran in a sodium chloride isotonic solution. Reopolyglyukin is capable of increasing the BCC, each 20 ml of the solution is associated with an additional 10-15 ml of water from the interstitial fluid. The drug has a powerful disaggregating in relation to erythrocytes, contributes to the elimination of blood state, to reduce its viscosity and strengthening blood flow, i.e. Improves the rheological properties of blood and microcirculation.
Reopolyglyukin has a large diuretic effect, therefore it is advisable to apply it at intoxication. The drug leaves the vascular channel for 2-3 days, but its main amount is removed with the urine in the first day. Indications for the use of the drug are the same as for other hemodynamic blood substitutes, but REOPOLIGULUKIN is also used for the prevention and treatment of thromboembolic disease, during post-transfusion complications and for the prevention of acute renal failure. Dose of the drug - 500-750 ml. Contraindication to its use are chronic diseases kidney.
Geitarian - This is an 8% solution of partially hydrolyzed gelatin in an isotonic solution of sodium chloride. The relative molecular weight of the drug is 20 000 ± 5000. Due to colloidal properties, the drug increases the BCC. Basically use the rheological properties of the gelatinally, the ability to disperse it (reduce viscosity) blood, improve microcirculation.
Nutrient value does not possess the drug, is excreted entirely during the day with urine, and only 20% of the drug remains in the bloodstream in the bloodstream. Injected drip and inkido intravenously, intraarterially; The drug is used to fill the apparatus of artificial blood circulation. Maximum dose Introduction - 2000 ml. Relative contraindications to its use are acute and chronic jade.
Transfusion therapy in emergency situations (in the treatment of shock, acute blood loss, acute vascular failure) should be started with funds capable of quickly restoring the BCC. The use of donor blood leads to a loss of 20-30 minutes of time necessary to determine blood groups, compatibility samples, etc. According to the ability of the OCC, donor blood does not have advantages over colloid plasma reference.
In addition, the shock and pronounced deficiency of the BCC occurs a microcirculation disorder is a disturbance of capillary blood flow, the causes of which are an increase in blood viscosity, aggregation of shaped elements and microtromotic formation, which are aggravated by donor blood transfusion. In this regard, to begin transfusion therapy with shock and even during blood loss, it follows from intravenous administration of anti-deposit blood deteriorates - polyglyukine and refooliglukin.
Disinfecting blood substitutes:
Hemodhez - This is a 6% solution of low molecular weight polyvinylpyrrolidone on a balanced electrolyte solution. Release in bottles with a capacity of 100, 200, 400 ml. Store at temperatures from 0 to -20 ° C. Shelf life is 5 years. Hemodheus has a good adsorption capacity: binds toxins circulating in the blood, including bacterial, partially neutralizes them and displays with urine.The drug is rapidly excreted by the kidneys: after 4-6 hours up to 80% of hemodesa is released. Hemodera has a property to eliminate erythrocyte stasis in capillaries, which is observed with intoxication. Due to the improvement of the capillary perfusion, the drug is able to remove toxins from tissues. The average one-time fraction of hemodesa is 400 ml. Introduction speed - 40-50 drops per minute.
Indications for the use of the drug serve severe purulent-inflammatory diseases, accompanied by purulent-resorbative fever, purulent peritonitis, intestinal obstruction, sepsis, burn disease, postoperative and post-traumatic states.
Phantise - This is a 3% solution of polyvinyl low molecular weight alcohol in a sodium chloride isotonic solution. Release in bottles with a capacity of 100, 200, 400 ml. Stored at a temperature not lower than -10 ° C.
The mechanism of action is similar to that of hemodesa. Indications for use are the same as hemodesa. One-time dose - 250 ml. The drug is injected twice with an interval of several hours, the rate of administration is 20-40 drops per minute, the volume of administration is 250 g per day.
Electrolytic solutions:
Balanced transfusion therapy involves the introduction of electrolyte solutions in order to restore and maintain osmotic pressure in an interstitial space. Electrolytic solutions improve blood rheological properties, restore microcirculation. With a shock, blood loss, severe intoxications, the dehydration of the patient occurs the transition of water from the intercellular spaces to the bloodstream, which leads to a deficiency of the liquid in the interstitial space.Salt solutions having a low molecular weight are easily penetrated through the wall of the capillaries in the interstitial space and restore the volume of the liquid. All salt-blowing solutions quickly leave bloodstone. Therefore, their use is most appropriate together with colloidal solutions, which extend the timing of their circulation in the blood.
