RU2286783C2 - Method for treatment of pleuropulmonic complications in patient suffering from pancreatonecrosis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: claimed method includes paracentesis of pleural cavity and exudate removing by at least tree hours before surgical aggression singly and then additionally over at least one day after surgical aggression. Interval between paracentesis must be not less than one day. After exudate removing during each paracentesis 2000 Units of contrical and 30 mg of mexidole are administered intrapleurally.

EFFECT: method for treatment of increased effectiveness due to improving of ventilation-perfusion ratio and reducing of amylasemia in pleural cavity exudate.

1 ex, 1 tbl

Description

The invention relates to medicine, namely to methods for treating pleuropulmonary complications in patients with pancreatic necrosis, which in 100% of cases are accompanied by pleuropulmonary complications.

There is a method of treating pleuropulmonary complications, namely pancreatogenic pleurisy (V.I. Filin, A.L. Kostyuchenko. "Emergency pancreatology". - St. Petersburg: Peter. - 1994. - P.301) which consists in performing puncture of the pleural cavity after surgery and removal of pleural effusion.

The disadvantages of this method is the lack of effectiveness of the procedure, since: the pleural cavity is punctured after surgery and only with functionally significant pleurisy, i.e. with an already significant decrease in the vital capacity of the lungs, blood oxygenation and a pronounced violation of ventilation-perfusion relationships.

In addition, in 70% of cases persistent relapses of pleurisy are observed, which require repeated repeated punctures of the pleural cavity. A high percentage of relapses of pleurisy results in costly monitoring of pleural cavities, including frequent chest x-rays and ultrasound. Often, pleural effusions are infected (hematogenous or lymphogenous), which leads to empyema of the pleural cavity, which must be drained from several points. Drainages require careful care for them and in 9-15% lead to phlegmon of the chest. Pleural empyema is often complicated by residual cavities, mooring, which require surgical treatment from thoracotomy access, often ending in lung decortication.

The present invention is simple to use, does not require additional equipment and devices, reliably and effectively solves the problem of treating pleuropulmonary complications in patients with pancreatic necrosis.

The resulting technical result consists in increasing the effectiveness of treatment. Using the proposed method, including multiple puncture sequential injection of a multicomponent drug solution into the pleural cavity, consisting of a protease inhibitor - Contrical (20,000 units) and a synthetic free radical processes inhibitor (membrane protector) - Mexidol (300 mg), allows to reduce the level of pancreatic enzymes in the pleural cavity (primarily amylases), kallikrein, and lipid peroxidation products (PPOL). This relieves the endotoxic bronchospastic effect and spasm of the pulmonary veins, causes a decrease in pressure in the pulmonary artery and reduces the volume of pulmonary bypass grafting, thereby improving the ventilation-perfusion relationship in the lungs, which leads to the rapid and reliable relief of pancreatogenic pleurisy.

The possibility of multiple puncture intrapleural administration of a multicomponent drug solution, including contracal and mexidol, both before surgery and in the postoperative period, improves the effectiveness of treatment.

Multiple puncture injection of a multicomponent drug solution into the pleural cavity, including contracal and mexidol, improves ventilation-perfusion relations in the lungs and, very importantly, has a long therapeutic effect of at least 24 hours. Reducing the level of amylasemia, kallikrein and PPOL in the exudate of the pleural cavity protects the pleura and alveolocapillary membranes of the lungs from destruction, prevents embolization and pulmonary thrombosis, reduces pulmonary hypertension, reduces arteriovenous bypass surgery, and arterial hypoxemia.

The proposed method of prevention and treatment is safe, simple and affordable for use by a surgeon of any skill.

The specified technical result is achieved by the fact that in the method of treating pleuropulmonary complications in patients with pancreatic necrosis, which consists in performing 3 hours before the operation, an additional single puncture of the pleural cavity and removal of the pleural effusion, and at least 24 hours after the operation, additional puncture of the pleural cavity is performed with an interval not less than a day, moreover, when performing each puncture and after removal of the pleural effusion, 20,000 units are successively introduced into the pleural cavity. Contrikal and 300 mg of Mexidol.

A method for the treatment of pleuropulmonary complications in patients with pancreatic necrosis is as follows.

To prepare solutions for introduction into the pleural cavity under sterile conditions, 20,000 units are bred. Contrical in 20 ml of water for injection and take in a 20 ml syringe, in another syringe 300 mg (6 ml - 5%) of Mexidol is diluted in 10 ml of saline and also taken in a 20 ml syringe.

The technique of intrapleural puncture does not differ from the classical one and is performed in the VII intercostal space along the posterior axillary line. After preparing the solutions, 3 hours before the operation, anesthesia is performed with a regular needle by introducing a 0.5% solution of novocaine along the upper edge of the VIII rib, after a dip in the pleural cavity, the needle is changed to a needle with a diameter of 1.5 mm with a blunt end, so as not to injure lung tissue, which is carried out in the pleural cavity. First, effusion from the pleural cavity is evacuated, then 20,000 units are sequentially injected through the same needle. Contrikala to 20 ml of water for injection and 300 mg of Mexidol per 10 ml of saline. After the operation, not less than one day later and with an interval of not less than a day, the pleural cavity is punctured, removal of the pleural effusion is performed, and at each puncture 20,000 units are administered. Contrikal and 300 mg of Mexidol.

