RU2005430C1 - Method for treating osteomyelitis of lower extremities - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: antibiotics on colloidal base are introduced at 12-h interval into pelvic fat through catheter thus intensifying barrier function of regional lymphatic system. EFFECT: improved results in treating patients with osteomyelitis of lower extremities of any genesis.

Description

 In the structure of purulent-septic diseases, osteomyelitis takes a leading place, and damage to the lower limb is more than 60%. Difficulties in the fight against modern infection are explained by the increase in antibiotic-resistant staphylococci and gram-negative bacteria to the most commonly used antibiotics and the participation of pathogenic microbes from the group of bacterioids and others that are naturally resistant to most antibiotics in purulent-inflammatory processes.

 The method of administering antibiotics for purulent bone diseases is important. Oral and intramuscular administration of antibiotics is often ineffective due to the fact that antibiotics enter the focus in low concentrations or do not reach the pathogen at all. The desire to obtain high concentrations of antibiotics directly in the focus of inflammation has led to the creation of various methods of their administration - intracranial, intravenous, intraosseous, intraarterial and regional perfusion.

 A simple method by the nature of the execution includes local infusion of antibiotics into the bone marrow canal using conventional bone needles. However, despite the duration of administration, a high concentration of antibiotics in the focus of inflammation is not achieved with this method, since they are carried away by the blood stream.

 Intraarterial administration or venous infusion of antibiotics for osteomyelitis does not create a long-term high concentration in the bones. Along with these shortcomings, the administration of antibiotics in such ways can cause phlebitis and thrombosis.

 It is known that microorganisms and their toxins from the focus of inflammation primarily enter the lymphatic system. However, the intramuscular method of administering antibiotics does not allow creating a high concentration of the drug in the lymph nodes, lymph, and blood at the usual frequency of administration and dosages. With the intravenous method of administering antibiotics, it is possible to create an increased concentration of the drug in the blood, but in lymph it is much lower. An increased dosage of the drug can have a toxic effect on the body, and antibiotics that selectively accumulate in the lymph and which could be used in the treatment of patients have not yet been created. All of the above led to the use of endolymphatic administration of antibiotics.

 It is known that intact blood capillaries of most organs and tissues are slightly permeable to the substance mole. m. more than 20,000. Permeability of the lymphatic capillaries is much higher. Therefore, large-molecular substances, in particular proteins, as well as coarse suspensions, are resorbed from tissues mainly through the lymphatic system.

However, the methods of endolymphatic administration of antibiotics are not widely used, mainly because of the complexity of their technical implementation. More rational in this category of patients, especially in pediatric practice, is the use of etiotropic indirect endolymphatic antibiotic therapy. Significant disadvantages of this method are:
it is necessary to perform injections in the calf muscle, which in some patients leads to the formation of infiltrate. The specified complication does not allow prolonged use of the specified method;
with the indicated method of antibiotic administration, the latter mainly enter the superficial lymphatic vessels and nodes. While in the osteomyelitis process in the lower limb, the deep lymphatic system is more interested.

 According to known data, lymph outflow from muscles, tendons, capsules of joints, periosteum, bones of the lower extremity is carried out through deep lymph vessels. The latter anastomose with iliac lymph nodes.

 Thus, following the structure of the lymphatic system of the lower limb, we can assume that there are favorable anatomical conditions for the proposed method of indirect regional lymphotropic antibacterial therapy in the treatment of lower limb osteomyelitis.

 As a prototype, a method was chosen consisting in the introduction of an intraosseous mixture consisting of 10 ml of a 5% solution of novocaine, 50 ml of an 8% solution of gelatin (or some other prolongator in the same dosage), 2,000,000-6000000 KD of penicillin, 10 ml of a 20% solution of sodium ethazole.

Significant disadvantages of the prototype method are:
a high concentration of antibiotics in the focus of inflammation is not achieved with this method, since they are carried away by the blood stream;
with this method of administration, antibiotics enter the lymphatic system in very small doses.

 It is known that microorganisms in any inflammatory process, including osteomyelitis, enter the lymphatic system, where they not only die, but can also multiply.

 The aim of the invention is to improve the results of treatment of patients with osteomyelitis of the lower limb by lymphotropic regional administration of antibiotics.

 This goal is achieved by catheterization of the pelvic tissue with the subsequent introduction of antibiotics on a colloidal basis, which leads to an increase in the barrier function of the regional lymphatic system and prevents the further spread of infection through the latter.

 The technique for catheterization of the pelvic tissue is as follows. Lymph nodes were homogenized by adding an equal mass volume of isotonic sodium chloride solution. The content of gentamicin in biological substrates was determined by agar diffusion.

 In the first three methods of administering the antibiotic, the concentration of gentamicin increased as much as possible to 58 μg / ml by the 4th hour of the experiment, and then gradually decreased by the 12th hour to almost 0. At the same time, with lymphotropic administration of gentamicin, the maximum concentration was 640 μg / ml noted at the 5th hour of the experiment and maintained at a very high level until the 12th hour of the experiment with a gradual decrease. But even after 24 hours, the concentration of gentamicin in the central lymph was 40 μg / ml. Based on the foregoing, it should be considered necessary to repeat the injection of the antibiotic with the proposed method every 12 hours. This allows you to maintain the concentration of the drug in lymph at a high therapeutic level.

