MD1560Z - Method for minimally invasive treatment of bacterial spontaneous ascites-peritonitis in patients with decompensated liver cirrhosis - Google Patents
Method for minimally invasive treatment of bacterial spontaneous ascites-peritonitis in patients with decompensated liver cirrhosis Download PDFInfo
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- MD1560Z MD1560Z MDS20210014A MDS20210014A MD1560Z MD 1560 Z MD1560 Z MD 1560Z MD S20210014 A MDS20210014 A MD S20210014A MD S20210014 A MDS20210014 A MD S20210014A MD 1560 Z MD1560 Z MD 1560Z
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- nacl solution
- dissolved
- ascites
- peritonitis
- patients
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- 206010003445 Ascites Diseases 0.000 title claims abstract description 10
- 230000001580 bacterial effect Effects 0.000 title claims abstract description 7
- 206010034674 peritonitis Diseases 0.000 title claims abstract description 7
- 230000002269 spontaneous effect Effects 0.000 title claims abstract description 7
- 208000019425 cirrhosis of liver Diseases 0.000 title claims abstract description 6
- 238000000034 method Methods 0.000 title claims description 13
- FAPWRFPIFSIZLT-UHFFFAOYSA-M Sodium chloride Chemical compound [Na+].[Cl-] FAPWRFPIFSIZLT-UHFFFAOYSA-M 0.000 claims abstract description 18
- 210000003567 ascitic fluid Anatomy 0.000 claims abstract description 13
- 239000003242 anti bacterial agent Substances 0.000 claims abstract description 12
- 229940088710 antibiotic agent Drugs 0.000 claims abstract description 7
- 239000002934 diuretic Substances 0.000 claims abstract description 7
- 229940030606 diuretics Drugs 0.000 claims abstract description 7
- 238000002560 therapeutic procedure Methods 0.000 claims abstract description 7
- 150000001413 amino acids Chemical class 0.000 claims abstract description 6
- 239000004599 antimicrobial Substances 0.000 claims abstract description 6
- UREBDLICKHMUKA-CXSFZGCWSA-N dexamethasone Chemical compound C1CC2=CC(=O)C=C[C@]2(C)[C@]2(F)[C@@H]1[C@@H]1C[C@@H](C)[C@@](C(=O)CO)(O)[C@@]1(C)C[C@@H]2O UREBDLICKHMUKA-CXSFZGCWSA-N 0.000 claims abstract description 6
- 229960003957 dexamethasone Drugs 0.000 claims abstract description 6
- 238000007911 parenteral administration Methods 0.000 claims abstract description 6
- 108010003272 Hyaluronate lyase Proteins 0.000 claims abstract description 5
- 102000001974 Hyaluronidases Human genes 0.000 claims abstract description 5
- 230000003115 biocidal effect Effects 0.000 claims abstract description 5
- 125000001271 cephalosporin group Chemical group 0.000 claims abstract description 5
- QTCANKDTWWSCMR-UHFFFAOYSA-N costic aldehyde Natural products C1CCC(=C)C2CC(C(=C)C=O)CCC21C QTCANKDTWWSCMR-UHFFFAOYSA-N 0.000 claims abstract description 5
- 229960002773 hyaluronidase Drugs 0.000 claims abstract description 5
- 238000001802 infusion Methods 0.000 claims abstract description 5
- ISTFUJWTQAMRGA-UHFFFAOYSA-N iso-beta-costal Natural products C1C(C(=C)C=O)CCC2(C)CCCC(C)=C21 ISTFUJWTQAMRGA-UHFFFAOYSA-N 0.000 claims abstract description 5
- 238000002690 local anesthesia Methods 0.000 claims abstract description 5
- 239000000203 mixture Substances 0.000 claims abstract description 4
- 238000002360 preparation method Methods 0.000 claims description 12
- 230000000845 anti-microbial effect Effects 0.000 claims description 3
- 150000004957 nitroimidazoles Chemical class 0.000 claims 1
- YZEUHQHUFTYLPH-UHFFFAOYSA-N 2-nitroimidazole Chemical group [O-][N+](=O)C1=NC=CN1 YZEUHQHUFTYLPH-UHFFFAOYSA-N 0.000 abstract description 4
- 238000013459 approach Methods 0.000 abstract description 3
- 239000003814 drug Substances 0.000 abstract description 2
- 229940127218 antiplatelet drug Drugs 0.000 abstract 1
- 239000000106 platelet aggregation inhibitor Substances 0.000 abstract 1
- 230000003187 abdominal effect Effects 0.000 description 3
- 206010062070 Peritonitis bacterial Diseases 0.000 description 2
