RU2233449C1 - Method for evaluating the flow and prediction for the development of purulent wounds in case of phlegmons in oral area - Google Patents

Abstract

FIELD: medicine, stomatology.

SUBSTANCE: one should carry out visual evaluation for the volume and character of exudation, diagnostic cytochemical methods to test neutrophilic granulocytes, detection of DNA chromatin activity and activity of myeloperoxidase, among them, moreover, one should detect an integral functional activity of neutrophilic granulocytes due to additional studying the content of cationic proteins and glycogen there followed by detection of total biological value of activity - tissue index of neutrophilic granulocytes (TING) by the following formula: TING = (DNA : (MP+CP+Gl) x 1000 expressed in conventional units, where DNA - activity of nuclear chromatin; MP - activity of myeloperoxidase; CP - the content of cationic proteins; Gl - glycogen content; 1000 - coefficient to transform one thousandths into whole numbers, and at increased TING value on the 3d d of therapy against its value detected right during lancing the phlegmon of oral area one should predict favorable flow of purulent wound, and at decreased TING value being below 100% one should predict chronic process of healing along the risk for the development of complications.

EFFECT: higher efficiency of evaluation.

2 ex

Description

The problem of treatment of phlegmon of the maxillofacial region (FFLO) is still relevant [N.N. Bazhanov, V.A. Kozlov et al., 1996]. The end result of the balanced and coordinated work of all regulatory systems of homeostasis in patients after opening the PCF is the relief of the inflammatory process in the purulent wound and its optimal regeneration. The most important cellular element of the first phase of the course of the wound process are neutrophilic granulocytes (NG). They are the first among other cells to appear at the site of acute inflammation and carry out “killing” of bacteria in the wound, their phagocytosis, and also take part in the regulation of processes of general nonspecific antimicrobial defense of the body [M.M.Dale, J.K. Formen, 1998]. The effectiveness of their action is to create the optimal level of alterative reactions in the wound for its purification and the development of further balanced proliferation. The criteria for the activity of NG can be selected cytochemical parameters of the nucleus and cytoplasm of these cells [M.I. Kuzin, B.M. Kostyuchenok, 1990]. However, information on the cytochemical study of NG in patients with PSF is mainly devoted to their study in peripheral blood. There is very little data on their functional activity directly in the wound in the available literature, it is largely limited by the expensive technique of electron microscopic radioautography and is mainly devoted to the study of purulent wounds with phlegmon of other localizations.

A known method for assessing the course of purulent wounds [V.E. Pigarevsky, 1981], based on cytochemical detection in blood smears and imprints from the surface of inflammatory foci of lysosomal cationic proteins with determination of the average cytochemical coefficient (SCC) by the formula

SCC = (3a + 2b + 1.5v + 1g + 0.5d + 0e) / 100,

where the letters (ae) are the number of cells of the same type stained with a certain degree of staining of the cytoplasm with solid green. Numbers (3-0) - the degree of staining intensity.

The decrease in the SCK of cationic proteins reflects the inhibition of the bactericidal function of polymorphonuclear leukocytes (PMNL). An increase in SCS is a criterion for stabilization.

So, for example, with PSF [NN Bazhanov et al., 1992] the SCK of cationic proteins of polymorphic nuclear leukocytes of peripheral blood is moderately reduced - 1.232 (normal - 1.58). With a favorable course, by the time the secondary sutures are applied, it increases to 1.328. In the focus of inflammation, the SCS of polymorphonuclear leukocytes increases from 0.861 to 0.980.

The disadvantages of this method are:

1) Reflects only one side of the functional activity of neutrophilic granulocytes - oxygen-independent microbicidicity, or rather the level of cationic protein content, and does not allow to take into account the significance and activity of other equally important factors of antimicrobial protection of NG.

2) The use of strong green FCF for the alcoholic solution methodology limits its widespread use due to its high cost

Despite these shortcomings, the discussed method is widely used for clinical and laboratory determination of cytochemical parameters of PMNL.

