RU2154505C1 - Method for treating abdominal cavity in acute peritonitis cases - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves treating the abdominal cavity with solution composed of oxygen and medicinal mixture having local anesthetic preparations, antiseptics, antibiotics, fibrinolytic agents, ganglioblockers, glucocorticoids, immunomodulators and antihistamine preparations transformed into aerosols in ultrasonic inhalator and introduced into the abdominal cavity by means of an artificial high frequency lung ventilation apparatus under pressure of 70 mm of mercury column at a rate of 3 l of the oxygen medication mixture per 1 min during 10-15 min. The whole treatment course is 9-20 treatments long. EFFECT: enhanced effectiveness of treatment; accelerated treatment course.

Description

 The invention relates to medicine, in particular to abdominal surgery, and in particular to methods for treating the abdominal cavity in acute peritonitis in the postoperative period.

Known methods for treating the abdominal cavity in acute peritonitis include:
- peritoneal dialysis by the flowing method, consisting in the introduction of fluid through the drainage in the hypochondria, with the assumption that, washing the abdominal cavity, it will be discharged through the drainage of the abdominal cavity in the small pelvis (Korzon I.I. Herald of Surgery, 1971, 2, pp. 44-46; Veronsky GI, Yaunts R.A. Flow-through washing of the abdominal cavity in the treatment of diffuse peritonitis, Surgery, 1980, 9, pp. 58-61; Radionov V.V. ., Lemin G.P., Abdominal lavage in the postoperative m period with diffuse purulent peritonitis of appendicular origin. Surgery, 1985, 9, pp. 99-102; Deryabin II, Lizonets MN, Peritoneal dialysis. M., Medicine, 1991, 168 S.);
- hypothermic perfusion, which consists in washing the abdominal cavity with a large amount of cold solution (up to 30 l per day), the fluid, washing the abdominal cavity, is independently removed through the drainage from the pelvis (Tatishvili G.G., Tamazashvili T.M., Tevdaradze I. D. Abdominal hypothermia in the treatment of postoperative peritonitis (Herald of Surgery, 1985, 12, pp. 139-142);
- hyperthermic perfusion, the technique of which is similar to the above method, with the only difference being that the abdominal cavity is washed with a hot solution at a temperature of 40 ^o C (Deryabin II, Lizonets M.N. Peritoneal dialysis. M., Medicine, 1991, p. 168);
- the introduction and aspiration of fluid for washing the abdominal cavity during laparoscopy (Petrov V.I., Sytkin A.P. Prolonged postoperative sanitation of the abdominal cavity with a laparoscope for widespread purulent peritonitis. Surgery, 1987, 7, pp. 30-34);
- using perfusants of various compositions (Bondarev V.I., Ablitsev N.G., Bazen A.P. Intra-abdominal lavage in the complex treatment of patients with diffuse peritonitis. Surgery, 1995, 2, p. 18-22).

The disadvantages of the above methods currently used to treat the abdominal cavity include:
1. The low efficiency of peritoneal dialysis due to the rapid formation of channels in the abdominal cavity due to prolapse of fibrin filaments and the formation of adhesions fragmenting it, which also limits the ability to conduct the required number of sessions;
2. The washing out of a large amount of protein from the body by flowing fluid, which leads to the development of hypoproteinemia.

 3. The need for each session of peritoneal dialysis of a large number (13-15 to 30 liters per day) of expensive medicinal solutions (Karimov Sh.I., Tursunov KN, Asrarov AA, etc. The effectiveness of peritoneal dialysis, intestinal lavage and enteral tube feeding in the complex treatment of diffuse purulent peritonitis. Methodical recommendations, Tashkent, 1984, 14 pp.).

 Of the above methods for treating the abdominal cavity as a prototype, we chose the method of peritoneal dialysis (Karimov Sh.I., Tursunov KN Asrarov A.A. et al. Effectiveness of using peritoneal dialysis, intestinal lavage and enteral tube feeding in the complex treatment of spilled purulent peritonitis.Methodical recommendations, Tashkent, 1984, 14 pp.).

 The disadvantage of the method selected as a prototype is the need for a large amount of a medicinal substance, the washing out of a large amount of protein with a liquid to be removed, the need for active aspiration of the output liquid, which leads to obstruction of the drainage holes in the pelvis by the mobile organs of the abdominal cavity, limiting the patient's mobility in connection with the duration of the procedure (13-15 liters of fluid are introduced during one session), high cost, the formation of adhesions the day after the operation.

 The objective of the invention is to develop an effective, cheap, easy for the patient method of treating the abdominal cavity in acute peritonitis.

