THE INFLUENCE OF CHANGES IN CARBOHYDRATE METABOLISM INDICATORS IN PATIENTS WITH POLYTRAUMA COMPLICATED BY ALCOHOLIC DELIRIUM ON THE CHOICE OF THE SEDATION METHOD.

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. PURPOSE: 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. MATERIALS AND 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 Care¼ named after Prof. O. I. Meschaninov¼ 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. RESULTS AND DISCUSSION: 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).

STUDY OF THE PROCESSES OF LIPID PEROXIDATION, THE STATE OF THE ANTIOXIDANT SYSTEM IN PATIENTS WITH POLYTRAUMA AND ALCOHOL ANAMNESIS.

The effectiveness of management of patients with severe combined trauma and alcohol withdrawal syndrome, complicated alcoholic delirium remains relevant and modern in intensive care. Sedation is the mainstay of treatment in patients with alcohol withdrawal complicated by alcohol delirium. Choosing the optimal scheme of treatment tactics, considering sedation, in victims with polytrauma becomes a difficult task due to a diverse combination of injuries and a lack of time for tactical decisions of patient management. Given the fact that polytrauma is characterized by pronounced oxidative stress, the development of hypoxia, especially when combined with chronic alcoholism, the expressiveness of biochemical disorders deepens significantly, the study of the course of biochemical processes and their mutual influence and the formation of current tactics of intensive therapy for these diseases is promising. Purpose - study of lipid peroxidation processes and the state of the antioxidant system in patients with polytrauma and alcohol withdrawal syndrome complicated by alcoholic delirium. The study was conducted on the basis of the Department of Anesthesiology and Intensive Care with 12 beds for patients with combined trauma of the communal non-profit enterprise "Kharkiv City Clinical Hospital of Rapid and Emergency Medical Care named after Professor O.I. Meschaninov". To achieve the goal of the study, 40 patients with polytrauma were examined (thoracic and/or abdominal trauma: rib fractures, hemothorax, pneumothorax, hematomas of the liver or spleen, fractures of the waist and/or upper and/or lower limbs, pelvic fractures), medium severity. During the study, to achieve the goal, the main indicators of the oxidant-antioxidant system in patients were determined. We determined the content of the main indicators of the oxidant system: active products of thiobarbituric acid, diene conjugates, 8-isoprostane to assess the intensity of lipid peroxidation. The state of the antioxidant system was assessed by the content of superoxide dismutase, catalase, and glutathione peroxidase. The study was conducted on the 1st and 7th day of hospitalization of the patients. The main indicators of the intensity of lipid peroxidation in the human body are diene conjugates and active products of thiobarbituric acid. This provides an autocatalytic self-accelerating character. The obtained results indicate that in patients with polytrauma and alcohol withdrawal syndrome, complicated by alcoholic delirium against the background of chronic alcoholism due to the generation of reactive oxygen species, which is evidenced by an increase in the content of active products of thiobarbituric acid, diene conjugates, 8-isoprostane, against the background of insufficient antioxidant the system can develop oxidative stress, which is accompanied by damage to biological molecules: lipids, proteins, nucleic acids. Thus, the obtained results indicate an increase in the intensity of free radical reactions and processes of lipid peroxidation. Changes in the content of lipid peroxidation parameters in the blood of patients with polytrauma and alcohol withdrawal syndrome, complicated by alcoholic delirium, indicate more pronounced violations of the integral redox state. Activation of lipid peroxidation processes leads to a violation of the elasticity and mechanical integrity of cell membranes, a decrease in the activity of lipid-dependent membrane-bound enzymes. In a complex analysis of the content of biochemical markers of lipid peroxidation, namely active products of thiobarbituric acid, diene conjugates and 8-isoprostane in the blood of patients with polytrauma and alcohol withdrawal syndrome, complicated by alcoholic delirium, it was found that distinct processes are observed upon admission to the intensive care unit lipid peroxidation and free radical processes. Against the background of increased activity of the oxidant system, a decrease in antioxidant resources was observed as a decrease in the content of superoxide dismutase, catalase, and glutathione peroxidase. The work revealed the dynamics of the indicators of the antioxidant system in patients and is related, on the one hand, to the exhaustion of the body's compensatory capabilities under the conditions of the development of strong oxidative stress, and on the other hand, it was probably a consequence of the negative impact of the products of chronic endogenous intoxication, alcohol, acetaldehyde on hepatocytes, where detoxification processes occur in the body of patients with chronic alcoholism and alcohol withdrawal syndrome. During the study, a significant suppression of the activity of all studied enzymes was found in patients with polytrauma, complicated by alcoholic delirium during admission to the intensive care unit, and on the seventh day after the therapy. Superoxide dismutase is part of the first link of antioxidant protection. This enzyme forms hydrogen peroxide from superoxide anions, which is further transformed into oxygen and water under the action of catalase. Considering the leading role of the activation of pro-oxidant processes in chronic alcoholism, indicators of the antioxidant-pro-oxidant status can be used to predict the course of this pathology, as well as the effectiveness of the selected treatment tactics for patients in this category.

