Physical methods for finally stopping bleeding. Temporary and definitive methods of stopping bleeding. Rules for the final stop of bleeding

There are 3 groups of causes that cause bleeding.

Group 1 includes mechanical damage to the vascular wall. These injuries can be open, when the wound channel penetrates the skin with the development of external bleeding, or closed (for example, as a result of injuries to blood vessels with bone fragments during closed fractures, traumatic ruptures of muscles and internal organs), leading to the development of internal bleeding.

The 2nd group of causes causing bleeding includes pathological conditions of the vascular wall. Such conditions can develop as a result of atherosclerosis, purulent melting, necrosis, specific inflammation, or a tumor process. As a result, the vascular wall is gradually destroyed, which can ultimately lead to “suddenly” occurring arrosive bleeding.

The 3rd group of reasons includes disorders of various parts of the blood coagulation system(coagulopathic bleeding). Such disorders can be caused not only by hereditary (hemophilia) or acquired (thrombocytopenic purpura, prolonged jaundice, etc.) diseases, but also by decompensated traumatic shock, leading to the development of disseminated intravascular coagulation syndrome (consumptive coagulopathy).

Depending on where the blood is poured out, there are external bleeding, in which blood is shed into the external environment (either directly or through natural orifices of the body), and internal, when blood accumulates in body cavities, interstitial spaces, imbibing tissue.

Depending on the time of occurrence, primary and secondary bleeding are distinguished.

Primary bleeding is caused by damage to the vessel at the time of injury and occurs immediately after it.

Secondary-early bleeding (from several hours to 2-3 days after injury) can be caused by damage to blood vessels or blood clot separation due to inadequate immobilization during transportation, rough manipulations during reposition of bone fragments, etc.

Secondary-later bleeding (5-10 days or more after injury), as a rule, is a consequence of destruction of the vessel wall as a result of prolonged pressure from a bone fragment or foreign body (bedsore), purulent melting of a blood clot, arrosion, or rupture of an aneurysm.

Depending on the anatomical structure of the damaged vessels, bleeding may be arterial, venous, capillary (parenchymal) and mixed.

Stop bleeding.

There are temporary (with the goal of creating conditions for further transportation of the victim) and final stopping of bleeding.

Temporary stop of external bleeding

performed when providing first medical, pre-medical and first aid. The following methods are used:

Finger pressure of the artery;

Maximum limb flexion;

Application of a tourniquet;

Applying a pressure bandage;

Applying a clamp to a wound (first medical aid);

Wound packing (first medical aid).

When providing qualified surgical care in case of damage to a great vessel, temporary shunting is performed (restoration of blood flow through a temporary prosthesis) - the only method of temporarily stopping bleeding inherent in this

type of help.

Final stop of bleeding

(external and internal) is the task of qualified and specialized surgical care. The following methods are used:

Applying a ligature to a bleeding vessel (ligation of a vessel in a wound);

Ligation of the vessel throughout;

Application of a lateral or circular vascular suture;

Vessel autoplasty (when providing specialized care).

First aid:

Hemostasis control; revision of the tourniquet (shifting the tourniquet, the residence time of which is approaching the maximum, finger pressure); application of hemostatic clamps, ligatures. For venous and capillary diseases, a pressure bandage is used.

Qualified help:

Final stop of external bleeding is performed in the dressing room, where victims with compensated shock or ongoing external bleeding are sent, as well as with a tourniquet for the purpose of its revision and removal. Victims with decompensated shock and a fully completed temporary stop of bleeding without the use of a tourniquet are sent to the anti-shock department; the final stop of bleeding in them is postponed until recovery from shock.

The final stop of bleeding is usually carried out in parallel with the primary surgical treatment of the wound and consists of applying ligatures to the damaged vessels.

Small vessels can be coagulated.

Methods for finally stopping bleeding, depending on the nature of the methods used, are divided into mechanical, physical (thermal), and chemical.

Mechanical methods.

Mechanical methods of stopping bleeding are the most reliable. When large vessels, medium-sized vessels, or arteries are damaged, only the use of mechanical methods leads to reliable hemostasis.

Vessel ligation.

There are two types of vascular ligation:

Ligation of a vessel in a wound;

Ligation of the vessel throughout.

Ligation of a vessel in a wound.

Ligating the vessel in the wound, directly at the site of injury, is certainly preferable. This method of stopping bleeding disrupts the blood supply to a minimal amount of tissue.

Most often, during operations, the surgeon applies a hemostatic clamp to the vessel, and then a ligature (the temporary method is replaced by the final one). An alternative to ligation is vessel clipping - placing metal clips (clips) on the vessel using a special clipper. This method is widely used in endoscopic surgery.

Ligation of the vessel throughout

Ligation of a vessel throughout is fundamentally different from ligation of a wound. Here we are talking about ligating a fairly large, often main trunk proximal to the site of injury. In this case, the ligature very reliably blocks the blood flow through the main vessel, but bleeding, although less serious, can continue due to collaterals and reverse blood flow.

The main disadvantage of ligating a vessel over its length is that a much larger volume of tissue is deprived of blood supply than when ligating a wound. This method is fundamentally worse and is used as a forced measure.

There are two indications for ligating the vessel along its length.

The damaged vessel cannot be detected, which happens when bleeding from a large muscle mass (massive bleeding from the tongue - the lingual artery on the neck is tied in Pirogov's triangle; bleeding from the muscles of the buttock - the internal iliac artery is tied, etc.);

Secondary arrosive bleeding from a purulent or putrefactive wound (bandaging the wound is unreliable, since arrosion of the vessel stump and recurrent bleeding are possible, in addition, manipulations in a purulent wound will contribute to the progression of the inflammatory process).

The technique is performed in accordance with topographic and anatomical data: the vessel is exposed and ligated along the length proximal to the damage zone.

Sewing the vessel.

In cases where the bleeding vessel does not protrude above the surface of the wound and it is not possible to grasp it with a clamp, a purse-string or Z-shaped suture is applied around the vessel through the surrounding tissue, followed by tightening the thread - the so-called suturing of the vessel

Twisting, crushing of blood vessels.

The method is rarely used for bleeding from small veins. A clamp is placed on the vein, it remains on the vessel for some time, and then is removed. Additionally, you can rotate the clamp several times around its axis. In this case, the vessel wall is maximally injured and it is reliably thrombosed.

Wound tamponade, pressure bandage.

Wound tamponade and application of a pressure bandage are methods of temporarily stopping bleeding, but they can also become permanent. After removing the pressure bandage (usually on the 2-3rd day) or removing the tampons (usually on the 4-5th day), the bleeding may stop due to thrombosis of the damaged vessels.

Vascular embolization.

The method refers to endovascular surgery. It is used for bleeding from the branches of the pulmonary arteries, the terminal branches of the abdominal aorta, etc. In this case, the femoral artery is catheterized using the Seldinger method, the catheter is brought to the bleeding area, a contrast agent is injected and, taking X-rays, the site of damage is identified (diagnostic stage). Then an artificial embolus (coil, chemical substance: alcohol, polystyrene) is brought through a catheter to the site of damage, closing the lumen of the vessel and causing rapid thrombosis.

The method is low-traumatic and allows one to avoid major surgical intervention, but its indications are limited. In addition, special equipment and qualified employees are needed.

Special methods to combat bleeding.

Mechanical methods of stopping bleeding include certain types of operations: splenectomy for parenchymal bleeding from the spleen, gastric resection for bleeding from an ulcer or tumor, lobectomy for pulmonary bleeding, etc.

One of the special mechanical methods is the use of an obturator probe for bleeding from esophageal varices - a fairly common complication of liver diseases accompanied by portal hypertension syndrome. Typically, a Blackmore probe is used, equipped with two cuffs, the lower of which is fixed in the cardia, and the upper, when inflated, compresses the bleeding veins of the esophagus.

Vascular suture and vascular reconstruction.

It is used for damage to large main vessels, the cessation of blood flow through which would lead to adverse consequences for the patient’s life. There are manual and mechanical seams.

When applying a manual suture, atraumatic non-absorbable suture material is used (threads No. 4/0-7/0 depending on the caliber of the vessel).

With different types of damage to the vascular wall, various options for reconstructive intervention on blood vessels are used: side suture, side patch, resection with end-to-end anastomosis, prosthetics (vessel replacement), bypass surgery (creating a bypass for blood).

When reconstructing blood vessels, autovenous vein, autoartery, or synthetic material are usually used as prostheses and shunts. For such a vascular operation, the following requirements must be met:

High degree of tightness;

No blood flow disturbances (constrictions and turbulence);

As little suture material as possible in the lumen of the vessel;

Precise matching of vascular wall layers.

It should be noted that only with this method the blood supply to the tissues is fully preserved.

Physical methods.

They are used only for bleeding from small vessels, parenchymal and capillary, since bleeding from a medium or large vein, and especially an artery, can only be stopped mechanically.

Physical methods are otherwise called thermal, as they are based on the use of low or high temperature.

Exposure to low temperature.

The mechanism of the hemostatic effect of hypothermia is spasm of blood vessels, slowing of blood flow and vascular thrombosis.

Local hypothermia.

To prevent bleeding and the formation of hematomas in the early postoperative period, place an ice pack on the wound for 1-2 hours. The method can be used for nosebleeds (ice pack on the bridge of the nose), stomach bleeding (ice pack on the epigastric area).

In case of gastric bleeding, it is also possible to introduce cold (+4°C) solutions into the stomach through a probe (usually chemical and biological hemostatic agents are used).

Cryosurgery.

Cryosurgery is a special field of surgery. Very low temperatures are used here. Local freezing is used in operations on the brain, liver, and in the treatment of vascular tumors.

Exposure to high temperature.

The mechanism of the hemostatic effect of high temperature is coagulation of the protein of the vascular wall, acceleration of blood clotting.

