RU2281123C1 - Method of treating abdominal cavity in patients with peritonitis - Google Patents

Abstract

FIELD: abdominal surgery, pulmonology, and immunology.

SUBSTANCE: abdominal cavity is first treated by hyperthermal perfusion with solution containing electrolytes, proteins, and dextrans at 41-42°C in solution and pressure 25-40 mm Hg, where solution is introduced at velocity 1.5-2 L/min. Exhausted solution is passed through filter sorbent and cleaned solution is reused for treatment of abdominal cavity. Exhausted solution cleaning procedure and reuse of cleaned solution is repeatedly performed during 20-30 min, whereupon abdominal cavity is subjected to treatment for 7-10 min by high-frequency insufflation with therapeutical aerosol and, 4-24 h later, above insufflation is performed for 10-15 min. In sum, patient is subjected to 2-4 sessions of combined treatment by hyperthermal perfusion and high-frequency insufflation with therapeutical aerosol and 4-8 sessions of high-frequency insufflation with therapeutical aerosol.

EFFECT: achieved cleaning of inclined sectors of peritoneum and pockets thereof, which contributes to reduction of postoperative complications.

3 ex

Description

The invention relates to medicine, in particular to abdominal surgery and can be used in clinics of a surgical profile.

Known methods of treatment for peritonitis:

1. Peritoneal dialysis - its essence lies in the introduction of fluid through the drainage located 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 (1, 2).

2. Hypothermic perfusion - washing the abdominal cavity with a large amount of cold solution (up to 30 liters per day); the fluid, washing the abdominal cavity, is independently discharged through the drainage from the pelvis (3).

3. Hyperthermic perfusion - washing of the abdominal cavity is carried out with a solution with a temperature of 40-41 ° C (4).

4. The introduction and aspiration of abdominal lavage fluid during laparoscopy (5).

Disadvantages of analogues:

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 makes it impossible to fully complete the full course of treatment, also limits the possibility of the required number of sessions.

2. The washing out of a large amount of protein and electrolytes from the body by the flowing liquid, which leads to the development of hypoproteinemia and disruption of water-electrolyte metabolism.

3. The need for each peritoneal dialysis session of a large number (from 13-15 to 30 liters per day) of expensive medicinal solutions (6).

As a prototype for the closest technical essence, we have chosen a method for treating the abdominal cavity with peritonitis (7).

The method consists in exposing the mesothelium of the abdominal cavity to a drug mixture consisting of oxygen, local anesthetics, antiseptics, antibiotics, fibrinolytics, glucocorticoids, immunomodulators, antihistamines. The drug mixture is administered as an aerosol using high-frequency insufflation at a rate of 2.5-3.0 l / min for 10-15 minutes under a pressure of 70 mm Hg with the number of sessions from 9 to 20.

The disadvantage of the method we have chosen as a prototype is the insufficiently high degree of purification of the abdominal cavity, since fibrins with microorganisms and necrotic tissues remain in the sloping areas of the peritoneum and its pockets, which can subsequently lead to the spread of infection and endotoxicosis and to an increase in the duration of postoperative treatment .

The objective of the invention is to increase the efficiency of treatment of the abdominal cavity with peritonitis due to a higher degree of cleaning of the flat sections of the peritoneum and its pockets, reducing postoperative complications, reducing the recovery time of peristalsis and reducing the time of postoperative treatment.

The problem is solved in that initially the abdominal cavity is treated by hyperthermic perfusion with a solution containing electrolytes, proteins and dextrans. The temperature of the injected solution is 41-42 ° C. The solution is injected under a pressure of 25-40 mm Hg. with a speed of 1.5-2 l / min. Subsequently, the spent solution is passed through a filter sorbent and the abdominal cavity is treated with the purified solution. The procedure for cleaning the waste solution and treating the abdominal cavity with the purified solution is repeatedly repeated for 20-30 minutes. After this, the abdominal cavity is treated with high-frequency insufflation with a medicinal aerosol consisting of oxygen, local anesthetics, antiseptics, antibiotics, fibrinolytics, glucocorticoids, immunomodulators, antihistamines. Medicinal aerosol is administered at a rate of 2.5-3.0 l / min for 7-10 minutes under a pressure of 70 mm RT. Art. Then, after 4-24 hours, an RFID session is carried out for 10-15 minutes. 2-4 sessions of complex treatment of the abdominal cavity with hyperthermic perfusion and VCHILA and 4-8 sessions of VCHILA are carried out.

