RU2247392C1 - Method for estimating enteric detoxication in the cases of generalized peritonitis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves studying lactoferrin content in blood serum and peritoneal exudates in postoperative period every day during the first three days. Lactoferrin concentration in blood serum being concurrently reduced by 0.02 mcmole/l or less and increasing lactoferrin concentration in peritoneal exudates by 0.04 mcmole/l or more, enteric detoxication is considered to be effective.

EFFECT: high quality of estimation.

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Description

The invention relates to medicine, in particular to anesthesiology and intensive care.

The urgency of the problem of widespread peritonitis is not in doubt, since this nosolation remains the leading cause of death in urgent surgery and critical state medicine. At the moment, it is very promising to use the so-called methods of intracoporal detoxification, that is, methods of introducing drugs into the body cavity that sorb and remove those components that can cause deterioration due to endogenous intoxication. The most significant is the method of enterosorption, that is, the introduction of various methods of sorbents into the lumen of the gastrointestinal tract with subsequent evacuation of the contents. One of the phases of the pathogenesis of common peritonitis is the translocation of microflora and endotoxins, that is, the migration of pathogenic microorganisms through the wall of the intestine and vascular endothelium into the systemic splanchnic blood flow and peritoneum. A similar factor can support endogenous intoxication syndrome and explain the severity of the patient’s condition, even with effective rehabilitation of the surgical site of infection. The method of enterosorption and enteric detoxification allows you to very effectively deal with endogenous intoxication, since the main direction of the movement of toxins is the transport of toxins from the intestinal lumen to the bloodstream and peritoneum, if we are talking about common peritonitis.

At the moment, there are no high-quality methods for evaluating the effectiveness of using the method of enterosorption with peritonitis widespread, in particular, there is no data on the relationship of indicators characterizing the biochemical parameters of blood serum, intestinal chyme and peritoneal exudate, as well as the possibility of assessing the correction of the phenomenon of translocation of endotoxins from the abdominal cavity into the bloodstream in the dynamics of enteral detoxification.

A known method for evaluating the effectiveness of intensive care of intestinal insufficiency syndrome [Popova TS, Tamazashvili T.Sh., Shestopalov A.E. Intestinal insufficiency syndrome in surgery. - M.: Medicine. - S.93-108]. In patients with widespread peritonitis, acute intestinal obstruction, a comprehensive assessment of several symptoms (radiography of the abdominal cavity organs, electroenterography, study of blood biochemical parameters) was carried out in the dynamics of intensive care, based on this complex, the effectiveness of the treatment of intestinal insufficiency syndrome was evaluated.

The disadvantage of this method is the fact of the development of multiple organ failure syndrome with widespread peritonitis (i.e., liver, kidney function insufficiency), which contributes to the formation of shifts in biochemical parameters, that is, there is not only intoxication from the intestinal lumen, but also a component of endogenous intoxication due to inefficiency of its own body detoxification organs. The complex is quite difficult to perform, since radiography of the abdominal organs requires the vertical position of the patient, electroenterography gives false positive results in the presence of drainage tubes in the abdominal cavity.

A known method for determining the effectiveness of enterosorption in intestinal insufficiency syndrome [Gelfand BR, Filimonov MI, Yusufov OG, Podachin PV, Nasibov SM, Kulaev DV Enterosorption in intestinal insufficiency syndrome // Anesthesiology and Intensive Care. - 1997. - No. 3. - S. 34-36]. The essence of the method is to study the parameters of biochemical metabolism (urea nitrogen, total bilirubin, cholesterol, albumin, creatinine, total protein and triglycerides) in the intestinal contents and in blood serum; an increase in the concentration of these indicators is an indication for enterosorption through a nasointestinal probe.

The disadvantage of this method is the use of biochemical parameters of the intestinal chyme not only of macroorganismal origin, but also of microbial origin. In addition, the fact of research and comparison of chyme and blood does not allow us to talk about the phenomenon of translocation and the effectiveness of enterosorption in the correction of the above phenomena.

Closest to the claimed is a method - a test to assess the effectiveness of enterosorption, based on biochemical indicators of blood toxicity and peritoneal exudate [N. Belyakov (Ed.) Enterosorption. L., 1991. - S.117-135]. The essence of the method is to measure the concentration of medium-weight molecules (MSM) in blood serum and peritoneal exudate and, with an increase in the concentration of MSM in exudate, the use of enterosorption was considered indicated.

The disadvantage of this method is the use of the presented model and indications only in the experiment, in clinical practice, studies have not been conducted. In addition, MSM are far from the only molecules - sources of endogenous intoxication in translocation syndrome in patients with peritonitis.

The objective of the invention is to improve the quality of evaluating the effectiveness of enteral detoxification with widespread peritonitis by examining the content of lactoferrin in blood serum and peritoneal exudate. Based on the data obtained, enteric detoxification (enterosorption via a nasointestinal probe) is considered effective or ineffective. Lactoferrin is a more specific and reliable marker for assessing enteric detoxification, as it determines the course of endogenous intoxication and explains the state of the hematoperitoneal barrier.

The task is achieved by the fact that in patients with advanced peritonitis, the content of lactoferrin in the blood serum and peritoneal exudate in the postoperative period is simultaneously examined and at the same time the concentration of LF in the blood serum is less than 0.02 μmol / L and the LF concentration in the peritoneal exudate is more than 0, 04 µmol / L find enteral detoxification effective.

The novelty of the method:

1. The study of LF is performed simultaneously in blood serum and peritoneal exudate. Determining the level of LF in the blood and exudate at the same time can explain the fact of damage to the histohematological barrier at the blood – peritoneum border or the so-called hematoperitoneal barrier, as well as the direction of movement of the LF and bacterial endotoxins from the abdominal cavity into the systemic circulation.