The sodium chloride isotonic solution is aqueous 0.9% sodium chloride solution. Released in hermetically soldered bottles or prepare in a pharmacy. With significant losses of the body of the fluid, accompanied by extracellular dehydration, it is possible to introduce it to 2 liters per day.
The drug quickly leaves the bloodstream, so the effectiveness of it with shock and blood loss is insignificant. Apply in combination with blood transfusion, blood-absorbing solutions. Ringer's solution - Locke. The composition of the drug: sodium chloride - 9 g, sodium bicarbonate - 0.2 g, calcium chloride - 0.2 g, potassium chloride - 0.2 g, glucose - 1 g, bidistalized water - up to 1 000 ml.
The solution in its composition is more physiological than isotonic sodium chloride solution. It is used to treat shock, blood loss in combination with blood transfuses, plasma, hemodynamic hemodynamic solutions.
Lactasol - composition of the drug: sodium chloride - 6.2 g, potassium chloride - 0.3 g, calcium chloride - 0.16 g, magnesium chloride - 0.1 g, sodium lactate - 3.36 g, distilled water - up to 1000 ml . The sodium lactate included in the solution turns into the body in sodium bicarbonate.
The drug contributes to the restoration of the acid-main state of the body and improving hemodynamics. As regulators of the acid-base state, a 5-7% sodium bicarbonate solution and a 3.66% trisamine solution are used.
Blood-blowing liquids (Synonym: Infusion media, blood substitutes, plasma substitutes, bloodstream solutions, plasma-substituting solutions, hemocorrectors) - means used with therapeutic goal To perform one or more physiological blood functions. Developed on the basis of biological or synthetic polymers, amino acids, carbohydrates, fats and salts.
In accordance with the functional properties of blood K. g. They are divided into the following groups: hemodynamic (anti-shock), disintellation, blood-absorbing, for parenteral nutrition, regulators of water-salt and acid-alkaline equilibrium and K. F, a comprehensive action. All K. Well, must meet the following requirements: be harmless to the body; fully excluded or split and absorbed by the body; do not have toxicity and pyric; be sterile and stable in the process of storage within the deadlines defined by the documentation; With repeated administrations, do not cause the body sensitization. To each group K.S. Special requirements are also present. So, hemodynamic K. g. Must long time to linger in the bloodstream and maintain blood pressure, and therefore, have a relatively high molecular weight (from 30,000 to 70,000). Disinfection k. g. Must have a low molecular weight (from 6000 to 15000), which contributes to their rapid excavation from the body together with associated toxic substances. Mandatory requirement to K. g. For parenteral nutrition is their assimilation and participation in the synthesis of protein.
Hemodynamic heating fluids Mainly produced on the basis of the glucose polymer dextran and gelatin. The first include polyglyukine (molecular weight of 60,000 ± 10,000), Reopolyglyukin (molecular weight 35000 ± 5000), isolated with acid hydrolysis, followed by fractionation, as well as rondex (molecular weight 65000 ± 5000) obtained by the radiation method. Reopolyglyukin maintains blood pressure for 6 c., Polyglyukin - for 1 day, then they are gradually derived from the body. Due to the high colloid-osmotic properties of polyglyukin and rondex, with inkjet administration, blood pressure is restored in patients with significant blood loss, traumatic and oome e. Reopolyglyukin is used in disruption of microcirculation, for the prevention of operational and treatment of oath and traumatic A, with impaired arterial and venous blood circulation, for Treatment of OV and A, ENDARTERITA, in operational interventions on the heart, vessels, e, e. As the anti-shock drug, the referdiglukin is inferior to the polyglyukine, since faster it is derived from the body.
Hemodinimic K. g based on gelatins (for example, gelatinol) is less effective due to low molecular weight (about 20,000), they are used in the treatment of operational and traumatic A I-II degree, when preparing a patient for operation, for disintellation.
Disinfecting blood flowing fluids Developed on the basis of low molecular weight polyvinylpyrrolidone (PVP) - synthetic polymer, inert for the body and non-splitting enzyme systems.
