RU2366366C1 - Estimation method of haemostatic therapy effectiveness in tooth extraction in patients with haemorragic diseases - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to dentistry. The wound surface is covered with 2 gauze tampons for 5 minutes to be removed consistently thereafter and placed in 3 graduated glasses each containing 50 ml of the transforming solution. The tampons are kept in each graduated glass for 3 minutes and wrung out thoroughly when carried to the next glass. The contents of the graduated glasses are poured out in a flask, stirred thoroughly. Then its optical density v. optical density of calibration solution is measured at wavelength 540 nm in a measuring cell. The index R is calculated by formula: R = E₁/E₂, where R is the ratio of optical density of the analysed sample to optical density of the calibration solution, E₁ is optical density of the analysed solution, unit of opt.dens., E₂ is optical density of the calibration solution, unit of opt.dens. If the R is 2.2 or more, haemostatic therapy is estimated to be inefficient.

EFFECT: method provides higher estimation accuracy by elimination of subjective estimation to effect on the results, as well as due to ingestion of unknown amount of blood, method is easy to implement, does not require expensive equipment and reactants.

4 dwg, 1 tbl.

Description

The invention relates to medicine, in particular dentistry, and can be used to assess the effectiveness of hemostatic therapy in patients with hemorrhagic diseases during dental interventions.

With hemorrhagic diseases (hemophilia, von Willebrand disease, thrombocytopenia of various etiologies, etc.), there is a need for prophylactic hemostatic therapy when performing surgical dental interventions, since lifeless hemorrhages develop in the absence or insufficient efficiency. Quite often, hemostatic therapy for hemorrhagic diseases is insufficient, and in some cases (for example, with an inhibitory form of hemophilia) is completely ineffective, which leads to life-threatening anemic bleeding.

Therefore, it is currently relevant to develop methods to objectively assess the effectiveness of hemostatic therapy in patients with hemorrhagic diseases

A known method of monitoring the effectiveness of replacement therapy for patients with hemophilia A, based on the determination of the concentration of factor VIII in platelet-poor plasma after the application of concentrates of coagulation factor VIII [Unified methodology for the single-stage quantitative determination of factors VIII and IX. Hematology and transfusiology. - 1991. - No. 4. - S.33-35].

However, the known method is designed to assess the severity of hemophilic defects (level of coagulation factors VIII and IX) and is not able to assess the effectiveness of hemostatic therapy for von Willebrand disease, for platelet defects in hemostasis and other coagulation defects, which is its significant drawback.

The authors propose a method for evaluating the effectiveness of hemostatic therapy in patients with hemorrhagic diseases, in which blood loss is measured by the concentration of hemoglobin, which is contained in gauze tampons installed on the wound surface of the gums after tooth extraction.

The technical result of the proposed method is to increase the accuracy of the assessment by eliminating the influence on the results of any subjective assessment, as well as due to the ingestion of an unknown amount of blood by the patient.

The technical result is achieved by the fact that to take into account the blood loss, the amount of hemoglobin from the blood, impregnated with two gauze swabs, sequentially installed on the wound in the gum after tooth extraction is determined.

The method is as follows.

Reagents and equipment

1. Gauze swabs (for the preparation of one swab use gauze tissue measuring 8 × 10 cm).

2. Potassium iron-hydrogen sulfide, 0.2 g, manufacturer Sintakon, Russia.

3. Measuring cup, 5 pcs. 50 ml capacity, manufacturer LLC "Minimed", Russia.

4. Acetone cyanohydrin, 0.5 ml, manufacturer "Syntakon", Russia.

5. Calibration solution of hemoglobin "Diagem K" with a concentration of 120 g / l, 1 bottle, manufacturer "Renam", Russia.

6. Spectrophotometer or photometer with a wavelength of 540 nm (green filter).

7. A measuring cell with an optical path length of 10 mm (included in the scope of delivery of the photometer and spectrophotometer).

8. Dispensers that allow the selection of liquid volumes of 0.02 and 5.0 ml, manufacturer "Biohit", Finland.

9. Stopwatch, manufacturer "Agat", Russia.

10 Sodium bicarbonate, 1.0 g, manufacturer "Syntakon", Russia.

11. Volumetric flask with a capacity of 1.0 l, manufacturer LLC "Minimed", Russia.

12. Gloves, rubber or plastic.

13. Medical tweezers.

14. Glass flask with a volume of 200 ml.

15. Equipment and materials for tooth extraction: Dental chair "US-30", Russia; 100 ml of a 0.006% aqueous solution of chlorhexidine; Carpool needle (manufacturer "Terumo Corporation", Japan), Carpool needle (manufacturer "SFM", Germany); articaine hydrochloride (4% -1.8 ml, injection, manufacturer Inibs Laboratory, Spain), sickle-shaped iron (manufacturer STRUM, Belorussia); dental forceps, disposable syringe (manufacturer "SFM", Germany).

