RU2161308C2 - Method for evaluating severity degree of a gynecological disease requiring emergent abdominal surgical intervention - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves determining the following parameter values of a patient at the moment of being admitted in hospital. Every value of age, anamnesis and palpation examination data of pelvic organs and peritoneum state, body temperature, pulse rate, Algover index, mean arterial blood pressure, hematocrit index, leukocyte number, diagnosis is expressed as score. The scores are summed and the disease severity degree is evaluated depending on score sum. EFFECT: high accuracy of prognosis; simplified method. 6 tbl

Description

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

 A number of approaches to assessing individual characteristics of the sick person’s body and the influence of various factors on his condition are proposed in separate literature. Each of the proposed options has a specific purpose and provides mainly anesthetic approach to this issue. Consider the most common of them.

 Of the domestic authors, the works of anesthetists N.N. deserve attention. Malinovsky and G.A. Ryabova et al. Both authors point to the need for a preoperative examination of patients with an objective idea of the degree of operational risk and tactics of an anesthesiologist before, during and after surgery, to predict the incidence of postoperative complications. By G.A. Ryabov (Emergency Anesthesiology, 1983) takes into account the somatic health of the patient, the estimated scope of the operation, its urgency. Risk assessment is more convenient according to N. N. Malinovsky (Handbook of Anesthesiology, 1987, edited by L.P. Chepky), where each risk factor (volume of operation and conditions that increase the risk of its execution; surgical pathology; concomitant diseases and age of the patient) evaluated in points and more objectively reflect the status of the patient.

 Foreign literary sources also reflect scientific research in assessing the severity of the condition of patients. Thus, the TISS system (Therapeutic intervention scoring syslem: a method for quantitative comparison of patient care 1974, edited by D.G. Cullen et al.) Estimates the severity of the patient's condition by the number and complexity of the research and treatment methods necessary for its management. Each procedure is rated from 1 to 4 points. The points are summarized, and depending on the final figure, patients are divided into 4 groups according to the severity of the condition. Each group provides a certain amount of observation and care. This method does not satisfy the assessment of the severity of the patient in connection with a subjective assessment of the need for a particular method of treatment or diagnosis, as well as the qualifications of the doctor.

 A known method for predicting possible adverse outcomes of a disease in patients of a therapeutic and surgical profile in intensive care units is based on the determination of data from the APACHE scale (The ARACNE-III prognostic system. 1991, edited by W. Knaus et al.). This method is based on the use of mathematical formulas with the calculation of the logarithm and allows us to predict the likelihood of death in severe patients. Its principle is that when examining a patient, his individual physiological characteristics, data of neurological status and detailed laboratory tests are evaluated on a special scale in points. The sum of the points is substituted into the corresponding formula along with the numerical value of one of 78 standard diagnoses (in the form of a decimal fraction). The result obtained is subjected to a logarithmic transformation, and the resulting figure is compared with a special scale of risk of death, which allows us to clarify the possibility of death in a patient. The large volume of laboratory analyzes used in the forecasting method according to W. Knaus (biochemical and anesthetic parameters) and the complexity of mathematical calculations require time and a certain material base.

 The closest analogue of the invention is a method for assessing the severity of the state of gynecological patients, which includes determining the patient's blood pressure, pulse, respiratory rate and other indicators (Obstetrics and gynecology, transl. From English under the general editorship of Savelyeva G.M. and Sichinava L. .G., A series of "Manual for doctors and students", M .: Medicine, 1998, S. 383-337). However, after a comprehensive assessment of the indicators used, their final interpretation depends on the qualifications and clinical experience of the doctor. The specified method is subjective and not accurate enough.

 Thus, none of the proposed methods for assessing the degree of severity takes into account the specificity of manifestations of urgent pathology in patients with a gynecological profile and there is no generally accepted scheme for assessing the severity of a gynecological disease requiring emergency abdominal surgery at the time of admission and in the dynamics of observation, including with planned hospitalization.

 In case of gynecological pathology requiring emergency surgical care, the minimum amount of time is allotted to assess the clinical situation. This complicates the work of the doctor in determining the severity of the gynecological disease before emergency abdominal surgery.

 The technical result is an increase in accuracy and a simplification of the method for assessing the severity of a gynecological disease that requires emergency abdominal surgery. The proposed method is as follows.

The patient is examined according to standard methods. The results of the examination are indicated on a separate sheet, namely: age, history and palpation of the pelvic and peritoneal organs, body temperature, respiratory rate, pulse, Algover index, mean blood pressure. From urgent laboratory tests of peripheral blood, the hematocrit index and the number of leukocytes are determined. Use the simplest calculations:
Medium blood pressure = (2xAD diastolic + systolic blood pressure) / 3;
Algover index = Pulse / BP systolic.

 For a score assessment of the parameters, diagnostic table 1 is used.

 In the absence of data on one of the proposed parameters, its score is equal to zero. According to the diagnostic table, each parameter and the diagnosis are evaluated in points that are summarized. The final ball characterizes the condition of the patient according to the gradation given in table. 2.

