Mark a diuretic for forced diuresis. Forced diuresis or artificial stimulation of urine output

Forced diuresis is a detoxification method, which is based on the accelerated removal of toxins from the body by increasing the volume. This effect is achieved by simultaneously introducing a large volume of fluid into the body and prescribing diuretics.

So, if it is 0.5-1.0 ml per minute, then with forced diuresis this figure increases to 8-10 ml/min.

When conducting detoxification therapy, take into account Chemical properties a substance that needs to be eliminated from the body. For good removal of toxins that exhibit alkaline properties (nicotine, procainamide, antihistamines, quinine, quinidine, imizine, phenamine, xanthine derivatives), the resulting urine must be made slightly acidic. And to remove substances that exhibit acidic properties (ethyl, methyl, isopropyl and other alcohols, barbiturates, ethylene glycol, salicylates, sulfonamides), the resulting urine must be slightly alkaline. With neutral urine, analgin, strychnine, phenacytine, bromides, fluorides, chloral hydrate, and meprotane are well excreted.

Indications for forced diuresis:

• poisoning with substances that are excreted in the urine;
• infectious intoxication (rare).

Contraindications:

• , in stage ;
• poisoning with poisons that have a toxic effect on;
• vascular thrombosis;
• cardiovascular failure;
• cerebral edema and intracranial hematoma;
• pulmonary edema;
• portal hypertension;
• pericarditis.

Method of performing forced diuresis:

• Detoxification therapy is carried out in a hospital.
• A catheter is installed in a large vessel: the subclavian or ulnar vein (for intravenous administration of solutions).
• Place a catheter in bladder(to assess the amount of urine excreted).
• Initially, hypertonic solutions are administered:
• 800 ml 20% glucose;
• or 400 ml of 40% glucose;
• or a solution of mannitol at the rate of 1 g per 1 kilogram of the patient’s weight.
• Then, to maintain the concentration of the main blood electrolytes, a solution containing K, Na, Ca, Mg is administered - six bottles of 400 ml of 0.85% NaCl solution + 400 ml of 5% glucose solution, to which are added:
• 10% KCl solution (15 ml);
• 10% CaCl solution (5 ml);
• 25% MgSO4 solution (3 ml).
• During the introduction of fluid, the need for targeted changes in accordance with the acid-base properties of the toxin is taken into account.
• Every 3-4 hours, 40-60 mg of furosemide is administered. The daily dose is 240-480 mg.
• Drugs that improve blood flow in the kidneys are administered - prostaglandin E. In addition, heparin and aminophylline can be used for this purpose.

The first 2-3 liters of liquid are administered at a rate of 1000 ml per hour. Then the volume of administration is reduced to 500 ml per hour and brought into line with the rate of urine formation. The amount of fluid administered should be at least 6 liters per day for women and 8 liters per day for men. If necessary, the volume is adjusted to 12 l/day or more.

Forced diuresis- a method of detoxification therapy based on artificial stimulation of urination through the simultaneous introduction of fluid and diuretics into the body in order to accelerate the excretion of toxic substances from the body in the urine. The normal rate of urine formation in a healthy adult is 0.7-1.3 ml/min, increases with D. f. until 8-10 ml/min.

Detoxification effect D. f. is mainly due to accelerated excretion of the toxin due to increased formation of glomerular ultrafiltrate (primary urine) and its rapid movement through the renal tubules, which reduces the reabsorption of the toxin in the tubules, increasing its excretion in the urine. When using the method, it is taken into account that simple substances that are not associated with proteins and have a neutral reaction are excreted mainly by glomerular filtration, and substances that have the properties of weak acids or bases, regardless of their binding to proteins, are secreted by renal tubular cells at a rate depending on Urine pH. With a slightly acidic urine reaction, substances with basic properties are better excreted; with an alkaline reaction, on the contrary, substances with slightly acidic properties are excreted. Thus, alkalinization of urine to a pH of 7.0 or more increases the renal clearance of phenobarbital by approximately 5 times, and of salicylic acid by 10 times.