Using hot solutions

The method can be applied during surgery. For example, with diffuse bleeding from a wound, with parenchymal bleeding from the liver, gall bladder bed, etc., a napkin with a hot saline solution is inserted into the wound and held for 5-7 minutes; after removing the napkin, the reliability of hemostasis is monitored.

Diathermocoagulation.

Diathermocoagulation is the most commonly used physical method to stop bleeding. The method is based on the use of high frequency currents, leading to coagulation and necrosis of the vascular wall at the site of contact with the tip of the device and the formation of a blood clot. Without diathermocoagulation, no serious operation is now unthinkable. It allows you to quickly stop bleeding from small vessels without leaving ligatures (foreign body) and thus operate on a dry wound. Disadvantage of the electrocoagulation method: with excessive coagulation, extensive necrosis occurs, which can complicate subsequent wound healing.

The method can be used for bleeding from internal organs (coagulation of a bleeding vessel in the gastric mucosa through a fibrogastroscope), etc. Electrocoagulation can also be used to separate tissues with simultaneous coagulation of small vessels (an instrument called an “electronic knife”), which greatly facilitates a number of operations , since the incision is essentially not accompanied by bleeding.

Based on antiblastic considerations, the electric knife is widely used in oncological practice.

Laser photocoagulation, plasma scalpel.

The methods relate to new technologies in surgery. They are based on the same principle as diathermocoagulation (creation of local coagulation necrosis), but allow more dosed and gentle stopping of bleeding. This is especially important for parenchymal bleeding.

Chemical methods.

According to the method of application, all chemical methods are divided into local and general (or resorptive action).

Local hemostatic agents.

Local hemostatic agents are used to stop bleeding in a wound, in the stomach, and on other mucous membranes.

Hydrogen peroxide. Used for bleeding in the wound, it acts by accelerating thrombus formation.

Vasoconstrictors (adrenaline). Used to prevent bleeding during tooth extraction, injected into the submucosal layer during gastric bleeding, etc.

Fibrinolysis inhibitors - ε-aminocaproic acid. Injected into the stomach for gastric bleeding.

Gelatin preparations (gelaspon). They are sponges made of foamed gelatin. They accelerate hemostasis, since upon contact with gelatin, platelets are damaged and factors that accelerate the formation of a blood clot are released. In addition, they have a tamponing effect. Used to stop bleeding in an operating room or an accidental wound.

Wax. Its tamponing effect is used. Damaged flat bones of the skull are sealed with wax (in particular, during craniotomy surgery).

Carbazochrome. Used for capillary and parenchymal bleeding. Reduces vascular permeability, normalizes microcirculation. Apply wipes moistened with the solution to the wound surface.

Caprofer. Used for irrigation of the gastric mucosa during bleeding from erosions of acute ulcers (during endoscopy).

Hemostatic substances with resorptive action

Hemostatic substances with a resorptive effect are introduced into the patient’s body, causing an acceleration of the process of thrombosis of damaged vessels.

· Fibrinolysis inhibitors (ε-aminocaproic acid).

Calcium chloride - used for hypocalcemia, since the ions

· Calcium is one of the factors of the blood coagulation system.

· Substances that accelerate the formation of thromboplastin - dicinone, etamsylate (in addition, they normalize the permeability of the vascular wall and microcirculation).

· Substances with specific actions. For example, pituitrin for uterine bleeding: the drug causes contraction of the uterine muscles, which reduces the lumen of the uterine vessels and thus helps stop bleeding.

· Synthetic analogues of vitamin K (vicasol). Promotes the synthesis of prothrombin. Indicated for liver dysfunction (for example, cholemic bleeding).

· Substances that normalize the permeability of the vascular wall (ascorbic acid, rutin, carbazochrome).

History of the doctrine of blood transfusion. Immunological basis of blood transfusion.

There are four main periods in the history of blood transfusion.

First period: from ancient times to 1628.

Second period: from 1628 to 1901.

Third period: from 1901 to the first blood transfusion, taking into account group affiliation (Kreil, V.N. Shamov).

Fourth period: from the 1st blood transfusion, taking into account group affiliation, to the present day.

In ancient times, among many peoples, the treatment of many diseases by ingesting blood became widespread. The dominance of so-called vampirism continued into the Middle Ages.

The idea of ​​rejuvenation by infusing blood into the vessels did not justify itself. It is known that Pope Innocent received a blood transfusion from two young men in 1492.

In 1628, Harvey described the blood circulation, and in 1667 Denis and Emerez in France transfused the blood of a lamb to a patient, but the fourth transfusion ended in the death of the patient. At a special court hearing, it was decided that any administration of blood should be used only after special permission from the Faculty of Medicine of the University of Paris.

However, in 1675 The Vatican issued a verdict prohibiting human blood transfusions, and work was curtailed for almost a century and a half.

In 1819, the English doctor I. Blendel first transfused blood from person to person using a special device.

The first successful blood transfusion in Russia was performed by G. Wolf in 1832. For wounds and blood loss, blood transfusion was used by N.I. Pirogov, I.V. Buyalsky, S.P. Kolomnin. In Russia, from 1832 to the end of the 19th century, 60 blood transfusions were carried out, however, both in our country and abroad, these works were of an empirical nature.

Blood transfusions became scientifically sound and less dangerous after K. Landsteiner established in 1901 that human blood serum can stick together (agglutinate) the red blood cells of another person. This phenomenon is called the “isohemagglutination phenomenon.”

Landsteiner described three blood groups, and in 1907 Jansky described the fourth blood group.

The blood group is determined by the presence of group-specific antigens in the erythrocytes - agglutinogens: A, B and O, and in the serum - antibodies: α and β. Agglutinogens are polypeptides that appear in the 3rd month of fetal development. Serum agglutinins are found in globulin fractions and their maximum titer is between the ages of 5 and 20 years.

The reaction of erythrocyte gluing occurs in cases where there is a meeting of the same agglutinogens and agglutinins: A and α, B and β. Moreover, red blood cells from donor blood are agglutinated.

According to the classification of K. Landsteiner and J. Jansky, the following blood groups are currently distinguished:

Group I - O (I) αβ - there are no agglutinogens A and B in erythrocytes, there is agglutinogen O, but since there are no antibodies to it, it has no practical significance. These individuals have agglutinins α and β in their plasma and serum.

Group II – A (II) β – erythrocytes contain agglutinogen A, serum contains agglutinin β.

Group III – B (III) α – agglutinogen B in erythrocytes, agglutinin α in serum.

Group IV - AB (IV)o - erythrocytes contain agglutinogens A and B, there are no agglutinins in the serum.

Blood type does not change throughout a person's life.

Based on the discovery of K. Landsteiner, in 1907. G. Kreil performed the first blood transfusion taking into account group affiliation. In 1919, the first blood transfusion in Russia taking into account group affiliation was performed by V.N. Shamov.

Sodium citrate, proposed in 1914 by V.A. Yurevich and N.K. Rosengart for the prevention of blood clotting, made it possible to begin research on its preservation. In 1934, the brilliant domestic scientists A.N. Filatov and N.G. Kartashevsky were the first in the world to separate donor blood into fractions, laying the foundation for the production of components and blood products, and, defining a new, modern direction of transfusiology - the use of individual components for transfusion and blood fractions.

In 1940, Landsteiner and Wiener discovered another antigen contained in human red blood cells, designating it Rh (Rh factor).

Rhesus factor, as it turned out, is unevenly distributed among representatives of individual races. Among the European population, this antigen is present in 85% of people (Rh - positive) individuals, and in 15% (Rh - negative individuals) it is absent. Among people of the Mongoloid race, Rhesus negative individuals account for only 0.5%.

Currently, there are 6 main types of antigens of the Rhesus system (Rh - Hr), which make up the polyallelic system:

Rh (D), rh | (C), rh || (E)

Hr (d), hr | (c), hr (e).

The most important of these is the Rh antigen, which has the greatest immune activity.

The discovery of Landsteiner and Wiener determined the basic requirements necessary for each blood transfusion: transfusion taking into account compatibility with the ABO and Rh antigens.

Group systems of erythrocytes. AB0 group system and Rh group system. Methods for determining blood groups using the ABO and Rh systems.

Depending on the presence of agglutinogens A and B in erythrocytes, and the corresponding agglutinins α and β in serum, all people are divided into four groups:

Group O (I) - there are no agglutinogens in erythrocytes, agglutinins α and β in serum.

Group A (II) - agglutinogen A in erythrocytes, agglutinin β in serum.

Group B (III) - agglutinogen B in erythrocytes, agglutinin α in serum.

Group AB (IV) - erythrocytes contain agglutinogens A and B, there are no agglutinins in the serum.

Recently, varieties of classical antigens A and B, as well as other antigens, have been discovered in the AB0 system.

The basis for determining the blood group is the reaction of direct hemagglutination at room temperature, which develops when the same agglutinins and agglutinogens meet.

There are 3 ways to determine blood group according to the ABO system:

1. using standard sera containing natural agglutinins in sufficient titer, allowing one to determine which agglutinogens are contained in the red blood cells of the test blood;

2. using hybridoma preparations containing immune antibodies anti-A, anti-B and anti-AB, which also make it possible to detect agglutinogens A and B in the red blood cells of the test blood;

3. using standard sera and standard erythrocytes (crossover method). In this case, both agglutinogens and blood agglutinins are simultaneously determined, which makes it possible to give the most complete group characteristics of the tested blood.

When using the first and third methods, 2 series of sera are taken (serum control) to avoid obtaining erroneous results.

Determination of blood group using standard sera.

Large drops of standard hemagglutinating sera of the first 3 groups in 2 series are applied to a plate, plate, tablet with a white wettable surface under the designations of the first 3 blood groups written with a glass graph. Each serum is taken with a separate pipette. In total, this results in 6 drops of serum (3 drops in 2 rows).

A small drop of the test blood is placed next to the drops of serum (a drop of blood should be 5-10 times smaller than a drop of serum).