The closest analogue adopted for the prototype is a method for predicting the course of the wound healing process (Patent for invention No. 2146367, Gumenyuk S.E. et al.), Which provides for the study of peripheral blood parameters in patients with purulent-inflammatory diseases of soft tissues, with a simultaneous study of indicators blood taken from a wound. In this case, a correlation relationship between these indicators is established and, when an inverse correlation relationship is detected, a torpid or complicated course of the wound process is predicted, and with a direct correlation relationship, an uncomplicated course of the wound process is predicted.

The disadvantages of the prototype are:

1) The authors emphasize that the basis for a favorable local course of a purulent wound is the functional activity of the leukocytes of the tissue pool, which can vary significantly depending on the combined local conditions. However, the principle of the proposed method is only a comparison of the cytochemical parameters of peripheral blood leukocytes and wound discharge, while it is not possible to identify specific quantitative cytochemical parameters of wound exudate leukocytes, which determine the unfavorable course of the local wound process, and therefore the possibility of septic complications.

2) In essence, the proposed method, the study must be carried out twice (peripheral blood and wound exudate), and therefore double the time and economic costs, indirect technical artifacts. The methodological need for additional invasion of severe patients is also obviously not its advantage.

3) The microbicidal activity of leukocytes was studied by evaluating the activity of myeloperoxidase and the HCT test, which are markers of oxygen-dependent systems. However, the killing function of leukocytes includes other equally important non-oxygen-dependent microbicidal systems, which was not reflected in the proposed method.

4) The proposed method also does not provide either a qualitative or quantitative study of the energy resource of the cell - glycogen, the necessary substrate for the implementation of biosynthetic functions.

5) One of the indicators of the functional activity of leukocytes in the compared method is the property of anisotropy of the nucleus, based on the well-known principle that heterochromatinisapia of the nucleus implies an increase in the functional activity of the cell, and euchromatization decreases. However, the study is based on measuring visual densitometric density, which significantly reduces the quantitative informational content of the method or assumes the presence of very expensive computerized equipment and its staff.

The objective of the invention is to increase the efficiency of the assessment of the course and prognosis of the development of purulent wounds with phlegmons of the maxillofacial region.

The essence of the invention is the determination of the integral functional activity of neutrophilic granulopites of wound exudate by further studying the content of cationic proteins and glycogen in them, after which the general biological indicator of activity is determined - tissue index of neutrophilic granulocytes (TING) of wound exudate according to the formula

TING = (DNA: (MP + KB + Hl)) · 1000, expressed in arbitrary units,

where DNA is the activity of nuclear chromatin; MP - myeloperoxidase activity; KB - cationic protein content; Hl - glycogen content; 1000 is the conversion factor of thousandths to integers, and with an increase in TING on the 3rd day of treatment relative to its value determined directly at the opening of the phlegmon of the maxillofacial region, a favorable type of purulent wound course is predicted, and if the TING value decreases below 100%, a protracted healing process, with the risk of complications.

The method is as follows.

The collection of cytological material is carried out according to the method of M.P. Pokrovskaya and M.S. Makarov (1942). Imprints of wound exudate are applied to fat-free glass slides and fixed with acetone ethanol (1: 1 ratio) and pairs of 40% formalin for 15 and 5 minutes, respectively. The smears fixed with the acetone-ethanol mixture are hydrolyzed in 5 N HCL at 37 ° C for 8 minutes [Ehrenpreis EA, 1990], and then stained with Felgen DNA Schiff reagent for standardized conditions. The prints thus stained, after washing in two shifts of sulfur dioxide and drying, are subjected to absorption photometry on a FEML-1a setup using the two-area method according to Garcia (1969) at a wavelength of 530 nm. Imprints fixed by formalin pairs are stained with cationic protein (KB) with bromphenol blue at a pH of 8.2 MT. Shubichu (1967). Myeloperoxidase (MP) is detected by the method of Sato and Selkia (1928), and glycogen (Hl) - by Mac Manusu in the modification of A. Pearce (1961). The results were taken into account by the semi-quantitative method of Astaldi and Verg (1957).