 The problem is solved in that the abdominal cavity is treated with a solution consisting of oxygen and a medicinal mixture, which includes preparations of local anesthetics, antiseptics, antibiotics, ganglioblockers, fibrinolytics, glucocorticoids, immunomodulators and antihistamines, converted by an ultrasonic inhaler into an aerosol and administered by the device for high-frequency artificial ventilation of the lungs into the abdominal cavity under a pressure of 70 mm Hg at a speed of 3 liters of an oxygen-drug mixture in 1 minute for 10-15 minutes, in the number of sessions from 9 to 20. Parameters (speed, volume and pressure of administration) were developed on bench experiments - obtaining an effective aerosol jet and in an experiment on pigs - the effectiveness of irrigation of the entire abdominal cavity, which depends on the method of drainage.

 The method is as follows.

 First, a drug solution is prepared to treat the abdominal cavity. It includes anesthetics, antiseptics, antibiotics, fibrinolytics, glucocorticoids, immunomodulators, antihistamines. The prepared solution is refilled with an ultrasonic inhaler (we use an Albedo ultrasonic inhaler with a high-frequency ventilator; a stationary unit for work in the intensive care unit or a Pari Master inhalation device, a portable device for working directly in the room), to which oxygen is supplied, based on the calculation 1 minute into the abdominal cavity of 3 liters. Using the apparatus for high-frequency artificial ventilation of the lungs, the prepared oxygen-drug mixture is fed through the drainage tubes into the abdominal cavity at a pressure of 70 mm Hg. at a speed of 3.0 l / min. In 1 minute, 6.0 ml of the drug mixture and 2994 ml of oxygen are fed into the abdominal cavity. Aerosol treatment of the abdominal cavity is carried out for 10-15 minutes, which allows you to enter into the abdominal cavity about 30 liters of oxygen and 60-75 ml of the drug mixture.

 The medicinal composition, with the goal of maximum effectiveness, contains the following components: 0.5% novocaine solution - 20.0, blocks the effect of peritoneal interoreceptors, stimulates peristalsis; furatselin solution - 15.0; gentomycin - 1.0 or another antibiotic, depending on sensitivity, antiseptics and antibiotics by creating the necessary concentration in the abdominal cavity carry out a bactericidal effect on pathological microorganisms; fibrinolysin - 20.0 (3000 units) - provides dissolution of fibrin filaments, preventing the occurrence of adhesions in the abdominal cavity; benzohexonium - 0.5, ganglion blocker, dilates peripheral vessels; prednisone - 1.0 (25 mg) - steroid hormones that inhibit the development of fibroblasts, reduce the inflammatory response of the peritoneum; atropine 0.5 - relieves the reflex effect of the peripheral nervous system, eliminates muscle spasm, reduces secretion, which leads to improved microcirculation; suprastin 1.0 - antihistamine, prevents allergic background; immunofan - an immunomodulator that enhances the antioxidant defense of the body, causes the inactivation of free radical and peroxide compounds, has a hepatoprotective and immunoregulatory effect; oxygen - creates a gas layer between the loops of the intestines, parietal and visceral peritoneum, thus preventing the development of the adhesion process, reduces the reaction to mechanical irritation, provides oxygenation of cells.

 Aerosol treatment is carried out three times a day. Depending on the complexity of the severity and stage of peritonitis, the procedure can be repeated for 3-5 days. The number of sessions can be increased. It depends on the severity of the process, its distribution, duration. The age and concomitant diseases of the patient do not limit the time and number of sessions. The proposed amount of medication administered after 8 hours is sufficient to maintain their high concentration in the abdominal cavity. The procedure does not affect the patient's condition and is not aggravating.

We give examples from clinical practice:
1. Patient Ch., 31 g., And.b. N 3159 was admitted to the clinic on 02.21.98 with a diagnosis of: Multiple, penetrating, stab wounds of the abdominal wall with damage to internal organs (large and small intestines), diffuse peritonitis. 02.21.98, an emergency procedure was performed laparotomy with sanitation of the abdominal cavity, suturing wounds of the intestines and external drainage of the abdominal cavity according to the technique used in the clinic. Immediately after the operation and subsequently for 4 days, the abdominal cavity was treated by high-frequency insufflation of the drug aerosol (a total of 13 treatment sessions were performed for the abdominal cavity for 10 minutes each with a flow rate of 60 ml of the drug mixture and about 30 l of oxygen for each session. The aerosol was delivered to the abdominal cavity under pressure 70 mm Hg). In addition to treating the abdominal cavity, a comprehensive treatment of peritonitis was carried out using generally accepted methods. Postoperative course without complications. The wounds healed by primary intention. In satisfactory condition, she was discharged for outpatient treatment on 03/06/98. The duration of treatment in the clinic was 13 days.