Using a clean, dry glass rod, mix drops of blood with serum so that the mixture turns a uniform red color. A separate glass rod is used for each drop. You can also use the corners of a glass slide for mixing.

After mixing the drops, shake the plate for 2-3 minutes, then leave for 2 minutes. at rest and rock again, observing the progress of the reaction. The reaction time must be at least 5 minutes.

After 3 minutes, add a small drop of isotonic sodium chloride solution to the drops while slowly shaking the plate (plate, tablet).

The results obtained are taken into account after 5 minutes.

Interpretation of the results.

The hemagglutination reaction can be positive and negative.

In case of a positive reaction, after mixing the test blood with serum, small flakes of agglutinates are formed, which, merging with each other, form large flakes visible to the naked eye. In this case, the serum becomes colorless or almost colorless.

In cases of a negative reaction, the mixture of serum and blood remains uniformly colored red throughout the entire observation period, and agglutinates are not detected in it.

A prerequisite for the correct interpretation of the study is the coincidence of the reaction results with sera from the same group of different series.

When conducting the described study, 4 combinations of positive and negative results are possible:

In all drops, the mixture of erythrocytes of the test blood and standard sera is colored uniformly red and agglutination is not detected anywhere, i.e. The agglutination reaction is negative in all 6 drops. This indicates the absence of agglutinogens α and β in the erythrocytes of the tested blood, i.e. – about its belonging to the O (I) group.

If the agglutination reaction developed when the test blood was mixed with sera of O (I) and B (III) groups, it means that the erythrocytes of the test blood contain agglutinogen α, i.e. it belongs to group A (II).

In cases of agglutination of erythrocytes of the test blood with standard sera of O (I) and A (II) groups, it can be argued that there is agglutinogen β on the erythrocyte membrane, i.e. blood belongs to group B (III).

If agglutination occurred in all drops, this may indicate the presence of agglutinogens α and β in the erythrocytes of the test blood, but this can only be confirmed by excluding nonspecific agglutination, for which in such cases a mandatory control study is carried out with group IV serum. If the agglutination reaction does not develop, we can confidently deny nonspecific agglutination in the previous experiment and classify the tested blood as group AB (IV).

Determination of blood group using zoliclones.

The use of coliclones, as well as the use of polyclonal sera, makes it possible to determine the blood group according to the AB0 system, thanks to the detection of erythrocyte agglutinogens in a direct hemagglutination reaction.

Coliclones anti-A, anti-B and anti-AB are class M monoclonal antibodies produced by mouse hybridomas.

1) Large drops of anti-A, anti-B and anti-AB coliclones are applied to the plane with separate pipettes under the appropriate inscriptions.

2) Next to the drops of reagents, 10 times smaller drops of the blood being tested are applied (one drop of blood next to each drop of reagent).

3) Blood is mixed with reagents using separate glass rods.

4) The plate or tablet is rocked for 3 minutes.

5) Take into account the reaction.

Interpretation of the results.

It is possible to obtain 4 options for research results:

1) If the agglutination reaction has not developed with anti-A, anti-B and anti-AB coliclones, then the blood being tested should be classified as group 0 (I), since its red blood cells do not contain agglutinogens A and B.

2) If an agglutination reaction is noted after mixing a drop of the test blood with anti-A and anti-AB reagents, it means that the red blood cells contain agglutinogen A, and the test blood should be classified as group A (II). In this case, there is no agglutination with anti-B coliclone.

3) If an agglutination reaction is observed with anti-B and anti-AB tsoliclones, but is absent with anti-A tsoliclone, the blood being tested belongs to group B (III), since its erythrocytes contain agglutinogen B.

4) If a positive agglutination reaction is observed in all 3 drops where the reagents are mixed with drops of the test blood, the red blood cells of the test blood contain agglutinogens A and B, which means the blood belongs to the AB (IV) group. But for a substantiated statement of this fact, it is necessary to exclude a spontaneous nonspecific reaction. To do this, mix a drop of the blood being tested with a drop of isotonic sodium chloride solution on a plane. In the absence of agglutination in the control study, the test blood can be confidently assigned to the AB (IV) group.

Determination of blood group by cross method.

This method of determining blood grouping involves the simultaneous determination of both agglutinogens in the red blood cells of the blood being tested and agglutinins contained in its plasma or serum. Both standard hamagglutinating sera and standard erythrocytes with a known group affiliation are used as diagnostic agents.

1) Under pre-made markings, large drops of standard hemagglutinating sera of the first 3 groups in two series are applied on a plate with a white wettable surface. Serum drops must have a volume of at least 0.1 ml. Thus, you get 6 drops arranged in 2 rows.

2) Small drops (0.01 ml) of a suspension of standard erythrocytes of the first 3 groups are applied to the lower part of the plate, also under the appropriate designations.

3) From a test tube containing centrifuged test blood, remove the serum (plasma) with a pipette and mix large drops of plasma (serum) with a volume of 0.1 ml with standard red blood cells.

Using the same pipettes, apply small (0.01 ml) drops of red blood cell sediment of the test blood next to drops of standard hemagglutinating sera.

4) Drops in which erythrocytes of the test blood are mixed with standard sera, and plasma of the test blood with standard erythrocytes, are mixed with separate glass rods, the plate is shaken, then left alone for 1-2 minutes and shaken again. Observation of the developing reaction is carried out for at least 5 minutes.

5) After 3 minutes, add a drop of saline solution to all drops, shake the plate again for better mixing of the reagents and take into account the results after 5 minutes.

Interpretation of the results.

Interpretation of the results involves comparing the results of the interaction of standard erythrocytes with the test blood plasma and standard hemagglutinating sera with erythrocytes of blood, the group of which must be established. There are 4 possible combinations:

1) When interacting with standard erythrocyte sera of the tested blood, agglutination did not develop in any of the samples. This indicates the absence of agglutinogens A and B in erythrocytes. When standard erythrocytes are mixed with test blood plasma, there is no agglutination only with erythrocytes of group 0(I), but there is with erythrocytes of groups A(II) and B(III). The latter confirms that the tested blood belongs to group 0(I), because indicates the presence of alpha and beta agglutinins in her serum.

2) When erythrocytes of the test blood interacted with standard sera, agglutination occurred with sera of groups 0(I) and B(III) in the absence of immune adhesion of erythrocytes in a drop of group A(II) serum. This indicates the presence of agglutinogen A in the erythrocytes of the test blood. The serum (plasma) of the test blood gives agglutination with standard erythrocytes B(III) of group, but not with erythrocytes 0(I) and A(II). This confirms that the tested blood belongs to group A(II), because indicates the presence of beta agglutinin in the serum.

3) If the agglutination reaction with standard sera of groups 0(I) and A(II) is positive, the presence of agglutinogen B in the erythrocytes of the test blood is determined, i.e. it is confirmed that it belongs to the B (III) group. When the serum (plasma) of the test blood is mixed with standard erythrocytes, the agglutination reaction turns out to be negative with erythrocytes of groups 0(I) and B(III), but positive with erythrocytes of group A(II). Thus, the presence of alpha agglutinin in the test blood serum is detected, which confirms that the test blood belongs to group B (III).

4) When mixing erythrocytes of the test blood with standard sera, an agglutination reaction is obtained in all 6 drops, where the test erythrocytes were mixed with sera of the first 3 groups in 2 series. In a control study with AB(IV) group serum, the agglutination reaction turns out to be negative, which suggests that the tested blood belongs to the AB(IV) group. A study of the results of the interaction of serum (plasma) of the test blood with standard erythrocytes in all cases will show the absence of agglutination, which indicates the absence of natural agglutinins against agglutinogens A and B in the plasma of the test blood, i.e. will confirm its belonging to the AB (IV) group.

Determination of Rh blood

Currently, there are several ways to determine the Rh status of blood (stating the presence or absence of Rh 0 D antigen in erythrocytes. It should be noted that the Rh factor D (Rh 0 D) plays the greatest role in transfusiology, therefore the commonly used tests for Rh status are This type of Rh antigen is detected.

Determination of Rh status using anti-D-Super zolicone.

The active principle of this drug is monoclonal complete anti-Rhesus antibodies belonging to the Ig M class.

1. Determination of Rh status on a plane.

Apply 1 drop of Tsoliklon Anti-D-Cynep to a plate with a wettable surface.

A drop of test blood or a suspension of red blood cells that is 5-10 times smaller in volume is placed nearby.

Blood (a suspension of red blood cells) is mixed with the reagent.

20-30 seconds after mixing, shake the plate slightly for 3 minutes.

The results are taken into account by inspection with the naked eye.

Interpretation of the results.

The appearance of agglutination when mixing the test blood with the reagent indicates that the red blood cells contain the Rh 0 D antigen, i.e. are Rh positive. In the absence of agglutination, the blood being tested is regarded as Rh negative.

Determination of the Rh factor Rh 0 (D) by a conglutination reaction using gelatin.

Add 1 drop of a suspension of the erythrocytes under study and 2 drops of a 10% gelatin solution, heated to 46-48 degrees until liquefied, into 2 test tubes.

Add 2 drops of group-specific (i.e. belonging to the same group according to the ABO system as the red blood cells being studied) anti-Rh human serum to one of the test tubes. Serum is not added to another tube (it serves to control the specificity of agglutination)

In parallel, in the same way, standard Rh-positive and Rh-negative erythrocytes are examined in separate labeled test tubes (they are mixed with anti-Rh serum and gelatin solution, as described in the previous paragraphs).

The contents of the test tubes are mixed and the test tubes are placed in a water bath at a temperature of 46-48 degrees for 15 minutes or in a thermostat at the same temperature for 30 minutes.

After the specified time, the test tubes are removed from the thermostat (water bath) and 5-8 ml of saline solution is added to each of them, with which the contents of the test tubes are thoroughly mixed.

