RU2093168C1 - Method of prophylaxis of suppurative-septic complications after surgery treatment of patients with uterine appendage inflammation - Google Patents

Abstract

FIELD: medicine, gynecology. SUBSTANCE: method involves endolymphatic infusion of gentamycin being the first dose is administrated 30 min before operation followed by two-fold administration of the same dose at 24 h interval after operation. EFFECT: decreased postoperative complications, enhanced immunological response of organism. 4 tbl

Description

 The invention relates to medicine, namely to obstetrics and gynecology.

 Inflammatory diseases of the female genital organs in frequency, duration of treatment and tendency to relapse take first place among gynecological pathologies. The prevalence of the inflammatory process of the uterine appendages depends not only on the pathogen, but also on the state of the endocrine, immune, nervous and other body systems.

 The protective mechanisms of the female genital organs are determined by their anatomical and physiological characteristics that limit the possibility of the spread of infection. This is achieved by a mechanical barrier to the penetration of pathological flora and a biological barrier, which is determined by the structure and function of the vagina. Infection of the upper genital area is prevented due to the presence of a mucous plug contained in the cervical canal and a pronounced narrowing of the internal pharynx. Cyclic detachment of the functional layer of the endometrium promotes regular self-cleaning of the uterine cavity.

However, the above protection mechanisms when exposed to complexes of adverse factors (microbial, mechanical, chemical, thermal, reduction of nominal status, etc.) can be violated, which often leads to the development of inflammatory diseases. Inflammatory processes of the uterine appendages often turn into tubo-ovarian formations that are not amenable to conservative treatment, which forces them to resort to surgical intervention. The proportion of surgical treatment of purulent-inflammatory diseases ranges from 46.6% to 96% and postoperative complications remain at relatively high numbers 40% 85%
Measures preventing purulent-septic complications are aimed at eliminating microorganisms and enhancing the immunological reactivity of the body. For this purpose, 2 g of cefotetan is administered intramuscularly once a day for 5 days after the operation, 1 g of cefazolin is administered intravenously 1 hour before the operation, after which it is administered intravenously 1 g 5 and 12 hours after the operation, meslocillin 4 g in combination with 2 g of oxacillin three times intravenously after 8 hours.

 The above methods of antibiotic prophylaxis do not provide therapeutic concentrations in the lymphatic system and are not always effective. To achieve a clinical effect, they are often forced to use high doses of drugs, which increases the risk of side effects.

 Close to the proposed method is a method that includes prophylactic intravenous and intramuscular administration of an antibiotic. In this case, 1 g of cefuroxime is administered intramuscularly twice a day for three days after the operation.

 However, this method requires a large dose of the antibiotic used and does not allow the creation of long-term and maximum antibiotic concentrations in the regional parts of the lymphatic system, which are actively involved in the pelvic inflammatory process. The search for ways to improve the treatment outcomes of patients led to the development of endolymphatic saturation of the regional lymph with antibiotics at their minimum doses.

 The purpose of the invention is to reduce the number and severity of postoperative complications, to enhance the immunological reactivity of the body.

 The essence of the proposed method lies in the endolymphatic infusion of gentamicin: the first dose of the drug is administered 30 minutes before the operation, followed by twice the same dose with an interval of 24 hours after the operation.

 The developed method of antibiotic prophylaxis of inflammatory diseases of the internal genital organs after surgery involves the administration of gentamicin at a rate of 1.0-1.2 mg / kg of body weight per day. Antibiotics are injected into a catheterized lymphatic collector vessel on the back of the foot. Lymphatic catheterization is performed according to the method of R.T. Panchenkova, 1984. Using a drug dispenser, this antibiotic is administered with a 20 ml syringe at a set speed (10 ml per hour), after which 1 ml of 0.25% novocaine is administered, then an aseptic dressing is applied at the site of catheterization of the lymphatic vessel. After removal of the catheter, a pressure-free aseptic dressing is left on the foot for two days.

 All patients under observation, both the main and the control groups, took blood before and on different days after surgery to assess cellular and humoral immunity. The immunostimulating effect of endolymphatic infusion of gentamicin was revealed (table 1).

 Among the observed patients with the development of postoperative purulent-septic complications, a relative inhibition of cellular immunity was noted (table 2).

 The direct proportionality of the temperature reaction of the body, as well as the patient’s stay in the hospital in the postoperative period from the antibiotic prophylaxis method was revealed (table 3).

 The invention is illustrated by the following examples.

