RU2089108C1 - Method for treating suppurative mediastinitis and double empyema of pyothorax after cardiosurgical interventions from transdoublepleural access - Google Patents

Abstract

FIELD: medicine; cardiosurgery; treatment of suppurative complications after operations on heart. SUBSTANCE: first patient's both pleural cavities and anterior mediastinum are subjected to sanitation under conditions of operating room, followed by draining each pleural cavity with help of double-lumen drain having perforated openings. For this purpose, drain is positioned in S-like manner in frontal plane in gently sloped areas of pleural cavities so that one ends of drain pipes are brought closer to breast bone, while other ends of drain pipes are drawn outwards between 6-7 ribs. Next breast bone ends are sutures together, wound is tightly sutured, and through-flow, ataractic drain is organized against background of desintoxicating and antibacterial therapy. EFFECT: effective treatment of suppurative mediastinitis and double empyema of chest. 1 dwg

Description

 The invention relates to medicine, namely to cardiac surgery, and can be used for purulent complications after heart surgery.

 In cardiac surgery, along with the widely used median sternotomy, overexpendicular access to the heart and great vessels is used. In the event of an infectious complication after an extradupleural thoracotomy, anterior mediastinitis develops in combination with bilateral pleural empyema. The treatment of this severe complication is carried out in an “open” way and consists in diluting the edges of the postoperative wound, sternum, removing purulent discharge from the wound surface, frequent dressings with hypertonic solution, followed by application of oil-balsamic dressings (1). The healing of large wound defects takes an extremely long time, with chest deformation, the formation of gross keloid scars, the development of bone chondral infection, septic complications in the form of erosive bleeding, thromboendocarditis.

 The proposed method eliminates these disadvantages, reduces the bed-day, prevents the development of septic complications, and achieves a better cosmetic effect.

 The method is illustrated by the drawing and is carried out in the following way: on the day of the diagnosis of purulent mediastinitis and bilateral pleural empyema, the patient in the operating room under intubation anesthesia undergoes surgical treatment: the chest is widely diluted, purulent masses, blood clots, necrotic tissues are removed. Then the pleural cavities, heart, and main vessels are washed with a large amount of antiseptic fluid (3% solution of hydrogen peroxide, furatsillina, "Microcida") in order to reduce microbial contamination of tissues. The sharp edges of the sternum are treated with Liston's nippers. After this, a double-lumen drainage with perforations is inserted into the pleural cavity by puncture of the VI-VII intercostal space along the midaxillary line and placed in an S-shape in the frontal plane with the drainage ends leading to the sternum. In this case, the perforation hole in the drainage, which evacuates the discharge to the outside, should be near the wall of the pleural cavity in order to avoid the formation of "blind space". Drainages are sutured to the skin. The edges of the sternum are sutured with separate wire sutures (stainless steel).

 In the postoperative period, along with detoxification and antibacterial therapy, flow-aspiration drainage of the pleural cavities is carried out. For washing, usually use standard containers of 400 ml of saline with the addition of 20 ml of a 1% solution of dioxidine, or saline with an antibiotic, to which this microflora is sensitive. The osmolarity of the solution should be at least 300 m / osmol. The solution is supplied from the vial through a single dropper installed on the side of the patient. Wash water is removed by active aspiration with a vacuum suction with a discharge of 1-2 atm. The rate of washing the first portion should be given jet (to prevent thrombosis of the fibrin drainage), then drip 30-60 drops per minute.

 The first day, washing should go on constantly. In the following days - fractionally, i.e. 6 times a day, then as the condition improves to 4 times a day. Postoperative suture dressings are performed daily with its tightness control. If necessary, an additional seam is applied when the solution flows through the seam.

 Flow-suction drainage is continued for 10-12 days. By this time, there are only traces of sediment in the wash water in the form of white fibrin flakes at the bottom of the can. Before removing the drains, a cytological control of the wash water is performed, and if the number of leukocytes in the field of view does not exceed 10-25, then the drains are removed. Stitches from the skin are removed on the 12-13th day. The drainage holes close independently.

Example: Patient Miller Elena Vladimirovna, 6 years old, medical history N 1610, was admitted to NIIPK on 07.20.93. During the clinical examination, the diagnosis was established: congenital heart disease, defect of the atrial septum of the secondary type, partial abnormal drainage of the right pulmonary veins in the mouth of the superior vena cava . Operation 2.08.93, in conditions of in-depth hypothermic protection, from abdominal access, the abnormally draining right pulmonary veins were transferred to the left atrium by closing the interatrial defect located in the mouth of the superior vena cava with a patch from the autopericardium. The postoperative period was difficult with symptoms of cardiopulmonary insufficiency, increased accumulation of fluid in the pleural cavities, about which pleural punctures were performed. The nature of the punctate obtained showed signs of infection (the number of leukocytes in the field of view is more than 45). Against this background, hypothermia appeared up to 38 ^o C, chills, symptoms of intoxication. The growth of Pseudomonas aeruginosa was obtained from pleural punctate. In this regard, an infectious complication is suspected - the development of bilateral empyema of the pleura, mediastinitis. 06.06.93, under conditions of intubation anesthesia in the operating room, surgical sanitation of the pleural cavities, anterior mediastinum was performed: yellow-turbid liquid, fibrin, and necrotic tissues were removed. Wound cavities are washed with a large amount of a 3% solution of hydrogen peroxide, furatsillina, Microcide solution, then double-lumen drainages are installed in the pleural cavity with a puncture in the VII m / r along the mid-axillary line, which have an S-shape with the drainage ends leading to the sternum. Drainages are sutured to the skin in separate sutures. The edges of the transverse cut are fixed with wire seams. Soft tissue of the thoracotomy wound is sutured in one layer. In the postoperative period, flow-aspiration drainage of the pleural cavities and the anterior mediastinum is performed. Drainages were removed on the 15th day, after cytological control, the sutures from the skin were removed earlier on the 13th day. The postoperative suture healed by type of primary tension. The child was discharged in satisfactory condition.

 In the table. 1 presents data on the outcome of treatment by a known method. In the table. 2 results of the treatment of purulent complications of the proposed method, which confirm the high efficiency of the method.

 The method is recommended for use in medical practice.

Claims (1)

 A method of treating purulent mediastinitis and bilateral pleural empyema after cardiosurgical interventions from extra-pleural access, including the diagnosis of complications, surgical treatment of the wound and dressing, characterized in that after the sanation of both pleural cavities and the anterior mediastinum, each pleural cavity is drained with a double lumen , placing it S-shaped in the frontal plane in the sloping places of the pleural cavities with summing up some at the ends of the drainages to the sternum and removing the other ends of the drainages outward in the 6 7 intercostal spaces, the ends of the sternum are sutured, the thoracotomy wound is sutured tightly, after which flow-aspiration drainage is performed against the background of detoxification and antibacterial therapy.

Images