The method is as follows:

A solution containing proteins, electrolytes and dextrans (as proteins it is possible to use albumin, proteins, amino acids, as electrolytes - Ringer-Locke solution, polyionic mixture, physiological solution, as dextrans - polyglyukin, reopoliglyukin), located in a sterile reservoir, served into the pump, from which the solution is supplied through the drains installed in the small omentum, into the abdominal cavity, from the abdominal cavity through the drains installed in the small pelvis, the solution enters the chamber with a filter -sorbent and heat exchanger. The solution is supplied at a speed of 1.5-2 l / min under a pressure of 25-40 mm Hg. The temperature of the solution is 41-42 ° C. This completes the initial abdominal treatment cycle. The next cycle begins with the receipt of the purified solution from the chamber with the filter sorbent and heat exchanger into the tank, from where it returns to the abdominal cavity with the pump. Within 20-30 minutes, 3.0-5.0 L of solution is passed through the described closed loop, that is, several cycles of treatment of the abdominal cavity are carried out. As a filter, you can use any hemosorbent. We used a combined filter sorbent from a mixture of polyvinyl alcohol and polypropylene fibers in a ratio of 2: 1. After treating the abdominal cavity with hyperthermic perfusion, the abdominal cavity is treated with drug aerosol using high-frequency insufflation. First, a drug aerosol is prepared. It includes anesthetics, antiseptics, antibiotics, fibrinolytics, glucocorticoids, immunomodulators, antihistamines. The prepared solution is refilled with an ultrasonic inhaler (we use the Albedo ultrasonic inhaler with the HF IVL device - a stationary unit for work in the intensive care unit or the Pari Master inhalation device - a portable device for working directly in the room). Oxygen is supplied to the apparatus, based on the intake of 3 liters per minute into the abdominal cavity. 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 under a pressure of 70 mm Hg. with a speed of 2.5-3.0 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 is carried out for 7-10 minutes, during which time 20.958-29.940 liters of oxygen and 42-60 ml of the drug mixture are introduced into the abdominal cavity.

The medicinal composition contains the following components: 0.5% novocaine solution - 20.0; furatsilin solution - 15.0; gentomycin - 1.0 or another antibiotic, depending on sensitivity, fibrinolysin - 20.0; benzohexonium - 0.5; prednisone - 1.0; atropine - 0.5; suprastin - 1.0; immunofan - 1.0.

A complex session of hyperthermic perfusion and RFID is carried out during the day no more than 2 times. The number of sessions depends on the severity of the process, its prevalence. The age and concomitant diseases of the patient do not limit the time and number of sessions.

Distinctive features of the proposed method are:

- before treating the abdominal cavity with high-frequency insufflation with drug aerosol, the abdominal cavity is treated by hyperthermic perfusion with a solution containing electrolytes, proteins and dextrans;

- the spent solution is passed through a filter sorbent and the abdominal cavity is treated again with the purified solution, the procedure for cleaning the spent solution and the treatment of the abdominal cavity with the purified solution is repeated repeatedly for 20-30 minutes;

- the temperature of the solution is 41-42 ° C, the rate of introduction of the solution is 1.5-2 l / min, the solution is injected under a pressure of 25-40 mm Hg

- after treatment of the abdominal cavity with hyperthermic perfusion, VCHILA is performed for 7-10 minutes;

- after 4-24 hours, 4-8 sessions of TAKE-UP are carried out.

- complex treatment, including hyperthermic perfusion of the abdominal cavity and RFID, consists of 2-4 sessions.

Pretreatment of the abdominal cavity with a solution containing proteins, electrolytes and dextrans is necessary in order to ensure the replenishment of proteins and electrolytes lost during the disease and during the treatment of the abdominal cavity, as well as to prepare favorable conditions for maximum exposure to drug aerosol, since the effect medicinal aerosol on the cleaned surface of the peritoneum will be much more effective.

When the spent solution is passed through a filter sorbent, microparticles, cellular elements, including pathogenic microorganisms, their toxins and the main components characterizing endotoxemia are removed. Used waste solution purification is used to save perfusate volume.

The selected temperature regime contributes to the expansion of blood vessels, which leads to an improvement in their microcirculation, and also creates adverse conditions for the growth of microorganisms.