LVL binds toxic substances of various structures and together with them is derived from the body by the kidneys. The lower its molecular weight, the faster it is displayed (mainly for 4-6 c.Fully - for 1 day.). Indications for the use of PVP: toxic forms of gastrointestinal diseases, audio and radiation diseases in the phase of intoxication, peritonitis and intestinal obstruction, liver disease (hepatitis, hepatocholangitis, liver, hepatic coma), hemolytic disease of newborns, intrauterine infection and newborne toxium, a number of other The diseases accompanied by OM, as well as the pre-and postoperative periods, to the preparations based on PVP are hemodhease (molecular weight of 12600 ± 2700), more efficient neogenesis (molecular weight 8000 ± 2600) and enterodez (apply orally as a solution, as a rule, 5%), which connecting toxic substances, excreted through the intestines, which is especially important in renal failure.Penteral Piece Fluids used to restore nitrogen balance, eliminate protein failure with the impossibility of enteric power, in postoperative period, in injuries, intestinal obstruction, massive blood loss, purulent and septic conditions, having disease, infectious diseases, malignant neoplasms and with other diseases accompanied by Belkova Yu. Evaluation of the effectiveness of treatment with these drugs is carried out on the rise of body weight, normalization of nitrogenous balance,
Indicators of general protein and albumin serum, albuminoglobulin coefficient, urea increment. For parenteral nutrition, protein hydrolyzates are developed: casein hydrolyzate and hydrolyzing - hydrolyzate from cattle proteins (used rarely) and their advanced forms - infusamine and aminotrophrof, in which ballast humic substances and ammonia, the content of free amino acids is significantly increased that contributing Their better absorption.As preparations for parenteral protein food, used in optimal ratios for protein synthesis in the body of amino acid mixtures are used. In the USSR, the first original amino acid-based drug is developed - polyamine containing 13 amino acids and the energy component - D-sorbitol. Since the polyamine has increased the content of amino acids, it is injected in fewer than hydrolyzates. In addition, due to the optimal ratio in it, amino acids, it is much more efficient than hydrolyzes. Its action is more pronounced and manifests itself faster. The listed preparations for parenteral nutrition should be used in conjunction with glucose solutions and fat emulsion drugs as energy sources that ensure the use of amino acids in direct intended, i.e. For protein synthesis.
Regulators of salt and acidic alkaline equilibrium Apply with different pathological conditions,
Especially with traumatic and oh no shock (at e medium and serious degree - in combination with blood and K. g. Hemodynamic action). In the USSR, it is used: lactasol, blisk in salt formation to a ringer solution, further comprising milk acid, quintassol - a complex saline; Polyglusol - a polyfunctional solution containing polyglyukin and salt. The solutions of mannitol and sorbitol are injected as diuretics - mannitol and sorbitol.Harvesting liquids of comprehensive action (Polyfunctional drugs) are developed based on a number of drugs listed above. They are used in many types of pathology: impaired hemodynamics, protein metabolism, diurus, appearance in the body of toxic substances, and the development of acidosis. These include: Polyfer (includes polyglyukine and iron salts), which has a hemodynamic and hematopoietic effect: a revolution, characterized by hemodynamic, hematopoietic, rheological and diuretic effects, polyglusol, corrective hemodynamics and acid-alkaline equilibrium, aminodez (based on low molecular weight PVP and polyamine) having disintellation properties and used for parenteral nutritional polyvisalin with hemodynamic and disintellation action.
Bibliography: Isakov Yu.F., Michelson V.A. and staff MK Infusion therapy and parenteral nutrition in children's surgery, M., 1985; Parenteral nutrition for heavy injuries, ed. R.M. Glanza, M., 1985; Sudzhan A.V Parenteral nutrition in Onkosurgery, M., 1973.
They are intended for different purposes:.
1. For the purpose of restoring: respiratory proofreaders of the respiratory function of blood; blood circulation Regulators Hemodynamics and Recoordarmers: Balance of Diuretics Balance.
2. For hemostasis, regulators of the coagulation properties of blood.
3. In order to stimulate the protective properties of blood immunobiological and hyposensitizing drugs.
4. For the purpose of disinfecting to remove the toxic substances from the outside or formed in the body.
5. With a trophic target of the means of parenteral nutrition.
6. In order to correct metabolism in the body.
Principles of bleeding fluids:
1. They must correspond to blood but ionic composition. For example. NaCl is 60-80% of all plasma salty.
2. The osmotic pressure of the solutions should be isotonic blood plasma (NaCl 0.9%, KCI 1.1%. Glucose 5.5%). But in some cases use and hypertensive solutions (for example. 40% glucose solution).