Example 1. Patient M., 34 years old, medical history N 4990, was admitted to the gynecological department of the KKB with complaints of weakness, malaise, aching pain in the lower abdomen. Sickly ill since March 1993 when there were pains in the lower abdomen. The patient was treated on an outpatient basis for subacute inflammation of the uterus. From 29 (05) 93 to 21 (06) 93 was in the Central Hospital. Received anti-inflammatory and antibacterial therapy without effect. After increasing the body temperature to 39 ^o C and increasing pain in the lower abdomen, the patient was transferred to the regional clinical hospital for further treatment 22 (06) 93 g. History of measles, colds. Menses from 12 years to 5-6 days, after 28 days, moderate, painless, established immediately. Sexual life since 19 years. Married. Last menstruation 30 (05) 93 g. Pain in the lower abdomen intensified after the onset of menstruation. Childbirth 1, medical abortion 3.

Upon receipt, a moderate condition. Body temperature 38 ^o C. The skin is pale pink. Pulse 92 per minute, rhythmic, satisfactory filling. HELL 90/60 mm RT. Art. The vesicular breathing, no wheezing.

The tongue is wet, coated with a white coating. On palpation of the abdomen, pain in the lower sections is observed. Gynecological examination: the external genitalia are developed correctly. In the mirrors the cervix giving birth, purulent discharge from the cervical canal. Bimanual examination: movement for the cervix is painful. The body of the uterus is not palpable separately. A conglomerate is determined up to 8-9 cm in diameter, with a dense consistency. Uterine appendages are not separately palpable. The vaults are sharply painful. With puncture of the posterior fornix pus is obtained. Hemoglobin 93 g / l, white blood cells 16 • 10 ⁹ / l, lymphocytes 32% T-lymphocytes 62% null cells 33% T-helpers 44% T-suppressors 20% B-lymphocytes 5% lgG 12.52 g / l, lgM 1.64 g / l, lgA -2.22 g / l.

 Diagnosis: bilateral tubo-ovarian abscess. Reactive posterolateral parametritis. Anemia of the I degree.

 The patient was urgently operated, laparatomy was performed. When the abdominal cavity was opened, it was found that the omentum and intestinal loops are soldered to the lateral surface of the pelvis, in the anterior arch, to the peritoneum of the bladder and appendages. Right appendages: the tube is infiltrated, thickened, the ovary is a formation 9 cm in diameter. When the formation is separated, the abscess opened and pus was released with a colibacillary odor.

 The appendages on the right, the tubes on the left, and the abdominal cavity were removed.

In the complex of preventive measures of purulent-septic complications, antibiotics were used according to the proposed technique. In the first two days after surgery, body temperature was at 37.4 ^o C and normalized on the third day.

 On the third day of surgery: lymphocytes -45% T-lymphocytes 81% zero cells 15% T-helpers 66% T-suppressors 17% B-lymphocytes 4% IgG - 19.9 g / l, IgM 2.17 g / l, lgA 1.98 g / l.

 The postoperative period was uneventful. The patient was discharged in satisfactory condition on the 12th day after surgery.

Example 2. Patient N. 33 years old, medical history N 1073, was admitted to the gynecological department of the city maternity hospital in Stavropol 13 (05) 93, complaining of aching pains in the lower abdomen, pain during defecation. Sick for two weeks, when there were pains in the lower abdomen, nausea, fever up to 39.4 ^o C, took sulfa drugs at home. Pain in the lower abdomen and an increase in body temperature first appeared, one month after the birth in 1978. Repeatedly treated in the gynecological department, where the back arch was punctured. In 1989 and 1991 treatment was carried out in a venereological clinic for gonorrhea. In childhood, she had measles and whooping cough. Tonsillectomy in 1970. Monthly from 10 years, established immediately for 6-7 days after 28 days. Last menstruation 29 (04) 93 g. Sexual life from 13 years. Childbirth 1, abortion 0. Not married.

Upon admission, the condition is satisfactory, T 37.6 ^o C. Proper physique, low nutrition. The skin and visible mucous membranes are pale pink in color. Lymph nodes are not enlarged. HELL 115/70 mm RT. Art. Pulse - 72 per minute, rhythmic, satisfactory properties. The abdomen is soft, moderately painful in the lower sections. There are no symptoms of peritoneal irritation.

Gynecological status: external genitalia are developed correctly. Urethra and paraurethral passages without features. The cervix of the uterus giving birth, from the cervical canal mucous discharge. Bimanually: the body of the uterus is normal in size, dense, mobile, painless. On the right, the formation is 8x4x4 cm, painful, on the left, a tumor measuring 8x4x4 cm, moderately painful with limited movement. Hemoglobin 146 g / l, white blood cells - 8.5 • 10 ⁹ / l.

 Diagnosis: bilateral pyosalpinx.

 Laparatomy with removal of the fallopian tubes, appendectomy, separation of adhesions was performed. Abdominal drainage. When opening the abdominal cavity: the uterus is normal in size. On the right, the pyosalpinx is 9x4x4 cm, on the left is 8x4x4 cm. The ovaries are polycystic changed, soldered to the rectum. Chronic inflammation of the appendix.