With the selected pressure parameters, the loss of tissue fluid into the free abdominal cavity is reduced.

With the selected parameters of the rate of introduction of the solution, the maximum leaching of necrotic masses and fibrins occurs.

The selected temporary regime of hyperthermic perfusion (20-30 min) allows you to enter 3.0-5.0 l of purified solution into the abdominal cavity. Such a volume of solution is sufficient for the effective preparation of the peritoneum for RFID. The temporary regimen of RFID (7-10 min) in a complex session is sufficient for the effective treatment of RFID prepared purified abdominal cavity.

Conducting RFA 4-24 hours after a complex session of treating the abdominal cavity with hyperthermic perfusion and RFA is necessary to prevent adhesions.

The set of essential features is new and allows to increase the efficiency of treatment of the abdominal cavity in patients with peritonitis due to a higher degree of cleaning of the flat parts of the peritoneum and its pockets, which reduces the number of postoperative complications by 9.5%, reduces the recovery time of peristalsis by 1-2 days and 5-6 days reduces treatment time. The set of essential features is new and allows you to increase the efficiency of the method of treating the abdominal cavity with peritonitis due to a higher degree of purification of the flat sections of the peritoneum and its pockets, which reduces the number of postoperative complications, reduces the recovery time of peristalsis and treatment time.

We give examples from clinical practice:

Example 1

I. / b. No. 3173: Patient S., 64 years old, was taken to the hospital in serious condition with a diagnosis of acute abdomen, peritonitis. An emergency median laparotomy was performed. In the abdominal cavity - fibrinous-purulent exudate in all anatomical areas (common peritonitis). The source of peritonitis is destructive (gangrenous-perforated) appendicitis. Appendectomy, abdominal lavage with antiseptic solutions and abdominal drainage were performed. Immediately after the operation, for the next two days, hyperthermic perfusion of the abdominal cavity and RFID were performed. A total of 2 complex sessions of hyperthermic perfusion of the abdominal cavity for 20 minutes and TAKES for 7 minutes and after 24 hours - 4 sessions of 10 minutes TAKED separately. For each abdominal GP session, a 3-liter solution of electrolytes, proteins, and dextvan, 50 ml of the drug mixture, and about 30 liters of oxygen were used for RFID. Drainage removed on the 4th day. Postoperative course without complications. The wound healed by primary intention. The patient was discharged on the 12th day in satisfactory condition for outpatient monitoring by a surgeon in a clinic.

Example 2

I / b No. 3707: Patient B., 45 years old. Transferred from the gynecological department with a diagnosis of acute intestinal obstruction (small bowel) - 360 degree inversion. Spilled peritonitis. Performed mid-median laparotomy. In the abdominal cavity, a cloudy effusion with fibrin flakes. Loops of intestines are moderately inflated with plaque of fibrin. At a distance of 40-50 cm from the bougain damper, a loop of a black small intestine twisted by 360 degrees with a fetid odor was revealed. In the mesentery of the small intestine, hemorrhage and necrosis sites were determined. Irreversible changes (black color, lack of peristalsis and mesenteric pulsation) in the wall of the small intestine for about 1.5 meters. A small bowel resection was performed with a side-by-side anastomosis. The abdominal cavity was rinsed with antiseptic solutions (1.5-2 l of furatsillin with chlorhexidine), after which the abdominal cavity was drained.

In the postoperative period, hyperthermic perfusion of the abdominal cavity and RFID were performed for 2 days. Altogether, 4 complex sessions of abdominal HP were performed for 30 minutes each and TANES were administered for 10 minutes and after 4 hours, 8 sessions TUES were taken separately. On the 4th and 5th day after the cessation of exudate secretion from the abdominal cavity, drainage was removed. Postoperative course without complications. Peristalsis on the 3rd day, an independent chair on the 5th day. The patient was discharged on the 15th day for outpatient treatment.

Example 3

And / b No. 2130: Patient B., 50 years old. He was admitted to the hospital in an emergency with a diagnosis of perforated gastric ulcer, diffuse peritonitis.

