Kabanov City Clinical Hospital #1,

Omsk State Medical Academy,

 Omsk, Russia

 

The patient K., age of 50, had a professional accident in 4:10 a.m., 29.03.2014. He suffered from traumatic disruption of the right upper extremity at the level of the shoulder. The accidental bystanders applied a dressing to the wound and called an ambulance. The emergency doctor found (4:30 a.m.) that the patient was in clouded consciousness (Glasgow Coma Scale = 12) and had no opportunity for contacting. The wound demonstrated significant pulsating bleeding. The skin was pale, cold and cyanotic. The tongue was dry. Arterial pressure was 60/0 mm Hg, HR ‒ 118, shock index (SI) ‒ 2, respiratory rate (RR) ‒ 24 per min. Oxygen saturation of capillary blood (SaO₂) was not measured. Blood loss (according to systemic hemodynamics, clinical symptoms and external blood loss) was 2,000-2,200 ml. The patient received emergency aid: dressing for the wound region, left subclavian vein catheterization according to Seldinger (negative central venous pressure [CVP]), infusion therapy with 1,500 ml (1,000 ml of isotonic sterofundin and 500 ml of 4 % oxypolygelatin, i.v. promedol, 2 %, 1 ml). During infusion therapy and anesthesia AP was 80/60 mm Hg, HR ‒ 108/min., SI ‒ 1.5, RR ‒ 22/min.

The patient was transferred by an ambulance car to the emergency surgery room, Kabanov City Clinical Hospital #1 (11:46 p.m.). The diagnosis was made: traumatic amputation of the right upper extremity at the level of the right shoulder joint; traumatic shock of degrees 2-3. Primary surgical preparation for the wound (during 40 minutes) and residual limb formation on the right upper extremity at the level of the right shoulder joint were carried out during total intravenous (fentanyl and ketamine) anesthesia with muscle relaxants and ALV with air-oxygen mixture. During surgical treatment AP was 80/60-90/60 mm Hg, HR ‒ 94-102/min., SI ‒ 1.2-1.1, CVP ‒ 3 cm of water. The volume of intrasurgical infusion-transfusion therapy was 1,500 ml of isotonic sterofundin and 1,000 ml of 4 % oxypolygelatin. The intrasurgical blood loss was about 300 ml. At the moment of admission to the intensive care unit ALV was continued with Chirolog SV-alfa+C (Chirana, Slovakia) in CMV mode (V_t – 380 ml, MV – 6,1 L, FiÎ₂ – 0.36%). Infusion (isotonic sterofundin, 1,500 ml; 4 % oxypolygelatin, 1,500 ml; 1:1) and transfusion (single group fresh frozen plasma, 920 ml; single group packed red cells, 710 ml; 1:1) therapy was initiated with the volume of 46,300 ml. Antibacterial (ertapenem at the beginning, and henceforth according to microbiologic examination results) and symptomatic (analgetics, sedative drugs, proton pump inhibitors, anticoagulants) treatment was performed. The blood examination showed anemia (hemoglobin ‒ 78 g/L; red blood cells ‒ 2.4 × 10⁹), hyperlactataemia (3.6 mmol/L) and consumption coagulopathy events (APPT ‒ 38.4 sec.; SFC ‒ 17 ug/100 ml). The hourly urinary output was 100 ml. At the same time, decreasing AP to 60/40 mm Hg and increasing HR to 150/min. (CVP ‒ 5 cm of water) were registered.

Non-invasive hemodynamic monitoring with MPR 6-03 device was initiated (Triton Electronics, Russia). It found circulation of hemodynamic type that was confirmed by decreasing circulation minute volume (CMV) to 5.8 L/min., decreasing stroke volume (SV) to 39 ml and total peripheral vascular resistance (TPVR) to 820 dyn×cm×s^-5. The vascular support was performed with noradrenaline using FmS infusion pump (B. Braun, Germany), 0.9 mg/h (for 48 h). The rate of infusion-transfusion therapy was increased that favored increasing AP (up to 90/60 mm Hg) and CVP (up to 5 cm of water), decreasing HR (up to 120/min.) and restoring hourly urine output (up to 150 ml/h). At the same time, the patient demonstrated changing the hemodynamic type of circulation to normodynamic type. It was confirmed by MBV (6.4 L/min.), SV (55 ml) and TPVR (1,180 äèí×ñì×ñ^-5).

Intensive care, which was initiated 48 hours after the performed treatment, favored correction of shock events (SI ‒ 0.8) and consumption coagulopathy (APTT ‒ 34.4 sec.; SFC ‒ 9.5 ug/100 ml), improving tissue perfusion (decreasing lactate to 1.6 mmol/L) and normalizing urine output (1,250 ml). Therefore, on day 3 the volume of infusion (isotonic sterofundin, 1000 ml; 4 % oxypolygelatin, 500 ml; 2:1) and transfusion (single group packed red cells, 250 ml) therapy was 2,250 ml. At the same time, the patient demonstrated transition from normodynamic circulation to hyperdynamic circulation (MBV ‒ 7.3 L/min., SV ‒ 69 ml, PR ‒ 1,542 dyn×cm×s^-5) that was associated with effective correction of hypovolemia and improving tissue perfusion confirmed by decreasing lactate in the venous blood (up to 1.2 mmol/L). At the same time, the arterial blood gas composition examination (during ALV) showed decreased oxygenation index (OI = ÐàÎ₂/FiÎ₂). ALV parameters were modified: positive end expiratory pressure was initiated (7 cm of water), FiO₂ increased (to 0.5 %) and neurovegetative blockade was enhanced. The repetitive examination of arterial blood gas composition did not find any positive dynamics of OI (295).