- 208000004880 Polyuria Diseases 0.000 description 2
- 206010071368 Psychological trauma Diseases 0.000 description 2
- 206010037660 Pyrexia Diseases 0.000 description 2
- VAAUVRVFOQPIGI-SPQHTLEESA-N ceftriaxone Chemical compound S([C@@H]1[C@@H](C(N1C=1C(O)=O)=O)NC(=O)\C(=N/OC)C=2N=C(N)SC=2)CC=1CSC1=NC(=O)C(=O)NN1C VAAUVRVFOQPIGI-SPQHTLEESA-N 0.000 description 2
- 229960004755 ceftriaxone Drugs 0.000 description 2
- 238000003745 diagnosis Methods 0.000 description 2
- 230000035619 diuresis Effects 0.000 description 2
- 230000002443 hepatoprotective effect Effects 0.000 description 2
- 238000001356 surgical procedure Methods 0.000 description 2
- 208000004998 Abdominal Pain Diseases 0.000 description 1
- 102000009027 Albumins Human genes 0.000 description 1
- 108010088751 Albumins Proteins 0.000 description 1
- 208000014644 Brain disease Diseases 0.000 description 1
- 229930186147 Cephalosporin Natural products 0.000 description 1
- 206010010075 Coma hepatic Diseases 0.000 description 1
- 208000032274 Encephalopathy Diseases 0.000 description 1
- NNJVILVZKWQKPM-UHFFFAOYSA-N Lidocaine Chemical compound CCN(CC)CC(=O)NC1=C(C)C=CC=C1C NNJVILVZKWQKPM-UHFFFAOYSA-N 0.000 description 1
- 206010030302 Oliguria Diseases 0.000 description 1
- 210000000683 abdominal cavity Anatomy 0.000 description 1
- 150000005693 branched-chain amino acids Chemical class 0.000 description 1
- 229940124587 cephalosporin Drugs 0.000 description 1
- 150000001780 cephalosporins Chemical class 0.000 description 1
- 238000004140 cleaning Methods 0.000 description 1
- 230000003247 decreasing effect Effects 0.000 description 1
- 238000001784 detoxification Methods 0.000 description 1
- 206010016766 flatulence Diseases 0.000 description 1
- 229940124307 fluoroquinolone Drugs 0.000 description 1
- 238000002695 general anesthesia Methods 0.000 description 1
- 201000001059 hepatic coma Diseases 0.000 description 1
- 208000007386 hepatic encephalopathy Diseases 0.000 description 1
- 230000004054 inflammatory process Effects 0.000 description 1
- 230000002427 irreversible effect Effects 0.000 description 1
- 108010065073 lidase Proteins 0.000 description 1
- 229960004194 lidocaine Drugs 0.000 description 1
- 230000003908 liver function Effects 0.000 description 1
- 238000007449 liver function test Methods 0.000 description 1
- 210000003622 mature neutrocyte Anatomy 0.000 description 1
- 208000007232 portal hypertension Diseases 0.000 description 1
- 208000011580 syndromic disease Diseases 0.000 description 1
- 230000000007 visual effect Effects 0.000 description 1
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- Pharmaceuticals Containing Other Organic And Inorganic Compounds (AREA)
Abstract
Description
Invenţia se referă la medicină, în special la hepatologie şi poate fi utilizată pentru tratamentul miniinvaziv al ascit-peritonitei spontane bacteriene la pacienţii cu ciroză hepatică decompensată. The invention relates to medicine, in particular to hepatology and can be used for the minimally invasive treatment of spontaneous bacterial ascites-peritonitis in patients with decompensated liver cirrhosis.
Este cunoscută metoda de tratament al ascit-peritonitei spontane bacteriene, care constă în efectuarea laparocentezei de volum cu evacuarea lichidului ascitic contaminat şi administrarea i/v a antibioticelor şi anume a preparatelor din grupa cefalosporinelor de generaţia III (ceftriaxonă câte 1 g de 2 ori, timp de 5...7 zile) şi administrarea preparatelor hepatoprotectoare, diureticelor, aminoacizilor cu catenă ramificată [1]. The method of treatment of spontaneous bacterial ascites-peritonitis is known, which consists of performing volume laparocentesis with evacuation of contaminated ascitic fluid and i/v administration of antibiotics, namely preparations from the group of cephalosporins of the third generation (ceftriaxone 1 g 2 times, for 5...7 days) and the administration of hepatoprotective preparations, diuretics, branched-chain amino acids [1].