With laparotomy in the abdominal cavity - effusion (fibrinous-purulent) in large quantities in all anatomical areas. During the audit, a perforated gastric ulcer was found on the front wall of the body closer to the lesser curvature with a diameter of about 0.7 cm. Suturing of the perforated ulcer with 2-row sutures. Washing the abdominal cavity with 3 l of furacilin. Abdominal drainage. In the postoperative period of 2 days, abdominal HPP and high-frequency insufflation with drug aerosol were performed. In total, 3 complex sessions of GP of the abdominal cavity were carried out for 25 minutes each and TAKEN 8 minutes each and after 14 hours 6 sessions TAKED into the abdominal cavity separately. Peristalsis recovered after 1 day. The wound healed by primary intention. The duration of treatment at the clinic was 14 days.

According to this method, the abdominal cavity was treated in 28 patients with widespread peritonitis. Of these, 13 women, 15 men aged 24 to 83 years. The cause of peritonitis was acute appendicitis, acute intestinal obstruction, acute cholecystitis, acute pancreatitis, perforated gastric ulcer and trauma to the abdominal organs. In 2 cases, that is, 7.1% of patients had complications: in one case, suppuration of a postoperative wound, postoperative pneumonia in another. According to our own data, in 30 patients with peritonitis who treated the abdominal cavity according to the prototype method, 4 complications were observed, that is, in 13.3% of patients: 2 cases - suppuration of the postoperative wound and 2 cases - postoperative pneumonia. According to the claimed method, the restoration of peristalsis in patients was observed for 2-3 days, by the method of the prototype for 3-5 days. The treatment period according to the claimed method in 12 patients was 12 days, in 5 patients - 15 days and in 7 patients - 12 days. According to our own data, of the 30 patients who treated the abdominal cavity according to the prototype method, in 14 the treatment period was 17 days, in 7 patients it was 21 days and in 9 patients it was 19 days.

The inventive method allows, in comparison with the prototype, to more effectively treat the abdominal cavity in patients with peritonitis due to a higher degree of purification of the flat sections of the peritoneum and its pockets, which reduces the number of postoperative complications by 6.2%; reduces the recovery time of peristalsis by 1-2 days and reduces the treatment time by 5-6 days.

Literature:

1. Veronsky G.I., Yaunts R.A. Flowing abdominal lavage in the treatment of diffuse peritonitis. Surgery, 1980, No. 9, p. 58-61.

2. Radionov V.V., Lemin G.P. Lavage of the abdominal cavity in the postoperative period with diffuse purulent peritonitis of appendicular origin. Surgery, 1985, No. 9, pp. 99-102.

3. Tatishvili G. G., Tamazashvili T. M., Tevdaradze I. L. Abdominal hypothermia in the treatment of postoperative peritonitis. Herald of Surgery, 1985, No. 12, p.139-142.

4. Deryabin I.I., Lizonets M.N. Peritoneal dialysis. M., Medicine, 1991, p.168.

5. Petrov V.I., Sytkin A.P. Prolonged postoperative rehabilitation of the abdominal cavity using a laparoscope with widespread purulent peritonitis. Surgery, 1987, No. 7, pp. 30-34.

6. Karimov Sh.I., Tursunov K.N., Asrarov A.A. and others. The effectiveness of peritoneal dialysis, intestinal lavage and enteral tube nutrition in the complex treatment of diffuse purulent peritonitis. Guidelines. Tashkent, 1984, 14 pp.

7. RU 2154505 C1, 08.20.2000.

Claims (1)

A method of treating the abdominal cavity with peritonitis by high frequency insufflation with a medicinal aerosol (RFA), consisting of oxygen, local anesthetics, antiseptics, antibiotics, fibrinolytics, glucocorticoids, immunomodulators, antihistamines and administered at a speed of 2.5-3.0 l / s under pressure 70 mmHg Art., characterized in that the pre-abdominal cavity is treated by hyperthermic perfusion with a solution containing electrolytes, proteins and dextrans at a solution temperature of 41-42 ° C, a solution injection rate of 1.5-2 l / min and a pressure of 25-40 mm RT. Art., subsequently, the spent solution is passed through a filter sorbent and the abdominal cavity is treated with a purified solution, and the procedure for cleaning the spent solution through a filter sorbent and treating the abdominal cavity with a purified solution is repeated several times for 20-30 minutes, after which the abdominal cavity for 7 -10 min is treated with high-frequency insufflation with a medicinal aerosol, then after 4-24 hours a VCHILA session is performed for 10-15 minutes, 2-4 sessions of complex treatment of the abdominal cavity with hyperthermic perfusion are performed and TAKEN and 4-8 sessions TAKEN.