The dissertation is devoted to solving an urgent problem of thoracic surgery – improving the prevention of thrombohemorrhagic complications in pleural diseases and during surgical and invasive interventions on the chest, particularly in wounded patients with combat-related injuries of the chest and pleura. The relevance of the study is determined by the fact that purulent-inflammatory and traumatic lesions of the pleural cavity are accompanied by a systemic inflammatory response, microcirculatory disorders, and activation of the coagulation–anticoagulation system of the blood. In wounded patients with combat-related trauma, these changes are more pronounced and prolonged due to the combination of tissue injury, blood loss, hypoxemia, and the risk of infection.
The aim of the study was to improve the results of surgical treatment of patients with inflammatory diseases and combat-related injuries of the pleural cavity through a comprehensive study of clinical, inflammatory, functional, and coagulation parameters, determination of their role in the development of postoperative pleuropulmonary and thrombohemorrhagic complications, and substantiation of the differentiated use of low-molecular-weight heparins.
The study included 109 individuals with pleural cavity pathology: 66 patients with inflammatory pleural diseases and 43 wounded patients with combat-related injuries of the chest and pleura. Clinical, laboratory, instrumental, microbiological, functional, and statistical methods were used. The course of the disease and the postoperative period, the frequency of complications, respiratory function, markers of the systemic inflammatory response, and hemostatic parameters were assessed. The dynamics of the coagulation–anticoagulation system parameters during the use of enoxaparin and rivaroxaban were compared.
It was established that pleural lesions of infectious and traumatic origin are accompanied by the development of a hypercoagulable state already at the stage of hospitalization, while the greatest activation of hemostasis is observed during the first day after surgical or invasive intervention. In wounded patients with combat-related trauma, platelet activation, suppression of fibrinolytic activity, and other manifestations of hypercoagulation persisted for a longer period. Hemostatic disorders were associated with pleuropulmonary complications, organization of hemothorax, fibrin deposits, atelectasis, pneumonia, and the need for repeated sanitation of the pleural cavity.
The important role of early physical activation and therapeutic exercise in comprehensive postoperative management was demonstrated. Early initiation of rehabilitation was associated with better respiratory function parameters in both groups and, in patients with inflammatory pleural diseases, also with a lower incidence of postoperative complications.
A key result of the study was the substantiation of the advantage of the low-molecular-weight heparin enoxaparin compared with rivaroxaban for correction of the hypercoagulable state after operations and invasive interventions on the pleura. During enoxaparin therapy, more controlled and predictable positive dynamics of hemostatic parameters were observed, including a more rapid decrease in fibrinogen levels, D-dimer levels, and platelet count, as well as partial restoration of fibrinolytic activity.
The scientific novelty of the study lies in the comprehensive comparative investigation of the coagulation–anticoagulation system of the blood in patients with pleural diseases of infectious origin and in wounded patients with combat-related injuries of the chest and pleura, as well as in establishing a more pronounced and prolonged hypercoagulable state in wounded patients. The expediency of differentiated use of low-molecular-weight heparins, primarily enoxaparin, for the prevention of thrombohemorrhagic complications was substantiated.
The practical significance of the study lies in the substantiation of a differentiated algorithm for the prevention of thrombohemorrhagic complications, including monitoring of hemostatic parameters at hospitalization, on the first day after intervention, and on the 7th day of treatment; the use of enoxaparin after stabilization of local or surgical hemostasis; adequate sanitation of the pleural cavity; antibacterial therapy; and early respiratory rehabilitation.