The main indication for use of D. f. are poisonings with substances excreted from the body mainly in urine. It is rarely used for infectious intoxication. Contraindications to the use of D. f. are severe cardiovascular, pulmonary edema, cerebral edema, intracranial, and conditions that threaten its development (for example, cerebral ischemic), portal, digitalis intoxication, poisoning with nephrotoxic poisons and substances that have an extrarenal route of elimination from the body, renal in the stage of anuria. A cautious attempt to stimulate diuresis can be made at the beginning of the oliguric stage of acute renal failure, which developed after massive blood transfusion, due to rhabdomyolysis. If there is no effect, treatment is stopped.

Method D. f. used in hospital settings. It begins with catheterization or puncture of a large vein (subclavian or ulnar); The bladder is also catheterized to visually assess the rate of urination. A hypertonic, usually 20% or 40% glucose solution (800 or 400 ml, respectively) or a 20% mannitol solution (at the rate of 1 g/kg patient's body weight) to obtain osmotic diuresis,

At the beginning of the procedure, solutions prepared for infusion are administered at a speed of 1000 ml/h, then (after infusion 2-3 l) infusion rate is reduced to 500 ml/h, bringing it into line with the rate of urination. The total amount of fluid administered is at least 8 l per day for men and 6 l per day for women, reaching 12 if necessary l per day or more. To prevent sodium retention in the patient’s body, during the procedure 40-60 doses are administered every 3-4 hours. mg furosemide, bringing its dose to 240-480 mg/day An increase in renal blood flow and glomerular filtration is facilitated by a constant infusion of dinoprostone (prostaglandin E 2); For the same purpose, aminophylline, heparin and other drugs that improve blood flow in the kidneys can be used for certain indications.

Duration of D. f. can range from several hours to several days. As a result of its use, the duration of toxic coma is reduced and the danger of complications inherent in comatose states is eliminated.

Complications of D. f. there may be acute cardiac and pulmonary edema due to intravascular administration of large amounts of fluid; cerebral edema due to osmotic imbalance leading to cell hyperhydration; disturbance of acid-base balance in case of overdose of alkalizing or acidifying agents; hypovolemia with a drop in blood pressure when the rate of diuresis exceeds the rate of fluid infusion; acute renal

To eliminate drug intoxication in a patient, forced diuresis is often used. The main goal is to remove dangerous, toxic components from the body by increasing fluid and accelerating urination. It is used only in hospital settings under the supervision of a doctor and the administration of solutions, not causing disturbances. It has no serious consequences and is widely used in medicine. Relevant for removing both one group of toxic elements and the presence of several types of drugs in the body. It is prohibited to carry out at home.

What is diuresis using the forced method?

The method of using forced diuresis is considered a multifunctional tool for treating intoxication.

The method of forced diuresis can be used to eliminate intoxication (poisoning) of the human body, due to the accelerated excretion of large amounts of urine. This is achieved by administering diuretics while giving the patient plenty of fluids. The norm for urination in an adult is healthy person is 0.7-1.3 ml/min. Using the method, the rate increases to 8-10 ml/min. With forced diuresis, it becomes possible to remove toxic breakdown products medicines from the patient's blood. Boosting drugs are used to improve the filtration functions of the kidneys and the ability to quickly remove harmful substances through the urine stream.

The effectiveness of forced diuresis is influenced by the degree of activity of cell fixation of toxins. This is explained by the transition of some toxic elements from the extracellular to the intracellular membrane. Being in the outer shell, the substances easily dissolve in water, and the products of their metabolism are freely amenable to diuresis. If the functionality of the diuretic organ is reduced and the degree of intoxication is high, then the chosen remedy for diuresis may not work.

The effects of drugs to reduce intoxication depend on the level of urine acidity (pH). When the pH is less than 7.0, toxins with basic properties are removed well; at a pH above 7.0, poisons with a slightly acidic effect are removed. For example, alkalinizing urine to 7 on the pH scale can improve the excretion of phenobarbital by 5 times, and salicylic acid by 10 times.