3. There must be a balanced content of inorganic salts (the Rule Rule should be taken into account about the electronically plasma).
4. They must have a certain oncotic pressure, G.S. contain large protein molecules. The role of protein molecules of solutions: a) "plump" the will into the vascular channel from tissues (and with it and in tissues dissolved toxic factors and metabolites) and increase the volume of circulating blood (BCC); b) Trnoprishtgi envelop and determine their disaggregation. TS Reduce the possibility of intrasosudesty
thrombova.
If large quantities of protein-containing solutions are used (for example, polyglyukine). It increases blood viscosity due to the deck of the ladder, the molecular weight of which is more than 100,000. What makes hemodynamics
86. Cancellation of the heart muscle. Features of the response of the heart muscle on irritation of various power. The law "All or nothing"
Society.
The properties of the myocardial contractivity ensures the contractile apparatus of cardiomyocytes associated with functional syntions using ionically permeable slit contacts. This circumstance synchronizes the spread of excitation from the cell to the cell and the reduction of cardiomyocytes. The increase in the reduction of the myocardial of ventricles is a positive inotropic effect of catecholamines - indirectly B1 -adrenoreceptors and CAMF. Cardiac glycosides also enhance the reductions of the cardiac ardor, having an inhibitory also enhance the reductions of the heart muscle, having inhibitory effect on Na. K. - Phase B. cell membranes cardiomyocytes.
Then they checked the participation of CA2 + in the regulation of muscle reduction by administering different cations inside the muscle fibers. Of all the studied ions, only calcium caused a reduction in concentrations, commensurate with Ca2 + concentrations, usually observed in lively tissue.
Subsequently, it was found that the skeletal muscle is not reduced in response to the depolarization of the membrane, if calcium reserves are exhausted in the internal depot, and the preliminary extraction drugs of the skeletal muscle fibers are not reduced by adding ATP, if there is no CA2 +.
The law of force. The case of excitability is the threshold of irritation minimum strength of the stimulus capable of causeing excitement.
In 1870, Bouldes in the experiment on the muscle of the heart by applying single threshold irritations, the response was recorded on it - it was found that the reaction was not the reaction, with the threshold strength and the super-threshold amplitude of the response was the same. Based on this, he proposed the "all or nothing."
After the introduction of B. experimental studies Microelectronic technology has been established that a response response appears on the subgrown irritation in the tissue.
With hemodynamic disorders due to both blood loss and some diseases, in addition to blood transfusion, various blood solutions use.
At the same time, the blood-absorbing solutions must meet the following basic requirements:
According to its physicochemical properties, they must be close to the main blood indicators (are isotonic, are ionic, etc.).
Lack of influence on the basic biological properties of blood.
Lack of toxicity and pyrogery.
Long stay in vascular bed.
To withstand sterilization and is stored for a long time.
Does not cause the body sensitization and do not lead to an anaphylactic shock when re-administration.
By functional purpose The bloodstream solutions are classified:
Hemodynamic (anti-shock), which include medium molecular weight (polyglyukine), low molecular weight (REOPOLIGLUKIN), gelatin preparation (gelatinol).
Disintellation (hemodez, polydatee). Used in poisoning of various origin, hemolytic disease of newborns, liver pathologies, kidney, with burns.
For parenteral protein food - protein hydrolysis products (hydrolysin, aminoptide, casein hydrolyzate, mixtures of amino acids polyamine, etc.).
For the normalization of water-salt metabolism and acid-alkaline state (saline, lactosol, ringer solution, solutions of polyhydric alcohol-mannitol and sorbitol, etc., which have dehydration or corrective blood composition).
BUT. Solutions:
The saline solution is 0.85 - 0.9% NaCl.
Ringer-Locke (composition in g): NaCl - 0.6; CaCl - 0.02; NaHCO 3 - 0.01; KCL - 0.02; Glucose - 0.1. H 2 O to 1 liter
Ringer's lactate solution (or lactosol) contains all major plasma electrolytes and 25-50 mmol / l of sodium lactate in physiological concentrations.
Azesol, Destil, Trisole, Gloss, etc.