 With the lymphotropic administration of an antibiotic in the pelvic lymph nodes, a high (62 μg / g) concentration of gentamicin was created in the first 10 hours, which was maintained at a significant level for 24 hours, and then gradually decreased and remained up to 13 days at a level of 10 μg / g. It should be noted that with other methods of administration of gentamicin, the concentration of the antibiotic in the lymph nodes was very low.

 Thus, after a single lymphotropic administration of the antibiotic in the regional lymph nodes, a high and long-lasting concentration of the antibiotic is created. The earliest increase is the concentration of the antibiotic in the pelvic lymph nodes. After 3-6 hours, the maximum content of gentamicin in the para-aortic lymph nodes (up to 40 μg / g) is noted, and up to 72 hours remain here. Even in the cervical lymph nodes quite high antibiotic concentrations are created (up to 30 μg / g), but after 12 hours here the antibiotic is no longer detected. This suggests that the method of lymphotropic antibacterial therapy may be useful not only for inflammatory processes in the bones of the lower extremity, but also for their “higher” localizations.

 In addition, with the lymphotropic administration of an antibiotic, a sufficient concentration of the antibiotic in the blood is created.

PRI me R. Patient A, 5.5 years entered 5/12/91, with the body temperature to 39.5 ^{° C} and pain in his right hip. Sick since 05/05/91, the disease is associated with trauma. A history of chronic tonsillitis.

At the time of admission, the condition is serious due to symptoms of intoxication. The skin and visible mucous membranes are pale. Pulse up to 124 beats / min. In the lungs, hard breathing, 36 in 1 min. Heart sounds are muffled. Liver increased by 3 cm. The right femur increased in volume by 6 cm, tenderness, is forced position (flexion of the knee ^to 25 ° C). Active movements in the latter are absent, and passive ones are sharply painful and limited.

 No bone changes were detected on the radiograph of the right thigh.

In the blood test, when the leukocytosis is up to 28 x 10 ⁹ , the shift to the left (stab up to 16%; segmented 78%; lymphocytes 5%; monocytes 3%). Leukocyte intoxication index 11.5, Biochemical blood test: albumin 32%; globulins 68%. The level of average molecules of 0.570 conv. units The average cytochemical coefficient of cationic proteins of neutrophilic granulocytes is 0.58 conv. units The binding ability of albumin 0.220 srvc. units

 The patient was hospitalized in the intensive care unit. Catheterization of the subclavian vein on the right according to Seldinger. Intravenous detoxification therapy has begun. A diagnostic puncture of the distal metaphysis of the femur was performed. Received pus. An osteoperforation operation with intraosseous dialysis was performed. The limb is laid on the Beler tire.

 A catheter is installed in the pelvic fiber on the right to carry out regional lymphotropic antibacterial therapy according to the proposed technique.

In the postoperative period, the patient continued to receive detoxification therapy. Antibiotic therapy was prescribed (carbenicillin 1.0 x 2 times a day intravenously and 20 mg negtamycin regionally lymphotropically into a catheter located in the pelvic tissue 2 times a day). Before the introduction of the antibiotic, 50.0 ml of a 0.5% solution of novocaine and 1000 units were injected into the pelvic tissue. heparin. After 10-15 minutes, 20 mg of gentamicin per 5.0 ml of 10% gelatin, previously heated in a water bath to a liquid state, was injected with a separate syringe. This procedure was repeated twice a day with an interval of 12 hours. Lymphotropic regional antibiotic therapy was carried out for 8 days. A day later, there was a decrease in the signs of toxicosis (a decrease in temperature to 37.0 ^about , a decrease in tachycardia to 90 in 1 min, tachypia to 24 in 1 min), purulent discharge from the wound decreased, swelling of the right thigh decreased. In the general analysis of blood leukocyte intoxication index decreased to 1.5, the level of medium molecules to 0.300 srvc. units , the level of the average cytochemical coefficient increased to 0.98 conv. units and the binding ability of albumin to 0.305 srvc. units

 On the 8th day, suppuration from the wound completely stopped, the volume of both lower extremities became equal, the leukocytosis index of intoxication decreased to 0.6, the level of medium molecules to 0.260 conv. units , the average cytochemical coefficient rose to 1.16 conv. units The binding ability of albumin was 0.350 srvc. units

 On the control x-ray from 05.31.91, there was a slight periostitis of the right femur. No destructive changes in the right thigh were detected.

 06/06/91, in satisfactory condition, the child was discharged under the supervision of a surgeon in the clinic. When discharged, the limb is of the usual form, full movement in adjacent joints, independently walks, does not limp.

 Re-examined in the clinic a year later (08/26/92 g). The baby is healthy. It does not limp, loading completely the right lower limb. Active and passive movements in adjacent joints of the right lower limb in full. On the control x-ray from 08/26/92, changes in the right femur were not detected. Recommendations are given for further follow-up of a child. (56) Polyakov V.A. Selected lectures on traumatology. M.: 1980, p. 39-41.

Claims (1)

 METHOD FOR TREATING LOWER EXTREMITIES OSTEOMYELITIS by introducing novocaine, antibacterial drugs, gelatin, heparin into the pelvic tissue, characterized in that 0.5 daily dose of antibiotic diluted in 5.0 ml of 0.5% is introduced into the tissue of the pelvic pelvis novocaine solution, 10.0 ml of a 10% solution of gelatin and 1000 units. heparin with an interval of 12 hours for 7 to 10 days.