 Example 1

 Patient G., 21 years old, (N history 8336) was admitted to the hospital on an emergency basis with complaints of pain in the hypogastric region, radiating to the rectum. From the anamnesis: 2 pregnancies ending in abortion, chronic bilateral adnexitis. During the examination: the abdomen during palpation is painful, the symptoms of peritoneal irritation are negative, with a bimanual examination, pain during movements behind the cervix, in the area of the left appendages, a test volumetric formation of 3 x 4 cm is determined, sharply painful. After examination, a preliminary diagnosis is made: an ectopic pregnancy. (Further see table. 3).

 The preliminary diagnosis of "Ectopic pregnancy" = 8 points, therefore, the final score = 32 + 8 = 40 points, which corresponds to a state of moderate severity and is an indication for emergency surgery.

 During the operation, a diagnosis was made: ovarian apoplexy. The scope of the operation is laparotomy, resection of the left ovary.

 The result of a histological examination is a follicular ovarian cyst.

 The operational diagnosis of ovarian apoplexy = 3 points, the final score = 32 + 3 = 35 points, which corresponds to a moderate state and also requires the provision of emergency surgical assistance.

 The postoperative period was uneventful, the patient was discharged in satisfactory condition on day 8 after surgery.

 Example 2

 Patient F., 62 years old, (N story 2667) was admitted to the hospital on an emergency basis with complaints of abdominal pain. From the anamnesis - an ovarian cyst for several years, was not operated on, sought medical help three days after the onset of the disease. During the examination: the abdomen is enlarged, on palpation it is painful in all departments, the symptoms of peritoneal irritation are positive, on the anterior abdominal wall is a large umbilical hernia, with a bimanual examination, a painful volume is determined in the area of the left appendages. After examination, a preliminary diagnosis was made: a tumor of the left ovary, diffuse peritonitis. (Further see table. 4).

 The specified diagnosis of "diffuse peritonitis" = 12 points, the final score = 126 + 12 = 138 points, which corresponds to the condition of "Doubtful life forecast."

 The scope of the operation is laparotomy, hysterectomy with appendages, drainage of the abdominal cavity. An updated diagnosis is a tumor of the left ovary with decay, the terminal phase of diffuse peritonitis, cirrhosis, ascites. On the third day after admission, death occurred.

 Autopsy protocol: pseudo-mucinous ovarian cystadenoma.

 Complication: diffuse fibrinous-purulent peritonitis. Hypostatic pneumonia, dystrophy of parenchymal organs, cachexia.

 Epicrisis: Data from a morphological study of surgical and autopsy material revealed pseudomucinous cystadenoma of both ovaries as the underlying disease. The tumor reached a large size, was accompanied by intoxication, increasing depletion. Surgical removal was performed at the stage of decompensation, spilled fibrinous-purulent peritonitis, which completed the case thanatogenesis.

 Example 3

 Patient S., 56 years old, (N history 3663) in a planned manner in the direction of a female consultation from City Clinical Hospital N 13 with a diagnosis of Uterine fibroids, metrorrhagia. Complaints of periodic spotting with clots from the genital tract for 13 days. Pregnancy 5, childbirth 1, medical abortion 4, without complications. Gynecological diseases - cervical erosion (DEC - in 1966). Somatic diseases - bronchial asthma of an infectious-allergic nature.

At the time of admission: during the examination: body temperature 36.5 ^o C, respiratory rate 19, pulse 72, blood pressure 140/80, white blood cells - unknown, the abdomen is soft, painless, there are no symptoms of peritoneal irritation, with a bimanual examination - the uterus is increased to 10- 11 weeks of pregnancy, dense, painless. Appendages are not palpable. The discharge is bloody, moderate. After examination, a preliminary diagnosis was made: uterine fibroids, metrorrhagia. (Further see table. 5).

 The preliminary diagnosis of uterine fibroids complicated by bleeding = 6 points, the final score = 16 + 6 = 22 points, which corresponds to a satisfactory condition. There are no indications for surgical treatment.

On the 5th day of hospital stay in connection with complaints of excessive bleeding from the genital tract, it is recommended to carry out surgical treatment in an emergency. During the examination: body temperature 36.5 ^o C, respiratory rate 19, pulse 94, blood pressure 140/90, white blood cells 4.1, the abdomen is soft, painless, there are no symptoms of peritoneal irritation, with a bimanual examination, the uterus is enlarged to 7 weeks of pregnancy, dense, tuberous. Of the genital tract - heavy bleeding. (Further see table. 6).

 Given the preliminary diagnosis of uterine fibroids complicated by bleeding = 6 points, the final score = 42 + 6 = 48 points, which corresponds to the "moderate" condition and objectively indicates homeostasis disorders and worsening conditions, which requires emergency abdominal surgery.

 The scope of the operation is laparotomy, hysterectomy with appendages.

 The result of a histological examination is the uterine body leiomyoma with fibrosis and stromal hyalinosis. Endometrium of the hypoplastic type. Endocervicitis.

 The postoperative period was uneventful. The patient was discharged in satisfactory condition on day 9 after surgery.