Indications and contraindications

Forcing is used to eliminate high intoxication with barbiturates, FenaminF, alkaloids, salicylates, Diphenhydramine, Haloperidol, Diprazine, methanol, Raunatin. To do this, to a large number Add a drug to the water that stimulates kidney function. Indications for use of the forced method:

• the presence of strong toxic substances in the patient’s body;
• poisoning with medications;
• intoxication with unspecified poisons;
• poisoning with combined medications.

Contraindications for using the forced method:

• patient's shock;
• presence of pulmonary edema;
• presence of cerebral edema;
• detection of renal and cardiovascular failure;
• pancreatitis;
• acute intestinal obstruction;
• peritonitis;
• the presence of internal hematomas, thrombosis.

How is it carried out?

Forced diuresis in case of poisoning is carried out exclusively in a hospital setting. The doctor conducts a preliminary assessment of kidney function and determines the rate of urine excretion. There is a large vessel where the catheter is installed. A diuretic drug is administered through it. To assess the rate of filling of the bladder, a catheter is also installed into it. Hypertonic solutions are administered, then solutions to maintain electrolytes in the blood, and urine alkalinity is measured.

First, 2 liters of liquid are introduced at a rate of 1000 ml/hour, then reduced to 500 ml/hour and made equal to the rate of urine formation. With an average degree of intoxication, 8 liters of liquid are administered to men, and 6 liters to women. In more dangerous and severe cases, the amount of liquid is 12 liters or more. At the time of boosting, Furosemide and Prostaglandin E are added every 3-4 hours to stimulate blood movement in the body. The duration of the procedure depends on the degree of accumulation of toxins and the severity of the connection with proteins and lymph. By increasing the amount of fluid, the doctor makes sure that it is equal to the volume of urine excreted. Only at a rate of at least 100 ml/hour of urination is diuresis considered forced. This procedure is not carried out at home.

Stages of the technique

The use of detoxification for forced diuresis is carried out in 4 stages:

1. Inject 500 ml of three percent sodium bicarbonate and 1500 ml of Lactasol (Acesol or Ringer). The mixture is introduced into 2000 ml of 2 components at a speed of 80 drops/min to 100 drops/min.
2. A 15% solution of Minnitol is used (except for patients with cerebral edema), 1 g/kg of the patient’s weight, adding 240 mg of Euphyllin. It is introduced in a stream.
3. Then 5% glucose (1 l) is used adding 40 ml of 7.5% potassium chloride emulsion, 50 ml of 10% calcium chloride.
4. The doctor administers 1-1.5 liters of protein or another protein preparation.

The catheter should be connected to the ulnar or subclavian vein. A second catheter should be inserted into the bladder (to monitor its filling rate). Constant monitoring is carried out by a specialist on a cardiac monitor and checks the patient’s water and electrolyte balance, breathing and hemodynamic data. The composition of the solutions used during the forced method depends on the types of toxins and the degree of poisoning by them, as well as the overall functionality of the body.

Dangerous complications

Carrying out treatment using the forced method requires observation and constant correction during application. Accompanied by the introduction of a high dose of electrolytes. They can appear if the rules for using the method are violated and if the technique is incorrect. In this case, hypokalemia, overhydration, and hypochloremia may occur. Long-term use of osmotic diuretics can develop osmatic nephrosis. To avoid this, they are recommended to be combined with saluretics. If the dose of acidifying or alkalizing agents is violated or exceeded, the normal indicators of the acid-base balance are disrupted using the forced method. It is possible to avoid any complications from the action of the drug only with stable control of the process by the attending physician and the correct technology of use.

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Forced diuresis as a method of detoxification is based on the use of drugs that promote a sharp increase in diuresis, and is the most common method of conservative treatment of poisoning, when hydrophilic toxicants are eliminated primarily by the kidneys.