Dezavantajul metodei date constă în eficacitatea redusă şi procentul înalt de mortalitate în rezultatul progresării procesului septic intraabdominal şi insuficienţei hepato-renale. The disadvantage of this method is its low effectiveness and high mortality rate as a result of the progression of the intra-abdominal septic process and hepatorenal insufficiency.
Mai este cunoscută metoda de tratament al ascit-peritonitei spontane bacteriene, care constă în aceea că se efectuează terapia intensivă cu administrarea parenterală a antibioticelor, hepatoprotectoarelor, plasmei, aminoacizilor, preparatelor reologice şi dezagregante, diureticelor, iar adăugător se efectuează laparocenteza cu evacuarea a 3...5 L de lichid ascitic contaminat. Apoi prin abord laparoscopic, după evacuarea suplimentară a lichidului ascitic din etajul abdominal superior sub controlul vizual se instalează un tub de drenaj în etajul abdominal inferior, prin care se insuflă CO2 în cantitate de 3000...5000 cm3, care se barbotează prin lichidul ascitic restant, timp de 3…5 min, după care gazul se evacuează prin troacarul superior. Apoi prin drenul menţionat se insuflă O2 în cantitate de 1000...3000 cm3, care se barbotează prin lichidul ascitic, timp de 2…3 min, după care se evacuează tot lichidul ascitic restant. Apoi prin drenul menţionat se introduce consecutiv sol. lidocaină de 2% în cantitate de 20...30 ml, dexametazon 8…16 mg, în 100...200 ml sol. NaCl 0,9 %, lidază 370…640 un. cu sol. NaCl 0,9 % în cantitate de 200…500 ml, un antibiotic din grupa cefalosporinelor şi antimicrobiene din grupa fluorchinolonelor, fiecare din ele cu sol. NaCl 0,9 % în cantitate de 200…500 ml. Procedura de introducere a preparatelor menţionate prin drenul instalat se efectuează zilnic, timp de 3...5 zile [2]. There is also a known method of treating spontaneous bacterial ascites-peritonitis, which consists in performing intensive therapy with parenteral administration of antibiotics, hepatoprotectors, plasma, amino acids, rheological and disaggregating preparations, diuretics, and additionally performing laparocentesis with evacuation of 3...5 L of contaminated ascitic fluid. Then, through a laparoscopic approach, after additional evacuation of ascitic fluid from the upper abdominal floor under visual control, a drainage tube is installed in the lower abdominal floor, through which CO2 is insufflated in an amount of 3000...5000 cm3, which is bubbled through the remaining ascitic fluid, for 3...5 min, after which the gas is evacuated through the upper trocar. Then through the mentioned drain O2 is insufflated in an amount of 1000...3000 cm3, which is bubbled through the ascitic fluid, for 2...3 min, after which all the remaining ascitic fluid is evacuated. Then through the mentioned drain 2% lidocaine solution is consecutively introduced in an amount of 20...30 ml, dexamethasone 8...16 mg, in 100...200 ml 0.9% NaCl solution, lidase 370...640 units with 0.9% NaCl solution in an amount of 200...500 ml, an antibiotic from the cephalosporin group and antimicrobials from the fluoroquinolone group, each of them with 0.9% NaCl solution in an amount of 200...500 ml. The procedure for introducing the mentioned preparations through the installed drain is performed daily, for 3...5 days [2].
Dezavantajul metodei date constă în aceea că pentru efectuarea metodei este necesară anestezia generală, care poate agrava starea pacientului cirotic decompensat, care poate conduce uneori la progresarea encefalopatiei cu trecere în comă hepatică ireversibilă. The disadvantage of this method is that general anesthesia is required to perform the method, which can worsen the condition of the decompensated cirrhotic patient, which can sometimes lead to the progression of encephalopathy with irreversible hepatic coma.
Problema pe care o rezolvă invenţia constă în elaborarea unei metode de tratament minim-invaziv al ascit-peritonitei spontane bacteriene, care constă în asanarea cavităţii abdominale prin accese multiple puncţionale atraumatice cu scop de a minimiza trauma fizică şi psihologică a pacientului şi reducerea cheltuielilor şi duratei de spitalizare. The problem solved by the invention consists in developing a minimally invasive treatment method for spontaneous bacterial ascites-peritonitis, which consists in cleaning the abdominal cavity through multiple atraumatic puncture accesses with the aim of minimizing the patient's physical and psychological trauma and reducing expenses and duration of hospitalization.