After the introduction of drugs, the solution spreads through the pleural cavity and envelops the root of the lung.

The method has proven to be highly effective, cheap, easy to perform and eliminating the disadvantages of the above prototype.

After the introduction of drugs into the pleural cavity according to the proposed method, all patients showed a decrease in the frequency of respiratory movements (NPV), increased lung capacity (VC), tidal volume (DO), reserve inspiratory volume (RVD), reserve expiratory volume (RVID) and mean expiratory flow rate (SOS), blood oxygenation (SpO ₂ ) also increased significantly.

Observations showed that in 90% of patients for reliable relief of pleurisy it was enough to perform a puncture of the pleural cavity with the introduction of drugs according to the proposed method before surgery and once after surgery.

Table 1 shows the indicators of ventilation-perfusion function of the lungs, characterizing the effectiveness of the treatment of pleuropulmonary complications in patients with pancreatic necrosis.

Clinical example: patient K., 57 years old, was admitted to the MUZ KB 25.02.2002. at 16 ³⁰ with complaints of acute pain in the upper abdomen of the "girdling" nature, bloating, nausea, repeated vomiting, shortness of breath. He considers himself to be a patient for 3 days, when after eating plenty of fatty foods with alcohol, severe pain suddenly appeared in the epigastrium and left hypochondrium, radiating to the left costal vertebral angle. The last day, a high body temperature joined - up to 39 ° C, weakness, dryness in the oral cavity, and bloating began to increase. I took analgesics and antispasmodics on my own - without effect. First aid delivered to the hospital.

Objectively: a serious condition. HELL 80/40 mm Hg, pulse 126 in 1 min. NPV - 28 per minute. The chest on the left lags behind in breathing. In the lungs, breathing is hard on the right, on the left it is audible only at the top. Percussion shortening the sound on the left to the V rib. The skin is pale, on the stomach with spots of Mondor. The nasolabial triangle is cyanotic. The sclera of the eyes is slightly icteric. The tongue is dry, coated with a brown coating. The abdomen is swollen, tense and sharply painful in the upper sections and along the right flank. Peristalsis is not determined, a positive symptom of Shchetkin-Blumberg, Kerte, Mayo-Robson. During the day there was no stool, the gases practically did not leave, diuresis was sharply reduced.

Biochemical analyzes determined hepatonephropathy I tbsp. gravity. In terms of hemostasis, activation of blood coagulation by type I stage of DIC was observed due to plasma factors.

Study of ventilation and perfusion function of the lungs (ETON-SPIRON apparatus): VC was 3.35 L, DO - 2.9 L, Rovd - 1.25 L, Rovyd - 1.15 L, SOS - 2.45 L. SpO ₂ was 82% ("NONIN 950" hemo-oximeter. Conclusion: a significant reduction in the ventilation capacity of the lungs due to impaired patency of the small bronchi. Restrictive-obstructive type.

On chest x-ray, fluid was determined in the rib-phrenic sinus from the left to the V rib.

Ultrasound of the chest: fluid in the pleural cavity on the left with a volume of up to 550 ml.

Ultrasound of the abdomen: Pancreatic necrosis. Retroperitoneal edema. Fluid in the stuffing bag and abdominal cavity. Changes in hepatorenal structures of Art. I Biliary hypertension.

Clinical diagnosis: Infected pancreatic necrosis. Omentobursitis. Peritonitis. Obstructive jaundice. Pancreatogenic shock. Pancreatogenic pleurisy on the left.

The prognosis of the severity of the course according to Ranson was 4 points. (age over 55 years, blood glucose - 14.8 mmol / L, leukocytes - 20 × 10 ⁹ , Alat - 1.15 mmol / L) + 6 clinical syndromes (pain + gastroenteric syndrome + hemodynamic syndrome + hepatorenal syndrome + respiratory syndrome + peritoneal syndrome).

After 8-hour preparation in the conditions of resuscitation, the patient was withdrawn from pancreatogenic shock. 3 hours before surgery, the patient underwent pleural puncture on the left of the VII intercostal space in the posterior axillary line, 450 ml of light serous fluid was evacuated. Amylase in it was 47 mg / s.l, lipid hydroperoxide - 18.2 mmol / l (in the peripheral blood - 35 mg / s l amylase, lipid hydroperoxide - 14.5 mmol / l). Introduced into the pleural cavity according to the method described above, successively 20,000 units. Contrikal and 300 mg of Mexidol. The breath on the left (hard) began to be heard in all fields. NPV decreased to 22 minutes. The ventilation and perfusion functions of the lungs improved, VC was 3.85 L, DO - 3.4 L, Rovd - 1.55 L, Rovyd - 1.42 L, SOS - 2.95 L, SpO ₂ - 88%. A significant improvement in ventilation of the small bronchi was noted.