These goals are best met by osmotic diuretics (urea, mannitol), the clinical use of which was started by the Danish physician Lassen in 1960. The osmotic diuretic is distributed only in the extracellular sector, does not undergo metabolic transformations, is completely filtered through the basement membrane of the glomerulus, and is not reabsorbed in the tubular apparatus kidneys

Mannitol is the best, widely used osmotic diuretic. Distributes only in the extracellular environment, is not metabolized, and is not reabsorbed by renal tubules. The volume of distribution of mannitol in the body is about 14-16 liters. Mannitol solutions do not irritate the intima of veins and do not cause necrosis if they get under the skin. They are administered intravenously in the form of a 15-20% solution of 1.0-1.5 g per 1 kg of body weight. The daily dose is no more than 180 g.

Urea is a conditional osmotic diuretic, distributed throughout the entire water sector of the body by free diffusion, and is not metabolized. The drug is non-toxic, but highly concentrated solutions damage the intima of the veins and can cause phlebitis. Long-term stored solutions produce hemolysis. It is used in the form of a 30% solution at a dose of 1.0-1.5 g per 1 kg of patient body weight. If kidney function is impaired, the introduction of urea can sharply increase the nitrogen content in the body, so in such cases it is not used.

Furosemide (Lasix) is a strong diuretic (saluretic) agent, the action of which is associated with inhibition of the reabsorption of Na+ and Cl ions, and to a lesser extent, K+.

The effectiveness of the diuretic effect of the drug, used in a single dose of 100-150 mg, is comparable to the effect of osmotic diuretics, however, with repeated administration, more significant losses of electrolytes, especially potassium, are possible.

The forced diuresis method is a fairly universal way to accelerate the removal of various toxic substances from the body, including barbiturates, morphine, OPI, quinine and pachycarpine, dichloroethane, heavy metals and other drugs excreted from the body by the kidneys. The effectiveness of diuretic therapy is significantly reduced as a result of the formation of strong bonds of many chemical substances that enter the body with blood proteins and lipids. This is observed, for example, in case of poisoning with phenothiazines, librium, leponex, etc. In case of poisoning with toxicants that give aqueous solution acid reaction (barbiturates, salicylates, etc.), the blood is first alkalized by intravenous administration of sodium bicarbonate (4% solution 500 ml).

Forced diuresis is always carried out in three stages: preliminary water load, rapid administration of a diuretic and replacement infusion of electrolyte solutions.

The following method of forced diuresis is recommended. The hypovolemia that develops in severe poisoning is first compensated for by intravenous administration of plasma-substituting solutions (polyglucin, 400 ml and 5% glucose solution in a volume of 1.0-1.5 l). At the same time, the concentration of the toxic substance in the blood and urine, the hematocrit are determined, and a permanent urinary catheter is inserted to measure hourly diuresis. Urea or mannitol (15-20% solution) is administered intravenously in a stream in an amount of 1.0-1.5 g per 1 kg of the patient’s body weight for 10-15 minutes, then a solution of electrolytes at a rate equal to the rate of diuresis.

The high diuretic effect (500-800 ml/h) persists for 3-4 hours, after which the osmotic balance is restored. If necessary, the entire cycle is repeated, but no more than two times to avoid the development of osmotic nephropathy. The combined use of osmotic diuretics with saluretics (furosemide) provides an additional opportunity to increase the diuretic effect by 1.5 times. However, the high speed and large volume of forced diuresis, reaching 10-20 l/day, pose the potential danger of rapid leaching of plasma electrolytes from the body.

For correction possible violations salt balance, a solution of electrolytes is administered, the concentration of which is slightly higher than in urine, taking into account the fact that part of the water load is created by plasma-substituting solutions. The optimal solution for this solution is: potassium chloride - 13.5 mmol/l and sodium chloride - 120 mmol/l, with subsequent monitoring and additional correction if necessary. In addition, for every 10 liters of urine excreted, 10 ml of a 10% calcium chloride solution is required.

