Artificial diuresis

Description:

The diuresis forced — the method of disintoxication therapy based on artificial stimulation of a mocheotdeleniye by simultaneous introduction to an organism of liquid and diuretics for the purpose of acceleration of allocation with urine from an organism of toxic substances. Speed of formation of urine, a component normal at healthy adult 0,7 — 1,3 ml/min., increases at D. ф. to 8 — 10 ml/min.

The disintoxication effect is caused, the removal of toxin generally accelerated owing to the increased formation of a glomerular ultrafiltrate (primary urine) and its bystry advance on renal tubules that reduces a toxin reabsorption in tubules, increasing its removal with urine. When using a method consider that the simple substances which are not connected with proteins and having neutral reaction are excreted preferential by glomerular filtering, and the substances having properties of weak acids or the bases irrespective of their linkng with proteins, cosecrete cells of renal tubules with a speed depending from рН urine. At subacidic reaction of urine substances with the main properties are better removed, at alkali reaction, on the contrary — substances with subacidic properties. So, alkalifying of urine to рН 7,0 and more increases renal clearance of phenobarbital approximately by 5 times, salicylic acid — by 10 times.

The main indication to use of an artificial diuresis are poisonings with the substances emitted from an organism preferential with urine. Seldom it is used at infectious intoxication. Contraindications to use of an artificial diuresis are the heavy cardiovascular insufficiency, a fluid lungs, wet brain, an intracranial hematoma, thrombosis and states menacing with its development (for example, cerebral ischemic crisis), a pericardis, portal hypertensia, digitalis intoxication, poisonings with the nephrotoxic poisons and substances having an extrarenal way of removal from an organism, a renal failure in an anury stage. A careful attempt of stimulation of a diuresis can be made at the beginning of an oligurichesky stage of the acute renal failure which developed after a massive hemotransfusion in connection with rabdomiolizy. In the absence of effect treatment is stopped.

The method of an artificial diuresis is applied in the conditions of a hospital. Begin its carrying out with catheterization or a puncture of a large vein (subclavial or elbow); catheterize also a bladder for a visual estimate of speed of urination. Intravenously in the beginning enter hypertensive, usually 20% or 40% glucose solution (respectively 800 or 400 ml) or 20% mannitol solution (at the rate of 1 g/kg of body weight of the patient) for receiving an osmotic diuresis, then for the purpose of hemodilution the polyionic isotonic solution containing sodium, potassium, calcium and magnesium for maintenance of concentration of these electrolytes in a blood plasma. Such solution 6 bottles on 400 ml of 0,85% of solution of sodium of chloride and 400 ml of 5% of solution of glucose with addition in them can make, for example, 15 ml of 10% of solution of potassium of chloride, 5 ml of 10% of solution of Calcii chloridum, 3 ml of 25% of solution of magnesium of sulfate. For the directed change рН urine use also solutions or Natrii hydrocarbonas (1 — 2 bottle on 200 ml of 4% of solution), or chloride ammonium (100 — 200 ml of 1% of solution). Alkalifying of urine to рН 7,8 — 8,5 is reasonable for treatment by means of an artificial diuresis of medium-weight poisonings methyl, ethyl, isopropyl and other alcohols, barbiturates of average and long action, streptocides, salicylates, ethylene glycol. Acidulation of urine to рН 5,0 — 4,5 raises medical effektpr poisoning with antihistaminic drugs, novokainamidy, nicotine, ksantinovy derivatives, an imipramine, quinine, quinidine, Phenaminum. At neutral reaction of urine by means of osmotic stimulation of a diuresis Meprotanum, strychnine, Chlorali hydras, bromides, fluorides, acetphenetidiene, analginum are well removed.

The solutions prepared for infusion at the beginning of the procedure enter with a speed of 1000 ml/h, then (after injection of 2 — 3 l) reduce the speed of infusion to 500 ml/h, bringing it into accord with an urination speed. Total quantity of the entered liquid makes not less than 8 l a day for men and 6 l a day for women, reaching in need of 12 l a day and more. To warn a delay in an organism of sick sodium, during the procedure each 3 — 4 hours enter 40 — 60 mg of furosemide, bringing its dose to 240 — 480 mg/days. Increase in a renal blood-groove and glomerular filtering is promoted by continuous infusion of Dinoprostonum (E2 prostaglandin); with the same purpose can be applied at certain indications the Euphyllinum, heparin and other drugs improving a blood stream in kidneys.

Duration of an artificial diuresis can make from several hours to several days. As a result of its use duration of a toxic coma is reduced and danger of the complications inherent to comas is eliminated.

The acute heart failure and fluid lungs owing to intravascular introduction of large amounts of liquid can be complications; wet brain owing to an osmotic imbalance of the leader to an overhydratation of cells; disturbance of acid-base equilibrium in case of overdose of alkaliziruyushchy or atsidifitsiruyushchy agents; a hypovolemia with falling of the ABP when speeding a diuresis over liquid infusion speed; the acute renal failure caused by osmotic damage of nephrons or potassium exhaustion.

To prevent development of complications when carrying out an artificial diuresis, watch the ABP level, pulse rate and breath; at least each 2 hours register an ECG, and in case of a coma as well EEG. During the day 3 — 4 times measure the central venous pressure and 1 — 2 time make the thorax X-ray analysis allowing to find early signs of an intersticial phase of a fluid lungs. Infusion speed in composition of the entered solutions is changed depending on dynamics of a condition of the patient, osmolarity of a blood plasma, indicators of a hematocrit, acid-base equilibrium, concentration in blood of crude protein, glucose, sodium, potassium, calcium, magnesium, chlorides, toxins. Are guided also by dynamics of an osmolyariost and рН urine.