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"Emergency medicine" 8 (71) 2015

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Current Approaches to the Correction of Hemostasis in Surgeries for Giant Uterine Myoma

Authors: Tarabrin O.O., Havrychenko D.H., Shcherbakov S.S., Mazurenko H.I., Turenko O.V., Kirpichnikova K.P. - Odessa National Medical University, Odessa, Ukraine

Categories: Medicine of emergency

Sections: Clinical researches

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Summary

Целью исследования было снижение периоперационной кровопотери у больных с гигантской миомой матки. В результате исследования были получены данные о том, что использование антифибринолитической терапии в виде назначения транексамовой кислоты за 30 минут до оперативного вмешательства в дозе 20 мг/кг с последующей инфузией 5 мг/кг в час в течение первых послеоперационных суток позволяет снизить периоперационную кровопотерю на 29 %. У больных второй группы уровень гемоглобина на вторые послеоперационные сутки был выше на 10 % (р < 0,05), кровопотеря была ниже на 29 % (р < 0,05), сроки пребывания в стационаре были меньше на 24 % (р < 0,05).

Метою дослідження було зниження періопераційної крововтрати у хворих із гігантською міомою матки. У результаті дослідження були отримані дані про те, що використання антифібринолітичної терапії у вигляді призначення транексамової кислоти за 30 хвилин до оперативного втручання в дозі 20 мг/кг з наступною інфузією 5 мг/кг на годину протягом перших післяопераційних діб дозволяє знизити періопераційну крововтрату на 29 %. У хворих другої групи рівень гемоглобіну на другу післяопераційну добу був вищим на 10 % (р < 0,05), крововтрата була нижчою на 29 % (р < 0,05), терміни перебування в стаціонарі були менше на 24 % (р < 0 , 05).

The objective of the study was to reduce the perioperative blood loss in patients with giant uterine myoma. As a result of studies, we have obtained evidence that the use of antifibrinolytic therapy as intravenous infusion of tranexamic acid 30 minutes before the surgery in a dose of 20 mg/kg followed by infusion of 5 mg/kg per hour for the first postoperative day helped to reduce perioperative blood loss by 29 %. In patients of the second group, hemoglobin level on the second postoperative day was higher by 10 % (p < 0.05), blood loss was lower by 29 % (p < 0.05), the length of stay in hospital was reduced by 24 % (p < 0.05).


Keywords

гигантская миома матки, кровопотеря, фибринолиз.

гігантська міома матки, крововтрата, фібриноліз.

giant uterine myoma, blood loss, fibrinolysis.

Actuality. Typical clinical manifestations of growth and development of uterine myoma is often accompanied by an increasing menstrual blood loss, and sometimes uterine bleeding, which some researchers consider "dysfunctional", and mainly dependent "neuroendocrine disorders". Thus, intraoperative blood loss, can act as an aggravating factor during the perioperative period. Reduced blood loss is an urgent problem in patients with uterine cancer, which is planned surgery.

The aim of the study was to reduce perioperative blood loss in patients with giant uterine myoma.

Materials and methods. Examined the results of surgical treatment of 92 patients with a diagnosis of giant uterine myoma. Research conducted at the Department of Gynecology and intensive therapy Odessa Regional Hospital in 2008-2015. The average age of patients with uterine myoьa was 48,31 ± 5,65 years. Blood clotting system was investigated using low-frequency pyezoelectric thromboelastography.

Patients were divided into two groups depending on the type of correction hemocoagulation disorders. 44 patients of 1 group received in complex correction epidural anesthesia at the level of L2-L3 7-12 ml of 0.5% bupivacaine and 10 mL of 0.5% bupivacaine in the first postoperative day fractionally. Anticoagulant therapy was bemiparin 2500 IU in the first post-operative day and for 7 days after. Antifibrinolytic therapy in these patients has not been evaluated. 48 patients of second group had complex correction which included epidural anesthesia at the level of L2-L3 7-12 ml of 0.5% bupivacaine and 10 mL of 0.5% bupivacaine in the first postoperative day fractionally. Anticoagulant therapy was bemiparin 2500 IU in the first post-operative day and for 7 days after. Patients in this group was assigned tranexamic acid for 30 minutes prior to surgery in a dose of 20 mg / kg, and followed infusion -  5 mg / kg per hour for the first postoperative day.

Statistical analysis was provided using the methods of parametric and non-parametric analysis (software Statistica 6.0 (StatSoft Inc., USA).

Results. In the preoperative period in patients with giant uterine myomas was found activation of fibrinolysis, increasing of platelet aggregation and hypercoagulability. Patients with uterine cancer had structural and chronometric activation of vascular-platelet hemostasis with an increased generation of thrombin and the activation of the fibrinolytic activity of the blood.

As a result of studies have provided evidence that the use of antifibrinolytic therapy as intravenous infusion of tranexamic acid for 30 minutes before the surgery in a dose of 20 mg / kg followed by infusion of 5 mg / kg per hour for the first postoperative day, helped to reduce perioperative blood loss by 29%. Hemoglobin level   was higher by 10% (p <0.05), blood loss was lower by 29% (p <0.05), the length of stay in hospital was reduced by 24% (p <0 05) in patients of the second group on the second postoperative day.

Conclusions. Patients with giant uterine myomas had changes of the hemostatic system in comparison with the norm state before treatment: hyperaggregation (the intensity of the contact phase of coagulation increased by 76% (p <0,05)), hypercoagulation (rate intensity of coagulation increased by 71% (p <0,05)) and activation of fibrinolysis (increase in the intensity of the retraction and clot lysis) by 65% (p <0,05). It was found that patients with giant uterine myoma, which at the perioperative stage of treatment did not receive antifibrinolytic therapy, on the third day after surgery had the rate of the intensity of the contact phase of coagulation increased by 24%, the intensity of coagulation drive has been reduced by 8% compared with the norm which indicating the recovery status of coagulation hemostasis. The intensity of clot retraction and lysis was not restored and has been increased by 27% compared to the norm (P <0.05), indicating that maintaining the activation of fibrinolysis. It was  found that patients with giant uterine myoma, which in the perioperative stage of treatment received antifibrinolytic therapy, on the third day after surgery had indicator intensity of the contact phase of coagulation increased by 19%, the intensity of coagulation drive was increased by 6% compared with the norm. The indicator intensity of clot retraction and lysis was increased by 6% (p <0.05) compared with group 1, indicating a normalization of fibrinolysis. Use of epidural anesthesia, tranexamic acid and bemiparin is the most appropriate to reduce blood loss and recovery of the hemostatic system capabilities. In patients with a hemoglobin level of the 2 group on the second postoperative day was higher by 10% (p <0.05), blood loss was lower by 29% (p <0.05), the need for transfusion of blood products decreased by 9.28% (p <0,05), length of stay in intensive care was 24% lower (p <0,05).


Bibliography

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