The results are assessed by viewing the tubes in transmitted light with the naked eye or through a magnifying glass with 2-5x magnification.

Interpretation of the results.

If the result is positive (the erythrocytes being tested are Rh-positive and give an agglutination reaction with anti-Rh sera), the agglutinates are clearly visible against the background of an almost discolored liquid. If the result is negative, the liquid in the test tube with a suspension of the tested red blood cells is colored uniformly red or pink, and agglutinate flakes are not detected. The result is considered true in the presence of agglutination in a parallel experiment with standard Rh-positive erythrocytes and in the absence of agglutination in an experiment with standard Rh-negative erythrocytes, as well as in a test tube containing only the test erythrocytes and gelatin (control of the specificity of the reaction).

A positive result indicates that the red blood cells of the tested blood contain the Rh antigen (i.e. they are Rh positive), and a negative result indicates that the red blood cells under test do not contain the Rh antigen, i.e. are Rh negative.

Addition. For research, either native blood or mixed with a preservative can be used, but in the latter case the preservative must be washed with a tenfold volume of isotonic sodium chloride solution. In addition, in each case of determining Rh status using this method, group-specific anti-Rh sera of 2 series should be used (serum control).

Determination of Rh status using the universal anti-Rh 0 (D) reagent.

The universal anti-Rh reagent is a human serum containing anti-Rh antibodies, but devoid of alpha and beta antibodies, which is why it can be used to determine the Rh blood of any group of the ABO system. In order to ensure the reaction proceeds, a 33% solution of polyglucin or a 20% solution of albumin is added to it

Place 1 drop of blood or red blood cell suspension into a conical tube.

Add 2 drops of universal anti-Rhesus reagent and mix with the blood being tested.

Tilt the test tube so that its contents spread over the walls, and slowly rotate the test tube around the vertical axis for better contact of red blood cells and the reagent for 5 minutes.

After 5 minutes, add 2-3 ml of isotonic sodium chloride solution and mix (without shaking) the contents of the test tube.

The result is taken into account by examining the contents of the test tube in transmitted light with the naked eye.

Interpretation of the results.

If agglutinates are present and the liquid in the test tube is clear, the red blood cells being tested contain Rh 0 (D) antigen, and the blood being tested is Rh positive. In the absence of agglutinates and the pink color of the liquid, which gives a pearlescent tint when the test tube is shaken, the blood being tested is Rh-negative.

The meaning and methods of determining individual compatibility (AB0) and Rh compatibility. Biological compatibility. Responsibilities of a blood transfusion physician.

Tests for individual compatibility of blood between donor and recipient.

When conducting tests for individual compatibility, it is determined whether there are antibodies in the recipient's plasma (serum) directed against the donor's red blood cells that can cause agglutination of red blood cells in the recipient's vascular bed, followed by their hemolysis. Since the antibodies contained in the donor blood plasma are diluted during transfusion by a significantly larger volume of the recipient's blood with a decrease in their titer, the reverse relationship (i.e., donor antibodies to recipient erythrocyte antigens) in transfusiology has no clinical significance.

Test for compatibility of the blood of the donor and recipient on a plane at room temperature.

A large drop (2-3 drops taken with a pipette) of the recipient's serum or plasma is applied to a white plate with a wettable surface.

A 10 times smaller drop of donor blood is added to it.

The donor's blood is mixed with the recipient's plasma (serum), and the plate is rocked for 1-2 minutes. Then leaving it alone for 1-2 minutes.

5 minutes after the start of the reaction (after mixing drops of blood and plasma), the reaction after adding a drop of saline solution to the mixture of reagents (blood and plasma) is taken into account.

Interpretation of the results.

The plate models what can happen in the recipient’s vascular bed. If flakes of agglutinates are formed, and the mixture of donor blood and recipient plasma (serum) becomes lighter, the blood of this donor cannot be transfused to this recipient, because The recipient's plasma contains antibodies against the erythrocyte antigens of donor blood. If the mixture of blood and plasma remains red and agglutinates are not detected, this indicates the absence of complete antibodies in the recipient’s plasma that can cause immune adhesion of donor blood red blood cells. Consequently, such blood can be transfused to this specific donor, whose plasma we manipulated.

Blood compatibility test between donor and recipient with a 33% polyglucin solution (Rh compatibility test).

A large drop of the recipient's plasma (serum) is placed into the test tube (2-4 drops taken with a pipette).

Add a small drop of donor blood (blood to plasma volume ratio 1:10)

A drop of a 33% polyglucin solution is added to the resulting reagent mixture.

The contents of the test tube are thoroughly mixed, the test tube is tilted so that the contents spread over its walls, and slowly rotated around the vertical axis for 5 minutes, ensuring the most complete contact of the elements of the test tube contents with each other.

After 5 minutes, 3-4 ml of isotonic sodium chloride solution is added to the test tube, and the contents are mixed without shaking.

The results are taken into account by examining the contents of the test tube with the naked eye or under a magnifying glass with 2-5x magnification.

Interpretation of the results.

When agglutinate flakes appear and the liquid in the test tube becomes clear, the donor's blood is incompatible with the blood of this recipient. If the liquid in the test tube is uniformly colored red, and agglutinates are not detected, we can conclude that the recipient’s plasma does not have incomplete antibodies against the antigens of donor red blood cells, and, therefore, the blood of this donor can be transfused to this recipient.

Compatibility test using a 10% gelatin solution (Rh compatibility test).

1 drop of washed donor red blood cells is placed in a test tube.

Add 2 drops of a warmed 10% gelatin solution and 2 drops of recipient serum to the donor's red blood cells.

Mix the contents of the test tube thoroughly.

Place the test tube for 10 minutes in a water bath at a temperature of 46-48 degrees.

After the specified time, add 5-8 ml of isotonic sodium chloride solution to the test tube and mix the contents of the test tube by inverting (without shaking).

The results are taken into account with the naked eye or under a magnifying glass with 2-5x magnification.

Interpretation of the results.

If the reaction is positive, i.e. the appearance of agglutinates against the background of discolored liquid is noted - this donor blood cannot be transfused to this recipient. If the liquid in the test tube is uniformly colored and no agglutinate flakes are detected, the donor’s blood is compatible with the recipient’s blood and can be transfused to him.

Indirect Coombs test.

When performing this test (very highly sensitive), the donor's red blood cells are washed with an 8-10-fold volume of isotonic saline solution, then centrifuged, and red blood cells from the sediment are used in the reaction, i.e. red blood cells should be as free as possible from the presence of other cellular elements and plasma.

One small drop (0.01 ml) of washed donor red blood cells is placed in a test tube.

Add 3 drops of recipient serum and mix the contents of the tube thoroughly.

The test tube is placed in a thermostat at a temperature of 37 degrees for 45 minutes.

After the specified incubation time, 8-10 times the volume of isotonic saline solution (sodium chloride) is poured into the test tube and the contents of the test tube are mixed.

Centrifuge the tube until red blood cells sediment.

The washing procedure is repeated 3-4 times, each time carefully removing the supernatant.

4-5 drops of isotonic sodium chloride solution are added to washed red blood cells to obtain a suspension of red blood cells.

One drop of red blood cell suspension is placed on a plate with a white wettable surface.

Add 1-2 drops of antiglobulin serum to the suspension of red blood cells on a plane and mix with a glass rod.

The plate is rocked periodically for 10 minutes.

The result is taken into account with the naked eye or under a magnifying glass with 2-5x magnification.

Interpretation of the results.

If, after adding antiglobulin serum to donor red blood cells incubated with the recipient's serum, agglutinates are formed with liquid clarification, the recipient's blood contains incomplete antibodies against the Rh antigen or other isoantigens of the donor's red blood cells, and therefore this donor blood cannot be transfused to such a recipient. If there is no agglutination, the blood of a given donor is compatible with the blood of a given recipient, and therefore, can be transfused to him.

Errors when conducting tests for group, Rh and individual compatibility.

In most cases, errors and difficulties during immunoserological studies are associated with violations of the technique of their implementation. Less commonly, individual characteristics of the blood being tested may be the cause of erroneous conclusions.

In all cases of obtaining questionable results, it is necessary to repeat the study using reagents of other series, strictly following the rules for conducting the sample. If questionable results are obtained again, a blood sample should be sent for testing to a specialized laboratory.

The most common causes of errors and difficulties when conducting immunoserological studies.

· Use of low-quality reagents (expired, cloudy, partially dried, etc.)

· Violation of temperature conditions for reactions. When determining blood grouping using the ABO system, the ambient temperature should be between 15 and 25 degrees Celsius. At lower temperatures, the development of nonspecific agglutination caused by cold agglutinins is possible, and at high temperatures, alpha and beta agglutinins reduce their activity.

· Violation of the correct ratios of reacting media. When conducting a test with serums (in cases of determining group affiliation using the ABO system), the ratio of blood and serum volumes should be 1:10, and when using monoclonal antibodies and samples with colloids (when determining Rhesus affiliation) - 2-3:10. Otherwise, agglutination may go undetected (due to shielding of agglutinates by non-agglutinated red blood cells or due to the small number of agglutinates).

· Violation of temporary testing schedules. The onset of agglutination (especially when conducting tests with monoclonal antibodies) can be noticeable in the first seconds from the moment of mixing the reacting media, however, the reaction must be recorded at a strictly defined time, because sometimes there are varieties of antigens that have weak agglutinability and give a late reaction (varieties of agglutinogen A, less often - B).

· Ignoring the need to conduct control studies (for example, with AB(IV) group serum when determining group affiliation with standard heagglutinating sera or tests with colloids when determining Rhesus affiliation).

· Increased agglutinability of erythrocytes - can be observed in severe purulent diseases, burns, liver cirrhosis, autoimmune and hematological diseases.

· Decreased erythrocyte agglutinability - often found in leukemia.

· Blood chimerism is a very rare phenomenon that occurs in fraternal twins, during a donor bone marrow transplant or after transfusions (forced) of a different group, but compatible blood in large volumes.