An urgent laparoscopic examination of the abdominal cavity was performed. The infected form of pancreatic necrosis was verified. Conversion to the upper median laparotomy. Diffuse enzymatic peritonitis, omentobursitis, purulent fusion of pancreatic tissue in the area of its tail and parapancreatic inlet with a transition to the mesentery of the colon were revealed. The pancreas was abdominated. Cryogenic effect on the pancreas has been performed. Parapancreatic fiber is widely drained by Penrose drainage and 2-lumen drainage through the gastrointestinal ligament and an additional lumbotomy incision, followed by the formation of a flowing drainage system of the stuffing box. The stuffing bag is marsupilized. Superimposed cholecystostomy. A nasointestinal probe was performed to the ileocecal angle. The umbilical vein and inguinal lymph node on the right are drained for subsequent drug injections. The thoracic lymphatic duct is drained for the purpose of extracorporeal electrochemical lymph detoxification.

Postoperative diagnosis: Infected pancreatic necrosis. Phlegmon retroperitoneal space. Diffuse enzymatic peritonitis. Pancreatogenic shock. Pancreatogenic pleurisy on the left.

24 hours after the operation, the left pleural cavity was punctured in the VII intercostal space, 120 ml of light serous fluid was evacuated, and (according to the method described above) 20,000 units were administered. Contrikal and 300 mg of Mexidol. On the 3rd day after the operation, vesicular breathing was heard from both sides in all fields. The chest on the left stopped breathing while breathing, NPV - 22 per min. The ventilation and perfusion functions of the lungs underwent a significant improvement, so VC increased to 4.45 L, DO - 3.9 L, Rovd - 2.15 L, Rovyd - 1.73 L, SOS - 3.65 L, SpO ₂ - 94 % Marked patency of the small bronchi - almost the norm. On control radiographs and ultrasound of the chest, data for pneumonia or pleurisy was not received.

Starting from day 4, the general condition began to improve. The purulent process in the pancreas and retroperitoneal fiber was limited. On control radiographs and ultrasound of the chest, pleuropulmonary complications were not observed, so the NPV was 20 per min, VC increased to 4.62 l, DO - 4.1 l, Rovd - 2.34 l, Rovyd - 1.79 l, SOS - 3.94 L, SpO ₂ - 95%. The patient activated the regime, normalized sleep, and appetite appeared. Diuresis has fully recovered. The chair is independent. On the 7th day, hepatonephropathy was stopped. Indicators of hemostasis by this time have come fully to normal. On the 15th day from the moment of the first operation, a planned sequestrectomy through a bursostomy was performed. The further course of the postoperative period without features.

Gallbladder drainage removed on day 22. The recovery has come. A patient in satisfactory condition for 34 days in a hospital was discharged under the supervision of a doctor at the place of residence.

The method allowed to reduce the development of pleuropulmonary complications, namely pleurisy, in patients with pancreatic necrosis from 74% to 32%, and the mortality associated with it - from 22.5% to 16.7%.

Table 1.
Dynamics of ventilation-perfusion function of the lungs after intrapleural injections of Contrical and Mexidol in patients with pancreatic necrosis with pleuropulmonary complications (pancreatogenic pleurisy) (N-28). Indicators Norm Before treatment After treatment Respiratory rate, units / min 16 ± 2 24 ± 2 20 ± 1 * Vital lung capacity, l 4,5 ± 0,3 3.3 ± 0.2 3.9 ± 0.1 * Tidal volume, l 0.6 ± 0.2 0.3 ± 0.05 0.5 ± 0.05 * The reserve volume of inspiration, l 1.9 ± 0.1 1.3 ± 0.1 1.7 ± 0.1 * Expiratory reserve volume, l 1.9 ± 0.1 1.3 ± 0.1 1.5 ± 0.1 The average volumetric rate during expiration, l / s 3.9 ± 0.3 2.7 ± 0.2 3.6 ± 0.3 * Blood oxygenation,% 96 ± 2 84 ± 2 93 ± 2 * Notes: * - significant differences with indicators obtained before treatment; - the norm is obtained from average data from 20 untrained people (age 18-24 years).

Claims (1)

A method of treating pleuropulmonary complications in patients with pancreatic necrosis, which consists in performing after the operation punctures of the pleural cavity and removing the pleural effusion, characterized in that at least 3 hours before the operation, an additional single puncture of the pleural cavity and removal of the pleural effusion are performed, and not less than a day later after the operation, additional puncture of the pleural cavity is performed with an interval of at least 24 hours, moreover, during each puncture and after removal of the pleural effusion in the pleural 20,000 units of Contrikal and 300 mg of Mexidol are successively injected into the cavity.