 2. Patient B., 35 years old, and. N 3718 was under treatment in the clinic from 02.03.98 in connection with gangrenous appendicitis, serous-fibrous peritonitis. 03/02/98, an emergency surgical guide was performed - appendectomy, drainage of the abdominal cavity. Within 3 days after the operation, high-frequency insufflation of the drug aerosol was performed (a total of 9 sessions were carried out lasting 10 minutes each, with a flow rate of 60 ml of the drug mixture and 30 l of oxygen for each session under a pressure of 70 mmHg). The postoperative course is smooth. The wound healed by primary intention. In satisfactory condition was discharged 03.03.98 for outpatient treatment. The duration of treatment was 7 days.

 3. Patient K., 80 years old, and. N 154 was admitted to the hospital in an emergency with a diagnosis of Spilled peritonitis. Operated urgently. The operation revealed gangrenous-necrotic perforated gall bladder, necrosis of the greater omentum, and a secondary-modified vermiform appendix. 01/05/98, performed cholecystectomy, resection of the greater omentum, appendectomy, debridement and drainage of the abdominal cavity. In the postoperative period, high-frequency insufflation of drug aerosol was performed for 7 days (20 sessions were performed (2 sessions on the first day after surgery)). Drainages are removed on the 7th day after surgery. In addition to insufflation, a comprehensive treatment of peritonitis was carried out. The wounds healed by primary intention. In satisfactory condition 01/20/98 was discharged for outpatient treatment. The length of stay in the hospital is 15 days.

 We give examples of the treatment of peritonitis by the prototype method.

 1. Patient S., 41 years old, and.b. N 6887 was admitted to the clinic 03/27/94, with a diagnosis of Penetrating stab wound of the abdominal wall with damage to the colon, serous-fibrous peritonitis. On March 27, 1994, an emergency operation was performed - sanitation of the abdominal cavity, suturing of the intestinal wound, drainage of the abdominal cavity in the hypochondria and iliac regions with 4 drainages were performed. After the operation, peritoneal dialysis was performed by the flowing method, which was effective only for one day. A comprehensive treatment of peritonitis was carried out by conventional methods. The fever lasted a long time. The wound healed by primary intention. The stool is irregular, stimulation of bowel function was required, 04/29/94 was discharged in satisfactory condition for outpatient treatment. The duration of treatment was 33 bed days. 3 years after the operation, she complains of discomfort, periodic bloating, irregular stools, which is an indirect sign of the development of adhesive disease.

 2. Patient O., 19 years old, and. N 929 was admitted to the clinic on January 12, 1994 in connection with gangrenous-perforated appendicitis, diffuse with serous-fibrous peritonitis, and operated on January 12, 1994 in an emergency. Appendectomy and drainage of the abdominal cavity after its rehabilitation by 4 drains were performed - in the hypochondria and iliac regions. Peritoneal dialysis was effectively managed only during the first days after surgery. On the second day, the amount of injected and removed fluid was different, there was a fact of fluid retention in the abdominal cavity, and therefore it was decided to refrain from further sessions of peritoneal dialysis. In the postoperative period, fever, intoxication phenomena persisted. It was treated by traditional methods, which required the patient to stay in the hospital for 18 days. She was discharged for outpatient treatment on 02/01/94. 3 years after the operation, she complains of periodic aching pain in the right iliac region, which makes it impossible to exclude the presence of adhesions in the abdominal cavity.

 According to the proposed method, 26 patients were operated on. In all patients in the postoperative period, complications in the form of intestinal abscesses, abscesses of Douglas space, early adhesive intestinal obstruction and others were not observed.

 Thus, the clinical examples given show that, in comparison with the selected prototype of the abdominal cavity treatment, the proposed method is: more economical, since 1- session of the abdominal cavity treatment requires 60-70 ml of the drug mixture, in contrast to 13-15 liters of the prototype method; makes it possible to more effectively use the drugs used, because they are fed into the abdominal cavity in suspension in a mixture with oxygen, have high biological activity, which allows them to be evenly distributed over the parietal and visceral peritoneum and penetrate deep enough into the tissues, in connection with which their pharmacological effect is enhanced; after the administration of the drug aerosol by high-frequency insufflation, fragmentation and formation of pockets in the abdominal cavity do not occur, which allows the procedure to be repeated the required number of times, to prevent the development of complications and the early postoperative period, and therefore to reduce the patient’s stay in a hospital bed from 5 to 20 days , to prevent the development of adhesive disease after surgery.

Claims (1)

 A method for treating the abdominal cavity in patients with acute peritonitis by exposure to a drug mixture, characterized in that the drug mixture consisting of oxygen, local anesthetics, antiseptics, ganglioblockers, antibiotics, fibrinolytics, glucocorticoids, immunomodulators and antihistamines is administered as an aerosol in the form of an aerosol using high-frequency insufflation at a rate of 3 liters per 1 minute for 10 to 15 minutes, under a pressure of 70 mmHg, with the number of sessions from 9 to 20.