Prevention of erroneous research results consists in strictly following the existing rules for determining group and Rh affiliation, compatibility tests, with mandatory consideration of the nature of the disease and the general condition of the recipient.

Biological sample.

A biological test is mandatory for transfusions of donor blood, erythrocyte-containing media, plasma, leukocyte concentrates, regardless of the volume and rate of blood transfusion.

A biological test is carried out immediately before transfusion and consists of 3-time transfusion of 10-15 ml of transfusion medium in a stream or at maximum speed (2-3 ml per minute) at intervals of 5 minutes, during which saline solutions are infused to avoid thrombosis needles. If during a biological test at least one of the symptoms appears indicating incompatibility of the transfusion medium, its transfusion is stopped and appropriate measures are taken. These symptoms include chills, pain in the lower back and lower abdomen, a feeling of tightness and pain in the chest, nausea, vomiting, tachycardia, and low blood pressure. During surgery under general anesthesia, signs of incompatibility may include increased tissue bleeding, decreased blood pressure, increased tachycardia, and the release of red or brown urine (in cases of bladder catheterization).

Blood transfusion. Indications and contraindications for blood transfusion. Modern rules of blood transfusion according to ABO and Rh system groups. Methods and techniques of blood transfusion.

Indications for blood transfusion were determined by the known mechanisms of its action:

· Substitute.

· Hemostatic.

· Immunostimulating.

· Detoxifying.

· Used for parenteral nutrition.

However, as accumulated experience has shown, such a widespread use of blood transfusions was not always effective; moreover, it often turned out to be dangerous: in addition to red blood cells, the patient received non-viable leukocytes, platelets, proteins, antigens and antibodies with blood.

Repeated blood transfusions led to alloimmunization of patients.

Currently, the main indication for blood transfusion is acute massive blood loss of at least 25–30% of the total volume with a decrease in hemoglobin below 70–80 g/l, hematocrit below 25% and the occurrence of circulatory disorders.

In addition, blood transfusion is indicated for shock and terminal conditions, in rare cases during exchange transfusions for hemolytic disease of the newborn, during operations accompanied by massive blood loss.

In all other cases, blood fractions or blood substitutes should be used.

Contraindications to blood transfusion.

There are no absolute contraindications to transfusion.

Relative contraindications:

· Acute cerebrovascular accident.

· Circulatory failure, stage II. – III Art.

· Hypertension stage III.

· Liver and kidney failure.

· Active (disseminated) pulmonary tuberculosis.

· Severe bronchial asthma.

· Allergic diseases.

Rules for blood transfusion.

Currently, transfusion of blood and its components is allowed only of the same group and Rh - affiliation.

In exceptional cases (for health reasons) in the absence of single-group blood or its components, transfusion of erythromass of group O(I), Rh - negative, but not more than 500 ml is allowed (except for children!).

In the absence of single-group plasma, the recipient can be transfused with group AB(IV) plasma.

A doctor performing a blood or erythromass transfusion is obliged to:

· Before each transfusion, determine the blood group and Rh - the recipient's affiliation.

· After making sure that the donor blood is suitable and having filled the system, determine the blood type and Rh affiliation of the donor and agree with the label on the hemocon.

· Test for individual compatibility of the blood of the recipient and the donor.

· Test for Rh compatibility.

· Carry out a biological compatibility test.

The remaining blood (10 - 15 ml) in the hemocon after blood transfusion is stored in the refrigerator for 48 hours.

Within 3 hours after the end of the blood transfusion, the patient's temperature, pulse and blood pressure are measured. The next morning, blood and urine tests are performed.

Each transfusion of blood, its fractions, as well as blood substitutes is recorded in the transfusion sheet, which is located in the patient’s medical history.

Methods and techniques of blood transfusion:

Direct transfusion. Blood is transfused using a machine directly from the donor's vein into the recipient's vein without the use of a preservative.

Due to the risk of donor infection, it is not currently used.

Indirect transfusion. Donor blood is preserved in a hemocone, or ampoule, and stored in a refrigerator at t 0 + 4 0 C.

If necessary, it is used for transfusion without special heating. Indirect transfusion of blood and its fractions is used very widely.

Blood reinfusion: transfusion of the patient’s blood, poured into the serous cavities (abdominal, pleural), during a closed injury or during surgery. The blood is taken using a special device or, in the absence of one, in emergency cases, it is filtered through 8 layers of gauze, a preservative is added and immediately transfused intravenously.

The method is very effective.

Contraindications: damage to hollow organs, presence of blood in the serous cavity for more than 12 hours, blood hemolysis.

Autotransfusion of blood. It is used in planned surgery, when a few days before the operation, 400-500 ml of blood is taken from the patient’s vein, a preservative is added, after which the hemocon is stored in the refrigerator, and during the operation the patient’s own blood is transfused.

The method is very promising.

Contraindication: initial anemia in the patient.

Exchange blood transfusions are partial or complete removal of blood from the bloodstream with simultaneous replacement with the same amount of donor blood.

Indications: hemolytic jaundice of newborns, blood transfusion shock, severe poisoning. In this case, blood is removed and simultaneously infused at a rate of 1000 ml in 15 to 20 minutes.

Exchange transfusions are rarely used.

Methods of administering blood:

Currently, intravenous blood transfusion is predominantly used.

After testing for compatibility, blood is most often transfused into the cubital vein by puncture, or less often through a special cannula placed in the vein. If it is necessary to transfuse large volumes of transfusion media, a permanent catheter is used, which is placed in the central vein (usually in the subclavian vein).

Typically, drip transfusion is used at a rate of 40–60 drops per minute.

If urgent replacement of blood volume is necessary, intravenous jet blood transfusion can be used.

Intra-arterial blood injection.

Indications: stage III – IV shock, terminal conditions.

Blood is pumped into the peripheral artery, which is previously exposed, under a pressure of 200 - 220 mm Hg. Art. at a speed of 200 ml in 1.5 - 2 minutes. Blood administered under pressure irritates angioreceptors and ensures restoration of coronary blood flow.

Intra-arterial, intracardiac blood injection is performed very rarely, only in intensive care practice and during chest surgery.

Intraosseous blood transfusion.

Currently practically not used. It was used for extensive burns when peripheral veins were inaccessible. Transfusion is carried out into the sternum, ilium, and calcaneus at a rate of 5 to 30 drops per minute.

In addition to complications associated directly with blood transfusion, the development of osteomyelitis is possible.

After any temporary cessation of bleeding, a hemostatic clamp is usually applied to the damaged vessel, and then tie the central and peripheral ends with ligatures .

If there is bleeding from a large main vessel that needs to be preserved, its integrity should be restored using vascular suture .

For bleeding from hard-to-reach areas, use selective embolization of a bleeding vessel . For this purpose, pieces of absorbable gelatin sponge, metal spirals and other devices are introduced into the affected artery through an angiographic catheter, acting as a kind of plug that clogs the damaged vessel. Arterial embolization in this situation avoids general anesthesia and major operations. This type of bleeding control is preferred for bleeding associated with vascular arrosion, since surgical intervention in such a situation is fraught with a high risk of complications.

All methods of finally stopping bleeding are usually divided into mechanical, physical, chemical and biological.

Mechanical methods .

Pressure bandage. The method consists of applying a tight circular or spiral bandage to the limb in the projection of the wound. This method can serve as a way to finally stop bleeding in case of external capillary bleeding and damage to the saphenous veins.

Wound tamponade. As a way to finally stop bleeding, tamponade can be used:

For capillary external bleeding;

In case of damage to subcutaneous and small deep veins with collaterals;

For minor parenchymal bleeding.

For external bleeding(in the presence of a wound), tamponade can only be used as a necessary measure. In some cases, tamponade can be used as the final stage of surgical treatment, for example, if there is unstoppable capillary bleeding due to a disorder in the blood coagulation system (diffuse bleeding).

For parenchymal bleeding tamponade is used more often. The ends of the tampons are brought out through additional incisions.

For nosebleeds tamponade may be necessary. There are anterior and posterior tamponade: the anterior one is carried out through the external nasal passages, the technique for performing the posterior one is shown in Fig. 5-11. Stable hemostasis almost always occurs.

Rice. 5-11. Method of posterior tamponade of the nasal cavity: a - passing a catheter through the nose and removing it through the oral cavity to the outside; b - attaching a nylon thread with a tampon to the catheter; c - reverse withdrawal of the catheter with retraction of the tampon.

Ligation of blood vessels in the wound. Ligating the vessel in the wound, directly at the site of injury, is certainly preferable. This method of stopping bleeding disrupts the blood supply to a minimal amount of tissue. Most often, during the operation, the surgeon applies a hemostatic clamp to the vessel, and then a ligature (the temporary method is replaced by the final one). In some cases, when the vessel is visible before damage, it is crossed between two previously applied clamps. An alternative to ligation may be vessel clipping - placing metal clips on the vessel using a special clipper. This method is widely used in endoscopic surgery.

Stitching a vessel in a wound. In cases where the bleeding vessel does not protrude above the surface of the wound wall and it is impossible to grasp it with a clamp, apply a Z-shaped suture around the vessel through the surrounding tissues, followed by tightening the thread - the so-called suturing of the vessel (Fig. 5-10).

Rice. 5-10. Stitching a bleeding vessel

Clipping. For bleeding from vessels that are difficult or impossible to bandage, clipping is used - clamping the vessels with silver metal clips. After the final stop of intracavitary bleeding, part of the organ is removed (for example, resection of the stomach with a bleeding ulcer) or the entire organ (splenectomy for rupture of the spleen). Sometimes special stitches are placed, for example, on the edge of a damaged liver.