DYNAMICS OF CHANGES IN 2,3 DIPHOSPHOGLYCERATE AND COGNITIVE DYSFUNCTION IN THE POSTOPERATIVE PERIOD IN PATIENTS WITH ABDOMINAL NEOPLASMS.

The problem of analysis of clinical - diagnostic and biochemical criteria of postoperative cognitive dysfunction in abdominal oncosurgery, depending on the degree and structure of disorders, remains unresolved, which determines its relevance. The role of 2, 3-diphosphoglycerate is essential, because its increase in the concentration of red blood cells in hypoxic conditions is one of the adaptive mechanisms that improve oxygen transport to tissues. Purpose. The influence of the dynamics of 2,3 diphosphoglycerate content, as the main indicator of hypoxia, on the occurrence of cognitive dysfunction in the postoperative period in patients with neoplasms of the abdominal cavity. The study was conducted on the basis of departments for patients of the surgical profile of the municipal institution "Kharkiv City Clinical Hospital of Ambulance and Emergency Care named after Professor OI Meshchaninov ". To achieve this goal, we examined 80 patients with abdominal neoplasms who underwent surgery under general anesthesia using propofol and fentanyl. All patients were divided into 2 groups depending on the age of patients on the WHO scale, who underwent surgery using general anesthesia: Group 1 (n = 39) - middle-aged patients (50-59 years); Group 2 (n = 41) - elderly and senile patients (60-80 years). The control points of the examination were the day before the operation and the 1st, 7th, 30th day from the moment of the operation. The state of cognitive function in these patients was determined by conducting neuropsychological tests. To assess the state of cognitive function of patients, neuropsychological tests were used: MMSE scale (Mini-Mental State Examination, MMSE), the method of memorizing 10 words AR Luria, frontal dysfunction battery (FAB), Schulte technique. To assess the state of energy metabolism in patients, the level of erythrocytes and hemoglobin in the blood analysis was determined by well-known methods, the level of 2,3 diphosphoglycerate in erythrocytes and its ratio to hemoglobin. Anemia in the first week after surgery in patients of group 1 contributes to the development of a hypoxic state, in erythrocytes there is an increase in the content of 2,3 41 diphosphoglycerate, which promotes the transport of oxygen to tissues. During the week there is an increase in the intensity of the formation of 2,3 diphosphoglycerate, as evidenced by the ratio of 2,3 diphosphoglycerate to hemoglobin. In patients of group 2, the changes are more pronounced: anemia with a significant decrease in erythrocytes and hemoglobin in the blood, a decrease in 2.3 diphosphoglycerate in erythrocytes, reflects changes in erythrocyte metabolism, namely a decrease in biosynthesis of important organophosphorus compounds, in particular 2,3 diphosphogly by reducing the basic enzymes of glycolysis. Decreased energy metabolism in the elderly contributes to impaired cell function. With age, the content of adenosine triphosphate, 2,3 diphosphoglycerate decreases, thus increasing the affinity of hemoglobin for oxygen, impaired transport of oxygen to tissues, which leads to the development of hypoxia. According to the results of neuropsychological tests, we found postoperative cognitive dysfunction in patients with neoplasms of the abdominal cavity. Disruption of energy metabolism and changes in the activity of glycolysis enzymes in erythrocytes contributes to a decrease in the concentration of 2, 3 diphosphoglycerate, increase the affinity of hemoglobin for oxygen and the development of tissue hypoxia. The obtained results indicate the interdependence of these processes and allow continuing research in this direction with the development of appropriate clinical and diagnostic measures and areas of intensive care to improve the condition of patients with abdominal tumors and their quality of life after surgery.

[TACTICS OF CHOOSING COGNITIVE DYSFUNCTION THERAPY IN THE POSTOPERATIVE PERIOD].

The aim of the study is to formulate the tactics of assigning adequate neuroprotective therapy to patients with postoperative cognitive dysfunctions on the basis of subtracting the indicator of the total cognitive deficiency. To achieve this goal, we conducted a study of cognitive function in patients of different age groups: young age, middle age, elderly age with acute surgical pathology before surgery and at 1, 7, 30 days after surgery compared with preoperative data. Methods of research. The study of the cognitive sphere: scale MMSE, test drawing hours, test "10 words", battery tests for frontal dysfunction, method Schulte. The indicator of the total cognitive deficiency was calculated.  The results of the study of cognitive function made it possible to formulate a scheme for the use of citicoline and cytoflavin in a complex of therapeutic programs. In each age group, on the seventh day of the study, there were patients with different dynamics of cognitive function recovery for the preoperative period. This allowed us to develop and propose a formula for calculating the total cognitive deficit, which makes it possible to formulate appropriate tactics for managing patients in the subsequent period in each specific case. We determine the values ​​of the percentage deviations of each study result from the norm and the indicator of the total cognitive deficit by the sum of the values ​​of the percentage deviation from the norm of the results of the study of cognitive impairment.