2. The study is performed during the postoperative period. Damage to the hematoperitoneal barrier is closely associated with the planned rehabilitation of the abdominal cavity, since surgical aggression is an important factor in the deterioration of the patient with common peritonitis. The determination of LF dynamics is carried out daily during the first three days of the postoperative period.

3. Calculation of the concentration of LF in biological fluids is carried out in mmol / l (in concentration, and not in weight values). This pursues the goal of comparative characterization between indicators in different biological environments,

4. The simultaneous achievement of a change in the level of LF in the blood serum of less than 0.02 μmol / L and in the peritoneal exudate of more than 0.04 μmol / L is a sign of effective enteric detoxification. These critical values of the level of LF in exudate and blood were obtained during studies of patients with advanced peritonitis, while the above values of the level of LF suggested the development of an unfavorable outcome of common peritonitis.

The essence of the method is as follows. The study of biochemical parameters is carried out during the postoperative period (surgical interventions for widespread peritonitis suggest radical debridement and removal of the primary focus of infection in the abdominal cavity). To determine the LF, peritoneal exudate and blood are used. Peritoneal exudate is obtained either during surgery before abdominal sanitation with antiseptic solutions, or during diagnostic laparoscopy, or from drains that complete the operation. In any case, a prerequisite is the absence of additional impurities (physiological saline, hydrogen peroxide solution, furatsilina solution) during the collection of exudate. The exudate is centrifuged at a speed of 2500 rpm for 3-5 minutes. After that, the upper portion (exudate without cellular elements) is taken in a volume of 3 ml, after which it is either subjected to investigation or frozen in a domestic refrigerator for subsequent investigation. Blood for examination is taken from a catheterized central vein (with mandatory washing of the lumen of the catheter with autoblood to avoid impurities in the form of infusion media), followed by centrifugation under the same conditions as the exudate. Subsequent studies and storage options did not differ from those for peritoneal exudate. Note that blood and exudate were taken simultaneously. Subsequently, an enzyme-linked immunosorbent assay for blood serum and exudate for LF content was performed.

The use of lactoferrin and the possibility of diagnosing damage to the hematoperitoneal barrier (blood – peritoneum barrier) is explained by the fact that LF is the product of synthesis and secretion by peritoneal macrophages. With a favorable course of the peritonitis process in the abdominal cavity, the hematoperitoneal barrier copes with increased secretion of LF, while there is no translocation phenomenon, that is, the transition of endotoxins and LF as a marker of translocation from the abdominal cavity to the systemic circulation. With an unfavorable course of the process, the hematoperitoneal barrier is insolvent, that is, the endotoxins of bacteria, as well as LF, are able to penetrate the histohematological barrier and enter the systemic circulation, which significantly worsens the course of the inflammation and endogenous intoxication syndrome. Monitoring is carried out daily during the first three days of the postoperative period, since it is this particular time period that is most dangerous for the development of increased translocation through the hematoperitoneal barrier.

EXAMPLE 1

Patient B., case history No. 156, was hospitalized on February 13, 2003 to the emergency surgery department of the city clinical hospital No. 1 with a diagnosis of perforated duodenal ulcer complicated by peritonitis. On an emergency basis: laparotomy, suturing of the perforated hole, sanitation of the abdominal cavity, nasointestinal drainage, laparostomy. The nearest postoperative period in the intensive care unit. According to the LF data in peritoneal exudate and blood, enteral detoxification was considered indicated,

Table 1
The dynamics of the concentration of LF in exudate and blood serum, mmol / l Day 1 2 3 Blood count 0.05 0.04 0.02 LF exudate 0.02 0.02 0,03

EXAMPLE 2

Patient N., medical history No. 1858, was hospitalized on May 13, 2002 to the General Surgery Department of the City Clinical Hospital No. 29 with a diagnosis of perforated duodenal ulcer, peritonitis widespread. An operation was performed on an emergency basis: laparostomy, Vitebsky gastric resection, nasointestinal drainage, laparostomy. According to the level of LF in peritoneal exudate and blood serum in the first day of the postoperative period, it was decided to add enteral detoxification to complex therapy. To this end, through a nasointestinal probe, 3 sessions of enterosorption were carried out by the Enterosgel sorbent, the duration of the session was 1 hour, and the volume of the sorbent was 1 g / kg of body weight.

table 2
The dynamics of the concentration of LF in exudate and blood serum, mmol / l Day 1 2 3 Blood count 0.05 0.04 0.08 LF exudate 0.02 0.02 0.01

On the third day, according to the LF data, the inefficiency of enterosorption was noted, which was confirmed by an increase in the concentration of LF in the blood serum and a decrease in LF in peritoneal exudate. The inefficiency of enterosorption has become an indication for changes in the intensive care complex: increased antibiotic therapy, the addition of extracorporeal detoxification - a plasmapheresis session.

The patient’s condition in dynamics improved, he was transferred to the general department on the 7th day of therapy and successful closure of the laparostomy.

Thus, evaluating the effectiveness of enteral detoxification by determining changes in the concentration of lactoferrin in the blood and peritoneal exudate can improve the quality of assessment of enteric detoxification due to a specific and reliable marker, which allows you to optimize the selected treatment regimen and increase the effectiveness of peritonitis therapy.

Claims (1)

A method for evaluating the effectiveness of enteric detoxification in advanced peritonitis, including a blood test and peritoneal exudate, characterized in that in patients with advanced peritonitis, the content of lactoferrin in the blood serum and peritoneal exudate is simultaneously examined during the postoperative period every day for the first three days and with a simultaneous decrease in the concentration LF in serum less than or equal to 0.02 μmol / L and with an increase in the concentration of LF in the peritoneal exudate more and and equal to 0.04 mol / l enteral considered effective detoxification.