Ligation of vessels “throughout”. The essence of the method is that the vessel is exposed through an additional incision and ligated above the site of damage. We are talking about ligating a large, often main trunk proximal to the site of injury. In this case, the ligature very reliably blocks the blood flow through the main vessel, but bleeding, although less serious, can continue due to collaterals and reverse blood flow. The most important disadvantage of ligating a vessel over its length is the deprivation of blood supply to a larger volume of tissue than when ligating a wound. This method is fundamentally worse; it is used as a forced measure.

There are two indications for ligating the vessel along its length.

The damaged vessel cannot be detected, which happens when bleeding from a large muscle mass (massive bleeding from the tongue - the lingual artery on the neck in Pirogov's triangle is ligated, bleeding from the muscles of the buttock - the internal iliac artery is ligated, etc.).

Secondary arrosive bleeding from a purulent or putrefactive wound (bandaging the wound is unreliable, since arrosion of the vessel stump and recurrent bleeding are possible, in addition, manipulations in a purulent wound will contribute to the progression of the inflammatory process).

In these cases, in accordance with topographic and anatomical data, the vessel is exposed and ligated along the length proximal to the damage zone.

Rice. Methods for finally stopping bleeding from a vessel: a - applying a ligature; b - electrocoagulation; c - ligation and intersection of the vessel at a distance; d - ligation of the vessel along its length; d - puncture of the vessel.

Application of a vascular suture. This is the main method of final hemostasis in case of damage to large vessels. Until now, hand stitching is most often used, for which synthetic threads with atraumatic needles are used.

Rice. 5-12.Carrel vascular suture technique

Vascular suture is a rather complex method that requires special training of the surgeon and certain instruments. It is used for damage to large main vessels, the cessation of blood flow through which would lead to adverse consequences for the patient’s life. There are manual and mechanical seams. The vascular suture must be highly sealed and meet the following requirements: it must not disrupt the blood flow (no narrowing or turbulence), and there must be as little suture material as possible in the lumen of the vessel.

With different types of damage to the vascular wall, various options for reconstructive intervention on blood vessels are used: side suture, side patch, resection with end-to-end anastomosis, prosthetics (vessel replacement), bypass surgery (creating a bypass for blood). A lateral vascular suture is applied when there is a tangential wound to a vessel. After application, the suture is strengthened with fascia or muscle. In vascular reconstruction, autoveins, autoarteries, or vascular prostheses made of synthetic materials are usually used as grafts (prostheses and shunts).

Artificial vascular embolization. The method is classified as endovascular surgery. Currently, artificial vascular embolization methods have been developed and implemented to stop pulmonary, gastrointestinal bleeding and bleeding from bronchial arteries and cerebral vessels. According to the Seldinger technique, the femoral artery is catheterized, the catheter is brought to the bleeding area, a contrast agent is injected, and the site of damage is identified using X-rays (diagnostic stage). Then an artificial embolus (polystyrene, silicone) is brought through a catheter to the site of injury, closing the lumen of the vessel and causing rapid thrombosis. At the site of embolization, a thrombus subsequently forms. The method is low-traumatic and allows one to avoid major surgical intervention, but the indications for it are limited; in addition, special equipment and qualified specialists are needed. Embolization is used both to stop bleeding and in the preoperative period to prevent complications (for example, embolization of the renal artery for a kidney tumor for subsequent nephrectomy on a “dry kidney”).

Special methods to combat bleeding. Mechanical methods of stopping bleeding include certain types of operations: splenectomy for parenchymal bleeding from the spleen, gastrectomy for bleeding from an ulcer or tumor, lobectomy for pulmonary hemorrhage, etc.

Blackmore probe . One of the special mechanical methods is the use of a Blackmore obturator probe for bleeding from esophageal varices - a fairly common complication of liver diseases accompanied by portal hypertension syndrome.

Blackmore tube, which is a gastric tube with two balloons inflated through separate channels, located at its end and surrounding the probe in the form of cuffs. The first (lower, gastric) balloon, located 5 - 6 cm from the end of the probe, when inflated, has the shape of a ball, the second balloon, located immediately behind the first, has the shape of a cylinder. A probe with uninflated balloons is inserted into the stomach up to the third mark. Then the lower balloon is inflated by introducing 40 - 50 ml of liquid and the probe is pulled up until the inflated balloon wedges into the cardiac part of the stomach. After this, the upper balloon located in the esophagus is inflated by introducing 50 - 70 ml of liquid. Thus, the veins of the cardiac part of the stomach and the lower third of the esophagus are pressed by inflated balloons to the walls of the organs and bleeding from them stops.

Rice. Blackmore probe for esophageal bleeding from varicose veins of the esophagus: a - before inflating the balloons with water; b - after fluid administration

Physical methods final stopping bleeding.

Non-mechanical methods of stopping bleeding are used only for bleeding from small vessels, parenchymal and capillary, since bleeding from a medium or large vein, and especially an artery, can only be stopped mechanically. Physical methods of stopping bleeding are based on the use of various physical factors leading to protein coagulation or vasospasm. The most commonly used temperatures are low and high. High temperatures coagulate proteins, and low temperatures cause vasospasm.

Local cooling of tissues. Local application of cold causes vasospasm, which leads to a slowdown in blood flow and vascular thrombosis. Almost any type of injury can be treated with an ice pack. To prevent bleeding and the formation of hematomas in the early postoperative period, place an ice pack on the wound for 1 - 2 hours. The method can be used for nosebleeds (ice pack on the bridge of the nose), gastric bleeding (ice pack on the epigastric area). If gastric bleeding continues, you can also rinse the stomach through a tube with cold (+4 C) water (usually chemical and biological hemostatic agents are also used).

Local heating of tissues. Heating to a temperature of 50 - 55 ° C also produces an effective vasospasm and causes coagulation of proteins in the flowing blood. Apply wipes soaked in a hot isotonic sodium chloride solution to the bleeding surface of the liver or bone. After 5-7 minutes, the napkins are removed and the reliability of hemostasis is monitored.

Diathermocoagulation - the most commonly used physical method to stop bleeding. The method is based on the use of high frequency currents, leading to coagulation and necrosis of the vascular wall at the site of contact with the tip of the device and the formation of a blood clot. A large area electrode is applied to the patient's body (thigh, lower leg, lower back). The second electrode (working) is made in the form of a scalpel, a button-shaped probe or tweezers. The method allows you to quickly stop bleeding from small vessels and operate on a “dry wound”, without leaving ligatures (foreign body) in the body.

Disadvantages of the electrocoagulation method: it is not applicable on large vessels; if excessive coagulation is incorrect, extensive necrosis occurs, which complicates subsequent wound healing. The method can be used for bleeding from internal organs (coagulation of a bleeding vessel in the gastric mucosa through a fibrogastroscope), etc.

It is also used to separate tissues with simultaneous coagulation of small vessels (the instrument is an “electronic knife”), which greatly facilitates a number of operations, since the incision is essentially not accompanied by bleeding. A wound inflicted with an electric knife or subjected to electrocoagulation is sterile and does not bleed. Based on antiblastic considerations, the electric knife is widely used in oncological practice.

Laser photocoagulation, plasma scalpel. These methods are considered new technologies in surgery and are based on the same principle as diathermocoagulation (creation of local coagulation necrosis), but allow a more dosed and gentle stop of bleeding. This is especially important for parenchymal bleeding. This method is also used to separate tissues (plasma scalpel). Laser photocoagulation and plasma scalpel are highly effective and enhance the capabilities of traditional and endoscopic surgery. Laser is electron radiation focused in the form of a beam.

Laser scalpel. The method is based on the thermal action of a laser beam (photocoagulation). The effect of a laser scalpel on tissue is similar to the effect of an electric knife. Laser scalpels are used in operations on parenchymal organs, in ENT practice (tonsillectomy), etc.

Plasma scalpel. The method is based on coagulation of bleeding vessels with a high-temperature plasma jet, i.e. the effect on tissue is similar to diathermocoagulation and the use of a laser scalpel.

Chemical and biological methods final stop of bleeding

The principles of action of chemical and biological methods of stopping bleeding are to enhance (accelerate) blood coagulation, inhibit the resorption (lysis) of formed clots, form vascular spasm, leading to a decrease in the rate of blood loss, slow down blood flow and accelerate the fixation of clots in the lumen of a vessel wound.

Hemostatic agents are divided into general (resorptive) and local agents. The general effect develops when the substance enters the blood, local - when it comes into direct contact with bleeding tissues.

Substances for general (resorptive) use

General use of various hemostatic (hemostatic) agents (under the control of blood coagulation and anticoagulation systems). Hemostatic substances of general (resorptive) action are widely used for internal bleeding. Hemostatic substances with a resorptive effect are introduced into the patient’s body, causing an acceleration of the process of thrombosis of damaged vessels.

The main drugs are listed below.

All methods of finally stopping bleeding can be divided into 4 groups:

1) mechanical,

2) physical,

3) chemical,

4) biological.

Mechanical methods.

These methods of stopping bleeding include ligation of the vessel in the wound and throughout, twisting of the vessel, wound tamponade, artificial embolization of the vessel, vascular suture, auto- and alloplasty of arteries and veins. When the intracavitary bleeding is finally stopped, part of the organ is removed (for example, gastric resection for a peptic ulcer complicated by gastroduodenal bleeding) or the entire organ (splenectomy for splenic rupture).

Ligation of a vessel in a wound is the most reliable and common method of stopping bleeding. After isolating the central and peripheral ends of the bleeding vessel, they are grabbed with hemostatic clamps and tied with a ligature. In order to prevent the ligature from slipping when a large vessel is injured, it is bandaged after preliminary suturing of the tissue around the vessel.

Ligation of the vessel along its length is used in cases where it is impossible to detect the ends of the bleeding vessel in the wound (for example, when the external and internal carotid arteries are injured, the greater gluteal artery), when the ligation in the wound is unreliable (in case of secondary late bleeding, when the arrozen vessel is located in the thickness inflammatory infiltrate), as well as in conditions of significant tissue crushing. This method is also used to prevent bleeding during surgery. In such cases, taking into account topographic and anatomical data, the vessel is exposed and ligated along its length outside the wound. The disadvantages of this method include continued bleeding in the presence of pronounced collateral circulation, as well as necrosis of the limb in case of poor development.