The method of forced diuresis is sometimes called blood washing, so the water and electrolyte load associated with it places increased demands on the cardiovascular system and kidneys. Strict accounting of injected and excreted fluid, determination of hematocrit and central venous pressure make it possible to easily control the body’s water balance during treatment, despite the high rate of diuresis.

Complications of the forced diuresis method (overhydration, hypokalemia, hypochloremia) are associated only with violation of the technique of its use. To avoid thrombophlebitis at the site of injection of solutions, it is recommended to use the subclavian vein. With long-term use of osmotic diuretics (over 3 days), the development of osmotic nephrosis and acute renal failure is possible. Therefore, the duration of forced diuresis is usually limited to these periods, and osmotic diuretics are combined with saluretics.

The method of forced diuresis is contraindicated in case of intoxication complicated by acute cardiovascular failure (persistent collapse, circulatory disorders II-III stage), as well as in cases of renal dysfunction (oliguria, azotemia, increased blood creatinine content more than 221 mmol/l, which is associated with low filtration volume). In patients over 50 years of age, the effectiveness of the forced diuresis method is noticeably reduced for the same reason.

Therapeutic hyperventilation

The effectiveness of this detoxification method for acute poisoning with carbon disulfide (up to 70% of it is excreted through the lungs), chlorinated hydrocarbons, and carbon monoxide has been proven in clinical settings. However, prolonged hyperventilation leads to the development of disturbances in the gas composition of the blood (hypocapnia) and the acid-base state (respiratory alkalosis). Therefore, under the control of these parameters, intermittent hyperventilation is carried out (15-20 minutes each) again every 1-2 hours throughout the entire toxicogenic phase of poisoning.

Regulation of enzymatic activity

Inducers can be used in cases of poisoning by substances whose immediate metabolites are significantly less toxic than the native substance.

Inhibitors can be used in case of poisoning by such compounds, the biotransformation of which proceeds according to the “lethal synthesis” type, i.e. with the formation of more toxic metabolites.

Currently, more than two hundred substances are known that can influence the activity of microsomal enzymes (cytochrome P-450).

The most studied inducers are barbiturates, in particular phenobarbital or benzonal, and a special Hungarian drug, zixorin. Under the influence of these drugs, the level and activity of cytochrome P-450 increases in liver mitochondria, which is due to stimulation of their synthesis processes. Therefore, the therapeutic effect does not appear immediately, but after 1.5-2 days, which significantly limits the possibility of their use only to those types of acute poisoning, the toxicogenic phase of which develops slowly and lasts longer than the periods indicated above.

The clinical use of inducers of enzymatic activity is indicated for poisoning (overdose) with steroid hormones, coumarin anticoagulants, contraceptives with a steroid structure, analgesics such as antipyrine, sulfonamides, antitumor drugs (cytostatics), vitamin D, as well as some insecticides (especially in subacute poisoning) from the group carbamic acid (dioxycarb, pyrimor, sevin, furadan) and organophosphorus compounds (actellik, valekson, chlorophos).

The doses of enzymatic activity inducers used in the clinic are: for zixorin - 50-100 mg per 1 kg of body weight 4 times a day, for reamberin - a 5% solution of 400 ml into a vein for 2-3 days. IN last years Chemo-hemotherapy methods using sodium hypochlorite infusions are most widely used as inducers of enzymatic activity; HBO and PHT can also be used for this purpose.

Many have been proposed as inhibitors of enzymatic activity. medications, in particular nialamide (monoamine oxidase inhibitor), chloramphenicol, teturam, etc. However, their clinical effectiveness in case of poisoning with substances that undergo lethal synthesis in the body is limited, since the inhibitory effect develops on the 3-4th day, when the toxicogenic phase of most poisonings is already ending.

E. A. Luzhnikov, G. N. Sukhodolova

Before talking about the method of using forced diuresis, you need to understand what kind of procedure it is and what it is. Forced diuresis is an increase in the volume of urine in the body and its elimination in order to reduce the volume of toxins and other harmful substances. Forced diuresis method carried out only in truly severe cases, when human life and health are at risk.

What is forced diuresis?

