RU2064798C1 - Method of purulent mediastenitis treatment - Google Patents

Abstract

FIELD: medicine, thoracic surgery. SUBSTANCE: method involves surgery operation with multiple drainage of mediastenium cavity, its washing with antiseptic solutions, antibacterial and disintoxicating therapy and additional purulent cavity washing with 0.5-1% aqueous suspension of highly dispersed silicon dioxide (polysorb). Method ensures to decrease treatment period an average by 15 ± 5 days. EFFECT: decreased treatment period.

Description

 The invention relates to medicine, in particular to thoracic surgery, and can be used in the treatment of purulent mediastinitis, viral and other etiologies.

 Acute purulent mediastinitis is an extremely serious disease, mortality in which to date reaches 50-70 Anatomical and physiological characteristics of the mediastinum determine the speed of development of the purulent process and its low tendency to limit.

 There is a method of treating purulent mediastinitis by surgery, tubeless drainage of the mediastinum with double-lumen drainage, washing and prolonged aspiration (N.N. Kanshin. Treatment of perforation of the esophagus and purulent mediastinitis. In the book Surgical and combination treatment of diseases of the esophagus and stomach (Materials of the Republican Conference // Tomsk: Tomsk University Press, 1973, pp. 55-57.) The wide drainage channels are connected to a vacuum device with a weak discharge, and constant drops are carried out through narrow channels infusion of a solution of furatsilin at a concentration of 1,500. To improve sanitation, the abscess cavity is periodically washed with the fractional method using active aspiration of the wash liquid. 1.5-2 liters of solution are consumed per day. Drainage is carried out for 14-16 days, and the patients are kept for the total time in the hospital is about 5 weeks.The common essential features of the known and claimed methods for the treatment of purulent mediastinitis are surgery with multiple drainage of the purulent cavity and subsequent myvaniem its antiseptic solution. The disadvantage of this method of treatment of purulent mediastinitis is the length of treatment.

 The closest in essence is a method of treatment of purulent mediastinitis, including surgery, drainage of the mediastinum, its subsequent washing with a solution of antiseptics, antibacterial and detoxification therapy (Traumatic purulent mediastinitis (clinic, diagnosis, treatment). Methodical recommendations // M. Ministry of Health of the RSFSR, 1978 , p. 3-25). Depending on the localization of the purulent focus, surgery is performed through the tracheal, transperitoneal or transpleural accesses. To ensure reliable evacuation of exudate from the purulent cavity, the method of tight drainage using double-lumen tubes with constant aspiration and washing of the mediastinum is used. Continuous aspiration is carried out through a wide drainage channel using a vacuum pump. Since the use of only one aspiration quickly leads to blockage of the drains with thick purulent discharge, constant washing of the purulent cavity with an antiseptic solution (furatsilin 1 5000) at a speed of 40-60 drops per minute or flow-fractional washing is used. The cavity in the mediastinum can be rinsed 2-3 times a day with the following antiseptics: a solution of furagin 1 13000, a solution of chlorhexidine 1 4000, chlorophyllipt (20 ml of the drug in 1000 ml of furacilin). Detoxification and antibacterial therapy involves the introduction of semi-synthetic penicillins at the maximum dosage or conventional penicillin at a dosage of 3-4 million units. 8 times a day intramuscularly. Important in the stimulation of the protective forces of the patient's body is the appointment of anabolic hormones, purine and pyrimidine bases. At least 1 time per week, the patient can be administered antistaphylococcal gamma globulin. Direct transfusion gives a good effect. Common essential features of the known and claimed methods for treating purulent mediastinitis are: surgical intervention with multiple drainage of the mediastinal cavity and subsequent washing with antiseptic solutions, antibacterial and detoxification therapy. The disadvantage of this method of treatment of purulent mediastinitis is the length of treatment.

 The objective of the invention is to reduce the treatment time. As a result of the invention, it is possible to reduce the treatment time for purulent mediastinitis by an average of 15 ± 5 days.

 The problem is achieved in that in the known method for the treatment of purulent mediastinitis, including surgery with multiple drainage of the mediastinal cavity and subsequent washing with antibiotic solutions, antibacterial and detoxification therapy, according to the claimed invention, the mediastinal cavity is additionally washed with an aqueous suspension of highly dispersed silicon dioxide.

 The method is as follows.

