Comparative Characteristics Of Rheological Properties Of Blood In Combined Face Injuries Before And After Treatment

Fractures are one of the most common components in multiple and associated injuries. Fractures of the lower jaw are observed in 76%, of the upper jaw in 24%, a fracture of the zygomatic-orbital complex in 12%. The actual problem of modern traumatology is the violation of reparative osteogenesis with injuries combined with facial trauma. The duration of the consolidation of fractures is determined by the degree of microcirculation disorders in the fracture zone, changes in cellular and coagulation hemostasis and mineral metabolism. In this connection, increasing the effectiveness of treatment of fractures of the bones of the face on the basis of early diagnosis of vascular and hemostasiological changes is of great importance for practical health care.


INTRODUCTION
Fractures of the lower jaw are the most common among all fractures of the bones of the facial skeleton and, according to different authors, range from 75 to 96.5%, and 28-36% of the total number of inpatient dental patients [1]. The high incidence of fractures of the lower jaw is explained by its extended ("borderline") position and relatively large size [2,3]. Traditionally, it is believed that the main reasons contributing to the occurrence of complications are late treatment of victims for medical care, diagnostic errors and incorrect treatment tactics at the prehospital stage, inaccurate reduction and inadequate fixation of fragments, incorrect tactics in relation to the tooth in the fracture gap [4].

Comparative Characteristics Of Rheological Properties Of Blood In Combined Face Injuries Before And After Treatment
Despite the constant improvement of the methods of complex treatment of mandibular fractures and their introduction into clinical practice, the frequency of pyoinflammatory complications remains high and fluctuates, according to different authors, from 9 to 41%, which necessitates further study of this issue [5]. There is no doubt that the high risk of developing infectious and inflammatory complications in a fracture is determined by the anatomical and physiological features of both the lower jaw itself and the soft tissues surrounding it, as well as the presence of a significant amount of opportunistic microflora in the oral cavity [6].
In The combined use of several drugs to influence various links of pathogenesis will inevitably lead to the summation of their undesirable effects. In this regard, it is especially important to search for more advanced drugs that are devoid of these drawbacks and, at the same time, have a multicomponent effect: antibacterial, anti-inflammatory, antioxidant, immunomodulatory, anabolizing, stimulating the processes of reparative bone regeneration.

PURPOSE OF THE STUDY
Study of the state of the hemostasis system in patients with injuries associated with facial trauma in acute trauma in the immediate and postoperative period.

MATERIAL AND METHODS
The study included patients who were treated in a multidisciplinary TMA clinic with damage to severe anemia, atherosclerotic and diabetic vascular lesions, chronic inflammatory diseases in the acute stage. According to the location of the fractures, the patients were divided into 2 groups. Group 1 -21 patients with fractures of the upper jaws, Group 2 -35 patients with fractures of the lower jaws. The control group consisted of 20 people, practically healthy men without traumatic injuries. To study the hemostasis system, venous blood was obtained from the cubital vein with a wide needle into plastic tubes in accordance with the recommendations of the Z.S. Barkagan and A.P. Momota (2001). The blood was immediately mixed with a 3.8% sodium citrate solution in a 9: 1 ratio. To study the function of platelets, platelet-rich plasma was obtained for which the blood was centrifuged at 1000 rpm (140-160g) for 7 minutes. It was centrifuged at 3000-4000 rpm (1200-1400 g) for 15 min at room temperature (+ 18… + 25 ° C). The resulting platelet-rich and platelet-poor plasma (PRP) was used in studies during the first 2 hours. When evaluating the hemostasis system, general parameters were determined using kits and reagents from Technologia-Standard Barnaul, NPO Renam Moscow: Arkhipov; the concentration of fibrinogen in plasma according to Clauss; activity of antithrombin III (AT-III) according to Abildgaard; screening of disorders in the protein C system -according to the assessment of the normalized ratio, which was determined in the PPP before and after the introduction of the protein C activator into it (patent No. 2184976, Russia); Studies of platelet hemostasis: spontaneous aggregation of platelets in the blood according to N.I. Tarasova; determination of platelet aggregation activity on a Biola LA 230-2 aggregometer with inductors; this method used aggregation inductors manufactured by TekhnologiyaStandart (Barnaul), NPO Renam (Moscow), in the following concentrations: ADP -2.5 µg / l (2-10 µM); adrenaline -0.5 μg / l; collagen -4 μg / ml (prepared according to the method of A.S. Shchitikova). Aggregation was recorded for 2 minutes with fixation of time values, then, if necessary, the degree of ADP release was assessed. indicates hypoaggregation, and an increase in the percentage of hyperaggregation. The von Willebrand factor activity was determined on a Biola LA 230-2 analyzer. The quality control of the coagulation tests was carried out using RNP-plasma (reference pooled plasma of donors) or standard-plasma (standardized for the activity of the determined component) for methods of quantitative determination of the activity of plasma procoagulants. All studies were carried out in the post-traumatic, postoperative periods and on the 10th day after the operation.