The X-ray examination showed bilateral pulmonary infiltrates that testified ARDS, with consideration of risk factors (traumatic shock) and acute initiation (during 72 h), absent clinical signs of left ventricle insufficiency. As result, simultaneously with non-invasive hemodynamic monitoring, metabolic monitoring (indirect calorimetry) was initiated. It identified hypermetabolism syndrome (according to indirect calorimetry, the energetic requirements were 2,895 kcal during neurovegetative blockade with morphine, propofol and sibazon). Hypermetabolism syndrome was indicated by albumin, total protein, urea and glucose in blood serum (table 1).

Table 1
Dynamics of energetic requirements, SOFA data and biochemical parameters in the patient K. during her treatment period

Note: control examinations were performed for 20 healthy donors.

Therefore, the treatment program was supplemented with nutritive support (for correction of hypermetabolism syndrome) [1] including isocaloric (1 kcal/ml) enteral polysubstrate mixture with dietary fibers (Nutricomp Fiber), 1,000 ml/24 h, using FmS infusion pump (B. Braun, Germany), 42 ml/h. Hyperthermia was found on 3d day (about 38.9° C), as well as increasing white cell count in peripheral blood (up to 16.8 10⁹/L) and increasing procalcitonin level (up to 5 ng/ml). It supposed severe infectious sepsis as result of traumatic shock.

Considering presence of ARDS in the patient, on the fourth day the intravenous fluid volume was decreased to 1,000 ml per day (isotonic sterofundin), and the enteral volume of polysubstrate mixture was increased to 2,000 ml. It was extremely significant for the patient with limited ability for fluid load sensing according to available ARDS [1].

For the present time it is the fact that enteral nutrition for ARDS is the most effective way for both volemic and nutritive support in patients with ARDS [1]. Also enteral feeding has some advantages compared to parenteral nutrition for this patient category [2, 3]. Therefore, parenteral feeding was not used for the patient. Moreover, enteral feeding (because of prebiotic contents) allowed correcting hypermetabolism events, and it was confirmed by daily energetic requirements, albumin, total protein, urea and glucose (table 1 and 2). Furthermore, use of enteral mixtures with dietary fibers in critically ill patients allows improving intestinal barrier function by means of inhibition of bacterial translocation from intestinal lumen to mesenteric lymph nodes and portal blood flow that intensifies proinflammatory effect of intensive care for patients with severe sepsis and ARDS, and decreases ALV period [4, 5].

On the next day the volume of infusion therapy was reduced (up to 500 ml), and enteral volume was increased to 2,500 ml (2,500 kcal). Enteral feeding was used during the whole treatment period in ICU under metabolic and biochemical monitoring, right up to transfer to the traumatology department on day 25.

On day 5 the examination of arterial blood gas composition found decreasing OI (up to 275). As result, ALV parameters were modified: increasing positive end expiratory pressure (up to 10 cm of water) and FiÎ₂ (up to 0,6 %). On day 7 the patient received tracheostomy for continuing ALV with previous mode. Intensive care favored correcting sepsis and multiple organ insufficiency on day 12 (table 1). A the same time one could observe involution of pulmonary dysfunction (OI ‒ 298) that allowed decreasing positive end expiratory pressure (up to 5 cm of water) and FiÎ₂ (up to 0.4 %) and making transition of the consciousness patient to SIMV+PS (RI ‒ 300) ventilation by day 14. On day 16 the patient received ventilation with CPAP+PS (RI – 315) mode and showed further regression of systemic inflammatory response and multiple organ insufficiency. Also increasing levels of albumin and plasma total protein were registered (table 2). At the same time the patient demonstrated dynamic decrease in energy requirements and serum urea (table 2) that testifies correction of hypermetabolism syndrome. On day 18 the patient was transferred to PS mode (OI ‒ 325), on day 21 ‒ to independent breathing (OI ‒ 347). The patient in middle severity state was transferred to the traumatology department on day 25.

Table 2 Dynamics of energetic requirements, SOFA data and biochemical parameters in the patient K. during her treatment period

CONCLUSION

Use of modern techniques of infusion and nutritive support in combination with other techniques for intensive care promoted both effective correcting the volemic, hemodynamic disorders and hypermetabolism syndrome during hemodynamic and metabolic monitoring. Parallel conduction of hemodynamic and metabolic monitoring in combination with estimation for severity of organ dysfunctions with SOFA allowed identifying the relationship between multiple organ insufficiency syndrome and hypercatabolism syndrome. Besides, the conducted monitoring showed that decrease in severity of multiple organ insufficiency that happened simultaneously with decrease in expression of hypermetabolism syndrome. The dynamic decrease in energy consumption during regressing multiple organ insufficiency allowed supposing the appropriateness of enteral nutritive support in the program for intensive care and improving clinical outcomes.