Esenţa invenţiei constă în aceea că se efectuează terapia infuzională cu administrarea parenterală a antibioticelor, hepatoprotectorilor, plasmei, aminoacizilor, preparatelor reologice şi dezagregante, diureticelor, şi concomitent, sub anestezie locală, se efectuează accese puncţionale în regiunea fosei iliace stângi şi drepte şi sub rebordul costal drept, se evacuează lichidul ascitic, apoi prin aceleaşi accese, în fiecare regiune se introduce câte un amestec, care conţine 4...8 mg de dexametazonă dizolvată în 50...100 ml de soluţie de NaCl 0,9 %, hialuronidază 124...248 UI dizolvată în 100...200 ml de soluţie de NaCl 0,9 %, un antibiotic din grupa cefalosporinelor dizolvat în 50...100 ml de soluţie de NaCl 0,9 % şi un preparat antimicrobian din grupa nitroimidazolilor, în doză de 5...10 mg/ml şi în volum de 25...75 ml, zilnic, timp de 3...5 zile. The essence of the invention consists in performing infusion therapy with parenteral administration of antibiotics, hepatoprotectors, plasma, amino acids, rheological and disaggregating preparations, diuretics, and simultaneously, under local anesthesia, puncture accesses are made in the region of the left and right iliac fossa and under the right costal margin, the ascitic fluid is evacuated, then through the same accesses, a mixture is introduced into each region, which contains 4...8 mg of dexamethasone dissolved in 50...100 ml of 0.9% NaCl solution, hyaluronidase 124...248 IU dissolved in 100...200 ml of 0.9% NaCl solution, an antibiotic from the cephalosporin group dissolved in 50...100 ml of 0.9% NaCl solution and an antimicrobial preparation from the nitroimidazole group, in a dose of 5...10 mg/ml and in a volume of 25...75 ml, daily, for 3...5 days.
Rezultatul invenţiei constă în ameliorarea stării pacientilor prin accese multiple puncţionale atraumatice pentru atenuarea procesului inflamator septic intraabdominal, ameliorarea proceselor de resorbţie peritoneală a lichidului ascitic cu scop de redresare a funcţiei hepatice, corecţia sindromului ascitic, totodată are loc minimizarea traumei fizice şi psihologice a pacientului cu reducerea cheltuielilor şi duratei de spitalizare. The result of the invention consists in improving the condition of patients through multiple atraumatic puncture accesses to alleviate the intra-abdominal septic inflammatory process, improving the peritoneal resorption processes of ascitic fluid with the aim of restoring liver function, correcting ascitic syndrome, while minimizing the patient's physical and psychological trauma with a reduction in expenses and duration of hospitalization.
Metoda se efectuează în modul următor. După pregătirea necesară a pacientului se efectuează terapia infuzională cu administrarea parenterală a antibioticelor, hepatoprotectorilor, plasmei, aminoacizilor, preparatelor reologice şi dezagregante, diureticelor, şi concomitent, sub anestezie locală, se efectuează accese puncţionale în regiunea fosei iliace stângi şi drepte şi sub rebordul costal drept, se evacuează lichidul ascitic, apoi prin aceleaşi accese, în fiecare regiune se introduce câte un amestec, care conţine 4...8 mg de dexametazonă dizolvată în 50...100 ml de soluţie de NaCl 0,9 %, hialuronidază 124...248 UI dizolvată în 100...200 ml de soluţie de NaCl 0,9 %, un antibiotic din grupa cefalosporinelor dizolvat în 50...100 ml de soluţie de NaCl 0,9 % şi un preparat antimicrobian din grupa nitroimidazolilor, în doză de 5...10 mg/ml şi în volum de 25...75 ml, zilnic, timp de 3...5 zile. The method is performed in the following way. After the necessary preparation of the patient, infusion therapy is performed with parenteral administration of antibiotics, hepatoprotectors, plasma, amino acids, rheological and disaggregating preparations, diuretics, and simultaneously, under local anesthesia, puncture accesses are performed in the region of the left and right iliac fossa and under the right costal margin, the ascitic fluid is evacuated, then through the same accesses, a mixture is introduced into each region, which contains 4...8 mg of dexamethasone dissolved in 50...100 ml of 0.9% NaCl solution, hyaluronidase 124...248 IU dissolved in 100...200 ml of 0.9% NaCl solution, an antibiotic from the cephalosporin group dissolved in 50...100 ml of 0.9% NaCl solution and an antimicrobial preparation from the nitroimidazole group, in a dose of 5...10 mg/ml and in a volume of 25...75 ml, daily, for 3...5 days.
