Therapeutic Plasmapheresis in Outpatient and Polyclinic Practice

Relevance of the problem

One of the most important contemporary medical problems is the gradually increasing share of elderly people and the cardiovascular and other chronic diseases associated with this age. This leads to hospitals being filled with patients who could be treated in outpatient and polyclinic settings.

In addition, hospitalization deprives elderly people of their familiar environment, places excessive medical-psychological demands on them, exposes them to an increased risk of nosocomial infections, not to mention the substantial financial costs.

Alongside cardiovascular diseases, drug addiction has become widely spread in the country in recent years. The development of effective outpatient methods of treatment for these patients is of great importance for preserving the life and health not only of the elderly but also of a significant part of the young population.

Therapeutic plasmapheresis, used in cases of insufficient efficacy of conventional drug treatment, exerts a multifaceted positive effect on various pathological processes, which is why it has gained considerable spread in the treatment of many diseases in recent decades [R.A. Mokeeva et al., 1964; P.A. Vorobyov, 1998; G.R. Thompson, 1981]. This method has also proved effective in the treatment of drug addictions [V.V. Chirko et al., 1994]. Despite the emergence of various specialized equipment and blood-substituting solutions, questions requiring study and improvement remain in the application of therapeutic plasmapheresis.

The safety of performing this transfusiological procedure for the patient is of no small importance, since the replacement infusion of significant volumes of blood components and preparations in place of the removed plasma, as well as plasma-substituting solutions, is associated with a known risk of various complications [Ziselman E.M. et al., 1984]. Experience of using an isotonic sodium chloride solution for replacement of the removed plasma in hospitalized patients with allergic and anaphylactoid predisposition has demonstrated the efficacy and safety of this technique [Postnikov A.A., 1993].

The development and implementation of effective and safe therapeutic plasmapheresis in outpatient and polyclinic practice would make this method accessible to a wider circle of patients, improve the quality of treatment and life, and reduce financial costs by decreasing the need for hospitalization and subsequent drug support. The present study is devoted to the development of an effective and safe technique of therapeutic plasmapheresis and to studying the effect of this method on the clinical and laboratory parameters of patients in order to implement this method in outpatient and polyclinic practice.

Purpose of the work

The purpose of the work is to develop effective and safe therapeutic plasmapheresis performed under outpatient and polyclinic conditions.

Tasks of the study:

• to develop an effective and safe technique of therapeutic plasmapheresis in outpatient and polyclinic practice;
• to determine the features and organizational principles of applying the therapeutic plasmapheresis method in outpatient and polyclinic practice;
• to investigate the effect of the plasmapheresis method used on the clinical and laboratory parameters of patients during the procedure, as well as in the early and late postoperative periods;
• to study the influence of therapeutic plasmapheresis on the acid resistance of erythrocytes;
• to investigate changes in hemorheological parameters under the effect of therapeutic plasmapheresis.

Scientific novelty and practical significance

An optimal method and regimen of effective and safe continuous-flow plasmapheresis have been developed and scientifically substantiated, allowing its use in the treatment of patients under outpatient and polyclinic conditions.

The comprehensive clinical and laboratory studies performed showed that in patients with various drug-resistant diseases, during the application of the original technique of removing 30-40% of the circulating plasma volume with replacement by a 1.5-2-fold volume of isotonic sodium chloride solution, hemorheological and hemodynamic parameters improve, and the level of total serum protein decreases substantially within physiologically acceptable limits. The method has a negligible effect on the acid resistance of erythrocytes.

The plasmapheresis technique is tolerated by patients without complications, has a favorable effect on the clinical course of the pathological process, and reduces the need for drug support. This provides a basis for using the developed technique of therapeutic plasmapheresis under outpatient and polyclinic conditions. Organizational and methodological principles for implementing this method in a multidisciplinary polyclinic have been developed.

The study performed is a scientific substantiation for using the developed technique of continuous-flow therapeutic plasmapheresis under outpatient and polyclinic conditions in the country. Implementation in practice: the scientific developments have been implemented in clinical practice at Moscow City Polyclinic No. 78, Diagnostic Center No. 6 of the Healthcare Administration of the Northern Administrative Okrug of Moscow, the Medical Center of LLC J1BP in Lobnya, Moscow Region, Klin City Hospital and Nelidovo Central City Hospital of Tver Oblast, and the day-stay ward of the Hematology Research Center of the Russian Academy of Medical Sciences.

Approval of the dissertation

The main positions of the studies performed were presented at 6-9 conferences of the Moscow Society of Hemapheresis (1998 - 2001); the II Scientific-Practical Conference "Anesthesia and Intensive Care in Unfitted Conditions" (1999); an International Symposium dedicated to the 90th anniversary of the birth of academician of the Russian Academy of Medical Sciences V.A. Negovsky (1999); the All-Russian Conference "Sorption, Electrochemical and Gravitational Methods in Modern Medicine" (1999); the Scientific-Practical Conference "Possibilities and Prospects of Aggressive Therapy in Plastic Reconstructive Surgery" (1999); the First All-Russian Conference "Preventive Cardiology" (2000); the Sixth All-Russian Congress of Cardiovascular Surgeons (2000); and the I and II Russian National Congresses of Cardiologists (2000, 2001). The dissertation materials were approved at a joint conference of the staff of the clinical and laboratory departments of the Research Institute of Pediatric Hematology of the Ministry of Health of the Russian Federation. Fourteen works have been published based on the dissertation materials.

Main positions submitted for defense

1. Continuous-flow plasmapheresis with removal of 30-40% of the circulating plasma volume and replacement by a 1.5-2-fold amount of isotonic solution is a sufficiently safe therapeutic method for application under outpatient and polyclinic conditions.
2. Therapeutic plasmapheresis produces in patients a complex of positive laboratory-clinical changes indicating the efficacy of the method.
3. The performance of therapeutic plasmapheresis under outpatient and polyclinic conditions reduces the acuteness and severity of the course of diseases, decreases the need for special drug support, and limits the necessity of hospitalization.

The work was carried out in the surgical department with a day-stay ward for patients of Diagnostic Center No. 6 of the Healthcare Administration of the Northern Administrative Okrug of Moscow (chief physician - T.V. Zakharchenkova), the day-stay ward for patients of the Research Center of the Russian Academy of Medical Sciences (head - Candidate of Medical Sciences N.N. Tsyba), the Department of Extracorporeal Blood Purification of the Research Center of the Russian Academy of Medical Sciences (head - Doctor of Medical Sciences, professor N.N. Kalinin), and the pathophysiology laboratory of the Research Center of the Russian Academy of Medical Sciences (head - Doctor of Medical Sciences, professor N.A. Gorbunova).

The author expresses gratitude to all staff members of Diagnostic Center No. 6 of the Healthcare Administration of the Northern Administrative Okrug of Moscow and of the Hematology Research Center of the Russian Academy of Medical Sciences who took part in carrying out this work.