Reagent Preparation

Dilution of the transforming solution. In the volumetric flask add 1.0 g of sodium bicarbonate, 0.2 g of potassium iron-hydrogen sulfide, then add 0.5 ml of acetone cyanohydrin. Dissolve the indicated reagents in a small amount of distilled water, and then bring the volume of the solution with distilled water to the mark of 1000 ml.

Dilution of the calibration sample. To obtain a calibration sample, 5.0 ml of a transforming solution is added to 0.02 ml of a hemoglobin calibration solution.

Hemostatic therapy and tooth extraction procedure

1. Half an hour before the dental procedure, a hemostatic drug recommended by the hematologist is used (for example, factor VIII concentrate for hemophilia A, factor IX concentrate for hemophilia B, Willebrand factor concentrate for von Willebrand disease, NovoSeven, etc.).

2. Tooth extraction and local anesthesia are performed in the surgical room of the dental clinic. To implement this procedure, the patient is seated in a dental chair and an antiseptic treatment is carried out by rinsing the oral cavity with a 0.006% chlorhexidine solution, 30 ml for 20 seconds. In the area of the projection of the tips of the roots of the tooth to be removed, using a carpul syringe, a mucous membrane of the oral cavity is pierced to the periosteum with a carpul needle and a 4% solution of articaine hydrochloride is injected and 10 minutes after setting up anesthesia with a sickle-shaped smoothing, the circular ligament is separated from the tooth neck; impose the cheeks of dental forceps on the vestibular and oral surfaces of the extracted tooth, and then, fixing the cheeks of the forceps, dislocate the tooth by swaying. Using a disposable syringe, the tooth hole is washed with a 0.006% chlorhexidine solution, after which the doctor brings the edges of the hole together with your fingers.

Preparation of the test sample includes the following steps:

1. Add 50 ml of transforming solution to three measuring glasses.

2. Immediately after tooth extraction, a No. 1 tampon is applied to the wound surface and the stopwatch is turned on.

3. After 5 minutes, remove gauze swab No. 1 with tweezers and place it in the first measuring cup containing 50 ml of the transforming solution.

4. A gauze swab No. 2 is applied to the wound surface and the stopwatch is started.

5. After 5 minutes, gauze swab No. 2 is removed and it is also placed in the same first measuring cup containing 50 ml of transforming solution and gauze swab No. 1.

6. Incubate the first measuring cup with a transforming solution and two gauze swabs at room temperature for 3 minutes. After incubation, the swabs are gently squeezed out with tweezers, and then the swabs are placed alternately in the next two measuring cups, each time keeping the gauze swabs in the next measuring cup for 3 minutes and carefully squeezing the gauze swabs with tweezers, they are transferred one by one to the next measuring cup. The contents of the first measuring cup are tinted brown and of moderate intensity, and the contents of the last glass almost always remain transparent.

7. The test sample is obtained by draining the contents of three measuring glasses into a flask and thoroughly mixing.

The course of determining the concentration of hemoglobin accumulated with gauze swabs

1. Measure the optical density of the test sample (flask contents) against a blank sample (transforming solution) at a wavelength of 540 nm in a measuring cell with an optical path length of 10 mm

2. Measure the optical density of the calibration sample against a blank sample (transforming solution) at a wavelength of 540 nm in a measuring cell with an optical path length of 10 mm

Evaluation of the results

Calculate the indicator R, evaluating the severity of blood loss after tooth extraction,

,

,

where R is the ratio of the optical density of the test sample to the optical density of the calibration solution;

E ₁ - the optical density of the test sample, units opt. density;

E ₂ - the optical density of the calibration sample, units opt. density.

The optical density of the test sample depends on the amount of hemoglobin, i.e. from the amount of blood that is contained in gauze swabs taken from the wound surface. However, with significant impregnation of tampons with blood, the linearity of absorption in the presented test system will be violated. In the event that the obtained R exceeds 2.2, the test sample should be diluted with a transforming solution. Figure 1 presents the dilution scheme of the test sample and the coefficient to refine the indicator R with significant impregnation of tampons with blood.

In samples in which the optical density of various dilutions (R> 2.2) made in accordance with Table 1 was re-determined, the indicator R should be recalculated, for which the indicator R should be multiplied by k (the factor) indicated in the last column of the table.

When examining healthy people, it was found that R in healthy people was equal to 1.57; standard deviation (SD) = 0.31; sampling error (m) = 0.06; the number of patients (n) = 24, and the limits of normal fluctuations (X ± 2SD) were 0.95-2.19. Test results are considered violated, i.e. hemostatic therapy is considered ineffective if R is equal to or greater than 2.2.