Metoda revendicată a fost utilizată pentru tratamentul a 21 de pacienţi. The claimed method was used for the treatment of 21 patients.
Exemplu Example
Pacientul D., 52 ani a fost internat în secţia chirurgie septică cu diagnosticul de ciroză hepatică decompensată HCV, Child “C”(11), hipertensiune portală, ascit-peritonită spontană bacteriană tensionată. Prezenta febră 37,8°C, dureri abdominale, meteorism, oligurie. S-a efectuat terapia infuzională detoxifiantă, reologică, hepatoprotectorie, transfuzii de plasmă, albumină, diureză forţată. S-a efectuat puncţia cavităţii abdominale cu examinarea lichidului ascitic la prezenţa de neutrofile polimorfonucleare (NPN), care s-a stabilit la nivelul de 320 mm3, ce a confirmat diagnosticul de peritonită spontană bacteriană. S-a efectuat terapia infuzională cu administrarea parenterală a antibioticelor, hepatoprotectoarelor, plasmei, aminoacizilor, preparatelor reologice şi dezagregante, diureticelor, iar concomitent sub anestezie locală s-au efectuat accese puncţionale în regiunea fosei iliace stângi şi drepte şi sub rebordul costal drept, s-a evacuat lichidul ascitic, apoi prin aceleaşi accese în fiecare regiune s-au introdus câte 6 mg de dexametazonă în 100 ml sol. NaCl 0,9 %, hialuronidază 248 UI cu sol. NaCl 0,9 % în cantitate de 200 ml, ceftriaxon 1,0 g cu sol. NaCl 0,9 % în cantitate de 50 ml şi antimicrobiene din grupa nitroimidazolului 10 mg/ml în volum de 75 ml, care s-a efectuat zilnic, timp de 5 zile. După 72 de ore starea generală s-a ameliorat, a dispărut febra, s-a restabilit diureza, ascita s-a micşorat, probele funcţionale hepatice s-au ameliorat. Pacientul a fost externat la tratament ambulatoriu peste 7 zile. Patient D., 52 years old, was admitted to the septic surgery department with a diagnosis of decompensated HCV liver cirrhosis, Child “C” (11), portal hypertension, tense spontaneous bacterial peritonitis-ascites. He had fever of 37.8°C, abdominal pain, flatulence, oliguria. Infusional detoxification, rheological, hepatoprotective therapy, plasma transfusions, albumin, forced diuresis were performed. Abdominal puncture was performed with examination of the ascitic fluid for the presence of polymorphonuclear neutrophils (PNF), which was established at the level of 320 mm3, which confirmed the diagnosis of spontaneous bacterial peritonitis. Infusion therapy was performed with parenteral administration of antibiotics, hepatoprotectors, plasma, amino acids, rheological and disaggregant preparations, diuretics, and simultaneously under local anesthesia, puncture accesses were performed in the region of the left and right iliac fossa and under the right costal margin, the ascitic fluid was evacuated, then through the same accesses in each region, 6 mg of dexamethasone in 100 ml of 0.9% NaCl solution, 248 IU of hyaluronidase with 0.9% NaCl solution in an amount of 200 ml, 1.0 g of ceftriaxone with 0.9% NaCl solution in an amount of 50 ml and antimicrobials from the nitroimidazole group 10 mg/ml in a volume of 75 ml, which was performed daily for 5 days. After 72 hours, the general condition improved, the fever disappeared, diuresis was restored, ascites decreased, liver function tests improved. The patient was discharged for outpatient treatment after 7 days.
1. Хохлов А.В. Хирургическое лечение резистентного асцита у больных циррозом печени. Автореферат дисс. докт.мед.наук.,Санкт-Петербург, 2002, 184 с. 1. Khokhlov A.V. Surgical treatment of resistant ascites in patients with liver cirrhosis. Dissertation abstract. докт.мед.наук., Санкт-Петербург, 2002, 184 с.
2. MD 926 Y 2015.07.31 2. MD 926 Y 2015.07.31
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