The patient is subjected to surgical intervention with access corresponding to the localization of the purulent focus (transdermal, transpleural, transperitoneal) with adequate multiple drainage of the purulent cavity in the mediastinum with double drains. Sanitation of the mediastinum is carried out by daily fractional washing with solutions of antiseptics (furatsilin, bifuran, trifuran, chlorhexidine) to clean water. Then anesthesia is carried out by washing the purulent foci with a 0.5% solution of novocaine or another local anesthetic, introduced through the drainage in an age-related dosage with an appropriate exposure in time. After that, the purulent cavity in the mediastinum is washed with a 0.5-1% aqueous suspension of finely divided silica in an amount corresponding to the volume of the purulent cavity and kept in the cavity for 3-5 minutes. Then the purulent focus is washed with an antiseptic solution to clear water. Fine silica is a white loose powder with a particle size of 5-20 nm and a specific surface area of 150-400 m ² / g, obtained as a result of high-temperature hydrolysis of SiCl4 (GOST 14922-77). The content of the main substance is 99.9. There is a permission of the Pharmaceutical Committee of the USSR dated February 28, 1991 (protocol No. 3) for the medical use of highly dispersed silicon dioxide in the treatment of purulent wounds. An aqueous suspension of silicon dioxide is obtained by mixing the corresponding amount in distilled water. An aqueous suspension can be prepared immediately before washing or in advance and stored in a hermetically sealed sterile container. Antibacterial therapy involves the appointment of antibiotics, mainly a wide spectrum of action. Detoxification therapy includes the appointment of glucose-salt solutions, hemodesis, reopoliglyukin, protein preparations (plasma, albumin). According to the indications, diuretics, analeptics, analgesics are prescribed. Great importance is attached to the stimulation of the body's defenses by the administration of anabolic hormones, purine and pyrimidine bases, antistaphylococcal gamma globulin. Direct transfusion is highly effective.

 The following is information confirming the possibility of carrying out the invention.

 Example 1. Patient Oksana B. 8 years old, medical history N 383/200. He was admitted to the clinic on March 25, 1991 with a diagnosis of odontogenic phlegmon of the bottom of the mouth and neck, complicated by upper purulent mediastinitis.

 Anamnesis of the disease: 03/17/1991, the patient removed a tooth. 03/18/1991, body temperature increased, pain and swelling appeared in the submandibular region of soft tissues. She was hospitalized in the maxillofacial department, where an opening and drainage of neck infiltrate on the right was performed. Despite the ongoing intensive antibiotic therapy and local treatment, the patient's condition worsened. An X-ray examination revealed the spread of the purulent process in the region of the upper mediastinum. 03/25/1991 the patient was transferred to the children's department of the Kiev scientific and practical center of thoracic surgery and pulmonology.

 Upon receipt, the condition is serious. The patient is languid, pale, adynamic, his voice hoarse. In the neck, pronounced edema, hyperemia and tension of the soft tissues. Through the available incisions of soft tissues on the neck on the right and in the area of the jugular notch, pus flows.

 03/25/1991 operation: bilateral cervicostomy, opening the phlegmon of the neck and upper mediastinum, drainage of the purulent cavities of the neck and upper mediastinum. At the opening of the abscesses, 50.0 ml of pus was released, the cavities were washed with a solution of antiseptics.

 A bacteriological examination of the wound discharge revealed a moderate growth of Pseudomonas aeruginosa, sensitive only to tetracycline and chloramphenicol. Intensive intravenous antibacterial (dalacin, metragil, brulamycin), detoxification immunomodulating and general stimulating therapy, physiotherapeutic procedures were prescribed. Nutrition through a nasogastric tube for 4 days. The course of the postoperative period was complicated by bleeding from the thin venous branches of the jugular plexus, requiring repeated surgery on March 26, 1991 with the goal of hemostasis.

 Sanitation of purulent foci was carried out by continuous flow washing with furatsilin and a solution of antibiotics (kanamycin) and additional fractional washing 1 time per day with a 1% aqueous suspension of highly dispersed silicon dioxide from 03/27. On April 2, 1991, the drains were removed on April 3, 1991 on the right and April 8, 1991 on the left. The drainage period was 14 days.

 Infusion therapy was carried out for 12 days. The postoperative wound healed by primary intention. Discharged on April 24, 1991 in satisfactory condition. The treatment period was 30 beds / days.