At the opening of the PCF, the cytochemical parameters of the nucleus and cytoplasm of NG wound exudate, determined by the proposed method, are in conv. unit: DNA - 0.81 ± 0.01; KB - 1.74 ± 0.06; MP - 0.95 ± 0.08; Ch - 1.51 ± 0.12. The estimated value of TING is - 192.86 ± 12.7 srvc. units In patients with a favorable type of the inflammatory process, the cytochemical parameters of NG wound exudate amounted to 3 days: DNA - 0.96 ± 0.002; KB - 0.87 ± 0.03; MP - 0.63 ± 0.04; Ch - 1.43 ± 0.07; TING - 327.64 conv. units At the time of applying the secondary sutures - DNA - 0.87 ± 0.001; KB - 1.96 ± 0.04; MP - 1.64 ± 0.06; Ch - 1.99 ± 0.05; TING - 155.63 conv. units In patients with an unfavorable type of the inflammatory process (re-examination of the purulent wound was required, the process tended to spread to adjacent cellular spaces, the bed-day was more than 8 days before the secondary suturing, etc.) the following cytochemical parameters of the nucleus and cytoplasm were determined NG wound exudate:

- on the 3rd day: DNA - 0.67 ± 0.002; KB - 2.11 ± 0.04; MP -1.42 ± 0.05; Ch - 2.0 ± 0.07; TING - 121.16 well. units

- at the time of applying the secondary sutures - DNA - 0.48 ± 0.001; KB - 2.98 ± 0.04; MP - 1.91 ± 0.06; Ch - 2.82 ± 0.05; TING - 62.25 conv. units

The technical result of the invention is:

- TING allows you to get accurate, objective reports on the implementation of the general biological activity of NG wound exudate based on the integrated and holistic use of the basic cytochemical parameters of the nucleus and cytoplasm of NG;

- used cytochemical indicators most adequately reflect the basic (oxygen-dependent and oxygen-independent) microbicidal functions of NG, realized on the basis of glycogen-energy substrate under the general determination of the synthetic activity of the nucleus;

- the application of the proposed cytochemical parameters, including the determination of the degree of dissociation between nucleic acids and histones, is not limited to technical and methodological difficulties and can be recommended for widespread use;

The theoretical premise of the proposed method was the Gertwig rule, which stipulates that only with a certain nuclear-cytoplasmic ratio the cell is in equilibrium (cited by E. Robertis, V. Novinsky, F. Saes, 1973) or expressed in the formula Vя / Vk-Vя = const ( cited by F. Shter, V. Melendorf, 1936), where Vя is the volume of the nucleus, Vk is the volume of the cell, with a change in biological activity, this ratio changes. However, due to the fact that the rule was deduced for histological studies, the calculation of the area of the conformationally complex NG nucleus presents certain difficulties, and the fact that the geometric ratio of the nucleus and cytoplasm squares only indirectly reflects the functional activity of the cell, use it for the integral biosynthetic activity of NG wound exudate is not possible. In this regard, only a simultaneous study of cytochemical parameters reflecting the complex functional activity of NG can give the most complete assessment of the latter.

The method was tested on 74 patients with phlegmons of the maxillofacial region. When analyzing case histories, patients were divided into 2 groups, including: 1 g. - Patients who had secondary sutures applied over 10 days and 2 g. - patients who have secondary sutures were applied in less than 8 days.

Example 1

The patient, L, 42 years old (medical history No. 2340) was admitted to the purulent department of the maxillofacial hospital of the regional clinical dental clinic (KKSP) at 13 ⁵⁵ 18.09. 2002 with a diagnosis of odontogenic phlegmon of the pterygo-maxillary, periopharyngeal spaces and the maxillofacial groove on the right and under mask anesthesia with external access from the submaxillary region, the interested cellular spaces were opened, purulent contents were obtained. A necrectomy, antiseptic treatment of the wound, smears, fingerprints. DNA 0.85; KB - 1.73; MP - 0.96; Chl - 1.53. TING = ((0.85 / (1.73 + 0.96 + 1.53)) 1000 = 201.4 srvc