The effectiveness of the procedure will depend on how much the toxins are entrenched in the healthy cells of the body. This can be judged by the penetration of a toxic substance into the cell area. If the toxins have not had time to penetrate too deeply and are still in the cell membrane, then they will be easily diuresable, they can be removed from the body without problems, and some of the harmful substances will completely dissolve in water.

If toxins have already penetrated into the cell nucleus, then the diuresis procedure will no longer be beneficial.

Indications for the forced diuresis procedure

Since such a procedure is considered strictly medical, it will not be performed on anyone who wants it; special medical indications are required for its implementation:

• Poisoning with substances that leave the body along with urine.
• Intoxication that occurred due to serious infectious disease(this happens quite rarely).
• The presence of strong toxic substances in the patient’s body.
• Poisoning with medications.
• Intoxication with poisons of unknown origin.
• Poisoning with medications that have a combined structure.

Contraindications to the forced diuresis procedure

This medical procedure is not for everyone. If there are any contraindications, you will have to find an alternative treatment method. Contraindications include the following diseases and conditions:

• Kidney problems, kidney failure, which has reached the stage of anuria. Anuria is a complication in which urine does not flow into the bladder area.
• Poisoning with toxic substances, the action of which is aimed at damaging the kidneys.
• Blood clots in the vessels are a serious indicator for the procedure of forced diuresis.
• Cardiovascular diseases.
• Brain swelling.
• Hematoma inside the skull.
• Edema of the lungs or one lung.
• Hypertension is a chronic and persistent increase in blood pressure.
• The patient is in shock.
• Pancreatitis is a disease characterized by severe inflammation of the pancreas.

Attention! Forced diuresis in children is used only for medical reasons.

How is the forced diuresis procedure performed?

Forced diuresis in case of poisoning or intoxication of the body is carried out only in a medical hospital; home treatment using this method is impossible. Before the procedure itself, the doctor must examine the patient and assess the state of his kidneys and determine the rate of urine output.

The technique of forced diuresis is carried out as follows: if the indicators satisfy such a procedure, then you will need to find a fairly large vessel into which the catheter is placed. A diuretic drug will be administered through it. In order to monitor the patient's bladder fullness, another catheter will need to be inserted. After such technical training will be completed, the patient begins to be administered the following fluids in strict order:

• For forced diuresis, a hypertonic solution is used.
• The main remedy for forced diuresis is a solution that will maintain blood electrolytes.
• First, 2 liters of fluid are administered, to which drugs for forced diuresis are added. , monitor the rate of urine formation.
• Then the remaining liquid is injected. For men - 8 liters, for women - 6, provided that the degree of intoxication or poisoning was average. In more dangerous and severe cases, up to 12 liters of liquid are administered.
• Every 3-4 hours, an additional drug is administered to speed up the movement of blood in the body and diuretics for forced diuresis.

Forced diuresis is carried out only in the presence of a specialist. The doctor is constantly next to the patient and makes sure that the amount of fluid that he introduces into the body is equal to the amount of urine that comes out of this body.

Forced diuresis is not carried out at home.

Attention! If the patient is poisoned by substances that contain an acidic environment, then to neutralize them it will be necessary to add alkali to the patient’s blood.

As for the duration of the procedure, it will be different in each individual case. The time it takes will depend on how severe the degree of poisoning or intoxication is. It can last from several hours to several days.

Can such a procedure lead to complications?

Yes, during the forced diuresis procedure the following complications may occur, since blood purification is not as safe as it might seem at first glance.

• Heart failure, which may begin to appear only some time after such treatment.
• Pulmonary edema.
• Brain swelling.
• Quite low blood pressure may persist for several days.
• Acute renal failure may develop after the procedure.

Interesting video on the topic of water, kidney function and circulating blood:

Conclusion

Thus, forced diuresis is a blood purification procedure that is carried out through the bladder. Using this method, you can quickly remove toxins and other harmful substances from the body that are usually eliminated through the kidneys and are harmful to kidney health.