Twisting of a vessel captured by a hemostatic clamp leads to crushing of the end of the vessel and twisting of its intima, which closes the lumen of the vessel and facilitates the formation of a blood clot. This method can only be used when small-caliber vessels are damaged.

Wound tamponade can be used to stop capillary and parenchymal bleeding. To do this, gauze swabs are inserted into the wound, which compress the damaged vessels.

In recent years, to stop pulmonary and gastroduodenal hemorrhages, methods of artificial embodization of vessels have been developed and introduced, when, under X-ray control, a catheter is inserted into the bleeding vessel and emboli are introduced through it, closing its lumen; At the site of embolization, a thrombus subsequently forms.

Application of a vascular suture, as well as auto- and alloplasty of arteries and veins are ideal methods for finally stopping bleeding. allowing not only to stop bleeding, but also to restore normal blood circulation along the damaged channel. More than 70 modifications of connections of blood vessels have been described, however, to obtain good results in reconstructive operations, it is not so much the type of vascular suture that is of key importance. how much is the quality of its implementation (Novikov Yu.V. et al., 1984).

The main principles of this method are:

1) strength,

2) tightness,

3) mandatory comparison of the intima of one part of the vessel with the intima of another part,

4) there should be no suture material in the lumen of the vessel,

5) the suture should minimally narrow the lumen of the vessel.

There are circular and lateral vascular sutures. To apply a vascular suture manually, atraumatic needles are used: vascular suturing devices are currently used for circular suturing of vessels, while the mechanical suture is quite perfect and resistant to infection. In case of significant diastasis between the ends of the vessel, significant tension that occurs when trying to bring the ends of the damaged vessel together, in case of vascular defects, especially in areas of increased physiological stress (popliteal, inguinal, elbow areas), it is more advisable to resort to plastic surgery of arteries and veins (Novikov Yu.V. with al., 1984). The best material for vascular reconstruction should be the victim’s own vein (great saphenous vein of the thigh or saphenous veins of the shoulder). To obtain a transplant, the veins of the damaged limb cannot be used due to the risk of developing possible venous insufficiency and an increased risk of deep vein thrombosis. A promising method for restoring the main blood flow is the use of autoarterial grafts. When using vascular prostheses made of synthetic materials, the risk of developing purulent complications increases. Reconstructive operations on blood vessels should be performed only by specially trained surgeons (angiosurgeons) with special instruments, optical devices, and suture material.

Physical methods.

Thermal methods of stopping bleeding were used by ancient doctors in Egypt, Greece, and the Roman Empire, cauterizing a bleeding wound with a hot iron and boiling oil. These methods are based on the property of low temperatures to cause vasospasm, and high temperatures to coagulate proteins and accelerate blood clotting. For local tissue hypothermia in the area of ​​a bleeding vessel, a medical bladder filled with ice, snow or cold water is usually used. Local hypothermia of the stomach with cooled water to a temperature of +4°, +6°C is widely used in a complex of therapeutic measures for acute gastroduodenal bleeding. The main thermal method of stopping bleeding is diathermocoagulation, based on the use of high-frequency alternating currents. This method is widely used during surgery to stop bleeding from damaged vessels of subcutaneous fatty tissue and muscles, from small vessels of the brain, as well as for endoscopic control of gastroduodenal bleeding. To stop capillary or parenchymal bleeding, wound irrigation with a hot isotonic sodium chloride solution is used.

Chemical methods.

These include the use of vasoconstrictors and blood clotting drugs. Vasoconstrictors include adrenaline (1:1000), used topically for bleeding from the mucous membranes, as well as ergot extract (uterine horns), used for uterine bleeding. Hydrogen peroxide, used in the form of a 3% solution, has a hemostatic effect. When a tampon soaked in a 3% solution is inserted, H0 decomposes into atomic oxygen and water. As a result of oxidation, blood clotting increases and a clot is formed. This group includes aluminum-potassium alum, which in the form of “hemostatic pencils” is used in the treatment of abrasions and small wounds. Among the agents that increase blood clotting, calcium chloride is widely used, which is administered intravenously in 10 ml of a 10% solution. Its hemostatic effect consists not only of stimulating coagulation, but also of influencing the vascular component of hemostasis, by reducing the permeability of the vascular wall and increasing the tone of peripheral vessels.

Biological methods.

Biological agents used to stop bleeding have a resorptive and local effect. Hemostatic substances of general resorptive action include freshly preserved blood and its preparations (plasma, cryoprecipitate, fibrinogen, etc.), biological (trasylol, contrical) and synthetic (aminocaproic acid) antifibrinolytic drugs, vitamin K (vicasol) and vitamin C (ascorbic acid) . Local hemostatic drugs that have the ability to stop bleeding when applied topically to a wound are widely used. These include thrombin, hemostatic and gelatin sponge, fibrin film, biological antiseptic tampon, etc. A unique biological tampon is muscle tissue, the greater omentum in the form of a free flap or a pedicled flap, fascia, rich in thrombokinase and used to stop bleeding from a parenchymal organ.

To enhance the effect of hemostasis, various methods of stopping bleeding are often combined.

Application of a tourniquet.

The standard tourniquet is a rubber band 1.5 m long with chain and hook at the ends

Indications: The method is usually used for bleeding from wounds on the extremities, although it is possible to apply a tourniquet in the groin and axillary region, as well as on the neck (the neurovascular bundle on the uninjured side is protected with a Kramer splint).

The main indications for applying a tourniquet are:

Arterial bleeding from wounds of the extremities;

Any massive bleeding from wounds of the extremities.

The peculiarity of this method is the complete cessation of blood flow distal to the tourniquet. This ensures reliable bleeding control, but at the same time causes significant tissue ischemia. In addition, the tourniquet can compress nerves and other formations.

General rules for applying a tourniquet:

· Before applying a tourniquet, the limb should be elevated.

· The tourniquet is applied proximal to the wound and as close to it as possible.

· It is necessary to place fabric (clothing) under the tourniquet.

· When applying a tourniquet, make 2-3 rounds, stretching it evenly, and the rounds should not lie on top of each other.

· After applying the tourniquet, be sure to indicate the exact time of its application (usually a piece of paper with the corresponding note is placed under the tourniquet).

· The part of the body where the tourniquet is applied must be accessible for inspection.

Victims with a tourniquet are transported and treated first. The criteria for a correctly applied tourniquet are:

Stop bleeding;

Termination of peripheral pulsation;

Pale and cold limb.

It is extremely important that the tourniquet cannot be held for more than 2 hours on the lower extremities and 1.5 hours on the upper extremities. Otherwise, necrosis may develop on the limb due to prolonged ischemia.

If it is necessary to transport the victim for a long time, the tourniquet is released every hour for about 10-15 minutes, replacing this method with another temporary method of stopping bleeding (finger pressure).

The tourniquet must be removed gradually by loosening it, with the preliminary administration of painkillers.

Finger pressure of arteries.

This is a fairly simple method that does not require any auxiliary items. Its main advantage is the ability to execute as quickly as possible. Disadvantage - it can be used effectively only for 10-15 minutes, that is, it is short-term.

Indications: The indication for digital pressure of the arteries is massive bleeding from the corresponding arterial basin.

Finger pressure is especially important in emergency situations, to prepare for the use of another method of hemostasis, such as applying a tourniquet.

Pressing a bleeding vessel in a wound.

Surgeons often use this technique when bleeding occurs during surgery. The site of damage to the vessel or the vessel more proximally is compressed with one or more fingers. The bleeding is stopped, the wound is dried and the most adequate final method of stopping the bleeding is chosen.

Maximum limb flexion.

The method is effective for bleeding from the thigh (maximum flexion at the hip joint), from the leg and foot (maximum flexion at the knee joint), hand and forearm (maximum flexion at the elbow joint)

The indications for performing maximum flexion are the same as for applying a tourniquet. The method is less reliable, but at the same time less traumatic. Maximum flexion of the elbow joint is often used to stop bleeding after puncture of the cubital vein (intravenous infusions, blood sampling for research).

Elevated position of the limb.

The method is extremely simple - you just need to lift the injured limb.

Indications for use: venous or capillary bleeding, especially from wounds on the lower extremities.

Pressure bandage.

Indications: A pressure bandage is used for moderate bleeding from small vessels, venous or capillary bleeding. This method is the method of choice for bleeding from varicose veins of the lower extremities. A pressure bandage can be applied to the wound to prevent bleeding in the early postoperative period (after phlebectomy, sectoral resection of the mammary gland, mastectomy, etc.).

To use this simple method, you only need a bandage and dressing material.

Technique: Apply several sterile napkins to the wound (sometimes a roll is formed on top) and bandage tightly. Before applying a bandage to the limb, it is necessary to give it an elevated position. The bandage should be applied from the periphery to the center.

Wound tamponade.

The method is indicated for moderate bleeding from small vessels, capillary and venous bleeding in the presence of a wound cavity. Often used in operations. The wound cavity is tightly filled with a tampon, which is left for some time. The bleeding is stopped, time is gained, and then a more adequate method is used.

Applying a clamp to a bleeding vessel.

The method is indicated for stopping bleeding during surgery. If bleeding occurs, the surgeon applies a special hemostatic clamp (Billroth clamp) to the bleeding vessel. The bleeding stops. Then the final method is used, most often ligation of the vessel. When applying a clamp, you must remember that this must be done extremely carefully, under visual control, otherwise, in addition to the damaged one, a major vessel or nerve may also get into the clamp, which will lead to adverse consequences.

Temporary bypass.

It is used for damage to large main vessels, mainly arteries, the cessation of blood flow through which can lead to undesirable consequences and even threaten the patient’s life.