The next day and the next day, the patient's condition is satisfactory. On day 3, a slight serous-hemorrhagic discharge remains in the wound. During dressing after active antiseptic treatment of the wound, smears are taken. DNA 0.94; KB - 0.88; MP - 0.64; Ch - 1.45; TING - 316.50 conv. units

On the 6th day of inpatient treatment (09.24.02), the patient does not show new complaints. General condition is satisfactory. Fresh juicy granulation is determined in the wound. After antiseptic treatment, fingerprints were taken from the wound, under local infiltration anesthesia (Sol. Lidocaini 2% - 5 ml), the surgical wound was sutured in layers (secondary sutures were applied). DNA 0.88; KB - 1.97; MP - 1.63; Ch - 1.89; TING - 160.29 conv. units

On the next day, the patient does not show new complaints. General condition is satisfactory. The skin around the surgical wound of normal color, painless on palpation. Drainage saved. Seams are wealthy. Antiseptic treatment of the wound. Wash water is clean. Glove drainage removed, aseptic dressing applied.

10/01/02, in connection with a satisfactory general and local condition, the patient was discharged from the hospital with full recovery.

Thus, the revealed increase in the value of TING on the 3rd day of treatment of a patient with PCF to 157% against the value determined when opening the PCF, hypothetically indicates a favorable type of purulent course. Indeed, the postoperative course was satisfactory. On the 6th day of inpatient treatment, secondary sutures were already applied. The total bed day was 13 days.

Example 2

Patient 3. (Case history No. 845) was admitted to the purulent department of the maxillofacial hospital of the Regional Clinical Dental Clinic (KKSP) in 09 ^{40 on} April 12, 2003 with a diagnosis of odontogenic phlegmon of the pterygo-maxillary, periopharyngeal and submaxillary spaces on the right. Under general anesthesia (mask anesthesia), external access from the submandibular region revealed the interested cellular spaces, and serous-purulent contents were obtained. A necrectomy, antiseptic treatment of the wound, smears, fingerprints. DNA 0.84; KB - 1.75; MP - 0.97; Chl - 1.55. TING = ((0.84 / (1.75 + 0.97 + 1.55)) 1000 = 196.72 conventional units

Rigid drains are left in the opened cellular spaces. An aseptic dressing is applied to the wound. Prescribed anti-inflammatory, antibacterial and desensitizing therapy.

04/13/03 and 04/14/03 the general condition of the patient was satisfactory, the local status did not undergo significant changes, antiseptic treatment of the wound and general anti-inflammatory treatment were carried out.

04/15/03 the patient began to complain about the appearance of swelling in the temporal region, which appeared the night before. There was a restriction in opening the mouth and pain appeared when swallowing on the right. General condition of moderate severity. An objective examination determines the spread of the purulent process to neighboring cell spaces. Infiltration of the temporal region, the skin is not collected in the fold, painful on palpation. Palpation behind the tubercle of the upper jaw and laterally from the front edge of the branches of the lower jaw is sharply painful, the mucous membrane of the oral cavity of these areas is hyperemic, swollen. Opening the mouth up to 0.5 cm. Drainage in the wound is preserved and functioning. Diagnosis: phlegmon of the temporal region, infratemporal and pterygopalatine fossae, pterygo-maxillary, periglottal and submasseterial spaces on the right.

04/15/03, under general anesthesia, an autopsy and revision of the concerned cellular spaces were performed. Purulent contents obtained. A necrectomy and abundant antiseptic treatment of the wound with sodium hypochloride was carried out, fingerprints were taken.

DNA 0.83; KB - 1.99; MP - 1.67; Ch - 1.87; TING - 150.09 well. units

Rigid drains are left in the opened cellular spaces. An aseptic dressing impregnated with sodium hypochloride is applied to the wound. Prescribed anti-inflammatory, antibacterial and desensitizing therapy. The patient was transferred to the intensive care unit.