The specificity of the method

The inventive method is highly specific, its readings depend only on the amount of blood that has soaked gauze swabs after tooth extraction, and do not depend on other factors, since the readings of the hemoglobin cyanide method depend on the amount of hemoglobin held by the swabs. In addition, its implementation does not require the use of any imported reagents and requires little time. And since the hemoglobin cyanide method for determining the level of hemoglobin is ubiquitous, its implementation is possible at any level, both in large research centers, and in district and district hospitals.

Clinical examples

Using the inventive method, hemostatic effect of various drugs was evaluated in patients with von Willebrand disease.

Example No. 1 (application of the proposed method for tooth extraction in patients with von Willebrand disease)

To test the proposed method, the hemostatic effect of the concentrate of factor VIII "Vilate" concentrate was evaluated in patient No. 1 with von Willebrand disease in the dosage recommended by the instructions for use of the drug.

As follows from figure 2, the indicator R, calculated by the claimed method, in a patient with von Willebrand’s disease, receiving a modern highly purified concentrate of von Willebrand factor ("Vilate") at a dose of 30 U / kg did not exceed the value of 2.2, which indicates that hemostatic the effectiveness of the drug in this patient was sufficient. After tooth extraction, any bleeding was not observed in the patient.

On the day after tooth extraction during the control examination and questioning it was established that no bleeding was observed during the day in the patient, the wound surface was covered by a dense clot of dark red color, no signs of inflammation, hematoma or tucking were found.

Thus, the claimed method allowed us to evaluate the good hemostatic effect of drug therapy.

Example No. 2 (application of the proposed method for tooth extraction in a patient with von Willebrand disease receiving cryoprecipitate)

To test the proposed method was evaluated hemostatic effect of cryoprecipitate in patient No. 2 with von Willebrand disease. The patient was prescribed cryoprecipitate before tooth extraction with hemostatic purpose. The results of determining the index R are presented in FIG. 3.

As follows from figure 3, the indicator R, calculated by the claimed method, in a patient with von Willebrand disease receiving cryoprecipitate significantly exceeds 2.2 and control values, which indicates that the hemostatic effectiveness of cryoprecipitate in this patient was low.

The obtained results of the determination of the indicator R allowed timely adjustment of the dosage of cryoprecipitate. After tooth extraction and the identification of high R values, the patient was additionally prescribed 4 doses of cryoprecipitate drip.

Thus, the inventive method allowed to quickly detect low hemostatic efficacy and increase the dosage of cryoprecipitate in a patient.

Example No. 3 (identification of latent hemostatic defect)

When testing the proposed method in one patient, a significantly larger amount of blood was infused with tampons than in others (Fig. 4). A thorough examination of this patient revealed episodes of nosebleeds. In addition, when studying the anamnestic data, it was found that the patient’s sister also has hemorrhagic manifestations (nasal and uterine bleeding).

These data served as the basis for the examination of this patient in a specialized laboratory of hemostasis. When examining the blood of patient No. 17, a moderate decrease in the concentration of von Willebrand factor and a violation of platelet aggregation with ristocetin were revealed. This combination of disorders in the hemostatic system is possible only with von Willebrand disease. Based on complaints, anamnestic and laboratory data, the diagnosis was made: von Willebrand disease, type II.

The application of the proposed method allows you to quickly assess the effectiveness of hemostatic therapy in the implementation of tooth extraction in patients with hemorrhagic diseases and a few minutes after tooth extraction to give the doctor information about the sufficient or insufficient hemostatic effect of the drug used, which allows you to quickly adjust the hemostatic therapy at low efficiency. Another positive feature of this method is the elimination of subjective assessment when comparing the effectiveness of two drugs that have the ability to reduce blood loss in patients with hemorrhagic diseases when removing teeth.

Claims (1)

A method for evaluating the effectiveness of hemostatic therapy for tooth extraction in patients with hemorrhagic diseases, which consists in placing two gauze swabs alternately on the wound surface for 5 minutes, which are then sequentially removed and placed in three measuring cups containing 50 ml of transforming solution, keeping in each for 3 minutes and carefully squeezing when transferring to the next glass, the contents of the measuring glasses are poured into a flask, mixed thoroughly, and then the optical density spine against the optical density of the calibration solution at a wavelength of 540 nm in the measuring cell and calculate the indicator R by the formula

,
where R is the ratio of the optical density of the test sample to the optical density of the calibration solution,
E ₁ - the optical density of the test solution, unit opt. Density,
E ₂ - the optical density of the calibration solution, unit opt.
and with an R value of 2.2 and higher, hemostatic therapy is evaluated as ineffective.

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