 The application of our proposed method for assessing the severity of the condition, compared with the method of prosthetics of adverse outcomes in severe patients with a therapeutic and surgical profile according to Knaus, allows us to assess the severity of a gynecological disease requiring emergency abdominal surgery without complicated laboratory tests and the use of special computer technology for complex mathematical calculations. New parameters for assessing severity using the history, palpation examination of the state of the pelvic organs and peritoneum, and Algover's shock index are proposed. For the first time, the most common nosological units of emergency conditions that occur in daily gynecological practice are identified. The proposed method also allows you to predict the worsening of the course of the gynecological disease both upon admission to planned surgical treatment, and in the dynamics in case of violations of homeostasis even before the appearance of vivid clinical symptoms.

 This method of assessing the severity of a gynecological disease requiring emergency abdominal surgery was used in 95 patients aged 16 to 79 years with emergency gynecological pathology. The forecast predicted by the proposed method turned out to be equally accurate in all observations. This allows us to recommend this method for use in emergency care in relation to urgent obstetric and gynecological pathology in hospitals with a surgical profile.

Claims (1)

A method for assessing the severity of a gynecological disease requiring emergency abdominal surgery, which consists in determining the age of the patient, at the time of admission and in dynamics, determining body temperature, respiratory rate, pulse, mean blood pressure, hematocrit, leukocyte count, further clarify the burden history, determine the Algover index, the condition of the pelvic organs and peritoneum, the diagnosis, evaluate each indicator in points, namely: age under 44 years old They rate as 0 points, 45 - 59 - as 6, 60 - 74 years - as 10, 75 - 84 years - as 16, older than 84 years - as 23 points; body temperature 34.5 - 34.9 ^o C is estimated as 18 points, 35.0 - 36.1 ^o C - as 6, 36.2 - 36.8 ^o C - as 0, 36.9 - 37.4 ^o C - as 6, 37.5 - 37.9 ^o C - as 10, 38.0 - 38.4 ^o C - as 16; 38.5 - 39.9 ^o C - as 28 points; a respiratory rate of less than 6 per minute is estimated as 35 points, 6 - 11 - as 18, 12 - 15 - as 6, 16 - 20 - as 0, 21 - 24 - as 6, 25 - 34 - as 16, 35 - 39 - like 23, 40 - 49 - like 28, more than 49 per min - like 37 points; a pulse of less than 40 per minute is estimated as 32 points, 40 - 49 - as 14, 50 - 59 - as 6, 60 - 80 - as 0, 81 - 90 - as 6, 91 - 109 - as 10, 110 - 119 - as 16, 120 - 139 - as 23, 140 - 154 - as 28, more than 154 per minute - as 34 points; mean blood pressure less than 40 is estimated as 41 points, 40 - 59 - as 32, 60 - 69 - as 18, 70 - 79 - as 14, 80 - 104 - as 0, 105 - 119 - as 10, 120 - 129 - as 16, 130 - 139 - as 23, more than 139 - as 28 points; a hematocrit value of less than 31% is estimated as 14 points, 31 - 35 - as 6, 36 - 44 - as 0, 45 - 49 - as 10, more than 49% - as 16 points; the number of leukocytes less than 1.1 • 10 ⁹ / l is estimated as 41 points, 1.1 - 2.9 - as 32, 3.0 - 3.9 - as 14, 4.0 - 8.8 - as 0.8 9 - 12.5 - as 6, 12.6 - 16.9 - as 10, 17.0 - 18.9 - as 16, 19 - 19.9 - as 23, 20 - 24.9 - as 28, more than 24.9 • 10 ⁹ / l - as 34 points; the history of extragenital pathology is assessed as 6 points, the obstetric-gynecological history is 10, the history of laparotomy is 14, hospitalization after 24 hours and later from the onset of the disease is 18, and the need for relaparotomy is 23 points; Algover index less than 0.49 is estimated as 14 points, 0.5 - 0.54 - as 0, 0.55 - 0.8 - as 6, 0.9 - 1.3 - as 23, 1.31 - 1, 49 - as 28, more than 1.49 - as 31 points; volumetric education in a bimanual study of the state of the pelvic organs and peritoneum is estimated as 6 points, symptoms of peritoneal irritation - as 10 points; the diagnosis of cyst capsule rupture is estimated as 1 point, torsion of the cyst legs as 2, ovarian apoplexy as 3, circulatory disorders in the myoma node as 4, infection of the myoma node as 5, uterine fibroids complicated by bleeding, as 6, profuse bleeding after a medical abortion - like 7, ectopic pregnancy - like 8, perforation of the uterus - like 9, purulent tuboavarial tumor - like 10, pelvio-peritonitis - like 11, diffuse peritonitis - like 12, infectious toxic shock - like 13 points, in the absence of data on one of the proposed parameters, its score the assessment is equated to 0, the obtained points are summarized, and with the number of points 0–24, the severity of the disease is assessed as satisfactory, 25–64 as moderate, 65–83 as severe, 84–122 as extremely severe, more than 122 as dubious life forecast.

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