04/16/03 the patient does not present new complaints. General condition of moderate severity. Hemodynamics is stable. Physiological administration and appetite are normal. Active patient moves independently within the ward and ward. Locally: the dressing is saturated with purulent-hemorrhagic discharge. Collateral edema of the temporal, parotid-chewing region is adequate to postoperative intervention. Drainages are functioning. In washings, blood clots and necrotic masses are moderate. Opening the mouth up to 1.5 cm. Swallowing and eating are independent. Data for the spread of purulent process is not revealed. The wound was treated with sodium hypochloride and an aseptic dressing impregnated with sodium hypochloride was applied. The patient continues to remain in the intensive care unit. He receives treatment according to an individual prescription sheet.

04/17/03 - 04/18/03 the patient does not present new complaints. General condition is satisfactory. From the wound, serous-purulent discharge.

Drainages are functioning. The wound is treated twice daily with sodium hypochloride. 04/18/03 smears taken from the wound. DNA 0.88; KB - 1.67; MP - 0.98; Chl - 1.52. TING = 211.03 conv. units

In the next day the patient was in the hospital, the general condition improved markedly. The patient was transferred from the intensive care unit to the purulent department. Wounds were treated daily with sodium hypochloride solution. Explicit exudative processes ceased, young fresh granulations appeared, which allowed the application of secondary sutures on 04.25.03 and smears were taken.

- At the time of applying the secondary sutures - DNA - 0.67 ± 0.002; KB - 2.11 ± 0.04; MP - 1.42 ± 0.05; Ch - 2.0 ± 0.07; TING - 121.16 conv. units

04/26/03 the patient does not show new complaints. General condition is satisfactory. The skin around the operating wounds of normal color, painless on palpation. Soft drainage saved. Seams are wealthy. Antiseptic treatment of wounds. Wash water is clean. Glove drains removed, aseptic dressings applied.

04/30/03, in connection with a satisfactory general and local condition, the patient with full recovery was discharged from the hospital.

The dynamics of TING in this patient is quite informative, it is of diagnostic and prognostic interest. A decrease in the value of TING to 76% against the value determined at the autopsy of the PCF correlates with the deterioration of the general condition of the patient, the spread of the purulent process to adjacent cellular spaces. Adequate opening and re-examination of the concerned cellular spaces, the active use of sodium hypochloride, which has a pronounced antiseptic and immunocorrective effect, finally stops the inflammatory process, which is inextricably linked with the restoration of the functional usefulness of NG wound exudate.

The use of TING for the study of NG wound exudate of a purulent wound in PCF does not represent technical and economic difficulties, it does not imply the use of expensive laboratory equipment, chem. reagents, specially trained personnel. It is possible to get the value of the TING indicator from the moment of taking the material from the patient in about 2 hours. Nevertheless, its use allows a precise assessment of the total biosynthetic activity of NG in the wound stage of a purulent wound in patients with CLP phlegmon, to predict the course of a purulent wound and, therefore, the terms of hospitalization of the patient.

Literature

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Claims (1)

A method for assessing the course and prognosis of purulent wounds with phlegmons of the maxillofacial region, including a visual assessment of the volume and nature of the exudation, diagnostic cytochemical methods for the study of neutrophilic granulocytes in the wound, including determination of DNA chromatin activity and myeloperoxidase activity, characterized in that they determine the integral the functional activity of neutrophilic granulocytes by further studying the content of cationic proteins and glycogen in them, after which they determine A general biological indicator of activity is the tissue index of neutrophilic granulocytes (TING) of wound exudate according to the formula TING = (DNA: (MP + KB + Gl) · 1000, expressed in arbitrary units, where DNA is the activity of nuclear chromatin; MP is the activity of myeloperoxidase; KB is the content of cationic proteins; Hl is the glycogen content; 1000 is the conversion coefficient of thousandths to integers, and when the value of TING is increased on the 3rd day of treatment relative to its value determined directly at the opening of the phlegmon of the maxillofacial region, they predict good riyatny type flow purulent wounds, and at lower values below 100% Ting predict prolonged healing process, with the risk of complications.