ОБРАЗОВАНИЕ НАУКА И ИННОВАЦИОННЫЕ
ИДЕИ В МИРЕ
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THE IMPORTANCE OF INFUSION THERAPY IN THE INTENSIVE
TREATMENT OF PATIENTS WITH OBSTRUCTIVE JAUNDICE
Joniev S.Sh.,
Shodmonov I. B., Yuldashev M.I., Togayev I.P.
Samarkand State Medical University, Samarkand, Uzbekistan
Keywords:
Obstructive Jaundice, Intensive Therapy, Low-Volume Infusion
Therapy
Abstract:
Pathologies occurring in the div are characterized by the induction of
severe complications affecting all systems. The significance of perioperative
monitoring of key homeostatic parameters, including colloid osmotic pressure, blood
plasma osmolality, and blood coagulation potential, is highlighted. Alterations in these
parameters are considered inevitable during surgical interventions, particularly in
patients with concomitant diseases. The correction of volume disturbances is
considered a primary task determining the outcome of surgical treatment. Infusion-
transfusion therapy utilizing colloid and crystalloid solutions, along with the
accompanying hemodilution, has a significant impact on homeostatic parameters. This
literature review was conducted to gain a deeper understanding of the pathophysiology
of these processes.
Factors Causing Obstructive Jaundice and Infusion Therapy
Rational infusion therapy is a fundamental component of anesthetic care and
intensive therapy. This is potentially due to the absence of an optimal infusion medium
that can be safely administered in the volume necessary to maintain circulating blood
volume (CBV). Another reason for the ineffectiveness of infusion therapy is the lack
of timely monitoring of various physiological and biochemical parameters that are
affected by infusion solutions [1, 2]. Difficulties also arise in their comprehensive
assessment. Analysis of the literature emphasizes the importance of monitoring and
correctly interpreting hemodynamic parameters, blood composition, osmolarity, and
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plasma oncotic pressure, as well as coagulation status, when conducting infusion
therapy [3, 5].
The Significance of Osmolality in Infusion Therapy
Maintaining osmotic pressure is the process of water movement across a
semipermeable membrane from an area of lower solute concentration to an area of
higher solute concentration. Osmotic pressure is the amount of hydrostatic pressure
required to stop the osmotic flow of water. Osmolality is a measure of a solution's
ability to draw water across a semipermeable membrane via osmosis. It is defined as
the total concentration of solute particles in a true solution (in mosmol/kg water),
irrespective of their size, shape, or electrical charge [6, 9, 11]. Normally, plasma
osmolality is approximately 285 ± 5 mosmol/kg water, and this range can expand under
compensated normo-osmolality. The osmolality created by substances that cannot
readily cross cell membranes, such as inorganic ions, glucose, and proteins, is referred
to as tonicity. The law of isoosmolality dictates that osmolality should be consistent
across all fluid compartments in the div. Deviations from this can lead to various
cellular dysfunctions, including mechano-osmotic tension of the plasma membrane,
detachment from the cytoskeleton, intracellular potassium loss, and disruption of
cellular bioelectrical processes. Some researchers note that fluid distribution in the
div is linked to the distribution of osmotically active substances [12]. Under normal
conditions, this distribution is maintained by biological barriers and ion pumps.
The importance of osmometry in the initial operative period is confirmed by the
research of F.I. Turayev. He demonstrated that changes in osmotic parameters, in
conjunction with neuroendocrine (insulin, glucagon, cortisol, antidiuretic hormone,
renin) and volemic (CBV) indicators, could predict the development of surgical and
purulent-septic complications in the early postoperative period. Early detection of these
changes allows for the implementation of preventative corrective therapy [13].
Furthermore, the widespread use of crystalloids, while advantageous due to their
affordability and low reactivity, can present certain challenges. For example, the excess
chloride present in "physiological saline" can lead to hyperchloremic acidosis in cases
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of high-volume infusion. Additionally, the hypo-osmolality of Ringer's solution also
raises some concerns [14]. It has been confirmed that altering plasma osmolality can
have a positive impact on hemodynamics. Thus, osmolality, by regulating water
movement across different fluid compartments, significantly impacts tissue perfusion
and cellular functional status, indirectly influencing the effectiveness of surgical
treatment [10].
Preparations Used for Infusion Therapy
One of the factors influencing blood volume is the interplay of opposing forces,
namely hydrostatic and colloid osmotic pressures, which operate both within and
outside the vascular system. Colloid osmotic pressure (COP), also known as oncotic
pressure, is a component of osmotic pressure generated by colloid molecules that are
unable to permeate capillary walls. Other researchers identify statistical differences
between colloid osmotic pressure (COP) and COP calculated using the Landis-
Pappenheimer formula, which utilizes the total protein concentration in plasma. Liquid
heparin coating the walls of a syringe or cannula can dilute the sample and lead to
erroneously low COP values; therefore, cannula walls should be coated with dry
heparin. Colloid osmotic pressure (COP) measurements may show elevated values
during hypernatremia (and alkalosis, which enhances the effect of the Gibbs-Donnan
effect on osmolality). Conversely, in cases of hyponatremia (and acidosis), values will
be reduced, which is related to the technical specifications of the oncometer. If sodium
levels in the sample are normal, but hyperosmolality is due to elevated levels of
glucose, urea, mannitol, or other non-electrolytes, this error is not observed. Dextran
and hydroxyethyl starch (HES) molecules are electroneutral, and their effect on plasma
colloid osmotic pressure (COP) is not accompanied by the Gibbs-Donnan effect, which
is observed with albumin preparations. COP measurements in plasma with these
infusion agents should be interpreted cautiously, as a significant proportion of HES
molecules can pass through the oncometer membrane with a permeability of 30,000
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Da. In such cases, using a membrane with a permeability limit of 10,000 Da may be
more appropriate.