 Example 2. Patient Alexander B., 6 years old, medical history No. 671. He was admitted to the hospital on October 14, 1991 as an ambulance for post-burn cicatricial stenosis of the esophagus, gastrostomy, and foreign body of the esophagus. From the anamnesis it is known that in March 1990 a child drank battery fluid. He was treated in the Kiev regional hospital and the children's department of the Kiev scientific and practical center of thoracic surgery and pulmonology. On May 8, 1990, a gastrostomy was superimposed. Subsequently, 12 courses of supporting esophageal bougienage with positive dynamics of the local process were carried out, nutrition was carried out through the mouth. 10/12/1991, the passage of food through the esophagus stopped. An X-ray contrast study revealed cicatricial narrowing of the thoracic esophagus, its complete obstruction for the contrast medium at the level of narrowing (Th 4-5).

 According to emergency indications, 10/14/1991, with general anesthesia, esophagoscopy was performed. A foreign body (a piece of bone) that obstructs the stenotic segment of the esophagus was revealed and removed. When trying to draw a bougie through the lumen of tube No. 7 with the aim of conducting the thread, a perforation of the wall of the thoracic esophagus occurred, which is confirmed radiographically.

 10/14/1991, the operation of mediastinotomy through retropleural access, suturing of the esophagus defect, drainage of the mediastinum.

 Intensive antibacterial (carbenicillins, dalacin, intravenous metrogil), detoxification, general stimulating and immunomodulating therapy were prescribed. The postoperative period is severe, complicated by right-sided pleural empyema (exudate study dated 10.16.1991 - leukocytes cover the entire field of view), left-side pyopneumothorax due to inconsistency of the joints of the esophagus defect and the resulting esophageal-mediastinal pleural fistula. The pleural cavity on the right is punctured with the introduction of kanamycin. The left pleural cavity is drained sequentially on 17 and 18.10.1991 in connection with the delimitation of empyema cavities. Sanitation of the latter was carried out by continuous flow washing with solutions of antiseptics and antibiotics (kanamycin) and, additionally, a 1% aqueous suspension of finely divided silica daily from 10/17/1991 to 10/27/1991.

 The mediastinal cavity is sanitized similarly to the left pleural cavity. Fine silica in the form of a 1% aqueous suspension was used twice on October 17 and 18, 1991.

 After the termination of exudation, antibiotics were administered fractionally at an age-related dosage. 10/22/1991, one mediastinal drainage and anterior drainage were removed from the left pleural cavity.

 10.24.1991, it has been clinically and radiologically confirmed that the esophago-mediastin-pleural fistula on the left has closed. 10.24.1991, in the washings from the left pleural cavity, microbacteria of tuberculosis were found. Special therapy (ethambutol, isoniazid, kanamycin intramuscularly, rafimpicin in the left pleural cavity) was added to the general treatment.

 10/25/1991, the exudation from the mediastinum stopped. November 4, 1991, the catheter and nasogastric tube were removed. Allowed to drink. November 6, 1991 the second drainage was removed from the mediastinum. The drainage period is 22 days. Exudation from the pleural cavity stopped. It is allowed to take pureed food through the mouth, swallow freely. 11/10/1991, removed subclavian drainage from the left pleural cavity. The drainage period is 24 days.

 Final clinical diagnosis: post-burn cicatricial stenosis of the thoracic esophagus. Gastrostoma Foreign body of the esophagus. Perforation of the thoracic esophagus, limited purulent mediastinitis. Bilateral pleural empyema. Esophago-mediastino-pleural fistula on the left. Bilateral acute postoperative pneumonia. Respiratory failure III degree. Tuberculosis of the intrathoracic lymph nodes in the infiltration stage. Tubcontact in the past.

 November 12, 1991 was transferred to the children's department of the Kiev Research Institute of Phthisiology. Infusion therapy for 20 days. Conducted three courses of antibiotic therapy. The course of treatment was 29 beds / days.

 Example 3. Patient Natalya P. 2 years 2 months. medical history N 593. Was admitted to the hospital 04/19/1991 with a diagnosis of traumatic rupture of the cervical esophagus when trying to remove a foreign body, purulent upper mediastinitis.