Sodium hydrogen sodium solution, sodium lower solution (for blood squeezing).
But since these solutions do not contain colloids, they are quickly introduced from the bloodstream, i.e. They can replenish the volume of lost blood for a short time.
B. synthetic colloidal Floating solutions (plas-mosage). Preparations based on dextrans of low-, medium and high molecular weight (Reopolyglyukin, Reomakodex, Macrodeks, Polyglyukin, etc.). Cause hemodilyuction (blood breeding), improve microcirculation. Delay in the body from 12 hours to 5 days.
Along with this, synthetic colloidal preparations are used, which are derivatives of polyvinylpyrrolidone (neocompensen, enterodez).
The negative property of colloidal blood-blowing drugs is that they can cause allergic reactions.
IN. Proteinpreparations:
Plasma native, canned, freshly frozen.
Albumin solution 5%.
Gelatinol - colloidal 8% solution of partially split food gelatin.
Protein is a protein preparation of an isogenic human plasma.
With intravenous administration, the BC increases, hemodilution occurs, the lack of blood is reimbursed. Bind toxic substances (disintellation properties). Comprehensive polyfunctional blood substitutes are being developed (for activation of erythropoese - polyfer, reinforcement of diuresis - revumanum) and a number of other preparations with an extended range of action (hemodynamic, disinfect, hematopoietic, rheological, etc.)
Work is carried out on the exquisite of drugs - blood substitutes with the transfer function O 2 and CO 2, using fluorocarbon compounds for this (fluorocarbon emulsions).
Transfusion whole blood Currently, it is extremely rare, and used for transfusion only those blood components in which the body needs: plasma or serum, erythrocyte, leukocyte or platelet mass. In these cases, a smaller amount of antigens are introduced into the organism of the recipient and thereby decreases the risk of post-transfusion complications.
G. Blood preparations: Canned blood, plasma, erythrocyte mass, Eritrow, washed red blood cells, leukocytes (fresh), platelets (fresh).
The kidneys are more than other organs, participate in maintaining the volume of blood plasma, and indirectly through it - and other liquid media of the body. This function is carried out by participating in the separation of water, inorganic ions, maintaining the osmotic and oncotic pressure plasma pressure. Through the plasma of blood controls the content of the intercellular fluid and the fluid level in the closed cavities of the organism, as well as the water content in the intermediate tissue.
The main mechanisms controlling the constancy of blood volume based on the control of blood pressure and blood volume that enters the atrium. The volume receptors are localized mainly in atrium. In addition, the plasma volume is regulated depending on the osmotic and oncotic pressure controlled by the Osoricceptors of the hypothalamus.
Blood loss. Groups of blood
The degree of disorders arising in the body after blood loss is defined as its size and speed. A gradual loss of even 40% of ECC (red blood cells) does not cause catastrophic disorders. At the same time, the sharp loss of 30% of blood may be fatal. About 15% of postoperative mortality due to massive blood loss during surgery.
The decrease in the BCC during blood loss leads to development acute insufficiency blood circulation. But if the blood loss was relatively insignificant (not higher than 15 ml1kg), then physically healthy man OCC due to plasma is restored in a few hours independently.
Artificial restoration of blood volume (hemotransphus).
After bloodstures, when the restoration of the previous blood volume begins at the expense of plasma, the concentration of red blood cells decreases. Maximum reduction of hematocrit is observed after 48-72 hours after massive blood loss. The natural recovery of erythron due to the acceleration of erythropoese is delayed for a long time (about 20 days). As a consequence, in the first hours and days after blood loss, the deficiency of erythrocytes, more pronounced, the more massive it was. And therefore the question arises about artificially filling it with blood transfusion. When hemotransphus, it is necessary not only to restore the OCC, but also to achieve such conditions of blood circulation, which will allow maximum reduced hypoxic metabolic disorders.
It should be remembered that hemotransfusion is a transplantation surgery of alien fabric. And its first formidable complication is an immune conflict (see below). Antigenic specificity is characteristic of both nuclear cells of blood and erythrocytes. The presence of antigenic specificity of the erythrocytes is determined by the so-called blood groups. Group antigens are fixed on the glycicalce of erythrocyte membranes. For chemical origin is glycolipids or glycoproteins. Today, more than 400 are discovered.
AB0 system.