Average normal COP values decrease with age: in individuals under 50 years of
age, the average is 21.1 ± 4.8 mm Hg, while in those aged 70–
89 years, this value is
19.7 ± 3.7 mm Hg. Even strict bed rest lasting several hours leads to a decrease in COP
of ap
proximately 15%. Daily fluctuations in COP levels within ±10% in the same
patient are considered normal. According to local researchers, plasma COP is a key
factor regulating water movement between tissues and capillaries. This implies that the
endothelium has high permeability for inorganic ions but low permeability for
polymeric ions, including proteins (under normal conditions). However, under
pathological conditions, this permeability increases [44]. Some authors highlight a
decrease in plasma colloid osmotic pressure (COP) levels in dogs receiving crystalloid
infusions and in dogs undergoing ovariohysterectomy who did not receive any
infusions [33]. The decrease in COP in the perioperative period is associated with blood
loss and its replacement with hypo-oncotic solutions, as well as the catabolic phase of
protein metabolism, tissue hypoxia and acidosis, and increased permeability of blood
vessel walls. The endothelial glycocalyx is considered a second protective layer, in
addition to the endothelial cell lining, against unrestricted extravasation. This layer, by
binding plasma proteins, performs a primary function of molecular filtration and
generates an effective oncotic gradient within a confined space [18]. Some researchers
emphasize the significance of the pressure gradient between blood hydrostatic and
oncotic pressures and the sub-endothelial glycocalyx space for transcapillary fluid
exchange, suggesting it is more crucial than interstitial pressure.
Damage to the endothelial glycocalyx during the perioperative period is
considered inevitable due to the effects of inflammatory mediators, leading to the
development of interstitial edema. A study by Brandstrup, using colorectal surgeries as
an example, demonstrated that reducing the volume of intravenous infusions
administered perioperatively to 2.7 L/day (restricted group) from 5.4 L/day (liberal
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regimen group) significantly decreased the incidence of postoperative complications
such as anastomotic leakage, pulmonary edema, pneumonia, and wound infection [5].
Concurrently, colloids were primarily used in the restricted group, whereas crystalloids
were used in the liberal regimen group. To assess circulating blood volume (CBV), J.
Boldt recommends considering hemodynamic indicators (arterial pressure, pulse
pressure variations, cardiac output), filling pressure parameters (such as central venous
pressure), diuresis data, and indicators of arterial and central venous blood gas
composition, including acid-base balance [9].
When evaluating the influence of plasma colloid osmotic pressure (COP) on
transcapillary fluid movement, it is crucial to consider the structural and functional
differences between systemic and pulmonary circulation. Researchers determined that
a 50% reduction in COP significantly elevates the risk of pulmonary edema, but only
in the context of left ventricular failure and when the left atrial end-diastolic pressure
exceeds 10 mm Hg. Demling R.H. and colleagues, in experiments conducted on sheep
lungs, found that in hypoproteinemia, the rate of transcapillary filtration in the lungs is
less dependent on low plasma oncotic pressure but is significantly correlated with
capillary hydrostatic pressure. Conversely, studies by V. Velanovich across numerous
experimental models and clinical trials have not demonstrated a clear correlation
between oncotic pressure and the volume of tissue water in the lungs [15]. According
to O. Habler, blood transfusions do not benefit ICU patients suffering from polytrauma
and sepsis if they raise hemoglobin levels above 90 g/L [12]. In such cases, the blood
coagulation system is activated, erythrocytes enter a state of rouleaux formation (coin
stacking), and they are also damaged within fibrin networks [13].
A. Shander argues that an individual's reaction to anemia depends on their ability
to adapt to this condition, and manifests differently in each person. Many symptoms
associated with anemia may arise from inadequate circulating volume repletion, and
simply normalizing this physiological parameter may be sufficient to eliminate them.
Despite a significant reduction in oxygen delivery, oxygen consumption also decreases,
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and the load on the left ventricle reduces even more than oxygen delivery. This positive
compensation occurs due to improved blood viscosity, a significant decrease in total
peripheral resistance, and a reduction in filling pressures within the cardiac chambers
[15]. A.V. Koloskov's assertion highlights the importance of considering hemoglobin
levels in patients with cardiovascular diseases, especially in the context of surgical
stress. Low hemoglobin levels (below 100 g/L) increase the risk of mortality in these
cases. The role of myocardial ischemia, which often manifests at the end of surgery but
is masked by anesthetics, is also emphasized, leading to delayed signaling of
cardiovascular decompensation [16]. Some researchers point out that red blood cells
play a crucial role not only in gas transport function but also in stabilizing hemostasis
when hematocrit is above 30% and hemoglobin levels are 100 g/L or higher [12, 13].
In the study by Singbartl K. and colleagues, the importance of a critically low plasma
fibrinogen concentration (below 1 g/L) as a limiting factor for hemodilution was
emphasized [14]. One of several explanations for changes in blood coagulation
associated with hemodilution is an imbalance between anti- and procoagulant
mechanisms. Some studies have reported the activation of fibrinolysis in the
perioperative period. S.G. Reshetnikov attributes this to the suppression of endogenous
antifibrinolytics by synthetic colloids and their incorporation into the thrombus
structure, resulting in a softer thrombus that is more easily lysed.
Conclusion:
In conclusion, to ensure the successful outcome of surgical treatment in the
intensive care of patients with obstructive jaundice, it is essential to address and correct
adverse conditions related to hematocrit and hemostasis disorders. This can be
achieved through the rational and judicious application of infusion solutions. Analysis
of the literature indicates that this problem remains unresolved in contemporary
practical medicine. The information presented here can enable specialists to more
effectively target and optimize infusion therapy for the underlying pathology.
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