Medical history: 04/12/1991, the child swallowed a coin. 04/13/1991, in the regional hospital, at the place of residence, an esophagoscopy was performed to remove a foreign body. The latter passed into the stomach and subsequently came out naturally. After esophagoscopy, which revealed swelling and hyperemia of the mucous membrane of the esophagus in the area of the first physiological constriction, a subfibril increase in body temperature was noted, the child refused to eat. 04/18/1991, the body temperature increased to 38 ^o C. During x-ray examination diagnosed perforation of the esophagus and mediastinitis. 04/19/1991, the child was transferred to the children's department of the Kiev Scientific and Practical Center of Thoracic Surgery and Pulmonology. Upon receipt, the condition is serious. The patient is sluggish, adynamic, the skin is pale gray. Body temperature 38 ^o C, salivation. A clinical and radiological examination confirmed the diagnosis of perforation of the esophagus and medistinitis. 04/19/1991, the operation was performed: 1. Gastrostomy according to Kader; 2. Cervicostomy on the right, suturing of the esophagus defect, drainage of the mediastinum. At the opening of the mediastinum, pus was released, bacteriological examination of which revealed the growth of an enterobacter, sensitive only to polymyxin. Intensive intravenous antibacterial (claforan, azlocillin), detoxification (hemodez, plasma, albumin, reopoliglyukin), immunomodulating general stimulating therapy, physiotherapeutic treatment methods have been prescribed. Sanitation of the purulent focus was carried out by continuous flow washing with solutions of antibiotics (polymyxin, kanamycin) and antiseptics. The patient was fed through a gastrostomy.

 On 2 and 5.06.1991, the upper and lower drainages from the mediastinum were sequentially removed. The drainage period was 47 days. A postoperative wound in the neck healed by secondary intention. Infusion therapy was carried out for 20 days. Discharged on June 13, 1991 in satisfactory condition. The duration of treatment is 55 beds / days.

 Example 4. Patient Alexander P. 2 years 6 months. medical history N 256. He fell ill acutely on 04/04/1988 when he swallowed a metal washer. April 4, 1988 was hospitalized in the regional children's hospital at the place of residence with a diagnosis of a foreign body of the esophagus. 04/04/1988 conducted esophagoscopy. Attempts to remove a foreign body were unsuccessful due to its introduction into the mediastinum. The patient's condition deteriorated sharply. The child was consulted and operated on by a pediatric thoracic surgeon at the Kiev Scientific and Practical Center for Thoracic Surgery and Pulmonology. Operation 04/04/1988 1. Gastrostomy by Kader; 2. Posterolateral thoracotomy. Mediastinotomy, removal of a foreign body, suturing of a defect in the wall of the esophagus. Remediation of the mediastinum and right pleural cavity with antiseptic solutions. Drainage of the mediastinum (double drainage) and the right pleural cavity. Intensive intravenous antibacterial (ampiox, gentamicin, metragil), detoxification, immunomodulating and general stimulating therapy were prescribed. Sanitation of the mediastinum was carried out by continuous flow washing with solutions of antiseptics and antibiotics. Postoperative clinical diagnosis: traumatic rupture of the cervicothoracic esophagus with a foreign body migrating to the mediastinum. Acute purulent mediastinitis. Pleural empyema on the right.

 The postoperative period is severe, complicated by the failure of the sutures of the esophagus wall and acute postoperative pneumonia.

 Due to the severity of the condition, on April 11, 1988, the child was transferred to the children's department of the Kiev Scientific and Practical Center for Thoracic Surgery and Pulmonology. Upon receipt, the condition is serious. During the examination, the failure of the sutures with the formation of an esophago-mediastino-pleural fistula on the right was diagnosed. Continued infusion antibacterial (claforan, amikacin), detoxification and general stimulating therapy. Flow washing of the mediastinum with solutions of antiseptics and antibiotics has been established. Food through a gastrostomy. The treatment includes ultraviolet autologous blood, intramuscular administration of antistaphylococcal gamma globulin and antistaphylococcal plasma. 05/23/1988 esophago-mediastino-pleural fistula was closed. On May 27, 1988, pleural drainage was removed. 06/08/1988, mediastinal drainage was removed. The drainage period is 65 days. Infusion therapy was carried out for 31 days (from 04/04 to 05/05/1988). Discharged home in satisfactory condition on 06/17/1988. The term of treatment was 74 beds / day, in the clinic 67 beds / days.

Claims (1)

 A method of treating purulent mediastinitis, including surgery with multiple drainage of the mediastinal cavity and subsequent washing with antiseptic solutions, antibacterial and detoxification therapy, characterized in that the mediastinal cavity is additionally washed with 0.5 to 1% aqueous suspension of finely divided silica.