Antigens of ABO systems have the greatest value. The molecule of these antigens consists of 75% of carbohydrates and by 15% from amino acids. Peptide component of all three antigens that designate N, A, B, same. Specificity is determined by carbohydrate part. People with a group of blood 0 have antigen H, whose specificity is due to the three end carbohydrate residues. The addition of a fourth carbohydrate residue to the H-antigen structure provides it with specificity, which is denoted by A (if №аsetyl-0-galak-tzu is connected), or in (if D-galactose is added).
If you mix the blood taken in two people, then the agglutination (gluing) of red blood cells will occur. After that, their hemolysis may occur. The same picture happens when overflowing incompatible blood. This leads to the closure of capillaries and other complications, ends with death. Agglutination occurs as a result of the reaction
"Antigen antibody". The indicated antigens A or B interact with antibodies available in the blood plasma are denoted by a or p. This is immunoglobulins ()%). The name of the antigens reaction is called aglutinogens and antibody- aggutinins. It is believed that agglutinins have two active centers, as a result of which two adjacent red blood cells are associated. At the same time, but it interacts with A, and in - with G. To agglutinogen H in blood serum there is no agglutinin. The next lysis of erythrocytes occurs with the participation of the complement system and proteolytic enzymes, are formed. Hemolysis occurs in the case of high antibody title. Antibodies a and r belong mostly to 1 $ L. and to a lesser extent - to the molecular weight of their non-etinakov: in g ^ g about 1 000 000, and in IGN - 170,000. IIM-type hemolyzines (When they interact with the corresponding antigens, which are on the erythrocyte membrane, compounds that destroy red blood cells are formed).
In natural conditions in human blood, the antigen and antibodies cannot simultaneously be at the same time, since this can cause red blood cell agglutination. But it is characteristic that in the absence of agyutinogen in erythrocyte A or in serum, it is imperative with the agletinin to it.
By the ratio of these factors, four groups of blood are distinguished: I group-erythrocytes contain 0 antigen, plasma A - and P-antibodies; II - A and g; III - B and A; IV - AB and 0 (Table 4).
Table 4.
The study of blood groups began the Ladstinener, which in 1901 described by Shch * four groups, referring to their symbols or erythrocyte antigens. These antigens are inherited, and and in - dominant. Currently, several subtypes of these antigens were revealed.
The plasma of the blood of a newborn, as a rule, has not yet has antibodies a and r. Gradually, they appear (the titer grows) to the factor that is not in red blood cells. It is believed that the production of these antibodies is connected
Fig. 71.
but with the flow of some substances from food or substrates in the crop of children, the intestinal microflora produces. These substances can come from the intestine to the blood due to the fact that the intestinal canal of the baby is still capable of sucking large molecules. The titer of agglutinins reaches a maximum of 10-14 years, in the future gradually decreased (Fig. 71).
Other erythrocyte antigens.
On the erythrocyte membrane, in addition to AVN antigens, there are other antigens (up to 400), which determine their antigenic specificity. Of these, about thirty happen quite often and can cause agglutination and hemolysis of red blood cells during blood transfusion. On the antigens Rh, m, s, p, a, uk and others allocate more than twenty various systems blood. However, in most of these factors in natural conditions in plasma, antibodies were not detected. They are formed in response to entering the body of antigens, as well as conventional immune antibodies. And this requires time (several weeks), during which the overclocking red blood cells leave the blood flow. The hemolysis of erythrocytes during the immune conflict will occur only after repeated transfusions. Therefore, during blood transfusion, compatibility is desired not only by ABO system, but also for other factors. In real conditions full compatibility It is hardly possible to achieve, so only from those antigens, which are desirable to take into account (Rh, m, n, s, p, a, etc.), it is possible to make almost 300 mall combinations.
Rhow-belonging.
currently, they believe that before overflowing the definition of group affiliation only on the ABO system is not enough. At a minimum, it is always necessary to determine the rhesus affiliation (RH). Most (up to 85%) people on the erythrocyte membrane contain the so-called resh factor (What is also contained in the red blood cells of monkeys of macaques). But unlike antigens A and in serum, there are no antibodies antibodies. They appear after the rhesus-positive erythrocytes fall into the blood stream of the reserves-negative people, which are approximately 15% of the total population.