 Postoperative diagnosis: bilateral pyosalpinx. Polycystic ovary disease, chronic appendicitis.

 A comprehensive prophylaxis was carried out with the inclusion of endolymphatic infusion of gentamicin 80 mg per day. The postoperative period was uneventful. On the 7th day after surgery: lymphocytes 20% T-lymphocytes 54% zero cells 43% T-helpers 43% T-suppressors 10% B-lymphocytes 3% lgG 8.3 g / l, lgM 1.09 g / l lgA 1.96 g / l. Postoperative wound healing by primary intention. In a bimanual study: the body of the uterus was found to be of normal size, mobile, painless. Uterine appendages are not palpable. There is no infiltration in the pelvis.

 Histological response: bilateral pyosalpinx, chronic nonspecific appendicitis.

 The patient was discharged on the 10th day after surgery in a satisfactory condition.

 Example 3. Patient S., 27 years old, case history No. 3111, was delivered to the gynecological department of the city maternity hospital on 24 (12) 92 with an ambulance complaining of pain in the lower abdomen radiating to the rectum, nausea, and fever.

 Considers herself a patient with 23 (13) 92 g in the evening, when pains began in the lower abdomen, more on the left, fever and a single vomiting. In childhood, she was ill with childhood infections. Menstruation from 14 years to 4-5 days after 28 days, regular, moderate, painless. Last menstruation - 05 (11) 92 g. Sexual life from 17 years. Childbirth -0, abortion 0. Married 3 months. IUD was protected from pregnancy for a year, IUD was removed 05 (11) 92 g. On the first day of menstruation.

Upon admission, a moderate condition, body temperature of 37.7 ^o C. The pulse -116 per minute, rhythmic, satisfactory filling, blood pressure 95/60 mm RT. Art. The vesicular breathing. The abdomen is painful on palpation, the symptoms of peritoneal irritation are determined, more to the left.

Gynecological examination: the external genitalia are developed correctly. Urethra and paraurethral passages without hyperemia. The vaginal mucosa and cervix are pink in color. The neck is cylindrical, nulliparous. Discharges from the cervical canal are purulent-mucous. The body of the uterus is slightly larger than normal, mobile and painful when displaced beyond the cervix. The appendages on the left are sharply painful. At a puncture of an abdominal cavity through the back arch 20 ml of liquid greenish pus are received. Hemoglobin 117 g / l, white blood cells 17x10 ⁹ / l.

 Diagnosis: acute bilateral purulent salpingitis. Peritonitis.

 The patient is urgently operated. With laparatomy, 70 ml of liquid pus was found in the abdominal cavity, the body of the uterus is slightly more than normal, the fallopian tubes are slightly thickened, hyperemic with purulent discharge. Ovaries without features. The revision of the abdominal cavity, its rehabilitation and drainage.

 Postoperative diagnosis: acute endometritis, acute bilateral purulent salpingitis. Spilled purulent peritonitis.

 Intramuscular administration of gentamicin 80 mg 3 times a day for 10 days was used in the complex of postoperative measures. On the third day after surgery: lymphocytes 26% zero cells 18% T-lymphocytes 71% T-helpers 38% T-suppressors 33% B-lymphocytes 11% lgG 9.31 g / l, lgM - 0.97 g / l, lgA 1.22 g / l.

The body temperature after surgery was kept within 37.6 ^o C for 5 days. On the 7th day after the operation, the sutures were removed. Primary healing. Gynecological status: external genitalia are developed correctly. Urethra and paraurethral passages without features. The mucous membrane of the cervix is not hyperemic, the discharge is a mucous membrane. The body of the uterus is moderately painful. Infiltrates are determined on both sides in the parameter area. White blood cells 8.9 • 10 ⁹ / l, lymphocytes 32% null cells 16% T-lymphocytes 69% T-helpers 54% T-suppressors 5% B-lymphocytes 15% lgG 10.61 g / l, lgM 1.21 g / l, lgA 2.11 g / l.

 The patient was discharged in satisfactory condition on the 18th day after the operation.

 Thus, the proposed method of antibiotic prophylaxis reduces the number of purulent-septic complications by 2.8 times (table 4) and the number of bed days by 3.8 (table 3) after surgical treatment of patients with inflammatory formations of the uterine appendages. Its use leads to the activation of both cellular and humoral immunity.

Claims (1)

 A method for the prevention of purulent-septic complications after surgical treatment of patients with inflammatory formations of the uterine appendages, including the introduction of an antibiotic, characterized in that, in order to reduce the number of complications, 1.0 1.2 mg / kg of gentamicin weight is administered endolymphatically 30 minutes before surgery with subsequent twofold administration of the same dose with an interval of 24 hours after surgery.

Images