RESULTS AND DISCUSSION
Changes in hemostasis were characterized by activation of the coagulation potential, decreased clotting time after injury on the upper jaw 210 ± 9.3 s 201 ± 5.1 on the lower, despite the introduction of standard doses of fraxiparine (0.3 U). The subsequent decrease in the postoperative period to 192.2 ± 4.1 s with PVK and 180.1 ± 8.1 s with PNK, with the preservation of the reduced indicators on day 10 to 175.3 ± 5.2 s with PVK and 170.2 ± 11,2 s at PNK. Spontaneous platelet aggregation was higher than the control value. The patients showed changes in platelet membrane activation, confirmed by increased aggregation with various inducers of ADP-aggregation -93.2 ± 3.7% with fractures of the upper jaw (UJ) and 108.2 ± 2.1% with fractures of the mandible. Adrenaline aggregation was 99.3 ± 3.1 and 110.9 ± 3.7%, respectively. After trauma, the level of collagen-induced aggregation was 120.8 ± 4.1%, which is higher than in the control group. With PVK, the indicators did not differ significantly from the control and amounted to 99.5 ± 5.4%.
After trauma, changes in the intracellular activity of platelets were noted, the thrombinaggregation index for PNA was 117.5 ± 6.5%, which is significantly higher than the control level p p <0.05. An increase up to 103.5 ± 4.3% is characteristic of the UJ. An increase in the activity of von Willebrand factor (VWF) in blood plasma was determined with PVK -102.1 ± 3.7% and PNA -132.5 ± 3.1%, which is 1.11 and 1.42 times higher than the control indicator, respectively (p <0.05). In the early postoperative period, hemostasis disorders persist, there is a further tendency to a decrease in the number of platelets, which is more pronounced by 25.12% with PNA. Spontaneous platelet aggregation remained accelerated by 28.3 ± 4.1% for PVK and 32.3 ± 2.7% for PNA. An increase in the induced ADPaggregation was determined: 96.4 ± 4.1%, 114.3 ± 4.5%, respectively. There was also an accelerated aggregation with the adrenaline inducer, compared with the control, 18.16%with PNA and 4.44% -with UJ. After the operation, abnormalities in the parameters of parietal platelet activation were revealed. The level of collagen-induced platelet aggregation was 107.3 ± 3.5% for PVK and 125.1 ± 7.3% for PNA, which is significantly higher than the control standard by 18, 56% and 38.23%, respectively. After the operation, increased intracellular platelet aggregation was determined: the level of thrombin-induced aggregation was 120.8 ± 6.2% for PNA, which significantly exceeds the control group by 1.  The level of aggregation with adrenaline was also higher than the control value in PVK and PNA and amounted to 98.5 ± 4.3% and 109.7 ± 3.4%, respectively, which significantly differed from both the control and the indicators of group 1. By the 10th day after surgical treatment, disturbances in parietal hemostasis persisted, the level of collagen-induced aggregation was accelerated and amounted to 112.1 ± 6.2% in PNA and 101.4 ± 2.8% in PVK, which significantly differed from the control values. The index of thrombin-induced aggregation in PNA was 116.8 ± 5.5%, which remained significantly higher than the control (p <0.05).
With UJ, the values approached those of the control group and amounted to 99.3 ± 4.1%. The activity of von Willebrand factor in blood plasma was 1.34 times higher than the control value, (p<0,05). The study of the parameters of plasmacoagulation hemostasis in patients with concomitant facial trauma revealed a syndrome of transient hypercoagulation ( Table  2). After injury, significant differences from the control were revealed in terms of APTT coagulation indices -34.1 ± 0.9 s with PVK and 32.2 ± 1.5 s with PNK. The concentration of fibrinogen in blood plasma significantly increased with a PNA of 6.9 ± 1.2 g / l (p <0.05).  significantly differed from the control 7.9 ± 0.52 g / l, while the thrombin time was lengthened and amounted to 18.85 ± 1.2 s. For a more complete study of hemostasiological changes in combined facial injuries, the indicators of fibrinolysis were studied (Table 3). with PVK and 87.2 + 4.5% -with PNA was determined. The level of protein C was reduced, but did not differ significantly from the control. In patients, inhibition of the fibrinolysis system (significant lengthening of XIIa-dependent fibrinolysis) was revealed, which was accompanied by an increase in the content of RFMK fibrin degradation products in plasma and against the background of a decrease in the activity of anticoagulant factors and protein C, which is associated with depletion of their reserve potential. These changes against the background of enhanced parietal and intravascular coagulation activation under conditions of endothelial dysfunction can determine a more pronounced degree of thrombinemia and the development of microthrombotic changes.

CONCLUSION
The state of systemic hemostasis in a patient with combined facial injuries is characterized by early pre-endothelial and endothelial platelet activation (adrenaline and collagen hyperaggregation). Strengthening the prothrombogenic potential of the vascular wall (von Willebrand factor), depletion of the anticoagulant reserve (protein C), along with changes in plasma coagulation hemostasis and fibrinolysis. Changes in the indicators of vascular platelet, plasma coagulation hemostasis and fibrinolysis depend on the location of the injury. The most pronounced disorders in all mechanisms of platelet activation (endothelial, membrane, intracellular), the system of plasmacoagulation hemostasis and fibrinolysis are observed in PNA, especially in the postoperative period. The persisting changes in systemic hemostasis on the 10th day of observation, mainly with PNA, necessitate a longer use of antiplatelet and antithrombin drugs.