Rhose-belonging is determined by the presence of several antigens in the erythrocyte membrane, which is denoted by C, D, E, C, D, E. The greatest value
Fig. 72. Rh factor during pregnancy(but) and transfusion Rh-incompatible blood(b)
B-agluient, since antibodies to it are generated more active than in others. Human blood is considered resh positive (CL +) if there is an O-factor in the erythrocyte, in case of its absence (C) - resh-negative (SG). The transfusion of the rees-negative person of rhesus-positive erythrocytes will cause immunization (Fig. 72). The maximum of the anti-cut bodies will be achieved after 2-4 months. By this time, the red blood cells are already overclocked before the blood flow. But the presence of antibodies is a danger in the event of re-transfusion of reserves-positive red blood cells.
The rhesus factor matters not only when overflowing blood, but also during pregnancy In the event that a woman does not have a ray factor in red blood cells, a rezes-positive fruit is pregnant. In response to entering her body, erythrocytes of the fetus gradually education will begin Antibodies against the Rh Factor.
When normal current Pregnancy This is possible, as a rule, only after childbirth, when a placental barrier is disturbed. Natural isoaglutinins A and g belong to the class and £ m. Aggulutinins against AI + -Factor, as well as some others, appear during immunization belong to the class of II0. Due to the difference in molecular weight through the placenta, the antibodies of type IgG are usually easily penetrated, while IGM does not pass. Therefore, after immunization in the case of re-convertible-conflict pregnancy, immune antibodies against the Rh, the factor penetrate the placenta and cause the destruction of the erythrocytes of the fetus with all the consequences arising from here. However, for some reason, the erythrocyte of the fetus fall into the blood circuit of a woman during the first pregnancy, the hemolytic anemia of newborns caused by rhesus incompatibility may be observed during this pregnancy. Sometimes the hemolysis of the erythrocytes of the fetus may be a consequence of penetration and natural isoaglutinins A and G of Mother.
Basics of blood transfusion
Of course, it is also impossible to overflow erythrocytes of the Rh-positive donor to the rezes-negative recipient. Although in this case, during the first blood transfusion, significant complications do not occur. Danger represents repeated transfusion of incompatible blood. Given these considerations, applying the blood of the same donor during re-overflowing should not be necessary for some of the rare systems. Immunization will occur. Thus, today not only an idea of \u200b\u200ba universal donor, but also a universal recipient. In fact, the "classic universal" recipient-person with the IV group of blood is a universal plasma donor, because there is no agglutinins in it. Undoubtedly, the best donor can only be the patient himself, and if there is an opportunity to prepare before the operation of autocrats, it should be done. The transfusion of the blood of another person, even with the observance of all these rules, will definitely lead to additional immunization.
Physiological principles for the preparation of bloodstream solutions
To replace blood during the hemotransfuses, first of all it is necessary to apply the principles isopianity and isopoticity solutions. Solution with pressure, which is more than in plasma, called hypertonic and with less hypotonic. 96% of the total osmotic plasma pressure falls on the proportion of inorganic electrolytes, among which the main (about 60-80%) is NaCl. Therefore, the simplest blearer is a solution crash salt, 0.9% of which creates an osmotic pressure close to 7.5 atm.
But if the solution is administered to compensate for the lost blood, it must contain a more balanced concentration of inorganic salts, according to the composition of a similar blood plasma (being isotonic), as well as large molecules (iso-acidic), poorly pass through the membranes and are slowly removed from the blood strength. Therefore, such solutions are considered more efficient blood resources. The most complete plasma replacement is, of course, plasma itself. Protein solutions, polyglyukin, etc. are also associated with such a condition, the use of polyglyukin contributes to achieving a more pronounced positive effect. In line with his blood, its shares are 2 times longer than plasma proteins. As a result, the effect of oncotic pressure is growing, which "sucks water", and due to the intake of the intercellular fluid increases the BCC. In addition, Polyglyukin, enveloping erythrocytes by ionic shell, causes their disaggregation, that is, the risk of intravascular thrombosis is reduced. But such effects occur when overflowing relatively minor quantities of polyglyukin. Large doses increase blood viscosity and increase the aggregation of erythrocytes (due to the impurity of the dextran, having a molecular weight of more than 100,000); They lead to significant blood dilution and a decrease in its coagulation properties, hypoproteinemia, violations of the acid-transporting blood function.