The surgeon can insert a tube (polyethylene, glass) into the damaged ends of the vessel and fix it with two ligatures. Blood circulation in the limb is preserved, there is no bleeding. Such temporary shunts function for several hours or even several days, which then makes it possible to apply a vascular suture or replace the vessel.

Methods for finally stopping bleeding.

Methods for finally stopping bleeding, depending on the nature of the methods used, are divided into mechanical, physical (thermal), and chemical.

Mechanical methods.

Mechanical methods of stopping bleeding are the most reliable. When large vessels, medium-sized vessels, or arteries are damaged, only the use of mechanical methods leads to reliable hemostasis.

Vessel ligation.

There are two types of vascular ligation:

Ligation of a vessel in a wound;

Ligation of the vessel throughout.

Ligation of a vessel in a wound.

Ligating the vessel in the wound, directly at the site of injury, is certainly preferable. This method of stopping bleeding disrupts the blood supply to a minimal amount of tissue.

Most often, during operations, the surgeon applies a hemostatic clamp to the vessel, and then a ligature (the temporary method is replaced by the final one). An alternative to ligation is vessel clipping - placing metal clips (clips) on the vessel using a special clipper. This method is widely used in endoscopic surgery.

Ligation of the vessel throughout

Ligation of a vessel throughout is fundamentally different from ligation of a wound. Here we are talking about ligating a fairly large, often main trunk proximal to the site of injury. In this case, the ligature very reliably blocks the blood flow through the main vessel, but bleeding, although less serious, can continue due to collaterals and reverse blood flow.

The main disadvantage of ligating a vessel over its length is that a much larger volume of tissue is deprived of blood supply than when ligating a wound. This method is fundamentally worse and is used as a forced measure.

There are two indications for ligating the vessel along its length.

The damaged vessel cannot be detected, which happens when bleeding from a large muscle mass (massive bleeding from the tongue - the lingual artery on the neck is tied in Pirogov's triangle; bleeding from the muscles of the buttock - the internal iliac artery is tied, etc.);

Secondary arrosive bleeding from a purulent or putrefactive wound (bandaging the wound is unreliable, since arrosion of the vessel stump and recurrent bleeding are possible, in addition, manipulations in a purulent wound will contribute to the progression of the inflammatory process).

The technique is performed in accordance with topographic and anatomical data: the vessel is exposed and ligated along the length proximal to the damage zone.

Sewing the vessel.

In cases where the bleeding vessel does not protrude above the surface of the wound and it is not possible to grasp it with a clamp, a purse-string or purse string is applied around the vessel.Z-shaped suture through the surrounding tissues followed by tightening the thread - the so-called suturing of the vessel

Twisting, crushing of blood vessels.

The method is rarely used for bleeding from small veins. A clamp is placed on the vein, it remains on the vessel for some time, and then is removed. Additionally, you can rotate the clamp several times around its axis. In this case, the vessel wall is maximally injured and it is reliably thrombosed.

Wound tamponade, pressure bandage.

Wound tamponade and application of a pressure bandage are methods of temporarily stopping bleeding, but they can also become permanent. After removing the pressure bandage (usually on the 2-3rd day) or removing the tampons (usually on the 4-5th day), the bleeding may stop due to thrombosis of the damaged vessels.

Vascular embolization.

The method refers to endovascular surgery. It is used for bleeding from the branches of the pulmonary arteries, the terminal branches of the abdominal aorta, etc. In this case, the femoral artery is catheterized using the Seldinger method, the catheter is brought to the bleeding area, a contrast agent is injected and, taking X-rays, the site of damage is identified (diagnostic stage). Then an artificial embolus (coil, chemical substance: alcohol, polystyrene) is brought through a catheter to the site of damage, closing the lumen of the vessel and causing rapid thrombosis.

The method is low-traumatic and allows one to avoid major surgical intervention, but its indications are limited. In addition, special equipment and qualified employees are needed.

Special methods to combat bleeding.

Mechanical methods of stopping bleeding include certain types of operations: splenectomy for parenchymal bleeding from the spleen, gastric resection for bleeding from an ulcer or tumor, lobectomy for pulmonary bleeding, etc.

One of the special mechanical methods is the use of an obturator probe for bleeding from esophageal varices - a fairly common complication of liver diseases accompanied by portal hypertension syndrome. Typically, a Blackmore probe is used, equipped with two cuffs, the lower of which is fixed in the cardia, and the upper, when inflated, compresses the bleeding veins of the esophagus.

Vascular suture and vascular reconstruction.

It is used for damage to large main vessels, the cessation of blood flow through which would lead to adverse consequences for the patient’s life. There are manual and mechanical seams.

When applying a manual suture, atraumatic non-absorbable suture material is used (threads No. 4/0-7/0 depending on the caliber of the vessel).

With different types of damage to the vascular wall, various options for reconstructive intervention on blood vessels are used: side suture, side patch, resection with end-to-end anastomosis, prosthetics (vessel replacement), bypass surgery (creating a bypass for blood).

When reconstructing blood vessels, autovenous vein, autoartery, or synthetic material are usually used as prostheses and shunts. For such a vascular operation, the following requirements must be met:

High degree of tightness;

No blood flow disturbances (constrictions and turbulence);

As little suture material as possible in the lumen of the vessel;

Precise matching of vascular wall layers.

It should be noted that only with this method the blood supply to the tissues is fully preserved.

Physical methods.

They are used only for bleeding from small vessels, parenchymal and capillary, since bleeding from a medium or large vein, and especially an artery, can only be stopped mechanically.

Physical methods are otherwise called thermal, as they are based on the use of low or high temperature.

Exposure to low temperature.

The mechanism of the hemostatic effect of hypothermia is spasm of blood vessels, slowing of blood flow and vascular thrombosis.

Local hypothermia.

To prevent bleeding and the formation of hematomas in the early postoperative period, place an ice pack on the wound for 1-2 hours. The method can be used for nosebleeds (ice pack on the bridge of the nose), stomach bleeding (ice pack on the epigastric area).

In case of gastric bleeding, it is also possible to introduce cold (+4°C) solutions into the stomach through a probe (usually chemical and biological hemostatic agents are used).

Cryosurgery.

Cryosurgery is a special field of surgery. Very low temperatures are used here. Local freezing is used in operations on the brain, liver, and in the treatment of vascular tumors.

Exposure to high temperature.

The mechanism of the hemostatic effect of high temperature is coagulation of the protein of the vascular wall, acceleration of blood clotting.

Using hot solutions

The method can be applied during surgery. For example, with diffuse bleeding from a wound, with parenchymal bleeding from the liver, gall bladder bed, etc., a napkin with a hot saline solution is inserted into the wound and held for 5-7 minutes; after removing the napkin, the reliability of hemostasis is monitored.

Diathermocoagulation.

Diathermocoagulation is the most commonly used physical method to stop bleeding. The method is based on the use of high frequency currents, leading to coagulation and necrosis of the vascular wall at the site of contact with the tip of the device and the formation of a blood clot. Without diathermocoagulation, no serious operation is now unthinkable. It allows you to quickly stop bleeding from small vessels without leaving ligatures (foreign body) and thus operate on a dry wound. Disadvantage of the electrocoagulation method: with excessive coagulation, extensive necrosis occurs, which can complicate subsequent wound healing.

The method can be used for bleeding from internal organs (coagulation of a bleeding vessel in the gastric mucosa through a fibrogastroscope), etc. Electrocoagulation can also be used to separate tissues with simultaneous coagulation of small vessels (an “electronic knife” instrument), which greatly facilitates a number of operations , since the incision is essentially not accompanied by bleeding.

Based on antiblastic considerations, the electric knife is widely used in oncological practice.

Laser photocoagulation, plasma scalpel.

The methods relate to new technologies in surgery. They are based on the same principle as diathermocoagulation (creation of local coagulation necrosis), but allow more dosed and gentle stopping of bleeding. This is especially important for parenchymal bleeding.

Chemical methods.

According to the method of application, all chemical methods are divided into local and general (or resorptive action).

Local hemostatic agents.

Local hemostatic agents are used to stop bleeding in a wound, in the stomach, and on other mucous membranes.

Hydrogen peroxide. Used for bleeding in the wound, it acts by accelerating thrombus formation.

Vasoconstrictors (adrenaline). Used to prevent bleeding during tooth extraction, injected into the submucosal layer during gastric bleeding, etc.

Fibrinolysis inhibitors - ε-aminocaproic acid. Injected into the stomach for gastric bleeding.

Gelatin preparations (gelaspon). They are sponges made of foamed gelatin. They accelerate hemostasis, since upon contact with gelatin, platelets are damaged and factors that accelerate the formation of a blood clot are released. In addition, they have a tamponing effect. Used to stop bleeding in an operating room or an accidental wound.

Wax. Its tamponing effect is used. Damaged flat bones of the skull are sealed with wax (in particular, during craniotomy surgery).

Carbazochrome. Used for capillary and parenchymal bleeding. Reduces vascular permeability, normalizes microcirculation. Apply wipes moistened with the solution to the wound surface.

Caprofer. Used for irrigation of the gastric mucosa during bleeding from erosions of acute ulcers (during endoscopy).

Hemostatic substances with resorptive action

Hemostatic substances with a resorptive effect are introduced into the patient’s body, causing an acceleration of the process of thrombosis of damaged vessels.

· Fibrinolysis inhibitors (ε-aminocaproic acid).

· Calcium chloride - used for hypocalcemia, as ions

· Calcium is one of the factors of the blood coagulation system.

· Substances that accelerate the formation of thromboplastin - dicinone, etamsylate (in addition, they normalize the permeability of the vascular wall and microcirculation).

· Substances with specific actions. For example, pituitrin for uterine bleeding: the drug causes contraction of the uterine muscles, which reduces the lumen of the uterine vessels and thus helps stop bleeding.